GROIN PAIN - BICYCLIST

Abstract

HISTORY - A 33-year-old former competitive cyclist completed a 200K bicycle ride which involved climbing and descending three mountain passes in windy conditions. He presented to the clinic two days later complaining of pain in the left groin region. The patient said the pain was excruciating when seated on the bicycle saddle, but otherwise was just a dull ache. He could feel a cord on his perineum, behind his scrotum which was very tender. He is married, sexually monogamous and admitted to having intercourse five times in the previous 48 hours. He and his wife have no dysuria or dysparunia. PHYSICAL EXAMINATION - Testing of hip flexors and adductors was negative. He had mild diffuse bilateral quadriceps tenderness. Testes were descended with mild bilateral varicoceoles. No testicular masses or epididymal tenderness. No penial lesions or surrounding erythema. Tender palpable cord running parallel to the left side of corpus spongiosum near the perineum. No tenderness of ischial tuberosities. No evidence of skin lesions, abscess formation, rectal fissuring, hemorrhoids or prostate masses. DIFFERENTIAL DIAGNOSIS Groin strain Thrombophlebitis of posterior scrotal artery/vein Acute epididymitis Inflammation of ductus deferens TEST AND RESULTS Urine culture - negative GC, Chlamydia cultures - negative Unable to perform doppler or angiography of scrotal vessels No radiographs FINAL WORKING DIAGNOSIS Inflammation of left ductus deferens TREATMENT No response to one week course of Doxycycline and high dose Ibuprofen. Stopped cycling for one week with partial resolution of symptoms. As soon as he began riding again, symptoms returned. Nose of bicycle saddle was angled 5° − 10° downward from the level position. One week later he returned to cycling with no return of symptoms. At three month follow-up he was pain free and examination was entirely normal.