Episode 110: Rare Pelvic Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:01):

Hi. Hello everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live. Our weekly question, answer question and answer session every Tuesday. We call it hernia talk two Tuesdays. My name is Dr. Shirin Towfigh. I’m your hernia and laparoscopic surgery specialist. Thank you to everyone who has joined me live on Facebook Live at Dr. Towfigh and on Zoom. As you know, you can follow me on Twitter and Instagram at hernia doc, and I will share our weekly sessions, like links on all of these social platforms. You can also share and watch all the prior Hernia Talk Live sessions, as well as tonight’s on my YouTube channel. And I’m very excited that we are upgrading everything for you so that you can share it better and have a much better experience. Thanks to some encouragement by some of my younger patients. A big shout out to my most recent young patient who told me I love all the content, but you know, could really improve the experience of the viewer.

Speaker 1 (01:10):

And so I will be doing that. Takes a lot of time and effort, but whatever it takes to make hernia talk even better, I will do so. If you have any advice that you can give me, please let me know. I’m in the process of updating all my platforms and making them better so that you have a better experience and you can find me better. And it’s visually and audio visually superior to what I have. As you remember, we started Hernia Talk Live way back two years ago during the pandemic. When the pandemic started. I was not allowed to see or treat patients electively in my city, Beverly Hills, and I was stuck at home and I felt that if I’m stuck at home, then you’re all probably stuck at home and I do not have access to doctors like me. And so maybe I should take it on the road.

Speaker 1 (02:07):

And Zoom became very popular and here we are. So as you know, every week we have a special topic and oftentimes the topics that I choose are inspired by my patients. So for example, if I have a patient who has had a major misdiagnosis because of a certain type of disease process, then often I bring that case in to discuss with you all. So the topic for this week’s session is called Rare Pelvic Hernias, and I’d like to share it with you because first of all, these are rare problems, which means that most people who have pelvic hernias will not be diagnosed in a timely fashion because we just don’t think of it as a potential problem. If it’s rare, it’s never in the top one, two, or three diagnosis that we think of. And pelvic hernias in general are very poorly known and understood, and they’re really rare.

Speaker 1 (03:10):

They’re just a handful of year that are even diagnosed and repaired in the United States. So it also means that your surgeon may or may not have had experience in performing these operations. So you’re kind of stuck a little bit either with a doctor that’s never really treated it or trying to travel around to try and find a doctor who has. So I was asked to give a talk at the American College of Surgeons meeting many, many years ago, I want to say maybe seven years ago. And the title of the talk was Rare Pelvic Hernias, and they thought, I’ll, I would just talk about femoral hernia, obturator hernia and just maybe show historical pictures. But during that time, I saw multiple peoples with perineal hernias, which I’ll discuss in addition to sciatic notch hernias. Sciatic notch hernia is the most rare, the rarest of all hernias you can get regardless of the type or location of the hernia. Absolutely the rarest and I’ve treated too, which is a lifetime’s worth for most people don’t even know there is such a thing as a sciatic not hernia. So it was kind of lucky that I had that experience right before I was supposed to give a talk on it.

Speaker 1 (04:37):

And so I was able to include my video and my experience, the patient presentation, the cat scan, everything to really teach the audience. And let me tell you, it was really cool because we were for some reason assigned the really huge auditorium, which usually is kept for the more popular talks. And that can be a hernia talk, but it’s often not such about such a rare problems. And so we were in the big auditorium, I had a huge audience, and ever since that, I think it was six or seven years ago, ever since that talk, I’ve had so many people come to me like, oh man, I listened to you at the ACS or American College of Surgeons meeting. And that was a great talk and it really was mostly because it was new and people don’t really relate to necessarily to what I was presenting, but it was good, positive information and it was very good talk.

Speaker 1 (05:37):

They had pictures and videos. And as surgeons, our meetings are really fun compared to our colleagues in let’s say nephrology or because we have a lot of pictures and videos as part of our talks. And it’s not just talking about concepts, but there’s a lot of hands. So, which is why I love surgery, of course, because it’s fun and creative. So based on that, I just wanted to share with you the fact that I’ve really enjoyed my, hold on. I really enjoyed my time, experience, and experience with pelvic hernias, and that session really inspired me to do even better with all my pelvic hernias. So I would like to share it today, the top four pelvic hernias, actually what we had some questions that were submitted, we’ll just go through the questions because they were so insightful. I think that that’s going to be great.

Speaker 1 (06:44):

So question number one, what you’re going to talk about obturator, perineal or sciatic not hernias. So the four main pelvic hernias are, and by pelvis I mean below the belly button and typically way down in the pelvis. So where your bladder lives, where your rectum lives, and around the pelvic bone. So there’s a femoral hernia, which is the most common of the pelvic hernias. It’s most common in women, although men can get it too. And it’s still rare in women and it is the only hernia we know of that has a very high risk of bowel getting stuck into it of percentage wise. And therefore, if you have intestine that’s stuck in your hernia, that is a surgical emergency. And because it’s between a ligament and a bone as opposed to through a muscle, it can’t stretch out or expand. It can’t like muscle can, and therefore the risk of bowel getting stuck and not being able to be unstuck is really, really high.

Speaker 1 (08:00):

And it has a 5% risk of death once that happens. So unlike other hernias where the risk of death is really, really low, it’s mostly a nuisance to have a hernia. With femoral hernias, you can actually die if it’s not adequately addressed or addressed in a timely fashion. So the European Hernia Society and others have recommended that all patients with known femoral hernias get it repaired, if doesn’t matter. Let’s say you’re, you had a cold, got CT scan for some reason, and it shows a femoral hernia totally unrelated to your symptoms, that femoral hernia should be repaired. Now, not emergently obviously because it’s not bothering you, but you know should plan on fixing it because the risk of death from that femoral hernia is real and the operation is relatively low risk for death. So risk and information you got die from surgery, very low risk, die from no surgery, very high risk. So 5% is considered high.

Speaker 1 (09:07):

If I told you you’re going to drive 5% risk of dying, that’s like right, very, very high. So you want to prevent that from happening. And so femoral hernias are the only hernia that we know of that watchful waiting is not considered safe. So that’s femoral hernias. Then there’s obturator hernia, and a lot of you guys love my little obturator meme. Hello, obturator. So the obturator hernia is a hernia through the obturator space, which is a hole in your pelvic bone. It has muscle, so it has to go through this muscle to become a hernia, but the borders are a bone and then there’s a natural hole there to allow for the obturator nerve, obturator artery and obturator vein to go through it. And so most hernias that we know of, belly button and inguinal, there’s already a hole there. So it’s more prone to herniation.

Speaker 1 (10:09):

And if that muscle gets larger or weaker, then you’re at risk for having things fall into it. The classic, classic situation that we have where we test our residents about and very important that they understand is a frail, thin, cachectic elderly female that’s maybe in a nursing home and chronically constipated and no one really knows much about her medical problems, comes to the emergency room with a really distended abdomen and very, very sick, low blood pressure, high fevers, et cetera. And imaging is, and they’re laying in bed very uncomfortable, and their legs are like frog lagged outwards, whichever side, let’s say the right side frog lagged outwards. That is a classic situation of an obturator hernia. And what has happened is they’ve been, they’re, they’re frail and weak and thin, and therefore they have very poor musculature. So that already identified coal within the obturator muscle through the obturator fascia or space in little weaker, and then they’re constipated.

Speaker 1 (11:28):

So they’re constantly pushing to empty their bowels, which is a major problem in most nursing homes. And then they start pushing and intestine into that hole, and no one knows about it because it’s not a bulge that you can see, but image on imaging, you’ll see it, and sometimes in surgery you’ll just notice that intestine in that area. So that is why obturator hernias are very important. It’s usually not diagnosed until the patient shows up to the emergency room really sick, and they’re usually elderly and constipated and not healthy to begin with. So unlike a femoral hernia where you may be able to see a bulging just at the groin crease, the obturator hernia is deeper in the pelvis, and that’s why pelvic hernias are so difficult to diagnose as you cannot feel them or see them in the average patient. It’s imaging that diagnoses it. So obturator hernia goes down into your thigh, you can think of it that way. And so it’s that pressure in the thigh or the bowel that goes into the thigh, that’s the pain. And so moving the hip is painful with an obturator hernia.

Speaker 1 (12:42):

The reason why I picked this topic was because I just saw a patient with an obturator hernia and she was referred to me by multiple colleagues of mine who live on the east coast, and she came to see me and she was as most people with pelvic floor hernias are misdiagnosed for a while, I want to say a two years, one year or two years, she had imaging which actually showed the obturator hernia, but they did not mention there was an obturator hernia until she had another set of imaging this year, which someone said, oh, there’s an obturator hernia, which is great. So she’s young also, which is very, very uncommon to s. She’s the youngest patient I’ve seen so far with an obturator hernia. So I’ve seen a couple of young people, but they tend to be in the forties and fifties, maybe sixties.

Speaker 1 (13:41):

She’s in her thirties. So that’s kind of uncommon to see someone so young. There’s really no prediction why this happened. Most likely it’s a genetic component. I believe her siblings also had hernias, so that makes sense. It’s a genetic component. So her symptoms were the following. It’s very interesting. I always tell you this, it’s all about the story. So people were just kind of put off by the story. They’re like, oh, she’s got so many weird complaints. It can’t all be like Occam’s razor, right? It can’t all be diagnosed by one diagnosis. Maybe she’s just nuts because she’s got back pain, leg pain, bladder pain, she has problems, urinate even has had incontinence as a 30 something year old, bloating, nausea, difficulty with certain stairs and hills and so on, and pain shooting down her leg. So in retrospect, the obturator hernia explains everything. So it’s like inside pelvic pain radiates down.

Speaker 1 (14:58):

Usually the inner thigh down towards the knee is where the obturator nerve feeds. And so pressure on the obturator nerve by the obturator hernia can cause those symptoms. And then the lower back pain is from pelvic floor spasm. The urinary incontinence, urinary frequency and painful urination are also due to the pelvic floor spasm from the obturator hernia. She was told she has Pudendal Neuralgia. If you go back to all of our prior guests where we talked about Pudendal Neuralgia, Dr. Michael Hibner is one of those experts that we spoke with. She’s misdiagnosed with that and kind of taken a little bit down that pathway that, oh, maybe you have Pudendal Neuralgia. No, 30 year olds should not have P Dental Neuralgia. There’s no mechanism for that. And I suggest that you go to our podcast on P Dental Neuralgia to really understand why it’s so rare to get dental Neuralgia as a diagnosis and why it’s possible that people with pudendal Neuralgia symptoms really have just pelvic floor spasm, which is what she has.

Speaker 1 (16:12):

And then she had this idea, oh, if you have nerve entrapment, first of all, I’ve said this multiple times, people don’t wake up with nerve entrapment. Something needs to happen. There needs to be an injury to the nerve directly, whether it’s a disc that pushes on the nerve or a surgeon who operated in the area. Now there’s scar tissue effect entrapping the nerve or the nerve was accidentally cut during that surgery or someone stabbed them in the area and they have injury in the right next to a nerve. But pudendal Neuralgia is really not something that most people get. Now, if you’re a cyclist and you cycle hundreds of miles a week, sometimes even a day, that puts you at much higher risk for Pudendal Neuralgia. There’s great stories of the surge soldiers in World War I where they were on their Jeeps and they’re kind of bouncing up and down on their Jeep kind of flatbed chairs with no cushion, and that kind of was basically injuring their pudendal nerve.

Speaker 1 (17:32):

If you’re paraplegic and you’re in a wheelchair, then you’re constantly sitting on your pelvic bones and you can have pudendal nerve pressure on it, an ischemia and pain from it. So those are situations where, yeah, I can imagine Pudendal Neuralgia in those or someone who’s had a really bad pelvic floor surgery, let’s say for cancer or something extreme, and they scraped the nerve as part of the cancer operation. I can understand that. But short of that, a young healthy lady who’s just doing her job should not be having dental Neuralgia or really any nerve entrapment. There should be a mechanism for the entrapment. So of course she was taken down that whole pain management and nerve blocks, and of course it didn’t work, and sometimes nerve blocks can make it pain worse because you’re shutting down any activity by that nerve kind of reducing the noise, the background noise, and then the hernia pain noise goes up.

Speaker 1 (18:43):

So ilio, they’re like, oh, it’s your ilioinguinal nerve, it’s your general femoral nerve. Of course, none of that. So fortunately for her, she was referred to me, like I said by some of my colleagues from the east coast, but even they were like, oh, it’s going to be difficult situation. This patient, we don’t know. She’s very complicated. This poor lady, not complicated. She had obturator hernia every, what had happened is her surgeons did not appreciate the connection between the obturator hernia and the symptoms associated with that and all these kind of atypical symptoms that any pelvic hernia can give you pelvic floor spasm. And the consequence of that, which include rectal pain, pain to urinate pain during penetrate penetrating intercourse and low back pain and rating pain down the leg. So that’s why they’re like, oh, there’s all these weird symptoms she has. No, these are all like obturator hernia symptoms.

Speaker 1 (19:48):

So she was not that complicated, which is great because you fix the obturator hernia and all those symptoms should go away, which is basically a laparoscopic hernia repair. The next more kind of less common pelvic hernia is a perineal hernia, very uncommon. So perineal hernia is exactly that. It is a hernia in the perineum. The perineum is, you can think of it as just your pelvic floor. So there’s a levator ani and the obturator internus and internus and so on. So basically it’s the pelvic floor, but it’s mostly the levator ani, the pubococcygeus and other muscles that attach to your pelvic bone and to your tailbone. And they all kind of form like a salad bowl. And within that is your rectum, your urethra to urinate. And in women, the vagina that goes through that, you can have surgery there. Let’s say you a C-section needed a episiotomy and that could cause the hernia.

Speaker 1 (21:12):

You could have had other injuries from your pregnancy that could cause a hernia. If you’ve had really large pregnancies or women, obviously large pregnancies and or multiple pregnancies and a very difficult labor, you can be pushing and causing injury and tears in your pelvic floor, which then become hernias. It’s very uncommon in men. In fact, I don’t recall repairing any perineal hernias in men yet. They’ve all been in women and many of these perineal hernias are missed and therefore the patients are just told, it kind of sucks to be you, but you’re going to have to live with us for the rest of your life. They’re may be small or they may just not noticed on imaging, but classically, you can’t sit or if you sit, you have to sit on one buttock versus the other. And then in some patients, they also have other pelvic floor dysfunctions or laxity, they call ’em rectocele, cystocele, enterocele.

Speaker 1 (22:29):

These are all weaknesses. And laxes in the pelvic floor, again, secondary to straining mostly because of large pregnancies are damaged from large pregnancies. But it can also happen if you have let’s say a natural tendency towards weakness in the muscles like a collagen disorder. We’ve talked about Ehlors Danlos syndrome, and we will be having guests in the future that are specialists in that to kind of discuss that diagnosis. And within a hernia realm, the treatment of it is very, very tricky because it’s in the perineum. I already told you all these different organs. So the rectum is in the way, the bladder is in the way. You can’t get rid of those. The uterus is in the way. Many of these people have already had a hysterectomy. There are nerves that feed all of these organs in the way. There’s a ureter that empties your urine from your kidney to your bladder in the way there are multiple large vessels that go down to your legs.

Speaker 1 (23:40):

The external iliac vessels, those are in the way. They’re these huge veins deep in the pelvis. Those are involved. I mean, there’s so much. That’s a very, very tricky, very sensitive part of the body that really needs expertise of anatomy number one. And then a delicate surgeon, number two, and I would say that in my patients with perineal hernias, the treatment is almost always with Mesh. I’ve had one patient recently that I did not use Mesh in because the defect itself was really, really small, and I thought that we can spare her from Mesh in the area, but almost always it is you need some type of Mesh because those muscles are super thin and closing them alone, it’s just going to fall apart. And you just don’t want to go back into a previously operated area with so many tricky critical organs nearby. I’ve had to do that in some patients that have had multiple hernia repairs and they’ve all failed.

Speaker 1 (24:58):

Often they were failed non match repairs or they tried to put biologic Mesh and it doesn’t work because that stuff just kind of absorbs and you don’t get hernias, you get hernias recurring. But what I do is I use a hybrid Mesh. As you know, I’m a big fan of this hybrid Mesh. It’s by Telabio. It’s mostly biologic, but there’s some synthetic. The key to it is that there’s enough synthetic permanent Mesh as part of it to prevent a hernia from occurring, but not so much to cause like injury erosion, et cetera, into the bowel or the bladder or the vessels or the nerves. And so I’m a big fan of that for these tricky areas.

Speaker 1 (25:45):

So perineal hernias are really complex to repair. Sometimes you need to collaborate with a colorectal surgeon or a female urologist if they have concomitant other diseases. So many of them have a perineal hernia, but they also have these other weaknesses like rectocele, cystocele et cetera. And those two go hand in hand because if you have, let’s say, a weakness of your pelvic floor and you’re trying to poop, right? The natural path is for the poop to go down straight into the rectum and evacuate. But if you have an abnormal pelvic floor muscle, the bowel may kink on itself because it’s not a straight shot, and you have extra colon because you’ve had constipation for a long time and the bowel kinks itself. So now you’re pooping against a kink bowel, which means you’re not going to empty your bowel, which means you’re going to strain some more, which actually makes the situation even worse.

Speaker 1 (26:44):

And then you get this perineal hernia. So you can’t fix the perineal hernia without addressing the recusal. So sometimes collaboration with a gifted pelvic floor hernia specialist or pelvic floor specialist is really key as well, because you don’t want to fix one problem but not address the reason why you have that one problem. And that’s where the kind of multi-specialty care comes into play. And you have to kind of understand that that is the case. Here’s a question, do you do all these procedures in an outpatient center or do you ever operate in the hospital? Right? So femoral hernias, outpatient obturator hernias, if it’s elective outpatient, if either of those are not elective, obviously they happen in the hospital, but perineal hernias, I’ve been doing them in the hospital with an outpatient stay, like an overnight stay, but you don’t, mostly because you don’t want them to have any pain control issues or there’s also risk of bleeding. And so you want to make sure that all that is addressed at the time of surgery. There’s also a risk of them not urinating because operating on the pelvic floor puts your bladder into spasm, sorry, put your pelvic floor into spasm, and therefore you may not be able to urinate immediately after surgery. And so those patients are done as an outpatient.

Speaker 1 (28:13):

Great question though. Here’s some more questions. I need to stop talking and going through your questions. Okay. Are there any other rare pelvic floor hernias? No. Oh, we didn’t talk about sciatic notch hernias. So sciatic not hernia is the rarest of all rare hernias. And let me tell you, it’s really interesting hernia. So the sciatic nerve starts in your back, right? You’ve heard of sciatica, goes through this notch in the bone called the sciatic notch. A bunch of vessels go with it. It’s a very, very tricky area. Almost no general surgeon works in that area. There’s the major vessels to your leg that goes through there. Your ureter is there and your sciatic nerve. So if that notch for some reason, there’s a hole in it. And usually, again, it’s usually elderly female, then you can by chance get a hernia there. Now it’s super, super uncommon. It’s kind of lateral to the sides. So people don’t usually get lateral hernias. They usually get we’re we’re upright being, so usually hernias go downwards or outwards.

Speaker 1 (29:28):

The patient that I treated that I remember the best they thought she had, so she had sciatic pain, right? Sciatica because the bowel was pushing on the sciatic nerve literally. And so she was sent to a neurosurgeon. The neurosurgeon got imaging and imaging showed this mass impinging on the sciatic nerve and they’d say, oh, this is, it’s a soft tissue mass. This is not a disc. So maybe of cancer, of course it wasn’t cancer, it was intestine, but for some reason they didn’t know that was intestine, they thought anyway. So they’re like, okay, let’s not operate yet. Let’s see if this gets bigger and watch it. So they kept getting more and more imaging until finally someone said, Hey, this is not a tumor, this is intestine. So they sent her to me.

Speaker 1 (30:20):

It’s a very, very tricky operation because there’s nothing, you can’t close the hole. It’s like bone and barely some muscle and you can’t put sutures through that. And then there’s a major sciatic nerve R running right through it, bunch of huge vessels and the ureter, which you need to urinate through. And so I think you shouldn’t be putting regular Mesh in there because what if the Mesh kinks or erodes into the ureter or your sciatic nerve? So you use kind of a biologic Mesh that doesn’t stick to any of those products as a repair. And I do that robotically and it’s actually a really fun operation. I love showing the video of it, but it is very, very, very tricky because let’s say you put your Mesh in, where do you sew your Mesh? You have to know exactly where your anatomy is. So you put sutures through bone or muscle, but not through any way impinging these major vessels and nerves.

Speaker 1 (31:24):

So it’s very tricky and also fun. So the next question was, are there any other rare pelvic floor hernias? There are. I mean there are some pelvic floor hernias that run randomly like little holes through the psoas muscle or those, many of them are really considered a family of the femoral hernia world. And then some of them are just, they happen to be a piece of fat burrowing into muscle, but it’s not really considered a hernia because it’s not symptomatic and no one really cares that you have it. It’s just noticed during the time of another operation. What testing is needed? Oh, actually, here’s another one which I did. It was a coccygeal hernia. So this patient had how some people can break their tailbone. So she broke her tailbone and then as part of the recovery, they had to remove the tailbone itself because it wouldn’t like fuse or it was very, so in doing so, they had to go through the muscle in the buttock area and then they took out the tailbone and then that muscle didn’t heal because she was sitting on it.

Speaker 1 (32:53):

So when you sit on, it kind of pulls the muscle, the two butt cheeks to the sides, and then the muscle associated with that was then torn. So then someone said, okay, well fix your hernia. So they went in and they put some Mesh in, but what the mistake was that they didn’t understand that Mesh shrinks. So they put a perfectly sized Mesh that’s a little bit too small and they put it in tightly. And then six weeks later when the Mesh has shrunken, she’s in a lot of pain. So I went in and redid the repair again from the back. So the incision right at the kind of butt crack, how to take out the Mesh, the colon was right there. So you can see how close all these structures are, like the tailbone, the rectum and the buttock and the pelvic floor and all that are together.

Speaker 1 (33:50):

So she’s doing really great, but the key is very wide overlap of Mesh, closure of the muscle, preventing the Mesh from touching the bowel, the rectum, and then allowing the Mesh to shrink as needed and not being too tight. Alright, here’s a question. What testing is needed to determine these rare pelvic hernias? How do you get the right doctor for imaging? I’ve had pudendal Neuralgia for 11 years following vaginal hysterectomy, and I have a lot of rectal symptoms. So pudendal Neuralgia after vaginal hysterectomy, transvaginal hysterectomy. I’m curious how that occurred because in the midline there’s not that many nerves left. A lot of the injuries have to occur from the sides. And so that transvaginal hysterectomy is through the middle. That said, there are little nerves just behind the clitoris that can be injured as part of the retraction like trying to expose the area, especially if you have a narrow pelvic opening and they’re trying to do everything through the vagina. And so what happens is the nerve is damaged at that time. It’s like a clitoral, preclitoral nerve.

Speaker 1 (35:16):

So I’m curious if you truly do have pudendal Neuralgia or could this be all related to your pelvic floor or even a hernia or something. But yes, the rectal symptoms can be dental Neuralgia or they can be related to pelvic floor spasm, replicating pudendal nerve pain, whereas the pain itself is not good, not addressed. So what testing is needed? So an MR Neurogram, which is very difficult to get because not only do they have to know how to do the the MRI with the neurography protocol, but you need a radiologist that knows how to read it. You may recall last year we had Dr. Jan Fritz, he works at NYU Langone. He is a very talented radiologist that does these MR Neurograms and can identify the let’s say pudendal nerve in all of its branches and help identify if there’s any direct injury to these nerves, whether it’s entrapment or neuroma, and then you’ll can get treatment for it.

Speaker 1 (36:32):

And he’s an interventional radiologist for in musculoskeletal specialty. So he’s Dr. Fritz in at NYU Langone. But really, and then for pudendal neuralgia really to seek a specialist, Dr. Michael Hibner is one of them. He was also one of our guests a little over a year ago. So go and listen to those Hernia Talk Live Q&A sessions because it’s just filled with information and those are top doctors that I really trust that come on and help. Next question, how do you handle postoperative urinary tension if you’re operating in an outpatient surgical center? Good question. So first of all, we try and risk assess our patients. There are plenty of men with enlarged prostates that are urinating more than twice at night while waking up in the middle of the night and have poorly treated enlarged prostates. So I identify those before surgery and help get their prostate shrunk before after surgery so that they don’t have problems urinating after surgery.

Speaker 1 (37:39):

Now, if you do have problems urinating after surgery, there is a medication we use called rapid flow. We give that immediately after surgery and that helps promote urinary ting by shrinking the bladder very quickly and promoting the urinary outflow. If none of that works, you unfortunately get a urinary catheter called the Foley catheter that catheters placed in you. We teach you how to take care of it at home. It needs to be in about two or three days and then you go see your urologist or see me in the office to do a voiding trial and you should be on some type of medication to shrink the prostate as a part of that kind of protocol. Hello, from Italy, what are symptoms of a hernia surgery failing? Well, it’s usually the same symptoms as a hernia. So if a hernia surgery fails, which I usually interpret as a recurrence, then what will happen is your hernia pain will come back and you’ll, many people just feel the same symptoms they had before surgery.

Speaker 1 (38:44):

However, and we’ve discussed this before in prior episodes, if you have Mesh in the area or you just have scar tissue from, but often Mesh, sometimes a hernia recurrence pain is actually worse than the original hernia because you’re trying to fail or recur or kind of whittle your way through a space that before was wide open and that’s the kind of symptoms you had. But now it’s trapped with scar tissue and Mesh. It’s narrower and maybe not a straight shot, but more of a zigzag depending on how the recurrence is occurring. And so you can have symptoms from that, but it can be pain, nausea, bloating, and really any of your prior hernia type pain would also be the same. And hello from Los Angeles. Two.

Speaker 1 (39:44):

How do rare pelvic hernias manifest and what challenges do their diagnosis pose? So the issue with the diagnosis of pelvic hernias is you cannot see or feel them on exam typically. Now, the lady that I had with the sciatic notch hernia, she was so thin that you could actually see a little bulge in her left buttock area. The lady with the perineal hernia that I talked to you about, it’s hard to feel the area down in her kind of buttock perineal region. Most femoral hernias are difficult to diagnose on examination, but if you have it and it’s large enough and you’re thin enough, sometimes you can see a bulging at the growing crease, obturator hernias, you can’t feel those even really thin patients. It’s really hard to feel. But it would be a bulging mass within the thigh, very hard to diagnose. If you do a pelvic exam, you may be able to feel it through going through the pelvis, pelvis internally and feeling the pelvic floor internally.

Speaker 1 (41:00):

And then once you get imaging, you have to look for it. So I always look for these rare pelvic hernias on all the imaging that I see because that’s just me and I’ve seen it before. I like it would be so cool if I diagnose it myself. And I’ve had a couple patients where I’ve, I’ve been able to diagnose it where the radiologist has not been just because I’m looking for it. But I would say that imaging is really the key to a lot of these diagnoses. Next question. Are rare pelvic floor hernias more difficult to fix and is Mesh used more often to treat? Yeah, so yes, almost always you need Mesh because for the sciatic notch hernia, the obturator hernia and the femoral hernia, there’s nothing to close. It’s like through, it’s a hole between ligaments and bones. You can’t close the bone, so you need something to bridge that gap. Many of the pelvic floor hernias, the perineal hernias you’re dealing with really thin dot muscle also. So just closing the muscle there will not do well. And then also because these are difficult areas and small areas, you can’t put a big wide Mesh to overlap, you’re relying on a better or really good repair, the outcomes from repairing of them tends to be not as good as well.

Speaker 1 (42:24):

Next question. If your post-operative pain is similar to your pre-operative pain but is more severe, persistent and more easily provoked, how can you tell if it is? Because the pain is from an abnormality not diagnosed before surgery and not addressed or relayed to something that occurred in the surgery. So usually in the early stages after surgery, if the pain is different than before the surgery, then that’s from the surgery. But if the pain is the same as before surgery, then you haven’t addressed it with the surgery. Does that make sense? So let’s say you have a certain quality, I’m not talking about the quantity of the pain yet, not the severity of the pain, but just the quality. Let’s say it’s a dull, sharp, maybe it’s a dull radiating pain if that goes away, but now you have this other pain after surgery, then that’s a surgically related pain. Hopefully it’ll go away. But the original pain from before surgery is gone, it’s replaced with other pain. That’s why it’s not useful to say, do you pain? You can say, I had pain before surgery. I had pain after surgery. Yeah, but what is the quality of the pain? If the quality of the pain is the same, then maybe the surgery did not address your pain because if it was a hernia surgery, maybe you didn’t have hernia pain, maybe you had hip pain. I’ll give you an example.

Speaker 1 (43:53):

Had a patient with this weird kind of pain towards the middle of the belly, like suprapubic low, low between the belly button and the lower abdomen kind of pelvis, mostly pelvic, but in the middle they’re like, oh yeah, you got these hernias that’s fixed the hernias. So they fixed the hernias and never really addressed that pain. Guess what? Diverticulitis, he had a Mesh repair, it didn’t work out well. He had complications for that. And guess what? The hernia pain never went away, but he does have active diverticulitis with multiple bouts of flares of it. So we’re treating him for the diverticulitis and I’m very hopeful that that would address the pain. So that’s a situation where you had the surgery and the pain before surgery is unchanged. You still have the pain after the surgery, which means you’re missing a diagnosis. Can these hernias be repaired similar to a diep flap instead of synthetic?

Speaker 1 (44:56):

Okay, so all hernias theoretically can be repaired with a flap, a tissue flap. So a diep flap typically is a type, it’s deep spelled D I E P it. It’s basically a plastic surgery method of taking a portion of your abdominal wall and transposing it to another part of your body. Often for the breast. So you’ve heard of flaps for breast reconstruction. Let’s say you have breast cancer and they do a mastectomy, so you’re missing your breast tissue and then you take tissue from the abdominal wall, usually skin and fat, sometimes muscle and you put it into where you remove the breast and you recreate a breast. The same thing can occur by these reconstructive amazing plastic surgeons to cover hernias in certain parts of the body. It is highly, highly morbid, very, very fraught with complications and never offered as first, second, or third options for hernia repairs. I’ve done it for some patients. It’s really not ideal. It’s very deforming in many patients and it is really kind of an end stage process usually in people that have had lots of radiation therapy and destruction of tissue and maybe infections in the past where you need to bring in normal healthy tissue to help with that. Very complicated situation. In fact, I think we’ve had plastic surgeon guests who’ve discussed those. I believe Dr. Janis and maybe Dr.

Speaker 1 (46:46):

Who was it from? D. Mo from Virginia I think plastic surgeons that we talked about that these flaps. Very interesting. So this was over a year ago, maybe a year and a half, two years ago. So go back to our Q&A sessions and look those up. Are there specific predisposing factors for developing rare pelvic floor hernias or do they share the same risk factors with common hernias? So it’s almost always number one genetic and number two, constipation or some other type of straining like pregnancy with vaginal deliveries. Almost always we don’t see people like coughs getting pelvic hernias. It’s really very high genetic predisposition. So we really don’t know. We really don’t know why they get it. Other than that or and or severe constipation with or without history of pregnancies and straining, are you at increased risk of developing a rare hernia if you have already had a common hernia?

Speaker 1 (48:01):

Yes. The fact that you have any hernia makes you at risk for having any other hernia. That is very true. That said, the term increased risk is, I don’t want to overstate it. It’s still a very, very low risk. These hernias are so rare. For example, the lady who patient who saw me with the obturator hernia, she’s asking me, how many of these do you do over year? I’m like maybe three, which is more than most people see in a lifetime, but it’s still a low number. And that’s all I do is these expo. I get exposed to a lot of these unknowns and so I end up seeing these rare diagnoses. But understand that your average surgeon will say zero, maybe one in their lifetime as opposed to per year. So the number that you want to hear, I can’t give you. I can’t say, oh yeah, I do hundreds of these a year.

Speaker 1 (49:03):

They don’t exist basically unless I’m like a op trader hernia specialist, which no one is. All right. Is there any particular demographic more commonly affected by rare pelvic hernias? Yeah, so women and the reason why it’s women, I think it has to do with the pregnancy aspect of it and not in your pregnancy slash delivery as opposed to men who may just be constipated or have a really bad genetic disorder, maybe Ehlors Danlos syndrome or other collagen vascular disorder, because I think the amount of pressure generated by multiple pregnancies on the pelvic floor is pretty intense, which takes me to some of our discussions about pregnancy and how you can help prevent that. Although it’s not ideal, many women choose to have elective cesarean sections and never undergo any type of, what do you call it, like delivery pain because they are protecting their pelvic floor and therefore in the future they will not have cystocele, rectocele, urinary incontinence, stool incontinence, severe constipation and so on.

Speaker 1 (50:40):

So to prevent that from happening, especially if you are prone to it, many women decide to have what’s called an elective C-section, which means you come in on a certain day, you have a C-section like you do an hernia repair, you don’t go through labor, that’s the word I was trying to find. Labor. You don’t go through labor and therefore you don’t strain and push and therefore you do not potentially tear any part of your pelvic floor muscle. In addition, I highly, highly recommend using some type of support system for your pregnancy. The last for sure, the last trimester after six months, maybe start at five months of pregnancy to hold the uterus up and off of your pelvic floor. That’ll help improve blood flow to your legs and reduce swelling. It’ll help reduce the urinary frequency that women get with a big baby, fetus, huge permanent uterus sitting on top of their bladder. It’ll help reduce pressure and separation of muscles and tearing of your pelvic floor and so on. And if you don’t have vaginal delivery, there’s a lower risk of needing a episiotomy or tearing your vagina and therefore tearing your pelvic floor. I know women who’ve had injuries to their pudendal nerve at the clitoral space trying to get a large baby through a narrow canal and really causing pressure necrosis in that area.

Speaker 1 (52:17):

Let’s see, Friday I’m having a CT scan to see if my bladder may become involved with an inguinal hernia because I’ve been having urinary issues. It’s on my left side where I had inguinal hernia surgery with Mesh and a plug in 2015 and I’ve had pain since. So remember you can have hernia involvement with it with your bladder if you’ve had a plug, the plug can be pushing on a full bladder and you can be having urinary pressure and urgency and pain with a full bladder. You can have erosion of Mesh into the bladder if you’ve had hernia surgery before, uncommon, but it can happen more common with the plug or you can just have pelvic floor spasm, which is caused by some pain or abnormality in the inguinal floor, including your inguinal hernia and or the Mesh and or the plug causing urinary frequency and urgency.

Speaker 1 (53:25):

So it’s not bad to get imaging. Make sure you do it with a full bladder so that they can see how the Mesh interacts with your bladder as opposed to an empty bladder where you’re like can’t see anything. That’s a little tip for you, don’t urinate before the CT scan is done. And then it’s also important if you’re planning on having Mesh removed that you evaluate where the Mesh is in relation to your bladder because the surgeon should kind of have this kind of roadmaps when they’re removing the Mesh. They understand that the Mesh may be stuck to the bladder, let’s say, and so you’ll, you’ll be much more careful about that.

Speaker 1 (54:15):

Next question, which test is best to show al hernia, Mesh and pluck? Okay, well we’ve reviewed this. We’ve had multiple radiology discussions. So in general, for the abdominal wall, Mesh is best evaluated just with a regular CAT scan, but for the pelvis it’s much more important to get a higher, a better quality imaging. They identify as a Mesh distinct from the muscles and so on. And therefore I recommend an MRI. Ultrasound is not good because it often too, it’s too complicated because their scar tissue and Mesh and prevents the hernia from or whatever the area to be adequately visualized.

Speaker 1 (55:04):

CT scan is hard to get a lot of good information from because the Mesh and the muscles are all the same color, so you can’t w l helps a little bit, but in the pelvis it really doesn’t help as much as the abdominal wall. So I usually go straight to MRI pelvis and it’s sometimes hard to get insurance approval because they don’t believe that MRI needs to be done. And that’s unfortunate because it’s absolutely the indicated procedure. So we deal a lot with insurance companies trying to get that approved and reimbursed for the patients. It’s so stupid because they have these outdated kind of protocols that they follow and insurance companies are like a roadblock to a lot of the care of my patients, but I digress. So MRI pelvis would be the best for inguinal hernia Mesh and plug again with a full bladder so that you can identify the interaction between the bladder and the Mesh. Whereas when the bladder is decompress, it’s usually not as helpful because that’s not when you have the pain. So that’s all I have for you guys today. We reviewed all the different rare pelvic hernias

Speaker 2 (56:22):

It this is the most you’ll ever hear about pelvic hernias anywhere. Let me tell you that because even the talk I gave I think was a 12 minute talk and when I put all this information to 12 minutes, because surgeons have very short attention span, you got to fill it with pictures and videos for them to listen to you, which is why I think they like my talk so much. But do know that we got some really exciting guests coming up, some very high profile doctors, some are surgeons, some are not, are slated for the fall and winter. So I’m super excited to learn from them and share everything from them and stay tuned because we’re going to have a new look for our YouTube channel and our website and I’m super excited about that. And one day I will have a dream of having a podcast for hernia talk, but got too many things going on right now. I love you all. Thank you so much for joining me and asking you all these great questions. I will see you next week. Hope you’re all well Talk to you later. Bye everyone.