James E. Wiedeman, MD
Associate Professor of Surgery
Department of Surgery
University of California Davis
Chief
Department of General Surgery
Sacramento VA Medical Center
Sacramento, CA

ABSTRACT
Introduction: Surgeons are frequently asked to evaluate patients who experience chronic pain and have normal or equivocal findings on physical examination or imaging studies. It is important for surgeons to have a clear understanding of the indications for operative intervention in these patients.

Results and discussion: An algorithmic management approach is presented for groin, anal, breast, and right upper quadrant abdominal pain in patients whose clinical findings are ambiguous.

Conclusion: Occult hernias and nonthrombosed hemorrhoids rarely cause pain, and other causes of the patient?s groin or anal pain should be investigated. In those with mastalgia, breast cancer must always be ruled out; once it is, reassurance is usually sufficient treatment. Patients who experience right upper quadrant abdominal pain and have a normal biliary ultrasound may benefit from cholecystectomy.

Many surgeons quickly dismiss chronic pain patients as malingerers when objective findings fail to correlate with the patients' perceived level of pain. Rather than sending these patients straight back to their referring providers, surgeons can apply basic algorithms to ensure serious pathology is not missed and to determine whether surgery is indicated. Management can range from simple reassurance to a carefully planned operation. What follows is an approach for algorithmic management of groin, anal, breast, and right upper quadrant abdominal pain in patients who have unclear clinical findings.

GROIN PAIN

Most nonsurgeons ascribe groin pain to an inguinal hernia even if the physical examination is inconclusive. Patients may be convinced even before their surgical consultation that a simple operation is all they need to alleviate the pain. When no inguinal hernia is identified, it frustrates both patient and surgeon.

Many patients who are referred to surgeons for chronic groin pain have undergone inguinal hernia surgery previously. Thirty percent or more of patients who have undergone hernia surgery experience groin discomfort 1 year postoperatively.¹ In the majority of these cases, no recurrent hernia is identified, and the etiology of the pain is poorly understood. Nerve entrapment or mesh inguinodynia have been incriminated, and a systematic approach of nerve blocks, triple neurectomy (ilioinguinal, iliohypogastric, and genital branch of genitofemoral), and mesh removal has had variable success.²,³ Fortunately, reassurance that no hernia is present and that the condition is not medically dangerous is all many patients need. It is unwise to re-explore a groin to look for a hernia.

Patients also can develop chronic groin pain without having undergone previous groin operations. Occult hernias are often suggested as the cause of groin pain, but reducible hernias rarely cause much pain. While occult hernias can be diagnosed using computed tomography, ultrasonography, or herniography, the significance of finding a small hernia on these examinations must be questioned. The best way to rule out an occult inguinal hernia is via transabdominal laparoscopic exploration. Laparoscopy is also a reasonable procedure to offer patients who report a history of a groin bulge but in whom no such bulge is palpable on physical examination.

Lumbosacral spine and hip pathology, such as disc protrusion, vertebral spondilosis, and degenerative arthritis, can be found in up to 50% of patients with groin pain and no previous hernias.⁴ Magnetic resonance imaging and neurosurgery or an orthopedic referral should be considered before performing more invasive interventions.

Sports "hernias" are wellknown among professional athletes, particularly hockey players when the conjoint tendon or the external oblique muscle is torn, which can result in nerve entrapment in 82% of cases.⁵ These patients may subsequently benefit from surgical intervention or trials of nerve blocks (Figure).

ANAL PAIN

According to the layman and many referring physicians, anal pain is usually attributable to hemorrhoids. In actuality, internal hemorrhoids cause pain only if they are incarcerated (fourth-degree prolapse), and external hemorrhoids are painful only if thrombosed. Both conditions will be evident on physical examination. A nonthrombosed external skin tag or minimal prolapsing hemorrhoid should not be excised with the expectation that a patient's anal pain will be alleviated.

An occult anal fissure is the most common etiology of undiagnosed anal pain. Anal fissures may be extremely difficult to see on physical examination in patients with deep gluteal clefts or spastic internal sphincters. Often the only sign is exquisite focal tenderness to precise circumferential anal palpation. Deep anorectal abscesses may also demonstrate minimal external findings, and closer examination with the patient under anesthesia may be needed to make a diagnosis. Topical nitroglycerin ointment (0.2%) is a safe treatment for patients thought to have an anal fissure and spastic sphincter, even when those findings cannot be confirmed on physical examination.⁶

Other causes of anorectal pain, such as proctalgia fugax or coccygodynia, should be considered if more clear-cut etiologies are not apparent. Unfortunately, up to 50% of patients with intractable anorectal pain of poorly understood etiology are refractory to all treatment modalities (Figure).⁷

BREAST PAIN (MASTALGIA)

The etiology of breast pain is often poorly understood but frequently labeled as "fibrocystic breast disease," which is more appropriately termed "fibrocystic breast disorder." Pathology can include cyst formation, epithelial hyperplasia, metaplasia, and adenosis. Although a malignancy is usually painless, it must be carefully excluded as a possibility in any woman with breast pain. Mammography and ultrasonography, coupled with careful clinical examination, should help establish whether biopsy is needed. Suspicious radiographic lesions or dominant breast masses on physical examination warrant biopsy regardless of the patient's symptoms. Open biopsy or fine-needle aspiration of a tender area of the breast that has no radiographic or palpable lesions of significance is clearly not indicated. Simple reassurance that no cancer is present is all that 85% of patients with mastalgia need.⁸ More extensive surgery for mastalgia, such as subcutaneous mastectomy, quadrantectomy, or simple mastectomy, should be considered in only a minority of patients, because fewer than 50% will get relief from such procedures.⁹

Effective medical measures for mastalgia include use of a properly fitting bra; decreasing dietary fat and caffeine intake; and the administration of evening primrose oil, followed by danazol, bromocriptine, or tamoxifen. The significant side effects of some of the latter treatments, however, may outweigh any benefits. Ineffective treatments include vitamins A, B, or E, diuretics, levothyroxine, antibiotics, and surgery (Figure).¹⁰

RIGHT UPPER QUADRANT ABDOMINAL PAIN

The term "biliary dyskinesia" was coined in 1953. At the time, a 60% improvement rate following cholecystectomy was reported for this poorly understood disease. Severe biliary colic in the absence of gallstones is a real entity; however, it is difficult to determine who will benefit from cholecystectomy. Once ultrasonography has ruled out gallstones, the most commonly used test is the CCK-HIDA (cholecystokinin- 99mTc hepatoiminodiacetic acid) scan, which assesses biliary function by measuring the gallbladder ejection fraction (EF). An EF below 35% is considered abnormal. A number of retrospective studies suggest that biliary colic symptoms improve in 60% to 100% of patients with a gallbladder EF below 35% who undergo cholecystectomy.^11,12 Another study suggests that even those who have an EF above 35% may experience a 75% improvement in their symptoms 36 months following cholecystectomy.¹³

Before considering cholecystectomy, it is important to rule out other upper gastrointestinal pathology. This can be done using upper endoscopy or radiographic contrast studies. More complex studies are rarely productive, such as evaluating for biliary crystals using endoscopic retrograde cholangiopancreatography (ERCP) or performing sphincter of Oddi manometry.

Patients may believe that simple gallbladder surgery will cure their condition. The number of cholecystectomies increased by 29% from 1986 to 1995, which coincides with the advent of a laparoscopic approach.¹⁴ Surgeons must not lower the clinical requirements for performing this procedure simply because the patient or the patient's referring physician perceives it to be safer (Figure).

CONCLUSION

The wise surgical dictum "never operate for pain" can prevent misery from the surgeon's perspective. Patients with poorly understood pain syndromes involving the groin, anus, breast, and right upper abdominal quadrant, however, must be completely evaluated to exclude surgically correctable pathology or medically manageable problems. In these cases, surgeons should remember three important points: (1) occult hernias and nonthrombosed hemorrhoids rarely cause pain; (2) mastalgia cannot be cured surgically, and breast cancer must always be ruled out in these patients; (3) a select group of patients with right upper quadrant abdominal pain and a normal biliary ultrasound will benefit from cholecystectomy.

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