AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Since 1924, osteitis pubis has been known as a noninfectious inflammation of the pubis symphysis causing varying degrees of lower abdominal and pelvic pain. Osteitis pubis was first described in patients who had undergone suprapubic surgery and remains a well-known complication of invasive procedures about the pelvis. However, it may occur as an inflammatory process in athletes. The incidence and etiology of osteitis pubis as an inflammatory process versus an infectious process continues to fuel debate among physicians when confronted by a patient who presents complaining of "abdominal pain" or "pelvic pain" and overlapping symptoms.

Pathophysiology

Osteitis pubis is thought to result from inflammation of the pubis symphysis and is characterized by sclerosis and bony changes of the pubis symphysis.

Frequency

United States

No available statistics are found in the literature for this condition.

International

No available international data exist; however, osteitis pubis may be more common in Europe due to the popularity of kicking sports such as soccer.

Mortality/Morbidity

While rare instances of mortality have been reported in the obstetric literature from femoral artery involvement, morbidity is observed more commonly secondary to pain and difficulty with ambulation.

Sex

The literature suggests that osteitis pubis is more prevalent in men. However, as women lead more active lifestyles, including a greater involvement in sports such as soccer, the incidence and prevalence may change.

Age

Osteitis pubis can affect all age groups. This condition rarely is encountered in the pediatric population. Osteitis pubis occurs most commonly in men aged 30-50 years. Women are affected more in their mid 30s.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Pain generally is localized over the symphysis and may radiate to the groin, medial thigh, or abdomen.
• • Onset can be abrupt or insidious (more than 1 mo).
  • Pain is exacerbated by activities such as running, pivoting on one leg, and kicking.
  • Lying on one's side also may exacerbate the pain.
  • Pain can occur with walking, climbing stairs, coughing, or sneezing.
• The patient may experience a sensation of clicking or popping when rising from a seated position, turning over in bed, or walking on uneven ground.
• The patient may report weakness and difficulty ambulating.

Physical

• Tenderness to palpation is noted directly over the pubis symphysis with bilateral compression of the greater trochanters.
• The patient may report weakness, chiefly in the hip adductors, but there also may be involvement within the hip flexors.
• A waddling gait may be observed.

Causes

• Pregnancy/childbirth
• Gynecologic surgery
• Urologic surgery
• Athletic activities (eg, running, football, soccer, ice hockey, tennis)
• Major trauma
• Repeated minor trauma
• Rheumatological disorders
• Unknown etiology

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Osteomyelitis of the pubis symphysis
Ischial intersection syndrome
Snapping hip syndrome
Stress fracture
Groin strain
Pelvic and hip fracture
Muscle contusions
Tendon injuries
Acetabular labral tears
Bursitis
Chronic symphyseal injury

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory studies are not required to make the diagnosis, but some authorities suggest testing for an elevated WBC count and/or erythrocyte sedimentation rate. This testing may eliminate other causes.

Imaging Studies

• Plain radiographs
• • Plain radiographs demonstrate sclerosis, cystic changes, or rarefaction of the medial portions of the pubic rami (ie, marginal irregularity).
  • Instability is defined as more than 2 mm of cephalad translation of the superior pubic ramus on each side, with the patient standing on one leg in turn.
  • Widening of the cleft usually is measured to greater than 10 mm.
  • The sacroiliac joints also should be evaluated since laxity of one or both may contribute to pubis symphysis instability.
  • Positive findings usually are not apparent until 4 weeks after the onset of symptoms.
• Bone scans may be negative but can demonstrate intense signal uptake at the pubis symphysis.
• Ultrasound may show abnormal widening of the cleft.
• CT scanning is also used for evaluation of the pubis symphysis and the posterior pelvic ring.
• MRI studies may indicate bone marrow edema at the pubic symphysis, but this finding may also be seen in asymptomatic individuals.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

Rest and time are the primary healing mechanisms. Physical therapy (PT) may be useful during the early stage. Modalities, such as heat or ice, may provide symptomatic relief. Progressive ambulation with the aid of an assistive device (eg, cane, crutches) and possible orthoses (eg, lumbar/sacral corset, sacroiliac belt) to unload the pelvis for pain relief and to maintain correct anatomical alignment may be necessary.

Avoidance of any therapeutic exercise that may place stress on the pelvic ring is prudent. A home exercise program that includes pelvic tilts may be prescribed. Experienced therapists may attempt dynamic stabilization techniques.

Surgical Intervention

Different surgical approaches have been described, including curettage, arthrodesis, wedge resection, and wide resection. One study showed that elite athletes respond well to curettage. Wedge resection of the pubis symphysis can be performed for those who fail conservative management; however, the natural progression of this condition may require months, and in some cases, years to improve. Surgical intervention is associated with early improvement of symptoms but may lead to later posterior pelvic instability. This instability may then require a second surgical procedure for stabilization.

Other Treatment

• Manipulation is performed in some instances to correct anterior translation of the symphysis.
• Intra-articular glucocorticoid injections are controversial.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Nonsteroidal anti-inflammatory agents (NSAIDs) are the DOCs for treatment of osteitis pubis. Narcotics also are employed for pain control in some cases, usually in the obstetric or postsurgical patient. Limited case reports suggest that use of antibiotics and heparin also has been successful.

Drug Category: Nonsteroidal anti-inflammatory drugs

Most commonly used for relief of mild to moderate pain. Although ibuprofen is the DOC for initial therapy, other options include, but are not limited to, ketoprofen and naproxen.

Drug Name	Ketoprofen (Actron, Orudis, Oruvail)
Description	For relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	<3 months: Not established 3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Name	Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)
Description	For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Adult Dose	500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose	<2 years: Not established >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Category: Cyclooxygenase-2 (COX-2) inhibitors

Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Rest is the primary treatment for osteitis pubis. Recommended duration of rest can vary from 2 weeks to 3 months. Athletes are advised to refrain from sporting activities for 3-6 months.
• Return to sports should be discussed between the patient, physical therapist, and physician.
• Regular use of anti-inflammatory medications can help with pain control and lessen recovery time. Narcotics have been used after initial injury, especially after lesions of the pubis symphysis resulting from obstetric, surgical, or traumatic conditions.
• Recommend participation in a physical therapy treatment program, including a gradual program for return to sports.
• Use of local corticosteroid injections remains controversial.
• Reserve surgery for those who fail conservative management. Surgical intervention rarely is indicated.

Complications

• Weakness and difficulty ambulating (possible)
• Femoral artery involvement (rare)

Prognosis

• Prognosis for recovery is excellent with definitive diagnosis and treatment. Reports indicate that the average time to full recovery is 9.5 months in men and 7.0 months in women. Some reports suggest that recovery may take up to 32 months. Recurrence is more common in males.

Patient Education

• The literature suggests that osteitis pubis is a frustrating condition both for the patient and the physician; therefore, patient education cannot be overemphasized.
• Rest is advised.
• Athletes are advised to refrain from sporting activities for 3-6 months and then to return on a gradual supervised basis.
• Avoid any activity or exercise that may place stress on the pelvic ring.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• No known literature exists about osteitis pubis occurring in work-related injuries (except for professional athletes). The clinician facing this situation may have to proceed at his/her best discretion.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Andrews SK, Carek PJ. Osteitis pubis: a diagnosis for the family physician. J Am Board Fam Pract. Jul-Aug 1998;11(4):291-5. [Medline].
• DiStefano VJ, Nixon JE. Osteitis pubis--a case of housemaid''s pubis?. Pa Med. Jan 1972;75(1):51-2. [Medline].
• Fon LJ, Spence RA. Sportsman''s hernia. Br J Surg. May 2000;87(5):545-52. [Medline].
• Fricker PA, Taunton JE, Ammann W. Osteitis pubis in athletes. Infection, inflammation or injury?. Sports Med. Oct 1991;12(4):266-79. [Medline].
• Harris NH, Murray RO. Lesions of the symphysis in athletes. Br Med J. Oct 26 1974;4(5938):211-4. [Medline].
• Holmgren G. The treatment of osteitis pubis with anticoagulants. A report of three cases in Africans. Cent Afr J Med. Jan 1972;18(1):10-2. [Medline].
• Lovell G, Galloway H, Hopkins W. Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad. Clin J Sport Med. Mar 2006;16(2):117-22.
• Mehin R, Meek R, O''Brien P. Surgery for osteitis pubis. Can J Surg. Jun 2006;49(3):170-6.
• Michiels E, Knockaert DC, Vanneste SB. Infectious osteitis pubis. Neth J Med. Jun 1990;36(5-6):297-300.
• Moore RS, Stover MD, Matta JM. Late posterior instability of the pelvis after resection of the symphysis pubis for the treatment of osteitis pubis. A report of two cases. J Bone Joint Surg Am. Jul 1998;80(7):1043-8. [Medline].
• Pizzarello LD, Golden GT, Shaw A. Acute abdominal pain caused by osteitis pubis. Am Surg. Nov 1974;40(11):660-1. [Medline].
• Vincent C. Osteitis pubis [published erratum appears in J Am Board Fam Pract 1993 Nov-Dec;6(6):616]. J Am Board Fam Pract. Sep-Oct 1993;6(5):492-6. [Medline].
• Wiley JJ. Traumatic osteitis pubis: the gracilis syndrome. Am J Sports Med. Sep-Oct 1983;11(5):360-63. [Medline].

Article Last Updated: Jan 24, 2007