Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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G.J. Mancini
Magnetic resonance imaging (MRI) of the abdomen has a significan t
role in the diagnostic evaluation of athletic pubalgia. It has a cost higher
than both ultrasound and CT, but no ionizing radiation of CT. Its sensitivity
to demonstrate soft tissue edema differences in T2-weighted
images is critical to identify non-hernia causes of groin pain. As for
occult hernia detection, MRI has been shown to have a sensitivity and
specificity figures of 94.5 and 96.3 % [ 7 ].
Treatment Treatment of occult hernia is fairly straightforward. This
can be done as an open or laparoscopic technique. Laparoscopy is often
suggested as a bridge between a diagnostic and therapeutic modality for
occult hernia. This is a false logic, as a diagnostic laparoscopy will miss
fat-containing hernias that give a normal contour to the pelvic floor. The
peritoneum must be taken down in either a transabdominal preperitoneal
(TAPP) or totally extraperitoneal (TEP) technique to ensure
all hernia sites and pathologies are evaluated. By combining thorough
patient history, physical exam, and the optimal imaging modality, the
risk of missing an occult hernia can be less than 5 %.
Osteitis Pubis
Background Osteitis pubis is an important clinical entity that
deserves significant consideration in any patient who presents with groin
pain without obvious hernia on exam. Several clinical features separate
osteitis pubis from other groin pain diagnoses. The pain most commonly
localizes within the lower abdominal wall and tends to be more medial
(between the external ring and the pubic symphysis). As radiographic
technology has improved, osteitis pubis is now recognized as a cluster
of different injuries to the muscles, tendons, and osseous structures of
the lower abdominal wall and pelvis. These include rectus tendinitis,
conjoined tendonitis, pubic ramus avulsion fractures, and pubis
symphysitis, adductor tendonitis, and gracilis tendonitis. The mechanism
of injury in athletic pubalgia combines two physical phenomena:
repetitive motion injury and muscle development asymmetry. Individuals
at highest risk for the development of osteitis pubis are young athletes in
sports that require high-intensity training in which quick changes in
speed and direction are required. Another component of this injury
mechanism is long-term training in which asymmetric muscle
development is promoted. This muscle development imbalance can be
either between legs and torso or between right and left sides of the body.