Vladimir Iakovlev1, Andreas Koch2, Kevin Petersen3, John Morrison4, David Grischkan5, Vali Oprea6, Robert Bendavid7. 1. Department of Laboratory Medicine, St. Michael's Hospital and the Keenan Research Centre of the Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada. 2. Day Surgery and Hernia Center, Cottbus, Germany. 3. Private Practice, Las Vegas, NV. 4. Chatham Kent Health Alliance, Chatham, Ontario, Canada. 5. Hernia Center of Ohio, Cleveland, OH. 6. Military Hospital of Cluj, Cluj-Napoca, Romania. 7. Shouldice Hospital, Thornhill & University of Toronto, Toronto, Ontario, Canada.
Abstract
OBJECTIVE: The ubiquitous use of polypropylene mesh in hernia surgery has spawned a new clinical syndrome: chronic post-herniorrhaphy neuralgia. A subset of that clinical picture is dysejaculation, sexual pain, and orchialgia. We propose to identify the processes that lead to that pain. SUMMARY OF BACKGROUND DATA: Specimens of vas adherent to polypropylene mesh, explanted in an attempt to control severe, life-changing inguinodynia are extremely difficult to obtain. This scarcity may be due to ingrained attitudes in our society about removal of vas and/or testicles for whatever reason. Attempts at preserving such damaged structures may paradoxically contribute to the chronicity and severity of such pain. METHODS: The medical files of patients who had mesh specimens explanted because of severe chronic post-herniorrhaphy pain were reviewed to identify cases with recorded evidence, at the time of surgery, of involvement of spermatic cord/vas deferens with mesh. These criteria were met in 13 cases and the specimens were analyzed histologically. RESULTS: The vas deferens was resected in 83% (5 of 6) of the patients with a history of sexual pain and/or dysejaculation (vs 14% of those without a history of sexual pain, P = 0.03). Histology demonstrated unequivocal mesh invasion of the spermatic cord, where the initial damage occurred to nerves (autonomic, somatic), then to the smooth muscle of the vas while the lumen remained patent. In 50% (3 of 6), the vas and other cord structures appeared to be completely invaded by the mesh and replaced by scar tissue. CONCLUSIONS: Irreversible damage of the nerves and vas musculature due to mesh migration is one of the mechanisms for sexual pain and dysejaculation. Attempts at all cost to preserve elements of the spermatic cord may not be justified in cases of severe pain, especially sexual pain (and/or dysejaculation) and intraoperative finding of cord involvement by the mesh. Vasectomy with mesh removal may well be indicated and be considered not a radical procedure but a conservative measure given the severity of the pain!
OBJECTIVE: The ubiquitous use of polypropylene mesh in hernia surgery has spawned a new clinical syndrome: chronic post-herniorrhaphy neuralgia. A subset of that clinical picture is dysejaculation, sexual pain, and orchialgia. We propose to identify the processes that lead to that pain. SUMMARY OF BACKGROUND DATA: Specimens of vas adherent to polypropylene mesh, explanted in an attempt to control severe, life-changing inguinodynia are extremely difficult to obtain. This scarcity may be due to ingrained attitudes in our society about removal of vas and/or testicles for whatever reason. Attempts at preserving such damaged structures may paradoxically contribute to the chronicity and severity of such pain. METHODS: The medical files of patients who had mesh specimens explanted because of severe chronic post-herniorrhaphy pain were reviewed to identify cases with recorded evidence, at the time of surgery, of involvement of spermatic cord/vas deferens with mesh. These criteria were met in 13 cases and the specimens were analyzed histologically. RESULTS: The vas deferens was resected in 83% (5 of 6) of the patients with a history of sexual pain and/or dysejaculation (vs 14% of those without a history of sexual pain, P = 0.03). Histology demonstrated unequivocal mesh invasion of the spermatic cord, where the initial damage occurred to nerves (autonomic, somatic), then to the smooth muscle of the vas while the lumen remained patent. In 50% (3 of 6), the vas and other cord structures appeared to be completely invaded by the mesh and replaced by scar tissue. CONCLUSIONS: Irreversible damage of the nerves and vas musculature due to mesh migration is one of the mechanisms for sexual pain and dysejaculation. Attempts at all cost to preserve elements of the spermatic cord may not be justified in cases of severe pain, especially sexual pain (and/or dysejaculation) and intraoperative finding of cord involvement by the mesh. Vasectomy with mesh removal may well be indicated and be considered not a radical procedure but a conservative measure given the severity of the pain!