What is osteitis pubis?

Osteitis Pubis

Osteitis pubis is an inflammatory condition affecting the pubic symphysis and surrounding bone, characterized by pain in the pubic region that can be exacerbated by physical activity, particularly movements involving the lower abdomen and pelvic region. It is a self-limiting condition that can significantly impact mobility and quality of life if not properly managed.

Clinical Presentation

• Primary symptoms:

  • Diffuse pain in the pubic symphysis area
  • Pain may radiate to the groin, lower abdomen, adductor region, perineum, or scrotum
  • Pain typically worsens with specific movements:
    • Running
    • Kicking
    • Pivoting on one leg
    • Climbing stairs
    • Coughing or sneezing 1

• Physical examination findings:

  • Point tenderness over the pubic symphysis
  • Pain with hip adduction and flexion against resistance
  • Discomfort with loading of the rectus abdominis 2

Etiology and Risk Factors

Osteitis pubis is primarily considered an overuse injury resulting from:

• Biomechanical overloading of the pubic symphysis
• Subsequent bony stress reaction
• Inflammation of the pubic symphysis 2

Common risk factors include:

• Athletic activities requiring kicking, twisting, and pivoting movements
• Previous pelvic surgery
• Childbirth
• Trauma to the pelvic region 1

Diagnosis

Diagnosis is primarily clinical, based on history and physical examination findings. However, imaging can be helpful to confirm the diagnosis and rule out other conditions.

• Imaging modalities:
  • MRI: May show bone marrow edema, though this finding is also common in asymptomatic athletes (65%) 3
  • X-rays: May show sclerosis, erosion, or widening of the pubic symphysis

It's important to note that abnormal MRI findings are common even in asymptomatic athletes, which decreases the value of MRI in surgical decision-making 3.

Differential Diagnosis

The differential diagnosis for osteitis pubis is extensive and includes:

• Osteomyelitis pubis (infectious etiology)
• Adductor tendinopathy
• Sports hernia
• Rectus abdominis injury
• Inguinal hernia
• Stress fracture
• Hip joint pathology 2, 4

Management

Treatment typically begins with conservative measures:

1. First-line treatment:

   • Activity modification and rest
   • NSAIDs for pain and inflammation
   • Progressive rehabilitation exercises
   • Physical therapy 5

2. Second-line options for refractory cases:

   • Therapeutic injections:
     • Corticosteroid injections
     • Prolotherapy (dextrose injections)
     • Platelet-rich plasma (PRP) injections 5

3. Surgical intervention for severe cases:

   • Reserved for cases with severe functional impairment
   • Options include laparoscopic mesh repair behind the symphysis
   • Studies show 88% of surgically treated athletes returned to sport activities after 2 months of convalescence 3

Prognosis

• Osteitis pubis is generally self-limiting but can be chronic and frustrating for patients
• Conservative treatment is successful in many cases
• Recovery time varies from weeks to months, and in some cases up to 2 years 5
• Surgical intervention has shown good results in severe cases resistant to conservative management 3

Important Considerations

• Osteitis pubis can sometimes be confused with osteomyelitis pubis, which requires antibiotic treatment
• If symptoms persist despite conservative treatment, consider biopsy and culture to rule out infection 4
• Athletes may need to be sidelined for extended periods during recovery
• The condition can significantly impact quality of life and athletic performance if not properly managed