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Osteomyelitis of the Pubic Symphysis After Urologic Surgery
Tm, JounNAL oF UROLOGY
Vol.
Copyright © 1977 by The Williams & Wilkins Co.
OSTEOMYELITIS
Nove:r,1hex inU.SA.
THE PUBIC SYMPHYSIS AFTER SURGERY
JOHN R. BURNS
AND
JOHN G. GREGORY*
From the Diuision of Urology, St. Louis Uniuersity School of Medicine, St. Louis, Missouri
ABSTRACT
represents a pyogenic infection of the bone and marrow. The diagnosis is based on criteria and often is difficult to make. Herein we present 2 cases initially thought to represent osteitis pubis but subsequently proved to be osteomyelitis and compare the 2 entities, with emphasis on differential ~"'~""'""~•JW and treatment. Despite certain differentiating characteristics the correct diagnosis is often uncertain without histologic examination. Since the treatment of these 2 entities is different cases should undergo surgical exploration and bone This ~~A~,~,.., will definite diagnosis to be made and proper treatment to be Case 2. M. B., a 64-year-old woman, was uu,-;µi.cct.uz.,su for urinary stress incontinence. After evaluation a Marshall-Marchetti procedure was done. Convalescence was uneventful and the patient was discharged from the 8 postoperatively. She was rehospitalized 5 days later with chills and suprapubic pain. Physical examination revealed marked tenderness over the pubic symphysis. Temperature was 103F_ Urine culture revealed greater than lO(i Pseudomonas and blood culture yielded Serratieae. Initially, the
Osteitis
uncommon ~v,u,.,-u~a,,,vu that of urologic procedures_ Its incidence but UAHUac,ac, 1 to 2 cent. In contrast, of the bone is a described In the last year we have had the opportunity to cases of osteomyelitis of the pubic symphysis. These cases differ from those reported in that neither involved trauma both occurred after urologic procedures. CASE REPORTS
Case L N. H., a man, first presented with an calculus at the left ureterovesical junction. After an unsuccessful basketing c,tJ-c,n,nt a transvesical ureterolithowas done. Convalescence was complicated excessive drainage around the cystostomy tube. The drainage nPrn'R'"'"' markedly after removal of the tube and the from the was cHu" 1-.11cccu.,,eu 2 months later with pain abdominal incision and i.n the left examination revealed tenderness over and minimal drainage from the inferior incision. Temperature was 98.6F. Urine and wound cultures greater than 10u Pseudomonas. Pelvic x-rays ¥.,ere normal. The patient was treated with indomethacin and oral carbenicillin sodium with relief of ,,.uµa-c.ccu
was again "~"'f''ccu«,cu 3 months later with bilateral pain. examination revealed marked tenderness and persistence of a small draining sinus tract at the inferior border of the old incision. Pelvic xwith tomograms showed an irregularity of the margins believed to be compatible with osteitis (fig. 1). Because of the prolonged course incision and of rami were performed. \J\Then the rami were curetted amount of material was seen from The was left open and packed. Urine, sinus tract and bone culture yielded Pseudomonas. Pathologic examination of the bone was consistent with osteomyelitis. After a 3-week course of intravenous carbenicillin indanyl sodium the was discharged from the hospital with no symptoms.
FIG. 1. Case 1. Tomograrn of pubis shows irregularity ofleft pubir: ramus.
Acce1Jtea for publication March 25, 1977. at annual meeting of the South Central Section, American Association, San Antonio, Texas, September 12-16, 1976, for reprints: Division of Urology, St. Louis University Medicine, 1325 S. Grand Blvd., St. Louis, Missouri 63104. 803
started on intravenous carbenicillin indanyl sodium, which was later changed to gentamicin sulfate. Pelvic normal. Although she rapidly became afebrile persisted. Repeat x-rays showed a lucency of the ramus, suggestive of osteomyelitis (fig. 2, A). A showed progression of bony destruction (fig. 2, B). weeks of antibiotic therapy curettage of the area was formed. Although the debris was sterile on culture it was histologically consistent with osteomyelitis. Convalescence was uneventful and the patient was discharged from the hospital 2 weeks later (fig. 3).
804
BURNS AND GREGORY
FIG. 2. Case 2. A, pelvic x-ray demonstrates lucency of right superior ramus. B, progression of bony destruction bilaterally.
thighs. Pain often forces the patient to assume a duck waddling gait. 1 Low grade fever is common. Radiologic abnormalities occur 2 to 4 weeks after the onset of symptoms. The picture may vary from minimal fraying of the periosteum to a moth eaten appearance of the entire symphysis. 1 Healing normally results in complete restoration of bone. The etiology of osteitis pubis remains unclear. Factors thought to be associated with its development include trauma, infection and impaired venous circulation to the symphysis. 2 • 3 Various therapeutic regimens have been advocated for the treatment of osteitis pubis. In the early stage of the disease antibiotics, heat, muscle relaxants and bed rest frequently are effective. In more chronic forms vitamin B therapy, radiation, cortisone, incision and drainage of the retropubic space, diathermy, adrenocorticotropic hormone and bone curettage have been effective.H Recently, oxyphenbutazone and heparin therapy have been used. 7 • 8 This long list would seem to suggest that the optimal treatment has yet to be found. Osteomyelitis represents a pyogenic infection of the bone and marrow. Recently, emphasis was placed on the difficulty in diagnosis. Acceptability as a bona fide case of osteomyelitis requires at least 2 of the following 3 criteria: 1) characteristic radiologic changes, 2) typical histologic changes on bone biopsy and 3) bacteriologic corroboration. 9 Most cases of osteomyelitis of the pubic bone previously described are related to cases of pelvic fracture with subsequent urinary extravasation, which is in contrast to both of our cases and to the majority of cases of osteitis pubis that occur postoperatively. Clinically, it is often impossible to differentiate between osteitis pubis and osteomyelitis. Both conditions may present as a low grade fever with leukocytosis and both show signs of local inflammation. The presence of a persistent sinus or ulceration with drainage points toward osteomyelitis. The differential diagnosis usually is based upon the radiographic findings. In osteitis pubis common findings include rarefaction and superficial bone destruction, never transecting bone. 10 The lesion usually is bilateral and symmetrical (fig. 4). In osteomyelitis the process is more localized. Large segments of bone devoid of blood supply can become separated to form the sequestra seen on x-rays. Healing often occurs with the formation of new bone. The radiologic changes usually are delayed in osteomyelitis. A significant percentage of patients show worsening of the radiologic picture while they are improving clinically. Therefore, one cannot base the adequacy of treatment solely on radiologic criteria.
FIG. 3. Case 2. Postoperative appearance of pubis
DISCUSSION
Osteitis pubis is an uncommon self-limiting disease affecting the pubic symphysis. It is seen most commonly after a bladder or prostate operation. It has been associated with ureterolithotomy, transurethral resections of the prostate and has even been described in abortion and normal delivery. Symptoms appear 2 weeks to 3 months postoperatively and consist of the acute onset of pain over the pubis and inner
FIG. 4. Appearance of pubis in typical case of osteitis pubis
OSTEOMYELITIS OF PU!!IC SYMPHYSIS AFTER UROLOGIC SURGERY
In with a
to
REFERENCES
VV. C. and Malament, M.: Osteitis pubis. Surg., Gynec. 117: 277, 1963. Steinback, fL L., Petrakis, :N. L., Gilfillan, R 8. and R: The suuc,;~u.~o,o of osteitis pubis. J. UroL, 74: 840, 3. E.: andostitisofthe rn1,;uy~,.~andrnmiofthe following sto,tm11iios , 20: 233, 1928. 4. Laval.le, L. L. and and treatment. J. UroL, 83, 1949. 5. lWa:rshall V. F., Vifhitr11ore 'W. F., Jr., Petro, /?'l._. T.) Poppell, J. 1
1
W., Grant, R R and Rawson, K W.: Osteitis with adlreno,cortJrrYt.r,m11whormone. J. UroL, 67: 6. Goldstein, A. K and S. W.: Osteitis pubis following results with deep roentgen 1947. 7.
8. 9.
1974. N .. Osteomyelitis: consideratio:n.s anr:!
New EngL 10.
following vesj_courethral 1964,.
Vol.
Copyright © 1977 by The Williams & Wilkins Co.
OSTEOMYELITIS
Nove:r,1hex inU.SA.
THE PUBIC SYMPHYSIS AFTER SURGERY
JOHN R. BURNS
AND
JOHN G. GREGORY*
From the Diuision of Urology, St. Louis Uniuersity School of Medicine, St. Louis, Missouri
ABSTRACT
represents a pyogenic infection of the bone and marrow. The diagnosis is based on criteria and often is difficult to make. Herein we present 2 cases initially thought to represent osteitis pubis but subsequently proved to be osteomyelitis and compare the 2 entities, with emphasis on differential ~"'~""'""~•JW and treatment. Despite certain differentiating characteristics the correct diagnosis is often uncertain without histologic examination. Since the treatment of these 2 entities is different cases should undergo surgical exploration and bone This ~~A~,~,.., will definite diagnosis to be made and proper treatment to be Case 2. M. B., a 64-year-old woman, was uu,-;µi.cct.uz.,su for urinary stress incontinence. After evaluation a Marshall-Marchetti procedure was done. Convalescence was uneventful and the patient was discharged from the 8 postoperatively. She was rehospitalized 5 days later with chills and suprapubic pain. Physical examination revealed marked tenderness over the pubic symphysis. Temperature was 103F_ Urine culture revealed greater than lO(i Pseudomonas and blood culture yielded Serratieae. Initially, the
Osteitis
uncommon ~v,u,.,-u~a,,,vu that of urologic procedures_ Its incidence but UAHUac,ac, 1 to 2 cent. In contrast, of the bone is a described In the last year we have had the opportunity to cases of osteomyelitis of the pubic symphysis. These cases differ from those reported in that neither involved trauma both occurred after urologic procedures. CASE REPORTS
Case L N. H., a man, first presented with an calculus at the left ureterovesical junction. After an unsuccessful basketing c,tJ-c,n,nt a transvesical ureterolithowas done. Convalescence was complicated excessive drainage around the cystostomy tube. The drainage nPrn'R'"'"' markedly after removal of the tube and the from the was cHu" 1-.11cccu.,,eu 2 months later with pain abdominal incision and i.n the left examination revealed tenderness over and minimal drainage from the inferior incision. Temperature was 98.6F. Urine and wound cultures greater than 10u Pseudomonas. Pelvic x-rays ¥.,ere normal. The patient was treated with indomethacin and oral carbenicillin sodium with relief of ,,.uµa-c.ccu
was again "~"'f''ccu«,cu 3 months later with bilateral pain. examination revealed marked tenderness and persistence of a small draining sinus tract at the inferior border of the old incision. Pelvic xwith tomograms showed an irregularity of the margins believed to be compatible with osteitis (fig. 1). Because of the prolonged course incision and of rami were performed. \J\Then the rami were curetted amount of material was seen from The was left open and packed. Urine, sinus tract and bone culture yielded Pseudomonas. Pathologic examination of the bone was consistent with osteomyelitis. After a 3-week course of intravenous carbenicillin indanyl sodium the was discharged from the hospital with no symptoms.
FIG. 1. Case 1. Tomograrn of pubis shows irregularity ofleft pubir: ramus.
Acce1Jtea for publication March 25, 1977. at annual meeting of the South Central Section, American Association, San Antonio, Texas, September 12-16, 1976, for reprints: Division of Urology, St. Louis University Medicine, 1325 S. Grand Blvd., St. Louis, Missouri 63104. 803
started on intravenous carbenicillin indanyl sodium, which was later changed to gentamicin sulfate. Pelvic normal. Although she rapidly became afebrile persisted. Repeat x-rays showed a lucency of the ramus, suggestive of osteomyelitis (fig. 2, A). A showed progression of bony destruction (fig. 2, B). weeks of antibiotic therapy curettage of the area was formed. Although the debris was sterile on culture it was histologically consistent with osteomyelitis. Convalescence was uneventful and the patient was discharged from the hospital 2 weeks later (fig. 3).
804
BURNS AND GREGORY
FIG. 2. Case 2. A, pelvic x-ray demonstrates lucency of right superior ramus. B, progression of bony destruction bilaterally.
thighs. Pain often forces the patient to assume a duck waddling gait. 1 Low grade fever is common. Radiologic abnormalities occur 2 to 4 weeks after the onset of symptoms. The picture may vary from minimal fraying of the periosteum to a moth eaten appearance of the entire symphysis. 1 Healing normally results in complete restoration of bone. The etiology of osteitis pubis remains unclear. Factors thought to be associated with its development include trauma, infection and impaired venous circulation to the symphysis. 2 • 3 Various therapeutic regimens have been advocated for the treatment of osteitis pubis. In the early stage of the disease antibiotics, heat, muscle relaxants and bed rest frequently are effective. In more chronic forms vitamin B therapy, radiation, cortisone, incision and drainage of the retropubic space, diathermy, adrenocorticotropic hormone and bone curettage have been effective.H Recently, oxyphenbutazone and heparin therapy have been used. 7 • 8 This long list would seem to suggest that the optimal treatment has yet to be found. Osteomyelitis represents a pyogenic infection of the bone and marrow. Recently, emphasis was placed on the difficulty in diagnosis. Acceptability as a bona fide case of osteomyelitis requires at least 2 of the following 3 criteria: 1) characteristic radiologic changes, 2) typical histologic changes on bone biopsy and 3) bacteriologic corroboration. 9 Most cases of osteomyelitis of the pubic bone previously described are related to cases of pelvic fracture with subsequent urinary extravasation, which is in contrast to both of our cases and to the majority of cases of osteitis pubis that occur postoperatively. Clinically, it is often impossible to differentiate between osteitis pubis and osteomyelitis. Both conditions may present as a low grade fever with leukocytosis and both show signs of local inflammation. The presence of a persistent sinus or ulceration with drainage points toward osteomyelitis. The differential diagnosis usually is based upon the radiographic findings. In osteitis pubis common findings include rarefaction and superficial bone destruction, never transecting bone. 10 The lesion usually is bilateral and symmetrical (fig. 4). In osteomyelitis the process is more localized. Large segments of bone devoid of blood supply can become separated to form the sequestra seen on x-rays. Healing often occurs with the formation of new bone. The radiologic changes usually are delayed in osteomyelitis. A significant percentage of patients show worsening of the radiologic picture while they are improving clinically. Therefore, one cannot base the adequacy of treatment solely on radiologic criteria.
FIG. 3. Case 2. Postoperative appearance of pubis
DISCUSSION
Osteitis pubis is an uncommon self-limiting disease affecting the pubic symphysis. It is seen most commonly after a bladder or prostate operation. It has been associated with ureterolithotomy, transurethral resections of the prostate and has even been described in abortion and normal delivery. Symptoms appear 2 weeks to 3 months postoperatively and consist of the acute onset of pain over the pubis and inner
FIG. 4. Appearance of pubis in typical case of osteitis pubis
OSTEOMYELITIS OF PU!!IC SYMPHYSIS AFTER UROLOGIC SURGERY
In with a
to
REFERENCES
VV. C. and Malament, M.: Osteitis pubis. Surg., Gynec. 117: 277, 1963. Steinback, fL L., Petrakis, :N. L., Gilfillan, R 8. and R: The suuc,;~u.~o,o of osteitis pubis. J. UroL, 74: 840, 3. E.: andostitisofthe rn1,;uy~,.~andrnmiofthe following sto,tm11iios , 20: 233, 1928. 4. Laval.le, L. L. and and treatment. J. UroL, 83, 1949. 5. lWa:rshall V. F., Vifhitr11ore 'W. F., Jr., Petro, /?'l._. T.) Poppell, J. 1
1
W., Grant, R R and Rawson, K W.: Osteitis with adlreno,cortJrrYt.r,m11whormone. J. UroL, 67: 6. Goldstein, A. K and S. W.: Osteitis pubis following results with deep roentgen 1947. 7.
8. 9.
1974. N .. Osteomyelitis: consideratio:n.s anr:!
New EngL 10.
following vesj_courethral 1964,.