For Health Practitioners

Assessment of Chronic Pelvic Pain – History

Assessment of Chronic Pelvic Pain - History

Assessment of Chronic Pelvic Pain – History

1. Pain from pelvic organs

One of the reasons that women find it difficult to get comprehensive care is that several organs may be contributing, and multiple comorbidities may be present. Care easily becomes fragmented across a range of specialists and allied health.

A common mix of comorbidities might include:

  • Endometriosis, adenomyosis ( past or current)
  • Chronic prostatitis
  • Painful bladder syndrome ( interstitial cystitis)
  • Headaches including migraine
  • Irritable bowel syndrome
  • Recurrent candidiasis or urinary tract infections
  • Vulvar vestibulitis, atrophic vaginitis
  • Vagismus

 

Symptoms suggestive of pelvic organ pain include:

  • Period pain, deep dyspareunia for females
  • Painful ejaculation for males
  • Urinary frequency, nocturia, urgency, dysuria
  • Irritable bowel (diarrhoea, constipation, bloating, food intolerances)
  • recurrent candidiasis (where confirmed by vaginal swab and culture)
  • vulval pain, superficial dyspareunia

2. The musculoskeletal response to pain

Just as back pain, chronic pelvic pain is usually complicated by muscle spasms of intrapelvic muscles. Due to the limited knowledge surrounding the complexity of the intrapelvic muscles and lumbosacral nerves, their contribution to pain is frequently undiagnosed.

Suggestive symptoms for pain from obturator internus include:

  • Stabbing pains felt on the sides of the lower abdomen that refer to the back or anterior thigh can limit walking and improve with heat packs and hip stretches including ‘fetal position’
  • generalised pelvic ache
  • Pain aggravated by movement or prolonged positions.
  • Pain exacerbated by core stenghtening exercises

 

Suggestive symptoms for pain from pelvic floor muscles include:

  • stabbing pains in the vagina or lower bowel
  • generalised pelvic ache
  • difficulty initiating a void, or poor emptying despite urge
  • pain with intercourse, speculums or tampons.
  • vulval pain, superficial dyspareunia

3. Central sensitisation of nerve pathways

Once pain of any kind is present on most days, central sensitisation of pain is likely present. Magnetic resonance imaging (MRI) has shown grey matter changes in a range of pain conditions including CPP.8 Brawn summarises the evidence for central changes in PPP.7

Suggestive symptoms of central sensitisation include:

  • Pain present on most days, even if less severe
  • Bloated or burning feelings
  • Nausea, dizziness, anxiety, low mood, fatigue, poor sleep and unusual sweating
  • ‘Hypersensitivity’ where normal sensations such as tight clothes or touch become interpreted as unpleasant or painful experiences (hyperalgesia/allodynia)
  • pain felt over a larger area when severe (wind-up pain)

4. The psychological sequelae of persistent pain

Pain affects mood and mood affects pain. Mood disturbances can predispose patients to pain. As with depression and pain, psychological stress and pain are frequently comorbid. Stress can increase the experience and perception of pain and the mode and degree in coping with the pain.

A person with CPP may have struggled with pain for many years. CPP may have impacted their relationships, sexual confidence, fertility, education, professional and financial opportunities. Thus, resulting in self-doubt and difficulties with their personal development. Such issues may have implications for medical management. Additionally chronic
pain also affects those who care for sufferers and society.

Suggestive symptoms of psychosocial difficulty include:

  • Withdrawal from social activities, study, or employment
  • Hypervigilance to pain symptoms
  • Anxiety, depression, low self-confidence (use K10, DASS 21)

Acute flares of CPP

Many women live with chronic pain every day. However, unexpected flares of uncontrolled pain, often causing the patient to fear that she must be in danger, result in presentations to the doctor or emergency department.

While ovulation pain, appendicitis, and ectopic pregnancy (positive pregnancy test) are possible, common causes of acute flares of pain include:

  • pelvic muscle spasm – often after an unusual activity/posture/exercise/pain or with severe period pain
  • bladder pain – possibly after diet triggers or urinary tract infection on a background of urinary problems
  • a functional ovarian cyst (usually only seen in patients not on OCP)
  • a hormonally ‘different’ month – her period may be delayed
  • recent severe stress with increased tension in pelvic muscles

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