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Dr. Towfigh (00:02):
Okay, and we’re back. Welcome everyone. It’s Dr. Towfigh again. Sorry there was a glitch. We are talking today about symptoms that you never thought would be due to your hernia, and the goal today is to go through everything that I know that can be related to your hernia that most doctors and patients and even chat GPT do not or does not know can be related to your hernia. Okay? So for those of you that are joining me on as a Facebook Live, it’s on my at Beverly Hills Hernia Center site. So that hopefully is working okay with you all because the Dr. Towfigh site for some reason didn’t work. Anyway, let’s talk about abdominal wall. So this week alone, and as you know, most of the time when I do these episodes, I pick and choose based on patients that I’ve seen and that’s how kind of topics come up. So today’s topic is based on multiple patients that I’ve seen that they were seen by another doctor, right? So they didn’t come to me for their hernia, they were seen by a gastroenterologist.
(02:08):
Okay, you hear me now? Okay, you can hear me now. I’m going to stop moving this microphone. Okay? So thank you very much for telling me that you lost my sound for a second. So basically I’ve had multiple, let’s start with something simple. So this gentleman came to his GI doctor mostly for bloating and of course there’s tons of GI reasons for bloating and what’s going on here and why am I no longer live on Facebook? This is horrible. Looks like I’m no longer live on Facebook. Why is that? This is so crazy. Let me try one more time.
(03:09):
I’m so sorry you guys. Okay, we’ll try and if it doesn’t work, we’ll post it on Facebook. Okay, so here’s the situation. He went to his GI doctor with bloating and of course there’s a million different things that can cause bloating. It could be stomach ulcers, commonly gallstones, you can have an infection or something, food poisoning, h pylori, infection of the stomach. And then there’s other things like sibo, like small intestine bacterial overgrowth. And so based on that, he went to the GI Doc. GI Doc said, yeah, it could be this, that or the other. And let’s do endoscopy. Colonoscopy normal. So they’re kind of scratching their head and this GI doctor is really smart and he did a full workup, couldn’t find any reason for the guy’s abdominal pain. So he sent ’em to me and not because there was a hernia issue, but specifically because I like to figure out abdominal pain of unknown etiology and that’s kind of like a thing I like to do.
(04:28):
So he says ’em to me and I look at the guy’s belly button and it’s, I can’t say it’s an Audi because he actually has an in, but there’s a little bulge with fat that’s stuck in his belly button hernia. A lot of people have that. So I started asking him questions and it turns out he was doing fine until covid and during Covid he had an event where he felt like a pop coming out of his belly button. And then in retrospect he didn’t really correlate one versus the other, but these were his symptoms. Bloating, generalized abdominal pain sometimes to the upper abdomen but mostly around the mid abdomen. So belly button, hello and it was mostly to one side of the belly button. Oh, and back pain. So guess what? Belly button hernias, which a lot of people have and most of them do not need to be repaired, can cause these enigmatic kind of mysterious pains.
(05:38):
They can cause bloating. Actually it’s not necessarily because there’s intestine in the hernia, although that will definitely cause bloating and maybe even intestinal obstruction. But the bloating is a response to the pain from the hernia. It can cause back pain. So usually it shoots straight around the same level as the belly button towards the back. And some people you fix their hernia, they’re like, wow, my back pain’s gone. And classically people think that the belly button hernia should hurt at the hernia. I don’t know why, but there’s a very large proportion of patients that I see where the hernia isn’t where the pain is but it’s to the side left or right. I haven’t seen a correlation, but these are common symptoms that isn’t ever in any textbook about belly button hernias. In fact, most people are saying you don’t need to fix those hernias, but if it does bother you and if it hurts, you should get it fixed. So that’s the belly button. We had an earlier question about steroids and whether steroids can cause abdominal worsening hernias, unlikely epidural injections, whether that could cause hernia pain or worsening. Definitely not correlated or anything related to that.
(07:09):
Now let’s go for, let’s see, what other hernias can we talk about that’s kind of not, well before we’ve gone, you know what, let’s do it. Let’s just go on to the groin hernia. So groin hernia, this is my baby, right? I really like groin pathology. So what’s interesting is male and female can both have groin hernias, inguinal hernias, and they can both also have what’s called radiating pain. So radiating pain means the hernia is not just at the groin or at the hernia, but it can shoot. So in men it can shoot into the testicle, it can wrap around to the lower back, it can go up to the hip, it can go down the inner thigh in women, it could shoot into the vagina, it can go down the inner thigh and also wrap around the lower back. More commonly than men, at least in our study which we published and bloating can be seen both males and females with groin hernias as well as belly body hernias and other hernias.
(08:16):
Again, the bloating is not necessarily because there’s intestine involved, but it’s a reaction to the pain associated with the hernia. And then the pelvic floor spasm, this one is not very commonly appreciated. So inguinal hernias, not so much ventral hernias or abdominal wall hernias, inguinal hernias and the pelvis can cause pelvic floor spasm. Now what’s the pelvic floor? So the pelvic floor, I describe it like a salad bowl. It’s a your whole pelvis, you got the bones and then there are these stirrups that hold all your organs within your pelvic bones. These are muscles called the pelvic floor. These muscles can go into spasm. What does that mean? That means same way you can get a groin stitch or a calf that gets hurt or spasmed or you can get neck spasm. Your pelvic floor can also spasm. There are three organs that go through the pelvic floor, the rectum in males and females, both the rectum goes, there’s a hole in your pelvic floor for your anus. When you urinate the urethra in both males and females mt, the bladder goes through a hole through your pelvic floor and you urinate. And in women there’s a third organ which is the vagina. So the uterus then exits via the vagina, which goes through the pelvic floor muscle. So if you have pelvic floor spasming, any of those two or three organs will also feel the spasm. So most commonly it would be urinary symptoms. So either urinary frequency. So I’ve had a woman she would urinate 40 times in one night, she couldn’t sleep.
(10:18):
It could be painful to urinate because you’re trying to urinate through a tube that’s constantly being obstructed with the spasm of the muscle. There’s some thought that pelvic floor spasm causes higher pressure and maybe even irritation of the bladder and therefore interstitial cystitis. So now we have a situation potentially where the interstitial sci is due to pelvic floor spasm and the pelvic floor spasm is due to the hernia. So if you have interstitial cystitis, you may have a hernia. If you fix the hernia, the pelvic floor spasm will go away, which may eventually heal your bladder. Never been proven but anecdotally we have patients where that’s been the situation. The rectum is not as commonly affected by pelvic floor spasm, but it can be. And the way it is is usually it’s painful to have a bowel movement and a lot of people have pain with bowel movements with their groin hernia and in women the other issue is their vaginal pain.
(11:30):
So any intercourse will be painful because the muscle around the vagina is very stiff and not accommodating and so there’s some sexual dysfunction and so the female goes to their gynecologist or medical doctor, they may correctly diagnose the patient who has vaginismus, which means kind of like a spasm of the vagina or painful vagina or vulvodynia, which is or pain around the outer part of the female genital system or vaginal, the term for vaginal pain. I don’t want to say vaginal nia, there’s another term for it. There are all these kind of pain symptoms for women and then they may also go to a sexual function specialist was usually gynecologist, sometimes urologist and most of them I would say are not aware, but many of them are that pelvic floor spasm will cause the sexual dysfunction. And then they sent the patient to pelvic floor muscle therapy therapist like a pelvic floor or therapist, a physical therapist that focuses mostly on the pelvic floor, which is a very complicated area of the body.
(13:01):
And guess what that patient, if the hernia was causing the pelvic floor spasm and therefore the, let’s say the sexual dysfunction or the urinary frequency or the rectal pain with bowel movements, that person hates going to physical therapy for their pelvic floor because it’s not helping the hernia. They’re trying to focus on the pelvic floor but it’s painful. So some people get Botox into the muscle to address the pain. Some people get vaginal suppositories into or rectal suppositories to help infuse a muscle relaxant through the suppository and so on. And unless you fix the hernia, if that’s a cause of your pelvic floor spasm, none of your downstream effects will get better. Vaginal. Yeah, we call that vaginismus. That’s when you have pain within the vagina. Yes, but there’s another term too. I’m trying to remember Nia, I’ll come up with it.
(14:12):
In both men and women, there are nerves that run through the pelvic floor and that nerve, the largest one and the most difficult one to assess is called the pudendal nerve. So many people who actually have groin hernias are diagnosed with pudendal neuralgia. Now what’s ental neuralgia? Neuralgia means nerve pain, so nerve pain of the pudendal nerve. Now the pudendal nerve like all other nerves starts in your spine and then comes out and around towards the front and it through the pelvic floor muscle and sends out branches. So it sends out a branch to your rectum, to your vagina, to your perineum and males to the pannus and females to the clitoris and pain along any of that maybe due to your neuralgia. Now what’s important to know is in most people I would say the majority of people, their predental nerve is totally normal. People who get injury to their predental nerve, either they had a major trauma with lots of muscle and nerves being injured and torn, especially like let’s say a pelvic fracture.
(15:38):
They may be wheelchair bound and sitting on their butt and their butt muscles are not strong because they’ve been wheelchair bound for whatever reason. So atrophied muscles, so you’re basically sitting on the nerve and putting a lot of pressure on it. Fun trivial fact. Denal neuralgia was first diagnosed in World War. I want to say one, the soldiers were in Jeeps, but the Jeeps had metal seats. There was no cushion and so their coys and NP nerve I guess was constantly being pushed on and on these bumpy rides because they’re sitting on metal and many of them had ental neurologist. So that’s a direct trauma to the nerve bicyclists. Professional bicyclists on that really very, very painful narrow bicycle seat can get denal neuralgia if there’s sitting in a way where there’s direct, very pointed pressure on the nerve. So those are all examples of denal neuralgia where there’s actually an injury to the nerve, but if you just a normal person and there’s no reason for you to have had injury to your pudendal nerve, what can happen is the nerve, like I mentioned course is through the muscle, the pelvic floor muscle.
(17:23):
So if your muscle is in spasm, that’s going to also stimulate or irritate the nerve, otherwise normal nerve but it’s running through muscle and the muscle is spasming and therefore you’ll have stimulation of that nerve abnormally and you may have penile pain or clitoral pain of sorts. A tip of pannus pain is one of those. So fixing the cause of the pelvic floor muscle spasm should address the clitoral pain, let’s say. And if it’s a hernia, the hernia is causing the pelvic floor spasm. So check this out, potentially you can fix a hernia and cure someone’s clitoral pain or tip a pannus pain. How cool is that? Right? So this is kind of things that I’m learning and I’m hoping to share and then I collaborate with my gynecologist urologist pain doctors and they get all excited because then they’re like, oh my god, I’ve had, let’s say this many patients in the past year who potentially that’s their problem now.
(18:48):
So very, very cool situation. Now, more nerve stuff. If you think of a groin hernia and we discussed this actually this is not as uncommon to know. Most doctors should know about this even though the majority still don’t. I should say some doctors should know about this even though majority do not. So the ileal nerve is a nerve that starts in the back again, comes out and around in the front and in men gives sensation to the base of pannus and the inner thigh and women give sensation to the moms and the labia and the inner thigh and in those patients, oh, before I move on, here’s your question. Can isolate pain in the groin and bone in males without rectal penal and peroneal pain be due to ental neuralgia? No, but I’ll tell you what it can be due to my surgeon is attributing post her neuropathy pain to ental neuralgia.
(19:59):
Yeah, that’s incorrect. So if you’ve had hernia surgery and now you have ental neuralgia, those two are not related, so there’s a hundred percent zero possibility that the pudendal nerve can be injured from a hernia surgery. It’s just not where we are. The nerve runs within the pelvic floor, we’re nowhere near the pelvic floor and it enters from the back to the front, which is not where any of the surgery that we do addresses it. No. Now you can have denal neuralgia and separately had a hernia repair and now they’re trying to say, well the pain is not from your hernia, it’s from your predental nerve, but if you had the pain only after your hernia repair, that doesn’t make sense for it to be do something other than your hernia. I hope that makes sense. Okay, so where was I? Oh, ileal inguinal nerve. So the ileal inguinal nerve travels between a fascia and muscle layer.
(21:15):
It’s also the same layer in which a hernia travels, which is called the inguinal canal. And so if you have something bulging like a piece of fat in the hernia, guess what? Now you’re competing for space between that piece of fat and everything else that’s there. So it could be the ileal inguinal nerve or the genital branch of the genital femoral nerve because that travels with the hernia sometimes in the internal ring anatomically. So the hole is called the internal ring through which the fat goes, but it’s also half the time where the genital nerve goes as well. And then secondly, as the fat comes further out, it can now also interact with the ileal inguinal nerve. So many people have either ile inguinal nerve pain or ileal inguinal neuralgia, which I said is base of penis and inner thigh or in women labia mons and inner thigh and in both men and women can wrap around your lower back following the track of the nerve as it goes toward the spine.
(22:32):
But people don’t just wake up with nerve pain. I say that all the time, you can’t just be normal and then one day have nerve pain. That doesn’t happen. But you can wake up one day with hernia pain and your hernia pain can be small enough that’s just not large enough to see the hole, to see the fat coming out or the intestines coming out, but enough to put pressure and irritate the ileal nerve or the genital nerve. The genital nerve in women causes sensation to the labia and in men causes sensation to the scrotal skin. So hypersensitivity to the labia or the scrotal skin can be due to a genital nerve. Irritation from a hernia do not, do not address the nerve. I see people who get ectomies so their nerve is cut. I see people that get nerve ablations like they have either cryotherapy or radiofrequency ablation where their nerve is either frozen or burnt.
(23:38):
I see people that get nerve stimulators implanted in their spine or their groin for their nerve pain and they’re given tons of narcotics and nerve pain muscle, all they need is a hernia repair. We have to understand these are all secondary problems. The primary problem is the hernia and that’s why I’m doing this episode so much I can share this is going to be one of our best episodes. There’s so much that I can share where people don’t and textbooks haven’t made the correlation between that pain and a hernia. Okay, let’s answer some questions. Can you get a new hernia even though you have two meshes? Yes, there’ll be a hernia recurrence. I have a mesh for incisional hernia by my navel. Now I have another hernia there. Yes, so what you’re describing is a hernia recurrence, so any hernia repair, whether it’s with or without mesh has a risk of recurrence in most situations.
(24:36):
The recurrence rate is significantly lower if you had mesh than if you did not have mesh, but it’s not zero and depending on your risk factors, you may be at higher risk for recurrence than the average patient. What are some risk factors being ill not having good diet or protein being morbidly obese diabetics, any sort of infection, nicotine use, those are all risk factor or obstructive sleep apnea. Those are all risk factors for having a higher risk for recurrence even if it was a perfectly good repair with mesh. Here’s another question going back to the question about predental neuralgia as a cause of post anal hernia pain. The surgeon said preoperative pain was always predental neuralgia and not from the hernia or the hernia surgery, but I have no involvement of the peroneum pannus or rectum. What do you think? I think they know what they’re talking about. Predental neuralgia does not just occur. You have to have an actual injury to the nerve and what is that injury? All those that I explained, trauma surgery to the somehow went awry and scraped the nerve and so on. So if you have, so pubic bone pain is not p dental neuralgia and groin pain is not P dental neuralgia, PD neurologist is very specific.
(26:11):
It’s tip of pannus pain in males and your urinary frequency, sorry, not frequency, rectal pain and peroneal pain. It’s very, very specific nerve. So yeah, I have a feeling you need someone a little bit more knowledgeable about these problems. Okay, so we talked about the different nerve pains and again I’ve had patients who’ve had triple neurectomy, okay, triple neurectomy and now have permanent nerve damage and all they had was a hernia and they miss the hernia. I’ve had surgeons that operate on nerves twice to the point where the patient is now wheelchair bound because of the pain from her hernia was never addressed and now she’s has neuromas from the nerve surgeries. So is none of this is in the books and we don’t have a good database or questionnaire to capture all of these questions. I’m doing my best, I published on it, but I’m just one person and we don’t have enough surgeons like me that a hundred percent devote their time to sit down with the patient and ask these questions.
(27:40):
So half the surgeons will say, if you don’t have a bulge, there’s no hernia. Anyone who follows me knows that’s completely incorrect and it’s just logic. There’s a spectrum, right? You don’t go from zero to bulge between zero and bulge, you’re going to have a widening of the hole, little piece of fat in there, a little more piece of fat in there, more widening of the hole, a little more piece of fat. 10 years later you’re going to have a bulge. But between that time you may have other symptoms because as the hernia is taking up space where it shouldn’t, it’s interacting with other things. So we already talked about the nerves it could interact with because those are also sharing the space in the inguinal canal that’s specifically the ileal nerve and the genital nerve. It’s never the ileal hypogastric nerve or the ator nerve.
(28:38):
However, one thing I didn’t discuss is in men. What else goes through that internal ring? That ring where the hernia goes through the spermatic cord are the nerves of the spermatic code? Yes. What nerves? The vast deference which carries the sperm from the testicle to the prostate has nerves. Those nerves are called vasal nerves or VAs deference nerves if that nerve is injured or irritated, testicular pain. And so I recently had a young kid who was sent to me by his urologist, chronic testicular pain. No one can figure out what’s wrong and he’s seen multiple urologists. All they kept doing is ultrasounding his testicle and saying there’s nothing there. And finally they got to the point where they offered him to have an orchiectomy, which means the testicle will be cut off.
(29:38):
He was offered a spermatic cord denervation procedure, which is a procedure that cuts out all the nerves to the testicle. Again, when I say the nerve is not the issue, the nerve is normal, it’s just being irritated by the hernia. So one of his urologists was smart enough to say, you know what? I’ve heard Towfigh talk about this before. Let me send you a Towfigh. I don’t feel a hernia but maybe she can feel a hernia and if it is, maybe that’s a cause of your pain. He comes to see me, I absolutely feel a hernia. Absolutely. So there was no bulge but you can feel it. And we did imaging confirmed actually it was a good size hernia, fixed his hernia and guess what?
(30:27):
Seven or eight, I think eight years of testicular pain gone with the hernia repair. I didn’t touch any nerves, I didn’t manipulate any nerves gone. So those are things that I hope a urologist who sees a testicular pain for example will say maybe it’s a hernia or a female, let’s say gynecologist that sees someone with vaginal pain and pain with intercourse will say maybe it’s a hernia or physical therapist. They’re actually the best referrals. Physical therapists are really good because they will definitely say, oh yeah, pelvic floor spasm doesn’t seem to be getting better. Send ’em to Towfigh, it may be a hernia. Okay, let’s do another question.
(31:16):
Let’s see. I have a very tight lower abdominal pain 24 7 with feeling of loose bowels. Male 54 keyhole repair. Okay, so keyhole repair refers to hernia mesh that’s made into a hole to wrap around the spermatic cord in men, we don’t usually do that in women, but you can. So very tight lower abdominal pain 24 7 maybe because of too tight of a hernia repair of your mesh. So replacing the mesh may help and I have a feeling of loose bowels if they cut any nerves that could be a problem, but usually that’s not the situation. Next question. I had spinal epidural for horrible pain in the right front side on my lower rib. The pain is worse at night and it helps when lying on my side. Now from what you say, this could be from my hernia by my navel. Yeah, absolutely, absolutely. If you have an incision hernia by your belly button or the belly lying on your, some people don’t like to lie on their side, some people do like to lie on their side.
(32:30):
It all depends on what’s in your hernia, how big’s the hernia and so on. If pain is worse at night that just maybe you’ve been upright for too long and that pain hurts over time and by the end kind of peaks at night you had a spinal epidural for horrible pain. The right front side on the lower end, yeah, that could be from your hernia for sure. Depends on where your hernia is though. Okay, can a damaged nerve by pressure recover enough from damage to relieve pain? So that’s an unknown question. The question is this, if you’re saying that you have a hernia and the hernia is irritating or putting pressure on the nerve, then you fix the hernia. Isn’t the nerve damage? There is a surgeon up in Oregon who I think is still in practice who theorizes that maybe a lot of the pain for patients, even though it’s from the hernia, is also due to permanent scarring and damage of the nerve due to the hernia.
(33:45):
So he did a study where he cut the ileal nerve in all of his patients and sent that nerve to the pathologist to do specific testing to see if there’s been neuritis, nerve damage, scarring of the nerve, whatever. And he found a very high percentage, I think 60 or 70% of the nerves were abnormal. Now his conclusion was all patients who have hernias will damage their nerves. So unless you cut the nerve, you’re not going to cure their chronic pain after surgery with a hernia repair. Those of us that never cut nerves obviously feel differently from that. And the way I interpret his paper is yes, hernias indeed do irritate and perhaps even damage. Unlikely damage. It’s hard to damage a nerve irritate these small nerves, but once you relieve that hernia, that nerve will recover. It’s possible it won’t recover in a fraction of patients, but the nerve will not recover.
(35:00):
And so what his study cannot prove is if you didn’t cut the nerve, will that same pathology just recover? Because nerves recover nerves, there’s a tendency for it. So the question, can a damage nerve by pressure recover enough from damage to relieve pain from a hernia? It should. I believe it should, but there is at least one study or one surgeon who strongly believes that as a surgeon you should not run that risk. I personally am not for neurectomy if it can be prevented. So talking to the wrong person about nerves. Okay, another question. Anglo hernias surgery on left side using shoulder dice technique. Okay, I was gradually recovering after surgery. I could sit about six weeks later, my scrotum got hit and was injured. Then I have pain when sitting. I could not even sit for one minute. About one year later the pain has improved.
(36:04):
I can sit 10 to 20 minutes but not fully recovered. Meial ultrasound found hernia recurrence. What shall I do to fix the pain when sitting? So a hernia recurrence or any hernia can cause pain with sitting. Common symptoms of groin hernias are include pain with sitting, pain with bending, pain with prolonged standing and pain with certain activities like long walks and going up and down hills and things like that. So it sounds like yes, you had a S shouldice for knee repair one event, yes, you had a scrotal injury, should not have caused the hernia recurrence necessarily another event and now you have a hernia recurrence, which I relate to. The first event is being clouded by the story about your scrotal pain. So if you have a hernia recurrence that you can see on ultrasound, that’s almost always correct. You should believe it if your symptoms correlate with that such as pain with prolonged sitting being a result of hernia recurrence.
(37:21):
But now you have two findings which are suggestive of your hernia recurrence causing your chronic pain, which can also give by the way testicular pain, usually not scrotal pain, although the, if this were done at the s shouldice clinic or by a s shouldice trained surgeon who routinely cuts the genital nerve, you can get scrotal skin sensitivity, but most likely what you’re describing is testicular pain, which can be due to ular hernias or recurrence as we mentioned earlier, right? So the hernia comes out, it irritates the genital nerve and you get testicular pain. And so the question is what is the status of your genital nerve? Was it cut, which is routinely done by the S shouldice clinic and most s shouldice trained surgeons or do you have an intact genital nerve and it’s being irritated by the hernia recurrence? Okay, so this is kind of the bulk. Let’s see, what have I missed?
(38:32):
A couple things. Opterator hernia very uncommon happens typically in a frail elderly patient that has constipation, a lot of abdominal pressure. It’s not normal to have an ator hernia, but many people have pain due to the nerve that runs through the opt or canal is being pinched by the fat from the ator nerve. So easy that is in the books by the way, it’s called ator neuralgia and it’s pain burning to the inner thigh at the level of the knee, so not the upper inner thigh, which we see with ileal neuralgia from an inal hernia but distal further, closer to the knee, far away, lower part of the inner thigh closer to the knee. That’s called OPT neurologist. So people with opt trait hernias usually don’t have a bulge because it’s kind of down lower in the perineum area, but what can happen is it presents with the kind of hypersensitivity there.
(39:48):
So they see the orthopedic doctor call it knee pain, then they see maybe a spine doctor because they call it radiculopathy or pain from your spine like an L four situation and it’s always like a hernia upstream from that. All right, here’s clarification to our most recent question. Yes, one nerve is cut done at the shouldice clinic. So that nerve is usually the genital nerve, the genital nerve. When it’s cut you can get numbness of your scrotal skin. So if you have numbness of your skin, that’s just part of the surgery. If you have pain at your squirrel skin, that could be from a neuroma from your genital nerve being cut low likelihood, but it’s a possibility. But if it’s testicular pain, that’s from hernia recurrence. So any hernia can cause testicular pain and so I would treat the hernia to treat the hernia recurrence and that should take care of all the downstream.
(40:56):
The moral of the story is if you can figure out and solve the puzzle of your pain, whether it’s abdominal pain, back pain, rectal pain, clitoral pain, vaginal pain, testicular pain, knee pain, if you can figure out that pain to be potentially cause of a caused by an inguinal hernia, then please don’t go to a pain doctor or urologist or a for another procedure other than your hernia repair. I’ll give you one last clinical scenario. You’ve heard me talk about hip disorders and sacro iliac joint or SI joint problems as kind of one of these problems that you always have to think about when evaluating someone with groin pain. So no, this is a reverse. This is someone with an obvious hernia that we have to say, okay, hold on, I see you have a hernia. Question number two is, is this hernia causing you pain?
(42:06):
And it’s so common to see people that have hernias be sent to a general surgeon who says, ah, hernia, let’s fix it. They fix their hernia and their underlying pain is still the same because it was never their hernia, it was their hip or it was SI joint or it was their lower back, like mid, lower back like L one, L two, L three disc disease. Okay? So you don’t want to be that surgeon that does an unnecessary procedure. Worst case scenario, you did the hernia repair on a patient that was technically had no symptoms from the inal hernia but had this other hip or spine disorder and now you have a complication from the surgery. Let’s say the mesh balled up, also known as oma, you injured a nerve, whatever, and then the patient has their original pain and on top of that chronic pain after their hernia repair, that’s worst case scenario and it happens.
(43:09):
I see at least a dozen of that a year in my practice. So what if this is a recent scenario? Imaging shows a little bit of disc, L one, L two, a fair amount of hip problems like osteoarthritis of the hip, maybe a labral tear of the hip, a hip click right hip clicking and then lastly, a groin hernia and your main symptom is groin pain and you have a inflammation of your S sacroiliac joint, SI joint. All four of those can cause groin pain by the way. So what do you do? Do you get your hernia repaired? Do you get your hip disorder repaired? Do you get your spine surgery? Do you have your SI joint or operate on? Here’s my take on it. I like to do the least invasive procedure first and try and rule out as much as possible. So least invasive would be inject the spine, inject the sacroiliac joint, inject the hip and see each time which one makes you feel better and gear it towards that.
(44:40):
If you have a situation where there’s more than one causing the pain, so those say you have your hernia hurts and you have a hip disorder, my recommendation would be fix the hernia first because of all those procedures, hips, spine, si, joint. My impression is a hernia repair is the least, how should I say this? It’s the lowest risk procedure, let’s put it that way. So let’s fix the hernia, take that out of the way. You may say, oh, I’m cured, right? My back pain is gone, my hip pain is gone, my leg pain is gone. Or you can say, okay, my groin pain is better. The pain radi into my inner thigh is gone, the pain into my vagina is gone, but I still have some back pain for example. Then you can focus on the other stuff. That’s kind of how I go about it and I work very closely with the orthopedic doctors and the neurosurgeons and the pain management doctors to try and figure this all out.
(45:46):
Let me do this one last question. Shall I do a MR Neurography to see if my pain when sitting is due to a muscle or nerve injury and to confirm the hernia recurrence, the MR. Neurography is the imaging of peripheral nerves based on magnetic resonance imaging techniques, correct? MR Nuerography is used to evaluate peripheral nerve disorders such as nerve entrapments and impingement as well as locate and grade nerve injuries. Not very good for the small nerves, which is what we’re talking about. The visual information of precise location and extent of nerve disorders provided by the MRN makes it a powerful tool to help physicians and surgeons to come to an accurate diagnosis and to decide on further medical or surgical therapy. You are a great doctor. Well thank you. I feel like you went to chat GBT and asked them what an MRN is. Let me explain to you more.
(46:42):
So MRI stands for Magnetic Resonance Imaging and it’s basically a cool way to look at mostly your soft tissue. Some tumors, it is great for hernias because it’s a soft tissue issue and it shows mesh separate from muscle, muscle separate from fat, it’s great. MRN is magnetic resonance neurography. So they manipulate the MRI so that the nerves look bright on it. Now it works great for the larger nerves, so spine, sciatic nerve, denal nerve, all the big nerves. But once you get to the front of the groin, the nerves have split, split, split, split. So it’s really tiny much, I’m not going to say hairlike, but maybe it’s like maybe 10 hairs worth or five hairs worth very, very thin. So if you have a genital nerve neuroma, okay, if it’s big enough, big nerve neuroma, it will show up on MRI as MR neurography.
(47:56):
It may also show up on an ultrasound, however it is not diagnostic for most people with groin, chronic groin pain an MR pelvis can, oh and by the way, most MR Neurogram focus on the back and the side and not the front. So that’s another negative. And number three, it’s really hard to interpret MR Neurography so it has to be done in an institution that does it often because the radiologist needs to know really what they’re doing and the doctor needs to talk with the neurologist, the neuroradiologist and make sure that they’re very clear where we want them to look.
(48:40):
It is not a good study for patients with chronic groin pain in general. MR Pelvis will help identify the hernia recurrence. You already have an ultrasound that shows it, so I don’t feel strongly about getting an MR Pelvis about it, especially if you’re a symptoms exam and ultrasound all confirm the same thing. So that’s where it is. I used to do a lot of MR Neurogram early in my stage in the year 2002 ish and it never helped me to be honest. It’s kind of cool. I thought it’d be a great idea. I never saw any nerve pathology that I could have said. That’s where it is. The nerve isn’t trapped, the nerve isn’t pain, there’s a neuroma. It was never that. So I’ve moved away from MR Neurogram, I get maybe one a year at most and that’s even pushing it. Okay, sorry for all this stuff early on we had a little bit of a glitch with meta, but I appreciate all of you that logged in on Facebook Live and asked me questions on that platform and on the Hernia Talk Live platform. I really appreciate it. I have fun with these guys and I really appreciate that many of you actually log in because I’m always amazed. I think we hit 40,000 downloads or something like that, something enormous and I’m really proud of that because it’s all because of you guys doing it and thank you for watching. So that’s the end of our show.
(50:35):
You know what? Let’s do one last question because I’m being generous. Hi Dr. T. I’m a 58-year-old male ileostomy in 2020. Reversal in 2021 had a stoma hernia. The hernia was repaired three times in 2022. Did they use mesh? Why did it take three times? Now I have a complex ventral hernia with occasional bowel obstruction. I do have I intense cramping during intercourse and no pain. Is this something that can be addressed during surgery? Hopefully robotic referral with Dr. Orenstein next month. Thanks for listening to you. Okay, Dr. Orenstein is great. Sean Orenstein at Oregon Health Sciences University. He was one of my guests. Feel free to listen to him on one of my prior podcasts. Just look up the name Orenstein Hernia Talk.
(51:29):
I would try and figure out why you recurred. Oh three hernias at once. Okay, not three separate hernia recurrences. Now I was concerned about that. So let’s see. So it sounds like you have a recurrence which needs to be addressed and cramping during intercourse, but no pain. If it’s abdominal wall cramping, that may just be from the hernia. It’s trapping things while it’s trying to contract. So yeah, fixing the hernia should hopefully deal with all that. And that my friend is the end of how you talk tonight. I’ll see you next week. I’m on a roll. I’m getting a lot of friends coming on soon so you can get to know even more hernia surgeons and I hope you all enjoy a great evening. Talk to you later. Bye.
