Beth Nash

Beth Nash is a 25-year-old respiratory therapist with the chief complaint of, “I’ve got a shooting pain into my groin since my C-section.” Beth went on to say that “other than the shooting pain, Buster and I have been doing great since our C-section.” I assumed that Buster was the rambunctious 6-month-old who was trying to escape his mother’s grasp. I asked Beth if this was her first child and she smiled brightly and said, “Yes, he is, and he is a real handful! Doctor, it’s been great except for this pain. At first I thought it was just postsurgical pain, but as I healed up, this shooting pain into my groin just wouldn’t go away. The crazy thing is, I feel like I can’t stand up straight, because when I do, I get this electric shock into my privates. Bill, my husband, says I am walking around like an old lady!”

I asked Beth if she ever had anything like this before, and she shook her head no. She also denied any other urinary or gynecologic symptoms, hematuria, or fever or chills. She also denied a history of kidney stones. She had started her periods again with her last menstrual period a week ago. Beth was using condoms for birth control, as she was still breast feeding. I asked what she was doing to manage the pain and she said that “nothing really works.” I asked her to rate her pain on a scale of 1 to 10, with 10 being the worst pain she had ever had, and she said the shocks were a 7 or 8. “Doctor, if I have to live with the pain, I can, but it is interfering with everything—getting dressed, taking care of Buster, sex—everything. I just never know when it’s going to hit.” Beth said that she looked up post-C-section pain on the Internet, and she wasn’t trying to be the doctor, but as best as she could tell, she thought it might be nerve damage from the incision. She gave me an inquisitive look, and I smiled and said that I thought that she was spot on. “Let’s take a look at you and see if we both have the correct diagnosis.”

I asked my nurse to hold Buster, then asked Beth to point with one finger to show me where it hurt the most. She pointed to the front of her right groin and said, “Doc, the pain shoots down into my right labia. The C-section incision itself doesn’t hurt, but there is this spot just below the incision that if I push on it, bang! It causes the electric shock—it really gets my attention. I’m worried it will hit and I will drop Buster.”

On physical examination, Beth was afebrile. Her respirations were 16. Her pulse was 68 and regular. Her blood pressure (BP) was normal at 110/70. Her nutrition appeared fine. Her head, eyes, ears, nose, and throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination was negative. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Her lower extremity neurologic examination was completely normal.

I asked Beth to lie back on the examination table with her knees bent so we could take a closer look at her cesarean section scar. Visual inspection of the scar revealed no obvious defect or infection. Inspection of the groin revealed no obvious abnormal mass or inguinal hernia. I again asked Beth to use one finger to point to the spot that caused the shooting pain, and she carefully pointed to a spot about 2 inches medial to the anterior superior iliac spine and 2 inches below that spot ( Fig. 3.1 ). This spot was just below the lateral aspect of the cesarean section scar. I asked Beth if I could palpate the spot that she identified and, after a moment’s hesitation, she nodded yes and said, “Sure, just be gentle.” I said, “No problem. Why don’t you hold my hand, and you do the pushing and I’ll do the feeling so together we’ll figure out what is going on.” She liked that idea, so I had Beth guide my index finger to the spot that was causing the trouble. There was no obvious surgical defect, but there was allodynia, and when Beth tentatively pushed my index finger into the spot just below the scar, I felt her suddenly withdraw her pelvis as she said, “Right there!” I said, “I think we have our answer. How about getting up and walking down the hall for me?” She carefully sat up and slid off the exam table, immediately assuming the novice skier position ( Fig. 3.2 ). When I asked her to stand up straight, the pain recurred and she reassumed the novice skier position.

The location of the ilioinguinal nerve in relation to the anterior superior iliac spine.

From Waldman SD. Atlas of Common Pain Syndromes . 4th ed. Philadelphia: Elsevier; 2019: Fig. 80.1.

Patients suffering from ilioinguinal neuralgia will often assume the novice skier position.

Key Clinical Points—What’s Important and What’s Not