Agonizing Pelvic Pain: What's Going On with this 17-year-old? | Case Study

A new case study in which the patient, a 17-yr-old African American female, is having ongoing, excruciating pelvic pain. This case study is based upon the very real experience of a woman I met several years ago. The patient’s diagnosis was hard to come by. Put on your thinking caps and see if you can figure it out. Nurses General Nursing Case Study

Updated:  

Chief Complaint

Patient presents to ER with pelvic pain that she says is 10/10. She is crying and hunched over, clutching her stomach. She says, "I can't stand this for much longer. It's been going on for so long. Why is this happening to me? Why can't anyone help me?” She also complains of poor appetite, constipation, and early feelings of satiety after eating. Her mother is worried her child might have cancer.

History of Present Illness

The patient began complaining to her mother of pelvic pain 6 months ago. The pain was a dull ache in her lower left abdomen that would come and go – sometimes occurring with menstruation, sometimes not. It was accompanied by bloating and a feeling of heaviness. When the pain spiked to a 10/10 and the patient began vomiting, her mother took her to urgent care where she was diagnosed with a hemorrhagic ovarian cyst (a fluid-filled sac or pocket on the surface of or within an ovary). Her physician took a "wait and see" approach and after a week, a follow-up ultrasound showed the cyst had resolved.

Over the past two months, the patient has had three trips to the ER for pelvic pain described as "significant, intermittent, vague abdominal and pelvic pain". The mother says, "The last time we were in the ER, they treated us like we were looking for drugs. The last thing we want is pain medication – we want answers. It is just so hard because you keep telling us there's nothing wrong, but my daughter is in agony. We are not crazy! We need help!”

Pelvic Ultrasound has revealed no further cystic involvement. She is not sexually active and pregnancy tests have been negative.

During her first ED visit, she was treated for abdominal migraine with IV Toradol, Compazine, and diphenhydramine, which did relieve the pain briefly.

General Appearance

Appears as stated age, well-nourished, healthy young adult. She looks tired and tense. Her brow is furrowed, and she moves constantly as if attempting to relieve her pain.

Past Medical History

Prior to the first complaint of pelvic pain, the patient has only had a sprained ankle two years ago from running track.

Family History

The patient is the oldest of four children. She has two brothers ages 15 and 10 and a sister who is 12 years old. No significant health issues for any of her siblings.

Mother: 48 years old, no history of gynecological issues or cancer, all four births were lady partsl, full term.

Father: 52 years old, high blood pressure and prediabetes which he is attempting to control with diet.

Social History

This has been a difficult experience for the patient and her family. Her father is a Baptist minister, and her mother directs religious education at their church. She has a large, extended family who have family suppers every Sunday and Wednesday evening. They are a very loving and close family, and it is obvious they want the best for their daughter, but they are struggling to find ways to talk about their daughter's pain. Their daughter is embarrassed and highly resistant to having internal exams. It was very hard for them to accept that oral contraception would be useful for their daughter, but they have been willing to try what providers have recommended if it seems it will help her.

Prior to her pelvic pain, the patient has been very active in school and church. She runs track, plays volleyball, is a member of the honor society, and sings in her church choir. Her activities have been limited due to her pain.

Medications

Oral contraception to limit/reduce recurrence of ovarian cysts (these do not shrink existing cysts), daily multivitamin

PRN Compazine, diphenhydramine, acetaminophen, ibuprofen

Allergies

NKA

Vital Signs

  • BP 132/85 sitting, RA
  • HR 89
  • RR 17
  • T 98.7o F
  • HT 5'4”’
  • WT 130 lbs

If you've had one ovarian cyst, you're likely to develop more. Most ovarian cysts develop as a result of menstruation (functional cysts). Other types of cysts are much less common. So far, there are no signs of any additional ovarian cysts. Here's a list of other possibilities – what have I missed?

  • Dermoid cyst
  • Cystadenoma
  • Endometriosis
  • Ovarian torsion
  • Pelvic infection
  • Cancer
  • Uterine fibroids
  • Pelvic inflammatory disease
  • GI issues
  • Porphyria
  • Abdominal migraines (was the ED doc right?)
  • Appendicitis
  • Mesenteric artery ischemia
  • Wilson's syndrome
  • Autoimmunity

What labs do you want?

What other diagnostic tests should we run?

Ask me some questions! Let's help this poor girl get her life back.

Specializes in Emergency Medicine.

She needs a CT of the abdomen and pelvis. I would also do a pregnancy test, CBC, and BMP. And I also think a pelvic exam would be appropriate. 

Specializes in Emergency Medicine.

A Doppler ultrasound of the pelvic vessels is also appropriate in this situation. Her pain could be caused by congestion of her pelvic blood vessels. 

Specializes in Student.

Looked at all those labs and the notes closely - everything seems very normal lab and scan wise, but you mentioned chronic pain so I'm shifting brain that side :). There's also the constipation bit which is the only mild symptom that's abnormal. So I'm rearranging our facts:

* The pain comes randomly and is not constant and when it comes its extremely sharp. This may point to something neurological to me which is triggered when something specific happens - maybe some inflammation in the pelvic area?

* Also because of this inflammation, it could be pushing on some part of the GI tract and compressing the path so it becomes harder to have a bowel movement

* The pain is left lower abdomen, so I wonder if she will consent to a colonoscopy for her constipation, in which we can also assess if that is the part that is swollen. Also does she tend to hold her stool for long times, which has caused the colon to swell up? Does the pain usually follow constipation, by any chance?

* Might be also worth looking at her myoglobin and CK levels as well as ESR right now when she has a lot of pain to check muscle inflammation.

* Has she visited a neural specialist so far? That might be interesting to know as well.

That's all for now haha. This is so much fun for me as a student :)

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

Sickle cell screen; nuclear medicine scan w/wo contrast; ortho to check for refererred pain from pelvic / LS spine / hips? 

Specializes in Education, FP, LNC, Forensics, ED, OB.

Just a reminder .....

Don't forget to register a "guess" at the diagnosis in the Admin Help Desk.

1 Votes
Specializes in Oncology, Home Health, Patient Safety.

Thank you so much for participating in this case study. I hope it was more meaningful to you knowing this is a real person. She's doing great now, running track and being a normal kid.

FINAL POST:

Over the course of a year of debilitating pain, the patient saw three different OBGYNs, a GI specialist and two Pediatricians.

As you might imagine, the family suffered along with their child – they continued to look for answers and kept coming up empty, leaving the family with a deep mistrust of the medical field. Finally, after many rounds of online research, the patient’s mother began to suspect pelvic floor dysfunction. She obtained an appointment with a nationally renowned women’s center for pelvic health where the patient was finally diagnosed with pelvic floor dysfunction.

Pelvic Floor Dysfunction

Pelvic floor dysfunction (PFD) is the inability to correctly relax and coordinate your pelvic floor muscles to have a bowel movement. Symptoms include constipation, straining to defecate, having urine or stool leakage, and experiencing a frequent need to pee. Initial treatments include biofeedback, pelvic floor physical therapy and medications.

Symptoms:

  • Frequently needing to use the bathroom. You may also feel like you need to ‘force it out’ to go, or you might stop and start many times.
  • Constipation, or a straining pain during your bowel movements. It’s thought that up to half of people suffering long-term constipation also have pelvic floor dysfunction.
  • Straining or pushing hard to pass a bowel movement or having to change positions on the toilet or use your hand to help eliminate stool.
  • Leaking stool or urine (incontinence).
  • Painful urination.
  • Feeling pain in your lower back with no other cause.
  • Feeling ongoing pain in your pelvic region, genitals, or rectum — with or without a bowel movement.

PFD is different for women and men. For more information about men, check out this website: https://my.clevelandclinic.org/health/diseases/14459-pelvic-floor-dysfunction

Diagnosis is one of exclusion and may involve a physical exam to determine how well the patient can control their pelvic floor muscles. The provider will check internally for spasms, knots, or weaknesses in these muscles.

Other tests include:

  • Surface electrodes to test pelvic muscle control
  • Anorectal manometry to test the efficacy of the anal sphincter
  • Defecating proctogram
  • Uroflow test to see how well the bladder can be emptied

Treatment:

  • Biofeedback – helps over 75% of those with PFD
  • Pelvic floor PT – the patient can be taught exercises to stretch muscles so coordination can be improved.
  • Medications to aid bowel movements.
  • Relaxation techniques such as meditation, warm baths, yoga and other stretching exercises, and acupuncture.

Symptoms typically become worse if they are not treated so it is important to seek a second opinion and obtain an accurate diagnosis.

Patient Outcome

The patient was initially prescribed lady partsl Valium with only mild improvement. The patient was enrolled in a three-week program offered by the specialty clinic. The clinic was 300 miles from their home, so the mother had to stay in a hotel while her daughter did Pelvic PT and body work that included massage therapy along with counseling geared toward dealing with chronic pain. The family was resistant at first to the inclusion of therapy with their daughter’s treatment asking, “Why does she need counseling? There’s nothing wrong with her mind?”

Why include counseling when treating chronic pain?

Codeine, tramadol and oxycodone are often prescribed for teens experiencing chronic pain; however, many families are not filling these prescriptions because of the uncomfortable side effects and the realization that they are serving as a temporary band-aid, along with the knowledge that opioid use in childhood may lead to opioid misuse in adulthood. There is inadequate evidence to support the use of opioids in managing pediatric chronic pain. Chronic pain is complex and deserves a complex treatment approach that includes exercise and psychological counseling including cognitive behavioral therapy. There are issues with access to these services as well as associated stigma with using mental health services. In addition, many teens go undiagnosed for months or even years before being directed to appropriate services.

It was explained to the family that intensive interdisciplinary pain treatment includes a mixture of physical therapy and psychotherapy which helps patients learn to cope better with pain and re-engage with meaningful activities.

Though they still had reservations, the family agreed to the clinic experience. After the clinic, the patient had some relief from the pain. She continued to do PT and three months after her treatment at the clinic, her pain finally resolved.

For an interesting take on treating chronic pain in adolescents, check out this podcast from NPR’s “Invisibilia”: For Some Teens With Debilitating Pain, The Treatment Is More Pain: https://www.npr.org/sections/health-shots/2019/03/09/700823481/invisibilia-for-some-teens-with-debilitating-pain-the-treatment-is-more-pain

References

 

3 Votes

The following are the guesses/diagnoses/rationales from members who came to the Help Desk during the "Agonizing Pelvic Pain: What’s Going On with this 17-year-old?" Case Study.

This was a difficult but very very interesting Case Study, @SafetyNurse1968. THANK YOU!

nursej22

Quote

With all negative labs and imaging, I think this poor girl has endometriosis, which requires laparoscopy for diagnosis. 

lde

Quote

 

This is one is very hard and I don't think this is full right but I am going with:

* Chronic pain with unknown cause r/t inflamed descending/sigmoid colon r/t insufficient hydration

 

NRSKarenRN

Quote

 

Torsion of the Ovary and Fallopian Tube is my guess -- occurs when ovary/fallopian tube becomes twisted on its ligament support.
Clues: 

sudden, severe pain left lower quadrant

nausea and vomiting

not pregnant confirmed with pregnancy test

reported not sexually active

hx ovarian cyst

MRI or laparoscopy indicated to confirm, surgery to repair/untwist structures.

https://www.childrens.com/specialties-services/conditions/torsion-of-the-ovary-and-fallopian-tube 

 

?Good job everyone! ?

Be on the lookout for the next Case Study by @SafetyNurse1968

1 Votes
Specializes in nutrition.

It's an interesting and detailed case study.
If diagnosed earlier, the pelvic floor can be treated by physiotherapy procedures. In this case, a traumatic injury to the pelvic area might be the reason -since it is the reason in many cases. Pelvic floor physiotherapy might b a great option as helps to relax the muscles and it would be of great relief to the patient. The therapist  will be able to locate which muscles (lower back, pelvis and pelvic floor) are really tight and teach specific exercises to stretch these muscles so their coordination can be improved.

1 Votes
Specializes in Oncology, Home Health, Patient Safety.
On 9/22/2021 at 2:29 AM, christenDavis said:

It's an interesting and detailed case study.
If diagnosed earlier, the pelvic floor can be treated by physiotherapy procedures. In this case, a traumatic injury to the pelvic area might be the reason -since it is the reason in many cases. Pelvic floor physiotherapy might b a great option as helps to relax the muscles and it would be of great relief to the patient. The therapist will be able to locate which muscles (lower back, pelvis and pelvic floor) are really tight and teach specific exercises to stretch these muscles so their coordination can be improved.

Yes! I’ve had pelvic floor PT and it’s incredible what they can do. It’s fairly invasive- the PT had her hands in some places this young lady wasn’t open to. It’s a difficult proposition for someone so young. I know gymnasts routinely get this therapy with great results. 

1 Votes
On 8/14/2021 at 5:44 PM, SafetyNurse1968 said:

Thank you so much for participating in this case study. I hope it was more meaningful to you knowing this is a real person. She's doing great now, running track and being a normal kid.

FINAL POST:

Over the course of a year of debilitating pain, the patient saw three different OBGYNs, a GI specialist and two Pediatricians.

As you might imagine, the family suffered along with their child – they continued to look for answers and kept coming up empty, leaving the family with a deep mistrust of the medical field. Finally, after many rounds of online research, the patient’s mother began to suspect pelvic floor dysfunction. She obtained an appointment with a nationally renowned women’s center for pelvic health where the patient was finally diagnosed with pelvic floor dysfunction.

Pelvic Floor Dysfunction

Pelvic floor dysfunction (PFD) is the inability to correctly relax and coordinate your pelvic floor muscles to have a bowel movement. Symptoms include constipation, straining to defecate, having urine or stool leakage, and experiencing a frequent need to pee. Initial treatments include biofeedback, pelvic floor physical therapy and medications.

Symptoms:

  • Frequently needing to use the bathroom. You may also feel like you need to ‘force it out’ to go, or you might stop and start many times.
  • Constipation, or a straining pain during your bowel movements. It’s thought that up to half of people suffering long-term constipation also have pelvic floor dysfunction.
  • Straining or pushing hard to pass a bowel movement or having to change positions on the toilet or use your hand to help eliminate stool.
  • Leaking stool or urine (incontinence).
  • Painful urination.
  • Feeling pain in your lower back with no other cause.
  • Feeling ongoing pain in your pelvic region, genitals, or rectum — with or without a bowel movement.

PFD is different for women and men. For more information about men, check out this website: https://my.clevelandclinic.org/health/diseases/14459-pelvic-floor-dysfunction

Diagnosis is one of exclusion and may involve a physical exam to determine how well the patient can control their pelvic floor muscles. The provider will check internally for spasms, knots, or weaknesses in these muscles.

Other tests include:

  • Surface electrodes to test pelvic muscle control
  • Anorectal manometry to test the efficacy of the anal sphincter
  • Defecating proctogram
  • Uroflow test to see how well the bladder can be emptied

Treatment:

  • Biofeedback – helps over 75% of those with PFD
  • Pelvic floor PT – the patient can be taught exercises to stretch muscles so coordination can be improved.
  • Medications to aid bowel movements.
  • Relaxation techniques such as meditation, warm baths, yoga and other stretching exercises, and acupuncture.

Symptoms typically become worse if they are not treated so it is important to seek a second opinion and obtain an accurate diagnosis.

Patient Outcome

The patient was initially prescribed lady partsl Valium with only mild improvement. The patient was enrolled in a three-week program offered by the specialty clinic. The clinic was 300 miles from their home, so the mother had to stay in a hotel while her daughter did Pelvic PT and body work that included massage therapy along with counseling geared toward dealing with chronic pain. The family was resistant at first to the inclusion of therapy with their daughter’s treatment asking, “Why does she need counseling? There’s nothing wrong with her mind?”

Why include counseling when treating chronic pain?

Codeine, tramadol and oxycodone are often prescribed for teens experiencing chronic pain; however, many families are not filling these prescriptions because of the uncomfortable side effects and the realization that they are serving as a temporary band-aid, along with the knowledge that opioid use in childhood may lead to opioid misuse in adulthood. There is inadequate evidence to support the use of opioids in managing pediatric chronic pain. Chronic pain is complex and deserves a complex treatment approach that includes exercise and psychological counseling including cognitive behavioral therapy. There are issues with access to these services as well as associated stigma with using mental health services. In addition, many teens go undiagnosed for months or even years before being directed to appropriate services.

It was explained to the family that intensive interdisciplinary pain treatment includes a mixture of physical therapy and psychotherapy which helps patients learn to cope better with pain and re-engage with meaningful activities.

Though they still had reservations, the family agreed to the clinic experience. After the clinic, the patient had some relief from the pain. She continued to do PT and three months after her treatment at the clinic, her pain finally resolved.

For an interesting take on treating chronic pain in adolescents, check out this podcast from NPR’s “Invisibilia”: For Some Teens With Debilitating Pain, The Treatment Is More Pain: https://www.npr.org/sections/health-shots/2019/03/09/700823481/invisibilia-for-some-teens-with-debilitating-pain-the-treatment-is-more-pain

References

 

Poor kid. So young to have such a rough condition. I’m 39 and have dealt with the pain since I was in my mid 20’s. Therapy for chronic pain is definitely needed. My experience was developing the pain, not understanding what it was, losing sleep bc of the pain, and then it spiraled out of control. I came home from work and laid down in bed. For years. Had to learn to live with an untreated chronic pain condition. My mental health declined further and further. I’m only now in physical therapy for it, and that’s because I specifically asked for it. Not one doctor recommended it to me. I just found it on Youtube. 

When I was first diagnosed with interstitial cystitis, not yet knowing it went beyond that to my whole pelvic floor, I was in so much pain at work one day. My boss told me to go home. I reached out to my urogynecologist and they were able to see me right then. I was in tears sitting in front of the doctor. He asked me, “What do you want me to do about it? Prescribe Vicodin?” In a very invalidating, just snarky tone. I didn’t have an idea of what I wanted from him because he was supposed to be the expert. He wrote me a script for Vicodin and sent me on my way. I later found a Dr who actually treated the condition. (Tried to, anyway. They didn’t  know then near as much as what we do now) I requested my medical records from my old doctor and that doctor wrote on my chart “Wants Vicodin.” I have a condition that literally causes suicidal ideation and this doctor just completely brushed me off and tried to tell another doctor I was seeking pain meds. Infuriating. 

1 Votes

My diagnosis is an ectopic pregnancy. Get  her into OR.

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