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Imagine a medical case of someone experiencing a prolonged, unexplained pain symptom in his lower left abdomen and groin area. Feeling the worst when sitting down, but much better standing up or lying down. CT and MRI are negative for lower abdomen and groin area. Hernia was not found (but can't be completely ruled out). STDs are ruled out. Physiotherapy doesn't seem to help. Symptoms have lasted for 1 year and counting.

Otherwise, patient is healthy.

What may be the possible cause of this kind of pain or soreness? Is it a muscular problem or nerve problem? Are there any suggested pain management?

  • Does it get better or worse with walking? Are there any bowel or urinary symptoms? I’ll try to think of a differential diagnosis. :) – Chris Aug 13 '18 at 22:40
  • Hi Chris, I am asking it for a friend. I remember he said sitting upright is the worst, so lying down is much better, I think walking is also less painful than sitting upright. Don't recall he mentioned any bowel or urinary symptoms. – KubiK888 Aug 15 '18 at 3:32
  • It could be helpful to know: 1) Age? 2) How physically active the person is and does he have any idea of the causing event? 3) For how long does the pain last now - years? 4) Is the area tender to touch? 5) Is pain dull or sharp? 6) Is pain triggered by bowel movements, urination or coughing/sneezing? 7) Any history (personal or family) of low back or leg pain (sciatica)? – Jan Aug 17 '18 at 9:05
  • Get a dynamic ultrasound done. – Graham Chiu Aug 18 '18 at 3:56
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The differential diagnosis of pain in the left lower quadrant of the abdomen or groin is quite extensive, which is why questions on history-taking and a clinical examination are so important. I see some investigations (MRI) have been completed, which should narrow it down a bit.

Anatomy

The abdomen

This diagram shows the position in question: the left lower quadrant (or left iliac fossa) and the left groin region.

Anatomy

This anatomical image shows the various deep structures in this area (though the image focuses more on hernia repair).

This is a very useful summary of the potential causes and has useful links itself. Using this as a guide, I will go through the possibilities.

Differential Diagnoses

Firstly, the pain is chronic rather than acute because it has gone on for a year now. This helps us exclude short term causes like urinary infections, diverticulitis and gastroenteritis.

Gastrointestinal causes

Constipation: Chrinic constipation is often due to diet and the pain is usually left sided or central lower abdomen.

Irritable bowel syndrome: This can cause a variety of symptoms, including cramps, bloating, nausea, constipation and loose stools. This is a diagnosis of exclusion, meaning that it is important to exclude other causes before diagnosing this, as there are no confirmatory tests.

Cancer of the rectum or descending colon: This would usually cause a change in bowel habit, weight loss and bleeding. The MRI scan would probably have excluded this, though colonoscopy would be useful.

Crohn's disease and ulcerative colitis: These are types of inflammatory bowel disease. They would usually cause a change in bowel habit as well.

Gynaecological causes

If the person is female, possible causes include pelvic or ovarian tumours and endometriosis. The MRI may have excluded the former, but laparoscopy is often needed to diagnose endometriosis.

Musculoskeletal causes

Left hip pathology: This could be arthritis or other mechanical problems with the soft tissues around the hip and upper leg. The fact that the pain changes with position might suggest one of these causes. MRI scans might miss muscular causes, but would detect arthritis. Sometimes nerves can be entrapped which will give the pain a different character.

An x-ray of hips and pelvis

Image of pelvis and hips from Radiopaedia.

Other causes

Hernia: Some groin and femoral hernias might be missed on MRI scanning if they are small or reducible.

Medically unexplained symptoms: Sometimes a purely physical diagnosis is not forthcoming. Sometimes this reflects the limits of diagnostic and imaging technology and sometimes it results from the fact that the human body is amazing and the interaction of mind, nervous system and body is complex. Sometimes this complexity gives rise to symptoms that doctors can’t explain.

Summary

The positional nature of the pain and (presumed) lack of bowel or urinary symptoms would probably make a musculoskeletal cause for the pain most likely, or possibly a hernia. Given that it has been there for a year and there have been some normal investigations, it is unlikely to be a serious or progressive problem. However, other investigations may be needed to find the cause more definitively. Please note that this answer is not providing medical advice. It is important to see a doctor or healthcare professional if you are suffering from these symptoms.

  • Hi Chris. This answer is great and I'm tempted to upvote, but I think that the question itself is asking for medical advice. You list multiple possibilities and note that the cause needs to be found and in the end refer OP to a doctor. We have made the experience that answering such questions will tempt OP to ask more of such a kind, so in the future if there is a clear request for a diagnosis (and "What might be the cause of this unexplained, prolonged groin pain symptom" certainly is) it would be better to not answer it. – Narusan Sep 7 '18 at 18:21
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    +1 for the huge effort though, and for a fairly comprehensive post. I don't understand how the main post got 4 upvotes, and why it hasn't been closed before. That is not your fault (and again - huge effort). Just for the future, maybe don't answer. With 500 reputation, you will be able to cast close votes instead – Narusan Sep 7 '18 at 18:23
  • @Narusan Thanks for this. You are absolutely right. As you can see the OP edited the question, but it does still amount to medical advice. I am relatively new on here and since then have become more properly aware that personal medical questions are off-topic. Once I pass that 500 rep mark I’ll use my close votes judiciously :) – Chris Sep 7 '18 at 18:26

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