Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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L.A. Cunningham and B. Ramshaw
patient’s experience and environment in the pre-, peri-, and postoperative
period. One single factor may not be the sole cause for chronic pain,
and most often multiple factors play a role. Because of this complexity,
there are many treatment options available to patients, which range from
noninvasive medications and lifestyle modifications to invasive procedures
such as nerve blocks and reoperation. The same treatment option
may not benefit each patient, and in some patients, a multimodal
approach is necessary to achieve maximal pain relief.
This chapter will focus on the surgical approach for the management
of chronic groin pain, including mesh removal, although some other
treatment options will be discussed. We will also discuss a team-based
model for providing care that attempts to deal with complex problems
such as chronic groin pain after inguinal hernia repair.
Types of Pain
In general, pain following an inguinal hernia repair can be divided
into two groups, nociceptive and neuropathic [ 3 ]. Nociceptive pain is
caused by activation or sensitization of peripheral nociceptors, specialized
nerve endings that respond to chemical, mechanical, or thermal
stimulus. Neuropathic pain is the consequence of injury to peripheral or
central nervous structures.
Acute pain from surgery is caused by noxious stimulation due to tissue
injury and is usually nociceptive. There are two subtypes of acute
pain, somatic and visceral. Visceral pain can occur in the groin when the
intestines become involved and may be due to mesh adherence and/or
erosion into the bowel. The somatic component of nociceptive pain further
subdivides into superficial or deep pain. Superficial pain is sensed
by unimodal nociceptors in the skin and subcutaneous tissues that evoke
a sharp, pricking type of pain, while deep somatic pain is sensed by
polymodal receptors in the muscles, tendons, joints, and bones that bring
about a long-lasting dull, aching, or burning pain that is typically less
well localized. The ability to localize pain is affected by the intensity
and duration of the painful stimulus. In addition, nociceptors display
sensitization following repeated stimulation that can manifest as an
enhanced response to noxious stimuli or an acquired responsiveness to
non-noxious stimuli. Sensitization of nociceptors is proposed as a key
component of peripheral pain disorders.
Neuropathic pain is due to partial or complete injury to the nerves.
This type of pain is characterized by partial or complete sensory loss or