Pathway for the initial management of non-acute pelvic pain final 2019 09 13 Version 1

Pathway for the management of non-acute pelvic pain in women in primary care

Symptoms: Low abdominal / pelvic pain, deep dyspareunia, painful periods, cyclical bowel or bladder symptoms

History:

Gynaecology, obstetric, contraceptive, bladder, bowels, sexual, past medical / surgical

Recent onset of pain Post-coital bleeding Recent partner change Onset after invasive procedure

including coil insertion, miscarriage or childbirth

Past history of PID or ectopic pregnancy

Pain throughout menstrual cycle (although may be worse during period)

Supports irritable bowel (IBS)

Supports endometriosis Supports pelvic inflammatory disease (PID)

Long duration of pain Periods painful Premenstrual pain Dypareunia Pain on defecation (especially

cyclical) Pain / bleeding on micturition

(especially cyclical) Better with pill / Depo-Provera

or during pregnancy Fertility problems associated

with at least one of the above

Pain related to food type or ingestion

Pain relieved with defecation Change in frequency and

appearance of stool (constipation, diarrhoea, or both)

Bloating

NB these are the commonest causes; other diagnoses are less common but should be

considered

Examination: Vulvovaginal (speculum), abdominal, bimanual

Mucopurulent discharge Cervical contact bleeding Low abdominal tenderness Uterine / adnexal tenderness

on bimanual examination No masses palpable

Supports PID Supports endometriosis

Uterus / adnexae non-mobile Nodules or irregularity in

posterior fornix Uterine / adnexal tenderness

on bimanual examination No masses palpable

Supports irritable bowel (IBS)

Normal Palpable tender colon General tenderness on

bimanual examination

Swabs: High vaginal and cervical for MC&S, vaginal or cervical for chlamydia PCR (NAATs)

Chlamydia or gonorrhoea ** Bacterial vaginosis Cervicitis (pus cells +++)

Supports PID *

Negative

Supports endometriosis Supports irritable bowel (IBS)

Negative

* Absence of infection in the lower genital tract does not exclude PID, but testing is recommended as a

positive result strongly supports the diagnosis

** All patients with positive gonorrhoea swabs should be referred to Sexual Health Dorset for

further management 0300 303 1948

Pathway for the initial management of non-acute pelvic pain final 2019 09 13 Version 1

Therapeutic trial:

Treat according to 2019 BASHH guidelines

• doxycycline 100mg bd PO x 2/52 + metronidazole 400mg bd PO x 2/52 + ceftriaxone 1g IM stat in 3mL 1% lidocaine) or

• ofloxacin* 400mg bd PO x 2/52 + metronidazole 400mg bd PO x 2/52 *contraindicated in <18 yr olds

Treat sexual partner as well

Suspected PID

Menstrual suppression for 3 months (oral contraceptive pill, progestogen-only pill, Depo-Provera, Mirena coil)

Suspected endometriosis Suspected irritable bowel (IBS)

Manage according to guidelines with dietary review, antispasmodics +/- bulking agents

Better

Supports diagnosis Regard as fully fertile (though

risk of infertility increases with repeated episodes of PID)

Supports diagnosis Advise continue menstrual

suppression unless trying to conceive

Supports diagnosis

Partial response

No better

May benefit from further antibiotics

Request pelvic ultrasound scan (USS)

Refer to GUM or gynaecology Consider psychosexual medicine

(PSM) referral

Request pelvic USS Refer to gynaecology (DCH,

RBCH or Poole) Consider PSM referral

Request pelvic USS Consider trial of menstrual

suppression Refer to gynaecology Consider PSM referral

Request pelvic USS Refer to gynaecology (Dorset

County, Royal Bournemouth or Poole hospitals)

Consider PSM referral

Refer to gastroenterology

Further management according to guidelines

Resources:

See over for referral details 2019 BASHH national guideline on the management of pelvic inflammatory disease 2012 RCOG guidelines on the initial management of chronic pelvic pain 2017 NICE guidelines on endometriosis diagnosis and management 2017 NICE CKS: irritable bowel syndrome

Pathway for the initial management of non-acute pelvic pain final 2019 09 13 Version 1

Referral following failed initial management of

non-acute pelvic pain in women in primary care

Indications for referral to Sexual Health Dorset:

• Assessment and management of women with pelvic pain prior to, or following, initiation of investigation and treatment

• Positive gonorrhoea swab

• Gonococcal or chlamydial PID

• Under 18 year olds, for whom ofloxacin is contraindicated, if ceftriaxone im cannot be given The sexual health clinics are not part of the choose and book system and patients should be referred directly. If the patient telephones for an appointment 0300 303 1948, they will normally be seen within 2 working days.

West Dorset: The Park Centre for Sexual Health, Melcombe Avenue, Weymouth, Dorset DT4 7TB 01305 762 682, Fax 01305 762 695. Dr C Priestley has a special interest in pelvic pain.

East Dorset: Department of Sexual Health, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW 01202 704 644, Fax 01202 304 509

Indications for referral to Gynaecology:

• Chronic pelvic pain of likely gynaecological origin, which has not responded to a trial of treatment for PID or endometriosis.

Refer via choose and book.

Dorset County Hospital (DCH): Department of Women’s Health Mr M Shoukrey, Miss B Dandewate and Mr A Mukherjee have an interest in pelvic pain and laparoscopic surgery.

Royal Bournemouth Hospital (RBH): Department of Gynaecology Mr A Taylor has an interest in pelvic pain and laparoscopic surgery.

Poole General Hospital (PGH): Department of Gynaecology Mr T Carpenter (Dorset Lead clinician for endometriosis), Miss L Melson and Mr D Webster have an interest in pelvic pain and laparoscopic surgery.

Indications for referral to Dorset Endometriosis Centre:

• Suspected severe endometriosis on history or examination

• Laparoscopy showing deep endometriosis involving bowel, bladder or ureter Refer via choose and book.

Poole General Hospital: Dorset Endometriosis Centre Mr T Carpenter is the Dorset Lead clinician for endometriosis.

Indications for referral to psychosexual medicine service:

• Chronic pelvic pain that is affecting sexual function

See Sexual Health Dorset website https://sexualhealthdorset.org/about-us/psychosexual-service for referral details.