What is the appropriate evaluation and management for a patient with left suprapubic and radiating leg pain, tenderness in the left suprapubic area, and a history of heavy, long, and irregular menstrual (menses) periods, now absent?

Evaluation and Management of Left Suprapubic Pain with Leg Radiation and History of Abnormal Uterine Bleeding

This patient requires combined transabdominal and transvaginal pelvic ultrasound as the initial imaging study, given the postmenopausal status (no longer menstruating) and history of heavy, irregular bleeding suggesting possible gynecologic pathology causing the current symptoms. 1, 2

Initial Diagnostic Approach

Primary Imaging Modality

• Pelvic ultrasound (combined transabdominal and transvaginal) is the first-line imaging study for postmenopausal patients with suprapubic pain and prior menstrual abnormalities, providing both anatomic overview and high-resolution evaluation of the uterus, endometrial canal, fallopian tubes, ovaries, and adnexal masses. 1, 2
• Include Doppler evaluation as a standard component to assess internal vascularity of any pelvic masses and distinguish cystic from solid lesions. 1

Key Clinical History Elements to Elicit

• Pain characteristics: Determine if pain worsens with specific foods/drinks, bladder filling, or improves with urination (suggests bladder pain syndrome). 1
• Relationship to bowel function: Pain related to bowel movements or dietary triggers points toward irritable bowel syndrome. 3
• Urinary symptoms: Assess for frequency, urgency, and whether patient voids to relieve pain (bladder pain syndrome) versus to avoid incontinence (overactive bladder). 1
• Prior gynecologic conditions: History of endometriosis or adenomyosis are primary gynecological causes of chronic pelvic pain. 2

Differential Diagnosis by Pain Pattern

Deep Pelvic Pain with Leg Radiation

• Gynecologic etiologies include endometriosis, adenomyosis, pelvic venous disorders, intraperitoneal adhesions, hydrosalpinx, or chronic inflammatory disease. 2
• Radiating leg pain may result from chemical radiculitis where inflammatory mediators from pelvic pathology leak through tissue planes and injure adjacent nerve roots, even without disc herniation. 4
• Catamenial neuropathy should be considered in reproductive-age women with recurring focal neuropathic leg pain, though this patient's cessation of menses makes active endometriosis less likely but not impossible. 5

Bladder-Related Pain

• Interstitial cystitis/bladder pain syndrome presents with suprapubic pain (or pressure/discomfort) related to bladder filling, often with pain throughout the pelvis including urethra, vulva, vagina, rectum, lower abdomen, and back. 1
• Patients may deny "pain" and instead describe "pressure", making it critical to use broad descriptors when taking history. 1

Advanced Imaging Considerations

When to Escalate Beyond Ultrasound

• MRI pelvis is the problem-solving examination when ultrasound findings are nondiagnostic or inconclusive, with gadolinium-based IV contrast preferred when clinically indicated. 1
• MRI has 86-94% sensitivity and 88-92% specificity for inflammatory conditions and superior soft tissue resolution without ionizing radiation. 3
• Time-resolved postcontrast T1-weighted MRI can directly demonstrate pelvic venous disorders including ovarian vein reflux if pelvic congestion syndrome is suspected. 1

CT Abdomen/Pelvis Role

• CT is usually not appropriate for primary evaluation of postmenopausal chronic pelvic pain localized to the suprapubic region with gynecologic history. 1
• CT becomes appropriate only if acute diverticulitis is suspected (fever, leukocytosis with left lower quadrant pain) or if structural gastrointestinal pathology needs exclusion. 1

Red Flags Requiring Urgent Evaluation

Immediate Emergency Assessment Needed If:

• Fever, inability to pass gas/stool, severe tenderness with guarding, vomiting, bloody stools, or signs of shock mandate immediate emergency evaluation. 3
• Weight loss, anemia, or change in bowel habits warrant colonoscopy despite prior normal studies to exclude malignancy. 3

Referral Strategy

Gynecology Referral

• Refer to gynecology if pelvic ultrasound reveals pathology (masses, endometriomas, hydrosalpinx, adenomyosis) or if high clinical suspicion remains despite negative imaging. 3, 2
• Hormonal therapy may be indicated if endometriosis or adenomyosis is confirmed, as these conditions respond favorably to hormonal manipulation. 5

Urology Referral

• Consider urology evaluation if bladder pain syndrome is suspected based on pain characteristics (worsens with bladder filling, improves with voiding, food/drink triggers). 1

Pain Management

• NSAIDs like ibuprofen 400 mg every 4-6 hours can be used for symptomatic relief while diagnostic workup proceeds, though doses above 400 mg show no additional analgesic benefit. 6

Common Pitfalls to Avoid

• Do not assume diverticulitis without the classic triad of left lower quadrant pain, fever, and leukocytosis; this patient's suprapubic location and gynecologic history point elsewhere. 1
• Do not overlook gynecologic causes in patients no longer menstruating, as endometriosis and adenomyosis can persist and cause symptoms postmenopausally. 2, 5
• Do not order plain radiography, as it has no role in evaluating chronic pelvic pain. 1, 2
• Do not delay imaging based on prior menstrual history alone; the combination of prior heavy/irregular bleeding with current suprapubic pain and leg radiation requires structural evaluation. 1, 2