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ADOLESCENT PELVIC PAIN Jami Goodwin, MD DISCLOSURE OF FINANCIAL INFORMATION I, Jami Goodwin, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. BACKGROUND Pelvic pain is a common and significant problem in women 15% in the general population Main indication in 12% of hysterectomies 60% of laparoscopies In adolescents 3-5% of all visits to PCP are for complaints of abdominal pain Chronic pelvic pain can lead to significant physical and cognitive disability Patients become frustrated with the ongoing nature of symptoms and difficulty in obtaining a definitive diagnosis with relief of symptoms Often involve numerous physicians including pediatricians, family practice, gynecologists, emergency medicine and psychiatrists DIFFERENTIAL DIAGNOSIS ACUTE CHRONIC-CYCLIC CHRONIC- NON-CYCLIC PID Dysmenorrhea Endometriosis Ectopic Mittelschmerz PID Adnexal torsion Endometriosis Ovarian Mass Ruptured Ovarian Cyst Torsion Adhesions Hemorrhagic Corpus Luteal cyst Obstructive Mullerian Duct Anomalies Constipation Appendicitis Inflammatory Bowel Gastroenteritis IBS Bowel Obstruction Bowel infection UTI Urolithiasis Urolithiasis Musculoskeletal Pyelonephritis Psychosomatic BACKGROUND Pelvic pain in adolescents can be even more challenging for health care providers Treatment requires knowledge of the developmental stages accompanying puberty Changes in the body due to thelarche menarche and adrenarche Psychological changes as an adolescent’s sense of self and body image develops Reluctancy to obtain gynecologic history or perform pelvic examination Increasing independence from parents affecting physician-patient relationship CONFIDENTIALITY Major concern in the delivery of health care to all adolescents, but there are special considerations to those that are minors Physicians should address confidentiality issues with every adolescent patient to build a trusting relationship with her and to facilitate a candid discussion with her regarding her health and health related behaviors Physicians who treat minors have an ethical duty to promote autonomy of minor patients by involving them in the medical decision making process CONFIDENTIALITY Physicians also should discuss confidentiality issues with the parent or guardian of the adolescent patient. Physicians should encourage their involvement in the patient’s health and health care decisions and when appropriate facilitate communication between the two. When minors request confidential services, encouragement to involve their parents is helpful Includes making efforts to obtain the minor’s reasons for not involving their parents Correcting misconceptions that may be motivating their objections For minors mature enough to be unaccompanied by their parents for their exam, confidentiality of information disclosed during an exam, interview, or in counseling should be maintained CONFIDENTIALITY Physicians should be familiar with state and local laws that affect the rights of minors to receive health care services and to give their own consent for health care Physicians should also be familiar with the federal and state laws that affect confidentiality in the provision of health care to adolescents, including the HIPAA Privacy rule TENNESSEE LAWS CONSENT The general rule is that a physician must obtain parental consent before treating a minor patient. All efforts should be made to obtain consent from a parent or legal guardian. Otherwise, there may not be informed consent. In the absence of informed consent, battery is committed HIPAA does not address a minor’s right to consent to treatment without a parent’s consent TENNESSEE LAWS HIPAA AND MINORS Parental access to minor’s PHIParents are recognized as personal representatives of unemancipated minors. There are exceptions to the parental access of minor’s PHI State or other law does not require parental consent in order for a minor to obtain a health service. If the minor consents, the parent is not the personal representative When a court authorizes someone other than the parent to make decisions for the minor. The parent is not the personal representative When the parent assents to the confidential relationship between physician and minor When a physician believes that the disclosure of the information endangers a child access is denied. EXCEPTIONS TO THE RULE COMMON LAW Mature Minor Doctrine In the absence of appropriate parental consent, courts will look to “the age ability, experience, education , training, and degree of maturity or judgment obtained by the minor at the time.” The court will basically look at the facts to determine if the minor was aware of the risks and benefits of the treatment Cardwell analysis “The Rule of Sevens” Under age 7 – no capacity to consent Age 7-14- rebuttable presumption of no capacity Age 14+ - rebuttable presumption of capacity In Cardwell, the TN Supreme court found informed consent existed and therefore no battery occurred when a minor female (17+7) consented to back manipulation therapy HIPAA AND THE “RULE OF SEVENS” If the minor has no capacity to consent, then the parent would have access to the HPI If the minor has a rebuttable presumption of no capacity and is found not to have the capacity, the parent would have access to HPI If the minor has the rebuttable presumption of capacity to consent, then the parent would not have access to the minor’s HPI EXCEPTIONS TO THE RULE Per state law, parental consent is not required for treatment of a minor in certain circumstances and would therefore not have access to PHI Minors with children Contraceptives Sterilization (if married) Juvenile Drug Users Emergency- physicians discretion Prenatal care STDs- including examination, diagnosis and treatment INTERVIEWING ADOLESCENTS Establish rapport- ideally a visit for pelvic pain would not be the first of rapport is already grounded meeting and a sense Good eye contact Nodding at important points Allow for silence Mirror patient actions Avoid judgmental terminology Important to establish that the adolescent is the patient and her feelings and views are most important Confidentiality- ensuring the patient and parents understand expectations Separating the Adolescent and parent HISTORY AND PHYSICAL Similar to adult history taking asking questions about Character Intensity Timing Location Radiation Duration The chronology of different symptoms is also important Relationship to menstrual cycle GI symptoms Urinary symptoms HISTORY AND PHYSICAL Significant PMH and Family history Sexual history Activity Dyspareunia Pregnancy Sexual or physical abuse Previous medical or surgical treatments and responses Impact of pain on everyday life PHYSICAL Abdominal exam Begin by asking the patient to point to site of the pain Remember to examine for any scars, hernias or masses Musculoskeletal Rule out scoliosis Difference in limb length Pelvic exam External genitalia Vaginal patency Lesions Trauma Urethra Rectal exam Bimanual Exam Speculum Exam Discharge Posterior cul-de-sac tenderness Pelvic floor tenderness Anterior wall tenderness (Avoided in virginal girls) Vaginal patency Discharge (Useful in younger teenagers) Localization of tenderness Evaluation of the posterior cul-de-sac WORK UP Laboratory tests including UPT UA/CX Cultures in sexually active patients TVUS IF unable to perform adequate pelvic exam or anomaly suspected Diagnostic Laparoscopy For refractory cases of pelvic pain, can often lead to precise diagnosis LAPAROSCOPIC FINDINGS IN ADOLESCENTS WITH CPP Finding Rate Normal Pelvis 25-40% Endometriosis 38-45% Ovarian Cyst 2-5% Uterine Malformation 5-8% Postoperative Adhesions 4-13% Pelvic Inflammation 5-15% Other 2% DYSMENORRHEA Defined as severe, cramping pain in the lower abdomen that occurs during and /or prior to menses Pain may occur in the lower back May be associated with nausea or vomiting Accompanying Headache Common problem in adolescent females Prevalence ranging from 40-90% Significant cause of school and work absence up to 14% age 12-17, 42% college aged PRIMARY DYSMENORRHEA Classified as primary when no pelvic pathology is evident to cause painful menstruation Diagnosis of exclusion Women under 20 Rate increases with age in adolescence attributable to increasing ovulatory cycles Usually present with symptoms 6-12 months following menarche Pain is associated with menstrual flow PATHOGENESIS Attributed to the presence of prostaglandins via cyclooxygenase and lipooxygenase pathways. PG produced by the endometrium to promote vasoconstriction and myometrial contraction Leads to ischemia of the endometrial lining Other associated factors Family history Early menarche Increased duration of menses Smoking SECONDARY DYSMENORRHEA Presents similarly to primary dysmenorrhea, starts at a later age Diagnosed when there is pelvic pathology believed to be the etiology of the pain Prior cervical surgery Menorrhagia Excessive vaginal discharge Common causes in adolescents include Endometriosis Congenital malformations Cervical stenosis Infections DYSMENORRHEA TREATMENT NSAIDS-prostaglandin synthetase inhibitors Initially prescribed on an as needed basis May need to use scheduled dosing Alternative regimens OCPS- thin the endometrial lining and decrease PG production Ideal in adolescents also desiring contraception ENDOMETRIOSIS Estimated incidence in menarchal females ranges from 4-17% Of adolescents with pelvic pain not controlled by medical management the incidence has been shown to be as high as 60-70% at the time of laparoscopy Majority present with stage one disease Adolescents can present with either acyclic or cyclic pelvic pain Dysmenorrhea, abnormal uterine bleeding, and deep dyspareunia are other common symptoms GI or bladder symptoms Unlikely to present with the classic triad of dysmenorrhea, dyspareunia, and infertility ENDOMETRIOSIS Symptom Incidence Cyclic and Acyclic Pain 62-95% Acyclic Pain 28% Cyclic Pain 9.4% Dysmenorrhea 95% Deep Dyspareunia 29% Irregular Menses 9-25% GI pain/nausea 34-43% Urinary Symptoms 12.5% Vaginal Discharge 6% ENDOMETRIOSIS Pelvic Exam May not detect abnormalities Can range from normal to generalized pelvic tenderness Endometriomas are less common in females under 20 Recto-vaginal exam may reveal focal tenderness in the posterior cul-de-sac or nodularity of the uterosacral ligaments Treatment NSAIDS OCPS Laparoscopy Clear papules and red lesions more likely in younger patients ENDOMETRIOSIS CONGENITAL ANOMALIES Congenital anomalies with genital tract obstruction can present with severe cyclic pelvic pain Estimated incidence of 3% Most present within few months to years after the onset of menses Pts with Imperforate hymen or a transverse vaginal septum may present with primary amenorrhea Imperforate hymen- perineal bulge due to hematocolpos Vaginal septum- normal hymen with a short vagina posteriorly, slight bulge CONGENITAL ANOMALIES Menstruating females with anomalies present with normal menses and pain due to obstruction of menstrual flow Unicornuate uterus with a noncommunicating obstructed uterine horn Uterine didelphys with obstructed hemivagina Diagnosed with US and confirmed by MRI Surgical management required for both conditions Resection of the noncommunicating horn Excision of the vaginal septum with creation of a single vaginal vault UTERINE DIDELPHYS WITH OBSTRUCTED HEMIVAGINA OVARIAN CYSTS Ovulation begin 6-12 months after menarche The period following the initiation of ovulation is associated with dysfunctional ovulation and ovarian cysts Preovulatory follicles measuring less than 2 cm are common A study of 130 adolescents who underwent serial ultrasounds during the follicular phase found cysts in 17 girls, all but 2 resolving over time Adolescents may present with cyclical pain, irregular menses and dysmenorrhea Pelvic exam, UPT, cultures Weight loss, nausea, bloating or palpable mass can suggest neoplasm Most common ovarian tumor= mature teratoma Sudden onset of pain could suggest torsion OVARIAN CYSTS Ultrasonography is useful for evaluation of a suspected mass as well as monitoring the mass over time Adnexal masses should be conservatively Most functional cysts will usually regress after 2 or 3 cycles Treatment Hormonal therapy has not been shown to improve regression rates of ovarian cysts vs expectant management If cysts do not regress over several cycles, surgical diagnosis is warranted PELVIC ADHESIVE DISEASE Role of adhesions in chronic pelvic pain is controversial Commonly detected at the time of surgical exploration of patients with chronic pelvic or abdominal pain Can occur secondary to a previous operation, however, adolescents typically have an unremarkable past surgical history Though adhesions may play an etiologic role in pelvic pain, they often do not produce pain The prevalence rate of adhesions in asymptomatic women undergoing separate laparoscopic procedure for sterilization is 14% More likely to play a role when they limit the mobility of intra-peritoneal organs ADHESIOLYSIS Controversial treatment Results from trials are mixed Patients with dense bowel adhesions show the most improvement in pain post surgery Overall approximately 40% of women with a chronic pain syndrome report some improvement in their pain PELVIC INFLAMMATORY DISEASE Acute infection of the upper genital tract involving any or all of the uterus, tubes, ovaries as well as other pelvic organs including bowel Major cause of infectious morbidity in females 15-25 years old Aggressive diagnosis and treatment in adolescent patients needed to avoid long term sequelae including infertility, chronic pelvic pain and ectopic pregnancy Many cases may go unrecognized and untreated due to minimal symptomatology PELVIC INFLAMMATORY DISEASE Adolescents at an increased risk for several reasons Lower levels of protective antibodies due to lack of exposure to pathogens Higher prevalence of N. gonorrhea, C. trachomatis in the younger population Greater penetrability of their often anovulatory cervical mucous Larger zones of cervical ectopy with more columnar cells for which infectious agents have greater affinity High risk behavior Less consistent use of condoms Concurrent use of alcohol or drugs during sexual activity Risk doubles in those with coitarche prior to 16 years old CDC GUIDELINES FOR DIAGNOSIS Minimal Criteria: Lower abdominal tenderness Adnexal tenderness Cervical motion tenderness Additional Criteria Oral temperature > 101 Abnormal vaginal or cervical discharge Elevated Sed rate Elevated C-reactive protein Lab documentation of cervical infection with N. Gonorrhea or C. Trachomatis Definitive Criteria Histopathologic evidence of endometritis on endometrial biopsy US showing thickened fluid-filled tubes or tubo-ovarian abscess Laparoscopic abnormalities consistent with PID TREATMENT OF PID Empiric treatment for PID should be initiated as soon as the diagnosis is suspected CDC Guidelines for Hospitalization Surgical emergency, such as appendicitis or adnexal torsion Pregnancy No response or unable to tolerate therapy Severe illness with nausea and vomiting or high fever Immunodeficiency CDC GUIDELINES FOR TREATMENT Parental therapy: Regimen A: Cefotetan 2g IV every 12 hours OR Cefoxitan 2g IV every 6 hours PLUS Doxycycline 100mg IV every 12 hours until improved, followed by Doxycycline 100mg PO BID to complete 14 days Regimen B Clindamycin 900mg IV every 8 hours Plus Gentamicin loading dose 2mg/kg followed by maintenance dose 1.5mg/kg every 8 hours until improved followed by doxycycline 100 mg oral BID to complete 14 days CDC GUIDELINES ORAL THERAPY Regimen A Ofloxacin 400 mg BID x 14 days PLUS Flagyl 500 mg BID x 14 days Regimen B Ceftriaxone 250 mg IM once OR Cefoxitin 2mg IM plus Probenecid 1g orally in a single dose concurrently once OR Other parental third generation cephalosporin PLUS Doxycycline 100mg orally BID x 14 days MUSCULOSKELETAL Can contribute to chronic pelvic pain Very little regarding this in pediatric and adolescent literature May develop as a response to an initial gyn problem or develop primarily Common problems include Shortening and spasm of the psoas muscle Shortening of the abdominal muscles Abnormal posture including increased lumbar lordosis and an anterior tilt of the pelvis If left untreated may induce tissue damage that results in trigger points. MUSCULOSKELETAL Physical Exam Attempt to isolate areas of hypersensitivity Single finger palpation to find trigger points starting in the dermatomal area closest to the pain When pain is reproduced the lower extremity should be elevated to flex the rectus abdominus Pain of visceral origin is usually not reproduced in this way. Trigger points may also be identified during a single digit pelvic exam of the lateral wall of the vagina and lateral fornices The injection of 0.25% bupivacaine into the trigger points can be both diagnostic and therapeutic IN one study of 122 pt undergoing trigger point injections with 3-5 ml of bupivacaine, 89% had relief or improvement with no further treatment required. PT with emphasis on the pelvis can also be beneficial IRRITABLE BOWEL SYNDROME IBS is defined as chronic abdominal pain usually in the lower segment and disturbed defecation in the absence of structural or biochemical abnormalities. Approximately 15-20% of adolescents have symptoms consistent with IBS Thought to be a result of the dysregulation of brain-gut interactions leading to altered perceptions of pain Diagnosis of exclusion with symptoms present for at least 12 weeks within the previous 12 months IBS Psychosocial factors such as early life experiences, physical stress, personal and social coping systems and psychological stress influence the expression of symptoms and illness behavior A high prevalence of prior physical and sexual abuse has been reported in women with IBS compared with organic disorders Psychiatric co-morbidities including anxiety, depression and adjustment disorders are prevalent. Treatment should be aimed at both reassurance and symptom relief. IBS Medical management should be directed at alleviating the predominant symptoms. Antispasmodics are the most frequently used medications Anticholinergic effects relax smooth muscle TCAs and SSRIs can be used for the symptomatic treatment of pain Reserved for patients with severe or refractory pain Fiber bulking agents or antidiarrheals used for stool symptoms Psychological and behavioral options including referral to a mental health specialist can be helpful PSYCHOSOMATIC Psychosocial stressors can cause chronic, recurrent pelvic pain Can originate from a single, traumatic event or can be the result of chronic stress Adolescents are particularly prone to dwell on their bodies given all the developmental changes and new stressors Coping mechanisms are developing and are influenced by chronic stress, family coping style, and lifestyle. The adolescent who does nothing when faced with stress is more likely to suffer organic symptoms when faced with chronic stress Have a heightened awareness of internal bodily sensations PSYCHOSOMATIC Initial management approach should be the same as with organic causes of CPP Care should be taken to reassure the patient that the physician believes the symptoms are real and the physician is going to do all that is necessary to find the cause RCT comparing patients considered for organic and psychosocial causes of pain at the initial visit with patients considered for psychosocial issues only after organic pathology had been ruled out showed the former group not only had better responses to therapy but also improved long term outcomes. Symptomatic treatment, frequent visits, and psychosocial referral are helpful CONCLUSION Pelvic pain is a significant problem that can pose a significant challenge to health care providers In adolescents, evaluation requires not only knowledge of etiologies but insight into the stages of adolescent development. Establishing a good rapport can facilitate a thorough history and physical and provide good information without having to use extensive diagnostic studies Both gyn and non-gyn diagnoses should be considered Early diagnosis and management can vastly improve daily life and improve future reproductive health outcomes. REFERENCES Ehrman WG, Matson SC. Approach to adolescents on serious or sensitive issues. Pediatr Clin North Am. 1998;45:189–204. Peters AAW, van Dorst E, Jellis B, et al: A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. J Obstetrics and Gynecology 77:740, 1991 Song AH, Advincula AP. Adolescent chronic pelvic pain. J Pediatric and Adolescent Gynecology. 2005; 18 (6) : 371-377 Stone SC: Pelvic pain in children and adolescents. Pediatric and Adolescent Gynecology. SE Carpenter and JA Rock New York, Raven Press Ltd, 1992 pp267-78 http://www.tnmed.org/uploadedFiles/Stay_Informed/Resources/Legal_Resources/Law_Guides/Minors,%20Tr eatment%20of%204.pdf?__taxonomyid=195 Guidelines for Adolescent Health Care. Second Edition. ACOG http://laparoscopyofadhesiolysis.com/wp-content/gallery/pelvic-adhwsions-explained/pict_6108e.jpg