PPOD Case Report 2

PPOD Syndrome Diagnosis: right-sided inguinodynia (right inguinal pelvic pain).

A 41-year-old woman presented with the complaint of right-sided inguinal pain. She stated that her pain began approximately one month earlier for no apparent reason and had progressively intensified over the subsequent two weeks. She found that the only way she could obtain any relief was to get off of her feet and lay down for several hours at a time. In addition, she noted that after rising from bed in the morning her pain would begin to increase, and if she were to sit for longer than 10-15 minutes this pain would progressively intensify and become more severe the longer she sat. She stated that there were no accompanying complaints of back or leg pain or numbness, or symptoms of bladder, bowel or sexual dysfunction. Because of the persistence and intensity of her pain, she consulted with a gynecologist who, after being unable to find any abnormalities following a complete examination and pelvic sonogram, diagnosed her with an inguinal hernia and referred her to a surgeon for further evaluation. It was at this point, at the insistence of her sister, that I had seen her. Of note in her history was the fact that she reported having undergone an appendectomy, due to the abrupt onset of right-sided inguinal pain approximately 15 years earlier. Having spent several weeks off of her feet while recovering from her operation she stated that her inguinal pain had improved although it had not resolved. She was advised by her surgeon that her persistent pain was probably due to the development of scar tissue that had likely formed at the incision site associated with her operation. Approximately 9 years later, her ongoing inguinal pain spontaneously increased. A pelvic sonogram at the time revealed the presence of an enlarging ovarian cyst and as a result she underwent an oophorocystectomy (removal of ovarian cyst). After the removal of the cyst her pain was improved, however it continued to persist at a similar level of intensity as it had following her appendectomy. Until the month before I had seen her this pain had remained relatively unchanged. On her examination she revealed clear evidence that her inguinal pain was being caused by an underlying occult spinal disorder. During the initial phases of treatment she experienced a distinct exacerbation of her inguinal pain (a typical response during the early phases of care – the “post-treatment flare”), however, by the end of two weeks of treatment she became aware that the intensity of her pelvic pain was diminishing. At the end of four weeks of treatment, her pelvic pain was occurring only on an intermittent basis, however, it was still easily provoked and exacerbated by sitting beyond 15 minutes. After eight weeks of treatment her pelvic pain had completely resolved (including the ongoing post-appendectomy pain) and she was able to sit for 45 minutes before her inguinal pain would begin to recur. Following 12 weeks of care her inguinal pain continued to remain absent and she had regained the ability to sit for extended periods without recurring pain.

Comment: Although by comparison (with later cases) the extensiveness of her overall involvement was minimal, having presented with a single symptom of localized pelvic pain, the severity of her pain was pronounced and had kept her from being able to work or function at any level near normalcy.