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% hysterectomies
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, vulva, vagina and cervix
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 hysterectomy 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
6 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
10 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
11 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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 Infertility
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
13 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
14 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
15 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
Progestins
Inhibit endometriotic tissue growth by directly causing initial decidualization and eventual atrophy of endometrium 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 ovaries 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 uterus Risk - multiparous, older Uterus diffusely enlarged and soft Diagnosed by ultrasound and MRI Best treated by TAH
Pelvic Congestion Syndrome
20 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
21 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
22 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
27 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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 Pelvic examination 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
29 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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.
30 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
31 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
32 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
34 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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 Colposcopy and biopsy
35 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
36 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
37 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
38 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
39 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
41 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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
42 Saturday at the University - February 27, 2010 1120 AM - Chronic Pelvic Pain - Dr Fay Weisberg
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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