It Hurts Down There: Diagnosing and Treating Vulvodynia and PFD in Adolescents

Transcription

1 It Hurts Down There: Diagnosing and Treating Vulvodynia and PFD in Adolescents Judith E. Hersh, MD, FACOG, NCMP, IF Medical Director/NJ Center for Sexual Wellness Clinical Assistant Professor RWJ Medical School Lifeline Medical Associates/Women s Care Source

2 Disclosures None

3 Learning Objectives At the conclusion of this workshop, participants will be better able to: 1. Differentiate and diagnose vulvodynia from other vulvar pain disorders. 2. Understand and be able to utilize various treatment options for vulvodynia 3. Assess and treat adolescents with high tone pelvic floor dysfunction

4 What is Vulvodynia?-Historical Sims published an article ré pt he saw in 1857 with vaginismus but upon further analysis of her history, she appears to have vulvodynia Thomas described a pt with excessive sensibility of the nerves supplying the mucous membrane of some portion of the vulva Skene commented on a condition characterized by supersensitiveness of the vulva 1928-Kelly noted exquisitely sensitive deep red spots in the mucosa of the hymeneal ring are a fruitful source of dyspareunia Friedrich coined the term vulvar vestibulitis syndrome and developed three diagnostic criteria

5 Friedrich s Criteria for Diagnosis of Vulvar Vestibulitis Syndrome Severe pain upon vestibular touch or attempted vaginal entry Tenderness to pressure localized within the vulvar vestibule Physical findings confined to vestibular erythema of various degrees Friedrich, E. G., Jr. (1987). Vulvar vestibulitis syndrome. Journal of Reproductive Medicine, 32(2),

6 What is Vulvodynia?-Today 2015 ISSVD, ISSWSH, IPPS Consensus Terminology and Classification of Vulvar Pain and Vulvodynia Vulvar pain of at least 3mo duration without a clear identifiable cause which may have potential associated factors, often described as burning, stinging, irritation or rawness Additional descriptors: localized, generalized or mixed Provoked or spontaneous or mixed Primary or secondary Temporal pattern (intermittent, persistent, constant, immediate, delayed

7 Vulvodynia- Potential Associated Factors Infection Other pain syndromes (IC, IBS, fibromyalgia) Hormonal factors Musculoskeletal/Trauma Neurologic Psychosocial Structural (can be associated with pelvic organ descent, more common in adults)

8 Possible Etiologies of Vulvodynia Homozygous for allele 2 of IL-1RA gene (seen with UC, Chron s and SLE More prolonged and severe proinflammatory response, studies showing increase in inflammatory cytokines(il-1β, TNF-α) (Giesecke,j,ReedB et al. Ob Gyn;7/2004) Increased density of nerve fibers (specifically c-fibers) more nociceptors Dysfunction of nl braking system for inflammation via Melanocortin-1 receptor gene (Foster, J Reprod Med. 2004)

9 Why is knowledge of vulvodynia important for adolescent caregivers? Population based studies of adult women show a prevalence of dyspareunia to be as high as 21%* Dyspareunia has many social and health repercussions: daily functioning, psychological well-being, accessing medical care, impact on relationships Few studies address the timing of dyspareunia, or even if vulvar pain initially presents in sexually naïve women *Laumann, EO, et al, JAMA 1999;281:

10 Why is knowledge of vulvodynia important for adolescent caregivers? 1425 girls ages 12-19, recruited from 7 HS Self report questionnaire presented as a general gyn health study Goals of study Determine prevalence of dyspareunia in a large scale sample of adolescent girls Describe the characteristics of vulvo-vaginal pain in sexual and non-sexual contexts in this population Landry T, Bergeron S, How Young does Vulvo-Vaginal Pain Begin? Prevalence and Characteristics of Dyspareunia in Adolescents. J Sex Med 2009;6:

11 How Young Does Vulvo-Vaginal Pain Begin? Questionnaire adapted from one used by researchers for adult women Controlled for sociodemographic characteristics, age, grade, culture, mother tongue, religion, perceived socioeconomic status Health questions: menstrual history, tampon use, vaginal infections, sexual activity, contraception if appropriate Pain questions Do you regularly (at least 75% of the time) experience pain with intercourse They were then asked about pain intensity, quality, site (vaginal opening, inside vagina, lower abdomen). Primary or secondary. A similar question was asked about tampon use and gyn exam Landry T, Bergeron S, How Young does Vulvo-Vaginal Pain Begin? Prevalence and Characteristics of Dyspareunia in Adolescents. J Sex Med 2009;6:

12 Results median age 15, majority Caucasian and identified as Canadian or Quebecer, French, Catholic and SE status perceived above mean 25.1% five or more sexual encounters (251 subjects) 20% reported regular pain during intercourse for at least 6 mo 42.3% reported moderate to severe pain with initial tampon insertion 80% without dyspareunia 16.3% reported moderate to severe pain with tampon insertions 74.9% sexually naïve (473 subjects who had already inserted tampons) 28.1% reported pain rating of 7 or higher ** vaginal opening was primary area of pain Landry T, Bergeron S, How Young does Vulvo-Vaginal Pain Begin? Prevalence and Characteristics of Dyspareunia in Adolescents. J Sex Med 2009;6:

13 Sexual Distress in Middle to Late Adolescents Study group: 405 subjects, M (180) and F (225) yo Completed 5 online surveys over 2y study period Outcomes: Sexual functioning, sexual distress, sexual self disclosure, h/o coercion, Both: Subscale of the Sexuality Scale, Sexual Self Disclosure Scale, Sexual Experiences Survey, Sexual Dysfunction Beliefs Questionnaire Male: International Index of Erectile Function and Premature Ejaculation Tool, Adapted FSDS Females: FSFI, FSDS O Sullivan, et al. A Longitudinal Study of Problems in Sexual Functioning and Related Sexual Distress Among Middle to Late Adolescents. J Adol Health, 2016; 59z;

14 Sexual Distress in Middle to Late Adolescents- Results 79% males, 84% females reported at least one sexual problem over 2y Females: 59% c/o inability to reach orgasm, 47% c/o pain The authors postulated that longstanding and distressing sexual complaints in adulthood might be prevented if risk factors were assessed earlier in an individual s sexual life O Sullivan, et al. A Longitudinal Study of Problems in Sexual Functioning and Related Sexual Distress Among Middle to Late Adolescents. J Adol Health, 2016; 59z;

15 2000 WHO and Pan American Health Organization Statement on Sexual Health Sexual Health: a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. (WHO, 2006a)

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17 Vestibulodynia Entire Vestibule Posterior Vestibule Only or Outside the Vestibule on PE Inflammation Hormonal Neuroproliferative High Tone Pelvic Floor Dysfunction congenital acquired

18 Presentation Multiple visits to several clinicians h/o multiple prescription and OTC medications Most commonly c/o burning, itching pain, razor blades Rarely if ever use tampons because they hurt May favor loose clothing because tight clothing exacerbates symptoms May also c/o bowel or bladder symptoms

19 Physical Examination Vulvoscopy with Q-tip test is considered mandatory to precisely identify location of pain and to assess hormonal integrity If not already done, cultures as appropriate (all candida strains, BV, GC, Chlamydia Wet mount can assess presence of WBCs as well as hormonal environment Vaginal/rectal exam when able to assess pelvic floor muscles and palpate urethra and bladder for pain

20 Optivisor- 2.5x at 8 inches

21 Assessment of Hormone Status Glans Clitoris Testosterone Labia Minora Estradiol Urethral Glans/Meatus Estradiol/Testosterone Minor Vestibular Glands Testosterone and Estradiol Vagina Estradiol Peri-Urethral Tissue - Testosterone

22 Embryology of Vulva Derived from endoderm Embryological homolog of male urethra Bartholin s, Skene s and minor vestibular glands are the female equivalents of the male Cowpers, Prostate and Glands of Littré Have androgen receptors

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24 Reprinted with permission, Irwin Goldstein, MD

25 PRINCIPLE OF VULVOSCOPY Glands of Littre Lateral border is Hart s line Medial border is the hymen and urethra Ostia of the Bartholin s, Skene s and minor vestibular glands are derived from the primitive urogenital sinus Different blood supply from the vagina Rich in AR and ER Reprinted with permission from Irwin Goldstein, MD

26 Evaluation- Q-Tip test Begin by touching lateral to Hart s line and then just medial Hart s Line Touch the vestibule at 1, 11 o clock adjacent to the urethra at the Skene s gland ostia, 12 o clock, accessory Skene s Touch the vestibule at 4 & 8 o clock at the Bartholin s glands ostia. Touch the vestibule 6 o clock.

27 Vulvoscopy Erythema (confined within Harts Line or past) Lichenification (atopic) Fissures, erosions, ulcerations (LS,candida) Scarring & architectural changes (LS) Atrophy (CHC) Hypopigmentation (LS) Phimosis (look for foreign body)

28 Vestibulodynia Entire Vestibule Posterior Vestibule Only or Entire vulva Inflammation Hormonal Neuroproliferative High Tone Pelvic Floor Dysfunction congenital acquired

29 Inflammatory Vestibulodynia

30 Vestibulodynia- Inflammatory History of chronic infections and multiple prescription and OTC treatments H/o other atopic dermatoses PE entire vestibule inflamed, but often the vestibular glands even more so Leukorrhea (consider Desquamative Inflammatory Vaginitis) Routine cultures show no specific infections

31 Inflammatory Vestibulodynia Remove any possible irritants Barrier ointments: A and D, coconut oil, Neogyn (currently unavailable) Decrease inflammatory response Oral Montelukast (Kamdar, et al. J Reprod Med ;52(10:912-6) Topical Baclofen (Keppel Hesselink JM et al. J Pain Res. 2016;9: )

32 Vestibulodynia Entire Vestibule Posterior Vestibule Only or Entire vulva Inflammation Hormonal Neuroproliferative High Tone Pelvic Floor Dysfunction congenital acquired

33 Hormonally Mediated Provoked Vestibulodynia Most commonly caused by hormonal contraceptives (may not resolve just by stopping OCPs.) Other causes include: menopause, oophorectomy, hormonal control of endometriosis or hirsutism, breastfeeding, infertility treatments, treatment of breast cancer Burrows LJ, Goldstein AT. Vulvodynia. J Sex Med 2008;5:5-15.

34 Hormonally Mediated Provoked Vestibulodynia Diffuse vestibular tenderness of the entire vestibule Ostia of glands are frequently erythematous The vestibule may have a diffuse pallor with superimposed erythema Low estradiol, low free testosterone, very high SHBG Burrows LJ, Goldstein AT. Vulvodynia. J Sex Med 2008;5:5-15.

35 Assessing Hormonal Environment Reprinted with permission, Irwin Goldstein, MD

36 Hormonally Mediated Provoked Vestibulodynia and OCP use Bouchard et al.am J Epidemiol vol 156, No 3, 2002

37 Hormonally Mediated Provoked Vestibulodyina and OCP use In women <50 yo, OC use did not increase the risk of subsequent vulvodynia questionnaire given to women already enrolled in Woman to Woman Health Study 906 women aged who reported onset of vulvodynia after coitarche were included in study Reed BD et al. Oral Contraceptive use and the risk of vulovodynia:a population-based longitudinal study,bjog 2013 Dec;120(13):

38 Possible Mechanism 30 cases (CHC + vestibulodynia) 17 controls (CHC, no pain) DNA analysis of androgen receptor gene (x chromosome) Results Mean CAG repeats in study group significantly greater in cases than controls (P= 0.025) Significance of longer CAG repeats: less efficient binding of androgens to androgen receptor Goldstein A, et al. J Sex Med Nov;11(11)

39 Goldstein A, et al. J Sex Med Nov;11(11) Figure 3 Cytosine adenine guanine (CAG) repeat allele frequency of long alleles. Inset: CAG repeat number (mean ± standard deviation [SD]) for the internal control group (CTRL), study group (STUDY), and external control group (EXT), as previously reported.25 Data were compared by one-way ANOVA (P = 0.011), followed bytukey s test for paired comparisons (*P < 0.05).

40 Hormonally Mediated Provoked Vestibulodynia Treatment: Stop hormonal contraceptives (if possible) Topical vestibular estradiol 0.02%/testosterone 0.1% in methylcellulose BID Expect no improvement for 6 weeks, 30-40% by 12 weeks ( if CHC stopped) Burrows LJ, Goldstein AT. Vulvodynia. J Sex Med 2008;5:5-15.

41 Vestibulodynia Entire Vestibule Posterior Vestibule Only or Entire vulva Inflammation Hormonal Neuroproliferative High Tone Pelvic Floor Dysfunction congenital acquired

42 Burrows LJ, et al. J Reprod Med. 2008;53(6):413-6 Bohm-Starke N, et al. Gyecol Obstet Invest 1999;48(4):

43 Congenital Neuroproliferative Vulvodynia Burrows LJ, et al. J Reprod Med. 2008;53(6):413-6 Bohm-Starke N, et al. Gyecol Obstet Invest 1999;48(4):

44 Vestibulodynia Entire Vestibule Posterior Vestibule Only or Entire vulva Inflammation Hormonal Neuroproliferative High Tone Pelvic Floor Dysfunction congenital acquired

45 Harlow BL et al. Ann Epidemiol. 2009;19(11): /Gerber S. Am J Obstet Gynecol. 2002;186(3): /Foster DC. Am J Obstet Gynecol. 2007;196(4):346.e1-346.e8 Bornstein J. Int J Gynecol Pathol. 2008;27(1):

46 Neuroproliferative Vestibulodynia Bronstein J et al. Int J Gynecol Path. 2008;27(1):

47 Acquired Neuroproliferative Vestibulodynia- Treatment Montelukast Sodium (if within first 6 mo of onset of symptoms) Sub-Q interferon x 5 weeks Capsaicin (after 6 mo) Topical Gabapentin Vestibulectomy (can often be avoided by proper use of capsaicin) (Presented at ISSWSH Annual Meeting. February 2018, San Diego, CA)

48 Rationale for Vestibulectomy

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50 References for Justification of Vestibulectomy Bohm-Starke N, et al.gynecol Obstet Invest.1999;48(4): Tympanidis P, et al. Br J Dermatol. 2003;148(5): Tympanidis P, et al. Eur J Pain. 2004;8(2): Goldstein AT, et al. J Sex Med. 2006;3(5):

51 Traditional Therapies for Vulvodynia Low oxalate diet Tricyclic antidepressants (amitriptyline) SSRIs (paroxetine, fluoxetine) SNRIs (desvenlafaxine,duloxetine) Pschosexual therapy (may not be appropriate in sexually naïve pt) Vestibulectomy study ages start at 18,

52 Treatment Recommendations From 4 th International Consultation on Sexual Medicine-2015 Interdisciplinary approach believed to be best, but data lacking Grade B Evidence: Psychological therapy (CBT) PT Vestibulectomy once other less invasive options fail Grade C Evidence Hormonal treatments Accupuncture Capsaicin Botulinum Toxin A (second line)

53 Treatment Recommendations From 4 th International Consultation on Sexual Medicine-2015 Grade D evidence for: Anti-inflammatories (topical cromolyn) Interferon (not first line)

54 ICSM 2015 Guidelines Recommend Against Grade A Tricyclic antidepressants Grade B Topical lidocaine for long-term management Grade C Topical corticosteroids Anticonvulsant therapies

55 Vestibulodynia Entire Vestibule Posterior Vestibule Only or Entire vulva Inflammation Hormonal Neuroproliferative High Tone Pelvic Floor Dysfunction congenital acquired

56 High Tone Pelvic Floor Dysfunction (HTPFD) Pelvic Floor Muscle (PFM) Principles: PFM are an integral part of postural support PFM work with large postural groups to maintain skeletal position (secondary muscles of posture) PFM provide local and visceral support(bladder, reproductive organs, colorectal compartments (primary muscles of posture- erecter spinae, abdominal muscles, quadratus laborum)

57 Pelvic Floor Anatomy

58 HTPFD Associated with: Mechanical trauma Chronic strain (repetitive activity, poor postural support) Skeletal abnormality (scoliosis, kyphosis) Surgical adhesions Infection/inflammatory conditions (endometriosis) Myofascial disorders (SLE, RA) Myofascial Pain and Dysfunction: The Trigger Point Manual-Vol 2, Travell JG, Simons D. Pelvic Pain in an Adolescent, J Pediatr Adolesc Gynecol (2002)15;

59 Findings in Patients HTPFD Increased tone results in: Decrease in blood flow and oxygen to the muscles of the pelvic floor causing a build up of lactic acid Symptoms Generalized vulvar pain or burning Superficial(mucosal)tenderness where muscles insert (4,6,8 o clock on the vestibule) resulting in: Introital dyspareunia/pain when trying to insert tampon Urinary symptoms Constipation, hemorrhoids, rectal fissures

60 History Activity- type and intensity Injuries Surgeries Physical therapy in past Thorough menstrual history

61 Assessment Visually inspect perineum for signs of muscle tension (pulling in) Starting at introitus gently, but firmly press down on perineal body Move slightly in and press on rectum and identify this sensation as pressure and urge to poop Insert finger to level of coccyx if possible rotate 90 to pt s right, then strum the levator ani from coccygeus, to iliococcygeus to pubococcygeus feeling for hypertonicity and trigger points Repeat above but on pt s left Kegel may actually be weak from muscle overuse Have pt stand facing away from you. Place thumb just below PSIS and cup hands over posterior superior iliac crest. Have pt bend over and touch knees. Thumbs should remain in horizontal plane

62 Assessment: Postural dissymmetry

63 Treatment of HTPFD Physical Therapy is the mainstay of treatment May need medication to assist therapist In adults: low dose diazepam suppositories, baclofen suppositories, trigger point injections with long acting anesthetic, botulinum toxin no studies of these medications in adolescents

64 Physical Therapist Need a PT specifically trained to treat PFD Ideally the PT should also have experience working with adolescents with PFD Ideally the PT should use a biopsychosocial model of treatment

65 Genetics, Nociception, Inflammation, System Dysfunction, Excessive Load, Tissue Pathology BIO Beliefs, Thoughts, Predictions, Knowledge, Feelings, Action PSYCHO Health SOCIAL Colleagues, Family, Friends, Access to Care, Community, Culture, Society Explain Pain Supercharged, Lorimer Moseley, David Butler

66 Initial PT Assessment Postural evaluation Gentle abdominal palpation supine (tension, pain, viscera) Musculoskeletal assessment Psoas, deep external rotators of hip Pelvic floor musculature (if able, can access vaginally or rectally) Dee Hartmann, PT, DPT, 2014

67 PT Treatments Manual therapy -myofascial release, soft tissue mobilization Usually begins externally, may progress to internal Thiele Massage Progressive PFM retraining Stretching and strengthening exercises in office and at home Instruction on proper bowel and bladder function

68 A Reasonable Do No Harm Approach Remove any possible irritants Vulvar hygiene Protective barrier such as A and D ointment/coconut oil Hypoallergenic lubricant if sexually active Oral Montelukast if no contraindications Topical estradiol or compounded estradiol/ testosterone if? hormonal component Massage Therapy/Physical therapy Psychotherapy

69 Resources Women s Sexual Function and Dysfunction-Study, Diagnosis and Treatment, Irwin Goldstein (lead author) Female Sexual Pain Disorders: Evaluation and Management, Andrew Goldstein When Sex Hurts, Andrew Goldstein (calculate Free T from total T and SHBG

70 Resources National Vulvodynia Association Physical Therapy Physical Therapy outside US,

71 Case Study 1- SC 3/14- started on CHC (17yo) 5/15 (18yo)WWE, c/o dyspareunia and said it had started before starting on CHC. Tried lubricants and saw 2 prior doctors, told her nothing was wrong. This gyn offered stop CHC to see if it helps with lubrication, advised to try a lubricant again. Given a trial of lidocaine jelly prior to intercourse and ordered a pelvic US which was normal. Did not f/u for pain 7/16- (19 yo)wwe with me, c/o longstanding dyspareunia. Exam showed atopic dermatitis of labia majora and atrophic vulva. Pt wanted to stay on pills. Plan- Started on topical estradiol qhs and told to avoid irritants and f/u for sex med evaluation

72 Case Study 1-SC 8/16- (19), f/u estradiol and complete exam for dyspareunia poor compliance with estradiol, no improvement in pain PE- atopic dermatitis resolved, AV, entire vestibule erythematous and tender, ostia inflamed Dx- hormonally mediated vulvodynia Plan- wanted to continue on CHC, declined estring or compounded e/t. Wanted to retry estradiol cream, add daily montelukast 11/16- (19), never took montelukast, rarely used estradiol PE- unchanged Plan- encouraged to stop CHC and change to IUD, declined. Wanted to see if she could be better with meds.

73 Case Study 1- SC 2/17- (20), vulvodynia better with estradiol cream, tried estrogen ring but did not like. Now c/o pain with deep thrusting PE- q tip test less pain, but still (+), tissues less pale and atrophic pelvic floor- no PFD Plan- increase estradiol cream to bid, try montelukast, sex therapy to help manage stress of chronic pain. Consider LNG IUD

74 Case Study 1- SC 5/17- (20yo), using estradiol cream and montelukast, no time for therapy, maybe a little better PE- q tip test negative, but pelvic floor tight and tender bl Plan- continue CHC, consider LNG-IUD, continue estradiol bid and montelukast, add PT 10/17-(20yo)using estradiol, no time for PT, never saw sex therapist PE- (+) q tip test, vestibule still somewhat erythematous, pelvic floor tight and tender Plan- continue CHC, but fill out paperwork for 19.5mg LNG IUD 2.5mg valium suppos qhs, PT

75 Case Study 1-SC 12/17- (20yo) routine WWE and STI screen, all neg 1/18- IUD insertion without incident 2/18-(21) IUD f/u. Bleeding x 2 weeks. Had sex once bleeding stopped. No pain. Stopped estrogen cream and valium. No pain, sex pleasurable for first time Plan- f/u as needed, 12/18 for annual

76 Case Study 2- RM HPI- 9/15/16 (12 11/12yo) pt called pediatrician c/o bee sting feeling in vagina. Pt told to use OTC yeast medication. No better so went to urgent care dr who thought she saw blood behind the hymen. Referred to another doctor who saw pt 9/19/16. Pt now c/o pain and pressure in vagina. US ordered. Menarche on 9/19/16. US showed? Bicornuate vs septate uterus, nl ovaries. MRI done 9/23/16 which showed arcuate uterus, no obstructive pathology and 4.2cm complex R ovarian cyst c/w hemorrhagic corpus luteum. On 10/4/16 pt had a fever and was started on antibiotics. Fever persisted and CXR was done, neg but still with fevers. Pt referred to me to see if MRI findings could explain pain/fevers. Pain so severe pt could not go to school or participate in sports.

77 Case Study 2- RM 10/16/16-first visit with me: PE unremarkable except for mild tenderness on rectoabdominal. No fever at time of exam. Hymen annular A/P- explained arcuate uterus not a worry and cyst likely related to menstrual cycle. f/u with pediatrician ré fevers and repeat US 3 mo. 12/16-f/u US normal ( I thought we were done) 2/7/17- (13 3/12yo) Presents c/o bee sting feeling in vagina. No cycle since first cycle 9/16. c/o yellow discharge and vulva itchy and burning when she pees, wipes, walks. Feels pressure going out when I walk. Always present but intensity varies. Cries daily, missing a lot of school ROS- BM almost daily, sensitive skin, treated with multiple antibiotics over past year for persistent/recurrent strep throat. No regular sports

78 Case Study- RM PE- poor hygiene, mild erythema, entire vestibule very tender to q tip test 5/5. Vaginal cultures done and neg A/P- Amenorrhea- prometrium x 10 days if no cycle by 3/17 because mom worried Inflammatory vulvodynia-reviewed vulvar hygiene, A and D ointment or coconut oil daily as barrier, Montelukast qhs, compounded atropine am, cromolyn in pm. Diflucan x 1 after pt finishes next course of antibiotics 3/31/17- did not need prometrium. Less stinging and pressure overall, but cromolyn stings a little when puts on. Wants to try to use a tampon PE- q tip test neg except at 4 o clock

79 Case Study- RM A/P- Inflammatory Vulvodynia- change base of cromolyn to phytobase, continue montelukast. Consider lidocaine jelly to assist with tampon placement. 5/17- (13 7/12) f/u. Feeling much better, only pain when tries to place tampon. Used Diflucan x 1 because she thought she had yeast. PE- vulva with poor hygiene, q tip test (+) 4,6,8. (-) 10,12,2 rectal assessment of pelvic floor trigger point pubococcygeous standing assessment- upshift on L A/P Inflammatory Vulvodynia- reviewed hygiene, continue Montelukast, pt offered stopping atropine/cromolyn but thought it was helping, check cultures (neg) HTPFD- PT

80 Case Study- RM 8/ /12, worsening symptoms since LMP, but still better than when first presented. Working with PT but not consistent. Therapist says she sees improvement, but pt not sure. Compliant with creams and montelukast. Still experiences episodes of terrible pressure. Also c/o itching on mons, labia majora, labia minora and vulva. PE- no change, cultures done, neg A/P- Vulvodynia (? Neuroproliferative)- continue current regimen HTPFD- continue with PT, add valium suppose 2.5mg qhs Generalized itching- no obvious etiology, Benadryl 11/ /12yo. Not very compliant with cream or PT. Stopped suppos. No improvement,

81 Case Study 2- RM A/P- Vulvodynia (? Neuroproliferative)- continue current regimen. HTPFD- restart suppos, restart PT 2/26/28- has not been doing PT, started playing soccer. Irregularly uses topicals and suppos. ROS- (+)constipation with BM maybe 2x/w, pain in stomach which starts at belly button and goes into her pelvic area. Took Diflucan x 2 because she thought she had a yeast infection PE- (-) umbilical pain, abdomen tender with stool palpable LLQ Q tip test (+) lower half of vestibule only

82 Case Study 2- RM A: Vulvodynia-no evidence of congenital neuroproliferation and q-tip test suggests that pain is secondary to HTPFD P: stop creams, continue Montelukast for general allergies, hygiene, barrier ointments A: HTPFD/Constipation P: miralax 1 capful daily, increase water intake, bowel hygiene stop valium, start baclofen suppositories, stressed importance of PT. Also offered second opinion. Mother and pt declined. Both said that although pt still had pain, her QOL had significantly improved. No crying spells, no missed school, able to participate in sports

83 Vestibulodynia Treatment Options Treatment options (limited data in adults, none in adolescents): Topical Cromolyn Sodium (5-10% cromolyn sodium in petrolatum) (no conclusive studies) Estradiol 0.01% or estradiol 0.01%/testosterone 0.025% Capsaicin 0.025%,0.05%, 0,075% in AM Traumeel injections into vestibular gland openings

84 Lubricants decrease pain but also ADD pleasure! N=2451 women ages % had purchased a lubricant in past 4 weeks 96% reported greater sexual comfort 94% reported greater sexual pleasure and increased ease of orgasm Jozkowski K, et al. J Sex Med.2013 Feb;10(2):484-92

85 DIV Intensely Inflammatory Vaginitis, unknown etiologys Copious yellow discharge Wet mount ph >5.5, WBCs, +++ parabasal cells Treat: compounded estradiol 0.10%/hydrocortiosone 10%/clindamycin 2%