- Email: [email protected]
Chronic Pelvic Pain: Can You Guess the Cause?
Chronic Pelvic Pain Can You Guess the Cause? Sue A. Woodson, CNM, MSN
Editor’s note: This marks the debut of “Solve This,” a new column in Nursing for Women’s Health that will present a case history of “clues” that readers can use to “solve” the case and determine the final outcome.
200
© 2007, AWHONN
The Case A 25-year-old G3P0030 woman presents for evaluation of pelvic pain described as central, deep and achy. Dysmenorrhea, which has been present since menarche at age 16, has resulted in numerous missed school days and several visits to the emergency room. In the past, pain was so severe that she actually “passed out.” Dyspareunia with deep penetration has been present for nearly three years. She reports cyclic diarrhea but denies any dysuria or dyschezia. Menstrual periods are somewhat irregular, but the interval never exceeds eight weeks; flow is described as normal. Her last menstrual period was one week ago. She denies any history of sexually transmitted infection. Following an elective pregnancy termination with dilatation and curettage several months ago, she has experienced constant
central pelvic pain. Current medications are limited to clonazepam for anxiety. Medical history reveals prior dysmenorrhea treatment with oral contraceptives pills, which were discontinued due to unbearable hot flashes. Nonsteroidal anti-inflammatory agents provided only minimal relief. A levonorgesterel-releasing intrauterine device (IUD) was removed after less than two months due to excessive cramping and spotting. A pelvic ultrasound report obtained just after an elective pregnancy termination two years ago raises questions about the presence of endometritis or possibly myometritis and notes the presence of nonspecific peritoneal fluid. She was subsequently treated with antibiotics without obvious sequelae. Surgical history is limited to a laparoscopic appendectomy three years ago. Physical examination reveals a welldeveloped, well-nourished female, who appears
Volume 11
Issue 2
her stated age. The abdomen is soft, nontender, with normal bowel sounds throughout and without hepatosplenomegaly or rebound tenderness. Groin lymph nodes are normal. Pelvic exam reveals normal female genitalia without lesions. The vaginal vault contains physiologic-appearing discharge. The uterus is normal sized; however, ten-
derness is noted with cervical motion. The adnexae are nontender without masses. Nodularity is not evident in the cul-de-sac; rectovaginal examination is negative. Based on the above information, what’s your diagnosis?
Sue A. Woodson, CNM, MSN, is a certified nurse midwife and a nurse practitioner in private practice at Charlottesville Gynecology Specialists in Charlottesville, VA.
Turn to page 202 for the answer
DOI: 10.1111/j.1751-486X.2007.00146.x
S O L V E
T H I S
Do You Have a Case to Share? Do you have clinical pearls to share based on actual patient care experience? Have you or your co-workers found yourselves intrigued or puzzled by a particular patient presentation or situation? Did this experience cause you to change your practice? Did you gain important clinical insight as a result of the experience?
If so, Nursing for Women’s Health would like to hear from you. We’re seeking case presentations for the “Solve This” column, in which you can share your experiences with colleagues. Each column will present a case and challenge readers to determine the diagnosis and develop an appropriate plan of care. The goal of this column is to highlight practical information, sharpen diagnostic skills and approaches and improve interpretation of diagnostic tests, images and so forth. All submissions should be based on actual clinical cases; however, all specific identifying data must be blinded. Case presentations should include pertinent history, physical examination findings and any photographs or graphics imperative for assessment, diagnosis or treatment. This may include, but is not limited to, FHM tracings, photographs or other visual aids. Visuals will be chosen based on their teaching value and seasonality to help recognize problems. We will provide you with a release form to gain permission to use patient information and visual aids. Submissions should include reference citations supporting the diagnosis and plan of care where appropriate. Practitioners in all areas of women’s health, obstetrics and newborn care are invited to submit cases.
Cases for “Solve This” column must be submitted at our online manuscript submission site,
Editorial Manager: http://nwh.edmgr.com. For questions e-mail to [email protected].
April | May 2007
Nursing for Women’s Health
201
Chronic Pelvic Pain: Can You Guess the Cause? (continued from page 201)
Chronic Pelvic Pain: A Conundrum
In this scenario, certain signs and symptoms can provide the alert practitioner with a means of culling out unlikely etiologies.
202
Few clinical presentations represent a more challenging conundrum to health care providers than chronic pelvic pain. The differential diagnoses are highly variable and numerous (see Box 1). By definition, chronic pelvic pain must be present intermittently or continuously in the pelvic area for at least six months. This is clearly the case in this patient, given that dysmenorrhea has persisted since menarche (primary dysmenorrhea) and dyspareunia has been present for nearly three years. Therefore, by definition, pathologies that result in acute pelvic pain can be ruled out; these include pregnancy-related complications, degenerating leiomyoma, appendicitis, ovarian torsion or cysts and urinary tract infection. In this scenario, certain signs and symptoms can provide the alert practitioner with a means of culling out unlikely etiologies. It’s doubtful that this particular woman has pudendal nerve entrapment because there is no report of pain alteration with sitting, lying down or standing (Allen, 2005). There is no mention of pain exacerbation with physical activity that would create a suspicion for musculoskeletal etiologies. The lack of urinary symptoms makes interstitial cystitis unlikely. Multiple pregnancy terminations, previous IUD use and a history of questionable endometritis/myometritis place this young woman at risk for pelvic inflammatory disease (PID) (Centers for Disease Control and Prevention, 2004). Cervical motion tenderness is a cardinal sign of PID; therefore, cervical and vaginal cultures were submitted for gonorrhea, chlamydia and “all vaginal pathogens.” All culture results were negative, and the patient remained afebrile. To discriminate among the remaining potential etiologies for her chronic pelvic pain, the patient was offered a trial of a gonadotropin-releasing hormone (GnRH) agonist (e.g., Lupron) to evaluate symptom response (Petta, 2005). GnRH agonists can be used to reveal symptom
Nursing for Women’s Health
response to a hypoestrogenic menopausal state, assisting in the ruling in or out of hormonally mediated factors, such as endometriosis. However, after consideration of her reaction to hot flashes from oral contraceptives, she declined a GnRH trial. At this point, the clinician was left with the following possibilities: endometriosis, which accounts for at least 33 percent of chronic pelvic pain in women (Guo, 2006); adenomyosis, a form of endometriosis involving the myometrium, which is frequently diagnosed only by pathological analysis after hysterectomy; pelvic adhesions, based on the history of laparoscopic abdominal surgery and possibly PID and, last, nongynecologic etiologies including diverticulitis or irritable bowel syndrome (also known as functional bowel syndrome) based on the cyclic diarrhea. Psychosomatic factors should be considered only after all other possibilities have been ruled out, unless there are compelling reasons to the contrary. Diagnostic laparoscopy was performed several weeks later due to chronic pelvic pain unresponsive to medical management. The operative report read in part as follows: The patient is taken to the operating room and placed in the modified dorsal lithotomy position where she was prepped and draped in the usual sterile fashion…. The … trocar was then inserted at a 45 degree angle where intra-abdominal placement
Box 1.
Potential Etiologies for Chronic Pelvic Pain Gastrointestinal pathologies adhesions, irritable bowel syndrome, diverticulitis Genitourinary pathologies adenomyosis, endometriosis, interstitial cystitis, pelvic inflammatory disease Musculoskeletal pathologies fibromyalgia Neurological pathologies pelvic nerve entrapment Pelvic congestion syndrome Psychosomatic factors
Volume 11
Issue 2
Figure 1. Dropped Clips in the Anterior Cul-de-sac
Figure 2. Close-up of Posterior Cul-de-sac Showing Two Clusters of Dropped Surgical Clips
Figure 3. Mild Endometriosis on Right Uterosacral Ligament (Note Clips in Posterior Cul-de-sac)
Figure 4. Close-up View of Mild Endometriosis
April | May 2007
Figure 5. Reperitonealized Clips at Appendectomy Site
Nursing for Women’s Health
203
was confirmed along the way…The patient was then placed in steep Trendelenburg. There were three clusters of surgical clips noted on the right side of the pelvis, two in the posterior cul-de-sac and one in the anterior cul-de-sac close to the uterus [see Figures 1 to 3]. These clusters of clips were peritonealized. They were not deep. There was also mild endometriosis along the right uterosacral ligament [see Figures 3 and 4]. There was no evidence of endometriosis on the ovaries, elsewhere in the pelvis, or the other area and fossa. The appendectomy site was within normal limits [see Figure 5]. The surgical clips were intact and there were no excessive adhesions. There was no other apparent cause for her pelvic pain….”
When faced with diagnostic challenges in the clinical setting, a systematic approach to assessment and intervention will ensure that even unanticipated outcomes will not be overlooked.
The postoperative course was uneventful. This woman has experienced a near complete resolution of her pelvic pain, both dysmenorrhea and dyspareunia, following surgery. Most likely, her pain was due to a combination of the endometriosis (a relatively common etiology) and the presence of foreign bodies (a relatively rare finding) within the pelvis. When faced with diagnostic challenges in the clinical setting, a systematic approach to assessment and intervention will ensure that even unanticipated outcomes will not be overlooked. While the endometriosis diagnosis was not entirely unanticipated, clearly the presence of a foreign body within the abdomen was a surprise. In hindsight, an x-ray or a computed tomography scan of the pelvis would have likely revealed the extraordinary clips. In addition to pelvic adhesions, suspicion of a foreign body should be included in the differential diagnosis when patients with pelvic pain have had previous pelvic surgery. NWH
pain. Gynecologic & Obstetric Investigation, 62(3), 121–130. Petta, C. A., Ferriani, R. A., Abrao, M. S., Hassan, D., Rosa, E., Silva, J. C., et al. (2005). Randomized clinical trail of a levonorgesterelreleasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Human Reproduction, 20(7), 1993–1998.
Get the Facts Information on endometriosis: Endometriosis Research Center
http://www.endocenter.org/ Medline Plus
http://www.nlm.nih.gov/medlineplus/ endometriosis.html Wikipedia
http://en.wikipedia.org/wiki/ Endometriosis Womenshealth.gov
http://www.4woman.gov/faq/ endomet.htm#b Information on foreign bodies: RadioGraphics
http://radiographics.rsnajnls.org/ cgi/content/full/23/3/731
References Allen, P. (2005, February 1). Pudendal nerve entrapment may be mistaken for IC, CPPS. Urology Times. Retrieved January 22, 2007, from http://www.urologytimes.com/urologytimes/article/articleDetail.jsp?id=147971 Centers for Disease Control and Prevention. (2004). Pelvic inflammatory disease—CDC Fact Sheet. Atlanta, GA: Department of Health and Human Services. Guo, S. W., & Wang, Y. (2006). The prevalence of endometriosis in women with chronic pelvic
204
Nursing for Women’s Health
Volume 11
Issue 2
Editor’s note: This marks the debut of “Solve This,” a new column in Nursing for Women’s Health that will present a case history of “clues” that readers can use to “solve” the case and determine the final outcome.
200
© 2007, AWHONN
The Case A 25-year-old G3P0030 woman presents for evaluation of pelvic pain described as central, deep and achy. Dysmenorrhea, which has been present since menarche at age 16, has resulted in numerous missed school days and several visits to the emergency room. In the past, pain was so severe that she actually “passed out.” Dyspareunia with deep penetration has been present for nearly three years. She reports cyclic diarrhea but denies any dysuria or dyschezia. Menstrual periods are somewhat irregular, but the interval never exceeds eight weeks; flow is described as normal. Her last menstrual period was one week ago. She denies any history of sexually transmitted infection. Following an elective pregnancy termination with dilatation and curettage several months ago, she has experienced constant
central pelvic pain. Current medications are limited to clonazepam for anxiety. Medical history reveals prior dysmenorrhea treatment with oral contraceptives pills, which were discontinued due to unbearable hot flashes. Nonsteroidal anti-inflammatory agents provided only minimal relief. A levonorgesterel-releasing intrauterine device (IUD) was removed after less than two months due to excessive cramping and spotting. A pelvic ultrasound report obtained just after an elective pregnancy termination two years ago raises questions about the presence of endometritis or possibly myometritis and notes the presence of nonspecific peritoneal fluid. She was subsequently treated with antibiotics without obvious sequelae. Surgical history is limited to a laparoscopic appendectomy three years ago. Physical examination reveals a welldeveloped, well-nourished female, who appears
Volume 11
Issue 2
her stated age. The abdomen is soft, nontender, with normal bowel sounds throughout and without hepatosplenomegaly or rebound tenderness. Groin lymph nodes are normal. Pelvic exam reveals normal female genitalia without lesions. The vaginal vault contains physiologic-appearing discharge. The uterus is normal sized; however, ten-
derness is noted with cervical motion. The adnexae are nontender without masses. Nodularity is not evident in the cul-de-sac; rectovaginal examination is negative. Based on the above information, what’s your diagnosis?
Sue A. Woodson, CNM, MSN, is a certified nurse midwife and a nurse practitioner in private practice at Charlottesville Gynecology Specialists in Charlottesville, VA.
Turn to page 202 for the answer
DOI: 10.1111/j.1751-486X.2007.00146.x
S O L V E
T H I S
Do You Have a Case to Share? Do you have clinical pearls to share based on actual patient care experience? Have you or your co-workers found yourselves intrigued or puzzled by a particular patient presentation or situation? Did this experience cause you to change your practice? Did you gain important clinical insight as a result of the experience?
If so, Nursing for Women’s Health would like to hear from you. We’re seeking case presentations for the “Solve This” column, in which you can share your experiences with colleagues. Each column will present a case and challenge readers to determine the diagnosis and develop an appropriate plan of care. The goal of this column is to highlight practical information, sharpen diagnostic skills and approaches and improve interpretation of diagnostic tests, images and so forth. All submissions should be based on actual clinical cases; however, all specific identifying data must be blinded. Case presentations should include pertinent history, physical examination findings and any photographs or graphics imperative for assessment, diagnosis or treatment. This may include, but is not limited to, FHM tracings, photographs or other visual aids. Visuals will be chosen based on their teaching value and seasonality to help recognize problems. We will provide you with a release form to gain permission to use patient information and visual aids. Submissions should include reference citations supporting the diagnosis and plan of care where appropriate. Practitioners in all areas of women’s health, obstetrics and newborn care are invited to submit cases.
Cases for “Solve This” column must be submitted at our online manuscript submission site,
Editorial Manager: http://nwh.edmgr.com. For questions e-mail to [email protected].
April | May 2007
Nursing for Women’s Health
201
Chronic Pelvic Pain: Can You Guess the Cause? (continued from page 201)
Chronic Pelvic Pain: A Conundrum
In this scenario, certain signs and symptoms can provide the alert practitioner with a means of culling out unlikely etiologies.
202
Few clinical presentations represent a more challenging conundrum to health care providers than chronic pelvic pain. The differential diagnoses are highly variable and numerous (see Box 1). By definition, chronic pelvic pain must be present intermittently or continuously in the pelvic area for at least six months. This is clearly the case in this patient, given that dysmenorrhea has persisted since menarche (primary dysmenorrhea) and dyspareunia has been present for nearly three years. Therefore, by definition, pathologies that result in acute pelvic pain can be ruled out; these include pregnancy-related complications, degenerating leiomyoma, appendicitis, ovarian torsion or cysts and urinary tract infection. In this scenario, certain signs and symptoms can provide the alert practitioner with a means of culling out unlikely etiologies. It’s doubtful that this particular woman has pudendal nerve entrapment because there is no report of pain alteration with sitting, lying down or standing (Allen, 2005). There is no mention of pain exacerbation with physical activity that would create a suspicion for musculoskeletal etiologies. The lack of urinary symptoms makes interstitial cystitis unlikely. Multiple pregnancy terminations, previous IUD use and a history of questionable endometritis/myometritis place this young woman at risk for pelvic inflammatory disease (PID) (Centers for Disease Control and Prevention, 2004). Cervical motion tenderness is a cardinal sign of PID; therefore, cervical and vaginal cultures were submitted for gonorrhea, chlamydia and “all vaginal pathogens.” All culture results were negative, and the patient remained afebrile. To discriminate among the remaining potential etiologies for her chronic pelvic pain, the patient was offered a trial of a gonadotropin-releasing hormone (GnRH) agonist (e.g., Lupron) to evaluate symptom response (Petta, 2005). GnRH agonists can be used to reveal symptom
Nursing for Women’s Health
response to a hypoestrogenic menopausal state, assisting in the ruling in or out of hormonally mediated factors, such as endometriosis. However, after consideration of her reaction to hot flashes from oral contraceptives, she declined a GnRH trial. At this point, the clinician was left with the following possibilities: endometriosis, which accounts for at least 33 percent of chronic pelvic pain in women (Guo, 2006); adenomyosis, a form of endometriosis involving the myometrium, which is frequently diagnosed only by pathological analysis after hysterectomy; pelvic adhesions, based on the history of laparoscopic abdominal surgery and possibly PID and, last, nongynecologic etiologies including diverticulitis or irritable bowel syndrome (also known as functional bowel syndrome) based on the cyclic diarrhea. Psychosomatic factors should be considered only after all other possibilities have been ruled out, unless there are compelling reasons to the contrary. Diagnostic laparoscopy was performed several weeks later due to chronic pelvic pain unresponsive to medical management. The operative report read in part as follows: The patient is taken to the operating room and placed in the modified dorsal lithotomy position where she was prepped and draped in the usual sterile fashion…. The … trocar was then inserted at a 45 degree angle where intra-abdominal placement
Box 1.
Potential Etiologies for Chronic Pelvic Pain Gastrointestinal pathologies adhesions, irritable bowel syndrome, diverticulitis Genitourinary pathologies adenomyosis, endometriosis, interstitial cystitis, pelvic inflammatory disease Musculoskeletal pathologies fibromyalgia Neurological pathologies pelvic nerve entrapment Pelvic congestion syndrome Psychosomatic factors
Volume 11
Issue 2
Figure 1. Dropped Clips in the Anterior Cul-de-sac
Figure 2. Close-up of Posterior Cul-de-sac Showing Two Clusters of Dropped Surgical Clips
Figure 3. Mild Endometriosis on Right Uterosacral Ligament (Note Clips in Posterior Cul-de-sac)
Figure 4. Close-up View of Mild Endometriosis
April | May 2007
Figure 5. Reperitonealized Clips at Appendectomy Site
Nursing for Women’s Health
203
was confirmed along the way…The patient was then placed in steep Trendelenburg. There were three clusters of surgical clips noted on the right side of the pelvis, two in the posterior cul-de-sac and one in the anterior cul-de-sac close to the uterus [see Figures 1 to 3]. These clusters of clips were peritonealized. They were not deep. There was also mild endometriosis along the right uterosacral ligament [see Figures 3 and 4]. There was no evidence of endometriosis on the ovaries, elsewhere in the pelvis, or the other area and fossa. The appendectomy site was within normal limits [see Figure 5]. The surgical clips were intact and there were no excessive adhesions. There was no other apparent cause for her pelvic pain….”
When faced with diagnostic challenges in the clinical setting, a systematic approach to assessment and intervention will ensure that even unanticipated outcomes will not be overlooked.
The postoperative course was uneventful. This woman has experienced a near complete resolution of her pelvic pain, both dysmenorrhea and dyspareunia, following surgery. Most likely, her pain was due to a combination of the endometriosis (a relatively common etiology) and the presence of foreign bodies (a relatively rare finding) within the pelvis. When faced with diagnostic challenges in the clinical setting, a systematic approach to assessment and intervention will ensure that even unanticipated outcomes will not be overlooked. While the endometriosis diagnosis was not entirely unanticipated, clearly the presence of a foreign body within the abdomen was a surprise. In hindsight, an x-ray or a computed tomography scan of the pelvis would have likely revealed the extraordinary clips. In addition to pelvic adhesions, suspicion of a foreign body should be included in the differential diagnosis when patients with pelvic pain have had previous pelvic surgery. NWH
pain. Gynecologic & Obstetric Investigation, 62(3), 121–130. Petta, C. A., Ferriani, R. A., Abrao, M. S., Hassan, D., Rosa, E., Silva, J. C., et al. (2005). Randomized clinical trail of a levonorgesterelreleasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Human Reproduction, 20(7), 1993–1998.
Get the Facts Information on endometriosis: Endometriosis Research Center
http://www.endocenter.org/ Medline Plus
http://www.nlm.nih.gov/medlineplus/ endometriosis.html Wikipedia
http://en.wikipedia.org/wiki/ Endometriosis Womenshealth.gov
http://www.4woman.gov/faq/ endomet.htm#b Information on foreign bodies: RadioGraphics
http://radiographics.rsnajnls.org/ cgi/content/full/23/3/731
References Allen, P. (2005, February 1). Pudendal nerve entrapment may be mistaken for IC, CPPS. Urology Times. Retrieved January 22, 2007, from http://www.urologytimes.com/urologytimes/article/articleDetail.jsp?id=147971 Centers for Disease Control and Prevention. (2004). Pelvic inflammatory disease—CDC Fact Sheet. Atlanta, GA: Department of Health and Human Services. Guo, S. W., & Wang, Y. (2006). The prevalence of endometriosis in women with chronic pelvic
204
Nursing for Women’s Health
Volume 11
Issue 2