Osteitis Pubis
Dr. KS Dhillon
Osteitis pubis is an aseptic painful inflammatory condition that affects the symphysis pubis. The onset is insidious and is characterized by erosion of one or both margins of the pubic symphysis followed by sclerosis.
It is self-limiting in the majority of the patients and may take a few months to years to resolve [1]. It was first described in 1924 by Edwin Beer, a urologist who described a series of patients with osteitis pubis after suprapubic surgery. At that time it was believed to be due to a subacute infection [2]. The literature describes osteitis pubis as a chronic condition that is difficult to diagnose and hard to treat [3].
In the 1950’s, osteitis pubis was believed to be a complication of urologic or gynecologic surgeries [1,2], athletic activities, major trauma, childbirth, rheumatologic disorders, or repeated minor trauma [1].
Osteitis pubis is more prevalent in individuals who play sports that involve kicking such as football and soccer, in marathon runners, and in basketball players. Other causes include traction micro trauma, childbirth in women, and instability of the symphysis pubis and sacroiliac joint [1]. The
incidence of osteitis pubis in athletes is between 0.5% to 7%. The prevalence in the general population has not been reported [3].
In men, osteitis pubis is more common between the ages of 30-40 years, while women are usually affected in their mid-30s.
Symptoms of osteitis pubis include pain while climbing stairs, walking, sneezing, and on doing the Valsalva maneuver. Sometimes a clicking sensation may be felt when rising from a sitting position [1].
X-ray of the pelvis will show marginal irregularity, sclerosis of the pubic symphysis, and osteophyte formation. Sometimes there can be more than 2mm cephalad translation of one of the superior pubic rami and widening of the symphyseal cleft of more than 10mm [1,3].
The symphysis pubis is a fibrocartilaginous joint. An imbalance between the abdominal muscles and hip adductors can lead to osteitis pubis. The rectus abdominis, external oblique and internal oblique muscles, the conjoined tendon, and inguinal ligaments all have attachments to the pubic rami. The hip adductor muscles arise from the superior and inferior pubic rami [3]. The blood supply through the periosteal vascular plexus to the pubic bones and symphysis pubis is poor. Nerves from S2, S3, and S4 levels carry parasympathetic fibers, and nerves from L1 and L2 provide the sympathetic supply.
Diagnosis is made clinically and can be confirmed by standard AP X-Ray of the pelvic. It will show irregularity of cortical margins and bone erosions of the symphysis pubis. Flamingo views i.e AP view with alternating right and left weight bearing may show more than 2mm movement of either side of symphysis [3-5]. A bone scan with Technetium 99m may show increased uptake of isotope by the pubic symphysis [5,6]. An MRI will show a low intensity signal on T1 weighted and a high-intensity signal on T2 weighted images. Bony sclerosis will have low intensity signal on both T1 and T2 weighted images [4,5].
Radiological findings often do not match the severity of the disease. Individuals can have these radiological findings and not have any symptoms. Osteitis pubis can mimic several other disease processes leading to unnecessary surgeries. These surgeries include appendectomy [5,7], hysterectomy, and prostatectomies [5].
It is important to differentiate osteitis pubis from osteomyelitis of the symphysis. Infection usually presents with fever and the x-ray will show lytic and sclerotic lesions rather than only sclerotic lesions with marginal irregularity [2,8].
Pathophysiology and Etiology
The true cause of osteitis pubis remains unknown. Several causes have been implicated in the development of osteitis pubis and these include trauma, low-grade infection, and venous congestion. The cause may be multifactorial.
Trauma as the cause of osteitis pubis was first proposed by Beer in the 1920s. Trauma to the pubic symphysis can lead to an inflammatory process involving the symphysis pubis. Osteitis pubis is seen in athletes with groin pain. This supports the theory that injury is a potential cause. Osteitis pubis is present in 10% to 80% of athletes complaining of groin and or suprapubic pain.
Microtears and injury to the pelvic girdle occurs in certain sports where there is rapid acceleration or deceleration, running, kicking, and rapid change of direction. This is commonly seen in individuals involved in athletic activities such as rugby, soccer, fencing, American football, ice hockey, and cricket [9].
Low-grade infection is believed to be another cause of osteitis pubis, especially in post-surgical patients.
In one series of osteitis pubis after Marshall-Marchetti-Krantz (MMK) urethropexy, 7 patients failed conservative management and required
surgery. Bone cultures from the surgery demonstrated infection in five
patients (71%) [10]. In another series, where bone material was collected for culture, there was no infection found. Urine infection was, however, found in 44% of these patients [11].
Theories regarding thrombosis, vascular obstruction, and impaired venous flow have also been proposed. Steinbach et al [12] in the 1950s, believed that an obstruction of the prostatic plexus in men was a possible cause.
This venous plexus drains some of the posterior veins of the pubic symphysis. Hence, obstruction of the plexus could cause hyperemia with resultant bone demineralization.
There is a close association between the veins of the urinary tract and those that drain the pubic symphysis. There are no valves in these vessels, hence infection-induced urinary stasis has also been proposed as an inciting factor for venous congestion [11].
The few studies that performed a histologic evaluation of osteitis pubis support inflammation as the cause of osteitis pubis. In a study by Coventry and Mitchell [11] of 45 patients diagnosed with osteitis pubis, 7 had tissue available for review. All the seven samples showed an inflammatory exudate composed of lymphocytes and plasma cells, with evidence of marrow fibrosis and thin layers of new bone in several samples.
Clinical Presentation
Patients with osteitis pubis usually present with generalized lower abdominal pain. The presentation can be broad and vague. The pain is localized to the lower abdomen and groin area, with radiation to the inner thigh. Sometimes there is disturbances of the gait. Discomfort is usually aggravated by activities that increase pressure on the pelvic girdle. This would include walking, sneezing, coughing, lying on the side, and walking up or down stairs. The pain can be sharp during these activities. The pain is commonly described as aching, throbbing, dull pain on cessation of the activity. Generalized symptoms often include malaise and sometimes a low-grade fever.
Individuals with osteitis pubis classically have a “waddling” gait, a form of an antalgic gait.
A thorough history should be taken and a thorough physical examination should be carried out in patients presenting with possible osteitis pubis. The focus should be on any recent or remote urologic or pelvic surgical procedures, any local trauma, or repetitive injury to the area in question.
Symptoms of osteitis pubis appear approximately 6 to 8 weeks after an offending surgical procedure, but the interval can be shorter or longer [11]. Physical examination will show point tenderness over the pubic symphysis or lateral to the pubic symphysis. Physical examination tests that can elicit classic pain include the “pubic spring” test and the “lateral compression” test. The spring test is performed by placing downward pressure on both pubic rami at the same time and if pain is reproduced at the pubic symphysis this is considered a positive sign. The test can also be performed on either side to see if the pain is localized. A positive lateral compression test occurs when the patient is in the lateral decubitus position and downward pressure on the superior iliac wing produces pain at the pubic symphysis [13].
Other tests that may reproduce symptoms include the FABER test (flexion, abduction, and external rotation of the hip) and the “adductor squeeze” test, in which the patient squeezes the doctor's fist that is placed between the patient’s knees, can elicit classic osteitis pubis discomfort.
Groin hernias should be ruled out. In men, a prostate examination should be carried out to rule out prostatitis. In women, a pelvic examination should be carried out to rule out other diagnoses such as pelvic inflammatory disease.
Osteomyelitis of the pubic symphysis should always be considered in the differential diagnosis, especially in the urologic patient who has undergone a surgical procedure. Patients with osteomyelitis typically appear more toxic, with high fever, and have laboratory evaluation indicative of infection [14].
Imaging
Several radiologic modalities are available for the diagnosis of osteitis pubis. These include conventional radiographs, magnetic resonance imaging (MRI), scintigraphy, and symphysography. A conventional radiograph will show irregularities of the joint margins, sclerosis, and osteophytes on the articular surfaces. There may be a widening of the pubic symphysis joint space.
In the early stages of the disease, the radiograph can be normal and a negative radiographic does not rule out osteitis pubis. A scintigraph will show focal accumulation of the injected radionuclide at or around the pubic symphysis on delayed scan images. For symphysography, direct injection of nonionic contrast directly into the symphyseal joint is carried out. The injection will provoke the symptoms which helps to confirm the diagnosis. At the same time, steroids and local anesthetic can be injected to obtain pain relief [15].
An MRI is probably the best imaging modality to diagnose osteitis pubis. It is because of its tissue inflammatory component, which can easily be demonstrated on MRI. With an MRI fine tissue details can be obtained to help differentiate osteitis pubis from osteomyelitis. Other findings found on an MRI include periarticular edema, fluid in the pubic symphyseal joint, and bone marrow edema in acute osteitis pubis lasting less than 6 months. In chronic cases lasting longer than 6 months, subchondral sclerosis, bone resorption, and osteophytes can be seen [16].
Treatment
Treatment modalities for osteitis pubis range from conservative treatment with rest to invasive surgical interventions. No prospective randomized controlled trial has been carried out to determine the best treatment approach since the condition is quite rare.
Initially, conservative treatment is carried out and the patient is told that this condition takes time to resolve. Conservative treatment includes a short period of bed rest followed by progressive ambulation with or without crutches or a cane. Activities that place stress on the pelvic girdle are minimized. Local cold or hot therapy over the pubic symphysis can also be used. Oral nonsteroidal anti-inflammatory agents such as ibuprofen or cyclooxygenase-2 inhibitors are also used.
Kavroudakis et al [17] reported the results of a small series of nonathlete women who were treated conservatively for osteitis pubis. Their series included 8 patients. The patients were advised bed rest for 4 to 6 days followed by ambulation with the assistance of crutches or a cane. All were treated with oral anti-inflammatory medications. At 2-month follow-up, they were encouraged to start a physical therapy program to strengthen the hip and abdominal muscles and improve adductor flexibility. Five patients were completely pain-free at 9 months and did not relapse at an average follow up of 24 months. Two patients continued to have pain with intense physical activity. One completely failed conservative treatment and was successfully treated by pubic symphysiodesis.
Since significant inflammation is present in these patients an oral glucocorticoid course with or without an appropriate taper can be attempted. When conservative measures fail, local corticosteroid injection with or without adjuvant anesthetic into the pubic symphysis can be attempted. This has been found to be effective with rapid reduction in pain in most patients.
There is very limited data (only a few case reports/series) on the use of anticoagulants for the treatment of osteitis pubis. If the thrombosis or venous congestion theory is correct, then anticoagulation may help to improve symptoms and treat these patients.
Holmgren [18] reported a series of three postoperative patients (1 following prostatectomy and 2 others following vaginal delivery), who developed osteitis pubis and were successfully treated with heparin therapy.
In another series of three patients with osteitis pubis following prostatectomy, conservative treatment failed and clinical improvement was only seen with initiation of intravenous heparin therapy [19].
Watkin et al [20] published a report of a patient with intractable pubic symphyseal pain following uncomplicated retropubic prostatectomy for benign prostate hyperplasia, who failed conservative treatment, but was successful treatment with a several-month course of warfarin, resulting in complete resolution of symptoms.
If all the above procedures fail, more invasive surgical options remain available. The best surgical approach remains unknown given the low numbers of surgically treated cases of osteitis pubis and a paucity of data. Surgical options include arthrodesis, curettage, and wedge and wide resection of the pubic symphysis. These surgical options can be associated with complications. Resection of the anterior pelvis can lead to pelvic instability.
Moore et al [21] published a report on two patients who presented with severe debilitation from posterior pelvic instability 12-18 years after resection of the pubic symphysis for treatment of osteitis pubis.
Mehin et al [22] carried out a small case review of 10 of their own patients and a larger review of the literature for patients undergoing surgical treatment for osteitis pubis. They recommended curettage of the joint for simple cases. In patients with osteitis pubis following urologic surgery, they recommended wedge resection, especially if there are concerns for possible residual infection. Surgical intervention is withheld until conservative treatments fail. In the postsurgical patient or in patients with severe symptoms, earlier surgical intervention is recommended.
Conclusions
The exact etiology of osteitis pubis is not completely understood and remains unclear. It is a potentially debilitating entity. It is believed to be a noninfectious inflammation of the pubic symphysis. It is seen most commonly in athletes. Approximately 1 in 100 patients undergoing urologic procedures are at risk for developing this condition. The onset is usually insidious and it occurs about 6 to 8 weeks after the index surgical procedure.
The diagnosis is usually a clinical one. A thorough history is taken and physical examination is carried out. The examination will include resisted adductor testing. Osteomyelitis has to be ruled out.
The treatment is usually conservative. It consists of rest, oral nonsteroidal anti-inflammatory drugs, and physical therapy. Invasive surgical techniques are used if conservative treatment fails. Osteitis pubis can be a crippling condition. It is, however, usually self-limiting.
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