POPSS (Pain Over Pubis and Surrounding Structures) syndrome, now called UGAP pain, is not an uncommon condition. It is an enthesopathy (tendonitis) and/or periosteitis, somewhat similar to periosteitis pubis.
POPSS has evolved from the well-known condition osteitis pubis. 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 specialists. It can present as sportsman’s hernia, abacterial 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).
UGAP pain also manifests as pain in the testicle, pain in the prostate, pain with intercourse (dyspareunia) and pain at the insertion of adductor tendons. A subset of patients complain of pain in the buttocks (ischial tuberosities), tail bone (coccyx) and/or lower back over the posterior superior iliac spine.
The scale of the problem
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 abacterial 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.
Shuttled from one specialist to another
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 (CT scans, MRI, bone scans, ultrasounds, etc.). Endoscopies, laparoscopies and sometimes even unnecessary surgeries (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.
Confirmation is made with strategically placed steroid injections. Treatment is multidisciplinary, involving pain management (mainly with steroid injections and occasional use of NSAIDs), emotional treatment with anti-anxiety/anti-depressants in the majority of chronic patients, and specialized pelvic physical therapy 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. Our challenge is to get them “out of the closet,” diagnose and treat them appropriately and in a timely fashion, or refer them to a specialized center.