cPOPSS (Pain Over Pubis and Surrounding Structures) sybdrome is not an uncommon condition. It is an enthesopathy (tendonitis) and/or periosteitis, 1.2 somewhat similar to peropsteotos pubis3. This paper will provide background and describe lessons learned in 23years' clinical experience trating this condition.
POPSS (pain over pubis and surrounding structures) has evolved from the well-known condition osteitis pubis.
This disease was firsst described in 1827 by Elliotson, in 1923 by Leglieu and Rochet and in 1924 by Beer et al4. Several different etiologies5 mentioned in the literature include infection, impaored circulation and venous congestion. The most convincing etiologic factor, however, seems to be an enthesopathy6 (tendonitis or periosteitis) similar to tennis elbow, plantar fascitis, etc.
It is a great masquerader mimicking several different conditions and is of interest to several different specialities (Fig.1). It can present as sportsman's hernia, abacterial prostatitis, interstitial cystitis, and chronic pelvic pain including dyspareunia. It can present as acute or chronic lower abdominal and/or groin pain mimicking appendicitis, diverticulitis, and hernias (including strangulated).
The volume of these patients incljuding evonomic impact is staggering. It is estimated that in
the USA alone literally millions of patients are reported as having chronic groin, abdominal and pelvic pain (POPSS syndrome). Nearly 15 million women have chronic pelvic pain (CPP)7 and in this subset 46% have dyspareunia. The annual medical cost of diagnosis and treatment is almost 1.2 billion dollars. And the cost of loss of productivity is estimated to be $15 billion annually. In males it is estimated that 50% (tens of millions) of all adult males suffer from abacterial prostatitis causing CPP.
Figure 1. This is a unique condition seen by so many different spcialists.
Interstitial cystitis affects half to one million people causing CPP8. Sportsman’s hernia affects 0.5% to 6.2% of all professional athletes.5
Also nearly 30% (225,000) of patients suffer from groin pain following repair of groin hernias.
Confirmation is made with strategically placed steroid injections. Several patients with atypical or refractory lower abdominal as well as groin/pelvic pain are shuttled from one specialist to another and undergo expensive diagnostic tests, (e.g., CT scans, MRI, bone scans, ultrasounds, etc). Endoscopies, laparoscopies and sometimes even unnecessary surgeries (e.g., exploratory laparotomies, hysterectomy, inguinal herniorrhaphy) are performed. Patients and physicians are equally frustrated because the diagnosis is elusive. Chronic pain causes emotional problems, sleep disturbances and even depression. Productivity and self-esteem are affected. Moreover, countless healthcare dollars are spent on unnecessary diagnostic studies and unnecessary interventions. Treatment is multidisciplinary involving pain management, mainly with steroid injections and occasional use of NSAIDS. Emotional treatment with anti-anxiety/anti-depressants is used in the majority of our chronic patients. Specialized pelvic physical therapy9 is used in almost all patients to prevent flare-ups.
Many of these unfortunate patients do not seek treatment for this disabling
condition because they fail to mention the complaint in their presenting symptoms. There are several reasons for this, including apathy, ignorance
and stigma, especially in patients with dyspareunia. Our challenge is to
“This advanced clinical picture is rarely seen nowadays. Milder forms of the disease with slightly different manifestations are commonly seen.”
“The omission of exam of pubic bone and anterior superior iliac spine on physical exam of abdomen (specifically in patients with lower abdominal pain) is the most embarrassing cause of missed diagnosis.”
|
get them “out of closet” and diagnose, then treat them appropriately and in a timely fashion, or refer to them to a specialized center.
|