A European algorithm and strategy for management of chronic postoperative inguinal pain (EurA-CPIP)

Chronic postoperative inguinal pain (CPIP) is a disabling complication affecting 8%-17% of all patients after inguinal hernia repair. It is a complex pain condition with several pathophysiological mechanisms involved, including neuropathic pain, inflammation, and mechanical effects (e.g., mesh or scar tissue). Management remains inconsistent, probably due to limited high-quality evidence, heterogeneous approach, and insufficient standardisation of outcomes. This study aimed to develop EurA-CPIP, a multidisciplinary treatment algorithm and prospective data-collection platform designed to support consistent phenotyping, step-up management, and standardised outcomes across centres, creating an iterative platform for future hypothesis-driven research and multicentre trials.

An international multidisciplinary working group from European tertiary referral centres developed the European Algorithm and Strategy for Management of Chronic Postoperative Inguinal Pain (EurA-CPIP). Development was informed by the evidence synthesis underpinning the updated international HerniaSurge guidelines and a critical appraisal of previously published CPIP algorithms. A pragmatic step-up algorithm was designed, integrating pharmacological, interventional, surgical and supportive treatments, with prospective outcome registration and planned data-driven revision on a regular basis.

EurA-CPIP provides a multidisciplinary algorithm with entry at multiple levels depending on prior treatment attempts. The concept is to begin and, if needed, advance from conservative measures such as systemic medication and topical therapy, to more invasive treatments such as trigger point injections, and ultrasound-guided nerve blocks; predefined investigational add-ons (radiofrequency, cryoneurolysis, botulinum toxin A) are embedded after documented block response. Multidisciplinary team review precedes escalation to more invasive interventions such as surgery. A supportive and rehabilitative coping trajectory is integrated early on. Standardised outcomes include patient-reported pain outcomes, functional impairment, psychological factors, analgesic use, and patient global impression of improvement.

EurA-CPIP is a pragmatic consensus-based strategy intended to harmonise and improve specialised CPIP care while utilising existing and developing emerging therapies. Future research should investigate pathophysiology and intervention effects within this step-up algorithm.