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chronic pain, pregnancy

Persistent pain after a c-section: when is it nerve pain and what can you do?

Surgical scar in patient with iliohypogastric neuropathy

Persistent pelvic and/or abdominal pain post c-section often poses a diagnostic and treatment dilemma, because most OB/GYNs know very little about pain and most pain doctors know very little about the pelvis.

But that’s where I come in, being both board certified in OB/GYN and Pain Medicine.

It is hard to know how many women have persistent pain post c-section, because it hasn’t really been studied. All I can tell you is that I see several women a month with this problem. We do know is that 1-3% of women will have persistent nerve pain post c-section (although this is only one cause of pelvic pain). Today’s post will focus on that one type of pain, which typically means pain from one or all of these three nerves in the belly wall: ilioinguinal nerve, iliohypogastric nerve, or genitofemoral nerve.

This kind of nerve pain does not imply that anything was done incorrectly at the time of surgery. Surgery is injury and unfortunately as surgeons cut tissues we also cut the small nerves in the skin (that is what produces the weird numbness or strange feelings that you have over a scar that came sometimes persist for years, because nerves don’t heal quite as well as other tissues). I had a nephrectomy when I was 11-years-old and my scar is still numb in places and gets odd sensations, especially itching, from time to time (that’s part of my massive scar in the picture, BTW).

With surgery we avoid the important nerves; however, the ilioinguinal, iliohypogastric, and genitofemoral nerves (which allow you to feel sensations on your abdomen) run quite close to the edge of a c-section incision and they can be bruised, crushed, or trapped by scar tissue. The nerve can also be cut, but this is less likely to cause pain and more likely to produce complete numbness. Sometimes when these nerves are cut both numbness and pain can result, a condition called anesthesia dolorosa, which can be very challenging to treat.

How do you know if the pain that is persisting after your c-section is this kind of nerve pain?

Pain from the ilioinguinal, iliohypogastric, and/or genitofemoral nerves is a superficial pain that is typically felt at the edges of the scar. It will almost always be described as a burning pain and sometimes there may be electric shock-like sensations. The area will hurt to light touch, meaning clothes, the waist band of pants/jeans, wearing a seat belt, or just touching the area lightly with your fingers will hurt. If you can push on the area and not reproduce the pain, the ilioinguinal/iliohypogastric/genitofemoral nerves are less likely to be the culprit.

The diagnosis is confirmed with a nerve block, basically injecting an anesthetic (numbing medication, typically lidocaine) around the nerve to cause temporary numbness. If there is both numbness and pain relief, the diagnosis of a peripheral nerve injury is confirmed. If there is numbness but no change in the pain the cause is probably something else. If there is no numbness then the nerve block was done incorrectly and should be repeated or you should see someone who can do it correctly. The doctor should keep you in the office after the nerve block and repeat their exam once the area is numb to A) confirm that they have done the nerve block correctly and B) to see if the nerve block worked.

Once neuropathic (nerve) pain from the ilioinguinal/iliohypogastric/genitofemoral nerves has been confirmed, initial treatment may include all or some of the following:

  • A Lidoderm® patch (topical numbing medication applied to the affected area).
  • A series of nerve blocks using steroid medication. At a cellular level, pain is related to inflammation and steroids are potent anti-inflammatories. Sometimes there is scaring around the nerve, and since steroids cause fatty tissue to shrink a little for some people this extra millimeter or two of space that is freed up after the injection takes the pressure off the nerve and reduces the pain. Most people feel improvement from steroids 5-7 days after the injection.
  • Adjunctive mediations, which work on how the pain is processed at a cellular level. The best and most studied option is a class of drugs called tricyclic antidepressants (TCAs, although they are no prescribed because your doctor thinks you are depressed, they are pretty poor antidepressants). Drugs traditionally used for epilepsy (like gabapentin or topiramate) can also be used. I favor nortriptyline because it has fewer side effects than some of the other TCAs and unlike the epilepsy drugs is only once a day. Nortriptyline is also generic and can be taken if you are breastfeeding. Often these types of medications are not needed long-term. The goal is to get the pain controlled for 4-6 months and then assess whether or not a trial of stopping the medication is indicated and desired.
  • Getting screened for depression. Depression makes pain worse. It’s not the cause of your pain, but it is like pouring fuel on a fire and you can’t put out a fire out with a steady infusion of gasoline.
  • Controlling the pain with ibuprofen or opioids, although in reality opioids are not that great for this kind of nerve pain. The BEST pain relief you can expect from opioids with any kind of chronic pain is about a 30-60% improvement, and in my experience it seems to be less than that for nerve injury related pain.
  • Weight loss if you are overweight. When you are overweight and your belly hangs down a little (I hate to use this term, but if I say muffin-top everyone knows what I mean) it puts traction on the ilioinguinal and iliohypogastric nerves. Some people can even develop nerve pain from the ilioinguinal and iliohypogastric nerves simply due to obesity without any prior surgery in the area.
  • Mind-body work. Stress and anxiety make pain worse. This doesn’t mean the pain is in your head, but rather the chemical changes of stress and anxiety will worsen your pain. Deep belly breathing (like Lamaze) or yoga are just a couple of ways to harness the mind-body connection to improve your pain.
If the nerve blocks work, but don’t give long-lasting relief advanced procedures on the nerves, such as pulsed radio frequency (sending an electrical impulse along the nerve) can sometimes be helpful. Other nerve blocks closer to the spine can also be considered. A peripheral nerve stimulator (an implant) to over ride the painful signals from the nerve may be an option for some people.

If all else fails (and in my experience this is rare) surgery on the nerve ending to clean up scar tissue or even removing the damaged end of the nerve can be an option. However, this should only be considered when A) the diagnosis is 100% certain (meaning confirmed by nerve blocks), B) the other treatments have been tried and failed and C) there has been an in-depth discussion about the bad things that can happen after this kind of surgery. 

There are certainly many other causes of persistent pain after a c-section and I will address those in another post in the next day or two. Remember, this blog does not represent individual medical advice. 

Discussion

115 thoughts on “Persistent pain after a c-section: when is it nerve pain and what can you do?

  1. I had my c-section 3 months ago(1 August) and suddenly I start feeling this stinging,burning feeling around the scar area. It gets worse when I sit up or there is any other tension on my belly. It is very sensitive around the area and becomes quite painful. I hate going to doctors,but will obviously go if it is really necessary. Any advice? Can the pain go away by itself?

    Posted by Desiree | November 3, 2013, 12:05 am
    • I’m so glad to know I’m not alone!! I had my 1st c-section in 2005 no problems but than I had my second in 2009 and my body hasn’t been right since. The stinging pain and soreness I feel on a daily basis is unbearable. I have fibroids as well but I don’t think the fibroids have anything to do with the pain I’m experiencing….. Doctors never seem to be of any help and the only relief I find that works for me is taking oxycodene….. My sex life is nonexistent with my husband because of this, if I knew having a csection would cause this much havoc I would have tried to have my second baby vaginal, vaginal birth was not an option for me for my first child bc he was early and had his own set of health problems and having him vaginally could’ve put too much stress on him according to my doctors….. I just wish there was an answer for this pain!!

      Posted by Ash Wilson | November 5, 2013, 7:41 am
  2. I’ve had crippling pain from my c-section which took place 3 years ago. After a doctor finally knew what was wrong with me (which took 2 years) At my three year mark he put in an implant device. But, now that some time has passed I’m wondering about a more perminate fix. The implant device shocks me a lot when I move certain ways, I have residual pain above the wires (it was placed in my abdomen) and its a pain to charge. Yes it keeps me mostly out of pain, but I want a full life where I’m not having to remember if I charged a battery in me, or did I remember to take the device with me on a trip. I had an pain doctor/anestisologist do the implant. So, my question is, if I’m looking for someone to burn the nerve endings should I seek out a nurosurgeon or a pain specialist?

    Posted by Lauren Merchian | November 15, 2013, 9:53 pm
  3. I’m having the same problem i had a csection a month ago it was an emergency csection. i am having pai. thru my in scar and into my right hip also it hurts more when i pee n when i move my bowels i have been to the emergency room. multiple times cuz it gets so bad. my period just started n i am having more problems now n its so bad i don’t know what to do i have an appt with my gyn and I’m hoping shr can tell me more of what’s going on… someone please if you have answrs please tell me….

    Posted by Megan Belford | December 6, 2013, 7:49 pm
  4. Dr Gunter,
    I’ve had 2 c-sections, 2003-2008. I’ve had No complications with either one. The only issue I experience is that I always feel gassy or full in my lower abdomen. I have felt this ways since the 2nd c-section. Also after sex I feel extremely full. No pain, just bloated feeling. What could that be?

    Posted by Briant | January 8, 2014, 12:59 am
  5. Dr. Gunter it is so impressive that you are both a gynecologist and a pain specialist. I hope you have a bit of direction for me. I didn’t have a C-section but had a fibroid tumor removed-same incision right? then diagnosed with hernia on scar. I had a hernia repair and ended much worse. I’ve been diagnosed with ilioinguinal/iliohypogastric neuromas. my case is a bit complicated in that the pain often refers to my bladder. I have previously diagnosed with IC. However the bladder pain only happens when the scar pain starts up. I have had several nerve blocks over the years. I had success in the past but the last one I had has made my pain worse. I’m considering surgery but I’m very scared. I have never tried an epidural type of pain block. Do you have a referral for me for a doctor such as yourself in the LA area?

    Posted by Martha cordoba | March 10, 2014, 5:36 pm
  6. I had my c section 3 years ago and almost 2 months before I felt strong pain in my bladder, stomach, left kidney, upper side of my stomach and lower side of my stomach.
    a small lump I found in my abdomen close to the surgery location I was under stress because of the lump I found several doctors told me the lump is under my skin and it is fat and is not dangerous.
    but still I feel pain in the location where the lump is located.
    can anyone help me or share if they the same lump in their abdomen.
    the doctor

    diagnosed the infection in my pelvic and I got antibiotics but still the pain and burning is improving.

    Posted by Huda | April 7, 2014, 2:38 am
  7. Hi, I had my baby 7years ago via c-section and lately my scar has been painful to the point that I pee every now and then because the scar hurts if the’s even small amount of liquid in my bladder should I be concern?
    Khensani from South Africa

    Posted by khensani | April 11, 2014, 7:18 pm
  8. Hello my name is Nicholas two years ago my wife had a c section ever since then she has had almost unbearable pain in the the left side of her stomach I think around the intestinal area it’s hard to the touch and I’m extremely worried about this because she says it feels as tho the doctors left gauze packing in her is this possible and if so wat can we do or who might we see to alleviate this plz help me and my wife

    Posted by Nicholas | April 18, 2014, 10:22 am
  9. My painful “scar tissue” ended up being an endometrium mass in my abdominal rectus muscle. Over 30 doctor visits in 33 months and I finally got it diagnosed. During my cesarean some endometrium tissue (uterus lining) remained in my abdominal muscle. Because of lack of awareness, doctors misdiagnosed me for so long. My name is Ana, to read my story and see why I started my mission on raising awareness of this overlooked cesarean risk please visit my website http://www.iatrogenicendo.com/
    Remember any painful “scar tissue” lump above your cesarean incision with pain in synced with your menstrual cycle is not “scar tissue”. In most cases the lump is most painful during the ovulation time. I have no endometriosis, simply the endometrioma mass they found was the direct implantation during my cesarean. I’ve ended up having a 8cm of my left abdominal rectus muscle since there is no cure and it’s a progressive condition. I encourage everyone to demand biopsy of their lumps.
    I’m trying to raise awareness of this overlooked cesarean risk so I can help as many women as I can. We need to bring attention to something that is overdue, this condition needs to be included as part of the diagnosis when postpartum problem arise.

    Posted by Ana Gri | May 9, 2014, 8:58 am
  10. I am 34 years old. I have had 6 c sections. I am experiencing pain very low. It is uncomfortable. After my 5th C section I didn’t have this pain that I am experiencing now. Once a month I get this gut grinching pain, and I must have sex to ease the throbbing pain. During sex it seems like a gallon of female ejaculation oozes out. Sounds gross right, but it’s the truth. If I’m in the grocery store shopping or where ever I am I will get this killer pain. After sex it’s like some type of relief. Other then that my lower abdomen aches and pains just throbbs all day. I can’t get comfortable when I bend forward. I have to lean back. I took Advil and it took away a little of the pain but it feels like a tender ball is in front of me. I think it’s my uterus that is so sensitive. I have been working out lately at the gym and trying to improve my health. I just don’t like this uncomfotable feeling. I will be making a appointment with my OBGYN soon.

    Posted by Asia | May 15, 2014, 9:30 pm
  11. I have had my cut for 4 years an i still feel pain in the an around the area,sometimes so deep in there its like something is on the inside tearing the area away,sex is awfull cause of the pain an the cut had to be re-opened due to the fact that it got infected…..but its still not feeling like i dont have to be worrying about the pain that may or may not hurt

    Posted by Chevel Johnson | May 27, 2014, 7:12 am
  12. Thanks for this insightful blog post. I’m leaving a message here in the hopes you receive it… I’ve been trying to reach you through your hospital office for two days with no luck- the Kaiser bureaucracy appears impenetrable.

    My ob-gyn surgeon recently diagnosed me with post c-section nerve entrapment (diagnosis by process of elimination). I’m 10 weeks post-partum and frustrated by the pain. I’m looking for a second opinion, and to talk to someone about pain management. I found your blog post, and noticed that you have a practice in San Francisco. I live in the area and would very much appreciate it if you would see me as a patient, even for just a consultation. Thank you in advance for any help!

    Posted by Christine | June 13, 2014, 3:11 pm
  13. Hi dr ! Was wondering if you knew of any doctors with similar background to yourself in the London area? Your article completely inline with what I’m experiencing, and am finding myself more knowledgable than some of the pain specialists because I’m using it as an example and telling them how to treat me! I’m yet to see anyone who has come across my situation ( or anything that resembles it!) before!!!

    Posted by S smith | June 19, 2014, 2:41 pm
  14. Hi. I’ve had 2 c-sections and its been a year since the last one and I do have the odd pain near the scare that feels like a deep paper cut once in a while. The area was numb for about 6 months an inch in each direction from the scar. My concern is that when I lift anything over 30lbs or stand for long periods of time or even crunches..anything that uses tummy muscles..I feel pain for days but not the tummy muscles.. Its my uterus.. I feel it up inside too its sore. It feels like my uterus has been beaten up and some times I start spotting a day after heavy lifting. My doctor sent me back to the surgeon and we did an ultrasound everything was OK and my surgeon refuses to see me for the issue now unless I lose my baby belly. Help! This isn’t in my head!

    Posted by jen | July 6, 2014, 9:56 am
  15. Been in pain for 5half years now after c section no one can help me please can you give me help to find out what wrong

    Posted by tracey rankint | September 2, 2014, 9:21 am
  16. I had a C-section in December, 2011…from time to time I experience whole body numbness-needle like pain is all I feel in my whole body especially when am in contact with something…I can’t even taste anything when am in this state..this state lasts for a week or two…months go by and then it appears again. I have been to the doctors and have been told it is an effect of the anaesthetic they used hence they can do nothin about it, I just have to indure the pain…but the pain is just too much and lasts for long…

    Posted by Katya | November 16, 2014, 9:45 pm
  17. I have a question. I had a c section almost 9 years ago and since then have not lost the weight that I gained during pregnancy. My stomach is now very heavy and saggy. I have excruciating hip pain in both hips and I am just wondering if you think it is from the heaviness of my stomach maybe or do you think I could be something worse. I’ve been experiencing this for about 9 years now but it comes and goes. Some days it hurts so bad I can barley walk sit stand or sleep. What do you think could be causing this pain and is there any way to make it better?

    Thanks
    Erin Wilmot

    Posted by Erin Wilmot | January 11, 2015, 2:23 am
  18. I hav a continuous pain in the middle stitch post 8 months what is the remedie pains even if I keep my finger

    Posted by preethi | May 27, 2016, 12:07 pm
  19. I had an emergency c-section 4 years ago, when I woke up from the anesthesia I was shaking from the pain, before I could even really communicate, I was in so much pain from my lower right side pelvic/abdominal area. It was a burning, ripping, lightning like pain. My incision area never even hurt compared to the area near my right hip. I told the nurses, docs- anyone who would listen. I was discharged however and the incision healed- meanwhile I had to have help from my husband to even turn over in bed. I couldn’t raise my arms, bend over, reach for something, or even walk without the burning ripping lightning pain. After a failed revision surgery with an added bonus of infection caused an open wound for 6 months and created more scar tissue on the area, I was sent to a chronic pain Doctor. We were told it was nerve entrapment. It’s been 4 years of this, I see a pain Doctor monthly – have had no lasting relief. The skin above my nerve entrapment is very sensitive – water from the shower, the fabric of my shirt rubs lightly against the skin and it is very painful. There is an option of having the nerve removed all the way to my spine, but I am too terrified to try another surgery- the last one made it worse. I’m used to this level of pain, can’t imagine if this got worse again. My nerve entrapment has forever changed my life.

    Posted by Maggie | July 9, 2016, 6:58 pm
    • Maggie I read your post today it made me so sad I cried. I have had the same pain as you for over 5 years now. I have had nerve burns nerve injections meds out the wazoooo. 2012 I had a major surgery to remove endo. I had so much damage over 80% of my vagina had to be removed. Like you the pain came back even worse. It took 6 months to heal. Then back to the pain doctor. I finally was refered to a doctor in Dallas Texas who did a MRN yes N it stands for MRI of the NERVES MRN.. It showed two nerves were damaged. Then she referred me to Dr Jonathan Cheng Dallas Nerve specialist. He cut out a damaged nerve at my right hip/abdominal/pelvic. My hip no longer burns. This was 3 weeks ago. I am still; having some burning. The doctor said it could take a year before I got completely healed. My pain over all is down more than 50%.Find a hospital in your area that performs MRNs . There are only 2 in Texas.It is a starting place!Good Luck and I will pray for you.

      Posted by Holly | July 10, 2016, 10:49 pm
    • Maggie, I too had no qulaity of life due to chronic pain. For 3 years I was bedridden. Then I met a doctor who understood nerve damage. He tried lidocaine shots, which helped but only in small incrimantes. So my other option was a peripheral nerve stimulator. They usually put them in people’s spines, but since my pain was in my abdomen, they put it there instead. The leads for the implant were placed right where I had pain if I put pressure on it. It gave me my life back, sure it has to run 24 hours a day for me, but I was able to completely stop taking pain meds. Find a doctor who is an anesthesiologist familiar with nerve stimulators. They might help a great deal.

      Posted by merchian | July 11, 2016, 7:03 am
      • How were you able to pinpoint an area of pain? I am too considering a stimulator. I have had 2 surgeries for the pain and several injections and a burn. And one damaged nerve removed.

        Posted by Hollye | December 9, 2016, 9:24 pm
      • By pressing on the abdomen, if that spot was most painful that’s where the lead should go. Do that in a straight line horizontally on your abdomen

        Posted by merchian | March 19, 2017, 3:05 am
  20. I’ve had throbbing, burning pain below my incision since day one. I’m 4 month post partum and the pain is still just as bad. My OB keeps brushing it off as “all people heal differently”, however I know something just isn’t right. How do you recommend I find a doctor with experience in post-op nerve pain and nerve anesthesia?

    Posted by Julie | July 10, 2016, 7:43 am
  21. I have had my baby girl through a csection four months ago. I am in so much pain. The pain comes from inside the pelvis, probably some parts internally as well as the pelvic floor. Its a throbbing steady pain, with twitching or muscle spasms. My uterus feels like it has doubled up in thickness. It also makes lots of groaning sounds. The scar is irritable to the touch even by slightest clothes and it is numb at some parts. Dr just examined by looking and said it is fine but I walk with pain. I tried sex once and shock waves shot through my entire body and I am scared to try again. I don’t know how to describe it exactly but it felt like I was having an electric shock. I am dry sometimes and feel like an empty jar without a lid….like lots of air goes in other times i’m having thick creamy discharge thats so smelly. My period also started two months down the line and its a nightmare, smelly and severe pp’s. Dr gave me antibiotic for smell, said its probably infection and I am taking them. Please help with the pain, I am worried. I want to start hitting the gym and playing my tennis but things feel like they are hanging all over my front and disorientated if you know what I mean. I wonder if all are settled in their right places.

    Posted by Selinah | July 12, 2016, 2:52 pm
  22. i’m seriously suffering from these kind of pains described here. I had a surgery 6months ago for Ecthopic pregnancy and since then have been suffering from sever pains down my pelvic areas. it gets worst if i have intercourse with my husband, at times it will be as if my inside wants to pull out from my vigina/anus. i’ve meet a gyn and carried out different texts and scans to know if the surgeons made mistake but the pains are still there. i will definitly try this nortiptyline. thanks so much for this write up

    Posted by Bridget | September 1, 2016, 4:56 am
  23. I had a C section in 2010. I still have nerve pain on my right side just below belly button and slightly to the right. I think when tying off an artery there, they tied off a nerve. I’ve seen C section videos and they always tie off an artery in that specific area. I also have a cyst on each ovary which I could have had removed during C section but my pregnancy was so stressful I didn’t even think of it. I want my tubes tied so I guess I can have those taken out same time. My lower back aches like menstral cramps all month while I’m not on period. While I’m ovulating is the worst and the discharge although natural and no strange odor is excessive and hurts. I want to get the ablation to stop my periods but it seems so scary. Its basically burning your uterus.

    Posted by Sarah | September 10, 2016, 9:04 pm
  24. Thank you so much! Always good to know the facts before doctors tell you” it’s nothing” or even “in my head “as my obgyn tried to tell me once.

    Posted by Amber Owen | November 4, 2016, 7:04 pm
  25. I had had csection 6 weeks ago and I felt as though it was healing up great however I now have been experiencing some pain it. I think. The pain is at the scar incisions.

    I took a warm bath and since have been having a sensation of pinching in the incision area almost like little elastics being snaped in the area

    I have also been having pain like an ache and pulling (quite painful) in my left side of my lower abdomen. I really feel it if I walk too much. The same pain radiates a bit lower in lower abdomen as well.

    I have hernia on the top and bottom of my belly button, which happened while pregnant

    Fyi: this is my second c-section

    I look forward in hearing from you

    Posted by Lori | December 9, 2016, 7:53 pm
  26. I had a c-section In July of 2016 and in the past few months I have been having excruciating pain at my incision sight. During the procedure, I felt the first initial cut and it felt just like a massive bee sting. Almost every single day I experience this pain but it’s 100 times more painful that my csection was. It doubles me over and makes it hard to get out of the bed. I can hardly stand to wear jeans, I mostly wear leggings and sweatpants,and loose fitting underwear. I also can not lay on my stomach. I just need advice as to what I should do once I see my og/gyn. This pain is unbearable and makes it especially difficult to care for my daughter the way that I need to.

    Posted by Brittany Smith | March 18, 2017, 8:53 pm

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