#311 Chronic Pelvic Pain

December 20, 2021 | By Molly Heublein

With Dr. Georgine Lamvu

Summary

Pelvic pain is not just a gyn issue!  As a PCP,  you can feel confident doing an initial workup and starting treatment for pelvic pain.  Dr. Lamvu shares a great framework to narrow down your diagnosis and provides amazing resources for those who work in an under-resourced center.   We’ll walk you through what to focus on in the history, a trauma-informed physical exam, and the first-line treatments.  Feel confident with your ability to help your chronic pelvic pain patients.

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Credits

• Writers/Producer: Molly Heublein, MD
• Infographic: Edison Jyang
• Cover Art: Kate Grant, MBChB MRCGP DipGUMed
• Hosts: Beth Garbitelli, Molly Heublein, MD
• Reviewer: Emi Okamoto, MD
• Executive Producer: Beth Garbitelli
• Showrunner: Matthew Watto MD, FACP
• Editor: Clair Morgan of nodderly.com
• Guest: Georgine Lamvu, MD MPH

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Show Segments

• Intro, disclaimer, guest bio
• Guest introduction and recommendations
• Picks of the Week
• Case from Kashlak
• Persistent Pelvic Pain Definitions
• Differential diagnosis/organ system approach
• History
• Physical Exam
• Trauma informed Care
• First line Treatments
• Resources for patient education and to build speciality team
• Summary and take home points 
• Outro

Pelvic Pain Pearls

1. The differential diagnosis for chronic pelvic pain is  long and many patients have multiple etiologies for their pain. Instead of looking for the one diagnosis, focus on the main organ systems: bladder, bowel, muscles/nerves, reproductive organs, and/or centrally mediated pain.
2. Viscero-visceral sensitization is the concept that organs in the pelvis share neuronal connections (a spider web of nerves instead of one nerve to each organ), so patients with chronic pelvic pain can experience symptoms across organ systems (ex: a patient with dysmenorrhea has urinary urgency and diarrhea with her menses).
3. Trauma-informed care takes practice.  Make sure to earn the patient’s trust and allow them to control the pace of the physical exam.
4. Initial treatments for chronic pelvic pain are easy for primary care doctors to offer- education, analgesics, hormonal suppression, and physical therapy.

Pelvic Pain Show Notes

Definition of Chronic Pelvic pain

Chronic pelvic pain is defined as pain perceived by clinician or patient to come from anywhere in the pelvis (below umbilicus including lower back, vagina, and vulva) persistent for typically at least 6 months, although when associated with disability, may qualify if persistent for a shorter period of time (i.e. 3 months). Chronic pelvic pain now includes recurrent cyclic pelvic pain or dysmenorrhea (ACOG Practice Bulletin 218).

Differential Diagnosis vs an Organ System Approach

The differential diagnosis of chronic pelvic pain is broad: interstitial cystitis/bladder pain syndrome, vulvodynia, pelvic inflammatory disease, endometriosis, myofascial pain, irritable bowel syndrome, etc.  Dr Lamvu suggests instead of thinking of an individual diagnosis focusing on organ systems:

• Bladder
• Bowel
• Muscles and neurons of pelvis
• Reproductive organs 
• Centrally mediated causes of pain

Hone in on specific symptoms- are they having more urinary symptoms?  More bowel symptoms?  (ACOG Practice Bulletin 218).

The problem with a “differential diagnosis” for persistent pelvic pain is that it supposes there is one right answer.  However in patients with chronic pelvic pain, 20-40% will have more than one cause.  Focusing in on one diagnosis can be confusing to patients too because it may not explain all of their symptoms.  Dr. Lamvu recommends it is ok to admit uncertainty to our patients.  Multiple diagnoses are possible and multiple therapies are needed, chronic pelvic pain is complex (Lamvu, JAMA 2021).

Viscero-visceral cross sensitization or convergence is an important concept for understanding pelvic pain syndromes.  The nerves and organs in the pelvis are closely intertwined. In the lower pelvis there is no one specific neuron going to each organ, instead there is a spider web of neurons that touch multiple organs.   When the bladder is hyperactive, this can stimulate the bowel and/or uterus to be hyperactive.  This helps explain why patients have confusing symptoms or multiple organ symptom involvement, for example a patient with dysmenorrhea who also has nausea and vomiting or urinary urgency and frequency with menses (Schwartz, Curr Top Behav Neurosci 2014, Brumovsky Auton Neurosci 2010).

History

In addition to the usual pain questions (how long does it last, what makes it better/worse, etc) ask about each of the organ systems.

Clues to specific locations:

Myofascial Pain: Pain with intercourse, pain that gets worse after standing for long periods or at the end of the day.

Reproductive Organs: Worse with ovulation or menstruation.

Central Nervous System: Mood (depression, anxiety, insomnia). 

Peripheral Nervous System: Radiating pain, sharp character,  or burning character consistent with a neuropathy.

Exam

Musculoskeletal: External exam back exam (back range of motion, muscle palpation), abd exam (elicit if the pain is worsened with contraction abdominal wall muscles ie Carnett’s sign, suggesting a myofascial pain rather than deep organ etiology).  Look for trigger points and scar pain externally for myofascial pain/

External vulvar exam Evaluating for allodynia or hyperalgesia (examine gently with cotton swab or wooden tip for exquisite pain).  

Internal pelvic exam: Single-digit internal vaginal exam- push on the different pelvic floor muscles.  Patients without myofascial pain can tolerate 2kg of pressure without pain.  Push around the clock face, if they report more than just pressure or says “that’s the pain I feel” that suggests myofascial pain.  A gentle speculum exam causing pain suggests myofascial pain.  Bimanual exam to examine for adnexal/uterus pain.  For male patients examine a single digit rectal exam for pelvic floor muscle pain.

Speculum exam: Only if the patient tolerates the digital exam and agrees.  Indicated for irregular discharge or bleeding (Lamvu 2021).

Trauma-Informed Care

This is essential when managing our chronic pain patients.  Consider open-ended questions that may elicit trauma history (which may include: physical, sexual, military sexual trauma, but also medical trauma with painful pelvic exams.)  Just because a patient is coming in for pelvic pain, do not assume they are coming in for a pelvic exam.  Ways to ask about trauma from our Trauma-Informed Care episode with Dr. Gerber include: the stem from the PC-PTSD-5 (“Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured,  having a loved one die through homicide or suicide. Have you ever experienced this kind of event?”) or an even more open-ended question like:  “Have you experienced anything that makes seeing a doctor difficult or scary for you?” (Millstein, 2020).

Always obtain verbal consent for the exam.  Build trust and let them know they are in control of the exam, the patient can choose to stop at any point.  Ok to break up the exam through multiple visits or perform the exam at a later date.   Don’t make it seem like the pelvic exam should be comfortable, Dr. Lamvu suggests words like “tolerable”.  Additionally, consider asking if the patient would like information about each step of an exam. 

Be aware of verbal and nonverbal cues of discomfort, especially when you can’t clearly see the patient’s face.  Go slowly and talk through the exam, then give time for the patient to process the next step.   

Be very careful with language.  Avoid the word “relax” during the pelvic exam- telling someone to relax can be hurtful and isn’t helpful.  Consider encouraging deep breathing, pushing posterior pelvis down into the table which can help release pelvic floor muscles (Lamvu 2021).  

Check out our prior Curbsiders episode with Dr. Megan Gerber for more on this.

Testing

Testing should be targeted toward specific symptoms, though in general sexually transmitted infection screening, urinalysis, pregnancy test, and pelvic ultrasound to look for structural issues are appropriate.  Otherwise target to specific symptoms (ex: if hematochezia or significant bowel dysfunction, consider colonoscopy, Tu, UTD 2019). 

Dr. Lamvu recommends to communicate with patients that diagnostic testing is usually normal, and this does not mean the patient does not have pain.  The most common causes (IBS, bladder pain syndrome, myofascial pain, etc) for persistent pelvic pain have normal testing.  

Treatment

Patients presenting to primary care are often in the early stages of their condition and respond well to basic measures.

Analgesia: Acetaminophen, NSAIDS, muscle relaxants.

Hormonal Suppression: If the pain is cyclic, offer continuous suppression of menstruation with a birth control pill, levonorgestrel IUD, or etonogestrel implant.

Behavioral Modification: What in their lifestyle is making the pain worse?  Encourage slow increase in physical activity.  Address fluid intake for bladder pain syndrome, dietary measures for IBS-C/D, etc.

Physical Rehabilitation: Pelvic floor physical therapy (Tu, UTD 2021).

Additional Treatments- referral to a subspecialist for more intensive treatments.  

Clinical psychologists/Psychiatrist for pain education, cognitive behavioral therapy, acceptance and commitment therapy.  Addressing mental health and insomnia.

Gynecology for more intensive hormonal suppression, trigger point injections or onobotulunum toxins.

Urology or urogynecology for bladder instillations, onabotulinum toxin, or neuromodulation.

Gastroenterology for colonoscopy, more intensive medical therapy for IBS.

Pain medication/neurology for nerve blocks, spinal blocks, trigger point injections.  (ACOG Practice Bulletin 218)

Pelvic Pain Treatment Resources

Some great resources to help find a health care professionals if you don’t have a pelvic pain center in your area:  American Physical Therapy Association to find local PT, International Pelvic Pain Society and Pelvic Pain Education Program for other providers.  

Make sure you communicate with these specialists to care well for our patients, have a unified message and a shared plan.  

Patient Education

Educating our patients on self management for pain and chronic pain is important.  Online resources:  Pelvic Pain Education Program,  Pain Guide, Chronic Pain Research Alliance.

Long-Term Prognosis

Dr Lamvu counsels patients that persistent pelvic pain is no different than diabetes.  This requires medical care and self care.  Dr Lamvu counsels patients, it can take 3-6  months to get better, but hopefully within a year pain should be more manageable and patients should have the tools to manage pain flares.  We can’t cure pain, but that does not mean we can’t make pain better.

Take home points

There is a lot of scientific evidence that pain is real.  Validate our patients’ experiences.

Have patience, it takes time to fully evaluate patients with chronic pain and help them improve.

You can make a huge difference in a patient’s life by using the right words, more than any medicine or therapy can provide.

Links*

1. Dr Lamvu’s book recommendations: Richard Harris’s Rigor Mortis, Hans Roling’s Factfulness, Anna Lembke’s Drug Dealer MD
2. Beth’s Pick: Better Chocolate Babka from Smitten Kitchen (via Ottolenghi’s Krantz Cake) and Uri Scheft’s Babka on Food52 via Breaking Breads by Uri Scheft  or just order chocolate babka from Breads Bakery 
3. Molly’s Pick: Chanel Cleeton’s Next Year in Havana

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goals

Listeners will establish a working differential for chronic pelvic pain, identify first line treatments to start in primary care, and understand the impact of central pain amplification.

Learning objectives

After listening to this episode listeners will…

1. Identify a working differential for chronic pelvic pain (CPP).
2. List important information in the patient’s history which can help differentiate causes of pelvic pain.
3. Perform an appropriate physical exam to evaluate CPP.
4. Define central pain amplification.
5. Identify first line treatments for CPP.

Disclosures

Dr Lamvu reports work as a consultant for Sola Physical Therapy, Abbvie, and Solvd Med. The Curbsiders report no relevant financial disclosures. 

Citation

Heublein M, Garbitelli B, Lamvu G, Williams PN, Watto MF. “#311  Chronic Pelvic Pain”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list 20 December, 2021.