Ms. Rhodes is a 46yo G0 with severe chronic pelvic pain and dysmenorrhea worsening since menarche. She complains of urinary frequency and bladder pain. She has pain with intercourse that lasts for 1-2 days after intercourse.
PM/SH: Recent diagnosis of constipation-dominant IBS. Depression and anxiety under treatment with therapist. Denies physical or sexual abuse. At her initial presentation her pain was (10/10). She has had 4 laparoscopies to treat pelvic/abdominal pain which resulted in temporal relief of her CPP for <3 months:
- 01/2009: Bilateral ovarian cystectomies for ovarian endometriomas
- 09/2009: Ablation of endometriosis and appendectomy
- 02/2010 : Ablation of endometriosis (Stage IV)
- 09/2010: no lesions or adhesions found
Assessment of CPP
- There are no standard diagnostic criteria or standard method of evaluating patients
- Proceed in a holistic systematic manner assessing for all sources of pain: physical, emotional and spiritual
- Consider all pelvic organ systems, neurological and musculoskeletal causes
- Evaluate for comorbid psychological conditions
A Holistic Approach
Integrative Medicine: “The practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.” (Consortium of Academic Health Centers for Integrative Medicine)
Focus on healing the whole person, alleviating suffering, and empowering the patient with knowledge.
American Holistic Nurses Association, 2010
Test Your Knowledge
The following statements about CPP are true, except:
CPP is defined as: Continuous or episodic pain in the lower abdomen or pelvis lasting ≥ 6 months and associated with a negative impact on quality of life (Williams, et al., 2004). CPP can be classified as cyclic or noncyclic although it seldom fits into those categories clinically.
Multiple systems interact and contribute to the pathophysiology of CPP (Howard, 2003).
In many cases a specific direct cause of CPP cannot be identified or the severity of the pain experience is not explained by the tissue damage identified.
It severely impacts quality of life: physical and sexual function, and emotional well-being and relationships.
Among women with CPP, there is an increased risk of a history of abuse, depression, anxiety, and PTSD which exacerbates painful symptoms.
Treatment for CPP is best approached with a multidisciplinary team (American College of Obstetricians and Gynecologists, 2008; Butrick, 2007; Daniels et al., 2010; Gunter, 2003).
Overview of Chronic Pain and CPP
Pain is widely unrecognized and under treated in the US
Ethnic minorities suffer the most from disparities in pain care.
Less access to pain management services and treatments, pain is poorly documented by health care providers and less likely to receive pain medications (Anderson, Green, & Payne, 2009).
Patient acceptance of pain treatment is influenced by cultural attitudes and beliefs about pain, health literacy, and mistrust of the health care system influence (Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003)
The estimated prevalence of CPP is 12-39% (Jamieson & Steege, 1996; Latthe, Latthe, Say, Gulmezoglu, & Khan, 2006; Mathias, Kuppermann, Liberman, Lipschutz, & Steege, 1996; Zondervan & Barlow, 2000)
CPP accounts for 20% of all referrals to gynecologists (Howard, 2003)
>40% of all laparoscopies (Howard, 1993)
15% of women report time lost from work 15% and 45% reduced productivity (Mathias et al., 1996)
$881.5 million are spent per year on outpatient management of chronic pelvic pain (Howard, 2003).
Case Summary Overview
In February of 2010, the patient underwent an operative laparoscopy with ablation of endometriosis and adhesiolysis for endometriosis implants on ovaries bilaterally and posterior cul-de-sac, and filmy adhesions between sigmoid colon and left pelvic side wall. In September of 2010, her diagnostic laparoscopy was normal. She is using continuous oral contraceptive pills and has improvement of dysmenorrhea and cyclic pain but continues to have 5-8/10 pain 2-3 times per week. She is expressing desire for another surgery for pain relief.
Interview With Ms. Rhodes
Ms. Rhodes sits on exam table and speaks with her provider, who gives her an AIDET greeting (Acknowledge, Introduce, Duration, Explanation, Thank You).
Provider: “Hello Ms. BLANK, my name is BLANK. I see here that you’ve been suffering from chronic pain. I’m here to talk to you about that. Thanks for coming.”
Ms. Rhodes: “Hi, nice to meet you. Thank you for seeing me.”
Provider: I’d like to understand more about what is going on with you. This should only take about 10 or 15 minutes.”
Ms. Rhodes: “OK.”
Provider: “Would you mind telling me a little bit more about your pain?”
Ms. Rhodes: “Sure.”
Provider: “Where is it located?”
Ms. Rhodes: “I have pain in my lower abdomen area.”
Provider: “When did it start?”
Ms. Rhodes: “I’ve had the pain for at least 5 years. At first my pain was mild, but it has gradually worsened over the last several years. Most recently, I’ve also had burning pain with sex.
Provider: “Do you have pain every day or just with sex?
Ms. Rhodes: “Pretty much—it gets worse or better depending on what I’m doing or what’s happening.”
Provider: “What makes it worse?”
Ms. Rhodes: “having sex definitely makes it worse and I have pain for a couple of days afterward.”
Provider: what part of sex is painful for you? For instance, do you have pain during arousal, penetration, any kind of touch or orgasm?
Ms. Rhodes: it doesn’t hurt until something touches near the opening. I definitely don’t like it when he goes inside. We just have to stop because it hurts too much! We just don’t have sex anymore.
Provider: “this is very helpful information, it helps me understand what is going on with you. Do you have any bowel or bladder symptoms?
Ms. Rhodes: “I’ve been peeing frequently and have had cramping in my bladder area. I’ve also had problems with constipation and have been told I have irritable bowel.”
Provider: “What helps your pain?
Ms. Rhodes: “The birth control pills have helped the pain I get with my periods, but I still have pain at a 5-8/10 scale 2-3 times a week. I’ve had four surgeries. They’ve ranged from ovaries, to appendix, and several ablations for endometriosis. More recently, six months ago, I had another surgery, but nothing was found. After some of the earlier procedures, I did have a few months of pain relief, but now I feel like I’m at the end of my rope again; nothing seems to help. I’m frankly wondering whether it’s time for another operation.”
Provider: “I’m sorry that this has been so difficult for you. Have you had any feelings of sadness or depression during all of this?
Ms. Rhodes: “Yes, I’ve struggled with depression and anxiety.
Provider: Have you ever been treated for depression or anxiety?”
Ms. Rhodes: “I’m in therapy.”
Provider: “Did any of your depression or anxiety exist before your pelvic pain?”
Ms. Rhodes: “I’ve struggled with depression off and on during my life, but never anything like this.”
Provider: “Have you ever felt like hurting yourself or someone else? How about now?
Ms. Rhodes: no, never.
Provider: Are you being threatened or hurt by anyone at home? Did you have any of these experiences as a child?”
Ms. Rhodes: “No”.
Provider: Has your pelvic pain interfered with your ability to do your usual activities: take care of yourself, do your work or have fun?
Ms. Rhodes: yes, I am missing work and I really can’t play with my kids because of the pain. I miss out on a lot of things.
Provider: “How do you cope with your pain?”
Ms. Rhodes: “I go to bed and curl up in a ball. Sometimes I pray.”
Provider: “How do your partner and family respond when you are in pain?”
Ms. Rhodes: “I think they get frustrated. They don’t know how to help.
Provider: “You mentioned you’re seeing a therapist. Has that been helping you cope?”
Ms. Rhodes: “A little bit—some, but I still feel that the situation is out of control and I feel powerless and alone.”
Provider: “I am hoping that I can help you be able to do more things and enjoy life more. I’d like to examine you and then we come up with a plan together. How does that sound?”
Test Your Knowledge: Pain Measurement
In addition to obtaining an NRS/VAS pain intensity score, should pain history should be assessed?
Quality, location, timing with menstrual cycle, contributing or relieving factors
- Body map: location and severity of pain.
- If patient is unable to give an adequate pain history then she should keep a pain diary for 3-5 days to record the information above.
Components of CPP History
- Pain history/diary: quality, location, timing with cycle, contributing or relieving factors, body map,
- Medical/surgical history including medications used presently and in the past
- Menstrual history
- Sexual history
- Obstetrical history
- GI symptoms
- Urinary symptoms: interstitial cystitis screening (example: pelvic Pain and urinary frequency / urgency Patient Symptom Scale (Parsons, 2004)
- Musculoskeletal issues: injuries, falls, accidents
- Quality of life/coping
- Psychological health: depression, anxiety, PTSD, and physical and sexual trauma
- Health habits: substance abuse, nutrition/exercise
- Review records: diagnostic tests, treatments including surgical findings
See International Pelvic Pain Society Website for history and PE forms: English, Spanish, French.