Page 244 Guide to Pain Management in Low-Resource Settings

232 Susan Evans

If any part of the examination causes pain, ask the • Regular gentle exercise (e.g., walking, stretching,
patient if this is the same pain she has with intercourse. gentle yoga), improved posture, sitting square in
It is important to examine the lower vagina gently with a comfortable chair with good support, keeping
one fi nger before using the speculum, or pelvic fl oor/ both feet fl at on the fl oor when sitting, and taking
bladder pain may be missed. Generalized dyspareunia, regular breaks.
especially where sharp pains are present, may be neu- • Heat packs to the pelvis and a warm bath 1–2
ropathic. Include in the consultation a discussion about times daily for 3–6 weeks
the relationship she has with her husband and whether • Management of anxiety and depression, if present.
he is supportive of her.
When should I refer my patient
How can I help my patient with pelvic pain to a surgeon?
with a painful vulva (vulvodynia)? Surgery should be considered where nonsurgical treat-
General vulval care is often helpful. Th e patient should ments have failed. Laparoscopy is preferred to laparoto-
not use soap and should avoid vulval products such my where it is safe and available. However, laparoscopy
as talc or oils. Recommend aqueous cream as a soap, requires advanced surgical equipment and skills, and
soother, and daily vulval moisturizer. Recommend cot- major surgical complications do occur. It is therefore
ton underwear and loose clothing. Treat any vaginal important to try nonsurgical options fi rst. Endometrio-
infection. Prescribe amitriptyline 5–25 mg at night or sis surgery is frequently diffi cult and requires the best
an anticonvulsant for vulval pain if present. For vulvar surgical skills available. Situations that suggest severe
vestibulitis, prescribe a course of oral ketoconazole (an- disease, possibly requiring a bowel surgeon as well as a
tifungal) 200 mg and betamethasone cream (0.5 mg/g) gynecologist, include:
applied thinly daily for 3 weeks. For lichen sclerosis, • Th e presence of ovarian endometriomas.
prescribe steroid cream applied thinly daily for intermit- • Nodules of endometriosis palpable in the recto-
tent courses only when symptoms are present. vaginal septum.
• An immobile uterus.
How can I help my patient • Pain opening the bowels during the menstrual
with painful pelvic muscles? period.
Th e muscles are in spasm and do not relax normally. In premenopausal women, if postoperative estro-
Th is type of pain can be secondary to painful bladder gen replacement is unavailable, bilateral oophorec-
symptoms, any type of pelvic pain, previous sexual as- tomy should be avoided, if possible. Endometriomas
sault, or anxiety regarding sexual intercourse. Pain is se- in young women should be managed with cystectomy
vere, just as pain from back spasms can be severe. Typi- rather than oophorectomy in most cases. Drainage
cal symptoms include dyspareunia (with pain for 1–2 alone of an endometrioma is usually followed by rap-
days afterwards), pain on moving, pain with insertion of id recurrence.
a fi nger or a speculum, and pain with tampons. Th ere
may be pain on prolonged sitting. Pelvic fl oor muscle What are common barriers to
spasm is involuntary, and the patient cannot “just relax.” eff ective pain management?
Th e best treatment involves pelvic fl oor physiotherapy,
instruction in relaxation techniques, and the regular use A long delay between the beginning of symptoms and
of vaginal dilators in a relaxed, secure, nonpainful situ- the diagnosis and management of pelvic pain is com-
ation. Intercourse should be avoided until the problem mon for many reasons. Th e patient’s family may not
has resolved because the problem will worsen with re- believe that her pain is real and severe, she may believe
peated painful intercourse. If intercourse continues, that severe pain with periods is normal, or her local
a vaginal lubricant and a slow approach to intercourse doctor may believe that she is too young for endome-
may help. Other treatments include: triosis or underestimate how severe her pain is.
• Resolution of initiating factors, e.g., bladder Other barriers to eff ective pain management include
symptoms/pelvic pain. fear of gynecological examination, especially where a
• Avoid straining with voiding or trying to stop female doctor is unavailable; fear of surgery, infertility,
passing urine in mid-void. and cancer; and fear of the unknown.