The Importance of Physical Exams and History-Taking in Chronic Pelvic Pain Assessment

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Dr. Paul Perry: "Good morning, I'm Dr. Paul Perry from Birmingham, Alabama. I'm Chairman of the Board of the International Pelvic Pain Society, and this morning we have with us Deborah Metzger. Dr. Metzger has been a founder of the International Pelvic Pain Society and has been on our board since it's conception. Deborah, good morning. I'd like for you to just introduce yourself, and tell us a little bit about yourself, and then we'll get into it."

Dr. Deborah Metzger: "Good morning. I'm Deborah Metzger, I have both a Ph.D. and MD. I had fellowship training in reproductive endocrine and infertility which makes me rather unique in a pelvic pain setting, and most of my practice is devoted to chronic pelvic pain. I'm at Helena Women's Health in Palo Alto, California, and I'm Medical Director there."

Dr. Paul Perry: "Dr. Metzger's been instrumental in having our research committee develop an instrument we hope will be available to all physicians. I'd like Deborah to explain that to us and also to talk about where she sees the society heading in the next four or five years."

Dr. Deborah Metzger: "I'm very, very pleased that this multidisciplinary group has been able to get together and develop a pelvic pain questionnaire designed for women with chronic pelvic pain. Why is that important? If you think about the pelvis, it contains the reproductive organs, the urinary tract, the bowel, muscles, joints, and nerves - so you're talking about a neurologist, urologist, gynecologist, and general surgeon all coming to some consensus on what historical questions are important in evaluating women with chronic pelvic pain. So this is a questionnaire that will be universally applicable to any woman with chronic pelvic pain regardless of who she initially sees for evaluation."

Dr. Paul Perry: "You know that's quite a job. Congratulations, Dr. Metzger, on getting that many physicians to agree on a form that could be used universally. And you might want to remind the clinicians that the form is available free of charge on our website - http://pelvicpain.org - if they want to they can download it and use it in their practice. What do you see is the next step for the Research Committee of the IPPS, and where do you see the future going?"

Dr. Deborah Metzger: "Let's start with where I see us ten years from now. Ten years from now I foresee that chronic pelvic pain will be an integral part of any residency program whether it's urologic, general surgery, or obstetrics and gynecology. I also foresee that there will be a pelvic pain fellowship which will be cross disciplinary so that someone who is initially trained in gynecology will then learn urologic procedures and everything else so they can be a really full service for someone with chronic pelvic pain or at least have the ability to assess the particular needs of a woman. So the question is - how are we going to get to that point? We have lists of diagnoses, and the lists are very long. So how do you hone it down to potential diagnoses and down to something where you can target the treatment or target future diagnostic tests and have it be meaningful in that the pain is addressed and the patients get better? So what I see as the future in order to get to the next ten years is to develop a standardized approach to doing an abdominal pelvic exam for an examination in these women with chronic pelvic pain. What does that mean? I mean, you can check every little place and everything and get places of pain, but what does it mean? For example, if we have pelvic congestion - which is a relatively common problem, and it can co-exist with other recent pelvic pain - how do you isolate that cause out from other reasons for pelvic pain that may or may not exist in the same woman? This is work that I've been doing but it really needs to be extended to other practitioners because right now it's only isolated to my practice and my particular way of doing things. But if we take this woman and we ask her - what kind of pain are you having, where is it, when you have bowel movements - what kind of pain is it? And you get it after discussing with the patient; you isolate it down to several different components of pain. Then you do your exam, and for a woman with pelvic congestion, pressing on the ovarian point on her abdomen and palpating her adnexa and finding out that it reproduces part of her pain. I've taken sixty of those women and have done transcervical neograms, and 81% of those women have evidence of pelvic congestion - so that part of the exam is highly predictive of that finding.

So what if you have a woman who has pelvic congestion, hernias, and endometriosis in the cul-de-sac - how are you going to first of all diagnose all those different components? Then when you're talking about follow up - to see how effective your treatment is - how are you going to follow up? That's why doing the exam is going to be so important because if you break it down to components, for example, we know that for diagnosing occult ingrown hernias - one of the most predictive part of the exam for determining hernias is actually an internal inguinal exam - that's a 100% predictive of hernias. When we do a hernia repair on a woman and three, six, or nine months later we want to see if that part of the procedure was effective at relieving that component of pain, we would repeat the pelvic exam. We would palpate the internal inguinal and find out what the pain score is from 0-10 and correlate that with her improved function and quality of life and all those other things. Likewise, if she also had endometriosis at the same time and most of her pain was in the cul-de-sac, you could palpate the cul-de-sac and get a pain score that way and correlate that with improvement. So we can break things down into components. We look at the most common reasons for chronic pelvic pain, at least that's done in my practice, and I'm at the point now where I would say we're able to assure 90-95% of these patients who basically had no hope. I think we're doing a much better job of putting all of this together, but the most common things are abdominal wall trigger points, pelvic congestion, endometriosis, adhesions, interstitial cystitis, hernias, and duodenum meralgia. Those are the most common ones - so how are we going to ease them out from this mass of symptoms that a woman presents with? That's what my goal is in the next couple of years, to work on developing a paradigm for diagnosis and treatment."

Dr. Paul Perry: "I've heard that's consistent with the philosophy that we're to educate the public, and that there is help available, and to educate professionals that you use the multidisciplinary approach and are trained in the physical diagnosis and history taking. Many of these patients who have no hope suddenly have hope, and I do think that it's true as you said - our success rate continues to climb because we put more and more things together. What do you think the research committee's disseminating role in training will be? You mentioned fellowship but how about the general clinician out there that's seeing only the office gynecologist, even physical therapists - how can we help them help the patients? They may not have a patient who lives in a rural area now that has a clinician trained in the diagnosis and treatment of chronic pelvic pain - so how do we help them gain access?"

Dr. Deborah Metzger: "Again, if we're talking about chronic pelvic pain, we also have to take a multidisciplinary approach to disseminating the information, and so far we've done it in a variety of ways. This meeting here, I think it's very, very important having OBGYN.net cover the meeting. It allows physicians and health professionals who live in rural areas or for one reason or another don't have access to these meetings to access this information and it can be disseminated. Also publishing - it means doing a lot of speaking, speaking out in the public press and also taking some leadership roles in, for example, for pre-op of a committee for residency training in obstetrics and gynecology. Right now physicians are not necessarily taught in their residency anything about common everyday things that they see everyday. They're not taught about the common things. If you see a proportion of time is spent in a residency on oncology or cancer which is usually about six to nine months before your residency, and compare that to how commonly we see pelvic pain - there's like a 50 to 1 ratio, but time spent in a residency is not proportional to how commonly we see these problems."

Dr. Paul Perry: "That's a great point, and I'm sure you agree that most of the things that we've learned about our patients - we've had to learn from our patients, and we weren't taught in our residency, and we weren't offered very frequently in our continued education courses, and that's again another reason for the existence of IPPS. Just to remind people again, it's pelvicpain.org if you want to download the pelvic pain assessment form - they're available. Our committee is going to be working at the Fort Lauderdale meeting in October on trying to correlate a common acceptable physical examination that would, hopefully, not miss any of these things that are common in this life - vestibulitis, hernias, and that type of thing. Dr. Metzger, maybe you better get downstairs to get the meeting started. She's been very busy these past 24-48 hours. I want to thank you again for being with us on OBGYN.net. Thank you very much."