Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Chronic Pelvic Pain
R10.2 Pelvic and perineal pain
I. DEFINITION
Pain in any region of the pelvis that is long term and unresponsive to treatment of symptoms and/or undiagnosed
II. ETIOLOGY
A. 50% enigmatic
B. 25% endometriosis
C. 25% other pathology, including subacute and chronic salpingitis
III. HISTORY
A. What the patient may present with
1. Chronic pelvic pain with or without menstrual exacerbation
2. Dysmenorrhea
3. Dyspareunia
4. Dyschezia
5. Chronicity of symptoms
6. Absence of chills, fever associated with pain
7. Nausea, vomiting, and/or diarrhea associated with pain
8. Chronic constipation
9. Chronic intermittent cramping
IV. ADDITIONAL INFORMATION TO BE CONSIDERED
A. Any symptoms of chronic bowel disease, any previous assessments for such, and results
B. Any symptoms of chronic urinary tract infection, urinary tract anomaly, kidney disease
C. Location of pain, duration, exacerbation, and what precedes increased symptoms
D. Description of pain: sharp, dull, aching, cramping, intermittent, continuous
E. Pain relief measures; what helps; use of over-the-counter (OTC) analgesics
F. Any weight gain or loss
G. Symptoms that accompany pain
H. Sexual history, including sexual responsiveness; STIs, PID; contr- aceptive history, including IUD (IUCD)
I. Surgical history, including hernia repair
J. Medical history
K. Pelvic surgery, including laparoscopy, laparotomy, tubal ligation, hysterectomy, repair of cystocele, rectocele, urethrocele, appendec- tomy, myomectomy, cervical cone biopsy, loop electrosurgical exci- sion procedure (LEEP), also called LOOP excision (surgical excision with a small wire loop)
L. Menstrual history
M. Pregnancy history, including extrauterine pregnancy or pregnancies, infertility assessments and/or treatments
N. Psychosocial history, including life stressors, major life changes, and timing in relation to onset of symptoms; depression, anxiety disorder, personality disorder
O. History of incest, other sexual assault, or abuse
V. PHYSICAL EXAMINATION
A. Vital signs as appropriate
B. Abdominal examination
1. Bowel sounds: normal, hypoactive or hyperactive, sluggish, absent, adventitious, bruits
2. Lower abdominal tenderness; sites of acute, dull pain elicited on superficial and/or deep palpation
3. Guarding
4. Rebound tenderness
5. Scars
6. Distention, asymmetry
7. Patient’s perception of pain location
8. On percussion, liver, spleen enlarged, bladder distended
9. Organomegaly, masses, hernias
C. Vaginal examination
1. Examine cervix for discharge
2. Examine vagina for masses, lesions, discharge, unusual odor, color
D. Bimanual examination
1. Examine cervix for cervical motion tenderness
2. Examine uterus for tenderness, masses, shape, size, consistency
3. Examine adnexa for ovarian shape, size, tenderness, masses, other adnexal masses or tenderness
E. Rectal examination
1. Pain, tenderness
2. Masses
3. Melena
4. Rectovaginal masses, fistulas, adhesions
5. Rectocele
F. Elicit psoas sign; perform obturator maneuver
VI. LABORATORY EXAMINATION
A. Cultures as indicated by history, physical findings
B. CBC/differential
C. Sedimentation rate, C-reactive protein
D. Urinary tract infection screen
E. Pregnancy test
F. Ultrasound evaluation based on pelvic examination
G. Consider consultation for CT scan and/or MRI if pelvic examination is abnormal
H. Consider psychological testing
I. Hormone testing, including TSH
J. Hysterosalpingography (HSG)
K. Barium enema, upper GI
L. Colonoscopy
M. CA-125
VII. DIFFERENTIAL DIAGNOSIS
A. Uterine
1. Dysmenorrhea (primary or secondary)
2. Adenomyosis
3. Leiomyomata
4. Positional (prolapse)
5. Pelvic congestion
B. Adnexal
1. Adhesive disease (infection, postsurgical)
2. Neoplasm
3. Functional ovarian cysts (Mittelschmerz)
4. Endometriosis
C. Peritoneal
1. Endometriosis
2. Adhesive disease
3. Adenomyosis—cells that normally line the uterus invade the myometrium
D. Gastrointestinal
1. Irritable bowel syndrome
2. Other bowel disease (e.g., Crohn’s disease, inflammatory)
E. Urinary
F. Musculoskeletal
G. Psychogenic (e.g., sexual abuse, rape)
H. Congenital, anatomical
I. Neurologic (neuroma)
J. Infections
VIII. CONSULTATION/REFERRAL
A. For laparoscopic diagnostic examination
B. For medical evaluation of suspected GI, GU conditions as indicated by history and physical examination
C. For pelvic venography
D. To confirm a suspected diagnosis and initiate treatment as coman- agers of care
E. For psychological evaluation
F. For ultrasound, MRI
IX. TREATMENT
A. Endometriosis: pain-only treatment; lowers estrogen
1. Create a pseudomenopause with Danocrine 200 to 800 mg orally twice a day for 6 months or gonadotropin-releasing hormone (GnRH) analogues for 3 to 6 months or leuprolide acetate (Lupron Depot) per protocol
2. Continuous monophasic oral contraceptives—no pregnancy plans—oral contraceptive pill (OCP), patch, ring, nonsteroidal anti- inflammatory drugs (NSAIDs)
B. Other pathologic causes
1. Diagnose and treat cause according to established guidelines (such as salpingitis, trauma from sexual assault, incest or rape, childbirth)
C. Enigmatic pelvic pain
1. Follow-up with diagnostic laparoscopy as appropriate for any findings
2. Multidisciplinary approach to pain management
D. Consideration of empiric therapy
1. Antidepressant
2. GnRH agonist
3. Musculoskeletal relaxant
X. FOLLOW-UP
A. As appropriate for diagnosis and treatment
B. As desired by patient if no definitive cause is found and palliative treatments are suggested
C. If symptoms continue, introduce the team approach.
1. Mental health care specialist
2. Physical therapist
3. Nutritionist
4. Urogynecologist
5. Gastroenterologist
See Bibliographies.
Websites: www.mayoclinic.com/health/chronic-pelvic-pain/DS00571; women
.webmd.com/endometriosis/endometriosis-treatment-overview