#323 Pelvic Pain, Constipation, Long COVID (TFTC)

February 23, 2022 | By Beth Garbitelli

Video

We recap the top pearls on pelvic pain, constipation, and Long COVID. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.

Note: There is no CME for this mini-episode, but visit curbsiders.vcuhealth.org to claim credit for shows #311, #314, and #315 at curbsiders.vcuhealth.org!

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Credits

• Written, Produced, and Hosted by: Beth Garbitelli, Matthew Watto MD, FACP; Paul Williams MD, FACP  
• Cover Art: Edison Jyang
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments

• Intro, disclaimer, guest bio
• Pelvic Pain
• Constipation
• Long COVID
• Outro

Episode #311 Chronic Pelvic Pain

Featuring Dr. Georgine Lamvu, Writers/Producer: Molly Heublein, MD, Infographic: Edison Jyang, Cover Art: Kate Grant, MBChB MRCGP DipGUMed

An Approach to pelvic pain

We are dismissive of pain in folks with uteruses and historically disadvantaged and marginalized groups (e.g., fibroids, especially Black women). We NEED to do better. 

Arrange your thinking by organ system: bladder, bowel, muscles/nerves, reproductive organs, and/or centrally mediated pain.

Shift the way we think about pelvic pain! Viscero-visceral sensitization means that organs in the pelvis share neuronal connections. Imagine a spider web of nerves instead of one nerve to each organ. Thus, a patient with dysmenorrhea may have urinary urgency and diarrhea with her menses.

How to Clue In

• Myofascial Pain: Pain with intercourse, pain that gets worse after standing for long periods or at the end of the day.
• GU Organs: Worse with ovulation or menstruation.
• Central Nervous System: Mood (associated depression, anxiety, insomnia).
• Peripheral Nervous System: Radiating pain, sharp character, or burning character consistent with neuropathy. 

Emphasis on TIC

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.  open-ended question like:  “Have you experienced anything that makes seeing a doctor difficult or scary for you?” (Millstein, 2020).

Exam

• MSK – back range of motion, muscle palpation
• Abdominal exam – elicit if the pain is worsened with contraction abdominal wall muscles (i.e. Carnett’s sign) suggesting a myofascial pain rather than deep organ etiology).  
• External vulvar exam – Evaluate for allodynia or hyperalgesia (examine gently with cotton swab or wooden tip for exquisite pain).  
• Internal pelvic exam: A gentle digital or speculum exam causing pain suggests myofascial pain. 

Treatment

• Focus on pain relief, cycle suppression, and make appropriate referrals if uro or GI involvement.
• Counseling/set expectations that an answer is not always found. This does not invalidate the experience of pain. 

Episode #314 Constipation

Featuring Xiao Jing (Iris) Wang with production and graphics by Elena Gibson

Defined

Formally diagnosed as three or fewer bowel movements per week and is chronic when symptoms persist for three consecutive months.

Symptoms include decreased stool frequency (duh), incomplete evacuation, changes in stool consistency, and difficulty with defecation.

History

Dr. Wang performs a Bowel Habit Review of Systems:

• Frequency – previous baseline and what has changed. Ask about Bristol stool form.
• Alarm symptoms include weight loss, change in stool caliber, pain with defecation, and bleeding.
• Questions to evaluate rectal evacuation disorders:
  • Straining
  • Sense of incomplete evacuation
  • Doing “toilet yoga.”
  • Manual evacuation
  • Needing to splint the back wall of the vagina

Evaluation

Dr. Wang first looks for secondary causes of constipation, including medications, electrolyte abnormalities, and alarm symptoms that would raise concern for malignancy.  If there is nothing localizing, she will begin a trial of treatment with fiber or laxatives.

If constipation does not respond to treatment, evaluate for defecatory disorders with anorectal testing ( Bharucha, 2020).  This can include anorectal manometry, balloon expulsion testing, and balloon rectal sensitivity testing. Defecography can be considered if testing is inconclusive.

A key point here is that you first look for pelvic floor dysfunction (manometry, defecography) because rectal distention causes signals that slow small bowel and colon transit.

If pelvic dysfunction is ruled out, a next reasonable step would be to evaluate colonic transit.  The most commonly used method is with radio-opaque markers (SITZMARK) that are swallowed and their transit through the bowel is observed via radiograph at day 0, day, and day 5.  The number remaining and distribution can help with diagnosis.  If they are evenly distributed, this suggests slow-transit constipation; if they are in the descending colon, sigmoid colon, and rectum, this suggests pelvic floor dysfunction.  Motility capsules and scintigraphy can also be used.

Treatment

Fiber is first-line, and dietary fiber is preferred (yes, with kiwis).  Osmotic laxatives such as polyethylene glycol or milk of magnesia are also a backbone of treatment.  Avoid lactulose if ileus or obstruction is suspected.  Stimulant laxatives such as senna and bisacodyl can be used once things get moving and can be taken at night so that peak onset can occur in the morning.  There are several secretagogues available, but at least one meta-analysis suggested that bisacodyl has superior efficacy.

In regard to suppositories and enemas, Dr. Wang suggests bisacodyl suppository first for ease of use.  Milk and molasses is evidently an option as well.  A reminder that Fleets (sodium phosphate) tablets or enemas can lead to hyperphosphatemia in patients with chronic kidney disease and thus have a black box warning for nephropathy (from FDA site, accessed 2/19/22).

Biofeedback can be helpful for patients with pelvic floor dysfunction, as can positioning techniques like those facilitated by the Squatty Potty.

Episode #315 Long COVID

Featuring Monica Verduzco Guitierrez, production by Avital O’Glasser, and graphics by Edison Jyang

Diagnosis

“Long COVID” is the syndrome characterized by varied persistent symptoms after initial COVID-19 infection. Definitions vary (CDC, WHO, etc.), but Dr. Gutierrez considers any symptoms persisting more than a few weeks to qualify (expert opinion). Long COVID symptoms (especially fatigue) may be present in 10-30% of patients even after mild disease (Phillips, 2021; Logue, 2021). Editorialists worry that even a small rate of debility after COVID infection will have massive lasting implications on QoL, function, etc. 

Pathogenesis = we don’t know

Ready for some hand waving (blushing emoji)? The pathogenesis is unclear. Inflammatory, autoimmune, and dysautonomic factors may contribute (Phillips, 2021). Is there persistent live virus? Dr. Gutierrez notes that testing is often normal but should not negate or diminish our management of symptoms. At least one group recommends focusing on biopsychosocial symptoms management rather than comprehensive diagnostic testing (Sykes, 2021).

POTS

Postural “Orthostatic” Tachycardia Syndrome (POTS)

• Recognize POTS as orthostatic tachycardia (rise of >30 bpm in adults) without hypotension w/in 10 minutes of standing (StatPearls 2021). Has anyone ever successfully ordered a tilt test? 
• Functional impairment is common. Symptoms often include: fatigue, headache, palpitations, sleep disturbance, nausea, bloating (StatPearls 2021)
• Consider nonpharmacologic care including compression stockings, abdominal binders, small frequent meals, and proactive hydration per Dr. Verduzco-Gutierrez.
• Counterpressure maneuvers, increased salt intake, avoiding bed rest, and focus on sleep quality should be encouraged (UpToDate).
• Pharmacologic therapy including beta-blockers or midodrine may be considered.

Neuropsychiatric symptoms

Fatigue: Long COVID has considerable overlap with Chronic fatigue syndrome/myalgic encephalomyelitis presents as a constellation of symptoms with prominent post-exertional malaise (PEM) and sleep problems (CDC CFS/ME accessed 2/5/2022). Work accommodations may be necessary as both physical and mental activity can trigger PEM. The writer recommends optimizing sleep, stress/mood, and lifestyle (diet, activity).

Follow the 3Ps (Pace, Plan, Prioritize)

Source: https://www.rcot.co.uk/conserving-energy 

1. Take your time. Stop when tired, NOT when exhausted. Recovery will be quicker, and you’re less likely to feel impaired the next day.
2. Plan activities spaced throughout the week instead of all on the same day.
3. Ask others to help. Push and pull rather than lift. Decide what you need and want to do. Drop other activities or outsource them.

Long COVID qualifies for disability assessments according to the Americans with Disabilities Act.

Loss of taste/smell

• Safety education tips: Make sure smoke alarms have batteries, have a trusted friend to smell your food, be sure to eat enough, and monitor your weight https://www.fifthsense.org.uk/safety-advice/  
• Steroid nasal spray
• Dr. Gutierrez recommends referring to ENT or taste/smell clinic for olfactory training (smell familiar smells, essential oils) 

General Management

• Patient validation, counseling, education are essential.
• Interdisciplinary care should be individualized by needs
• Focus on what you can optimize or treat.  For example, optimize nutrition, exercise/activity, and sleep. Treat headaches. Consider vestibular rehab for dizziness.; speech therapy for cognitive support tools.
• Long COVID qualifies for disability assessments according to the Americans with Disabilities Act.
• Vaccinate patients to prevent (Ledford 2021) and potentially mitigate the symptoms (LongCovidSOS 2021) of Long COVID.

Goal

Listeners will review top pearls from recent Curbsiders episodes.

Learning objectives

After listening to this episode listeners will…

1. Develop an approach to pelvic pain and perform a trauma-informed exam.
2. Develop a framework for the diagnosis and management of constipation.
3. Recognize, manage and counsel patients about the symptoms of long COVID.

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Garbitelli B, Williams PN, Watto MF. “#323 Pelvic Pain, Constipation, Long COVID (TFTC)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date February 23, 2021.