CHRONIC PELVIC PAIN
DEBORAH A. METZGER, PhD, MD
Considering the perceived rarity of hernias in women , the association between chronic pelvic pain and occult hernias is not generally considered when evaluating women with chronic pelvic pain . However, based on a review of the literature and personal experience, nonpalpable, or occult hernias are a common source of chronic pelvic pain in women.
Most gynecologists and general surgeons are unaware of occult hernias and many do not believe that they exist; and therefore, they are controversial. However, Nyhus  described a spectrum of hernias differentiated by size, presence or absence of a sac, and the degree of deformity of anatomy. Type III hernias are more common in men, whereas Type I and II hernias (occult hernias) appear to be more common in women. Type I and II hernias, often referred to as occult inguinal hernias, have been reported to be associated with groin pain in men, women, and athletes .
Except for a mass in the groin, pain is the most common symptom of a hernia . Pain is more common in the incipient stages of hernia, when the tissues are being stretched , and is by far the most common sole initial symptom caused by hernia. The pain is often sharp and may even be of the neuralgic type . Symptoms may develop long before a palpable hernia develops. Thus, in women with chronic pelvic pain, it would be anticipated that the earlier, nonpalpable stages of hernias would predominate.
Because a variety of organ systems are involved in the spectrum of presentations of occult inguinal hernias, the diagnosis can be confusing. The primary symptom is groin pain that the patient may describe as “ovarian pain” (Figures 1 and 2). Other symptoms, such as pain with bowel movements, full bladder, or with intercourse, are related to exacerbation of the pain with increased intraabdominal pressure. Back pain, either uni- or bilateral, appears to be due to piriformis muscle spasm as this muscle is often quite tender on vaginal examination. Likewise, sciatica may be due to the stretch of the sciatic nerve as it passes over the tensed piriformis muscle. The exacerbation of groin pain with menses, which patients describe as different from cramps, is not readily explained, but commonly observed. Ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal neuralgia symptoms may predominate, and the patient may complain of sharp, shooting pains up the vagina, around the hip and back, into the flank, down the thighs, and into the labia. These secondary problems make it more difficult to make the diagnosis of inguinal hernia especially since the patient may see a variety of specialists who may not connect all of the symptoms. Thus, the patient may have been diagnosed with lumbar disc problems, pelvic floor tension myalgia, sacroiliac instability, interstitial cystitis, endometriosis, abdominal wall trigger points, neuropathy, pudendal neuralgia, orthopedic problems of the hip, or psychosomatic problems.
Diagnosis of nonpalpable hernias in women relies almost exclusively on clinical examination. The small size of these hernias and the presence of incarcerated fat make it difficult to obtain useful information from ultrasound, computed tomography, magnetic resonance imaging, or herniography.
Examination of the abdomen in a supine position with the abdominal wall tensed may reveal tenderness over the course of the ilioinguinal or iliohypogastric nerves, or both. Abdominal examination in a standing position sometimes reveals a subtle bulge associated with the external inguinal canal. More often, however, there may be tenderness of the ring reproducing a component of the patient’s pain. The best predictor of an occult hernia is the vaginal examination. Often the pelvic floor muscles are tense and tender. Likewise, the ischial spines may be tender. Most telling is a reproduction of the patient’s pain by palpation of the internal inguinal area. The positive predictive value of this latter sign approaches 100% .
Oral medications that specifically target nerve pain, such as gabapentin, amitriptyline, and tramadol, are often helpful. Antiinflammatory medications, such as ibuprofen, naprosyn, and the cox-2 inhibitors, can be helpful. Narcotic medications in general are not particularly helpful for nerve-related pain. Topical medications, such as Lidoderm, 10% ketoprofen, 5% amitriptyline, 5% lidocaine, and/or 10% gabapentin, may reduce pain.
Myofascial release performed by a physical therapist trained in internal manual methods can sometimes be helpful in alleviating some of the muscle spasms. Nerve blocks may produce temporary relief, but the pain invariably returns.
Surgery is considered only when a patient has tried the medical treatments described above and still has a level of pain that interferes with her quality of life. Hernias are generally not visible at the time of laparoscopy and thus are usually missed by prior surgeons. To make the diagnosis, inguinal exploration of the affected side(s) is performed using a laparoscopic approach. A transverse incision is made in the peritoneum, and a careful exploration is performed to look for incarcerated fat or dilation of the indirect inguinal, direct inguinal, femoral, and obturator spaces. All 4 spaces are explored because it is common to find more than one type of hernia . The incarcerated fat is removed, and a soft mesh is placed over the hernias. We do not use staples or tacs to hold the mesh in place because these fixation devices can cause pain and require additional surgery to remove them . The peritoneum is then closed with an absorbable suture.
As with any type of laparoscopic surgery, risks are associated with hernia repair. Bleeding from vessels in the inguinal area, permanent damage to nerves, infection, adhesions, and continued pain are all potential risks. Postoperative pain is somewhat greater than with other types of laparoscopic procedures and should be treated with appropriate narcotics. Neuropathy may initially resolve and then reappear within 1 to 3 weeks following surgery and last 2 to 3 weeks before it spontaneously resolves. Some women require a series of nerve blocks to completely resolve the nerve pain. Overall, 80% to 85% of women obtain complete or significant pain relief from surgery for occult hernias .
The treatment of chronic pelvic pain has been limited by our ability to specifically diagnose and treat the cause(s) of pain. Because occult hernias are not generally apparent on laparoscopic evaluation, they should be considered in chronic pelvic pain patients with negative laparoscopy results or where the observed pathology is insufficient to explain the degree and type of pain.
Figure 1. Location of the ovarian point.
Figure 2. Patterns of pain in the presence of occult hernias. The pain can be unilateral or bilateral.
Address reprint requests: Deborah A. Metzger, PhD, MD, Harmony Women’s Health, 851 Fremont Ave, Ste 104, Los Altos, CA 94024, USA. Tel: 650 229 1010, Fax: 650 229 1011, E-mail: DrDebMetz@pol.net
Deborah A. Metzger, PhD, MD, is a gynecologic surgeon and reproductive endocrinologist whose major interest is the integrated treatment of women with chronic pelvic pain. After graduating from college (SUNY at Buffalo, 1973), she obtained a PhD in molecular endocrinology from Baylor College of Medicine in Houston, Texas (1979). She attended medical school at the University of Texas Medical School at Houston (1982) and completed her residency in Obstetrics and Gynecology (1986) and a fellowship in Reproductive Endocrinology and Infertility (1988) at Duke University in North Carolina. She has served on the medical school faculties of the University of Connecticut, Yale, and Stanford. Currently, she is Medical Director of Harmony Women’s Health in Los Altos, California.
She is recognized as one of the leading authorities in the treatment of endometriosis and chronic pelvic pain. In addition to her involvement in many professional societies, she is a founding member and past-President of the International Pelvic Pain Society. She has lectured extensively throughout the world, published widely in peer-reviewed journals and textbooks, and is one of the editors of Chronic Pelvic Pain: An Integrated Approach, the first book on the subject.
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