Also, 39% of my female patients have radiating pain into the vagina (Table 18.1). This is analogous to the pain radiating to the base of penis and/or testicle in men. Such a complaint can trigger a gynecologic workup of obscure diagnoses such as vulvodynia, pudendal neuralgia, and chronic pelvic pain. These diagnoses often have complex syndromes that are not seen among patients with inguinal hernia.

Symptoms unique to women include pain during menses. In my practice, 25% of women with symptomatic inguinal hernias report exacerbation of their symptoms during their menses (Table 18.1). This is considered to be due to fluctuations in hormones. As estrogen levels plummet at the onset of menstruation, pain levels increase. This phenomenon has been shown in multiple other disease processes, including joint disorders, autoimmune disorders, and gastrointestinal diseases. In such cases, women are commonly worked up for endometriosis, which is a cyclical disease. Unlike endometriosis, hernias are not pain-free in between menstrual periods.

In women, hernias can be painful during sexual intercourse as well as with orgasm. The reason for pain with intercourse is often a simple phenomenon of direct contact and pressure on the groin. Similarly, vaginal penetration can cause pain by direct pressure onto the external ring, which we noted earlier could be palpable transvaginally. Pain with orgasm is considered to be due to pelvic floor contraction against a full inguinal canal.