Rapid response to intravenous corticosteroids in osteitis pubis after Marshall–Marchetti–Krantz urethropexy

C. Garcia-Porrua, M. A. Gonzalez-Gay and J. A. Picallo1

Rheumatology and
1 Urology Divisions, Hospital-Xeral Calde, 27004, Lugo, Spain

SIR, Osteitis pubis is a painful inflammatory condition that involves the pubic bone, symphysis and surrounding structures [1]. It is an infrequent complication of pelvic surgery, parturition or athletic activities [2, 3]. It occurs in only 0.74% of instances after Marshall–Marchetti–Krantz urethropexy [3] and its aetiology, pathogenesis and optimal treatment remains controversial [4]. We report a case of osteitis pubis after Marshall–Marchetti–Krantz urethropexy with impressive radiographic changes, and a rapid response to intravenous steroids.

A 60-yr-old woman was sent to our Rheumatology Division because of pubic pain. One year previously she had been diagnosed as having urinary incontinence, and consequently underwent Marshall–Marchetti–Krantz urethropexy. Forty-five days after surgery, she began to notice low abdominal pain and pubic tenderness. Urological study did not disclose any pathological changes. Four months after surgery she was referred to our unit because of persistent pubic pain. On admission, she complained of pain in the pubic area, both groins and the lower rectus abdominis muscles. The pain prevented her from walking. Physical examination revealed a temperature of 36.7°C, severe pubic pain and the impossibility of hip abduction. The erythrocyte sedimentation rate (31 mm/h) and C-reactive protein (12 mg/l; normal <5 mg/l) were slightly elevated. No abnormality of other laboratory parameters was found. The chest radiograph was also normal. A pelvis radiograph performed before surgery was normal (Fig. 1Go) and a new pelvis radiograph performed 4 months after surgery showed rarefaction and osteolytic changes of the pubic symphysis (Fig. 2AGo). Pubic osteomyelitis and malignant neoplasm were considered, and for this reason needle bone biopsy and culture were performed. A closed, CT-guided needle biopsy disclosed avascular necrotic tissue. Bone culture was negative. Bed rest and intravenous glucocorticoids (methylprednisolone 40 mg every 8 h) for 3 days yielded rapid improvement of symptoms. A pelvis radiograph performed 1 yr later also showed radiographic improvement (Fig. 2BGo).



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FIG. 1. Pelvis radiograph performed before surgery, showing no important changes.

 


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FIG. 2. (A) Pelvis radiograph performed 4 months after surgery showing widening, rarefaction, irregularity and osteolytic and sclerotic changes of pubic symphysis. (B) Pelvis radiograph performed 1 yr later, showing sclerotic reaction of pubic symphysis.

 
The diagnosis of osteitis pubis is based on physical and radiographic examinations. Our patient had suffered pelvic surgery and one and a half months later she began to suffer from abdominal and pubic pain. At that time no diagnosis was made and treatment was not considered. However, since then she recalled progressive and insidious worsening of symptoms. Indeed, at the time she was examined in our Division, the radiographic changes of the pubis were striking. In osteitis pubis, when bone is cultured, organisms are obtained 71% of the time [3]. In our case septic or malignant conditions [46] were excluded by the closed CT-guided needle biopsy and, although some authors recommend an open biopsy if a needle biopsy is inconclusive [4, 7], treatment with bed rest and intravenous glucocorticoids was sufficient to yield a dramatic improvement of symptoms.

Treatment of non-infectious osteitis pubis is usually with non-steroidal anti-inflammatory drugs [1]. Introduction of local steroids into the pubic joint results in a quicker return to activity in college athletes [8], but intravenous steroid therapy is not standard and its efficacy should be studied prospectively.

Notes

Correspondence to: M. A. González-Gay, Division of Rheumatology, Hospital Xeral-Calde, c/ Dr Ochoa s/n, 27004 Lugo, Spain. Back

References

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  4. Sexton DJ, Heskestad L, Lambeth WR, McCallum R, Levin LS, Corey GR. Postoperative pubic osteomyelitis misdiagnosed as osteitis pubis: report of four cases and review. Clin Infect Dis1993;17:695–700.[ISI][Medline]
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  8. Holt MA, Keene JS, Graf BK, Helwig DC. Treatment of osteitis pubis in athletes. Results of corticosteroid injections. Am J Sports Med1995;25:601–6.
Accepted 14 March 2000





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