What is the workup and management of osteitis pubis?

Workup and Management of Osteitis Pubis

The management of osteitis pubis should begin with NSAIDs/COXIBs at maximum tolerated dosage, followed by intravenous bisphosphonates or TNF inhibitors if initial treatment fails, with treatment decisions guided by clinical symptoms and radiological evidence of inflammation. 1

Diagnostic Workup

Clinical Assessment

• Evaluate for bone pain localized to the pubic symphysis
• Check for pain aggravation with:
  • Running, cutting movements
  • Hip adduction and flexion against resistance
  • Loading of the rectus abdominis 2
• Assess for referred pain to:
  • Adductor region
  • Lower abdominal muscles
  • Perineal region
  • Inguinal region 2

Imaging Studies

• Whole-body imaging should be considered at initial evaluation to map clinically silent but radiologically active lesions 1
• Recommended imaging modalities:
  • MRI (with sagittal images of the spine)
  • [99mTc]Tc-HDP SPECT/CT
  • PET/CT
  • Plain bone scintigraphy 1

Laboratory Tests

• Inflammatory markers (ESR, CRP) may be elevated but are not specific 1
• Bone biopsy is not routinely recommended unless there is:
  • Suspicion of malignancy
  • Suspicion of infectious osteomyelitis 1

Disease Activity Assessment

Categorize patients based on clinical symptoms and radiological findings:

1. Active disease: Both clinical symptoms and radiological evidence of inflammation
2. Inactive disease: Neither clinical symptoms nor radiological evidence
3. Probable inactive disease: Clinical symptoms without radiological evidence
4. No clinically relevant activity: Radiological evidence without clinical symptoms 1

Management Algorithm

First-Line Treatment

• NSAIDs/COXIBs at maximum tolerated dosage 1
  • Options include:
    • Naproxen (500-1000 mg/day)
    • Indomethacin (150 mg/day)
    • Ibuprofen (1800 mg/day)
    • Celecoxib (200-400 mg/day)
    • Etoricoxib (90 mg/day)
    • Piroxicam (20 mg/day)
    • Meloxicam (15 mg/day) 1
• Evaluate response at 2-4 weeks:
  • If sufficient response: Continue and re-evaluate at 12 weeks
  • If insufficient response: Consider NSAID rotation or advance to second-line treatment 1

Supportive Measures

• Rest and activity modification 3, 4
• Physical therapy focusing on:
  • Core strengthening
  • Pelvic stabilization
  • Gradual return to activity 3, 5
• Consider short courses of oral prednisolone or intra-articular glucocorticoid injections as bridging therapy 1

Second-Line Treatment (if NSAIDs fail after 2-4 weeks)

• Intravenous bisphosphonates (preferred first option) 1
  • Pamidronate: 3 × 30 mg on 3 consecutive days, every 3 months, OR
  • Pamidronate: 45-90 mg (or 1 mg/kg) monthly or every 3 months, OR
  • Zoledronate: 5 mg intravenously, according to symptoms 1, 6
• Alternative: TNF inhibitors 1
  • Options include:
    • Infliximab
    • Etanercept
    • Adalimumab
    • Golimumab
    • Certolizumab 1
• Evaluate response at 3-6 months:
  • If sufficient response: Continue and re-evaluate at 6-12 months
  • If insufficient response: Switch to the alternative second-line treatment or consider combination therapy 1

Special Considerations

• For non-athletic female patients, conservative treatment with NSAIDs and physical therapy is usually sufficient 3
• Athletes may require more aggressive management and earlier progression to second-line therapies 5, 2
• Surgical intervention (arthrodesis) is rarely required for non-athletes but may be considered if all conservative measures fail 3

Treatment Response Evaluation

• Primarily based on clinical measures (pain reduction, improved function)
• Integrate radiological measures (reduction in bone marrow edema or tracer uptake)
• Consider biochemical measures if previously elevated 1

Prognosis

• Non-athletes typically respond well to conservative treatment 3, 4
• Athletes may have more prolonged recovery periods 5, 2
• With proper diagnosis and treatment, prognosis for recovery is excellent 4

Common Pitfalls

• Misdiagnosis as abdominal or pelvic pain from other causes 4
• Failure to distinguish between non-infectious osteitis pubis and infectious osteomyelitis pubis 4
• Inadequate duration of first-line therapy before advancing to second-line options
• Overlooking the need for activity modification and physical therapy as part of comprehensive management