Current System of Triage

There is a tendency to respond to a patient’s complaint of pelvic pain in the following manner:

1. The patient calls the physician and states that she is having pain and desires an appointment. In a large health system she is triaged by the appointment clerk with a simple question of the region of the pain. The patient identifies the anatomic area as being in the pelvic area and therefore she is referred to a women’s health specialist. The patient may also refer herself directly to a gynecologist.
2. The patient is screened as having already identified pain in the pelvic area and therefore the assumption is that the pain is of an organic nature related to the internal pelvis. After a brief history and physical examination, laparoscopy is then scheduled to identify the source of the pain.
3. In < 50% of the cases is pathology related to the pelvic anatomy identified and therefore over half of these patients are not assisted by the laparoscopic procedure.²
4. The patient is then frequently given a referral for psychiatric evaluation with the comment that since the laparoscopic examination of the pelvis is negative, the pain must be associated with some psychological disorder ("the pain is in her head").

The differential diagnosis of the patient with chronic pelvic pain includes the following:

1. Gynecological disease including endometriosis, adhesions (chronic pelvic inflammatory disease), leiomyoma, pelvic congestion syndrome, and adenomyosis.
2. Gastrointestinal disease including irritable bowel syndrome, diverticulitis, diverticulosis, chronic appendicitis, and Meckel’s diverticulum.
3. Genitourinary disease including interstitial cystitis, abnormal bladder function (bladder dyssynergia), and chronic urethritis.
4. Myofascial disease including fasciitis, nerve entrapment syndrome, and hernias (inguinal, femoral, spigelian, umbilical, and incisional).
5. Skeletal disease including scoliosis, L1-L2 disk disorders, spondylolithesis, and osteitis pubis.
6. Psychological disorders including somatization, psychosexual dysfunction, and depression.

There is another condition which may be related to complaints of pelvic pain in those individuals who have had pelvic surgery and now are re-experiencing pain. This is a syndrome whose parallel is the "phantom limb" syndrome in amputees. A neuropathy may develop that is generated from regrowth of nerve tissue or development of a neuroma that causes a reinstigation of the firing of the neural elements in the brain which had previously identified an area as being a source of pain.

With such a broad range of anatomical and disease entities that may exist in the patient with chronic pelvic pain, it is not surprising that attempts to identify the source of pain by immediate laparoscopy would result in a very low percentage of positive findings.² Prior to any operative procedures being performed, a very careful history must be obtained from these patients. However, obtaining a history from a patient in pain is a very difficult enterprise because patients who are in pain are frequently depressed and find accurate communication difficult.

To obtain useful information by interviewing a patient with pain, a systematic approach must be utilized. This type of systematic approach was first described by Kresch,¹⁰ who developed a series of forms to obtain information from the pelvic pain patient. The use of these types of forms for acquisition of information has been found to be very useful in the evaluation of patients with pelvic pain. Forms provide the interviewer with the opportunity to obtain detailed histories and give the interviewer data which can be analyzed with the use of the Wilcoxon Signed Rank Test for comparison of pre- and post-treatment states.¹¹ Five sets of forms are recommended which are derived from the original Kresch style but which utilize scaling on a 0 to 10 basis to allow the individual to more completely identify the level of discomfort and provide the researcher with an opportunity to evaluate pre- and post-treatment based on known statistical evaluation tools (These five forms are provided full sized in the appendix for photo copying purposes.).

The addition of the Beck Depression Inventory¹² to these forms is a useful adjunct to identify patients for whom immediate psychological evaluation should be provided.

The history for a pelvic pain patient requires the use of five separate forms:

1. Monthly pain calendar
2. Symptoms checklist
3. Pain questionnaire
4. Pain mapping
5. Psychological assessment (related history form)

It may be helpful to perform the Minnesota Multiphasic Evaluation¹³ for those patients in whom psychological disorders are suspected or are felt to play a major part in the patient’s complaints.

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