Objectives Abdominal and Pelvic Pain By the end of this lecture, participants will be able to: Identify common causes of acute abdominal and pelvic pain Identify common causes of chronic abdominal and pelvic pain Identify triage questions for nurses related to this topic Differentiate urgent vs. non urgent presentations Describe the components of a pain evaluation Provide appropriate patient education 01/31/13 1 2 Case Study Lisa, a 39 year old female veteran, calls the primary care clinic with a complaint of pelvic pain that started 24 hours ago. Nurse s critical thinking process: Assess the urgency of Lisa s complaint. 3 Triage Questions for Acute and Chronic Abdominal and Pelvic Pain Are you/could you be pregnant? LMP? Where is the pain? Does it radiate elsewhere? Has the location of the pain changed over time? How long have you had the pain? Where/when did it occur? Was the onset of pain sudden or gradual? What have you used to treat your pain? Does anything make it worse or better? Have you had similar pain before? If yes, how was it treated? Is the pain sharp, dull, or stabbing? Does it come and go (cyclic)? Rate the pain on a scale of 1=minor to 10= unbearable What form of birth control do you use? Other symptoms (e.g., nausea, vomiting, vaginal discharge/bleeding)? Past gynecologic surgeries? Past sexually transmitted infections? Bowel movement pattern? 4
Case Study, continued Lisa states that she has never had pain like this before. She tried acetaminophen and ibuprofen, but neither helped. Her last menstrual period was 2 weeks ago and she has a history of tubal ligation. Nurse s critical thinking process: Lisa is probably not pregnant. A clinic appointment is appropriate. Signs and Symptoms Purulent vaginal discharge suggests STI Cramping and vaginal bleeding commonly seen with ectopic pregnancy or threatened abortion Dyspareunia and dysmenorrhea suggest endometriosis Anorexia, nausea, vomiting often seen with appendicitis, as well as inflammatory pelvic processes (pelvic inflammatory disease, adnexal torsion, degenerating leiomyoma) Trauma may cause acute pelvic pain Dysuria Constipation and/or diarrhea 5 6 Definition of Acute Abdominal/Pelvic Pain Common Causes of Acute Abdominal/Pelvic Pain Definitions vary Pain of less than one week duration. Undiagnosed pain of less than 10 days duration. Working definition: Pain so bad that the patient cannot wait until tomorrow or next week for a physician appointment. Gynecologic Pelvic inflammatory disease Dysmenorrhea Ruptured ovarian cyst Ovarian and fallopian tube torsion Endometritis Torsion or degeneration of a uterine fibroid Rupture of an endometrioma Gynecologic with a positive pregnancy test Ectopic Pregnancy Miscarriage Non gynecologic Appendicitis Acute cystitis Diverticulitis Urinary tract calculi Abdominal wall trauma Interstitial cystitis 7 8
Exam Nursing Role Take vitals immediately If patient has marked hypotension, tachycardia, or fever, she may need emergency treatment If patient says she is pregnant, follow local policy for disposition of acutely ill pregnant patient Set up supplies for complete pelvic exam Potential lab tests: All women of reproductive age will need a pregnancy test CBC with differential, ESR, CRP Urinalysis, protein C and protein S for clotting disorder Tests for chlamydia and gonorrhea Patient Education for Acute Abdominal/Pelvic Pain Any additional questions about treatment plan and discharge instructions? How to reach the provider with questions including afterhours contact Clear understanding of when/if she is to return for follow up care Clear understanding to seek emergency care if Pain worsens Fevers develop Orthostatic symptoms occur (lightheadedness, confusion, nausea, passing out, weakness, blurred vision, shaking) 9 10 Definition of Chronic Pelvic Pain (CPP) Chronic Abdominal and Pelvic Pain Non cyclical pain of at least 6 months duration that appears in locations such as the pelvis, anterior abdominal wall, lower back or buttocks, and that is serious enough to cause disability or lead to medical care. 11 11 12
Epidemiology of CPP Co-Morbidities with CPP Occurs in 15% of reproductive aged women Cited as a diagnosis in up to 10% of all outpatient gynecologic consultations, 40% of all laparoscopies, and 18% of all hysterectomies Over $2 billion in estimated annual costs for US Up to 50% of women with pelvic pain also have depression Drug and alcohol abuse predispose to pain No difference in prevalence of CPP based on race, ethnicity, education, or socioeconomic status 13 14 Physiologic Causes of CPP CPP is Associated with Abuse Physical or sexual abuse Of 713 women seen in a pelvic pain clinic (Meltzer Brody et al, 2007): 46.8% had history of sexual or physical abuse 31.3% had PTSD symptoms Women with trauma history had worse medical symptoms such as headaches, muscle aches, constipation or diarrhea Military sexual abuse Prevalence of MST among all women veterans is 1 in 5 Women with a history of MST are twice as likely to report chronic pelvic pain (Frayne et al, 1999) 15 Gynecologic GI Urologic Musculoskeletal Endometriosis IBS Interstitial cystitis Pelvic adhesions Pelvic congestion Chronic pelvic inflammatory disease IBD (UC, Crohn s, etc.) Chronic constipation Colitis Chronic UTI Urethral syndrome Radiation cystitis Adenomyosis Diverticulitis Urinary calculi Vulvodynia Ovarian cyst/varicosity Uterine myomas 16 Myofascial pain (abdominal wall or pelvic floor muscles) Fibromyalgia Coccygeal or low back pain Nerve pain
Most Common Diagnoses of CPP Definitive diagnosis is not made for 61% of women Up to 40% of women with CPP in primary care have more than one diagnosis The four most commonly diagnosed causes of CPP are: Endometriosis Adhesions Irritable bowel syndrome (IBS) Interstitial cystitis Chronic Pain Questions Have you had this type of pain in the past? How would you describe today s pain? Does today s pain differ from previous episodes? If yes, how? Associated symptoms? Pain timing: Constant? Associated with menses? Associated with eating? Associated with intercourse? Associated with stress? Rate the pain on a scale of 1=minor to 10=unbearable What have you done to treat the pain? Today? In the past? Does anyone in your family have chronic pain? If yes, what? Do you have a pain plan? If yes, are you following it? When did it stop working? 17 18 Exam Nursing Role Take vital signs Set up supplies for a complete pelvic exam Potential lab tests: All women of reproductive age will need a pregnancy test Pap if patient is due CBC with differential Liver and renal function tests Urinalysis, protein C and protein S for clotting disorder Tests for chlamydia and gonorrhea Be Alert for Signs of Trauma Be aware of patient behaviors during the interview or exam that may indicate prior trauma Becoming tearful Becoming silent or staring Nervous talking Reluctance to have a GU exam If a patient shows signs of distress Bring someone else in the room so you are not alone with her Change the subject until she can collect herself Ask her if she would like to take a minute to relax or if she would like to delay the interview or exam 19
What Women with CPP Want To be addressed as an individual by a supportive, understanding, interested provider/team To feel that both she and her pain are taken seriously and legitimized To receive an explanation for her condition (more so than a cure). Information and discussion. Reassurance that it is: Not all in her mind A common problem Not serious/cancer Price et al, 2006 Patient Education for CPP Any additional questions regarding treatment plan and discharge instructions? How to reach the provider with questions including after hours contact Clear understanding of when/if she is to return for follow up Clear understanding to seek emergency care immediately if Pain worsens Fevers develop Orthostatic symptoms occur (lightheadedness, confusion, nausea, passing out, weakness, blurred vision, shaking) 21 22 IBS Most Common Causes of CPP Abdominal pain/discomfort with altered bowel habits for at least 3 months Colon spasms, causing food to move too quickly or too slowly through the intestines Cause is unclear Affects 20% of the population; 1.5 times more common in women Onset before age 35 in 50% of cases IBS sufferers report poorer physical and mental health IBS care costs up to $20 billion annually 23 23 24
Fundamentals of an Elimination Diet Goal: remove foods that may be irritating the lining of the intestine Don t eat the foods whole or as ingredients in other foods for 2 weeks Once intestinal wall has returned to normal, slowly add one food group every 3 days Keep a record of symptoms Eliminate for 2-Week Trial Dairy (lactose) Wheat (gluten) High fructose corn syrup Sorbitol (chewing gum) Eggs Nuts Shellfish Soybeans Beef Pork Lamb IBS Patient Education Symptom diary is useful Dietary manipulation is most effective May need nutritional consult Add fiber slowly Stress management Increase physical activity Medication management Alternative/complementary therapy Biofeedback Probiotics (Nikfar et al, 2008) Peppermint oil (Merat et al, 2009) 26 Endometriosis Endometrial tissues that occur outside the uterus Multiple theories as to cause Affects 3 15% (avg 10%) of the general population Occurs in 25 50% of the infertility population Mean age at diagnosis is 25 30 Endometriosis Symptoms Pelvic pain 70 75% of women with endometriosis Severity not related to pathology by laparoscopy Can include: Increasing dysmenorrhea Deep dyspareunia Premenstrual dysmenorrhea Lower abdominal pain, often bilateral Lower back pain Infertility 27 28
Endometriosis Diagnosis History Physical exam Laparoscopy (gold standard) Patient Education for Endometriosis Management with medications NSAIDs Monophasic oral contraceptive, vaginal ring, or contraceptive patch continuously for 3 months Refer to Gynecology GnRH analogues Surgery (destruction of lesions, hysterectomy) 29 30 Interstitial Cystitis (IC) Defined as 3 6 months of pain, pressure, or discomfort over the suprapubic area or the bladder, accompanied by frequency of urination during the day and night in a patient who does not have a UTI 90% of cases are female Symptoms very over time with flares and remissions Cause is unknown but may be related to defect in the protective lining (epithelium) of the bladder IC Signs, Symptoms, and Diagnosis Dysuria, frequency, urgency, chronic pelvic pain, dyspareunia, vulvodynia Often a diagnosis of exclusion (exclude UTI, bladder cancer, gynecologic disease) UA, potassium sensitivity test Refer to Urology for evaluation Cystoscopy usually with biopsy Testing of bladder capacity 31 32
IC Patient Education Dietary management: low potassium, low acid trial for 2 weeks No carbonated drinks, caffeine (including chocolate), citrus products, tomatoes, pickled foods, alcohol, spices, artificial sweeteners Some patients urinate up to 60 times per day. Retrain bladder by slowly increasing voiding intervals. Pelvic floor/easy stretching exercises to reduce muscle spasms Medical management can include oral medications, nerve stimulation in pelvic area, bladder distension with water or gas, and medications instilled into the bladder Some patients report being helped by acupuncture, guided imagery, biofeedback, visualization Pelvic Adhesions Bands of scar tissue that form between two pelvic organs Risk factors include infection, pelvic surgery including C section, or trauma Can lead to infertility and chronic pain 33 34 Pelvic Adhesion Signs, Symptoms, and Diagnosis Usually signal their presence by aggravating the symptoms of IBS or by causing pain during sexual intercourse Diagnose by excluding other pathology Refer to Gynecology Laparoscopy Patient Education for Pelvic Adhesions Avoid constipation High fiber diet Pain management Surgical lysis Indicated for dense adhesions Some practitioners use substances intraoperatively to prevent more adhesions from forming 35 36
Conclusion Patients complaining of abdominal/pelvic pain need a good triage assessment to determine urgency of care Chronic pelvic pain is a complex condition Many women have concurrent depression, PTSD, MST, IPV. Multidimensional care is often necessary. Existing data is hampered by lack of standard definitions, algorithms, and adequate clinical trials, BUT. Our patients rely on us to listen and come up with the best treatment plan possible Patient Education Resources Womenshealth.gov. Irritable bowel syndrome. http://www.womenshealth.gov/publications/our publications/factsheet/irritable bowel syndrome.cfm Endometriosis. http://www.womenshealth.gov/publications/ourpublications/fact sheet/endometriosis.cfm Interstitial cystitis/bladder pain syndrome. http://www.womenshealth.gov/publications/our publications/factsheet/interstitial cystitis.cfm International Pelvic Pain Society. Chronic pelvic pain. http://www.pelvicpain.org/pdf/patients/cpp_pt_ed_booklet.pdf 37 References Primary Authors: Megan Gerber, MD, MPH VA Boston Healthcare System, Boston, MA Bordman & Jackson. Below the belt: approach to chronic pelvic pain. Can Fam Physician 2006;52:1556 62 Ford et al. Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome. BMJ 2008;337:a2313. Latthe et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ 2006;332:749 55. Meltzer Brody et al. Trauma and posttraumatic stress disorder in women with chronic pelvic pain. Obstet Gynecol 2007;109:902 8. Pearce & Curtis. A multidisciplinary approach to self care in chronic pelvic pain. Br J Nurs. 2007;16:82 5. 39 Contributor: Sarina Schrager, MD, MS University of Wisconsin Department of Family Medicine, Madison, WI Linda Baier Manwell, MS University of Wisconsin Center for Women s Health Research, Madison, WI WH Nurse Reviewers: Barbara Palmer, MS, ANP Rebecca Feria, RN, MSN Joan Galbraith, RN, MSN, NP Cindy James, RN, MSN Laurie Pfeiffer, RN, BSN Barbara Polak, RN, MSN 40