Currently, in the U.S., there are fewer than five programs considering or offering treatment for inguinal hernias as a cause of pelvic pain in women. These hernias are called hidden because they are not appreciated on an exam, X-ray, or even visible initially on laparoscopy.
This is a clinical syndrome that is diagnosed solely based on history, with some findings on exams that relate to the location of the pain. The diagnosis is confirmed with a special search or dissection into the inguinal region at laparoscopy and the treatment is administered at that time in the same way a traditional hernia is repaired. To further define this, while typical hernias are visible immediately at laparoscopy because of the prolapse of the peritoneum through the inguinal ring, with occult hernias, there is no prolapse of peritoneum in most cases and therefore would be “missed” in standard laparoscopy. This is a large part of the confusion with this diagnosis.
Little research has been done or exists on this topic but the buzz words for the syndrome are “sports hernia” or “runner’s hernia.” Even so, less than 15 articles exist on this topic. Dr. Debra Metzger, a reproductive endocrinologist, was instrumental in developing this diagnosis and treatment approach back in the 1980s and ’90s. She treated hundreds of patients with great success and promoted the procedure.
Diagnosis and treatment of hernias, however, is done by general surgeons as an integral part of their specialty. The vast majority of general surgeons on a philosophical basis do not operate solely for pain without diagnostic findings. This certainly would be a prudent approach for traditional hernias where a bulge is usually appreciated. This approach though would exclude 90+ percent of the occult hernias that we see and treat. Gynecologists on the other hand have been operating for pain for over 100 years to diagnose and treat endometriosis. The idea of operating on pain without specific findings is therefore not at all foreign to us.
At JCRM, we have established a working relationship with some general surgeons in Jacksonville who were open-minded enough initially to work with us and now see the dramatic results in their patients.
Other surgeons have been critical of the approach and universally would tell our patients that they do not have a hernia if the patient was evaluated by these physicians. This is not a criticism of them as surgeons, this is simply a very obscure description and we wouldn’t expect any physician to understand this without specific education. This syndrome is very common in association with endometriosis and about 30-40% of our pain surgeries include attention to this problem.
The History: Patients may report the following*:
- Lateral low quadrant pain (often, “my ovaries”) that is sharp and intermittent or constant
- Radiates
- down the front of the leg / inner thigh/groin
- Through or around to the back
- Less commonly to the hip or up towards ribs
- Pain is worse with intercourse, periods and with exercise or standing for a long time
- The pain can be relieved by recumbent position
- Often relieved some by pressing on the area
- Generally worsens over time but may come and go.
- A prior laparoscopy seems to be able to relieve this pain for 3-12months.
- A common history is a patient who has had several laparoscopies for endometriosis followed by losing one ovary (the bad pain side) followed by hysterectomy only to continue with the same pain localized to the groin.
The Physical Exam:
- Pain just above the crease of the leg to palpation.
- Valsalva or straining can make the pain increase in some.
- Pain on the vaginal exam when directed toward the inguinal ring.
- The exam findings are not subtle in the vast majority of cases.
- *Few patients exhibit all of these symptoms. Most patients have several of these key elements.
- Xrays: CT would almost never find this. MRI might see it in a minority of cases.
Michael D. Fox, MD
Jacksonville Center Reproductive Medicine
Advanced Reproductive Specialists
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