Specialists and GPSIs offer their advice on managing five tricky pain presentations in primary care
1. Breast pain
Breast pain can be categorised into one of three types: cyclic, noncyclic, or nonbreast (musculoskeletal).
Diagnosis
Differentiating between breast and musculoskeletal pain can be difficult; the best way is to ask the woman how she perceives the pain and show where she feels it originates.
Most cases are cyclic mastalgia – a diffuse, bilateral tenderness that occurs during the luteal phase of the menstrual cycle predominantly in women in their 30s and 40s and is uncommon in postmenopausal women. The pain is sometimes described as heaviness, soreness, or an aching sensation occurring just before menses that improves as the cycle continues.
Non-cyclic mastalgia pain tends to be sharp, burning, localised and unilateral. This condition tends to affect an older population of women in their 40s and 50s and can occur postmenopause, unlike cyclic mastalgia. The cause is unknown.
Examination and investigations
Physical examination of the breasts, regional lymph nodes, chest wall, cervical and thoracic spine, and upper extremities should be performed, in both the supine and seated positions to differentiate chest wall versus breast pain.
A breast pain diary can help differentiate cyclical and non-cyclical mastalgia. The only laboratory test that should be performed is a urine pregnancy test. Serum hormone assays are not useful in diagnosis of mastalgia or in managing the condition.
Management
The initial treatment for both cyclic and non-cyclic mastalgia is to offer reassurance – 70% to 85% of cases are self-limiting.
Well-fitted bras and sports bras may limit breast movement and improve mastalgia. Lifestyle changes, such as smoking cessation and caffeine avoidance, have been recommended, but there is little evidence.
Relaxation therapy was found to reduce mastalgia symptoms compared with a control group in one study1 and massage with ice or heat may also help.2
If conservative treatment does not help and no underlying pathology is identified there are a number of treatment options. Women with non-cyclic mastalgia may not respond to medication as well as those with the cyclical form but the same treatments can be used in both:
• Danazol, a synthetic androgen, is licensed for severe pain and tenderness in benign fibrocystic breast disease which has not responded to other treatment. GPs inexperienced in its use may wish to refer to a consultant before prescribing. Adverse effects (commonly nausea, dizziness, rash, backache) can be minimised by reducing the dose to 100mg from an initial starting dose of 300mg daily, and restricting treatment to two weeks preceding menstruation. Non-hormonal contraception is essential as danazol has androgenic effects.
• Tamoxifen is not licensed for mastalgia in the UK but one trial suggested its benefits lasted longer than those of danazol.3 Its use should be limited to six months under specialist care because of the high incidence of adverse effects.
• Goserelin is occasionally used for
severe refractory mastalgia. Side-effects include vaginal dryness, hot flushes, decreased libido and irritability. These can be reduced by co-prescribing tibolone or HRT.
• Bromocriptine is rarely used because of frequent and intolerable adverse effects (mainly nausea, dizziness, postural hypotension, constipation).
Other medications may be useful as sole or adjunctive therapy. Oral or topical NSAIDs can be considered for pain control. Topical NSAIDS have been shown to be effective and have similar therapeutic responses to evening primrose oil.
Patients with refractory mastalgia that does not respond to conservative treatment and medications may be candidates for surgery. A few cases have improved with bilateral mastectomy and breast reconstruction but surgical management should remain a last resort.
Dr Susan Lloyd-Jones is a GPSI in women's health in Newport, Wales
Competing interests None declared
2. Persistent vulval pain
Vulval pain syndromes occur at any age throughout adult life. Cases presenting in childhood have been raised anecdotally although not yet formally reported in the literature. The diagnosis is usually confined to white women and is seldom made in developing countries.
Diagnosis
Vulval pain syndrome is a diagnosis of exclusion based on a typical history, absence of vulval pathology and, in localised vulval dysaesthesia, the presence of touch tenderness.
There are two categories, summarised below. In both, the vulva appear normal. Some women will present with features of both types.
• Generalized vulval dysaesthesia:
– can occur in women of any age
– is characterised by chronic discomfort – burning, stinging, irritation or a feeling of rawness
– is not usually worse during intercourse
– may be worse at the end of the day.
• Localised vulval dysaesthesia – there are three types.
a) Vestibulodynia is the most common variant and:
• tends to occur in young sexually active women, usually pre-menopausal
• there is superficial dyspareunia
• insertion of a tampon or riding a bicycle provokes pain
• pain may persist after intercourse
• there is no pain at other times
b) Clitoridynia
c) Other localised forms of vulval dysaesthesia
Most patients will improve or fully recover – with one study finding 50% of patients recovered within 12 months of diagnosis.4 A small minority of patients will have intractable disease. Others will recover and relapse but if they have previously responded to treatment they will probably do so again.
Examination and investigations
Typically the history is long, sometimes years. Commonly, it presents as dyspareunia. The vulva usually looks normal. In generalised vulval dysaesthesia, touching the affected area with, for example, a cotton bud, does not exacerbate symptoms. In localised vulval dysaesthesia, patients are symptom free until the vulva is touched. Commonly the pain is in the vestibule but in some women the whole labia minora is affected. The distribution may also be asymmetrical.
There are no specific investigations to confirm a vulval pain syndrome.
Biopsy and/or screening for infection is indicated when the vulva looks abnormal. But it is worth remembering that vulval pain and specific skin disease may coexist. Formal neurological assessment may be useful in women with symptoms or signs supporting a neurological diagnosis.
Management
Most specialists favour a combined medical and psychosexual/psychological approach.
Drug therapy
Topical agents such as moisturising creams and steroids may soothe but rarely produce any sustained improvement in symptoms. Topical local anaesthetics work for some patients – but normally temporarily.
Low-dose tricyclic antidepressants are the mainstay of treatment – for their analgesic and possibly anxiolytic effects. Start with low-dose amitriptyline or impramine (10mg at night), increasing after one month to 25mg. Patients who are likely to respond do so at doses of 40-75mg, though it is worth trying doses of up to 125mg. Those who respond should remain on a maintenance regimen for three to six months or longer. Try reducing the dose after a few months of symptom relief.
Psychosexual and psychological management
Most women, especially those with localised vulval dysaesthesia, will suffer impaired sexual function, commonly loss of desire and avoidance of sex. Vaginismus can occur in localised vulval dysaesthesia, compounding the pain associated with sexual intercourse. Psychosexual approaches may help, including an explanation of how pain can be provoked, as well as the effects of muscles contracting, which may worsen the pain.
Practical hints include:
• the use of lubrication
• pelvic floor exercises
• positional advice showing how penetration can be achieved with minimal discomfort.
In some cases, especially those of generalised vulval dysaesthesia, a psychological assessment may help both in providing an overview of the patient and in assisting her to develop coping strategies.
The management of non-responders is difficult but anecdotal reports suggest gabapentin may help. Some have suggested surgical resection of the vestibule for intractable localised vulval dysaesthesia, but there is no good evidence on efficacy and many patients relapse.
Dr Susan Lloyd-Jones is a GPSI in women's health in Newport, Wales
Competing interests None declared
3. Recurrent abdominal pain in children
Recurrent abdominal pain is a common problem in school-age children, with prevalence rates of 10% in an unselected group of children. An organic cause is identified in fewer than 10% of these.
Diagnosis
The typical features of functional abdominal pain are:
• age 4-14 years
• periumbilical
• difficult for the patient to describe
• unrelated to food
• interrupts normal activity
• history of clustering of episodes.
It has been suggested that the further the site of the abdominal pain is from the umbilicus, the more likely there is to be an organic cause. Look for these red flags:
• Pain localised to the epigastrium and which wakes the child. This is a pointer to gastritis or peptic ulcer disease. Pain radiating to the back might suggest pancreatitis.
• Vomiting, particularly if bile stained, should warn of possible malrotation.
• Rectal bleeding may indicate inflammatory bowel disease or Meckel's diverticulum.
• Co-existent diarrhoea may be seen in irritable bowel syndrome and dietary intolerance, as well as parasitic infection.
• Constitutional symptoms such as fever, rash and arthralgia might suggest inflammatory bowel disease.
• Short stature, weight loss and finger clubbing can be presenting features of Crohn's disease or coeliac disease.
• The most common cause of an abdominal mass is faeces associated with constipation.
Investigations
Indiscriminate use of investigations should be avoided but suggested first lines are FBC, urine culture, ESR, CRP, U&E and coeliac disease serology. Second-line investigations should be requested only on the basis of specific findings on history or examination, or on results from first-line tests.
Management
If no organic disease – such as IBS, IBD, coeliac disease or abdominal migraine – is found it's better to try to make a positive diagnosis of functional abdominal pain rather than use it as a ‘catch-all' term for abdominal pain in which all investigations are negative.
There is a general consensus that the pain in functional abdominal pain is genuine, and that there is an underlying pathogenesis involving gastrointestinal dysmotility or visceral hypersensitivity.
It has equal incidence in males and females below the age of nine years, but above this age it is more common in females.
Aggravating factors include stress and anxiety. In girls, there is an association with anxiety disorders and in boys with oppositional-defiant disorder and attention-deficit hyperactivity disorder.
Girls with functional abdominal pain may be at higher risk of developing irritable bowel syndrome in adolescence and young adulthood5 and there is evidence to suggest that children with recurrent abdominal pain may be at increased risk of psychiatric problems in later life.6
Aggressive investigation should be avoided other than the first-line investigations, which offer some reassurance.
After that, an explanation of the syndrome, emphasising the genuine nature of the pain, the role of aggravating factors and the lack of physical sequelae are often enough to reassure the parents and patient, and in many children the symptoms resolve quickly after their outpatient appointment.
If specific aggravating emotional or psychological factors are identified, a referral to clinical psychology may be indicated.
Dr Mike McKay is a consultant paediatrician for Lothian Health Board.
Competing interests None declared
4. Chronic scrotal pain
Chronic scrotal pain is defined variously as:
• intermittent or constant pain of unknown cause lasting at least three months
• or a continuous or intermittent pain that can be unilateral or bilateral and lasts for a minimum of three months
• or pain lasting at least six months.
Diagnosis
The pathophysiology of chronic scrotal pain is not well understood but it may result from a variety of causes including infection, malignancy, hernia, scrotal pathology, trauma or referred pain. It is idiopathic in 25% of cases.
History is not often useful in finding a cause of chronic pain.
Examination and investigations
Examine the scrotum to identify any specific areas of pain. It is important to perform a digital rectal examination of the prostate and to check the integrity of the pelvis and spine. Urinalysis should be performed. Ultrasound examination should include the upper urinary tracts, bladder and prostate, although in most cases ultrasound serves only to reassure both patient and surgeon that no significant physical cause is to blame.
If no diagnosis is apparent, MRI or CT should be considered, although these are best considered after urology referral.
Management
Management options in primary care are limited. Measures that have been recommended include modification of any postural cause, use of long-term (at least one month) NSAIDs, antibiotic treatment, or a trial of low-dose antidepressants – especially amitryptiline. But the evidence in favour of these approaches is scant.
Should these measures fail, a multidisciplinary approach via the local pain clinic may be of value. TENS may give some relief.
Local anaesthetic blockade of the spermatic cord can lead to protracted relief, although some patients may need repeated blocks. Success has also been reported for transrectal ultrasound-guided blockade of the pelvic plexus.
If these fail, surgery may be required. Initial techniques include epididymectomy on the affected side, although this is best reserved when the pain is localised to the epididymis. Some studies show 90% of patients will require orchidectomy to relieve the pain. So orchidectomy may be preferred from the outset. But other studies suggest some patients continue to experience significant pain despite orchidectomy so many surgeons choose to avoid this altogether. A more recent advance is microsurgical denervation of the spermatic cord.
Mr Chris Dawson is a consultant urologist at the Edith Cavell Hospital, Peterborough
Competing interests None declared
5. Spinal compression fractures
These are common in an elderly population and there is often no history of injury or a minimal injury. They are the most common type of osteoporotic fracture, particularly in women, but are often missed.
Diagnosis
As a general rule, spinal compression fractures should be suspected in anyone over 50 with a sudden onset of back pain. After a single spinal fracture, the risk of a second is increased three to five times, because of the patient's altered weight distribution.7
The most common presentation is with back pain, although a kyphotic deformity may also be seen. Neurological symptoms can be seen but are thankfully rare. The most common site is in the thoracic spine, particularly in the lower vertebrae of that section (T10-T12).
Examination and investigations
Physical examination may show kyphosis. There is also tenderness over the injured vertebrae. A spine X-ray shows at least one vertebra that is shorter than the others.
Management
Treatment usually consists of pain control measures with NSAIDS and simple analgesics. Bed rest, while a useful measure for pain control, can exacerbate osteoporosis. Back braces have a limited role to play.
Most patients suffer with pain for 8 to 12 weeks before settling down. Balloon kyphoplasty can be useful, both for pain control and to restore vertrebral height.8 Future fractures are always a possibility. Prevention is better than cure and so treatments for osteoporosis are to be encouraged.
Mr Sean Curry is consultant orthopaedic surgeon at the London Orthopaedic Clinic www.londonorthopaedic.com.
Competing interests None declared
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