Inguinal Hernia Surgery in Men - Chronic Pain and Sexual Dysfunction

Abstract: Life time occurrence of inguinal hernia is 30% of men. Most are symptomatic and will require surgical treatment. Operation will commonly cure the hernia but remaining chronic pain or new pain is seen in 10–15%. Groin pain due to an inguinal hernia can cause impairment of sexual functions. This is sparsely studied. The aim was to analyse postoperative long term chronic pain and sexual impairment in a large cohort of endoscopically (TEP) operated men registered in the Swedish Hernia Register (SHR) were all levels of surgical skills were present. Secondly to analyse within an RCT, using highly standardized techniques for open Lichtenstein (Lich) and TEP repairs, the influence of chronic pain and sexual impairment.PAPER I: a mail enquiry based study on 1110 patients retrieved from SHR comparing mechanically fixated to unfixed mesh in consecutive TEP operated men 30-75 years with a primary hernia during a 5 year time period. Chronic pain was seen in 7.7% with no long term difference (median 33 months). Pain did not attenuate over time. A recurrent operation was low (1.4%) without difference between fixated and unfixed mesh at median 7.5 years follow up. Quality of life was excellent. A postop complication was a risk factor for chronic pain.PAPER II: a RCT including 482 patients comparing Lich to TEP in men 30–75 years with a primary inguinal hernia. Pain was reported preoperatively in 73% and postop “pain past week” by 7.4% after TEP and 9.8% after Lich (ns) and “pain right now” by 4.2% after TEP and 5.9% after Lich (ns) at one year. Patients restored QoL to above norm levels. All short term outcomes favoured TEP. Postoperative sensory disturbances increased markedly at one year after Lich. Low rates for both chronic pain and recurrence can be explained by operations performed in a highly standardized setting by specialists.PAPER III: a cohort of 538 patients within the register-based TEP study in sexually active men, 30–60 years old. A new short form questionnaire (SexIHQ) was developed to assess sexual dysfunction due to groin pain after inguinal hernia repair to be used in large cohorts. Pain during sexual activity showed a surprisingly high incidences of 8.2%. A postoperative complication was a risk factor for pain during sexual activity.PAPER IV: a cohort of 243 patients from the RCT, men 30–60 years old were included. A questionnaire of sexual function was distributed. 35% reported pain at sexual activity preoperatively. At one year 5.8% in TEP and 12.3% in Lich (ns) and after three years 6.8% vs 9.1% (ns). Hernia repair reduce pain at sexual activity and restore QoL in most patients. New pain at sexual activity (harms) was though seen in 3.5% at one year. Risk factors for postoperative pain at sexual activity are Lich technique and preoperative pain.CONCLUSIONS: Both TEP and Lichtenstein repair result in low rates of chronic pain and recurrence without differences between groups. Both techniques reduces symptom and restore QoL in most patients. TEP has short term advantages. Sexual dysfunction due to groin pain in inguinal hernia patients is surprisingly high and reduces the QoL in these patients. Hernia repair by both TEP and Lichtenstein markedly reduce the preoperative sexual dysfunction and restore QoL in most patients. The Lichtenstein technique is through a risk factor for pain at sexual activity.