Chronic Groin Pain Clinic

Podcast Transcript

Scott Steele: Butts and Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

So welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chairman of Colorectal surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. And today we're welcoming Dr. David Krpata, the director of Cleveland Clinic's center for chronic groin pain here at Cleveland Clinic. David, welcome to Butts and Guts.

David Krpata: Thanks for having me.

Scott Steele: So we're going to talk a little bit about chronic groin pain, something that obviously can be very, very devastating to patients and difficult to manage for practitioners. But before we get into that, tell us a little bit about yourself, where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

David Krpata: Yeah, so I actually grew up in New York and moved out to Arizona when I was 13 years old, and that's where I did all my schooling. I went to undergraduate at the University of Arizona as well as the medical school there. And that's actually where I met my wife, who turns out that she's from Cleveland, which really explains why I'm back here in Cleveland. I did my residency at University Hospitals Case Medical Center and did my fellowship at the Cleveland Clinic and I've been here ever since.

Scott Steele: Well we're very excited and glad to have you here, so let's jump right into things. So chronic groin pain is something that you know you hear a lot about and we can see sometimes with famous athletes and other things like that, but give us an overview of this. How does somebody end up with chronic groin pain?

David Krpata: Yeah. One of the biggest areas that we focus on with chronic groin pain is after inguinal hernia repairs, and it's actually a much higher than the risk of a hernia recurrence. So the hernia coming back after they get an inguinal hernia repair. And there's probably multiple reasons for that, but there's actually a really interesting study that they did in Sweden where they looked at 22,000 patients that had an inguinal hernia repair in one year. Afterwards, they asked them in the last week, rate your pain on a scale of one to seven. And right there in the middle at four they essentially described pain that impacted their ability to concentrate on a daily basis. And about 15% of people describe having that level of pain one year after an inguinal hernia. In the United States we do about 800,000 inguinal hernia repairs. So if you extrapolate from that, there's a lot of people that traditionally have been in somewhat ignored for their chronic groin pain after something like an inguinal hernia repair.

Scott Steele: So we've discussed hernias on Butts and Guts before and I encourage all of our listeners to go back and listen to some of our previous episodes. But as a refresher, can you give us a little bit of an overview about what is a hernia and how does somebody wind up with getting a hernia?

David Krpata: Yeah, so when we're talking about even, specifically inguinal hernias or any type of hernia really is the simplest definition is a hole that allows things to go through it that shouldn't. So you get a weakness or a hole in your abdominal wall and that allows the contents inside of your abdominal cavity to push through. And that can lead to complications like bowel getting stuck in it or bowel even dying off if the blood supply gets cut off. So traditionally for those reasons, people that are having symptoms, we would repair them.

Scott Steele: So there's a lot of different definitions out there that might be thrown around. Direct, indirect, strangulated, incarcerated. What are all those terms mean?

David Krpata: Yeah, so when it comes to inguinal hernias, the direct and indirect is purely an anatomical definition based on the location in the groin. From an academic standpoint, it's important, but from a patient standpoint, you get the same repair. So it's not as important. When it comes to things like incarceration or strangulation. So first off, incarceration is when something goes into, namely a piece of bowel, goes into the hole and cannot be reduced out of it. Now when that happens, the bowel can potentially kink off either and caused an obstruction or if the blood supply kinks off, it can cause a ischemia or essentially you're not getting adequate blood supply to the bowel and it could die off. And that is a surgical emergency.

Scott Steele: So we talked a little bit about chronic groin pain, but a couple of things that's continued along the definition. So what makes chronic groin pain, and again, if a patient has prior hernia repair surgery, it may seem obvious, but most people I would imagine have some pain. So what makes it into chronic groin pain?

David Krpata: Yeah, so we definitely differentiate between acute pain after an operation and chronic pain. It is normal to have some level of pain after surgery, but traditionally it should go away. If you have pain that lasts for over three months, you fall into the category of chronic groin pain. So basically pain that persists for more than three months or comes on after three months from the operation.

Scott Steele: So what is this pain like? Is it in the incision? Is it in the testicles? Is it up the belly wall? What are we talking about here?

David Krpata: Yeah, so it's a great question because it can be actually a variety of all those. Traditionally what we would try and do is characterize the pain into two different categories. And the first is if people have more of a constant dull, aching type of pain, something that we'd call nociceptive type pain. And that can be foreign body relation from the mesh that's placed in there, which is what is most commonly performed. Or some people can get what we call neuropathic pain, where they get sharp burning, radiating types of pain in the groin, which can be related to a nerve injury. Additionally, there is a nerve that heads down towards the testicle. And so for some men after this operation, they can end up with testicular pain or what we call orchialgia.

Scott Steele: So we talked a little bit before that it's probably a little bit more of a common problem than people think. But can you wrap some numbers around that and also put it in relation to men versus women? Are there other risk factors for this?

David Krpata: Yeah. So there's a lot to unpack there. So, in terms of numbers, we talked about 15% of people after an inguinal hernia pair have pain that impacts their concentration on a daily basis. But it's really only about one to 3% that are seeking medical attention where it's that level of severity but about 10% of people will feel pain when they do physical activity. So it really impacts what is your quality life with that pain? And if it's bothersome to you, you should have it evaluated. In terms of risk factors, it is actually a higher risk factor for women. We see it more in men only because men tend to get more inguinal hernia repairs. But for a younger age, if you have a postoperative complication after your inguinal hernia, you're more likely to develop chronic groin pain as well.

Scott Steele: We spoke a little bit about mesh versus just normal tissue repair. Is that worrisome or is it just kind of something that comes along with the surgery?

David Krpata: Yeah, so one of the reasons why we use mesh is because we know that it significantly reduces the chances of the hernia coming back and there's been several studies that have looked at this and we've seen the rates of chronic groin pain are different based on the approaches and that can be with mesh, without mesh. That can also be between minimally invasive approaches or open repairs. So you can still get chronic groin pain with a non-mesh repair, but you can also get it with a mesh repair and there are some meshes that may have higher rates, like if there's a mesh that has more bolt to it, what we would call a plug repair is more commonly associated with chronic groin pain.

Scott Steele: Can we wrap our minds around yet what really causes the pain? Is this a nerve that's getting trapped? Is it a body's response to a mesh? What is it that's actually causing the pain itself?

David Krpata: Yeah, that can be very difficult to determine because some of it can be mechanical, if people are feeling the mesh, some of it can be scar formation, which normally occurs after an operation and some of it can be directly related to the nerves and if they're injured during the operation or if they're getting scarred on top of. So as I mentioned earlier, we try to put people into these categories of nociceptive neuropathic meaning do they have more of a mechanical feeling, constant dull, aching pain, or is it sharp burning radiating. But a lot of times there's crossover. And before an operation and even after an operation, if we were to remove a mesh, it's still hard to determine what the exact cause is.

Scott Steele: So I remember back when I was a resident and reading a lot more about the hernia repairs, and some people would advocate dividing one of the nerves that run in that area for inguinal hernia. Is that a commonly done and does that have any impact on whether or not a patient gets chronic groin pain?

David Krpata: Yeah, so that nerve is the ilioinguinal nerve and some people do what we call a prophylactic neurectomy and cut that nerve. But the studies have not shown any benefit to doing that. And so what we really try and do is practice what we call pragmatic neurectomy. And what that means is if the nerve really appears to be involved in the repair, if it's come out of its and its fascial layers and it's had to be mobilized during an operation or moved during an operation, then we will typically take it because those patients can have a higher risk of chronic going pain.

Scott Steele: Okay. So now let's walk us through a patient's journey. How do they wind up in your clinic and who are they meeting with? What can they expect as they kind of go through this process?

David Krpata: So we've developed something a little bit unique here, not many centers have a multidisciplinary chronic groin pain center. So what happens is when somebody comes in, they're going to see three different providers and that's going to include not only a surgeon but they're going to see a pain psychologist, and they're also going to get imaging with one of our radiologists, what we call a dynamic ultrasound. And part of that is also for the convenience of the patient so that they can get everything done in one visit. But these patients can be quite complex in decision making and we need as much information as possible. So we've put this clinic together here at the Cleveland Clinic so that people can benefit from that.

Scott Steele: So wait a minute, you're saying that I meet with a psychiatrist? So are you saying this is all in my head?

David Krpata: I'm certainly not saying that, but I will say that pain in itself has is multifactorial and it can be treated on multiple levels with medication as well as with surgery. But one thing that we find is that patients benefit the most when you do all of those things. And so if we can have somebody managing some of their pain medications as well as getting an intervention like surgery, they tend to perform better.

Scott Steele: Okay. So let's dig a little deeper into the details. What are the treatment options for patients with chronic groin pain? How do you go about this and make a determination of who gets medication, who goes back to surgery and if they do have to go back to surgery, walk us through that part of it.

David Krpata: Yeah, so certainly we're not trying to just perform surgery on everyone because there are consequences to that. If you remove the mesh, they can have a hernia back, so we see if we can get them through with things like physical therapy, which can be initiated right away. We start medications that can be neuropathic medications, the things that you would traditionally hear for diabetic nerve pains. If those don't work, there are higher levels that we can go to, like antidepressant medications can be beneficial for pain.

We also do interventions like injections of the nerves to see if people get some sort of response with that. It may improve their pain, but it can also be diagnostic and let us know if that nerve is involved with the pain. If all that fails and they need an operation, then we consider two things. Does the mesh need to come out, or if we cut some of those nerves or what we call an erectomy, can people get a benefit of that? Oftentimes that's patient specific depending on what operation they've had before, as well as what we've learned from their previous interventions, like the injections and the response to some of those medications.

Scott Steele: So what is next for the center for groin pain? Do you see this growing? Is there research that's being done that can help improve patient outcomes either after hernia surgery or just for chronic groin pain in general?

David Krpata: Yeah, I think that's one of the really important things is that we're a center that's dedicated to trying to find answers for this because right now in the literature we do not have a great knowledge of what the best way is to treat all these individuals. So we're dedicated to collecting information, doing research, and really trying to find the answers of best management for individuals with chronic groin pain over the next years to come.

Scott Steele: So what's a final take home message for our listeners regarding chronic groin pain? And I guess the question that may jump out to others is: is it worth undergoing surgery up front?

David Krpata: Yeah, so I think I'll take that second part first. So in terms of individuals deciding whether or not to get a hernia repair, the biggest thing I tell people is if you have a large hernia and it's bothering you, you should get it fixed, because there are risks associated with that. You don't want to end up with incarceration. If you have a small hernia and it doesn't bother you, you can't undergo something we call watchful waiting. But what we have learned is that if you observe those people over 10 years, it's about a 60 to 70% chance that they will eventually get an operation because it will become symptomatic. So if you are feeling like you want to have an operation for your inguinal hernia, I still think it's reasonable to do so.

Most important thing is to be aware of some of the complications after it, like chronic groin pain. And I think one of the biggest take home after all this for not only patients, but practitioners to acknowledge that chronic groin pain really does exist after inguinal hernia repairs. And the good news is we do have treatment options. So it's not like if you get an operation and get chronic groin pain, you're guaranteed to have it for the rest of your life.

Scott Steele: So this is the time when we'd like to get to have an opportunity to know you a little bit better with some of our quick hitters. So first off, what's your favorite sport?

David Krpata: Soccer.

Scott Steele: And what is your favorite meal?

David Krpata: Lasagna.

Scott Steele: And what's the last nonmedical book that you've read?

David Krpata: Never Split the Difference by Chris Voss.

Scott Steele: And finally name something that you like about being here in Cleveland, Ohio.

David Krpata: So I think the best thing about being in Cleveland is the diversity of opportunities in not only the sports, because we have all three major sports, but there's actually a lot of outdoor activities and there's a lot of opportunity for eating good meals around here. So I'm a big foodie and there's a lot of great food and Cleveland.

Scott Steele: Absolutely. So if you or someone you know has chronic groin pain resulting from hernia surgery and are interested in an evaluation, please call 216.445.9989. That's 216.445.9989, and for more information on Cleveland Clinic's Hernia Center and Chronic Groin Pain Center, please visit ClevelandClinic.org/hernia. That's ClevelandClinic.org/hernia.

Scott Steele: David, thanks for joining us on Butts and Guts.

David Krpata: Thanks for having me.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.