Osteitis pubis after Marshall-Marchetti-Krantz urethropexy: a pubic osteomyelitis

The challenges in diagnosis and management of osteitis pubis: An algorithm based on current evidence

Objective

The objective of this study is to summarise the contemporary evidence regarding the prevalence, diagnosis, and management of osteitis pubis (OP) specially from urological point of view, while proposing an algorithm for the best management based on the current evidence.

Methods

We performed a literature search using the PubMed database for the term ‘osteitis pubis’ until December 2020. We assessed pre‐clinical and clinical studies regarding the aetiology, pathophysiology, and management of OP. Case reports and case series were evaluated by study quality and patient outcomes to determine a potential clinical management algorithm.

Results

Osteitis pubis is a chronic painful condition of the symphysis pubis joint and its surrounding structures. Still, there is a paucity of data outlining the management plan and the possible triggers. The aetiology seems to be multifactorial with different proposals trying to explain the pathophysiology and correlate the findings to the outcome. The diagnosis is usually based on high suspicion index and clinical experience. The infective variant of the disease is aggressive and requires strict and active management. Universal consensus is still lacking regarding a formal algorithm of management of the condition, especially due to multiple specialities involved in the decision‐making process. Conservative management remains the cornerstone; nevertheless, surgical interventions may be needed in special settings. Hence, a multi‐disciplinary approach is of pivotal value in fashioning the plan for each case. The prognosis is usually satisfactory; however, a longstanding debilitating disease form is not uncommon.

Conclusion

OP remains a rare condition with real challenges in its diagnosis. The current management is focused on conservative management; however, surgical intervention is still needed in some difficult scenarios. Continued research into the triggers of OP, multidisciplinary approach, and standardised clinical pathways can improve the quality of care for patients suffering from this condition.

Surgical Management of Female Voiding Dysfunction

Surgical intervention for female voiding dysfunction is common, involving a single or multifaceted approach affecting multiple organ systems in the pelvis. Surgical success relies on knowledge of surgical history, anatomic approaches, and judicious use of supports or materials. Owing to the varied repairs used over the last few decades, it is important for the general surgeon to understand both current and historic approaches. This understanding will help in planning future pelvic surgery as well as in evaluating current ramifications of prior surgery.

A case report of osteomyelitis pubis in a hemodialysis patient with diabetes mellitus

Osteomyelitis pubis is a rare form of osteomyelitis. Known risk factors are urogynecologic surgery, trauma caused by sport activities, pelvic malignancy and intravenous drug use. Immunocompromised patients, including hemodialysis patients, and those with diabetes are also susceptible to infection. Particularly in the hemodialysis population, the use of intravenous catheters frequently results in bacteremia and metastatic infectious complications such as osteomyelitis. We describe the first case of osteomyelitis pubis in a woman on chronic maintenance hemodialysis with diabetes mellitus.

Actinomyces meyeri osteomyelitis of the symphysis pubis following pubovaginal sling

Previous reports of pubic osteomyelitis associated with bone anchors describe symptoms presenting 10 days to 12 months postoperatively with typical pathogens including Streptococcus, Staphylococcus, Citrobacter, and Pseudomonas (Fitzgerald et al., Int Urogynecol J 10:346-348, 1999 Enzler et al., J Bone Jt Surg Am 81-A(12):1736-1740, 1999; Graham and Dmochowski, J Urol 168:2055-2058, 2004; Fialkow et al., Urology 64(6):1127-1132, 2004; Matkov et al., J Urol 160(4):1427, 1998). This case illustrates the potential for protracted symptoms and delayed diagnosis of pubic osteomyelitis with the fastidious pathogen of Actinomyces meyeri.

Infection and musculoskeletal conditions: Osteomyelitis

Osteomyelitis can result from hematogenous or contiguous microbial seeding of the bone. Staphylococcus aureus is the most common infecting microorganism. Although any bone can potentially develop osteomyelitis, long-bone, vertebral, and foot osteomyelitis account for the majority of cases. Confirmatory diagnosis of osteomyelitis often depends on the results of a bone biopsy and bone cultures. Radiologic and laboratory studies are often helpful in leading to the diagnosis, determining the extent of the disease, and following up selected patients with osteomyelitis. Optimal therapy for osteomyelitis requires the collaboration of a multidisciplinary team of physicians. Debridement is often needed in contiguous osteomyelitis, whereas acute hematogenous and vertebral osteomyelitis can often be treated with a prolonged course of antimicrobial therapy.

Pubic osteomyelitis due to Klebsiella pneumoniae in a patient with diabetes mellitus

Osteomyelitis of the pubic symphysis or pubic osteomyelitis is a rare entity that is encountered in certain groups of people such as athletes, intravenous drug users, patients with pelvic malignancy, and patients who have undergone surgical manipulations of the genitourinary system. The most frequent causative organism is Staphylococcus aureus. K pneumoniae is a common pathogen in diabetic patients, but pubic osteomyelitis due to K pneumoniae has not previously been described. We present a diabetic patient with pubic osteomyelitis caused by K pneumoniae without known predisposing factors.

Complications from transvaginal pubovaginal slings using bone anchor fixation

OBJECTIVES

To evaluate the history and management of complications from transvaginally placed pubovaginal slings using bone anchor fixation.

METHODS

During a 3-year period, 10 patients were referred to us for complications related to transvaginally placed pubovaginal slings using bone anchor fixation.

RESULTS

The patient age ranged from 42 to 73 years. All women had a vaginally introduced bone anchor sling for stress urinary incontinence. The presenting symptoms after surgery included fever, pain, and difficulty ambulating in 1; pain and/or vaginal dyspareunia with discharge in 5; pain or dyspareunia alone in 2; and vaginal discharge alone in 2 patients. Two patients ultimately developed bone lesions on radiologic studies consistent with osteomyelitis. Six patients developed sinus drainage tracts associated with granulation tissue from at least one bone anchor that was unresponsive to outpatient management. One of the patients with pain alone had a permanent suture extending into the bladder neck. Nine patients underwent surgery, of whom five had resolution of their presenting complaint. Four of these patients were continent at last follow-up.

CONCLUSIONS

Transvaginally placed pubovaginal slings using bone anchors can be associated with serious complications that may be intractable to common therapies. This knowledge may enable practitioners who use this technique to better counsel their patients regarding these significant complications.

Osseous complications after transvaginal bone anchor fixation in female pelvic reconstructive surgery: Report from single largest prospective series and literature review

OBJECTIVES

To report, from our prospective database and review of published studies (including primary reported patient series and case reports for osseous complications after transvaginal bone anchor fixation in female pelvic reconstructive surgery), our results and those from previously reported patient series to determine the incidence of osteitis pubis and osteomyelitis.

METHODS

A total of 440 patients from our database of cadaveric transvaginal sling (n = 127) and cadaveric prolapse repair with sling (n = 313) procedures had at least 3 months of examination follow-up and were included in this report. We found 15 primary reported patient series involving transvaginal bone anchor fixation in published studies, for a total of 788 patients. The combined patient population of 1228 was assessed for the incidence of osteitis pubis and osteomyelitis.

RESULTS

Of our 440 patients included in this study, 2 developed osteitis pubis (0.45%), and none had osteomyelitis (0%). In the published studies we reviewed, no case of osteitis pubis and 1 case of osteomyelitis (1 of 788, 0.13%) were reported. One additional case of osteomyelitis with transvaginal bone anchor fixation was reported. The combined incidence of osteitis pubis was 2 (0.16%) of 1228, and the combined incidence of osteomyelitis was 1 (0.08%) of 1228.

CONCLUSIONS

In procedures using transvaginal bone anchor fixation in female pelvic reconstructive surgery, the combined incidence, from our experience and that reported in published studies, of osteitis pubis and osteomyelitis was 2 (0.16%) and 1 (0.08%) of 1228, respectively. The infectious osseous complication rate associated with transvaginal pubic bone anchor fixation appears to be less than that previously reported for suprapubic bone anchor placement. In our experience, when using careful surgical technique and proper prophylactic precautions, infectious osseous complications have not been encountered.

Septic arthritis of the pubic symphysis: review of 100 cases

We report a novel case of septic arthritis of the symphysis pubis due to Streptococcus pneumoniae and review 99 previously reported cases of infection of this joint. Typical features of pubic symphysis infection included fever (74%), pubic pain (68%), painful or waddling gait (59%), pain with hip motion (45%), and groin pain (41%). Risk factors included female incontinence surgery (24%); sports, especially soccer (19%); pelvic malignancy (17%); and intravenous drug use (15%). Septic arthritis of the pubic symphysis is often misdiagnosed as osteitis pubis, a sterile inflammatory condition. Causative organisms differed according to risk factors. Staphylococcus aureus was the major cause among athletes, Pseudomonas aeruginosa among intravenous drug users, and infections among patients with pelvic malignancies were usually polymicrobial, involving fecal flora. Patients with recent urinary incontinence surgery usually had monomicrobial infection, with no predominant pathogen. Since osteomyelitis is present in 97% of patients, we recommend antibiotic courses of 6 weeks' duration. Surgical debridement is required in 55% of patients.

Osteitis pubis after Marshall-Marchetti-Krantz urethropexy

We report a case of osteitis pubis after Marshall-Marchetti-Krantz urethropexy. There are several theories on the pathogenesis of the postoperative osteitis pubis and inconsistent results with a wide variety of treatments. Also, osteomyelitis and osteitis pubis can have identical symptoms. In our case, the use of a Mitek anchor system and its migration within the joint cavity might have induced a foreign-body reaction as the responsible mechanism of the joint destruction.

Pubic osteomyelitis following bladder neck surgery using bone anchors: a report of 9 cases

PURPOSE

We reviewed 9 cases of pubic osteomyelitis associated with placement of bone anchors for bladder neck suspension procedures for risk factors, bacterial speciation and sensitivities, and interventions performed.

MATERIALS AND METHODS

Nine women were treated for pubic osteomyelitis following the use of bone anchors for bladder neck suspension surgery. In 8 cases the bone anchors had been placed through a suprapubic incision and in 1 the bone anchors were placed by a vaginal route.

RESULTS

Patient ages ranged from 36 to 74 years (mean 51.8). Symptomatic presentation ranged from 2 to 18 months following initial operation. Presenting symptoms included pain over the pubis and/or a draining wound. Staphylococcus species were cultured in all cases, most commonly Staphylococcus epidermidis. Resistance to methicillin was present in 7 cases (78%). Wound débridement and removal of the anchors provided definitive treatment in all but 1 patient, who eventually required partial pubectomy. Pain (3 of 9 cases) and mild incontinence (5 of 9) were present at last followup.

CONCLUSIONS

Bone anchors used in surgery for urinary incontinence can be associated with pubic osteomyelitis. Infection characteristics are similar to those seen with other urological prosthetic implantation procedures. Aggressive treatment with surgical débridement and long-term antibiotics is usually effective. Staphylococcus species, especially methicillin resistant strains, are the most common bacteria identified in this setting. Careful attention to implantation technique, including appropriate perioperative antibiotic selection, should be considered when using this technique.

Medullary and odontogenic disease in the painful jaw: clinicopathologic review of 500 consecutive lesions

Ischemic jawbone lesions were first discussed in the dental literature more than a century ago, but then seemingly forgotten. In recent years, there has been considerable resurgence in interest in this unique pathological condition. Controversy surrounds the subject. Some proclaim these lesions to be mere fabrications of the imaginations of non-traditional or alternative dental surgeons. Others attribute all human maladies to these maxillofacial lesions. Aside from these philosophical and metaphysical arguments, are there common diagnoses of jawbone pathologies that produce pain? This present investigation reviews the clinicopathologic features of 500 consecutive jawbone surgeries with pathological confirmation in patients with idiopathic facial pain. Four hundred seventy-six (476) of the 500 lesions (95.2%) were directly attributed to impaired blood flow in the jawbone, tooth, or both, according to histopathological analysis and confirming Cavitat (bone ultrasound) examination. Statistical data concerning the location, frequency, and pathological diagnoses of these bony lesions are presented, as are brief methods of diagnosis, and treatment is also discussed.

Bone anchor infections in female pelvic reconstructive procedures: a literature review of series and case reports

PURPOSE

We determined the reported prevalence of infectious osseous complications due to the use of bone anchors for suture fixation in female pelvic reconstructive procedures. In addition, the type and method of bone anchors as well as the reported pathogens associated with osseous infections were reviewed.

MATERIALS AND METHODS

Primary reported series of female pelvic reconstructive procedures involving bone anchor suture fixation referenced in Index Medicus from January 1990 to July 2000 were extracted using the MEDLINE bibliographic database on English language articles involving humans. All case reports of infectious osseous complications due to bone anchor use in female reconstructive procedures were also reviewed during this period.

RESULTS

Since the inception of bone anchor suture fixation for female pelvic reconstructive procedures 10 years ago, the overall prevalence of related infectious complications has been 6 cases in 1,018 procedures (0.6%). This type of adverse event developed between followup weeks 1 and 24. The prevalence of suprapubic bone anchors has been 6 cases in 698 procedures (0.86%). For transvaginal bone anchor procedures no infectious cases have been reported in the combined series of 314 procedures and the same is true for 1 reported case of sacral bone anchor placement in 6 procedures. No statistical difference was noted in regard to the prevalence of infection in procedures involving suprapubic bone anchors and transvaginal bone anchor combined with sacral bone anchor placement (Fisher's exact test p = 0.19). The organisms reported in case reports suggest a coliform, skin or hematogenous source for contamination of the bone anchor site.

CONCLUSIONS

An infectious bone anchor complication in female pelvic reconstructive procedures is an uncommon event with a reported prevalence of 0.6%. Currently there is no evidence of differences in the prevalence of osseous complications after transvaginal versus suprapubic bone anchor fixation. Preoperative broad-spectrum antibiotics are recommended to decrease the potential of infectious bone anchor complications.