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Speaker 1 (00:00:10):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. We are here again on a Tuesday. We call Hernia Talk Tuesdays. I am your host, Dr. Shirin Towfigh. Thank you everyone for joining me. Many of you’re here via Zoom and some of you are also logged in on my Facebook page at Dr. Towfigh where we do this every week as a Facebook Live as well as you know, you can also follow me and get all the updates about our hernia talk episodes on Twitter and Instagram as well at Hernia doc. And as always, this episode and all prior episodes will be all prior. 130 episodes I should say, will be posted on my YouTube channel at Hernia doc, so I’m super excited to have you all there. All right, so let’s talk about testicular pain.
Speaker 1 (00:01:10):
This is something that unfortunately is very much related to hernia surgery and hernias in general in the groin al hernias, those are the females on this. It’s not really relevant to the female anatomy. Women don’t have testicles. However, it is important to know that for men, the testicle is often part of the diagnosis of hernias and also can be involved in postoperative complications. And the reason why I chose this topic today is I know that we’ve had several urologists, I believe three in the past, all specialists, all really super knowledgeable that have been my guest on Hernia, Talk Live in the past. And we’ve discussed testicular pain and pain with intercourse and so on, and how it’s related to me as a hernia surgeon and me diagnosing my patients. However, I feel like I still need to talk specifically about testicular pain. This past week I’ve had several patients come to see me.
Speaker 1 (00:02:20):
Of course, all male, all from out of state, all have had some type of testicular chronic pain after their hernia repair, repair. All of them were misdiagnosed, mistreated and basically had the wrong diagnosis, given the wrong treatment options and misled for years, for years. And it seems like as a female, I’m more worried about this problem than many of my male colleagues. I don’t know how to explain that. However, it’s an issue and I hope that this hour we can go through all the of how testicular pain is related to hernias and hernia surgery in men and therefore get that information out not only for you as a patient, but also to general doctors, general surgeons that are hernia surgeons and also urologists who may be watching this video if they’re searching for stuff for their patients because it’s very, very important. So very briefly, patients who have indirect or sometimes even direct inguinal hernias can present with testicular pain as the cause of their hernia.
Speaker 1 (00:03:38):
Now there’s many, many, many different reasons why you a male can have testicular pain, they can have a testicular problem. It could be spermatic cysts. They can have spermatocele, which is like a little bit leakage of sperm. They can have a testicular problem itself. A cancer usually doesn’t present with pain. Varicoceles could be there and so on. Usually, typically the patient has testicular pain, but it’s activity related, which is why it’s different than most testicular problems. And they go to the urologist or family medicine doctor and they get an ultrasound of the testicle. It’s just called testicular ultrasound, ultrasound or scrotal ultrasound when they look at everything in the scrotum and it comes back normal. So no varicoceles, no weird cyst, no weird growth, no abnormality seen. Testicle is normal inside and test testicle has normal blood flow. Those are all the components of a normal testicular or scrotal ultrasound and no fluid collection, which would be a hydrocele.
Speaker 1 (00:04:53):
Then the doctor is at a loss. I don’t know why you have testicular pain and many urologists and other doctors do not understand that you can have testicular pain due to an inguinal hernia. There are clinics out there that specialize in testicular pain and I’ve seen a lot of patients from these clinics where they don’t diagnose the patient with a hernia even though that was the cause of the pain. And they do all these procedures focusing on the testicle, including removing the testicle, which never works. By the way, removing the testicle ironically does not get rid of testicular pain because your brain still feels the pain almost like phantom pain and they do something called spermatic cord denervation surgery. It’s a very complicated operation where they take out all the nerves, basically all the nerves that feed the testicle through the spermatic cord and hope for the best.
Speaker 1 (00:05:57):
Again, it’s not addressing the root of the problem and those people will often just need a hernia repair. So if you have testicular pain and there’s no testicular main diagnosis, you very well may have an inguinal hernia and the inguinal hernia needs to be repaired to understand if your testicular pain is from that. Now, testicular pain due to inguinal hernia is almost always activity related. So the more upright you are, if you have a cough or if you’re more active, that will cause more hernia symptoms and in that patient specifically would be testicular pain. So that’s kind of the gist of dealing with testicular pain as a primary problem. That means as a primary problem, excuse me, as a problem from primary hernias, what I see a lot more confusion even is when a patient has had inguinal hernia surgery and now they have testicular pain, that becomes much more complicated because now you’re dealing with a urologic problem after a general surgical operation.
Speaker 1 (00:07:13):
So what you’re doing is you’re going to your hernia surgeon saying, I have testicular pain. And your surgeon, if they’re not a specialist, often do not correlate or understand why a hernia repair may cause testicular pain. And they said, oh, well that’s not my problem. Why don’t you go to a urologist? Well, urologist specializes in the testicle, but they typically don’t do a lot of hernia repairs and they don’t deal with Mesh. And therefore now you have a urologist that understands a testicle but does understand hernias who then says, I don’t know why you have testicular pain. And they do all these studies and procedures and fail to diagnose. What you really need is a hernia specialist who understands the urology aspects of hernia surgery to help you. And that’s why I was able to help some of my patients and it’s, it’s kind of been the same story as a typical male oftentimes has a very simple hernia. It can be complex hernia too. I haven’t seen a correlation of whether it’s a large hernia or a small hernia as a problem. They undergo a hernia repair. That’s if you read the operative report, perfectly done laparoscopic open with Mesh. Typically with Mesh, I haven’t really seen too many specifically testicular pain that wasn’t caused by the Mesh.
Speaker 1 (00:08:47):
And then the patient is lost to in the medical system because no one can figure out why they have a testicular pain. They go to the general surgeon. The general surgeon says Your hernia repair is fine, the Mesh looks good, they get an MRI possibly or an ultrasound and everything looks fine. So they say, not my problem. Maybe you have some type of urologic problem. They go to the urologist. The urologist is a specialist in male genitalia, et cetera, and they do a full workup. It usually includes a testicular ultrasound and they may find certain things, oh, you got a varicocele or hydrocele or et cetera, and they focus on that. And some, I have people that are told they need their testicle removed, also called orchiectomy, that they need orchiopexy where their testicle needs to be sewed down so it doesn’t twist. They’ve been told they need varicocelectomy, so they have varices or venous engorgement of the veins and that’s what their problem is.
Speaker 1 (00:09:52):
They’ve been told they need neurectomies, they’ve had nerve transactions. All of these in my patients have been unuseful because that was not the reason for the testicular pain. So what I really want you to understand is that testicular pain after inguinal hernia repair has a lot of potential reasons for it. One of them very strongly is the Mesh interaction with the spermatic cord and no amount of procedures downhill at the testicle will help what’s going on uphill, which is the hernia Mesh. And these patients are often from out of town because the urologist I work with locally all know this. They’ve all shared patients with me, we’ve operated together, they understand this interaction whereas surgeons outside of my area may not necessarily understand this problem. So here’s what happens. You have a routine standard, very well done hernia repair. I’m not talking about complications of like a badly done hernia. This is a routine well done hernia repair.
Speaker 1 (00:11:04):
Why would that cause testicular pain? First of all, they could have injured aspects that go down to the testicle. So the there’s muscle, there’s blood vessels, there’s nerves, and there’s the vas which carries the sperm from the testicle to the prostate. If they injure the muscle or if they entrap the cut the muscle, you can actually have an inappropriately placed testicle. And in doing so, if you actually injure the nerve, the genital branched nerve to the cream hysteric muscle as part of the operation or you cut it as the Shouldice used to do, I think they’ve stopped doing that. Maybe they haven’t. I don’t know. I’ve heard different things. I believe the last time I interviewed someone from the Shouldice clinic, they said it’s optional now. So their tendency is to cut the ch hysteric muscle because they found in their study to reduce it reduces recurrence rates. However, if a patient chooses or requests not to have it cut, they will change their technique. That’s what I was told. And that’s one of our past hernia talks with the Shouldice clinic surgeon.
Speaker 1 (00:12:32):
Now if the muscle is cut or the nerve that feeds the muscle is cut, that testicle can fall down and be very low riding to the point where it may actually touch the toilet bowl if you’re sitting on the toilet. That’s how extreme it can be, and that’s very uncomfortable because of how you sit and the type of clothing you wear. It can be a discomfort. There are vessels, the veins and the arteries. If this is a very large hernia and it needs a lot of dissection, you may inadvertently injure some of the veins as part of the dissection, peeling the hernia off of the spermatic cord vessels. Or if you’re a heavy-handed surgeon, you can be injuring the veins. Or if it’s a redo, redo where the patient had, let’s say an open surgery, now it’s having laparoscopic surgery or vice versa, then in all of these scenarios, the venous the vein blood flow can be affected and therefore what can happen is you can have almost like poor drainage of the blood that’s going to the testicle.
Speaker 1 (00:13:46):
So blood goes from the artery to the testicle and the veins take the blood away from the testicle and people get engorgement or a feeling of heaviness in the testicle because they don’t have good venous flow back to the heart. And that can be one reason. The other reason why you can have abnormal venous blood flow, so obstruction of venous blood flow is from the Mesh. So the Mesh can stick or obstruct or push or impinge on the spermatic cord including the vessels depending on how the Mesh is placed in how the Mesh heals, whether it heals flat or with angles.
Speaker 1 (00:14:31):
And certainly if you have a plug that can be a big, big problem where there’s impingement of blood flow going back to the heart. So now you have normal blood flow going down to your testicle via the artery, but it doesn’t drain efficiently. So you get intermittent swelling and pain in the testicle because the blood flow to it, the outflow is blocked and that’s a consequence of the Mesh actually impinging on it. So there are patients that were totally normal before surgery and now have what’s called varicocele or engorged veins after surgery. That engorgement of the veins is not a true varicocele. It’s caused artificially by the Mesh upstream. So if you go to a typical urologist, they will diagnose you with a varicocele. But what you need to do is to let them know that you have Mesh upstream. You do not have this feeling of heaviness and dull achiness in the scrotum and testicle before surgery.
Speaker 1 (00:15:41):
Now the Mesh is there, it may be causing an obstruction of the venous outflow causing backflow and obstruction of the veins with engorgement of the veins and therefore are varicocele. So the treatment is not a varicocelectomy because that’s not the main problem, that’s a secondary problem. The main problem is addressing the way the Mesh is interacting with your SP sperm rheumatic cord veins, your spermatic veins uphill from that. Okay, there’s the vessel’s issue. The other issue is the nerves. So there are nerves that feed the testicle. So if you injure the nerves that give you sensation of the testicle, the injury to those nerves can be felt as testicular pain. Where are those nerves? Well, they’re all along the spermatic cord, but importantly they’re also all on the vast. The vas deferens is a pasta al dente type structure with a narrow lumen through it which carries the sperm from the vast deference to the prostate and eventually out of the urethra.
Speaker 1 (00:17:01):
And if there’s any damage to the outer area of the vas, which implies which is where those nerves are, where those nerves are, if those nerves are now irritated, injured, damaged, impinged on eroded onto by Mesh, then the injuries up by the Mesh repair. But the pain is down in the testicular problem area. So in that situation it could be from open surgery or laparoscopic surgery. I’m seeing it more often with laparoscopic surgery before I was seeing it with open surgery. So with open surgery it was because the Mesh was eroding around the spermatic cord because of the keyhole procedure laparoscopically. I’m seeing it in two manners. Sometimes surgeons do a keyhole technique and I’ve told you if many of you are following me do not have a keyhole procedure done laparoscopically. That’s not an ideal situation. But if you do, there’s the main risk is testicular pain because the keyhole is too tight around the spermatic cord and it injures those nerves and it can also obstruct and cause the vein dilation,
Speaker 1 (00:18:21):
engorgement also varicocele, which causes adult more of dull pain in the testicle and scrotum. However, the flat Mesh the flat typical TEP, TAPP laparoscopic robotic inguinal hernia repair with Mesh that implies a fairly long length of Mesh that overlaps with the spermatic cord, includes the vas and the deferens which have nerves on it and it includes the vessels and it’s possible that that interaction is abnormal and therefore causes abnormal adherence of the Mesh to the vas deferens nerves or the vasal nerves and that can cause pain the way. Well, we’ll talk about diagnosis next, but that can be a problem. And some patients the Mesh is placed too low or there’s a longer than usual length of Mesh that overlaps with the spermatic cord and in those patients they may present with testicular pain. Again, they have testicular pain, but the problem is not the testicle, the problem is everything upstream going on at the base of in the pelvis at the hernia repair.
Speaker 1 (00:19:40):
And then I’ll get to your questions in a second because they’re piling up. I’m sorry, the last one is the actual injury to the vas. So you can have an inadvertent injury during surgery to the vas. That’s really not common, although you may have seen I had a report, I think it was last year or the year before where it happened to a child. So it was like a four or five year old boy who had basically vasectomies at the time of his inguinal hernias inadvertent as the surgeon miscalculated where she was operating in the kid had vasectomies less common in adults because it’s much larger vas.
Speaker 1 (00:20:30):
So one reason for testicular pain would be a injury to the vas and because there’s injury to the, the flow of sperm from the vas towards the prostate is affected, obstructed or completely destroyed. And that can cause pain, usually pain on ejaculation and can cause engorgement of the testicle or what we call spermatocele, which is leaking of sperm out of the testicle because of the increased pressure. So the other reason for vas being injured is the Mesh can impinge on it, it can kink it and or it can erode into the vas and as an implant that can happen with both open and laparoscopic or robotically placed meshes. That usually is more common with open repairs than laparoscopic, but it can happen with any of ’em. And so any disruption of flow of the sperm can cause testicular pain, pain with ejaculation and spermatic, which also causes testicular pain.
Speaker 1 (00:21:40):
So before I go to diagnosis and kind of explained some of these situations I’ve seen lately in this past week, let me answer some of your questions. Is this topic related to a Mesh removal surgery with nerve pain near the groin area? Sure, we can definitely answer those questions because Mesh removal surgery is one of the different treatment options for testicular pain. And this other question says I have testicular pain which comes and goes after Inguinal hernia open Mesh repair. Five months ago I asked a surgery for a pelvic MRI, he said no and told me to see a pain specialist. Sometimes they say no because they don’t know what to do with the MRI once the results are back. So instead of falling into a rabbit hole where they’re, they’re they’re getting images that they don’t know to how to interpret, they prefer to send you to a specialist.
Speaker 1 (00:22:42):
Let’s see, he said no and told me to see a pain specialist for cortisone injections. So this is a big pet peeve. It really, really picks me up. First of all, pain specialists are great, however, they don’t understand, most of them don’t understand what we do as general surgeons. So for a general surgeon to say just go to pain management without really identifying what the pain management specialist needs to do, I think is not right. And that’s why I say you should go to a hernia specialist because a hernia specialist understands what needs to be done and can help the pain management specialist. Otherwise you’re sending them to a specialist for pain and that person, all they know about is medications and injections and they don’t understand. Let’s say maybe your Mesh needs to be removed or maybe you have a hernia recurrence. How is a pain doctor supposed to treat a hernia recurrence?
Speaker 1 (00:23:33):
So it sounds like you had hernia repair five months ago open and you have testicular pain which comes and goes. You also have pain under your incision by the Mesh which comes and goes, good days and bad. So I don’t know the details of everything else, but having pains that’s persist for five months after surgery A is not normal and B is not only due to nerve. That’s my biggest pet peeve, which is guys nerves are one of many reasons why people have pain. You can have pain from a hernia recurrence from a Mesh being balled up from nerve injury from an infection. Did I say hernia recurrence? I think I said hernia, recurrence injuries to the different spermatic, cord vessels, lack of blood flow and so on, too tight of a repair. There’s so many different reasons and nerve is just one of them and it’s usually not even the most common. So why so many doctors, medical doctors, pain medicine doctors and even surgeons go straight to cortisone injection? I have no idea because it, it’s not, you have to really sit down and listen to the patient’s story. So if they say, you know what, I feel a tugging in my testicle or my test keeps having pain, that’s not like an ileal nerve issue. For example, and I’ll explain to you how common this is because I’ll, one of my patients had exactly this problem.
Speaker 1 (00:25:18):
Okay, so let’s see. Thanks doctor, you were so knowledgeable. I talked with Nurse Bel, I need to see you. My other doctor is a three hour drive, but I prefer to fly to LA. Yeah, happy to see you. And Nurse Bel is great. She’s my nurse. She’s the best. She’s so knowledgeable. I’m willing to bet you the most knowledgeable hernia nurse in the nation if not the world because that’s all we do here. And she’s very, very involved in the care of my patients both evaluating and treating and she’s there with me during surgery so she knows exactly what’s done in surgery. So it’s l, it’s the most amazing experience and for those of you that call my office and speak with Nurse Bel, you all already know how wonderful she is, so she will help you through the process to see me, happy to see you.
Speaker 1 (00:26:15):
What I want to say, okay, diagnosis. So your surgeon, your general surgeon, not your urologist, not your pain medicine doctor, not because they’re all great but they don’t do what we do. They don’t even know what we do in the operating room. Often your general surgeon and therefore preferably a hernia surgery specialist, needs to sit down with you and figure out where exactly is the pain. Is it in the groin or is the testicle? When you say testicle, do you mean the actual testicle or do you mean the scrotum? When you say scrotum, do you mean the scrotum or do you mean the testicle? Very different because the blood flow and the nerves that go to those areas are very different.
Speaker 1 (00:26:56):
Is the pain sharp, blunt, dull burning? Does a radiate anywhere? Do you have pain that goes to your inner thigh pain that goes to the base of the penis pain that goes around your lower back? Is your scrotal skin sensitive? Do your types of underwear make a difference? Do you prefer boxers or briefs? That actually makes a big difference and people with testicular pain, so if you have a patient that for example, prefers to wear briefs where the testicle is held up higher and any dangling of the testicle is painful, then you have a spermatic cord problem up high at the level of the Mesh and that needs to be addressed. If the reverse is true, you don’t want anything touching the testicle, you want just to be free and nothing touching it, that’s probably a nerve issue. And now you got to deal with general femoral nerve and those branches to see if it’s a scrotal issue and that’s usually not a testicle issue.
Speaker 1 (00:28:06):
Then there’s a question of duration and what makes it worse. If it’s activity related or standing, then you got to think of blood flow, right? The more you stand the blood flow issues or you could have something simple like a hernia recurrence. If you say that it hurts every time I cough for example, or bend down, that could just be a simple hernia recurrence. So imaging is very important. Ultrasound preferably my preference is MRI. To look at your hernia repair, first of all, you need to know what was done, so please get your operative reports. I need to know how the surgery was done, read the description by the surgeon because that gives me a little bit of idea if they are like three lines saying, yeah, we just kind of saw hernia fixed it, to me that means they don’t care about hernias and therefore they may not care how carefully they did the surgery.
Speaker 1 (00:29:05):
If it’s a two page operation and tells exactly the size of the Mesh, what they found, how they put it in the technique and all that, that means usually it’s a surgeon that actually cares about hernias and therefore potentially their surgical technique is also better. Little things that matter. So the imaging will then identify certain things that are mechanical or hernia recurrence can cause testicular pain. No amount of nerve block is going or steroids or cortisone shots is going treat that. It could show me if the Mesh is balled up. That’s another mechanical problem. If the Mesh is balled up, it can pinch impinge on or obstruct either blood flow from the testicle to the heart or the spermatic flow sperm flow through the VA and both of those can cause testicular pain. And so that’s important to understand. Then there’s also what other activities, ejaculation or orgasm, do those cause pain?
Speaker 1 (00:30:13):
Specifically if there’s ejaculatory pain in addition to orgasmic pain, then the problem is often some type of disruption of the vas, either it’s kinked or it’s eroded into or it’s being tugged on and that’s that’s all Mesh related usually. And what else? So that should do the imaging. You specifically are looking for infection or fluid balling up of the Mesh or hernia recurrence. If there’s none of that and you’re really, really good at reading MRIs, you can then identify how the spermatic cord interacts with the Mesh. That’s very hard to do. There’s a lot of MRIs where you can’t really identify it, but there’s some really good MRIs where you’re like, oh wow, look at that. That spermatic cord is so tightly adhered to the Mesh, that’s even thickened in that area. And those would be somewhat abnormal. Maybe give you a little hint that maybe it really is a spermatic cord issue. So what’s what it doesn’t tell you is if there’s another problem like a nerve injury or a local reaction to the Mesh.
Speaker 1 (00:31:31):
So then you’re in my office, review the imaging, okay, we don’t have a hernia recurrence because that could explain your hernia, your testicular pain, and of course orchiectomy and doing all these urologic procedures on the testicle will not address a hernia recurrence, which is why it’s important that your general surgeon is involved in the evaluation and then we’ll say, okay, the Mesh looks pretty flat, so there’s no need to actually redo your hernia or take out the Mesh because that’s not the problem. So then the last thing that is left is actual nerve involvement or of the Mesh with the spermatic cord with the hernia Mesh. That’s where it gets tricky and that’s where most people don’t know what’s going on. So what happens is the Mesh sticks to the spermatic cord and it holds on to the spermatic cord in one place, cementing it into one position as many of the testicle likes to move up and down as needed.
Speaker 1 (00:32:39):
If you have surgery and this spermatic cord is tethered adhesed stuck in a position that’s abnormal already, that’s going to be uncomfortable, it may also change the position of your testicle and maybe move it up higher because it’s kind of contracted up also uncomfortable. And if that only happens on one side, I’ve actually saw a patient who had two testicles in normal position before surgery and then guess what happened? Oh my god, one testicle was raised up higher and it was perfectly raised up, almost a testicles height up higher. And so now the two testicles, they lock into each other very, very uncomfortable. So two testicles lock into each other and he has to constantly unlock them on top of each other.
Speaker 1 (00:33:36):
Two blocks of a kid’s play blocks, so you have one testicle and another testicle is on top of it instead of to its side. Very uncomfortable that kind of keeps getting trapped there because one testicle is abnormally riding higher than the other very uncomfortable situation. Another situation is when one testicle is pulled up and it kind of changes the anatomy and the axis of the scrotum and then you get it like a little bit of twisting. So now instead of having testicles left and right now you have ’em forward and backwards. So now you have a testicle that’s behind the other testicle and when you sit, you’re sitting on your testicle. It’s a very uncomfortable situation. So these are all when you have abnormal displacement of the testicle because as part of the operation, the Mesh holds hostage, that spermatic cord in an abnormally high scarred in level.
Speaker 1 (00:34:37):
The other situation is that the nerves on the vas are in some ways disturbed, irritated, grown into. And the what do those nerves do? Those nerves cause testicular symptom like sensation. So if you’re going upstream and inadvertently tickling or disrupting those nerves, then the patient gets testicular pain. So I’ll give you a story which is this is exactly what happened to a patient all, all the urologists had to do because general surgeons typically don’t do this, I do it, but typically it’s a urology procedure. I learned it from urologists is do what’s called a spermatic cord block. Remember this super simple procedure can be done in the office, no sedation necessary. spermatic cord block, it’s a block which means local anesthetic to your spermatic cord specifically to the nerves in the spermatic cord, specifically around the vast deference. What that does is it numbs the testicle and it replicates getting rid of the noise from this hyperactive injured nerve higher up by the nerve, by the Mesh interacting with the spermatic cord.
Speaker 1 (00:36:11):
If that gets rid of your pain and you’ve had a Mesh repair, then releasing the Mesh off of those nerves higher up most likely will cure you. It’s a genius operation. We presented us doing this I think back in, I want to say 2009, no, sorry, 2014 I want to say at sages, the Society of American Gastrointestinal and Endoscopic Surgeons meeting that I’ll be in a couple weeks in Montreal, annual sages meeting. I love sages. So we presented our video there and I think it’s also on my YouTube channel if you want to go visit it. But basically the situation is this. You have to release the Mesh off of the spermatic cord and in doing so, you’ll get rid of the downstream effects of having the Mesh interact. It’s a complicated operation. It can be done open or laparoscopically, robotically. I prefer to robotically, but I’ve done both and the outcomes are really good, really, really good.
Speaker 1 (00:37:19):
And the key is to take the Mesh off of the spermatic cord and then put an anti-adhesive there to prevent it from getting it together in the first place. Questions, if the person has a nerve pain four months after anal hernia pair with Mesh and then constant pain after that and the Mesh is removed two months later and three weeks later the nerve pain on the pelvis and three weeks later nerve pain on the pelvis area, is that normal? If not, even though still recovering from the hernia surgeon, what can be addressed? I don’t understand the question. So first of all, I have to assume you’re right that there’s nerve pain because you’re going to have other pains that are not nerve pain, which people think are nerve pain, but they’re really not. And I’m going to assume the nerve pain is a correct diagnosis because I doubt all diagnoses, I’m constantly questioning everything because I want to make sure it’s it’s correct.
Speaker 1 (00:38:26):
So it seems that the Mesh was removed, but you can’t remove Mesh for nerve pain. You have to deal with the nerves. So is there neurectomy done as part of the Mesh removal? Because the Mesh isn’t causing the nerve pain, it’s the nerve is being injured so you don’t have to touch the Mesh if it’s purely a nerve pain. That’s why this question discretion doesn’t make much sense to me and two months later the Mesh is removed and three weeks later nerve pain in the pelvis area. So if your nerve was not addressed as part of the Mesh removal process, that’s a problem because Mesh removal removal and we’re talking open surgery, Mesh removal surgery almost for open surgery almost always requires at least one nerve to be cut because the actual act of the mess removal alone can cause problems. And now you already know you have a nerve problem, then that nerve should have been addressed. It was robotic. Wait a minute, hold on. Robotic.
Speaker 1 (00:39:34):
Okay, so now you’re telling me you had laparoscopic or robotic al hernia pair but you had nerve pain. So those don’t give nerve pain. Those give, let me back, back out. The risk of nerve pain with a laparoscopic or robotic AL hernia pair is very low because the only two nerves that can be injured are the general femoral nerves and the lateral femoral cutaneous nerves. And those two nerves are rarely injured. They’re deeper than most surgeons typically go, and therefore very uncommon to have nerve pain. That’s why I’m questioning that you’re having nerve pain. So then you had the Mesh removed and now you have pain in the pelvis that they treat your hernia when they remove the robotic Mesh because maybe your hernia has just come back. That’s what happens when you remove Mesh. So if you had Mesh removal robotically to address some type of pain, I don’t understand what the pain was.
Speaker 1 (00:40:37):
If it was nerve pain, the nerve should have been addressed. If it was hernia related pain and the Mesh was removed, then the hernia needed to have been addressed. And if you didn’t have the hernia address, then maybe your pain is from the hernia recurrence. I’m happy to get it more clear if you want. Here’s another answer. Wow, thank you. I wish I had seen you. There are no hernia specials within 200 miles of me. Happy to see you. I love these. I actually enjoy these complex ones. I’m kind of weird that way. Next question, what if my post post open tissue hernia pair of pain is not in the testicle but more in the spermatic cord as it exits the superficial ring approaching and entering the upper scrotum but does not extend into the testicle or deeper into scrotum? What is the significance?
Speaker 1 (00:41:28):
Okay. Okay, so you had open Inguinal hernia repair without Mesh, okay, that’s very important because the Mesh can erode and can cause a lot of complications that you don’t see in the non Mesh repairs. Now what you’re telling me is you have pain at the spermatic cord, but by the superficial rig, what you may actually have is pain from the repair, the tissue repair because the spermatic cord doesn’t usually hurt one area and not hurt in another area. It’s a continuum. It’s not like it’s, I dunno, like a muscle where one part can hurt and the other part could not. So if you’re having pain, what you feel is at the spermatic cord, what you may actually have is pain where the tissue repair was done at the pubic tubercle. That’s the most common place for the Mesh for the tissue repair to hurt because it’s sewing right by the bone, the pubic bone, pubic bone can’t stretch.
Speaker 1 (00:42:30):
So it’s tightest there. And especially if you had a direct hernia, that’s a pain where you’re going to have place where you’re going to have the most pain. So that may be it. An injection into the tissue repair may help determine if that’s the cause of your pain. And sometimes if it’s too tight of a tissue repair, I give Botox to my patients to loosen up the repair as the patient’s recovering. What is the significance of a testicle feeling like it’s hanging lower but it does not actually appear to be hanging lower following open tissue repair. So depends on how the tissue repair was performed. If you had a Shouldice repair at the Shouldice or your surgeon chose to cut the cremasteric muscle, and then what they do is actually take that cremasteric muscle and they hitch it or they sew it up at the level of the pubic bone.
Speaker 1 (00:43:31):
So if you had that done, that could be a feeling that your testicle is kind of hanging but it’s not hanging and it can cause pain, right where that suture is, which is in the upper area by the external ring where you’re saying where that suture is. So if you had a Shouldice repair at the Shouldice or your surgeon cut the cremasteric muscle and then did that Shouldice hitch where they sew the cremasteric muscle up to the pubic bone to prevent the testicle from hanging, that could be the cause of your pain. Again, very important that you can see your operative report and understand what exactly was done by your surgeon and then you can have local injections right into the area where that suture is to help determine if that’s where the cause of your pain is. I did have a patient, actually, I’ve had multiple patients who have had operations that completely made no sense.
Speaker 1 (00:44:35):
And not only did it help the patient and some patients actually hurt them, I’ve had multiple patients that have had their testicle removed for testicular pain after hernia repair doesn’t work, please just don’t do it. Just don’t do it. It doesn’t work. There’s so many other options. Cutting out the testicle will not get rid of testicular pain. Ironically, I’ve had patients undergo spermatic cord degradation surgery. What that does is it actually denude the whole spermatic cord which connects the testicle to their body of nerves That will work if nothing else works. And almost caught a sneeze there and the local anesthetic into the spermatic cord, an injection of local anesthetic into the spermatic cord results in improvement in pain. So spermatic cord denervation procedure only works if number one, you’ve ruled out everything else, hernia, recurrence, match problem, et cetera, and putting local anesthetic and recreating what happens surgically by numbing those nerves gets rid of the pain in which case a surgery will help.
Speaker 1 (00:45:56):
There are institutions, all they do is spermatic cord denervation and I’ve seen a lot of patients from them where the patient never needed it. In fact, they didn’t get better. That’s why they saw me like we’re still not better. So maybe it’s the Mesh, maybe it’s a hernia repair and indeed it was. And unfortunately now they have an at-risk area of their testicle because the blood flow to it is now at risk. How does wearing briefs relief pain related to this sperm rheumatic cord and pinpoints spermatic cord as cause of the pain? So if good question, what briefs do is it takes attention off the spermatic cord. So if your spermatic cord is tethered up high and any tugging on it, tethered up high because of your Mesh or your prior operations and any tugging on it causes pain or any dangling of the testicle causes pain, then wearing briefs and providing extra support against gravity will provide you with relief.
Speaker 1 (00:47:02):
That’s how it helps other, going back to other procedures that have been done that don’t work. We talked about orchiectomy, which is removal of testicle, spermatic cord, denervation nerve blocks, ilioinguinal iliohypogastric nerve blocks, general nerve blocks. I feel like as one of the patients that asked a question earlier said the general surgeon said not my problem and then sent the patient to pain management, the first thing pain management did was steroid injections to what and why. So for example, if you had a laparoscopic inguinal hernia repair with Velcro Mesh, no, no tacking nothing, there’s zero chance zero that you have an ilioinguinal or iliohypogastric nerve injury.
Speaker 1 (00:47:59):
Please don’t get an ilioinguinal nerve block or iliohypogastric nerve block. That’s a waste of time and energy and money. And I’ve had patients that actually even went further and they had their ilioinguinal nerve cut from a laparoscopic cardio repair, completely unnecessary procedure has its own risks. And the surgeon that did it was so proud that he claimed that he was one of few people who even does this in the nation and in fact it wasn’t even necessary to be done. So definitely do not do that. The reverse is also true if you have an open surgery and they do like some weird nerve block that’s completely unrelated, like nerve blocks are not the answer. So like P oh, this is the best one. pudendal nerve blocks and pudendal nerve surgery after a hernia repair, you can’t enter the pudendal nerve with a hernia repair.
Speaker 1 (00:48:56):
So don’t let a pain doctor take or urologist take you down the pudendal nerve block rabbit hole. We have a whole episode with Dr. Hibner on Pudendal Neuralgia, go watch it. It’s so misused and so misdiagnosed and there are a lot of surgeons that don’t know what they’re doing and pain doctors that are doing these injections. What all that you had to do was fix the person’s hernia, let’s say question can massive dilation of the scrotal sac from massive blood collecting, collecting in it, falling surgery, stretch the scrotal sac so it no longer supports a testicle? No, that’s not, no it doesn’t. And the scum doesn’t provide that much support to the testicle. But no, what will happen is you will then scar into that space and it’s going to take a while for that scar to go away because of the blood in that space. But no, it wouldn’t change how well your testicle is supported. Most of the support of the testicles is from the cremasteric muscle and the sperm rheumatic cord itself.
Speaker 1 (00:50:05):
What’s the other one I wanted to say? Talking about things that shouldn’t be done? Oh, torsion, varicocelectomy, hydrocelectomy. These are all urologic procedures that don’t help, but I don’t know how much to stress the importance of seeing a hernia specialist. Now that said, the testicle testicular pain issue where it’s an issue of Mesh to nerve and Mesh to spermatic cord, unfortunately still is not something that most of my colleagues that are hernia specialists understand very well. We presented our experience with it back in 20, I think 2014 at sages with a video. It’s on my channel, you can go watch it. We’ve actually changed our technique since then to make it even better where we’re lifting off. We’re not cutting the Mesh, we’re just lifting it off the cord so that your hernia repair is not affected. And we use a great anti-adhesive barrier.
Speaker 1 (00:51:08):
There are two on the market that are really good. Hopefully there’ll be a third one on the market that I’m really excited about, which are good anti-adhesive barriers. My personal preference, I actually have patents pending on improving hernia. Mesh design is why don’t we just make meshes that don’t stick to these areas. You don’t need Mesh to stick to this spermatic cord, to the nerves, to the vessels. You just needed to stick to the hernia repair and the muscles. And it really pisses me off that there’s so many injuries from bad Mesh design that can be improved and yet there’s no company that’s interested in improving it. That really irks me. Question, if you’re an older male, how can you tell if scrotal and testicular are hanging are a complication of your surgery just or just related to body change with aging? Well, I mean if you’ve had surgery and you’re significantly different than you were before surgery, that would be abnormal it it’s a drastic, drastic difference.
Speaker 1 (00:52:12):
Unfortunately on Instagram and them and Twitter, I can’t post these pictures, but I have pictures where the testicle and on one side versus the other side are dramatically, they’re like inches, like five inches apart hanging very far from each other. Those are obviously extreme situations, but it would have to be a dramatic difference from before surgery. Remember hanging of the testicle, part of it is from the cremasteric muscle and part of it is, so you need an intact cremasteric muscle to allow it to go up and down. And if you don’t have a viable cremasteric muscle, it can just lay down. There are people that have spasms or their cremasteric muscle where it’s pulling up and I’ve had, okay, so here’s the thing. If you have had surgery from hernia and your testicle is brought up, I’ve had people get Botox for their cremasteric muscle, I’m sorry, that will not work.
Speaker 1 (00:53:10):
The muscle and the cord is all trapped up by the surgery scar that you need surgically to release that scar to bring the testicle back down. No amount of Botox is going to work and Botox is so expensive. So I just feel that, I mean because kind of pisses me off. I’m sorry. Someone said your you care so much about your patient’s outcome and your passion is obvious. I’m just tired of seeing the same mistakes over and over again. If in an ideal world, in the best of all possible world, just let me take care of everyone and I’ll be happy. Unfortunately can’t. It’s part of what motivates me to do these weekly episodes because not only do I get to answer your questions, but I get to release some of my frustration. It really pisses me off and oh this is a good one.
Speaker 1 (00:54:07):
I had a patient who went urologist, a urologist, and the urologist were trying to gaslight him and say that it’s actually not that bad. So your testicle’s a little bit rotated or a little bit hurting and you get some tugging and you keep sitting at your testicle. I mean life happens and no surgery is perfect. Why don’t you just live with that? And I’m thinking it’s a totally treatable problem. Why would a male urologist tell another male patient that this is a problem? Question, can an injured non-viable cremasteric muscle be helped of due to cutting, no scarring and adherence? I don’t know what that means, but if you have a cremasteric muscle that is involved in scarring and adhesions that can be released. If you have a cremasteric muscle that’s no longer functional because the genital nerve branch to it has been severed, then a pullup to artificially place the testicle in a more appropriate position can be done. And surprisingly I do those. So many urologists don’t do that procedure again, I don’t know why, but it is what it is. Let’s see.
Speaker 1 (00:55:33):
I’ll tell you a funny story. This will be it. And then we’re going to go. So this is way back when I was at USC, so it’s going to be before 2008, somewhere reaching 2002 and 2008. I was among five or six people. Oh, hold on. Let me ask this question, answer this question before I tell you my story. Cause I want to finish out with my story question. I want to rephrase my question. If after three weeks of successful hernia meshoma surgery, the nerves near the groin still hurt the same way before this last surgery was done. Is that normal or do we need time to heal?
Speaker 1 (00:56:15):
There should be no nerves related to robotic Mesh removal before or after surgery. That’s where I’m kind of having a problem. I don’t know if this nerves or you actually have a hernia. So maybe you just had a hernia issue or the reason why you had surgery was not addressed by the hernia Mesh removal procedure. So no, it’s not normal. Okay, so here’s my story. So 2000, I’m going to say sometime between 2002 and 2008, I was still at USC as a surgeon totally into doing hernias and kind of building that as my career though I wasn’t a hundred percent dedicated to hernias yet. I was working at the county hospital, but I was gaining enough notoriety within the hernia field that I was invited to be among I think five surgeons nationally that are KOLs. So Key Opinion Leaders. And I was the only female.
Speaker 1 (00:57:25):
I was very young back then too. I was in my thirties. I was the only female. There were a bunch of men and mostly older men. I would say probably many, many probably twice my age. So I go there and I said, and this is how long ago? This is 15 years ago. I said, I feel part of the problem is that we are having a lot of Mesh complications. Well this is an industry industry a asked us to get come by and they wanted these brains to come and tell them what the problems are and how they can improve Mesh. And I said, part of the problem that I’m seeing is there’s a lot of interaction of Mesh with the spermatic cord. And what we need to do is to develop a Mesh that doesn’t stick to this spermatic cord. Why do we need the Mesh to stick?
Speaker 1 (00:58:22):
I don’t understand. Let’s design something that reduces pain related to sexual function and testicular pain. I was young back then and I was already seeing these problems with open surgery and they said, yeah, we kind of tried that no one wanted to buy the Mesh and we stopped making that Mesh. They actually had made something and there was like five other surgeons, all male, mostly older than me and they all poo-pooed what I said. They’re like, ah, that’s not a problem. Oh, there’s no big deal. Like Mesh doesn’t stick to stuff and it doesn’t erode and it doesn’t do this doesn’t, Mesh is benign a lot of BS. And I was like, yes it does. And I don’t understand why would you be against a design that reduces the interaction of Mesh with your testicle, right? You are the males, it’s not affecting my population, it’s yours.
Speaker 1 (00:59:23):
And they again, poo poo, it just not knocked it down. I said, it’s really interesting. I’m the only female here, but I’m the only one fighting for the viability of your testicles and sexual function. None of you care. I don’t understand that. Why am I the one that cares so passionately that your testicles don’t hurt? So anyway, that was a long time ago and I’m still to this day fighting for improved testicular health after hernia surgery. And I don’t understand why no one’s listening. I’ve gone to company after company to ask them. I have the design, it’s actually patented. I own the patents to use this patented Mesh design to reduce both in women and men, reduce how Mesh interacts with critical structures such as nerves, vessels, and the spermatic cord and not a single one is interested. I just don’t get it. I don’t get it. We had a lot of questions submitted. I feel really bad we didn’t get to all the questions.
Speaker 1 (01:00:36):
One was specifically sent to me, why can’t inguinal hernias be repaired with natural tissue? The answer is they can be. And yes, there’s less risk of testicular complications with those. And here’s what I’d like to make sure that I answer because the patient specifically asked me for it. So we will run a little bit longer today, but here’s a question. I had an asymptomatic Anglo hernia repair two and a half years ago with lightweight Mesh. Since then I’ve had right testicle and penis pain and urgency to urinate. Cystoscopy was normal. I’m not sure if it’s nerve pain or the Mesh causing the pain. I’ve tried physiotherapy, osteopathic medicine, acupuncture, gabapentin, which is a nerve medication, and Lyrica, which is a nerve medication. I have not had any nerve blocks. I regret having the surgery as it was not urgent. What are my options? So this is one of the reasons why I tell patients s watchful waiting is perfectly good.
Speaker 1 (01:01:37):
Don’t run into having surgery. And many of my surgeon colleagues don’t agree with me because they say, well, you’re going to have the hernia anyway at some point, but I just don’t think it’s cool to wake up from having no growing pain now having chronic pain. So two and a half years ago, lightweight matched, it sounds like maybe it’s open or laparoscopic, it’s unclear, but the right testicle and penis pain. So an urgency to urinate. So the penis pain and urgency to urinate are both from pelvic floor spasm. So you need to be evaluated for pelvic floor spasm and the pain in the right testicle may be too tight of a Mesh repair. So I’d like to see what kind of Mesh repair you had. No amount of local anesthetic will affect that muscle. Relaxants may help you suppositories for pelvic floor muscle spasm, anti muscle, excuse me, muscle relaxants for pelvic floor via suppositories may also work.
Speaker 1 (01:02:50):
And that’s why you have urgency to urinate and penis pain. That’s due to, not a urologic problem, but a hernia Mesh related problem, which is your pelvic floor spasm and the right testicle may be too tight of a hernia pair. So that’s what I recommend. I’m happy to see you. In fact, I recommend you come to see me because that is the type of patient I love to see. And I’ll be the team captain to help get you the care that you need because I have great urologists too all over the world that I’d like to ring in to help you. Okay, thank you for your time. We went a little bit over, but I had to get that one question in, the two questions in and therefore now is the time for me to go. Thanks everyone again. My name is Dr. Shirin Towfigh. Thank you for joining me on Hernia Talk Live. Please do join me on my YouTube channel, subscribe and watch today’s and all the archives. Love you all. Thank you for all the caring you’re showing me on Facebook at Dr. Towfigh. Do follow me on Twitter and Instagram at hernia doc and I will see you all next week. Take care everyone. It’s been a pleasure. Bye.
