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At the heart of general practice since 1960

GPs have a vital role in managing pelvic pain

How should patients with pelvic pain be assessed?
What are the common causes of pelvic pain?
What are the red flags for urgent referral?

How should patients with pelvic pain be assessed?
What are the common causes of pelvic pain?
What are the red flags for urgent referral?

Pelvic pain is a common symptom that accounts for a large proportion of consultations in primary care. There is a steady monthly incidence and prevalence of 1.58/1,000 and 21.5/1,000 respectively.1

Chronic pelvic pain presents as frequently as migraine or low back pain and needs to be managed appropriately and effectively.1,2

An algorithm for the suggested management of chronic pelvic pain is attached (see figure 2).

Pelvic pain is not a single entity. It encompasses both acute and chronic conditions that may have different origins and management.

Pain is described by the International Association for the Study of Pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage'. 3

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 is gradual in onset. It may be constant or intermittent and has usually been present for more than 6 months. Although in some cases it may have been precipitated by acute tissue damage, there may not always be evidence of this. Chronic pelvic pain is not associated with pregnancy and is not necessarily associated with menses or intercourse either. Major changes are seen in the nerve pathways and visceral function and pain perception may be altered. Pain as a result of changes in the nerve itself, i.e. neuropathic pain, is often described as burning, aching or shooting.

Generally acute pain is easier to manage as symptoms and signs can be elicited from the patient and treatment results in resolution.

Side-effects, complications or a delay in referral in the acute setting can have a negative impact on the patient's quality of life and in some circumstances result in the development of chronic pelvic pain.

Prompt diagnosis and referral of acute and chronic pelvic pain not only improves the patient's quality of life, but also enables NHS resources to be used appropriately and reduces the economic burden.4

Chronic pelvic pain carries a heavier social and economic burden, through lost working days. One large retrospective cohort study in primary care showed that despite a follow up of 6 years, 60% of patients with chronic pelvic pain had not been referred to a specialist.5 Interestingly, where referrals were made, the most common diagnosis was irritable bowel syndrome (IBS) with a gynaecological cause identified in only 28% of cases.

History
GPs play a vital role in the management of patients presenting with acute pelvic pain. There can be initial uncertainty in the differential diagnosis of lower abdominal pain, especially if the patient is clinically compromised, because of overlapping symptoms and signs, between different specialties. A careful history and examination will shed light on the cause of the pain and there are simple bedside tests that can aid in the differential diagnosis.

It is useful to remember that a patient is far more likely to have a common condition with an atypical presentation than a rare disorder.

It is vital to take a thorough history and no system should be overlooked. In order to achieve this, direct questions need to be asked about menstruation, bladder function, bowel movement and psychological symptoms. Directed questions to explore the woman's own ideas about the origin of the pain will assist the doctor-patient relationship and compliance with treatment. It may also be appropriate to enquire about the patient's sexual history and whether there is 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.

Examination and investigations

In primary care, simple observation and measurement of temperature, pulse and blood pressure can assist in assessing the need for urgent admission. Urinalysis and a pregnancy test are essential investigations.

Women presenting with symptoms suggestive of pelvic inflammatory disease (PID) should have swabs taken. Endocervical swabs for nucleic acid amplification testing (NAATS) are the most sensitive for the detection of chlamydia and gonorrhoea. Treatment should be started pending results if there is clinical suspicion of PID.

Symptoms should be reviewed after 48-72 hours and referral for admission reconsidered if there has been no significant improvement.

It is recommended that opportunistic screening for chlamydia should be offered and performed for all women under the age of 25 years.

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 suggestive of PID, ovarian cyst etc. Cervical excitation is the equivalent of rebound tenderness. A rectal examination is useful if gastrointestinal pathology is suspected.

Providing there are no abnormal findings on pelvic examination then empirical treatment of irritable bowel syndrome with a trial of antispasmodics and diet modification can reduce referrals to the gastroenterology department.

If the pelvic examination is abnormal, the most appropriate investigation is a pelvic ultrasound scan. Ultrasound is able to identify pelvic masses i.e. fibroids, ovarian or tubal masses and any free fluid. It should be remembered that a normal scan does not exclude a diagnosis of endometriosis or adhesions.

If the ultrasound scan is normal, women with cyclical pain can be offered a therapeutic trial of treatment using the combined oral contraceptive pill (COCP) for 3-6 months before considering referral for a diagnostic laparoscopy. The COCP can be an effective treatment for pain associated with endometriosis and treatment therefore may be a useful diagnostic tool. In a randomised trial comparing the COCP with a gonadotrophin releasing hormone (GnRH) agonist, the COCP appeared to be as effective in terms of pain relief for the treatment of endometriosis.6 In addition, it provides an option for long-term treatment.

Other treatment options include a 3-month trial of progestogens (such as medroxyprogesterone 10 mg td) or Depo-Provera (150 mg im every 12 weeks). The progestogen-only pill is less reliable in producing ovarian suppression, but could be considered if oestrogen were contraindicated. The levonorgestrel-releasing IUS could also be considered. A Cochrane review found it produced a significant reduction in the recurrence of painful periods in women who have had surgery for endometriosis.7

Management strategies can be complex, especially when there is no pathological cause identified and signs and symptoms may not correlate with the clinical findings.

In approximately one third of patients undergoing diagnostic laparoscopy, findings will be negative. The explanation is thought to be related to the complex pattern of neuromodulation from visceral organs transmitting signals to the brain. If the signal process is altered, it can lead to a sensation of pain even though there is no pathology. Patients that fall into this category should be managed by a multidisciplinary team, involving pain specialists and psychologists.

Common conditions presenting with acute and chronic pelvic pain are listed in tables 1 and 2, respectively, attached.

Ectopic pregnancy

Ectopic pregnancy classically presents with six weeks' amenorrhoea or more commonly, abnormal vaginal bleeding with a positive pregnancy test, unilateral pain and/or bleeding. There may be associated gastrointestinal symptoms such as vomiting or painful defecation. Vaginal examination is not mandatory. The patient should be referred urgently to the gynaecology department.

Pelvic inflammatory disease
Bilateral lower abdominal pain, abnormal vaginal discharge and fever (greater than 38oC) are the hallmarks of PID. There may be abnormal vaginal bleeding (intermenstrual, postcoital or breakthrough bleeding) or deep dyspareunia. Cervical motion tenderness and adnexal tenderness may be present on vaginal examination. Endocervical swabs for nucleic acid amplification testing (NAATS) are the most sensitive for the diagnosis of chlamydia and gonorrhoea. Treatment should be started, while swab results are awaited, with oral ofloxacin 400mg bd plus oral metronidazole 400mg bd for 14 days. Partners should also be referred for investigation and treatment.

Consider admission to hospital under the care of a gynaecologist in the following situations:
• a surgical emergency cannot be excluded
• clinically severe disease or tubo-ovarian abscess
• there is vomiting so that oral antibiotics cannot be tolerated

The patient should be reviewed after 72 hours and referred to a gynaecologist if there has been no clinical improvement.

Ovarian cyst accident
This is characterised by sudden onset of severe unilateral pain often described as ‘worse than labour'. The pain may radiate to the ipsilateral loin or leg. With torsion, the pain may disappear as quickly as it started if the pedicle untorts. There may be nausea and vomiting. Urgent ultrasound scan as an outpatient is recommended or referral to the outpatient gynaecology department depending on the clinical presentation.

Endometriosis
Premenstrual pain, dysmenorrhoea, deep dyspareunia and chronic pelvic pain are the cardinal symptoms of endometriosis. Associated symptoms include subfertility, bladder and bowel symptoms. Endometriosis is a chronic condition that requires specialist input. Ultrasound is a useful adjunct on referral.

Irritable bowel syndrome
IBS is characterised by a 3-month history of continuous or recurrent abdominal pain, associated with at least two of the following, pain relieved by defecation and/or change in frequency of stool and/or a change in the appearance or form of stool.

Symptoms such as abdominal bloating and the passage of mucus are suggestive of IBS. Extraintestinal symptoms such as lethargy, backache, urinary frequency and dyspareunia may also occur. Providing there are no abnormal findings on pelvic examination then empirical treatment with a trial of antispasmodics and diet modification can reduce referrals.

Interstitial cystitis
This condition is characterised by urinary frequency, urgency and pelvic pain. It is a diagnosis of exclusion. Cystoscopy allows exclusion of bladder pathology. It may be worth trying empirical treatment with antispasmodics before specialist referral.

Neuropathic pain
This is non-cyclical pain described as burning or shooting, worse on movement. If it is present in conjunction with a normal pelvic examination, the patient should be referred to a physiotherapist or pain specialist.

Red flag symptoms
If a patient presents to primary care with any of the symptoms or signs listed in table 3, attached, further investigation is warranted, and specialist referral should be made.

Conclusion
GPs play a vital role in the diagnosis and management of pelvic pain. The site and nature of the pain are useful clues in the diagnosis and can aid referral pathways. Initial management can be commenced in primary care before referral if appropriate and a review arranged within 72 hours. Patients then need to be referred if there is no improvement.

Authors

Mrs Claire Park
MB BS MRCOG
registrar in obstetrics and gynaecology

Mrs Caroline Overton
MB BS MD FRCOG
consultant obstetrician and gynaecologist subspecialist in reproductive medicine and surgery
St Michael's University Hospital, Bristol

Table 1: Common causes of acute pelvic pain Table 2: Common causes of chronic pelvic pain Table 3: Red flag symptoms Key points Useful information

Endometriosis UK
Tel: 020 7222 2781
www.endometriosis-uk.org

NHS Choices
www.nhs.uk

Figure 2: Suggested management of chronic pelvic pain GPs have a vital role in managing pelvic pain

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