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Primary Care Management of Abdominal and Pelvic Pain
INTRODUCTION
In the Netherlands, the General Practitioner (GP) is seen as the gatekeeper to the health care system. Essentially all patients have to pass via the GP to gain access to specialist care. Access to GP’s is free of charge leaving no financial barricades in seeking his or her help. All patients with abdominal pain are seen by a GP, other specialists (if necessary) for treatment, or when they remain in chronic pain for which no diagnosis is found. During all stages of treatment or follow-up, GP’s will be involved either directly or indirectly.
This chapter deals with basic aspects of abdominal pain as seen in primary practice. The occurrence of abdominal pain and the most common diagnoses are explored as well as when and to whom to refer. Finally the management of chronic abdominal pain is dealt with.
The family doctor due to his role and relationship with the patient is pivotal in the whole process of diagnosis, treatment and support of patients with (chronic) abdominal-pelvic pain.
BASIC ASPECTS
The term used in general practice to describe abdominal-pelvic pain is ‘abdominal pain’. This might seem rhetoric but quite often no clear diagnosis is made during the first contact. During follow-up abdominal pain can be specified (e.g. Inflammatory Bowel Disease). However, more often than not the term used to describe the patients complaint remains abdominal pain. The terms pelvic pain and abdominal pain are often used to describe the same phenomena.
Epidemiology of Abdominal Pain in Primary Practice in the Netherlands
Abdominal pain comes in many forms and is a common complaint in all ages and both sexes. It can be presented as localized pain or a more general complaint; furthermore, it can be episodic or more chronic.
On average, one fifth of all people have a period of abdominal pain each year. A mere quarter of these patients will actually visit a doctor. An average GP with a population of 2,300 patients will see slightly more than 100 people with acute abdominal pain each year. Women are seen twice as often as men [1].
In 80% of the cases, the final diagnosis of an episode of acute abdominal pain is found to have its origin in the gastro-intestinal system. The majority is a “symptom” diagnosis like Irritable Bowel Syndrome or constipation. Approximately 10% of abdominal pain is a urinary system diagnosis [1].
To illustrate the treatment of patients with (sub) acute abdominal pain by Dutch GP’s a case study concerning Johanna will be presented.
Johanna, a case study
Johanna is a 22 year old woman. You have known her for 15 years as a generally healthy individual. You have seen her once for an ear infection and as a high school attendee she suffered from menstrual pains for which you prescribed anti-inflammatories. You have lost sight of her during the last few years as she started studying psychology in a nearby town.
She is suffering from lower abdominal pain for the last few days and is additionally slightly constipated. The pain is more or less continuous. Her last period started almost a week ago and was slightly less productive than she is used to. She has no further health complaints. She is a student and has no steady relationship. She is heterosexual. She stopped using oral contraceptives 6 months ago. For the occasional sexual encounter she uses condoms. She has had no untoward sexual experiences in the past.
She is concerned about the pain and wonders if it has anything to do with her period.
Upon examination, you find a slightly tender lower abdomen whereby the left side is more tender. There are no signs of acute inflammation. On vaginal examination there is some discharge and you can feel a fecal mass in the rectal pouch. She has no fever. Her urine is clean. Her CRP is < 5. You have taken vaginal swabs for PCR testing on Chlamydia as there is a likelihood of a sexually transmitted disease, even though there are no real signs of pelvic inflammatory disease upon investigation. After a few days you get the results back and no Chlamydia was detected.
After considering your findings the most likely diagnosis in Johanna’s case is dysmenorrhea, possibly due to endometriosis. Constipation could possibly also play a part.
You decide to treat her constipation with advice and possibly laxatives. You restart oral contraceptives, which will also solve the problem of unreliable contraception. Obviously the risk of PID will only be reduced by using barrier contraception.
You instruct her to come back if there is no improvement in the condition and sooner than planned if alarm-symptoms like fever, rectal blood loss or general feeling of illness arise. In three months’ time, you decide to review her.
DESCRIBING THE SUBJECT
SOEP Methodology
GP’s in the Netherlands use the so called SOEP (Subjective, Objective, Evaluation, Plan) methodology. This helps to structure the consultation and makes a uniform registration possible and can easily be done within ten minutes.
• The “S” stands for subjective; essentially history-taking. As well as inquiring to the history of the current complaint other involved systems also are inquired into. In the case of abdominal/pelvic complaints this includes the gastro-intestinal and urogenital systems. In the case of menstrual complaints it is important not to forget to ask about previous sexual experiences. There is a significant correlation between untoward sexual experiences and menstrual complaints [9].
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