How do you manage osteitis pubis?

Management of Osteitis Pubis

Conservative treatment with NSAIDs/COXIBs at maximum tolerated dosage should be the first-line therapy for osteitis pubis, with surgery rarely required for non-athletic patients. 1

Diagnosis and Assessment

• Key diagnostic findings:

  • Pain in the pubic area, groin(s), and lower rectus abdominis
  • Pain exacerbation with exercise or specific movements (running, kicking, pivoting)
  • Pain relief with rest
  • Possible distributions: perineal, testicular, suprapubic, inguinal areas
  • "Groin burning" sensation, discomfort with stairs, coughing, or sneezing

• Differential diagnoses to exclude:

  • Sports hernia
  • Femoroacetabular impingement
  • Adductor lesion
  • Infectious osteomyelitis (if fever or elevated inflammatory markers present)

Treatment Algorithm

First-Line Treatment

• Start NSAIDs/COXIBs at maximum tolerated and approved dosage 2

  • Options include: naproxen, indomethacin, ibuprofen, celecoxib, etoricoxib
  • Evaluate treatment response at 2-4 weeks
  • If sufficient response: continue and re-evaluate at 12 weeks
  • Consider tapering or on-demand treatment with sustained improvement

• Concurrent conservative measures:

  • Bed rest during acute phase 1
  • Physical therapy focusing on core strengthening 1, 3
  • Activity modification to avoid symptom exacerbation 3

Second-Line Treatment (If Insufficient Response to NSAIDs)

• Consider NSAID/COXIB rotation to a different agent 2
• Short courses of oral prednisolone or intra-articular glucocorticoid injections may be used as bridging therapy 2, 4
• Avoid long-term use of glucocorticoids 2

Advanced Treatment Options

• For persistent cases unresponsive to conservative measures:
  • Consider corticosteroid injections into the pubic symphysis 4
  • Dextrose prolotherapy has been reported in some case series 4

Surgical Intervention

• Surgery should be reserved for cases that fail conservative management 1, 5
• Surgical options include:
  • Pubic symphysis curettage
  • Polypropylene mesh placement
  • Pubic bone stabilization/arthrodesis 1, 4

Special Considerations

Infectious vs. Non-infectious

• If fever or significantly elevated inflammatory markers are present, rule out infectious osteomyelitis pubis 6
• Osteomyelitis pubis requires antibiotic therapy based on culture results 6
• Biopsy and culture of the pubic symphysis may be necessary to confirm diagnosis in suspected infectious cases 6

Athletic vs. Non-athletic Patients

• Non-athletic patients typically respond well to conservative treatment 1
• Athletes may require more aggressive treatment and earlier surgical intervention 5, 4
• For non-athletic female patients, surgery is rarely required 1

Monitoring and Follow-up

• Regular assessment of:

  • Pain reduction
  • Functional improvement
  • Return to normal activities
  • Radiological changes (if previously abnormal)

• Treatment success indicators:

  • Pain relief
  • Improved mobility
  • Return to pre-illness activity levels
  • Resolution of radiological abnormalities

Prognosis

• Osteitis pubis is often self-limiting with appropriate rest and anti-inflammatory treatment 6, 3
• Non-athletic patients generally have excellent outcomes with conservative management 1
• Prognosis for recovery is excellent with definitive diagnosis and appropriate treatment 6

The management approach should be tailored based on symptom severity, response to initial treatment, and whether the condition is infectious or non-infectious in nature.