Genitofemoral Neuralgia

What is Genitofemoral Neuralgia?

Genitofemoral neuralgia is a long-term pain condition caused by pressure or injury to the genitofemoral nerve and its branches. This nerve is located in the groin area. The condition typically results in constant burning pain or discomfort in the groin area, and sensitivity or lack of sensation in the genitals and inner thighs. This condition is a common source of groin pain in both men and women, particularly after surgeries that may have unintentionally damaged the genitofemoral nerve.

This condition was first discovered and described by Magee in 1942 and was then renamed genitofemoral neuralgia by Lyon three years later due to its unique pain characteristics. The genitofemoral nerve starts from two points in the lower back (L1 and L2) and travels through a muscle in the lower back, making its way down to the inguinal region or groin. This path makes it easy to injure if too much force is used. The nerve passes under a tube that carries urine from the kidney to the bladder (the ureter) and splits into two branches. One branch goes to the genitals and the other branch goes to the thigh.

In men, the branch that goes to the genitals runs along the spermatic cord, which is a tube-like structure in the testicles. In women, the genital branch runs along the round ligament that supports the uterus. The femoral branch of the nerve, which travels to the thigh, does not enter the inguinal canal or groin area; instead, it travels under a ligament in the groin area and outside a protective layer around a blood vessel in the thigh.

Additionally, the genitofemoral nerve can be damaged by cancer that spreads to other parts of the body (such as sarcomas), fractures in the femur (the thigh bone), and orthopedic surgeries, leading to a reduced sense of sensation. The cremasteric reflex, which is a reflex action of the testicles in males in response to a touch sensation, is achieved through nerve pathways including the genitofemoral nerve.

Due to variations in the placement and structure of the genitofemoral nerve in different individuals, surgical planning and interventions must be done carefully to avoid damaging the nerve. Awareness of these variations can help in the proper diagnosis and treatment of patients suffering from neuralgia, which is nerve-related pain.

What Causes Genitofemoral Neuralgia?

Genitofemoral neuralgia, which is pain linked to the genitofemoral nerve, often results after recent surgeries. This nerves runs through the groin area, so procedures such as appendectomy (removal of the appendix), cesarean sections (c-section), lymph node biopsies, hysterectomies (removal of the uterus), vasectomies, hernia repairs, kidney removals, and urethrectomies are often associated with this type of pain. Hernia repairs, whether performed with a traditional open technique or using a laparoscope, are surgeries most commonly linked to genitofemoral nerve pain.

Studies have shown that groin pain from nerve damage is a common complication after an open hernia repair. Scars from this and other surgeries, especially an open appendectomy, can lead to nerve compression, causing this pain. However, this is less common with laparoscopic surgeries, where smaller incisions are used. Still, certain surgeries using mesh, like hernia repair, can also cause irritation to the genitofemoral nerve from the mesh being too tight, caught or direct damage to the nerve.

Overstretching of a muscle called the psoas, located in our lower spine to the thigh, could damage the genitofemoral and cutaneous nerves (nerves that supply the skin), which lies on the muscle’s surface. This, along with other surgical procedures near the major vessels of our lower bodies, can also cause inadvertent nerve damage. Furthermore, issues related to the surgical mesh like an infection or the formation of a lump of scar tissue can lead to nerve injury.

Surgeons must take extra care when placing the mesh during surgeries to prevent nerve damage. And it’s been found that placing mesh in the back and avoiding a specific tissue structure called the deep cremasteric fascia can significantly reduce nerve damage risk.

Unfortunately, a large number of patients experience long-term pain after hernia repair — likely due to nerve damage from scar tissue or accidental tying off, or ligating, of the nerve, which results in growth of a neuroma (a painful mass).

Direct compression of reproductive nerve, which happens with abscesses, blood clots, or certain types of diseases, like Pott’s disease, could be the reason for genitofemoral neuralgia. The nerve can also be trapped due to situations such as an injury to the abdomen, congestion of internal abdominal organs or tissues, late pregnancy, or a tumor.

Indirect nerve damage also occurs in a group of conditions where a granulomatous process (where the body walls off an area of infection or inflammation) compresses the genitofemoral nerve or its branches. Similarly, nerve compression can occur in people who repeatedly use their hip joint — like those who bike frequently — or in people exposed to long periods of abdominal compression.

Risk Factors and Frequency for Genitofemoral Neuralgia

There isn’t a lot of information in recent scientific literature about how common genitofemoral neuralgia is. But, studies have shown that 1.8% of people experience general nerve pain after having a gynecological surgery. Interestingly, a similar percentage of patients reported full recovery. After pelvic surgery, it’s reported that 2% of people experience a nerve injury. Genitofemoral neuralgia appears to affect both males and females equally.

• Genitofemoral neuralgia’s prevalence is not well documented in recent studies.
• About 1.8% of patients experience general nerve pain after gynecological surgery.
• A similar rate of patients has been reported to fully recover from the pain.
• 2% of patients reportedly get a nerve injury after undergoing pelvic surgery.
• The condition affects both males and females at the same rate.

Signs and Symptoms of Genitofemoral Neuralgia

Genitofemoral neuralgia is a condition that commonly causes constant or intermittent burning pain in the lower side of the abdomen or groin. This pain may also extend to the upper inner thigh and the genital area. Walking, cycling, strong changes in abdominal pressure, or over-extension of the hip and thigh can often aggravate the pain. One may find relief by sitting, lying down, bending the hip, or standing in a bent-over position. This can start immediately after surgery or be delayed for months or years.

Some other symptoms include numbness in the upper inner thigh and genital area, increased sensitivity to pain along the path of the nerve, a tingling feeling, sensitivity to touch, and tenderness in the groin area. Female patients might experience a burning sensation in the genital area and inner thigh, while male patients might experience pain in the scrotum. Touching the affected area lightly might not elicit a response, but a sharp contact might cause discomfort or an exaggerated response to pain. Activities like extending the hip, cycling, or wearing tight clothing could worsen the discomfort.

Identifying genitofemoral neuralgia requires a thorough medical history and a physical examination. Notable points that healthcare professionals should inquire about include:

• The nature and spread of the patient’s pain
• The presence or absence of numbness or increased sensitivity to pain
• The origin and progression of symptoms over time
• What makes the pain better or worse
• Any past surgeries or traumas in the area
• Recent illnesses, surgeries, travel, or medications
• Any chronic pain syndrome, cancer, chemotherapy, radiation therapy, and abdominal trauma in the history

Physical examination involves comparing both sides of the body, thoroughly inspecting the skin and tender areas, assessing sensitivity to touch and pinprick sensation, evaluating muscle strength and mobility, and doing special tests to rule out nerve root compression or joint problems. Patients may show a characteristic hunched posture while sitting, and a bent posture while walking. Their gait can also show recent changes. High-paced walking, running, lifting heavy objects, climbing, squatting, or stooping can exacerbate the pain, while lying on their back may alleviate it.

Testing for Genitofemoral Neuralgia

When a doctor isn’t sure about the cause of your nerve pain, they might perform a nerve block on the ilioinguinal or genitofemoral nerves. A nerve block is when a doctor injects medication that numbs a specific nerve to prevent pain signals from reaching your brain. This procedure helps them pinpoint the source of the pain. The ilioinguinal nerve block is done more commonly because it’s easier to access from the front of the body. The genitofemoral nerve, which is located behind the stomach area and beneath the inguinal ligament (a band of fibers running from the abdomen to the groin), is less reachable and carries a higher risk of complications.

Images from MRI or CT scans are not typically used to diagnose genitofemoral neuralgia, or nerve pain in the genital or femoral areas, directly. However, they may help rule out other possible causes of the pain. Previously, nerve blocks were performed using a rough estimate of the nerve’s location based on body anatomy. With advancements in technology, procedures have become more precise using imaging methods such as ultrasound, computed tomography, magnetic resonance imaging, and x-ray fluoroscopy. Magnetic resonance neurography in specific is a developing tool; it can provide detailed images to show areas where a nerve might be trapped or damaged.

Ultrasound and 3-Tesla (3-T) magnetic resonance neurography-guided retroperitoneal genitofemoral nerve blocks have been proven successful in diagnosing genitofemoral neuralgia, with a success rate of around 90%.

Electrophysiology, which studies the electrical properties of the body, doesn’t work well for diagnosing neuralgia, a type of nerve pain. However, it can be somehow beneficial when studying genital neuralgia involving the genital branch of the genitofemoral nerve. The genitofemoral nerve controls the cremasteric reflex, a contraction of the abdominal muscles in response to touch. A lack of this reflex typically does not significantly impact a patient’s quality of life.

Treatment Options for Genitofemoral Neuralgia

Living with neuropathic pain can be challenging. It’s important to understand that managing such pain usually needs a combination of strategies before considering surgery. Often, it can take at least 6 to 12 months of treatment before a surgical evaluation. Meanwhile, some people might find relief in non-drug treatments such as exercises, acupuncture, massage, heat treatments, physiotherapy, myofascial release (a type of massage to release tension in the muscles), and reflexology (pressure applied on certain points on the feet, hands, or ears). Specifically, acupuncture may help with neuropathic pain after genital surgery.

Medical Management

There are various medications available that could help manage neuropathic pain. Topical anesthetics like lidocaine, menthol, and capsaicin, which you apply directly to the skin, are often used in the early stages of treatment because they could relieve certain skin sensations related to nerve pain. However, the standard treatment for most types of neuropathic pain involves certain kinds of antidepressants. Additionally, other medications like gabapentin, pregabalin, anti-inflammatory drugs, selective serotonin/norepinephrine reuptake inhibitors (these medications affect chemicals in the brain that send pain signals), antiepileptics, N-methyl-D-aspartate antagonists, and opioids could be used to assist in managing neuropathic pain.

Generally, a trial of these treatments lasts about 3 to 8 weeks and during the course of this period, doctors will evaluate the effectiveness of the treatment and make adjustments as necessary. Combination therapy with more than one treatment can be effective, but it can also lead to more side effects. If medications aren’t helpful, then localized injections might be considered.

One common treatment involves injections of local anesthetics and corticosteroids near the area of injury. This strategy has been successful in treating acute neuropathic pain, especially that which follows trauma or surgery, and can provide evidence that a specific nerve is causing the discomfort. Some patients experience sustained or even permanent relief from such treatment. However, it usually does not last longer than six months and will likely need to be repeated for sustained pain relief.

If these measures are not enough, nerve ablation, (a procedure where a portion of a nerve is destroyed), or neurectomy (surgical removal of a nerve) may be considered. More advanced techniques, such as ultrasound-guided nerve block injections and magnetic resonance neurography-guided nerve blocks, are also available and have shown promising results in diagnosing and treating nerve pain, with fewer risks and better outcomes.

In severe cases, botulinum toxin type A, a potent toxin produced by a particular bacterium, has been reported to successfully treat nerve pain that has not responded to other treatments.

Advanced Treatments

For some people, implantable peripheral nerve stimulation devices have been shown to improve neuropathic pain. This involves using electric currents to stimulate specific nerves, thus reducing pain. However, the procedure has some risks, such as formation of hematomas (collections of blood outside of the vessels), the need for periodic battery replacement, and possible additional trauma during device placement, with an infection risk in about 5% of cases.

Another strategy for long-term pain control is radiofrequency ablation, which causes thermal damage to the nerve without damaging its outer protective layer. Cryoablation is another similar procedure where the nerve’s internal structures are frozen, resulting in degeneration without damaging the protective layers. This allows the nerve to regenerate with a low risk of other complications.

Surgical Management

As a final step, if other treatments are not successful, neurectomy might be considered. This involves surgically removing the troublesome nerve, a permanent and invasive procedure, but it has been reported to provide total pain relief in about 70% of patients. The side effect is a decreased sensation in the area supplied by the removed nerve.

For instance, in patients who have persistent pain after a hernia repair surgery, a triple neurectomy (removal of three major nerves of the lumbar plexus) should be considered if nonsurgical management has failed and they had no pain or non-nerve-related pain before the surgery. This procedure has been reported to provide better results than other surgical approaches, with an overall success rate of about 70%.

If a mesh (a type of medical device used to provide extra support to weakened tissues) is identified as the cause of the nerve injury, it should be removed, and a more extensive neurectomy should be performed to prevent recurrence of symptoms.

What else can Genitofemoral Neuralgia be?

Diagnosing genitofemoral neuralgia, a type of nerve pain, can be challenging, as the nerve it involves is close to other nerves with similar functions, particularly the ilioinguinal nerve. When a patient has symptoms like this, doctors also consider the possibility of ilioinguinal neuralgia. These conditions can be hard to distinguish, as both affect related areas of the body. Generally, however, genitofemoral neuralgia often causes pain in the lower abdomen that can be increased by touching the area or extending the hip.

Ilioinquinal neuralgia is a condition that can cause burning, stabbing pain, and changes in sensation in the lower abdomen and upper thigh. For men, it might lead to less sensation in the front of the scrotum and the base of the penis. For women, the areas this condition affects can overlap with those affected by genitofemoral neuralgia, which are the major outer folds (labia majora) and the fatty area overlying the pubic bones (mons pubis). A type of pain relief procedure called an ilioinguinal nerve block can help doctors tell the difference between these two conditions.

A similar condition, iliohypogastric neuralgia, often presents with burning pain shortly after surgery. The pain usually starts at the site of the abdominal incision and radiates towards the pubic area and the groin. This discomfort can even extend into the genital area, making it difficult to diagnose accurately. While medical testing can sometimes help diagnose this condition, it is not always definitive.

Pudendal neuralgia is another type of nerve-related condition that typically causes long-lasting pain in the pelvic, perineal, and genital regions. This condition usually develops gradually and subtly, with symptoms often being less noticeable in the morning and worsening throughout the day. Sitting often makes the pain associated with pudendal neuralgia worse. In addition to pain, people with pudendal neuralgia may also have issues with bowel, bladder, and sexual functions. This condition is often treated with local nerve blocks and non-invasive treatments, but sometimes surgical intervention may be necessary.

Another similar issue could be femoral cutaneous neuralgia, which results in pain and abnormal sensations in the back and front of the thighs. This condition is often diagnosed when pain relief is observed following a local anesthetic block targeting specific nerve roots.

Obturator nerve injury is another possibility, which typically results in the loss of sensation in the inner thigh and weakness when moving the thigh inward, potentially affecting how a person walks. This condition is typically diagnosed by how a patient presents and can be confirmed with a local anesthetic nerve block. If the obturator nerve is cut, immediate surgical repair provides a good recovery of muscle function.

Lastly, the condition known as orchalgia or chronic testicular pain, which can occur after hernia surgery, is frequently mistaken for genitofemoral neuralgia. It’s important to note that the testes themselves don’t have any sensations related to the body’s sense of position and movement (somatic sensations). The genital branch of the genitofemoral nerve affects the sensations in the scrotum, which must be distinguished from orchalgia through a careful examination. If necessary, a nerve block can help clarify the diagnosis.

What to expect with Genitofemoral Neuralgia

The outcome of genitofemoral neuralgia, a type of nerve pain in the genital and thigh area, depends on how long you’ve been experiencing symptoms and how much your nerve has been damaged. Typically, this condition is due to nerve compression that causes an interruption in the nerve function (neuropraxia).

In some cases though, more severe damage can result in complete cutting of the nerve (neurotmesis), usually as a direct result of abdominal surgery. This situation can seriously disrupt the nerve’s ability to recover. You might want to visit StatPearls’ online resource on neurotmesis for more information.

The potential and speed of nerve regeneration can vary greatly depending on the extent of injury. It can take from several months to years to heal, and there’s no guarantee that the nerve will completely recover or be able to properly send signals to the affected parts of the body.

Individuals with neuropathic pain like this can sometimes develop long-term pain conditions, which require a team of specialists for effective symptom management. Approaching pain management from many angles can help to improve these nerve-related symptoms.

Possible Complications When Diagnosed with Genitofemoral Neuralgia

Chronic symptoms of a condition called genitofemoral neuralgia can negatively impact one’s daily life. If not taken care of, these symptoms can cause behavioral changes that can affect a person’s health and interactions with others. These changes can include overusing medication, overeating, not engaging in physical activities, becoming physically weaker, isolating oneself from social activities, and suffering from severe psychological stress.

If you are scheduled to undergo surgery to manage genitofemoral neuralgia, it is important to understand that there are risks involved. Before agreeing to any surgery, it is essential to be well-informed about the potential complications. One procedure, called peripheral nerve ablation, which may use radiofrequency or cryoablation, can result in cell death and damage to your body’s tissues.

The process of radiofrequency ablation uses high temperatures from radio waves to effectively decrease pain caused by nerve damage. But, this procedure is not without risks. It can cause thermal injury to tissues nearby, form a hematoma (bloodmass), infection, and damage to the nerve. There can also be a complication of pain and weakness caused by neuritis (nerve inflammation).

Surgical removal of a nerve or neurectomy, which includes a triple neurectomy, is commonly followed by hypoesthesia, a decreased sense of touch or sensation, in the areas controlled by the ilioinguinal, iliohypogastric, and genitofemoral nerves. This generally does not come with associated muscle weakness. Despite this, a triple neurectomy is considered a safe and effective treatment for stubborn cases of genitofemoral neuralgia.

Risks Involved:

• Overuse of medication
• Overeating
• Lack of physical activity
• Physical weakening
• Social isolation
• Severe psychological stress
• Thermal injury to nearby tissues
• Bloodmass formation
• Infection
• Nerve damage
• Neuritis-related pain and weakness
• Decreased sense of touch or sensation

Preventing Genitofemoral Neuralgia

Genitofemoral neuropathy is a condition that happens when the genitofemoral nerve (a nerve in your abdomen) gets hurt, squeezed, or trapped, usually due to complications of abdominal surgery. The seriousness of the nerve damage often matches the chance of the nerve healing by itself. Leaving the nerve pain untreated can significantly impact your life, affecting your physical activities and lifestyle, and can cause noticeable issues with movement and sensation.

Your nerve regenerating or healing itself takes a lot of time and isn’t always guaranteed, as there’s no current treatment that promises full nerve recovery. However, there are several things you can do to encourage nerve growth and reduce any disability. It’s essential for you to keep your blood sugar levels controlled, as high blood sugar can further harm your nerves and slow down recovery. It would be best if you also cut out smoking and alcohol, which can make the nerve pain worse. Losing weight can help lower the chances of your nerves being squeezed, and eating a balanced diet with plenty of vitamins and minerals is crucial for your body to get the nutrition it needs during the nerve repairing and regrowth process.

Keeping up with regular physical exercises can prevent muscle loss, decrease disability, and encourage your peripheral nerves (nerves outside the brain and spinal cord) to work properly. It’s also a good idea to figure out and avoid activities that trigger or worsen your symptoms, like playing certain sports or wearing tight clothes, to prevent further nerve damage.

Before considering medications, it’s recommended to look into treatments that don’t involve medication or surgery. If you have uncontrolled neuropathy, you are more likely to develop mental health conditions like depression and anxiety.