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Home , Atrophic vaginitis, Cystocele, Enterocele, Pelvic organ prolapse, Rectocele, Urethrocele

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ALEECE FOSNIGHT, MSPAS, PA-C, CSC, CSE , WOMEN’S HEALTH, SKIN, BONES, HEARTS, & PRIVATE PARTS 2019 Disclosures .Speaker for Lupin Pharmaceuticals. Objectives .Explain the importance of a thorough female pelvic exam and demonstrate the components of a normal female pelvic exam. .Discuss challenging including vaginal candidiasis and along with risks if left untreated. .Identify the unique to women’s pelvis including genitourinary syndrome of , , pelvic organ , and pelvic . Steps to a Thorough Pelvic Exam .Superficial Muscles . Ischiocavernosus . Bulbospongiosus . Transverse perineal .Deep . Puborectalis . Pubococcygeus . Illiococcygeus . Coccygeus .Obturator internus Challenging Vaginitis .Vaginitis = inflammation of the .Symptoms = discharge, odor, pruritis, burning, pain, , .Common condition affecting almost all women at some point in their life .Most common causes . Candidiasis . Bacterial vaginosis . Trichomoniasis .After puberty, 90% of cases are infectious vaginitis – Gardnerella .Contributing factors . Lack of . Anatomy . Hygiene – too much and too little . Lack of pubic hair . Contact irritants . . Comorbidities Recurrent Vaginal Candidiasis .Vulvovaginal candidiasis is a common vaginal affecting 70-75% of women at least once in their reproductive years .Primary symptom = vulvar pruritis . Additional symptoms can be burning, soreness, irritation .Physical exam . Vulvar edema/erythema . Fissures . Excoriations (scratching) . Discharge – thick, white, clumpy *** Can you have a candida infection without discharge? *** .Diagnosis . Obtain a vaginal swab for wet mount with saline or KOH – will see budding yeast and hyphae . No microscope? Send for fungal culture – PCR can help differentiate between species and sensitivities . 90% of all vaginal candida are from C. Albicans (second most common is C. Glabrata) .Treatment . All OTC imidazoles (butoconazole, clotrimazole, miconazole) and Rx single-dose oral fluconazole Recurrent Vaginal Candidiasis .Criteria for complicated/recurrent candidiasis . Four or more episodes in one year . Severe symptoms or findings . Suspected or confirmed non-albicans Candida infection . Comorbidities – diabetes, severe medical illness, immunosuppression . Co-vulvovaginal infections . Pregnancy .Treatment . Candida glabrata . 50% improvement with “azoles” . Topical Gentian Violet . Vaginal boric acid 600mg daily for 14 days . Flucytosine 15.5% vaginal cream , 5g daily for 14 days with/without amphotericin B 50mg suppositories nightly . Longer duration of initial therapy – fluconazole 100/150/200mg on the 1, 4, 7 days . Fluconazole 100-150mg PO weekly for 6 months . with vulvar cellulitis rare – swollen, beefy-red and pain, tenderness, fever, chills, lymphadenopathy .Management of sex partners Bacterial Vaginosis .Most common vaginal infection in women between the ages of 15-44 .84% of women with BV have no symptoms .18% of women with BV had never had vaginal penetration .African Americans and Latino women are at higher risk .Caused by the lack of normal hydrogen peroxide- producing lactobacilli . Overgrowth of anaerobes – Gardnerella vaginalis, Mycoplasma hominis, Atopobium vaginae . Other possible causes – menstrual flow, intercourse, douching, female partner .Complications . Preterm labor . Pelvic inflammatory disease . Urinary tract infections . Acquisition/transition of STIs including HIV Bacterial Vaginosis

Available Tests for Diagnosis of BV Test Time for Results Description Amsel Criteria <30 minutes Meets 3 out of 4: • Homogeneous white/gray thin discharge • Vaginal pH >4.5 • Positive amine (whiff) test • Wet prep – 20% or more clue cells seen Affirm VP III test <1hr Automated DNA probe assay for detecting G. vaginalis OSOM BV Blue system 10 minutes Chromogenic diagnostic test based on presence of elevated sialidase enzyme activity Vaginal Culture 3 days Not recommended by the CDC due to decreased viability of bacteria after 24 hours and failure to distinguish pathogens from normal flora Bacterial Vaginosis .Treatment options . New option – Secnidazole 2g oral granules single dose . Metronidazole 500mg PO BID x 7 days . Metronidazole 0.75% gel, 1 applicator PV daily for 5 days (not for use in the first 13 wks of pregnancy) . Clindamycin 2% cream, 1 applicator PV daily for 7 days . Alternative therapies . Tinidazole 2g PO daily x 2 days . Tinidazole 1g PO daily x 5 days . Clindamycin 300mg PO BID x 7 days . Clindamycin ovules 100g PV QHS x 3 days .Other considerations . Recurrence is high! Consider higher doses and longer courses of medications used for initial therapy . Routine testing of partner or partner treatment is not recommended . Oral and vaginal probiotics are currently being studied . Condom use after treatment to allow the vaginal ecosystem time to heal . Clean sex toys after each use and avoid sharing . Avoid douching, multiple sex partners, spermatocides Vaginal Microbiome .Undergoes dramatic shifts that coincide with hormonal and lifestyle changes. .Lactobacilli in the vagina produce lactic acid and create a low pH environment to protect against pathogens . L. crispatus, L. iners, L. gasseri and L. jensenii . Although otherwise healthy individuals have vaginal microbiota lacking significant numbers of lactobacilli and harbor other anaerobes .Relationship between mother and baby .Disruption of ecological equilibria is believed to increase the risk to invasion by infectious agents . Hormonal contraceptives . Antibiotics . Sexual activity . Vaginal products and douching Genitourinary Syndrome of Menopause (GSM) .Vaginal vs. vs. GSM . ISSWSH and NAMS 2012 .Menopause-related genitourinary symptoms affect up to 50-64% of midlife to older women .High concentrations of estrogen/testosterone receptors in the vagina, vestibule, musculature of the , endopelvic , and trigone of the bladder

.Anatomic changes . Physiological changes . Reduced collagen content and hyalinization . Reduced vaginal blood flow . Decreased elastin . Diminished lubrication . Thinning of the . Decreased flexibility and . Altered appearance and function of smooth muscle cells elasticity . Increased density of . Increased pH . Fewer blood vessles . Increased vulnerability to trauma and physical irritation GSM .Symptoms . Vaginal burning, fissures, irritation, Symptoms Signs dryness • Genital dryness • Decreased moisture . Bleeding postcoitally • Decreased lubrication • Decreased elasticity . Suprapubic discomfort or increased during sexual activity • minora resorption pelvic pressure • Dyspareunia • Pallor, erythema . Decreased sexual function • Post-coital bleeding • Loss of . Urinary – urgency, frequency, dysuria • Decreased arousal, • Tissue friability, fissures, desire, orgasm petechiae .Quality of Life • Irritation, pruritis, burning • Urethral eversion or . GSM symptoms are chronic and of the vulvovaginal prolapse rarely resolve on their own (vs. VSM) tissues • Loss of hymenal . Negatively impacts self-esteem and • Dysuria remnants intimacy with partners • Urgency • Prominence of urethral . CLOSER study – vaginal discomfort • Frequency meatus (urethral had a direct, negative impact on • Recurrent UTIs caruncle) intimacy of both woman and her partner and loss of libido • Introital retraction GSM Pictures GSM

Pharmacological Treatments for GSM Treatment Product Name Initial Dose Maintenance Notes Vaginal Creams 17β- Estrace (generic) 0.5-1g/d x 2 weeks 0.5-1g 1-3x a week FDA appr higher load dose Conjugated Premarin 0.5-1g/d x 2 weeks 0.5-1g 1-3x a week FDA cyclic approval Vaginal Inserts Estradiol hemihydrate Vagifem, Yuvafem 10μg 1 tab/daily x 2 weeks 1 tab twice weekly 17β-estradiol soft gels Imvexxy 4 or 10μg 1 tab/d x 2 weeks 1 tab twice weekly DHEA () Intrarosa 6.5mg/day 1 supp daily 17β-estradiol Estring 2mg releases (7.5μg/d) x 90 d Change q 90 days SERMs Ospemifene Osphena 60 mg/d 60 mg/d FDA approved for dyspareunia Other Topical Lidocaine 4% aqueous lidocaine Apply to vestibule minutes prior to intercourse GSM .Off label hormone options . Vaginal testosterone 0.1% cream (no formulations in US – need to compound) . Vaginal in gels, creams, or suppository . Vaginal lasers . Microablative CO2 laser . Nonablative vaginal Erbium YAG laser (VEL) .Other considerations . Lubricate, moisturize, and stretch . Vaginal dilators . Pelvic floor physical therapy . If you don’t use it…you lose it. .NAMS and ISSWSH 2018 Position Statement . Local hormone therapy and breast cancer Urinary Incontinence .47-56% of women aged 20-80 overall prevalence of urinary incontinence .Fewer than 50% of those women seek help from a health care provider .A costly condition - $20 billion every year ($900/woman/year) . Incontinence pads, adult diapers, dry cleaning, medications, office visits .Types . : involuntary loss of urine during an increase of intra-abdominal pressure produced from activities such as coughing, laughing or exercising . OAB/urge incontinence: involuntary loss of urine preceded by a strong urge to void, whether or not the bladder is full . Mixed incontinence: combination of stress and urge incontinence . Overflow incontinence: urine loss associated with overdistension of the bladder . Lack of continuity or deformity: most common cause is a fistula . Functional incontinence: urinary incontinence caused by chronic impairment of physical or cognitive function Simple Questionnaire for Urinary Urinary Incontinence Incontinence Do you leak urine when you , laugh, .Preliminary diagnosis can be determined by the history, lift something or sneeze? How often? (stress) physical exam, and simple in-office labs or diagnostic tests. Do you ever leak urine when you have a strong urge on the way to the bathroom? .Use a simple urinary incontinence questionnaire How often? (urge) .Other considerations How frequently do you empty your bladder . Diabetes, stroke, pelvic trauma/injury, bowel function, DDD, during the day? (urge) OB/GYN hx (gravida, parity, mode of delivery, interval between , gyn , vaginal/bladder ), pelvic How many times do you get up to urinate radiation, medications after going to sleep? Is it the urge to urinate that wakes you? (urge) .Physical Exam . Abdominal – diastasis recti, organomegaly, ascites Do you ever leak urine during sex? . Pelvic – urethral mobility, pelvic floor muscles, vulvovaginal tissues, (urge/stress) bladder distention, fecal impaction Do you wear pads that protect you from .Labs and Tests leaking urine? How often do you have to change them? (severity) . Urinalysis . Post Void Residual (<100cc) Do you ever find urine on your pads or . Bladder diary clothes and were unaware of when the leakage occurred? (severity) . Cystoscopy . Urodynamics Does it hurt when you urinate? (IC/UTI) . KUB () Do you ever feel that you are unable to completely empty your bladder? (IC/UTI) Urinary Incontinence – Treatment .Stress Incontinence . Conservative measures first . Weight loss, pelvic floor physical therapy (70% improve), timed voiding, fluid modifications, decrease intra-abdominal pressure, Poise Impressa®, urethral plugging . – mimics a retropubic urethropexy . Medications – Cymbalta (Europe) and Sudafed, vaginal hormone therapy . Surgery . Macroplastique (Intrinsic sphincter deficiency – urethral bulking agent) . Mid-urethral slings (TOT, TVT) . Retropubic colposuspension Urinary Incontinence – Treatment .Urge Incontinence . Conservative measures first . Weight loss, pelvic floor physical therapy (70% improve), timed voiding, fluid modifications, decrease intra- abdominal pressure . Medications . Antispasmodics (Levsin, Flavoxate, Urispas) . Anticholinergics (Oxybutynin, Toviaz, Vesicare, Santura, Ditropan, Detrol, Enablex, Gelnique) . Beta-Adrenergic (Myrbetriq) . Bladder Botox . Neuromodulation . Percutaneous Tibial Nerve Stimulation (PTNS) . Interstim® .Other Tips and Tricks . Overflow incontinence . . BOO – Flomax can improve . Urethral stenosis . Neurogenic bladders . Retention – in/out catherizations . Urgency – add urge incontinence therapies . Correct underlying problem if possible . Functional incontinence . Avoid anticholinergics . Timed voiding . Fluid management Signs and Symptoms . Feeling of pelvic heaviness or fullness . Bulging from the vagina .Pelvic relaxation – often co-exists with urinary incontinence . Organs bulging out of the vagina . Think hernia, such as protrusions into the vagina by the bladder, rectum, and vault caused by weakness of pelvic , . Pulling or aching feeling or a feeling connective tissue, muscles of pressure in the lower abdomen or pelvis .Prevalence: WHI found 41% of women, >60yoa, retained parts . Lower back pain .Risk factors . Improves with lying down or rest . Parity is the strongest risk factor by 11x . Leakage of urine (stress or overflow . Risk increases with increasing parity, lessens after 2 SVD incontinence) or problems having a . Birth weight bowel movement or splinting . SVD vs. Cesarean deliveries . Incomplete bladder emptying or . Aging, menopause, and estrogen deficiency recurrent UTI’s . Constipation and chronic valsalva/straining . Needing to push organs back up into . Pelvic surgeries the vaginal cavity to empty bladder . or previous prolapse surgery or have BM . Increased abdominal pressure . Sexual difficulties or dyspareunia . and Chronic pulmonary disease . Problems inserting tampons or . Occupational physical stress applicators . Genetic and pelvic skeletal structure abnormalities . Pelvic pressure that gets worse with standing, lifting, coughing, or as the day goes on. Pelvic Organ Prolapse .Types of pelvic organ prolapse . : uterus drops into vagina . Prolapse: top of vagina drops or folds down into the vaginal canal. . Risk factor = hysterectomy . Cystocele: bladder drops into the vagina . : bulges into vagina . Risk factor = cystocele . : small intestine pushes against back wall of vagina. . Risk factor = vaginal vault prolapse . : rectum bulges into or out of vagina . Complete Genital Prolapse: Total procidentia, protrusion of entire female organ out of vagina. Pelvic Organ Prolapse .Treatment . When considering therapies, take into consideration . Degree of prolapse . Desire to preserve sexual function . Desire to preserve fertility . Acceptance of surgical intervention . Level of fitness . Conservative therapies . Observation or watchful waiting . Lifestyle changes . Proper voiding and defecating techniques . Incontinence – limiting fluid intake and caffeine . Constipation – increase fiber or stool softners . Bladder training – timed or scheduled voiding . Weight loss . Pelvic floor therapy (Kegels and/or personal trainer) . Mechanical support › Pessary: a device inserted into the vagina to support pelvic organs Pelvic Organ Prolapse .Surgical therapies . Candidates for surgery include women that are symptomatic who have failed or declined conservative measures . Delay surgical repair until after childbearing is complete . Reconstructive surgical repair . Vaginal approach . Anterior (cystocele) or posterior (rectocele) repair What is the . Sacrospinous or uterosacral suspensions . Abdominal approach number one . Sacrocolpopexy - mesh attached to vaginal vault or uterus and attached to the (good for vaginal vault prolapse) treatment for . Laparoscopic and robotic . Hysteropexy – Quicker recovery and smaller scars prolapse? . Vaginal closure surgery (colpocliesis) . Complete removal of vagina . Only to be performed If severe prolapse, not sexually active or has no intention of becoming sexually active in the future . Complications . Scar tissue, recurrence, incisional hernias, disruption of normal sexual response, , mesh erosion, fistula formation Pelvic Pain .Give me the numbers… . 1 in 3 women during their lifetime . 9 million women in the US – 15% chronic pelvic pain and 8.9% . Comorbid pain conditions are common – IC, IBS, TMJ, Fibromyalgia . $3 BILLION spent every year Barriers to diagnosis and treatment ◦ Lack of awareness and training The Breakdown… ◦ Frustration – difficult to diagnose, to treat, to cure 10% of women 20-39 ◦ Embarrassment by provider and patient 27% of women 40-59 37% of women 60-79 Burden of Illness 50% of women >80 ◦ 75% of women feel “out of control” of their bodies ◦ 60% report that it compromises their ability to enjoy life ◦ 60% cannot have due to pain ◦ 60% of women consulted at least three doctors in seeking a diagnosis and 40% of those who sought professional help remain undiagnosed Pelvic Pain .Chronic Pelvic Pain . Non-cyclic pain, lasting more than 6 months in duration causing significant discomfort and distress, requiring medical or surgical intervention . Significant impaired function at home or work . Signs of depression and altered family roles . Localization . Pelvic pain, below the umbilicus . Lower back discomfort or pain . Inner aspect of thighs and/or buttocks . Organic Pain = specific, identifiable cause . Functional Pain = pain without identifiable cause and/or exacerbated by psychological factors . Peak age for chronic pelvic pain is 30 Pelvic Pain .Where does vulvar pain fall into pelvic pain? . Vulvodynia = vulvar pain of at least 3 months’ duration, without clear identifiable cause, which may have potential associated factors . Localized vs. generalized, mixed . Provoked vs. spontaneous, mixed . Primary or secondary . Intermittent, persistent, constant, immediate, delayed . Highest between ages 18 and 25, with lowest being after age 35 Pelvic Pain Symptoms

.Urinary frequency .Discomfort/Relief after Bowel Movement .Urinary urgency .Reduced Libido .Dysuria .Anxiety . .Depression .Reduced urinary stream .Distress .Hesitancy of .Sleep Disturbances .Perineal Pain .Decreased Self Esteem .Dyspareunia .Stress .Sitting Pain .Social Withdrawal .Genital Pain .Helplessness or Hopelessness .Suprapubic Discomfort Imperative Questions for Pelvic Pain:

• When did the pain start? • Did the pain start with an event or injury? • Where is the pain located? Pelvic Pain – Diagnosis • Any sexual positions more or less painful? • Severity, duration, characterization of .Comprehensive pain history pain? . Character – location, onset, pruritic, burning • When does the pain occur? Initiating . Pain diary and assessment form – www.pelvicpain.org factors or association with menstrual . Distress scale cycle? • Does it occur with every sexual .Past medical history encounter? .Sexual history – Dyspareunia, STIs, sexual • Has pain occurred with both current and abuse/trauma past partners? .Surgical/procedural history • Do non-sexual activities cause pain? .Obstetrical/Reproductive history • Any prior treatments for the pain? What type? .Social history • ? Color, consistency, . Psychological factors – depression, distress, relationship odor, pruritus? . Tobacco, alcohol, recreational drugs • Other sexual dysfunctions? Arousal? .Medications Desire? Orgasm?

What is essential to get you better? What are your goals for treatment? Pelvic Pain .Physical Exam . Review beginning slides . Things to consider . Use smaller speculum (Pederson) . If pain is intermittent, it is best to examine the patient when she is in pain may also defer to follow up/return appointment . Remember…the exam could be completely normal .Diagnostic testing . No known labs associated with pelvic pain or vulvodynia . Important to exclude other potential causes! . Infection, inflammatory disorders, neoplasia . Consider biopsy only if refractory . Wet mount is definitely recommended – atypical candida species . Get a closer look – vulvoscopy . Imaging studies . Pelvic MRI with and without contrast . CT scan only for pelvic masses . Ultrasonography . Pelvic masses, cysts, pelvic varicosities, and hernias . Perineometry – pelvic floor muscle strength .Others – bowel, bladder, fractures Pelvic Pain –

.Gynecologic Causes .Adhesions . Uterine Leiomyomas .Pelvic Organ Prolapse/Dysfunction . Pelvic Congestion Syndrome .Diverticular Disease . .Irritable Bowel Disease . Menstrual Cycle .Inflammatory Bowel Disease . .Constipation . Cervical Stenosis .Hernia . Pelvic Inflammatory Disease .Urology . Adnexal Cysts .Musculoskeletal . Intrauterine Contraceptive Device .Foreign Body . Vulvodynia .Malignancy . Vaginal Atrophy .Pregnancy/Postpartum/Lactation . Vulvar dermatoses Vulvodynia

Symptoms ◦ Most common = BURNING ◦ Pain can be irritating, sharp, prickly, pruritic, stinging, rawness ◦ Vestibule Pain ◦ Think  tampon insertion, gynecological exam ◦ Generalized ◦ Think  Activities that apply pressure to the vulva ◦ Factors that lessen the pain ◦ Potential causes and risk factors ◦ Injury to nerves ◦ Abnormal cell response ◦ Genetic factors ◦ Localized hypersensitivity to candida ◦ Pelvic floor muscles ◦ Estrogen deficiency www.nva.org Vulvodynia Treatment

.Start with self help strategies and . Sexual intercourse prevention . (water vs silicone vs combo) . Clothing and laundry . Rinse well afterward, cool water . Topical anesthetic (lidocaine gel) . 100% cotton underwear with no underwear at night . Frozen gel pack or coconut oil ball . Avoid tight fitted clothing . No dryer sheets or fabric softeners . Physical activities . Extra rinse during wash cycle . Avoid exercises that has direct pressure to vulva – bicycling . Hygiene . Everyday living . Discontinue all OTC skin irritants – no benzocaine products . Foam rubber donut, frozen gel pack, sitz bath, no prolonged standing . No douching . Use mild soaps for bathing and water ONLY to clean the vulva . No vaginal wipes, deodorants or bubble bath . No pads or tampons with fragrance . White cotton gloves at night Vulvodynia Treatment

.Topical Medications .Oral Medications that can block pain – can take up to 6 . Topical estrogen – Estrace or 0.02% compound as weeks to work directed if atrophy is suspected . Antihistamines – Itchy vulvovaginal symptoms . Topical testosterone – 0.1% as directed (can do T/E2 . Hydroxyzine (Vistaril) 25-50mg at bedtime combo) . Tricyclic antidepressants (TCA’s) . Clobetasol propionate ointment 0.05% BID . Amitriptyline (Elavil) – start at 10mg, increase 5-10mg/week until max dose (150mg) . Tacrolimus ointment 0.1% BID . Others: Nortriptyline, Desipramine . Topical anesthetics – lidocaine (2% or 5% ointment) max . Serotonin-Norepinephrine Reuptake Inhibitors dose 20g/24hr . Venlafaxine (Effexor) – 37.5mg daily with titrate to 75mg to 150mg daily . Cotton ball test . Duloxetine (Cymbalta) – start 20mg daily, increase to BID after 7 days. . Topical compounded formulations – antidepressant or Max dose 120mg/day anticonvulsant . Anticonvulsants . Amitriptyline 2%/Baclofen 2% in WWB – 0.5mL TID to affected area PRN . Good for patients with shooting, stabbing, or knife-like pain . Gabapentin 3% or 6% cream – 0.5mL TID to affected area PRN (can also . Gabapentin – 300mg daily, increasing every 5 days by 300mg per day mix with xylocaine) (TID) till max dose of 900 TID (2700mg/day) . Vaginal valium suppository (2.5mg, 5mg, or 10mg) . Others: Pregabalin and Oxcarbazepine . Opioids . Use only short term or for flares as well as early in treatment . Examples: Oxycodone or Hydrocodone Vulvodynia Treatment

.Pelvic Floor Muscle Therapy and Biofeedback . Aids with pelvic floor weakness or spasms . Education, exercises, manual therapies, other modalities in combination with biofeedback . Vaginal Dilators . Soul Source (silicone and medical grade plastic – www.soul-source-sd.myshopify.com) . (medical grade plastic – www.vaginismus.com) .Nerve Blocks . Usually pudendal nerve block (vulvar or spinal) . Bupivacaine (0.25% large area or 0.5% small area) and 40mg/cc Kenalog (use 1cc in single dose) . Inject into specific area or use as a block – can repeat monthly .Diet Modification . Elimination of acidic or high-sugar food . Food diary: eliminate one item or food group at a time .Complimentary or Alternative Medicine . Acupuncture, massage therapy, relaxation techniques, and cognitive behavior therapy .Surgery . Contraindicated for women with generalized vulvodynia . Vulvar Vestibulitis Syndrome or Provoked Vestibulodynia . Vestibulectomy with vaginal advancement or Modified Vestibulectomy . Not indicated for chronic pelvic pain unless cause is identified References

.CDC 2015 Sexually Transmitted Disease Treatment Guidelines, available at https://www.cdc.gov/std/tg2015/bv.htm. Accessed November 30, 2018. .Hillier SL, Nyirjesy P, Waldbaum AS, et al. Secnidazole Treatment of Bacterial Vaginosis. Obstetrics & Gynecology. 2017;130(2):379-386 .Pentikis H, Adetoro N. An integrated efficacy and safety analysis of single-dose secnidazole 2 g granules in the treatment of bacterial vaginosis from pivotal phase 2 and phase 3 trials. American Journal of Obstetrics and Gynecology. 2018;219(6):647-648. .Bradshaw CS, Morton AN, Garland SM, Morris MB, Moss LM, Fairley CK. Higher-Risk Behavioral Practices Associated With Bacterial Vaginosis Compared With Vaginal Candidiasis. Obstetrics & Gynecology. 2005;106(1):105-114. .Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. Obstetrics & Gynecology. 2004;104(6):1392. .CDC 2015 Sexually Transmitted Disease Treatment Guidelines, available at https://www.cdc.gov/std/tg2015/candidiasis.htm. Accessed November 30, 2018. .Kingsberg S, et al. Handbook of Female Sexual Health and Wellness, www.arhp.org. Accessed November 30, 2018. .Bø K, Berghmans B, Mørkved S, Kampen MV. Evidence-Based Physical Therapy for the Pelvic Floor - E-Book: Bridging Science and Clinical Practice. Churchill Livingstone; 2014. .Borgdorff H. The Vaginal Microbiome: Associations with Sexually Transmitted Infections and the Mucosal Immune Response. S.l: s.n.; 2016. References

.Kingsberg S, Larkin L. Shining the light on genitourinary syndrome of menopause in survivors of breast cancer. Menopause. 2017;24(12):1336-1337. .Faubion SS, Larkin LC, Stuenkel CA, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer. Menopause. 2018;25(6):596-608. .Ma B, Forney LJ, Ravel J. Vaginal Microbiome: Rethinking Health and Disease. Annual Review of Microbiology. 2012;66(1):371-389. .Ford AA, Rogerson L, Cody JD, Aluko P, Ogah JA. Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database of Systematic Reviews. 2017. .Dmochowski R. Treating women with refractory urge urinary incontinence. Nature Reviews Urology. 2016;14(1):11-12. .Wein AJ. Re: Guideline of Guidelines: Urinary Incontinence. The Journal of Urology. 2016;196(2):499-500. .Ahangari, Alebtekin. Prevalence of Chronic Pelvic Pain Among Women: An Updated Review. Pain Physician 2014, 17: E141- E147. .ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet. Gynecol. 103(3), 589-605 (2004). .Engeler, D. et al. Guidelines on Chronic Pelvic Pain. European Association of Urology 2014. . The International Pelvic Pain Society Pelvic Pain Assessment Form. www.pelvicpain.org. Accessed November 30, 2018. .Goldstein, AT, et al. Vulvodynia: Assessment and Treatment. J Sex Med. April 2016, 13 (4): 572-590. Thank you!

Questions?

Aleece Fosnight, MSPAS, PA-C, CSC, CSE Urology, Women’s Health, Sexual Medicine Skin, Bones, Hearts, & Private Parts 2019