Dr. Robert J. Echenberg is a board certified obstetrician-gynecologist, who completed his residency training at the University of Michigan in 1972, practiced privately in Bethlehem,Pennsylvania
for more than 20 years, and has worked for hospital based systems since
1994 in New Mexico and more recently back in Bethlehem with St. Luke's
Hospital. In 2006, he has returned once again to private practice in
Bethlehem , PA.
In years past he had a full obstetric and
gynecological surgical program with emphasis on team approach,
education, family participation and holistic management. He has had extensive experience with sexual counseling, grief counseling, and provided special programs for premenstrual syndrome, infertility, pre-conceptual and renatal education, and has provided a caring approach to women throughout the life cycles from adolescence through the menopausal years.
He has spoken at local, regional and national levels concerning women's health care issues. He was most influential in helping to establish many of the family-centered and technologic changes in obstetric and gynecological practice at St. Luke's Hospital in Bethlehem, PA for over twenty years, and was instrumental in helping to allow families to participate in and fully appreciate their birthing experiences. Dr. Echenberg has demonstrated his technical expertise and skills in both basic gynecologic surgery and in all aspects of obstetrics as he maintained at least 15-20 births per month and a comparable number of surgical procedures throughout most of his career.
Even while maintaining a busy practice of clinical medicine throughout those years, Dr. Echenberg's administrative skills and management activities focused on patient centered issues. All of the committees, programs, and organizations that he either helped to establish or that he participated in required a high degree of organizational skills as well as a deep commitment of time and energy. He was recognized throughout the Lehigh Valley in Southeast Pennsylvania as one of the key forces and influences in fighting for the best interests of the women and children of his community for over two decades.
His foresight and vision paved the way for many of the changes that took place in the routine medical care of women, both in the various community hospitals in the region as
well as in the private offices and clinics throughout that community in
Pennsylvania. Upon moving to New Mexico in 1995, Dr. Echenberg was part
of a multi-specialty hospital-based group in Las Cruces, New Mexico. Working for the "First Step Women's Health Center", Dr. Echenberg practiced in professional collaboration with other physicians and Certified Nurse-midwives, caring for a large population of indigent women in the Southern New Mexico region. The physicians within the group were responsible for all of the high risk Ob and operative births.
Dr. Echenberg took great satisfaction in working within collaborative groups and took pride in helping to maintain an excellent record of quality outcomes of mothers and babies in these programs. There were approximately 120-130 births per month in this high risk population among almost exclusively uninsured and mostly indigent families in this economically poor region of Southern New Mexico. The C-section rate of about 11% was only one example of the quality care provided by this multi-disciplined group sponsored by Memorial Medical Center in Las Cruces.
Dr. Echenberg's teaching skills and experience can be appreciated by the fact that throughout all the years in Bethlehem, Pennsylvania, St. Luke's Hospital maintained an accredited Ob/Gyn Residency program and he was on the teaching faculty for that program. He was also affiliated with Temple University as an associate faculty member, working with Temple University medical students who rotated through that service. For one year before coming to New Mexico, Dr. Echenberg was on the faculty of the Ob/Gyn Residency program at Lehigh Valley Hospital Center in Allentown, Pennsylvania.. He remained actively teaching in New Mexico in their Family Practice Residency program. In 1999, he was appointed Clinical Instructor by the Health Sciences Center of the West Virginia University School of Medicine.
In addition, for the past 25 years, Dr. Echenberg has guest lectured at many courses in local colleges and universities in both Pennsylvania and New Mexico.
Finally, for about the past 18 years, Dr. Echenberg's biggest professional interest outside of women's healthcare has been in the area of medical ethics. Once again, his managerial and executive skills have been utilized in creating and chairing various ethics committees and programs both in Pennsylvania and New Mexico, including one of the first Perinatal Ethics Committees in the country in 1984. It should be mentioned that without him, the ethics program at Memorial Medical Center in Las Cruces, NM would probably not have been established in its current form, and that he was commended for his work after JCAHO gave the hospital high marks in this complex area of ethics-related programming. Additionally, in 1999, he sat on the ethics committee of St. Joseph?s Hospital in Buckhannon, WV, and is currently back on the Ethics Consultation Committee at St. Luke?s Hospital in Bethlehem, PA. He was also reappointed Chair of the Perinatal Ethics Committee at that institution.
During the last 2 years of his stay in New Mexico, Dr. Echenberg was Chairman of the Ob/Gyn Department at Memorial Medical Center. He ran regular administrative meetings in this capacity and sat in on numerous other decision-making meetings for his department. In his position on the Medical Executive Committee, he was sent to several management training seminars by the hospital. In addition to all of these hospital-related professional activities, Dr. Echenberg has devoted extensive volunteer time to the local community sexual assault crises centers, both in Pennsylvania and in New Mexico, as a member of the Board of Directors. He was on the personnel committee in New Mexico, and spent extensive time participating in the recruiting and hiring of an executive director for this organization. He was also medical director of the "SANE" program in which nurses were trained to perform sexual assault physical exams and collect forensic evidence, and then testify in court when needed.
It should be noted that virtually all of the professional and community activities that Dr. Echenberg has participated in outside of his regular clinical duties required a great deal of managerial and leadership skills. This has been the case for many years, and he has been recognized in numerous ways for his vision, depth of interest and accomplishments in these endeavors.
Chronic Pelvic Pain
Description of Overall Program
The
following is a descripton of the program for chronic pelvic pain that
has been developed by Dr. Echenberg. This program is unique in the
Lehigh Valley and is based on sound principles of evidenced based
medicine. Chronic pelvic pain and lower genital tract disorders
including painful bladder syndrome (interstitial cystitis), irritable
bowel syndrome, low back disorders, vulvar burning/pain and sexual pain
disorders, are among the most common reasons for women seeking help
from their gynecologists or other primary health care providers.
Special hours are set aside for Dr. Echenberg to be able to spend the
time necessary to sort out, diagnose, and provide appropriate therapies
for these varied disorders.
WHAT IS THE CHRONIC PELVIC PAIN PROGRAM?
The
Chronic Pelvic Pain Program is a special program for women who have a
history of pain in the lower abdomen, pelvis, lower back, or in the
lower genital tract for a period of at least 3 - 6 months. Chronic
female pelvic pain also involves many women with long term histories of
bladder irritability (urinary frequency, urgency, and night time
voiding), vaginal irritation, and increasingly difficult discomfort
with sexual relations, all of which may have been unresponsive to many
different attempts at therapy.
There is only a limited amount
of appointment times available due to the amount of time spent with
each patient. Dr.Echenberg works in association with health care
psychologists and physical therapists, in Bethlehem, Allentown, and
Emmaus.
WHAT TESTS SHOULD BE DONE BEFORE BEING SEEN?
We
recognize that you may already have had various tests, including urine
tests, blood tests, ultrasound and x-ray examinations, and even
surgical procedures such as laparoscopy (surgery done to view the
pelvic organs). There is no need to get any further testing before
entering our program, but it is very important that you make
arrangements to get your previous medical records to us. Please contact
your doctor?s office to sign the necessary releases to send us these
records. (We will send you the necessary release forms when you make an
appointment).
These forms as well as other health
questionnaires and registration and insurance forms for our office can
be mailed or E-mailed to you depending on your preference.
WILL MY INSURANCE COVER THESE VISITS?
Yes.
Appropriate coding of your visits will be submitted to insurance in
order to maximize coverage of your specific problems.
WHAT HAPPENS AT THE FIRST VISIT?
A
detailed history of your problem will be assessed by the doctor and his
nurse. This first visit usually concentrates on a great deal of
education and offering you many resources in the form of handouts, both
published and Internet sites. Usually a comprehensive physical
examination, concentrating on the areas of greatest concern, is carried
out as well. If you feel that it would be helpful for you to have a
significant other person with you at any visit it would be acceptable
for you to do so. These first visits will range from 60-120 minutes.
WHAT ABOUT SUBSEQUENT VISITS?
We feel strongly that mind and body issues
are very closely linked in anyone having chronic pelvic pain. Everyone
entering our program will likely be asked to see a health psychologist
and/or a physical therapist as part of their therapeutic program. An
overall assessment and plan of treatment will then be implemented on an
individual basis.
WHAT ARE THE GOALS OF THE PROGRAM?
Our
major goal is to help you regain control of your life. Chronic pain
affects every part of your life - work, family, and social
relationships. Stressful times in your life can also make pain worse.
Therefore, we use a holistic approach in helping you learn to manage
your pain - things like stress management, exercise, nutrition, and
relaxation techniques. We also treat specific causes of pain. This will
include various medications and treatments for your specific problems.
DO WE THINK THAT YOUR PAIN IS ALL IN YOUR HEAD??
No!
We know that your pain and its impact on your life are very real. That
does not mean that there is a major disease causing your pain that has
been missed. We often find treatable conditions which are not dangerous
but which can trigger very serious chronic pain. The model of therapy
for these chronic pelvic pain issues is very similar to the model of
treatment used in many established chronic pain management centers.
Also, very few of our patients are found to have dangerous illness, and
surgery is rarely indicated.
WHAT DO WE FEEL ARE SOME ?NO ? No?s??
There
are some things that we do not recommend in the Pelvic Pain Program,
since they do not seem to help and may make pain or disability worse.
1.
We do not routinely prescribe long term narcotics. (Research shows that
these drugs can make chronic pain worse over time). (Opiates may be
used as rescue medication for severe pain flares). 2. We do not sign permanent disability papers. (Our goal is to help you get back to work!) 3. We rarely recommend surgery. (We do not think surgery helps in the vast majority of cases of chronic pelvic pain.)
Program for Female Lower Genital Tract Disorders and Chronic Pelvic Pain
A Therapeutic Program offered by Robert J. Echenberg MD
A
variety of common symptoms in many women may result from disorders of
the various organ systems in the female pelvic area. Some of these
disorders are quite common but are often not diagnosed routinely or
easily. Combinations of these disorders may sometimes be present for
months or even years, and may lead to varying degrees of physical and
emotional disabilities if they remain undiagnosed or treated
ineffectively.
Lower genital tract disorders may include any combination of the following symptoms complexes:
-
Symptoms of Recurrent Urinary Tract Infections: Recurrent episodes of
increased urinary frequency, urgency, and night time awakening for
urination ? often with negative urinalysis and cultures. -
Symptoms of Recurrent Vaginal Infections: Recurrent episodes of vaginal
burning, itching, redness, irritation, and variable vaginal discharges
? often with inconclusive vaginal smears and cultures. - Persistent
or Recurrent Vulvar Pain: burning, itching, redness, and unexplained
hypersensitive painful areas on the vulva or the vaginal opening. - Chronic Dyspareunia: increasingly difficult and painful sexual intercourse.
Conditions
such as Interstitial Cystitis and Vulvodynia are examples of disorders
that may cause any or all of the above symptoms and often go
undiagnosed for many years.
Chronic pelvic pain may also
co-exist with any or all of the above symptom complexes. The presence
of unexplained non-cyclic persistent or recurrent lower abdominal pain,
back pain, hip or even inner thigh pain may alert one to this
diagnosis.
Any of these symptoms, especially if associated
with variations of chronic pelvic pain for 3-6 months or longer, may
represent a diagnosis of a Central Regional Pain Syndrome. Other
examples of central regional pain syndromes include Fibromyalgia,
Reflex Sympathetic Dystrophy (RSD), Irritable Bowel Syndrome (IBS),
Migraine Headaches, Chronic Fatigue Syndrome, and Trigeminal Neuralgia.
Severe Seasonal Allergies may also be associated with these syndromes.
Quality
of life can be greatly impaired with these symptoms and syndromes, and
many women suffer for years without being adequately diagnosed. Many
have seen multiple specialists and often are treated both medically and
surgically without significant reduction of their symptoms.
Our
program offers a careful assessment of these diverse problems and
symptoms, and focuses on diagnostic accuracy. Individualized treatment
plans are initiated early, and often include multidisciplinary
therapeutic approaches.
Dr. Robert Echenberg is the primary
medical provider of these services. Dr. Echenberg has over 30 years of
experience as a practicing Board Certified Obstetrician and
Gynecologist, and he has developed special interest and expertise in
the diagnosis and management of chronic pelvic pain and lower genital
tract disorders over the past several years - since 2001.
The
major goal of this therapeutic program is to aid patients with these
debilitating problems regain control of their lives. With a combination
of medical therapies, physical therapy of the pelvic floor musculature,
psychological counseling and acupuncture and relaxation techniques when
indicated, this holistic approach has proven itself by regularly
contributing to improved quality of life of those women cared for in
our program.
We know that your chronic symptoms and pain have
had a significant impact on your life. You will not be treated as
though your problems are only ?in your head?. However very few of our
patients are found to have serious diseases and seldom are surgical
interventions required. Painful symptoms that have been present for
prolonged periods of time may show no current acute tissue damage. We
believe that these chronic problems need to be addressed entirely
differently than acute pain and discomfort.
Please fill out
the questionnaire and bring it with you to your first appointment. We
will go over the questions with you at the time of your visit. We have
a limited number of new appointment spaces due to the amount of time
spent with each patient.
A large part of recovery in this
therapeutic program depends on positive patient motivation. We
encourage each patient to learn as much as possible about her specific
condition and participate actively in her own treatment. Time will be
spent for education, and reading materials and web sites will be
provided.
Bladder Issues and Pelvic Pain
Painful Bladder Syndrom/Interstitial Cystitis
Background Interstitial
cystitis can be a chronic, debilitating disease. Since there is no
known cause or cure, our approach has been one of active patient
participation and patient education. We welcome the opportunity to
assist those in need of attention and understanding as our practice
grows with an increasing number of interstitial cystitis patients.
Interstitial
cystitis (IC), also known as "painful bladder syndrome" or "frequency-
pain syndrome," is a complex, chronic disorder that has baffled doctors
for as long as it has been recognized. Patients with interstitial
cystitis may have an inflamed bladder wall that can lead to scarring,
decreased bladder capacity, glomerulations (pinpoint bleeding) and, in
rare cases, ulceration. In other cases, the bladder wall can appear
normal without any evidence of disease process.
Estimates of the
number of people who have been diagnosed with IC vary. Studies have
indicated that up to 20 to 25% of all reproductive age women have some
degree of this disorder. It is likely that millions who suffer this
disease have yet to be diagnosed. About 90 percent of IC patients are
women. While people of any age can be affected, about two-thirds of the
patients are in their twenties, thirties, or forties. IC is rare in
children. In a few cases, IC has afflicted both mother and daughter,
but there is no evidence that the disorder is hereditary, or
genetically passed from parent to child.
Because IC varies so
much in symptoms and severity, many researchers have considered that it
may actually be not one, but several diseases. In the past, cases were
mainly categorized as ulcerative IC or non-ulcerative IC, based on
whether ulcers had formed on the bladder wall. But many clinicians have
questioned the usefulness of this classification, since the vast
majority of cases do not involve ulcers, and their presence or absence
does not influence treatment options or response to treatment as much
as other factors do.
CAUSE The cause of IC is unknown, but
the disorder is believed to be a real, physical phenomenon, not a
result, symptom, or sign of an emotional problem. Research has focused
on the glycocalyx (mucus) lining of the bladder made up primarily of
mucins and glycosaminoglycans (GAGs). This layer normally protects the
bladder wall from toxic effects of urine and its contents. Researchers
at the University of California, San Diego, found that this protective
layer of the bladder was "leaky" in about 70 percent of IC patients
they examined and may allow substances in urine to pass through the
bladder wall mucosa and trigger IC symptoms. The researchers also found
that patients with bladder wall ulcers had "leakier" bladders than
patients without the ulcers.
An allergic reaction that causes
specialized mast cells to release histamine is considered another
possible cause, however these changes are seen in a minority of biopsy
specimens. Infection, drug reactions and autoimmunity are other causes
under investigation, however no significant advances have been
forthcoming.
SYMPTOMS The symptoms of IC vary greatly from
one person to another but typically have similarities to those of a
urinary tract infection:
* Decreased bladder capacity * Severe urinary frequency, day and night
* Feelings of pressure, pain, and tenderness around the bladder, pelvis
and perineum that may increase as the bladder fills and decrease as it
empties. * Painful sexual intercourse * In men, discomfort of pain in the penis and scrotum * In most women, symptoms usually worsen around the menstrual cycle * As with many other illnesses, stress may also intensify symptoms.
DIAGNOSIS Because
symptoms are similar to those of other disorders of the urinary system,
and because there is no definitive test to identify IC, other
conditions must be ruled out before considering a diagnosis of IC.
Among these disorders is a urinary tract or vaginal infection, bladder
cancer, radiation cystitis, kidney stones, endometriosis, neurological
disorders, sexually transmitted diseases, and in men, prostatitis.
Spasm of the muscular pelvic floor must also be considered.
IC
may also be associated with diseases such as vulvodynia (vulvar/vaginal
pain), fibromyalgia (musculoskeletal pain) and irritable bowel disease.
Complete
evaluation may include a urinalysis, urine culture, urodynamic (bladder
pressure) study, cystoscopy (looking into the bladder using a miniature
telescope with anesthesia), biopsy of the bladder wall, and, in men,
laboratory examination of prostate secretions.
Because bladder
distension is painful in IC patients, cystoscopy must be performed with
either regional or general anesthesia. The diagnostic finding is
pinpoint hemorrhage, known as "glomerulations" which appear only after
the bladder is distended. A small bladder capacity under anesthesia
also helps to support the diagnosis of IC.
In review, the diagnosis of IC is based on:
* Presence of frequency, urgency, with pelvic/bladder pain (PUFF Scale questionairre)
* Cystoscopy sometimes indicated - Cystoscopic evidence (under
anesthesia) of bladder wall inflammation and pinpoint bleeding
(glomerulations) or Hunner's ulcers * Absence of other diseases that may cause the symptoms
TREATMENT We
have not yet found a cure for IC, nor can we predict who will respond
best to which treatment. Symptoms may disappear without explanation or
coincide with an event such as a change in diet or treatment. Even when
symptoms disappear, however, they may return after weeks, months, or
years. This is known as IC FLAIR and it is important to understand that
the symptoms of IC can recur or "flair" up at any time without cause or
reason.
Because we do not know the cause of IC, treatments are
aimed at symptomatic relief. One or a combination of treatments, many
of which are described below, helps most people for variable periods of
time.
Bladder Instillation:
Bladder instillation
is a treatment procedure that is done in the office. A tiny soft
catheter is placed into the bladder. Medication is then poured into the
bladder and the catheter is removed. The patient then leaves the office
and is instructed to empty her bladder about 1 1/2 to 2 hours later.
* "Rescue Solution" is now becoming first line treatment for initial
severe pain and symptoms of flair. This is a mixture of lidocaine, (a
topical anesthetic), heparin and Sodium Bicarbonate. It is very
soothing and quickly reduces pain levels by "breaking the pain cycle".
This results in dramatic reduction of anxiety and allows more time for
office assessment to determine long term treatment options. Treatments
are usually needed over the course of about 6 weeks to gain durable
results.
* Heparin or pentosanpolysulfate (Elmiron) can also be
instilled as a single agent and are thought to work by replacing or
repairing the "leaky" bladder lining.
* A variety of other
drugs have been used experimentally for bladder washes, but have not
been shown to be beneficial and in many cases can be extremely
irritating. These include silver nitrate, sodium oxychlorosene
(Clorpactin WCS-90) and BCG.
Oral Medication Pentosan
polysulfate sodium (Elmiron) and amitriptyine are two medications that
have been shown to be effective in randomized, placebo-controlled
studies.
* Elmiron is an FDA approved medication which helps
restore the damaged lining of the bladder. Results are evident by the
third month of use and there appears to be a 40 % to 50% response rate.
It is taken three times a day and is generally well tolerated.. The
most common side effect is gastric upset and about four percent have
hair loss that is completely reversible when medication is stopped.
* Amitriptyline (Elavil) is an antidepressant that has the ability to
block pain and reduce bladder spasms. Studies have now documented
statistically significant improvement in pain and urgency when compared
to placebo. Most people who respond to this drug show improvement 3 or
4 weeks after starting treatment. Side effects include drowsiness and
weight gain.
* Hyoscyamine (Levsin) and oxybutynin (Ditropan,
Ditropan-XL) and tolterodine (Detrol, Detrol LA) have excellent
properties to reduce bladder spasms and are well tolerated. Dry mouth
is the most common side effect of this class of medication.
* Hydroxyzine (Vistaril, Atarax) is an antihistamine that has been reported to be effective in limited studies.
Supplements Non-prescription
supplements are also under investigation and some have been shown to
benefit some patients in limited, uncontrolled studies.
*
L-Arginine is an amino acid (protein building blocks) that breaks down
into nitrous oxide, (a neurotransmitter) that can reduce pain and
frequency in some patients.
* Kava Kava is an herbal
preparation that has anti-anxiety effects. Even though this is a plant
extract and is not under FDA control, it can produce serious side
effects and a physician's supervision is needed if it is taken for more
than 3 months.
* Quercitin is one kind of several substances
called bioflavonoids that are found in onions, red wine, green tea and
other plants. In limited and preliminary clinical reports, a
non-standardized preparation seems to have improved symptoms in about
half of the patients. Quercitin has strong anti-oxidant and
anti-inflammatory properties that may explain its beneficial effects,
but further well-controlled studies are needed to determine its
effectiveness.
Diet There is no scientific evidence linking
diet to IC, however many patients obtain considerable relief by
limiting intake of alcohol, tomatoes, spices, chocolate, caffeinated
beverages, citrus and high-acid foods. Some patients also notice a
worsening of symptoms after eating or drinking products containing
artificial sweeteners. An "elimination diet" can be used to pinpoint
specific food irritants and is recommended for all IC patients. For
those who are sensitive to food acidity, "Prelief" is available locally
as tablets or granules that reduce the acidity of food and helps to
reduce pain. Their toll-free hotline is 1-800-994-4711.
PAIN CONTROL: A different kind of pain. Most
of us are familiar with typical pain of a sprained ankle or a cut
finger. This is called "somatic" pain and is easily localized to the
area of injury, is easy to describe (sharp, dull or aching) and heals
in a short period of time. The pain of IC is called "visceral" pain and
is very different because it arises from the bladder, an internal organ
located deep in the pelvis. This kind of pain is difficult localize,
can be very difficult to describe and occurs on a long-term, chronic
basis. One reason why IC is so frustrating is because a patient may
have difficulty telling a doctor where the pain is located and be
unable to describe its character. A typical patient will point to
several areas including the back thighs abdomen and pelvis calling the
pain "pressure-like" or "cramping". This is not the typical description
of distinct and localized somatic pain that most doctors are familiar
with and feel comfortable treating. One of the most important aspects
of receiving good care is to choose a physician who is experienced in
treating IC and is comfortable assessing and treating visceral pain.
Opioid Narcotics For
some IC patients the most effective control of long-term pain is
obtained with the use of opioid narcotics. They are derived from the
opium poppy and are excellent at providing pain relief, Vicodin and
oxycodone are the most commonly prescribed oral preparations. Side
effects include sedation, respiratory depression and constipation.
These can be very significant and require careful dose adjustment and
monitoring.
Unfortunately, all opioids have the potential for
tolerance, physical dependence, and addiction. These characteristics
have lead to many misconceptions about narcotic use and prevent many
health care providers from considering prescribing them for long-term
use.
Tolerance to opioid medication is common. It refers to the
progressive decrease in pain control and the need of higher doses to
provide the same level of pain relief.
Physical dependence
always occurs. with long-term use of opioids. If the medication is
abruptly withdrawn or the dose is markedly reduced patients will
experience a withdrawal syndrome that includes abdominal cramping,
sweating, nausea, diarrhea and irritability. It is strictly a medical
condition and should not be taken as a sign of psychological weakness.
Addiction is a behavioral disorder that results in psychological
dependence of a substance. It refers to compulsive drug use and
continuing drug use despite harm. Unfortunately, addiction is all too
often incorrectly equated with physical dependence and withdrawal
syndrome. To provide proper chronic pain management it is crucial for
physicians to recognize this critical difference.
Objectives of Pain Control The patient and physician should have realistic expectations regarding the use of opioids.
Obtaining
an excellent Quality of Life should be the main goal by adequate
control of pain, not the complete elimination of pain. Outcomes should
focus on developing a daily routine schedule involving work,
participation in social functions, and family needs.
Just like
long-term medication controls but does not cure diabetes or high blood
pressure, long term medication is required to adequately control
chronic pain.
Because of the abuse potential of narcotic pain
medication many physicians require patients to agree to an Opioid
contract. This is a reasonable approach that creates the obligation of
both parties to effectively communicate dose requirements, dose
changes, reports of side effects and refill authorization.
Anxiety and IC Anxiety
is a significant component of IC that tends to be misunderstood.
Patients coping with chronic pain often restrict activities for fear of
increased pain or further injury. Withdrawal from normal activities
such as work, family responsibilities and social events can result in a
high degree of anxiety, worry, frustration and fear of loss. Research
has shown that individuals with a high disposition to become anxious
report significantly higher pain levels than those with low levels of
anxiety. It is also known that as anxiety increases, the intensity of
reported pain increases. This results in a vicious cycle that needs to
be treated.
Pain and Anxiety Cycle
Unfortunately, in
many situations the pain-anxiety cycle is not treated because the
physician or patient does not recognize or refuses to accept the
presence of anxiety. The impact that psychological factors have on the
perception of pain does not mean that the pain is "in the persons head"
or not real. Those with IC who report pain are really experiencing it,
even if a physical cause cannot be identified.
Relief of anxiety can be obtained by two approaches:
* Behavioral changes include relaxation techniques and stress
management. There are many options available that can be individualized
according to personal preference. These include: o Progressive muscle relaxation o Meditation o Prayer o Visualization o Breathing techniques o Biofeedback
* Medication can relieve symptoms quickly and safely. The most
effective and most prescribed class of medication is benzodiazepines
(Valium, Xanax, Klonopin). The most common side effect is drowsiness
and tolerance (see above) can develop so short-term use is recommended.
Because these drugs are often used in combination with antidepressants
such as amitriptyline, the lowest possible dose should be prescribed to
minimize side effects.
No one should ever be denied treatment
for pain. But because of the reluctance of certain physicians to treat
chronic pain, there is an alternative to help obtain proper pain
management.
Pain Management Programs Pain clinics are now
becoming popular for patients who continue to have difficulty obtaining
adequate pain control. These are specialized, integrative pain
management programs that are available at many community and academic
hospitals. Dr. Echenberg's practice offers such a comprehensive pain
management program for chronic pelvic pain in women. Therapies offered
typically include conventional pain medications, interventional
pudendal nerve blocks, trigger point injections, referral for
acupuncture, neural therapies (i.e. Neurontin, Lyrica, Topomax),
massage therapy, physical therapy, deep tissue and spinal manipulation,
dietary recommendations and counseling.
Sacral Nerve Stimulation This
can be used to relieve severe frequency when all other options have
failed. Our program can refer you for this procedure though it is
rarely needed. The InterStim device is an implanted stimulation system
that sends electrical impulses to the nerve near the tailbone that
influences bladder control. Stimulation of this nerve may relieve the
symptoms related to urge incontinence.
The effectiveness of the
therapy is first tested on an outpatient basis. If the test is
successful, the patient may choose to have the device implanted.
The
final procedure requires general anesthesia, A small wire is placed
near the sacral nerve through an incision and is passed under the skin
to a silver dollar sized neurostimulator. The neurostimulator is then
placed under the skin in the upper buttock.
Adjustments can be
made with a wireless programming device that sends a radio signal
through the skin to the neurostimulator. The patient can make further
adjustments at the doctor's office or at home.
This treatment is
about 50% effective. Complications such as infection are frequent,
permanent nerve damage have been reported and migration of the
implanted wires can render the system ineffective. However, it is an
excellent alternative to any major surgical procedure.
Self Help The
emotional support of family, friends, and other people with IC is very
important in helping patients cope with the disorder. Studies have
found that IC patients who learn about the disorder and become involved
in their own care do better than patients who do not. We encourage our
patients to visit the superbly designed web site: www.ic-network.com
which has a wealth of information regarding all aspects of IC including
chat groups. We also suggest our patients visit www.ichelp.com which
provides access to professional publications, support groups and
research funding.
RESOURCES ICN Patient Handbook. This is an on-line manual available at www.ic-network.com . Very accessible and pertinent information.
The
Interstitial Cystitis Survival Guide. Moldwin, New Harbinger, 2000. The
most comprehensive review of IC available. Easy to read. Highly
recommended.
Overcoming Bladder Disorders. Chalker and Whitmore,
HarperPerennial, 1990. An excellent comprehensive manual including
self-help strategies. A bit outdated but still extremely useful.
Conquering
Bladder and Prostate Problems. Blaivas, Plenum Trade, 1998. Somewhat
technical chapters covering all aspects of the urinary system.
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Interstitial Cystitis Updates
In
an attempt to further understand this disease and to discover new
treatment options and research discoveries, we will post reviews of
recent articles and other significant matters that relate to
interstitial cystitis.
Antiproliferative activity is present in bladder but not renal pelvic urine from interstitial cystitis patients.
Keay
S, Warren JW, Zhang CO, Tu LM, Gordon DA, Whitmore KE Department of
Medicine' University of Maryland School of Medicine' the Research
Service' Baltimore Veterans Affairs Maryland Health Care System ë21201'
USA.; J Urol; 1999 Oct; 162(4):1487-9
PURPOSE: To determine
whether an antiproliferative urine factor that we previously discovered
to be specific for urine from interstitial cystitis (IC) patients
originated in the lower urinary tract or a more proximal site.
MATERIALS
AND Methods: Sequential catheterized urine specimens were collected
under sterile conditions from the bladder and renal pelvis of 20 IC
patients and one control patient (with stress incontinence).
Antiproliferative activity was determined by 3H-thymidine incorporation
of primary normal adult bladder epithelial cells cultured with pH- and
osmolality-corrected bladder or ureteral urine specimens; significant
inhibition was defined as a change in 3H-thymidine incorporation
greater than 2 standard deviations from the mean of control cells.
Results:
Bladder urine specimens from 19 of 20 IC patients significantly
inhibited 3H-thymidine incorporation as compared to cell medium alone
(mean change for bladder specimens = -68.7+/-7.5%)' while a renal
pelvic specimen from only 1 of 20 IC patients inhibited proliferation
significantly (mean change for renal pelvic specimens = 3.2+/-3.4%)
(p<.001 by Fisher's exact test). The one inhibitory IC renal pelvic
specimen inhibited by 31% while a bladder specimen obtained during the
same procedure inhibited by 94%. In comparison neither bladder nor
renal pelvic urine from the control patient had inhibitory activity.
Conclusions:
The antiproliferative factor previously found in the urine of IC
patients appears to be made and/or activated in the distal ureter or
urinary bladder.
New Clinical Marker for Interstitial Cysitis
The
cause of interstitial cystitis is thought to be a deficiency in the
protective mucous layer of the bladder. More specifically, it is
thought that potassium diffusion becomes more prominent and potassium
acts as an irritant to the superficial and muscle layers of the
bladder, producing symptoms of interstitial cystitis.
GP 51 is a
urinary glycoprotein that functions as a protective barrier to the
bladder wall. A recent study at Thomas Jefferson University evaluated
urinary GP 51 levels in patients with and without interstitial
cystitis. It was found that these levels are significantly reduced in
patients with the disease. Although, it does not explain why levels
were lower, it certainly raises the possibility of using GP 51 as a
clinical marker for diagnosing interstitial cystitis using a
non-invasive urinary test. It may also become an excellent way of
monitoring treatment and the ongoing effects of drug therapy.
Reduce Acid Content in Foods
Many
patients with interstitial cystitis have difficulty tolerating acidic
foods such as pizza, tomato sauces, coffee and juices. It is thought
that the bladder pain is caused by high levels of potassium that leaks
through the bladder wall. A product called Prelief, which reduces acid
content in food, is available over the counter as tablets and granules
and may be of value in the diets of interstitial cystitis patients who
are sensitive to acidic foods. Check out their website at
www.prerelief.com.
Vulvar pain/Vestibulitis
Dr.
Echenberg may have prescribed Lidocaine Ointment for you for your
persistant irritation at the vaginal opening. 5% Lidocaine Ointment is
a local topical anesthetic ointment that has been shown to gradually
diminish the senstivity of the nerve fibers that supply the vaginal
opening (the "vestibule" of the vagina). The instruction for use of
this ointment is as follows: Apply a small portion of the Lidocaine
Ointment to a cotton ball each evening at bedtime and place it in the
vaginal opening overnight and throw it away in the morning or if you
have to get up to the bathroom during the night. Some patients find
that the Lidocaine provides a soothing comfortable feeling when it is
there overnight while it gradually is desensitizing the nerve endings
that cause the burning and pain during intercourse. Please call for an
appointment with Dr. Echenberg if you wish to be evaluated for this all
too common problem.
For Patients Guidelines for Vulvar Skin Care
NOTE: The goal is to promote healthy vulvar skin. This is done by decreasing and/or removing any chemicals, moisture, or rubbing (friction). Any products listed below have been suggested for use because of their past success in helping to decrease or relieve vulvar/vaginal itching and burning.
LAUNDRY PRODUCTS Use a detergent free of dyes, enzymes and perfumes (such as ALL-Free and Clear or Earth-Rite) on any clothing that comes in contact with your vulva such as your underwear, exercise clothes, towels, or pajama bottoms. Use 1/3 to 1/2 the suggested amount per load. Other clothing may be washed in the laundry soap of your choice. Do not use a fabric softener in the washer or dryer on these articles of clothing. If you do use dryer sheets with the rest of your clothes, for any loads, you must hang dry your underwear, towels, and any other clothing that comes in contact with your vulva. Stain Removing Products. Soak and rinse in clear water all underwear and towels on which you have used a stain removing product. Then wash in your regular washing cycle. This removes as much of the product as possible.
CLOTHING Wear white all cotton underwear, not nylon with a cotton crotch. Cotton allows air in and moisture out. Avoid pantyhose. If you must wear them, either cut out the diamond crotch (if you cut out the crotch be sure to leave about 1/4 to 1/2 inch of fabric from the seam to prevent running) or wear thigh high hose. Many stores now carry thigh high nylons. Avoid tight clothing, especially clothing made of synthetic fabrics. Remove wet bathing and exercise clothing as soon as you can.
BATHING AND HYGIENE Avoid bath soaps, lotions, gels, etc. which contain perfumes. These may smell nice but can be irritating. This includes many baby products and feminine hygiena products marked "gentle" or "mild". Dove-Hypoallergenic, Neutrogena, Basis, or Pears are the soaps we suggest. Do not use soap directly on the vulvar skin just warm water and your hand will keep the vulvar area clean without irritating the skin. Avoid all bubble baths, bath salts and scented oils. You may apply a neutral (unscented, non-perfumed) oil such as Keri Oil to damp skin after getting out of the tub or shower. Do not apply oils directly to the vulva. Do not scrub vulvar skin with a washcloth, washing with your hand and warm water is enough for good cleaning. Pat dry rather than rubbing with a towel. Or use a hairdryer on a cool setting to dry the vulva. Baking Soda soaks. Soak in lukewarm (not hot) bath water with 4-5 tablespoons of baking soda to help soothe vulvar itching and burning. Soak 1 to 3 times a day for 10-15 minutes. Use white, unscented toilet paper. If paper has a perfumed scent or lotion, avoid using it. Avoid all feminine hygiene sprays, perfumes, adult, or baby wipes. Pour lukewarm water over the vulva after urinating if urine causes burning of the skin. Pat dry rather than rubbing with a towel. Avoid the use of deodorized pads and tampons. Tampons should be used when the blood flow is heavy enough to soak one tampon in four hours or less. Tampons are safe for most women, but wearing them too long or when the blood flow is light may result in vaginal infection, increased discharge, odor, or toxic shock syndrome. Also, use only pads that have a cotton liner that comes in contact with your skin. Avoid all over the counter creams or ointments, except A&D Ointment. Ask your health care provider first. Small amounts of A&D Ointment may be applied to your vulva as often as needed to protect the skin. It may also help to decrease skin irritation during your period and when you urinate. Brands that have been helpful are the Fougera brand, Toys R Us brand, Rugby brand, or NMC brand.
DO NOT DOUCHE. Baking soda soaks will help rinse away extra discharge and help with odor.
DO NOT SHAVE the vulvar area. Some women may have problems with chronic dampness. Keeping dry is important. Choose cotton fabrics whenever you can. Keep an extra pair of underwear with you in a small bag and change if you become damp during the day at work/school. Gold Bond Powder or Zeosorb Powder may be applied to the vulva and groin area one to two times per day to help absorb moisture. Dryness and irritation during intercourse may be helped by using a lubricant. Use a small amount of a pure vegetable oil such as Crisco (solid or oil). The vegetable oils contain no chemicals to irritate vulvar/vaginal skin. Vegetable oils will rinse away with water and will not increase your chances of infection. Water-based products like K-Y Jelly are helpful, but may tend to dry before intercourse is over and also contain chemicals that can irritate your vulvar skin. It may be helpful to use a non-lubricated, non-spermicidal condom, and use vegetable oil as the lubricant. This will help keep the semen off the skin which can decrease burning and irritation after intercourse.
BIRTH CONTROL OPTIONS The new low-dose oral birth control pills do not increase your chances of getting a yeast infection. Lubricated condoms, contraceptive jellies, creams, or sponges may cause itching and burning. Ask your health care provider for help. The use of latex condoms with a vegetable oil as a lubricant (#14 above) is suggested to protect your skin. Oil based lubricants may affect the integrity of condoms when used for birth control or prevention of sexually transmitted diseases. Our experience has not found this to be a problem with vegetable based oils. However,the Centers for Disease Control recommends that condoms not be used with any oil based lubricants for birth control or prevention of sexually transmitted disease.
| | | The Vulvar Self-Exam
Just
as you would examine your breasts or skin for changes, you should
examine your vulva. Many diseases of the vulva have similar symptoms.
The vulvar self-exam will help you to be aware of any changes in the
vulvar area that may need ongoing evaluation. Some changes in the vulva
may mean cancer. Tell your physician if you see any changes or have
symptoms that don?t go away, such as itching, bleeding or discomfort.
If a problem does occur, catching it at an early stage--when treatment
is most successful--is in your best interest. Learning how to do a
vulvar self-exam can best accomplish this.
1. Wash your hands carefully before you begin. Lie
or sit up in a comfortable position with good lighting and a hand
mirror (a magnifying mirror may work best). It may help to prop up your
back with pillows, or you can squat or kneel. Finding a comfortable
position is important so you can clearly see the vulvar area, perineum,
and anus. First, just look and learn. Things may appear different from
what you expect, and that does not necessarily mean they are abnormal.
2.
Gently separate the outer lips of the vulva. Look for any redness,
swelling, dark or light spots, blisters, bumps or other unusual colors.
3. Next, separate the inner lips and look carefully at the area
between them for the same changes. Also, look at the entrance of the
vagina.
4. Gently pull back the skin covering the clitoris and examine the area under the hood at the tip of the clitoris.
5.
Be sure also to inspect the area around the urethra, the perineum, the
anus, the outside of the labia majora and the mons pubis.
SOME SUGGESTED VULVAR PAIN & ITCHING MEASURES
The
vulva is the external genitalia in the female. The skin of the vulva
can be quite sensitive. Because it is moist and frequently subjected to
friction while sitting and moving, this area can be easily injured.
There are various strategies that can be used to prevent irritation and
allow the vulva to heal. Keeping this area dry can accelerate healing.
Chemicals found in toilet tissues, laundry soaps and detergents that
come in contact with the vulva can cause irritation. Avoiding contact
with potential irritants that contain chemicals is important. Fabric
softeners in undergarments, chemicals in deodorant soaps, bubble baths,
feminine hygiene spray and panty liners etc., can all cause irritation
to the vulva. The following recommendations are specific measures that
can help minimize vulvar irritation.
Wear white 100%
cotton underwear, and do not wear pantyhose, tights, or other
close-fitting clothes. Enclosing this area with synthetic fibers holds
both heat and moisture in the skin, conditions which potentiate the
development of secondary infections. Tight-fitting clothes may also
increase your symptoms of discomfort.
After washing
underwear, put it through at least one whole cycle with water only.
Some women have suffered needlessly from irritants in detergents whose
residue was left in clothes by incomplete rinsing. Rinsing clothes
thoroughly is more important than which detergent is used although to
be on the safe side, the milder the soap, the better. Wash new
underwear before wearing. Fabric softeners and dryer sheets should not
be used.
Rinse skin off with plain water frequently.
Use tap water, distilled water, sitz baths, squirt bottles, or bidets.
Pat the skin gently dry, or dry with a cool setting on a hair dryer if
you prefer.
Use very mild soap for bathing. It is best
not to use any soaps on the vulva. The vulva should be rinsed with warm
water. Bars of soap such as Neutrogena unscented face soap, Basis,
Pears (made in England), and castile soap with olive oil (Conti) are
gentle to the other skin areas. They are found at pharmacies or health
food stores. Remember that frequent baths with soaps may increase the
irritation. You cannot wash away your symptoms.
A
compress of oiled Aveeno (a powdered oatmeal bath treatment) has been
recommended by some. It is placed over the vulva three to four times a
day. Put two tablespoons of Aveeno in one quart of water. Mix in a jar
and refrigerate. This is often helpful after intercourse or when
symptoms of burning and itching are present.
Use
lubricants suggested by your physician to make intercourse more
comfortable. Astroglide is a product with a natural lubricating action.
Other water-soluable lubricants include Lubrin, Moisturel, Replens and
KY Jelly. Vegetable oils such as olive oil also provide lubrication.
Use
100% cotton menstrual pads and tampons. Many women with vulvar pain
experience a significant increase in irritation and pain every month
when they use commercial paper pads or tampons. This monthly increase
in pain can often be reduced by using 100% washable and reusable cotton
menstrual pads. Some disposable cotton pads are available. Pure cotton
tampons are also available.
Don?t sit or remain in a wet bathing suit for prolonged periods.
Avoid condom and spermicidal creams or gels if they cause increased irritation of sensitive tissues.
Additionally,
it is often recommended that the vulva is left uncovered at night (i.e.
no underwear) to allow adequate exposure to the air.
Many
of the disease processes will require a biopsy to diagnose your
condition. If a biopsy is performed during your visit, after care is
important. Keep the area clean and dry. Avoid application of creams or
ointments to the biopsy site. Sitz baths twice a day for three or four
days following the biopsy will aid in healing. If increase redness,
severe pain, heavy discharge, or heavy bleeding occurs at the biopsy
site, call for further instrucitons. Avoid intercourse until the biopsy
site is healed.
Adapted From:
The Vulvar Pain Foundation, "Natural and Prophylactic Measures Suggested", Vulvar Pain Newsletter 1993: Spring: 5-6
The Interstitial Cystitis Association Vulvar Pain handout
Vulvar Pain
A
large proportion of the patients seen at the University of Michigan
Center for Vulvar Diseases have vulvar pain. The following information
is a comprehensive review of the different aspects of vulvar pain.
Definition:
Throughout history many different terms have been used to describe
vulvar pain. Vestibulodynia (previously called vulvar vestibulitis)
consists of pain at the entranceway to the vagina. Vulvar dysesthesia
(previously called dysesthetic vulvodynia) consists of a burning or
pain on the vulva present in areas outside of the vestibule. Patients
with dysesthetic vulvodynia may also have burning or pain at the
vestibule. Symptoms consist of burning, stinging, irritation or
rawness. Other terms used to describe the vulvar discomfort include:
itching, stretching and throbbing.
Causes: Vulvar pain
can be divided into two major categories: those with a known cause and
those where a cause cannot be identified.
Pain with a known cause
Vulvar
pain can be associated with simple chemical irritation, so-called
contact dermatitis. Common irritants include soaps, shampoos, scented
toilet paper, douches, fabric softeners and scented menstrual pads. It
can also be caused by certain medications which have been used to treat
vulvar problems. Various infections can also be causes of vulvodynia.
Women with chronic vulvar and vaginal yeast infection can frequently
have vulvar itching and burning. Often symptoms worsen before menses as
the changes in ovarian hormone production and the local vaginal
environment can favor yeast growth during that time. Recurrent herpes
simplex virus infection can also cause vulvar pain. These infections
wax and wane, often starting at stressful times and lasting anywhere
from a couple of days to a week or more. Irritation of the nerves which
supply the vulva can also cause vulvar pain. This type of vulvar pain
may radiate from the vulva to the perineum and into the groin and
thigh. Some patients have lower back problems which may be associated
with this pain also. Vulvar pain also results from injury (i.e.
childbirth, vaginal/vulvar trauma).
Pain without a known cause
Physical
examination of this group of patients does not demonstrate any visible
abnormalities. It is important to understand that vulvar pain with a
normal appearing vulva does not mean that there is not a cause of the
vulvar discomfort, rather a cause cannot be identified. Despite the
fact that a cause of vulvar pain cannot be established in all cases,
two things are important to keep in mind: 1) frequently the discomfort
associated with vulvar pain can be controlled, and 2) it is clear that
there is generally no relationship between vulvar pain and the
subsequent development of vulvar cancer.
Pain on the
Vestibule of the Vulva: Some women present with distinct tenderness and
at times erythema (redness) in the vestibule. Intercourse is painful
and, in some cases, impossible due to the severe pain. Typically, women
with pain on the vulvar vestibule present with a varying duration of
symptoms from weeks to several years. Symptoms often begin after
experiencing some type of infection or trauma followed by difficulty
with intercourse. Burning, stinging, irritation or rawness at the
vaginal opening with intercourse are the most common complaints. This
same sensation may also be experienced when placing tampons or touching
in the area of the vestibule. Women with severe symptoms may also feel
this same sensation when riding a bicycle, horseback riding or jogging.
In more extensive cases, some patients experience these symptoms while
sitting, walking or even without any movement. Typically, these women
have seen a number of health care practitioners and have had numerous
attempts at therapy with topical or oral antifungals, topical steroids,
and antibiotics. Usually, these provide no long term relief.
The
cause(s) of pain on the vestibule is not known. Early studies
implicated the human papilloma virus as a cause, but this is no longer
considered to be associated with vulvar vestibulitis. There appears to
be a small subset of women who have chronic yeast infection as a cause
of their vestibular pain, and long-term yeast suppression has met with
promising results in these women. There is also another group of women
who appear to have both pain at the vulvar vestibule and interstitial
cystitis (a condition of the bladder which causes urinary frequency and
burning). Because the vestibule and a portion of the bladder are the
only two tissues in the body derived from the same embryologic tissue,
investigators have begun to look for an irritant which might affect
both of these structures. To date, no causative agent has been proven.
Some patients relate the onset of their pain to a gynecological or
obstetric event. It is important to recognize that there is absolutely
no evidence that vestibular pain is a sexually transmitted disease,
therefore, it cannot be contracted from or given to your sexual
partner.
Treatment: Treatment of vulvar pain
conditions is confounded by the fact that the cause is unknown in a
great majority of cases, and the best treatment will likely come only
when the cause has been identified. Where chronic yeast infection can
be identified, suppression of yeast growth can be gratifying. Other
topical therapies such as steroids and antibiotics have not met with
success. Topical anesthetic agents (e.g., viscous or liquid xylocaine)
can sometimes help with temporary relief. The greatest success in
treating vulvar pain conditions comes from using a group of medications
called antidepressants. This group of drugs (e.g., Elavil?, Pamelor?,
Norpramin?) has been used to treat many chronic pain conditions where a
cause cannot be found. The TCA (tricyclic antidepressant) may work by
inhibiting certain pain fibers which supply (innervate) the vulva. This
in turn can prevent these specific nerves from transmitting the message
to the brain where it is processed and pain is perceived. Another group
of drugs, anticonvulsants, are used as treatment for other chronic pain
conditions and may be used for vulvar pain. The use of the CO2 laser
has not been successful, and in some cases, the results of treating
vestibulitis with the CO2 laser have worsened the pain.
It
has been suggested burning on the vestibule may be associated with
elevated levels of oxalates in the urine. A group of investigators have
described patients whose symptoms improve while on a low oxalate diet
combined with taking a mineral called calcium citrate. Calcium citrate
may decrease calcium oxalate formation in the urine, which is proposed
to cause vulvar pain. (See page 21) Surgical excision of the vulvar
vestibule may be offered as treatment for pain on the vestibule if
conservative measures have failed.
There is no standard
treatment for patients with vulvar pain since there are likely multiple
causes. Treatment suggested will depend on your individual case.
Modifications of treatments and medication dosages may need to be
altered if your symptoms vary. The doctors and nurses at the Center for
Vulvar Diseases will discuss your individual case with you and develop
an individual treatment plan based on your history, prior treatments
and severity of symptoms.
Vulvar pain can be a
difficult process to treat. Improvement may take weeks to months (even
years) of long-term treatment. Spontaneous remission of symptoms has
occurred in some women, while with others multiple attempts with
medical management has proven unsuccessful in relieving 100% of
symptoms.
IMPORTANT THINGS TO REMEMBER ABOUT VULVAR PAIN
Vulvar pain is not generally associated with malignancy
Despite
the fact that the cause of vulvar pain cannot be established in many
cases, careful investigation has established that it is not a sexually
transmitted disease and is not contagious to your partner.
Vulvar
pain is not due to poor hygiene, and the use of strong soaps and
detergents can worsen the condition. Use gentle soaps to the skin and
no soap on the vulva, allowing water alone to cleanse the perineum.
Improvement often takes weeks to months.
Although
the cause of vulvar pain cannot always be determined, it has been
characterized well enough to allow treatment of the pain with a
reasonable expectation of significant improvement, if not complete
alleviation of pain.
Treatment setbacks may occur; they are not necesarrily the fault of your care provider or you.
We understand that chronic pain is exhausting and can be demoralizing.
There is nothing wrong with you as a person, the problem is your pain.
Don?t
feel that because this is genital pain that you can?t talk to other
people. People with chronic problems need others for support. Family
and friends can help.
If you are in a relationship, both of you are affected by this problem. Appropriate couple counseling may be needed.
It is OK to seek information on your own. The more you know about this disease, the more control you have over your situation.
Sometimes patients become depressed if new treatments fail. Remember this as we work through this problem.
Physical Therapy and Biofeedback
Physical
therapy and biofeedback have been important in the treatment of vulvar
pain. Our pelvic floor program at University of Michigan Hospital began
in December of 1999, and we have had much success in treating multiple
pelvic floor dysfunctions. Evaluation and treatment may include
observation, palpation, use of topical vaginal or rectal sensors for
biofeedback and / or electrical stimulation, vaginal probes for
biofeedback, soft tissue mobilization, education, relaxation exercises,
ultrasound and ice.
Various pain conditions can be
aggravated or caused by muscle tension. When a person experiences pain
the body?s natural response is to protect that body part by tightening
the muscle. PT uses biofeedback to help educate patients on how to
relax a contracted or tightened muscle. Biofeedback gives you immediate
information on whether your pelvic floor musculature is relaxed or
tensed and helps you to gain voluntary control of your muscles. It aids
in developing self-regulation strategies for confronting and reducing
pain This allows you to become actively involved in your own treatment
and learn how to relax the pelvic floor muscles in various positions.
Sensitive detectors can be used on the vulva to tell you what is
happening in your vulvar nerve environment. With the aid of an
electronic measurement and amplification system or biofeedback machine,
an individual can view a display of numbers on a meter, or colored
lights to assess nerve and muscle tension. In this way it is possible
to develop voluntary control over those biological systems involved in
pain and discomfort.
The body has a protective muscle spasm
to protect painful areas. The muscles react by tightening up. Patients
are taught to isolate their pelvic floor muscles and learn how to
strengthen them. After exercise therapy, the muscles return to a
stronger, more relaxed and more stable state. Physical therapy programs
established are based on patient goals. Each program is very
individualized according to findings from the patient?s initial
evaluation.
A doctor's prescription is necessary for
evaluation and treatment in physical therapy. Precertification from
your primary care physician may also be required. It is recommended
that you contact your insurance company prior to scheduling your
initial physical therapy visit to assure physical therapy is covered by
your insurance program.
SEXUALITY AND PAIN?A real challenge.
There
are some conditions which can cause women to experience pain with sex,
whether the activity is heterosexual intercourse, masturbation, partner
attempting to penetrate the vagina with fingers, or other sexually
stimulating activity. Many times numerous treatments have been tried,
with little success. The pattern of experiencing pain with sex,
sometimes for a long period of time, can be very challenging for women
and for their partners. Sometimes the pain comes and goes, but the fact
that the women cannot predict when they may or may not experience pain
means that they are always vigilant that pain could happen. This can
set up a cycle of women and partners anticipating pain, which, in
itself, is distracting.
The sexual response cycle
is generally separated into three categories. These are the desire
phase, the excitement phase, and the orgasm phase. Seeing sexual
response in phases can be helpful, because women can begin to
understand where their problem is occurring. This can be beneficial, if
only to help women and their partners understand the impact of
attempting to maintain a healthy sex life while coping with chronic
pain.
The desire phase refers to a woman?s interest in
engaging in sexually arousing activity. We know that how a woman feels
about herself and her body, what she expects from sexual experience in
general and her partner in specific, and her experience with intimate
relationships, whether sexual or not, all come together to influence
sexual desire. Chronic pain can be a secondary cause of low sexual
desire. For example, in the Vulvar Disorders Clinic women frequently
tell us that the quality of their sexual interest and desire before
they had pain was just fine. In other cases, some women state that they
have always had some difficulty with sexual interest. This can vary
from feeling they aren?t nearly as interested in sex as their partners,
to feeling that they would like to avoid sex forever if it was
possible. In cases where sexual desire has always been problematic,
this issue should be addressed. If this issue isn?t dealt with, for
some women resolving pain could mean that there is no longer an
acceptable reason to avoid sexual contact. We hesitate to include this
as an example about what can happen, because many women have been told
that their vulvar pain is not real, and we know that the pain is real.
We can?t leave this factor out of a discussion about sexual desire.
The
excitement phase describes what is happening in a woman?s body during
sexually stimulating activity. She usually feels focused on the
activity. Her vagina becomes moist with lubrication, and her genital
region feels "full" because of blood flow into the area. This is
similar to a man having an erection during sexual arousal. Pain is not
supposed to be a part of sexual arousal, and so when it occurs we call
it an excitement phase difficulty. This refers more or less to the
"mechanics" of sexual functioning. By itself a pain problem means only
that something isn?t functioning as it should. It is a symptom, and
does not tell us anything about the woman?s desire to be sexual or to
experience sexual attraction. Of course pain with sex is a catch 22 for
women, and their sexual partners. Anticipating that sex might hurt can
certainly affect sexual desire.
The orgasm phase is the
discharge of pent-up sexual tension. Some women have orgasms regularly
with sexual intercourse, and some women do not. This is normal, and is
not a dysfunction. If a woman can have an orgasm with her sexual
partner in some manner, the orgasm phase is intact. Vulvar or vaginal
pain does not in itself lead to difficulties with orgasm. However,
pleasure can be substantially blunted if pain or anxiety about pain is
a part of the sexual experience. Distraction because of pain or fear of
pain can also affect whether or not a woman is orgasmic.
HELPFUL STRATEGIES TO DEAL WITH PAIN AND SEX
Establish
a working alliance with a health care provider. This should include a
working relationship with a provider or team who validates the pain you
are experiencing. Of course this does not mean false reassurance on the
part of the team to you, or blind faith on your part that this provider
will completely eradicate pain you have had. This alliance should
include:
Medical evaluation and treatment recommendations. Your part will be to provide clear background information and medical records.
An
acknowledgment of the pain you are experiencing. The clinician will
understand that you have pain, and that pain is interfering with your
sexual pleasure and sense of well being. You will understand that even
pain that is 100% physical in origin will have some psychological
effects, because sexuality is a part of primary identity, and when you
repeatedly experience pain with sex that identity is also injured.
The
provider or team can help "normalize" the experience of frustration you
may be having. This can help with a feeling of isolation. Couples
dealing with painful sex often feel they are quite alone in the
experience.
Honest exchange and communication.
Expand your sexual repertoire.
Focus
on sensual as well as sexual. When sex begins to be associated with
pain, the experience of sensual pleasure can be lost as well.
Sensuality can be re-introduced with "non-demand" massage, cradling,
backrubs or other activities. Some couples become touch avoidant when
they have experienced the cycle of pain.
Avoid sex that
hurts. This may seem obvious, but we have found conversely, some women
may grit their teeth through uncomfortable sex because they feel that
they are unfairly depriving their partner of the partner?s
satisfaction. We have noted, however, that partners are distressed when
they sense that the woman is not being straightforward about the fact
that she is in pain. They don?t want to cause hurt or harm, and
generally do not find sex pleasurable that causes pain.
Experiment
with sexually stimulating activity that does not involve penetration.
Oral sex, sex using a vibrator, massage, kissing, fondling, have all
been found to be pleasurable alternatives to intercourse. If some of
these ideas are objectionable to one or both partners, this should be
frankly discussed. We have found that many couples have gradually
become interested in alternative activities by slow exposure and
experimentation. Again, clear communication is important, including
paying attention to what is experienced as unpleasant.
Sexual
activity - not orgasm oriented. Our culture tends to reduce sex to the
idea of orgasm and ejaculation. Incorporating sexual and sensual play
where the goal is simply to experience the moment has been liberating
to many couples. Couples tell us that?if anything can be considered
positive about vulvar pain?they have greatly expanded their definition
of sex by concentrating on the pleasure of the moment and to greatly
de-emphasize orgasm.
When other problems occur, secondary to vulvar pain
Muscle
spasm (vaginismus). Sometimes muscles spasm involuntarily as a response
to fear of pain. This is much like involuntary blinking which will
happen if there is a threat that something is flying straight for your
eye. Sometimes it is difficult to sort out the origin of the pain. We
will work with you to carefully determine whether you may be
experiencing a muscle tightening in addition to vulvar pain.
Fortunately there are techniques which work to overcome this symptom.
You will work with your clinician or team to determine a treatment.
Partner
sexual difficulty. Your partner could develop a sexual difficulty in
response to your vulvar pain. This is understandable when you consider
how frustrating the cycle of pain with sex can be for both of you.
Sometimes partners withdraw from initiating sexual contact, or even
touch contact, because of the fear of causing pain. Some men have
developed erection difficulties. Perhaps they don?t see the connection
between not being able to get an erection and the fear of causing their
partner pain. Couples who are experiencing more than one sexual problem
at once may benefit from discussing this with a therapist who
understands sexual functioning.
Low interest in sex. This
bears repeating. If your experience with sexual activity before the
onset of vulvar pain was positive, and your energy for sex was fairly
high, the fact that you don?t have interest in sex now is probably
because of the frustrating challenge of the presence of pain. If you
never had interest in sex and primarily engaged in sex for your
partner?s sake, you may want to examine for yourself what you want your
sexual life to be and what it would take (besides being without pain)
for this to happen. If you have always wanted to avoid sexual contact
because you find it unpleasant or fearful, discussing this with a
therapist or trusted advisor may provide you with some insight about
this problem.
At times, the use of vaginal dilators for your
vulvar condition may be recommended. The following is a discussion on
the use of vaginal dilators.
HOW TO USE VAGINAL DILATORS
Pain
with sexual activity can cause some reflexive tension in pelvic
muscles. Anticipating that an activity may be painful can cause muscles
to tense voluntarily or involuntarily, as a way to be self-protective.
Sometimes a woman can benefit from learning more about how to gain
voluntary control over the pelvic muscles. At times, vaginal dilators
may be recommended. Vaginal dilators are cylinders, rounded at the end,
which come in various sizes. The dilator is inserted into the vagina in
the privacy of your home ? to help stretch and relax the vaginal
muscles. The smallest dilator is about the diameter of a tampon.
Dilators will be provided for you in the recommended sizes, with
discussion about how to use them. These instructions can be used for
reference in between clinic visits. You may want to keep this handout
with you when you are first using dilators. Various types of dilators
are available. The most common is made of white, smooth, hard plastic.
At the Vulvar Clinic, we also have foam tubing that you can shape and
use with a condom.
Getting ready to use dilators. Select a time
and place when you can have privacy to do dilator therapy. Many women
elect to use their bedroom, and to use dilators while lying down. Plan
for about 10 to 15 minutes a day, four to five times a week. If this
seems like too often or too long, start with what you feel comfortable
with. But do start! We want you to be successful, and this will require
repetition.
What you?ll need. At first you may benefit from
using a mirror in order to see the vulva and vaginal opening. Locate
the labia and clitoris as well as the opening to your vagina. You will
need the dilator, and lubrication. Lubrication can be purchased in any
drug store. Lubrication products are located in the same area as birth
control items and condoms. Use a water based product rather than
petroleum jelly. Many women like Astroglide. KY Jelly and Surgilube are
also preferred products. You can also use vegetable oil.
Beginning
with dilators. Use a small amount of lubrication on the dilator. Tense
and relax the pelvic floor muscles a few times. When you are in the
"relax" phase of the exercise, insert the prescribed dilator. Some
women find it helpful to push against the dilator, as if they were
attempting to expel it. Notice your breathing. If you are tense and
breathing is shallow, stop and attend to the tension before you
proceed. Insert the dilator about two inches or so. You may be able to
insert the dilator further. The pelvic muscles which tend to tense up
are about an inch or so inside the vaginal opening, so the goal of this
therapy is not how far you can insert the dilator, but what is
happening to the muscles when you insert.
If you have pain,
stop. Dilator therapy won?t be effective if you are in pain. Check with
the health care provider supervising your dilator therapy. If you are
feeling a physical tension, and you want to see if you can proceed with
the dilator and learn some relaxation of that muscle, go ahead, but
stop if there is pain.
Leave the dilator in place for 10
minutes or so. You may want to catch up on a little reading during
these minutes. Remove the dilator.
Changing dilator sizes. When
you can effortlessly insert the dilator, it may be time to move to a
larger size. Follow the steps above. At first use the dilator that you
have become accustomed to. Then after a few minutes remove this dilator
and use the next size. Again, stop if you have pain.
Care of
dilators. Dilators do not need any special treatment. They can be
cleaned with soap and water, making sure they are rinsed thoroughly.
Kegel
exercises. Kegel exercises can help you gain voluntary control over
pelvic muscles. When you are urinating, contract your pelvic muscles to
start and stop the stream of urine. The goal of Kegel exercises is not
to tense the muscles, but to learn to relax them. When you are
contracting the pelvic muscles, you are tensing them. When you stop the
contracting, push slightly as if you were attempting to expel urine or
a tampon. This is part of the relaxation of the pelvic muscles. Pay
particular attention to this relaxation aspect. These exercises should
be repeated several times a day, and they can be helpful to strengthen
the pelvic floor. Since the pelvic floor muscles are also involved in
orgasmic pleasure, you may also be able to enhance orgasm.
Other
helpful exercises. You can locate the trouble spots that muscle tension
and spasms can cause. If you are lying on your back, the problem spot
most often reported is the lower part of the vaginal opening?nearest
the perineum (the area between the vaginal opening and the anal
opening). You may use a thumb or finger to gently massage the muscle to
see if it responds to your attempts to relax. Some women have found it
effective to "work" the pelvic floor muscles while they are taking a
shower. They put a foot up on the side of the tub, use a little bit of
lubrication (which is slipperier than water) on their fingers, and
again locate the muscle and massage it gently.
Low Oxalate Diet with Calcium Citrate Supplementation for Vulvar pain
Over
the last few years, there has been an emphasis on using a low oxalate
diet with calcium supplementation to treat vulvar pain. Citrate
inhibits the activity of hyalurinodase an enzyme which triggers the
breakdown of a component of connective tissue ? hyaluronic acid. This
breakdown results in oxalate releasing histamine, which may be
associated with pain.
The following information was prepared by a dietitian at the University of Michigan Hospitals.
GOALS:
® To alleviate and control pain associated with vulvar pain.
® This diet should be considered a "trial" for 3 months to 1 year. It may alleviate the pain for some individuals.
® If symptoms decrease, ask your doctor about how long to continue.
GUIDELINES:
® Eliminate all foods in the high oxalate column.
® Limit foods in the moderate oxalate list to 3 times a week.
® Drink at least 12-14 cups of water each day.
SUPPLEMENT:
® Take calcium citrate without Vitamin D.
® Two Citracal tablets, three times a day is recommended.
® Take calcium citrate without food on an "empty stomach" approximately forty-five minutes before eating.
® Take no more than 250 mg of Vitamin C per day. It is a precursor of calcium citrate.
Dietary Recommendations:
If
you do decide to pursue the low oxalate diet with calcium citrate
supplementation, some dietary recommendations are included below:
Diet Guidelines
Little or No Moderate High Oxalate
FOOD Oxalate (<2mg/serving) Oxalate
(2-10mg/serving) Foods (>10mg/serving)
Beverages Limeade and lemonade (no peels)
Alcohol: bottled beer, distilled alcohol and wines Coffee (limit to 8 oz/day)
The Low Oxalate Diet Book. General Clinical Research Center, University of California, San Diego; 225 Dickinson Street, 8203; San Diego, California 92103-8203.
The Vulvar Pain Foundation, 433 Ward Street, Graham, NC 27253.
SAMPLE MENU
Breakfast: Skim milk
Bagel
Grapefruit or grapefruit juice
Margarine, jelly
Lunch: Tuna fish sandwich
Mayonnaise
Grapes
Skim milk
Dinner: Baked chicken
Mashed potatoes
Peas
Bread, margarine
Fruit
Skim milk
Snacks: Fruits from "little or no oxalate list"
Milk or yogurt
OTHER VULVAR CONDITIONS
Yeast Infections
Yeast
infections are a common vulvar infection. Diabetes, pregnancy,
antibiotic use, a suppressed immune system and zinc deficiencies are
factors that predispose women to yeast infections. Candida albicans is
the most frequent cause. The vagina may be infected also. Many women in
the reproductive age group have yeast present in the vagina or vulva
without symptoms. Yeast infections generally are not sexually
transmitted, but there are exceptions and you may want to address
whether or not your partner should be treated. Symptoms of yeast
infections can include redness, itching and a whitish, clumpy
discharge. For women with recurrent yeast infection, the symptoms tend
to flare at the same time during each menstrual cycle. Sometimes women
have burning with urination. Intercourse may be painful. Some women
complain of vaginal dryness.
Many times patients with
symptoms thought to be from yeast do not have the fungus. To diagnose
this infection, the discharge on the skin of the vulva or in the vagina
may be taken and examined under a microscope. A culture may be sent to
the laboratory. If an infection is present, antifungal drugs are the
usual treatment. A cream or tablet (or both) can be inserted into the
vagina and applied to the vulvar skin. Oral medications can also be
used to treat yeast infections (see Fluconazole). Many women with
recurrent vaginal candidiasis can be effectively treated with
intravaginal boric acid. An 0 gel capsule is filled half way (600 mg,
boric acid) and placed into the vagina twice weekly (for example, on
Monday night and on Thursday night). Many resistant candida strains
will respond to boric acid.
Patients with recurrent
infections may benefit from limiting large amounts of sugars (sucrose
and lactose) from their diets. Such sources would include candies,
syrup, milk, cottage cheese and artificial sweeteners containing
lactose.
Condyloma acuminatum
Genital warts
(condyloma acuminatum), like warts on other parts of the body, are
caused by the human papilloma virus (HPV). This is the same kind of
virus that causes warts on the hands and feet. They are usually spread
to the vulva through sexual contact but can in some instances be spread
by other means. Women of childbearing age are the most susceptible to
infection with HPV. The growths are occasionally seen before puberty or
after menopause. The vulva, particularly at the opening of the vagina
(vestibule) and the labial folds, is the most common site of this
disease. Lesions can also arise on the skin near the anus, vagina,
cervix and urethra. They usually appear first as a small thickened area
of skin with definite edges. The wart may become surrounded by
seedlings (smaller warts) that may grow to involve other areas.
Occasionally, they spread and enlarge, forming a large cluster of warts
that look like tiny cauliflower. The warts appear on the vulva as
raised and sometimes reddened patches that may hurt or itch.
There are several ways to treat genital warts:
One
topical therapy is the application of Trichloroacetic acid (TCA) to the
warts. Treatments occur weekly until the warts are gone. Burning may
temporarily follow its application. Podophyllin is another drug that is
painted on the warts. It needs to be washed off. It is used less often
due to side effects and the need to rinse it off. Some topical
self-administered therapies may be recommended such as Aldara or
Condylox. Interferon, a drug that is injected into the warts or into a
muscle, may be used for recurrent lesions or for immunosuppressed
patients. Laser treatment or Loop electroexcision (regional or general
anesthesia for large areas) are used to treat condylomata at times.
Excision with a scalpel under local or general anesthesia is sometimes
necessary.
These treatments are not always successful; the warts may come back. It is important to watch for recurrences.
Lichen sclerosus
Lichen
sclerosus is a skin disorder that affects the vulva. It may occur in
any age group. The exact cause of lichen sclerosus is unknown. The
condition resembles the appearance of lichens (mixture of fungi and
algae) found in nature but is not caused by fungi or algae. It is not
an infection that you caught from anyone, and you cannot transmit it to
others. There have been reports of family members with lichen
sclerosus, thus it may have a genetic link, although this is
questionable. There is also the possibility that it has an autoimmune
component.
It is characterized by small white patches that
are thin and have a crinkled appearance, looking like cigarette paper
at times. It may involve the entire vulvar area (from the clitoris to
the anus). Often, changes of the clitoral foreskin hides the clitoris.
The labia minora almost completely disappear at times. Not uncommonly,
splitting of the skin in the midline is seen. Tears may also develop in
the natural folds of the vulva. The vaginal opening may become smaller,
interfering with intercourse. Occasionally the tissue breaks down,
forming an ulcerative lesion. It may be a chronic process which at
times is not curable. The disease does not spread into the vagina.
Itching is the primary symptom.
A biopsy (a minor surgical
procedure to remove a small piece of tissue that is then examined under
a microscope), is performed to make the diagnosis.
The goal
of treatment is to eliminate itching and protect the skin from damage.
Occasionally, complete resolution of the abnormal vulvar appearance may
occur. More commonly, the skin changes of lichen sclerosus will not
completely resolve. This does not mean the treatments are not helping.
Various medications are used to improve the skin condition. Although
testosterone had been used frequently in the past for treatment, the
current therapy is potent topical steroids in creams and ointments.
Temovateâ (clobetasol propionate 0.05%) is a frequently prescribed
topical treatment. Following the initial use of Temovateâ ointment or
cream, the steroid content of the ointment or cream is decreased
gradually. Ointments tend to be gentler than creams on vulvar skin.
Long term topical steroid use is often required. During early
treatment, avoidance of tight clothing will prevent further tissue
damage. Several follow-up appointments will be necessary to evaluate
response to treatment.
Many people have wondered if lichen
sclerosus can turn into cancer. Lichen sclerosus scars the skin, and in
theory, could increase the risk for a local skin cancer (this happens
in 5% of cases or less, however). You will need to be followed closely
to have the vulva examined at regular intervals. A sore or ulcer that
doesn?t heal in a few weeks, a lesion that bleeds easily, or bumps or
raised lesions that are becoming larger are signs of a skin cancer. In
some cases, an additional biopsy may be indicated. You should examine
the vulva as you would examine any other part of your skin and have
regular visits with your health care provider to follow the skin
appearance. (see Vulvar Self Exam, p. 5)
SQUAMOUS CELL HYPERPLASIA
Squamous
cell hyperplasia (formerly termed hyperplastic dystrophy) is an
abnormal growth of the skin of the vulva. It has a variety of
appearances. It may present as a pink or red vulva . It frequently
appears as elevated white patches. Moisture, scratching, scrubbing and
medications may cause variations in the appearance of the lesions. The
size of the lesions ranges from small to extensive. The areas most
frequently involved are the hood of the clitoris, labia majora, outer
aspect of the labia minora and the posterior commissure. Lesions may
also extend to the lateral surface of the labia majora and even to the
thighs. When the skin becomes too thick, hardened patches on the vulvar
area may appear. This is related to chronic irritation. A biopsy (a
minor surgical procedure to remove a small piece of tissue that is then
examined under a microscope) is often performed to diagnose this
problem.
Many things can trigger itching on the vulva. The
itching generally stops when the skin heals. Remember that it took a
long time for the squamous cell hyperplasia to develop, so don?t expect
it to improve overnight. It is often chronic and may require long-term
treatment with steroid creams or ointments. These are rubbed into the
vulvar tissue. Squamous cell hyperplasia is sometimes observed next to
lesions of invasive squamous cell cancer. You will need to be followed
closely while you have squamous cell hyperplasia. Patients with a
combination of lichen sclerosus and squamous cell hyperplasia are at an
increased risk for development of vulvar cancer.
Vulvar Intraepithelial Neoplasia
Vulvar
intraepithelial neoplasia (VIN) is a type of precancerous vulvar tissue
abnormality. It is caused by changes in the cells of the vulvar tissue
that allow them to grow abnormally. Genital warts caused by human
papilloma virus (HPV) infection have been linked to VIN. VIN can
progress to invasive cancer of the vulva. This happens in only a small
portion of cases and usually progresses slowly.
Patients
may be without symptoms or complain of pruritus (itching) or burning.
Raised brown, red, pink, white, or gray lesions of various colors may
be present. Tests to diagnose VIN include colposcopy (viewing of the
cervix, vulva or vagina under magnification with a special instrument)
and biopsy (a minor surgical procedure to remove a small piece of
tissue that is then examined under a microscope).
Treatment
depends on the degree of the disease. VIN 3 can usually be treated
successfully with surgical or laser removal. VIN may reoccur. For this
reason, and because VIN may not produce any symptoms, it is important
to have regular checkups by your physician. This is especially true if
you smoke, as this contributes to the recurrence and progression of the
disease.
Vulvar care following laser surgery
The following are instructions for vulvar care after laser therapy:
Apply ice for the first 12-24 hours.
Take a Sitz bath 3 times per day with warm water and instant ocean, sea salt or Epsom salts.
Dry area well thereafter with a hairdryer set on low.
Apply silvadene cream (if not allergic to sulfa medications), Carrington?s gel, or Bacitracin afterwards.
Cleanse area with salt water solution after each void or bowel movement if soiled.
For symptomatic relief you may use warm tea bags or lightly apply witch hazel in between Sitz baths.
You will be given oral pain medication as well as a stool softener to prevent constipation.
If you develop extreme redness around the lasered area or a foul discharge, then contact your physician.
Paget's Disease of the Vulva
Vulvar
Paget's disease appears as a red velvety area with white islands of
tissue on the vulva. At times it may be pink. Occasionally there are
moist oozing ulcerations that bleed easily. Itching is present in over
half of the patients. Soreness may also be present. Almost all patients
are postmenopausal, Caucasian women. The cause of Paget's disease is
unknown. It is diagnosed by biopsy (a minor surgical procedure to
remove a small piece of tissue that is then examined under a
microscope) and is usually treated with surgery. It is rarely
associated with an underlying cancer on the vulva. Genital Paget's
disease may however be related to a primary carcinoma of the rectum,
urethra or bladder.
Lichen planus
Lichen
planus is a skin condition characterized by itchy bumps on the shins,
the inner wrist, and the hands. A particular type of lichen planus
affects the mucous membranes of the mouth and external genitalia. It
often involves the vagina as well as the vulva. It can resemble other
vulvar skin conditions. It is diagnosed by biopsy. This is a minor
procedure often done in the office under local anesthesia. Small areas
of skin are removed and sent for analysis.
The exact cause
of lichen planus is unknown. It is not an infectious disease. The
lesions consist of inflamed skin, but what causes the inflammation is
unknown. The thin mucous membranes inside the mouth and vagina lose
their top layer when they become involved with lichen planus, so red
erosions rather than bumps develop in these areas.
Erosive
lichen planus may be painful in the mouth and vagina and secondary
infection may occur. If the areas touch one another, scarring may occur
resulting in a narrowing of the vagina.
Lichen planus is
often improved with various creams and ointments. Several drugs are
used to treat this condition. If scarring has occurred, vaginal
dilators may be used to help prevent further scar formation. Surgical
separation of the vaginal scar tissue is sometimes necessary.
You
should pay close attention to any changes in the vaginal discharge. If
vaginal discharge occurs, it may indicate an erosion or secondary
infection. Medication is most often used on a regular basis to maintain
optimal tissue status, rather than only with flares in disease. There
is a slightly increased risk of squamous cell carcinoma of the vulva
developing in patients with vulvovaginal lichen planus. Regular visits
with your physician will be necessary.
Various Medications Used for Vulvar Diseases
Multiple
medications are used in treating various vulvar conditions. The
following information will be helpful to you in understanding the
medication prescribed for your particular condition.
SAFETY GUIDELINES
1. Certain medications are not to be taken if you are pregnant or planning a pregnancy.
2.
Discuss questions regarding medication effects and side effects with
your physician/nurse. Report significant side effects or changes.
3. Discuss compatibility of new medications with the prescribing physician.
4. Avoid mixing medications with alcohol.
5. Avoid driving and hazardous activities if you are drowsy or in severe pain.
6. Take medications as prescribed - please follow instructions.
7.
The prescription of medications requires close medical monitoring.
Appointments will be scheduled at appropriate intervals, at which time
prescriptions will be refilled, changed, or discontinued.
The
following are several drugs used to treat various vulvar conditions.
The first category described, tricyclic antidepressants are often used
for the treatment of vulvar pain.
TRICYCLIC
ANTIDEPRESSANTS are classically used to relieve depression and anxiety.
Drugs that are in this category include, Elavilâ (amitriptyline),
Norpraminâ (desipramine) and Pamelorâ (nortriptyline). Tricyclic
antidepressants may also be used for the treatment of a variety of pain
conditions. They must be taken regularly to be effective. Do not skip
doses, even if you feel that you do not need them. The drug must be
taken regularly for three to six weeks before its full effect is felt.
Do not stop taking these medications abruptly, especially if you have
taken large dose for a long time. You will need to gradually decrease
your dose per your doctor?s recommendations.
Before using this medication
Tell your doctor, nurse, and pharmacist if you . . .
are pregnant or intend to become pregnant while using this medicine
are allergic to any medicine, either prescription or nonprescription (OTC - over the counter)
are breast-feeding
are taking any other prescription or nonprescription (OTC) medicine
have any other medical problems (for example, seizures, overactive thyroid gland, heart condition)
have more than one alcohol-containing drink per day
Proper use of this medicine. Take this medicine only as directed by your doctor.
This
medicine will add to the effects of alcohol and other CNS depressants
(medicines that make you drowsy or less alert). Check with your doctor
before taking any such depressants while you are taking this medicine.
This
medicine may cause some people to become drowsy or less alert than they
are normally. Make sure you know how you react before you drive, use
machines, or do other jobs that require you to be alert. Dizziness,
lightheadedness, or fainting may occur, especially when getting up from
a lying or sitting position. Getting up slowly may help.
Before
having any kind of surgery or dental or emergency treatment, tell the
physician or dentist in charge that you are taking this medicine.
The
effects of this medicine may last for 3 to 7 days after you stop taking
it. Make sure you continue to follow the precautions during this time.
If
you take tricyclic antidepressants once a day at bedtime and do not
remember to take it until the next morning, omit the missed dose. Do
not take a double dose.
Possible side effects of this medicine
Dry mouth, drowsiness, weight gain and constipation..
Less
common side effects that should be reported to your doctor: Blurred
vision, memory loss, confusion or delirium, decreased sexual drive;
difficulty in swallowing; irregular heart beat
Tricyclic antidepressants can make your skin more sensitive to sunlight than usual.
Suggestions
to counteract specific side effects: suck sugarless hard candies,
increase fluids, stool softeners, eat a high fiber diet, and wear
protective clothing and a sunscreen preparation.
Drug interactions
Monoamine
Oxidase Inhibitors (MAO?s)- do not use in conjunction with cyclic
antidepressants. These drugs are Phenelzine (Nardil) and
Tranylcypromine (Parnate) and Isocarboxazid (Marplan).
Amphetamines should not be used with antidepressants
Antihistamines/anticholinergics
(Benadryl, Hydroxazine, Brompheniramine in Dimetapp, Chlorpheniramine
in Chlorteimacon)- activity may increase with tricyclic antidepressant
drugs. The effects are dry mouth, constipation. Urinary retention and
glaucoma have been seen.
Barbiturates (Phenobarbital,
Pentabarbital, Amobarbital, Vutalbital in Fioricet) - patients on
tricyclic antidepressants respond better without barbiturates; it has
been recommended that barbiturates be avoided. Benzodiazepines do not
appear to affect tricyclic antidepressant serum concentrations.
Alcohol- do not drink more than one drink per day
Bethanidine- avoid cyclic antidepressants.
Clonidine (Catapres)- Cyclic antidepressants should be avoided if possible.
Guanabenz
(Wytensin)- monitor for reduced antihypertensive response when cyclic
antidepressants are added to Guanabenz therapy. If Guanabenz is
withdrawn in the presence of cyclic antidepressants, monitor for
exaggerated rebound hypertension.
Guanfacine (Tenex)-
monitor for reduced antihypertensive response. If Guanfacine is
withdrawn in the presence of cyclic antidepressants, monitor for
exaggerated rebound hypertension.
Debrisoquin- Cyclic antidepressants inhibit the antihypertensive response to Debrisoquin.
Antabuse (Disulfiram)- acute organic brain syndrome has been reported.
Prozac- Monitor for increased antidepressant levels; adjustment of the antidepressant dosage is likely to be required.
Guanethidine (Ismelin)- avoid with antidepressants.
Cimetidine
(Tagamet)- increased serum concentrations of doxepin (Zonalon). Be
alert for evidence of Doxepin toxicity (severe dry mouth, blurred
vision, urinary retention, tachycardia, constipation, postural
hypotension). It also increases Nortriptyline (Pamelor) concentrations.
Lithium- Lithium and cyclic antidepressants should be used
cautiously in elderly patients. Monitor for evidence of neurotoxicity
such as tremors, disorders of mentation, ataxia, and seizures.
Ritalin- enhanced antidepressant effect may occur.
Neuroleptics-
if combined with cyclic antidepressants, be alert for evidence of
increased toxicity and altered therapeutic response.
Neo-Synephrine- Enhanced pressor responses have been reported. Do not use with cyclic antidepressants.
Other drugs which may interact:
Charcoal
Dicumarol - Coumadin
Haloperidol (Haldol)
Levodopa
Pargyline (Eutonyl)
Phenothiazines
Selegiline (Eldepryl)
CORTICOSTEROIDS
are used to help relieve redness, swelling, itching, and discomfort of
many skin problems. They belong to the general family of medicines
called steroids. These medications may be prescribed orally, topically,
or, injected into the skin during a clinic visit.
Before using this medication
Tell your doctor, nurse, and pharmacist if you?
are allergic to any medicine, either prescription or nonprescription (OTC - over the counter)
are pregnant or intend to become pregnant while using this medicine
are breast-feeding
Proper use of this medicine
Do
not use more often or for a longer time than ordered. To do so may
increase absorption through the skin and the chance of side effects. In
addition, too much use, especially on areas with thinner skin (for
example, face, armpits, groin, vulva), may result in thinning of the
skin and stretch marks.
Apply a thin film to the affected area as directed.
Do not bandage or otherwise wrap the area of the skin being treated.
This
medicine was prescribed for a specific skin problem. Do not use any
leftover medicine on other skin problems without first checking with
your doctor since the medicine should not be used on many kinds of
bacterial, virus, or fungus skin infections.
If you miss a
dose of this medicine, apply it as soon as possible. Then go back to
your regular dosing schedule. However, if it is almost time for your
next dose, do not apply the missed dose at all. Instead, go back to
your regular dosing schedule.
Possible side effects
The most common side effect seen on the vulva is increased vascularity and skin thinning.
When
the gel, lotion, cream, ointment or aerosol form of this medicine is
applied, a mild, temporary stinging may be expected. This generally
resolves gradually.
Side effects that should be reported to your doctor:
Less common or rare:; unusual tiredness or weakness; vomiting; weakness of the arms, legs, or trunk.
Other
side effects not listed above may also occur in some patients. If you
notice any other effects, check with your doctor or nurse.
ANTIFUNGALS:
Topic: Azole Topical Antifungals (Vaginal)
blood-containing
blisters or pus-containing blisters on skin; increased skin
sensitivity; lack of healing of skin condition; loss of top skin;
numbness in fingers; raised, dark red, wart-like spots on skin; skin
pain, redness, itching, thinning of skin with easy bruising
With
long-term or improper use: acne or oily skin; backache; burning or
itching of skin with pinhead-sized red blisters; irritability; mental
depression; muscle cramps, pain, or weakness; nausea; rapid weight gain
or loss; reddish purple lines (stretch marks) on arms, legs, trunk, or
groin; skin color changes; softening of skin; stomach bloating, pain,
cramping, or burning; swelling of feet or lower legs; tearing of the
skin; unusual increase in hair growth; unusual loss of hair
About your medicine: Topical antifungals are used to treat fungus (yeast) infections of the vulva and the vagina.
Before using this medication
Tell your doctor, nurse, and pharmacist if you . . .
are allergic to any medicine, either prescription or nonprescription (OTC - over the counter)
Proper use of this medicine:
antifungals usually come with patient directions. Read them carefully before using this medicine.
Use this medicine at bedtime, unless otherwise directed by your doctor.
To
help clear up your infection completely, it is very important that you
keep using this medicine for the full time of treatment, even if your
symptoms begin to clear up after a few days. If you stop using this
medicine too soon, your symptoms may return.
Do not stop using this medicine if your menstrual period starts during the time of treatment.
Do not miss any doses.
If
you do miss a dose of this medicine, insert it as soon as possible.
However, if it is almost time for your next dose, skip the missed dose
and go back to your regular dosing schedule.
To help clear up your infection completely and to help make sure it does not return, good health habits are also required.
Wear cotton panties (or pantyhose with cotton crotches) instead of synthetic (for example, nylon or rayon) panties.
Many
vaginal infections are spread by having sex. A male sexual partner may
carry the fungus on or in his penis. In certain circumstances, it may
be necessary for your partner to be treated. Do not have sex during
treatment. Discuss with your health care provider if your partner
should be treated.
Precautions while using this medicine:
If your symptoms do not improve within a few days, or if they become worse, check with your doctor.
Vaginal
medicines usually will come out of the vagina during treatment. To keep
the medicine from getting on your clothing, wear a minipad or sanitary
napkin.
The use of tampons is not recommended since they may soak up the medicine.
Side effects that should be reported to your doctor:
Less common--Vaginal burning or other irritation not present before use of this medicine
Rare--Skin rash or hives
Side effects that usually do not require medical attention:
These
possible side effects may go away during treatment; however, if they
continue or are bothersome, check with your doctor, nurse, or
pharmacist.
Less common or rare--abdominal or stomach cramps or pain; burning or irritation of penis of sexual partner; headache.
Other side effects not listed above may also occur in some health care provider.
Diflucan (Fluconazole)
Fluconazole is an oral antifungal used to treat fungus infections.
Tablets: You may swallow the tablet whole or crush it.
Precautions:
Check
with your health care provider before taking if you are pregnant or
breastfeeding or if you have liver disease, kidney disease, or other
medical problems.
Ask your doctor or pharmacist before taking any other medications, including over-the-counter (nonprescription) products.
Take this medicine exactly as your doctor ordered. If you stop taking it too soon, the infection might return.
Store at room temperature, and protect from heat, moisture, and direct light.
Missed Dose:
Take the missed dose as soon as possible.
Skip the missed dose if it is almost time for your next regular dose.
Do not take two doses at the same time.
Side effects:
If
you have problems with these or other side effects, tell your doctor:
nausea, vomiting, stomach pain, bloating, diarrhea, headache, or skin
rash. Some patients may have other side effects that are not listed
below.
The following side effects may be associated with
more serious complications. Call your doctor immediately if any of the
following effects occur: Yellowing of skin and eyes; unusual bleeding
or bruising; dark oramber
Liver Effects:
Notify your care provider if you have a history of liver disease.
Liver toxicity has occurred with antifungal treatment.
Abnormal
liver function has been observed during Fluconazole therapy.
Approximately 1% of Fluconazole-treated patients have developed
abnormal liver studies.
When elevations of liver function
tests are observed during Fluconazole therapy, close monitoring is
recommended to detect the development of more serious liver injury.
Fluconazole
should be discontinued in patients who develop signs and symptoms
consistent with liver disease. Liver disease is usually reversible upon
discontinuing Fluconazole.
Blood studies to check liver function may be required after six months of therapy.
Drug Interactions
Make sure your doctor knows if you take any of the following medications.
Oral Hypoglycemics (medicines to treat diabetes).
Coumarin-Type Anticoagulants (blood thinners).
Phenytoin(Dilantin or other seizure medications).
Cyclosporine.
Rifampin (antituberculin).
Theophylline (asthma medication).
Terfenadine (Seldane).
Propulsid
Lipitor
AZT
Tagamet
Amitryptyline (Elavil).
Fluconazole tablets taken with oral contraceptives: The clinical significance of these effects is presently unknown.
Contraindications:
Do
not use this medicine if you have ever had an allergic reaction to
Fluconazole or similar medicines such as Miconazole. Fluconazole should
be used cautiously in patients with hypersensitivity to other azoles. Dose reductions are recommended in patients with renal insufficiency. Immunocompromised
patients who develop skin rashes while on Fluconazole should be
monitored closely and the drug discontinued if the lesions progress. NEURONTIN ? GABAPENTIN (ORAL)
GABAPENTIN
is used to help control some types of seizures in the treatment of
epilepsy, but is also used by pain clinics to control various forms of
pain. It helps control pain by decreasing the excessive impulses of
nerves that transmit pain and by preventing the spread of increased
excitation from abnormal to normal neurons. BEFORE USING THIS MEDICINE
Tell your doctor, nurse, and pharmacist if you, are allergic to any medicine, either prescription or non-prescription (OTC); are pregnant or intend to become pregnant while using this medicine; are breast-feeding; are taking any other prescription or non-prescription (OTC) medicine, especially antacids; have any other medical problems, especially kidney disease.
PROPER USE OF THIS MEDICINE
Take
this medicine only as directed by your health care provider, to help
your condition as much as possible. Do not take more or less of it, and
do not take it more or less often than your doctor ordered. Gabapentin may be taken with or without food. Take it as directed. If
you have trouble swallowing capsules, you may open the Gabapentin
capsule and mix the medicine with applesauce or juice. Mix only one
dose at a time just before taking it. Do not mix any doses to save for
later, because the medicine may change over time and may not work
properly. If you miss a dose of this medicine, take it as soon as
possible. However, if it is less than two hours until your next dose,
take the missed dose right away, and take the next dose one to two
hours later. Then go back to your regular dosing schedule. Do not
double doses. This medicine will add to the effects of alcohol and
other CNS antidepressants (medicines that may make you drowsy or less
alert). Check with your doctor or dentist before taking any such
antidepressants while you are using this medicine. This medicine
may cause blurred vision, double vision, clumsiness, unsteadiness,
dizziness, drowsiness, or trouble in thinking. Make sure you know how
you react to this medicine before you drive, use machines, or do other
jobs that require you to be alert, well-coordinated, or able to think
or see well. If these reactions are especially bothersome, check with
your care provider. Do not stop taking this medicine without first
checking with your care provider. Your care provider may want you to
gradually reduce the amount you are taking before stopping completely. POSSIBLE SIDE EFFETS OF THIS MEDICINE
SIDE EFFECTS THAT SHOULD BE REPORTED TO YOUR DOCTOR:
More common: clumsiness or unsteadiness; continuous, uncontrolled back and forth and/or rolling eye movements. Less common: depression, irritability, or other mood or mental changes; loss of memory. Rare: fever or chills; cough or hoarseness; lower back or side pain; painful or difficult urination. SIDE EFFECTS THAT USUALLY DO NOT REQUIRE MEDICAL ATTENTION:
These
possible side effects may go away during treatment; however, if they
continue or are bothersome, check with your doctor, nurse, or
pharmacist. More common: blurred or double vision; dizziness;
drowsiness; muscle ache or pain; swelling of hands, feet, or lower
legs; trembling or shaking; unusual tiredness or weakness. Less
common: diarrhea; dryness of mouth or throat; frequent urination;
headache; indigestion; low blood pressure; nausea; noise in ears; runny
nose; slurred speech; trouble in thinking; trouble in sleeping;
vomiting; weakness or loss of strength; weight gain.
