Mild to moderate regional pubic pain during pregnancy and parturition is normal. Sometimes, however, the pain and symptoms are so severe that you have to consider more serious conditions.
Osteomyelitis ossis pubis, also known as septic arthritis of the pubic symphysis, is rare. General risk factors are noted to include female incontinence surgery (retropubic urethropexy), sports, trauma, diabetes, pelvic malignancies and intravenous drug abuse.1 2
The clinical findings are similar to those of pelvic girdle pain, pubic osteitis (non-bacterial inflammation) and separation or rupture of the pubic symphysis: severe pubic pain, painful and waddling gait, pain with hip motion, bladder dysfunction (difficulty voiding) and low-grade fever.
Mild leucocytosis is not uncommon in osteitis and symphysis rupture, but in cases of osteomyelitis, leucocytes, C reactive protein (CRP) and erythrocyte sediment rate (ESR) are significantly increased.
The radiological findings are similar to those of osteitis (non-bacterial inflammation). X-ray findings reveal reactive sclerosis, rarefaction and osteolytic changes all of which lag behind the symptoms and clinical findings by approximately 4 weeks (). Ultrasound examination may be more sensitive to show abscess formation. Some suggest a three-phase bone scan to differentiate between infection and inflammation, as increased uptake in all three phases pleads for osteomyelitis while the typical finding for osteitis is increased uptake in the mineralisation phase or delayed phase only.2
X-ray showing signs of osteitis or osteomyelitis at the pubic symphysis (reactive sclerosis, rarefaction, osteolysis and joint irregularity).
In a review of 100 cases of pubic osteomyelitis of different genesis, cultures of needle aspirates from the symphysis were positive in 19 of 22 (86%) while bacteraemia was detected in 32 of 44 (73%) cases examined.1
The pathogen isolated is usually Staphylococcus aureus
, in drug misusers. Pseudomonas aeruginosa
predominates and in patients with pelvic malignancies, polymicrobial flora involving faecal bacteria are found. In cases related to healthy womens' vaginal deliveries, aspirates/biopsies have shown the growth of S aureus
, P aeruginosa
, Streptococcus pneumoniae
and Streptococcus intermedius
Treatment of pubic osteomyelitis consists of long-term intravenous antibiotics and aspiration from the site, partly to ensure the diagnosis and partly to drain any abscess formation. Some have been treated with implants of antibiotic-impregnated beads. The review mentioned showed that surgical debridement was required in 55%, overall mortality was 2% while 8% developed chronic pelvic pain. Chronic urinary incontinence, urinary bladder perforation and pelvic instability are the complications described (the pubic symphysis accounts for approximately 40% of the pelvic stability).1 3 7
Since pubic osteomyelitis, if not treated properly, can result in serious short- or long-term complications, it is very important to diagnose the condition.
During a short period of time, we diagnosed two such cases with osteomyelitis of the pubic symphysis following normal vaginal deliveries. The diagnosis was verified by paraclinic, ultrasound and microbiological examination.