Female Patient Cases 3
Chronic pelvic pain (CPP) is a symptom that can indicate illness in one or more organ systems and a chronic pain syndrome. Because females with CPP may have multiple etiologies for their pain, the evaluation’s goals include finding treatable sources of pain and distinguishing particular peripheral causes from those overlapping with centralized pain syndromes, as treatments can differ significantly (Tu & As-Sanie, 2019). Although there is no universal agreement on what constitutes chronic pelvic pain (CPP), it is commonly described as non-cyclic discomfort in the pelvic area that lasts three to six months or more and is unrelated to pregnancy.
The most common symptom of CPP in women is non-cyclic discomfort in the pelvis that lasts three to six months or more. Women suffering from CPP may have pain that extends beyond the pelvic. Other symptoms, including urinary or gastrointestinal issues, decreased quality of life causing no longer participating in particular activities, and changes in mental health can all be associated with CCP. Women may suffer more stress or difficulties in their personal and professional relationships due to these changes. The particular type of concomitant, disturbing, non-pain symptoms frequently aids in determining the cause of CPP and guiding treatment (Tu & As-Sanie, 2019).
CPP is a complex illness with both gynecologic and non-gynecologic causes; chronic pain is frequently the consequence of numerous overlapping pain syndromes, each of which contributes to the development of pain and therefore needs therapy (Tu & As-Sanie, 2019). CPP can be caused by visceral sources such as the gynecologic, genitourinary, or gastrointestinal systems; somatic origins such as the pelvic bones, ligaments, muscles, and fascia; and nerves inside the abdomen and pelvis; and psychologic components. Therefore, a thorough physical examination and a detailed evaluation of body systems, including a psychosocial history, are critical components of the CPP diagnostic method (Schuiling & Likis, 2022).
Differential diagnoses:
Endometriosis ICD10-CM N80.9: is usually asymptomatic. Patients typically present with pelvic pain, including dysmenorrhea and dyspareunia, infertility, or an ovarian tumor. Other symptoms include bowel and bladder issues, irregular uterine bleeding, low back pain, and persistent tiredness, but these are less common (Schuiling & Likis, 2022).
Pelvic inflammatory disease (PID) ICD10-CM N73.9 usually presents as an abrupt onset of acute lower abdomen discomfort following menstruation. Abdominal, pelvic, and lower back pain and abnormal vaginal discharge, intermenstrual or postcoital hemorrhage, fever, nausea and vomiting, and urine frequency are common signs and symptoms (Schuiling & Likis, 2022).
Adenomyosis ICD10-CM N80.0 is distinguished by small endometrial tissue in the myometrium, causing hypertrophy in the adjacent myometrium. Common symptoms include uterine enlargement, abnormal uterine bleeding, and painful menstrual periods (Schuiling & Likis, 2022).
Gastrointestinal:
Irritable bowel syndrome (IBS) ICD10-CM K58. 9: Irritable bowel syndrome (IBS) is a functional gastrointestinal condition characterized by recurrent abdominal pain and abnormal bowel habits. Diarrhea, constipation, alternating diarrhea and constipation, or regular bowel habits alternating with either diarrhea or constipation are all symptoms of IBS. Diarrhea is typically defined as frequent, tiny to moderately sized feces. Bowel movements usually happen during the day, most typically in the morning or after meals. Patients may experience constipation with intermittent diarrhea or regular bowel function (Wald, 2021).
Genitourinary:
Interstitial cystitis ICD19-CM N30.10 is a chronic pain illness with an unknown cause. The primary goal of management is to deliver symptom relief to accomplish a satisfactory quality of life. Therapy is based on specific patient factors such as disease severity and development, prior effective or ineffective treatments, and patient preference (Clemens, 2021).
Musculoskeletal:
Fibromyalgia (FM) ICD19-CM M78.7 is characterized by chronic generalized musculoskeletal pain, frequently accompanied by fatigue, cognitive impairment, mental disorders, and various somatic symptoms. The cause of the syndrome is unknown, as is the pathophysiology. Despite signs of soft tissue pain, there is no indication of inflammation in the muscles, ligaments, or tendons (Goldenberg, 2020).
Patient education.
The patient and their family should be aware of the multifaceted nature of chronic pain. They require multidisciplinary and all-encompassing management plans. Patients should be educated by their providers about moderate exercise, decent sleeping habits, and a well-balanced diet. And to avoid stressful positions and poor posture. They may also benefit from biofeedback and relaxation techniques (Singh, 2021).
The diagnosis usually determines the treatment strategy, and the goal of treatment is to manage pain and optimize function, even if the pain is not relieved. If no pathology is found, treatment focuses on pain management associated with dominant symptoms (Schuiling & Likis, 2022).
Nonpharmacologic Treatment includes (Schuiling & Likis, 2022):
Physical therapy
Pelvic floor therapy: muscle training and strengthening exercises, biofeedback, manual therapy, acupressure, and mobilization techniques
Aerobic and Non-aerobic exercises,
Complementary and Alternative Medicine: Acupuncture, herbs, and/or nutritional supplements, massage, meditation, guided imagery, and transcutaneous nerve stimulation.
Pharmacologic Treatment (Schuiling & Likis, 2022):
Oral analgesic: acetaminophen (Tylenol) or NSAIDs,
Hormonal treatment: Combined hormonal contraceptives (pills, vaginal ring, transdermal patch) relieve primary dysmenorrhea and endometriosis, Progestin-only contraceptives (progesterone pills, levonorgestrel-releasing intrauterine system, progestin-releasing implanted rods, and intramuscular depo-medroxyprogesterone).
For neuropathic pain, tricyclic antidepressants can be used as first-line therapy.
Surgical intervention may be required in some patients, depending on their diagnosis (Schuiling & Likis, 2022):
Presacral neurectomy: laparoscopic removal of the presacral plexus.
Laparoscopic uterosacral nerve ablation
Neuromodulation: An implanted device sends electrical impulses to the damaged nerves.
Hysterectomy is only used as a last option.
Following the prevalence of lower abdominal discomfort in the women’s clinic, health parameters were considered. The physical aspects of health are not the only factors in being healthy, but also mental and social. Alongside the physiological parameters, we must consider other elements like social environment, culture, and mental health to provide holistic care (Karaca & Durna, 2019). Those parameters are essential for reaching maximal health potential in individuals at the women’s health clinic with lower abdominal comfort and chronic pelvic pain.
Psychological Parameters: Mental health is an integral part of the whole concept of health. The case considered anxiety and depression as risk factors due to pelvic pain. Hence, there is a need to assess the mental health of these women with CPP.
Social Parameters: Culture is another aspect to consider. The case mentioned that the population, in particular, is very averse to reporting any disease symptoms. We need to consider the social environment because it can predispose individuals to anxiety, depression, and stress. The women at this clinic should consider their social environment to reduce anxiety, stress, and depression (to a degree) and promote holistic and complete health.
Family Parameters: The clinic mentioned that these women could have a family history of pelvic pain. It would be appropriate to screen for family developmental stages and look up any patient’s family health history. It is important to include family history and health history to make proper care plans for these women (Ott & Olsen, 2019).
The family developmental stages include independence (Unattached adult), marriage formation, childbearing, parenting, and senior years (retirement) (Karaca & Durna, 2019). Independence occurs when one has to leave their parents and live on their own. An example of marriage formation is when one marries for the first time. Childbearing consists of pregnancy and the birth process. An excellent example of parenting is when one has their children. Senior years is when one has retired.
- The family life cycle includes the different stages of development, but the “function” depends on how the family copes with responsibilities, potential conflicts, and problems. Some variables can affect the structure and function of a family (Karaca & Durna, 2019). Some examples of these variables are gender roles, family size, social security, and employment status. In healthcare, providers should consider a person’s family structure and function to determine the effect of their influence on health care.
- References
- Clemens, J. Q. (2021, November 4). Interstitial cystitis/bladder pain syndrome: Management. UpToDate. Retrieved November 22, 2021, from https://www.uptodate.com/contents/interstitial-cystitis-bladder-pain-syndrome-management?search=Interstitial+cystitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H12621973.
- Goldenberg, D. L. (2020, August 26). Clinical manifestations and diagnosis of fibromyalgia in adults. UpToDate. Retrieved November 22, 2021, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-fibromyalgia-in-adults?search=Fibromyalgia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.
Karaca, A., & Durna, Z. (2019). Patient satisfaction with the quality of nursing care. Nursing open, 6(2), 535-545.
Ott, M. J., & Olsen, G. H. (2019). Impact of quality assessment on clinical practice, Intermountain healthcare. In Quality Spine Care (pp. 301-313). Springer, Cham.
Schuiling, K. D., & Likis, F. E. (2022). Gynecologic Health Care: With an introduction to prenatal and postpartum care (4th ed.). Jones & Bartlett Learning.
Tu, F. F., & As-Sanie, S. (2019, July 22). Chronic pelvic pain in adult females: Evaluation. UpToDate. Retrieved November 22, 2021, from https://www.uptodate.com/contents/chronic-pelvic-pain-in-adult-females-evaluation?search=chronic+pelvic+pain+female&source=search_result&selectedTitle=1~124&usage_type=default&display_rank=1#H2253078916.
Singh, M. K. (2021, October 16). Chronic pelvic pain in women follow-up: Further outpatient care, further inpatient care, patient education. Chronic Pelvic Pain in Women Follow-up: Further Outpatient Care, Further Inpatient Care, Patient Education. Retrieved November 22, 2021, from https://emedicine.medscape.com/article/258334-followup#e5.
Wald, A. (2021, February 24). Clinical manifestations and diagnosis of irritable bowel syndrome in adults. UpToDate. Retrieved November 22, 2021, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-irritable-bowel-syndrome-in-adults?search=irritable+bowel+syndrome&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H14.


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