What is the best course of management for a 47-year-old female with a history of adenomyosis, diabetes (Diabetes Mellitus), and hyperlipidemia (Hyperlipidaemia), who presents with severe left hip and groin pain following a uterine artery embolization (UAE) procedure, despite current analgesia with Panadol (Paracetamol) and ibuprofen?

Management of Post-UAE Hip and Groin Pain

This patient requires urgent advanced imaging with MRI of the left hip to exclude avascular necrosis (AVN) of the femoral head, a known but rare complication of uterine artery embolization, followed by immediate orthopedic consultation if AVN is confirmed.

Immediate Diagnostic Workup

Critical Differential: Avascular Necrosis

• Non-target embolization during UAE can cause AVN of the femoral head, presenting with deep groin pain that is constant and sharp, worsening with weight-bearing activities and hip rotation 1
• The temporal relationship (pain onset immediately post-UAE) and characteristic symptom pattern (deep inner hip/groin pain, difficulty with sit-to-stand, car transfers, stair climbing) are highly suspicious for this complication 1
• Plain radiographs are often normal in early AVN, making MRI the gold standard for diagnosis 1
• The patient's preserved range of motion and ability to walk without limping does NOT exclude AVN in early stages 1

Required Imaging

• MRI of the left hip with and without contrast is mandatory to evaluate for:
  • Femoral head AVN (bone marrow edema, subchondral fracture, collapse)
  • Occult hip fracture (given history of previous fall)
  • Soft tissue pathology
  • Joint effusion or synovitis 1

Concurrent Evaluation for Adenomyosis-Related Pain

Consider Adenomyosis as Pain Source

• The patient has known adenomyosis, which can cause persistent pelvic and referred hip/groin pain even after UAE 2, 3
• UAE for adenomyosis has lower success rates than for fibroids alone, with 45.5% of patients reporting symptom deterioration at 2 years 4
• Adenomyosis-related pain may be referred to the hip/groin region through shared nerve pathways 5, 2

Additional Imaging Considerations

• Pelvic MRI should be obtained simultaneously with hip MRI to assess:
  • Adequacy of fibroid/adenomyosis infarction
  • Post-embolization syndrome complications
  • Exclude underlying leiomyosarcoma (recommended 3-6 months post-UAE) 1

Pain Management Escalation

Inadequate Current Analgesia

• Paracetamol and ibuprofen are insufficient for severe post-UAE pain (8-9/10) 1
• Immediate pain control requires:
  • Short-term opioid analgesia (tramadol or stronger opioids for severe pain) 6
  • Continuation of NSAIDs (if no contraindications with diabetes/renal function) 6
  • Consider neuropathic pain agents (gabapentin or pregabalin) if nerve involvement suspected 6

Post-Embolization Syndrome Management

• Although typically occurs within 24-48 hours post-procedure, delayed presentations can occur 1
• Dexamethasone may provide anti-inflammatory benefit if post-embolization syndrome is contributing 6

Urgent Specialist Referrals

Orthopedic Surgery Consultation

• Immediate referral if MRI confirms AVN, as early intervention may prevent femoral head collapse 1
• Treatment options range from protected weight-bearing to core decompression or arthroplasty depending on stage 1

Interventional Radiology Follow-up

• Return to performing interventionalist to evaluate for:
  • Non-target embolization complications
  • Incomplete embolization requiring repeat procedure
  • Post-procedure complications (infection, ischemia) 1

Gynecology Re-evaluation

• Assess adequacy of adenomyosis treatment 2, 3
• Consider alternative treatments if UAE failed:
  • Hormonal therapy (progestin IUD, GnRH antagonists) for persistent adenomyosis symptoms 2
  • Hysterectomy if fertility not desired and conservative measures fail 1, 2

Critical Pitfalls to Avoid

Do Not Delay Imaging

• Normal plain radiographs do NOT exclude AVN or occult fracture in the setting of severe hip pain 1
• The 8-week delay between injury and UAE, followed by symptom onset post-procedure, suggests either procedure-related complication or reactivation of previous injury 1

Do Not Attribute All Pain to Musculoskeletal Causes

• Post-UAE complications can present with referred hip/groin pain including:
  • Pelvic infection/abscess
  • Ovarian failure/ischemia
  • Bladder/bowel ischemia (rare but serious) 1

Monitor for Red Flags

• Fever, leukocytosis, or systemic symptoms suggest post-embolization syndrome or infection requiring urgent evaluation 1
• Inability to bear weight or progressive neurological symptoms mandate immediate imaging and consultation 1

Diabetes Management Considerations

• Ensure optimal glycemic control, as hyperglycemia impairs bone healing and increases infection risk 1
• NSAIDs should be used cautiously given diabetes and potential renal involvement 6
• Monitor for diabetic complications that may contribute to pain (neuropathy, vascular disease) 1