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Osteitis Pubis

Pubic Symphysitis

Osteitis pubis is a disease characterized by inflammatory changes in the pubic symphysis and surrounding pubic structures. Repetitive and chronic trauma is thought to be the primary cause of this condition, which is why the majority of patients are athletes. The diagnosis is made by imaging studies, while treatment principles include conservative therapy with NSAIDs, rehabilitation through physiotherapy and exercise. In some cases, surgical management is necessary.


Presentation

The main complaint of individuals with osteitis pubis is chronic pain in the pelvic region that can appear in various regions and can range from mild to severe[10]. Based upon clinical findings in patients with this condition, four stages have been identified [8] [9]:

  • Stage I - Pain is localized to the kicking leg, unilaterally, and is aggravated after practice.
  • Stage II - Pain extends bilaterally into inguinal regions, but is still aggravated only after exercise.
  • Stage III - In addition to bilateral inguinal regions, lower abdominal muscle pain is noted. Exacerbation of pain is noted during kicking, fast running, change in direction and changes in stance.
  • Stage IV - The inguinal, lower abdominal and lower back regions are reported to be painful, while pain is reported to occur when defecating, sneezing, or even walking.

Pain might be quite debilitating for patients, especially athletes, which is why a prompt evaluation and confirmation of the underlying cause is necessary.

Aspiration
  • Two patients developed osteitis pubis after transrectal aspiration biopsy of the prostate. We recommend that prophylactic antibiotics should be given before all such procedures.[ncbi.nlm.nih.gov]
  • Joint aspiration yielded Pseudomonas aeruginosa and the patient was successfully treated with oral ciprofloxacin.[ncbi.nlm.nih.gov]
  • We advise an aggressive diagnostic approach to cases of apparent postoperative osteitis pubis including biopsy and needle aspiration of the symphysis pubis guided by computer-assisted tomography.[ncbi.nlm.nih.gov]
  • Sometimes, an aspiration biopsy and subsequent culturing of the obtained material is needed for its exclusion in patients with inconclusive results.[symptoma.com]
  • Febrile patients with negative blood cultures should go for aspiration of pubic symphysis. Imaging X-rays In early osteitis pubis, x-rays do not have any finding. Widening of the pubic symphysis may be seen on anteroposterior view after few weeks.[boneandspine.com]
Severe Pain
  • Surgery is rarely indicated and should be reserved for patients who have severe pain or pubic instability that has not responded to conservative therapy.[ncbi.nlm.nih.gov]
  • Osteitis Pubis is serious injury of the pubic symphysis or pubis symphysis causing mild to severe pain and tissue damage of the lower pelvis.[hxbenefit.com]
  • But by the time I see most athletes, their futile “groin pull” therapy piled on top of a full training schedule has produced severe pain, with particular tenderness right on the pubic bone.[nydailynews.com]
  • Using a BP cuff may demonstrate a squeeze To grade severity: pain on passive abduction pain/weakness with resisted adduction pain on squeeze test pain on resisted hip flexion adductor muscle guarding on passive abduction/ER pain on resisted flexion/adduction[bsems.com.au]
  • Symptoms : Mild to severe pain can be felt on the groin region due to the swelling of pubic symphysis. The pain will not be sudden and develops gradually due to repeated exercise.[diseasespictures.com]
Inguinal Pain
  • The inguinal pain diminished, and the patient's blood pressure increased to 112/76 mm Hg. He was discharged on day 10 after admission.[ncbi.nlm.nih.gov]
  • Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000; 28:2. McMurtry CT, Avioli LV.[scottsdalesportsmedicine.com]
  • Management of severe lower abdominal or inguinal pain in high-performanceathletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000 Jan-Feb; 28 (1): 2–8 PubMed Google Scholar 71.[link.springer.com]
Perineal Pain
  • The presentation is typical with varying degrees of pelvic and/or perineal pain, reproduced on hip adduction.[radiopaedia.org]
  • Patients may also experience postejaculatory scrotal or perineal pain. Range of motion may be decreased in one or both hips. Plain films of the pubis may be normal or may show sclerosis and irregular cortical margins.[aafp.org]
Periodontitis
  • In this report, we describe a case of osteitis pubis whose symptoms were completely ameliorated following tooth extraction attributable to periodontitis.[ncbi.nlm.nih.gov]
  • She had severe periodontitis. After treatment of infection, her symptoms relieved completely.[archivesofrheumatology.org]
Hip Pain
  • The pain can be difficult to localise, as it moves around the pelvic area and may include hip pain. Persistent groin or hip pain should be fully investigated by a GP to eliminate the chance of other more serious conditions.[ossurwebshop.co.uk]
  • Men also presented with lower abdominal, hip and perineal or scrotal pain; women with hip pain. Most common signs were tenderness of the pubic symphysis and tenderness of adductor longus muscle origin.[ncbi.nlm.nih.gov]
  • A Word From Verywell Osteitis pubis is an uncommon condition that can cause groin and hip pain. This condition should be considered in people who have symptoms of groin pain that do not seem to be responding to typical treatments.[verywell.com]
  • Because MRI studies assessing hip pain are not routinely evaluated for pathology at the pubic symphysis, many cases of osteitis pubis may be missed.[healio.com]
  • Pain Groin Pain Hip Joint Pain Hip Arthritis - Osteoarthritis Hip Labral Tear Hip Pointer Femoroacetabular Impingement - FAI Perthes Disease Slipped Femoral Capital Epiphysis Stress Fracture Avascular Necrosis of the Femoral Head Lateral Hip Pain Gluteal[physioworks.com.au]
Scrotal Pain
  • Athletes most commonly present with a complaint of anterior and/or medial groin pain but also can present with lower abdominal, adductor, inguinal, perineal, and/or scrotal pain.[ncbi.nlm.nih.gov]
  • Men also presented with lower abdominal, hip and perineal or scrotal pain; women with hip pain. Most common signs were tenderness of the pubic symphysis and tenderness of adductor longus muscle origin.[ncbi.nlm.nih.gov]
  • Symptoms Groin Pain of gradual onset and progression Exercise -induced pain Adductor pain in medial thigh (80%) Pubic symphysis pain (40%) Lower Abdominal Pain (30%) Hip Pain (12%) Referred Scrotal Pain (8%) VII.[fpnotebook.com]
Suggestibility
  • In each patient, the bacterial cause was suggested by a known infectious process adjacent of the symphysis pubis.[ncbi.nlm.nih.gov]
  • 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.[ncbi.nlm.nih.gov]
  • Thirty-five patients with pain suggesting a prostatic origin but with no evidence of active prostatic inflammation presented between 1979 and 1982 and were diagnosed as having osteitis pubis.[ncbi.nlm.nih.gov]
  • Imaging of the pubic area suggested bony infection and inflammation. Biopsy and culture confirmed the presence of Staphylococcus aureus, a very common pathogen.[ncbi.nlm.nih.gov]
  • Reports suggest this condition is more common in men than women. Confirmatory radiographs, bone scans, and magnetic resonance imaging aid the diagnosis. Once diagnosed, the prognosis for full recovery is good, although lengthy.[ncbi.nlm.nih.gov]
Waddling Gait
  • One month after a Burch operation, performed because of urinary stress incontinence, a 65-yr-old woman developed progressive suprapubic pain and a characteristic waddling gait.[ncbi.nlm.nih.gov]
  • The symptoms included a waddling gait and crepitus, pain, and tenderness over the symphysis pubis. The early radiographic signs of the disease were rarefaction of the adjacent pubic bones and widening of the symphysis pubis.[ncbi.nlm.nih.gov]
  • Twelve months following this single-stage surgery, the patient reported high satisfaction with decreased pain, improved function, and resolution of a classic waddling gait.[ncbi.nlm.nih.gov]
  • 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.[ncbi.nlm.nih.gov]
  • May have waddling gait. Osteitis Pubis Xray / Diagnositc Tests Plain films of the pelvis may demonstrate sclerosis, lysis and widening of the pubic symphysis MRI: inflammatory signal changes in the pubic symphysis /- bone marrow edema.[eorif.com]

Workup

The diagnostic workup of patients with suspected osteitis pubis should be thorough and a high dose of clinical suspicion is needed [7]. Because numerous conditions may cause similar symptoms, both laboratory and imaging studies should be used to confirm osteitis pubis and exclude other pathologies. Laboratory studies should include a complete blood count, CRP, ESR and fibrinogen to exclude osteomyelitis, which invariably shows the presence of active inflammation and elevations of these parameters [5]. Sometimes, an aspiration biopsy and subsequent culturing of the obtained material is needed for its exclusion in patients with inconclusive results. However, the initial differentiation can be made by the presence of fever, as infectious etiologies tend to manifest with increased body temperature [3]. Physical examination or ultrasound techniques may reveal muscle tears or sports hernia, while plain radiography may reveal stress fractures or soft-tissue tumors.

To confirm the diagnosis of osteitis pubis, MRI studies are necessary. Bone marrow edema that spans across the entire symphysis or suchondral resportion are diagnostic hallmarks of this condition [4]. In some cases, widening of the pubic symphysis may be noted as well.

HLA-B27
  • Because HLA-B54 cross-reacts with HLA-B27, the patient's osteitis pubis was considered to be a form of reactive arthritis associated with periodontitis.[ncbi.nlm.nih.gov]

Treatment

Treatment principles may significantly vary and depend on the severity of the condition [3], but a multimodal approach is found to be of most benefit [11]. However, conservative management is the initial strategy, consisting of bed rest, use of NSAIDs and appropriate physical therapy composed of exercises that are aimed to improve strength and range of motion of lumbar and pelvic muscle groups, in order to relieve the weight of the pubic bones and the symphysis [12]. In the majority of patients, an individualized approach is necessary to achieve optimal therapeutic outcomes [13]. Adjuvant use of various modalities, such as ultrasound, electrical stimulation, friction massage and laser has been mentioned in literature and may provide better results compared to exercise alone [9]. Studies have estimated that return to regular sports activities was achieved in approximately 9 weeks with conservative therapy only [3]. If conservative management is not sufficient, or if the clinical severity of the condition necessitates other forms of treatment, the use of corticosteroids and dextrose has been documented, but with variable results. Some reports indicate marked reduction of symptoms with repeated injections of corticosteroids such as betamethasone or methylprednisolone combined with an anesthetic such as lidocaine or buvipacaine. This treatment modality has shown a return to professional physical activity within several weeks in certain studies[12]. Injection of dextrose with lidocane has also shown to be effective in reducing pain [14], but their efficacy remains to be confirmed in larger studies. Surgical management is reserved for those in whom neither of the recommended regimens manage to reduce symptoms and allow return to previous activities, making about 5-10% of all patients [15]. Curettage of the pubic symphysis, insertion of a polypropylene mesh into the retropubic space and bone grafting are procedures that may be performed and show variable success rates [13].

Prognosis

Osteitis pubis is a self-limiting condition that does not pose any risk to the patient's overall condition, but various obstacles exist in its resolution. Firstly, making the diagnosis may last up to several months, because a plethora of other conditions present with almost identical symptoms, including osteomyelitis, stress fractures, pubic tendinopathy, sports hernia and various other, which have to be excluded in the diagnostic workup [1]. Secondly, the recovery depends on the severity of structural damage. Thirdly, the recovery process may be significantly prolonged in severe cases who require a multimodal approach to successfully treat this condition.

Etiology

Various factors have been proposed to contribute in the pathogenesis of osteitis pubis since its initial clinical description almost 100 years ago [6]. Repetitive trauma and shear stress, however, seems to be the most likely candidate, while direct trauma, pelvic surgery and childbirth described as potential causes [5]. Regardless of the cause, the end-result is inflammation and damage of the pubic symphisis and the bony structures that are attached to this fibrocartilaginous structure.

Epidemiology

The most significant risk factor for this condition is strenuous physical activity. Conversely, it is most frequently diagnosed in elite athletes of both gender. Some studies report a slight predilection toward male gender [7] [1], but large-scale epidemiological studies without bias have not been performed yet and epidemiology data solely rest on isolated studies. The incidence rate of osteitis pubis is established to range between 0.5-7% in the general athletic population [8], indicating that this condition is not commonly encountered in medical practice. Specific types of sports have shown to predispose athletes to this condition, such as those that put significant pressure on the hip and the pubic bones, including ice hockey, soccer, rugby, tennis, but also long-distance running [9].

Sex distribution
Age distribution

Pathophysiology

The pathogenesis model of osteitis pubis remains incomplete, but it is thought that initial events include trauma that induces abnormal activity of osteoclasts and propagate inflammatory changes [2]. During physical activity such as running or kicking, great mechanical forces are exerted on the pelvis, but also on the muscle groups that are involved in these motions. These changes lead to osseous resorption and reduced stability of the pubic symphisis and the adjacent bony structures that should maintain adequate tendon attachment of hip adductors and abdominal muscles [2]. Consequently, the appearance of pain as a result of structural damage to either tendons or the bony structures is the hallmark of this condition.

Prevention

Some preventive measures may include an immediate visit to the physician in order to prevent further aggravation of the condition. The most significant preventive measure, however, is maintaining adequate muscle strength and fitness in athletes who are susceptible to this type of injury. Through appropriate exercises and regular stretching, the risk of osteitis pubic can be greatly reduced.

Summary

Osteitis pubis is a self-limiting but potentially debilitating condition that is characterized by noninfectious inflammation of the symphysis pubis and the adjacent pubic bones. Repetitive trauma seems to be the causative event, which is supported by the fact that the vast majority of patients are athletes who are engaged in strenuous physical activity [1]. Various sports have shown to prone athletes to this condition - soccer, ice hockey, rugby and several other that are particularly demanding for the hip joint and involve kicking, twisting and pivoting motions as well as direct trauma to the pubic bones [1]. The symphysis pubis is composed of a fibrocartilaginous tissue and binds the pubic bones into a firm, stable joint. In its close proximity are the pubic rami, the sites for attachment of various muscles, the most important being the adductor muscles of the hip and abdominal muscles (rectus abdominis, as well as external and internal oblique) [2]. As the inflammatory changes in this disorder most commonly affect the site where adductor muscles attach, pain when attempting adduction that can be felt either anteriorly or medially in the groin is the most common symptom [3]. Based on severity of clinical findings, osteitis pubis is divided into four stages, but additional features are usually abdominal discomfort, aggravation of pain when attempting to perform physical activity that involves either adductor or abdominal muscles, while a physical examination may reveal tenderness in the area of the pubic symphysis [3]. To make the diagnosis, magnetic resonance imaging (MRI) is shown to be the imaging study of choice. Tendon injury and bone marrow edema are identified with very high sensitivity. MRI can greatly aid in distinguishing this condition from various other that may have similar symptoms, particularly osteomyelitis, due to its progressive nature and substantially different treatment strategy [4]. For these reasons, laboratory parameters such as C-reactive protein (CRP), sedimentation rate (ESR) and leukocyte count should be performed to make the distinction between the two clinical entities, as osteitis pubis does not cause elevations of inflammation markers [5]. Treatment principles encompass various approaches, including conservative management with non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy and appropriate exercising techniques to improve muscle strength. Surgery serves as a last resort for patients who are not recovering with non-invasive therapy.

Patient Information

Osteitis pubis is a condition that results from inflammation of the symphysis pubis, the anatomical structure that binds the pubic bones in front of the urinary bladder, and the surrounding bony structures. The cause of this condition is thought to be repeated and prolonged stress to this area as a result of strenuous exercise and trauma, which is why this condition is almost exclusively seen in athletes. Other causes include childbirth, trauma and surgery in the pelvic region. Various sports have shown to increase the risk of developing this type of injury, such as rugby, ice hockey, tennis and long-distance running, all of putting very high amounts of pressure on the hips and the muscles in the groin region. In fact, pain in the groin is the main clinical presentation of these patients and may range from mild to severely debilitating. Pain may last for weeks, months, or even years and depending on the severity of the condition, it may occur in the lower abdomen, or in severe cases, the lower back may be affected as well. In all patients, pain is aggravated during physical activity, while patients with serious injury may report pain during coughing or sneezing. Because these symptoms may significantly impair the quality of life of the patient, the diagnosis should be made as early as possible. However, this condition mimics numerous other, such as bacterial infection of the bone (osteomyelitis), fractures, or even malignant diseases. For these reasons, making the diagnosis can take up to a few months. To confirm osteitis pubis, the use of laboratory and imaging studies are necessary. Magnetic resonance imaging (MRI) is the gold standard in identifying changes specific for this condition, after which appropriate treatment strategies may be carried out. Initial management includes conservative measures, such as bed rest, avoiding movement that aggravates pain, use of non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy to improve muscle strength. Injections of corticosteroids and dextrose have shown good effects in certain studies and surgery, as the last resort, may be performed if all other modalities fail. Return to normal sports activities may be expected in several weeks, but the outcome depends on the severity of tissue injury.

References

Article

  1. Angoules AG. Osteitis pubis in elite athletes: Diagnostic and therapeutic approach. World Journal of Orthopedics. 2015;6(9):672-679.
  2. Koulouris G. Imaging review of groin pain in elite athletes: an anatomic approach to imaging findings. AJR Am J Roentgenol. 2008;191:962–972.
  3. Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med. 2011 Jan; 45(1):57-64.
  4. Zoga AC, Kavanagh EC, Omar IM, Morrison WB, Koulouris G, Lopez H, et al. Athletic pubalgia and the "sports hernia": MR imaging findings. Radiology. 2008;247(3):797-807.
  5. Pauli S, Willemsen P, Declerck K, et al. Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature. Br J Sports Med 2002;36:71.
  6. Legeu MB, Rochet WL. Les cellulites perivescicales et pelviennes après certaines cystostomies ou prostatectomies sus-pubiennes. J Urol Med Chir 1923;15:1–11.
  7. Johnson R. Osteitis pubis. Curr Sports Med Rep 2003;2(2):98-102.
  8. Rodriguez C, Miguel A, Lima H, Heinrichs K. Osteitis Pubis Syndrome in the Professional Soccer Athlete: A Case Report. J Athl Train 2001;36:437.
  9. Henning PT. The Running Athlete: Stress Fractures, Osteitis Pubis, and Snapping Hips. Sports Health. 2014;6(2):122-127.
  10. Robertson BA, Barker PJ, Fahrer M, Schache AG. The anatomy of the pubic region revisited: implications for the pathogenesis and clinical management of chronic groin pain in athletes. Sports Med. 2009;39(3):225-234.
  11. Vijayakumar P, Nagarajan M, Ramli A. Multimodal physiotherapeutic management for stage-IV osteitis pubis in a 15-year old soccer athlete: a case report. J Back Musculoskelet Rehabil. 2012;25:225–230.
  12. Holt MA, Keene JS, Graf BK, Helwig DC. Treatment of osteitis pubis in athletes. Results of corticosteroid injections. Am J Sports Med. 1995;23(5):601-606.
  13. Jarosz BS. Individualized multi-modal management of osteitis pubis in an Australian Rules footballer. J Chiropr Med. 2011;10:105–110.
  14. Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005;86:697–702.
  15. Mehin R, Meek R, O'Brien P, Blachut P. Surgery for osteitis pubis. Can J Surg. 2006;49(3):170-176.

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Last updated: 2018-06-22 11:23