In chronic pain states, the pain is no longer adaptive. The initial painful input produces a persistent abnormal state of increased responsiveness called central sensitization (67). It is not known why in some individuals or in certain settings, prolonged stimuli or injury will result in sensitization. Different regions of the CNS are important in modulating the sensory and affective components of the pain response. Pain persistence is fostered by adverse or traumatic early experience, conditioning, fear, arousal, depression, and anxiety.
On the first visit, a thorough pain history should be performed, taking into consideration the nature of each pain symptom: location, radiation, severity, aggravating and alleviating factors; effect of menstrual cycle, stress, work, exercise, intercourse, and orgasm; the context in which pain arose; and the social and occupational toll of the pain (Table 16.4). A visual or verbal analog pain scale to record pain severity 0 through 10 and stating “no pain” and “worst possible pain” is important in assessing the severity of pain and comparing the changes in severity over subsequent visits. The evaluation should include a comprehensive questionnaire that addresses depression, anxiety, emotional, physical and sexual trauma, quality of life, and criteria to assist with the diagnosis of irritable bowel syndrome and interstitial cystitis or bladder pain syndrome. The International Pelvic Pain Society published a comprehensive pain assessment tool in order to facilitate the history and physical examination, which can be found on the International Pelvic Pain Society’s Web site and reprinted and reproduced (68).
Diagrams of a woman’s abdomen, back, and genital area should be used to help the patient define the location of pain (2). The patient should be questioned about symptoms specific to the types of pathology listed in Table 16.3.
1.
Genital (abnormal vaginal bleeding, abnormal vaginal discharge, dysmenorrhea, dyspareunia, sub-fertility, sexual functioning) 2.
Enterocoelic (constipation, diarrhea, ﬂatulence, hematochezia, and relationship of pain to times of altered bowel function or form and pain relief with bowel movements) 3.
Musculoskeletal/neuropathic (physical trauma—surgical or injury, exacerbation with exercise or postural changes, weakness, numbness, lancinating pain)
Table 16.4 Pain History Mneumonic
GI, gastrointestinal; GU, genitourinary. From Rapkin AJ, Howe CN. Chronic pelvic pain: a review. In: Family practice recertification. Monroe Township, New Jersey: Medical World Communications, 2006; 28:59–67.
4.
Urologic (urgency, frequency, nocturia, hesitancy, dysuria, hematuria, incontinence) 5.
Psychological (previous diagnoses, hospitalizations, and medications, current depression, anxiety, panic, including suicidal ideation, past and current emotional, physical, or sexual trauma)
Record a thorough gynecological, medical, and surgical history; medication, ethanol, or recreational drug intake; prior evaluations for pain with outcome; and review prior operative and pathology reports. Prior physical, emotional, and sexual trauma or abuse should be ascertained (69–71). The attitude of the patient and her family toward the pain, resultant behavior of the patient and her family, and current upheavals in the patient’s life should be discussed. The part of the history relating to sensitive issues may have to be revisited after establishing rapport with the patient.