LAKE BUENA VISTA, FLA. — The cornerstones of an evaluation for chronic pelvic pain are a complete and thorough history and a physical examination directed toward detecting the location of the pain and replicating it through systematic palpation.
Having the patient fill out a questionnaire before an initial consultation is essential for eliciting the necessary historical details in this complex, multifactorial condition, said Dr. Fred M. Howard, professor of obstetrics and gynecology, University of Rochester (N.Y.) Medical Center. A comprehensive questionnaire developed by the International Pelvic Pain Society (www.pelvicpain.org
During the initial consultation, listen to the patient and take the time to establish trust. “Dismiss nothing as ridiculous, impossible, or unimportant,” Dr. Howard said.
The history should be a multidimensional assessment of pain, encompassing gastrointestinal, gynecologic, urinary, and musculoskeletal causes, and should address the patient's symptoms, lifestyle, and psychological state. How the patient understands and interprets her pain is also important, he said at the annual meeting of the International Pelvic Pain Society.
Prominent among potential gastrointestinal causes is irritable bowel syndrome (IBS), which today is defined by the Rome criteria as a pain syndrome. IBS can be identified with questions about whether, during the previous 3 months, the patient had at least 3 days of abdominal pain or discomfort that was relieved by a bowel movement or if there was a change in stool frequency, form, or appearance.
Possible sources of pain in the reproductive tract are endometriosis and pelvic congestion syndrome. Endometriosis is a likely cause if the pain worsens with or before menses, it is associated with deep penetration during intercourse, or there are problems with conceiving.
Pelvic congestion syndrome can be associated with dull, aching low back pain and premenstrual exacerbations, as well as with deep dyspareunia with postcoital ache that can last up to 24 hours. Other common causes include abdominal wall myofascial pain in a patient reporting activity that could acutely or repetitively overload the pelvic or abdominal muscles, such as gymnastics, or a history of trauma or injury.
Findings suggesting pelvic floor pain syndrome include pain that is aching or throbbing or described as “heaviness,” that presents acutely in the rectum or vagina or increases with sitting or standing in one position at length.
In doing the work-up, laboratory and imaging studies don't add much to the evaluation. “Only tests that are needed to rule out life-threatening diseases or that will definitively confirm your clinical diagnoses should be ordered.”
The physical exam should focus on “pain mapping” to detect the locations of pain and tenderness, and replicate the pain with palpation in a “four S” sequence: standing, sitting, supine, and in stirrups, he said. “If the patient is anxious, try palpating gently with your stethoscope. Patients don't expect that to hurt.”
While the patient is standing, evaluate her for groin and abdominal hernias, injuries to the pubic symphysis, fibromyalgia, and short leg syndrome. Also palpate any possible abdominal trigger points, pushing only hard enough to reach the rectus or external oblique muscles, which should reproduce all or part of her pain.
When she is sitting, look for asymmetric posture, which can be a manifestation of pain in the buttocks or perineum. In the supine position, inspect and palpate for lordosis or pelvic tilt, as well as for distension or masses.
Dr. Howard leaves the pelvic examination for last. “It helps to do it last when she may be less anxious.”
Always consider the possibility of depression, a major psychological comorbidity with chronic pain, and particularly ask about suicidality. And be mindful of other unrelated problems, he warned.
'Dismiss nothing as ridiculous, impossible, or unimportant,' and ask about depression and suicidality. DR. HOWARD