A CAJM report on Africans on the treatment of Osteitis Pubis with Anticoagulants in Zimbabwe (Rhodesia

Holmgren, G.

Central African Journal of Medicine

English

IDS OpenDocs

The Centra] African Journal of Medicine
l O r D A V I D  L I V I N G S T O N E
I
Editor: j(,
MICHAEL GELFAND, C.B.E., M.D., F.R.C.P. 'j
Assistant Editor:
JOSEPH RITCHKEN, M.D.
Volume Eighteen 
JANUARY- DECEMBER 
1972
c'ib il/_____
3 6 0 0 1 8 3 6 8 1 8 L ib r a r y
Vol. 18. No. 1. January, 1972. T h e  Ce n t r a l  A fr ic a nJ o u rn al  of M e d ic in e
The Treatment of Osteitis Pubis 
with Anticoagulants
A REPORT OF THREE CASES IN 
AFRICANS
BY
GUNNAR HOLMGREN,
B.SC., M.B., CH.B. (BIRM.)
Harare Hospital
Case 1.
W.M. is a 66-year-old farm labourer from near 
Beatrice, Rhodesia. He presented to Harare Hos­
pital on the 6th January, 1971, with a history of 
inability to pass urine for three days. He was 
found to have acute retention of urine, with a 
moderately enlarged prostate.
Transvesical prostatectomy was carried out on 
the 15th January. Histology showed a benign 
hyperplasia of the prostate with no evidence of 
malignancy.
He had a stormy post-operative period with clot 
retention, developing sepsis in the wound, and 
ultimately a suprapubic urinary fistula which did 
not close. It was thought that he had a stricture 
of the urethra and bouginage was performed on 
the 1st February. Four days later he suddenly 
collapsed with what appeared to be septicaemie 
shock. He responded well to vigorous medical 
measures.
On the 3rd of March, six and a half weeks after 
his original operation, he began to complain of 
severe pain in his pelvis, such that he was unable 
to walk. On examination he was found to be 
' exquisitely tender over his symphysis pubis and 
it was impossible to abduct his legs because of the 
severe pain. An X-ray of his pelvis showed the 
classical picture of osteitis pubic with rarefaction 
of the bone next to the symphysis with a moth- 
eaten ragged appearance. (See Fig. 1.)
On the 6th of March the patient suddenly col­
lapsed while in the bathroom and was found to be 
severely shocked with marked cyanosis, cold 
clammy skin, a fast thready pulse, tachypnoea and 
a jugular venous pulse that was raised 5 cm. It 
was assumed that he had suffered a pulmonary 
embolus and he was heparinised, given oxygen, 
digitalised and put on to frusemide. A central 
venous pressure manometer was put up and 
showed a central venous pressure (C.V.P.) of 16 
cm. His fluids were restricted and given accord­
ing to the C.V.P. reading. He was also given 
hydrocortisone.
The following day he developed a pleural 
friction rub at the left base. His E.C.G. showed 
S-T segment depression with inverted T waves 
but not the classical S1Q2T 3 picture. Chest X-rays 
never showed any collapse or consolidation.
Over the next 11 days he was treated with in­
travenous heparin, antibiotics and hydrocortisone 
as well as digoxin and diuretics. His clinical con­
dition improved greatly, but the most striking 
change was the disappearance of pain over his 
pubis. At the end of this period there was no 
tenderness over the symphysis and the legs could 
be widely abducted without any pain. X-rays 
of his pelvis showed little change at this stage.
Case 2.
Mrs. M. C. is a 20-year-old para 1 who pre­
sented to Harare Hospital eight days after a nor­
mal vaginal delivery, with marked tenderness 
over the symphysis pubis. She was unable tc 
walk due to the pain and had. marked adductor 
spasm. An X-ray of the pelvis confirmed the 
diagnosis of osteitis pubis, with rarefaction of the 
pubic bones next to the symphysis. Within 4 
hours of commencement of treatment with h< 
arin she had dramatic relief of pain and tend 
ness, and after 10 days on heparin was dischar;. 
symptom-free on oral anticoagulants.
Case 3.
Mrs. E. M. is a 36-year-old para 6 who pre­
sented two days after a normal vaginal delivery 
with pup era! sepsis and marked tenderness ovcir 
the symphysis pubis, adductor spasm and inability 
to walk. X-rays confirmed a diagnosis of osteitis
Fig. 1—X-ray pelvis showing rarefaction of medial borders 
of pubic bones, especially on right.
1 0
January, 1972. OSTEITIS PUBIS T h e  Ce n t r a l  A fr ic a nJ o u rn al  of M e d ic in e
pubis. She was treated with heparin and anti­
biotics, and six days after commencement of 
treatment she had marked relief of pain and 
tenderness. She was discharged after 10 days of 
heparin on oral anticoagulants, with no tender­
ness over the symphysis.
These cases are presented beoause of the com­
parative rarity of osteitis pubis. This diagnosis 
has not been recorded before at Harare Hospital. 
The three oases have shown an unusual dramatic 
improvement on treatment with heparin.
D iscussion
Osteitis pubis was originally described by 
Legueu and Rochet in 1923. It is defined as a 
self-limiting, non-suppurative osteonecrosis which 
usually begins at the symphysis pubis and extends 
ito the pubic bones (Lisker and Knox, 1964). It 
is often associated with operations close to the 
pubis and, although it frequently follows infection 
,;in the retropubic space, is to be distinguished from 
true osteomyelitis of the pubis (Coventry and 
rlfiitchell, 1961). It may. follow all types of prosta- 
I’Ktomy, although it is probably more common in 
Isag retropubic approach (Warwick, 1960). It is 
also a recognised complication of symphysiotomy 
in labour, hernia repairs and other operations in 
this area.
.^.In a series of 45 patients with this condition 
reviewed from the Mayo clinic over a 23-year 
period, the average time of presentation after an 
operation was six and a half weeks. This was 
exactly the time interval elapsed in the first 
case. Most showed the same clinical features as 
the patients being presented, namely, exquisite 
tenderness over the pubic bone with severe spasm 
of the adductor muscles and inability to walk 
(Coventry and Mitchell, 1961).
There are four main theories as to the aetiology 
of this condition:
1. It has been related to trauma to the periosteum 
at the time of operation (Beer, 1924).
2. Some have postulated a low-grade infection of 
the bone and have isolated organisms of low- 
grade virulence from the bone (Goldstein and 
Rubin, 1947). However, this is an unusual 
finding and true infection in the bone is prob­
ably-not the common cause.
3. There is evidence of venous thrombosis in the 
veins draining the pubic bone. Steinbach et al. 
(1955) showed by osseous phlebography an 
obstruction to venous flow from the pubis in 
this condition compared with other patients 
after the same operation, who had not de­
veloped osteitis pubis. Venous thrombosis
would appear to be a major factor in this 
condition (Thornley, 1955).
4. It has been related to irritation of the sensory 
pelvic nerves by infection, causing trophic 
changes in the bone by a causalgia-like 
mechanism (Wheeler, 1941). It has, in this 
way, been linked to Suedeck’s atrophy.
Lisker and Knox feel that a true infective pro­
cess of the bone is unlikely because of the sym­
metrical bone changes on X-ray, the spontaneous 
recovery whatever treatment is given, the absence 
of abscess formation, the minimal systemic symp­
toms, and healing which occurs without excess 
bone formation. Very few investigators have iso­
lated organisms from the pubic bone and anti­
biotics do not seem to influence the course of the 
disease in any way.
The treatment is generally unsatisfactory and a 
plethora of regimens have been advocated, at 
various times, including immobilisation in a spica 
body cast, radiation therapy, vitamin B therapy, 
antibiotics, other chemotherapeutic agents, dia­
thermy, injection of jjlocal anaesthetic into the 
prostate, prostigmin, ACTH, cortisone, bone curet­
tage, and phenylbutazone. The disease appears to 
run an inexorable course for three to 12 months 
with pain and debility -and finally a spontaneous 
recovery. The only definite alleviation of symp­
toms has come from the use of steroids (Coventry 
and Mitchell, 1961), and phenylbutazone (Barnes 
and Malament, 1963), and in the more severe 
cases, excision of the affected bone (Samellas and 
Finkelstein, 1962). Response even to these mea­
sures is usually slow and partial.
If this condition follows thrombosis of the veins 
draining the pubis as the evidence suggests, it 
would seem logical that anticoagulant therapy 
would be an important measure in treatment. The 
dramatic response to heparin in the present cases 
(albeit given for the pulmonary embolus in the 
first case) would suggest that this may be the 
ideal treatment. No reference has been found 
to the use of anticoagulants in the immediate 
treatment of osteitis pubis. The first patient 
had also received steroids in the course of his 
treatment, but the rapid complete disappearance 
of symptoms cannot be accounted for by this 
alone.
Conclusion
Evidence suggests that osteitis pubis is a disease 
caused by thrombosis of the veins draining the 
pubic bone, and anticoagulant therapy is advocated 
as the logical treatment of this condition in the 
acute phase. Three cases are presented where 
treatment with heparin gave dramatic symptoma­
tic relief.
11
Vol. 18. No. 1. January, 1972.
REFERENCES
Barnes, W. C. & Malament, M. (1963). Surg. Gynaec. 
Obstet., 117, 277.
Beer, E. (1924), Ini. J. Med. Surg., 37, 224.
Coventry, M. B. & M itchell, W. C. (1961). J. Amer. 
med. Assoc., 178, 898.
Goldstein, A. E. & R ubin , S. W. (1947). Amer. J. Surg., 
74, 480.
Legueu & R ochet (1923). J. Urol. Med. Chir., IS, 1. 
L isker, S. & K nox, E. W. (1964). J. Irish med. Aw., 
54, 79.
Samellas, W. & F inkelstein , P. (1962). J. Urol., 87, 
553.
Steinbach, H. L., Petrakis, N. L., G ilfillian, R. S. & 
Sm ith , D. R. (1955). J. Urol., 74, 840.
T hornley, R. (1955). Brit. J. Urol., 27, 1.
Warwick, R. T. T. (1960). Brit. J. Urol., 32, 464. 
W heeler, W. K. (1941). J. Urol., 45, 467.
Acknowledgments
I would like to thank Professor J. M. Mynors 
for help in preparing this paper and 'to Mrs. P. 
Ferguson for typing the manuscript.
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The Treatment Of Osteitis Pubis With Anticoagulants A Report Of Three Cases In Africans

Holmgren,  G.

National Research Database of Zimbabwe

https://opendocs.ids.ac.uk/opendocs/bitstream/20.500.12413/5205/1/Holmgren%20Gunnar%20%20%20CAJM%20%20vol.%2018%2c%20no.1.pdf

The Treatment Of Osteitis Pubis With Anticoagulants A Report Of Three Cases In Africans

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