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Five-minute Practitioner: March 2009

Only got five minutes? Then just read these key points on: rheumatoid arthritis, pelvic pain and infertility

Only got five minutes? Then just read these key points on: rheumatoid arthritis, pelvic pain and infertility

Rheumatoid arthritis
The management of rheumatoid arthritis (RA) has undergone major changes over the past decade. The old paradigm of ‘start low, go slow' has been rejected and a new therapeutic approach has been developed with early, intensive intervention in all patients with RA or suspected RA.

Furthermore, in patients with definite RA, regular review with tight control using predefined disease activity measures has been found to improve outcomes.

With the evolving concept of early inflammatory arthritis or very early RA, the ARA criteria have become inadequate in the clinic and nodules are usually late features and rheumatoid factor (RF) and erosions may be absent at the time of diagnosis. NICE has taken the bold, yet progressive, step of accepting a clinical diagnosis of RA as being more important than the ARA criteria.

Any patient with suspected persistent synovitis of undetermined cause should be referred to a specialist.

Urgent referral is warranted for patients with: involvement of the small joints of the hands or feet; more than one joint affected or a delay of 3 months or longer between onset of symptoms and seeking advice.

Patients with new or possible RA should be investigated for the presence of raised inflammatory markers (ESR and CRP) and rheumatoid factor (RF) by their GP. Further investigations can be undertaken once referral has been made to the specialist.

Testing for RF may be misleading as it is non-specific, especially in low titres in elderly people. However, when the index of suspicion remains high for RA and the RF is negative, testing for anti-CCP antibodies (which are more specific for RA and present in up to 40% of RA patients who are RF-ve in early disease) should be undertaken.

Methotrexate should be used as the anchor drug in combination with another DMARD such as hydroxychloroquine or sulphasalazine unless contraindicated.

Objective measures of disease need to be incorporated into daily practice. One such tool is the disease activity score (DAS) comprising a composite of swollen joint count, tender joint count, VAS and ESR or CRP.

Pelvic pain

Acute pelvic pain is generally classified as lower abdominal pain of rapid onset, progressive in nature with a short duration. It reflects fresh tissue damage and resolves as healing occurs.

Chronic pelvic pain presents as frequently as migraine or low back pain. It is gradual in onset, may be constant or intermittent, and has usually been present for > 6 months. Chronic pelvic pain is not associated with pregnancy and is not necessarily associated with menses or intercourse.

It is vital to take a thorough history and no system should be overlooked. Direct questions need to be asked about menstruation, bladder function, bowel movement and psychological symptoms. Directed questions to explore the woman's ideas about the origin of the pain will assist the doctor-patient relationship and compliance. It may be appropriate to enquire about sexual history and any history of abuse.

Classically, cyclical pain is gynaecological in origin, until proven otherwise. However, dense adhesions from previous surgery or infection or IBS may also have a cyclical pattern.

Observation and measurement of temperature, pulse and BP can assist in assessing the need for urgent admission. Urinalysis and a pregnancy test are essential. Women with symptoms suggestive of PID should have swabs taken, and treatment started pending results.

An abdominal examination will help determine the severity of the pain and identify palpable masses. A bimanual pelvic examination will elicit tenderness, fixation and pelvic masses. A rectal examination is useful if GI pathology is suspected. If the pelvic examination is abnormal, the most appropriate investigation is ultrasound. However, a normal scan does not exclude a diagnosis of endometriosis or adhesions.

Infertility
One in seven couples are diagnosed as infertile. A detailed history should be taken for the woman and the man, including duration of infertility, coital problems, previous conceptions, and frequency of intercourse.

For women assessment should include: a physical examination, menstrual history, general health, including BMI, and factors which can affect fertility e.g. STIs and smoking.

For men, general health, testis size and obvious abnormalities of the reproductive system should be noted. Sperm dysfunction, the most common cause of infertility, affects 1 in 15 men.

Intercourse every 2-3 days optimises the chance of pregnancy. About 85% of couples will conceive within 12 months. If conception has not occurred after 1 year (less in women over 35), offer investigations including assessment of ovulation and/or semen.

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