14 Aug 2026 Sexual Pain After Hernia Surgery: The Question No One Asks!

Where Are These Patients?

Inguinal hernia repair is one of the most commonly performed operations in general surgery. Yet this operation has a rarely discussed complication: pain that occurs in men during erection and/or after ejaculation. The surgeon doesn’t ask, the patient doesn’t tell. Because the surgeon doesn’t ask, the patient doesn’t think it could be related to the surgery; because the patient doesn’t tell, the surgeon never finds out. Behind this silence lie two truths: surgeons overlook this picture as part of chronic groin pain, and patients cannot voice their complaints out of shame and hesitancy. Yet dysejaculation — the medical name for this syndrome — is a condition that can be recognized, scored, and treated. This article is written for both surgeons and for patients experiencing sexual pain after surgery.

Definition

In the relevant chapter of Abdominal Wall Hernias, which he edited in 2001, Robert Bendavid introduced the term Dysejaculation into the medical literature. His description: a condition occurring on the same side as the hernia repair, characterized by brief but often severe attacks of pain in the groin during ejaculation. Typically, this pain — which can vary in its timing before, during, or after ejaculation — lasts anywhere from a few seconds to 30 seconds. The quality of the pain is described as a burning or “searing” sensation.

More Common Than You’d Think!

After routine inguinal hernia repair, 3–4% of men report pain during sexual activity and ejaculation. The true frequency is much higher than reported, because the answer to a question that is never asked cannot be recorded. How common dysejaculation actually is depends on how the question is asked. The most striking illustration of this gap is when Robert Bendavid first described this syndrome in 1992; he reported its frequency as approximately 1 in 2,500 hernia repairs. But that figure was based only on cases patients reported spontaneously — that is, cases the surgeon never asked about and the patient volunteered on their own. Later studies revealed the true figure to be far higher. Current data show that nearly two-thirds of men suffering from dysejaculation experience a genuine deterioration in their sexual activity. In a study drawn from the Swedish Hernia Register covering 538 male patients operated on using the TEP technique, 8.2% of patients were found to experience pain during sexual activity after surgery. Of those affected by this pain, three-quarters went on to develop significant sexual dysfunction. An even more striking finding: among patients re-evaluated for pain after chronic inguinal hernia surgery, this rate rises to as high as 34%. In other words, one in every three men who present with chronic post-operative groin pain also has dysejaculation — but the vast majority never mention it to their surgeon.

The picture that emerges is this: 15% of patients have given up sexual activity altogether, and 14% report regretting having had the surgery. These figures show that dysejaculation carries not only a medical burden but a profound psychosocial one as well.

Why Does It Happen? Mechanism and Anatomy

Ejaculation is, in itself, a complex neuromuscular process. It begins with peristaltic contractions of the testis, epididymis, and vas deferens; the seminal vesicles and prostate then contract to deliver fluid into the urethra. In this process, the vas deferens plays a critical role both mechanically and neurally. Innervation of the vas deferens is provided by the genital branch of the genitofemoral nerve and by sympathetic fibers arising from the deep pelvic hypogastric plexus of the autonomic system. In a healthy vas deferens, the sudden, forceful flow of fluid during ejaculation does not cause pain. But if this structure is injured, kinked, or bound by adhesions, the picture changes entirely.

Causes Related to Inguinal Hernia Surgery

1. At the root of post-operative dysejaculation lies mechanical and inflammatory injury to the vas deferens. This injury can arise in several different ways. First, the vas deferens can be directly damaged during surgery through traction or instrument contact — an injury that, while unintentional, can be unavoidable.
2. Second, the healing process itself can become a source of the problem: the vas deferens may adhere to the floor of the inguinal canal, become kinked, or develop an intraluminal stricture. These changes prevent the vas deferens from stretching and expanding normally during ejaculation, and the resulting hydrostatic pressure sets the stage for pain. This mechanism closely resembles the colicky pain seen in other luminal organs, such as the ureter or common bile duct.
3. Third, mesh use. Mesh-related fibrosis and adhesions can lead to both mechanical obstruction and inflammation of the paravasal nerve fibers.
4. Fourth is nerve injury. The ilioinguinal nerve, the iliohypogastric nerve, and the genital branch of the genitofemoral nerve run close together in the groin, and injury to these nerves during surgery can trigger ejaculatory pain.

The relatively late onset of symptoms — sometimes months after surgery — suggests that this picture is not the result of an acute injury, but of a slowly developing disorder of healing.

Dysejaculation Seen Without Surgery

Dysejaculation is not specific to inguinal hernia surgery alone. Conditions such as chronic recurrent epididymitis, prostatitis, radiation therapy, and vasectomy can also affect the vas deferens and produce a similar picture. However, these causes fall outside the scope of this article.

Why Does the Patient Stay Silent, and Why Doesn’t the Surgeon Ask?

The Patient’s Silence

For men, voicing sexual dysfunction is extremely difficult, both culturally and psychologically. What’s more, this complaint points to an intensely private moment — the moment of ejaculation itself. The patient often wonders: “Could this be related to the surgery? Or is it something else?” Left in uncertainty, the patient buries the complaint under shame and hesitancy. A 2014 study by Verhagen and colleagues laid this reality bare in striking fashion: dysejaculation was found in one-third of patients re-evaluated for chronic groin pain, yet the vast majority of these patients had never mentioned this complaint to their surgeon before.

The Surgeon’s Question

So why doesn’t the surgeon ask? There are several reasons. First, a lack of awareness. Dysejaculation has for many years received insufficient attention in medical education and in the hernia surgery literature. Many surgeons are unaware that this picture even exists, or seriously underestimate how often it may occur. Second, the symptom tends to disappear into the background. When the patient comes for a post-operative check-up and says “I have groin pain,” the surgeon evaluates this as post-herniorrhaphy pain and proceeds with the standard treatment protocol. Dysejaculation becomes invisible within this picture. Third is the intimacy of the subject. For a surgeon to ask, “Do you experience pain during ejaculation?” falls well outside the usual routine of surgical follow-up. Asking this question requires both awareness and clinical courage.

The result is a vicious cycle: the surgeon doesn’t ask, the patient doesn’t tell; the patient doesn’t tell, no diagnosis is made; no diagnosis is made, no treatment is given. Yet what it takes to break this cycle is remarkably simple — asking the right question.

Measuring Dysejaculation: The Post-Herniorrhaphy Dysejaculation Score (PHDS)

The first step in taking a complaint seriously is naming it. The second step is measuring it. For many years, dysejaculation was neither defined by a standard nor measured systematically. To fill this gap, Verhagen and colleagues developed a scoring system specifically to assess post-herniorrhaphy dysejaculation: the Post-Herniorrhaphy Dysejaculation Score (PHDS).

The PHDS measures three core dimensions:

1. Pain Intensity (0–4 points)

The intensity of pain felt during or after ejaculation is assessed.

0: No pain at all

1: Mild

2: Moderate

3: Severe

4: Very severe

2. Pain Frequency (0–4 points)

How often the pain occurs across ejaculations is assessed.

0: Never

1: 0–50% of the time

2: 50–75% of the time

3: 75–100% of the time

4: Always

3. Impact on Sexual Life (0–4 points, double-weighted)

Because this domain is considered more decisive than the other two, its score is doubled.

0: No effect at all on my sexual life

2: Affects my sexual life but does not lead me to give up activity

4: I completely give up sexual activity because of this pain

The total score ranges from 0 to 12. A patient without dysejaculation scores 0. A score of 8 or above is defined as “severe dysejaculation.”

The PHDS is a practical tool that can be applied in the clinic in just a few minutes, without the need for long, complex questionnaires. It can be used both for pre-operative screening and for monitoring treatment effectiveness. Three simple questions from the surgeon can prevent years of silence.

Treatment: From Watchful Waiting to Surgery

Once dysejaculation is diagnosed, the first question for both patient and surgeon is the same: what can be done? The answer depends on the severity and duration of the complaint and its impact on the patient’s quality of life. Treatment approaches span a wide range, from conservative observation to complex surgical procedures.

Conservative Approach: Time and Patience

One fact has been known since Bendavid’s original series: the natural course of dysejaculation largely improves over time. Symptoms may gradually diminish, without any intervention, over a period ranging from 2 months to 5 years. For this reason, in patients whose complaint is new, whose PHDS score is low, and whose sexual life has not been severely disrupted, the preferred initial approach is conservative observation. Patients should be clearly informed that this process may take time, and should be counseled to avoid unnecessary anxiety. However, it must also be emphasized: “conservative” does not mean “neglect.” These patients should be kept under close follow-up, with the course of their complaints reassessed at regular intervals.

Medical Treatment

No specific drug therapy for dysejaculation has yet become standard in the literature. However, in patients where a neuropathic pain component predominates, anti-inflammatory drugs, agents used in neuropathy treatment, and local nerve blocks may help within a pain-management framework. A nerve block also has diagnostic value: if a patient’s complaints resolve following a block of the ilioinguinal nerve or the genital branch of the genitofemoral nerve, this points to nerve involvement as the dominant mechanism and helps guide surgical planning.

Surgical Treatment

Surgery becomes an option for patients who fail to respond to conservative treatment, whose PHDS score is high, and whose sexual life has been significantly affected. Surgical treatment has three core components:

Selective neurectomy: Division of one or more of the ilioinguinal nerve, the iliohypogastric nerve, and the genital branch of the genitofemoral nerve. The word “selective” — that is, tailored and personalized to the patient — matters: not every patient requires the same combination of nerves to be cut. Clinical assessment, the localization of symptoms, and the response to nerve block determine which nerves are targeted. Notably, in some patients ilioinguinal neurectomy alone completely resolves dysejaculation, suggesting that nerve involvement can be a mechanism independent of mechanical vas deferens injury.

Freeing (mobilization) of the vas deferens: the release of a vas deferens that has become kinked and restricted in movement due to mesh-related fibrosis or adhesions. This release may be critical to allow the vas deferens to carry out its normal peristaltic movement during ejaculation.

Mesh removal: Direct contact between the paravasal nerve fibers and the mesh is known to cause chronic inflammation and neuropathic pain. This is especially critical for preperitoneal meshes, given their relationship to the spermatic cord and vas deferens. However, it should be kept in mind that mesh removal is one of the most complex and challenging issues in inguinal hernia surgery, technically demanding, and carries a particular risk of vascular injury.

Paravasal neurectomy: A 2024 study by David Chen and colleagues added a new dimension to the treatment of dysejaculation and orchialgia: paravasal neurectomy. This procedure, which involves dividing the autonomic nerve fibers surrounding the vas deferens that arise from the deep pelvic plexus, can be performed more safely and effectively in the preperitoneal space, particularly via a laparoscopic or robotic approach. In the preperitoneal space, the paravasal nerve fibers between the vas deferens and the spermatic vessels can be clearly visualized without interference from the cremasteric muscle. This approach offers both anatomical and technical advantages.

Orchiectomy: In severe, treatment-resistant cases — particularly when accompanied by testicular atrophy or hypertrophy — orchiectomy may be considered. However, this decision must be made with extreme caution; androgen deficiency, cosmetic concerns, psychological trauma, and the risk of phantom pain must all be discussed with the patient in detail.

Association with Orchialgia

Another pain syndrome that can arise after inguinal hernia surgery is orchialgia — that is, testicular pain. While orchialgia is a separate topic in its own right, it frequently occurs together with dysejaculation, and this co-occurrence is often missed by the surgeon.

In the 2024 study by Chen and colleagues, concurrent orchialgia was found in roughly one-fifth of patients operated on for chronic groin pain following inguinal hernia surgery. This co-occurrence is not a coincidence. The structure common to both conditions is the vas deferens and the paravasal nerve fibers. The same injury can set the stage for both testicular pain and ejaculatory pain. The clinical message is clear: a surgeon who sees orchialgia should also ask about dysejaculation, and a patient reporting dysejaculation should also be evaluated for testicular pain. Recognizing the two together both completes the diagnosis and leads to successful treatment.

A Call to Surgeons: Asking Is Also a Treatment

Every male patient presenting with chronic groin pain should be asked this question: “Do you experience pain during sexual activity, particularly at the moment of ejaculation?” This question is not strange. It is medical, necessary, and important. Let us remember that the vast majority of patients do not volunteer this complaint on their own. There are also precautions that can be taken from a surgical-technique standpoint. Minimal contact with the vas deferens, avoiding excessive dissection, gentle handling of the spermatic cord structures, and appropriate mesh selection are chief among these precautions. The “no-touch” principle for the vas deferens — leaving it untouched — is especially critical for preventing paravasal nerve injury, particularly in minimally invasive approaches.

Finally, it must be said: dysejaculation is a treatable condition.

A Message to Patients: You Are Not Alone

What you are experiencing is a defined, named, and treatable medical condition. Research shows that a significant proportion of men who undergo inguinal hernia surgery experience similar complaints. Most of them, just like you, have stayed silent — out of shame, because they couldn’t bring themselves to wonder, “Could this be related to the surgery?”, or because they assumed their surgeon would never ask. So don’t hesitate to bring this complaint to your surgeon. Saying “I have pain in my groin during ejaculation since the surgery” is simply sharing medical information.

The treatment process may require patience. In some patients, the complaints gradually diminish on their own over time. In others, medical treatment is enough. In still others, surgical intervention is required — and the results of that intervention are promising.

One last thing: if this pain is affecting your relationship, your emotional well-being, and your daily life, and you feel unable to find your way out of it, don’t hesitate to consult a urologist or hernia surgery specialist. The right physician will ask the right questions and will listen to you. Because this pain has a name — and it can be treated successfully.