The patient was diagnosed with ilioinguinal neuralgia . This was due to direct injury at the time of his operation versus entrapment due to scar or mesh. He had no other obvious causes for his postoperative pain, including no evidence of hernia recurrence, infection, inflammation, or meshoma. He was offered nonsurgical treatment as the initial modality for cure. This includes a combination of nerve blocks and neuromodulating medications and anti-inflammatories. If these provide short-term success, they are continued with the goals of long-term success. In our experience, most patients who respond to local injections require 3–5 cycles of nerve blocks and tend to have weeks to months of pain-free episodes after each block as well as overall reduction in their pain score. Only those that have short-term response but no long-term cure are offered surgical options.

I first offered the patient a diagnostic nerve block in the office, which was performed with 0.5 % bupivacaine, injected medial and inferior to the anterior superior iliac spine. This resulted in near-complete resolution of the patient’s pain. Wiping the area clean after the injection resulted in no pain. As per our protocol among patients with purely neuropathic pain, if they respond positively to local nerve blocks, they are offered serial blocks, no more than every 2 weeks, as their primary mode of treatment. The therapeutic nerve blocks include steroids (10 mg Kenalog). The patient indeed had a very clear improvement with the blocks. These were continued and resulted in reduction of his pain such that he was able to return to work, which involved sitting and standing. The scrotal sensitivity resolved. He did have continued pain along his groin and would even pass out at times due to the pain.

The patient already was under the care of a pain management specialist. He did not tolerate duloxetine, due to rash, and did not tolerate gabapentin due to its side effects. He was using Traumeel topically and 5 % lidocaine patch with no major improvement in symptoms.

The patient did not wish to undergo an operation unless absolutely necessary. After five cycles, the patient was agreeable to surgical exploration.

The patient was offered targeted ilioinguinal neurectomy. This was performed in open fashion, anteriorly, with identification of the nerve as it coursed anteriorly and just proximal to the lateral edge of the mesh.