What are the causes of pain over the pubic tubercle?

Causes of Pain Over the Pubic Tubercle

Pain localized over the pubic tubercle most commonly results from osteitis pubis, an inflammatory condition of the pubic symphysis and surrounding structures, though other musculoskeletal, infectious, and referred pain etiologies must be considered in the differential diagnosis.

Primary Musculoskeletal Causes

Osteitis Pubis

• Osteitis pubis is the most common inflammatory disease of the pubic symphysis, presenting as a self-limiting inflammation secondary to trauma, overuse, pelvic surgery, or childbirth 1, 2.
• This condition occurs more commonly in men during their 30s and 40s, causing pain directly over the pubic symphysis that radiates to one or both groins and the lower rectus abdominis muscle 1.
• Pain is characteristically exacerbated by exercise, running, kicking, pivoting on one leg, climbing stairs, coughing, or sneezing, and is relieved with rest 1.
• Pain distributions can be variable, including perineal, testicular, suprapubic, inguinal regions, and patients often describe "groin burning" sensations 1.
• In athletes, osteitis pubis represents an overuse injury from biomechanical overloading of the pubic symphysis with subsequent bony stress reaction, commonly seen in sports involving kicking, twisting, and cutting activities 3, 4.
• The characteristic "waddling gait" with difficulty ambulating is a clinical hallmark 5.
• Low-grade fever, elevated sedimentation rate, and mild leukocytosis may be present 5.
• Radiographic findings lag behind symptoms by approximately 4 weeks and include reactive sclerosis, rarefaction, and osteolytic changes 5.

Stress Fractures

• Insufficiency or fatigue fractures of the pubic rami can cause localized pain over the pubic tubercle 6.
• MRI without contrast is the most sensitive imaging modality for detecting occult pelvic stress fractures when radiographs are negative 6.

Infectious Causes

Osteomyelitis of the Pubic Symphysis

• Pyogenic and tuberculous infections can involve the symphysis pubis, representing the major differential diagnosis for osteitis pubis 2.
• The self-limiting nature of osteitis pubis and its response to non-antibiotic therapy distinguishes it from osteomyelitis 5.
• Genitourinary tuberculosis can affect the pelvis and present with non-specific symptoms including abdominal pain, though this is rare in non-endemic regions 6.

Acute Epididymitis

• Epididymitis is characterized by pain, swelling, and elevated temperature of the epididymis, with pain that can radiate to the lower abdomen and pubic region 6.
• In up to 90% of cases, pathogens migrate from the urethra or bladder, with predominant organisms being Enterobacterales, Chlamydia trachomatis, and Neisseria gonorrhoeae 6.

Fournier's Gangrene

• This aggressive polymicrobial soft-tissue infection of the perineum and external genitalia can present with painful swelling that may extend to the pubic region 6.
• In up to 40% of cases, onset is insidious with undiagnosed pain, requiring high clinical suspicion 6.

Urological and Gynecological Causes

Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

• Pain (including pressure and discomfort) is the hallmark symptom, with typical patients reporting suprapubic pain related to bladder filling 6.
• Pain extends throughout the pelvis including the urethra, and many patients use "pressure" rather than "pain" to describe symptoms 6.
• In men, symptoms may begin with mild dysuria or urinary urgency, progressing to severe voiding frequency, nocturia, and suprapubic pain 6.

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

• CP/CPPS is characterized by pain in the perineum, suprapubic region, testicles, or tip of the penis, often exacerbated by urination or ejaculation 6.
• The diagnosis of IC/BPS should be strongly considered in men whose pain is perceived to be related to the bladder 6.

Pelvic Inflammatory Disease (PID)

• PID can cause lower abdominal and suprapubic pain with uterine/adnexal tenderness or cervical motion tenderness 6.
• Empiric treatment should be initiated in sexually active young women with minimum criteria present and no other identifiable cause 6.

Inguinal Hernia

• Strangulated inguinal hernia can present as acute scrotal and lower abdominal pain extending to the pubic region 6.

Pelvic Venous Disorders

Pelvic Congestion Syndrome

• Pelvic congestion syndrome causes chronic pelvic pain from engorged and refluxing pelvic veins, characterized by dilated periuterine and periovarian veins 7.
• Ultrasound with Doppler is the initial imaging study of choice, showing engorged veins ≥8 mm with low-velocity and retrograde flow 7.
• Mechanical venous obstruction (Nutcracker syndrome, May-Thurner syndrome) can contribute to pelvic venous congestion 7.

Postmenopausal Considerations

• In postmenopausal women, pelvic pain may indicate ovarian cysts, fibroids, or pelvic infection 8.
• Transvaginal ultrasound combined with transabdominal approach is the initial imaging study of choice for evaluating postmenopausal subacute or chronic pelvic pain 6.

Diagnostic Approach

For suspected osteitis pubis:

• Obtain detailed history focusing on recent trauma, surgery, childbirth, or athletic overuse 1, 5.
• Examine for tenderness directly over the pubic symphysis and assess gait pattern 5.
• Order plain radiographs initially, recognizing findings will lag symptoms by 4 weeks 5.
• Consider MRI for early diagnosis or when radiographs are negative 6, 4.

For suspected infectious etiology:

• Assess for fever, elevated inflammatory markers, and systemic signs 5.
• Obtain appropriate cultures and consider imaging (CT or MRI) to differentiate osteomyelitis from osteitis pubis 6.

Common pitfall: Failing to recognize that osteitis pubis is a diagnosis of exclusion requiring differentiation from infectious, neoplastic, and other inflammatory conditions affecting the pubic symphysis 2, 5.