What is the appropriate treatment for acute groin pain?

Treatment of Acute Groin Pain

The appropriate treatment for acute groin pain depends on the underlying cause, with NSAIDs such as diclofenac 75mg intramuscularly being the first-line treatment for renal colic, which is a common cause of acute groin pain. 1

Diagnostic Approach

When evaluating acute groin pain, it's essential to determine the underlying cause:

Common Causes of Acute Groin Pain:

1. Urological causes 2:

   • Renal colic (kidney stones)
   • Testicular torsion (urological emergency)
   • Epididymitis

2. Musculoskeletal causes 3, 4:

   • Adductor muscle strain/tendinitis
   • Sportsman's hernia (weakness of abdominal muscle wall)
   • Osteitis pubis
   • Stress fractures

3. Neurological causes 5:

   • Ilioinguinal nerve entrapment
   • Genitofemoral nerve entrapment
   • Lateral femoral cutaneous nerve entrapment

4. Other causes 4:

   • Inguinal hernia
   • Acetabular labral tears
   • Avulsion fractures

Key Diagnostic Indicators:

• For renal colic: Abrupt onset of severe unilateral flank pain radiating into groin or genitals 1
• For musculoskeletal causes: Positive adductor test (pain with resisted hip adduction) 3
• For testicular torsion: Acute onset testicular pain with nausea/vomiting 2

Treatment Approach

1. For Renal Colic:

First-line treatment:

• Diclofenac 75mg intramuscularly for rapid pain relief 6, 1
• Alternative: Oral diclofenac 50mg initially, followed by 50mg every 8 hours as needed 1

If NSAIDs are contraindicated:

• Opioids with antiemetics (avoiding pethidine due to higher rates of vomiting) 1
• Oxycodone, hydromorphone, or fentanyl for patients with kidney disease 1

Follow-up:

• Telephone follow-up 1 hour after initial assessment 6, 1
• Fast-track investigation within 7 days of symptom onset 6
• Urological referral within 7-14 days if imaging shows problems requiring intervention 6

Patient instructions:

• Maintain high fluid intake
• Strain urine to catch any passed calculi 6, 1

2. For Musculoskeletal Causes:

Conservative treatment:

• NSAIDs (ibuprofen 400mg every 4-6 hours as needed) 7, 3
• Muscle relaxants 3
• Gradual physical therapy including:
  • Stretching and strengthening of adductor muscles
  • Strengthening abdominal wall muscles
  • Exercises for iliopsoas, quadriceps, and hamstrings 3

If conservative treatment fails:

• Surgical intervention based on specific cause 3

3. For Neurological Causes:

Conservative treatment:

• NSAIDs for pain management
• Physical therapy

If conservative treatment fails:

• Surgical management:
  • Decompression for lateral femoral cutaneous nerve
  • Resection for ilioinguinal, iliohypogastric, or genitofemoral nerves 5

4. For Testicular Torsion:

• Immediate urological consultation - this is a surgical emergency 2

Special Considerations

NSAID Contraindications:

• Severe renal impairment
• Heart failure
• Pregnancy (especially after 30 weeks)
• History of peptic ulcer disease
• Cardiovascular disease 1

Red Flags Requiring Immediate Hospital Referral:

• Shock
• Fever
• Oligoanuria
• Age over 60 years
• Delayed menses in women 1

Treatment Algorithm

1. Assess for red flags requiring immediate hospital referral
2. Determine likely cause based on history and examination
3. For suspected renal colic:
   • Start diclofenac 75mg IM (if no contraindications)
   • Arrange imaging within 7 days
4. For suspected musculoskeletal cause:
   • Start ibuprofen 400mg every 4-6 hours
   • Refer for physical therapy
5. For suspected testicular torsion:
   • Immediate urological consultation
6. Follow up within 1-7 days depending on severity and diagnosis

Remember that proper diagnosis is essential for appropriate management, and MRI may be needed for definitive diagnosis in complex cases 8.