General Surgery and Gynecology

Undiagnosed Groin, Abdominal, and Pelvic (UGAP) pain is not an uncommon condition and millions of patients, both females and males suffer from it. It is a great masquerader mimicking several different lower abdominal, groin and pelvic conditions.
Let’s all think of UGAP pain in patients presenting with atypical pain over the lower abdomen, groin, and pelvis. This is one of the few enigmatic conditions where a diagnosis can be strongly suspected in the majority of the patients just on clinical examination.

Let’s help these “Silent Sufferers” and prevent them from doctor shopping, minimize expensive diagnostic workup and prevent unnecessary endoscopies and even unnecessary surgeries. In the process, we will be saving billions of dollars which are currently spent in diagnosing and treating these unfortunate patients.

General surgeons see several patients with chronic pain mimicking chronic diverticulitis, prostatitis, and epididymoorchitis. Patients may also present with post inguinal herniorrhaphy pain or simply idiopathic pain. Amongst females on detailed questioning nearly 70% had dyspareunia some had rectal pain, some had bladder symptoms, some had gluteal and coccygeal pain. All of the above suggest pelvic pathology.

Another interesting subset that general surgeons see are patients with undiagnosed rectal pain, pain over ischial tuberosities (sitting bones) and coccygeal pain (coccydynia). Also patients with non-bacterial prostatitis and interstitial cystitis are also seen. Another commonly discussed topic among general surgeons is groin pain following repair of groin hernias. Typically after the initial incisional pain subsides, usually within 2-3 weeks, depending on the techniques used, there is a short pain-free interval of 1 to 4 weeks. Pain of UGAP pain starts after 4-6 weeks postoperatively. Rutkow noticed chronic groin pain in 102 patients out of 1,442 groin surgeries he performed over 3 years. More importantly they observed that 99 out of 102 patients had pain in the groin prior to herniorrhaphy. The majority of these patients continue to have persisting groin pain after the surgery. Our observations have been similar and we feel that pain in the groin associated with – clinically documented groin hernia during a preoperative visit is usually due to enthesopathy and, in fact, I give steroid injections during the repair and also repeat one or 2 more injections 2 weeks apart during the postoperative follow-up.

Rutkow discounts nerve entrapment theory on the grounds that 99 of 102 post hernia groin pain patients had preoperative pain in the groin.

Up to 10% of gynecology office consultations are for chronic pelvic pain. Chronic pain affects the sleep, performance and self esteem. This leads to depression which, in turn, alters the neurotransmitter level in brain and thus leads to a greater experience of pain and lowers the threshold for pain. Chronic pelvic pain can manifest as pain in the groin area and in some patients as pain over the perineum which includes coccydynia and tenosynovitis of ischial tuberosities. It may be associated with severe physical dysfunction in relation to voiding (dysuria), defecation (tenesmus) causing frequent and painful bowel movements and pain with sex (dyspareunia). As many as 60% of women experience dyspareunia when the term is broadly defined as pain during and after intercourse. In the gynecology literature, few articles have been published about the significant incidence of myofascial (musculoskeletal) origin of chronic pelvic pain.