Solving a Perplexing Problem
Peter C. Vitanzo, Jr, MD; John M. McShane, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO.7 - JULY 2021
In Brief: 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.
Osteitis pubis, a painful condition involving the pubic symphysis and surrounding tendinous attachments, was first described in 1924 by Beer, a urologist, who reported on a patient who had undergone suprapubic surgery (1). Spinelli reported the condition in fencers in 1932 (2-4). Osteitis pubis has since been associated with parturition, trauma, nonurologic surgery, urinary tract infections, and arthritic disorders (4-16). The true prevalence of this condition has yet to be conclusively determined (3,6,9,14,15).
Many consider osteitis pubis a perplexing problem of unclear etiology with a wide array of vague, nonspecific presenting symptoms, and encompassing a vast differential (2,4-19). Despite its relatively frequent occurrence in active individuals, diagnosis of osteitis pubis is often delayed or not made at all (2,5-7,12,15). Therefore, it is essential that primary care physicians recognize and understand this disorder to consider it appropriately in their workup, differential, and treatment, particularly of active patients who present with persistent abdominal, pelvic, or groin pain. To highlight diagnosis and treatment decisions, we discuss a case below.
An Illustrative Case
A 39-year-old man, who previously had participated in recreational athletics, presented with lower abdominal and midline anterior pelvic pain. Pain was especially apparent with any twisting motion of the trunk and pelvis. His symptoms had begun 6 years earlier while he was playing basketball. At that time, his physician diagnosed the problem as a lower abdominal strain. Treatment included rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and avoidance of aggravating activities. In the ensuing months, his symptoms progressively worsened, and he developed increasing difficulty with ambulation, running, lifting, pivoting, and lying in any position in bed. Occasionally, it hurt to cough or sneeze. Subsequently, he was prescribed an abdominal binder on which he eventually became dependent for walking. In addition to pain and disability, he suffered psychologically from the persistence of his pain and loss of full function.
Initial diagnosis and treatment. One year after the onset of symptoms, the patient consulted another physician who diagnosed osteitis pubis and prescribed a physical therapy program that emphasized stretching of the pelvis and hip muscles. The patient continued to use the abdominal binder, but after 3 years of the program his symptoms gradually resolved and he stopped using it. He started a progressive exercise program, beginning with pool workouts. Eventually, he returned to his previous level of recreation and did well for about 3 years.
Recurrence and exam. The patient came to our office after experiencing recurrent pelvic symptoms. He was uncertain of the actual inciting event. He now described a "grinding or rubbing sensation" prior to any actual pain. Physical therapy and NSAIDs were not helpful.
The patient was a well-developed, well-nourished man weighing 230 lb and standing 6 ft 7 in. tall. His abdominal, genitourinary, and neurovascular exams were unremarkable.
Musculoskeletal examination revealed pain in the pubic symphysis area with lateral compression over the iliac wing while the patient was in the lateral decubitus position. He also had pain while holding one iliac wing down and applying stress to the contralateral crossed leg (6,9,10,12,14).The patient had equal leg lengths and full range of motion in both hips but a somewhat wide-based, antalgic gait. Both hips resisted adduction, and passive abduction elicited pain. Spinal exam was unremarkable. He was, however, very apprehensive about side-to-side bending or twisting of the trunk, as these motions provoked pain. Straight-leg-raise testing was negative. He was exquisitely tender to palpation over the pubic symphysis as well as the tendinous origins of the adductor muscles bilaterally.
Imaging and therapy. Anteroposterior (AP) and lateral pelvic radiographs revealed asymmetric sclerosis and irregularity along the symphysis consistent with osteolysis. The left pubic bone was 1.5 mm higher than the right. This difference corrected on flamingo-view radiographs (AP views of the pelvis while the patient stands on one leg) when he stood on the right leg. A technetium methylenediphosphonate (Tc-99 MDP) bone scan demonstrated symmetrical uptake in the pubic symphysis and the bordering pubic rami (figure 1). These findings correlated with the diagnosis of osteitis pubis.
The patient received an uncomplicated fluoroscopic-guided injection of a mixture of 2 mL (12 mg) of betamethasone and 1 mL of bupivacaine into the pubic symphysis. He continued in his graduated rehabilitation program and had about 2 weeks of complete pain resolution before his pain recurred with any side-to-side or twisting motions. He was referred for consideration of surgical intervention. Initially, he agreed to a stabilization/fusion procedure but changed his mind and opted to continue with physical therapy. Unfortunately, conservative therapy did not alleviate his symptoms and, ultimately, he required surgery. He had a good surgical outcome.
Osteitis pubis may result from activities that create either acute or continuous shearing forces across the pubic symphysis (table 1). Such activities may include twisting, cutting, pivoting on one leg, excessive side-to-side motion, or multidirectional motions with frequent acceleration and deceleration (2,4-7,10-19). Men and women may be equally affected, typically during their 20s or 30s, but the condition has been diagnosed in nearly every age-group (3,6,9,12,14,15). Interestingly, the incidence in nonathletes may be the same as in athletes (11). Acute episodes of osteitis pubis can develop as a consequence of forced hip abduction or rotation, kicking, trauma from a fall, or a direct blow (2,5,6,8,9,13-16).
There is still no consensus about the disorder's exact cause and course. The literature, however, does seem to favor a biomechanical process with an initial inciting event involving acute or persistent microtrauma (2-5,7-10,12,13,15-17,19). Frequently, the irritating event (particularly in athletes) is repetitive strain or tendinopathy of one or more muscles (especially the adductors) inserting or originating from the pubic rami (2,4,5,7,10,12,13,15-17,19). Subsequently, shearing forces develop across the pubic symphysis and provoke an inflammatory response (2,5,7,10,12,15,16). Ultimately, a self-perpetuating cycle of events leads to further worsening of the problem.
The diagnosis of osteitis pubis can prove very challenging, even to the most astute clinician. Although the differential diagnosis can be broad (table 2) (2,4-7,9-12,15,16,18,19), a thorough history and examination, complemented by the appropriate diagnostic studies, can make the task significantly less arduous.
History and presenting complaints. It is important that physicians inquire about the nature of the patient's activity or sport and the motions required. Associated constitutional symptoms as well as any trauma or falls should be noted. Often, there is no definite history of injury (11,13,14,18). Any prior workup or treatment that the patient may have had should be documented.
Presenting complaints include the insidious development of progressively worsening pain—unilateral or bilateral groin (inguinal), medial thigh, testicular, scrotal, perineal, suprapubic, anterior pubic area, and/or hip—along with restricted motion. Pain is often described as sharp, stabbing, or even burning and is exacerbated by running, pivoting (especially one-legged), twisting, climbing stairs, kicking, sit-ups, leg raises, or Valsalva maneuvers (2-19). Patients may have difficulty lying in bed at night (5,14). If instability is present, patients may describe an audible or palpable clicking sensation at the symphysis pubis with certain activities (eg, arising from a seated position, turning in bed, or walking on uneven surfaces) (6,9,10,13,14,19). Rest usually relieves the symptoms, but not entirely.
Physical exam. Usually, tenderness is present on palpation of the area over the pubic symphysis (4-18), and there may be either unilateral or bilateral discomfort with palpation over the superior (rectus abdominus) and/or inferior (adductors) pubic rami (2,4-6,11-15). Hip motion can be restricted because of surrounding muscle spasm, especially of the adductors (2,5,6,10,12,14,15). Passive hip abduction or resisted hip adduction and flexion may elicit pain (2,5,6,8-16,18,19). Specific tests, such as the lateral pelvic compression or cross-leg tests, are often positive (6,9,10,12,14). Trendelenburg's test, if positive, indicates weak hip abductors (12). In severe cases, patients may demonstrate a wide-based (antalgic) gait disturbance, with the hips and knees partially flexed (6,9,10,14,17).
Imaging. Plain radiographs (AP and lateral) of the pelvis are an integral component in the diagnostic workup. However, it is important to realize that most abnormalities are not specific for osteitis pubis, and radiographs can lag behind clinical symptoms by as much as 4 weeks (9,11-13,16,17).
Early in the course, it is not uncommon for radiographs to be normal (2,6,7,9-11,17). After about 4 weeks, findings such as unilateral or bilateral fraying or roughening of the marginal periosteum and widening of the symphysis joint space may be seen (2-19). As the disease progresses over several months, radiographic changes include reactive sclerosis of adjacent pubic bones, erosion and resorption of the symphysis margins, and widening of the joint space (2-10,12-19). Bilateral, symmetric rarefaction and cortical bone destruction are common findings (7-9,14,16,17). Gradual reossification with complete restoration of the joint is associated with healing and can take several months. Residual sclerosis, osteophytes, and cysts may occur (3-8,14). Additional one-legged, standing flamingo views are beneficial if instability is suspected (3-5,8,12,13,19). Instability is defined as greater than 2 mm of height difference between the superior rami of the symphysis (4,13,19). Many experts also recommend sacroiliac joint films since they are frequently involved in the process (3,5,8,12-14).
Radionuclide scans or magnetic resonance imaging (MRI) can be valuable adjuncts in early detection. They often reveal symmetric involvement of the pubic symphysis, in contrast to tumors, tendinitis, strains, or pelvic stress fractures, which are usually asymmetric (2-7,9-12,16,17,19). MRI has the added benefit of displaying disruption of cartilage, bone, and periosteum (3,4,9,10).
Plain films are not helpful for prognosis, and bone scans are not useful in determining progression of the condition (12). There is a poor correlation between radiographic and radionuclide scan findings and the site and duration of symptoms and signs (4,15,19). Many consider patients with normal plain films and a positive bone scan or MRI to have pubic symphysitis, which is felt to be a precursor or variant of osteitis pubis (7,12).
Although not very specific, tests such as urinalysis, erythrocyte sedimentation rate, and complete blood count with differential can assist in determining if there is any evidence of infection (6,8-11,15,16).
Various treatment options have been suggested in the literature, but we recommend the conservative approach outlined by Batt et al (5). Initially, the goal is to reduce inflammation and pain by using rest from provocative activities, ice, and physical therapy modalities. Medications may include NSAIDs, but one should not hesitate to use oral corticosteroids if the patient demonstrates intense pain from inflammation (2,3,5-19). Physical therapy may include therapeutic ultrasound, phonophoresis with hydrocortisone lotion, and electrogalvanic stimulation (5,12,13). Thermally protective compression shorts have also been advocated (5,15,19). If symptoms persist, injected corticosteroids may be considered, but only after infection has been excluded (2,5,7,9-19). This step, however, is controversial.
When pain and inflammation are reduced, patients should begin structured physical therapy program that, ultimately, progresses to a graduated exercise program. Eventually, sport-specific activities will be incorporated. In the early stages of this program, pain may actually increase (5).
Return to preinjury level of functioning may take from 3 to 6 months and occasionally longer (5,9,13,15,16,18).The prognosis of this apparently self-limited condition is very good, with success rates as high as 90% to 95% with the previously noted program (9,11,14). Residual symptoms may occur but do not usually prohibit the patient from participating in activities (5,9,11). Only patients who fail to respond to conservative measures should be considered candidates for surgery (2,3,10,12-16,19).
Dr Vitanzo is a clinical assistant professor, assistant director of the sports medicine fellowship, and assistant director of fellowship programs in the department of family medicine; and Dr McShane is director of sports medicine and the sports medicine fellowship, and a clinical assistant professor in the department of medicine at Jefferson Medical College-Thomas Jefferson University Hospital in Philadelphia. Address correspondence to Peter C. Vitanzo, Jr, MD, 1015 Walnut St, Curtis Bldg, Suite 401, Philadelphia, PA 19107; e-mail to [email protected].