Musculoskeletal Causes of Pelvic Pain — MCQs
A young athlete complains of pain in the groin and weakness in the hip following a sports injury. An MRI shows a tear in which muscle that is commonly associated with groin injuries?
The clinical manifestations of cauda equina lesion include the following EXCEPT:
Which of the following statements about the Levator Ani is false?
A patient complains to a physician of chronic pain and tingling of the buttocks. The pain is exacerbated when the buttocks are compressed by sitting on a toilet seat or chair for long periods. No lumbar pain is noted. Pain is elicited when the physician performs Freiberg's maneuver. Most likely diagnosis?
A patient has dyspareunia, and dysmenorrhea with adnexal tenderness. What is the first step of investigation?
A 35-year-old woman presents with widespread musculoskeletal pain, fatigue, and poor sleep. She has tenderness in 14 of 18 specific points on physical exam. What is the best treatment strategy?
Violin string adhesion is seen in ?
Fitz‐Hugh‐Curtis syndrome involving perihepatitis is present in the following:
60-year-old female with a history of intermittent bleeding. What is the diagnosis based on the ultrasound image?
Which of the following symptoms are seen in endometriosis? 1. Infertility 2. Dysmenorrhea 3. Vaginal discharge 4. Vaginal bleeding
Musculoskeletal Causes of Pelvic Pain Indian Medical PG Practice Questions and MCQs
Question 1: A young athlete complains of pain in the groin and weakness in the hip following a sports injury. An MRI shows a tear in which muscle that is commonly associated with groin injuries?
- A. Adductor longus (Correct Answer)
- B. Iliopsoas
- C. Rectus femoris
- D. Gluteus medius
Explanation: ***Adductor longus*** - The **adductor longus** is a primary **groin muscle** involved in hip adduction and commonly injured during sports activities requiring sudden changes in direction or kicking. - A tear in this muscle is a frequent cause of **groin pain** and weakness in athletes. *Iliopsoas* - The **iliopsoas** is a powerful hip flexor, and while injuries can cause pain in the groin region, a tear typically manifests as weakness in **hip flexion**, not primarily adduction. - Pain from an iliopsoas injury is often felt deeper in the groin or hip, sometimes radiating down the thigh. *Rectus femoris* - The **rectus femoris** is one of the quadriceps muscles that crosses both the hip and knee joints; tears cause pain and weakness in **hip flexion** and **knee extension**. - Injuries are more common with activities involving sprinting or kicking, but the primary pain location is usually more anterior thigh rather than deep groin. *Gluteus medius* - The **gluteus medius** is a primary hip abductor and stabilizer; injuries typically cause pain on the **lateral aspect of the hip** or buttock, not the groin. - Weakness in this muscle would primarily affect hip abduction and stability during weight-bearing.
Question 2: The clinical manifestations of cauda equina lesion include the following EXCEPT:
- A. Saddle anesthesia
- B. Radicular pain
- C. Urinary retention
- D. Extensor plantar reflexes (Correct Answer)
Explanation: ***Extensor plantar reflexes*** - Extensor plantar reflexes (Babinski sign) are indicative of an **upper motor neuron lesion**, typically affecting the **corticospinal tract**, not the cauda equina [4]. - The cauda equina comprises **lower motor neurons**; therefore, a lesion here would more likely result in absent or diminished deep tendon reflexes, and a flexor plantar response or no response [4]. *Saddle anesthesia* - This is a classic symptom of cauda equina syndrome, involving numbness or sensory loss in the **perineal and gluteal regions** due to compression of sacral nerve roots. - It results from damage to the **sensory fibers** of the cauda equina innervating these areas [1]. *Radicular pain* - Cauda equina syndrome often causes severe **low back pain** radiating down the legs, similar to sciatica, due to compression or irritation of the **nerve roots** [1]. - This pain can be bilateral and is a significant symptom, reflecting the involvement of multiple nerve roots [3]. *Urinary retention* - **Bladder dysfunction**, particularly urinary retention, is a critical red flag for cauda equina syndrome, caused by damage to the **sacral nerve roots** responsible for bladder control [2], [3]. - It signifies significant neurological compromise affecting **autonomic function** [2].
Question 3: Which of the following statements about the Levator Ani is false?
- A. Converges downwards & medially
- B. Attached to the pelvic brim. (Correct Answer)
- C. Made up of iliococcygeus, pubococcygeus, and puborectalis.
- D. Supports pelvic viscera.
Explanation: Attached to the pelvic brim - This statement is **false** because the levator ani does not attach to the pelvic brim (the inlet of the true pelvis). - The levator ani originates from: the **posterior surface of the body of pubis**, the **tendinous arch of obturator fascia** (thickening of obturator fascia on lateral pelvic wall), and the **ischial spine**. - All these attachments are on the **lateral pelvic wall below the pelvic brim**, not at the pelvic brim itself. - The muscles insert into the **perineal body**, **anococcygeal ligament**, and walls of pelvic viscera. *Converges downwards & medially* - This statement is **true** - the levator ani muscles arise from lateral attachments on the pelvic sidewalls and converge **medially and downward** toward the midline. - This creates the characteristic **funnel-shaped pelvic diaphragm** that narrows inferiorly. - The fibers run inferomedially to form a muscular sling supporting pelvic structures. *Supports pelvic viscera* - This is the **primary function** of the levator ani muscle group [1]. - It forms a muscular floor that supports the **bladder, uterus/prostate, and rectum**, preventing prolapse. - The muscle maintains the position of pelvic organs against intra-abdominal pressure. *Made up of iliococcygeus, pubococcygeus, and puborectalis* - This statement is **correct** - the levator ani consists of three main components [1]: - **Puborectalis** - forms a sling around the anorectal junction, important for fecal continence [1]. - **Pubococcygeus** - middle portion, supports pelvic viscera [1]. - **Iliococcygeus** - most posterior portion, extends from ischial spine to coccyx [1].
Question 4: A patient complains to a physician of chronic pain and tingling of the buttocks. The pain is exacerbated when the buttocks are compressed by sitting on a toilet seat or chair for long periods. No lumbar pain is noted. Pain is elicited when the physician performs Freiberg's maneuver. Most likely diagnosis?
- A. Disk compression of the sciatic nerve
- B. Fibromyalgia
- C. Popliteus tendinitis
- D. Piriformis syndrome (Correct Answer)
Explanation: ***Piriformis syndrome*** - The symptoms of **chronic pain and tingling in the buttocks**, exacerbated by sitting, and the positive finding on **Freiberg's maneuver** (passive internal rotation of the hip) are hallmark signs. - This condition involves **entrapment or irritation of the sciatic nerve by the piriformis muscle**, which is located deep in the buttock. *Disk compression of the sciatic nerve* - While it can cause similar symptoms, the absence of **lumbar pain** makes a primary disc issue less likely. - **Freiberg's maneuver** is specific to piriformis irritation, not typically for disk compression. *Fibromyalgia* - Fibromyalgia presents with **widespread musculoskeletal pain** and tenderness, not typically localized to the buttocks with specific positional exacerbation. - It does not involve nerve entrapment or specific orthopedic maneuvers like Freiberg's maneuver. *Popliteus tendinitis* - Popliteus tendinitis causes pain in the **posterolateral aspect of the knee**, not the buttocks. - It is typically associated with activities involving downhill running or pivoting of the knee.
Question 5: A patient has dyspareunia, and dysmenorrhea with adnexal tenderness. What is the first step of investigation?
- A. Colposcopy
- B. Diagnostic laparoscopy
- C. Transvaginal USG (Correct Answer)
- D. Transabdominal pelvic ultrasound
Explanation: ***Transvaginal USG*** - This is the **first-line investigation** for evaluating pelvic pain, dyspareunia, dysmenorrhea, and adnexal tenderness due to its ability to provide **high-resolution images** of the uterus, ovaries, and surrounding structures to identify potential pathology like **endometriomas** or other adnexal masses. - It allows for detailed assessment of **ovarian cysts**, fibroids, and other pelvic abnormalities, which can explain the patient's symptoms. *Colposcopy* - This procedure is primarily used to closely examine the **cervix, vagina, and vulva** for abnormal cells, often following an abnormal Pap test. - It is not the initial step for investigating generalized pelvic pain, dyspareunia, or adnexal tenderness. *Diagnostic laparoscopy* - While a **diagnostic laparoscopy** can provide a definitive diagnosis for conditions like **endometriosis**, it is an **invasive surgical procedure** and typically reserved for cases where non-invasive imaging, such as transvaginal ultrasound, has not yielded a clear diagnosis or when conservative management has failed. - It is not considered the first-step investigation due to its **invasive nature** and associated risks. *Transabdominal pelvic ultrasound* - A **transabdominal pelvic ultrasound** provides a broader view of the pelvic organs but often has **lower resolution** and is less accurate for detailed assessment of the uterus, ovaries, and adnexa compared to transvaginal ultrasound, especially in obese patients. - It is often used if a transvaginal ultrasound is not feasible or for assessing larger pelvic masses, but the **transvaginal approach** is superior for detailed evaluation of the female reproductive organs.
Question 6: A 35-year-old woman presents with widespread musculoskeletal pain, fatigue, and poor sleep. She has tenderness in 14 of 18 specific points on physical exam. What is the best treatment strategy?
- A. Pharmacological pain management with opioids
- B. CBT and exercise (Correct Answer)
- C. Anti-inflammatory medications
- D. Surgical intervention for pain relief
Explanation: ***CBT and exercise*** - **Cognitive Behavioral Therapy (CBT)** addresses the psychological factors contributing to pain perception and coping, which is crucial in managing **fibromyalgia**. - **Exercise**, particularly low-impact aerobic activities, has been shown to improve widespread pain, fatigue, sleep disturbances, and overall function in patients with **fibromyalgia** [1]. *Pharmacological pain management with opioids* - **Opioids** are generally not recommended for fibromyalgia due to their limited efficacy for chronic widespread pain and significant risk of **dependence** and side effects [2]. - Their use can lead to **hyperalgesia** and worsened pain perception over time, contrary to the desired outcome. *Anti-inflammatory medications* - **NSAIDs** are typically ineffective for fibromyalgia because it is not primarily an inflammatory condition [1]. - While they might provide mild symptomatic relief, they do not address the central sensitization and neurochemical imbalances characteristic of **fibromyalgia** [1]. *Surgical intervention for pain relief* - **Surgical intervention** is not indicated for fibromyalgia, as it is a systemic chronic pain condition without a focal structural anomaly requiring surgery. - There is no evidence supporting the efficacy of surgery for the relief of widespread musculoskeletal pain in **fibromyalgia**.
Question 7: Violin string adhesion is seen in ?
- A. Ruptured ectopic pregnancy
- B. Endometriosis
- C. PCOS
- D. Fitz-Hugh-Curtis syndrome (Correct Answer)
Explanation: ***Fitz-Hugh-Curtis syndrome*** - **Fitz-Hugh-Curtis syndrome** is a perihepatitis characterized by inflammation of the liver capsule and adjacent peritoneal surfaces. - The classic "violin string" adhesions are **fibrinous adhesions** that form between the liver capsule and the anterior abdominal wall or diaphragm. *Ruptured ectopic pregnancy* - A ruptured ectopic pregnancy typically presents with acute abdominal pain and **hypovolemic shock** due to hemoperitoneum. - While it can cause pelvic adhesions, "violin string" adhesions are not a characteristic finding; the primary concern is **intra-abdominal hemorrhage**. *Endometriosis* - **Endometriosis** involves the presence of endometrial-like tissue outside the uterus, causing pain, inflammation, and adhesions, especially in the pelvis. - While it does lead to adhesions, these are usually **dense and diffuse pelvic adhesions**, not the specific "violin string" pattern associated with the liver capsule. *PCOS* - **Polycystic ovary syndrome (PCOS)** is an endocrine disorder characterized by hormonal imbalances, anovulation, and polycystic ovaries. - It primarily affects **ovarian function** and metabolism and does not directly cause adhesions in the abdominal cavity.
Question 8: Fitz‐Hugh‐Curtis syndrome involving perihepatitis is present in the following:
- A. Syphilis
- B. Tuberculosis
- C. Moniliasis
- D. Gonorrhoea (Correct Answer)
Explanation: **Gonorrhoea** - **Fitz-Hugh-Curtis syndrome** is a complication of **pelvic inflammatory disease (PID)**, which is predominantly caused by sexually transmitted infections like *Neisseria gonorrhoeae* and *Chlamydia trachomatis*. - Perihepatitis, or inflammation of the liver capsule, occurs when bacteria from the pelvic infection spread to the liver surface. *Syphilis* - **Syphilis** primarily presents with chancres, rashes, and neurological or cardiovascular complications in later stages. - It does not typically cause **perihepatitis** as a direct complication of the infection itself. *Tuberculosis* - **Tuberculosis** is caused by *Mycobacterium tuberculosis* and usually affects the lungs, but can spread to other organs. - While it can cause peritonitis, it is not associated with **perihepatitis** in the context of **Fitz-Hugh-Curtis syndrome**. *Moniliasis* - **Moniliasis** (candidiasis) is a fungal infection caused by *Candida* species. - It is commonly associated with vaginal yeast infections or thrush but does not cause **Fitz-Hugh-Curtis syndrome** or perihepatitis.
Question 9: 60-year-old female with a history of intermittent bleeding. What is the diagnosis based on the ultrasound image?
- A. Endometrial polyp (Correct Answer)
- B. Ca endometrium
- C. Submucosal fibroid
- D. Endometrial hyperplasia
Explanation: ***Endometrial polyp*** - The ultrasound image shows a well-defined, **echogenic focal lesion within the endometrial cavity**, which is characteristic of an endometrial polyp. - In a 60-year-old female with intermittent bleeding, a polyp is a common cause of **postmenopausal bleeding** and is often identified as an intracavitary mass on ultrasound. - Endometrial polyps appear as **focal, hyperechoic or isoechoic masses** with a smooth contour projecting into the endometrial cavity. *Ca endometrium* - **Endometrial carcinoma** typically appears as diffuse endometrial thickening (>4-5 mm in postmenopausal women), irregular endometrial-myometrial interface, or heterogeneous endometrial echoes, often with evidence of myometrial invasion. - While bleeding is a cardinal symptom of endometrial carcinoma, the distinct **focal, well-circumscribed nature** of the lesion on ultrasound is less typical for carcinoma, which tends to be more diffuse and irregular. *Submucosal fibroid* - A **submucosal fibroid** (leiomyoma) is a benign smooth muscle tumor originating from the myometrium that protrudes into the endometrial cavity. - While it can appear as an intracavitary mass and cause abnormal bleeding, fibroids often have a more **heterogeneous or hypoechoic appearance** with posterior acoustic shadowing, compared to the isoechoic to hyperechoic appearance of a polyp. - The feeding vessel sign (blood flow at the base) is more characteristic of polyps than fibroids. *Endometrial hyperplasia* - **Endometrial hyperplasia** presents as **diffuse, uniform endometrial thickening** rather than a focal intracavitary mass. - It typically shows homogeneous increased echogenicity of the entire endometrium without a discrete, well-defined lesion as seen with a polyp. - While it can cause postmenopausal bleeding, the focal nature of the lesion in this case makes hyperplasia less likely.
Question 10: Which of the following symptoms are seen in endometriosis? 1. Infertility 2. Dysmenorrhea 3. Vaginal discharge 4. Vaginal bleeding
- A. 2,3
- B. 1,2,4
- C. 3,4
- D. 1,2 (Correct Answer)
Explanation: ***Correct: 1,2 (Infertility and Dysmenorrhea)*** - **Infertility** is present in 30-50% of women with endometriosis, making it one of the most common presentations. Caused by inflammation, adhesions, altered pelvic anatomy, and inflammatory mediators that impair reproductive function. - **Dysmenorrhea (painful menstruation)** is the hallmark symptom of endometriosis. The pain is typically severe, progressive, and occurs due to cyclic bleeding from ectopic endometrial tissue, causing inflammation and irritation of surrounding structures. - These are the two most characteristic and consistent symptoms of endometriosis. *Incorrect: 2,3* - While dysmenorrhea is correct, **vaginal discharge is NOT a characteristic symptom of endometriosis**. Vaginal discharge is typically associated with infections (vaginitis, cervicitis) or other gynecological conditions, not endometriosis. *Incorrect: 1,2,4* - While infertility and dysmenorrhea are correct, including "vaginal bleeding" makes this option less accurate. Although some women with endometriosis may experience menorrhagia or irregular bleeding (particularly with adenomyosis or ovarian endometriomas), **abnormal vaginal bleeding is not a primary or pathognomonic symptom** of endometriosis. *Incorrect: 3,4* - **Vaginal discharge** is not associated with endometriosis. - **Vaginal bleeding** as a standalone symptom is not a primary feature of endometriosis, though menstrual abnormalities can occasionally occur. **Note:** Other classic symptoms of endometriosis include dyspareunia (painful intercourse), dyschezia (painful defecation), and chronic pelvic pain.
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