EUROPEAN JOURNAL OF MEDICAL RESEARCH June 30, 2003 Abstract: In males inguinal hernia and varicocele are frequent diseases with a reported incidence of 1-2 % for hernia (Klinge 2000) and up to 20 % (Mickevicius et al. 2002) for varicocele. In 1997 approximately 220,000 inguinal herniotomies were performed in Germany (Horeyseck 1997). Leading symptoms in both diseases are complaints and dragging pain in the inguinal region radiating into the testis. Surgeons treat traditionally ingui- nal hernia whereas varicocele is the domain of urologists. Coincident appearance of inguinal her- nia and varicocele is expected to be more frequent with regard to the pathogenesis (Friedman et al. 1993; Nakada et al. 1994; Rosch et al. 2002; Rovsing 1916; Santoro et al. 2000; Wagh and Read 1972). Therefore both surgeon and urologist should see patients with inguinal hernia or varico- cele. If patients with hernia repair postoperatively suffer from similar complaints again, it should not be interpreted rashly as mesh complication (Conze et al. 2001). The need for an improved as- sessment has been recognized (Kehlet et al. 2002). It sounds reasonable to assume, that quite a num- ber of patients with complaints after successful hernia repair may suffer from an undiagnosed va- ricocele. We present a case of inguinal hernia with mesh implantation and concomitant varicocele as an ex- ample for mesh-unrelated postherniorrhaphy pain. Key words: Inguinal hernia; varicocele; mesh; Lichtenstein procedure; postherniorrhaphy pain CASE REPORT A 34 years old male presents with the typical symptoms of an acute left inguinal hernia. Intraoperative diagnosis consists of a direct hernia with defect of the posterior wall (Nyhus IIIa); an indirect hernia is excluded. The patient is treated according to the Lichtenstein procedure with mesh (VYPRO II, Ethicon Hamburg, Germany) under general anaesthesia. He receives one shot antibiotic prophylaxis (cephazolin 2g) and postop- eratively diclophenac 100 mg for 3 days for pain relief. The weeks after the operation neither intra- operative nor postoperative complications nor complaints about pain were reported. 5 months later the patient presents with complains in the left inguinal region, especially during sexual activ- ity. After exclusion of a recurrent hernia or a mesh complication - e.g. inflammation, infection or dislocation - the patient is sent to the urologist for further evaluation. Palpation and inspection reveals no abnormalities of testis and spermatic cord; sonography of the left testis and epididymis shows a homogenic echo of the parenchyma. Duplexsonography excludes any damage to the vascular structure of spermatic cord and testis. At last during valsalva manoeuvre a significant reflux of the testicular vein into the enlarged veins of the plexus pampiniformis, typical for a varicocele, is demonstrated. The urologist recommends sclero- therapy of the varicocele. DISCUSSION Inguinal hernia is a frequent illness of the male (Klinge 2000). The incidence of male inguinal her- nia in Great Britain is 2 % and in females 0.3 % (Keith 1923). In 1997 approximately 220.000 in- guinal herniotomies were performed in Germany (Horeyseck 1997). Chronic pain of patients after herniotomy is often considered to be caused by intra-operative injury to the inguinal nerves (Kehlet et al. 2002) or mesh complication (Conze et al. 2001); however, other factors, e.g., concomi- tant and previously asymptomatic varicocele, may be involved when recurrence or mesh complica- tion has been excluded as in our case. Others have found no evidence that mesh influences sexual function or testicular perfusion (Zieren et al. 2001). Varicocele, an abnormal enlargement of the veins of the plexus pampiniformis of the spermat- ic cord, was observed in 1-2% of males in older re- ports (Rovsing 1916). According to newer obser- vations there may be an incidence of up to 20 % in young males (Mickevicius et al. 2002). There are no scientific reports available on the incidence of inguinal hernia and concomitant varicocele. The frequency and pathogenesis of both diseases in males may lead to the assumption that this coinci- 254 Eur J Med Res (2003) 8: 254-256 © I. Holzapfel Publishers 2003 Case report I NGUINAL HERNIA AND CONCOMITANT VARICOCELE MIMICKING MESH COMPLICATION R. G. Holzheimer 1 , A. Schreiber 2 1 Center for Short Stay Surgery, Munich Sauerlach / Department of Surgery, Martin-Luther Universität Halle-Wittenberg, 2 Department of Urology, Krankenhaus Barmherzige Brüder, Munich, Germany