Pelvic Pain Learning Objectives - PowerPoint Presentation

Pelvic Pain

Learning Objectives

Becky, a 39-year-old female veteran calls with a complaint of pelvic pain that started 24 hours ago. Case Study Nurse’s Critical Thinking : Assess the urgency of the complaint. VETERANS HEALTH ADMINISTRATION 3

Triage Questions to Assess Acute Pelvic Pain Pregnancy LMP ? Form of birth control? Pain characteristicsLocation? 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 surgeryHysterectomy, oophorectomy, or tubal ligation?Past STIsWhen? How treated?Other symptomsNausea, vomiting, vaginal discharge/bleedingBowel movement patternConstipation? Diarrhea? Both? 4

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. Case Study (continued) Nurse’s Critical Thinking : Becky is probably not pregnant. A clinic appointment is appropriate. 5

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 VETERANS HEALTH ADMINISTRATION 7

Definition of Acute Pain Definition Varies … Pain <1 week Pain undiagnosed for <10 days 8

Common Causes of Acute Pelvic Pain 9

Physical exam and nursing role for acute pelvic pain Immediate vitals Set up supplies for a complete pelvic exam 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 10

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-upWhen to seek immediate emergency careIf pain worsensIf fever developsIf orthostatic symptoms appear (lightheadedness or passing out, confusion, nausea, blurred vision) Patient Education for Acute Pelvic Pain 11

Pregnancy should be ruled out for every woman of reproductive age who complains of acute pelvic pain. VETERANS HEALTH ADMINISTRATION 12

Chronic Pelvic Pain VETERANS HEALTH ADMINISTRATION 13

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 14

Epidemiology of CPP

Co-Morbidities 16

CPP is also associated with: Of 713 women in pelvic pain clinic: 46.8% hx of sexual/physical abuse31.3% PTSD symptomsTrauma hx = worse medical symptoms (headache, muscle ache, constipation, diarrhea) Physical and sexual abuse Military sexual trauma 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 17

Common Physiologic Causes of CPP Gynecologic (e.g., endometriosis) GI (e.g., irritable bowel syndrome) Urologic (e.g., interstitial cystitis) Musculoskeletal (e.g., fibromyalgia) 18

CPP Diagnosis 61% of cases, no diagnosis 40% more than 1 diagnosis Four most common physiologic causes: Endometriosis Adhesions Irritable bowel syndrome (IBS) Interstitial cystitis 19

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 obstructionPain timing? Constant? Associated with menses, eating, intercourse, or stress? Pain intensity? Rate on scale: 1=minor to 10=unbearableTreatments 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 21

Trauma-Informed Care: Before the Exam Nursing: T ell 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 symptomsState that, to do a complete assessment, a pelvic exam is necessary because the exam may reveal more than her historyDiscuss ways to relieve her stress Reassure her that she can stop the exam at any point 22

Be Alert for Signs of Trauma Nursing: Watch for: Tears Silence or staring Nervous chatter Employ distractions Providers: Get permission before starting and re-starting the examIf 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 Trauma-Informed Care: The Exam 23

Important Aspects of Care for CPP Patients 24

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 medicationsHow 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 careIf pain worsens or fever develops If orthostatic symptoms appear (lightheadedness or passing out, confusion, nausea, blurred vision) 25

Most Common Causes of CPP Irritable Bowel Endometriosis Interstitial Cystitis Pelvic Adhesions 26

Irritable Bowel Syndrome (IBS) A bdominal 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 IBS27

IBS Patient Education

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 Elimination Diet

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 population25-50% of infertility populationEndometriosis 30

Endometriosis Symptoms 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 The stage of endometriosis is NOT correlated with the presence or severity of symptoms. Instead, symptoms are more related to local peritoneal inflammatory reaction . 31

VETERANS HEALTH ADMINISTRATION Could treat based on H&P alone. Laparoscopy, however, is “gold standard”. History Physical Exam Laparoscopy Endometriosis Diagnosis

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 33

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 UTIMajor 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 controlledSymptoms vary over time with flares and remissionsCause is unknown; may be defects in protective lining (epithelium) of the bladder No cure; goal is to relieve symptoms and improve quality of life P atients often referred to Urology for further evaluation/management 34

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 spasmsSome improvement reported with acupuncture, guided imagery, biofeedbackSymptoms 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.

VETERANS HEALTH ADMINISTRATION

Pelvic Adhesion Diagnosis 37

Addressing Co-Morbidities with Pelvic AdhesionsThese 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. 38

Avoid constipation High-fiber diet Pain management Medications, physical therapy, trigger point injections, Botox injections, biofeedback G oal is to try to keep them out of the OR as long as possible Patient Education for Pelvic Adhesions 39

The bottom line regarding CPP… 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 crucialMultidimensional 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. 40

Bordman & Jackson. Below the belt: approach to chronic pelvic pain. Can Fam Physician 2006;52:1556-62. 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.Helpful Resources 41

Womenshealth.gov Irritable bowel syndrome Endometriosis Interstitial cystitis/bladder pain syndrome International Pelvic Pain Society. Chronic pelvic pain booklet (6 p.) Patient Education Resources 42

AuthorsMegan Gerber, MD, MPHVA Boston Healthcare System Sarina Schrager , MD, MS University of Wisconsin-Madison Department of Family Medicine Lisa Roybal, MSN, WHNP-BCLoma Linda VA Health Care System Linda Baier Manwell, MSUniversity of Wisconsin-Madison Division of General Internal Medicine Molly Carnes, MD, MSUniversity of Wisconsin-Madison Center for Women’s Health Research 43