Psoas Abscess: A Primer for the Internist

, Department of Internal Medicine, Lincoln Health Center and Durham Regional Hospital, Durham, NC

South Med J. 2001;94(1)

Abstract and Introduction

Psoas abscess is a rare condition with vague clinical presentation. In this article, its epidemiology, etiology, bacteriology, diagnosis, and treatment are discussed. Common diseases that may be erroneously diagnosed in patients with psoas abscess are presented.

Many abdominal conditions are so dramatic in their presentation that patients may go to the emergency room. Psoas abscess has an insidious onset, and patients may be seen by their primary care physician. Because psoas abscess is rare and is uncommonly discussed in primary care medical literature, primary care physicians may miss this diagnosis. Therefore, these practitioners need to be familiar with psoas abscess to prevent delay in diagnosis and treatment. Psoas abscess may be classified as primary or secondary, depending on the presence or absence of underlying disease.

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Table 1. Conditions Associated With Secondary Psoas Abscess
Disease Site	Conditions
Gastrointestinal	Diverticulitis, appendicitis, Crohn's disease, colorectal carcinoma, appendiceal tumor
Genitourinary	Urinary tract infection, extracorporeal shock wave lithotripsy, cancer
Musculoskeletal	Vertebral osteomyelitis, lumbar spondylodiskitis, infectious sacroiliitis, septic arthritis
Other	Endocarditis, femoral artery catheterization, infected abdominal aortic aneurysm, hepatocellular carcinoma, trauma, intrauterine contraceptive device, acupuncture, spinal surgery sepsis, suppurative adenitis, long-term hemodialysis or peritoneal dialysis

Table 2. Clinical Syndromes With Pain Similar to That Due to Psoas Abscess
Clinical Syndrome	Differentiating Findings
Muscle strain	Usually attributed to muscle injury by the patient. The pattern of pain radiation seen in psoas abscess is absent. No systemic symptoms.
Meralgia paresthetica	Often causes only paresthesia but can also cause shooting pain to the anterior and lateral surface of the thigh due to compression of lateral femoral cutaneous nerve (originates from L2 and L3) around the groin.
Sciatica	Back pain due to irritation of lumbar or sacral nerve roots typically radiates to the posterior or lateral surface of the thigh, knee, or leg. This sometimes involves the dorsum of the foot, first or second and third toes (L5 root), or plantar surface of the foot and forth or fifth toes (S1 root). The presence of paresthesia in the distribution of pain is suggestive of sciatica. Rarely, irritation of L3 or L4 root can lead to back pain that radiates to the anterior thigh and knee, but the knee jerk is usually diminished or absent and there is associated paresthesia.
Renal colic/pyelonephritis	Characteristically causes flank pain, which radiates to the groin. Nausea and vomiting are common. Fever and malaise unusual except when there is associated kidney infection.

Table 3. Tests for Iliopsoas Inflammation
*	These maneuvers may also yield positive results in conditions such as appendicitis in which there is inflammation of the iliopsoas without the formation of psoas abscess.

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