Postoperative MR Imaging of the Pubic Symphysis and Athletic Pubalgia.

MR imaging evaluation can be valuable in patients with prior surgery for athletic pubalgia presenting with new, recurrent, or persistent groin pain. The clinical and interventional history as well as comparison with preoperative imaging is essential for imaging interpretation. Imagers should be aware of expected and unexpected postoperative findings. MR imaging findings concerning for infection, new injury, contralateral injury, or concomitant sources of symptoms (such as hip pathology) should be reported when present.

Three female patients with a periurethral mass: from various complaints to rare pathology.

In this case report, we will discuss three cases of women diagnosed with a periurethral mass. The specific diagnosis of a periurethral mass can vary and includes rare diseases. Therefore, they provide a challenge to medical professionals. All patients underwent diagnostic evaluation with cystoscopy and pelvic MRI followed by surgical removal. Based on the MRI and pathology report, different diagnoses were made for each patient. The three diagnoses will be discussed: subpubic cartilaginous cyst, leiomyoma and clear cell adenocarcinoma of the urethra. Our case report is useful for other medical professionals, and they can evaluate how to optimal approach a periurethral mass.

[Unexpected discovery of isolated osteochondroma in the pubic symphysis]. / Ostéochondrome solitaire de la symphyse pubienne de découverte fortuite.

Osteochondroma is the most common benign bone tumor. It usually affects the metaphyses of the long bones, in particular around the knee and the proximal humerus. It very rarely affects the pubic symphysis, usually with an atypical symptomatology. We here report the case of a 35-year old man in whom osteochondroma in the pubic symphysis encroaching on the iliopubic branch was fortuitously discovered. Radiological examinations as well as macroscopic and histological examination confirmed the diagnosis and the absence of signs of malignancy.

MR imaging of pubic symphysis after uncomplicated vaginal delivery and planned caesarean delivery in the first postpartum week.

PURPOSE: To compare changes in the pubic symphysis between women with vaginal delivery and women with caesarean sections within the first postpartum week. MATERIALS AND METHODS: After institutional review board approval 30 healthy women were prospectively examined with MRI (transverse STIR-sequence) three days after delivery. 17 women with vaginal delivery (mean age 33.2 ±â€¯4 years) and 13 with caesarean delivery (35.2 ±â€¯5.6 years) were compared by two musculoskeletal radiologists. Bone marrow edema (location and extent), fluid in the joint gap, joint space width and stress fractures were assessed. RESULTS: Prevalence of bone marrow edema was high and not different between groups (13/17 (76.5%) vaginal deliveries) and 10/13 (76.9% caesarean deliveries) for reader 1 (p = 0.992) and 14/17 (82.4%) and 10/13 (76.9%) for reader 2 (p = 0.762). Size of bone marrow edema was not statistically significantly different for both readers (results reader 1: right side 2.5 ±â€¯3.3 mm vs. 6.3 ±â€¯7.3 mm, p = 0.300; left side 3.4 ±â€¯4.1 mm vs. 4.1 ±â€¯4.6 mm, p = 0.837). Fluid in the joint was seen in 4/17 (23.5%) vs. 2/13 (15.4%) (p = 0.580) for reader 1 (similar for reader 2). Joint space width did not differ between groups (2.6 ±â€¯0.7 mm vs. 3.1 ±â€¯1.2 mm, p = 0.198). Pubic symphysis diastasis (joint space width > 10 mm) was not observed. Interreader agreement for these parameters was substantial to almost perfect (0.671-0.984, kappa values/intraclass correlation). Reader 1 found no stress fractures, while reader 2 suspected 1 stress fracture on a right pubic bone in a woman after caesarean delivery. CONCLUSIONS: Pubic bone marrow edema is present in 3 of 4 women in the first postpartum week unrelated to the delivery mode.

Congenital prepubic sinus presenting with purulent discharge after circumcision: a case report.

BACKGROUND: Congenital prepubic sinus is a rare anomaly found in the midline of the lower abdomen. Congenital prepubic sinus is usually asymptomatic in neonates, and a diagnosis is often achieved later in life after spontaneous extrusion of purulent material from the pre-existing hole in the pubic region. We present a case of congenital prepubic sinus presenting with purulent discharge after circumcision. A 4-year-old Caucasian boy presented to our urology out-patient clinic with purulent discharge from the distal part of the dorsum of his penis. He had a history of circumcision performed at a different center, 6 months ago. His parents stated that although various antibiotics were used, the purulent discharge continued for 6 months and the child had no complaints before circumcision. His condition was reported as superficial dorsal venous thrombosis, known as penile Mondor disease, in magnetic resonance imaging that was performed in the previous hospital. A physical examination revealed a small pinhole lesion at the distal part of his penis and a rigid cylindrical tube extending to the proximal side of his penis. We performed fistulography by injecting contrast material through a small angiocatheter and confirmed the diagnosis of prepubic sinus. Surgical exploration was performed and a long sinus, apparently ending as a fibrous tract at the anterior surface of his pubic symphysis, was found and resected. CONCLUSIONS: Before congenital prepubic sinus surgery, it is critically important to rule out penile Mondor disease and the possibility of a circumcision complication (especially infective complications) mimicking congenital prepubic sinus.

Necrotizing Myositis: A Rare Necrotizing Soft Tissue Infection Involving Muscle.

INTRODUCTION: Necrotizing myositis (NM) is an extremely rare necrotizing soft tissue infection involving muscle. Unlike similar infections (eg, necrotizing fasciitis, clostridial myonecrosis) that can be more readily diagnosed, NM can have a benign presentation then rapidly progress into a life-threatening condition with a mortality rate of 100% without surgical intervention. CASE REPORT: A 74-year-old man with a history of prostate cancer with radiation therapy, seed implants, and 2 transurethral resection procedures presented to the emergency department after a fall. He was initially diagnosed and treated for urosepsis. Sixteen hours after presentation, he complained of pain and swelling of his right groin. Computed tomography of the abdomen and pelvis showed gas findings suspicious for necrotizing infection of the bilateral thighs. Surgical exploration revealed NM. Separate cultures from the left thigh and bladder grew Streptococcus intermedius, Clostridium clostridioforme, and Peptostreptococcus, suggesting a possible common source of infection from the prostate gland or the osteomyelitic pubic symphysis, which subsequently spread to the bilateral thighs. CONCLUSIONS: To the best of the authors' knowledge, this is the first reported case of S intermedius and C clostridioforme causing NM. A high index of suspicion is required for extremely rare conditions like NM, because early diagnosis and surgical intervention significantly reduce mortality.

Time-dependent regulation of morphological changes and cartilage differentiation markers in the mouse pubic symphysis during pregnancy and postpartum recovery.

Animal models commonly serve as a bridge between in vitro experiments and clinical applications; however, few physiological processes in adult animals are sufficient to serve as proof-of-concept models for cartilage regeneration. Intriguingly, some rodents, such as young adult mice, undergo physiological connective tissue modifications to birth canal elements such as the pubic symphysis during pregnancy; therefore, we investigated whether the differential expression of cartilage differentiation markers is associated with cartilaginous tissue morphological modifications during these changes. Our results showed that osteochondral progenitor cells expressing Runx2, Sox9, Col2a1 and Dcx at the non-pregnant pubic symphysis proliferated and differentiated throughout pregnancy, giving rise to a complex osteoligamentous junction that attached the interpubic ligament to the pubic bones until labour occurred. After delivery, the recovery of pubic symphysis cartilaginous tissues was improved by the time-dependent expression of these chondrocytic lineage markers at the osteoligamentous junction. This process potentially recapitulates embryologic chondrocytic differentiation to successfully recover hyaline cartilaginous pads at 10 days postpartum. Therefore, we propose that this physiological phenomenon represents a proof-of-concept model for investigating the mechanisms involved in cartilage restoration in adult animals.

Septic arthritis of the pubis symphysis: clinical and therapeutic features.

Septic arthritis of the pubis symphysis is rare and difficult to diagnose. The objective of our study was to describe the biological, clinical, radiological and therapeutic aspects of this disease. This is a retrospective study of 4 cases of septic arthritis of the pubic symphysis collected in the Department of Rheumatology and Orthopaedics in Sousse in Tunisia over a period of 16 years (2000-2016). Our population consists of 3 women and one men. The mean age was 47 years (18-83). Clinical signs of appeal were inflammatory groin pain, pubic pain and fever. Symptoms appeared after forceps delivery in 2 cases, after surgery on the pelvis in one case and in a context of sepsis in one case. Radiographs showed pubic disjunction with irregular shoreline in all cases. CT performed in all patients and MRI in 2 patients showed erosions of the banks of the pubic symphysis with infiltration of the soft parts in all cases. The causative organisms were isolated in 3 cases by biopsy of soft tissue abscess under CT in 2 cases and vaginal swab in one case. Identified germs were staphylococcus aureus Méti-S (n=1), proteus mirabilis (n=1) and varied flora (n=1). The treatment consisted of appropriate antibiotics in all cases and surgical drainage of soft tissue abscess resistant to medical treatment in 2 cases. The outcome was favorable in all cases. Diagnosis of septic arthritis of the pubic symphysis is based on clinic supported by microbiologic culture results, image methods, and proteins augment during acute phase.

Complete spontaneous regression of a subpubic cartilaginous cyst: a case report.

Subpubic cartilaginous cyst was recently reported as a rare degenerative mass on the pubic symphysis. We report here a 59-year-old woman who presented with a vulvar mass that showed complete spontaneous regression 48 months after the initial visit. Treatment was only wearing brace. This is the first report of complete spontaneous regression of a subpubic cartilaginous cyst. In the case of small subpubic cyst, observation and follow-up alone may be sufficient. J. Med. Invest. 63: 319-322, August, 2016.

Groin injuries in athletes--development of clinical entities, treatment, and prevention.

The doctoral thesis is based on eight papers published in peer-reviewed journals and a review of the literature. The papers are published between 1997 and 2013 in cooperation with Sankt Elisabeth Hospital, Herlev Hospital, Glostrup Hospital, Rigshospitalet, Hvidovre Hospital, Amager Hospital, Copenhagen Trial Unit, and Institute of Preventive Medicine, Copenhagen. Groin injuries in sport are very common and in football they are among the most common and most time-consuming injuries. These injuries are treated very differently around the world. There is no consensus in the literature regarding definitions, examination methods, diagnosis or treatment and in general the level of evidence is very low. There is a need for identification of the painful anatomical structures, how to examine them and how to define clinical entities to develop effective treatment and prevention. The aim of these studies were: - To review the literature to create an overview of the ideas and the knowledge in order to plan future studies in this field. - Develop and test clinical examination techniques of the relevant tendons and muscles in the region. - Since no evidence-based diagnosis exist; to develop a set of clinical entities to identify the different groups of patients. - To test the effect of a dedicated exercise program developed for treatment of long-standing adductor-related groin pain in athletes in a randomised clinical trial comparing it to the treatment modalities used at that time. - To examine the long-term effect of the above mentioned training program for treatment of long-standing adductor-related groin pain. - To develop a training program for prevention of groin injuries in soccer and test it in a randomised clinical trial. - To describe the occurrence and presentation in clinical entities of groin injuries in male football and to examine the characteristics of these injuries. - Evaluate if radiological signs of femuro-acetabular impingement (FAI) or dysplasia affect the clinical outcome of treatment of long-standing adductor-related groin pain, initially and at 8-12 year follow-up.   The main findings of the eight papers were: - No randomised trials existed in this area; there was no consensus in the literature and the majority of the literature was Level 4 and 5. From the existing literature and the author' experience an injury mechanism was suggested and the term ''adductor-related groin injury'' was suggested. - A well-defined clinical examination of the adductor-, iliopsoas, and abdominal muscles and the symphysis joint for pain, strength, and flexibility was reproducible with only limited intra- and inter-observer variation. - By utilising a well-defined classification long-standing groin injuries could be classified with a system of clinical entities.

Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes.

BACKGROUND: Sport-related pubalgia is often a diagnostic challenge in elite athletes. While scientific attention has focused on adults, there is little data on adolescents. Cadaveric and imaging studies identify a secondary ossification centre located along the anteromedial corner of pubis beneath the insertions of symphysial joint capsule and adductor longus tendon. Little is known about this apophysis and its response to chronic stress. AIM: We report pubic apophysitis as a clinically relevant entity in adolescent athletes. METHODS: The clinical and imaging findings in 26 highly trained adolescent football players (15.6 years ± 1.3) who complained of adductor-related groin pain were reviewed. The imaging features (X-ray 26/26, US 9/26, MRI 11/26, CT 7/26) of the pubic apophyses in this symptomatic group were compared against those of a comparison group of 31 male patients (age range 9-30 years) with no known history of groin pain or pelvic trauma, who underwent pelvic CT scans for unrelated medical reasons. RESULTS: All symptomatic subjects presented with similar history and physical findings. The CT scans of these patients demonstrated open pubic apophyses with stress-related physeal changes (widening, asymmetry and small rounded cyst-like expansions) that were not observed in the comparison group. No comparison subject demonstrated apophyseal maturity before 21 years of age, and immaturity was seen up to the age of 26 years. CONCLUSIONS: This retrospective case series identifies pubic apophyseal stress (or 'apophysitis') as an important differential consideration in the adolescent athlete who presents with groin pain.

[Pregnancy-related pelvic ring disease and its treatment].

Pregnancy-related pelvic ring disease brings great suffering to pregnant women, including the separation of the pubic symphysis and sacroiliac joint pain. Hormonal changes leading to ligamentous laxity is the main reason for Pregnancy-related pelvic ring disease. In normal pregnant cases, and the physiologic widening at the symphysis is about 3-7 mm. When the widening of the symphysis is more than 10 mm, it may lead to symptoms and need active treatment. Currently the diagnosis of the pubic symphysis separation is based on the clinical symptoms and signs. The treatment of acute pubic symphysis separation bases on conservative therapy, includes bed rest and physical therapy. But when the widening of the symphysis is more than 4 cm, the surgery intervention may be a good treatment. If the conservative treatment is not obviously effective, the surgery consists of plate fixation in the pubic symphysis and sacroiliac screw fixation. Other indications for the surgical intervention include inadequate reduction, recurrent diastasis, intractable symptoms, and open rupture.

Posterior symphyseal spurs--an unusual differential diagnosis in athletes with groin pain.

We set out to highlight the significance of posterior symphyseal spurs as an unusual diagnostic possibility in athletes with chronic groin pain and to demonstrate that operative resection was successful in quickly and safely returning the patients to sporting activities. Five competitive nonprofessional male athletes, three soccer players, and two marathon runners (median age: 30 [26/33] years), who presented to us with significant groin and central pubic pain with duration of at least 12 months, and who had failed conservative or surgical interventions (symphyseal plating), were evaluated. Physical examination as well as pelvic radiographs confirmed the diagnosis of posterior symphyseal spurs. Four out of five athletes underwent complete resection of the spur. Size of spurs was 2.2 (1.3/2.9) cm (median) with four of them posterosuperiorly and one posterocentrally located. All of them had uneventful postoperative recovery period and were still pain-free at the latest follow up after 26.6 months (24/30). Median time-to-return to competitive sports level was 10 weeks (8/13). None of the patients developed pubic instability due to symphyseal spur resection. The results of considerable postoperative improvement in our patients highlight the significance of posterior symphyseal spurs as a diagnostic possibility in athletes with chronic groin pain.

Anatomical measurement and finite element study on screw channel parameter in percutaneous fixation of canulated screw for symphyseolysis.

To provide anatomical basement for symphyseolysis treatment with percutaneous fixation of canulated screw, through anatomical measurement on pubic symphysis and the surrounding tissues, and conduct the finite element studies on screw channel parameters. 20 cases of normal pelvic specimens from embalmed adult cadavers were taken to measure the anatomical parameter of bony remark of pubic symphysis and the space between spermatic cord (round ligament of the uterus) and pubic tubercle. Anatomical measurement results showed that the narrowest diameter of the superior ramus of pubis was 9.127 ± 1.189 mm, distance between two pubic tubercles was 55.656 ± 3.780 mm, thickness of the upper pubic symphysis was 10.510 ± 0.814 mm, and distance between upper and lower pubic symphysis was 40.872 ± 1.211 mm; the distance between round ligament of the uterus and pubic tubercle was 4.408 ± 0.304 mm, and the distance between spermatic cord and pubic tubercle was 5.196 ± 0.251 mm. The angle between canulated screw guide pin and horizontal plane was 8.342 ± 2.152°, the one between guide pin and coronal plane was 5.236 ± 1.612°, and the distance from entry point to the outer edge of pubic tubercle was 10.023 ± 1.245 mm, which was measured by Mimics software. Percutaneous surgery at horizontal position was simulated on cadaver. And the screw was correctly placed in postoperative imaging examination. According to the anatomical data and finite element studies of screw channel parameter in percutaneous fixation of canulated screw for symphyseolysis, the method can improve the accuracy of screw placement and reduce complications.

The Copenhagen Standardised MRI protocol to assess the pubic symphysis and adductor regions of athletes: outline and intratester and intertester reliability.

BACKGROUND: There is currently no standardised MRI evaluation protocol for athletes who present with symptoms that may relate to the pubic symphysis, the pubic bones, and the adductor muscle insertions. We outline the protocol and reliability data. MATERIAL AND METHODS: Three musculoskeletal radiologists developed an 11-element MRI evaluation protocol defined according to precise criteria and illustrated in a pictorial atlas. Eighty-six male athletes (soccer players and non-soccer players) underwent standardised 3 Tesla MRI of the pelvis. Two external musculoskeletal radiologists were trained to use the protocol and pictorial atlas during two sessions of 2-4 h each. Each radiologist rated all 86 MRI independently. One radiologist evaluated the scans once, the other twice 2 months apart. Cohen κ statistics were used to determine intraobserver and interobserver agreement. RESULTS: The main findings were (1) substantial intraobserver (κ range 0.65-0.67) and moderate interobserver (κ range 0.45-0.52) agreement in rating pubic bone marrow oedema, (2) substantial to moderate intraobserver (κ range 0.49-0.72) and moderate-to-fair interobserver (κ range 0.21-0.52) agreement in rating most other MRI findings, (3) slight intraobserver and interobserver (κ range -0.06-0.05) agreement in rating adductor longus tendinopathy. CONCLUSIONS: The Copenhagen Standardised MRI protocol demonstrated moderate-to-substantial reliability in rating bone marrow oedema, and varied from fair-to-substantial agreement for the majority of MRI features, but showed only slight agreement in rating adductor longus tendinopathy. This rigorous investigation also confirms that while MRI evaluation seems to provide reasonable reliability in rating pubic bone marrow oedema, the evaluation of adductor tendinopathy in a clinical and research setting needs further resolution by continued development and testing of MRI acquisition protocols.

Osteomyelitis pubis: a rare and elusive diagnosis.

Osteomyelitis pubis is an infectious inflammation of the symphysis pubis and accounts for 2% of hematogenous osteomyelitis. This differs from osteitis pubis, a non-infectious inflammation of the pubic symphysis, generally caused by shear forces in young athletes. Both conditions present with similar symptoms and are usually differentiated on the basis of biopsy and/or culture. A case of osteomyelitis pubis is presented with a discussion of symphisis pubis anatomy, clinical and laboratory presentation, etiology and risk factors, and optimal imaging studies.