Genitofemoral Nerve Entrapment:
Pelvic
Thais Khouri Vanetti, Alexandra Tavares Raffaini Luba,
Fabrcio Dias Assis, and Charles Amaral de Oliveira
Introduction
Despite the paucity of literature on the genitofemoral nerve
(GFN), impairment of this nerve, which may result in chronic
pain, is not uncommon but rather likely under-recognized.
Blunt trauma or pelvic operations such as inguinal hernior-
rhaphy, C sections, and others are often accompanied by
chronic inguinal and perineal pain and paresthesias, which
may be due to GFN pathology [1].
The GFN, iliohypogastric nerve (IHN), and ilioinguinal
nerve (IIN) originate from similar levels of the spinal nerves;
therefore, it is often clinically difficult to determine which
nerve is causing the pain. The major differential diagnosis of
GFN is ilioinguinal neuralgia. Diagnostic blocks can aid in
making this diagnosis. The femoral branch of the GFN is
also known as the lumboinguinal nerve.
T.K. Vanetti, MD, FIPP (*)
Singular Centro de Controle da Dor,
Campinas, So Paulo, Brazil
Instituto do Cncer do Estado de So Paulo,
Rua Doutor Arnaldo 251, So Paulo 01246-000, So Paulo, Brazil
e-mail: thavanetti@yahoo.com.br
A.T. Raffaini Luba, MD
Singular Centro de Controle da Dor,
Campinas, So Paulo, Brazil
Instituto do Cncer do Estado de So Paulo,
Rua Doutor Arnaldo 251, So Paulo 01246-000, So Paulo, Brazil
Santa Casa de So Paulo, So Paulo, Brazil
e-mail: alexaraffaini@yahoo.com
F.D. Assis, MD, FIPP
Medical Director, Singular Centro de Controle da Dor,
Campinas, So Paulo, Brazil
e-mail: FABRICIOASSIS@TERRA.COM.BR
C.A. de Oliveira, MD, FIPP
Singular Centro de Controle da Dor,
Campinas, So Paulo, Brazil
e-mail: charles@singular.med.br
Springer International Publishing Switzerland 2016
A.M. Trescot (ed.), Peripheral Nerve Entrapments: Clinical Diagnosis and Management, DOI 10.1007/978-3-319-27482-9_45
45
Clinical Presentation (Table 45.1)
Chronic inguinal and perineal pain and paresthesias may be
due to GFN pathology [1]. Postoperative neuropathies after
major pelvic surgeries are rare, with a total estimated inci-
dence of 1.9 %; postoperative GFN neuropathy is estimated
at 0.3 % [6]. Magee first reported the syndrome of genito-
femoral neuralgia in 1942 [7], but it remains a rarely encoun-
tered (or diagnosed) clinical entity. The most common
clinical presentation of GFN entrapment consists of intermit-
tent or constant pain, burning dysesthesia, and sensory
changes in the inguinal region (Fig. 45.1), with radiation of
the pain to the skin of the genitalia (scrotum, vagina, labia
majora) and upper middle thigh (Fig. 45.2) [1]. Female
patients usually present with dyspareunia and pelvic pain,
and GFN neuralgia can be misdiagnosed as interstitial cysti-
tis or pudendal neuralgia (Fig. 45.3). The pain is exacerbated
by activities such as walking and hyperextension of the thigh
and is ameliorated by recumbent position and thigh flexion
[1]. Paresthesia and persistent pain in the lower abdomen or
pelvic region, including the lateral scrotum or labia majora
and the anterior proximal thigh, may also represent GFN
Table 45.1 Occupation/exercise/trauma history relevant to genito-
femoral nerve entrapment
Compression Hematoma and adhesions
associated with surgery
Lumbar plexus abnormalities Psoas abscess, psoas entrapment [2]
(see Chap. 49)
Mechanical Pubic symphysis irritation
Late pregnancy
Trauma Lumbar sympathetic neurolytics
Celiac plexus neurolytics
Surgery Trans-obturator sling surgery for
incontinence [3]
Inguinal hernia repair [4]
Hysterectomy and cesarean section
[5]
Entrapment Surgical scar, adhesions
479
480 T.K. Vanetti et al.

Table 45.2 Genitofemoral nerve anatomy

Origin L1 and L2 anterior (ventral) rami
General route Perforates the psoas at L3 and L4,
descends along the medial psoas border,
divides into genital and femoral
branches just above the inguinal
ligament
Genital branch
Males: inside internal inguinal ring
with spermatic cord to scrotum
Females: accompanies the round
ligament
Femoral branch
Located caudally and laterally to the
genital branch, travelling caudally
Fig. 45.1 Patient complaints of genitofemoral pain (Image courtesy of with external iliac artery, behind
Andrea Trescot, MD) inguinal ligament through fascia lata
to femoral sheath
Sensory distribution Pelvic region, groin, scrotum or labia
majora, and anterior proximal thigh
area; femoral branch: anterior proximal
thigh in the femoral triangle
Motor innervation Cremaster muscle and cremasteric
reflex
Anatomical variability Ilioinguinal occasionally provides
genital branch of GFN
Other relevant structures Pubic tubercle, Pouparts ligament

neuropathy. There can be a great deal of overlap between the

ilioinguinal (see Chap. 44), genitofemoral, and lateral femo-
ral cutaneous nerves (see Chap. 61). Benes et al. [8] sug-
gested using the term abdomino-inguinal pain syndrome, to
describe the combination of these nerve pathologies.

Fig. 45.2 Pain pattern from genitofemoral neuralgia (Image courtesy

of Andrea Trescot, MD) Anatomy (Table 45.2)

The iliohypogastric (IHN), ilioinguinal (IIN) (see Chap. 44),

Fig. 45.3 Innervation of perineum: A genitofemoral nerve, B obturator
nerve, C inferior cluneal nerve, D peroneal branch of the posterior fem-
oral cutaneous nerve, E ilioinguinal nerve, and F pudendal nerve
(Image courtesy of Andrea Trescot, MD)
and genitofemoral (GFN) nerves are known as border
nerves because they innervate the transitional area between
the abdomen and lower extremity: the lower abdominal wall,
groin, labia majora, and medial thigh. These nerves arise
from the lumbar plexus (see Chap. 49), whose cutaneous
branches include the IHN, IIN, GFN, lateral femoral cutane-
ous nerve (LFCN), and obturator nerve (Fig. 45.4).
The GFN arises from L2 with occasional L1 contribu-
tions, which unite within the psoas muscle, while the IHN
and IIN arise from the L1 anterior rami with contributions
from T12 and L2. The GFN is mainly sensory, with a small
motor component that innervates the cremaster muscle and
provides the motor component of the cremasteric muscle
(cremasteric reflex). The GFN emerges from the psoas mus-
cle anteriorly at the L3 and L4 level and descends to the
medial border of the psoas muscle, where it divides into a
genital and femoral branch just above the inguinal ligament
(Fig. 45.5). The GFN innervates, and thus may refer pain to,
45 Genitofemoral Nerve Entrapment: Pelvic 481

Fig. 45.4 Lumbar plexus

(Image courtesy of Springer)

Subcostal nerve

Iliohypogastric nerve

Genitofemoral
nerve (cut)

Ilioinguinal nerve Lumbar plexus

Lateral femoral Psoas major muscle

cutaneous nerve
Genitofemoral nerve
Obturator nerve

Lumbosacral trunk
Femoral nerve

Fig. 45.5 Genitofemoral nerve anatomy, modified from an image

from Bodies, The Exhibition, with permission. A ilioinguinal nerve,
B iliohypogastric nerve, C site of ilioinguinal nerve entrapment at the
external oblique, D ilioinguinal nerve over the inguinal ligament,
E lateral femoral cutaneous nerve, F genitofemoral nerve, G genital
branch of the genitofemoral nerve, H femoral branch of the
genitofemoral nerve, I femoral nerve, J saphenous nerve, K inferior
hypogastric plexus, L obturator nerve (Image courtesy of Andrea
Trescot, MD)
482
Fig. 45.6 Genital and femoral
branches of the genitofemoral nerve
(Image courtesy of Springer)
Anterior cutaneous
nerves
areas including the pelvic region, groin, scrotum or labia
majora, and anterior proximal thigh area.
The genital branch of the GFN accompanies the psoas
muscle. In males, it passes inside the internal inguinal ring
together with the spermatic cord, supplying motor fibers to the
cremaster muscle and sensation to the lateral scrotum. In
females, it accompanies the round ligament, innervating the
mons pubis and the labia majora. The femoral branch (also
known as the lumboinguinal nerve) is located caudally and
laterally to the genital branch and travels with the external iliac
artery beneath the inguinal ligament, piercing the fascia latae
and entering the femoral sheath to innervate the skin of the
anterior proximal thigh in the femoral triangle (Fig. 45.6) [9].
Though the course of this nerve and its branches is sim-
ilar in men and women, anatomical studies suggest great
variability among individuals, with only about 37 % of
individual innervation patterns conforming to the conven-
tional description [10]. The location where the genital and
femoral branches split is typically reported just superior to
the inguinal ligament, but variations are common [11].
Additionally, in males, the relation between the genital
branch and the spermatic cord varies considerably; it can
travel outside the spermatic cord, dorsally, ventrally, or
inferiorly [12]. In a cadaver dissection study, the genital
branch of the GFN was found in 28 % of subjects to arise
from the IIN nerve and hence from T12, L1, and L2 [10].
Special attention to the great variation of the nerves in
the groin region (ilioinguinal, iliohypogastric, and genito-
femoral) is warranted, because of the free communication
between these branches. According to a cadaver study, the
T.K. Vanetti et al.
T7
T8
Thoracoabdominal
T9 nerves
T10
T11
Subcostal nerve (T12)
Iliohypogastric nerve (L1)
Ilioinguinal nerve (L1)
Femoral branch of the
genitofemoral nerve
Genital branch of the
genitofemoral nerve
ilioinguinal nerve was solely responsible for cutaneous
innervation of the genital branch of the genitofemoral nerve
in 28 % of the dissections and shared innervation with the
genital branch of the genitofemoral nerve in 8 % [10].
Entrapment
The GFN may be entrapped during its association with the
psoas muscle and in the pelvis, by a spasm of the muscle, or
by the presence of intramuscular hematoma, abscess, or
adhesions. During the retroperitoneal course of this nerve, it
may also become entrapped by a retroperitoneal hematoma
or lymphoma [13]. A more common cause of entrapment is
surgery involving the pelvis or inguinal area, including C
section, appendectomy, and inguinal hernia repair, particu-
larly when done laparoscopically [4]. Pain may begin months
or years after surgery, due to gradual scar tissue formation at
the surgical site [10]. On its passage above the pubic ramus,
the genitofemoral nerve is vulnerable to surgical trauma.
Albeit less common, this nerve can also be compressed and
injured during the final stages of pregnancy [14].
Physical Examination
Careful neurological sensory examination may demonstrate
sensory changes in the border zone between the abdomen
and thigh, groin, anterior proximal thigh, and lateral scrotum
or labia majora. Tender points may be found on the internal
45 Genitofemoral Nerve Entrapment: Pelvic 483

Table 45.3 Differential diagnosis of inguinal and perineal pain

Potential distinguishing features
Lumbar plexopathy EMG testing, as genitofemoral nerve
does not have significant motor
component
IIN and IHN neuropathy First perform a block of the
ilioinguinal nerve; if this does not
relieve the pain, perform blocks of the
ipsilateral L1 and L2 nerves, as with a
paravertebral block
Iliopectineal bursitis Lack of neuropathic features,
calcification on X-ray
Inguinal hernia Palpable abdominal wall defect
Spermatic cord disorders Palpable spermatic cord mass
Pelvic tumor Mass on bimanual exam or on MRI
Endometriosis Endometrial implants on laparoscopy

Table 45.4 Diagnostic tests for genitofemoral nerve entrapment

Physical exam Pain more prominent around pelvic
tubercle
Fig. 45.7 Location of tenderness to palpation, which is consistent with Diagnostic injection Ilioinguinal nerve block should not
genitofemoral nerve pain. Note the white arrow showing the InterStim relieve pain, while L1/L2 nerve
placed for interstitial cystitis pain that offered no relief (Image cour- block should relieve pain
tesy of Andrea Trescot, MD) Ultrasound Scarring or neuroma may be visible
in nerve course
MRI May show abscess or hematoma in
part of the inguinal ring, with pain on palpation of the lower retroperitoneal section of nerve
pubic area and pain on vaginal palpation [3]. Arteriography Not useful
Sensory changes can include hypoesthesia, paresthesias, X-ray May detect urolithiasis as a cause of
and allodynia. Sensory changes in the upper thigh and the pain
groin region occur when the femoral branch of the GFN has Electrodiagnostic studies Not useful
been affected [3].
Palpation of the psoas muscle and maneuvers to activate The innervation patterns of the genitofemoral, ilioinguinal,
or tighten the psoas muscle may aggravate the pain. Pain and iliohypogastric nerves can be very challenging to
may be exacerbated by Valsalva maneuvers, such as cough- distinguish, particularly as there is considerable anatomical
ing or rising from a seated position. Hip mobilization or peri- variation and overlap in the innervation of these three nerves
staltic movements, such as during defecation, may also be [11]. A methodical approach to diagnosis, including a detailed
pain provoking [3]. The cremasteric reflex in male patients is exam and sequential diagnostic blocks, can usually clarify the
lost with more severe neuropathy, particularly neuropathy pain generator involved in a specific patient. While specific
involving the genital branch. In females, there may be ten- techniques for blocking the GFN will be discussed below,
derness with palpation of the lateral vagina and vulva [3]. many experts suggest a process of exclusion: first performing
This pain may also be exacerbated in women by the men- a block of the ilioinguinal nerve, if the patient has pain and
strual period and by intercourse [14]. There will be tender- sensory changes in the inguinal region; then, if this does not
ness over the pubic tubercle, palpation of which will replicate relieve the pain, performing blocks of the GFN, followed by
the pain (Fig. 45.7). the ipsilateral L1 and L2 nerves [15]. See Table 45.4.

Differential Diagnosis (Table 45.3) Identication and Treatment of Contributing

The challenge of diagnosing GFN neuropathy involves rul-
ing out the other conditions of the lumbar spinal nerves, lum-
bar plexus, and tributary nerves that can produce a similar
clinical picture. Lumbar plexopathy in particular may pres-
ent with a complex pattern of motor and sensory symptoms
that may resist clarification [2].
Factors
Strenuous exercise and overstretching of the psoas muscle
or injury of the psoas; infra-abdominal incision
(Pfannenstiel) or laparoscopic operations [4,14]; past
abdominal or pelvic surgeries, particularly repeated sur-
geries; and open or laparoscopic inguinal hernia repair,
484 T.K. Vanetti et al.

appendectomy, and C-section hernia repairs with mesh the utmost care must be taken in relation to important
placement or done laparoscopically are all causes of GFN spermatic cord structures (testicular artery) and peritoneal
entrapment. Retroperitoneal surgery and pregnancy are cavity transgression.
also causes.
Treatment of the underlying conditions that caused the
nerve entrapment should be incorporated into treatment. Fluoroscopy-Guided Technique
Physical therapy can provide mobilization and strengthening
to decrease spasm and dysfunction; desensitization therapy With the patient in the supine position, the area of maximal
can be used for treating hyperpathic or allodynic areas. If the tenderness (just lateral to the pubic tubercle) is identified by
perpetuating factor is nerve compression by a surgical scar, it fluoroscopy (Fig. 45.7). After a sterile skin prep and local
is possible to remove the scar tissue, thereby releasing the anesthetic infiltration subcutaneously, a 22-gauge needle is
nerve. If compression is caused by muscle hypertrophy, the advanced to the periosteum. The use of a PNS will facilitate
treatment of choice is to inject local anesthetic to enable identification of the nerve (Fig. 45.8). One cc of local anes-
muscle relaxation and, if necessary, botulinum toxin for lon- thetic and deposteroid is then injected.
ger-lasting relaxation. Early recognition and treatment of Another technique for GFN diagnosis and treatment is the
surgical complications such as hematoma will also help limit dorsal root ganglion (DRG) local anesthetic block at T12, L1,
the extent of nerve injury. and L2, ipsilateral to the pain (Fig. 45.9). The T12 DRG should
be included because it is common for the ilioinguinal and gen-
itofemoral nerves to communicate. If the injection results in
Injection Technique significant pain relief (at least 50 % improvement), but is
short-lived, cryoneuroablation or pulsed radio frequency may
As noted above, it can be challenging to distinguish geni- be applied posteriorly to these ganglia (see below) [11].
tofemoral from ilioinguinal and iliohypogastric neuralgia,
due to the adjacent areas of innervation and the consider-
able anatomical variation. One common diagnostic Ultrasound-Guided Technique
approach is to first perform diagnostic blocks of the ilioin-
guinal and/or iliohypogastric nerves as appropriate, given Another approach is to perform a selective injection of the
the patients symptoms, preferably using ultrasound guid- genital branch of the GFN under ultrasound guidance.
ance for maximum accuracy. If these blocks successfully
create appropriate areas of numbness without decreasing
the pain, then a follow-up block may be performed of L1
and L2 as a selective nerve root block or paravertebral
block. If this block relieves the pain, it is likely a result of
an entrapment of the GFN. This process has the disadvan-
tage of requiring two or three distinct procedures with the
attendant time and risk. A block which successfully
relieves the pain symptoms may be followed up with cryo-
neuroablation or pulsed radiofrequency treatment (see
below) [11].

Landmark-Guided Technique

Trescot described a landmark-guided (blind) technique to

inject the genital branch of the GFN [16]. The patient is
placed in the supine position with a pillow under the knees if
extending the lower limbs evokes pain. After a sterile skin
prep, the pubic tubercle is palpated, and 1 cc of local anes-
thetic and deposteroid is injected via a 25-gauge needle, just
superior and lateral to the tubercle. The use of a PNS can
Fig. 45.8 Peripheral nerve stimulation identification of the genito-
facilitate the accuracy of the injection. The accuracy of this
femoral nerve. Note the white arrow showing the InterStim placed for
technique has not been studied in comparison to ultrasound- interstitial cystitis pain that offered no relief (Image courtesy of
guided approaches. When performing the blind technique, Andrea Trescot, MD)
45 Genitofemoral Nerve Entrapment: Pelvic
Fig. 45.9 Injection of the dorsal root ganglia at L1 (Image courtesy of
Fabrcio Assis, MD)
Fig. 45.10 Location of ultrasound probe for genitofemoral identifica-
tion (Image courtesy of Andrea Trescot, MD)
The genital branch is slender and cannot be directly visu-
alized, but the external iliac artery is easily found at the
inguinal canal, and the genital branch is immediately
medial to it, within the internal inguinal ring [5,17]. A
high-frequency linear probe is utilized, oriented perpen-
dicularly to the inguinal ligament (Fig. 45.10), with its tip
about one fingerbreadth lateral to the pubic tubercle. It is
suggested that the practitioner start in the internal ingui-
nal ring, where it is possible to visualize the longitudinal
(lengthwise) section of the artery. When the probe is
advanced cephalad, the artery is seen to penetrate deep
inside the inguinal ligament. At this point, an oval or
round structure (the cremaster in males, the round
485
ligament in females) superficial to the femoral artery can
easily be visualized (Fig. 45.11). The probe is then
advanced in the medial direction, slowly, moving away
from the femoral artery. The needle may be inserted in-
plane (Fig. 45.12) or out-of-plane, injecting local anes-
thetic without vasoconstrictors, to avoid the adverse
effects of testicular artery vasoconstriction. Because of
anatomical variability, it is recommended to use 5 mL
inside and 5 mL outside the spermatic cord [18].
Shanthanna [19] described the use of US to identify and
inject the GFN in a patient with disabling groin pain after
testicular cancer; the patient noted excellent relief after
the US-guided GFN injection, lasting >12 months.
CT-Guided Technique
A fourth approach is to perform a block of the GFN proximal
to the genital-femoral split, while it is still retroperitoneal.
This requires CT guidance to avoid inadvertently violating
the peritoneum or perforating bowel, as well as the use of a
nerve stimulator, since the GF nerve is not visible on CT [9].
The needle entry point is just above the L4 transverse pro-
cess and, utilizing the nerve stimulator, stimulation radiating
to the groin and the upper ipsilateral thigh should be achieved
[9]. This technique is limited by the availability of CT-guided
technology and is discussed more fully in the GFN abdomi-
nal section (Chap. 41).
Neurolytic Techniques
Cryoneuroablation
Cryoneuroablation at the pubic tubercle can be performed
by either fluoroscopy-guided or ultrasound-guided tech-
niques. Because the tissue at the pubis is usually relatively
thin, it is conceivable that one could identify the GFN by
just landmarks and the built-in nerve stimulator on the
cryoprobe, but this is not a recommended technique.
Trescot [14] described placement of the cryoprobe onto
the pubic tubercle, using fluoroscopy and the nerve stimu-
lator to find the nerve (Fig. 45.13). In that same publica-
tion, Trescot also described cryoneuroablation at the L1
foramen to treat the GFN proximally (Fig. 45.14). Campos
et al. [20] described cryoneuroablation of the femoral
branch of the GFN under US guidance. The details of that
approach are described more fully in the GFN lower
extremity section (Chap. 59).
Over a 2-year time frame, Agnes Stogicza, MD (personal
communication), described treating 18 post-herniorrhaphy
patients with persistent groin pain using cryoneuroablation
placed under US guidance (Fig. 45.15). She often lesioned
486 T.K. Vanetti et al.

a b

Fig. 45.11 Composite cross-sectional ultrasound image of the internal (superficial) and external iliac artery (deep) (Image courtesy of Thiago
inguinal ring. Dotted line represents the internal inguinal ring; (a) male, Nouer Frederico, MD)
(b) female, CR cremaster, RL round ligament, ART femoral artery

a b

Fig. 45.12 Cross-sectional ultrasound image of the internal inguinal male, (b) female, CR cremaster, RL round ligament, ART femoral artery
ring filled with local anesthetic and needle tip near the cremaster or (superficial) and external iliac artery (deep), (Image courtesy of Thiago
round ligament. Dotted line represents the internal inguinal ring; (a) Nouer Frederico, MD)

multiple sites, primarily at the GFN but occasionally also at cryoneuroablation, and these consecutive cryoneuroablations
the ilioinguinal nerve. All patients had post-procedure numb- yielded longer-lasting results. Interestingly, she has observed
ness of the scrotum, with increased function and increased that the pain does not return to the same area that was treated,
ability to lift and carry objects; three patients underwent repeat suggesting an element of unmasking (see Chap. 1).
45 Genitofemoral Nerve Entrapment: Pelvic 487

Fig. 45.13 Cryoneuroablation of the genitofemoral nerve at the pubic

c
tubercle. Note the white arrow showing the InterStim placed for
interstitial cystitis pain that offered no relief (Image courtesy of
Andrea Trescot, MD)

Fig. 45.15 Cryoneuroablation of the genitofemoral nerve at the internal

inguinal ring under ultrasound guidance. (a) Ultrasound identification of
the internal inguinal ring and the genitofemoral nerve (white arrow);
(b) cryoprobe placement; (c) cryo-ice ball (Image courtesy of Agnes
Stogicza, MD)

similar to that described above) gave excellent but only tem-

porary relief. The patient underwent a pulsed RF treatment,
again using the same ultrasound technique. At 7 months, the
patient was still noting excellent relief.

Phenol

Fig. 45.14 Cryoneuroablation probe positioned on the proximal geni- Weksler and colleagues [22] described injecting 4 % phenol
tofemoral nerve at L1 (Image courtesy of Andrea Trescot, MD) on to a variety of painful structures (including the GFN) in
35 patients; they noted good relief and no complications.
Radiofrequency Lesioning

Pulsed radiofrequency treatment of the GFN has been Neurostimulation

described. Terkawi and Romdhane [21] treated a young man
suffering from chronic orchialgia; a diagnostic injection of Peripheral nerve stimulation has been used for chronic groin
the genital branch under US guidance (using a technique and genital pain (Fig. 45.16) [23,24]. The trial electrodes are
488
Fig. 45.16 Peripheral nerve stimulation of abdominal wall (Image
courtesy of Gladstone MacDowell, MD)
placed percutaneously through introducers, and, if there is
significant temporary relief, the leads can be placed perma-
nently. Rosendal et al. [23] described the successful use of a
dual lead peripheral nerve stimulator over the ilioinguinal
and genitofemoral nerves to treat persistent testicular pain.
Surgical Techniques
Excision of scar neuroma can give relief, but the neuroma is
often difficult to localize. One technique that has been suc-
cessful (Trescot, personal correspondence) is mixing local
anesthetic with methylene blue. If the local anesthetic abol-
ishes the pain, then the neuroma is within the dyed tissue,
and the surgeon is instructed to take out everything blue.
Another surgical option is to locate the genitofemoral
nerve in the inguinal region, near the round ligament or sper-
matic cord. Dissection is performed under sedation and local
anesthesia, which can prove very useful to identify these lit-
tle nerve branches, especially in obese patients, by allowing
the patient to report when a determined structure reproduces
the pain sensations.
Endoscopic retroperitoneal neurectomy (ERN) is a surgical
technique involving the insufflation of the retroperitoneal space,
T.K. Vanetti et al.
allowing neurectomy before the GFN becomes embedded in the
psoas muscle [25]. This technique has been used successfully in
the treatment of postsurgical groin pain [26]. Triple neurectomy
(IIN, IHN, and GFN) has also been advocated, with a reported
80 % success rate in relieving postsurgical groin pain [27].
Complications
Any injection may cause the usual complications of bleeding,
infection, and nerve damage. Psoas hematoma is a potentially
serious complication of nerve blocks but is usually encoun-
tered in the setting of anticoagulation. A retroperitoneal tech-
nique also runs the risk of peritoneal injury, retroperitoneal
hematoma, and lumbar plexus injury. It is thought that CT- or
ultrasound-guided techniques have lower rates of complica-
tions, but this has not been conclusively proven. ERN may
rarely result in genital anesthesia in women [25].
Summary
The GFN is an under-recognized cause of pelvic pain, as
well as abdominal pain (see Chap. 41) and lower extremity
pain (see Chap. 60). A careful history and physical, as well
as a high index of suspicion, will help the clinician to begin
to recognize and then treat GFN entrapments.
Acknowledgments The authors would like to thank Camille Khan for
her translation of this manuscript from Brazilian Portuguese to English.
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