Patrick T. Gomella, MD, MPH
Leonard G. Gomella, MD, FACS
BASICS
DESCRIPTION
• Osteitis pubis is a painful sterile inflammatory condition affecting the pubic symphysis
– Most commonly seen in athletes
• First described with suprapubic surgery and remains a potential complication of pelvic procedures
EPIDEMIOLOGY
Incidence
• Overall incidence in nonathlete populations unknown
– 0.16% in procedures using bone anchors
Prevalence
Overall prevalence in nonathlete populations unknown
RISK FACTORS
• Invasive pelvic procedures
– Several urologic procedures implicated
Radical prostatectomy
Prostate cryotherapy
TRUS Bx of prostate
TURP
Retropubic urethropexy: Specifically Marshall–Marchetti–Krantz procedure
Sling procedures
Pelvic radiation
• Trauma
• Rheumatic disorders
• Pregnancy/parturition
• Overuse syndrome in athletes
Genetics
No known genetic predisposition
PATHOPHYSIOLOGY
• Symphysis pubis is a nonsynovial amphiarthrodial joint at the confluence of the two pubic bones, consisting of an intrapubic fibrocartilaginous disc between thin layers of hyaline cartilage
• Etiology unknown but may be related to periosteal trauma
ASSOCIATED CONDITIONS
• Ankylosing spondylitis
• Rheumatoid arthritis
GENERAL PREVENTION
N/A
DIAGNOSIS
HISTORY
• Inciting event such as a pelvic procedure or trauma
• Insidious onset of suprapubic pain
• Pain radiating to thigh adductors, lower abdomen, perineum
• Pain worse when walking or when rising from a seated position (1)[C]
PHYSICAL EXAM
• Point tenderness over pubic symphysis
• Waddling gait
• Low-grade fever
• Increased pain with coughing or Valsalva
• Painful hip abduction
DIAGNOSTIC TESTS & INTERPRETATION
ALERT
Must rule out osteomyletis, especially in postoperative patients.
Lab
• Not generally required to make diagnosis
• May see moderate leukocytosis and an increased erythrocyte sedimentation rate (2)[C]
Raised levels of acute phase proteins (fibrinogen, C-reactive protein), and increased erythrocyte sedimentation rate are more suggestive of osteomyelitis
Imaging
• Pelvic radiograph
– Typically normal in acute phase
– Articular surface erosion, sclerosis, osteophyte formation
• Scintigraphy
– Increased uptake around pubic symphysis
• Symphysogram of joint
– Extravasation of contrast material
– Diagnostic and therapeutic
• Magnetic resonance imaging (MRI) most sensitive and considered gold standard
– Acute (<6 mo): Bone marrow edema, fluid in joint, periarticular edema
– Chronic (>6 mo): Subchondral sclerosis/resorption, bony margin irregularities, osteophytes (3)[C]
Diagnostic Procedures/Surgery
• Symphysogram of joint
– Pain on injection of contrast diagnostic (4)[C]
– Generally replaced by MRI
• Aerobic/anaerobic culture of joint aspirate to rule out infection if clinically indicated
Pathologic Findings
Sclerotic changes in bony architecture and degeneration of hyaline cartilage with normal periosteum (5)[C]
DIFFERENTIAL DIAGNOSIS
• Osteomyelitis (the most critical)
• Neoplasia of pelvic rami
• Bony metastases
• Pubic osteolysis
• Sports hernia (athletic pubalgia, sportsman’s hernia)
• Adductor strain
• Muscle tears
• Avulsion injuries
• Stress fractures
• Tears of acetabular labrum
TREATMENT
GENERAL MEASURES
• Rest, heat, or ice
• Physical therapy to strengthen pelvic girdle can be considered
MEDICATION
First Line
• Nonsteroidal anti-inflammatory
– Ibuprofen 200–800 mg 2–4×/d (max dose 2.4 g/d)
– Naproxen 250–500 mg 2×/d (max dose 1.5 g/d for limited time)
• Cyclooxygenase-2 (COX-2) inhibitor
– Celecoxib 100–200 mg 1–2×/d
– Adverse CV events noted with COX-2 inhibitors, use lowest effective dose for shortest duration possible
Second Line
• Oral glucocorticoids such as prednisone if local glucocorticoid injections fail
– Typical short course (ie, 60 mg for 5 days)
– Can use a taper dose
SURGERY/OTHER PROCEDURES
• Glucocorticoid injection in joint may be useful for cases refractory to rest and NSAIDs (4)[C]
– Any steroid preparation can be used based on provider preference
Include an adjuvant anesthetic
• Various surgical techniques can be used for cases refractory to medical management
– Curettage
– Wedge resection
– Wide resection
– Arthrodesis
• If bone anchors are in place, their removal may be necessary
ADDITIONAL TREATMENT
Radiation Therapy
Has been attempted in the past with mixed results, but not recommended due to risk of neoplasia
Additional Therapies
• Cryotherapy, ultrasound therapy, laser therapy, and electric stimulation have been used with variable success in athletic osteitis pubis
– No data on success of these modalities for nonathlete populations
• Anticoagulant therapy with heparin has been suggested as a possible treatment in a postoperative setting with some minimal success
Complementary & Alternative Therapies
Physical therapy
ONGOING CARE
PROGNOSIS
• Typically a drawn out and variable clinical course
– Symptoms can last several months to several years
– Operative procedures may be needed in 5–10% of cases
COMPLICATIONS
• Wedge or wide resection of pubic symphysis—risk of posterior instability of pelvic girdle leading to damage to sacroiliac joints
• Arthrodesis—risk of nonunion or death of bone graft site requiring additional surgery
FOLLOW-UP
Patient Monitoring
Follow-up depends on patient symptomatology and procedures obtained
Patient Resources
N/A
REFERENCES
1. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008;24(12):1407–1421.
2. Lentz SS. Osteitis pubis: A review. Obstet Gynecol Surv. 1995;50(4):310–315.
3. Kunduracioglu B, Yilmaz C, Yorobulut M, et al. Magnetic resonance findings of osteitis pubis. J Magn Reson Imaging. 2007;25(3):535–539.
4. O’Connell MJ, Powell T, McCaffrey NM, et al. Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes. AJR Am J Roentgenol. 2002;179(4):955–959.
5. Mehin R, Meek R, O’Brien P, et al. Surgery for osteitis pubis. Can J Surg. 2006;49(3):170–176.
ADDITIONAL READING
• 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;36:71–73.
• Weber MA, Rehnitz C, Ott H, et al. Groin Pain in Athletes. Rofo. 2013;185(12):1139–1148.
See Also (Topic, Algorithm, Media)
• Suprapubic Pain, General Considerations
• Sports Hernia (Athletic Pubalgia, Sportsman’s Hernia)
• Osteitis Pubic Images 
CODES
ICD9
733.5 Osteitis condensans
ICD10
M85.38 Osteitis condensans, other site
CLINICAL/SURGICAL PEARLS
• Osteitis pubis pain and osteomyelitis pain worse when walking or when rising from a seated position.
• Essential to rule out osteomyelitis as a more significant cause.
• Rarely osteitis pubis and osteomyelitis of the pubis can coexist.
• To distinguish between osteomyelitis and osteitis pubis, a biopsy and culture of the affected area are necessary.
• Suspect the condition in a urologic patient where the pubic symphysis has been involved in urologic surgical intervention such as bone anchors or sling procedures.