Arthrosis of the symphysis pubis: treatment, causes, diagnosis

A rare but serious disease of the osteoarticular system is arthrosis of the symphysis pubis. The pathology is characterized by pain in the pubic area or hip joints that occurs against the background of an inflammatory process. This disease has serious complications. The appearance of pain in the articular joint of the pelvis is the basis for contacting a specialist. Early diagnosis and timely therapy will help avoid disability and prevent death.

How does it manifest?

Damage to the symphysis pubis occurs gradually. Aching pain occurs in the pubic area, then moves to the perineum. As the disease progresses, the pain intensifies, the pain does not stop even at rest, and lameness occurs. There are 3 degrees of development of arthrosis of the symphysis pubis:

It manifests itself as vague symptoms, mild pain during movement, the formation of marginal bone growths, the muscle structure is in good shape.
There is an increase in pain radiating to the groin and thigh area. Due to the displacement of the articular parts, stiffness of the hip joint appears, arthritis develops, and osteophytes are abundantly formed.
There is constant sharp pain, discomfort and movement functions are limited. The tendon junction between the pubic bones contracts, causing lameness.

Return to contents

Treatment of symphysis pubis tears

If a rupture occurs, the patient needs strict bed rest. The hip joint area is subject to tight bandaging. It is optimal to use a wide linen bandage for this purpose. Legs should be placed on the headboard and blocks should be attached to them at the level of the pelvis. The ends of the bandage must be tied on wooden strips, which are tied with cords. These cords pass through the blocks, and a load must be suspended from their ends, starting with a couple of kilograms and gradually increasing to 10 kg.

Thanks to early recognition of the rupture, restoration of the symphysis pubis occurs within 2-3 weeks. In case of delayed treatment, the bandage is applied for at least 1 month. Bandages made of fabric resembling a hammock are often used for this purpose. Its edges are attached to the longitudinal straps. The pelvic bones begin to converge due to the patient’s own weight. The recovery time when staying in a hammock is the same.

The musculoskeletal functions of the pelvis are completely restored when the treatment approach is carried out without delay. With a more delayed definition of the rupture, the inflammatory process of cartilage tissue contributes to difficult healing and protracted rehabilitation.

Diagnosis of arthrosis of the symphysis pubis

Affordable and most informative methods.
Diagnosis of pathology consists of examining the source of inflammation and instrumental studies. To exclude injuries to the hip joints or other diseases of the musculoskeletal system, the following is carried out:

Ultrasound;
radiography;
CT and MRI.

Return to contents

Why do hip joints hurt during pregnancy - how to treat?

Features of treatment

Therapy for arthrosis of the symphysis pubis consists of conservative measures. It is aimed at relieving pain and eliminating the causes of pathology. The first step in treatment is to reduce the load on the joints, for which it is recommended to use a bandage. Doctors advise avoiding prolonged stay in one position. Based on the severity of the disease, complex therapy is used for grades 1 and 2:

The use of medications includes analgesics, non-steroidal anti-inflammatory drugs, vitamin complex, hormonal injections.
Chondroprotectors are used to renew the cartilage structure.
Physical therapy is carried out after the onset of remission.
Manual and physical therapy are aimed at restoring blood circulation and motor ability of the limbs.

Complex therapy should be carried out under the strict supervision of an orthopedic surgeon.

Return to contents

Surgical treatment

Surgical intervention is indicated for advanced stage 3 arthrosis. The operation is carried out after a comprehensive medical examination confirming the nature of the destruction and the possibility of endoprosthetics. The functions of the musculoskeletal system are restored during postoperative measures:

use of anti-inflammatory drugs;
antibiotic therapy;
physiotherapeutic procedures.

Joint pain not only causes discomfort, but also indicates the presence of pathologies in the body that can lead to limited movement or complete immobility. If even mild pain occurs in the pubic area, you should consult a specialist. Early diagnosis and prescription of correct therapy will help avoid irreversible consequences and prevent further destruction of the cartilage of the symphysis pubis.

9836

A rare but rather severe pathology of the musculoskeletal system is arthrosis of the symphysis pubis (symphysis pubis), a non-synovial semi-movable joint of the pelvic ring. The disease is characterized by pain in the pubic area and hip joints, which occurs against the background of an inflammatory reaction.

Degenerative-dystrophic changes can lead to limited mobility of the lower extremities and decreased quality of life.

Possible complications

With a discrepancy of 1-2 degrees of the symphysis pubis, in most cases there are no consequences for the woman. At grade 3 there is a risk of severe complications:

bladder rupture;
damage to the urethra;
clitoral trauma;
fracture of the pubic bones;
hemorrhage in the fracture area.

Some women may develop arthrosis of the symphysis pubis. It usually occurs in women with many children, in whom each pregnancy proceeded with symptoms of symphysitis.

All these phenomena occur as a result of pathological displacement of the pubic bones. To prevent complications from occurring, it is necessary to promptly identify the pathology and begin preventive and therapeutic measures.

Etiological factors

The disease develops due to slowly progressive degeneration and subsequent destruction of the fibrocartilaginous disc - the symphysis. It is known for certain that excessive physical activity leads to a thinning of the connective layer between the bone structures of the skeleton, as a result of which its shock-absorbing function is seriously affected. The cartilage tissue wears out and osteophytes form. Violation of the regenerative ability of the joint and the accompanying inflammatory process create favorable conditions for bone destruction. The following are the main causes of arthrosis of the pubic symphysis:

inflammation that occurs as a response to rheumatoid factor, purulent damage to osteochondral elements, autoimmune disease;
mechanical damage received during increased physical activity or during surgery;
dysplasia, which is characterized by inferiority of the articular joint due to its improper development;
destructive changes provoked by metabolic disorders;
congestion in the hip joints;
hormonal imbalance.

The vertical connection of the upper branches of the pubic bones located in the midline is especially vulnerable during pregnancy, therefore destructive processes in this area in women carrying a child are common.

Why joint pain occurs during pregnancy and how to get rid of it

It is also worth noting other factors that can cause arthrosis of the symphysis pubis:

Age. With aging, the body's regenerative functions inevitably decline, and blood flow deteriorates. Cartilage tissue does not receive enough nutrients and, gradually wearing out, is destroyed.
Physical inactivity. People who lead a sedentary lifestyle are more likely than others to experience problems with hip articulation and joints of the lower extremities. A lack of physical activity leads to thickening of the blood, which reduces the number of vessels supplying the joints with oxygen and nutrients.
Hypothermia. Regular exposure to low temperatures causes capillary spasms, which negatively affects regional blood microcirculation.
Unbalanced diet. Lack of vitamins and minerals is another reason for the appearance of destruction in the articulating surfaces of the pubic bones.

Clinical picture

Dystrophic changes in the symphysis pubis do not occur spontaneously and for no apparent reason. At first, a person may feel aching pain in the pubic area, radiating to the perineum. Soreness is usually caused by stretching of the semi-joint and an increase in the range of motion.

Unpleasant sensations intensify while walking, as well as when climbing stairs.

As the pathological process progresses, arthralgia becomes more pronounced. In a horizontal position, when a person lies on his back, the symptoms subside slightly. An increase in the distance between the pubic bones causes unbearable pain in the lumbar and sacrum areas. A characteristic click is heard in the pubic symphysis, and lameness develops. Symptoms of a disease of the osteoarticular system will vary depending on its stage:

First. Edge bone growths are formed, the tone of the muscle fibers is preserved. Attacks of mild pain occur only during physical activity or during intense movements.
Second. With arthrosis of the symphysis pubis stage 2, pain spreading to the groin and thigh area is present even at rest. Displaced articular segments cause stiffness of the hip joint, and osteophytes are abundantly formed.
Third. The person complains of constant sharp pain and discomfort, movement functions are significantly limited. The tendon joint located between the pubic bones contracts, causing a change in gait.

Degrees of divergence of the pubic bones

The ligaments of the pubic symphysis are very plastic and have a good margin of safety. The severity of the condition in case of discrepancy can only be assessed by measuring the distance to which the pubic bones have moved away from each other. Based on this criterion, the following degrees of divergence of the symphysis pubis are distinguished:

The first is that the width of the diastasis (the space between the bones) is in the range from 0.5 to 1 cm. The symptoms are mild, most often no treatment is required - the bones will subsequently restore their original configuration.
The second is that the pubic bones diverge by 1-2 cm, which is accompanied by severe pain and can complicate childbirth and the postpartum period.
The third, or direct rupture of the pubis, is a discrepancy exceeding 2 cm and can be determined by palpation.

With the second and third degrees of divergence of the symphysis pubis, a pregnant woman should be in a hospital in order to be able to receive qualified medical care at any time.

Diagnostic measures

First of all, a thorough physical examination of the patient is performed. The doctor determines the sensitivity and tone of the muscles of a particular area, resorting to the palpation diagnostic method. It is important to note that palpation can be used to study only the posterior articular sections and only in the case of a small amount of subcutaneous tissue. To make a final diagnosis, additional examination may be prescribed, including:

Blood chemistry. Against the background of arthrosis of the symphysis pubis, an increase in the level of ESR is noted.
X-ray. A diagnostic procedure that allows you to confirm or exclude traumatic damage to the pelvic bones.
MRI, CT. These instrumental diagnostic methods make it possible to detect tumor formations.
Transvaginal ultrasound (for women). They are carried out in order to exclude pathologies of the pelvic organs, which may be accompanied by pain localized in the area of the pubic symphysis.

How is an ultrasound of the symphysis pubis performed?

Before going to the doctor, you should find out how an ultrasound of the symphysis pubis is performed during pregnancy. A pregnant woman only needs to make an appointment and come to the doctor at the appointed time. To begin the procedure, you need to remove clothes from the area being examined - lift your jacket and lower your pants. The doctor applies a special gel to the area of the body being examined, which is necessary to eliminate air between the body and the device. The study takes about 10 minutes, and sometimes even less.

Therapeutic methods

Treatment of arthrosis of the pubic joint must necessarily be comprehensive. Its main task is to eliminate etiological factors. The first thing the doctor recommends that the patient do is to reduce the load on the problem joints, for which you need to avoid staying in one position for a long time and get a fixing bandage. Conservative therapy involves the use of the following pharmaceuticals:

Non-steroidal anti-inflammatory drugs. They alleviate the patient’s condition, but are characterized by an exclusively symptomatic effect.
Hormonal drugs. Prescribed for severe pain syndrome. It is not recommended to use for a long time.
Chondoprotectors. They have a targeted effect on the affected cartilage tissue, promoting its regeneration.
Muscle relaxants. Relieve muscle tension and reduce pain.
Vasodilators. Designed to improve blood circulation in tissues, so that joints receive more nutrients.

Physiotherapy, massage, and acupuncture are useful to activate metabolic processes in the symphysis pubis. A set of gymnastic exercises perfectly helps to improve joint mobility, restore blood circulation and strengthen muscle fibers. An individual training program is developed for each patient, taking into account the stage of the disease and the degree of damage to the joint.

The operation is indicated for advanced forms of arthrosis, when traditional methods of treatment are powerless. Endoprosthesis replacement is carried out after a comprehensive clinical examination, which confirms the irreversible nature of the destruction.

Features of pathology during pregnancy

The two large bony elements that form the pelvis are connected in the anterior part by a rigid articulation reinforced by a dense network of elastic ligaments. This anatomical feature allows the child to overcome the pelvic region without difficulty. The hormone relaxin plays an important role in this, thanks to which the ligamentous apparatus of the expectant mother becomes more elastic and mobile.

Shooting pain in the area of the pubic bone, radiating to the groin area and lower spine, most often occurs due to softening, divergence or rupture of the symphysis pubis. The arthrosis process is diagnosed both in the first trimester and after childbirth.

Many medications are contraindicated for pregnant women, as they can have a negative effect on the fetus. To relieve pain, breastfeeding women can take painkillers, but only after approval by their doctor.

Pelvic pain in pregnant women: causes and methods of elimination

Prevention of symphysitis

All women should be concerned about prevention, but this applies to a greater extent to the risk group, when there are all the reasons for the occurrence of symphysitis and rupture of the symphysis pubis.

No doctor can guarantee a pregnant woman that she will not have symphysitis. You can reduce the likelihood of this pathology by following simple recommendations:

Adequate nutrition throughout the entire period of bearing a child. The diet should be enriched with proteins and calcium.
Taking vitamin complexes and microelements according to indications.
Regular ultrasound examinations to assess the expected weight of the child.
Timely treatment of any concomitant diseases.
Preventing excess weight gain.

If, despite all the preventive measures, pain in the pubic area still appears, then you should not delay it - you should immediately consult a doctor for advice. Early initiation of treatment significantly improves the prognosis and reduces the likelihood of complications.

Possible complications and preventive measures

Considering the typical clinical manifestations of the disease, one cannot ignore the potentially dangerous consequences of damage to the pubic symphysis. These include:

damage to the bladder, genitals, rectum;
neurological disorders (radiculitis, paresthesia, muscle wasting);
internal or retroperitoneal bleeding;
infectious damage to the joint and surrounding tissues (osteomyelitis, thrombophlebitis);
gait disturbance, lameness;
difficulties with childbirth.

damage to the bladder, genitals, rectum;
neurological disorders (radiculitis, paresthesia, muscle wasting);
internal or retroperitoneal bleeding;
infectious damage to the joint and surrounding tissues (osteomyelitis, thrombophlebitis);
gait disturbance, lameness;
difficulties with childbirth.

To prevent pregnancy-related illnesses, you should plan the birth of your child with special care. The expectant mother should take specially developed vitamin complexes that strengthen both the general immune system and the joints.

Simple exercises that can help you strengthen the muscles of your back, abdomen and buttocks will help prevent arthrosis. Air and sun baths will not be superfluous. Fresh air and ultraviolet radiation promote the active production of vitamin D, which is so necessary for the absorption of calcium and phosphorus in the small intestine.

We need to fight excess weight, establish a daily routine, and give up bad habits. People who play sports at a professional level should use a special bandage or orthosis for the hip joint and try to limit the load on the affected joint.

Joint pain not only takes away vitality, but also indicates the presence of disorders in the body that can result in stiffness of the joints of the skeleton bones or even total immobilization.

If you experience even the slightest discomfort in the pubic area, you should see a doctor.

Methods of timely diagnosis and the prescription of adequate therapy will avoid severe complications and prevent further destruction of the cartilage tissue of the symphysis pubis.

Reading time: 10 minutesCommentsPhoto: ainridzuan.com

How to avoid the occurrence of symphysiopathy?

The occurrence of this disease is not fully understood. In order not to think about how the ultrasound procedure of the symphysis pubis is performed, it is worth familiarizing yourself with a number of general recommendations. These include the following:

A pregnant woman needs to eat more foods that contain calcium;
It is best to take vitamin complexes that will enrich the body with essential nutrients;
you need to take medications with bifidobacteria and lactobacilli;
moderate physical activity is indicated;
A pregnant woman should take up swimming, which has a beneficial effect on the general condition of the body;
It is useful to regularly walk in the fresh air;
You cannot spend a lot of time in the same position, and you also need to monitor your posture.

If symphysitis has already manifested itself, you will need to follow a certain regime, including bedtime.

Description

Symphysitis is an inflammatory lesion of the pubic symphysis, accompanied by separation of the pubic bones.

The woman's pelvis looks like a ring, which consists of eight parts (coccyx, sacrum, two ischial bones, two pubic bones and two pelvic bones). At the bottom of the abdomen, in its middle part, there are two pubic bones, which are connected to each other by fibrous tissue (symphysis). During pregnancy, this tissue becomes much softer. This is necessary to ensure that the birth proceeds normally and that there are no difficulties during the passage of the child through the birth canal. However, in some cases, the connective tissue can stretch too much and lead to pathological mobility of the pubic bones, which is accompanied by an inflammatory reaction. This is an unpleasant, but quite common pathology. According to statistics, symphysitis occurs in women in 50% of cases during pregnancy. As a rule, the first symptoms appear at 7–8 months of pregnancy, but in severe cases they can appear at 4–5 months.

There are 3 degrees of severity of symphysitis:

1st degree, in which the bones of the pubic symphysis diverge by 0.5 - 0.9 cm;
Grade 2 is characterized by a divergence of the symphysis by 1.0 – 1.9 cm;
Grade 3, in which the distance between the pubic bones is more than 2.0 cm.

At the moment, it has not been possible to find out the exact reasons for the development of symphysitis. However, there are two theories that explain why women experience severe separation of the pubic bones and why an inflammatory process develops in this area:

calcium deficiency in the body (during pregnancy, a woman should consume at least 1000 mg of this mineral per day);
high levels of relaxin in the body (a hormone secreted by the female sex glands and placenta, leading to weakening of the ligaments).

Factors that increase the risk of developing symphysitis include:

genetic pathologies of bone and connective tissue, as well as joints;
disruption of collagen production;
sedentary lifestyle;
numerous births or repeated births that took place a short period of time after the previous ones;
history of pelvic injuries (often found in people involved in sports);
large fetal weight (more than 4 kg);
symphysitis in previous pregnancies;
large weight gain during pregnancy.

Symphysitis is often inherited. If a woman’s mother had this pathology, then her daughter will most likely also develop it in the future.

The prognosis of symphysitis depends on the severity of the process and clinical manifestations. If the disease is detected at an early stage, the prognosis is quite favorable. In the case of diagnosing grades 2 and 3 symphysitis, the prognosis is less favorable, since treatment takes a fairly long period of time. If left untreated, the consequences of symphysitis can be quite serious. These include rupture of the symphysis pubis, resulting in the inability to walk, stand, or simply raise your legs. To avoid complications of symphysitis, it is recommended to promptly seek help from an obstetrician.

Where is the symphysis pubis located?

The human pelvic ring closes in front - that’s where it is located. Every person can feel it quite freely; difficulties may arise only in very plump people. If you place your hand 15-20 centimeters below the navel and press on the skin, you can feel the bones of the pubic symphysis underneath it.

The bladder is located directly behind the pubis in both men and women, so the location of the symphysis pubis can be determined by one more sign: when a person really wants to urinate, it is behind the pubis (behind the pubis) that the urge to urinate is felt.

Symptoms

Photo: typeset-beta.imgix.net

The main symptom indicating the possibility of symphysitis is pain in the pubic area. Pain syndrome comes in varying degrees of intensity. Increased pain is observed in the following situations:

when spreading your legs to the sides;
when raising straightened legs up while lying on your back;
when pressing with your hand on the womb;
in the evening or at night;
during sexual intercourse.

In addition to the localization of pain in the area of the symphysis pubis, pain can occur in the lower back and hip joints. The pain is aching or pulling.

Since the development of symphysitis is often associated with calcium deficiency, symptoms such as general weakness, fatigue, decreased ability to work, muscle cramps (mainly at night), increased brittleness of nails, hair loss, paresthesia (characterized by a tingling, burning sensation, “ crawling")

A change in the nature of gait indicates progression of the process. In this case, the gait becomes a “duck”, which is characterized by swaying movements from side to side. You can also hear various clicking, crackling, and grinding sounds while the patient walks.

In the event of a rupture of the symphysis pubis with complete damage to the ligaments responsible for stabilizing the pubic symphysis, the person is immobilized. This condition is called “symphiolysis.” Rupture of the symphysis pubis is accompanied by severe pain. In addition, in this state, a person cannot lift his legs, spread them, there is no ability to walk, and even standing on his feet causes certain difficulties. Movement disorders significantly reduce the patient’s quality of life. A woman does not have the opportunity to lead a daily life, take care of her loved ones, moreover, she herself needs care.

Causes of pubic bone problems

The area of the symphysis pubis in women is very susceptible to various pathological processes, which sometimes leads to problems during and after childbirth. All reasons can be grouped into several categories:

Heredity - it has been clearly proven that the risk of symphysitis and rupture of the symphysis pubis in primiparous women is several times higher if their mothers also suffered from this problem.
Hypocalcemia - in pregnant women, a relatively large percentage of dietary calcium is used to build the fetal skeleton. This fact, as well as hormonal changes, as a result of which the absorption of calcium by a woman’s joints deteriorates, leads to weakness of the pubic symphysis.
Vitamin D deficiency - this cause is especially noticeable in women who are pregnant in the autumn-winter period, when due to lack of sunlight their own vitamin is not produced.
Endocrine disorders - diseases of the endocrine system can cause excessive calcium excretion in the urine, which leads to softening of the pubic symphysis.

It is especially difficult for those women who have a combination of several causes at the same time.

Diagnostics

Photo: uib.no

Diagnosis begins with collecting the patient’s complaints and medical history. After which the doctor prescribes a range of laboratory and instrumental examinations, the results of which will help make the correct diagnosis.

First of all, general laboratory tests are performed (general blood count, general urinalysis and biochemical blood test), which allow us to assess the general condition of the human body. With symphysitis, there is no specific change in indicators characteristic exclusively of this disease. Since one of the reasons for the development of symphysitis is a violation of calcium metabolism, special attention should be paid to the level of calcium in the blood.

During vaginal examination using a speculum, pain is noted in the area of the pubic symphysis. It is impossible to palpate a slight discrepancy in the symphysis; only when the distance between the pubic bones is more than 2.0 cm, which is typical for the 3rd degree of severity of symphysitis, the discrepancy is revealed in the form of a sensation under the fingers of a certain depression at the junction of the pubic bones.

The most accurate information about the distance between the pubic bones is provided by ultrasound examination of the symphysis pubis. The results of the study allow us to assess not only the severity of the disease, but also makes it possible to choose the method of delivery.

In the postpartum period, an X-ray examination of the pelvic bones is performed. The purpose of this study helps to assess the distance between the pubic bones, on the basis of which a conclusion can be made about the severity of the disease. In addition, the x-ray visualizes the displacement of the pubic bones, if any. The offset can be to the side or up/down in relation to each other. During pregnancy, the use of this diagnostic method is prohibited.

Diagnostic examinations are necessary to establish an accurate diagnosis, which allows you to determine further treatment tactics.

Causes of divergence of the pubic symphysis

The symphysis pubis is threatened during pregnancy due to impaired metabolism and lack of vitamin D. For example, hormones produced by the parathyroid gland are involved in the regulation of phosphorus-calcium metabolism in the body. If there is a lack of calcium supply, required for the full development and growth of the fetus, the body begins to draw the necessary substance from the mother’s reserves. The main source of calcium for the future baby will be the mother’s teeth and bones. Also, gastrointestinal diseases and diabetes mellitus can cause calcium deficiency. In turn, vitamin D significantly affects the body's absorption of incoming calcium.

The divergence of the symphysis pubis begins to develop long before the birth of the child. However, the effects of hormones and fetal weight contribute to the manifestation of the above symptoms only in the second or third trimester. Often, the signs of pathology that appear are not given due attention and are attributed to osteochondrosis, radiculitis, or the threat of miscarriage.

Timely diagnosis is extremely important. It will help you take the necessary treatment measures in time, prevent negative consequences through natural delivery or resort to caesarean section.

Treatment

Photo: i0.wp.com

When symphysitis is detected in a pregnant woman, in most cases delivery is performed by cesarean section. Childbirth through the natural birth canal is possible only in cases where the discrepancy of the bones of the pubic symphysis does not exceed 1 cm. However, despite this, in the following cases a caesarean section is also performed:

in the presence of severe pain that is not amenable to drug treatment;
bearing a large fetus;
the presence of an anatomically narrow pelvis (one or more pelvic sizes are 1.5 - 2 cm less than normal);
with polyhydramnios - a pathological condition during pregnancy, which is characterized by an increase in amniotic fluid in the amnion.

To eliminate pathophysiological changes in the tissues of the symphysis that occur with symphysitis, nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed. This group of drugs affects the activity of inflammatory mediators, which leads to a decrease in the inflammatory process. In addition, non-steroidal anti-inflammatory drugs have an analgesic effect, which plays a huge role in eliminating the pain syndrome characteristic of symphysitis.

In the fight against hypocalcemia, which is often the cause of the development of symphysitis, calcium supplements are prescribed. Taking them allows you to replenish calcium deficiency in the body. In addition, vitamin-mineral complexes are used, which contain not only the necessary calcium, but also other useful vitamins and minerals that help strengthen the body.

Non-drug treatment methods are used:

physiotherapy. Magnetic therapy of the pubic area is very successful. The effect of this method of treatment is to improve microcirculation, stimulate metabolic processes, slow down the transmission of pain impulses along nerve fibers, which is achieved through exposure to a magnetic field;
use of a bandage. This device helps reduce the load on the pelvic bones, including the pubic symphysis;
physiotherapy. Allows you to strengthen the muscles of the pelvic floor, hips and lower back.

Anatomy of the pelvis, or what is the womb

The dense pelvic bones in combination with the sacrum form a complete structure - the pelvic ring. Its task is to unite the skeleton of the lower extremities with the spine. Nature assigns another important function to the pelvis: it serves as a container and support for internal organs.

This aspect takes on particular importance in women during pregnancy - the pelvis becomes a natural container for the pregnant uterus, which during this period almost completely displaces other organs (intestines, omentum). All large muscles of the lower extremities, muscles of the anterior and lateral walls of the abdominal cavity are attached to the pelvic bones. Large nerves (sciatic, obturator) and vessels (femoral veins and arteries) pass through the openings in the pelvic bones.

Functions of the pelvis:

Supportive - the entire weight of the upper half of the body is transferred to the pelvis through the spine.
Motor - the muscles of the legs and back, which are responsible for movement, are attached to the pelvis.
Balancing - the interaction through the pelvis between the legs and spine allows a person to maintain balance.
Protective - protects large vessels and nerve trunks from damage.
Hematopoietic - in the flat bones of the pelvis there is a significant mass of red bone marrow that produces blood cells.

Medicines

Photo:

sochi-informburo.ru

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in the treatment of symphysitis to eliminate the inflammatory process. In addition, these drugs have an analgesic (pain-relieving) effect. Currently, the pharmacological market is rich in various representatives of non-steroidal anti-inflammatory drugs, but not all can be used during pregnancy.

In the first and second trimesters of pregnancy, drugs such as diclofenac and ibuprofen are prescribed, which have a pronounced anti-inflammatory effect. The mechanism of action of diclofenac is based on inhibition (suppression) of the synthesis of substances that play a key role in the process of inflammation (prostaglandins and cyclooxygenase). In addition to the anti-inflammatory effect, diclofenac has an analgesic effect. However, it is worth noting that it is rational to use diclofenac only for moderately severe pain, as it has a slight analgesic effect. Ibuprofen has an anti-inflammatory effect by inhibiting cyclooxygenase and reducing prostaglandin synthesis. As a result, vascular permeability decreases and microcirculation improves. In later stages of pregnancy, taking these drugs is prohibited, as there is a risk of premature closure of the ductus arteriosus in the fetus, impaired renal and liver function in the newborn, etc.

Calcium preparations are used when a deficiency of this microelement is detected in a woman’s body. The following names of drugs exist:

Calcium-D3 Nycomed;
Calcium-D3 Nycomed Forte;
Calcium-D3-MIC;
Calcemin.

For best absorption, it is recommended to take calcium supplements with meals or immediately after meals. These drugs are well tolerated; in rare cases, side effects such as periodic pain in the epigastric region (upper abdomen), nausea, and bowel disorders such as constipation may occur. A contraindication to taking the drug is individual intolerance to the components. The drug is discontinued if adverse reactions develop, as well as with increased calcium levels in the blood and urine.

Vitamin and mineral complexes are used to strengthen the general condition of the body. They contain a specially combined list of vitamins and microelements necessary for the normal functioning of our body.

Folk remedies

Photo: yandex.ru

Symphysitis should be treated by a qualified specialist. The use of various traditional medicines is strictly prohibited.

At home, a woman who has the problem in question should monitor her diet. First of all, preference should be given to dairy products (cheese, cottage cheese, milk, etc.), which are rich in calcium. You should also be careful with flour products and fatty foods, as their excess consumption leads to weight gain. In turn, excess weight increases the load on the pelvic ring, and as a result, pain increases.

It is important to reduce excessive physical activity, refrain from climbing stairs, fast walking, and staying in one position for a long time (over 30 minutes - 1 hour). It is also recommended to perform specially designed physical exercises daily that strengthen the gluteal, thigh and perineal muscles. We suggest the following exercises, which should be performed several times a day:

Take a lying position. Place your feet as close to your buttocks as possible. Then spread your bent knees to the sides as far as possible and stay in this position for a few seconds, after which you close your knees again. It is necessary to repeat this exercise from 5 to 10 times, gradually increasing the number of exercises.
Take a lying position. Bend your knees and lift your pelvis so that you form a straight line with your body. It is recommended to perform this exercise 5 to 10 times daily, gradually increasing the number of exercises. If pain occurs, you should stop doing the exercise.
Get on your knees and place your palms on the floor so that they point forward. The correct position should look like this: arms straight, knees bent at right angles to the body, back straight. As you inhale, round your back as much as possible and lower your head down. As you exhale, slowly return to your starting position. Then, while inhaling, bend your body down as much as possible. As you exhale, return to the starting position. The exercise should be repeated 5 – 10 times.

The information is for reference only and is not a guide to action. Do not self-medicate. At the first symptoms of the disease, consult a doctor.

Ultrasound diagnostics of the condition of the symphysis pubis in women

Bone pelvic pathology occupies a certain place in the structure of abnormal births. Pathological expansion or the appearance of pain in the symphysis is classified as dysfunction of the symphysis pubis (PA) (symphysiopathy, symphysitis). This complication, which occurs during gestation, is considered in the structure of the syndrome of pelvic girdle pain during pregnancy (Pregnancy-related pelvic girdle pain (PPGP)). When examining a large population of women, it was proven that up to 50% of pregnant women experience pelvic pain, which may be a consequence of changes in the joints of the pelvis, most often the pubic joint, and require additional examination. In 25% of cases, pelvic pain requires treatment and in 8% of women it leads to limitation of daily activities, in fact, to temporary disability. According to various authors, pelvic pain persists for 4–6 months. after childbirth in 26.5–43% of women [1, 2].

Despite the low incidence, rupture of the pelvic joint remains a serious complication of labor during symphysiopathy; restoration of the function of the pelvic joints takes up to 5 months. after childbirth. Trauma to the left leg may be accompanied by rupture of one of the sacroiliac joints and damage to adjacent organs [3]. The incidence of this complication is low historically and currently. In recent decades, discrepancies and ruptures of the LM occur, according to various authors, from 1:380 to 1:3400 births [4–6].

Anatomy and pathogenesis

The LS is formed by the fibrocartilaginous interpubic plate (lamina fibrocartilaginca interpubica or Discus interpubicus) and fibrous ligaments: on top - lig. pubicum superius, below - lig. arcuatum pubis, front - lig. fibrosum ant. and behind - lig. fibrosum post [7].

One of the most detailed descriptions of the morphology and structure of the drug was given by M.F. Eisenberg in 1962. According to him, the drug “has sexual characteristics and has individual differences. All types of joints are observed - from synchondrosis to a real joint. Features of the structure and condition of drugs... in women... of course... are in close connection with the endocrine and functional processes occurring in the body.” Morphologically, the cartilaginous interpubic plate is heterogeneous - most of it is represented by hyaline cartilage; along the periphery of the interpubic gap there is a zone of fibrous cartilage. With age, hyaline cartilage is displaced and in some cases is defined as separate islands [8].

Sexual and gender dimorphism of the structure of the drug, as well as age-related changes, confirm the latest literature data [9].

N. Lottering and MS Reynolds (2013) state age-related changes in the structure and zones of ossification of the LM during its three-dimensional CT reconstruction [10].

The pathogenesis of changes in drugs, in particular during pregnancy, cannot be called thoroughly studied.

Some changes, such as expansion, are described in sufficient detail in the literature. During pregnancy, edematous impregnation and loosening of tissue in the articulation area occurs, as a result of which the articular ends of the pubic bones acquire greater mobility than before pregnancy [11]. This point of view is also supported by authoritative Russian researchers [4, 12, 13].

Due to the loosening of the symphysis during pregnancy, the cavity in the interpubic cartilaginous plate can increase to a significant size, sometimes with a divergence of the symphysis bones by 1–2 cm. Some authors believe that this phenomenon in pregnant women can also be considered from the point of view of metabolic disorders and interpreted as the initial stages of osteomalacia. Disturbances in the structure and function of drugs can occur under the influence of other etiological factors (syphilis, TBC, jaundice, hemorrhagic diathesis, arthritis) [8].

The influence of hormones, mainly relaxin, is considered one of the main factors in changes in pelvic articulations during pregnancy, but a direct relationship between the degree of expansion of the pelvis, the levels of circulating relaxins and pelvic pain during pregnancy has not been identified [14].

Sports medicine specialists believe that symphysis lesions are the result of injury to the ligamentous apparatus of the pelvic ring and the muscles of the hip and lower back [15].

There is a theory of muscle spasm in the genesis of symphysiopathy, which may be due to disturbances in calcium metabolism.

Diagnostic methods

Until recently, X-ray methods were considered the “gold standard” in diagnosing changes in LM.

During pregnancy, preference is given to ultrasound diagnosis of drugs (Fig. 1). Magnetic resonance imaging is used primarily in sports medicine. The advantages of the ultrasound method are accessibility, the ability to assess not only the degree of divergence of the ligaments, but also, in contrast to the x-ray method, to determine the condition of the soft tissues and ligaments.

The ultrasound method for studying the symphysis in pregnant women, proposed over the past 20 years by a number of authors for diagnosis and prognosis in symphysiopathies, mainly comes down to measuring the width of the symphysis. By itself, this indicator does not reflect the degree of pathological changes in the symphysis, and also poorly or does not correlate at all with clinical manifestations and complaints and does not allow one to predict the most dangerous complication of symphysitis - discrepancy or rupture of the womb during childbirth. As a result of the study, we can propose new ultrasound symptoms that reflect structural changes in the LM during symphysitis in pregnant women, promising in terms of their use for differential diagnosis.

Materials and methods

195 patients were examined, divided into 3 main groups:

Group 1 - pregnant and postpartum women without clinical signs of drug dysfunction:

1A — at full-term pregnancy (n=30) — a single ultrasound of the LM was performed;
1B - primigravida women (n=27) - dynamic observation;
1C - multiparous pregnant women (n=30) - dynamic observation;
1D - after childbirth (n=18).

Group 2 - non-pregnant women of fertile age (n=30) without clinical manifestations of LS pathology.

Group 3 - 60 pregnant women with clinical manifestations of symphysitis.

On sagittal scanning, the LS appears as an oval formation of a heterogeneous structure with a clearly distinguishable “core”, which includes hyperechoic and hypoechoic areas. Based on the outer surface of the cartilaginous girdle, in most cases it is possible to differentiate along the upper edge of the lig. pubicum superius, below - lig. arcuatum pubis, front - lig. fibrosum anterior and posterior - lig. fibrosum posterior (Fig. 2).

When comparing the ultrasound picture with the data of morphological studies, it can be assumed that the hypoechoic rim of the symphysis represents the hyaline part of the cartilaginous disc, and the hyperechoic “core” represents areas of replacement with fibrous cartilage. In the structure of the cartilaginous girdle, hyperechoic inclusions of round or irregular shape, single or grouped, can be found - zones of ossification (Fig. 3). The linear dimensions of the LM in women during ultrasound examination are presented in Table 1.

Like other researchers, we saw that during pregnancy there is an increase in the width of the LM, with a more significant increase in the upper parts of the cartilage. The width of the symphysis in the upper third of a pregnant woman was on average 1.45 times greater than in the lower third (1.23–1.70 times).

The total area of the lamina is on average 1.96 (1.81–2.09) times larger than the cross-sectional area of the “cartilaginous core” of the pubic symphysis. The width of the symphysis in the upper third in the postpartum period was on average 1.31 times greater than in the lower third (1.07–1.51 times).

When comparing the ultrasound picture of the symphysis in groups of nulliparous (group 1B) and multiparous (group 1C) pregnant women, the following significant features were identified:

1) the minimum diastasis of the pubic bones in groups 1 °C and 1B did not differ significantly (5.4 ± 1.3 (3.7–8.0) mm versus 5.4 ± 1.0 (3.8–8.2 ) mm; p=0.83);

2) maximum diastasis in groups 1B and 1 °C also did not differ significantly (6.2±1.7 (3.5–10.0) mm versus 4.5±9.0 (3.4–9.0) mm; p=0.76);

3) unevenness (notching) of the upper edge of the pubic bone was observed in 26% in group 1B (87% in group 1 °C);

4) visualization of the “apophysis” in 33.3% in group 1B (43.3% in group 1 °C);

5) single hyperechoic inclusions in the structure of the symphysis in 48% in group 1B (in 93% in group 1 °C);

6) grouped hyperechoic inclusions in 22% in group 1B (40% in group 1 °C);

7) the thickness of the superior ligament of the left limb in group 1B was 3.8±1.02 mm on the right, 3.8±0.98 mm on the left (p=0.98); in the 1 °C group - 4.2±1.0 mm on the right, 4.4±1.0 mm on the left (p=0.46). The difference in superior ligament thickness between groups 1B and 1°C was not statistically significant on the right (p=0.20), but significant on the left (p=0.04). When measuring the superior ligament in the middle above the symphysis, the latter was thickened in women in the 1 °C group (7.8 ± 1.7 mm versus 6.6 ± 1.5 mm) (p = 0.01).

As an additional research method, we studied the echo density of the cartilaginous interpubic plate in women. The construction of histograms of tissue density of the left leg in all examined patients was carried out in the same scanning modes. The echo density of the interpubic cartilaginous disc was measured in various zones. No significant differences in tissue density were found within the groups. The results of the study are presented in Table 2.

Thus, the relative echographic density of the fibrous “core” of the LM is higher than the density of the hyaline cartilage.

As a result of the study, we found that by the end of pregnancy the LM undergoes the following changes: moderate diastasis of the womb relative to the womb of non-pregnant women, an increase in the echo density of the cartilaginous disc - both the hyaline and cartilaginous parts.

Of greatest interest is the study of group 3 - patients with clinical manifestations of drug dysfunction during pregnancy. In 60 pregnant women with varying degrees of pain and limitation of movement during a traditional examination, significant differences in the width of the LM from the norm, i.e., signs of pubic divergence, were detected in 2 (3.3%) observations (Fig. 4). The measurement results are presented in Table 3.

As can be seen from the presented material, the average values of the linear dimensions of the symphysis do not have significant differences in different clinical groups, with the exception of the width of the symphysis. In this regard, the results of the study do not contradict previously presented literature data. However, even with statistically reliable indicators, the difference in the width of the symphysis in normal conditions and in pathology is within the limits of measurement error acceptable when using the ultrasound method. Consequently, this research method does not reflect the degree of tissue damage to the LM with the so-called “symphysitis”.

In all patients with clinical signs of LM dysfunction, sagittal scanning of the cartilage disc revealed changes in the structure of the fibrous part of the cartilaginous interpubic plate in the form of irregularly shaped foci with a hypo- and anechoic structure. To evaluate the echographic picture, we measured the area of the fibrous part of the cartilaginous disc, the area of each lesion using the function of tracing a linear contour, calculated the total area of the changed areas, and measured the echo density of pathological zones (Fig. 5). The average echo density of the lesions was 64.5 (11–132) units. with an average echo density of the fibrous “core” of LS 126.6 units. (52–187), a focal decrease in the echo density of fibrocartilage tissue was revealed from 2 to 4 times compared with a normal echo picture (Table 4). Using the histogram function to assess the “echo density” of tissues is more correct and indicative if the grayscale level is compared not between different patients, but within the same scan. This study shows that dysfunction of the drug during pregnancy is based on morphological changes associated with the course of pregnancy itself. The formation of hypoechoic zones in the structure of fibrocartilage is probably associated with an increase in tissue hydrophilicity due to inflammatory or autoimmune disorders of the macroorganism.

conclusions

Our study showed that in order to diagnose the state of the symphysis during pregnancy and timely assess its dysfunction, it is necessary not only to assess the width of the symphysis, but also to examine its internal structure.

Gestational changes in the LM are characterized by moderately pronounced expansion and an increase in the relative echo density of the fibrous part of the cartilaginous disc. The study revealed a number of distinctive features of the structure of the symphysis in multiparous women, probably associated with previous births.

Clinical manifestations of LM dysfunction in all cases are accompanied by the appearance of structural heterogeneity and the identification of areas of reduced echogenicity in its structure. Timely diagnosis of morphological changes and assessment of the degree of their severity will ensure a favorable birth outcome for the mother and newborn.

Literature

Robinson P. Musculoskeletal Ultrasound of the Adult Hip and Groin – Anatomy and Pathology // Proceeding of 2010 Annual Convention TSUM. 2010. P. 73–77
Hansen A. et al. Postpartum pelvic pain—the “pelvic joint syndrome”: a follow-up study with special reference to diagnostic methods // Acta Obstet. Gynecol. Scand. 2005. Vol. 84(2). P. 170–176.
Brandon CJ, Jacobson JA et al. Groin Pain Beyond the Hip: How Anatomy Predisposes to Injury as Visualized by Musculoskeletal Ultrasound and MRI // AJR. 2011. Vol. 197. P.1190–1197.
Chernukha E.A., Ananyev E.V. Diagnostics. Treatment and choice of delivery method for symphysis pubis dysfunction in pregnant women // Obstetrics and Gynecology. 2010. No. 3. P. 65–69.
Bjorklund K., Lindgren PG, Bergstrom S., Ulmsten U. Sonographic assessment of symphyseal joint distention intra partum // Acta Obstet. Gynecol. Scand. 1997. Vol. 76(3). P. 227–232.
Dunk RA, Langhoff-Roos J. Osteomyelitis of the pubic symphysis after spontaneous vaginal delivery // BMJ Case Reports. 2010. doi:10.1136/bcr.01.2010.2610.R1
Sinelnikov R.D. Atlas of human anatomy in 4 volumes. 1996 Vol. 1 1996 ISBN: 5-225-02722-9. M.: Publishing house "Medicine", 232 p.
Eisenberg M.F. Articulation of the pelvis during pregnancy and childbirth // State Medical Publishing House of the Ukrainian SSR. Kyiv, 1962. 110 p.
Wink AE Pubic Symphyseal Age Estimation from Three-Dimensional Reconstructions of Pelvic CT Scans of Live Individuals.// J Forensic Sci. 2014 Feb 6. doi: 10.1111/1556-4029.12369
Lottering N. Morphometric modeling of aging in the human pubic symphysis: Sexual dimorphism in an Australian population. // Lottering N., Reynolds MS, Macgregor DM, Meredith M., Gregory LS Elsevier Ireland Ltd. All rights reserved. 2014. Vol.10.
Schoellner C., Szoke N., Siegburg K. Pregnancy – associated symphysis damage from the orthopedic viewpoint – studies of the pubic symphysis in pregnancy, labor and post partum // Z. Orthop. Ihre Grenzgeb. 2001. Vol.139(5). P. 458–462.
Ananyev E.V. Optimization of diagnostics, tactics of pregnancy and childbirth with dysfunction of the symphysis pubis: abstract of thesis. diss. Ph.D. M., 2012.16 p.
Sergeeva O.P. State of the symphysis pubis during pregnancy and the postpartum period: abstract. diss. Ph.D. Kazan, 2005.
Bjoklund K., Bergstrom S., Nordstrom ML, Ulmsten U. Symphyseal distention in relation to serum relaxin levels and pelvic pain in pregnancy //Actsa Obstet. Gynecol. Scand. 2000. Vol. 79(4). P. 269–275.
Anderson J., Read J. Atlas of Imaging in Sports Medicine. 2007.
Quote by Read J. Groin disruption injury // https://www.sportsmedicineimaging.com/topics/groin-disruption-injury.