Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Chronic Pelvic Pain

An Approach

Chronic Pelvic Pain Scope of the Problem

„ Accounts for 10% of gyne assoc visits „ 15-40% laparoscopies „ 12%

Chronic Pelvic Pain

„ Pain localized in the pelvic area nonmenstrually related for >6 months „ Interferes with daily living-impaired function „ Difficult to treat - often incomplete relief „ Difficult to localize „ In best case requires a multidisciplinary approach

1 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Chronic Pelvic Pain

„ Many sources of pain in the lower abdomen „ Not always gynecological „ An excellent history and a high index of suspicion important

Chronic Pelvic Pain Taking a History

„ Detailed chronology of the pain „ Aggravating and alleviating factors „ Previous treatments „ Sense of patient’s interpretation „ Look for nongyne sources „ Establish current impact on daily life „ Standardized history/physicial forms www.pelvicpain.org „ Be sensitive, listen, validate patient

Chronic Pelvic Pain Physical Examination

„ Often defer it to establish rapport „ Best to examine with pain „ Try to reproduce pain- use pictures to document „ Single finger triggers „ Slow and careful detail of abdomen, , and

2 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Chronic Pelvic Pain

Chronic Pelvic Pain Investigations

„ Ultrasound „ Pelvic masses „ adenomyosis „ MRI „ Deep endometriosis, scarring „ adenomyosis „ Diagnostic laparoscopy

Non-gynecologic Causes of Pelvic Pain

„ Gastrointestinal „ Urologic „ Musculoskeletal „ Psychologic

3 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Gastrointestinal Sources of Pain

Gastrointestinal Causes of Pelvic Pain

„ Irritable bowel syndrome „ Chronic appendicitis „ Inflammatory bowel disease (Crohn’s) „ Diverticulitis „ Diverticulosis „ Meckel’s diverticulum

Irritable Bowel Syndrome

„ Most common functional GI complaint – 30% of all patients „ Female:male = 2:1 „ Altered motor reactivity to meals, stress, etc. „ Variations: chronic pain and constipation „ Painless, intermittent diarrhea „ Alternating constipation/diarrhea „ Complicated by hysterics, depressive, bipolar personality disorders „ RX: bulk agents, dietary fiber, sedation

4 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Irritable Bowel Syndrome and Chronic Pelvic Pain

„ 48% of dx scope patients; 40% of patients „ 1 yr after scope, IBS patients less improved „ 1 yr after hyst, IBS less improved

Longstreth, Oct. 1990

Urological Causes of Pain

Urologic Causes of Pelvic Pain

„ Unstable bladder (detrusor instability) „ Urethral syndrome (chronic urethritis) „ Interstitial cystitis

5 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Urethral Syndrome - Diagnosis

„ Diagnosis of exclusion „ No UTI, bladder pathology, detrusor instability „ Symptoms complex „ Urgency, frequency, dysuria „ Urethroscopic findings „ Erythema, exudate, inflammatory fronds and cysts

Urethral Syndrome: Etiologies

„ Chronic urethritis „ Hypoestrogenism „ Urethral spasm „ Urethral stenosis

Urethral Syndrome Clinical Clues: History

„ Pelvic pain „ Dyspareunia „ Post-coital voiding problems

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Urethral Syndrome Physical Examination

„ Urethral tenderness „ Bladder base tenderness „ Absence of uterine tenderness „ Absence of adnexal tenderness

Urethral Syndrome Work-Up

„ Urinalysis „ Cysto-urethroscopy „ Voiding studies

Urethral Syndrome Treatment

„ Chronic antibiotic suppression „ Macrodantin 50 mg qhs x 3 months „ Urethral dilatations „ x3 q 2 weeks

7 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Interstitial Cystitis

„ Chronic, irritative voiding symptoms „ Frequency, urgency, nocturia, pelvic/suprapelvic pain „ Relief with voiding „ Dyspareunia common „ Incontinence unusual „ Dysuria, 1/3

Interstitial Cystitis

„ ? Collagen vascular „ ? Autoimmune „ ? Allergic „ ? Infectious

Interstitial Cystitis

„ Anterior vaginal tenderness „ Sterile urine „ Cytology negative „ Cystoscopy under anesthesia „ Reduced bladder capacity „ Mucosal ulceration „ Petechiae on redistention

8 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Interstitial Cystitis - Treatment

„ Hydrodistention „ Bladder retraining „ Biofeedback „ Antidepressant (e.g., Elavil, Tofranil) „ Antihistamines „ SSRIs „ Pentosan polysulfate (Elmiron)

Muskuloskeletal Causes

Musculoskeletal/Myofascial Causes of Pelvic Pain

„ Fibromyalgia „ adhesions „ Hernias (inquinal, femoral, umbilical, incisional) „ Nerve entrapment (neuritis) „ Fasciitis „ Scoliosis „ Disc disease „ Spondylolisthesis „ Osteitis pubis

9 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Musculoskeletal Screening Examination for Patients Presenting with Chronic Pelvic Pain - History

„ Normal laparoscopy „ History of trauma to low back or lower extremities, including motor vehicle accident or fall „ Pain is altered by positional changes, particularly prolonged standing or sitting „ Lack or response to previous gynecologic intervention „ Exacerbation with stress

Myofascial Syndromes

„ Physical examination „ “Trigger points” „ Pressure reproduces pain

Psychologic Causes of Pelvic Pain

„ Depression „ Anxiety „ Psychosexual dysfunction/abuse „ Hypochondriasis „ Somatization „ Personality disorder

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Chronic Pelvic Pain and Sexual Abuse

„ More dissociation „ Alterations in memory, consciousness, identity „ More psychological distress „ Medically disabled „ Vocational and social dysfunction „ Physical symptoms amplified „ Childhood sexual abuse „ 18/22; 9/21 control „ Severe 12/22 CPP; 1/22 controls

Walker et al. Am J Psych, 1992

Chronic Pelvic Pain

Gynecological Causes

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Gynecologic Causes of Pelvic Pain

„ Endometriosis „ Adhesions „ Chronic PID „ Leiomyomata „ Adenomyosis „ Pelvic congestion syndrome „ Mittelschmertz „ Adnexal masses

Endometriosis

„ Presence of endometrial glands and stroma outside of the endometrial cavity and uterine musculature

Endometriosis

„ Often associated with many distressing and debilitating symptoms „ Pelvic pain „ Dysmenorrhea „ Deep dyspareunia „ Cyclical bowel or bladder symptoms „ Abnormal menstrual bleeding „

12 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Endometriosis

„ Sometimes asymptomatic „ Often incidentally discovered at laparoscopy „ Stage of endometriosis is not correlated with presence or severity of symptoms

Endometriosis: Prevalence

„ 1 % of women undergoing major gynecological surgery „ 1 – 7 % of women undergoing tubal sterilization „ 12 – 32 % of women undergoing laparoscopy for pelvic pain „ 9 – 50 % of women undergoing laparoscopy for infertility

Endometriosis: Management

„ Choice of treatment is dependent on: „ Presence and severity of symptoms „ Extent and location of disease „ Desire for pregnancy „ Age of the patient

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Treatment Options

„ Expectant management „ Medical therapies „ Surgical therapies „ Combination therapies „ Alternative therapies

Medical Therapies

„ Recommended for women with more severe symptoms „ Often first – line treatment „ Choice of treatment depends on „ Severity of pain „ Previous medications used „ Side effects „ cost

Medical Therapies

„ Analgesics „ Hormonal contraceptives „ Progestins „ Gonadotropin - releasing hormone agonists „ Danazol „ Aromatase Inhibitors

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Analgesics

„ Non - steroidal anti - inflammatories (NSAIDs) „ Cox – 2 inhibitors „ Narcotics

„ No large randomized trials „ Effective in controlling pelvic pain usually taken cyclically and preventatively before pain starts „ Does not treat endometriotic lesions

Hormonal Contraceptives

„ Combination of estrogen and progesterone „ Create a pseudopregnancy hormonal environment avoiding fluctuations in estrogen and progesterone levels

„ Cyclical or continuous

Hormonal Contraceptives

„ Good choice as first – line therapy „ Provide contraception „ Low side effect profile „ Low cost

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Progestins

„ Inhibit endometriotic tissue growth by directly causing initial decidualization and eventual atrophy of and endometriosis „ Inhibit pituitary gonadotropin secretion and ovarian hormone production

Progestins

„ Medroxyprogesterone acetate ( MPA ) 10mg TID (up to 50mg daily) „ Norethindrone acetate 5mg OD „ Depot MPA 150mg intramuscularly q 3 months „ Levonorgestrel - releasing intrauterine device ( IUD )

Progestins

„ > 80 % of women have partial or complete relief of pain „ High dose oral MPA as effective as danazol Telimaa et al. Gynecol Endocrinol 1987; 1: 363

„ Depot MPA effective in improving endometriosis- associated pain „ As effective as low dose danazol combined with an OCP but fewer side effects Vercellini et al. Am J Obstet Gynecol 1996; 1: 13

16 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Progestins

„ Levonorgestrel – IUD reduces both pelvic pain and dysmenorrhea Fedele et al. Fertil Steril 2001; 75: 485

„ Side effects: irregular bleeding, nausea, breast tenderness, fluid retention, depression

GnRH Analogs

„ Leuprolide 3.75 mg intramuscular injections q 1 month

Danazol

„ 19 – nortestosterone derivative „ Progestin – like effects „ Inhibits pituitary gonadotropin production and ovarian steroid release „ Direct inhibition of endometriotic implant growth „ Improves endometriosis-associated pelvic pain „ 400 mg bid

17 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Medical Therapies: Advantages

„ Avoids risk of damaging pelvic organs during surgery „ Avoids risks of postoperative adhesion formation „ Treats implants not visualized during surgery

Medical Therapies: Disadvantages

„ Side effects of medications „ High recurrence rates after discontinuation „ No effect on existing adhesions „ No effect on endometriomas „ Infertility during treatments involving suppression of ovulation

Surgical Therapies

„ Conservative „ Definitive „ Ablative

18 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Endometriosis, Chronic Pain and Surgery

„ Fertility not desired, failed medical management - TAHBSO considered treatment option „ Removal of should be considered when doing hysterectomy for pain (even so 3% chance of continued CPP)

Pelvic Adhesions

„ Caused mainly by previous surgery or PID „ Found in 25% - 50% of women with CPP „ Adhesiolysis not always successful for pain relief

Chronic PID

„ CPP reported in approx 20% of patients with previous PID regardless of tx „ Less likely, however, with adequate treatment and no occurrence

19 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Fibroids

„ Not high on the list of cause of CPP „ Dependent on size and location and patient „ Rare for small fibroids to cause pain „ Posterior low fibroids often most likely „ Treatment - surgery

Adenomyosis

„ Presence of endometrial glands in muscle of the „ Risk - multiparous, older „ Uterus diffusely enlarged and soft „ Diagnosed by ultrasound and MRI „ Best treated by TAH

Pelvic Congestion Syndrome

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Pelvic Congestion Syndrome

„ First described in 1857 „ Associated with dilated ovarian and pelvic veins „ Caused by incompetent valves in pelvic veins (6-10% of women have no valves) „ Varicies put pressure causing symptoms „ Most common ages 20-40 „ Pain worse after standing, intercourse or menstruation „ Diagnosed by CT, confirmed by venography „ Treat- clipping, embolization,

Dysmenorrhea

A Review of an Old Friend

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Dysmenorrhea - Definitions

„ “difficult menstrual flow” „ Primary „ Recurrent, crampy pain with menses in the absence of any pathology „ Occurs in adolescents with beginning of ovulatory cycles „ Secondary „ Menstrual pain associated with pathology

Dysmenorrhea Pathophysiology

Estrogen PGF2a Senitized Progesterone PGE2 nerves

pain

Vasopressin MYOMETRIAL CONTRACTION Uterine ischemi a

Cervical Obstruction

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Primary Dysmenorrhea

„ Most common gyne symptom reported by women „ Widespread in diverse population „ 1/3-1/2 report severe enough symptoms to miss work/school „ More common in younger and older women

Primary Dysmenorrhea Risks

„ Early menarche „ Increased menstrual flow „ Family history „ Smoking „ Stress

Primary Dysmenorrhea Diagnosis

„ Crampy suprapubic pain begins just before or after the onset of bleeding-peaks and lasts <24 hrs „ Colicky pain midline and may travel to back or thighs „ Associated with diarrhea, nausea, vomiting, sweats and fever „ Onset soon after menarche or if anovulatory may mean outflow obstruction

23 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Dysmenorrhea History and Physical

„ Menstrual history „ Type, location, radiation of pain „ Associated symptoms and chronology of pain to bleeding „ Associated symptoms „ Dyspareunia „ Physical exam should be normal

Differential Diagnosis

„ Secondary Dysmenorrhea „ Endometriosis „ Adenomyosis „ Fibroids „ Cervical stenosis „ Other causes of pain „ Chronic PID „ Adhesions „ GI „ Sudden onset „ PID „ ectopic

Investigations

„ A good and thorough history „ Complementary investigations if needed to rule out secondary dysmenorrhea „ Laparoscopy if failure to respond to medical management or high index of suspicion for endometriosis

24 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Dysmenorrhea Non-Medical Treatment

„ Exercise „ Exercise associated decrease in pain „ TENS and acupuncture „ Significantly decreases pain „ Topical Heat „ Low topical heat as effective as ibuprofen

Dysmenorrhea Non-Hormonal Treatment

„ OTC meds „ Acetominaphen • Analgesic drug - raises pain threshold „ Ibuprofen • Prostaglandin synthetase inhibitor „ Pamabrom • Mild diuretic „ NSAID „ Start with the onset of bleeding or assoc symptoms „ COX-2 Inhibitors „ Selective cyclo-oxygenase inhibition with less GI „ Meloxicam 7.5mg

Dysmenorrhea NSAID

„ Block synthesis of PG by blocking the enzyme

25 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Dysmenorrhea Hormonal Treatment

„ Combined oral contraceptive „ Suppress ovulation „ Decrease endometrial gland flow „ Decrease prostaglandin production and secretion „ Progestin „ Suppress ovulation, atrophic endometrium „ Levonorgestrel IUD „ Reduction of menstrual blood flow therefore PG

Vulvodynia

Unravelling the mystery

26 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Case #1

„ 28 yo GoPo „ C/O persistent itching (?yeast) monthly after her period „ She has not responded to the OTC meds prescribed by you over the phone „ Cultures are negative

Case #2

„ 32 yo GoPo „ Not currently sexually active „ Screams at PAP smear and you cannot insert the speculum

Case #3

„ 35 yo G2P2 „ Can no longer have intercourse due to extreme pain „ Claims she loves her husband but no longer is interested in sex

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Case #4

„ 40 yo G3P3 „ C/O painful, dry vagina „ Burning after swimming „ Underwear is uncomfortable „ Unable to insert tampon

What is the Common Denominator here?

Case #1

„ 28 yo GoPo „ C/O persistent itching (?yeast) monthly after her period „ She has not responded to the OTC meds perscribed by you over the phone „ Cultures are negative „ Examination reveals normal vagina „ Speculum exam painful yet normal „ Tender to touch at introitus 5 and 7 o’clock

28 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Case #2

„ 32 yo GoPo „ Not currently sexually active „ Screams at PAP smear and you cannot insert the speculum „ Examination reveals tenderness at introitus to touch at 5 and 7 o’clock „ normal

Case #3

„ 35 yo G2P2 „ Can no longer have intercourse due to extreme pain „ Claims she loves her husband but no longer is interested in sex „ Examination painful at introitus at 5 and 7 o;clock - same pain „ Unable to insert speculum

Case #4

„ 40 yo G3P3 „ C/O painful, dry vagina „ Burning after swimming „ Underwear is uncomfortable „ Unable to insert tampon

„ Examination reveals main tenderness at introitus at 5 and 7 o’clock

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What is the Common Problem?

Vulvar Pain Syndromes

„ Chronic vulvar discomfort of at least 3 – 6 months duration „ Burning „ Stinging „ Irritation „ Rawness

Incidence

„ True incidence not known „ Survey of > 4900 women „ 3000 respondents „ 16% reported vulvar pain > 3 months „ 7% had vulvar pain at time of survey

Harlow & Stewart, JAMWA, 2003.

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Incidence

„ 210 consecutive patients assessed in a general gynecology practice „ 37% positive testing for vulvar discomfort „ 15% provoked vestibulodynia „ 20% cases postpartum

Goetsch, AJOG, 1991.

Etiology

„ Poorly understood „ Most cases idiopathic „ Various proposed etiologies „ Most likely neuropathic pain „ Original neural injury can be insignificant or inapparent

Etiology

„ Infectious factors „ Genetic factors „ Immune factors „ Hormonal factors „ Embryologic abnormalities „ Chemical irritants „ Pelvic floor muscle instability

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Clinical Manifestations

„ Diffuse or focal

„ Unilateral or bilateral

„ Constant or sporadic

Clinical Manifestations

„ Raw sensation, burning „ Feeling of grating or sandpaper „ Sensation of swelling, pressure „ Feeling as if sitting on a hard ball or knot „ Triggers „ Coitus, tampon insertion, light touch „ Urinary symptoms

Diagnosis

„ Diagnosis of exclusion

„ Rule out other causes

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Diagnosis: History

„ Onset „ Duration „ Location – focal or generalized „ Provoked or unprovoked „ Intensity – visual analog scale (VAS) „ Associated signs and symptoms

Diagnosis: History

„ Specific skin complaints „ Pruritus „ Localized burning „ Pressure, throbbing „ Skin lesions „ Mass „ Ulceration „ Colour changes

Diagnosis: History

„ Vulvar hygiene practices „ Past medical history „ Herpes simplex or zoster „ Surgeries „ Trauma „ Past psychological history „ Depression and anxiety „ Trauma, post – traumatic stress disorder

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Diagnosis: History

„ Sexual history „ Abuse or trauma

„ Impact on quality of life

Provoked Vestibulodynia

„ Burning not constant „ Localized to vestibule „ Symptoms provoked by „ Coitus, tampons, bicycling, horseback riding, tight pants „ Urinary symptoms common „ May have acute onset of symptoms after some trigger (trauma, childbirth, surgery, infection)

Unprovoked Vulvodynia

„ Commonly postmenopausal „ Chronic, continuous, unprovoked genital burning, stinging, rawness, aching at rest „ Pain generalized, not limited to vestibule „ Pain in perianal, perineal region, inner thighs, vulva, urinary tract „ Often no dyspareunia

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Diagnosis: Physical Examination

„ Inspection of vulva „ Neurologic evaluation „ Tenderness „ Anterior vaginal wall tenderness „ Q - tip testing „ Periurethral and clitoral testing „ Skin and mouth lesions

Q – tip Test

„ Cotton swab applied at 2, 4, 6, 8 and 10 o’clock positions along the vestibule, periurethral and on clitoris, clitoral hood „ Localize painful areas „ Quantify pain (VAS)

Diagnosis: Laboratory Evaluation

„ No laboratory abnormalities associated with vulvodynia „ Lab studies used to exclude specific causes of vulvar pain „ Vaginal pH „ Wet mount „ Yeast culture „ Viral cultures, herpes serology „ and biopsy

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Management

„ No large randomized trials to guide therapy

„ No single treatment effective in all women

Management

„ Education „ Vulvar care measures „ Pharmacotherapy „ Biofeedback and physical therapy „ Counseling „ Surgery „ Multidisciplinary approach

Education

„ Validation „ Education

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Vulvar Care Measures

„ Eliminate irritants „ Loose, white cotton undergarments „ Avoid panty liners „ Avoid scented soaps, shampoo, bubble baths „ Avoid scented detergents „ Avoid washcloths

Vulvar Care Measures

„ Cleanse with water „ Use of mild soap or no soap „ Pat vulva dry „ Apply an emollient without preservatives „ Vegetable oil „ Cool plain petrolatum jelly „ Apply cool packs „ Use lubricants for intercourse

Pharmacotherapy

„ Based on observational data

„ Topical therapies „ Systemic therapies „ Intralesional injections

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Topical Therapies

„ Ointments better tolerated than creams

„ Minimum of 3 weeks allowed before expecting any therapeutic effects

Local Anesthetics

„ Lidocaine 5 % ointment or 2 % jelly „ 30 minutes prior to sexual activity „ Side effects: „ Stinging „ Penile numbness „ Avoid oral contact

Topical Therapies

„ Topical therapies NOT shown to benefit vulvodynia „ Topical testosterone „ Topical antifungal medications

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Systemic Therapies

„ Tricyclic antidepressants „ Anticonvulsants

Tricyclic Antidepressants

„ Commonly used for generalized vulvodynia to treat neuropathic pain „ Reports of benefit for localized vulvodynia „ Nortriptyline / amitriptyline / desipramine „ Amitriptyline 10 mg to 25 mg qhs „ Increase by 10 mg to 25 mg weekly „ Maximum dose of 100 – 150 mg daily „ Should not be stopped suddenly

Tricyclic Antidepressants

„ 4 - 12 weeks before deciding on lack of efficacy „ Side effects: sedation, dry mouth, visual disturbances, tinnitus, palpitations „ 47% complete response in 33 women attending a vulvar pain clinic

Munday, J Obstet Gynaecol, 2001

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Gabapentin

„ 300mg qhs for 3 days „ 300 mg BID for 3 days „ 300 mg TID for 3 days „ Maximum 3600mg daily in TID divided doses „ Side effects: sedation, dizziness, ataxia

Gabapentin

„ 3 – 8 weeks to allow development of tolerance to adverse effects „ Once reach maximum dose, allow 2 weeks before giving assessment on efficacy „ 17 women with vulvar pain - 82% had partial or complete relief with gabapentin

Ben-David & Freidman, Anesth Anal, 1999

Intralesional Injections

„ Trigger point injections „ Triamcinolone acetonide 0.1 % and bupivacaine „ Botulinum Toxin A

40 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg

Biofeedback and Physical Therapy

„ May be used for localized and generalized vulvodynia „ Especially useful with associated vaginismus „ Patients with vulvodynia are more likely to exhibit increased resting pelvic floor muscle tension with fasciculations and overall weakness

Biofeedback and Physical Therapy

„ Physical therapy assessment and treatment „ Exercises „ Manipulations „ Vaginal dilation

Biofeedback and Physical Therapy

„ Surface electromyography to assist pelvic floor rehabilitation „ 79% of women with vestibulodynia returned to sexual activity within 16 weeks of treatment Glazer et al, J Reprod Med, 1995

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Vulvar Vestibulitis

Vulvar Vestibulities

„ Abnormal sensation at the vestibule „ Tenderness „ Sensation of burning „ hot, stinging, rawness, swelling, itching, „ Sensation of "being cut at the bottom” „ Pain upon contact with clothes, especially tight fitting „ Urinary frequency „ Severe pain to touch / attempted vaginal penetration „ Often confused with vaginismus or dyspareunia

Vulvar Vestibulitis Diagnosis

„ High index of suspicion „ Ask about tampons vs pads „ Ask about exercise and changing clothes „ Ask about douching, cleansing and other irritants that touch the vulva „ Ask about OTC treatment

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Vulvar Vestibulitis Treatment

„ Make the diagnosis „ Remove the irritant „ Tampons, cotton pads, „ Remove wet clothing asap „ No bath soaps, soaking, „ Reassurance that with time it can be treated

Vulvar Vestibulitis Fay’s Treatment

„ High dose steroid ointment „ (betnovate) „ Apply SMALL amount „ Q.I.D. for 7 days „ T.I.D. for 7 days „ B.I.D. for 7 days „ O.D. for 21 days „ AVOID INTERCOURSE „ Reasses in 6 weeks

Vulvar Vestibulitis Fay’s Treatment

„ Lidocaine gel before intercourse „ If vaginismum a problem, use relaxation exercises - go slow „ Continue betnovate 1-2 times per week

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