What is the recommended treatment for an adult patient with osteitis pubis, possibly following intense physical activity or pelvic surgery?

Treatment for Osteitis Pubis

Start with NSAIDs at maximum tolerated dosage combined with complete rest and structured physical therapy for 2-4 weeks, as this conservative approach successfully resolves symptoms in the vast majority of cases. 1, 2

First-Line Treatment: Conservative Management

Pharmacologic Therapy

• Initiate NSAIDs or COX-2 inhibitors at maximum approved dosage as the cornerstone of initial therapy 3, 1, 2
  • Specific dosing options include: indomethacin 150 mg/day in divided doses, ibuprofen 1800 mg/day in divided doses, celecoxib 200-400 mg/day, etoricoxib 90 mg/day (or temporarily 120 mg/day), or meloxicam 15 mg/day 3
• Consider NSAID rotation if insufficient response occurs at 2-4 weeks 3
• Short courses of oral prednisolone may be used as bridging therapy while awaiting effect of other agents, but avoid long-term glucocorticoid use 1

Physical Therapy Protocol

Follow a progressive, staged rehabilitation program rather than intensive sessions from the start 1:

• Begin with isometric strengthening exercises for both legs (even if pain is unilateral), targeting quadriceps and proximal hip girdle muscles 1
• Progress to range of movement and stretching exercises as tolerated 1
• Advance to aerobic activity only after pain subsides with basic exercises 1
• Link exercise regimens to daily activities so they become habitual 1
• Apply the "small amounts often" pacing principle rather than intensive sessions 1

Adjunctive Conservative Measures

• Complete rest from aggravating activities 1, 2
• Consider electrical stimulation, ultrasound, laser, and cryotherapy 2, 4

Response Evaluation Timeline

Assess treatment response at 2-4 weeks based primarily on pain reduction and functional improvement 1, 2:

• If sufficient response: continue treatment and re-evaluate at 12 weeks, then consider tapering to on-demand treatment 3, 1
• If insufficient response: escalate to second-line therapy 2

Second-Line Treatment: Refractory Cases

For patients failing conservative management after 2-4 weeks, add intravenous bisphosphonates as the preferred second-line option 3, 2:

• Pamidronate is the first choice: 30 mg IV on 3 consecutive days, repeated every 3 months, or 45-90 mg (or 1 mg/kg) IV monthly or every 3 months 3
• Pamidronate appears more effective for pain reduction than zoledronate based on clinical experience 3
• TNF-α inhibitors are an alternative if bisphosphonates fail or are contraindicated 3, 2
  • Options include: infliximab 3-5 mg/kg IV at 0,2, and 6 weeks then every 6-8 weeks, adalimumab 40 mg subcutaneously every 2 weeks, or etanercept 50 mg/week subcutaneously 3

Local Corticosteroid Injections

• Consider local corticosteroid injections into the pubic symphysis as a bridging management option 2

Response Evaluation for Second-Line Treatment

• Reassess at 3-6 months 3, 2
• If sufficient response: continue and re-evaluate at 6-12 months, then consider tapering 3
• If insufficient response: switch between bisphosphonates and TNF inhibitors or consider combination therapy 3

Treatment Goals and Monitoring

Establish clear treatment objectives with patients before starting therapy 1, 2:

• Relieve bone pain localized to the pubic symphysis, groin, or lower abdomen 1, 2
• Maintain or regain functional capacity including range of motion and quality of life 1, 2
• Reduce inflammation as measured by focal tenderness, elevated CRP/ESR, and radiological findings (bone marrow edema on MRI or increased tracer uptake on bone scan) 1, 2
• Prevent structural damage to the pubic symphysis 1, 2

Surgical Intervention

Reserve surgery for the rare patient who fails all conservative and medical management 5, 6:

• Surgery is rarely required in non-athletic patients, with conservative treatment representing a fair option for most 5
• Surgical options include: pubic symphysis curettage (open or endoscopic), wedge resection with bone grafting and plating, or arthrodesis 6, 7
• Open pubic symphysis curettage is currently the most common surgical method when posterior sacroiliac joint stability exists 7
• Consider surgery only after prolonged conservative failure (typically many months) with persistent pain, disability, and inability to perform desired activities 6, 7

Important Caveats

This condition differs from chronic non-bacterial osteitis (CNO), which is a systemic autoinflammatory disease requiring more aggressive immunosuppressive therapy 3. The guidelines for CNO 3 apply to that distinct entity, not to typical osteitis pubis following physical activity or pelvic surgery, which responds well to conservative management in most cases 1, 2, 5.

Monitor for adverse effects of bisphosphonates including atypical femoral fractures and osteonecrosis of the jaw (though risk is very low at dosages used for osteitis pubis), and ensure good dental hygiene before treatment 3. For TNF inhibitors, screen for latent infection and vaccinate for relevant pathogens before starting treatment 3.