Evaluating Chronic Pelvic Pain

A series of presentations at the 43rd AAGL Global Congress on Minimally Invasive Gynecological Surgery explored the challenges of diagnosing and treating chronic pelvic pain. Erin Teeter Carey, MD, of the Center for Pelvic Pain and Sexual Health at University at Kansas Medical Center in Overland Park gave a presentation entitled "A Systematic Approach to the Evaluation of Chronic Pelvic Pain."

Chronic pelvic pain is not only debilitating but also frustrating for patients and practitioners. When evaluating patients with chronic pain, OB/GYNs need to consider the physical sources of pain as well as the psychosocial issues that go hand-in-hand with pelvic pain.

In her presentation, Carey reviewed:
- The definition of chronic pelvic pain (CPP).
- How pertinent history and physical exam findings relate to the etiology of the pain.
- The process to evaluate and manage chronic pelvic pain.
- How to understand the psychosocial issues associated with chronic pelvic pain.

Chronic pain is described by ACOG as pain in the lumbosacral back, abdomen (below the umbilicus), or the pelvis that lasts 6 months or longer and results in disability or in a patient's seeking out medical care. The condition is common, may be accompanied by dysmenorrhea or dyspareunia, and could affect as many as 38 of every 1000 women.

Dr Carey explains that practitioners shouldn't expect all chronic pain to result from one particular diagnosis but instead to treat the pain as a diagnosis in and of itself. OB/GYNs should also assess the entire person, considering any unique history, biopsychosocial situations, and the possibility of pain being from several contributors.

Further, Dr Carey points out that evaluating chronic pain is time consuming and may require help from prior physicians, as well as any reports from previous surgery or hospitalizations. The mnemonic "OPQRST-ASPN," if you can remember it, can be helpful in taking a history:

- Onset
- Provocation/Palliation
- Quality
- Region/Radiation
- Severity
- Time
- Associated Symptoms (gastrointestinal, genitourinary)
- Pertinent Negatives

Listen to the patient, but also ask deeper questions. Ask the patient to describe the pain, including what it feels like (is it pulling, cramping, stabbing), how intense it is (daily, cyclic, or are there pain-free times), whether there are any triggers (such as food, stress, or sex), and what time of day it is present. If the pain was treated in the past surgically or medically, determine if any treatments were helpful. Query about involvement of other organ systems and whether there are bowel or bladder symptoms, headaches, or head and neck pain. Physical history should include medical, surgical, family, social, psychiatric, sleep, and sexual history.

Carey explains that multiple diagnoses and providers at the outset of treatment can result in fragmented care. The start of treatment typically starts with centrally acting medication, lifestyle changes, and physical therapy. The outcome when pelvic pain is managed with surgery remains unclear, but treatment should begin with an evaluation of multiple organ systems. Chronic pelvic pain requires a multidisciplinary approach and is costly to diagnose and treat, but appropriate and timely interventions can lead to effective management and a restoration of quality of life.

References:

Erin Teeter Carey, MD, MSCR. Didactic: No Pain, No Gain. A Systematic Approach to the Evaluation of Chronic Pelvic Pain. 43rd AAGL Global Congress on Minimally Invasive Gynecology. ANAT-702. Available in: http://mobile.aagl.org/api/v1/modules/documents/files/pelv609.pdf.

Mazza D. Women's Health in General Practice. Elsevier. Australia; 2011.