Osteitis pubis: a diagnosis for the family physician

Surgical debridement of infected pubic symphysitis supports optimal outcome

INTRODUCTION

Infected pubic symphysitis (IPS) is a rare bacterial infection of the pubic symphysis that causes subpubic pain, disability and ultimately permanent immobility. Due to difficult diagnosis, patients present with long-standing complaints and consult several doctors. To date, no validated treatment protocol exists and most patients are treated conservatively with antibiotics. This study was aimed to assess the results after careful surgical debridement and pathogen-specific antibiotic treatment in IPS.

MATERIALS AND METHODS

A chart review of eight patients with proven IPS was performed. Five of eight patients filled in a specific own-developed questionnaire and could be examined clinically and radiologically at a mean of 13 months (range: 6-30 months) postoperatively.

RESULTS

There were six males and two females with an average age of 69 years (range: 55-80 years). The mean duration of symptoms before surgical treatment was 10.5 months (range: 1-30 months). There were no complications due to the surgical debridement. There was no recurrence of infection at the pubic symphysis during the follow-up period. The most common pathogen was Pseudomonas aeruginosa in three patients. Mean preoperative pain, measured on the visual analogue scale (VAS, range: 0-10) for the four analysed categories in the five follow-up patients was 7.2, 30 days postoperatively 2.7 and 13 months postoperatively 0.4. There was a steady increase in the quality of life (QoL) 30 days postoperatively and at the 13 months follow-up when compared to preoperative values.

CONCLUSIONS

Surgical debridement is the keystone for treatment of IPS and should be combined with local and systemic antibiotic therapy.

Utility of bone scintigraphy in diagnosis of post- traumatic osteitis pubis

Minor musculoskeletal injuries usually heal within few weeks with conservative treatment, but in pelvic injuries, symptoms may persist for long duration and patient need medical attention to get relief from disturbing pain symptoms. We present a case of post-trauma osteitis pubis in a 58-year-old female, who reported with lower abdominal and left side hip joint pain since 2 months, after an episode of trivial trauma to her pelvis. Technetium-99m methylene diphosphonate bone scintigraphy was performed, which confirmed the site of injury in symphysis pubis and left hip joint, by increased radiotracer localization at both of these symptomatic sites.

Treatment of osteitis pubis in non-athlete female patients

BACKGROUND

Osteitis pubis represents a non-infectious inflammation of the pubic symphysis causing varying degrees of lower abdominal and pelvic pain. Although, the disease is believed to affect mainly young athletic patients, it is also encountered in other specific patient groups. Both conservative and surgical treatment options are available. While for elite athletes surgical treatment is indicated, leading to fast pain relief and mobilization, for non-athletic patients no clear indication can be established.

METHODS

Eight non-athletic women with osteitis pubis, referred to our Department for treatment, were evaluated. All were initially treated conservatively with bed rest, per os non steroidal anti-inflammatory drugs and physical therapy.

RESULTS

Seven patients improved significantly with conservative treatment while one displayed no improvement and was treated surgically with arthrodesis.

CONCLUSION

We conclude that, for non-athletic female patients suffering from osteitis pubis, surgery is rarely required and that conservative treatment by means of non steroidal anti inflammatory drugs and physical modalities represents a fair option regarding pain and limitation of everyday activity.

Presentation of osteitis and osteomyelitis pubis as acute abdominal pain

Osteitis pubis is the most common inflammatory condition of the pubic symphysis and may present as acute abdominal, pelvic, or groin pain. Osteomyelitis pubis can occur concurrently and spontaneously with osteitis pubis. Primary care physicians should consider these conditions in patients presenting with abdominal and pelvic pain. A thorough history, including type of physical activity, and a focused physical examination will be useful, and imaging modalities may be helpful. A biopsy and culture of the pubic symphysis will usually confirm the diagnosis. Treatment for osteitis pubis generally involves rest and anti-inflammatory medications. Failure with this conservative treatment should alert the physician to the possibility of osteomyelitis, which needs treatment with antibiotics. Prognosis for recovery is excellent with definitive diagnosis and treatment.

Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes

BACKGROUND

In athletes, osteitis pubis is regarded as a problem of overuse, with instability and movement of the anterior pelvis. There is no evidence to conclusively support any treatment modality. Recovery with nonoperative management can take an extended period of time, often unsatisfactory for professional athletes.

HYPOTHESIS

Curettage of the pubic symphysis is a viable option for nonoperative treatment of resistant osteitis pubis in athletes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This retrospective study presents the results of curettage of the pubic symphysis in 23 athletes with osteitis pubis that was refractory to initial nonoperative therapies. Patients met the criteria for the study if they had symptoms suggestive of osteitis pubis and underwent isolated pubic symphysis curettage. The discomfort had been present for a mean of 13.22 months before presentation. Patients were reviewed at 24.31 months (range, 12.5-59.6 months) postoperatively. Twelve of the patients also underwent a postoperative magnetic resonance imaging scan at 19.10 months; any findings of residual osteitis pubis were noted.

RESULTS

Mean visual analog scale for pain improved from 6.9 preoperatively to 2.8 postoperatively (P = .36). Twenty-one patients returned to pain-free running by 3.14 months (range, 1.5-6 months), 17 to training by 4.44 months (range, 2.5-7 months), and 16 to full activity by 5.63 months (range, 2.5-12 months). Overall, 61% of patients reported an activity grade of 4 at postoperative review, defined as no pain with full activity. There were no significant postoperative complications in the study group. Marrow edema improved in most cases for which magnetic resonance imaging was available preoperatively and postoperatively. Patient satisfaction with the procedure was high, with 78% of participants feeling their symptoms were better or much better than preoperatively.

CONCLUSION

The authors suggest that this relatively simple procedure can be of significant benefit to those athletes wishing to return to their previous levels of physical activity when more nonoperative measures have proven unsuccessful.

Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain

OBJECTIVE

To determine the efficacy of simple dextrose prolotherapy in elite kicking-sport athletes with chronic groin pain from osteitis pubis and/or adductor tendinopathy.

DESIGN

Consecutive case series.

SETTING

Orthopedic and trauma institute in Argentina.

PARTICIPANTS

Twenty-two rugby and 2 soccer players with chronic groin pain that prevented full sports participation and who were nonresponsive both to therapy and to a graded reintroduction into sports activity.

INTERVENTION

Monthly injection of 12.5% dextrose and 0.5% lidocaine into the thigh adductor origins, suprapubic abdominal insertions, and symphysis pubis, depending on palpation tenderness. Injections were given until complete resolution of pain or lack of improvement for 2 consecutive treatments.

MAIN OUTCOME MEASURES

Visual analog scale (VAS) for pain with sports and the Nirschl Pain Phase Scale (NPPS), a measure of functional impairment from pain.

RESULTS

The final data collection point was 6 to 32 months after treatment (mean, 17 mo). A mean of 2.8 treatments were given. The mean reduction in pain during sports, as measured by the VAS, improved from 6.3+/-1.4 to 1.0+/-2.4 ( P <.001), and the mean reduction in NPPS score improved from 5.3+/-0.7 to 0.8+/-1.9 ( P <.001). Twenty of 24 patients had no pain and 22 of 24 were unrestricted with sports at final data collection.

CONCLUSIONS

Dextrose prolotherapy showed marked efficacy for chronic groin pain in this group of elite rugby and soccer athletes.

Osteitis pubis: solving a perplexing problem

Osteitis pubis is a painful condition that affects the pubic symphysis and surrounding tendinous attachments. One common cause stems from unusual biomechanical stress to the pelvis. Patients typically have a variety of vague and nonspecific symptoms, which makes accurate diagnosis of this condition difficult, particularly for clinicians not familiar with the disorder. A systematic approach to evaluating these patients is essential because the differential can be quite large and includes isolated muscle tears, lumbar radiculopathy, and stress fractures. Fortunately, once the diagnosis is confirmed, conservative treatment such as rest and nonsteroidal anti-inflammatory drugs usually leads to a favorable outcome.