Picture this: your next patient is a 35-year-old female presenting to the ED with pelvic pain. You biopsy the chart—this is the fifth visit this month. Over the past six months, she’s been coming in two to three times per month with the same chief complaint. She’s had all the tests you’ve ever heard of, some you haven’t heard of, and enough CT scans that you expect she might glow in the dark a little. Yet nothing definite has been found. In further discussion with the patient, you find that she’s been dealing with this for at least a year now, mostly by coming to the ER.
Sound familiar? I’m sure it does. We’ve all seen this patient and shared in her frustration. So what can we offer someone with chronic pelvic pain?
Let’s start with a definition.
The International Association of the Study of Pain (IASP) defines chronic pain as “pain that has persisted for more than 3 months and is associated with significant emotional distress and/or functional disability, and the pain is not better accounted for by another condition. All subtypes of the diagnosis are considered to be multifactorial in nature, with biological, psychological, and social factors.”
In the ED, we often default to endometriosis as the cause of chronic pelvic pain—but the differential is wide, and overlaps are common. Dysmenorrhea, myofascial pain or pelvic floor pain, vestibulodynia, and interstitial cystitis are just a few examples.
What Can We Do in the ED?
First, rule out life-threatening causes: ovarian torsion, ruptured ectopic, hemoperitoneum from a hemorrhagic cyst, etc. Once those are off the table, you might ask, “Is this pain new or different? Or is it similar to the pain you’ve experienced before?” Most patients will tell you it’s the same or perhaps more intense, but of the same character and location. It also helps to delineate if this pain is constant or intermittent, if there is a baseline pain that flares, or if it’s associated with their menstrual cycle.
Exam and Imaging
Pelvic ultrasound is often the first imaging test to reach for, but a thorough physical exam can often reveal a likely cause.
Start with palpating the patient's back; it’s less intrusive, and you may find some tenderness that’s contributing to the pelvic pain. Then move to the abdomen. With patients who have chronic pain, it helps to narrate your steps: “I’m going to examine your belly/abdomen next, if that’s ok.” This can help them feel more comfortable.
After palpating the abdomen, have the patient perform a half sit-up to engage the abdominal wall musculature and palpate again; this may help isolate any tenderness to the abdominal wall or deeper viscera.
Finally, move on to the pelvic exam. A digital exam with one or two fingers is often adequate to obtain the necessary information unless specific situations dictate that a speculum is necessary (discharge, bleeding, etc.). After examining the uterus and adnexa, you should palpate the pelvic floor at the 5 and 7 o'clock positions and the 3 and 9 o'clock positions to test the levator ani and obturator internus muscle groups—common culprits in hypertonic pelvic floor pain.
Offering Relief
Your final job is twofold: provide what relief you can and refer them to a specialist for follow-up. The long-term treatment of chronic pelvic pain is generally multimodal, and sending them to a pelvic pain specialist is helpful. These providers can be found through the International Pelvic Pain Society (IPPS) at pelvicpain.org if your hospital system doesn’t have someone specific to this area or medicine.
As for what you can offer in the ED, if the pain seems related to the menstrual cycle, hormonal contraceptives may be of benefit. NSAIDs and muscle relaxants can also be helpful, especially if those muscle groups are tender. Avoiding opioids is recommended as they are not often helpful in non-cancer pain. Often, the patient just needs some reassurance and validation that their pain is real, and to know that you are helping them through the acute episode of pain.