Clinical assessment

History taking

History taking and establishing a good patient-doctor relationship are the keys to success in the management of CPP. Building a good rapport with the patient leads to better acceptance, compliance, and therapeutic outcome.

The interview should be carried out in a comfortable, non­intimidating, private room where the patient is relaxed and able to disclose sensitive information to the physician. The patient should feel well respected and believed as many patients worry that their doctors may think that their condition is ‘all in their head'. From time to time, patients may find the consultation therapeutic if the doctor is a sympathetic listener, able to validate how they feel, and provides opportunities for them to express their own feelings. Consultations for CPP are usually time- consuming and so sufficient time should be allocated for the interview.

It is helpful to start off with a basic sociodemographic history as it can provide a general overview of the essential background infor­mation. Sometimes it is also useful to ask the patient to complete a structured questionnaire which may not only save time, but also elicit sensitive information which the patient may feel uneasy expressing during the consultation. The International Pelvic Pain Society gen­erated a very thorough and useful questionnaire for use and this can be downloaded from their website (http://www.pelvicpain.org.uk).

Details about the pain including the onset, duration, severity, lo­cation, radiation, and any exacerbating or relieving factors should be enquired about.

Exactly when the pain started is an important piece of informa­tion as it may provide clues to its association with specific events such as a surgical episode, medical illness, trauma, accident, or stressful life experience. CPP that occurs after an adverse life event may point towards a psychological cause.

The history should involve a general systematic review of the dif­ferent organs. The presence of specific associated symptoms and their temporal relationship with the menstrual cycle, coitus, pos­ture, urination, or bowel movements will point towards the likely underlying cause. Cyclical pain, which occurs only at a specific time of the menstrual cycle, is likely to be caused by a gynaecological con­dition whereas pain associated with a particular posture or physical activity is more likely to be musculoskeletal in origin. Pelvic pain associated with urinary frequency, urgency, or nocturia is typically due to interstitial cystitis. Improvement of pain with defecation and pain associated with a change in bowel movement is indicative of irritable bowel syndrome.

The severity of the pain should be evaluated. Quantifying the se­verity of the pain may be facilitated by using a pain score of 0-10 or 0-100, a visual analogue scale (marking the pain severity on a 10 cm long line), or a pain questionnaires such as the McGill Pain Questionnaire or more commonly nowadays, the short- form McGill Pain Questionnaire (18, 19), which is less time-consuming and easier to complete. Asking the patient to complete a pain diary also helps to identify potential aggravating factors and assess response to treatments.

The impact of the pain on daily activities should be assessed. The effect on quality of life can be determined by using health-related quality of life questionnaires such as the Short-Form 36 (20). Otherwise, simple questions regarding the effect of pain with refer­ence to work, leisure, sleep, and sexual relationship should be asked. The Society of Obstetricians and Gynaecologists of Canada sug­gested asking two simple and effective questions: ‘On a scale of 0-10, 0 being no pain and 10 being the worst pain imaginable, how is your pain today and how was your pain 2 weeks ago?' (15, 16).

Sensitive issues including a previous history of physical or sexual abuse should be elicited. Sexual dysfunction can also lead to CPP. Infrequent sexual intercourse may indicate a need to seek further details of the woman's sexual history. Patients may not be willing to voice out intimate aspects of their relationship during the first visit but they may do so in subsequent visits, after they have developed a certain amount of trust with the doctor. In cases where her partner always accompanies the patient, a separate consultation with the patient alone is required to allow the patient to freely discuss any hidden matters.

Social history is another important aspect. The patient's occu­pation, lifestyle, and the amount of support she obtains from her partner, family, and friends will influence management options.

A careful drug history especially the patient's response to various analgesics, is necessary to help planning if an additional or alterna­tive analgesic should be offered. Pain improvement after hormonal manipulation is consistent with an underlying gynaecological condition.

At the end of the interview, it is useful to ask about the patient's self-perception of the underlying cause of the pain and her expect­ations about treatment outcome. Any fears and worries brought up should be addressed. Sometimes, patients need reassurance that there is no cancer or life-threatening condition. Setting a realistic goal together with the patient is an important key in developing a good rapport with the patient.

Physical examination

The examination process should begin as the patient enters the consulting room. The patient's gait, posture, body language, and fa­cial expressions should be observed.

Physical examination in women with CPP may require a different approach to that used for other gynaecological patients. Pelvic examination may need to be deferred to a later visit depending on the outcome of the initial consultation and the rapport achieved with the patient.

It is good to be open- minded when performing the exam and have the list of differential diagnoses in your mind. Listen to the patient as you perform the examination as she may volunteer valuable clues during the time of examination. General examination should be performed first and the most uncomfortable bimanual examination and speculum examination should be left to the end.

Explain to the patient what will happen and let her know that the examination can be stopped at any time if she feels uncomfortable. Examination should be performed with confidence and in a system­atic manner. Documenting your examination findings onto a dia­gram or chart may be useful and allows better communication and reference between doctors, as well as the patient. Having a checklist will also make the examination easier and ensures completeness of the exam.

The examination should commence with the patient in the standing position. The presence of any scoliosis and the symmetry of the iliac crest should be noted. The inguinal and femoral hernia sites should be palpated while asking the patient to perform the Valsalva manoeuvre. Any local tenderness in the abdominal wall or low back or sacroiliac joint should be carefully looked for. Varicosities or oedema in the lower limb, if present, should be documented. In selected cases, neurological examination of the lower limb should be performed.

When the patient is in the supine position, apart from routine ab­dominal examination, a single digit palpation should be performed in all four quadrants to illicit any trigger points over the abdominal area.

The patient should now be placed in the lithotomy position. The patient should be offered a mirror to participate in the exam­ination so to allow better understanding of her anatomy as well as better identification the site of pain. Inspection of the external genitalia is carried out to identify any distorted anatomy, scarring, discoloration, trauma, or lesions. A cotton swab or the ‘Q-tip test' is used to identify any trigger points or altered sensation, including the urethral and clitoral region. Care should be taken to identify pos­sible vulval vestibulitis and sometimes further colposcopic examin­ation may be required. Again, any scars from previous episiotomy or perineal repair should be gently palpated to elicit undue tenderness. An intact anal reflex indicates intact pudendal nerve and functional levator ani.

In some cases, vaginal examination may be deferred to a subse­quent visit to allow time to establish rapport. It is useful to begin with ‘unimanual examination', that is, examination with one finger inserted into the vagina, to verify if there is any evidence of vagin­ismus. The lateral vaginal walls should be palpated for any tender­ness, which may indicate reflex sympathetic hypersensitivity.

Finally, bimanual examination should be performed. The uterus should be examined systemically to ascertain the position, size, con­tour, consistency, mobility, support, and any tenderness. A fixed retroverted uterus points towards endometriosis, a bulky tender uterus suggests adenomyosis. The adnexal region is also assessed for any tenderness or masses. Speculum examination is performed in the usual way. Sometimes a smaller speculum may be required. Per rectal examination is not routinely performed but may be indicated if there are significant bowel symptoms.