eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Osteitis Pubis: Treatment & Medication
Updated: Jul 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
Rest and time are the primary healing mechanisms. Physical therapy (PT) may be useful during the early stage. Modalities, such as heat or ice, may provide symptomatic relief. Progressive ambulation with the aid of an assistive device (eg, cane, crutches) and possible orthoses (eg, lumbar/sacral corset, sacroiliac belt) to unload the pelvis for pain relief and to maintain correct anatomical alignment may be necessary.5
Avoidance of any therapeutic exercise that may place stress on the pelvic ring is prudent. A home exercise program that includes pelvic tilts may be prescribed. Experienced therapists may attempt dynamic stabilization techniques.
Surgical Intervention
Different surgical approaches have been described, including curettage, arthrodesis, wedge resection, and wide resection.5,6 A report by Radic and Annear suggested that curettage is an effective treatment for athletes with osteitis pubis in whom nonoperative therapy has been unsuccessful.7 The investigators found that 21 of the study's 23 athletes were able to run without pain one and a half to 6 months following curettage of the pubis symphysis, while 17 of them returned to training two and half to 7 months after the procedure, and 16 of the athletes resumed full activity two and a half to 12 months after curettage.
Wedge resection of the pubis symphysis is another technique that can be performed on patients in whom conservative management has failed; however, the natural progression of osteitis pubis may require months, and in some cases years, to improve. Surgical intervention is associated with early improvement of symptoms but may lead to later posterior pelvic instability. This instability may then require a second surgical procedure for stabilization.
Other Treatment
- Manipulation is performed in some instances to correct anterior translation of the symphysis.
- Intra-articular glucocorticoid injections are controversial.
Medication
Nonsteroidal anti-inflammatory agents (NSAIDs) are the DOCs for treatment of osteitis pubis. Narcotics also are employed for pain control in some cases, usually in the obstetric or postsurgical patient. Limited case reports suggest that use of antibiotics and heparin also has been successful.
Nonsteroidal anti-inflammatory drugs
Most commonly used for relief of mild to moderate pain. Although ibuprofen is the DOC for initial therapy, other options include, but are not limited to, ketoprofen and naproxen.
Ibuprofen (Advil, Motrin, Midol, Nuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h; some patients may require doses as large as 800 mg PO q8h; not to exceed 3.2 g/d
Pediatric
<12 Months: Not established
12 months to 12 years: 10 mg/kg q6-8h; not to exceed 40 mg/kg/d
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; renal insufficiency; peptic ulcer disease; recent GI bleeding; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; caution in congestive heart failure; renal and hepatic dysfunction; hypertension; anticoagulation therapy (monitor levels)
Ketoprofen (Actron, Orudis, Oruvail)
For relief of mild to moderate pain and inflammation.
Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Cyclooxygenase-2 (COX-2) inhibitors
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results
More on Osteitis Pubis |
| Overview: Osteitis Pubis |
| Differential Diagnoses & Workup: Osteitis Pubis |
 Treatment & Medication: Osteitis Pubis |
| Follow-up: Osteitis Pubis |
| Multimedia: Osteitis Pubis |
| References |
| Further Reading |
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References
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Zoga AC, Kavanagh EC, Omar IM, et al. Athletic pubalgia and the "sports hernia": MR imaging findings. Radiology. Jun 2008;247(3):797-807. [Medline]. [Full Text].
Paajanen H, Hermunen H, Karonen J. Pubic magnetic resonance imaging findings in surgically and conservatively treated athletes with osteitis pubis compared to asymptomatic athletes during heavy training. Am J Sports Med. Jan 2008;36(1):117-21. [Medline].
Lovell G, Galloway H, Hopkins W, et al. Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad. Clin J Sport Med. Mar 2006;16(2):117-22. [Medline].
Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med. Sep 30 2008;[Medline].
Mehin R, Meek R, O'Brien P, et al. Surgery for osteitis pubis. Can J Surg. Jun 2006;49(3):170-6. [Medline]. [Full Text].
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Harris NH, Murray RO. Lesions of the symphysis in athletes. Br Med J. Oct 26 1974;4(5938):211-4. [Medline].
Holmgren G. The treatment of osteitis pubis with anticoagulants. A report of three cases in Africans. Cent Afr J Med. Jan 1972;18(1):10-2. [Medline].
Michiels E, Knockaert DC, Vanneste SB. Infectious osteitis pubis. Neth J Med. Jun 1990;36(5-6):297-300.
Moore RS, Stover MD, Matta JM. Late posterior instability of the pelvis after resection of the symphysis pubis for the treatment of osteitis pubis. A report of two cases. J Bone Joint Surg Am. Jul 1998;80(7):1043-8. [Medline].
Pizzarello LD, Golden GT, Shaw A. Acute abdominal pain caused by osteitis pubis. Am Surg. Nov 1974;40(11):660-1. [Medline].
Vincent C. Osteitis pubis [published erratum appears in J Am Board Fam Pract 1993 Nov-Dec;6(6):616]. J Am Board Fam Pract. Sep-Oct 1993;6(5):492-6. [Medline].
Wiley JJ. Traumatic osteitis pubis: the gracilis syndrome. Am J Sports Med. Sep-Oct 1983;11(5):360-63. [Medline].
Further Reading
Related eMedicine articles:
Adductor Strain
Groin Injury
Osteitis Pubis [Sports Medicine]
Keywords
osteitis pubis, pelvic pain, groin pain, pubis, osteitis, symphysis, pubic symphysis, pubis symphysis, symphysis pubis, symphysis pubica, symphysis dysfunction, pubis dysfunction, symphyseal separation, pubis diathesis, gracilis syndrome
