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An unusual cause of inguinal pain
  1. V K Gautam,
  2. V Nigam,
  3. A Jaiswal,
  4. V Jain
  1. Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
  1. Correspondence to:
 Dr V K Nigam
 House no C 401, Jagdambe Apartments, Plot No C58/25, Sector 62, Noida-201303, India; v_nigamdryahoo.com

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Answers on p 202.

An 82 year old man was operated on for benign hypertrophy of prostrate. The surgery chosen was transurethral resection of the prostrate with high frequency current. Six weeks after surgery, the patient experienced pain in the inguinal region, more pronounced on the left side. The pain increased on coughing and straining, and was non-radiating in character.

The pain increased in severity over the next month and produced noticeable Trendlenberg gait on attempted walking. The pain then reached a plateau for six months and continued for 1.5 years.

Fine needle aspiration cytology showed only acute inflammatory cells. Interestingly, the patient had relief of pain lasting for 7–10 days after multiple needle pricks for fine needle aspiration cytology. Urine culture and sensitivity showed Escherichia coli two weeks after surgery that cleared with antibiotics. Haemoglobin decreased from initial 13 g% to 7 g% and the erythrocyte sedimentation rate rose to a high of 110 mm in first hour by the Westergreen method. Leucocytosis remained a consistent finding for as long as the pain was severe.

With improvement in symptoms after six to seven months, haemoglobin started rising and the erythrocyte sedimentation rate started decreasing.

Magnetic resonance imaging showed bone oedema in the pubic rami but pelvis radiography continued to be normal for six weeks after the first changes identified on magnetic resonance imaging. Technetium-99m MDP bone scan also showed a hot spot in the symphysis area, some time before radiological findings became positive.

The first pelvic radiograph that identified pubic erosions was five to six months after surgery (fig 1). Successive radiographs over the next month showed progressive erosions of the pubic bone at the symphysis pubis (fig 2).

Figure 1

 Radiograph of the pelvis with bilateral hips AP view five months after the operation.

Figure 2

 Radiograph of the pelvis with bilateral hips AP view six months months after the operation.

Pain and disability subsided over the next six months with anti-inflammatory and analgesic agents. Indomethacin proved to be most helpful drug to relieve the symptoms.

QUESTIONS

  1. What is the diagnosis?

  2. What are the diagnostic modalities that are helpful in diagnosis?

  3. What is the aetiopathogenesis in this case?

  4. What is the treatment recommended for this condition?

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