DOCSLIB.ORG

Common Causes of Chronic Pelvic Pain Diagnoses Description Dysmenorrhea • Dysmenorrhea Is Pain During Menstruation That Is Not Associated with Well-Defined Pathology

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Common Causes of Chronic Pelvic Pain Diagnoses Description Dysmenorrhea • Dysmenorrhea Is Pain During Menstruation That Is Not Associated with Well-Defined Pathology Common Causes of Chronic Pelvic Pain Diagnoses Description Dysmenorrhea • Dysmenorrhea is pain during menstruation that is not associated with well-defined pathology. • Primary dysmenorrhea: cramping pain in the lower abdomen, originating in the uterus • Secondary dysmenorrhea: painful menstruation resulting from pelvic pathology such as endometriosis • Dysmenorrhea is considered a chronic pain syndrome if it is persistent and associated with negative cognitive, behavioral, sexual or emotional consequences. Dyspareunia • Dyspareunia is characterized as pain before, during, or after sexual activity. It is not solely caused by lack of lubrication. • Dyspareunia may present as superficial, deep, or both. • Superficial: discomfort at entry of vaginal introitus • Deep: complaint of pain or discomfort on deeper penetration • Causes of dyspareunia include atrophic vaginitis, vulvar vestibulitis, lichen sclerosis, endometriosis, scar adhesions, and trauma. Endometriosis • Endometriosis is when endometrial tissue typically found in the uterus is found outside of the uterus. • Most women with endometriosis experience pelvic pain during their menstrual cycles but many also have pain that is unrelated to their period. Fibromyalgia syndrome • Fibromyalgia affects the muscles, tendons, ligaments, and soft tissues of the body. • Fibromyalgia causes pain throughout entire body, including the vulvar and pelvic/hip region. • Symptoms of fibromyalgia include extreme fatigue, sleep disturbances, burning sensations throughout body. Interstitial cystitis/ • Interstitial cystitis is characterized by: painful bladder syndrome o Urinary urgency: feeling the need to urinate o Urinary frequency: urinating up to every 5-10 minutes o Pelvic Pain: in the vulva, pain with intercourse, or pain in the lower back and hips. • Many foods and drinks may trigger interstitial cystitis. Fruit juices such as oranges, cranberry and tomato are bladder irritants. Caffeine stimulates bladder nerves, causing pain, inflammation and irritation of the bladder. Additionally, nerve stimulation produces urinary frequency. Pudendal Neuralgia • Neuralgia is a pain in the distribution of a nerve • Pudendal nerve is formed primarily by S2-S4. It branches into rectal, perineal, and dorsal nerve • Pain will be in the region of the three branches • May be exacerbated by sitting • There will not be sensory deficits (this would be associated with neuropathy) • Bowl, bladder, sexual dysfunction Vaginismus • Vaginismus is the involuntary clenching of the pelvic muscles that surround the outer third of the vagina, specifically the perineal and levator ani muscles. • Vaginismus can cause pain in the hips, lower back, and gluteal muscles during or after sex. Vulvodynia • Vulvodynia is an umbrella term used to describe idiopathic pelvic pain lasting at least three months. • The pain can be intermittent or constant and may be generalized, localized, or mixed. Pain is often worse at night and right before periods. Other Adhesions/scar tissue • Adhesions are areas of fibrous scar tissue. Adhesions are part of a normal healing process but for some can lead to pain. • Adhesions pain may result from surgeries including c-sections, myomectomy, hysterectomy, laparoscopic procedures, episiotomy, vestibulectomy, hymenotomy, perineal tear, or vulvar biopsies. • Adhesion pain may also result from endometriosis, previous abdominal surgery, or infection, such as appendicitis. Trauma • The chronic pelvic pain population has estimated 48-56% history of abuse • This does not only include sexual trauma, it is important to consider other events that individuals may not consider as a trauma such as a laborious birth Herman & Wallace (2020, March). Pelvic Pain Specific Diagnoses. In Kimberly Glow. Pelvic Floor Function, Dysfunction and Treatment (Level 1). Lecture conducted from Princeton, NJ. .
Load more

Recommended publications
  • Vaginitis and Abnormal Vaginal Bleeding
    UCSF Family Medicine Board Review 2013 Vaginitis and Abnormal • There are no relevant financial relationships with any commercial Vaginal Bleeding interests to disclose Michael Policar, MD, MPH Professor of Ob, Gyn, and Repro Sciences UCSF School of Medicine [email protected] Vulvovaginal Symptoms: CDC 2010: Trichomoniasis Differential Diagnosis Screening and Testing Category Condition • Screening indications – Infections Vaginal trichomoniasis (VT) HIV positive women: annually – Bacterial vaginosis (BV) Consider if “at risk”: new/multiple sex partners, history of STI, inconsistent condom use, sex work, IDU Vulvovaginal candidiasis (VVC) • Newer assays Skin Conditions Fungal vulvitis (candida, tinea) – Rapid antigen test: sensitivity, specificity vs. wet mount Contact dermatitis (irritant, allergic) – Aptima TMA T. vaginalis Analyte Specific Reagent (ASR) Vulvar dermatoses (LS, LP, LSC) • Other testing situations – Vulvar intraepithelial neoplasia (VIN) Suspect trich but NaCl slide neg culture or newer assays – Psychogenic Physiologic, psychogenic Pap with trich confirm if low risk • Consider retesting 3 months after treatment Trichomoniasis: Laboratory Tests CDC 2010: Vaginal Trichomoniasis Treatment Test Sensitivity Specificity Cost Comment Aptima TMA +4 (98%) +3 (98%) $$$ NAAT (like GC/Ct) • Recommended regimen Culture +3 (83%) +4 (100%) $$$ Not in most labs – Metronidazole 2 grams PO single dose Point of care – Tinidazole 2 grams PO single dose •Affirm VP III +3 +4 $$$ DNA probe • Alternative regimen (preferred for HIV infected
    [Show full text]
  • ICD-9-CM and ICD-10-CM Codes for Gynecology and Obstetrics
    Diagnostic Services ICD-9-CM and ICD-10-CM Codes for Gynecology and Obstetrics ICD-9 ICD-10 ICD-9 ICD-10 Diagnoses Diagnoses Code Code Code Code Menstral Abnormalities 622.12 Moderate Dysplasia Of Cervix (CIN II) N87.2 625.3 Dysmenorrhea N94.6 Menopause 625.4 Premenstrual Syndrome N94.3 627.1 Postmenopausal Bleeding N95.0 626.0 Amenorrhea N91.2 627.2 Menopausal Symptoms N95.1 626.1 Oligomenorrhea N91.5 627.3 Senile Atrophic Vaginitis N95.2 626.2 Menorrhagia N92.0 627.4 Postsurgical Menopause N95.8 626.4 Irregular Menses N92.6 627.8 Perimenopausal Bleeding N95.8 626.6 Metrorrhagia N92.1 Abnormal Pap Smear Results 626.8 Dysfunctional Uterine Bleeding N93.8 795.00 Abnormal Pap Smear Result, Cervix R87.619 Disorders Of Genital Area 795.01 ASC-US, Cervix R87.610 614.9 Pelvic Inflammatory Disease (PID) N73.9 795.02 ASC-H, Cervix R87.611 616.1 Vaginitis, Unspecified N76.0 795.03 LGSIL, Cervix R87.612 616.2 Bartholin’s Cyst N75.0 795.04 HGSIL, Cervix R87.613 Cervical High-Risk HPV DNA 616.4 Vulvar Abscess N76.4 795.05 R87.810 Test Positive 616.5 Ulcer Of Vulva N76.6 Unsatisfactory Cervical 795.08 R87.615 616.89 Vaginal Ulcer N76.5 Cytology Sample 623.1 Leukoplakia Of Vagina N89.4 795.10 Abnormal Pap Smear Result, Vagina R87.628 Vaginal High-Risk HPV DNA 623.5 Vaginal Discharge N89.8 795.15 R87.811 Test Positive 623.8 Vaginal Bleeding N93.9 Disorders Of Uterus And Ovary 623.8 Vaginal Cyst N89.8 218.9 Uterine Fibroid/Leiomyoma D25.9 Noninflammatory Disorder 623.9 N89.9 Of Vagina 256.39 Ovarian Failure E28.39 624.8 Vulvar Lesion N90.89 256.9 Ovarian
    [Show full text]
  • How to Evaluate Vaginal Bleeding and Discharge
    How to Evaluate Vaginal Bleeding and Discharge Is the bleeding normal or abnormal? When does vaginal discharge reflect something as innocuous as irritation caused by a new soap? And when does it signal something more serious? The authors’ discussion of eight actual patient presentations will help you through the next differential diagnosis for a woman with vulvovaginal complaints. By Vincent Ball, MD, MAJ, USA, Diane Devita, MD, FACEP, LTC, USA, and Warren Johnson, MD, CPT, USA bnormal vaginal bleeding or discharge is typically due to either inadequate levels of estrogen one of the most common reasons women or a persistent corpus luteum. Structural causes of come to the emergency department.1,2 bleeding include leiomyomas, endometrial polyps, or Because the possible underlying causes malignancy. Infectious etiologies include pelvic in- Aare diverse, the patient’s age, key historical factors, flammatory disease (PID). Additionally, a variety of and a directed physical examination are instrumental bleeding dyscrasias involving platelet or clotting fac- in deciding on diagnosis and treatment. This article tors can complicate the normal menstrual period. Iat- will review some common case presentations of rogenic causes of vaginal bleeding include hormone nonpregnant female patients with abnormal vaginal replacement therapy, steroid hormone contraception, bleeding, inflammation, or discharge. and contraceptive intrauterine devices.3-5 Anovulatory bleeding is common in perimenar- ABNORMAL VAGINAL BLEEDING chal girls as a result of an immature hypothalamic- To ensure appropriate patient management, “Is she pituitary axis and in perimenopausal women due to pregnant?” should be the first question addressed, declining levels of estrogen. During reproductive since some vulvovaginal signs and symptoms will years, dysfunctional uterine differ in significance and urgency depending on the bleeding (DUB) is the most >>FAST TRACK<< answer.
    [Show full text]
  • Vaginal Atrophy (VVA)
    Information Sheet Vulvovaginal symptoms after menopause Key points • Vulvovaginal symptoms are numerous and varied and result from declining oestrogen levels. • Investigate any post- menopausal bleeding or malodorous discharge. • Management includes lifestyle changes as well as prescription and non- prescription medications. • As women age they will experience changes to their vagina and urinary system largely due to decreasing levels of the hormone oestrogen. • The changes, which may cause dryness, irritation, itching and pain with intercourse1-3 are known as the genito-urinary syndrome of menopause (GSM) and can affect up to 50% of postmenopausal women4. GSM was previously known as atrophic vaginitis or vulvovaginal atrophy (VVA). • Unlike some menopausal symptoms, such as hot flushes, which may disappear as time passes; genito-urinary problems often persist and may progress with time. Genito-urinary symptoms are associated both with menopause and with ageing4. • Changes in vaginal and urethral health occur with natural and surgical menopause, as well as after treatments for certain medical conditions (Please refer to AMS Information Sheet Vaginal health after breast cancer: A guide for patients). Why is oestrogen important for vaginal health? • The vaginal area needs adequate levels of oestrogen to maintain tissue integrity. • The vaginal epithelium contains oestrogen receptors which, when stimulated by the hormone, keep the walls thick and elastic. • When the amount of oestrogen in the body decreases this is commonly associated with dryness of the vulva and vagina. • A normal pre-menopausal vagina is naturally acidic, but with menopause it may become more alkaline, increasing susceptibility to urinary tract infections. A number of factors, including low oestrogen levels, have been implicated in the development of UTIs4-7 and vaginitis8-9 in postmenopausal women.
    [Show full text]
  • The Woman with Postmenopausal Bleeding
    THEME Gynaecological malignancies The woman with postmenopausal bleeding Alison H Brand MD, FRCS(C), FRANZCOG, CGO, BACKGROUND is a certified gynaecological Postmenopausal bleeding is a common complaint from women seen in general practice. oncologist, Westmead Hospital, New South Wales. OBJECTIVE [email protected]. This article outlines a general approach to such patients and discusses the diagnostic possibilities and their edu.au management. DISCUSSION The most common cause of postmenopausal bleeding is atrophic vaginitis or endometritis. However, as 10% of women with postmenopausal bleeding will be found to have endometrial cancer, all patients must be properly assessed to rule out the diagnosis of malignancy. Most women with endometrial cancer will be diagnosed with early stage disease when the prognosis is excellent as postmenopausal bleeding is an early warning sign that leads women to seek medical advice. Postmenopausal bleeding (PMB) is defined as bleeding • cancer of the uterus, cervix, or vagina (Table 1). that occurs after 1 year of amenorrhea in a woman Endometrial or vaginal atrophy is the most common cause who is not receiving hormone therapy (HT). Women of PMB but more sinister causes of the bleeding such on continuous progesterone and oestrogen hormone as carcinoma must first be ruled out. Patients at risk for therapy can expect to have irregular vaginal bleeding, endometrial cancer are those who are obese, diabetic and/ especially for the first 6 months. This bleeding should or hypertensive, nulliparous, on exogenous oestrogens cease after 1 year. Women on oestrogen and cyclical (including tamoxifen) or those who experience late progesterone should have a regular withdrawal bleeding menopause1 (Table 2).
    [Show full text]
  • Vulvovaginal Atrophy: a Common—And Commonly Overlooked— Problem Mary H
    The Warren Alpert Medical School of Brown University GERI A TRI C S FOR THE Division of Geriatrics PR ac TI C ING PHYSICIAN Quality Partners of RI Department of Medicine EDITED B Y AN A Tuya FU LTON , MD Vulvovaginal Atrophy: A Common—and Commonly Overlooked— Problem Mary H. Hohenhaus, MD, FACP Mrs. K is a 67-year-old woman presenting for a brief All postmenopausal women are at risk for vaginal atrophy. follow-up visit. You treated her for an E. coli urinary Smokers are more estrogen deficient compared with nonsmok- tract infection last month, but she feels well today and ers and may be at higher risk. Engaging in regular sexual activ- offers no complaints. Her blood pressure and lipids ity, whether through intercourse or masturbation, appears to are well controlled on low doses of a single antihyper- decrease risk, possibly through increased blood flow. Women tensive and a lipid lowering agent. She still struggles using anti-estrogen medications, such as aromatase inhibitors with smoking, but has cut down to a few cigarettes a for adjuvant treatment of breast cancer, are more likely to experi- day. She also reports her husband has finally turned ence severe symptoms. over the family business to their children, and they Women may not volunteer symptoms related to vulvovagi- are enjoying spending more time together. When you nal atrophy. The symptomatic woman can experience vaginal ask if there is anything else she needs, she hesitates dryness, burning, and pruritus; yellow, malodorous discharge; for a moment before asking, “Is there anything I can urinary frequency and urgency; and pain during intercourse and do to make sex more comfortable?” bloody spotting afterward.
    [Show full text]
  • Female Chronic Pelvic Pain Syndromes 1 Standard of Care
    BRIGHAM AND WOMEN’S HOSPITAL Department of Rehabilitation Services Physical Therapy Standard of Care: Female Chronic Pelvic Pain Syndromes ICD 9 Codes: 719.45 Pain in the pelvic region 625.9 Vulvar/pelvic pain/vulvodynia/vestibulodynia (localized provoked vestibulodynia or unprovoked) 625.0 Dyspareunia 595.1 Interstitial cystitis/painful bladder syndrome 739.5 Pelvic floor dysfunction 569.42 Anal/rectal pain 564.6 Proctalgia fugax/spasm anal sphincter 724.79 Coccygodynia 781.3 Muscular incoordination (other possible pain diagnoses: prolapse 618.0) Case Type/Diagnosis: Chronic pelvic pain (CPP) can be defined as: “non-malignant pain perceived in structures related to the pelvis, in the anterior abdominal wall below the level of the umbilicus, the spine from T10 (ovarian nerve supply) or T12 (nerve supply to pelvic musculoskeletal structures) to S5, the perineum, and all external and internal tissues within these reference zones”. 1 Specifically, pelvic pain syndrome has been further defined as: “the occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction with no proven infection or other obvious pathology”.1 Generally, female pelvic pain has been defined as pain and dysfunction in and around the pelvic outlet, specifically the suprapubic, vulvar, and anal regions. A plethora of various terms/diagnoses encompass pelvic pain as a symptom, including but not limited to: chronic pelvic pain (CPP), vulvar pain, vulvodynia, vestibulitis/vestibulodynia (localized provoked vestibulodynia or unprovoked vestibulodynia), vaginismus, dyspareunia, interstitial cystitis (IC)/painful bladder syndrome (PBS), proctalgia fugax, levator ani syndrome, pelvic floor dysfunction, vulvodynia, vestibulitis/vestibulodynia dyspareunia, vaginismus, coccygodynia, levator ani syndrome, tension myaglia of the pelvic floor, shortened pelvic floor, and muscular incoordination of the pelvic floor muscles.
    [Show full text]
  • The Prevalence of Bacterial Vaginosis and Candidiasis in Postmenopausal Women
    THE PREVALENCE OF BACTERIAL VAGINOSIS AND CANDIDIASIS IN POSTMENOPAUSAL WOMEN Ivanka Hadji Petrusheva Meloska1, Konstantin Icev1, Branko Jaglikovski1, Anica Hadji-Petrusheva Jankijevikj2, Biljana Curcic-Trajkovska2. 1Avicena Laboratory, Skopje, Macedonia.; 2Clinical Hospital Acibadem Sistina, Skopje, Macedonia Graph 3. Nugent‘s score among different age groups INTRODUCTION MATERIAL AND METHODS RESULTS The prevalence of BV (assessed as a Bacterial vaginosis (BV) is the most A total of 750 vaginal and cervical 500 NS of >or=7) in postmenopausal common cause of vaginal symptoms swabs, collected from 450 women was low (5,6% - 42 cases) and 400 characterized by a change of vaginal postmenopausal women age 40-69 350 NS1-4 GV was isolated in most of those 300 flora from years, were examined. BV was NS 4-6 cases. A high percentage (51.0% - 383) 250 predominant Lactobacillus to diagnosed microscopically by 200 NS>7 of postmenopausal women (NS of 1-4) 150 replacement with anaerobes such as Nugent's score (NS), the presence of had decreased number of lactobacilli 100 Gardnerella vaginalis (GV). Bacterial leukocytes in the slides was noted and no BV -associated 50 0 vaginosis occurs when the normal too. Detection of aerobic and microorganisms. In this category there age 40-49 age 50-59 age 60-69 lactobacilli of the vagina are replaced anaerobic bacteria and fungi was were 35 cases with leukocytes in the Graph 4. Microbiology findings by mostly anaerobic bacteria. performed by conventional vaginal smear, where cultures 60 p<0.05 Diagnosis is commonly made using microbiological methods. revealed presence of enterobacteriaceae and gram positive 50 the Nugent criteria, which include 40 cocci.
    [Show full text]
  • FAQ028 -- Vaginitis
    AQ FREQUENTLY ASKED QUESTIONS FAQ028 fGYNECOLOGIC PROBLEMS Vaginitis • What is vaginitis? • What can cause vaginitis? • How is vaginitis diagnosed? • How is vaginitis treated? • What is a yeast infection? • What causes yeast infections? • What factors increase the risk of getting a yeast infection? • What are the symptoms of a yeast infection? • What treatments are available for vaginal yeast infection? • Should I use an over-the-counter medication to treat a yeast infection? • What is bacterial vaginosis? • What are the symptoms of bacterial vaginosis? • How is bacterial vaginosis treated? • What is trichomoniasis? • What are the symptoms of trichomoniasis? • How is trichomoniasis treated? • What is atrophic vaginitis? • Glossary What is vaginitis? Vaginitis is an inflammation of the vagina. As many as one third of women will have symptoms of vaginitis sometime during their lives. Vaginitis affects women of all ages but is most common during the reproductive years. What can cause vaginitis? A change in the balance of the yeast and bacteria that normally live in the vagina can result in vaginitis. This causes the lining of the vagina to become inflamed. Factors that can change the normal balance of the vagina include the following: • Use of antibiotics • Changes in hormone levels due to pregnancy, breastfeeding, or menopause • Douching • Spermicides • Sexual intercourse • Infection How is vaginitis diagnosed? To diagnose vaginitis, your health care professional will take a sample of the discharge from your vagina and look at it under a microscope. Your health care professional also may suggest other tests. How is vaginitis treated? Treatment will depend on the cause of the vaginitis.
    [Show full text]
  • SOME GYNECOLOGICAL PROBLEMS in the Agedt
    SOME GYNECOLOGICAL PROBLEMS IN THE AGEDt Gerald W. Korn, M. I have selected just three topics for this dis- However, carcinoma of the vulva and the vagina have cussion and try to give some practical tips as to the a higher incidence in the aged. management of some of the problems that fall under Where there has been a definite blood loss, it is these headings. For the purpose of this discussion, I mandatory to perform a comprehensive examination am using the age of seventy as the lower limit of of the pelvic organs. This should include (1) a care- the aged female, although, or course, many of the ful inspection of the external genitalia (2) a speculum problems that I will mention can occur in women examination (3) a bimanual examination (4) a cer- much younger than that. However, I am trying to vical and posterior vaginal wall smear (5) a curet- avoid getting into the perimenopausal era, which has tage in almost all cases (6) a biopsy of any lesions its own particular problems. suspected as being the site of the bleeding. Postmenopausal bleeding is my first large group Even where one has found an obvious vaginal, of problems and, as you are well aware, there is a urethral or cervical lesion, a curettage should be per- long list of causes of this symptom. However, in the formed where the bleeding has been of significance. aged, the number of likely causes can be reduced to Perhaps the only exclusions should be where there a small list-others being of considerable rarity.
    [Show full text]
  • Common Gynaecological Histories
    Common Gynaecological Histories Remember history taking in gynaecology requires you to ask extra questions on the Menstrual history, Obstetric history, Sexual history and Cervical/contraception history (MOSC) – see the gynaecological history section! Presenting Exploding symptom Relevant system reviews Differential diagnoses Clues to differential complaint Grouping Differentials Pelvic pain Site General Gynaecological PID/acute •Bilateral pelvic pain Onset •Fever, sweats salpingitis •Vaginal discharge Character •Dyspareunia and dysmenorrhoea Radiation Gynaecological •Fever Associated symptoms •PV bleeding: menorrhagia/inter- •May be post-coital or inter-menstrual Timing & relation to period menstural/post-coital/post- bleeding Exacerbating/relieving factors menopausal Ectopic pregnancy •Recent period of amenorrhoea Severity •PV discharge •Trying to get pregnant or unprotected sex •Pain: dysmenorrhoea, •May be some vaginal spotting dyspareunia •In tubal rupture, collapse and shoulder tip •Chance could be pregnant pain Ovarian cyst •Sudden unilateral pelvic pain Urological torsion/rupture/ •May be fever/vomiting •Storage: frequency, volume, haemorrhage urgency/ nocturia •Infection: dysuria, haematuria Endometriosis •Cyclical pelvic pain •Dysmenorrhoea Gastrointestinal •Deep dyspareunia •Weight: loss, appetite change •Menstural disturbance •Work down body: dysphagia, Urological Pyelonephritis •Fever, chills, rigors nausea/ vomiting, indigestion/ •Loin pain heartburn, bowel habit change, •Urinary frequency and dysuria blood/ mucus in stool
    [Show full text]
  • Evaluation and Differential Diagnosis of Dyspareunia LORI J
    PROBLEM-ORIENTED DIAGNOSIS Evaluation and Differential Diagnosis of Dyspareunia LORI J. HEIM, LTC, USAF, MC, Eglin Air Force Base, Florida Dyspareunia is genital pain associated with sexual intercourse. Although this con- dition has historically been defined by psychologic theories, the current treatment O A patient infor- approach favors an integrated pain model. Identification of the initiating and pro- mation handout on dyspareunia, written mulgating factors is essential to reaching a successful diagnosis. The differential by the author of this diagnoses include vaginismus, inadequate lubrication, atrophy and vulvodynia article, is provided (vulvar vestibulitis). Less common etiologies are endometriosis, pelvic congestion, on page 1551. adhesions or infections, and adnexal pathology. Urethral disorders, cystitis and interstitial cystitis may also cause painful intercourse. The location of the pain may be described as entry or deep. Vulvodynia, atrophy, inadequate lubrication and vaginismus are associated with painful entry. Deep pain occurs with the other con- ditions previously noted. The physical examination may reproduce the pain, such as localized pain with vulvar vestibulitis, when the vagina is touched with a cotton swab. The involuntary spasm of vaginismus may be noted with insertion of an examining finger or speculum. Palpation of the lateral vaginal walls, uterus, adnexa and urethral structures helps identify the cause. An understanding of the present organic etiology must be integrated with an appreciation of the ongoing psycho- logic factors and negative expectations and attitudes that perpetuate the pain cycle. (Am Fam Physician 2001:63:1535-44,1551-2.) Members of various yspareunia is genital pain ex- Epidemiology family practice depart- perienced just before, during ments develop articles There are few reports of clinical trials relat- 1 for “Problem-Oriented or after sexual intercourse.
    [Show full text]