Chronic Groin Pain After Hernia Surgery Gets a European Treatment Roadmap

Chronic pain after groin hernia surgery is one of those complications that surgeons would rather not talk about and patients rarely see coming. Between 8 and 17 percent of the millions of people who undergo inguinal hernia repair each year end up with pain so persistent and disabling that it limits their daily activities for more than three months. For them, an operation meant to fix a bulge in the abdominal wall becomes the start of a long, fragmented journey through pain clinics, imaging suites and, sometimes, operating rooms again. Now a multidisciplinary working group from five European tertiary referral centres has published a unified strategy to bring order to that chaos, called EurA-CPIP, the European Algorithm and Strategy for Management of Chronic Postoperative Inguinal Pain.

The scale of the problem is easy to underestimate. Inguinal hernia repair is among the most common operations performed worldwide, which means that even a double-digit percentage of chronic pain translates into an enormous burden of long-term morbidity. The pain is not a single entity. It can be neuropathic, driven by injured or entrapped nerves such as the ilioinguinal, iliohypogastric or genital branch of the genitofemoral nerve; it can be nociceptive and inflammatory, linked to the mesh or the healing tissues; it can be mechanical, caused by a folded mesh or a meshoma; or it can be nociplastic, a sensitisation phenomenon with no clear structural correlate. Many patients present with a mixture of these mechanisms, which is precisely why no single treatment works for everyone.

Management has remained stubbornly inconsistent. The updated international HerniaSurge guidelines acknowledge that the evidence base for most chronic postoperative inguinal pain, or CPIP, interventions is sparse and heterogeneous, with few advances over the past decade and correspondingly weak recommendations. Several treatment algorithms have been proposed over the last twenty years, but none has achieved universal acceptance. Many were built predominantly around a surgical perspective, lacked standardised patient evaluation and follow-up, and were developed without multidisciplinary input, even though CPIP patients present to both surgeons and pain specialists. The EurA-CPIP group set out to translate the broad HerniaSurge recommendations into a practical clinical framework that could actually be implemented, measured and improved.

The design process was pragmatic. A working group of surgeons, anaesthesiologists and pain specialists from centres in Denmark, the Netherlands, Belgium and the United Kingdom critically appraised all previously published CPIP algorithms through a scoping review, examining their underlying evidence, patient selection criteria, outcomes and follow-up durations. Through iterative consensus meetings, they agreed on a step-up structure that progresses from the least to the most invasive interventions, ultimately reaching reoperation with neurectomy or mesh removal. Patients may enter the algorithm at different stages depending on what treatments they have already received before referral, which reduces selection bias. Critically, the algorithm is not a static document: it is paired with a prospective data-collection platform and will be revised regularly as real-world outcomes accumulate, in the spirit of a learning healthcare system.

The pathway begins with a thorough work-up designed to identify or exclude treatable structural causes such as recurrent hernia or mesh complications, supplemented when necessary by imaging and review of previous operative reports. A standardised assessment form, including the Douleur Neuropathique 4 questionnaire, supports phenotyping of the pain as predominantly neuropathic, inflammatory, visceral, mechanical, nociplastic or mixed. From there, conservative pharmacological treatment comes first: paracetamol and non-steroidal anti-inflammatory drugs, plus first-line neuropathic agents such as tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors or gabapentinoids when neuropathic features dominate. Long-term strong opioids are explicitly discouraged. Topical lidocaine or capsaicin may be tried despite limited evidence, given their low risk profile. Response is assessed after three to six weeks.

If medication fails, the algorithm escalates to interventional options. Trigger point injections with local anaesthetics serve a dual diagnostic and therapeutic role, since temporary relief suggests a peripheral pain generator. Ultrasound-guided peripheral nerve blocks of the ilioinguinal, iliohypogastric and genitofemoral nerves follow, used primarily to confirm a peripheral neuropathic source and to map the sensory territory. For patients who show a meaningful, reproducible response to these diagnostic blocks, three investigational add-ons are embedded in the pathway: pulsed radiofrequency, which modulates nociceptive transmission without creating a thermal lesion; cryoneurolysis, which uses a probe freezing to between minus 20 and minus 100 degrees Celsius to induce temporary axonal degeneration while preserving the nerve’s connective tissue scaffold; and botulinum toxin A, which may inhibit the release of pain-related neurotransmitters such as substance P, CGRP and glutamate from peripheral sensory terminals. All three remain investigational in CPIP and are permitted only with systematic outcome registration and clear stopping rules.

Before any escalation to surgery, a formal multidisciplinary team review is mandatory. The team must include an experienced hernia surgeon and a pain specialist, ideally supported by physiotherapy, psychology and other specialties as the clinical picture demands. Psychological screening is built into the framework using validated instruments: a score of 8 or more on the Hospital Anxiety and Depression Scale flags possible anxiety or depression, while a Pain Catastrophizing Scale score of 30 or more indicates clinically relevant catastrophising. Patients exceeding these thresholds are at increased risk of poor outcomes and may benefit from early referral into the multidisciplinary pathway, reflecting the biopsychosocial understanding that successful CPIP care extends well beyond anatomical correction.

Surgery itself is reserved for carefully selected patients and should not be considered until at least six months after the index hernia repair, allowing time for non-surgical treatment and for mesh-related inflammation to settle. The sobering benchmark is that roughly 30 percent of patients do not achieve meaningful pain relief after remedial CPIP surgery, and a small proportion may even experience worsening pain. Options include exploration, selective or triple neurectomy, mesh removal, or combinations thereof, with spermatic cord denervation possible in trial settings. The best comparative evidence comes from the GroinPain trial, in which selective neurectomy achieved more than 50 percent pain reduction in 71 percent of patients at six months. Mesh removal reports success rates of 60 to 100 percent, though these are confounded by concomitant nerve resection, and laparoscopic mesh removal carries a risk of serious complications including major vascular injury. For refractory neuropathic or nociplastic cases where surgery is not appropriate, advanced pharmacological escalation and, exceptionally, dorsal root ganglion stimulation remain options within specialist centres.

What most distinguishes EurA-CPIP, however, is its measurement infrastructure. Every patient is assessed at baseline and at roughly six-month intervals with a standardised battery of patient-reported outcome measures: the numeric rating scale for pain severity, with a reduction of at least two points defined as clinically meaningful improvement; the Patient Global Impression of Improvement; the Activities Assessment Scale for function; sexual function questioning; the Hospital Anxiety and Depression Scale; the Pain Catastrophizing Scale; and the SF-12 quality-of-life survey. Success is therefore defined not solely by pain reduction but by function and global improvement, a patient-centred perspective increasingly demanded in surgical research. Supportive and rehabilitative care, including cognitive behavioural therapy, acceptance and commitment therapy and mindfulness-based approaches, is integrated early as a core component rather than a last resort, with the aim of functional restoration and improved self-management.

The authors are candid about the limitations. Many recommendations rest on expert consensus because randomised controlled trials in CPIP are rare, and the algorithm’s success depends on consistent implementation, adherence to outcome protocols and timely data entry across centres with varying resources. Registry-based observation cannot establish causation, and prospective comparative studies will still be needed. Yet the framework’s ambition is clear: by harmonising phenotyping, treatment sequencing and outcome capture across an expanding network of centres, and by linking eventually to national hernia registries, EurA-CPIP aims to identify which patient characteristics predict response to which treatments, stratify patients toward therapies with the highest probability of success, and generate the well-characterised populations needed for future intervention trials. For a condition that has languished in the gap between surgery and pain medicine for decades, that would be a genuinely transformative step.

Subject of Research: Management of chronic postoperative inguinal pain after inguinal hernia repair using a European multidisciplinary treatment algorithm

Article Title: A European algorithm and strategy for management of chronic postoperative inguinal pain (EurA-CPIP)

Article References: Andersen, K. G., van der Meer, T. W. K., van Veenendaal, N., Foss, N. B., Loos, M. J. A., Miserez, M., Pawlak, M., Roumen, R. M. H., Naddaf, T., Togsverd-Bo, M., Stadeager, M. W., Aasvang, E. K., & Zwaans, W. A. R. (2026). A European algorithm and strategy for management of chronic postoperative inguinal pain (EurA-CPIP). Journal of Abdominal Wall Surgery, 5, Article 16944. https://doi.org/10.3389/jaws.2026.16944

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.16944

Keywords: chronic postoperative inguinal pain, inguinal hernia repair, persistent postsurgical pain, treatment algorithm, multidisciplinary care, neurectomy, mesh removal, nerve blocks, cryoneurolysis, botulinum toxin A, patient-reported outcomes, HerniaSurge guidelines