What causes pain in the pubic symphysis in an elderly female patient?

Pubic Symphysis Pain in Elderly Females: Differential Diagnosis and Evaluation

In an elderly female with pubic symphysis pain, the primary diagnostic considerations are osteitis pubis (inflammatory condition of the symphysis), pelvic instability, degenerative joint disease, and less commonly, gynecologic pathology such as ovarian cysts or fibroids, though malignancy must always be excluded in this age group. 1, 2, 3

Most Likely Musculoskeletal Causes

Osteitis Pubis

• Osteitis pubis is the most common inflammatory disease of the pubic symphysis and should be the leading consideration when focal pain and tenderness are present at this location 4, 3
• This condition presents as a self-limiting, non-infectious inflammation of the pubic symphysis causing focal pain directly over the symphysis pubis, often with a characteristic "waddling gait" and difficulty with ambulation 4, 5
• Pain is typically exacerbated by physical activity such as standing, walking, climbing stairs, coughing, or sneezing, and relieved with rest 2, 4
• While historically more common in men during their 30s-40s and athletes, it occurs in elderly females particularly following trauma, pelvic surgery (including gynecologic procedures), or as a complication of chronic pelvic instability 2, 4, 5

Pelvic Instability and Degenerative Disease

• Pelvic instability is commonly associated with osteitis pubis, though the causal relationship remains unclear—either condition may precipitate the other 2
• Degenerative joint disease of the symphysis can cause groin pain resulting from instability or abnormal pelvic mechanics, particularly relevant in the elderly population 3

Gynecologic Considerations in This Age Group

While musculoskeletal causes are most likely for isolated pubic symphysis pain, gynecologic pathology must be systematically excluded in elderly females due to elevated malignancy risk 1:

• Ovarian cysts account for approximately one-third of gynecologic pelvic pain in postmenopausal women 1
• Uterine fibroids are significantly more common causes of pain in postmenopausal versus premenopausal women, particularly when undergoing torsion or necrosis 1
• Ovarian neoplasm accounts for 8% of postmenopausal pelvic pain cases and carries substantially higher malignancy risk in this population 1

Diagnostic Workup Algorithm

Initial Clinical Assessment

• Physical examination should demonstrate focal tenderness directly at the symphysis pubis with absence of tenderness over sacroiliac joints or lumbar region to support the diagnosis of osteitis pubis 2
• Assess for the characteristic waddling gait and difficulty with weight-bearing activities 4, 5
• Evaluate for any palpable masses, as any mass requires urgent imaging and potential tissue diagnosis 1

Laboratory Investigations

• Low-grade fever, mildly elevated sedimentation rate, and mild leukocytosis may be present in osteitis pubis 5
• These findings help differentiate from osteomyelitis, though the self-limiting nature and response to non-antibiotic therapy confirms osteitis pubis as a separate entity 5

Imaging Strategy

• Plain radiographs are the initial imaging modality, though findings (reactive sclerosis, rarefaction, osteolytic changes) typically lag behind symptoms by approximately 4 weeks 5
• CT and MRI provide definitive diagnosis by demonstrating characteristic findings of osteitis pubis and assessing for pelvic instability 2
• Pelvic ultrasound (transvaginal and transabdominal) should be performed to exclude gynecologic pathology, particularly ovarian cysts, fibroids, or masses that are common in this age group 1, 6

Critical Diagnostic Pitfalls

• Failing to exclude malignancy: In postmenopausal women, any pelvic pain warrants systematic evaluation for gynecologic malignancy given the substantially elevated risk in this population 1
• Assuming purely musculoskeletal origin: Without imaging to exclude gynecologic pathology, serious diagnoses including ovarian neoplasm may be missed 1
• Misdiagnosing as osteomyelitis: The key differentiating features are the self-limiting nature of osteitis pubis and its response to anti-inflammatory rather than antibiotic therapy 5, 3
• Overlooking pelvic instability: This may be the primary pathology causing secondary osteitis pubis and requires specific surgical management if conservative treatment fails 2

Treatment Approach Based on Etiology

For Osteitis Pubis Without Instability

• Conservative management is first-line for non-athletic patients: bed rest, oral non-steroidal anti-inflammatory drugs, and physical therapy result in significant improvement in the majority of cases 7
• Most cases are self-remitting and rarely require surgical intervention 2, 3
• Treatment is directed at the associated inflammation, with more recalcitrant cases requiring systemic steroids 5

For Osteitis Pubis With Pelvic Instability

• Surgery should be considered when conservative measures fail after appropriate trial (typically several months) 2
• Surgical approach includes wide resection of all non-viable bone at the symphysis pubis with tri-cortical iliac bone graft and double plating to maximize fusion rate and stabilize fixation 2
• This is particularly relevant when chronic, persistent pain significantly impacts quality of life despite maximal conservative therapy 2