1. Pelvic Pain

2. Learning Objectives Discuss common causes of acute pelvic pain
Discuss common causes of chronic pelvic pain
Identify triage questions to differentiate urgent vs. non-urgent presentations
Describe components of a pain evaluation
Provide appropriate patient education
We have 5 learning objectives for the session. By the end of this lecture, you will be able to:
Identify common causes of acute pelvic pain
Describe common causes of chronic pelvic pain
Identify triage questions to differentiate urgent vs. non-urgent presentations
Describe the components of a pain evaluation
Provide appropriate patient education with regard to common causes of pelvic pain

3. Case Study
Becky, a 39-year-old female veteran calls with a complaint of pelvic pain that started 24 hours ago.
Let’s start the discussion with a case study…
Becky, a 39-year-old female veteran calls with a complaint of pelvic pain that started 24 hours ago.
The nursing critical thinking process here is: you need to assess is the urgency of the complaint. You would do this by asking focused triage questions related to her pain.
Nurse’s Critical Thinking:
Assess the urgency of the complaint. 3
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4. Triage Questions to Assess Acute Pelvic Pain
Pregnancy
LMP? Form of birth control?
Pain characteristics
Location? Does it radiate elsewhere? Has location changed?
Duration? Where/when did it occur?
Onset sudden or gradual? Sharp, dull, stabbing? Pain come and go (cyclic)?
Rate pain on scale: 1=minor to 10=unbearable
What makes it worse/better? Treatment tried?
Similar pain before? If yes, how treated?
Past gyn surgery
Hysterectomy, oophorectomy, or tubal ligation?
Past STIs
When? How treated?
Other symptoms
Nausea, vomiting, vaginal discharge/bleeding
Bowel movement pattern
Constipation? Diarrhea? Both?
What kind of questions should you ask to triage this complaint of new onset pelvic pain?
Are you/could you be pregnant? LMP?
You should assess Pain characteristics:
Where is the pain? Does it radiate elsewhere?
Has the location of the pain changed over time?
How long have you had the pain? Where/when did it occur?
Was the onset of pain sudden or gradual?
Is the pain sharp, dull, or stabbing? Does it come and go (cyclic)?
Rate the pain on a scale of 1=minor to 10= unbearable
Does anything make it worse or better?
What have you used to treat your pain?
Have you had similar pain before? If yes, how was it treated?
You want to know what form of birth control she uses -- if any
You might want to ask about past gynecologic surgeries
Query past sexually transmitted infections
Ask about other symptoms (e.g., nausea, vomiting, vaginal discharge/bleeding)
Ask about her bowel movement pattern 4

5. Case Study (continued)
Becky states that she has never had pain like this before. She tried acetaminophen and ibuprofen, but neither helped. Her LMP was 2 weeks ago and she has a history of tubal ligation.
Let’s return to the case study…
Becky states after your questioning that she has never had pain like this before. She tried acetaminophen and ibuprofen, but neither helped. Her LMP was 2 weeks ago and she has a history of tubal ligation.
Nurse’s critical thinking process: Becky is probably not pregnant. A clinic appointment is appropriate.
Nurse’s Critical Thinking:
Becky is probably not pregnant. A clinic appointment is appropriate. 5

6. Signs & Symptoms Purulent vaginal discharge (possible STI)
Cramping, vaginal bleeding (may be ectopic pregnancy or threatened AB)
Dyspareunia, dysmenorrhea (suggest endometriosis)
Anorexia, nausea and vomiting (seen with appendicitis)
Pelvic pain (inflammatory process such as PID, or adnexal torsion/twisting, or degenerating fibroid)
Dysuria (suggestive of UTI)
Constipation and/or diarrhea
After asking several question you can associate some of the signs and symptoms with a possible cause.
Purulent vaginal discharge may suggest a possible STI
Cramping and vaginal bleeding is commonly seen with an ectopic pregnancy or threatened abortion
Dyspareunia (painful intercourse) and dysmenorrhea (painful menses) suggest endometriosis
Anorexia, nausea, and vomiting often seen with appendicitis
Consider inflammatory pelvic processes (pelvic inflammatory disease, adnexal torsion/twisting, maybe even a degenerating fibroid)
Trauma may cause acute pelvic pain
Dysuria can be suggestive for a UTI
Constipation and/or diarrhea could be the cause of her acute pelvic pain

7. ACUTE PELVIC PAIN
We’re going to discuss both acute and chronic pelvic pain. First let’s talk about ACUTE pelvic pain. 7
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8. Definition of Acute Pain
Definition Varies…
Pain <1 week
Pain undiagnosed for <10 days
Definitions of acute pain vary…
Pain of less than one week duration.
Undiagnosed pain of less than 10 days duration.

9. Common Causes of Acute Pelvic Pain
Gynecologic Conditions (PID, dysmenorrhea)
Gynecologic and Pregnant (ectopic pregnancy, miscarriage)
Non-Gynecologic Conditions (appendicitis, UTI, diverticulitis, kidney stones, trauma)
Acute pelvic pain can be caused by a lot of conditions. I will mention only a few here:
Common gynecologic conditions include PID or dysmenorrhea
Gynecologic conditions related to pregnancy must also be considered like ectopic pregnancy and miscarriage
Non-gynecologic conditions that can cause acute pelvic pain include appendicitis, UTI, diverticulitis, kidney stones, and trauma. 9

10. Physical exam and nursing role for acute pelvic pain
Marked hypotension, tachycardia, or fever: may need emergency treatment
Pregnant: follow local policy for disposition of acutely ill pregnant patient
Heavy vaginal bleeding: consider orthostatic vitals
Immediate vitals
What is the nursing role during a physical exam for acute pelvic pain?
Take vitals immediately
If the patient has marked hypotension, tachycardia, or fever, she may need emergency treatment
If the patient says she is pregnant, follow local policy for disposition of acutely ill pregnant patients. If the patient is reporting heavy vaginal bleeding, you should consider orthostatic vitals.
Set up supplies for complete pelvic exam
Set up supplies for a complete pelvic exam 10

11. Patient Education for Acute Pelvic Pain
Questions about treatment plan or discharge instructions?
How to reach provider including after-hours contact (e.g., 24-hour nurse advice line)
Understanding of when/if she is to return for follow-up
When to seek immediate emergency care
If pain worsens
If fever develops
If orthostatic symptoms appear (lightheadedness or passing out, confusion, nausea, blurred vision)
What kinds of things would you talk about when educating a patient who has acute pelvic pain after she has seen the provider?
Does she have any additional questions about treatment plan and discharge instructions?
Does she know to reach the provider with questions including how to contact the provider after-hours?
Does she have a clear understanding of when/if she is to return for follow- up care?
Does she understand when to seek emergency care if:
Pain worsens
Fevers develop
Orthostatic symptoms occur (lightheadedness, confusion, nausea, passing out, weakness, blurred vision, shaking) 11

12. Pregnancy should be ruled out for every woman of reproductive age
who complains of acute pelvic pain.
At our facility, years old is considered reproductive age. 12
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13. Chronic Pelvic Pain
We’ve discussed ACUTE pain. Now let’s talk about CHRONIC pelvic pain… 13
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14. Definition of Chronic Pelvic Pain (CPP)
Non-cyclical pain for at least 6 mos in pelvis, anterior abdominal wall, lower back or buttocks AND serious enough to cause disability or lead to medical care
Chronic pelvic pain is defined as…
Non-cyclical pain of at least 6 months’ duration that appears in locations such as the pelvis, anterior abdominal wall, lower back or buttocks, and that is serious enough to cause disability or lead to medical care.
It is important to develop an understanding of the effect of CPP on all facets of a woman’s life including work, school, relationships, exercise, and sleep.

15. Epidemiology of CPP Occurs in 15% of reproductive-aged women
Cited as diagnosis in 10% of outpatient GYN consultations
40% of women undergo laparoscopic surgeries due to CPP
The reason for 18% of all hysterectomies
>$2 billion in costs per year
Not associated with race, ethnicity, education, socioeconomic status
Chronic pelvic pain is a huge problem.
Occurs in 15% of reproductive-aged women
Cited as a diagnosis in up to 10% of all outpatient gynecologic consultations
40% of women undergo laparoscopic surgeries due to their CPP
CPP is the reason for 18% of all hysterectomies
Over $2 billion in estimated annual costs for US
No difference in prevalence of CPP based on race, ethnicity, education, or socioeconomic status

16. Co-Morbidities 50% of women with CPP also have depression
(consider depression screening)
Drug and alcohol abuse may make women more susceptible to pain
Several common co-morbidities are associated with chronic pelvic pain:
Up to 50% of women with pelvic pain also have depression; consider doing depression screening and referring to your provider if it is positive
Keep in mind that drug and alcohol abuse may make women more susceptible to pain 16

17. CPP is also associated with:
Physical and sexual abuse
Of 713 women in pelvic pain clinic:
46.8% hx of sexual/physical abuse
31.3% PTSD symptoms
Trauma hx = worse medical symptoms (headache, muscle ache, constipation, diarrhea)
Military sexual trauma
Prevalence of MST, which includes harassment, is 1 in 5 among all women Veterans
Hx of MST = twice as likely to report chronic pelvic pain
Chronic pelvic pain can also be associated with abuse:
Meltzer-Brody did a study of women seen in a pelvic pain clinic in Of 713 patients:
46.8% had history of sexual or physical abuse
31.3% had PTSD symptoms
Women with trauma history had worse medical symptoms such as headaches, muscle aches, constipation or diarrhea
The prevalence of military sexual trauma, which includes harassment , among all women veterans is 1 in 5
Women with a history of MST are twice as likely to report chronic pelvic pain, as noted in a study by Frayne 17

18. Common Physiologic Causes of CPP
Gynecologic
(e.g., endometriosis) GI
(e.g., irritable bowel syndrome)
Urologic
(e.g., interstitial cystitis)
Musculoskeletal (e.g., fibromyalgia)
There are many physiologic causes of chronic pelvic pain.
Some are gynecologic like endometriosis.
Others are related to the GI tract like irritable bowel syndrome.
Interstitial cystitis is a urologic cause
Fibromyalgia is related to the musculoskeletal system.
These are just a few examples of common causes of CPP. 18

19. CPP Diagnosis 61% of cases, no diagnosis 40% more than 1 diagnosis
Four most common physiologic causes:
Endometriosis
Adhesions
Irritable bowel syndrome (IBS)
Interstitial cystitis
Diagnosing why chronic pelvic pain occurs is tricky…
Definitive diagnosis is not made for 61% of women, so we might not be able to give her a condition to hang her hat on
Up to 40% of women with CPP may have more than one diagnosis
But the four most commonly diagnosed physiologic causes of CPP are:
Endometriosis
Adhesions
Irritable bowel syndrome (IBS)
Interstitial cystitis
We will explore these causes in more detail later on in this lecture 19

20. Triage Questions to Assess Chronic Pelvic Pain
Had this type of pain before?
Describe today’s pain
Location, duration, intensity, etc.
Today’s pain differ from prior episodes?
If yes, how?
Associated symptoms?
Sudden weight loss may occur with malignancy
Nausea and vomiting may occur with bowel obstruction
Pain timing?
Constant? Associated with menses, eating, intercourse, or stress?
Pain intensity?
Rate on scale: 1=minor to 10=unbearable
Treatments tried?
Today? In the past?
Anyone in her family have chronic pain?
If yes, what?
Does she have a pain plan?
If yes, is she following it? When did it stop working?
What kinds of questions should you ask a woman presenting with chronic pelvic pain?
Have you had this type of pain in the past?
How would you describe today’s pain?
Does today’s pain differ from previous episodes? Most women with CPP know their pain cycle and can tell when it is different. If yes, how?
Associated symptoms? Symptoms that occur in relation to pelvic pain may give important information…
sudden weight loss may occur in association with malignancy,
nausea and vomiting with bowel obstruction
Asking about Pain timing:
Constant? Associated with menses, with eating, with intercourse or with stress?
Ask her to rate the pain on a scale of 1=minor to 10=unbearable
Query what she has done to treat the pain. Today? In the past?
Does anyone in her family have chronic pain? If yes, what?
Does she have a pain plan? If yes, is she following it? When did it stop working?

21. Physical exam and nursing role for CPP
Vital signs
Listen to her concerns and prepare provider
Set up supplies for complete pelvic exam
What is the nursing role during a physical exam for chronic pelvic pain?
Assess vital signs
Listen to her concerns so that you can prepare the provider for what the patient complaints are for this visit.
Prepare the patient the exam and ensure supplies are ready for a complete pelvic exam. 21

22. Trauma-Informed Care: Before the Exam
Nursing:
Tell your provider if the patient has a trauma history or if she is reluctant to have a pelvic exam
Provider:
Talk with the patient (while dressed) about her symptoms
State that, to do a complete assessment, a pelvic exam is necessary because the exam may reveal more than her history
Discuss ways to relieve her stress
Reassure her that she can stop the exam at any point
During the intake and exam, be alert for signs of trauma:
Be aware of patient behaviors during the interview or exam that may indicate prior trauma…
Becoming tearful
Becoming silent or staring
Nervous talking
Reluctance to have a GU exam
If a patient shows signs of distress
Ask her if she would like to take a minute to relax or if she would like to delay the interview or exam
Nursing…tell your provider if a women is reluctant to have a pelvic exam. The provider should sit down with the woman before she is undressed. Together, they can go over the symptoms that brought the patient to the clinic. The provider can then let her know that, in order to do a complete assessment, a pelvic exam is necessary because the exam may reveal more than her history reveals. They can discuss what can be done to relieve the patient’s stress. The provider should also ensure that the patient knows that she can stop the exam at any point, and that the provider will honor her request. The key is to always get permission before starting, or before continuing the exam if the patient asked the provider to stop. 22

23. Be Alert for Signs of Trauma Trauma-Informed Care: The Exam
Nursing:
Watch for:
Tears
Silence or staring
Nervous chatter
Employ distractions
Providers:
Get permission before starting and re-starting the exam
If signs of distress appear, ask if she would like a minute to relax or if she would like to delay the rest of the exam
During the intake and exam, be alert for signs of trauma:
Be aware of patient behaviors during the interview or exam that may indicate prior trauma…
Becoming tearful
Becoming silent or staring
Nervous talking
Reluctance to have a GU exam
If a patient shows signs of distress
Ask her if she would like to take a minute to relax or if she would like to delay the interview or exam
Nursing…tell your provider if a women is reluctant to have a pelvic exam. The provider should sit down with the woman before she is undressed. Together, they can go over the symptoms that brought the patient to the clinic. The provider can then let her know that, in order to do a complete assessment, a pelvic exam is necessary because the exam may reveal more than her history reveals. They can discuss what can be done to relieve the patient’s stress. The provider should also ensure that the patient knows that she can stop the exam at any point, and that the provider will honor her request. The key is to always get permission before starting, or before continuing the exam if the patient asked the provider to stop. 23

24. Important Aspects of Care for CPP Patients
Addressed as an individual by a supportive team
Pain is taken seriously and legitimized
Explanation for her condition (more so than a cure)
Information and involvement in her plan of care
Reassurance:
Pain is not “all in her mind”
Not serious/cancer
In A 2006 study by Price and colleagues investigated what women with chronic pelvic pain want from their health care team; they found out the following:
A woman with CPP wants to be addressed as an individual by a supportive, understanding, interested provider/team
She wants to feel that both she and her pain are taken seriously and legitimized
She wants to receive an explanation for her condition (more so than a cure)
Information about her condition is key and she wants to be involved in the discussion about her plan of care
Lastly she wants reassurance that the pain is:
“Not all in her mind”
Not serious/cancer
Study source: Price J, et al. Attitudes of women with chronic pelvic pain to the gynaecological consultation. BJOG 2006; 113:446–52. 24

25. Patient Education for CPP
Questions about treatment plan or discharge instructions?
e.g., If she is to keep a pain diary, reinforce what she should record (episodes of pain including location, severity, mood at the time as well as associated factors such as menses, activity, intercourse, bowel functions, and medications
How to reach provider including after-hours contact (e.g., 24-hour nurse advice line)
Understanding of when/if she is to return for follow-up
When to seek immediate emergency care
If pain worsens or fever develops
If orthostatic symptoms appear (lightheadedness or passing out, confusion, nausea, blurred vision)
What kind of patient education should you provide for a woman with chronic pelvic pain?
Any additional questions regarding treatment plan and discharge instructions? For example if the provider wanted her to keep a pain diary you could reinforce what details would be necessary: patient should record episodes of pain including location and severity and associated factors (such as menses, activity, intercourse, bowel functions, medications and her mood at the time of her pain)
How to reach the provider with questions including after-hours contact. Like the 24hour nurse advice line
Clear understanding of when/if she is to return for follow-up
And a understanding of when to seek emergency care immediately
If her pain worsens
She develops a fever
Review the Orthostatic symptoms like lightheadedness or passing out, if she becomes confused, nausea,, blurred vision NEXT SLIDE 25

26. Interstitial Cystitis
Most Common Causes of CPP
Irritable Bowel
Endometriosis
Interstitial Cystitis
Now, we’ll discuss the four most common causes of chronic pelvic pain:
Irritable Bowel Syndrome
Endometriosis
Interstitial Cystitis
Pelvic Adhesions
Pelvic Adhesions 26

27. Irritable Bowel Syndrome (IBS) Abdominal pain/discomfort with altered bowel habits for at least 3 mos
Colon spasms and food moves too quickly or too slowly through intestines
Affects 20% of the population
1.5x more common in women
Onset before age 35 in 50% of cases
Poorer physical and mental health reported with IBS
We are going to start by discussing the definition and facts regarding Irritable bowel syndrome.
IBS is defined as abdominal pain/discomfort with altered bowel habits for at least 3 months
What may be happening is the colon spasms, causing food to move too quickly or too slowly through the intestines
IBS affects 20% of the population;
1.5 times more common in women
Onset is before age 35 in 50% of the cases
It is important to know that IBS sufferers report poorer physical and mental health 27

28. IBS Patient Education (biofeedback, probiotics, peppermint oil)
Diary
(document everything eaten and symptoms)
Dietary manipulation
(nutritional consult, add fiber slowly)
Exercise and Stress Management
Medication and Other Therapies
(biofeedback, probiotics, peppermint oil)
Patient education is a critical part of managing irritable bowel syndrome.
A symptom diary is useful (educate the patient to write down everything she eats and to document any symptoms she might experience)
Dietary manipulation is most effective
She may need a nutritional consult
Advise her to add fiber slowly
She should also increase her physical activity
Stress management may be helpful; if you dial down the mind it could help dial down the motility of the bowel as well.
Medication management is variable
Alternative/complementary therapy may help
Biofeedback
Probiotics (Nikfar et al, 2008)
Peppermint oil (Merat et al, 2009) is thought to have the ability to relieve some gastrointestinal problems by blocking the flow of calcium into muscle cells in the intestines, which in turn reduces muscle contractions
IBS Patient Education

29. Eliminate all for 2 weeks; slowly add one food group every 3 days; record symptoms
Dairy (lactose)
Wheat (gluten)
High fructose corn syrup
Sorbitol (chewing gum)
Eggs
Nuts
Shellfish
Soybeans
Beef
Pork
Lamb
Elimination Diet
Let’s spend a minute discussing the Elimination Diet. This method that can help manage IBS… As nurses you can easily help the patient navigate this management strategy
The goal is to remove foods that may be irritating the lining of the intestine. This is a list of food we want the patient to eliminate.
We want them to avoid eating any of theses foods, either whole or as ingredients in other foods, for at least 2 weeks
Once the intestinal wall has returned to normal, slowly add one food group every 3 days
Keep a record of symptoms…she may identify a food that has been the culprit
Example
A 34yo female patient came to see me for the first time for a gender-specific exam. Because I asked if she had any bowel or bladder problems (it is a routine question for all my patients) she shared that she has been paralyzed with IBS and severe cramping due diarrhea mixed with constipation for several years. She explained that because she had pain “down there”, at first everyone she talked to labeled it as a women’s issue. She had been through a few upper GIs, one colonoscopy, and several medications looking for the cause/cure of her symptoms. She had even undergone a laparoscopy which was normal. After a detailed history, I worked closely with the GI specialist at my facility and my women’s mental health provider to encourage her to keep a symptom diary. We began to manage the stress related to her symptoms which interfered with her work. We were finally able to determine that a gluten allergy was the root of her symptoms. Using the elimination diet strategy changed this patient’s quality of life. So you can see that, as nurses, if you were to talk with a patient about the elimination diet this could be a simple fix for patients experiencing IBS .

30. Endometriosis Mean age at diagnosis 25-30
May be caused by endometrial cells implanting outside uterus
Exact cause not known
Affects 3-15% (avg 10%) of population
25-50% of infertility population
Another common cause of chronic pelvic pain is endometriosis.
The mean age at diagnosis is 25-30
The cause is thought to be related to endometrial cells that implant outside the uterus. In the illustration, the implants are located on the fallopian tubes and ovaries and pelvic cavity.
The exact cause of endometriosis, however, has not been identified.
It affects 3-15% (avg 10%) of the general population
It occurs in 25-50% of the infertility population
Infertility is one of the consequences of endometriosis. Scarring or adhesions in the pelvis, for example, may cause infertility. The fallopian tubes and ovaries may adhere to the lining of the pelvis or to each other, restricting their movement.
The scarring and adhesions that takes place with endometriosis may mean that the ovaries and fallopian tubes are not in the right position, so the transfer of the egg to the fallopian tubes cannot take place.
Because endometriosis often causes painful intercourse, couples may fail to have intercourse during the woman’s most fertile time, which will obviously impede the possibility of conception.

31. Endometriosis Symptoms
Pelvic pain in 70-75% of women
Increasing dysmenorrhea
Deep dyspareunia
Premenstrual dysmenorrhea
Lower abdominal pain, often bilateral
Lower back pain
Bowel or bladder symptoms
Difficult or painful defecation, bloating, constipation, diarrhea
The stage of endometriosis is NOT correlated with the presence or severity of symptoms.
Instead, symptoms are more related to local peritoneal inflammatory reaction.
Endometriosis is related to multiple symptoms:
Pelvic pain in 70-75% of women
Increasing dysmenorrhea
Deep dyspareunia
Premenstrual dysmenorrhea
Lower abdominal pain, often bilateral
Lower back pain
Bowel or bladder symptoms such as difficult or painful defecation, bloating, constipation, diarrhea
It is important to note that the stage of endometriosis is NOT correlated with the presence or severity of symptoms. Instead, the symptoms are more related to a local peritoneal inflammatory reaction. 31

32. Physical Exam History Laparoscopy Endometriosis Diagnosis
Could treat based on H&P alone. Laparoscopy, however, is “gold standard”.
Endometriosis
Diagnosis
Endometriosis is diagnosed by history and a physical exam and a provider could treat based on this alone. However, laparoscopy is the “gold standard” for diagnosis.
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33. Patient Education for Endometriosis
Can often be managed in primary care setting with medications alone
NSAIDs
Monophasic oral contraceptive, vaginal ring, or contraceptive patch continuously for 3 months
If you take away her menses, you REMOVE most of the pain cycle!
Endometriosis can often be managed in the primary care setting with medications alone
NSAIDs
Monophasic oral contraceptive, vaginal ring, or contraceptive patch continuously for 3 months
Sometimes, however, patients with endometriosis will need a referral to Gynecology for further management
Common treatment plan for chronic pelvic pain:
A woman presents with symptoms consistent with endometriosis. Patients typically do not have to undergo laparoscopy. Treat her with NSAIDS and/or continuous monophasic OCPs if they have not been tried previously. If you take away her menses, you REMOVE most of the pain cycle.
Sometimes, however, patients will need GYN referral for further management 33

34. Interstitial Cystitis (IC)
Definition: 3-6 mos of pain/pressure/discomfort over suprapubic area or bladder, with frequent urination day and night in a patient without a UTI
Major symptoms in women are dysuria, frequency, urgency, chronic pelvic pain, dyspareunia
Bladder pain can be variable; most consistent feature is increased discomfort with bladder filling and relief after voiding
90% of all IC cases are female; diagnosis should be high on suspicion list if her pelvic pain can’t be controlled
Symptoms vary over time with flares and remissions
Cause is unknown; may be defects in protective lining (epithelium) of the bladder
No cure; goal is to relieve symptoms and improve quality of life
Patients often referred to Urology for further evaluation/management
Interstitial cystitis is another common cause of chronic pelvic pain.
IC is defined as 3-6 months of pain, pressure, or discomfort over the suprapubic area or the bladder, accompanied by frequency of urination during the day and night in a patient who does not have a UTI.
For women, the major symptoms are dysuria, frequency, urgency, chronic pelvic pain, and dyspareunia
It is important to remember that bladder pain or discomfort in women with IC can be variable , but the most consistent feature is increased discomfort with bladder filling and relief after voiding.
90% of all IC cases are female. This diagnosis should be high on the suspicions list if her pain can’t be controlled.
The symptoms vary over time with flares and remissions
The cause of IC is unknown, but it is thought to be related to defects in the protective lining (epithelium) of the bladder.
Unfortunately at this time there is no cure. The goal is to relieve the symptoms and improve quality of life. Often, these patients are referred to Urology for further evaluation and management. 34

35. IC Patient Education
Dietary management: low potassium, low acid diet trial x 2 wks. Eliminate:
- carbonated drinks - pickled foods
- caffeine (including chocolate) - alcohol
- citrus products - spicy food
- tomatoes - artificial sweeteners
Some patients urinate up to 60x per day
- Retrain bladder by slowly increasing voiding intervals. Patients may mention knowing location of every bathroom in town. Some are confined to their homes due to incontinence if a bathroom is not readily available.
Pelvic floor/easy stretching exercises can reduce muscle spasms
Some improvement reported with acupuncture, guided imagery, biofeedback
Symptoms can sometimes be managed by applying heat or cold over perineum. Encourage patients to try both to see what works.
Psychosocial support is also an integral part of treatment for chronic pain disorders.
Patient education is critical for managing interstitial cystitis.
Start with dietary management – a low potassium, low acid diet trial for 2 weeks. Eliminate:
carbonated drinks
caffeine (including chocolate)
citrus products
tomatoes
pickled foods
alcohol
Spicy food
Artificial sweeteners
Urinary frequency is a common problem with IC. Some patients urinate up to 60 times per day.
Educating patients on how to retrain their bladders by slowly increasing voiding intervals is important. These patients may mention that know where every bathroom is in their town. Unfortunately, some are confined to their homes for fear of incontinence if a bathroom is not readily available.
Pelvic floor/easy stretching exercises have been found to reduce muscle spasms
Some patients report being helped by acupuncture, guided imagery, and biofeedback.
Symptoms can sometimes be managed by applying heat or cold over the perineum. Encourage patients to try both to find what works.
In summary, fluid management, diet modifications, and bladder training are key for these patients. Psychosocial support is also an integral part of treatment for any chronic pain disorder. Again, treatments are not curative and the goal is symptom management and improved quality of life.

36. Pelvic Adhesions Bands of scar tissue form between pelvic organs
Risk factors: infection, pelvic surgery, trauma
Lead to infertility, chronic pain
Our last common cause of CPP is pelvic adhesions.
This is caused by a bands of scar tissue that form between two pelvic organs
Risks for developing pelvic adhesions include infection, pelvic surgery including C-section, or trauma to the pelvis
Pelvic adhesions can also lead to infertility
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37. Pelvic Adhesion Diagnosis
Aggravated IBS symptoms or pain during sexual intercourse
Diagnosed by excluding other pathology
GYN referral for potential laparoscopy
Adhesions usually signal their presence by aggravating the symptoms of IBS or by causing pain during sexual intercourse
Diagnosis is usually done by excluding other pathology
Often patients are referred to Gynecology for potential laparoscopy 37

38. Addressing Co-Morbidities with Pelvic Adhesions
These patients can be the most difficult to manage. They present with a chronic pain history that is suggestive of adhesions mainly because everything else has been ruled out. Sending them back to surgery is not the best option. The first step is a depression screen and a good assessment of the patient’s alcohol and drug use to rule out abuse. As mentioned in an earlier slide, pain can be exacerbated by overuse of alcohol and drugs. This is the point where the involvement of a mental health provider is crucial.
Example of a treatment plan for adhesions:
These patients can be the most difficult to manage. They present with a chronic pain history that is suggestive of adhesions mainly because everything else has been ruled out. Sending them back to surgery is not the best option. The first step is a depression screen and a good assessment of the patient’s alcohol and drug use to rule out abuse. As mentioned in an earlier slide, pain can be exacerbated by overuse of alcohol and drugs. This is the point where the involvement of a mental health provider is crucial. 38

39. Patient Education for Pelvic Adhesions
Avoid constipation
High-fiber diet
Pain management
Medications, physical therapy, trigger point injections, Botox injections, biofeedback
Goal is to try to keep them out of the OR as long as possible
As with other causes of chronic pelvic pain, patient education is critical for pelvic adhesions.
Avoid constipation
High-fiber diet
Pain management including pain medications, physical therapy, trigger point injections, and Botox injections
Additionally, biofeedback classes may be very successful in helping patients manage chronic pain. The goal is to try to keep them out of the OR as long as possible. 39

40. The bottom line regarding CPP…
Chronic pelvic pain is a complex condition.
Patients need a good triage assessment to determine care urgency
Many women have concurrent depression, PTSD, MST, or IPV
Existing data is hampered by a lack of standard definitions, algorithms, and adequate clinical trials; regardless, our patients rely on us to listen and arrive at the best treatment plan possible
Nurses are on the front line. Your involvement in taking a complete history, encouraging compliance with the plan of care, and listening when women become frustrated with their chronic pain is crucial
Multidimensional care is often warranted; recognize when to bring in the team to help manage these patients. Consider involving your mental health provider or your PACT team or the social worker.
So what is the bottom line?
Chronic pelvic pain is a complex condition.
Patients complaining of pelvic pain need a good triage assessment to determine the urgency of care
Many women have concurrent depression, PTSD, MST, or IPV. Multidimensional care is often necessary.
Existing data is hampered by a lack of standard definitions, algorithms, and adequate clinical trials,
BUT….
Our patients rely on us to listen and come up with the best treatment plan possible.
Nurses are on the front line, interacting with these patients before they get to the providers. Your involvement in taking a complete history, encouraging compliance with the plan of care, and being a good listener when women become frustrated or even angry with their chronic pain is crucial.
Remember that multidimensional care is often warranted. It is important to recognize when to bring in the team to help manage these patients. Consider involving your mental health provider or your PACT team or the social worker. 40

41. Helpful Resources
Bordman & Jackson. Below the belt: approach to chronic pelvic pain. Can Fam Physician 2006;52:
Meltzer-Brody et al. Trauma and posttraumatic stress disorder in women with chronic pelvic pain. Obstet Gynecol 2007;109:902-8.
Price J, et al. Attitudes of women with chronic pelvic pain to the gynaecological consultation. BJOG Int J Obstet Gynaecol 2006; 113:446–452. 41

42. Patient Education Resources
Womenshealth.gov
Irritable bowel syndrome
Endometriosis
Interstitial cystitis/bladder pain syndrome
International Pelvic Pain Society. Chronic pelvic pain booklet (6 p.) 42

43. Authors Megan Gerber, MD, MPH Sarina Schrager, MD, MS
VA Boston Healthcare System
Sarina Schrager, MD, MS
University of Wisconsin-Madison Department of Family Medicine
Lisa Roybal, MSN, WHNP-BC
Loma Linda VA Health Care System
Linda Baier Manwell, MS
University of Wisconsin-Madison Division of General Internal Medicine
Molly Carnes, MD, MS
University of Wisconsin-Madison Center for Women’s Health Research 43