202. Hernia & Sexual Dysfunction

This week, the topic of discussion was: 

• Inguinal hernia
• Groin pain
• Testicular pain
• Sexual dysfunction
• Pelvic floor spasm
• Pudendal neuralgia
• Penile pain
• Painful orgasm
• Infertility
• Painful ejaculation
• Clitoral pain
• Vulvovaginal pain
• Female urology
• Physical therapy 
• Urology
• Gynecology 

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh, call +1-310-358-5020 or email info@beverlyhillsherniacenter.com.

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Transcript

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Dr. Towfigh (00:10):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m coming to you live as a Zoom as well as a Facebook Live this time from my Beverly Hills Hernia Center page. As many of you know, I am Dr. Shirin Towfigh, I am your hernia and laparoscopic surgery specialist. Thanks for joining me and for those of you that also follow me on social media, you know that you can follow me on Instagram and at Hernia doc and on Facebook at Dr. Towfigh and my YouTube channel is pretty busy. So we’ve got great videos for you, over 200 episodes of prior hernia talk lives. This I believe is episode 202, and I’m really excited about it. So let’s get this started. Okay, everyone. So the reason why today’s topic is interesting is as you know, I often try to incorporate what I learn or what I experience or the patients that come to see me into our hernia talk live.

(01:15):
And often the situation is such that things happen in twos or threes and then I’m like, okay, we need to talk about it on hernia talk live. So this is something that happened in threes and I’m very excited about it. So for three days, not last week, but the week before, I had the pleasure of hanging out with my friends that were sexual medicine specialists. Now, why would a general surgeon be interested in that? Well, as you know, I do more than just general surgery as part of my hernia surgery practice. I have learned a lot from my friends in urology, female urology, male sexual health, but in addition to other things like orthopedic surgery, physical therapy, pain management, physiatry, gynecology, et cetera. So this weekend I hung out with gynecologists, urologists, pelvic floor specialists, physical therapists, male and female sexual health specialists, and it was so unique. First of all, I was the only general surgeon there. As you would expect, it’s not really something that general surgeons seek to learn or know about much, et cetera. Because of my specialty, I actually have a special interest in it.

(02:40):
So the more I learned, the better it is. For three days in a row, I either went to an open house, a fundraiser, a seminar, or I met with one of my dear dear friends who’s a great specialist to catch up with her. And it was truly unique. The reason for it is my personal purpose was to go and interact with many of the same therapists, physical therapists, urologists that refer me patients, but also to meet with their friends because they don’t really know necessarily how a general surgeon can help their patient. So for example, I’ll give you an example. So in the past two weeks I’ve treated two patients, both male who were sent to me by urologists, and I’ve interviewed many of these urologists and they were kind of at a loss because they’re young males and they had testicular pain of unknown etiology.

(03:48):
And the testicular pain affected their erectile function, but also was like penile pain too. So usually people, if they’re smart enough, will consider inal hernia as a cause of testicular pain, but not usually a penile pain. But we figured out how the two can be related because technically the nerves to the pannus and the nerves to the testicles are completely different, different nerves, different levels, different anatomy, they come in in a different way, et cetera. So usually as a hernia surgeon, I will not see a patient with penile symptoms, and if they do, I send ’em to urology because that’s usually not a general surgery problem. However, there’s one caveat. Those of you that follow me know that am I not live on Beverly Hills Center? Yeah, those that follow me know that hernias can cause pelvic floor spasm. And women, we know that pelvic floor spasm can cause sexual function problems, including pain with sexual intercourse in addition to all the urologic problems such as urinary frequency and pain with urination, as well as rectal pain, and sometimes predental neurologist symptoms, which gives you clitoral pain.

(05:22):
But many of you already know the clitoris and the pannus are biologically or embryologically the same. And therefore what can happen is you can have a patient who is a male and presents with penile pain, which is due to pelvic floor spasm, usually penile tip pain, and then the pelvic floor spasm is due to the inguinal hernia and you fix the ral hernia and the pelvic floor spasm goes away and the penile tip pain goes away. I never knew about this. I had to learn this by meeting and talking with other doctors, especially every time I see a specialist, I just sit them down. I’m like, okay, give me more information, more information, because I have so many questions. And these are not things that are taught in class. These are not things that are part of the textbook. There’s no textbook that talks about this.

(06:21):
I would say even in our book stages, manual of groin pain, which is the bible of groin pain manuals of which I’m an editor, co-editor, we don’t really talk specifically about this. We do talk about pelvic floor spasm. So I’m really excited by this opportunity to learn and so on. So like I said, two patients were sent to me, both male, both young, both with three to eight years of testicular pain and or penile pain. No one can figure out what it was. They were told that they should have the orchiectomy, which means their testicle would be cut off. One was told he needs to just live with this. They were not functional. I mean it was just a horrible situation they sent to me. They definitely had hernias and they had actually good size hernias. These were not small hernias, but small hernias can cause this syndrome of problems.

(07:23):
And this week I was able to get updates from both of them. They’re both cured, super excited, fix their hernias. All these male sexual function symptoms go away. The same is true for female sexual function. So you’ve probably heard me talk about patients that are female that have pain with intercourse or clitoral pain or something called PGAD, which is persistent, sorry, PGAD, persistent genital arousal disorder, PGAD. These are also syndromes, which can be brought on by pelvic floor spasm in the pelvic floor. Spasm is due to called inguinal hernia. You fix the hernia, the pelvic floor spasm gets better and then they have resolution of their symptoms. So at least one patient that I’ve treated with PGAD has gotten better. She’s not cured yet, but she’s gotten better. So I go to this meeting, this was two weeks ago, Friday, Saturday, Sunday, four meetings total. So Friday one meeting, two meetings on Saturday and one meeting on Sunday.

(08:37):
And we talk about PGAD caused potentially by inguinal hernias. Penile tip pain caused potentially hernias, pudendal neuralgia and so on. So that was really, really great. And then on Sunday I got to learn myself about all the other female issues down there, right? So that’s vulva vaginal pain. There’s a fundraiser I went to by this patient, this patient advocacy group called tightlipped.org. If you want to donate money or learn more of them is tightlipped org. So it’s tightlipped kind of like talking about vulva pain and that pain is very difficult to treat because no one knows what the trigger is. Is this psychological? Is this neurological? Is this muscular and less often vulvar vaginal pain, less often it’s a hernia, but I was there to kind of see, because there are patients that maybe will come to me thinking maybe this is all pelvic floor related.

(09:55):
And it turns out it’s actually something that a gynecologist needs to treat. There are things like clitoral adhesions, there’s things like vestibular dinia, vulvodynia, lichen planus, genital urinary syndrome of menopause, all of these things that are often treated hormonally, sometimes surgically, sometimes with therapies. So I learned a lot and I thought we would spend this hour to have me kind of share from a hernia surgeon standpoint how all of these things matter and why it’s important as a hernia surgeon, not to just say, I just fix hernias. Because at some point you have to diagnose the hernia and when you diagnose the hernia, that’s the most difficult part. Most people who think about hernias like, oh, hernia, that’s easy. Let’s bulge. Yeah. In fact, one of my patients today said their medical doctor didn’t even examine them. They looked at the groin like, oh yeah, hernia done, send him to a surgeon.

(11:10):
Well, that’s your typical hernia. However, it doesn’t mean that you need a hernia surgeon for that problem. I was sent a patient, I was a third surgeon to see the patient. This was last week. So last week I saw a lovely gentleman, he came to see me because he did his own research and he had seen one surgeon for his groin pain and hernia bulge and he’s like, yeah, let’s do surgery. I can fit you in next week. He’s like, oh, that seems like a little bit too fast for me. He went and saw another surgeon who said, yeah, you have a hernia, we can schedule you or we cannot.

(12:02):
Leaving it up to the patient, leaving it up to the patient. And then I saw the patient, I actually examined him and importantly I asked him very specific questions and except for the fact that he had an actual hernia, nothing else sounded like the hernia was a problem. For example, lying flat didn’t make it better. Going up hills made it worse. Sorry guys, it’s very dry weather lately in LA he had upper buttock pain. Crossing his legs was painful, walking was the worst. In fact, he walked in with a limp. My office is so smart, they know if a patient is limping in the office, it’s not a hernia nine, nine out of a hundred times, that’s kind of an issue that many doctors don’t understand. They see you in the office, you’re sitting down, they don’t really know what your gait is. They don’t ask you about your gait and therefore it’s not even considered. Maybe he’s got an orthopedic problem and that’s why the gait is affected. Usually hernias do not affect gait. It’s very uncommon for an inguinal hernia to cause gait problems.

(13:32):
E femoral hernia can infrequently an opterator for hernia can, but a true anal hernia, which is the most common hernia, should not cause gait problems. So that’s kind of the situation that he had. So he walked in with a limp. The pain was not better when he laid flat, he had symptoms that to me sound like it was the hip. Yes, he had a hernia, but that doesn’t mean I have to fix it as not all hernias need to be fixed. So I’m like, listen, I’m a hernia surgeon. I fix hernias, but I fix hernias to help people. I’m not a plumber where I’m not a technician where half hernia will get fixed. You have to have the right treatment for the correct diagnosis for your problem. So when his thing is like, yeah, I am limping and sitting is really painful and I can’t lie on the side, and when I lie in bed, excuse me, when I lie in bed, I’m no better.

(14:49):
And in fact, when I lie in bed, I need to prop up my knee. That’s another good one. If you lie in bed, you need to prop up your knee to help with the pain. That’s a hip problem usually. So he just emailed me so thankful I sent him to two different hip specialists. He saw them both. They both agreed he has a hip disorder and he needs some injections, maybe surgery, maybe not. It sounds like he has bursitis actually. Oh, you got some questions here. What about post inal hernia, apathy, pain? Can that affect gait also? Usually not. So there are people that have chronic post inguinal hernia repair pain and the reason for the pain is nerve injury. The mesh is balled up, the is recurred or some combination of all those. Usually that doesn’t affect how you walk. Now in some patients, if they put weight on that side after a hernia repair, if it’s a big mesa that’s sitting on their SOAs muscle like a mesh plug sitting on the SOAs muscle, that could be painful and going up and down stairs in hills can be painful, but that’s not the majority of patients.

(16:25):
And so if you just have anything else related to her phy pain, usually your gait is not affected by it. It can be, but it’s usually not.

(16:39):
It would be the exception, not the rule. Whereas with a hip disorder, it’s closer to the rule that your gait is affected by it. So I hope that clears things up. So once again, another situation where the diagnosis is so important, just because you have a her does not mean it needs to get fixed. Where were we? Okay, sexual dysfunctions. So what I’m hoping to do is bring some of the specialists that I saw and met at these four different meetings over the weekend to future hernia talk lives and if you have an interest to learn more about vulvovaginal pain or male erectile dysfunction and how it can be related to hernia is hormonal disorders in both men and women, the lack of testosterone in men and how testosterone can help them or issues related to female hormones, whether it’s testosterone, progesterone, or estrogen and how perimenopausal or just a lack of testosterone can affect your health.

(17:55):
I can bring those specialists in because I met some really amazing ones. One of my friends flew in from DC actually she was one of our guests, Dr. Rachel Rubin, and so we’re going to be working more closely with her, but we had other surgeons, some around here in Los Angeles and others who flew in or drove up that did a really, really good job of sharing their stories and their patient stories and then educating everyone. And lastly, I just want to give a big shout out to the physical therapist because physical therapy, physical therapists do a really, really good job of figuring out why people have certain pain triggers and a large proportion of my patients are sent by their physical therapist because the physical therapist knows a lot about how all the muscles and nerves and bones interact and they do a really good physical exam. I’m sorry to say, a lot of doctors just don’t do good physical exams and it’s a bit worrisome to me, but it’s also a reality which has made it so that we have situations where literally that patient that I saw their doctor just from afar said, oh yeah, hernia and walked away and this patient, maybe they had a hernia but the hernia was not their problem. Right. That’s what I’m trying to get. Okay, so let’s see. We got some questions here.

(19:44):
Okay, so here’s some more. What is the incidence of pain after elective hernia repair and to what extent can the latter determine sexual dysfunction? That’s a good question. I do see men who are referred to me and one of their concerns is they have erectile dysfunction and actually I read much more about online on Reddit or some of the Facebook groups. A lot of people say I have erectile dysfunction. Some of them are before surgery, so they have erectile dysfunction, they believe their hernia, it’s causing their erectile dysfunction and they’re worried that that’s not going to go away or they’re worried a hernia repair would affect their sexual function. It’s one of the more common questions I ask. I get asked from males, which is, so you’re going to fix my hernia, but is this going to affect my sexual function? And the answer is, it should not.

(20:47):
Men who have erectile dysfunction and a hernia can have improvement in their sexual function if the reason for their erectile dysfunction is groin pain. So if you have hernia related pain, then the kind of psychological issue is that your body does not want to have an erection or orgasm because it’s painful because your hernia is painful functionally you’re fine. It’s just the pain issue prevents you from functioning normally. So you fix the hernia and then the erectile dysfunction should come back. However, there are men that have erectile dysfunction regardless of whether they have a hernia or not. And so I can’t promise I’m going to cure everyone’s ed erectile dysfunction by fixing their hernia. That would be nice, but there’s obviously a lot of reasons why you can have dysfunction. That’s why there are urologists, and specifically within urology, there are sexual function experts within urology that can help determine is it a blood flow issue, is it a nerve issue, is it a functional issue, is it a hormonal issue that was very common or can it be a hernia?

(22:11):
So that’s one issue. The second issue I’ve always asked is about fertility. So I people who get hernia repaired, it may affect their sperm count in their ejaculate. Let me explain to you. So your testicle stores sperm. There’s a tube called the vas deferens that carries the sperm up to the prostate and it gets some prostate juices with it and then it comes, you pee it out, right? That’s your ejaculate. So the testicle part is not usually affected unless the blood flow to your testicle is affected. If your blood flow to your testicle is affected by your hernia surgery, not the hernia but the hernia surgery, then you can have a shrunken testicle and therefore not enough sperm in that testicle. If your other testicle is perfectly fine, you can still be very fertile and naturally have a child.

(23:20):
So that’s one option, which is that the hernia surgery affects, disrupted the blood flow to your testicle and therefore your testicle shrink. That’s usually because you’ve had multiple surgeries, so you had laparoscopic surgery, open surgery, another open surgery, let’s say another laparoscopic surgery. Every time you have surgery, the blood flow to your testicle gets potentially disrupted until you eventually don’t get enough blood flow to the testicle and then your testicle shrinks and becomes very soft. The good news is you have two of them, so if one is disrupted, the other one still has enough sperm and therefore testosterone to take over, and you may notice that if one testicle is the other one may get larger to make up for the difference.

(24:10):
That’s one issue. The other issue is actual obstruction. So the tube, the vast deference that carries a sperm to the prostate may be injured from your hernia surgery. That could be due to the mesh or due to an accidental cutting or it’s kinked or whatever the situation is as a result of the surgery. Again, more common with multiple operations than with one operation. Also more common with mesh than non mesh. The same is true of the blood flow issues more common with mesh than non mesh. If you have a kink in the tubing or a narrowing or a cutting of the tubing, then the sperm within the testicle will not make its way to the prostate and out and therefore again, fertility issues and that you can’t naturally have child if both sides are affected. Usually it’s a single side. So in people that already have fertility issues, it’s a good idea to have this discussion with your surgeon about whether the surgery that you’re having for your hernia would affect it.

(25:18):
Most people who have hernias for surgery are not infertile. Most people who have laparoscopic open mesh or non mesh repairs will not have fertility issues. It’s usually when there’s complications that then there’s a problem. Here’s another question as you are aware, I had my mesh removed in 2019 since the removal. I have an intimate a couple of times, but always have increased groin pain, which makes me fearful of intimacy. Is this classified as sexual incontinence? Is this also a diagnosable medical condition? Yes, it is a diagnosable medical condition in that the chronic pain is preventing you from performing sexually. So the recommendation is to address the pain, and then once the pain is addressed, then your erectile function will improve. It’s very hard to overcome chronic groin pain and still be sexually functional at your optimal level. So yes, I’m not sure it’s called sexual incontinence.

(26:19):
I haven’t heard of that term. I mostly understand sexual dysfunction or erectile dysfunction. I’ve never heard the word incontinence about sex. I don’t know what that means, but yes, so there’s scar tissue in the area. If you’ve had mesh removed, there’s potentially still pain from scarring. I don’t recall how your groin area was addressed after the mesh removal, but any of that can affect your ability to perform. Now the good news is it’s unlikely that you have any permanent damage. So once the groin pain is improved, and you have to figure out why do you have the groin pain? Is it from scar tissue? Is it nerve damage? Is it recurrent hernia? Is it too tight? Are you trying to tear all of these things? Next question, if a hernia is pressing on the vast deference, could that affect the amount of sperm that comes out during ejaculation or something called incomplete ejaculation?

(27:28):
Yes, yes, yes, yes. Not the hernia though. So a hernia is a soft tissue phenomenon. So the soft tissue phenomenon is such that it may nudge the vast deference, but mesh can erode into or cut into the vast deference and be obstructive. So certain types of operations can make the vast effort zigzag instead of being a straight shot, and you can have kinking of the tubing or direct injury to the tubing, which makes a scar, and then on the inside it’s obstructed. So those can all happen, but just a pure hernia with no other problem, like no hernia surgery, no mesh should not cause any obstruction of the vast deference. What can occur is obstruction of the vast deference at the prostate. Some people have prostate stones like prostate lifts or stones, and some people can have prostate cysts that then kind of obstruct flow and that could be sometimes painful.

(28:52):
Okay, I’m glad you guys are sending me some questions because this is really helpful to discuss. Next question. Are pelvic floor spasms caused by hernia treatment complications central in determining sexual dysfunction? Okay, are pelvic floor spasms caused by hernia treatment complications central in determining sexual dysfunctions? Yes. So much of the sexual dysfunction is there’s spasm of muscle and that muscle can be at the groin level or it can be at the pelvic floor level. And when you have spasm of the pelvic floor, let’s say a, and that’s painful, or if you have groin pain, that’s painful than having an orgasm which is severe pelvic floor spasm can be very painful and therefore people don’t want to get to that point where they’re having pelvic floor spasm and therefore they’re stopping it from happening and they end up not performing or not reaching orgasm and therefore ejaculation.

(30:09):
So that’s kind of the situation why there’s so much depression and sadness, even suicidal ideation is because injuries from a prior hernia surgery can have so many levels of pain and if it affects your sexual function as well, then it just becomes really horrible. There’s a lot of people that lose their loved ones and lose their relationships, whether it’s a divorce or they lose their girlfriend or boyfriend as a result of complications from hernia repairs, which is why I don’t like to push hernia repairs. It should be done ideally by a specialist. We know that’s not reality, but if you’re interested to reduce the risk of complications in a situation where you absolutely would benefit from a hernia surgery, then as much as possible, I urge you to get it done by a hernia specialist. I’ll give you an example. I saw a patient today, he mostly wanted talk to me because he just wasn’t sure that he’s getting all the right information from the other doctors in his part of town, not Los Angeles.

(31:25):
And the concern was that other doctors were trying to sell him surgery. So they were saying, oh, we have zero complications, we have zero recurrences and so on, and I’ve literally treated their patients like the surgeon that was claiming he has zero complications, zero hernia, recurrences, I’ve seen at least two of his patients. And so it’s disingenuous to claim 0%. I don’t claim 0%. None of US specialists can ever claim 0% of anything. That just implies they say if you have no complications, then you’re either lying or you’re not operating. So that’s the reality. Every surgery has a potential for a complication. There’s nothing that’s 0%. So one surgeon was selling him the surgery and then the other surgeon was kind of claiming that he’s the best and he’s not. He is a good surgeon, but I don’t think you can be the best in something if it’s 10, 15, 20, 30% of what you’re doing, you can be better if it was a hundred percent of what you’re doing or 80% of what you’re doing or 75% of what you’re doing, definitely more than 50% of what you’re doing.

(32:49):
So I truly believe in specialization as a way of improving outcomes. And then the other thing too are these surgeons that claim they’re excellent because they’ve done a lot of it. So I used to have this chairman that would, he was kind, I mean I don’t think you can say these things nowadays anymore, but he used to say things like, oh, someone would say, oh, I’ve been doing this operation for 30 years. He’s like, you’ve been doing it wrong for 30 years. Just because you’ve put in the time doesn’t mean you put in the effort and are doing it correctly there. Plenty of surgeons have been operating for 20, 30 years that are horrible surgeons. So the fact that you have the experience doesn’t necessarily mean that you’re good at it. There are definitely surgeons that was better than that were senior to me and I was just a resident, right?

(33:50):
So my point is just because your surgeon had, I dunno, 10,000 hernia repairs or whatever number they want to make up then doesn’t mean they’re better surgeon. We don’t really have a good way of vetting out the good and bad surgeons in a constructive way. I try and do my best, at least for hernias and surgeons that I think are good or talented or thoughtful or caring, I try and bring them on to the show and give my pseudo stamp of approval. That’s my way of contributing. So when people call the office and they say, do you know anyone in Texas? I’ll say Go to hernia talk and I have interviewed surgeons from Texas and those are surgeons that I stand by that I think are good surgeons, they’re thoughtful, they’re caring, we’ve shared patients, I can rely on them if I need some help for a patient in Texas and therefore you can consider them. So that’s kind of my thought about that. Next question. Let’s see what mesh complications are more prone to determining sexual dysfunction? Okay, so usually sexual dysfunction due to mesh related problems, that’s a very good question, are in the groin.

(35:19):
Usually they affect either blood flow or nerve issues or the vas deferens to the testicle in men or they cause severe pelvic floor spasm in women. So it’s either too tight of a repair in women or men or it’s too tight around the spermatic cord causing either obstruction of venous blood flow from the vein or obstruction of this spermatic cord or it’s impinging, right? It’s impinging into it so it’s too tight of a repair, too tight of a keyhole portion. Oftentimes too thick of a mesh can cause this heaviness and chronic pain which can contribute, but those are the main ones. Sensitive and pain to shave pubic area after inal mesh surgery in women is this normal surgery with 10 months ago. That is not normal. So this is very important point. This is a female who had in mesh surgery, so inal hernia repair with mesh.

(36:27):
I assume this was an open repair, which is why I’m not a fan of the open mesh based repair in most patients, especially women. So there are nerves in the area that can be injured by any open surgery and especially if there’s mesh involved and that includes the genital nerve and the ileal nerve. Some surgeons electively cut those nerves, so if you cut the nerves and you don’t know how you’re cutting it or why you’re cutting it or you don’t have the right technique to cut it, you can cause inflammation of the nerve or neuroma, which is chronic pain of the nerve and wherever that nerve was supposed to serve is where you’ll have pain. So the pubic area sensitivity can come from that in the mons, basically the hairline, if you were numb and you’re getting better, you can say maybe just the surgery itself is a and the incision was the problem.

(37:33):
However, in most women that’s not the situation. So what I would be very concerned with are surgeons that routinely cut the ileal inguinal nerve and or the genital nerve In women, we don’t like to have that nerve cut. That nerve gives sensation to the moms, which is an important part of sexual pleasure in women and therefore I do not recommend willy-nilly cutting of genital nerve or the ileal nerve in females. So if your surgery was 10 months ago and you have sensitivity and pain to shaving the pubic area after your hernia repair, it can be related to inflammation from the mesh on the nerve or actual cutting of the nerve or direct injury to the nerve as part of the surgery. What I do recommend initially is some type of topical therapies. There’s salon P has a lidocaine patch you can buy over the counter to help with that.

(38:33):
You can also try arnica cream or CBD cream over the area and then in addition, you may want to start doing local nerve injections to both the ileal angle and genital nerve branch to see if those can provide you with help. And if they do provide you help with help, then a couple of injections should help cure you if too heavy a mesh can cause groin pain. How do you balance excessive mesh weight with the need for the mesh to be strong enough to treat hernia and prevent recurrence? So all mesh products are strong enough? No, even the really thin meshes are strong, they’re much stronger than your own tissues, so don’t worry about strength. Stiffness does not imply strength and thickness does not imply strength. If anything, thickness can become so thick, it’s almost like armor or cardboard and can cause chronic pain and you can tear the tissue if it’s too thick, you can tear your own natural tissue that’s sewn to the very thick mesh. So there needs to be a balance between your own natural tissues and the mesh that’s placed that’s put in place.

(39:48):
How do you avoid having amans after surgery, especially with a tram or deep? How do you avoid having Aman? So amans is a natural part of your body. It’s kind of the fluffy area down in the groin. Let’s see, I have no feeling to my private area. What can I do if you have no feeling, it’s hard to bring feeling back if the nerve is either injured, cut, destroyed, et cetera. Most of the time when you have surgery you’re skin area where the cut was will have the nerves cut. Those are very superficial nerves. You can’t even see those nerves and in some people that numbness in the area will come back and others it’ll never come back and they’re permanently numb around the area of their scar. If you have what’s called painful numbness, that’s a nerve injury usually. So numbness is just a nerve that’s cut. Painful numbness is a different situation, which is usually a nerve injury and so a pain doctor or a hernia specialist should be able to help you with that.

(41:08):
The area of the mons in some women is puffy. It’s usually fat and in some I’m told in some cultures it’s a sign of beauty. So you have to understand how your moms looked before surgery and if you had a DIEP flap, let’s say, usually there’s a tummy tuck involved in it in some ways and there may be disparity between the way the amount of fat in your abdominal wall and the amount of fat in your mons because the mons usually is not touched and so some plastic surgeons do undermine the area and take out extra fat from the mons to make it look commensurate with the rest of your abdominal wall.

(41:59):
So it could be a fat issue. How common is testicle swelling with inal hernias? So good question. The question is, is it really a swelling of the actual testicle or is it the area with the testicle is swollen? So the testicle itself technically is not swollen, but the area of the scrotum that houses the testicle is swollen, so it’s not uncommon for the scrotum to be swollen with her inal hernias and that could be swelling due to hernia content, fluid collection, the hernia or backup of venous blood flow called the varie from the hernia. So all of those can occur together separately, et cetera. The testicle itself should not swell with inal hernias. That is usually not a normal finding and should be worked up as a primary testicular problem assuming the other was also normal. I had a S shouldice repair for inguinal hernias about one year ago.

(43:15):
When the inguinal region and pubic bone areas are pressed, I feel pain, what can be causing the pain? Okay, so shouldice hernia repair is four layers of tissue to close up a hole and the tightest area where this closure occurs is where you are explaining which is the ular region and pubic bone area. If that area is tender to touch, then either you have very tight tissue repair over the area and so it’s trying to tear apart or you already tore it apart and you have a hernia recurrence imaging either dynamic hernia ultrasound or an MRI with Val Salva can help differentiate the two. Also other symptoms can help differentiate the two. You can get local anesthetic to the area if it’s just painful because it’s trying to tear or if a couple of two of the patients I saw today, it may be a tearing of the tissues, which is more of a muscle strain and not the full thickness tear, which is a hernia recurrence and sometimes PRP, which is a blood plasma tissue injection, they basically take your own blood, they spin it down and all the great proteins, the plasma rich area is re-injected into your area of the muscle strain and it helps really concentrate goodness down there to get your pain out of control to help with the healing there.

(45:05):
Great questions you guys. Going back to the question about mesh and mesh weight, do you make a decision about what mesh to use on the table when you evaluate patient’s tissues often? No, but I’m a planner so I usually determine what mesh I want before surgery, but I do sometimes change what my decision based on what I see during surgery. Would you use a lighter mesh in an operation for post inal hernia repair pain or does that not affect your decision? I’m concerned about the use of mesh least likely be another source of pain since I already have pain probably from multiple causes that you talked about today. Okay, very good. So the question is how do you determine which weight, like thick, thin, lightweight, heavyweight mesh do you use and then does does the risk of chronic pain based on that decision factor in tear decision?

(46:12):
So we used to think it kind of makes sense that the lighter weight the mesh, the less foreign body sensation and the less chronic pain and we have some really good studies that show actually it’s the reverse or it’s nothing. Either it doesn’t matter or there’s more chronic pain with the lighter weight tissues, lightweight matches. It’s kind of counterintuitive. My interpretation is you can’t just say use lightweight on everyone or use heavyweight on everyone. So if you’re a thin patient or the hernia is small, lightweight mesh, if you’re a heavy patient or the hernia is large heavyweight mesh, that will help balance the pathology with the mesh placement and therefore reduce your risk of chronic pain because if you use a small mesh in a big person or a big hernia, you’re going to tear and you’re going to get chronic pain. If you use a thick mesh in a thin patient or a small hernia, it’s going to feel like armor and that’s where you get chronic pain.

(47:17):
So it’s not like one size fits all, that’s number one. Second is the goal of using mesh is twofold. One is to reduce the risk of recurrence and the second is to give the most stable hernia repair to therefore reduce chronic pain. So it may be that a heavier weight mesh is appropriate in a really big hernia or one that’s kind recurred multiple times and by using a lighter weight measure, you’re actually implying a more unstable repair and therefore higher chronic pain. So the choice of mesh is by me at least is often made before surgery because I see you, I look at the imaging, I look at the quality of the muscles that I’m dealing with, I look at the size of the hernia I’m dealing with, I look at your body habitus and then I also know something about you like you’re a skier or you like to surf or you sit at home and like to binge on Netflix, whatever the situation is. I kind of factor your lifestyle into that as well. Is it possible that stainless steel suture is pinching the nerve?

(48:40):
Yes. If you had a shouldice repair at the shouldice clinic and they use steel, then what we do see is sometimes the steel breaks and so now you have the poking of the sharp edges of the steel poking into your muscle or maybe even nearby nerve and causing pain. So yes, that can occur, but imaging, whether it’s a CAT scan or an x-ray, can easily determine if you have breakage of your shoulder steel suture. Why is bloating an ular hernia symptom? Do people do it to relieve the pressure? Okay, so good question. Bloating we have learned over time is a common symptom of any pelvic pain. So often it’s from a groin or any abdominal or pelvic pain. So if umbilical hernia or you have a groin hernia, your pain is manifest in different ways. One of them can be bloating, so you fix the hernia and then the bloating goes away. So it’s not that you have intestines stuck in the hernia causing gas trapping and bloating. It’s more a, because I’ve had patients with this much et bt little piece of fat in their hernia and that causes significant bloating, you fix the hernia, the bloating goes away. So it’s really the bloating is really a pain response.

(50:21):
How does the nerve management strategy during hernia repair affect the risk of postoperative sexual dysfunction? It shouldn’t. None of the nerves in the area. That’s a good question. None of the nerves in the area of hernia repair are directly related to sexual function. So those nerves for sexual function are sacral nerves. I can’t hurt them or injure them even if I tried. It’s just not there. It’s not in the area. And so that’s why I’m saying it’s not a direct problem, it’s an indirect problem. So sexual dysfunction is often related to pelvic floor spasm or pain and not a direct injury to the nerve. But a lot of people ask me that question. Like I said, a lot of the men say, how can I have, how is this going to affect my ability to have sex? I’m like, it shouldn’t affect the surgery I do should not affect your sexual function. But that’s a very good question. What hernia related procedures and complications, if any, are high risk for gen femoral neuralgia and how does the ladder affect the insurgents of sexual dysfunctions? Again, gentle femoral neuralgia not related to sex function.

(51:50):
Mostly it’s a sensory nerves which causes sensation to the mons or base of pannus and in some cases also it helps with the cremaster muscle, but none of those are truly sexual functions, which hernia related procedures and complications are high risk for general femoral neuralgia. That’s actually a board’s question for graduating general surgery residents and they should know the answer to that. The answer to that is laparoscopic repair or robotic repair with mesh. I would say especially if the surgeon puts the mesh too low, which is why I always promote excellent femoral coverage without too much lateral coverage. So what I do is I take an extra large mesh and I cut it to decrease how much overlap there is of mesh with the genital nerve and the lateral femoral cutaneous nerve, but then have maximum overlap over the femoral space.

(52:53):
If people feel moderate groin pain one year after inguinal hernia surgery, moderate, that’s too much at one ear, shall he have sex or wait until the pain is gone, which may never happen. Will having sex damage, shouldice repair? No, it will not damage. It will shouting loudly and angrily for 10 minutes damage, a shouldice repair. I mean it’s probably, I don’t know if it’s a healthy or not healthy to shout loudly and angrily also, who are you shouting to? That’s maybe the important question. I would say all of that activity should be safe to perform after any type of hernia repair, including a shouldice repair, especially when you’re out. So I had a grandma once, so this is so cute. So she had a laparoscopic repair, but it was an unstable repair. Like I mentioned earlier, she was kind of a big lady.

(53:52):
She was a little manly. I’ll tell you this. She was a little manly. She was huge. She was like six two, probably 260 pounds or 250 60 pounds and she was like a big grandma and she had a hernia. So someone did her laparoscopic repair. I don’t recall the story in detail and she had a laparoscopic repair, but they used a lightweight meash because I think they wanted to do the right thing. They thought they were doing the right thing. So they used lightweight match. This is where that unstable hernia repair story comes into play. So her story was every time she goes to her grandson’s soccer game where she was yelling out loud and interacting and shouting and cheering her son and yelling at the other players or the umpire or the coach or whoever she was yelling at, it caused her groin pain. So what was happening is she was pushing, that generates a lot of abdominal pressure.

(54:55):
She was pushing on the hernia and the hernia repair was unstable because the hernia was just bridged with this thin mesh. So instead of using a heavier weight mesh with some structure to kind of be able to bridge this hole, she got a thin mesh so the mesh would fall or below into the defect. And in doing so we recreated her hernia pain. I mean technically there’s no hernia because the mesh is there, but she was herniating the mesh through the hole. So I explained that to her. I said, listen, your repair is just a little unstable. You need better support of your mesh so that every time you’re generating abdominal pressures, such as at your grandson’s soccer games that you don’t have the mesh fall into. So she needed an open surgery to actually close off this muscle so that there was more support of the laparoscopic mesh.

(56:07):
So the mesh is not just bridging a gap, it’s actually supported by muscle and then that cured her pain. So I see a patient or two like that almost every year where they have a perfectly good repair on imaging, but if you listen to their story every time they generate pressure, they have hernia type pain and that’s because it’s an unstable repair. That’s where the story comes about with lightweight versus it’s heavyweight mesh and bridging a hole versus closing a hole and so on. And the same is true of sexual function. So if you have with sexual function, there can be a lot of abdominal pressure generation, whether it’s due to orgasm or the act of intercourse and that can cause groin pain and then it gets it to a point where you don’t want to continue with a sexual function because it’s too painful and therefore your label is having erectile dysfunction or sexual incontinence as was one of the terms that was used earlier today. And yet if you just fix the hernia or address the unstable hernia repair by providing a more stable repair, then all of that should kind of fall into place. Hope that makes sense.

(57:31):
Okay, that was quite an hour. I can’t believe an hour went by so quickly you guys. So many questions. I really enjoyed it. Oh, there’s one more. Should we do one more? Please go back to the mesh question one more time. If you have to use a heavier weight mesh based on signs of hernia in a thin patient with a slight body habit is how can you remediate the potential for heavier weight mesh to cause a muscles and tissues from tearing or the potential strain on these muscles? Oh, well that’s a good answer. Well, you try not to bridge so you don’t need that much mesh. So you try not to bridge the hole. You try and close the hole, for example, to give a more stable repair. Then you can use a lighter weight mesh as an example. Could the same be said about a hernia if I’ve lost depth and volume in my voice because I feel like something is digging in my angle canal when I do? Yes, yes, yes, yes. So singers, some of them can’t get to either expression of their volume of voice or they can’t get certain tones because of their hernia, fixed, their hernia and all that can go back to normal.

(58:47):
My groin pain got worse after I child loudly and angrily for 10 minutes. Well first of all, maybe that teaches you you shouldn’t be shouting loudly and angrily for 10 minutes. But jokes aside, you may have a hernia recurrence. So that’s possible. You either tore and it’s causing pain in which PRP may help or you have a hernia recurrence, in which case you need another hernia repair. So that’s it for me. I’ve got to go. This has been great. I really appreciate all of you with your time and effort with and enjoying the one hour with me. This was great. A lot of really good questions and I hope we do more of these with some experts once I get them scheduled. I look forward to next week with you all. Hope to see you all. Take care. Bye.