Transcript NurseLecture_PelvicPain_060514x

Pelvic Pain
Learning Objectives
Discuss common causes of acute pelvic pain
Discuss common causes of chronic pelvic pain
Identify triage questions to differentiate urgent vs.
non-urgent presentations
Describe components of a pain evaluation
Provide appropriate patient education
Case Study
Becky, a 39-year-old
female veteran calls
with a complaint of
pelvic pain that started
24 hours ago.
Nurse’s Critical Thinking:
Assess the urgency of the complaint.
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Triage Questions to Assess Acute Pelvic Pain
Pregnancy
• LMP? Form of birth control?
Pain
characteristics
• Location? Does it radiate elsewhere? Has
location changed?
• Duration? Where/when did it occur?
• Onset sudden or gradual? Sharp, dull,
stabbing? Pain come and go (cyclic)?
• Rate pain on scale: 1=minor to 10=unbearable
• What makes it worse/better? Treatment tried?
• Similar pain before? If yes, how treated?
Past gyn surgery
Past STIs
Other symptoms
Bowel movement
pattern
•
•
•
•
Hysterectomy, oophorectomy, or tubal ligation?
When? How treated?
Nausea, vomiting, vaginal discharge/bleeding
Constipation? Diarrhea? Both?
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Case Study (continued)
Becky states that she has never
had pain like this before.
She tried acetaminophen and
ibuprofen, but neither helped. Her
LMP was 2 weeks ago and she has
a history of tubal ligation.
Nurse’s Critical Thinking:
Becky is probably not pregnant. A clinic appointment is appropriate.
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Signs & Symptoms
Purulent vaginal discharge (possible STI)
Cramping, vaginal bleeding (may be ectopic
pregnancy or threatened AB)
Dyspareunia, dysmenorrhea (suggest
endometriosis)
Anorexia, nausea and vomiting (seen with
appendicitis)
Pelvic pain (inflammatory process such as PID, or
adnexal torsion/twisting, or degenerating fibroid)
Dysuria (suggestive of UTI)
Constipation and/or diarrhea
ACUTE
PELVIC PAIN
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Definition of Acute Pain
Definition Varies…
 Pain <1 week
 Pain undiagnosed
for <10 days
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Common Causes of Acute Pelvic Pain
Gynecologic Conditions (PID, dysmenorrhea)
Gynecologic and Pregnant (ectopic
pregnancy, miscarriage)
Non-Gynecologic Conditions (appendicitis,
UTI, diverticulitis, kidney stones, trauma)
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Physical exam and nursing role for
acute pelvic pain
Immediate
vitals
− Marked hypotension, tachycardia, or
fever: may need emergency treatment
− Pregnant: follow local policy for
disposition of acutely ill pregnant
patient
− Heavy vaginal bleeding: consider
orthostatic vitals
Set up supplies for a complete pelvic exam
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Patient Education for Acute Pelvic Pain
• Questions about treatment plan or discharge
instructions?
• How to reach provider including after-hours contact
(e.g., 24-hour nurse advice line)
• Understanding of when/if she is to return for follow-up
• When to seek immediate emergency care
─ If pain worsens
─ If fever develops
─ If orthostatic symptoms appear (lightheadedness or passing
out, confusion, nausea, blurred vision)
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Pregnancy
should be ruled out
for every woman of reproductive age
who complains of acute pelvic pain.
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CHRONIC
PELVIC PAIN
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Definition of Chronic Pelvic Pain (CPP)
Non-cyclical pain for at least 6 mos in pelvis, anterior
abdominal wall, lower back or buttocks AND 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 diagnosis in 10% of outpatient GYN consultations
40% of women undergo laparoscopic surgeries due to CPP
The reason for 18% of all hysterectomies
>$2 billion in costs per year
Not associated with race, ethnicity, education,
socioeconomic status
Co-Morbidities
50% of women with CPP
also have depression
(consider depression
screening)
Drug and alcohol abuse
may make women more
susceptible to pain
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CPP is also associated with:
Physical
and sexual
abuse
Military
sexual
trauma
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• Of 713 women in pelvic pain clinic:
− 46.8% hx of sexual/physical abuse
− 31.3% PTSD symptoms
− Trauma hx = worse medical symptoms
(headache, muscle ache, constipation,
diarrhea)
• Prevalence of MST, which includes
harassment, is 1 in 5 among all women
Veterans
─ Hx of MST = twice as likely to
report chronic pelvic pain
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Common Physiologic Causes of CPP
GI
Gynecologic
(e.g., irritable bowel
syndrome)
(e.g., endometriosis)
Urologic
Musculoskeletal
(e.g., interstitial
cystitis)
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(e.g., fibromyalgia)
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CPP Diagnosis
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•
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61% of cases, no diagnosis
40% more than 1 diagnosis
Four most common
physiologic causes:
− Endometriosis
− Adhesions
− Irritable bowel syndrome
(IBS)
− Interstitial cystitis
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Triage Questions to Assess Chronic Pelvic Pain
Had this type of pain before?
Describe today’s pain
Location, duration, intensity, etc.
Today’s pain differ from prior episodes?
If yes, how?
Associated symptoms?
• Sudden weight loss may occur
with malignancy
• Nausea and vomiting may occur
with bowel obstruction
Pain timing?
Constant? Associated with menses,
eating, intercourse, or stress?
Pain intensity?
Rate on scale: 1=minor to
10=unbearable
Treatments tried?
Today? In the past?
Anyone in her family have chronic pain? If yes, what?
Does she have a pain plan?
If yes, is she following it? When did
it stop working?
Physical exam and nursing role for CPP
Vital signs
Listen to her concerns
and prepare provider
Set up supplies for
complete pelvic exam
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Trauma-Informed Care: Before the Exam
Nursing:
• Tell your provider if the patient has a trauma history or if she is
reluctant to have a pelvic exam
Provider:
• Talk with the patient (while dressed) about her symptoms
• State that, to do a complete assessment, a pelvic exam is
necessary because the exam may reveal more than her history
• Discuss ways to relieve her stress
• Reassure her that she can stop the exam at any point
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Be Alert for
Trauma-Informed
Care: The Exam
Signs
of Trauma
Nursing:
• Watch for:
 Tears
 Silence or staring
 Nervous chatter
• Employ distractions
Providers:
• Get permission before starting and re-starting the exam
• If signs of distress appear, ask if she would like a minute to relax
or if she would like to delay the rest of the exam
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Important Aspects of Care for CPP Patients
Addressed as an
individual by a
supportive team
Pain is taken
seriously and
legitimized
Information and
involvement in
her plan of care
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Explanation for
her condition
(more so than a
cure)
Reassurance:
Pain is not “all in
her mind”
Not serious/cancer
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Patient Education for CPP
• Questions about treatment plan or discharge instructions?
─ e.g., If she is to keep a pain diary, reinforce what she should
record (episodes of pain including location, severity, mood at
the time as well as associated factors such as menses, activity,
intercourse, bowel functions, and medications
• How to reach provider including after-hours contact (e.g., 24-hour
nurse advice line)
• Understanding of when/if she is to return for follow-up
• When to seek immediate emergency care
─ If pain worsens or fever develops
─ If orthostatic symptoms appear (lightheadedness or passing
out, confusion, nausea, blurred vision)
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Most Common Causes of CPP
Irritable Bowel
Endometriosis
Interstitial Cystitis
Pelvic Adhesions
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Irritable Bowel Syndrome (IBS)
Abdominal pain/discomfort with altered bowel habits for at least 3 mos
• Colon spasms and
food moves too
quickly or too slowly
through intestines
• Affects 20% of the
population
• 1.5x more common
in women
• Onset before age 35
in 50% of cases
• Poorer physical and
mental health
reported with IBS
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Diary
(document
everything
eaten and
symptoms)
Dietary
manipulation
(nutritional
consult, add
fiber slowly)
Exercise and
Stress
Management
Medication
and Other
Therapies
(biofeedback,
probiotics,
peppermint
oil)
IBS Patient Education
Elimination Diet
Eliminate all for 2 weeks; slowly add one
food group every 3 days; record symptoms
● Dairy (lactose)
● Wheat (gluten)
● High fructose corn syrup
● Sorbitol (chewing gum)
● Eggs
● Nuts
● Shellfish
● Soybeans
● Beef
● Pork
● Lamb
Endometriosis
• Mean age at
diagnosis 25-30
• May be caused by
endometrial cells
implanting outside
uterus
• Exact cause not
known
• Affects 3-15% (avg
10%) of population
• 25-50% of infertility
population
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Endometriosis Symptoms
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Pelvic pain in 70-75% of women
Increasing dysmenorrhea
Deep dyspareunia
Premenstrual dysmenorrhea
Lower abdominal pain, often
bilateral
• Lower back pain
• Bowel or bladder symptoms
─ Difficult or painful
defecation, bloating,
constipation, diarrhea
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The stage of endometriosis
is NOT correlated with the
presence or severity of
symptoms.
Instead, symptoms are
more related to local
peritoneal inflammatory
reaction.
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Physical Exam
History
Laparoscopy
Endometriosis
Diagnosis
Could treat based on
H&P alone.
Laparoscopy,
however, is “gold
standard”.
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Patient Education for Endometriosis
Can often be managed in primary care
setting with medications alone
• NSAIDs
• Monophasic oral contraceptive, vaginal
ring, or contraceptive patch continuously
for 3 months
─ If you take away her menses, you
REMOVE most of the pain cycle!
Sometimes, however, patients will need
GYN referral for further management
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Interstitial Cystitis (IC)
• Definition: 3-6 mos of pain/pressure/discomfort over suprapubic area or
bladder, with frequent urination day and night in a patient without a UTI
− Major symptoms in women are dysuria, frequency, urgency, chronic
pelvic pain, dyspareunia
• Bladder pain can be variable; most consistent feature is increased
discomfort with bladder filling and relief after voiding
• 90% of all IC cases are female; diagnosis should be high on suspicion list if
her pelvic pain can’t be controlled
• Symptoms vary over time with flares and remissions
• Cause is unknown; may be defects in protective lining (epithelium) of the
bladder
• No cure; goal is to relieve symptoms and improve quality of life
• Patients often referred to Urology for further evaluation/management
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IC Patient Education
• Dietary management: low potassium, low acid diet trial x 2 wks. Eliminate:
- carbonated drinks
- pickled foods
- caffeine (including chocolate)
- alcohol
- citrus products
- spicy food
- tomatoes
- artificial sweeteners
• Some patients urinate up to 60x per day
- Retrain bladder by slowly increasing voiding intervals. Patients may
mention knowing location of every bathroom in town. Some are confined
to their homes due to incontinence if a bathroom is not readily available.
• Pelvic floor/easy stretching exercises can reduce muscle spasms
• Some improvement reported with acupuncture, guided imagery, biofeedback
• Symptoms can sometimes be managed by applying heat or cold over
perineum. Encourage patients to try both to see what works.
Psychosocial support is also an integral part of treatment for chronic pain disorders.
Bands of scar
tissue form
between
pelvic organs
Pelvic
Adhesions
Lead to
infertility,
chronic pain
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Risk factors:
infection,
pelvic
surgery,
trauma
Pelvic Adhesion Diagnosis
Aggravated IBS symptoms or pain during
sexual intercourse
Diagnosed by excluding other pathology
GYN referral for potential laparoscopy
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Addressing Co-Morbidities with Pelvic
Adhesions
These patients can be the most difficult to manage. They
present with a chronic pain history that is suggestive of
adhesions mainly because everything else has been ruled
out. Sending them back to surgery is not the best option.
The first step is a depression screen and a good assessment
of the patient’s alcohol and drug use to rule out abuse. As
mentioned in an earlier slide, pain can be exacerbated by
overuse of alcohol and drugs. This is the point where the
involvement of a mental health provider is crucial.
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Patient Education for Pelvic Adhesions
•
•
•
Avoid constipation
High-fiber diet
Pain management
Medications, physical
therapy, trigger point
injections, Botox injections,
biofeedback
•
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Goal is to try to keep them
out of the OR as long as
possible
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The bottom line regarding CPP…
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Chronic pelvic pain is a complex condition.
Patients need a good triage assessment to determine care urgency
Many women have concurrent depression, PTSD, MST, or IPV
Existing data is hampered by a lack of standard definitions,
algorithms, and adequate clinical trials; regardless, our patients rely
on us to listen and arrive at the best treatment plan possible
• Nurses are on the front line. Your involvement in taking a complete
history, encouraging compliance with the plan of care, and listening
when women become frustrated with their chronic pain is crucial
• Multidimensional care is often warranted; recognize when to bring
in the team to help manage these patients. Consider involving your
mental health provider or your PACT team or the social worker.
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Helpful Resources
•
Bordman & Jackson. Below the belt: approach to
chronic pelvic pain. Can Fam Physician 2006;52:155662.
•
Meltzer-Brody et al. Trauma and posttraumatic stress
disorder in women with chronic pelvic pain. Obstet
Gynecol 2007;109:902-8.
•
Price J, et al. Attitudes of women with chronic pelvic
pain to the gynaecological consultation. BJOG Int J
Obstet Gynaecol 2006; 113:446–452.
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Patient Education Resources
•
Womenshealth.gov
− Irritable bowel syndrome
− Endometriosis
− Interstitial cystitis/bladder pain syndrome
•
International Pelvic Pain Society. Chronic pelvic pain
booklet (6 p.)
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Authors
Megan Gerber, MD, MPH
VA Boston Healthcare System
Sarina Schrager, MD, MS
University of Wisconsin-Madison Department of Family Medicine
Lisa Roybal, MSN, WHNP-BC
Loma Linda VA Health Care System
Linda Baier Manwell, MS
University of Wisconsin-Madison Division of General Internal Medicine
Molly Carnes, MD, MS
University of Wisconsin-Madison Center for Women’s Health Research
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