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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S. Towfigh
were irregular and sometimes missed. Sexual intercourse was painful.
She was chronically fatigued. She was unable to work and uses a wheelchair,
as she cannot tolerate walking long distances. She is found lying
in bed most of the day.
Physical Exam
The patient was found in fetal position, shivering, unable to be examined
comprehensively due to severe pain. Temperature and other vital
signs were normal. Abdomen was mildly distended but soft. Incisions
were well healed. She had 4+ tenderness to light touch along bilateral
lower groin and upper thigh areas, without specific dermatomal distribution
and no skin changes.
Nonoperative Management Options
The patient was first admitted to the hospital for pain control. This
included epidural catheter placement, which helped relieve many of her
symptoms. This allowed us to perform imaging and gynecologic and GI
evaluation to help determine the plan of care. She had already had intolerances
to many medications as well as certain tapes as noted from her prior
operation. During this hospitalization, she also showed intolerances (nausea,
rashes, swelling) from more medications, tapes, and even IV needles.
She was evaluated for autoimmune disorders as well as endocrine abnormalities
and complement and nutritional deficiencies, all of which were
normal.
Imaging
Abdominal x-ray showed normal pelvis with normal bowel gas pattern.
Also, there was a normal number and placement of spiral titanium
tacks (i.e., 3–4 on each side, and none placed laterally). Magnetic resonance
imaging (MRI) of the anterior pelvis, non-contrast, with valsalva
and dynamic views demonstrated intact flat extraperitoneal mesh with
no hernia recurrence and no evidence of mesh-related fluid collection or
inflammation (Fig. 33.1 ). Pelvic ultrasound was concerning for adhesive
disease and endometriosis.