Transcript Pelvic Pain - Linda Baier Files

Abdominal and Pelvic Pain
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01/31/13
Objectives
By the end of this lecture, participants will be able to:
• Identify common causes of acute abdominal and pelvic pain
• Identify triage questions for nurses related to this topic
• Differentiate urgent vs. non-urgent presentations
• Describe the components of a pain evaluation
• Provide appropriate patient education
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Case Study
Lisa, a 39-year-old female veteran,
calls the primary care clinic with a
complaint of pelvic pain that
started 24 hours ago.
Nurse’s critical thinking process: Assess
the urgency of Lisa’s complaint.
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Triage Questions for Acute and Chronic Abdominal
and Pelvic Pain
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Are you/could you be pregnant? LMP?
Where is the pain? Does it radiate elsewhere?
Has the location of the pain changed over time?
How long have you had the pain? Where/when did it occur?
Was the onset of pain sudden or gradual?
What have you used to treat your pain?
Does anything make it worse or better?
Have you had similar pain before? If yes, how was it treated?
Is the pain sharp, dull, or stabbing? Does it come and go (cyclic)?
Rate the pain on a scale of 1=minor to 10= unbearable
What form of birth control do you use?
Other symptoms (e.g., nausea, vomiting, vaginal discharge/bleeding)?
Past gynecologic surgeries? Past sexually transmitted infections?
Bowel movement pattern?
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Case Study, continued
Lisa states that she has never had pain
like this before. She tried
acetaminophen and ibuprofen, but
neither helped. Her last menstrual
period was 2 weeks ago and she has a
history of tubal ligation.
Nurse’s critical thinking process: Lisa is
probably not pregnant. A clinic appointment
is appropriate.
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Signs and Symptoms
• Purulent vaginal discharge suggests STI
• Cramping and vaginal bleeding commonly seen with ectopic
pregnancy or threatened abortion
• Dyspareunia and dysmenorrhea suggest endometriosis
• Anorexia, nausea, vomiting often seen with appendicitis, as well
as inflammatory pelvic processes (pelvic inflammatory disease,
adnexal torsion, degenerating leiomyoma)
• Trauma may cause acute pelvic pain
• Dysuria
• Constipation and/or diarrhea
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Definition of Acute Abdominal/Pelvic Pain
Definitions vary…
• Pain of less than one week duration.
• Undiagnosed pain of less than 10 days duration.
• Working definition: Pain so bad that the patient
cannot wait until tomorrow or next week for a
physician appointment.
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Common Causes of Acute Abdominal/Pelvic Pain
Gynecologic
• Pelvic inflammatory disease
• Dysmenorrhea
• Ruptured ovarian cyst
• Ovarian and fallopian tube
torsion
• Endometritis
• Torsion or degeneration of a
uterine fibroid
• Rupture of an endometrioma
Gynecologic with a positive
pregnancy test
• Ectopic Pregnancy
• Miscarriage
Non-gynecologic
• Appendicitis
• Acute cystitis
• Diverticulitis
• Urinary tract calculi
• Abdominal wall trauma
• Interstitial cystitis
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Exam – Nursing Role
• Take vitals immediately
– If patient has marked hypotension, tachycardia, or fever, she
may need emergency treatment
– If patient says she is pregnant, follow local policy for
disposition of acutely ill pregnant patient
• Set up supplies for complete pelvic exam
• Potential lab tests:
– All women of reproductive age will need a pregnancy test
– CBC with differential, ESR, CRP
– Urinalysis, protein C and protein S for clotting disorder
– Tests for chlamydia and gonorrhea
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Patient Education for Acute Abdominal/Pelvic Pain
• Any additional questions about treatment plan and discharge
instructions?
• How to reach the provider with questions including afterhours contact
• Clear understanding of when/if she is to return for follow-up
care
• Clear understanding to seek emergency care if
– Pain worsens
– Fevers develop
– Orthostatic symptoms occur (lightheadedness, confusion,
nausea, passing out, weakness, blurred vision, shaking)
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Chronic Abdominal and Pelvic Pain
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Definition of Chronic Pelvic Pain (CPP)
Non-cyclical pain of at least 6 months’ duration
that appears in locations such as the pelvis,
anterior abdominal wall, lower back or buttocks,
and that is serious enough to cause disability or
lead to medical care.
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Epidemiology of CPP
• Occurs in 15% of reproductive-aged women
• Cited as a diagnosis in up to 10% of all outpatient
gynecologic consultations, 40% of all laparoscopies,
and 18% of all hysterectomies
• Over $2 billion in estimated annual costs for US
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Co-Morbidities with CPP
• Up to 50% of women with pelvic pain also have
depression
• Drug and alcohol abuse predispose to pain
• No difference in prevalence of CPP based on race,
ethnicity, education, or socioeconomic status
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CPP is Associated with Abuse
• Physical or sexual abuse
– Of 713 women seen in a pelvic pain clinic (Meltzer-Brody et al, 2007):
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46.8% had history of sexual or physical abuse
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31.3% had PTSD symptoms
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Women with trauma history had worse medical symptoms
such as headaches, muscle aches, constipation or diarrhea
• Military sexual abuse
– Prevalence of MST among all women veterans is 1 in 5
– Women with a history of MST are twice as likely to report
chronic pelvic pain (Frayne et al, 1999)
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Physiologic Causes of CPP
Gynecologic
GI
Urologic
Musculoskeletal
Endometriosis
IBS
Interstitial
cystitis
Myofascial pain
(abdominal wall or
pelvic floor muscles)
Pelvic adhesions
IBD (UC,
Crohn’s, etc.)
Chronic UTI
Fibromyalgia
Pelvic congestion
Chronic
constipation
Urethral
syndrome
Coccygeal or low back
pain
Chronic pelvic
inflammatory disease
Colitis
Radiation
cystitis
Nerve pain
Adenomyosis
Diverticulitis
Urinary calculi
Vulvodynia
Ovarian cyst/varicosity
Uterine myomas
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Most Common Diagnoses of CPP
• Definitive diagnosis is not made for 61% of women
• Up to 40% of women with CPP in primary care have
more than one diagnosis
• The four most commonly diagnosed causes of CPP are:
– Endometriosis
– Adhesions
– Irritable bowel syndrome (IBS)
– Interstitial cystitis
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Chronic Pain Questions
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Have you had this type of pain in the past?
How would you describe today’s pain?
Does today’s pain differ from previous episodes? If yes, how?
Associated symptoms?
Pain timing:
– Constant? Associated with menses? Associated with eating?
Associated with intercourse? Associated with stress?
Rate the pain on a scale of 1=minor to 10=unbearable
What have you done to treat the pain? Today? In the past?
Does anyone in your family have chronic pain? If yes, what?
Do you have a pain plan? If yes, are you following it? When did
it stop working?
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Exam – Nursing Role
• Take vital signs
• Set up supplies for a complete pelvic exam
• Potential lab tests:
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All women of reproductive age will need a pregnancy test
Pap if patient is due
CBC with differential
Liver and renal function tests
Urinalysis, protein C and protein S for clotting disorder
Tests for chlamydia and gonorrhea
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Be Alert for Signs of Trauma
• Be aware of patient behaviors during the interview or exam that
may indicate prior trauma…
– Becoming tearful
– Becoming silent or staring
– Nervous talking
– Reluctance to have a GU exam
• If a patient shows signs of distress
– Bring someone else in the room so you are not alone with her
– Change the subject until she can collect herself
– Ask her if she would like to take a minute to relax or if she
would like to delay the interview or exam
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What Women with CPP Want
• To be addressed as an individual by a supportive,
understanding, interested provider/team
• To feel that both she and her pain are taken seriously
and legitimized
• To receive an explanation for her condition (more so
than a cure). Information and discussion.
• Reassurance that it is:
– “Not all in her mind”
– “A common problem”
– Not serious/cancer
Price et al, 2006
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Patient Education for CPP
• Any additional questions regarding treatment plan and discharge
instructions?
• How to reach the provider with questions including after-hours
contact
• Clear understanding of when/if she is to return for follow-up
• Clear understanding to seek emergency care immediately if
– Pain worsens
– Fevers develop
– Orthostatic symptoms occur (lightheadedness, confusion,
nausea, passing out, weakness, blurred vision, shaking)
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Most Common Causes of CPP
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IBS
• Abdominal pain/discomfort with altered
bowel habits for at least 3 months
• Colon spasms, causing food to move too quickly or too slowly
through the intestines
• Cause is unclear
• Affects 20% of the population; 1.5 times more common in women
• Onset before age 35 in 50% of cases
• IBS sufferers report poorer physical and mental health
• IBS care costs up to $20 billion annually
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Fundamentals of an
“Elimination Diet”
• Goal: remove foods that may
be irritating the lining of the
intestine
• Don’t eat the foods whole or
as ingredients in other foods
for 2 weeks
• Once intestinal wall has
returned to normal, slowly add
one food group every 3 days
• Keep a record of symptoms
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Eliminate for 2-Week Trial
• Dairy (lactose)
• Wheat (gluten)
• High fructose corn syrup
• Sorbitol (chewing gum)
• Eggs
• Nuts
• Shellfish
• Soybeans
• Beef
• Pork
• Lamb
IBS Patient Education
• Symptom diary is useful
• Dietary manipulation is most effective
– May need nutritional consult
• Add fiber slowly
• Stress management
• Increase physical activity
• Medication management
• Alternative/complementary therapy
– Biofeedback
– Probiotics (Nikfar et al, 2008)
– Peppermint oil (Merat et al, 2009)
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Endometriosis
• Endometrial tissues that occur
outside the uterus
• Multiple theories as to cause
• Affects 3-15% (avg 10%) of the general population
• Occurs in 25-50% of the infertility population
• Mean age at diagnosis is 25-30
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Endometriosis Symptoms
Pelvic pain
• 70-75% of women with endometriosis
• Severity not related to pathology by laparoscopy
• Can include:
‒ Increasing dysmenorrhea
‒ Deep dyspareunia
‒ Premenstrual dysmenorrhea
‒ Lower abdominal pain, often bilateral
‒ Lower back pain
Infertility
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Endometriosis Diagnosis
• History
• Physical exam
• Laparoscopy (gold standard)
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Patient Education for Endometriosis
• Management with medications
− NSAIDs
− Monophasic oral contraceptive, vaginal ring, or contraceptive
patch continuously for 3 months
• Refer to Gynecology
− GnRH analogues
− Surgery (destruction of lesions, hysterectomy)
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Interstitial Cystitis (IC)
• Defined as 3-6 months of pain, pressure, or
discomfort over the suprapubic area or the bladder,
accompanied by frequency of urination during the
day and night in a patient who does not have a UTI
• 90% of cases are female
• Symptoms very over time with flares and remissions
• Cause is unknown but may be related to defect in the
protective lining (epithelium) of the bladder
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IC Signs, Symptoms, and Diagnosis
• Dysuria, frequency, urgency, chronic pelvic pain,
dyspareunia, vulvodynia
• Often a diagnosis of exclusion (exclude UTI, bladder
cancer, gynecologic disease)
• UA, potassium sensitivity test
• Refer to Urology for evaluation
– Cystoscopy usually with biopsy
– Testing of bladder capacity
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IC Patient Education
• Dietary management: low potassium, low acid trial for 2 weeks
– No carbonated drinks, caffeine (including chocolate), citrus
products, tomatoes, pickled foods, alcohol, spices, artificial
sweeteners
• Some patients urinate up to 60 times per day. Retrain bladder by
slowly increasing voiding intervals.
• Pelvic floor/easy stretching exercises to reduce muscle spasms
• Medical management can include oral medications, nerve
stimulation in pelvic area, bladder distension with water or gas,
and medications instilled into the bladder
• Some patients report being helped by acupuncture, guided
imagery, biofeedback, visualization
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Pelvic Adhesions
• Bands of scar tissue that form between two pelvic
organs
• Risk factors include infection, pelvic surgery including
C-section, or trauma
• Can lead to infertility and chronic pain
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Pelvic Adhesion Signs, Symptoms, and Diagnosis
• Usually signal their presence by aggravating the
symptoms of IBS or by causing pain during sexual
intercourse
• Diagnose by excluding other pathology
• Refer to Gynecology
– Laparoscopy
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Patient Education for Pelvic Adhesions
• Avoid constipation
• High fiber diet
• Pain management
• Surgical lysis
– Indicated for dense adhesions
– Some practitioners use substances intraoperatively to
prevent more adhesions from forming
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Conclusion
• Patients complaining of abdominal/pelvic pain need a
good triage assessment to determine urgency of care
• Chronic pelvic pain is a complex condition
• Many women have concurrent depression, PTSD, MST,
IPV. Multidimensional care is often necessary.
• Existing data is hampered by lack of standard
definitions, algorithms, and adequate clinical trials,
BUT….
Our patients rely on us to listen and come up with the
best treatment plan possible
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Patient Education Resources
• Womenshealth.gov.
– Irritable bowel syndrome.
http://www.womenshealth.gov/publications/our-publications/factsheet/irritable-bowel-syndrome.cfm
– Endometriosis. http://www.womenshealth.gov/publications/ourpublications/fact-sheet/endometriosis.cfm
– Interstitial cystitis/bladder pain syndrome.
http://www.womenshealth.gov/publications/our-publications/factsheet/interstitial-cystitis.cfm
• International Pelvic Pain Society. Chronic pelvic pain.
http://www.pelvicpain.org/pdf/Patients/CPP_Pt_Ed_Booklet.pdf
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References
• Bordman & Jackson. Below the belt: approach to chronic pelvic pain. Can
Fam Physician 2006;52:1556-62
• Ford et al. Effect of fibre, antispasmodics, and peppermint oil in the
treatment of irritable bowel syndrome. BMJ 2008;337:a2313.
• Latthe et al. Factors predisposing women to chronic pelvic pain:
systematic review. BMJ 2006;332:749-55.
• Meltzer-Brody et al. Trauma and posttraumatic stress disorder in women
with chronic pelvic pain. Obstet Gynecol 2007;109:902-8.
• Pearce & Curtis. A multidisciplinary approach to self care in chronic
pelvic pain. Br J Nurs. 2007;16:82-5.
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Primary Authors:
Megan Gerber, MD, MPH
VA Boston Healthcare System, Boston, MA
Sarina Schrager, MD, MS
University of Wisconsin Department of
Family Medicine, Madison, WI
Contributor:
Linda Baier Manwell, MS
University of Wisconsin Center for Women’s
Health Research, Madison, WI
WH Nurse Reviewers: Barbara Palmer, MS, ANP
Rebecca Feria, RN, MSN
Joan Galbraith, RN, MSN, NP
Cindy James, RN, MSN
Laurie Pfeiffer, RN, BSN
Barbara Polak, RN, MSN
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