Zoey Hart: A 25-Year-Old Female With Suprapubic Pain

Learning Objectives

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Learn the common causes of groin pain.
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Develop an understanding of the anatomy of the nerves of the groin and pelvis.
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Develop an understanding of the anatomy of the symphysis pubis.
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Develop an understanding of the causes of osteitis pubis.
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Learn the clinical presentation of osteitis pubis.
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Learn how to use physical examination to identify osteitis pubis.
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Develop an understanding of the treatment options for osteitis pubis.
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Learn the appropriate testing options to help diagnose osteitis pubis.
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Learn to identify red flags in patients who present with groin pain.
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Develop an understanding of the role in interventional pain management in the treatment of osteitis pubis.

Zoey Hart

Zoey Hart is a 25-years-old physical therapist with the chief complaint of, “I’ve got pain in my suprapubic region ever since my C-section.” Zoey went on to say that she had a bad urinary tract infection following the placement of a urinary catheter that was a real pistol to get rid of. “I took six different antibiotics before we got a handle on it. It made the first few weeks at home a real nightmare. No breast feeding, constantly getting up to pee—it was no fun at all.” I asked if Zoey knew what they cultured and she said that her cultures never grew anything, which made it all the more frustrating. “The UTI symptoms are better, but I am still having a lot of suprapubic pain. I feel like the pain is making me walk funny. My gait is really off, so I have to waddle like a duck.”

I asked Zoey if she had any fever or chills with her urinary tract infection and she shook her head and said that she didn’t think so. “I just had to pee about 500 times a day.” I asked Zoey if this was her first child and she smiled brightly and said, “Yes, and she is a real angel! Doctor, it’s been great except for this pain. At first I thought it was just a combination of the UTI and post-C-section pain, but as I healed up, the suprapubic pain just didn’t go away. The pain and the crazy walking thing have made it really hard to get back in shape and lose weight.”

I asked Zoey if she had ever had anything like this before and she shook her head no. She also denied any current urinary or gynecologic symptoms, hematuria, or fever or chills. She also denied a history of kidney stones. She had started her periods again with her last menstrual period a week ago. Zoey was using oral contraceptives, but volunteered that the pelvic pain made sex pretty unpleasant. I asked what she was doing to manage the pain and she said that “nothing really works.” I asked her to rate her pain on a scale of 1 to 10, with 10 being the worst pain she had ever had. She said the pain was a 7 or 8. “Doctor, if I have to live with the pain, I can, but it is interfering with everything—getting dressed, walking, exercise, taking care of my daughter, sex—everything. I just really need to get my life back on track.”

I asked Zoey to point with one finger to show me where it hurt the most. She pointed to her suprapubic area and said, “Doc, the pain is right here. The C-section incision is all healed up and although I won’t be wearing a bikini any time soon, it really doesn’t hurt, but there is this spot right here in the center right over my pubic bone that is really killing me.”

On physical examination, Zoey was afebrile. Her respirations were 16. Her pulse was 72 and regular. Her blood pressure (BP) was normal at 112/72. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination was negative. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Her lower extremity neurologic examination was completely normal. I asked Zoey to lie back on the examination table with her knees bent so we could take a closer look at her cesarean section scar. Visual inspection of the scar revealed no obvious defect or infection. Inspection of the groin revealed no obvious abnormal mass or inguinal hernia. I again asked Zoey to use one finger to point to the spot that hurt, and she carefully pointed to a spot overlying the pubic symphysis ( Fig. 8.1 ). I asked Zoey if I could palpate the spot she identified, and after a moment’s hesitation she nodded yes and said, “Sure, but be gentle. It really is sensitive.” I said, “No problem, why don’t you hold my hand and you do the pushing and I’ll do the feeling and together we’ll figure out what is going on.” She liked that idea and I had Zoey guide my index finger to the spot that was causing the trouble. The spot was right over the symphysis pubis, and when Zoey tentatively pushed my index finger a little harder, I felt her suddenly withdraw her pelvis as she said, “Right there!” I said, “I think I know what’s going on. How about getting up and walking down the hall for me?” She carefully sat up and slid off the exam table. As she took off down the hall, I immediately noticed a waddling gait and I was pretty sure that I had my answer as to what was causing Zoey’s pain and physical disability ( Fig. 8.2 ).

Key Clinical Points—What’s Important and What’s Not

The History

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A history of the recent onset of suprapubic pain following a cesarean section, which was complicated by persistent urinary tract infections
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No history of gynecologic symptoms related to the pain
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No history of kidney stones
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No history of hematuria
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Difficulty in ambulating without suprapubic pain
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Abnormal waddling gait noted by patient
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Pain is localized to symphysis pubis
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No fever or chills

The Physical Examination

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The patient is afebrile
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Normal visual inspection of the cesarean section scar
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Palpation of the symphysis pubis elicits pain
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Patient has waddling gait (see Fig. 8.2 )
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The lower extremity neurologic examination is within normal limits

Other Findings of Note

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Normal BP
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Normal HEENT examination
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Normal cardiopulmonary examination
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Normal abdominal examination
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No peripheral edema
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No groin mass or inguinal hernia
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No CVA tenderness

What Tests Would You Like to Order?

The following tests were ordered:

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X-ray of pelvis with special attention to the symphysis pubis
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Magnetic resonance imaging (MRI) of the pelvis with special attention to the symphysis pubis

Test Results

Plain radiograph of the pelvis demonstrates noninfectious changes of the symphysis pubis consistent with osteitis pubis ( Fig. 8.3 ). MRI of the pelvis reveals high signal intensity marrow edema in both pubic bones as well as periosteal edema consistent with osteitis pubis ( Fig. 8.4 ).