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Pubic Inguinal Pain Syndrome
(PIPS)
GiampieroCampanelli, PieroGiovanniBruni,
FrancescaLombardo, andMartaCavalli
38
38.1 Introduction
The pubic inguinal pain syndrome (PIPS) is a
controversial condition which presents itself as
chronic groin pain. There has been no clear consensus, especially on its nomenclature (sportsman’s hernia, inguinal disruption, athletic
pubalgia, and chronic groin pain), which has
been regarded as difcult to accurately diagnose
and manage.
There are many publications on the effect of
treatments in athletes with long-standing groin
pain but very limited information on acute groin
injuries. Only 6% of the included studies were
high quality [1].
We have proposed the term PIPS to give a
more complete denition; it is a clinical condition where there is often no real hernia, and it
G. Campanelli (*) · P. G. Bruni · F. Lombardo
M. Cavalli
University of Insubria, Varese, Italy
General and Day Surgery Unit,
Center of Research and High Specialization for the
Pathologies of Abdominal Wall and Surgical
Treatment and Repair of Abdominal Hernia,
Milano Hernia Center,
Istituto Clinico Sant’Ambrogio, Milan, Italy
e-mail: Giampiero.Campanelli@grupposandonato.it
frequently occurs in professional athletes but can
affect anyone, even a non-sportsman [2].
38.2 Clinical Aspect
Patients affected by PIPS are usually males and
the average age at the time of diagnosis is
20–50years [2–4]. The incidence is between 0.5
and 6.2% and is more common in soccer and ice
hockey players where specic activities and
stress involve rapid accelerations and decelerations with sudden directional changes [5–7].
Other sports such as cycling and swimming
have rare occurrences of this condition as these
sports do not have the increased pelvic and torso
movements that are known to predispose to a
painful groin [8]. Pain can become a serious
debilitating condition and may place an athlete’s
career at risk [9]. Moreover, PIPS can be
encountered even in normally physically active
people [6, 10, 11].
It is accepted that this chronic pain caused by
abdominal wall weakness or injury occurs without a palpable hernia [6, 8]. In PIPS the pain
experienced is recognized at the common point
of origin of the rectus abdominis muscle and the
adductor longus tendon on the pubic bone and the
insertion of the inguinal ligament on the pubic
bone [7].
The absence of the bulge therefore leads to the
need to exclude another pathology prior to the
inguinal canal. Multiple coexisting pathologies
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_38
367
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G. Campanelli et al.
are often present such as posterior inguinal canal
weakness, conjoint or adductor tendinopathy,
osteitis pubis, and peripheral nerve entrapment
syndrome [12].
Anatomy of the groin, although a small
area, is rather complex. The inguinal ligament
itself arises from the anterior superior iliac
spine and inserts into the pubic tubercle, and at
the pubic level also arise both the rectus
abdominis muscle and the adductor longus tendon. Therefore, there are a number of forces
that are either pulling or pushing at the pubic
bone, and over time this can present with pain.
In addiction the inguinal canal has two congenital weaknesses with the internal and the
external inguinal rings [13].
The inguinal area is mainly supplied by three
nerves which all come from the lumbar plexus.
The iliohypogastric nerve (L1) pierces the
transversus abdominis muscle above the iliac
crest and then travels in the neurovascular plane
between the transversus abdominis and the internal oblique muscles. It then pierces internal
oblique at a variable point along the anterior
abdominal wall, eventually passing through
external oblique, providing sensory innervation
to the suprapubic skin.
The ilioinguinal nerve (L1) similarly pierces
the transversus abdominis muscle to travel in the
neurovascular plane and then passes through the
internal oblique to enter the inguinal canal. It
runs with the cord structures and exits the canal
via the external ring to provide sensory innervation to the overlying skin of the upper medial
thigh, anterior scrotum, and base of the penis (or
labium majus and mons pubis).
The genitofemoral nerve (L1–L2) divides into
a genital and a femoral branch. The genital
branch travels along the external iliac artery and
then ascends to meet the vas deferens at the internal ring. Entering the inguinal canal, it becomes
part of the spermatic cord lying on its inferior
surface with a companion vein. In the male, it
passes into the scrotum via the external ring and
provides motor innervation to the cremaster muscle and sensory innervation to a small part of the
scrotum. In the female, it provides sensory innervation to the mons pubis.
38.3 Diagnosis
The diagnosis of chronic groin pain is difcult
due to considerable etiological variability and the
fact that most injuries are not identiable on
physical examination or even with specialized
imaging.
However, early diagnosis is very important,
since morbidity will be reduced. The combination of complex anatomy [5], variability of presentation, and the non-specic nature of the signs
and symptoms make the diagnostic process
problematic.
There is no evidence-based consensus available to guide decision-making, and most studies
available concerning investigation and management are only level IV recommendations at best
[6, 10]. Only one randomized, prospective study
was conducted on 60 patients with a diagnosis of
chronic groin pain and suspected sportsman’s
hernia. This controlled clinical trial demonstrated
that an endoscopic, preperitoneal hernioplasty
was more effective than nonoperative treatment
for sportsman’s hernia [14].
Proper and detailed medical history paying
attention to the type and intensity of pain, the
time of onset and its correlation with physical
activity, its resolution, drugs, and physical therapies, if done, is very important [15]. The history
must include questions directed at referred lumbar abnormalities, including back pain, radiculopathy, and sensory disturbances. Urologic
information must be gathered, including urinary
symptoms and any testicular lumps or masses.
The majority of patients complain of unilateral inguinal pain, often radiating to the pubic
tubercle and inner thigh or across the midline,
and may recall the specic event that initiated the
pain, but more often the onset is insidious. The
symptoms are exacerbated by activity such as
kicking, sprinting, and forceful, lateralizing
movements and relieved with rest [6, 10, 16].
However, the pain returns when these activities
are resumed.
Physical examination is the essential step in
the diagnosis of groin pain, although symptoms
are often vague and diffuse. Meticulous physical
examination is so important, rst in upright
38 Pubic Inguinal Pain Syndrome (PIPS)
369
Fig. 38.1 The rectus test: the patient should be lying
supine with hips adduced and extended. The test is positive if the patient, while lifting both, feels a keen groin
pain
position and then in supine position. In upright
position, the testis is evaluated and inguinal canal
explored: a small bulge of the posterior wall is
usually present during coughing or Valsalva
maneuver, and the patient often complains of dull
and burning pain at this moment, although the
absence of a real inguinal hernia is crucial. In
supine position, the rectus and the adductor tests
are accomplished [15]. The rectus test: the patient
should be lying supine with hips adduced and
extended. The test is positive if the patient, while
lifting both, feels a keen groin pain (Fig.38.1).
The adductor test: the patient should be lying
supine with hips abducted and exed and with
knees exed at 90°. The test is positive if the
patient, while attempting to adduct his legs
against pressing in the opposite direction, feels a
sharp pain in the groin [9] (Fig.38.2).
The regional examination is crucial for positive and negative ndings and to help the differential diagnosis. Findings include tenderness at
the pubic tubercle, pain with resisted hip exion,
internal rotation, and abdominal muscle contraction. [6, 10, 16]
The lumbar spine, sacroiliac, and hip joints
must be put through a range of motion and examined for tenderness. The symphysis is examined
for instability and tenderness, as osteitis pubis is
a relatively common entity in the athletic population. Muscle origins, including the rectus femoris
and sartorius, are palpated for sites of tenderness,
Fig. 38.2 The adductor test: the patient should be lying
supine with hips abducted and exed and with knees
exed at 90°. The test is positive if the patient, while
attempting to adduct his legs against pressing in the opposite direction, feels a sharp pain in the groin
possibly indicating muscle strain. In addition,
these muscles are tested against resistance, in an
attempt to provoke the symptoms. The testis and
rectum should be examined for the presence of
masses, and the prostate palpated for tenderness
or bogginess. A gynecologic examination may be
required in a female patient [6].
Currently there is no consensus on the ideal
imaging method for sportsman with chronic
inguinal pain.
Inguinal pain due to acute muscular, tendinous, or osseous injuries may be radiologically
visualized. Ultrasonography (US) is a useful noninvasive and less expensive imaging modality
[17]. It provides information about tendinous
injuries allowing to visualize discontinuous bers
within the brillary tendon tissue [11]. Dynamic
ultrasound scan can be useful to assess the conjoint tendons and inguinal ligament as far as the
tendon of rectus for size, integrity, echotexture,
and tenderness, detect the presence of a protrusion of the posterior wall, evaluate the symphysis
pubis for irregularity and tenderness, and assess
the adductor longus origin for size, integrity,
echotexture, and tenderness. The common disadvantages of this technique are that it is operator
dependent and, therefore, has variable
reproducibility.
Direct X-ray may reveal congenital abnormalities such as femoroacetabular impingement,
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G. Campanelli et al.
developing dysplasia of the hip, as well as degenerative conditions of hip-spine-sacroiliac joints.
They may also indicate the symmetric bone
resorbs in osteitis pubis, sclerosis, and symphysis
widening [18].
Pelvic and lumbar MRI should be done to
exclude the presence of osteitis pubis and vertebral disease. MRI is superior to CT for musculotendinous imaging, and it should be used always
to exclude other copathologies such as vertebral
disease.
However, imaging studies are often negative,
and the only clinical sign is a deep pain to palpation
located near the pubic tubercle and below inguinal
ligament at adductor insertion. In such cases, a
clinical diagnosis of PIPS can be suspected [11].
38.4 Management
38.4.1 Conservative Treatment
The rst line of management includes rest from
physical activities for 2months and inammatory
and pain killing drugs for a week or until complete resolution of the pain. Very important is an
evaluation by a physiotherapist to start exercises
with the goal of stretching iliopsoas, rectus
abdominis and adductor longus muscles. After
2months, if pain persists when physical activities
restart, operative management may be necessary.
38.4.2 Surgical Treatment
Based on available literature, operative intervention is indicated for chronic groin pain refractory
to conservative treatments including rest, physical therapy, nonsteroidal anti-inammatory medications, and nerve blocks [19].
Various operative approaches for groin pain in
athletes have been proposed depending on the
suspected nature of injury. These operative
approaches include methods of hernia repair,
tenotomies of muscle tendons close to the pubic
bone, transection of inguinal ligament, as well as
release or transaction (neurotomy) of nearby
nerves [14].
Surgery has been at the forefront of treatment
for patients with PIPS. Surgical approach
includes various types of open techniques with or
without mesh and laparoscopic transabdominal
preperitoneal (TAPP) and totally extraperitoneal
(TEP) herniorrhaphies with mesh. These techniques are the same as those used in the repair of
inguinal hernia. Although the results reported in
several studies are good, the superiority of either
laparoscopic technique or open technique as performed by experienced hands has not been demonstrated to date [
20].
A controlled clinical trial demonstrates clearly
that an endoscopic, preperitoneal hernioplasty
was more effective than nonoperative treatment
for PIPS with groin pain in athletes [
14].
However, it should be kept in mind that 10% of
the patients in this group received preoperative
open tenotomy.
Other studies underline the efcacy of TEP
technique [20]; it is less traumatic than intraabdominal or anterior technique. Postoperative
pain and wound complication are less as compared to the open technique, and it is characterized by low mobility and rapid return to full
sports activity [21]. However, TEP might not be
performed due to prostate surgery or previous
lower abdominal surgery.
Many surgeons have acknowledged that laparoscopic therapy ensures an effective and quicker
return to full sports activity (82–92% of patients
in 2–8weeks) [17, 22].
Other surgeons encourage open minimal
repair (OMR) for the posterior wall weakness
especially when someone promotes the use of no
mesh combined with an early return to sporting
activity [
18].
Dojcinovic proposed a Shouldice repair with
resection of the genital branch of genitofemoral
nerve and ilioinguinal nerve neurolysis, and,
when adductor tendinosis was present, the complete adductor tenotomy was done [23].
Our approach is based on the etiopathogenetic
theory that the situation is caused by three factors: (1) the compression of the three nerves of
the inguinal region, (2) the imbalance in strength
of adductor and abdominal wall muscles caused
by the hypertrophy and stiffness of the insertion
38 Pubic Inguinal Pain Syndrome (PIPS)
of rectus muscle and adductor longus muscle,
and (3) the partial weakness of the posterior wall.
We propose a surgical procedure with the
release of all three nerves of the region, the correction of the imbalance in strength with the partial calibrated tenotomy of the rectus and adductor
longus muscles, and the repair of the partial
weakness of the posterior wall with a lightweight
or biological mesh sutureless.
After a blood test, ECG, and chest X-ray,
patients are operated on under local anesthesia.
No patients received any sedation, so they are
able to cooperate during surgery with cough, soft
crunch, and leg adduction in order to calibrate the
double partial tenotomy of the rectus abdominis
and of the adductor longus. The inguinal canal is
approached through a transversal inguinal small
incision (3–5cm) [15]. At this step, the iliohypogastric nerve is usually found to be piercing the
aponeurosis about 1–2cm cranially to the medial
pilaster of the external ring. The medial pilaster is
usually inserted on the pubic tubercle in a stiff
manner so that the iliohypogastric nerve appeared
stretched. After accurate inltration of the external oblique muscle aponeurosis, in order to share
it from the nerves running below, the inguinal
canal is opened.
The cord with the ilioinguinal nerve and the
genital branch of genitofemoral nerve often
appear pressed between the aponeurosis of external stiff ring and a small bulge of the posterior
wall. The rectus muscle tendon generally is tense
and contributed to making the iliohypogastric
nerve stretch. The tendon of the adductor longus
also appears tense and hypertrophic: both tendons are evaluated dynamically during surgery
by asking the patients to cooperate with their
contraction (crunch and adductor). A little indirect lipoma or sac is often isolated and reduced.
The procedure that we perform is the same on
all the patients:
– Partial tenotomy (1 cm) of the insertion of the
rectus muscle on the pubis. At this level we
nd also an interesting intraoperative pecu-
liarity in PIPS: a thickened sheet (lamella)
behind the rectus, where normally there
should not be any fascia (Fig.38.3). This atyp-
371
Fig. 38.3 Intraoperative peculiarity in PIPS, thickened
posterior sheet to the rectus muscle
ical nding stresses us to persist in the research
on PIPS to understand if this lamella is the
result of a brotic process that is formed as an
effect of a constant stress on the region of tendons insertion on the pubic bone or if this
lamella is a genetic predisposition. Dissecting
this lamella, the usual yellow preperitoneal fat
is seen. The partial tenotomy allows to stretch
the rectus muscle and release the iliohypogastric nerve (Fig.38.4)
– Partial section (1cm) of the insertion of the
adductor longus tendon on the pubis
(Fig.38.5)
– Positioning below the cord a lightweight or
biological mesh sutureless or xed sometimes
with brin glue in order to reduce the
372
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G. Campanelli et al.
Fig. 38.4 Partial section of the insertion of the rectus
muscle on the pubis and of its atypical posterior band in
order to stretch the muscle and release the iliohypogastric
nerve
Fig. 38.5 Partial section of the insertion of the adductor
longus tendon on the pubis
compression of the cord and nerves by the
posterior wall (Figs.38.6 and 38.7)
– Closure of the external oblique muscle apo-
neurosis moving the entire cord, together with
ilioinguinal nerve and genital branch of geni-
tofemoral nerve in the subcutaneous space
(Figs.38.8 and 38.9)
Fig. 38.6 Positioning below the cord a lightweight
sutureless xed with brin glue
Fig. 38.7 Positioning below the cord biological mesh
sutureless xed with brin glue
In this way the nerves were released and the
posterior wall was softly reinforced [15].
All the patients are discharged the day of operation or the following day if they live more than
1h by car or 40km from the hospital.
Paracetamol or conventional nonsteroid antiinammatory drugs are used for postoperative
Fig. 38.8 The entire cord with ilioinguinal nerve and
genital branch of genitofemoral nerve in the subcutaneous
space
38 Pubic Inguinal Pain Syndrome (PIPS)
Fig. 38.9 Releasing of ilioinguinal nerve and genital
branch of genitofemoral nerve
pain relief. Patients are allowed to resume normal
activities the day after surgery except physical
exercise and lifting more than 10kg. They resume
FKT after 15 days and sport or physical exercise
1 month after surgery.
This treatment reported excellent results with
complete relief of symptoms after resumption of
physical activity in more than 90% of cases [15].
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Surgical Emergencies inInguinal
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Hernia
S.Rocchetti, R.Ariotti, G.Burtulo, andM.Carlucci
39
Emergency surgery for inguinal hernias is associated with a high risk of postoperative complications as well as increased perioperative mortality
rates.
Complicated hernias may have different presenting symptoms such as local or abdominal
pain, hernia irreducibility, vomiting, and intestinal obstruction. Different studies showed older
patients in the emergency patient groups, usually
with higher ASA scores and, sometimes, previous nonsurgical indication due to clinical story or
comorbidity.
The most common emergency hernias are
inguinal, but emergency femoral hernias need a
small bowel resection in a higher percentage of
cases.
Although therapeutic management of inguinal
hernia allows elective treatment in the vast majority of cases, complications frequently constitute
real surgical emergencies; these are represented
by incarceration, intestinal obstruction, and
strangulation.
39.1 Denition andClinical
Presentation
39.1.1 Incarcerated Hernia
It is a condition that occurs when the herniary
content is no longer reducible into its original cavity (abdomen). It is generally caused by adherence between the hernia content (the sac) and the
ring. Usually this condition can occur more frequently when the constricting ring is weak in elasticity and small in size compared to the hernia
content, in fact we can observe a higher incidence
of incarcerated hernia in femoral hernia than
inguinal ones. An incarcerated hernia generally
appears as a non-reducible swelling; however,
clinical presentation may not always be obvious
especially in cases where the hernia is small and/
or the somatic constitution of the patient does not
allow physical examination. Especially when it
occurs acutely (e.g., following a physical effort),
the patient can experience intense local pain, and
it can be difcult to clinically distinguish incarceration from strangulation. Therefore, the onset
of an acute non-reducibility must be treated as an
emergency.
39.1.2 Intestinal Occlusion
S. Rocchetti · R. Ariotti · G. Burtulo
M. Carlucci (*)
General and Emergency Surgery Unit,
IRCCS San Raffaele Institute, Milan, Italy
e-mail: carlucci.michele@hsr.it
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_39
Inguinal hernia is the second cause of small bowel
occlusion (in the United States). It is usually due
to accumulation and difcult transit of intestinal
375
376
S. Rocchetti et al.
material inside the hernia bag. This can occur
because of compression caused by the collar or
for an abnormal rotation of the intestinal limbs
inside the sac. This condition can often be solved
by reducing the hernia content, but it is frequently
associated with real incarceration and subsequent
irreducibility. This results in mechanical occlusion: symptoms may include constipation, local
pain, cramping abdominal pain, abdominal swelling, and vomiting; the abdomen may become
hyper-tympanic, and the bowel sounds may be
initially hyperactive and high- pitched and lately
reduced or absent due to onset of ileus.
39.1.3 Strangulation
It is denitely the most dangerous complication;
it occurs when the blood supply to part of the
bowel is blocked.
Although it is often the result of an acute event
(such as a physical effort), it can also occur in the
absence of an apparent cause.
Strangulation is characterized by irreducibility and acute pain, usually of considerable intensity (both to palpation and spontaneous); almost
always it leads to intestinal occlusion.
It must be quickly treated, since in a few hours
it evolves to gangrene of the ischemic bowel, followed by perforation, peritonitis, and septic
shock.
39.2.1 Physical Examination
Physical examination must always be accurately
performed both in the supine and in the orthostatic positions, evaluating both the inguinal and
the femoral regions with and without Valsalva
maneuver. The inguinal canal should be examined by inserting the tip of the nger inside the
inguinal outer ring. Any inguinal swelling should
be evaluated for size, reducibility, consistency,
and pain. The whole abdomen should be evaluated in an attempt to look for any sign of
obstruction.
39.2.2 Ultrasound
Ultrasound, performed with dynamic poses, is
the rst-choice instrumental investigation. It is
cheap, always available, and fast and does not
expose the patient to biologically potentially dangerous radiations. However, the sensitivity and
specicity of this method are operator dependent.
US may be useful in identifying undiagnosed
hernias and can provide information about the
size of the collar and the content of the hernia bag
(small or large bowel tract, liquid effusion, fat,
etc.).
39.2.3 Abdominal Radiographs
39.2 Diagnosis
Clinical history and physical examination are of
crucial importance in the diagnosis of inguinal hernias and their complications with particular attention paid to the duration and severity of symptoms.
Although complications are rarely the symptom of
the onset of hernias, in most cases, they occur in
patients with a previous history of inguinal hernia
or with a history of a previous surgery for hernia.
When clinical examination does not allow a
certain diagnosis, several instrumental investigations can be helpful, such as ultrasound, X-ray,
computed tomography, and nuclear magnetic
resonance imaging.
Incarcerated and strangulated groin hernias frequently occur with abdominal pain that can be
precisely localized or arise with peritonitis and
acute abdomen. Abdominal X-ray (both with clinostatic and orthostatic acquisition) is a simple
and fast method necessary to exclude differential
causes and investigate the possible occurrence of
abdominal obstruction.
39.2.4 Computed Tomography
Although computed tomography represents a
second-level instrumental investigation for inguinal hernia, according to some authors, this is the
method of choice for investigating the sudden
39 Surgical Emergencies inInguinal Hernia
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Fig. 39.1 CT scan showing an incarcerated femoral her-
nia containing bowel that shows reduced enhancement of
the wall as for ischemia
change, or worsening, of the symptoms.
Computed tomography has a high positive and
negative predictive value (respectively, 94 and
96%) and high specicity and sensitivity (83%),
especially when performed with dynamic poses
and with oral administration of contrast medium.
It may help to understand presence/absence of
bowel ischemic suffering and to choose the subsequent adequate operative treatment (Fig.39.1).
39.2.5 Nuclear Magnetic Resonance
Imaging
For its ability to discriminate soft tissues, magnetic resonance imaging offers the highest sensitivity and specicity, even higher than computed
tomography. However, this method is expansive
and too time-consuming to be actually used under
emergency conditions.
39.2.6 Laparoscopy
Incarcerated and strangulated hernias are traditionally repaired through open surgery.
Laparoscopy is time-consuming and requires
an experienced laparoscopic surgeon. However,
recent studies have shown its importance as diagnostic tool allowing an exhaustive inspection of
the intestinal loops ruling out ischemic damage.
Laparoscopy approaches (transabdominal or
total extraperitoneal) are discussed in the following chapter.
377
39.2.7 Deep Inguinal Ring
Laparoscopy
Following inguinotomy, the trocar is inserted
through the deep inguinal ring. This allows an
evaluation of possible ischemia damage in the
intestinal loops.
Hernias may spontaneously be reduced, for
example, after administration of muscle-relaxing
anesthetic drugs. In this case, ischemic damage
should be nevertheless ruled out before performing the hernia repair, especially if the hernia was
incarcerated or strangulated. In this case, laparoscopy is both feasible and safe, and it is also a
quite accurate diagnostic tool. Compared to laparotomy, complications are less frequent, and
postoperative recovery is both faster and less
painful for the patient.
39.3 Surgical Options
The European Hernia Society (EHS) guidelines
state that the gold standard for elective inguinal
hernia repair in adults is the Lichtenstein technique. However, the optimal technique to cure
incarcerated and/or strangulated inguinal hernia
remains controversial. Morbidity and mortality
are signicantly increased in patients presenting
with a complicated hernia, and likewise, the durability of these repairs is signicantly lower than
elective repairs. As expected, emergent groin hernia repairs have increased morbidity and mortality compared to elective repairs. The pathology
that contributes to this increased morbidity and
mortality is often the presence of necrotic or ischemic bowel causing intracrux of the clinical decision is operating early on
incarcerated hernias prior to the transition to
strangulation. This decreases the likelihood of
bowel ischemia, perforation, and need for resection. Strangulated hernias have a much greater
likelihood of mortality and morbidity and signicantly limit the choices for repair.
Patients undergoing emergent inguinal hernia
repair in the absence of bowel resection, ischemia, or peritonitis have no increased risk of
mesh-related morbidity.
abdominal sepsis. The
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