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An unusual cause of inguinal pain

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Q1: What is the diagnosis?

The diagnosis is osteitis pubis. However, a differential diagnosis of hernia had to be considered because of increase in pain on cough and strain. Multiple myeloma and secondaries were also kept in differential diagnosis on account of age and peculiar site of pain. Avascular necrosis, stress fractures, and bursitis were also kept in the differential diagnosis.

Q2: What are the diagnostic modalities that are helpful in diagnosis?

Magnetic resonance imaging and technetium-99m MDP bone scan are the most helpful diagnostic modalities in the early phase of disability. However, the most characteristic changes seen are in radiographs. These changes appear two to three weeks after onset of symptoms. Progressive radiographs show resorption of the medial end of the pubic bone, widening of the pubic symphysis, and rarefaction along pubic rami.1

Q3: What is the aetiopathogenesis in this case?

Disease may in some way be related to partial separation of sites of attachment of adductor tendons. This is suggested by complete relief obtained by local anaesthetisation and repeated needling of the area. Thus after transurethral prostatectomy, osteitis pubis may in some way be related to trauma to the adductor tendon attachment during patient positioning and procedure. It may also be related to subclinical or overt infection causing subacute osteomyelites locally. The consistent relation of symptoms with decreasing haemoglobin and rising leucocytosis suggests an inflammatory/infective origin.

(4) What is the treatment recommended for this condition?

It is a self limiting condition. Treatment is rest and non-steroidal anti-inflammatory drugs. If pain continues, repeated needling of the area may be helpful. Rarely, operative resection of symphysis may be helpful after conservative trial for six months.2

Discussion

Osteitis pubis as a complication of gynaecological and urological surgery has been reported as a rare complication,3 but this morbidity as a sequel of transurethral prostatectomy has not been reported in the medical literature. Osteitis pubis is a painful, non-infectious, inflammatory condition involving the pubic bone, symphysis, and surrounding structures.4 It has been reported after various urological and gynaecological procedures. A gradual onset pain in the pubic region is the primary complaint. Eventually, increasing pain makes ambulation difficult and an antalgic or waddling gait develops. Position of comfort is in adduction and flexion.5

After transurethral resection of prostrate, mid-inguinal pain may be related to osteitis pubis apart from more common causes like hernia, osteomylites, bursitis, Avascular necrosis, secondaries or stress fractures.

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