(646) 355-8777

Herman & Wallace Blog

Testicle and penis pain or numbness after hernia repair

Most people are told that inguinal hernia repair is a low risk surgery. While death or severe injury is rare, penile or testes pain after hernia repair is not a novel or recent finding. In 1943, Magee first discussed patients having genitofemoral neuralgia after appendix surgery. By 1945, both Magee and Lyons stated that surgical neurolysis gave relief of genital pain following surgical injury (neurolysis is a surgical cutting of the nerve to stop all function). However, it should be noted that with neurolysis, sensory loss will also occur, which is an undesired symptom for sexual function and pleasure. In 1978 Sunderland stated genitofemoral neuralgia was a well-documented chronic condition after inguinal hernia repair.

Let’s do a quick anatomy review. The inguinal canal is located at the lower abdomen and is actually an extension of the external oblique muscles. Is travels along the line from the ASIS to the pubic tubercle, occupying grossly the medial third of this segment. It has a lateral ring where contents from the abdomen exit and a medial ring where the contents of the canal exit superficially. This ring contains the spermatic cord (male), round ligament (female), as well as the ilioinguinal and genitofemoral nerves. For males, in early life, the testes descend from the abdominal cavity to the exterior scrotal sac through the inguinal canal, bringing a layer of the obliques, transverse abdominus, and transversalis fascia with them within the first year of life. Just as a female can experience prolapse from prolonged increased intra-abdominal pressure, a male can have a herniation through the anterior abdominal wall and inguinal canal with increased abdominal pressure. Such pressure inducing activities can be lifting, coughing, and sports activities. When this occurs, an inguinal hernia repair is generally indicated. Because the genitofemoral nerve is within the contents of the inguinal canal, it can be susceptible to surgery in this area. The genitofemoral nerve has sensory innervation to the penis and testes and is responsible for the cremasteric reflex. Symptoms of genitofemoral neuralgia in men can be penis or testes pain, numbness, hypersensitivity, and decreased sexual satisfaction or function.

In 1999 Stark et al noted pain reports as high as 63% post hernia repair. The highest rates of genitofemoral neuralgia are reported with laparoscopic or open hernia repair (Pencina, 2001). The mechanism for GF neural entrapment is entrapment within scar or fibrous adhesions and parasthesia along the genitofemoral nerve (Harms 1984, Starling and Harms 1989, Murovic 2005, and Ducic 2008). It is well known that scar and adhesion densify and visceral adhesions increase for years after surgery. Thus, symptoms can increase long after the surgery or may take years to develop. In 2006, Brara postulated that mesh in the region can contribute to subsequent genitofemoral nerve tethering which can be exacerbated by mesh in the inguinal or the retroperitoneal space. With an anterior mesh placement, there is no fascial protection left for the genitofemoral nerve.

Genitofemoral neuralgia is predominately reported as a result of iatrogenic nerve damage during surgery or trauma to the inguinal and femoral regions (Murovic et al, 2005). However, genitofemoral neuropathy can be difficulty and elusive to diagnose due to overlap with other inguinal nerves (Harms, 1984 and Chen 2011).

In my clinical experience, I have seen such symptoms after hernia repair, but also after procedures near the inguinal region such as femoral catheters for heart procedures, appendectomies, and occasionally after vasectomy.

As a pelvic PT, what are we to do with this information? First off, we can realize that all pelvic neuropathy is not necessarily due to the pudendal nerve. In the anterior pelvis, there is dual innervation from the inguinal nerves off the lumbar plexus as well as the dorsal branch of the pudendal nerve. When patients have a history of inguinal hernia repair, we can consider the genitofemoral nerve as a source of pain. Medicinally, the only research validated options for treatment are meds such as Lyrica or Gabapentin that come with drowsiness, dizziness and a score of side effects. Surgically neurectomy or neural ablation are options with numbness resulting, however, many patients do not want repeated surgery or numbness of the genitals. As pelvic therapists, we can manually fascially clear the path of the nerve from L1/L2, through the psoas, into and out of the canal and into the genitals. We can also manually directly mobilize the nerve at key points of contact as well as doing pain free sliders and gliders and then give the patient a home program to maintain mobility. Pelvic manual therapy can offer a low risk, side-effect free option to ameliorate the sequella of inguinal hernia repair. Come join us at Lumbar Nerve Manual Assessment and Treatment in Chicago this Spring to learn how to effectively treat all the nerves of the lumbar plexus.


Cesmebasi, A., Yadav, A., Gielecki, J., Tubbs, R. S., & Loukas, M. (2015). Genitofemoral neuralgia: a review. Clinical Anatomy, 28(1), 128-135.
Lyon, E. K. (1945). Genitofemoral causalgia. Canadian Medical Association Journal, 53(3), 213.
Magee, R. K. (1943). Genitofemoral Causalgia: New Syndrome. The Journal of Nervous and Mental Disease, 98(3), 311.
Sunderland S. Nerves and nerve injuries. 2nd ed. Edinburgh: Churchill Livingstone, 1978

Physical Therapy Considerations for Patients with ...
Patterns of POP in Nepali Women & the Roles of Cul...

Upcoming Continuing Education Courses

Mobilization of Visceral Fascia: The Gastrointestinal System - Arlington, VA (RESCHEDULED)

Jul 10, 2020 - Jul 12, 2020
Location: Virginia Hospital Center

Mobilization of Visceral Fascia: The Gastrointestinal System

Jul 10, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 Part 1 - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Short Form Remote Course

Athletes & Pelvic Rehabilitation - Remote Course

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Bowel Pathology and Function - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Newark, NJ (Rescheduled)

Jul 12, 2020 - Jul 14, 2020
Location: Rutgers University - Doctoral Programs in Physical Therapy

Pregnancy Rehabilitation - Remote Course

Jul 16, 2020 - Jul 17, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Foothill Ranch, CA (RESCHEDULED)

Jul 18, 2020 - Jul 19, 2020
Location: Intercore Physical Therapy

Pelvic Floor Level 1 - Colorado Springs, CO (SOLD OUT)

Jul 18, 2020 - Jul 19, 2020
Location: Manual Edge Physiotherapy

Postpartum Rehabilitation - Remote Course

Jul 18, 2020 - Jul 19, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1- Bangor, ME (Rescheduled)

Jul 18, 2020 - Jul 19, 2020
Location: Husson University

Pelvic Floor Level 1 - Columbus, OH

Jul 18, 2020 - Jul 19, 2020
Location: Fitness Matters

Pelvic Floor Level 1 Part 1 - Remote Course (SOLD OUT)

Jul 21, 2020 - Jul 22, 2020
Location: Short Form Remote Course

Nutrition Perspectives for the Pelvic Rehab Therapist - Columbia, MO (Rescheduled)

Jul 24, 2020 - Jul 26, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Pelvic Floor Level 1 - Chicago, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Advocate Illinois Masonic Medical Center

Pelvic Floor Level 1 - Fayetteville, NC (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Methodist University School of Health Sciences

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course

Jul 25, 2020 - Jul 26, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Glenwood Springs, CO (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Valley View Hospital

Pudendal Neuralgia and Nerve Entrapment - Maywood, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Loyola University Health System

Pelvic Floor Level 2B - Los Angeles, CA (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Mount Saint Mary’s University

Manual Therapy for the Abdominal Wall - Remote Course

Jul 31, 2020
Location: Short Form Remote Course

Parkinson Disease and Pelvic Rehabilitation - Remote Course

Jul 31, 2020 - Aug 1, 2020
Location: Short Form Remote Course

Neurologic Conditions and Pelvic Floor Rehab - Washington, DC

Jul 31, 2020 - Aug 2, 2020
Location: George Washington University Hospital Outpatient Rehabilitation Center

Restorative Yoga for Physical Therapists - Remote Course

Aug 1, 2020 - Aug 2, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Chicago, IL (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: Midwestern Regional Medical Center

Pelvic Floor Level 2A - Washington, DC (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: The George Washington University

Pelvic Floor Level 1 - New York City, NY (RESCHEDULED)

Aug 2, 2020 - Aug 3, 2020
Location: Touro College

Pelvic Floor Level 1 - Birmingham, AL (SOLD OUT)

Aug 8, 2020 - Aug 9, 2020
Location: Shelby Baptist Medical Center