FIGURE 1 The basic algorithm in caring for patients with chronic pelvic pain.
DESCRIBING THE SUBJECT
The above-mentioned basic choice is important, but of course there is more to say. It is also a dilemma. Doing comprehensive somatic investigation and then drawing the conclusion that nothing serious is wrong and that no disease causing the pain is found, might satisfy both patient and clinician. On the other hand, it has the intrinsic risk of giving the patient the idea that the pain is somatic and needs to be seen in a biomedical perspective. This may interfere with the next step: developing a pain management programme in which there is no biomedical solution offered. Looking the other way round, there is the possible risk of harm when not doing investigations. Two kinds of harm can be mentioned. The first one is missing a well known or serious disease causing the pain and yielding a treatable cause. The other one is the ongoing discussion between patient and clinician about this subject. This may be based on important anxieties unaddressed in the patient and even in the clinician. This uncertainty can be a large obstacle in pain management and can have huge consequences for the patient-clinician relationship. As a clinician, one might lose contact with the patient who will then go to the next doctor to get his questions answered. This risk versus harm dilemma makes us clear that it is of utmost importance to work closely together with your patient as a team. The assessment done, the therapy proposed and the evaluation of the results, all should be performed with consent of both clinician and patient. In these team meetings the relatives (partner, children, parents) should be invited to take part in the discussion. Looking at chronic pain using a bio-psycho-social model will lead to the involvement of all three compartments. One might say that the ‘clinician-patient-relatives’ model is the practical application of the model. The earlier in the whole process the integrated model of pain is introduced, the more options will be available for negotiations with the patient and the stronger the team will become. Combining is the word that should be remembered by all dealing with chronic pelvic pain patients. Do not go for a purely somatic approach. Do not go for a purely psychological approach. Apply both from the very beginning. Consequence of this saying is that medical doctors need to have a form of psychological training allowing them to understand the needs of the patient. On the other hand the psychologist should be aware of the somatic items involved with CPP. For now in practice this means that patients with CPP are seen in a multidisciplinary practice by a team of experts in pain management.
Medical doctors often seem to hesitate introducing the role of psychology and consequently the psychologist, when talking about chronic pelvic pain. For those clinicians it might help to start talking about these aspects from the very beginning and in the same manner as talking about the physical aspects. Starting to ask the patient what his beliefs about the pain are and then build the plan on this beliefs will provide the basis for an explanation of functional changes in the pain system that constitute chronic pain.
Assessment
Diagnosing a patient with chronic pelvic pain, without appropriate investigations is unacceptable. In every patient a thorough history should be taken and physical examination must be done. When taking a history it is important to pay attention to the function of all the tracts that are represented in the pelvis: lower urinary, anorectal, gynaecological, neurological, and sexual. The psychological aspects are also addressed in the history taking. Including childhood and development, the family in which the patient has grown up along with the current social situation. Are there any losses in life (relatives, jobs); is there any trauma (physical, sexual, emotional) that need to be discussed further?
The physical examination should be focused on, but not limited to, the pelvis. Inspection and palpation are the most applicable testing methods. Inspection of the skin and mucosal tissue is the starting point. In women, a quantification of pelvic organ prolaps is mandatory. After inspection palpation of the internal and external pelvic organs is performed. In women a vaginal and sometimes rectal examination is done to palpate the pelvic organs including bladder, uterus and anal canal. In men, the external genitalia should be palpated and the prostate and bladder should be screened by performing a rectal exam. In both men and women the pelvic floor muscles should be palpated and testing of the function should be done. Classification of the pelvic floor muscle function is preferably done according to the International Continence Society (ICS) system [3].
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