Case Study (continued) Abdominal and Pelvic Pain. Learning Objectives. Case Study. Signs &Symptoms. Triage Questions to Assess Acute Pelvic Pain

Transcription

1 Learning Objectives Discuss common causes of acute pelvic pain Discuss common causes of chronic pelvic pain Abdominal and Pelvic Pain Identify triage questions to differentiate urgent vs. non urgent presentations Describe components of a pain evaluation Provide appropriate patient education Case Study Nurse s Critical Thinking: Assess the urgency of the complaint. Becky, a 39 year old female veteran calls with a complaint of pelvic pain that started 24 hours ago. Triage Questions to Assess Acute Pelvic Pain Pregnant? LMP? Pain characteristics: Location? Does it radiate elsewhere? Has location changed? Duration? Where/when did it occur? Oonset sudden or gradual? Sharp, dull, stabbing? Pain come and go (cyclic)? Rate pain on scale of 1=minor to 10= unbearable Does anything make it worse or better? Treatments tried? Had similar pain before? If yes, how was it treated? Form of birth control? Other symptoms (nausea, vomiting, vaginal discharge/bleeding)? Past gynecologic surgeries? Past sexually transmitted infections? Bowel movement pattern? 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. 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

2 Definition of Acute Pain ACUTE PELVIC PAIN Definition Varies Pain <1 week Pain undiagnosed for <10 days Our Definition: Pain so bad that she cannot wait until tomorrow or next week for an appointment Common Causes of Acute Pelvic Pain Nursing role during a physical exam for acute pelvic pain Gynecologic Conditions (PID, dysmenorrhea) Gynecologic and Pregnant (ectopic pregnancy, miscarriage) Non Gynecologic Conditions (appendicitis, UTI, diverticulitis, kidney stones, trauma) 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 complete pelvic exam 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) Pregnancy should be ruled out for every woman of reproductive age who complains of acute pelvic pain.

3 CHRONIC PELVIC PAIN 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 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 CPP is also associated with: Common Physiologic Causes of CPP Physical and sexual abuse 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) Gynecologic (e.g., endometriosis) GI (e.g., irritable bowel syndrome) 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 Urologic (e.g., interstitial cystitis) Musculoskeletal (e.g., fibromyalgia)

4 CPP Diagnosis 61% of cases, no diagnosis 40% >1 diagnosis Four most common physiologic causes: Endometriosis Adhesions Irritable bowel syndrome (IBS) Interstitial cystitis Triage Questions to Assess CPP Had this type of pain before? Describe today s pain? Does today s pain differ from previous 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? Rate the pain on a scale of 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? Nursing role during a physical exam for CPP Vital signs Listen to her concerns and prepare provider Set up supplies for complete pelvic exam Be Alert for Signs of Trauma Watch for: Tears Silence or staring Nervous chatter Reluctance to have a GU exam If a signs of distress appear, ask if she would like a minute to relax or if she would like to delay the interview or exam. Tell your provider if a women is reluctant to have a pelvic exam. Provider can: Talk with the woman (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 hx. Discuss ways to relieve her stress. Reassure her that she can stop the exam at any point. Always get permission before starting/re starting the exam. What Do Women with CPP Want? Addressed as an Pain is taken Explanation for individual by a seriously and her condition (more so than a supportive team legitimized cure) Information and Reassurance: involvement in Pain is not all in her mind her plan of care Not serious/cancer 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)

5 Most Common Causes of CPP Irritable Bowel Endometriosis Interstitial Cystitis Pelvic Adhesions 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 Diary Dietary Medication and Other (document manipulation Exercise and Therapies everything (nutritional Stress (biofeedback, eaten and consult, add Management probiotics, symptoms) fiber slowly) 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 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 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.

6 Physical Exam Patient Education for Endometriosis History Laparoscopy Can often be managed in primary care setting with medications alone Endometriosis Diagnosis Could treat based on H&P alone. Laparoscopy, however, is gold standard. 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 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 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 Adhesion Diagnosis Aggravated IBS symptoms or pain during sexual intercourse Lead to infertility, chronic pain Pelvic Adhesions Risk factors: infection, pelvic surgery, trauma Diagnosed by excluding other pathology GYN referral for potential laparoscopy

7 Pelvic Adhesions and Mental Health 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. Patient Education for Pelvic Adhesions Avoid constipation High fiber diet Pain management Medications, physical therapy, trigger point injections, Botox injections, biofeedback Goal is to try to keep them out of the OR as long as possible 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 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. Helpful Resources Bordman & Jackson. Below the belt: approach to chronic pelvic pain. Can Fam Physician 2006;52: Meltzer Brody et al. Trauma and posttraumatic stress disorder in women with chronic pelvic pain. Obstet Gynecol 2007;109: Price J, et al. Attitudes of women with chronic pelvic pain to the gynaecological consultation. BJOG Int J Obstet Gynaecol 2006; 113: Patient Education Resources Womenshealth.gov Irritable bowel syndrome Endometriosis Interstitial cystitis/bladder pain syndrome International Pelvic Pain Society. Chronic pelvic pain booklet (6 p.) Ask the Presenter Authorizations are on file for the names used in this presentation, but all clinical indications presented are entirely fictitious.