By: Elizabeth Akincilar
Explaining to someone who has never heard of pelvic floor physical therapy what type of physical therapy I practice is always an interesting conversation. People usually assume certain things about my practice. Most assume I primarily treat older women with “bladder issues” and new moms. People are always surprised to find out that almost 50% of the population I treat are men! Newsflash folks! Men also have a pelvic floor! Therefore, they can, and do, also suffer with pelvic floor disorders.
There are many reasons why men develop pelvic pain, but I’m going to focus on one particular cause for this post. Hernias. In particular, inguinal hernias. What are they? Why do they happen? How can they cause pelvic pain? How are they treated? How can physical therapy help?
An inguinal hernia is when tissue protrudes through a weak spot in the abdominal muscles. This bulge can be painful, particularly with coughing, bending over, or lifting something heavy. Typical symptoms are pain and/or pressure in the groin (inguinal canal), pain around the pubic bone, base of the penis, and/or testicles and occasionally pain upon ejaculation. A hernia is usually not dangerous, but can be if it becomes strangulated; therefore, it should always be evaluated by a physician. A few years ago Dr. Towfigh, a hernia specialist in Los Angeles, wrote an excellent blog post for PHRC on how she diagnoses a hernia. Check out her post for a quick review.
Hernias can occur without a cause. However, most are caused by an increase in abdominal pressure such as during straining with urination or bowel movements, chronic coughing or sneezing, pregnancy, and strenuous activity. Some people have a pre-existing weakness in their abdominal wall which makes them more susceptible to developing a hernia.
We mostly see men with hernias because men are eight times more likely to develop an inguinal hernia than women are. Sorry guys! Other risk factors include being caucasian, chronic coughing, chronic constipation, a family history of inguinal hernias, and just being older because muscles weaken as we age. So, if you’re an older white dude that is chronically constipated and smokes, an inguinal hernia is likely in your future.
If the hernia is small and not causing discomfort, treatment may not be necessary. Watchful waiting may be sufficient. However, if it is causing significant discomfort, a surgical repair is typically indicated.
I’m sure you’re wondering where physical therapy fits into this scenario since I just told you surgery is the most appropriate treatment for inguinal hernias. It turns out that approximately 25% of people that undergo hernia repairs experience chronic (lasting longer than three months) groin pain after surgery, with 10% of those people reporting moderate or severe pain.1 It is this group of patients, typically men, that look to physical therapists for conservative treatment to help them decrease their pain.
Persistent pain after a hernia repair can have several causes. There are two primary surgical techniques to repair inguinal hernias: laparoscopic and open. Both surgical methods can potentially injure nerves, specifically, the ilioinguinal, genitofemoral, and iliohypogastric nerves. All three of these nerves travel close together, in part, along the inguinal canal. To make things more complicated, anatomic variation is fairly common with these nerves. Meaning, in some people, the nerves aren’t exactly where they are expected to be. Therefore, during surgery, one, or more, of these nerves may be more susceptible to injury. Additionally, the vast majority of hernia repairs utilize mesh to close the hernia. The mesh itself can be a source of persistent pain. The surgical tacks used to affix the mesh to the pubic tubercle can also cause pain. Lastly, the surgical scars themselves can cause pain.
Physical therapists utilize soft tissue mobilization techniques to decrease persistent pain after many surgical procedures, including hernia repairs. With manual therapy, we can improve the mobility of the surgical scar and the surrounding muscle and fascia. Mobilizing the scar will decrease pain coming from the scar itself. As scar tissue forms around the mesh, the mesh becomes very stuck to the surrounding fascia and muscle. As a person bends, lifts, or coughs, the stuck mesh can cause pain because it’s yanking on surrounding muscles, tissue and nerves. Ouch! Improving the mobility of the muscle and fascia around the mesh can decrease that pain. Lastly, improving the mobility of these soft tissues will create more space for, and decrease tension on, the surrounding nerves that may have been negatively affected during surgery. With manual therapy, we can help to normalize the mobility of these nerves so they can slide, glide, and stretch normally. Manual therapy also decreases ischemia (improves blood flow) for these nerves facilitating healing, and ultimately decreasing pain.
In addition to physical therapy, the patient may also benefit from interventional pain management, such as a nerve block, to the affected nerve or nerves. In the case that conservative therapy does not reduce the pain sufficiently, a neurectomy, may be indicated. A neurectomy is a surgical procedure that cuts the involved nerve to reduce pain. Dr. Linn, a surgeon from Chicago, reviewed these interventional pain management options as well as surgical treatment options for patients suffering from persistent pain after hernia repair, at the 2018 International Pelvic Pain Society Meeting. Read a summary of his lecture here.
As I mentioned at the beginning of this post, inguinal hernias are only one cause of pelvic pain in men. In May, which is Pelvic Pain Awareness Month, PHRC will present our first Pelvic Pain Pow Wow! This will consist of five video webinars, one every week in May, each focusing on a different aspect of pelvic pain. Follow us on Instagram for more information about our Webinar series. Tune in the week of May 20th as I review other causes of male pelvic pain and how pelvic floor physical therapy can help.
- Poobalan AS, Bruce J, Smith WC, et al. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain 2003;19:48–54