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Anatomy and Related Etiology of Groin Pain

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George S. Ferzli
George S. Ferzli
Salud y medicina
1 de 45
ANATOMY AND RELATED ETIOLOGY OF GROIN PAIN George S. Ferzli MD, FACS Anne Erickson, CMI Tabulae Sceletie Musculorum Corporis Humani Barnhard S. Albinus, London, 1747. Jan Wanderlaar, artist.
[object Object],[object Object],[object Object],Albrecht Durer, Vier Bucher von menschlicher Proportion, Nurenberg, 1528. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
DIFFERENTIAL DIAGNOSIS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],Could groin pain be due to a sports injury?
Gilmore’s Groin (sportsman’s hernia) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Differential diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],De humani corpus fabrica libri septem. Andreas Vesalius, Basel, 1543.
[object Object],[object Object],[object Object],[object Object]
[object Object],Albrecht Durer, Vier Bucher von menschlicher Proportion, Nurenberg, 1528. ,[object Object],[object Object],[object Object],[object Object],One year later, she files a lawsuit based on these symptoms: ,[object Object],[object Object],[object Object]
The charge: ,[object Object],[object Object],[object Object],[object Object],[object Object]
FRIDAY ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],MONDAY ,[object Object],[object Object],[object Object],[object Object],* Kumar S, Wilson RG, Nixon SJ and Macintyre IMC. Chronic pain after groin hernia surgery. BJM 2002, 89, 1476-1479
Genitofemoral causalgia was first reported by Magee in 1942*. It is often debilitating and reflects chronic neuralgia including paresthesia, hypesthesia and dysesthesia. * Magee RK. Genitofemoral causalgia (a new syndrome). CMAJ 1942, 46: 326-9.
Related Dermatome Regions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Albrecht Durer, Vier Bucher von menschlicher Proportion, Nurenberg, 1528.
The ilioinguinal nerve (T12 and L1) supplies sensory innervation to the proximal and medial thigh. In the female innervation is supplied to abdominal skin of the mons pubis and labium majus. In the male, the ilioinguinal nerve innervates the root of the penis and upper scrotum. The iliohypogastric nerve supplies similar sensory innervation to that of the ilioinguinal nerve. Iliohypogastric n. Ilioinguinal n. Cross innervation
Surgeon’s testimony continues ,[object Object],[object Object],[object Object]
Genitofemoral nerve innervation (L1,2) The genital branch of the genitofemoral nerve supplies sensation to the mons pubis and labium majus. In the male, sensation is supplied to the scrotum and motor fibers to the cremasteric muscle. Genital branch, genitofemoral nerve
Pudendal nerve innervation of female external genitalia (S2,3,4)
Surgeon’s testimony continues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
TUESDAY ,[object Object],[object Object],[object Object],[object Object],[object Object]
TUESDAY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],* Admitted to have never observed the patient–his conclusions were based on a 17 page diary that the plaintiff had prepared for him.
[object Object],[object Object],[object Object],[object Object],[object Object]
WEDNESDAY ,[object Object]
Groin pain could be neuropathic: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Nerves prone to injury during laparoscopic repair: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Lateral femoral cutaneous nerve innervation (L2,3) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Femoral branch of genitofemoral nerve-innervation (L1,2) The femoral branch supplies sensory innervation to the anterolateral thigh.
Femoral nerve innervation (L2,3) ,[object Object],[object Object],[object Object],[object Object],[object Object]
Pain could be non-neuropathic and related to: ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object]
THURSDAY ,[object Object],[object Object],[object Object]
The ilioinguinal nerve (T12 and L1) supplies sensory innervation to the proximal and medial thigh. In the female innervation is supplied to abdominal skin of the mons pubis and labium majus. In the male, the ilioinguinal nerve innervates the root of the penis and upper scrotum. The iliohypogastric nerve supplies similar sensory innervation to that of the ilioinguinal nerve. Iliohypogastric n. Ilioinguinal n. Cross innervation
Pudendal nerve innervation of female external genitalia (S2,3,4)
Genitofemoral nerve innervation (L1,2) The genital branch of the genitofemoral nerve supplies sensation to the mons pubis and labium majus. In the male, sensation is supplied to the scrotum and motor fibers to the cremasteric muscle. Genital branch, genitofemoral nerve
Groin pain could be neuropathic: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pain could be non-neuropathic and related to: ,[object Object],[object Object],[object Object],[object Object],[object Object]
THURSDAY Jury Verdict 4:10pm ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],William Cheselden, Osteographia, London 1733.
[object Object],[object Object],William Cheselden, Osteographia, London 1733.
An indepth knowledge of anatomy and the multiple etiologies of groin pain is essential. De humani corpus fabrica libri septem. Andreas Vesalius, Basel, 1543.
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Questions: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
2. Groin pain can result from all the following except: a. Vas deferens fibrosis post hernia b. Herpes zoster infection c. Reflex sympathetic dystrophy d. Rolled up, bulk forming mesh material e. Torsion of the appendix testes N.B. (e) is the correct answer ,[object Object]
3. Chronic post herniorrhaphy neuropathic groin pain is the result of all the following except: a. Neuroma formation b. P perineural fibrosis c. Entrapment by staples, sutures or prosthetic material d. Nerve damage from stretching, contusion, crushing, electrical damage, partial or complete division e. Periosteal reaction N.B. e. is the correct answer ,[object Object]
4. In comparison to open mesh (tension-free) hernia repair, the nerves prone to injury during laparoscopic hernia repair are: a. Ilioinguinal and iliohypogastric nerves b. Ilioinguinal and genital branch of the genitofemoral nerve c. Ilioinguinal and lateral femoral cutaneous nerves d. Femoral branch of the genitofemoral nerve and iliohypogastric nerve e. Femoral branch of the genitofemoral nerve and lateral femoral cutaneous nerve N.B. (e) is the correct answer ,[object Object]
5. Which of the following statements is incorrect? a. Femoral nerve injury may result in atrophy of the quadriceps muscle b. Lateral femoral cutaneous nerve injury may result in severe burning sensation along the anterolateral aspect of the thigh c. Peripheral communication between the ilioinguinal, iliohypogastric and genital branch of genitofemoral nerve is very common and results in an overlap of their sensory innervation d. A mesh placed taut and fixed with too many staples during laparoscopic preperitoneal hernia repair may result in “meshalgia” or “staplealgia” e. Sport related groin pain may result from injury to the abductor muscles N.B. e. is the correct answer ,[object Object]

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Anatomy and Related Etiology of Groin Pain

  • 1. ANATOMY AND RELATED ETIOLOGY OF GROIN PAIN George S. Ferzli MD, FACS Anne Erickson, CMI Tabulae Sceletie Musculorum Corporis Humani Barnhard S. Albinus, London, 1747. Jan Wanderlaar, artist.
  • 2.
  • 3.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11.
  • 12. Genitofemoral causalgia was first reported by Magee in 1942*. It is often debilitating and reflects chronic neuralgia including paresthesia, hypesthesia and dysesthesia. * Magee RK. Genitofemoral causalgia (a new syndrome). CMAJ 1942, 46: 326-9.
  • 13.
  • 14. The ilioinguinal nerve (T12 and L1) supplies sensory innervation to the proximal and medial thigh. In the female innervation is supplied to abdominal skin of the mons pubis and labium majus. In the male, the ilioinguinal nerve innervates the root of the penis and upper scrotum. The iliohypogastric nerve supplies similar sensory innervation to that of the ilioinguinal nerve. Iliohypogastric n. Ilioinguinal n. Cross innervation
  • 15.
  • 16. Genitofemoral nerve innervation (L1,2) The genital branch of the genitofemoral nerve supplies sensation to the mons pubis and labium majus. In the male, sensation is supplied to the scrotum and motor fibers to the cremasteric muscle. Genital branch, genitofemoral nerve
  • 17. Pudendal nerve innervation of female external genitalia (S2,3,4)
  • 18.
  • 19.
  • 20.
  • 21.
  • 22.
  • 23.
  • 24.
  • 25.
  • 26.
  • 27. Femoral branch of genitofemoral nerve-innervation (L1,2) The femoral branch supplies sensory innervation to the anterolateral thigh.
  • 28.
  • 29.
  • 30.
  • 31.
  • 32. The ilioinguinal nerve (T12 and L1) supplies sensory innervation to the proximal and medial thigh. In the female innervation is supplied to abdominal skin of the mons pubis and labium majus. In the male, the ilioinguinal nerve innervates the root of the penis and upper scrotum. The iliohypogastric nerve supplies similar sensory innervation to that of the ilioinguinal nerve. Iliohypogastric n. Ilioinguinal n. Cross innervation
  • 33. Pudendal nerve innervation of female external genitalia (S2,3,4)
  • 34. Genitofemoral nerve innervation (L1,2) The genital branch of the genitofemoral nerve supplies sensation to the mons pubis and labium majus. In the male, sensation is supplied to the scrotum and motor fibers to the cremasteric muscle. Genital branch, genitofemoral nerve
  • 35.
  • 36.
  • 37.
  • 38.
  • 39. An indepth knowledge of anatomy and the multiple etiologies of groin pain is essential. De humani corpus fabrica libri septem. Andreas Vesalius, Basel, 1543.
  • 40.
  • 41.
  • 42.
  • 43.
  • 44.
  • 45.