Introduction

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.

POPSS (Pain Over Pubis and Surrounding Structures) syndrome is not an uncommon condition. It is an enthesopathy (tendonitis) and/or periosteitis, somewhat similar to peri osteitis spubis. This paper will provide background and describe lessons learned in 35 years’ clinical experience treating this condition.

UGAP pain syndrome has evolved from the well-known condition osteitis pubis. This disease was first described in 1827 by Elliotson, in 1923 by Leglieu and Rochet and in 1924 by Beer et al. Several different etiologies mentioned in the literature include infection, impaired circulation and venous congestion. The most convincing etiologic factor, however, seems to be an enthesopathy (tendonitis or periosteitis) similar to tennis elbow, plantar fasciitis, etc.

It is a great masquerader mimicking several different conditions and is of interest to several different specialties (Fig.1). It can present as sportsman’s hernia, a bacterial prostatitis, interstitial cystitis, and chronic pelvic pain including dyspareunia. It can present as acute or chronic lower abdominal and/or groin pain mimicking appendicitis, diverticulitis, and hernias (including strangulated).

This condition was formerly known as POPSS syndrome

The volume of these patients including economic impact is staggering. It is estimated that in the USA alone literally millions of patients are reported as having chronic groin, abdominal and pelvic pain.. Nearly 15 million women have chronic pelvic pain (CPP) and in this subset 46% have dyspareunia. The annual medical cost of diagnosis and treatment is almost 1.2 billion dollars. And the cost of loss of productivity is estimated to be $15 billion annually. In males it is estimated that 50% (tens of millions) of all adult males suffer from a bacterial prostatitis causing CPP.

Interstitial cystitis affects half to one million people causing CPP. Sportsman’s hernia affects 0.5% to 6.2% of all professional athletes. Also nearly 30% (225,000) of patients suffer from groin pain following repair of groin hernias.

Confirmation is made with strategically placed steroid injections. Several patients with atypical or refractory lower abdominal as well as groin/pelvic pain are shuttled from one specialist to another and undergo expensive diagnostic tests, (e.g., CT scans, MRI, bone scans, ultrasounds, etc). Endoscopies, laparoscopies and sometimes even unnecessary surgeries (e.g., exploratory laparotomies, hysterectomy, inguinal herniorrhaphy) are performed. Patients and physicians are equally frustrated because the diagnosis is elusive. Chronic pain causes emotional problems, sleep disturbances and even depression. Productivity and self-esteem are affected. Moreover, countless healthcare dollars are spent on unnecessary diagnostic studies and unnecessary interventions. Treatment is multidisciplinary involving pain management, mainly with steroid injections and occasional use of NSAIDS. Emotional treatment with anti-anxiety/anti-depressants is used in most of our chronic patients. Specialized pelvic physical therapy is used in almost all patients to prevent flare-ups.

Many of these unfortunate patients do not seek treatment for this disabling condition because they fail to mention the complaint in their presenting symptoms. There are several reasons for this, including apathy, ignorance and stigma, especially in patients with dyspareunia. This advanced clinical picture is rarely seen nowadays. Milder forms of the disease with slightly different manifestations are commonly seen. The omission of exam of pubic bone and anterior superior iliac spine on physical exam of abdomen (specifically in patients with lower abdominal pain) is the most embarrassing cause of missed diagnosis.