Medication Summary
The goals of medical intervention for osteitis pubis are to decrease inflammation and to control pain. The major concern with all the drugs that are used is the effects they have on the gastrointestinal (GI) tract with long-term use. Long-term use of corticosteroids has myriad adverse effects, which are beyond the scope of this article, but should be recognized and considered.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs of choice for treating osteitis pubis. Narcotics also are employed for pain control in some cases, usually in the obstetric or postoperative patient. Limited case reports suggest that antibiotics and heparin have also been successful.
Nonsteroidal Anti-inflammatory Drugs
Class Summary
NSAIDs are used to help reduce inflammation and relieve mild-to-moderate pain. Multiple drugs are in this class, and every physician should be aware of the drugs in each subclass; some patients respond better to one subclass than another. Ibuprofen is the drug of choice for initial therapy. Other options include, but are not limited to, ketoprofen and naproxen.
Although increased cost can be a negative factor, the incidence of costly and potentially fatal cases of GI bleeding is clearly lower with cyclooxygenase (COX)–2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeding will further define the populations that will find COX-2 inhibitors the most beneficial.
Ketoprofen
Ketoprofen has good anti-inflammatory properties and exceptional analgesic properties. It is a first-line medication because of its daily dosing, which helps with compliance. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.
Indomethacin (Indocin)
Indomethacin is thought to be the most effective NSAID for the treatment of ankylosing spondylitis, although no scientific evidence supports this claim. It is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis. It is not always as easily tolerated by the GI system as other NSAIDs.
Naproxen or naproxen sodium (Naprelan, Naprosyn, Aleve, Anaprox)
Naproxen is used for relief of mild-to-moderate pain and inflammation; it inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis. Naproxen is available in many dosages and delivery systems. It is fairly inexpensive and has a therapeutic profile similar to those of other NSAIDs. An oral suspension (125 mg/mL) is available.
Ibuprofen (Advil, Motrin, NeoProfen)
Ibuprofen is the drug of choice for patients with mild-to-moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Diclofenac (Voltaren, Cataflam XR, Zipsor, Cambia)
Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.
Celecoxib (Celebrex)
Celecoxib primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to the GI toxicity of NSAIDs. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. The lowest dose that is effective in a given patient should be given.
Corticosteroids
Class Summary
Corticosteroids are among of the strongest anti-inflammatory agents available. The injectable preparations make it possible to deliver the drug directly to the affected joint in a concentrated dose, while greatly decreasing the systemic effects.
Prednisone (Rayos)
Prednisone is used in cases where the inflammation is severe and steroid injections are contraindicated. Because of its systemic effects, it must be used with great caution.
Prednisolone (Millipred, Orapred, Orapred ODT, Prelone)
Corticosteroids act as potent inhibitors of inflammation. They may cause profound and varied metabolic effects, particularly in relation to salt, water, and glucose tolerance, in addition to their modification of the immune response of the body. Alternative corticosteroids may be used in equivalent dosage.
Betamethasone (Celestone, Celestone Soluspan)
Betamethasone is the author's drug of choice for intra-articular injections. It does not crystallize if used with paraben-free anesthetic preparations.
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Radiograph in 19-year-old athlete who presented with 3-week history of groin pull that was not resolving. On clinical examination, pubic spring test reproduced patient's pain, and radiograph was obtained. This image shows classic sclerosis and lysis findings of osteitis pubis around pubic symphysis, with widening of symphysis.
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Magnetic resonance image (MRI) from 20-year-old National Hockey League (NHL) player who presented with complaint of pain in testicles, which was worse with skating and with performing off-ice plyometric conditioning. MRI of pelvis combined with history and physical examination indicated diagnosis of osteitis pubis.
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Pelvis, frontal view.
