Evaluation and Management of Persistent Left Groin Pain in a 43-Year-Old with Bipolar Disorder
Begin with a systematic physical examination focusing on the four major musculoskeletal causes—adductor, pubic, inguinal, and iliopsoas pathology—while simultaneously screening for hernias and genitourinary conditions, as groin pain has a broad differential that requires methodical exclusion of both musculoskeletal and non-musculoskeletal etiologies 1.
Initial Diagnostic Approach
The evaluation must be structured around direct palpation and specific provocative testing for each anatomical region 1:
- Adductor-related pain: Palpate the adductor tendons at their pubic insertion and perform resisted hip adduction
- Pubic-related pain: Direct palpation over the pubic symphysis and surrounding structures
- Inguinal-related pain: Examine for posterior abdominal wall weakness and occult hernias
- Iliopsoas-related pain: Assess with hip flexion maneuvers and consider concomitant hip joint pathology
Key Clinical Considerations
Groin pain affects approximately 7% of the general population, with higher rates (12%) in adolescents and 5-8% annual incidence in young men related to trauma 2. The differential diagnosis encompasses surgical, urological, gynecological, neurological, orthopedic, oncological, and vascular pathologies 2.
Imaging Strategy Based on Clinical Findings
Your imaging approach should be diagnosis-specific rather than shotgun 1:
- If adductor-related pain is suspected: Order pelvic MRI if the diagnosis remains unclear after initial examination or if conservative management fails
- If inguinal-related pain without obvious hernia: Obtain dynamic ultrasonography to evaluate for true hernia and posterior abdominal wall weakness
- If iliopsoas-related pain is suspected: Perform hip radiography and MRI, as concomitant hip pathology is common
Initial Management Algorithm
For Musculoskeletal Causes
Active, supervised physical therapy is the first-line treatment for both adductor-related and pubic-related groin pain 1. For inguinal-related pain without hernia, initiate physical therapy focusing on core strengthening and neuromuscular rehabilitation 1.
Special Considerations for Bipolar Disorder
The presence of bipolar disorder significantly impacts your pain management strategy and requires explicit attention to mental health screening 3. The 2025 AUA guidelines on chronic pelvic pain emphasize several critical principles:
- Directly inquire about anxiety, depression, and life stressors, as these are particularly relevant in chronic pain patients 3
- Encourage treatment for mental health needs and discuss family, spousal, and local support systems 3
- Avoid re-traumatization: Instead of direct trauma inquiries, provide education and space for open communication about exam concerns, paying attention to non-verbal cues 3
Multimodal Pain Management Approach
If pain control is inadequate (defined as pain interfering with daily life), utilize a multidisciplinary approach involving pain management, physical therapy, psychology, and physiatry 3. Multimodal pharmacological therapy is preferred—using several medication classes at lower doses rather than one class at high dose to minimize side effects 3.
Critical Pitfalls to Avoid
Opioid Prescribing Caution
Exercise extreme caution with opioids in this patient. Evidence shows modest efficacy for chronic non-cancer pain with high attrition rates due to side effects 4. For most chronic pain conditions, opioids are second-line at best, with NSAIDs, acetaminophen, and targeted therapies preferred 4.
Bipolar Medication Interactions
Be aware that this patient is likely on mood stabilizers (lithium, valproate, lamotrigine) or atypical antipsychotics (quetiapine, aripiprazole) 5, 6. These medications have significant drug interaction potential and metabolic side effects that may complicate pain management.
Treatment Reassessment
Periodically reassess treatment efficacy and discontinue ineffective therapies 3. If no improvement occurs after multiple treatment approaches, reconsider the clinical diagnosis. No single treatment demonstrates consistent efficacy for all chronic pelvic pain patients 3.