In this example, we learn about a mid-40s male whose lower-back pain turned into more serious pelvic symptoms.
History: This is a 46-year-old male that presented with pain in the left lower back and pelvis. The patient has a long history of focal left lower back discomfort since he was a teenager that did not affect his ability to participate in physical activities.
Approximately five to six years ago he developed rectal prolapse however as it resolved he began to note an onset of pelvic symptoms. He notes that he was experiencing significant pain focal to the left testicle, which made it difficult to properly assess the other involved areas of pain; however, in 2010 following first a varicocele, then an epididymis removal and eventually a left orchiectomy he experienced significant resolution of the testicular pain. However, he had some mild recurrence.
After the orchectomy, he began to be able to evaluate his remaining symptoms, which included numbness to the perineum that was sporadic, a sensation of spasm tightness to the left upper and lower quadrant with sensation of poor gastric motility, as well as pain and burning down to the rectal region. He also notes that he has pain that radiates in the left lower back around to the rectal, inguinal and hip region with rare shooting pain into the foot in the past two months.
The patient did undergo an ilioinguinal nerve block; however, during the procedure he specifically noted an area of discomfort to his physician, which was identified then as an iliohypogastric nerve block, which improved the sensation of pain to the left upper and lower abdominal quadrants; however, no improvement to the sensation of effects on intestinal motility.
He has trialed physical therapy with no improvements and had numerous gastrointestinal, urologic and pain management evaluations with no improvement. Currently, he primarily manages his symptoms with OxyContin and gabapentin, as well as a TENS unit for increased pain.
He notes that in the past year he has noted a 30% improvement overall to his symptoms with the use of a heel lift in the left shoe. When he performs mild soft tissue adjustments to his hip and back he will also notice improvement to the sensation of restricted abdominal motility.
Physical examination: Examination in the sitting position at the hips for flexion, extension, abduction and adduction was 5/5, with some reproduction of symptoms with resisted adduction of the left thigh.
Additional directed exam in a supine position with straight leg raising, passive hip rotation, and resisted abduction and adduction of the flexed, internally rotated thigh did demonstrate reproduction of symptoms with passive external rotation and also to less extent with resisted external rotation; relief with crossed leg traction on the left and aggravation with crossed leg traction on the right.
No effect with elevation of the extended leg against resistance. Palpation in the inguinal region over the obturator foramen is positive on the left.
Examination in a standing position with palpation and percussion along the thoracic, lumbar, sacral and coccygeal spine reveals a point of tenderness in the low lumbar region; more distally left to midline palpation in the posterior pelvis in the left reveals significant sciatic notch sensitivity; tenderness on the medial aspect of the ischial tuberosity, negative on the lateral aspect of the ischial tuberosity and negative over the greater trochanter and negative in the upper buttock.
Lumbar evaluation with forward flexion, extension, twisting and lateral bending did cause aggravation of symptoms with twisting and bending towards the left side.
Plan: Based on the history, exam, data and findings, it was identified that the bulk of the patient’s symptoms are related to obturator internus spasm and pudendal involvement causing both testicular and rectal area pain, as well as affecting the sphincters and perhaps thereby the perception of altered motility.
The sciatic notch tenderness and the tenderness on the medial aspect of the obturator internus are consistent with piriformis and obturator internus involvement.
Going forward, the patient was recommended for an MR Neurography study to evaluate the nerve elements in this area, and then an open MRI-guided injection for the piriformis and obturator internus muscle.
The open MRI guided injection of the piriformis and obturator internus muscle did immediately lead to significant improvements in his overall pain level.
