What is the appropriate management for a patient with bilateral inguinal (groin area) pain?

Management of Bilateral Inguinal Pain

The initial priority is to determine whether this represents an acute surgical emergency (incarcerated/strangulated hernia) versus chronic pain, as this fundamentally changes management—acute presentations require urgent imaging and potential emergency surgery, while chronic pain follows a stepwise conservative-to-interventional approach.

Immediate Assessment for Surgical Emergencies

The first critical step is ruling out complications requiring urgent intervention:

• Assess for signs of incarceration or strangulation: Look specifically for irreducibility of any palpable mass, tenderness over the inguinal region, erythema, or systemic symptoms including fever or signs of systemic inflammatory response syndrome (SIRS) 1
• Examine both inguinal regions bilaterally: Palpate for bulges that increase with Valsalva or coughing, and specifically check for femoral hernias which carry higher strangulation risk 1
• In males, palpate the testes: Ensure they are in normal position and not involved in herniation; testicular pain can be the presenting symptom of incarcerated inguinal hernia with bowel content extending into the scrotum 2, 1
• Duration matters critically: Symptomatic periods >8 hours, presence of comorbidities, and signs of strangulation significantly increase morbidity and mortality, with delays >24 hours associated with higher death rates 1

Emergency Imaging When Indicated

• CT scanning with contrast should be obtained if strangulation is suspected but diagnosis unclear—it can predict bowel strangulation with 56% sensitivity and 94% specificity for reduced wall enhancement 1
• Ultrasound with Doppler is the initial imaging modality for acute scrotal pain presentations, with sensitivity 91.7% and specificity 99.2% for testicular pathology; standard examination includes bilateral scrotal AND inguinal areas 3

If No Emergency: Differential Diagnosis Approach

Once acute surgical emergencies are excluded, bilateral inguinal pain requires systematic evaluation:

Primary Considerations

Inguinal hernias (most common):

• Examine for bulges bilaterally that increase with coughing/straining 1
• Note that physical features (size, ease of reduction) do NOT reliably predict incarceration risk 1
• History of previous abdominal or groin surgery increases hernia risk 1

Chronic postoperative inguinal pain (CPIP) if prior hernia repair:

• Affects 10-15% of hernia repair patients, with 2-4% experiencing severe persistent pain 4, 5
• Typically involves ilioinguinal, iliohypogastric, or genitofemoral nerve neuromas 6
• When testicular pain predominates, suspect genital branch of genitofemoral nerve involvement 6

Athletic pubalgia/sports hernia: Consider in active patients without obvious hernia

Lymphadenopathy: Palpate for inguinal nodes; assess for infectious, inflammatory, or malignant causes

Management Algorithm

For Confirmed Inguinal Hernias

Elective surgical repair is indicated for all symptomatic inguinal hernias to prevent complications that would necessitate emergency surgery with higher complication rates 1:

• Surgical approach selection depends on patient age, comorbidities, hernia characteristics, and surgeon expertise 1
• Laparoscopic approaches (TEP or TAPP) are viable options and may reduce hospital stay 1
• Open repair remains appropriate, particularly when laparoscopic expertise is limited 1
• Patients should avoid activities increasing intra-abdominal pressure while awaiting repair 1

For Chronic Postoperative Inguinal Pain

Initial management must be conservative and sequential 5, 7:

1. Diagnostic nerve blocks to identify which nerve (ilioinguinal, iliohypogastric, or genitofemoral) is causing symptoms 6

2. Nonsurgical therapies first 5:

   • Pharmacological management (neuropathic pain medications)
   • Physical therapy
   • Interventional pain management (nerve blocks)
   • Cognitive behavioral therapy

3. Surgical intervention only after conservative failure 5, 7:

   • Neurectomy with or without mesh removal provides long-lasting analgesic effects in most patients with severe CPIP 4
   • For testicular pain specifically: resect genital branch of genitofemoral nerve proximal to previous operative field with retroperitoneal placement 6
   • Evidence from 25 studies supports neurectomy ± meshectomy for refractory cases 4

Critical Pitfalls to Avoid

• Missing femoral hernias: Always examine below the inguinal ligament, as femoral hernias have higher strangulation risk 1
• Failing to examine contralateral side: Bilateral pathology is common 1
• Delaying evaluation with any strangulation signs: Redness, warmth, swelling, or systemic symptoms require immediate surgical consultation 1
• Jumping to surgery for chronic pain: Conservative management must be exhausted first, as surgical outcomes for CPIP are variable 5, 7
• Assuming reducibility means safety: Physical hernia characteristics don't predict incarceration risk 1