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HISTORY:
Both of these female patients are complaining of focal pain at the pubic articulation. One of them developed this pain after a difficult delivery of a child and the other patient after surgery for a retroverted uterus.
Figures 1 & 2. Characteristic changes are visible at the pubic symphysis with subchondral sclerosis, articular erosions, small osteophyte formation and a slight offset of the pubic bones. This radiographic appearance is characteristic of osteitis pubis.
Discussion:
Osteitis pubis is a painful condition of the pubic symphysis articulation characterized by bony resorption and spontaneous reossification. Although the pathogenesis is uncertain, the most common related antecedent event is surgery within close proximity to the symphysis.1
Clinical Features
Onset of signs and symptoms is usually within one to three months after surgery in the locality of the symphysis pubis articulation. The frequency of this postsurgical complication is between 1 percent and 3 percent. The most common types of surgery are for the prostate, bladder, urethra, uterus and cervix. Statistically, prostate surgery is the most commonly associated surgical procedure. Additional causes include pregnancy, trauma, and, often, unknown factors.1
Symptomology may be localized or referred and is usually described as groin burning.2 Pain is often excruciating on direct palpation. Exercise or activities involving thigh adduction, trunk flexion or even walking may refer pain to the perineal, testicular, suprapubic or inguinal area. In addition, an audible click in the area of the pubic symphysis may be heard during these activities. Postejaculatory pain referral to the scrotum and perineum has been noted in males. The symptoms are generally relieved by rest. Redness or heat is usually not present. The gait is antalgic, with trunk flexion and waddling to prevent symphyseal stress.
Pain typically subsides over an indefinite period up to one or two years, but may require arthrodesis.1,3 With persistent pain and biomechanical alterations in gait, early sacroiliac degenerative changes could ensue.2
Radiologic Features
There is a radiographic latent period after the onset of symptoms of one to three weeks; however, some patients will never manifest definitive radiologic changes. When present, the findings may simulate joint infection.1,2
The most characteristic radiographic appearance is a bilateral and usually symmetric involvement of the pubic bone and adjacent rami. Irregularity of the joint margin, subchondral sclerosis, and a moth-eaten type of osteoporosis, with widening of the joint space can be striking. 3 With resolution, there is reconstitution of normal bone density, but the joint margin frequently remains irregular and may even be ankylosed.1
References
1. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3rd ed., Williams & Wilkins, Baltimore, Maryland, 2005.
2. Cibert J: Post-Operative Osteitis Pubis Cause and Treatment, Br. J. Urol, 24:213, 1952.
3. Pauli S, et al., Osteomyelitis Pubis Versus Osteitis Pubis, Br. J. Sports Med. (1):71, 2002
Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 303-940-9400 or by e-mail at [email protected].
Dr. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 303-690-8503 or e-mail [email protected].