The Onstep technique for inguinal hernia repair is associated with a lower incidence of postoperative pain during sexual activity than the Lichtenstein surgical technique, according to a paper published online in Surgery.

This study was a part of the Onli trial, the objective of which was to evaluate chronic pain and sexual dysfunction after inguinal hernia repair involving mesh fixation with sutures (Lichtenstein), compared with no mesh fixation (Onstep). The investigators reported the findings of a large study: 20.8% of inguinal repair patients experienced pain during sexual activity 1.4-1.7 years after their operation ( Pain. 2006;122:258-63 ).

The Onli trial was a randomized clinical trial comparing the Onstep method with the Lichtenstein method in 259 patients undergoing inguinal hernia repair found that pain during sexual activity 6 months after the operation was reported by 17 patients (13.1%) operated on with the Onstep technique and 30 patients (23%) operated on with the Lichtenstein technique (P = .034). A questionnaire, specific to pain-related impairment of sexual function, was administered at 6 months’ follow-up (Surgery. 2017 Mar 2. doi: 10.1016/j.surg.2016.12.030 ).

“The Onstep technique could be considered when surgeons and patients are discussing the optimal technique for repair of an inguinal hernia,” wrote Kristoffer Andresen, MD , of the University of Copenhagen, and his coauthors. “If the patient has pain during sexual activity as part of the complaint from the hernia, the Onstep technique seems to have a greater chance of removing this pain and alleviating the complaints.”

Among the 17 patients in the Onstep group who experienced postoperative pain during sexual activity, 8 had experienced preoperative pain during sexual activity and 7 had not. In the Lichtenstein group, 14 of the 30 patients who experienced postoperative pain had experienced preoperative pain, 14 had not. The remaining patients in both groups reported not having sexual activity before surgery or declined to answer.

The Lichtenstein technique was associated with new pain in 14 of the 70 patients (20%) while 7 of the 74 patients (9%) in the Onstep group reported new pain after surgery.

“For patients who experienced pain during sexual activity preoperatively, the Onstep technique removed the pain during sexual activity in the majority of patients while still resulting in few new cases,” the authors wrote.

Among the Lichtenstein group, 20 patients experienced pain from the surgical scar, compared with 7 patients in the Onstep group.

When asked about the degree of impairment of sexual function because of the postoperative pain, four patients in the Lichtenstein group said they had moderate to severe impairment, but none in the Onstep group reported that level of impairment.

Commenting on the possible mechanisms that might result in pain during sexual activity after hernia repair, the authors noted that mesh has been found to shrink from a mass around the vas deferens after a Lichtenstein repair. Previous studies have also found sutures around the iliohypogastric and the ilioinguinal nerves, which could also result in some pain.

“Because the mesh in the Onstep technique is not fixed with sutures, the risk of capturing nerves during the fixation of mesh is nonexistent,” they wrote. “There could, however, still be a risk of scar tissue and mesh shrinkage.”

PolySoft mesh (Bard Davol) was used for the Lichtenstein group and SoftMesh (Bard Davol) was used for the Onstep group.

In the 6 months’ follow-up period, two patients in the Lichtenstein group and one patient in the Onstep group experienced a recurrence of their hernia.

Three authors reported personal fees and travel grants from private industry – including Bard Medical – outside the submitted work. No other conflicts of interest were declared.