Acute management of persistent pelvic pain

When first approached to write on the above topic, Coronavirus and the strain it is placing on our health systems was not even a consideration.

Given that the last place a patient currently wants to present is to a hospital emergency department, hopefully this will help to provide you with some tools to assist you and your patients through their acute flare of their persistent/ chronic pelvic pain (PPP). I have prepared this with the benefit of various meetings I have attended with pain specialists as well as using the excellent article published in the O&G magazine, Winter 2019 Vol 21 No 2. PPP is caused by a complex combination of visceral and musculoskeletal pain, central sensitisation and pelvic floor

Key messages PPP affects 15-20% of women Flare-ups can be managed in the community Identify and manage triggers

hypertonicity, often accompanied by evolving psychological dysfunction. It affects 15-20% of women.

Acute exacerbations (flares), which can last days to months, are often occupied with significant fear and anxiety relating to escalation of pain. They are often triggered by menstruation, constipation, UTI/ bladder pain and pelvic muscle spasms.

We should aim to prevent unnecessary investigations,

admission and surgery and focus on identification and treatment of specific triggers while providing validation, reassurance and education to patients.

Management principles need to include excluding acute intraabdominal pathology, recognition and management of likely triggers of the flare, appropriate analgesia with the avoidance of opioids, assessment of psychological stressors and self-harm risk, acknowledgement of the patient’s pain, education and emphasis on self-management and appropriate follow-up.

Long-term management involves a multidisciplinary team approach including laparoscopic gynaecologist, pain specialist, psychologist, physiotherapist and referral pathways to psychiatry,

functional gastroenterology as well as colorectal surgeons.

For acute presentations, history should focus on symptoms suggestive of pelvic muscle spasm; pain of sudden onset, unilateral or bilateral location, pain worse with movement, pain referring to anterior thigh, tender lower back or gluteal region, periods of overactivity or stress. Mental health assessments as well as medication history and prior services engagement is essential.

Examination should focus on excluding peritonism, deferring speculum examination unless warranted (PV bleeding or D/C) and bimanual examination of the uterus and adnexa for localised tenderness or masses. Acute spasm of the pelvic floor muscles will be evident in most women with PPP and often vaginal examination will not be tolerated.

Investigations should only be performed to support clinical findings. Urine dipstick to exclude pregnancy and UTI, bloods and imaging only if clinical evidence of alternate pathology. If indicated, pelvic ultrasound is the best imaging modality to define acute pelvic pathology. Targeted acute management needs to include treatment of acute pathology as indicated, explanation of the likely trigger for the flare where it is known such as acute pelvic muscle spasm. Address reversible causes such as constipation, UTI, dysmenorrhoea and hypertonic pelvic floor.

Non-pharmacological management should include heat packs as well as mindfulness and deep breathing.

A stepwise pharmacological approach is advised: • Simple analgesia – oral paracetamol with either oral or

PR diclofenac • For anxiety and pain related to central sensitisation, Pregabalin 25-75mg • For pelvic floor spasm PV/PR diazepam 5mg (in a fatty base – compound pharmacy made) • For painful bladder symptoms – Ural or 500ml water with a tablespoon of bicarbonate soda • For constipation – mild: Movicol two sachets daily with up to four sachets daily for moderate; add dulcolax mane until bowel movement; severe: two microlax enemas with three dulcolax tablets and eight sachets of Movicol in 1L of liquid over 12 hours For dysmenorrhoea – Diclofenac 100mg PR Opioids increase central sensitisation when used regularly and should be avoided where possible when acute pathology is excluded If required consider, Tramadol 50-100mg, Tapentadol IR 50mg.

The acute exacerbation of PPP can be a frustrating encounter for both the patient and clinician, frequently resulting in unnecessary intervention that yields little information or clinical improvement. By directing acute management at diagnosing and treating triggers, providing education and instituting multi-disciplinary team follow-up allows for outpatient management and avoids admission and its associated problems.

The author acknowledges Drs Thea Bowler, Michael Wynn Williams, Susan Evans, Jayne Berryman and Natalie Kiel of the Mater Mothers Hospital in Brisbane

Author competing interests – nil

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