Hernia (2015) 19:53–59
DOI 10.1007/s10029-013-1150-3
ORIGINAL ARTICLE
Role of orchiectomy in severe testicular pain after inguinal hernia
surgery: audit of the Finnish Patient Insurance Centre
K. Rönkä • J. Vironen • H. Kokki • T. Liukkonen
H. Paajanen
Received: 19 February 2013 / Accepted: 28 July 2013 / Published online: 9 August 2013
Ó Springer-Verlag France 2013
Abstract
Purpose Testicular ischemia and necrosis are uncommon
complications after inguinal hernioplasty. Our aim was to
evaluate the incidence of severe urological complications
related to adult inguinal hernia surgery in Finland with
special reference to orchiectomy in relieving intractable
chronic testicular pain.
Methods All urological complications related to inguinal
hernia surgery during 2003–2010 were analysed from the
Finnish Patient Insurance Centre. The patients with
intractable chronic scrotal or testicular pain that resulted in
orchiectomy were re-evaluated after a median follow-up of
7 years (range 2–15 years). The operative factors related to
chronic testicular pain and atrophy were analysed using
multiple regression analysis.
Results Altogether 62 urological complications (from 335
litigations) were recorded from 92,000 inguinal hernia
K. Rönkä
H. Paajanen (&)
Department of General Surgery, Kuopio University Hospital,
70211 Kuopio, Finland
e-mail: hannu.paajanen@esshp.fi; hannu.paajanen@kuh.fi
J. Vironen
Department of Surgery, Helsinki University Hospital,
Helsinki, Finland
H. Kokki
Department of Anesthesia and Operative Services,
Kuopio University Hospital, Kuopio, Finland
H. Kokki
Department of Anaesthesiology and Intensive Care, School
of Medicine, University of Eastern Finland, Kuopio, Finland
T. Liukkonen
H. Paajanen
Department of Surgery and Urology, Central Hospital
of Mikkeli, Mikkeli, Finland
•
operations. The distribution of claimed urological compli-
cations consisted of 34 testicular injuries, ten bladder
perforations, seven massive scrotal haemorrhage or 11
miscellaneous injuries. Seventeen atrophic testes were left
in situ and 17 (six early \ 7 days, 11 late [ 8 days) or-
chiectomies were performed due to necrosis or chronic
testicular pain syndrome. In the conservative group of
moderate scrotal or testicular pain (n = 17), all patients
had late pain symptoms ([8 days), but pain was not so
severe that orchiectomy was attempted. Using a multivar-
iate analysis, postoperative infections were associated with
chronic testicular or scrotal pain and atrophy, but hospital
status, surgeon’s training level, laparoscopic or open
operation, type of hernia or use of mesh did not correlate
with testicular injuries. During follow-up, 11/17 (65 %)
patients with orchiectomy were free of testicular pain.
Conclusion Urological injuries form one-fifth of the
major complications after inguinal hernioplasty. Orchiec-
tomy appears to help the majority of patients with severe
testicular pain syndrome.
Keywords Inguinal hernioplasty
Urological
complications
Orchiectomy
Inguinal neuralgia
Introduction
After inguinal hernioplasty, either scrotal or testicular pain
can appear to the patient [1, 2]. Usually the former is
caused by nerve damage and the latter by ischemic or
mechanical sequelae of inguinal hernia surgery. Testicular
pain can also be divided into neuropathic (damage of
nerves) vs. nociceptive (testicular tissue injury) pain. In
both cases, the aetiology of pain can be ischemic or
mechanical nerve damage during surgery. Testicular
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ischemia and necrosis after inguinal hernia surgery are
uncommon complications [1, 2]. The current incidence is
difficult to calculate and the most reports predate laparo-
scopic hernia repairs. For primary open inguinal hernio-
plasty, testicular atrophy occurs in 0.5 %, while for open
recurrent hernioplasty the incidence can approach even
5 % [3–5]. Orchiectomy as a result of acute ischemia or
chronic intractable testicular pain has been reported rarely
after open or laparoscopic hernia repair [6, 7]. Other tes-
ticular adverse events including swelling and orchitis are
observed in between 0.9 and 1.5 % of laparoscopic ingui-
nal hernia repairs [8]. Testicular injury after inguinal hernia
surgery is thought to be due to acute thrombosis of the
venous plexus, arterial or nerve injuries, or mesh irritation
of cord [9, 10].
Approximately 11,000 inguinal herniorrhaphies are
performed each year in Finland with a population of 5.4
millions, over 80,000 operations in United Kingdom and
over 800,000 in the United States [11–13]. Recently, data
from national hernia registers have been available from
Denmark and Sweden. These registers have mainly focused
on hernia recurrences and the frequency of chronic inguinal
pain after surgery, but not on testicular adverse effects [14,
15]. Recent urological reviews of chronic testicular pain
have discussed the role of inguinal hernia surgery as a
cause of pain, but no prevalence data have been reported so
far [1, 2].
The Finnish Patient Insurance Centre offers a reliable
source of information for the analysis of serious urological
complications related to inguinal hernia surgery [11]. In the
present study, we analysed all the reported urological
complications related to adult inguinal hernia surgery from
the Patient Insurance Centre during an 8-year period. A
long-term quality-of-life survey of patients undergoing
orchiectomy as a result of intractable scrotal or testicular
pain and/or ischemia was also performed.
Patients and methods
The patient Injury Act in Finland was brought into force on
the first of May 1987. To obtain full compensation for
patient injury, proof of malpractice is no longer required.
The Patient Injury Act ensures compensation for patient
injury that has sustained in connection with medical
treatment and health care, e.g. (1) probably has arisen as a
consequence of examination or treatment, (2) has been
caused by an infection or inflammation, and (3) has been
caused by an accident connected with examination or
treatment. Every Finnish hospital has an official patient
ombudsman who helps the patient to prepare a claim when
necessary. Every patient is insured by the Finnish Patient
Insurance Centre, to which all major and majority of
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Hernia (2015) 19:53–59
moderate surgical complications and bodily injuries are
reported. Bodily injuries refer to an illness, treatment
injury, equipment-related injury, infection or unreasonable
injury during or after surgical procedures. Patient insurance
compensates such costs as medical treatment expenses, loss
of income, pain and suffering, permanent functional defect
or permanent cosmetic injuries after surgery.
Our national register study consisted of all 335 com-
plications related to inguinal and femoral hernia surgery
reported to the Patient Insurance Centre from January
2003 through December 2010 (Fig. 1). The study data
were retrospective and based on the records of Finnish
Patient Insurance Centre. In the present study, all uro-
logical complications (n = 62) occurring in open or lap-
aroscopic hernia repair in adult patients (18 years or older)
were included. In the analysis, we divided inguinal hernia
procedures into four categories: laparoscopic vs. open
surgery and mesh vs. non-mesh operations. Furthermore,
hospital status (university, central, local or private hospi-
tals) and surgeon’s training level (resident, specialist) were
separately analysed. Surgery for inguinal hernias in Fin-
land was performed in 37 local hospitals, 14 central
community-based hospitals and five university hospitals.
The patients suffering from moderate testicular or scrotal
chronic pain and treated without orchiectomy (n = 17),
intractable chronic testicular pain or atrophy resulting in
late orchiectomy (n = 11) or early orchiectomy due to
necrosis of testicle (n = 6) were further analysed using
pain and quality-of-life questionnaire (letter/telephone
call) approximately 7 years (range 2–15 years) after
inguinal hernioplasty. Early orchiectomy as a result of
total vascular occlusion of testicular vessels and total
testicular necrosis was performed usually during the first
week after inguinal hernioplasty. Late orchiectomy as a
result of intractable pain syndrome was performed after
first week (usually after months) of inguinal hernioplasty.
Scrotal ultrasound was always used as a diagnosis of early
vascular changes of the testicles and nerve blocks for late
testicular or scrotal pain. Persistent inguinal and testicular
pain was asked separately using numeric rating scale
(NRS; range 0 = best outcome/no pain, 10 = worst out-
come/most pain). The study protocol was approved by the
Research Ethics Committee of the Hospital District of
Northern Savo, Kuopio, Finland.
The annual number of all inguinal and femoral hernio-
plasties in Finland was acquired from the Finnish Hospital
Discharge Register, which collects information regarding
diagnosis, dates of admission, discharge and surgical pro-
cedures of each patient. The purpose of this register is for
research development, administration and planning. The
register is maintained by the National Board of Health.
Every communal and private hospital collects data that are
automatically sent to the register at the end of each year
Hernia (2015) 19:53–59 55

Inguinal hernioplasties Table 1 The total number of inguinal hernia procedures and operated
in Finland 2003-2010 femoral hernias in Finland in 2003–2010
n=91923
Number of patients (%)

Inguinal Femoral Total

a,b b b
Patient insurance Open mesh Open Laparoscopic
claims hernioplasty sutured
n=335
2003 7,960 (69) 2,444 (21) 934 (8) 179 (2) 11,517
2004 8,370 (71) 2,073 (17) 1,137 (10) 180 (2) 11,760
2005 9,256 (72) 2,127 (16) 1,373 (10) 170 (2) 12,926
Urological Non-urological
2006 8,512 (72) 1,868 (16) 1,237 (10) 178 (2) 11,795
complications complications
n=62 n=273 2007 7,809 (72) 1,695 (16) 1,190 (11) 126 (1) 10,820
2008 8,113 (73) 1,681 (15) 1,100 (10) 163 (2) 11,057
2009 8,271 (74) 1,611 (14) 1,150 (10) 165 (2) 11,197
2010 8,028 (74) 1,535 (14) 1,128 (10) 160 (2) 10,851
Testicular atrophy or Other urological n=28
necrosis n=34 (bladder perforation, Total 91,923
haemorrhage, urinary
retention) Population 5.4 millions
a
Most of the patients were operated using Lichtenstein technique
b
Inguinal hernioplasty
Orchiectomies n=17: Conservative n=17:
outcome analysis outcome analysis
after 7 years after 7 years Results
(range 2-15 years) (range 2-15 years)
Between 2003 and 2010, 335 serious adverse events related
Fig. 1 Flow chart of the study to inguinal hernia surgery were reported to the Finnish
Patient Insurance Centre (Fig. 1). Of the 335 reported
[16]. From 2003 through 2010, some 91,923 inguinal and complications, 62 (18.5 %) were urological complications
femoral hernioplasties were carried out in Finnish com- and these were rather equally distributed throughout the
munal and private hospitals (Table 1). The majority of study period (Fig. 2). Seventeen patients out of 62 uro-
procedures ([70 %) were performed using an open mesh logical complications had moderate testicular or scrotal
technique. The number of laparoscopic repair remained pain without severe testicular tissue changes. The relative
rather small and stable across the study period (10 %). The rate of urological complications in litigation cases was 0.67
data were utilised to calculate the annual incidence of per 1,000 inguinal hernia procedures compared to 3.0 per
urological complications per 1,000 hernioplasties. 1,000 procedures in non-urological complications. The
The data analysis was carried out using IBM SPSS for demographic and clinical data of patients with and without
WindowsÒ, Release 20.0 (IBM, Somers, IL, USA). Uni- urological complications were similar (Table 2). Use of
variate analyses for categorical variables were calculated prophylactic antibiotics and general anaesthesia was more
with the Fisher’s exact test, and for continuous variables often related to urological complications than to non-uro-
with the Mann–Whitney U test. A two-sided p value of logical claim reports. No explanation was found to explain
\0.05 was regarded as significant for both tests. The odds this. Type of hernia, operation time, type of surgery or
ratio (OR) served as an approximate estimate of relative surgeon’s training level was similar in patients with or
risk since the prevalence of urological complications without urological adverse events (Table 2). The claims
related to inguinal hernia surgery was low. Factors asso- concerning femoral hernia surgery (n = 11) did not include
ciated with chronic testicular pain and atrophy were any urological complications.
determined in univariate and multivariate unconditional The final diagnosis of urological complaints was chronic
logistic regression models with a forward selection process. testicular pain, ischemic or atrophic testis in 34 patients
The following independent variables were included: body (Fig. 1). Half of these patients (n = 17) were followed-up
mass index (kg/m2), type of hernia (direct, undirect, fem- without any surgical intervention because testicular or
oral, recurrent), method of repair (open/laparoscopic), time scrotal pain was moderate (Table 3). Early orchiectomy
of surgery (elective/emergency), type of anaesthesia (local/ either as a result of total vascular occlusion of testicular
spinal/general), length of surgery (\60 min, [60 min), use vessels (n = 6) or late orchiectomy (n = 11) as a result of
of mesh, surgeon’s training level (resident/specialist) and intractable pain syndrome was performed in 17 patients.
complications (bleeding, infection) in hernia surgery. The latter procedure was performed without any attempts

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56 Hernia (2015) 19:53–59

80 Table 3 Operative and follow–up data of patients with severe tes-

All
ticular complication after inguinal hernioplasty. Data are reported as
70 mean ± SD, [range] or number of patients
Urological
60 Orchiectomy Painful/atrophic p value
Number of patients

(n = 17) testis (n = 17)

50
Early/late 11/6 –/17 0.0001
40
Mean age of patients 53 ± 17 50 ± 16 [26–80] 0.60
30 (years) [30–80]
Type of primary operation
20
Lichtenstein 15 12 0.40
10 Bassini 1 1
Laparoscopic 1 4
0
2003 2004 2005 2006 2007 2008 2009 2010
Operated by resident 5 8 0.48
Year Mean follow-up time 6.6 ± 3.3 7.7 ± 2.2 [4–12] 0.26
(years) [2–15]
Fig. 2 Annual number of all claims and urological complications Mean testicular pain 1.6 ± 1.4 3.5 ± 2.7 [0–10] 0.01
after inguinal hernioplasties score (0–10) [0–7]
Mean inguinal pain 2.5 ± 2.9 3.5 ± 3.4 [0–10] 0.36
score (0–10) [0–9]
Table 2 Demographic and clinical characteristics of patients with Need of analgesics
urological complications compared to the patients with non-urologi-
cal complications. Data are reported as mean ± SD, [range] or Daily 4 2 0.66
number of patients Weekly 0 1
Sometimes 2 3
Number of patients (%)
Never 11 11
Urological Non-urological p value Feeling of inguinal 5 7 0.72
(n = 62) (n = 273) mesh
Male/female 62/– 230/43 0.0001
Age of patients 54 ± 16 56 ± 15 [16–86] 0.35
(years) [26–88]
BMI (kg/m2) 26 ± 3.9 26 ± 3.6 [19–46] 1.0 most likely nociceptive pain due to testicular tissue injury
[18–40]
than neuropathic pain due to testicular nerve injury. Fur-
Mean operation time 71 ± 38 62 ± 32 [15–250] 0.07
(min) [15–165]
thermore, 11/17 (65 %) patients were free of pain (NRS
score 0 or 1) after orchiectomy compared to 4/17 (24 %) in
Primary/recurrent 53/9 246/27 0.36
hernias the conservatively treated group (p = 0.037). In the late
Open/laparoscopic 51/11 235/38 0.43 orchiectomy group, 8/11 patients were free of pain com-
hernioplasty pared to 3/6 in the early orchiectomy group (p = 0.6).
Emergency/elective 4/58 10/263 0.30 After orchiectomy, four patients (25 %) still needed anal-
Prophylactic 22/40 74/199 0.0001 gesics and three patients (19 %) had NRS scores [5 (range
antibiotics: yes/no 0–10). In multivariate analysis, the only statistically sig-
Anaesthesia nificant factor associated with severe testicular pain and
Local 5 27 atrophy was the presence of wound infection (Table 4).
Spinal or epidural 26 163 There was a non-significant tendency towards increased
General 31 83 0.005 risk for testicular disorders related to obesity and the
Resident/specialist 17/45 103/170 0.14 operations performed by residents.
Use of mesh/no mesh 55/7 242/31 1.00 Other urological complications in litigation cases
BMI body mass index
included bladder perforation (n = 10) or major scrotal
haemorrhage (n = 7). Urinary retention related either to
inguinal hernia surgery or spinal anaesthesia was a severe
of neurectomy or mesh removal. Our long-term question- long-term complication in five patients and was treated by
naire study (Table 3) indicated that the mean testicular pain multiple catheterizations or prostatic endoscopic surgery.
scores were significantly lower in patients with orchiec- Scrotal infections or other miscellaneous complications
tomy than in patients with atrophic, painful testicle in situ (n = 4) were very rare reasons for claim. One death in
(p = 0.002). The patients benefited from orchiectomy had connection with urological complication was reported. The

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Hernia (2015) 19:53–59 57

Table 4 Risk factors for severe

Factor Univariate analysis Multivariate analysis
testicular pain and atrophy after
inguinal hernioplasty calculated p value p value Odds ratio 95 % CI
by univariate and multivariate
logistic analysis BMI (B30/[30 kg/m2) 0.256 0.054 3.221 0.982–10.56
Type of hernia (primary/recurrent) 0.296 0.505 1.180 0.725–1.920
Type of surgery (open/laparoscopic) 0.822 0.936 0.953 0.299–3.037
Time of surgery (elective/emergency) 1.000 0.957 0.938 0.091–9.696
Type of anaesthesia (local/spinal/general) 0.590 0.697 1.323 0.323–5.415
Length of operation (B60 min, [60 min) 0.627 0.696 0.839 0.347–2.025
Use of mesh (yes/no) 0.853 0.982 0.991 0.434–2.260
Surgeon (resident/specialist) 0.063 0.071 2.500 0.926–6.751
Infection (yes/no) 0.001 0.009 0.135 0.030–0.602
CI confidence interval, BMI Haemorrhage (yes/no) 0.001 0.997 0.000 0.00–0.00
body mass index

patient (71-year-old male) died after the laparoscopic
hernia repair associated with scrotal haemorrhage, scrotal
infection and subsequent cardiac failure.
Altogether 31 patients (50 %) with urological compli-
cations received financial compensation from their hospi-
tals. The mean sum of money was 3,600 ± 2,670 Euros
(range 825–10,920 €).
Discussion
After inguinal hernia repair, testicular necrosis and sub-
sequent atrophy as a result of ischemic orchitis is a well-
known but a very rare complication. The distinction
between scrotal vs testicular pain and neuropathic vs
nociceptive pain was not attempted in the present study,
because our data were register-based and retrospective. Our
main goal was to evaluate the value of early or late
orchiectomy in relieving intractable testicular pain syn-
drome after inguinal hernia surgery. One-fifth of litigation
claims related to inguinal surgery was due to urological
complications, and in half of them the final diagnosis was
testicular ischemia, atrophia or pain. We found that half of
the patients with serious testicular injuries were referred to
orchiectomy and in two-thirds, the removal of testis was
beneficial. Intractable chronic testicular pain resulted more
often in late orchiectomy than early ischemia. In most
severe cases of testicle pain, late orchiectomy may be the
final operative intervention in these patients. These patients
had most likely nociceptive pain due to testicular tissue
injury than neuropathic pain due to testicular nerve injury.
In our study, 20–25 % of patients continued to have severe
orchialgia despite orchiectomy, which is much lower rate
than reported (80 %) by previous reviews [1, 2]. In patients
with failed orchiectomy, testicular pain was more than
likely neuropathic because of testicular nerve injury rather
than nociceptive due to testicular tissue injury. However,
orchiectomy should be postponed until all other testis
preserving strategies have been considered.
Early ischemic orchitis typically presents 2–3 days after
inguinal hernia surgery and can progress to infarctation,
total necrosis and atrophy of testis. The early ischemic
injury is likely due to thrombosis of the venous plexus,
rather than iatrogenic arterial injury or inappropriate clo-
sure of the inguinal canal. Ultrasound/duplex scanning of
the postoperative acute scrotum can help to differentiate
ischemic orchitis from infection or haemorrhage [7].
Unfortunately, testicular torsion cannot be ruled out using
radiological imaging and prompt scrotal exploration may
sometimes be necessary. Although ischemic orchitis,
atrophy and subsequent orchiectomy are uncommon inju-
ries, all patients should be informed of these potential
complications and operative consent should include these
risks irrespective of the type of hernia or the surgical
approach. An operation for recurrent hernia carries a par-
ticularly high risk for testicular injuries. Testicular ische-
mia can be reversed with prompt mesh loosening, removal
of mesh or too tight sutures. Early evaluation and explo-
ration of suspected ischemic orchitis after inguinal hernia
repair may allow symptomatic relief and prevention of
testicular atrophy [9]. In prompt re-operation, there are no
evidence-based studies to guide surgeon whether ischemic
testis should be removed or left in situ to avoid chronic
pain syndrome. Furthermore, there are no guidelines to
treat acute vascular thrombosis in testicular vessels using
anti-thrombotic agents. Our retrospective study indicated
that early orchiectomy did not always benefit the patient,
but substantial pain relief and alleviation of other symp-
toms were achieved in over half of the patients.
Clinical management of chronic testicular pain after
inguinal hernia surgery includes a careful assessment of
differential diagnosis, such as haematoma or infection [17].
After clinical examination, urine analysis, inguinal sonog-
raphy, computerised tomography and magnetic resonance

123
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imaging may give additional information [1, 2]. Nonsur-
gical management of testicular pain includes analgesics,
injection therapy with corticosteroids/local anaesthetics
and other pharmacological treatment of chronic neuro-
pathic pain (e.g. tricyclic antidepressants, such as ami-
triptyline; gabapentinoids, gabapentin or pregabalin;
serotonine-norepinephrine re-uptake inhibitors, duloxetine
and venlafaxine). When testicular pain is a result from
nerve entrapment or mesh-induced fibrosis, removal of the
mesh or inguinal nerve transection by laparoscopic or by
open approach may be the treatment of choice [18–20].
Very recent reports suggest that extension of the standard
triple neurectomy to include proximal genitofemoral
nerve for treatment of inguinodynia or scrotal pain after
hernioplasty is a safe and effective procedure [19, 20].
Triple neurectomy may help in scrotal pain but not in
testicular pain. Before removing painful testis, microsur-
gical denervation of the cord may also be attempted [1,
2], but this technique does not address neuropathic lesions
proximal to the cord. In Finland, this technique is very
seldom utilised in chronic testicular pain syndrome. In the
present patient cohort, no mesh was removed before
orchiectomy, nor was any nerve resection tried to relieve
the pain. However, non-operative treatment, such as
injections of lidocaine/corticosteroids was attempted with
many patients.
How to avoid testicular complications during inguinal
hernia surgery? Too extensive dissection of a distal hernia
sac, dislocation of the testis from the scrotum into the
wound and concomitant scrotal surgery should all be
avoided [4]. Another cause of the testicular infarctation in
the laparoscopic inguinal hernia surgery is the cautery
excision of the hernia sac that may lead to venous injury
[6]. Ultrasound and Doppler sonography studies have
indicated that mesh implantation or perimesh fibrosis does
not adversely affect ipsilateral testicular blood flow in open
or laparoscopic techniques and thus, mesh application is
still a safe procedure in male patients in whom testicular
function is important [21, 22]. Accordingly, no certain type
of mesh was related to increased urological complaints in
postoperative outcome in this study.
To our knowledge, nationwide review of severe uro-
logical complications related to inguinal hernia repair has
not been performed earlier [23–26]. One Swedish popula-
tion-based analysis indicated that the patient’s self-report
frequency of testicular pain was 120/1,643 (8.3 %) [23].
Our register-based study indicated that inguinal hernia
repair is very rarely associated with serious urological
postoperative complications. The majority of litigation
claims were related to the repair of primary hernias, non-
emergency operations and to open technique. This is in line
with the frequency and type of hernia procedures per-
formed annually in our country. We found no difference in
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Hernia (2015) 19:53–59
the frequency of pain in open versus laparoscopic surgery,
in mesh versus non-mesh techniques, in the hospital status,
in the surgeon’s training level or in patients with recurrent
hernia repair. We believe that almost all serious events
leading to orchiectomy after inguinal hernia surgery were
reported to the Patient Insurance Centre.
Summary
Urological injuries form one-fifth of the major complica-
tions after inguinal hernioplasty. Our study indicated that in
two-thirds of patients with persistent nociceptive testicular
pain, pain can be substantially diminished by performing
orchiectomy as the last operative choice.
Acknowledgments The technical assistance of Mrs. Saija Lehtinen
and Mrs. Pirjo Halonen (bio-statistical analysis) are greatly
acknowledged. The experiments comply with the current laws of
Finland.
Conflict of interest Kirsi Rönkä, Jaana Vironen, Hannu Kokki,
Tapani Liukkonen and Hannu Paajanen declare no conflict of interest.
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