Download Pelvic Pain Referral Form

Pelvic Pain Referral Form
GSTT gynaecology clinic
details
Address
Contact details:
Phone
Fax
Referral date
Referring
doctor:
Address:
Gynaecology Out patients
McNair Centre, Guy’s
Hospital SE1 9RT
020 7188 2000
020 7188 3674
KCH gynaecology
clinic details
Gynaecology
outpatients, Suite 8,
3rd floor, Golden
Jubilee Wing, KCH,
Denmark Hill
London, SE5 9RS
0203 299 3246
(option 1)
Other
0203 299 3471
Email
n/a
System Date
n/a
Referral
urgency
Referring Doctor
Patient
name:
DOB:
Title Forenames Surname
Address:
(include
postcode)
Patient Address List
Phone:
Home Telephone
Mobile Telephone
NHS Number
Practice Address Stacked
Practice Main Telephone
Phone:
NHS number:
DOB
Hospital
Number:
Referral Checklist
This check list is for all patients where the referrer is confident of the diagnosis. DO NOT use if
the pt meets the criteria for 2 wk wait referral or if there is any concern about malignancy
Yes
No
Does the patient have pelvic pain, not associated exclusively with menstruation Yes
No
or intercourse?1
Has pregnancy been excluded?1
Have they had a bimanual examination to try to determine possible causes for
acute pelvic pain e.g. pelvic infection or other pathology?2
Is a GI tract problem, such as IBS, considered unlikely from the history?3
Has a urological cause for the pain been considered e.g. normal MSU?4
Has a musculoskeletal cause for the pain been considered?5
Are there psychological factors contributing to the perception of pain?6
Has the patient had an ultrasound to exclude pelvic pathology?7
Has the patient had an adequate trial of analgesia?
If the pain is cyclical, has the patient had a therapeutic trial of the COC or GNRH
agonist for a period of 3-6 months?8
Is the patient available for surgery within 3 months of appointment?
Reason for referring if answering ‘No’ to any of above:-
NOTES
769887440
Review date: October 2012
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
1Chronic
pelvic pain can be defined as intermittent or constant pain in the lower abdomen or pelvis of at least 6 month’s duration, not occurring
exclusively with menstruation or intercourse and not associated with pregnancy. Patients with a positive pregnancy test fall outside this
guideline.
2 Causes of acute pain include pelvic infection, ruptured or torted ovarian cyst, appendicitis, etc.
3 In one study, 50% of women referred to gynaecologists with pelvic pain had symptoms suggestive of IBS. Symptom-based diagnostic criteria
can be used with confidence to make the diagnosis of IBS with a positive predictive value of 98%. The Rome II criteria for the diagnosis of IBS
are: At least 12 weeks of continuous or recurrent abdominal pain or discomfort associated with at least 2 of the following

relieved by defaecation

associated with a change in frequency of stool

associated with appearance or form of stool.
Other common symptoms of IBS include abdominal bloating and the passage of mucus. Extra-intestinal symptoms such as lethargy,
backache, urinary frequency and dyspareunia may also occur in association with IBS.
4 Studies suggest 38-84% of women with pelvic pain referred to secondary care had symptoms suggestive of interstitial cystitis.
5 The only published study reviewing patients with pelvic pain for musculoskeletal abnormality, suggested that 75% of patients presenting with
pelvic pain had a musculoskeletal abnormality
6 Addressing psychological and social issues which commonly occur in association with chronic pelvic pain may be important in resolving
symptoms.
7 Abdominal ultrasound can be useful to determine possible causes of pain and appropriate clinic for referral.
8 Ovarian suppression can be an effective treatment for pain associated with endometriosis or pelvic venous congestion. Ovarian suppression
can be used as an empirical treatment for cyclical pain prior to laparoscopy.
Information required for referral
Medical history &
examination
Allergies
Medications
Medication Table
Allergy Table
Medication Table
GP comments (including any other relevant information)
769887440
Review date: October 2012