In an adult male who recently underwent laparoscopic inguinal hernia repair and now has testicular pain with a sensation of testicular retraction, what are the likely causes and how should this be evaluated and managed?

Post-Laparoscopic Inguinal Hernia Repair Testicular Pain and Retraction

Immediate Priority: Rule Out Testicular Torsion

This patient requires urgent Duplex Doppler ultrasound of the scrotum and inguinal canal within hours to exclude testicular torsion, as this is a surgical emergency requiring intervention within 6-8 hours to prevent permanent testicular loss. 1

While testicular torsion is less common in adults, the presentation of testicular pain with a sensation of retraction (high-riding testicle) following recent surgery mandates immediate exclusion of this diagnosis. 1

Diagnostic Evaluation

Urgent Imaging Protocol

• Obtain Duplex Doppler ultrasound immediately to assess testicular blood flow, looking specifically for: 1

  • Decreased or absent blood flow to the affected testicle compared to the contralateral side 1
  • The "whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
  • Enlarged heterogeneous testis appearing hypoechoic 1
  • Ipsilateral hydrocele or scrotal wall thickening 1

• Use Power Doppler in addition to color Doppler, as it is more sensitive for detecting low-flow states 1

• Compare to the contralateral testis as an internal control for relative flow assessment 1

Critical Clinical Pitfall

• False-negative Doppler evaluations occur in 30% or more of cases, particularly with partial torsion or spontaneous detorsion. 1 If clinical suspicion remains high despite normal Doppler findings, proceed directly to surgical exploration. 1

Differential Diagnosis Specific to Post-Laparoscopic Hernia Repair

Most Likely Causes in This Context

1. Spermatic Cord Entrapment or Injury (Most Common Post-Laparoscopic Complication)

• The spermatic cord structures (vas deferens, testicular vessels) can become entrapped by mesh or tacks during laparoscopic repair 2
• This presents with severe testicular pain, possible varicocele formation, and the sensation of testicular retraction 2
• Ultrasound may show normal testicular perfusion but abnormal cord anatomy 2

2. Focal Testicular Infarction

• Can occur from vascular injury during laparoscopic dissection, presenting as testicular swelling and pain that increases over days 3
• Doppler ultrasound shows a wedge-shaped or focal avascular area, typically affecting the upper pole 3
• May present with a tender, swollen, high-riding testicle mimicking torsion 3

3. Neuropathic Pain (Genital Branch of Genitofemoral Nerve)

• Injury to the genital branch of the genitofemoral nerve during mesh placement or tacking causes predominantly testicular pain 4, 5
• This nerve runs along the spermatic cord and is vulnerable during laparoscopic dissection 5
• Pain may be severe and debilitating, often requiring nerve blocks for diagnosis 5

4. Retained Omental Tissue ("Omentaloma")

• Incomplete reduction of omentum from the hernial sac can cause persistent scrotal swelling and new-onset pain 6
• Ultrasound shows a well-defined hypoechoic scrotal lesion; MRI reveals fat-containing mass 6

5. Testicular Torsion (Must Be Excluded First)

• Although rare in adults, recent surgical manipulation increases risk 1
• The "high-riding" testicle description is particularly concerning for torsion 3

Management Algorithm

If Torsion is Confirmed or Highly Suspected

• Immediate urological consultation and surgical exploration within 6-8 hours of symptom onset 1
• Perform bilateral orchiopexy during surgery to prevent contralateral torsion 7

If Torsion is Excluded

Step 1: Assess Testicular Viability

• If focal infarction is identified on ultrasound with preserved overall testicular perfusion, conservative management with observation is appropriate 3
• Serial ultrasounds may be needed to monitor progression 3

Step 2: Identify Mechanism of Pain

• For suspected cord entrapment: Laparoscopic re-exploration may be the preferred approach, allowing better visualization of anatomic structures and release of entrapped vas deferens or vessels with minimal tissue damage 2

• For neuropathic pain: Consider diagnostic nerve blocks of the genital branch of the genitofemoral nerve 5

  • If nerve blocks provide relief, surgical neurectomy via open or hybrid approach can be performed 4
  • Paravasal neurectomy combined with inguinal neurectomy shows 99% improvement rate, with >50% pain reduction in 64% of cases 4

• For retained omental tissue: Surgical exploration and excision of the encapsulated mass provides definitive treatment 6

Step 3: Timing of Intervention

• If pain is severe and debilitating, early surgical intervention (within days to weeks) is warranted 4, 2
• Conservative management with analgesics and observation is appropriate only if pain is mild and improving 3

Key Clinical Pearls

• Never delay surgical exploration if clinical suspicion for torsion is high, even with equivocal imaging findings 1

• The sensation of testicular retraction (high-riding testicle) is a red flag that should prompt urgent evaluation 3

• Laparoscopic complications causing testicular pain often require surgical correction rather than prolonged conservative management 4, 2

• Orchialgia after hernia repair affects approximately 10% of patients and can result from multiple mechanisms requiring tailored surgical approaches 4

• Ultrasound sensitivity for detecting vascular compromise ranges from 69-96.8%, so clinical judgment must guide management when imaging is inconclusive 1