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.
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.
Featuring Dr. Georgine Lamvu, Writers/Producer: Molly Heublein, MD, Infographic: Edison Jyang, Cover Art: Kate Grant, MBChB MRCGP DipGUMed
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.
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).
Featuring Xiao Jing (Iris) Wang with production and graphics by Elena Gibson
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.
Dr. Wang performs a Bowel Habit Review of Systems:
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.
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.
Featuring Monica Verduzco Guitierrez, production by Avital O’Glasser, and graphics by Edison Jyang
“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.
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).
Postural “Orthostatic” Tachycardia Syndrome (POTS)
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)
Long COVID qualifies for disability assessments according to the Americans with Disabilities Act.
Loss of taste/smell
Listeners will review top pearls from recent Curbsiders episodes.
After listening to this episode listeners will…
The Curbsiders report no relevant financial disclosures.
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.
Got feedback? Suggest a Curbsiders topic. Recommend a guest. Tell us what you think.
We love hearing from you.
Yes, you can now join our exclusive community of core faculty at Kashlak Memorial Hospital along with all the perks:
Close this notice to consent.