Possible Hernia?

The purpose of my inquiry is to determine if I (52 yr. old male) might be experiencing pain from a hernia despite tests that appear to “rule out” hernia.  The pain is deep in the lower abdominal area centered around the left abdominal obliques.

In the spring of 2005, I experienced left pelvic pain when taking part in physical activity.  Today, the pain persists and is exacerbated when I perform physical activity greater than a slow walk or if I sit too long.  I have no digestive problems except occasional constipation and gas.

I have undergone tests that appear to rule out hernia.  Tests include a colonoscopy, pelvic ultrasound, and two CT scans of the abdominal and pelvic region.  A surgeon found several very small hernias that he said didn’t need surgery.  I’ve also seen a gastroenterologist, urologist and physiatrist with no conclusive diagnosis.  The physiatrist unsuccessfully tried prolotherapy.

Other treatment has included stretching, exercise physical therapy, and trigger point release.  The exercise physical therapy worsened my condition.  The trigger point release, through direct pressure and dry needling, has provided temporary improvement, but the trigger points and accompanying symptoms keep returning following treatment.    

My questions are:

• Is it possible or likely for very small hernias to be painful?
• Is it possible or likely to have pelvic area hernias that aren’t detected by the tests above?
• What are the other possibilities?  
• Where can I find doctors who are skilled at making such nuanced evaluations?

[Kevin Pho, MD]

To answer your questions:
1) A small hernia may result in the symptoms.  However, a negative CT scan would make the possibility of a hernia less likely.

2) No test is 100% sensitive, and it may be possible for a hernia to be missed during the imaging studies.

3) Malabsorption, celiac disease, or an infection can still be possible.  Your workup has been thorough thus far, making things like inflammatory bowel disease or a mass less likely.  I would consider testing the blood for celiac disease and sending off the stool for a fat analysis.

4) A second opinion GI referral, at a major academic medical center, should be considered.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
www.kevinmd.com