Any treatment option is prescribed and guided by the symptoms and signs experienced by the patient. The treatment will take time to work and in all cases any treatment is monitored for at least one year. The large majority of patients will have some effect if the treatment has worked in 3-6 months.There is unfortunately no guarantee of success for any treatment with most clinicians that manage this condition quoting a 70% success rate. In addition most patients may require at least two or more forms of treatment which will involve medication and another modality as described below.
Pain killers/ medication
The basic mainstay of initial treatment will involve the use of painkillers such as Non-steroidal inflammatory medication as well as possibly neuropathic medications, opioids, topical anaesthetics such as lignocaine patches, behavioral therapy and physical plus physiotherapy. The help of a chronic pain Consultant will be utilised as deemed appropriate. Common strong ‘nerve’ painkillers used include gabapentin and amitriptyline.
These are best described as non-surgical interventional treatment and include local nerve blocks, steroid injections, cryotherapy, alcohol or phenol injections, transcutaneous nerve stimulators and neurolysis. It will depend on the diagnosis and location of each patients respective CGP as to whether this treatment will be required or not. A specialised musculoskeletal radiologist under ultrasound guidance will carry out the large majority of injection treatment.
This is reserved for patients that are refractory to the above treatments only. In cases of clear mesh infection then the mesh will require surgical removal, so an operation is inevitable.
Other surgical options include; groin exploration, mesh removal and neurectomy (nerve division). After nerve division some patients can experience worsening of their pain due to a cross innervation of nerve fibres, but this can settle with time although it can take up to one year. Surgery is a last resort and in most cases may involve nerve division as well a mesh removal, which will lead to a permanent numbness in the groin, over the wound, outside of thigh and base of penis and top of the scrotum (labia majora in women). Some patients describe a ‘heavy’ feeling in the groin and thigh as well as a patch of loss of sensation down the front of the thigh. This is usually well tolerated especially if the CGP has improved. Surgery unfortunately gives no guarantee of success and is accompanied by medication to control any residual pain.
Division of nerves can be undertaken by both open or keyhole surgery. In some circumstances, the genitofemoral nerve is also divided. This technique is reserved for the very difficult cases where the other three nerves have already been divided. Your clinician will discuss with you if this treatment is considered an option as well as the risks associated with such surgery.