Chronic Pelvic Pain Diagnosis and Management Annapolis MD
(click on each example form for a printable PDF version--Adobe Acrobat Reader required)
Monthly Pain Calendar
The patient is requested to complete the monthly pain calendar (Figure 1) by grading her symptoms on a scale of 0 to 10 with 0 indicating no pain and 10 indicating the worst pain that she has experienced. By utilizing numbers from 0 to 10 a scalar ranking is obtained which allows the practitioner to evaluate pre- and post-treatment levels using the Wilcoxon Signed Rank Test. In this manner data is obtained which can be used for determining the effectiveness of treatment. In addition, the use of this type of form allows multiple practitioners within a clinic setting to care for patients with consistency and to follow their progress.
It is helpful to group the symptoms according to the six major diagnostic categories. In this way the patient is able to categorize her complaints by the six different areas of concern.
Category 1 of the Monthly Pain Calendar is gynecologic. The patient is asked to identify the times of her periods and to identify whether the periods are light, moderate or heavy again by using a 0 to 10 scale with 10 being the heaviest bleeding she has experienced. The use of medications is recorded by type of medication and the amount of medication taken. Mid-pelvic cramps and cramps in other areas of the pelvis are then recorded as well as left pelvic pain, right pelvic pain and low middle pain. Pain during sexual intercourse and pain after sexual intercourse are both recorded.
Musculoskeletal issues are dealt with by questions on backache and general aches and pains. The gastrointestinal system is evaluated with questions relating to pain before, during, and after bowel movement. Issues relating to urinary tract problems are monitored with questions on pain, urgency and frequency during each day of the month. Psychological issues are then considered with questions relating to anger, anxiety, and depression. The patient is then asked to identify any myofascial pain, specifically abdominal wall pain on a scale of 0 to 10.
The patient is asked to keep this form for each day of the monthly cycle and to identify the date that she starts the form. For purposes of ensuring that the patient is completing the form correctly, give this form to the patient and request that she complete this form for the days of the cycle prior to the current visit. Ask her the date of the first day of her last period and ask her to complete this form for each cycle day since that day. Give her approximately 15 minutes to work on this form and then return to evaluate how she is doing with the form. If she understands the questions and the way to complete the form, have her complete the form up to the date of this visit. Have her take additional forms home and complete the form for every day for the entire time she is in treatment. This establishes a contractual relationship between the caregiver and the patient which ensures that the patient will complete the information that the caregiver requests on a daily basis in order for the caregiver to provide therapy to the patient..
Figure 2 shows an example of a form which is divided between the various symptom categories.
In the gynecologic area the patient is asked to rate the pain she experiences with her periods, ovulation, and intercourse. In addition she is asked how heavy her bleeding is with her periods, and whether her periods are irregular.
In the gastrointestinal area she is asked to comment on a series of symptoms including pain with bowel movement at the time of periods and at non-period times, urgency of bowel movement, blood in the stool, bloating, constipation, diarrhea, nausea and vomiting.
The musculoskeletal and myofascial areas are dealt with together with questions on the level of pain in the lower back as well as pain with certain movements and activities and the patient is asked to identify those movements and activities.
The psychological area is dealt with by requesting the patient to rank her stress, depression, anxiety, and anger from 0 to 10.
In the urinary tract area the patient is asked to comment on the level of pain she experiences with urination and whether she has problems with frequency.
In addition, the patient is asked to comment on other areas that may be of concern such as whether she is experiencing hot or cold flashes and whether she is experiencing fatigue or headaches.
It is very helpful with a patient who is experiencing chronic pain to have her complete forms rather than attempt a formal question and answer interview at the very beginning of her visit. By having her complete these forms, the physician is able to obtain the maximum amount of information concerning the patient’s complaints while also being in a position to spend time with other patients.
The third form is a questionnaire which requires the physician to participate directly with the patient in her evaluation (Figure 3). On this form, the patient is specifically asked by the caregiver to identify locations of pain and to reference this pain to Form 4, the body grid. For each pain identified on Form 3, the patient is asked to locate the pain and identify the level of pain on a scale of 0 to 10 with 10 being the worst pain she has ever experienced.
Case Study 1
A 34-year-old G2P2 requested a second opinion regarding a recommendation that she have a laparoscopic right salpingo-oophorectomy for her problem with severe right-sided pain. It was evident from the first two forms that she did have significant right-sided pain which increased and became very much disabling during time of ovulation. However, she stated she first noticed this pain as early as age 6. Since ovarian pain is very rare at age 6, it was necessary to determine what occurred prior to the time the patient noticed the pain. When asked to describe the events that preceded her pain she remembered that at age 5 she had been taken to the hospital with severe abdominal pain, temperature, nausea and some vomiting. She nearly underwent an operation but she improved and was sent home. Since that time she had experienced pain on her right side and sometimes that pain was made worse with exercise and at times even caused her to experience extremely sharp pain along the right side. When she started ovulation she found that this was painful as well. The pain had been getting progressively worse with ovulation for the last several years. This patient consented to a laparoscopic appendectomy and lysis of adhesions. She was found to have adhesions from the periappendiceal area over the right ovary and a firm, fibrotic, retrocecal appendix. The pathology report was chronic appendicitis and adhesions.
After describing the pain location, intensity, first occurrence, and antecedent events, the patient is asked to describe the overall effect of the pain on life activities with 0 being no interference and 10 being cannot perform normal functions. She is requested to describe the effect of this pain on work, school, social activities, child care, relationships, sports, exercise and any other categories the patient considers important.
Case Study 2
This 37-year-old G1P1 requested a second opinion concerning a recommendation for a laparoscopy to evaluate her pain. She described her pain as being in the lower pelvic area, specifically on the right side. She had noticed a sudden onset and stated the pain became worse at time of menses. However, this pain did not interfere with work, school life, social activities or child care relationships. It did interfere with sports. The pain interfered severely with her ability to ski especially with her ability to assume a crouching position. Also, she was unable to do her standard knee thrust exercise in which she placed her hands on the ground, held up her body with her hands and her toes and then thrust her knees toward her head. This type of rigorous exercise was performed 100 times each morning by this fitness instructor.
The examination of this patient concentrated on the areas of her complaints, specifically along the anterior abdominal wall at the insertion of the rectus fascia to the pubic bone. With careful palpation of this area it was possible to locate an area of significant tenderness. Having identified that this pain was in fact myofascial in nature the patient was advised to discontinue her exercise, use nonsteroidal anti-inflammatories and she was given injection therapy into the area of pain. The pain resolved with this treatment and the patient was able to go back to her normal activities. Laparoscopy was not necessary and would not have been helpful in her diagnosis.
Patients are asked to describe those things that increase and decrease pain, specifically with emphasis on areas such as intercourse and bowel movement. Generally speaking a patient who complains of pain with deep intercourse (deep dyspareunia) will frequently be found to have nodules and areas of tenderness in the uterosacral ligaments, rectovaginal septum, or the posterior cul-de-sac consistent with endometriosis.
A careful evaluation of prior treatment and medical workups is performed and all medical records are reviewed. The use of medications is discussed and recorded as well as other symptoms besides pain....