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Amer ML, Omar K, Malde S, Nair R, Thurairaja R, Khan MS. The challenges in diagnosis and management of osteitis pubis: An algorithm based on current evidence. BJUI COMPASS 2022; 3:267-276. [PMID: 35783593 PMCID: PMC9231671 DOI: 10.1002/bco2.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Mohammed Lotfi Amer
- Faculty of Medicine Tanta University Tanta Egypt
- Department of Urology Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Kawa Omar
- Department of Urology Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Sachin Malde
- Department of Urology Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Rajesh Nair
- Department of Urology Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Ramesh Thurairaja
- Department of Urology Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Muhammad Shamim Khan
- Department of Urology Guy's and St. Thomas' NHS Foundation Trust London UK
- MRC Centre for Transplantation, Faculty for Life Sciences and Medicine, NIHR Biomedical Research Centre King's College London London UK
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Affiliation(s)
- Maurice Muschat
- From the Urological Service No. I, Mt. Sinai Hospital, Philadelphia, Pa
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Tuberculosis of the pubic symphysis: four unusual cases and literature review. Clin Orthop Relat Res 2013; 471:3372-80. [PMID: 23670672 PMCID: PMC3773122 DOI: 10.1007/s11999-013-3037-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 04/25/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence of extrapulmonary tuberculosis (TB) has increased in the chemotherapeutic era owing to the increasing presence of immunodeficiency disorders. Pubic symphysis TB, although uncommon, is again important as these infections once were in the prechemotherapeutic era. CASE DESCRIPTION We present the cases of four patients with pubic symphysis TB in which one patient had a horseshoe-shaped abscess in the pubic region and another had a double lesion of the pelvis leading to vertical shear-type pathologic displacement. Three patients were diagnosed by cytology and PCR. These patients were treated successfully with antituberculosis treatment with or without minimal surgical intervention despite their late presentation and advanced disease. The fourth patient remains under treatment and followup. LITERATURE REVIEW We identified 40 patients with TB of the pubic symphysis in the English language medical literature. Of these 40 patients, only five are from India despite TB being endemic in this country. Followup information is available for 32 of the 40 patients with followups ranging from 1 to 84 months (mean of approximataly 20 months). PURPOSES AND CLINICAL RELEVANCE We suspect TB of the pubic symphysis is increasing in frequency owing to drug resistance, use of biologics, immunomodulating drugs, and anticancer drugs. Therefore, it is important for clinicians to have a high index of suspicion in patients at risk. Initially patients may be asymptomatic or present with adductor region pain or spasm, sacroiliac strain, limp, or a hypogastric, inguinal, or thigh mass that mimics an inguinal hernia, genitourinary, abdominal, or thigh tumor. CONCLUSION It is important to diagnose and treat pubic TB early in the course of the disease before the destructive stage. After relevant investigations most patients can be treated with antitubercular drugs with or without a minor surgical procedure.
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GOLDSTEIN AE, RUBIN SW. Osteitis pubis following suprapubic prostatectomy; results with deep roentgen therapy. Am J Surg 2010; 74:480-7. [PMID: 20266032 DOI: 10.1016/0002-9610(47)90145-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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BONE ANCHOR INFECTIONS IN FEMALE PELVIC RECONSTRUCTIVE PROCEDURES: A LITERATURE REVIEW OF SERIES AND CASE REPORTS. J Urol 2001. [DOI: 10.1016/s0022-5347(05)66256-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Rackley RR, Abdelmalak JB, Madjar S, Yanilmaz A, Appell RA, Tchetgen MB. Bone anchor infections in female pelvic reconstructive procedures: a literature review of series and case reports. J Urol 2001; 165:1975-8. [PMID: 11371895 DOI: 10.1097/00005392-200106000-00032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- R R Rackley
- Section of Voiding Dysfunction and Female Urology, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Kammerer-Doak DN, Cornella JL, Magrina JF, Stanhope CR, Smilack J. Osteitis pubis after Marshall-Marchetti-Krantz urethropexy: a pubic osteomyelitis. Am J Obstet Gynecol 1998; 179:586-90. [PMID: 9757956 DOI: 10.1016/s0002-9378(98)70049-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Our purpose was to review cases of osteitis pubis encountered at our institution after Marshall-Marchetti-Krantz retropubic urethropexy. STUDY DESIGN The charts of patients diagnosed with osteitis pubis subsequent to Marshall-Marchetti-Krantz retropubic urethropexy from 1980 to 1994 were reviewed. RESULTS Fifteen cases of osteitis pubis were diagnosed after 2030 Marshall-Marchetti-Krantz procedures (0.74%). Onset of symptoms related to osteitis pubis began a mean of 69.8 days postoperatively (range 10 to 459 days). Although initial plain films of the symphysis pubis were normal in 7 (54%), radiographic abnormality was eventually demonstrated in all a mean of 25.7 weeks after surgery (range 4 to 78 weeks). A variety of conservative treatments resulted in symptomatic relief in 47%. Seven of the remaining patients underwent operative therapy with partial or complete relief noted in all. Subsequent bone cultures were positive in 5 (71%). At follow-up a mean of 58 months after the Marshall-Marchetti-Krantz procedure complete resolution of symptoms was noted in 33% and continued pain or ambulatory difficulty in the remainder. There was no relationship between postoperative urinary tract infections, postoperative complications, presenting sign of fever, elevated leukocyte count or sedimentation rate, and subsequent operative intervention (P > .05). CONCLUSIONS Osteitis pubis after urogynecologic surgery is an uncommon event requiring aggressive surgical and antibiotic therapy. When bone cultures are performed, a microbial cause may be demonstrated in as many as 71% of patients.
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Affiliation(s)
- D N Kammerer-Doak
- Department of Operative Gynecology, Mayo Clinic, Scottsdale, Arizona, USA
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Abstract
Osteitis pubis is a painful, noninfectious inflammatory condition that involves the pubic bone, symphysis, and surrounding structures. Initially associated with urologic procedures, osteitis pubis has been described as a complication of various obstetrical and gynecological procedures including vaginal deliveries. An incidence of approximately 2 to 3 percent has been observed after the Marshall-Marchetti-Krantz urethropexy. Although the pathogenesis of osteitis pubis is not clear, periosteal trauma seems to be an important initiating event. Pain is the primary symptom associated typically with difficulty in ambulation and the characteristic "waddling gait." A low grade fever, elevated sedimentation rate, and mild leukocytosis may be observed. Radiographic findings which include reactive sclerosis, rarefaction, and osteolytic changes lag behind the symptoms by about 4 weeks. The major differential diagnosis is osteomyelitis; however, the self-limiting nature and its response to nonantibiotic therapy indicates that osteitis pubis is a separate clinical entity. Treatment is directed at the associated inflammation with most minor cases responding to antiinflammatory agents and bedrest. Other more recalcitrant cases require more involved therapy including systemic steroids and rarely surgical resection. The diagnosis of osteitis pubis should be considered when pelvic pain is present in association with potential trauma to the symphysis pubis. Also, with more women participating in sporting activities patients may present to the physician with osteitis pubis related to athletic injury.
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Affiliation(s)
- S S Lentz
- Department of Obstetrics and Gynecology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC 27157, USA
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Teichman JM, Tsang T, McCarthy MP. Osteitis pubis as a complication of transrectal needle biopsy of the prostate. J Urol 1992; 148:1260-1. [PMID: 1404650 DOI: 10.1016/s0022-5347(17)36879-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We report a case of osteitis pubis complicating transrectal needle biopsy of the prostate. This case best supports direct trauma to the symphysis pubis as an etiology. A literature review of osteitis pubis is presented.
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Affiliation(s)
- J M Teichman
- Division of Urology, University of California, San Diego
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Abstract
Periostitis pubis is a clinical syndrome previously undescribed in the literature. It is characterized by lower abdominal pain that may have persisted for several weeks to several years. Physical findings are limited to tenderness in one of the lower abdominal quadrants and over the os pubis on the affected side. The diagnosis can be confirmed by injecting lidocaine hydrochloride into the area of point tenderness over the os pubis, which should relieve tenderness in both sites. An elaborate laboratory workup is not necessary. The condition can be cured with an injection of prednisolone tebutate at the site of tenderness over the os pubis.
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Affiliation(s)
- N H Rubenstein
- Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
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Abstract
We studied 78 cases of traumatic aseptic osteitis pubis among Saudi athletes to elucidate the clinical and radiological features of the condition as well as the outcome of management and the etiology. The most common presenting complaints were pain in the groin and lower abdomen, and tendernedd over the symphysis pubis. Widening and osteolysis of the symphysis pubis were the most frequent radiological changes. Routine laboratory tests showed no abnormalities in any of our patients. Conservative treatment, consisting of avoidance of sporting activity, use of nonsteroidal antiinflammatory drugs, and physiotherapy, effected cure in 75% of our patients. Further management was needed in the remaining 25%. The disorder is relatively common among Saudi football players, with trauma the likely cause. Conservative treatment is successful in most patients.
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Affiliation(s)
- A M Shaker
- Department of Surgery, King Khalid University Hospital, and Sports Medicine Hospital, Riyadh, Saudi Arabia
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Abstract
In brief:An 18-year-old male varsity basketball player complained of lower left abdominal pain of a month's duration. Laboratory tests were normal, and no hernia was present. A computed tomography scan showed no abnormality, and fraying of the pubic bone along the symphysis was too subtle to detect on x-ray. A bone scan (pelvic views), however, confirmed a diagnosis of osteitis pubis. Although this disease is self-limited, the patient was treated with corticosteroids and anti-inflammatory medication to enhance his comfort. His condition gradually improved within a few months, and he returned to competition the following season. Follow-up bone scans at one and two years were normal.
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Abstract
Osteitis pubis is a well-recognized painful inflammation involving the structures of the anterior half of the pelvic girdle, but its cause remains controversial. Biopsy and culture of the pubic bone in 3 patients with osteitis pubis after implantation of a urinary anti-incontinence device were consistent with pubic osteomyelitis which responded to antibiotic therapy. Infection was also found in almost all previously reported cases of osteitis pubis subjected to similar biopsy and culture. Bone biopsy and culture should be strongly considered before initiating frequently unsuccessful empirical therapy in patients with osteitis pubis.
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Lurie A, Fischelovitch J, Lazebnik J. Osteitis Pubica following Prostatectomy. Urologia 1973. [DOI: 10.1177/039156037304000612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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STUTTER BD. The complications of osteitis pubis; including a report of a case of sequestrum formation giving rise to persistent purulent urethritis. Br J Surg 1954; 42:164-72. [PMID: 13209040 DOI: 10.1002/bjs.18004217208] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Discussion. J Urol 1951. [DOI: 10.1016/s0022-5347(17)74923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Affiliation(s)
| | - Frank C. Hamm
- From the Urological Service, the Brooklyn Hospital, Brooklyn, New York
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Affiliation(s)
- Milton L. Rosenberg
- From the Department of Urology, University of Virginia, Hospital, Charlottesville, Virginia
| | - Samuel A. Vest
- From the Department of Urology, University of Virginia, Hospital, Charlottesville, Virginia
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