Surgical management of chronic inguinal pain syndromes - Liespijn

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n (%)Previous visits to a physician because of persisting pain*General Practioner 32 (4.6)Gynaecologist 15 (2.2)General surgeon 5 (0.7)Other (Speciality consulted physician unknown) 3 (0.4)Frequency of pain medication intake*Yes, occasionally 16 (2.3)Yes, regularly 5 (0.7)Cyclic pain* 56 (8.1)Bulge noticed* 130 (18.8)Numbness* 199 (28.8)Functional impairmentNone 628 (91.0)Mild 45 (6.5)Moderate 16 (2.3)Severe 1 (0.1)Figure 3 Pain frequency in patients following a Pfannenstiel incision (n = 689, one patient missing).Table 2 Chronic pain characteristics reported by patients that responded to the questionnaire (n= 690).*Pain located at the Pfannenstiel incisionUnivariate modelMultivariate modelOR (95% CI) p OR (95% CI) pAge 1.0 (1.0-1.0) 0.079 -Follow up duration 0.99 (0.99-1.0) 0.036 -Emergency CD* 1.53 (1.07-2.20) 0.021 1.56 (1.01-2.40) 0.020*No of Pfannenstiel incisionsN = 2 1.60 (1.07-2.39) 0.020 1.27 (0.82-1.97) 0.291N > 2 2.95 (1.62-5.37) 0.000 2.92 (1.44-5.93) 0.003Numbness 3.19 (2.25-4.51) 0.000 3.01 (2.05-4.40) 0.000Scar length 1.06 (1.01-1.11) 0.029 -Table 3 Logistic regression analysis of risk factors predicting chronic pain development following a Pfannenstiel incision (n=690).*Emergency CD in multivariate analysis among CD patients.Figure 4 Pain intensity in patients following a Pfannenstiel incision (n=690).40 Chapter 3The Pfannenstiel approach as a source of chronic pain 41
Outpatient assessmentAll patients with moderate or severe pain (n=61) as determined by the VRS-scoringsystem were eligible for follow up. As 29 patients did not participate in this assessmentfor reasons as stated in figure 2, a population of 32 patients was evaluated using anextensive interview and a physical examination. The demographic and clinical detailsof these patients are shown in table 1. This subgroup forms a representative portion ofthe entire population. Findings of pain history and physical examination are listed intable 4.n (%)Plan HistoryCharacterNeuropathic 23 (72)Non-neuropathic 9 (28)FrequencyOccasionally 2 (6)Regularly 12 (38)Always 20 (58)CourseConstant 22 (68)Intermittent 4 (13)Progressive 2 (6)Decreasing 4 (13)Other chronic pain syndromes** 23 (72)Physical examinationBulge 1 (3)NeurophysiologyNormal 14 (44)Hypoesthesia 14 (44)Hyperesthesia 3 (9)Allodynia 1 (3)Trigger point 17 (53)Nerve block (lidocain 1%) 9 (28)Significant pain reduction (10 minutes)*** 6 (18)Persisting total pain reduction (12 months) 2 (6)Table 4 Pain history and physical examination in patients who visited the outpatient department based on high pain scores(VRS = moderate or severe*, n=32).*VRS = Verbal Rating Scale, **Chronic pain syndromes = chronic headache, low back pain, complex regional pain syndrome,irritable bowel syndrome, *** Pain reduction following nerve block after 10 minutes and after 12 months.Neuropathic pain caused by an entrapment of the iliohypogastric or ilioinguinal nervewas present in 17 patients (17/32, 53%). Nine patients opted for a diagnostic nerve blockthat led to a significant pain reduction in six of them. The initial pain reduction persistedfor at least 12 months in two of these 6 patients. The remaining eight patients refusedinjection.A variety of non-neuropathic causes was diagnosed including non-specific diffuse scarpain. Bulges indicating incisional hernias were not found, although one patientpresented with bulging of the entire lower abdominal wall due to muscle atrophy. Twopatients complained of a ‘pulling’ pain confined to the midline which was classified asmusculotendinous in origin. Keloid formation and fat necrosis produced local scar painin two other patients. Three additional patients were diagnosed by the gynaecologistwith endometriosis, secondary vaginism and primary dysmenorrhoea, respectively.A diagnostic classification of post-Pfannenstiel syndromes is proposed in table 5.n (%)1. Neuropathic 17 (53.1)2 Non-neuropathicNon-gynaecological- Diffuse scar pain 7 (21.9)- Musculotendinous 2 (6.3)- Abdominal wall atrophy with bulging 1 (3.1)- Keloid 1 (3.1)- Fat necrosis 1 (3.1)DISCUSSIONGynaecological- Endometriosis 1 (3.1)- Secondary vaginism 1 (3.1)- Dysmenorrhoea 1 (3.1)Table 5 Diagnostic classification of patients with chronic pain following a Pfannenstiel incision (n=32).The current study showed that chronic pain after a Pfannenstiel incision is common.These results are thought valid and representative as 80% of a large sample sizeresponded to the questionnaire. Even if all non-responders were pain-free, the painprevalence would still be 26%. As far as we know, the well known international ‘TermBreech Trial’ is the only study that prospectively assessed pain after both cesarean42 Chapter 3The Pfannenstiel approach as a source of chronic pain 43
Page 1 and 2: Surgical managementof chronic ingui
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Page 5 and 6: CHAPTER 1Introduction, aims and out
Page 7 and 8: pathway for the cremasteric reflex.
Page 9 and 10: aims at classifying postherniorrhap
Page 11 and 12: ABSTRACTBackgroundThe aim of this s
Page 13 and 14: The study population consisted main
Page 15 and 16: evaluate if preservation or electiv
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Page 19 and 20: INTRODUCTIONThe Pfannenstiel incisi
Page 21: significantly and independently pre
Page 25 and 26: 6 Did you ever visit a physician be
Page 27 and 28: CHAPTER 4Evaluating postherniorrhap
Page 29 and 30: INTRODUCTIONThe introduction of mes
Page 31 and 32: VAS*Values no pain mild moderate se
Page 33 and 34: CHAPTER 5Classifying postherniorrha
Page 35 and 36: INTRODUCTIONChronic pain following
Page 37 and 38: not attained in the remaining ten p
Page 39 and 40: damage, dysfunction of periurethral
Page 41 and 42: CHAPTER 6Tailored neurectomy for tr
Page 43 and 44: INTRODUCTIONWorldwide, many patient
Page 45 and 46: Patients with chronic postherniorrh
Page 47 and 48: operative exploration for a patient
Page 49 and 50: CHAPTER 7Randomized controlled tria
Page 51 and 52: INTRODUCTIONHernia recurrence rates
Page 53 and 54: at the outpatient department as wel
Page 55 and 56: CHAPTER 8Surgical management ofingu
Page 57 and 58: INTRODUCTIONWorldwide millions of l
Page 59 and 60: ‘diagnostic’ nerve block. A one
Page 61 and 62: DISCUSSIONIn the present study a ne
Page 63 and 64: CHAPTER 9Occupational disability du
Page 65 and 66: INTRODUCTIONIn the Netherlands, app
Page 67 and 68: period, a 25% reduction on their in
Page 69 and 70: 17 Madura JA, Madura JA 2nd, Copper
Page 71 and 72: SUMMARIZING DISCUSSION1. Prevalence
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Results of our study are in concert
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and possible treatment effect. Idea
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CHAPTER 11Nederlandse samenvatting1
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patiënten beschreef hij drie versc
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CHAPTER 12List of publications158 C
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CHAPTER 13Dankwoord162 Chapter 13Da
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CHAPTER 14Curriculum Vitae166 Chapt
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Surgical management of chronic inguinal pain syndromes - Liespijn

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