Osteitis Pubis

Original Editor - Tehseen ZahraTop contributors-{Tehseen Zahra, Lucinda hampton, Pacifique Dusabeyezu, Kim Jackson, Shreya Pavaskar and Aminat Abolade

Introduction

Osteitis pubis is defined as non-infectious idiopathic, inflammatory condition of the pubic symphysis and surrounding structures with multiple causes, resulting in groin or lower abdominal pain. It is most likely related to overuse or trauma. Osteitis pubis was first described in patients who had undergone suprapubic surgery, and it remains a well-known complication of invasive procedures about the pelvis. It may also occur as an inflammatory process in athletes.

Image 1: anterior view of the pelvis.

Quick Facts

• Osteitis pubis is a rare cause of groin pain but is more common in athletic patients, specifically soccer players, runners, and rugby players.
• Patients often present with groin pain made worse with activity.
• Plain radiographs and MRIs may aid with the diagnosis.
• The condition is usually treated with NSAIDs, activity restriction, and physical therapy.
• In rare cases, surgical intervention may be required.

Clinical presentation

The most common symptom of Osteitis pubis is pain in the pelvis area. The clinical presentation of osteitis pubis can vary from person to person, but common signs and symptoms may include:

• Pain localized over the symphysis and radiating outward
• Patients with osteitis pubis often present with anterior and medial groin pain.
• Adductor pain or lower abdominal pain that then localizes to the pubic area
• Pain is worsened by activities such as turning, walking, coughing, sneezing, lying on one side, and walking up or down stairs.
• In severe cases a waddling antalgic gait and crepitus may be present in individuals with osteitis pubis on examination or while doing daily activities.
• Individuals suffering from osteitis pubis commonly experience tenderness around the pubic symphysis and pubic ramus, along with painful muscle spasms in the adductor region.

The presentation is typical with varying degrees of pelvic and/or perineal pain, reproduced on hip adduction.

Epidemiology

To date, there has been no epidemiological study to determine the true incidence of osteitis pubis. The incidence in athletes has been reported as 0.5% to 8%, with a higher incidence in distance runners and athletes in kicking sports, in particular, male soccer players who account for 10% to 18% of injuries per year.

Etiology

Abnormal physical stresses at the pubic symphysis and parasymphyseal bone have been singled out as the likely cause of osteitis pubis. Although the aetiology is sometimes unknown, the most common causes are:

• Pregnancy/childbirth
• High-level of athletic activity: see athletic pubalgia
• Urological or gynaecological surgery
• Trauma
• psoriatic arthritis
• ankylosing spondylitis Image 2: Anterior view pelvis, pubis bone red.

Pathophysiology

Osteitis pubis is thought to be a stress injury of the peri-symphyseal pubic bones secondary to increased strain on the anterior pelvis. The pubic symphysis is a non-synovial amphiarthrodial joint with an interposed fibrocartilaginous disc separating hyaline cartilage. The joint normally has minimal motion due to the static ligamentous complex. The pubic symphysis serves as the insertion point of the rectus abdominis and origin of the adductor complex. The antagonistic nature of the rectus abdominis, which elevates the pubic symphysis while the adductors depress the joint, serves as a nidus for the development of osteitis pubis—the repetitive use of the anterior pelvic musculature results in chronic tendinosis. The chronic muscle imbalance results in abnormal forces across the pubic symphysis, causing symphyseal instability, pubic bone stress reaction, and eventually degeneration of the hyaline cartilage. Another emerging theory poses that osteitis pubis develops secondary to increased compensatory motion across the joint because of limited motion elsewhere in the kinetic chain, such as in femoroacetabular impingement.

Diagnosis

Both radiographs and MRI aid in the diagnosis of osteitis pubis. In the early stage, plain radiographs might appear normal.

• In chronic osteitis pubis, the pubic symphysis demonstrates lytic changes, sclerosis, sub-chondral resorption, bony margin irregularities and widening.
• Dynamic instability of the pubic symphysis can be observed on the flamingo view (obtained by double- and single-legged stance positions bilaterally on a pelvic anterior-posterior radiograph). Greater than 2 mm of subluxation is considered a positive finding for symphyseal instability.
• MRI has become the imaging modality of choice. MRI has a high sensitivity for distinguishing between chronic and acute cases.

Treatment

The management of osteitis pubis includes both non-surgical and surgical approaches, with the initial preference being non-surgical (conservative) methods.

The first option remains conservative treatment.

• Conservative management involves a combination of rest, non-steroidal anti-inflammatory drugs (NSAIDs) and a progressive course of physical therapy (see Pubalgia). There is no standard conservative treatment protocol resulting in a variety of outcomes. The conservative treatment of osteitis pubis can be protracted. It may take some athletes six months or more to return to the preinjury level, but more commonly, most return by 3 months.
• Albeit protracted, conservative management remains the mainstay of treatment. Only approximately 5% to 10% of athletes require surgical treatment.

Steroid injections have been demonstrated as a useful adjunctive therapy

If conservative management does fail, surgical intervention may be required. The timeframe of when to consider conservative treatment as a failure ranges and no set timetable has been established. Commonly, a minimum of six months of conservative treatment is attempted before surgical options are discussed.

Differential Diagnosis

• Athletic Pubalgia
• Osteomyelitis
• Adductor strain
• Rectus Abdominus strain
• Sacroiliac joint dysfunction
• Genitourinary disease

Viewing

The short video below is of Physiotherapy techniques used for osteitis pubis

Complications

Surgical treatment of individuals with osteitis pubis can result in:

• Chronic pain
• Infection
• Nonunion of fusion
• Recurrence
• Scrotal or labial swelling

Prognosis

The prognosis of individuals with osteitis pubis is very good. Those who undergo conservative treatment typically recover and can resume sports activities in about three months, with a low likelihood of experiencing a recurrence. A small number of patients with osteitis pubis, around 5% to 10% , need surgical intervention. However, those who undergo surgery generally experience highly positive outcomes, with the majority returning to their sports activities within approximately 3 to 4 months

References

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