What is the best treatment for pubalgia?

Treatment of Pubalgia

Pelvic floor physiotherapy should be offered as first-line treatment for pubalgia, followed by surgical intervention if conservative measures fail. 1

First-Line Conservative Treatment

• Pelvic floor physiotherapy is the recommended initial approach for pubalgia, addressing muscle imbalances and dysfunction that contribute to pubic pain 1
• Conservative treatment should include:
  • Pelvic floor muscle training to enhance strength and endurance of pelvic floor muscles 2
  • Education about proper bladder/bowel function and aggressive management of constipation 1
  • Lifestyle modifications including proper toilet posture with buttock support and comfortable hip abduction 1
  • Biofeedback therapy to improve muscle isolation using perineal EMG surface electrode feedback 1

Medication Options

• Low-dose vaginal estrogen can be used for women with more severe symptoms or those who don't respond to initial conservative measures 1
• Lidocaine can be offered for persistent pain, particularly for introital pain and dyspareunia 1
• For pain management, topical anesthetics (both OTC and prescription) may provide relief 3

Advanced Interventions

• If conservative treatment fails after 3-6 months, surgical intervention should be considered 4
• Laparoscopic surgery has been shown to be more effective than nonoperative treatment in a randomized clinical trial of 60 patients with athletic pubalgia 4
• Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy has demonstrated good outcomes with 92.5% of patients returning to athletic activity within 28 days 5
• Surgical options include:
  • Endoscopic placement of retropubic mesh 4
  • Open inguinal repair reinforced with mesh 6
  • Adductor tenotomy when appropriate 5, 6

Special Considerations

• Athletic pubalgia often involves multiple anatomical structures including the pubic symphysis, adductors, rectus abdominis, posterior inguinal wall, and related nerves 7
• There is growing evidence of a link between femoroacetabular impingement (FAI) and pubalgia, suggesting that in some cases, addressing FAI may help resolve pubic pain 7
• Pelvic floor abnormalities frequently involve multiple compartments, requiring comprehensive assessment 1
• Behavioral or psychiatric comorbidities should be addressed concurrently for optimal treatment outcomes 2

Treatment Algorithm

1. Start with pelvic floor physiotherapy for 3-6 months 1, 4
2. Add medication management as needed (topical anesthetics, vaginal estrogen for women) 3, 1
3. If no improvement after 3-6 months of conservative therapy, consider surgical intervention 4
4. Select surgical approach based on specific pathology:
   • For athletic pubalgia/sports hernia: laparoscopic mesh placement or open inguinal repair 4, 6
   • Consider adductor tenotomy in cases with significant adductor involvement 5, 6
5. Implement structured rehabilitation protocol post-surgery to facilitate return to activities 5

Outcomes and Follow-up

• With appropriate surgical intervention, up to 90% of athletes can return to sports activities within 3 months 4
• Laparoscopic repair has shown significantly better outcomes than continued conservative treatment in randomized controlled trials 4
• Potential complications include recurrence of pain (7.5%), urinary retention (2.2%), and adductor-related complications (2.2%) 5
• Regular follow-up is essential to monitor progress and address any persistent or new symptoms 1