What is the most likely diagnosis and appropriate work‑up and treatment for a male who develops lower abdominal pain, dysuria, and anterior thigh pain after heavy pulling?

Likely Diagnosis: Sports Hernia (Athletic Pubalgia) with Secondary Lower Urinary Tract Symptoms

The most likely diagnosis is a sports hernia (athletic pubalgia) causing referred pain and secondary urinary symptoms, rather than a primary urologic condition, given the clear temporal relationship to heavy pulling and the constellation of lower abdominal, anterior thigh, and urinary symptoms.

Clinical Reasoning and Differential Diagnosis

Primary Musculoskeletal Injury

• Sports hernia (athletic pubalgia) classically presents with lower abdominal pain after forceful pulling or twisting movements, with radiation to the anterior thigh and groin. The mechanism described—pulling heavy weight toward the body—creates shearing forces across the pubic symphysis and inguinal floor that can tear the rectus abdominis insertion, conjoint tendon, or posterior inguinal wall.

• The anterior thigh pain is consistent with referred pain from the ilioinguinal or genitofemoral nerve irritation that commonly accompanies athletic pubalgia, rather than a primary urologic distribution.

Secondary Urinary Symptoms

• Dysuria and lower abdominal pain in this context may represent referred pain from musculoskeletal injury rather than primary bladder pathology. The proximity of the injured structures to the bladder and urethra can create a sensation of burning during urination without true cystitis or urethritis.

• However, urinalysis with culture must be obtained to exclude urinary tract infection or hematuria that could indicate bladder injury from trauma. 1

Essential Diagnostic Work-Up

Immediate Evaluation

• Obtain urinalysis to detect infection, hematuria, or glycosuria, and urine culture if infection is suspected to rule out concurrent UTI that could complicate the clinical picture. 1

• Perform focused physical examination including external genitalia examination, palpation of the inguinal canal for hernia, and assessment of the pubic symphysis and adductor insertion for tenderness. 1

• Measure post-void residual (PVR) volume to rule out significant urinary retention that could indicate bladder outlet obstruction or neurogenic bladder from nerve injury. 1

Red Flags Requiring Urgent Evaluation

• Gross hematuria, inability to void, or signs of bladder injury (suprapubic mass, severe suprapubic tenderness) require urgent imaging with CT cystography to exclude bladder rupture, particularly if the trauma was significant. 2

• Blood at the urethral meatus or inability to pass a catheter would indicate urethral injury requiring retrograde urethrography before catheterization attempts. 2

Treatment Algorithm

If Urinalysis is Normal (Most Likely Scenario)

• Conservative management with NSAIDs, ice application, and activity modification is first-line for sports hernia. Avoid heavy lifting and movements that reproduce the pain for 2-4 weeks.

• Physical therapy focusing on core strengthening and pelvic floor rehabilitation should be initiated once acute pain subsides, typically after 1-2 weeks.

• Reassess at 2-4 weeks; if symptoms persist or worsen, refer to sports medicine or general surgery for consideration of MRI pelvis to evaluate for occult hernia, pubic symphysis injury, or adductor tendon pathology.

If Urinalysis Shows Infection

• Initiate appropriate antibiotic therapy based on urine culture results. 1

• If dysuria persists after infection treatment, consider alpha-blocker therapy (tamsulosin 0.4 mg daily) for 2-4 weeks to address potential urethral spasm or bladder outlet symptoms. 3, 1

If PVR is Elevated (>100-150 mL)

• Consider alpha-blocker initiation (tamsulosin 0.4 mg daily) and reassess PVR in 2-4 weeks, as trauma-related pelvic floor spasm can cause functional obstruction. 3, 1

• If PVR remains elevated or symptoms worsen, refer to urology for comprehensive evaluation including uroflowmetry and consideration of cystoscopy. 1

Common Pitfalls to Avoid

• Do not assume all dysuria in males represents prostatitis or UTI—referred pain from musculoskeletal injury is common and can mimic urologic symptoms. 2

• Do not overlook the possibility of occult inguinal hernia or sports hernia when lower abdominal pain follows heavy lifting, even if no obvious bulge is palpable. Physical examination may be falsely negative in early athletic pubalgia.

• Do not delay urologic referral if hematuria is present or if urinary retention develops, as these findings suggest true bladder or urethral pathology requiring specialized evaluation. 1

• Do not prescribe anticholinergics or antimuscarinics without first measuring PVR, as men with elevated baseline PVR are at risk for acute urinary retention. 4

Follow-Up Strategy

• Reassess at 1-2 weeks to evaluate response to conservative management and confirm resolution of urinary symptoms. 3, 1

• If musculoskeletal symptoms persist beyond 4-6 weeks despite conservative therapy, refer to sports medicine or general surgery for advanced imaging and consideration of surgical repair. Chronic athletic pubalgia often requires surgical intervention for definitive treatment.

• If urinary symptoms persist or worsen independent of musculoskeletal improvement, complete urologic evaluation with IPSS scoring, uroflowmetry, and possible cystoscopy is indicated to exclude underlying bladder pathology. 1