Pelvic Pain

Case 5 – Pelvic Pain in a 36 year old Woman
1.0 History
1.1 Presenting Complaint
A 36 year old woman presented with 4/12 history of suprapubic pain, radiating to her lower back and legs. The pain is worse at the start of her menstrual cycle (pain scale 8/10) and is intermittent, but not fully relieved at any time during the month. She also feels like there is pressure on her bowels and her bladder, she states she feels as if she needs to pass urine and faeces “all the time”. Regular paracetamol and ibuprofen has been useful in controlling the pain.
1.2 History of Presenting Complaint
She has regular menstrual cycles lasting 28 days, her LMP was 18/04/2016. She has had no menorrhagia or intermenstrual bleeding. The pain is not worse with
A referral letter was written for Bunbury ED. She was told to continue using anti-inflammatory meds and paracetamol PRN for pain relief.
Critique
Personally I don’t like the idea of referring patients with pelvic pain for ultrasound without first doing a speculum examination and bimanual palpation. I understand that some GPs don’t do them if they can be avoided as they potentially increase the risk of complaints, but I think that this needs to be done as part of a routine examination for pelvic pain.
She was referred directly to ED because the GP was concerned about this pain being caused by something more sinister
6.0 Follow Up
The patient was followed up in GP clinic following results of the tests done in Bunbury ED. She was informed about the diagnosis of Adenomyosis being the likely source of her pain, and that she would be referred to a specialist gynaecologist for discussion about treatment options. As of this time she is still waiting for that appointment.
7.0 Evidence Based Medicine
7.1 EBM
A 2007 review of prospective studies used the criteria discussed above to determine the diagnostic accuracy of TVS and MRI, comparing imaging findings to histopathology findings after hysterectomy.2 TVUS was found to have a sensitivity of 74%, specificity of 87%, a PPV of 68% and NPV of 89%.2 Comparatively, MRI was found to have a sensitivity of 81%, specificity 91%, PPV 76%, and NPV 93%.2 This result demonstrated a slightly greater diagnostic accuracy for MRI (though not statistically significant), however both techniques demonstrated sufficient diagnostic accuracy required for diagnosis. Another systematic review published in 2010 also concluded that both modalities produced sufficiently high accuracy for diagnosis of adenomyosis, with comparable sensitivities and specificities.3 This review included 6 prospective studies and demonstrated pooled sensitivities and specificities for TVS as 72% and 81% respectively; in comparison, pooled sensitivities and specificities for MRI were 77% and 80%