Management of patients with CPP/RAP begins with the initial evaluation.
The approach of the clinician is key in setting the tone for the future relationship with the patient and her family, in convincing the patient that her symptoms are believed to be real, and in assuring her and her family that the clinician will do everything in her/his power to help alleviate the patient’s symptoms.
A thorough history is essential. The physician must elicit all facets of the symptoms, the situations in which they occur, the intensity, factors which help or exacerbate them, and the impact that the symptoms have on the patient’s daily activities and functions, e.g. school absences or limitation of the patient’s social activities. Patients and parents must be interviewed separately for at least part of the visit. The parents must be queried as to their fears about what might be causing the patient’s symptoms. If they, for example, are worried that the patient might have cancer because an older relative who had cancer presented with chronic pain, the clinician must do all that is possible to convince them of the rarity of cancer as cause of chronic pain in children and adolescents and therefore why cancer in their daughter is not a serious consideration.
A thorough physical examination is necessary. This should include a pelvic examination with attention to the adnexa, uterine tenderness, ligaments, and the rectal tone and contents. The patient’s affect should be assessed and compared to their stated expression of tenderness during the examination. A discrepancy between visible signs of discomfort and stated discomfort may be significant.
Once the history and physical examination are completed, pertinent laboratory and imaging studies should be obtained. With almost all causes of CPP, there is little help to be gained from these studies, however.
Finally, at the first visit, a good psychosocial assessment must either be performed or scheduled. This is critical for delineation of stressors that might be precipitating the patient’s symptoms. It also can reveal such phenomena as underlying depression and sexual abuse. By asserting, at the beginning of the diagnostic/management process, that psychosocial factors are just as important as organic ones in detecting the cause of CPP/RAP, the clinician demonstrates to the patient and her family the importance of these issues and makes acceptance of them as possible etiologies much more palatable.
Prior to being sent home, the patient needs some management strategies for her symptoms. Patients and parents are very grateful for things that they can do to help alleviate the pain. Simple things are best. These can include use of heat to the abdomen/pelvis to alleviate muscle tenderness. Mild analgesics can be tried. Diet alterations frequently are helpful if a functional bowel syndrome is suspected. The recording of symptoms in a diary that is to be brought in to the physician at the follow-up visit is a valuable tool for clearer elucidation of the symptom pattern.
It is critical at the first visit to explain and to ‘sell’ the concept of the BPSM to the patient and her family. Frequently, the physician can draw on descriptions of everyday phenomena to explain how the mind, the body, and the social situation are connected. Most teens and adults are aware that when a person has to speak in public, for example, they can get stomach pains or diarrhea. This can be used as an example of such a connection.
Lastly, a follow-up visit needs to be scheduled. At that visit, laboratory and imaging study results are reviewed. If a symptom diary has been kept, it needs to be discussed. If no purely organic cause for the CPP has been found, then the clinician must use this visit and future ones to continue to sell the concept of the BPSM as a cause of functional pain. If depression has been found to be significant, antidepressants can be described. If the patient has been found to have significant amounts of stress in her life, psychotherapy can be very helpful, and it needs to be arranged. Discussions with the girl’s school might need to be held in order to help alleviate stressful situations in that environment. Subsequently, frequent visits for reassurance and to minimize the possibility of future crises should be arranged.
CPP/RAP is a problem that commonly confronts the primary care clinician. By using a reasoned approach based on sound evidence, most patients can be relieved of their symptoms and be helped to resume a normal and active life that will lead to a successful adulthood.
Revision date: June 20, 2011
Last revised: by Jorge P. Ribeiro, MD