P018: CHRONIC PELVIC PAIN SYNDROME: A CASE REPORT ON A PATIENT SEEN OVER TELEMEDICINE WITH LIFE-THREATENING PATHOLOGY
Jacob Topfer, DO; Melanio Bruceta, MD; Danielle Horn, MD; University of Miami, Department of Anesthesiology, Perioperative Medicine and Pain Management
Introduction: Chronic pelvic pain syndrome can be a difficult pathologic process to identify and treat given the diverse range of symptoms and systemic comorbidities that are often present (4). We are presenting a case of chronic pelvic pain syndrome in a patient seen over a virtual consultation with life-threatening associated symptoms.
Case Report: The patient is a 44 year old male with a PMH significant for low back pain, COVID-19, and prostatitis who presents complaining of bilateral leg, groin, and deep pelvic pain. The pelvic pain occurred after an injury sustained during intercourse. His pelvic pain was described as a burning and sharp and had been present for 3 months prior to his initial visit. He was seen at an outside hospital and was diagnosed with prostatitis. Subsequently, he was treated with antibiotics and prednisone, which helped his symptoms. While on his initial visit to our clinic, he described having severe bilateral leg pain, but could not ascertain whether this pain was similar to his radicular back pain. This pain was noted to be worse in the calf region with associated redness, swelling, and engorged veins. He also endorsed numbness in his feet. The interaction was done virtually, so it was difficult to do a proper physical exam. Ultimately, the patient was given gabapentin 600mg TID, Cymbalta 60mg daily and pelvic floor therapy. He was also instructed to go to the emergency room for ultrasound evaluation of his lower extremities. This was done shortly thereafter, and was found to have multiple DVTs in the left lower extremity with an associated pulmonary embolism. He was started on anticoagulation and will be following up to determine if any autoimmune or hypercoagulable disorder played a roll in this presentation. It was discussed with the patient that there are interventional pain procedures that could be indicated for the treatment of his intractable pelvic pain, however it is important to address the underlying health issues prior to any interventional procedure.
Discussion: Chronic pelvic pain is characterized by noncyclical pain in the pelvis for greater than 3 months while interfering with daily function (4). The best treatment option includes a wide range of modalities such as anti-inflammatories, antibiotics, neuropathic drugs, pelvic floor physical therapy, as well as interventional procedures (4). It is our duty as health care providers to obtain a comprehensive HPI and be vigilant for new symptoms that can help us determine if any disease process has changed (2). On initial evaluation, our patient reported lumbosacral radiculopathy and chronic pelvic pain. However, the new “clue” was bilateral calf pain, leading to the diagnoses of lower extremity DVT and PE. Venous thrombosis is uncommon in patients less than 45 years old, with an annual incidence of about 1 per 1000 adults (1). Chronic low back pain has an incidence up to 40%, even when associated with radicular symptoms (2). This provides evidence that it may be easy to overlook rare diagnoses solely based on a diverse range of presenting symptoms of a chronic condition.