Presentation of Iliohypogastric Nerve Pain in an 8-week Postpartum Woman: A Case Report
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Jessica Angowski
CoPIs:
Hailey Piemonte, Andria Reber,
College:
The College of Health Professions and Human Services
Major:
Physical Therapy
Faculty Research Advisor(s):
Jennifer Gentile, Jenna Tucker
Abstract:
Purpose: The iliohypogastric nerve (IHN) traverses the abdominal wall, pierces the transverse abdominis, internal oblique and external oblique, and then travels anteroinferiorly on the trunk before terminating in the suprapubic region where it provides cutaneous innervation. This path places the IHN at risk for injury during pregnancy due to increased tension on the abdominal wall from the gravid uterus. Pain from IHN entrapment occurs in approximately 1 in 3000 pregnancies, yet is often missed as a differential diagnosis by clinicians. This can result in unnecessary treatments and surgeries, and unnecessary cost to the healthcare system. The purpose of this case is to review the findings from a patient presenting with suprapubic pain from IHN entrapment.
Subject: A 29-year-old who was presented with pain in the suprapubic region during exercise at 6-weeks postpartum
Case Description: The patient was a 29-year-old who was presented with pain in the suprapubic region during exercise. Prior to pregnancy, she engaged in 20-30 minutes of exercise 4 times each week consisting of strength training, Peloton Bike and running. She was diagnosed with placenta previa early in her pregnancy and stopped all exercise. Following exercise clearance at her 6-week postpartum visit, she began gentle core strengthening and walking. With each bout of exercise she reported pain above her pubic bone. Clinical findings by the physical therapist included decreased local core strength, decreased load transfer, pain to palpation in deep pelvic floor (PF) muscles, discoordinated PF muscle/core activity and facial restrictions in lower left quadrant. She demonstrated decreased ability to control pelvic position followed by symptom exacerbation. Further core examination revealed consistent and repeatable trigger of her suprapubic pain with left psoas palpation. Resisted left hip flexion revealed weakness and inability to stabilize her pelvis. Physical Therapy (PT) interventions were performed to address PF discoordination, hyperactivity, and core and iliopsoas weakness.
Results: The patient received 4 PF PT visits over 3 months. PT included manual techniques, therapeutic exercise, neuromuscular reeducation including diaphragmatic breathing and patient education. The patient reported pain of 2/10 on a numerical rating scale for pain and a 5/10 report of bother on a similar scale at the initial visit. She was unable to participate in core exercises or a walking program without triggering her pain. At discharge, she reported 0/10 pain and bother levels, and a full return to her exercise program without symptoms.
Conclusions: The patient in this case sought the care of a PF physical therapist for management of pain in the bladder region during the postpartum period. However, meticulous history taking, and differential diagnosis revealed a primary issue of IHN entrapment.
Clinical Relevance: Interventions aimed at addressing the IHN entrapment at the psoas are effective in addressing nerve related symptoms and can assist in resolving impairment for return to full function.