Longstanding anterior pelvic pain

CASE

The patient is a 74-year-old white woman who presented with complaints of longstanding anterior pelvic pain over the symphysis pubis. She reported a baseline dull and aching pain but experienced sharp, stabbing sensations at the pubic symphysis when performing benign activities such as rising from a seated position or getting in and out of her car. After conservative treatment had failed to resolve her pain, the patient was referred to orthopedics by her family practice physician.

History The patient denied any history of trauma or insult to the pelvis. She said that the pain had begun approximately 1 year ago but was intermittent in nature and bothered her only with increased lower-body activities and long periods in a seated position. However, over the past 2 to 3 months, the pain had worsened in severity and frequency to the point where she now had nonstop discomfort and in any position. She denied any empiric signs or symptoms of infection. She admitted to regular gynecologic examinations with no significant pathologic findings. She denied symptoms of urinary tract infection and stated that her bowels were regular. Her surgical history included a recent colonoscopy with normal findings and a cesarean section more than 30 years ago. She had also undergone an appendectomy as a juvenile. She enjoyed occasional alcohol consumption but did not use tobacco. She lacked any significant medical conditions.

Physical examination The patient was pleasant and did not appear distressed. She was, however, uncomfortable sitting in any position for a prolonged period of time. Her vital signs were normal. Her abdomen was soft and bowel sounds were present. The patient had no discernable pain in response to palpation deep in either groin, but palpation directly over the pubic symphysis elicited significant discomfort. The skin was intact in this region, and no inguinal lymphadenopathy was noted. Passive abduction of the lower extremities aggravated her condition, as did active adduction against resistance. Her pelvis was stable on examination, and leg lengths were equal. She exhibited an antalgic gait because of pain.

Plain radiographs of the pelvis were taken and showed significant inflammatory changes at the pubic symphysis. Bony sclerosis, cysts, and irregularity of the medial margins of the pubic symphysis were clearly demonstrated (see Figure 1). There seemed to be no involvement elsewhere in the pelvis, and the pelvic ring was intact and anatomic.

WHAT IS YOUR DIAGNOSIS?

• Pubic ramus fracture
• Pubic symphysis osteomyelitis
• Osteitis pubis

DISCUSSION

The diagnosis for this patient is osteitis pubis, a painful, inflammatory, noninfectious condition affecting the pubic bone, symphysis, and surrounding soft tissue structures.1 Osteitis pubis most commonly affects young athletes and individuals who have recently undergone either gynecologic or urologic procedures. The etiology is not fully known, but most believe that the condition is a result of microshearing forces on the anterior pelvic ring. In the case of an athlete, such as a long-distance runner or weightlifter, these shearing forces are greatly exaggerated. In the urologic or gynecologic patient, a recent intervention is thought to simply exacerbate an underlying inflammatory condition. Our patient fit into neither of these two categories, making her diagnosis unique. To avoid missing a more serious diagnosis such as osteomyelitis of the pubic bone, a CBC, C-reactive protein, and ESR were ordered. With the exception of a mildly elevated ESR (35 mm/h), all results were within normal limits.

Comment The mainstay of treatment for osteitis pubis has long been rest and oral anti-inflammatory use. Corticosteroid injection directly into the pubic symphysis under fluoroscopic guidance often benefits patients.2 In rare cases, surgical management is indicated and might include curettage or resection of the symphysis pubis. Resection can lead to pelvic instability mostly affecting the sacroiliac joints.3

Treatment After several treatment options were presented to our patient, she ultimately decided on surgical resection. She tolerated the procedure well and shortly after surgery experienced a drastic reduction in her symptoms. Pathologic evaluation of the resected symphysis showed chronic inflammatory changes consistent with osteitis pubis. She was followed for several months post-op and continued to do well, returning to many of her favorite daily activities. JAAPA

Chris Webb practices at PeaceHealth Medical Group, Eugene, Oregon. Matthew Jimenez practices at the Illinois Bone & Joint Institute, Chicago, Illinois; serves as medical director for a PA residency program in orthopedics at Lutheran General Hospital, Park Ridge, Illinois; and is on the faculty at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois. The authors have indicated no relationships to disclose relating to the content of this article.

REFERENCES

1. Canale ST, Daugherty K, Jones L, eds. Campbell's Operative Orthopaedics. Vol 1. 10th ed. St Louis, MO: Mosby; 2003.

2. O'Connell MJ, Powell T, McCaffrey NM, et al. Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes. AJR Am J Roentgenol. 2002;179(4):955-959.

3. Grace JN, Sim FH, Shives TC, Coventry MB. Wedge resection of the symphysis pubis for the treatment of osteitis pubis. J Bone Joint Surg. 1989;71(3):358-364.