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    Mysterious Case of Persistent Groin Pain

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    By Halfalah (haitham alfalah) [Attribution], via Wikimedia Commons

    Early on in my career, I had one of my most interesting cases to date.  To start off our relationship, a 44 year old male, showed up to his new patient appointment with active chest pain.

    So, I sent my patient straight to the emergency room, and subsequently, he was transferred to a larger facility for immediate heart catheterization. Two stents were placed in his LAD and RCA.

    After my patient was discharged, I saw him back in the office. At the time, he was doing well, and no longer had any symptoms of angina, but did note the inside of his right thigh was painful.

    He described the pain as burning and throbbing; bruising and swelling was also noted over the area where the catheterization took place.

    BruceBlaus (https://commons.wikimedia.org/wiki/File:Coronary_Angiography.png), https://creativecommons.org/licenses/by-sa/4.0/legalcode

    I believed, as well as the cardiologist, that this was due to the trauma at the insertion site from his catheterization. At that time, I ordered an ultrasound for the area, to rule out any possible pseudo-aneurysm or complication from the catheterization – the results were negative.

    During this same visit, the patient also revealed two weeks prior to his initial visit, he had a right-sided open hernia repair, but had been doing well without any concerns.  He mentioned the pain medication which was given post-operatively, had been helping reduce the pain, but was not resolving it completely.

    The patient was seen back in the office two weeks later, and at that time, he stated that his symptoms were not getting any better, and in fact were worsening.

    Labs were drawn (CBC, CMP, TSH, ANA, ESR, CRP, CK) and a right hip x-ray was taken as well.  I also stopped his statin therapy to rule out any risk of statin induced myopathy.

    These tests were all negative and there was only mild hip osteoarthritis present on the radiograph. I gave my patient a prescription for gabapentin and tramadol to take as needed, but his pain persisted and worsened.

    I decided to order an MRI of the pelvis and right upper leg, but there were no significant findings that could be contributing to an underlying etiology.

    At this point, I was thoroughly confused with what was causing his symptoms. I called him to come back into the office, and I could tell by the look in his face, that he was feeling depressed, because his pain was limiting his function and activities of daily living.

    In all honesty, I felt like I was failing this patient.  Not only could I not find what was causing his pain, but I could not provide him any relief either.

    Now, he was describing numbness and tingling, radiating from his mid right thigh into his groin. He additionally stated there were sharpshooting pains in his right thigh and scrotum. He also noted he was having pain during intercourse, which was a new, and an abnormal symptom for him.

    Even with this new information, I was unsure what the diagnosis could be. I consulted the patient’s cardiologist, and he had proverbially washed his hands from the case, noting he did not believe that it was related from the catheterization that had been done.

    I consulted the general surgeon who performed the hernia repair, and he did not think that there were any postoperative complications contributing to the symptoms either.

    Needless to say, I was stumped.

    At this point, I knew that I had to delve into the literature, to see if I could connect the dots.

    After searching up-to-date, I found an article titled post-herniorrhaphy groin pain that fit the majority of my patient’s symptoms to a T.

    In this syndrome, the nerves of the groin, during a procedure such as an open or laparoscopic hernia repair, are damaged or irritated, leading to neuropathic pain, along with hyperalgesia, and sexual dysfunction.

    In addition, the pain may radiate to the hemiscrotum, upper leg, or back.  Men may complain of testicular pain and women may complain of labial pain due to genitofemoral nerve irritation.

    Men can have pain with ejaculation as well.

    At this time, I felt as if I had a good idea that this could be contributing or could be the etiology of my patient’s symptoms. He was referred to pain management for further evaluation and possible treatment, including a genitofemoral/ileohypogastric nerve block.

    The patient underwent evaluation from pain management, and the following week, he underwent a successful ultrasound guided illioinguinal/ileohypogastric nerve block, with an 8 mL mixture of 50% Sensorcaine and 50% 1% Xylocaine along with 40 mL of Kenalog.

    I saw patient in clinic five days after the procedure, and he noted that he finally had great relief of his pain and symptoms. You could hear it in his voice, and see in his face, that he was pain free.

    This one nerve block procedure resulted in resolution of his pain and cured the post-herniorrhaphy neuralgia, but in some instances, these injections provide only temporary relief.

    If a patient only gains temporary relief, the specific problematic nerve can be sacrificed by a nerve ablation or surgical neurectomy.

    Unfortunately, there are patients who do not respond, and do not benefit from a nerve block at all. In these patients, medical pain management can include antiepileptic medication, such as gabapentin or pregabalin, or antidepressants such as duloxetine or amitriptyline.

    Nonsteroidal anti-inflammatory medications and opioids have not been shown to be as effective for this chronic neuropathic type pain.

    Nerve stimulation, such as a procedure that implants an electrode in contact with the injured nerves, is thought to potentially be useful in patients who show limited benefit to nerve blocks, but this has not been widely studied at this time.

    Other therapy such as heat compresses, topical analgesics, acupuncture, and physical therapy have been trialed, but there has been varied success in short-term, and much limited benefit in the long term for relieving chronic neuropathic groin pain.

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    Clay Walker
    Clay Walker is a board-certified physician assistant practicing in family medicine and urgent care in rural southern Illinois. He is a graduate of Southern Illinois University School of Medicine Physician Assistant Program - class of 2016. Prior to going to PA school, Clay worked as a histology technician in southern Illinois.  From an early age, he has been interested in medicine. Clay was diagnosed as a type 1 diabetic in the first grade. He began learning about his condition and teaching others about T1DM; since then, he began to have a passion to learn medicine and make a difference in the lives of others. In his free time, Clay enjoys watching sports and going to sporting events, specifically the Chicago Cubs and Philadelphia Eagles.