Clinical case text with master prompt only.
AI Model: Sonnet 4 (Claude) on September 25th, 2025.
Expert: Dr Patrik Noack

Clinical case

A 28-year-old cyclist reports cramp-like lower abdominal pain while abroad. She had an IUD inserted eight weeks ago and has not felt quite right since. A check-up with her gynecologist four weeks ago was uneventful. In addition to the lower abdominal pain, she also experiences bloating, flatulence, and a strange feeling when urinating, but no actual pain. She went to her family doctor in Denmark, where red and white blood cells were detected in her urine, and was then given antibiotics for 5 days. This caused diarrhea and vomiting, but she felt better after taking probiotics. After a brief improvement, the athlete reported the following symptoms again 7 days after taking antibiotics:
– ”Cramps and a lot of pressure in the rectal area (not in the abdomen), as if I always had to go to the toilet”.
– “My stools are not diarrhea but abnormally soft, and when I push, my entire lower body contracts and cramps really badly in the entire rectal area”.
– Sometimes like “cramps” in the anal area.
– “When I sit upright on a chair or saddle, it hurts around my tailbone”.
– The pain is not constant, it comes in waves.

What would you recommend for clarification? Differential Diagnosis?

Introduction

As a sports medicine physician, I frequently encounter complex presentations where athletic demands intersect with reproductive health concerns. The female cyclist with pelvic pain represents a particularly challenging diagnostic scenario that requires careful consideration of both sport-specific and gynecological factors. Recent consensus statements from the International Olympic Committee (IOC) have emphasized the importance of understanding female athlete health beyond traditional injury paradigms [1].
Pelvic pain affects up to 15% of women of reproductive age, with cyclists experiencing additional unique risk factors related to saddle positioning, training intensity, and biomechanical stresses [2]. The evolution of our understanding has shifted from viewing pelvic pain as a singular entity to recognizing it as a complex interplay of musculoskeletal, visceral, and neurological components [3]. In competitive cycling, where athletes spend extensive time in forward-flexed positions with perineal pressure, these presentations demand ­sophisticated clinical reasoning.

Case Analysis

The cyclist’s presentation exemplifies the diagnostic complexity we face when recent gynecological interventions coincide with sport-specific symptoms. Her symptoms following IUD insertion, combined with the characteristic distribution of pain and the temporal relationship to antibiotic treatment, highlight several critical clinical considerations. The geographical element—seeking care abroad—adds layers of diagnostic uncertainty and treatment continuity challenges that many of our athletes face during international competition seasons.
The wave-like nature of her pain, combined with the rectal pressure and sitting intolerance, suggests a complex pelvic floor dysfunction potentially triggered or exacerbated by multiple factors. This presentation requires us to move ­beyond simple cause-and-effect thinking toward a more ­nuanced understanding of pelvic pain mechanisms.

Clinical Background

The differential diagnosis for this presentation encompasses several overlapping categories. Gynecological causes include IUD-related complications such as perforation, infection, or malposition, pelvic inflammatory disease, or endometriosis exacerbation [4]. The temporal relationship to IUD insertion cannot be ignored, as up to 2-5% of insertions result in complications requiring intervention [5].
Gastrointestinal etiologies merit strong consideration given the antibiotic-associated symptoms and current bowel dysfunction. Post-infectious irritable bowel syndrome occurs in 7-31% of patients following bacterial gastroenteritis [6]. Inflammatory bowel disease, particularly proctitis, could explain the rectal symptoms and sitting intolerance.
Musculoskeletal causes are paramount in cyclists. Pelvic floor dysfunction, coccydynia, and pudendal neuralgia frequently occur in this population due to prolonged saddle pressure and hip flexion positioning [7]. Levator ani syndrome presents with rectal pressure sensations and can be triggered by pelvic trauma or inflammation [8].
Urological conditions including interstitial cystitis or bladder pain syndrome could explain the urinary symptoms and pelvic pressure. The recent positive urinalysis adds complexity, as inflammatory conditions can cause sterile pyuria.
Recent advances in pelvic pain assessment include validated questionnaires such as the Pelvic Floor Disability Index and imaging techniques like MRI defecography for functional assessment [9].

Management

My systematic approach begins with comprehensive history taking, focusing on menstrual patterns, sexual function, ­bowel and bladder habits, and detailed sport-specific factors including saddle type, positioning, and training volume changes.
Physical examination requires a multisystem approach. Abdominal examination should assess for masses, tenderness, and bowel sounds. Pelvic examination must evaluate IUD position, cervical motion tenderness, and adnexal masses. Critically, external assessment of pelvic floor muscles, coccyx mobility, and pudendal nerve territories should be performed [10].
Initial investigations include complete blood count with inflammatory markers, comprehensive metabolic panel, and urinalysis with microscopy and culture. Pelvic ultrasound is essential to confirm IUD position and evaluate for ovarian pathology. Consider transvaginal ultrasound if tolerated, as it provides superior pelvic organ visualization.
Advanced investigations depend on initial findings. If gynecological causes are suspected, gynecological consultation with consideration for hysteroscopy may be warranted. For persistent bowel symptoms, inflammatory markers including calprotectin, and potentially flexible sigmoidoscopy should be considered. MRI of the pelvis can evaluate for structural abnormalities and soft tissue inflammation.
The multidisciplinary team approach is crucial. Gynecological input helps determine IUD-related complications. Gastroenterology consultation addresses inflammatory ­bowel concerns. Pelvic floor physiotherapy assessment is invaluable for musculoskeletal components. Sports psychology support may be needed given the impact on training and competition.
Treatment interventions vary by suspected etiology. For suspected pelvic floor dysfunction, specialized physiotherapy including internal techniques, biofeedback, and graduated exercise progression is first-line treatment [11]. Saddle modification or temporary training cessation may be necessary. If IUD complications are confirmed, removal or repositioning may be required.

Diagnostic Reasoning and Clinical Decision-Making

The key to unraveling this complex presentation lies in systematic diagnostic reasoning that considers the temporal relationships and symptom patterns. The wave-like pain pattern, combined with rectal pressure sensations and sitting intolerance, suggests neurogenic or muscular components rather than simple inflammatory processes.
The post-antibiotic symptom evolution is particularly telling. While the initial urinary symptoms and positive urinalysis suggested bacterial cystitis, the subsequent development of bowel dysfunction and pelvic floor symptoms indicates either antibiotic-associated complications or unmasking of an underlying condition [12].
Critical decision points include determining whether the IUD insertion triggered pelvic floor dysfunction, whether the antibiotic course caused significant microbiome disruption leading to functional bowel disorders, or whether we’re dealing with a primary inflammatory condition affecting multiple pelvic structures.

Prognosis and Athlete Counseling

The diagnostic uncertainty inherent in complex pelvic pain presentations requires careful counseling regarding expectations and timelines. I emphasize to athletes that reaching a definitive diagnosis may require sequential investigations and potentially multiple specialist consultations.
Prognostic discussions should address several scenarios. If IUD complications are identified, resolution may be relatively rapid following appropriate intervention. However, if pelvic floor dysfunction has developed, recovery typically requires weeks to months of specialized treatment. Post-infectious functional disorders may persist for extended periods, requiring ongoing symptom management [15].
Key counseling points include the importance of symptom tracking, adherence to activity modifications during the diagnostic phase, and understanding that symptom fluctuation is common in functional pelvic pain disorders. The athlete should understand that training modifications may be necessary even before a definitive diagnosis is reached.
I also discuss the potential for symptom chronicity and the importance of early intervention to prevent central sensitization and development of chronic pain syndromes. Setting realistic expectations about diagnostic timelines while maintaining hope for full recovery is essential for psychological well-being during this challenging period.
Table 1 outlines the systematic diagnostic and management approach for female cyclists with pelvic pain, emphasizing the multidisciplinary nature of care and sport-specific considerations.

Take-Home Messages

• Complex pelvic pain in female cyclists requires systematic evaluation prioritizing exclusion of IUD-related complications, followed by comprehensive assessment of gastrointestinal, neurological, and musculoskeletal causes.
• The temporal relationship between IUD insertion and symptom onset demands immediate imaging to exclude perforation or malposition, as these complications can have serious consequences if missed.
• Post-antibiotic bowel dysfunction combined with pelvic floor symptoms suggests either microbiome disruption or unmasking of underlying inflammatory conditions, requiring targeted investigation including fecal inflammatory markers.
• The wave-like pain pattern with rectal pressure and sitting intolerance is characteristic of pelvic floor dysfunction or pudendal neuralgia, conditions that may require specialized diagnostic techniques and treatment approaches.
• Multidisciplinary evaluation involving gynecology, gastroenterology, and pelvic floor physiotherapy is essential, with careful coordination to avoid over-investigation while ensuring comprehensive assessment.
• Early symptom tracking and activity modification during the diagnostic phase can prevent symptom progression and provide valuable diagnostic information, even before a ­definitive diagnosis is established.

Image credits: OpenAI (2025).
DALL-E (Version 3). https://chatgpt.com/
Prompt: “Photorealistic image of a 28-year-old female cyclist during a training stop on a countryside road. She is wearing a modern cycling kit (jersey, shorts, helmet, sunglasses on helmet), standing next to her road bike. She looks visibly uncomfortable, one hand resting on her lower abdomen, body slightly bent forward, with a pained expression on her face as if experiencing cramp-like lower abdominal pain. The scene is realistic, natural daylight, high detail, 4k. Negative prompt: no gore, no blood, no sexualization, no cartoon, no text, no logos, no watermarks.”

References

1. Mountjoy M, et al. The IOC consensus statement: beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2014;48(7):491-7.
2. Leibovitch I, et al. The vascular safety of cycling. J Urol. 1999;162(1):103-8.
3. Zondervan KT, et al. Chronic pelvic pain in the community-symptoms, investigations, and diagnoses. Am J Obstet Gynecol. 2001;184(6):1149-55.
4. Braaten KP, et al. Intrauterine contraception: a comprehensive review. Contraception. 2017;95(4):327-36.
5. Heinemann K, et al. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices. Contraception. 2015;91(4):274-9.
6. Spiller R, et al. Guidelines on the irritable bowel syndrome. Gut. 2007;56(6):770-98.
7. Jeong SJ, et al. Prevalence and characteristics of pelvic floor disorders in female cyclists. Neurourol Urodyn. 2006;25(5):469-76.
8. Rao SS. Advances in diagnostic assessment of fecal incontinence and dyssynergic defecation. Gastroenterology. 2004;126(1 Suppl 1):S14-22.
9. Barber MD, et al. Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet Gynecol. 2001;185(6):1388-95.
10. Loving S, et al. Pelvic floor muscle dysfunctions are prevalent in female chronic pelvic pain. Eur J Pain. 2014;18(9):1259-70.
11. Berghmans B, et al. Conservative treatment of stress urinary incontinence in women: a systematic review of randomized clinical trials. Br J Urol. 1998;82(2):181-91.
12. Solli GS, et al. The training and development of elite female athletes from youth to senior levels. Sports Med. 2013;43(9):943-56.
13. Camilleri M, et al. Diagnosis and treatment of narcotic bowel syndrome: a systematic review. Aliment Pharmacol Ther. 2014;40(10):1142-61.
14. Amarenco G, et al. Diagnosis and treatment of pudendal nerve entrapment syndrome: an evidence-based approach. Eur J Obstet Gynecol Reprod Biol. 2008;138(2):137-43.
15. Spiller R, et al. Post-infectious irritable bowel syndrome. Gastroenterology. 2019;156(7):1877-89.

Not all references were assigned by AI.

The expert’s review

Dr Patrik Noack

As a sports physician, one is often confronted with abdominal problems and urinary tract infections in female athletes. This makes it all the more important to take a detailed medical history, conduct a thorough examination and carry out targeted further investigations. Providing remote care for female athletes abroad is even more difficult. A detailed medical history can easily be taken by telephone or online consultation. However, examinations and further investigations require the assistance of colleagues abroad. For this reason, both the clinic and the examination results must be critically questioned. I find this starting point lacking in the AI’s initial assessment of the case. The introduction refers to the 2014 IOC Consensus by Mountjoy M, et al., which deals with REDs and, in my opinion, is not relevant to the assessment of this case.
I disagree with the following points in the clinical assessment:
1) The data on whether the insertion of an IUD increases the risk of urinary tract infection is unclear. In addition, the athlete was examined by the treating gynecologist four weeks after insertion and the first symptoms appeared, with no abnormalities found.
2) The presence of white blood cells (leukocytes) and red blood cells (erythrocytes) in the urine alone is not sufficient to reliably diagnose a urinary tract infection. Neither this nor the administration of antibiotics in question was questioned by AI.
3) Both the case analysis and management focus heavily on possible pelvic floor pathologies, whether caused by sport or IUD insertion. This is despite the fact that the athlete’s symptoms, with the exception of discomfort when sitting, do not fit this diagnosis.
4) Further diagnostics mention pelvic MRI, pelvic floor examination, etc., but do not explicitly mention a readily available and ‘inexpensive’ ultrasound examination of the abdomen, including the internal female reproductive organs. Nor is there any mention of determining ß-hCG to rule out pregnancy.
Conclusion: in this athlete’s case, further diagnostics using ultrasound and ß-hCG in the blood should have been carried out during the first consultation, given the mild inflammation values in the blood and non-specific urine status (The athlete ultimately had an ectopic pregnancy despite using condoms for contraception and eventually had to undergo emergency surgery). Gynecological problems should always be included in the differential diagnoses for female athletes!

Author profile

Dr Patrik Noack
patrik.noack@medbase.ch

 

Affiliation: Head of Medbase Sports Medical Center Abtwil, Swiss Olympic Medical Center
Specializations: Internal Medicine, Sports Medicine, Manual Medicine and Ultrasound Abdomen
Year of my medical school graduation: 2001
Sports organizations/federations I work with: HPO Swiss Olympic, CMO Swiss Cycling and Swiss Athletics, Team Doctor Swiss Aquatics and Swiss Triathlon, Vice President SEMS
Fields/topics I am fond of: Sports- and Exercise Medicine, Pneumology and Allergology, Ultrasound
Outside of Sports & Exercise Medicine, I also love: Reading English Crime Books, Traveling
How I use AI: To prepare presentations (framework), Research