UGAP Pain Syndrome · Undiagnosed Groin, Abdominal and Pelvic Pain

Understanding UGAP pain

A great masquerader

UGAP pain is an enthesopathy (tendonitis) and/or periosteitis, inflammation of the lining of the bones. It mimics many common conditions, so patients are often shuttled between specialists.

Acute Appendicitis
Acute Sigmoid Diverticulitis
Incarcerated Inguinal Hernia
Endometriosis
Ruptured/Twisted Ovarian Cysts
Interstitial Cystitis
Fibromyalgia
Pulled Muscles
Undiagnosed Rectal Pain
Chronic Prostatitis
Sportsman’s Hernia
Epididymo-orchitis

Read the introduction

UGAP Pain is not an uncommon condition. It is an enthesopathy (tendonitis) and/or periosteitis (inflammation of the lining of the bones). This site provides background information and shares lessons learned during 35 years of practice treating these patients.

POPSS syndrome is a fascinating and enigmatic condition and presents as undiagnosed groin, lower abdominal, or pelvic pain (UGAP). It is a great masquerader and mimics several different groin, lower abdominal and pelvic conditions.

It is not an uncommon condition, and unfortunate patients with severe disabling pain are often shuttled from one specialist to another, hoping to find some relief. Because the condition is widespread, physicians in several specialties encounter patients with this presentation.

Tens of millions of adult males suffer from abacterial prostatitis causing UGAP pain. Nearly half to one million patients with interstitial cystitis have UGAP pain. Also 0.5% to 6.2% of professional athletes have groin pain also known as “sportsman’s hernia.”

“UGAP pain” can be mistaken for the following commonly seen conditions

In patients with acute pain (only 8% of the patients in our series), it can mimic acute appendicitis, acute diverticulitis, incarcerated groin hernias, etc.
In male patients with chronic groin and pelvic pain, it can mimic sportsman’s hernia, prostatitis, and epididymorchitis.
In females with chronic pelvic pain, it can mimic commonly seen pelvic and groin conditions such as endometriosis, pelvic congestion, ovarian cyst, diverticulitis, and groin pain, including hernias.

Clinical signs

Diagnosis starts with the exam

Dr. Wasudev’s signs let the diagnosis be strongly suspected on clinical examination in most patients. Final confirmation comes from a series of steroid injections.

In females

Wasu’s Triad

Rectus flexion sign
The examiner’s hand is placed on the insertion of the rectus muscle over the pubic bone. If the patient experiences severe pain on flexion of the rectus muscle when attempting to sit up, it is considered a positive sign.
Adductor resistance sign
Positive if the patient experiences pain when the examiner places a finger over the insertion of the adductor longus tendon and asks the patient to adduct the bent knee against the assistance hand.
Vaginal hook sign
Positive if the patient experiences pain over the suprapubic area on vaginal exam when hooking fingers anteriorly over the pubic bones.

In males

Wasu’s Triad Plus

Rectus flexion sign
As in females: severe pain over the pubic bone when the rectus muscle is flexed while attempting to sit up.
Adductor resistance sign
Pain at the insertion of the adductor longus tendon on resisted adduction of the bent knee.
Spermatic cord traction sign
Examined in a standing position: traction of the spermatic cord produces radiating pain over the pubic bone. The spermatic cord itself is not tender when examined lying down.
Paraprostatic sign
On digital rectal exam there is mild or no pain over the prostate gland itself, but tenderness and muscle spasm lateral to the prostate. This suggests chronic pelvic pain, also known as nonbacterial prostatitis.

How the diagnosis is made

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“He showed me respect and reassurance that there is someone out there who cares and will not make you feel like you are crazy, like it’s all in your head.”

Cindy B. · Pain after hysterectomy, with dyspareunia

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