A 67-year-old man presents to the clinic complaining of cramping buttock pain after walking a few blocks. The pain is relieved after several minutes of rest. He also complains of being unable to achieve a firm erection for the last 6 months, despite having increased libido. His past medical history includes hypertension, diabetes and dyslipidemia, which have been treated appropriately. He smokes 2 packs/day for the last 40 years. His vital signs are normal, except for a slightly increased blood pressure. On physical examination, his abdomen is normal. He has normal pulses throughout. Both of his lower limbs and feet are well perfused and warm. No pain is elicited during passive movement of his legs relative to his hips. His resting ankle-branchial index (ABI) is 1.0 and it does not change after exercise. Neurological examination is normal.
The correct answer is: B. Isolated internal iliac artery disease
The patient complains of buttock pain that is elicited by mild exercise and erectile dysfunction for the last 6 months. Given his past medical history and smoking status, peripheral vascular disease is the most likely diagnosis. Of the answers given above, only Answer B is the most relevant. Lower extremity arterial disease is a highly prevalent disease usually caused by atherosclerosis. Several risk factors for lower extremity arterial disease have been identified, including smoking, hypertension, diabetes, and dyslipidemia.1
Internal iliac artery stenosis can be affected by atherosclerosis and has been associated with pain elicited by walking and reflecting to the lower back, hip, buttock, or thigh.2 Thus, the pain related to internal iliac atherosclerosis might mimic the pain caused by other non-vascular diseases (e.g. hip osteoarthritis). Ankle-brachial index (ABI) is used as screening tool for lower extremity arterial disease, with the cutoff point being 0.90. However, the ABI can remain within normal limits in case of isolated internal iliac artery disease.3
Hip osteoarthritis is associated with pain typically in the groin provoked by internal or external rotation of the hip, so given the patient's normal physical examination, this diagnosis is less likely. Moreover, the patient's erectile dysfunction and intermittent claudication cannot be explained by osteoarthritis (Answer A).
Although spinal stenosis can present with buttock, thigh and hip pain, it is usually relieved by changing body positions (e.g. sitting or leaning forward). Furthermore, patients with spinal stenosis have a chronic history of progressive back pain that is not elicited by exercise (Answer C).
Bone metastasis commonly presents with steady aching bone pain, which is not easily relieved. Symptoms related to malignancy are usually apparent. However, in this case significant weight loss, anorexia and signs of cancer are not present making this diagnosis less unlikely (Answer D).
Educational Objective:
Lower extremity arterial disease is mainly caused by atherosclerosis and can affect the internal iliac artery, causing lower back, hip, buttock, or thigh pain and erectile dysfunction. Due to the "atypical" pain localization and often normal ABI values, there should be a high clinical suspicion in order to diagnose this entity.
References
- Jaquinandi V, Abraham P, Picquet J, Paisant-Thouveny F, Leftheriotis G, Saumet JL. Estimation of the functional role of arterial pathways to the buttock circulation during treadmill walking in patients with claudication. J Appl Physiol 2007;102:1105–12.
- Jaquinandi V, Bouye P, Picquet J, Leftheriotis G, Saumet JL, Abraham P. Pain description in patients with isolated proximal (without distal) exercise-related lower limb arterial ischemia. Vasc Med 2004;9:261–5.
- Mahé G, Kaladji A. Le Faicjeir A, Jaquinandi V. Internal iliac artery stenosis: diagnosis and how to manage it in 2015. Front Cardiovasc Med 2015;2:33.
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