– May/June 1996-p Whag t Are the Guidelines for Treating Pelvic and A Nude Nude dominal Pain? – May/June 1996-p Whag t Are the Guidelines for Treating Pelvic and A Nude Nude dominal Pain?John S. McDonald, MD
Department editor's note: This is the fourth article in a series on pelvic and abdominal pain problems in women. We have discussed the various diagnoses, the importance of a differential diagnosis list, and methods related to determining the diagnosis case illustrations of acute and chronic conditions. We have also considered the psychological implicinspecifications of chronic pelvic pain. This article focuses on the various treatment modalities available for gaining relief from the acute and chronic pelvic and abdominal pain problems that many women suffer.
In the first two articles (APS Bulletin, 5(4), p. 12; 5(6), p. 20) of this series, I discussed the reasons that gynecological patients with acute and chronic pain often receive many different diagnoses, all to no avail and without satisfactory management of the pain. The various guidelines in this article on treating pelvic and abdominal pain are not to be interpreted as the only methods of satisfactory treatment for a given disease process. However, all of the suggested treatment methods have either proved satisfactory in my experience or are commonly accepted.
The initial treatment or management steps for a patient with acute pain problems are important in both diagnosis and determination of the best treatment. The first step is a careful and complete evaluation of the problem that the patient complains of in the initial visit. The last step is a follow-up evaluation of the patient who is no longer in severe pain, to determine the effectiveness of the therapy plan and its impact on the patient's life. In common terms, this is the outcome of the treatment; it is very important in today's expectations of medical care.
There are at least 10 stages in the management of patients with acute pain disorders:
Pain scale: On a scale of 1 to 10, the patient compares her present pain to the worst pain she has ever experienced. A pain history is necessary to ascertain that the patient has experienced a sufficiently severe pain in the past to enable her to quantify the present pain.
History: A careful history includes the points that are important to the patient and the facts and features that the physician needs to know about the way the pain began, the circumstances at the time it began, the location and migration of the pain, and the changes that make the pain worse or better.
Physical examination: A general physical exam is in keeping with good medical practice and is in order unless the patient has recently had a complete physical exam by her primary care physician. If so, an exam will suffice that is limited to the area of the pain and the areas immediately adjacent. A restricted “area” exam may result in a missed diagnosis, but this risk can be minimized by examining all possible areas related to the diagnoses under consideration.
Diagnosis: The diagnosis requires a careful and detailed history, physical examination, and consideration of differential diagnoses that are inclusive enough to encompass the most likely cause of the problem. Unfortunately, in 1996, few medical schools teach the logical rule-out processes involved in the development of differential diagnoses of pain states.
Goals: Just after the development of the differential diagnosis list, and even before a definitive diagnosis, a physician can talk to the patient about goals in therapy. There are at least two immediate and end-point goals in any therapeutic plan: (a) improvement in personal and vocational functioning, and (b) reduction in pain levels. If the patient is included in the goal-setting discussion, she will feel involved in decision making as a member of the team in charge of her particular case. The patient is the most important individual in her case, and she needs to realize that. She needs some understanding of her disease process, the knowledge that there are a number of therapeutic options, and the assurance that she has the attention of concerned and interested physicians. Of course, early discussions about pain treatment results must avoid any promises of definite end points. It is unwise to tell a patient who presents with a pain score of 8/10 that by the end of therapy she can expect a 2/10 or 1/10. It makes more sense to discuss a general goal over time, in terms of reducing the beginning pain score from the severe category (7-10) to the moderate category (4-6) and, finally, to the mild category (1-3). In addition, it is important to stress functional improvement by noting the patient's level of functioning from personal and vocational standpoints. It is necessary to identify the patient's levels of personal and vocational functioning at a full 100% and then to identify the levels of functioning at the current pain score level. The dual goal, as the patient sees it, is improved function in both the personal and vocational areas and, at the same time, a reduction in pain level.
Therapy: Discussing an extensive treatment or therapy hierarchy with the patient helps lay out a plan for improvement, so that the patient can see the means of eventual progress. It lets the patient know there are several therapeutic possibilities, not just a single one, and it can enhance the patient's cooperation with the various therapeutic models. It is wise to go over the possibilities with the patient and to discuss how the possible pathology can be related to the anatomy in the area. The physician may use anatomical pictures to demonstrate.
Initial follow-up: Follow-up should begin just 1 week after the initial visit, either at the time of the patient's return to the clinic or during a follow-up telephone call. This is an excellent time to review the treatment hierarchy, so as to allay any disquietude that the patient may have about her treatment thus far or about the eventual goals of the therapy.
Therapy adjustment: If progress stops, as evidenced by the results of a repeat visit and examination, then the physician must make therapy adjustments to redirect the effectiveness of the medication, so as to optimize subsequent responses and follow-up question sessions.
Follow-up visits: Follow-up visits should be scheduled at the initial visit or at the time of goal-setting discussion. A reasonable follow-up schedule might call for appointments at 1 week, 2 weeks, 4 weeks, and 8 weeks after the initial visit. By definition, 3 months' duration separates acute pain from chronic pain. Some acute pain patients will shift to a chronic pain category as their pain continues and the therapy fails to achieve its goal of pain relief and improved function within the 3-month window. Every time a patient presents for follow-up in the clinic or responds by telephone to questions about her therapy, the physician should be made aware of untoward events or responses or of a deterioration of the patient's wellness. Adjustments in therapy should take place immediately, not be postponed until the next visit.
Outcome: This is the final “graduation” of the patient from the therapy regimen. The outcome criteria are the standards for measuring success or failure. They are the single most important focus from the patient's viewpoint, because originally she came to the physician with pain, a need to reduce that pain, and a need to improve her functional ability to work and enjoy life. Outcome assessment can take place whenever the clinic contacts her for follow-up queries.
Bartholinitis. Infection is the chief problem here. It often requires surgical incision and drainage to reverse the effects of inflammation and sequestration of purulent matter. Complete disruption of all communicating and infected sacs should be carried out, along with placing the patient on antibiotics (Cheetham, 1985).
Skene's urethritis. This, too, involves a set of glands lying along the urethral orifice. Usually heat applications and gentle pressure can empty the infected material, but sometimes patients may require incision and drainage and antibiotics (Dodson, Cliby, Pettavel, Keeney, & Podratz, 1995).
Herpes. The chief pain problems initially include dysuria, dyspareunia, vesicular eruptions, and groin pain, which can be treated, respectively, with suppositories, avoidance of sex, acyclovir cream, and systemic analgesics. Long-term pain can be due to actual neuropathic changes that accumulate over time. Treatment for such pain requires identification of the involved nerve or nerves and local-anesthetic blocks for pain relief trials spaced over several weeks. Some patients who are refractory to such interventions merit other methods of nerve treatment such as cryotherapy or thermolysis (Buntin, 1994).
Condyloma. In early stages, colposcopy helps make the diagnosis. Treatment consists of 5-fluorouracil until all wart activity appears neutralized. The skin will recover over a short period of time and will develop normal texture again. In some cases, larger lesions may require removal by cryotherapy, fulgeration, or surgical excision (Spitzer & Krunholz, 1992).
Vaginitis.
dAmerican Pain Society
– May/June 1996-p Whag t Are the Guidelines for Treating Pelvic and A Nude Nude dominal Pain?g Lady Lady
nAmerican Pain Society
– May/June 1996-p Whag t Are the Guidelines for Treating Pelvic and A Nude Nude dominal Pain?h j Lady Lady