The Journal of Family Practice

The Journal of Family Practice

This is another form of medication (ointment or cream) similar acting to the steroids to help stop ‘symptoms’ but would most likely replace steroid use, although some physicians may use them together, varying them. To address the lack of guidance, OBG Management Contributing Editor Neal M. Lonky, MD, assembled a panel of experts on vulvar pain syndromes and invited them to share their considerable knowledge. Most doctors won’t diagnose as vulvodynia until they can firmly rule out an STD like herpes. What about herpes and genital warts? The ensuing discussion, presented in three parts, offers a gold mine of information. Dr.

The Journal of Family Practice
However, more than two dozen diseases can cause the symptoms of  genital itching, burning, irritation, rawness, throbbing, urinary frequency, urinary urgency, and pain during sex. In view of the psycho-social, sexual and behavioural problems, nurses, psychologists and physiotherapists with specific training in managing these symptoms in urogenital related female pain should be involved in patient care. (Patients see an average of five doctors before being diagnosed.) It’s essential to find a supportive practitioner who is knowledgeable about the vulva and who will explore treatment options with you. Part 2, in the October issue, took as its subject the treatment of vulvar pain. Medications to treat vaginitis Can vaginitis be prevented? A colposcopy can also be used to identify other viral infections, skin conditions and, in the rare cases when it occurs, vulvar cancer. After discussions, a consensus terminology proposal was unanimously reached at that meeting.

• Pain can begin suddenly when provoked (by intercourse for example). Which of the following is t the most appropriate next step in maagement? However, the definition of vulvodynia is pain—i.e., burning, rawness, irritation, soreness, aching, or stabbing or stinging sensations—in the absence of skin disease, infection, or specific neurologic disease. This feeling is temporary. There is generalized edema and erythema of the vulva. Basal cell carcinoma, which is the most common type of cancer that occurs on parts of the skin exposed to the sun, very rarely occurs on the vulva. Candida albicans is usually primarily pruritic, and BV produces discharge and odor, sometimes with minor symptoms.

Both are tension headaches despite the different locations. Careful vaginal examination may allow direct observation of vaginismus. The term vulvar vestibulitis syndrome was introduced in 1987 by Eduard Friedrich (1) to group together a constellation of signs and symptoms that involved, and were limited to, the vulvar vestibule. For example, herpes (particularly primary herpes infection) is classically associated with vulvar pain. The pain is so great that, at times, the patient requires admission for pain control. Surprisingly, despite the known pain of herpes, approximately 80% of patients who have it are unaware of their diagnosis.

You may also like

The Journal of Family Practice

The Journal of Family Practice

Many cases of generalized vulvodynia and localized vulvodynia (vestibulodynia) are mistakenly attributed to yeast infection, pudendal neuralgia, and other entities. Most vulvar pain, burning and itching isn’t a major concern, but according to OB-GYN Montgomery County Dr. and the 13th anniversary of our office in New York City. This article will discuss the epidemiology, pathophysiology and management of these women where pain is the main symptom. Studies indicate that as many as 15 per cent of women (one in six) experience periods of vulvar pain, with symptoms that include severe burning, pain, itching, stinging, and irritation. Are they causes of vestibular pain? What causes vaginitis?

Colposcopy A colposcope is a microscope-like device used to magnify and examine the cervix, vagina and vulva. Several studies and treatments have been introduced, based on putative etiologies of Vulvodynia, for example: tricyclic antidepressants for a neuropathic etiology; nerve surgery for excision of neuroma or removal of compression from branches of the pudendal nerve. It was only in 1983 that recognition of vulva pain and the effects it has on the lives of women all over the world led to the adoption of the term “vulvodynia” by the International Society for the Study of Vulvovaginal Diseases (ISSVD). Examination shows normal findings. It can start because of problems elsewhere in the pelvis which cause muscle spasm. If your test shows yeast or your feel yeast in contributing to your vulvodynia (and I feel that most of us would benefit from trying to eradicate yeast in our bodies), there are a few ways to clear it from our systems and allow our bodies to heal. This is a very distraught young lady.

This means that precancerous cells are present in the surface layer of skin. Currently there is no cure for vulvodynia. Most likely, there isn’t a single cause. Have artificial lubricants been tried? The remaining two symptom groupings are just that, not diagnoses but symptoms and are, by definition, diagnosed by exclusion. Edwards: I feel strongly that vestibulodynia and generalized vulvodynia are the same process. For example, tension headaches are supposed to be occipital, but some people experience tension headaches that are periorbital.

Non-albicans Candida (e.g., Candida glabrata) is nearly always asymptomatic, but it occasionally causes irritation and burning. And almost all patients who experience any subset of vulvodynia have provoked vestibular pain. Physical abnormalities Dr. For example, herpes (particularly primary herpes infection) is classically associated with vulvar pain. The pain is so great that, at times, the patient requires admission for pain control. I have seen it reported for steroids too, not only in evidence based literature but also anecdotally with members. Dr.

Edwards: Skin diseases that affect the vulva are usually pruritic—pain is a later sign. I deal with it by spreading lidocaine over the affected skin before sex, the rest of the time it doesn’t affect me much, only hurts when touched. Vulvodynia and depression often travel together. They are such common comorbidities, in fact, that some physicians theorize that vulvodynia may be a symptom of an underlying mood disorder, such as depression, or that depression may be one manifestation of chronic vulvar pain. Suffice it to say that chronic pain and depression are often associated, and it is frequently difficult to determine whether the relationship is one of cause and effect. Comprehensive care of the patient who has vulvar pain, therefore, should include a thorough history, looking specifically for depression (including sleep disorders) and eliciting information on any suicidal thoughts or intentions. Endometriosis is a condition affecting women predominantly in the reproductive age group and characterised by the presence of endometrial glands and stroma outside the endometrial cavity.

The Journal of Family Practice
This can occur when inflammation in the joints and muscles along the nerve’s path results in scarring that presses on or traps the nerve. Together, we monitor the patient and fine-tune the therapeutic response. Dr. Haefner: Controversy surrounds the question of whether vestibulodynia and OC use are linked. The associated factors were grouped in an appendix, and not in the main table, because they are not terminology terms, and also to allow future amendment, when research yields further knowledge, without revising the whole terminology. Vulvar atrophy Pale, thinning vulva tissue, possible vulva tears. He says that he has been feeling strange, “like being in a dream,'and talks to his great-great-grandfather who died 50 years ago.

I do not find the studies demonstrating an association convincing. Given the supraphysiologic levels of hormones during pregnancy, if high hormone levels played a role, we should also see a greater incidence of vestibulodynia among women who have several pregnancies at an early age. for pain. Abnormal Pap smears. Topical estrogen supplementation in the occasional OC user who has signs of low estrogen has been useful at times. Dr. Haefner: Herpes is sometimes associated with vulvar pain.

Another suggestion is that both of these conditions represent a form of vulvar reflex symathetic dystrophy with sensitization of nociceptive ‘c’ fibers, so that touch sensation is replaced with an experience of pain. As with shingles, a low threshold for starting a patient on gabapentin to control pain after herpes may be beneficial. Dr. Edwards: I don’t know whether any of these variables make a difference. My own impression—confirmed by informal study in my office—is that vulvodynia patients weigh less than my general dermatology patients and are better educated. I sometimes get the sense that my vulvodynia patients are more likely to be fair. Dr.

Edwards: In my experience the most common age group is women 25 to 45 years old, probably because they are the most sexually active group old enough and tough enough to pursue this issue. Dr. Haefner: Women who have vulvodynia often have other medical problems as well. In my practice, when new patients who have vulvodynia complete their intake survey, they often report a history of headache, irritable bowel syndrome, interstitial cystitis, fibromyalgia,6 chronic fatigue syndrome, back pain, and temporomandibular joint (TMJ) disorder. Gunter: That depends on many variables. It is far more challenging to cure a patient who has multiple pain syndromes (for example, fibromyalgia, migraines, and irritable bowel syndrome) than the woman who simply has vestibulodynia or generalized vulvar pain. In addition, stress, anxiety, coping skills, and depression all play a role.

In my opinion, a woman without comorbidity has a good chance of having her symptoms well-controlled. Some will be cured (that is, able to discontinue medications), and others will need ongoing treatment but will not be bothered by their symptoms. As well as changes in sensory perception, central nervous system efferent activity may be abnormal. If anger, depression, or isolation is getting the best of you, it may help to talk to a counselor, attend a support group meeting, or just talk to the local support contact. Someone who has had pain for 30 years will probably not be cured 3 months after starting treatment. However, someone with a short duration of pain often gets good improvement. One hundred percent improvement is rare, however.

Many patients are able to approach the 80% improvement mark. Vestibulectomy technique (A) Incision. In many cases, the incision needs to extend up to the opening of the Skene’s ducts on the vestibule before it is carried down laterally along Hart’s line to the perianal skin, with the mucosa undermined above the hymeneal ring. (B) Excision. Remove the tissue superior to the hymeneal ring. (C) Advancement of vaginal mucosa. Surgery would involve excision of pelvic organs (pelvic exenteration), radical vulvectomy, and lymphadenectomy.

(D) Suturing. Close the defect in two layers using absorbable suture. I offer surgery for vestibulodynia after the patient has failed at least two therapies (two topical treatments or one topical and one oral treatment). Using this training procedure, it was simply not possible to produce a contraction of adequate amplitude to reliably release the resting tension. I do not offer vestibulectomy to patients who have unprovoked pain or pain outside of resection margins. Dr. Haefner: Surgical excision of the vulvar vestibule has met with success, in some studies, in more than 80% of cases, but it should be reserved for women who have longstanding and localized vestibular pain in whom other management options have failed.

You may also like

The Journal of Family Practice

The Journal of Family Practice

The cornea is the clear front window of the eye. In general, if you have pain, light sensitivity and/or reduced vision of sudden onset, you should be seen urgently so contact us on 0777 22 33 150 if you would like to be seen. Current culture techniques for herpes simplex virus (HSV) take several days and commercially available HSV laboratory based diagnostic techniques such as Herpchek vary in sensitivity. The outermost layer is called the epithelium. Eye disorders may include any of the following: vision problems, including astigmatism (vision difficulties due to a football-shaped cornea), diabetic retinopathy, myopia (nearsightedness), or hyperopia (farsightedness); conjunctivitis (inflammation of the conjunctiva); uveitis (inflammation of the uvea); keratitis (inflammation of the cornea); xerophthalmia (dry eye); glaucoma (an increase in intraocular pressure); age-related macular degeneration; and cataract (an opacity that develops in the crystalline lens of the eye). Physical examination revealed a well appearing baby who was active, alert, irritable, and crying. The corneal abrasion is therefore highlighted using a white or cobalt blue light, the latter wavelength illuminating the fluorescein.

CASE 2 A 20-year-old man was playing touch football while wearing contact lenses. Measure visual acuity. Symptoms include foreign body sensation, light sensitivity, redness, tearing, and swelling. The last case was a patient who used it 10 times a day for three months. It is caused by physical or chemical trauma and can often be missed. Corneal ulcers can also develop in a previously intact cornea from certain viral infections (such as getting shingles in the eye from a herpes virus) or as a complication of a systemic disease such as an autoimmune disease (like rheumatoid arthritis) or from other illnesses such as Hepatitis C. Send the patient home with an eye patch to relieve the photophobia.

Retinal vein occlusions are the second most common cause of blood vessel-related vision loss, the first being diabetic retinopathy. Press Cmd-0 to reset your zoom Press Ctrl-0 to reset your zoom It looks like your browser might be zoomed in or out. It’s also vital to check the vision; you’d be surprised how often this is omitted when a patient presents to a doctor with eye symptoms. This article will briefly outline those problems as well as their management and prevention. Fuchs’ Dystrophy: Seemingly happening for no apparent reason – although you may have a genetic predisposition to the disease – Fuch’s Dystrophy involves the gradual deterioration of endothelial cells. The device provides a better assessment of corneal defects or infiltrates than ophthalmoscopy or visual inspection. IF THESE PRODUCTS ARE USED FOR 10 DAYS OR LONGER INTRAOCULAR PRESSURE SHOULD BE ROUTINELY MONITORED EVEN THOUGH IT MAY BE DIFFICULT IN CHILDREN AND UNCO-OPERATIVE PATIENTS.

Ask the doctors at Newsom Eye if you may be at risk. These lesions or erosions may become recurrent. CASE 5 A 21-year-old college student complains of pain in her left eye that started a day ago. Pupillary constriction and consensual photophobia may be present due to ciliary spasm. The patient reports that she used a friend’s steroid eye drops twice yesterday, but the drops didn’t help. The pain is worse today. It feels as if there’s something in her eye, she says, and she finds it hard to open her eye.
The Journal of Family Practice

Young persons whose vision cannot be corrected to 20/20 with glasses should be evaluated by an eye doctor experienced with keratoconus. For patients with corneal abrasions related to contact lens wear, consideration for possible pseudomonas infection and treatment with antibiotics to treat this infection should be used (ciprofloxacin, gentamicin, tobramycin, ect.). Patch the patient’s left eye, prescribe antibiotics, and tell her to return tomorrow. Prescribe steroid eye drops and follow up in 2 days. Patients self rated their pain about 50/100 on the VAS. Physical findings An eye exam will reveal conjunctival erythema, corneal edema and cloudiness, iris irregularity, a shallow anterior chamber (visible with a slit lamp), a dilated pupil (4-6 mm) that reacts sluggishly to light, and increased ocular pressure. The cupping of the optic disc seen in this patient’s retinal exam ( FIGURE 6 ) is more commonly associated with chronic open-angle glaucoma.

A doctor will ask about any eye pain or discomfort. It lies directly over the colored part of your eye (the iris). Did your author group use one of these instruments? Remove any particles and shield. Some abrasions can be seen with the naked eye, so a penlight exam should be performed before applying fluorescein stain. If a corneal lesion is suspicious for herpesvirus infection ( SEE CASE 5 ), fluorescein should not be applied, as it can interfere with the antibody test.10 Refer the patient to an ophthalmologist instead. Management Patients with corneal abrasions or ulcers should receive topical antibiotics to prevent infection.

Click here to read more about dry eye and other treatments such as punctal plugs. Pain control is achieved with cycloplegics11 like cyclopentolate 0.5% to 1% or a one-day course of systemic opioids. For children, over-the-counter analgesics for mild pain and mild opioids for severe pain may be used. Dilating drops usually keep the pupils open for a few hours before their effect gradually wears off. While the pain and foreign body sensation are the same for bacterial and viral keratitis, herpesvirus is distinguishable by the branching opacity that develops on the cornea. Varicella zoster is the most common cause of viral keratitis, although it can also be caused by herpes simplex and adeno-virus. Because a person who is infected with herpes has the virus for life, however, multiple attacks are possible.

Reactivation is associated with stress and a weakened immune system, but may occur spontaneously, as well. Patients who wear contact lenses are no more likely than those who don’t to be infected with the herpesvirus. Signs and symptoms Patients with keratitis typically complain of eye pain, a sensation of having a foreign body in the eye, photophobia, tearing, and vision changes; a mucopurulent discharge is sometimes present, as well.3 The condition is easily distinguished from conjunctivitis, which typically does not involve eye pain or vision changes. 27. Jabs DA, Nussenblatt RB, Rosenbaum JT. Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data.

Results of the First International Workshop. Am J Ophthalmol. Some doctors may prescribe prophylactic antibiotics, while others may hold off on them unless infection becomes apparent.

You may also like

The Journal of Family Practice

The Journal of Family Practice

Cold sores, sometimes called fever blisters, are groups of small blisters on the lip and around the mouth. STIs, which affect both men and women, are a worldwide public health concern. Transfer serum into sterile, plastic vial and store refrigerated or frozen. It usually becomes active again from time to time, traveling back up to the skin and causing more sores. Post-Surgical Zosteriform Herpes Simplex II in Two Widely Separate Dermatomes. Further more, you’ll feel less pain, fewer physical symptoms, and be one day closer to remission. is an experienced Mohs and dermatological surgeon who has been practicing in Westfield, NJ since 1998.

The Journal of Family Practice
While the CDC spends more than $100 million on efforts to prevent and treat syphilis, gonorrhea and chlamydia, herpes gets next to nothing. The primary difference between chickenpox and shingles, however, is that the discomfort of shingles is pain rather than itching. 3,916 women were diagnosed with gonorrhea in New Jersey in 2011. The researchers advise that their findings should be interpreted with caution. Essex County, New Jersey had the highest number of gonorrhea cases in 2012 with 1,027. At the end of 2012, Blacks accounted for 54% of New Jersey residents living with HIV/AIDS. A total of 3,798 cases of gonorrhea were diagnosed in New Jersey in 2012.

Males in the state of New Jersey have accounted for 773 cases of new syphilis infections in 2011. The rate of female gonorrhea infection in New Jersey in 2011 was 86.79 for every 100,000 resident. During the follow-up period, a mean of 11.3 years, 430 people developed a dementia disorder, including 245 who developed AD. The presence of anti-HSV IgG antibodies did not increase the risk of AD, but anti-HSV IgM antibodies, a sign of reactivated infection, nearly doubled it. The risk for AD did not seem to increase until about 8 to 10 years after a positive anti-HSV IgM serum sample, the researchers say, possibly pointing toward HSV reactivation being an early event in the development of AD pathology. Sources: Lövheim H, Gilthorpe J, Johansson A, Eriksson S, Hallmans G, Elgh F. Alzheimers Dement.

2015:11(6):587-592. Silver the herbal doctor was able to cure me from my Herpes Virus with his herbal medicine. If you have a lot of outbreaks, you may take medicine every day to limit the number of outbreaks. Alzheimers Dement. 2015;11(6):593-599. Bij volwassenen staan keelpijn en halsklierzwellingen op de voorgrond.

You may also like

The Journal of Family Practice

The Journal of Family Practice

Table of contents for Human virology Table of contents for Human virology : a text for students of medicine, dentistry, and microbiology / Leslie Collier and John Oxford ; with illustrations by Jim Pipkin. Although a correlation between human herpesvirus 8 (HHV-8) infection and abortion or low birth weight in children has been suggested, and rare cases of in utero or perinatal HHV-8 transmission have been documented, no direct evidence of HHV-8 infection of placenta has yet been reported. Scrapie may not be considered in the differential diagnosis of neurological diseases in small ruminants, particularly in countries with low scrapie prevalence, or not recognized if it presents as nonpruritic form like atypical scrapie. The relationship of serum MBL to gestational age is controversial. These results indicated that HHV-6 and/or HHV-7 exists in the cervixes of infected women in late pregnancy and may cause perinatal infection. Epidemiology Infection with HSV1 is almost universal. Results of investigations for human immunodeficiency virus, syphilis, Lyme disease, human herpesvirus 6 and 7, and species of Babesia, Toxoplasma, Histoplasma, Cryptococcus, Blastomyces, and Brucella were negative.

Carcinogenicity Raltegravir was neither mutagenic nor clastogenic in a series of in vitro and animal in vivo screening tests. They should be tested with a supplemental HIV-1/HIV-2 antibody differentiation assay. Tests were two-tailed and performed at a significance level of 0.05. Lancet, 1391, 1989. Lassen J, Jensen AK, Bager P, et al. Parvovirus B19 infection in the first trimester of pregnancy and risk of fetal loss: a population-based case-control study. Am J Epidemiol.
The Journal of Family Practice

Italy is an area of subendemicity, where the seroprevalence of HHV-8 mirrors the incidence of classic KS at the microgeographical level (8, 17, 42). 12. American College of Obstetrics and Gynecologists. ACOG practice bulletin. J Pediatr October 2007;151:409-413). Number 20, September 2000. (Replaces educational bulletin number 177, February 1993).

MMWR Recomm Rep. 2002;76:95-107. 16. Richardson M, Elliman D, Maguire H, et al. Evidence base of incubation periods, periods of infectiousness and exclusion policies for the control of communicable diseases in schools and pre-schools. Pediatr Infect Dis J. 2001;20:380-391.

19. Nicolson GL, Gan R, Nicolson NL, et al. Here we investigated the susceptibility of human placental cells to in vitro HHV-8 infection using a placental histoculture system and found that HHV-8 may productively infect placental trophoblasts and endothelial cells. The intraluminal monofilament model of middle cerebral artery occlusion (MCAO) involves the insertion of a surgical filament into the external carotid artery and threading it forward into the internal carotid artery (ICA) until the tip occludes the origin of the MCA, resulting in a cessation of blood flow and subsequent brain infarction in the MCA territory 4. In the C4b molecule, a thioester group is exposed.

You may also like

The Journal of Family Practice

The Journal of Family Practice

Clearly, there is a need for comprehensive information on vulvar pain and its causes, symptoms, diagnosis, and treatment. I can only imagine how frustrating and difficult this must be for you. Among the questions explored by the panelists in this article is whether vestibulodynia and generalized vulvodynia are distinct entities—or different manifestations of the same process. To address the lack of guidance, OBG Management Contributing Editor Neal M. If you are experiencing vulvar pain, burning and itching and you need a caring and experienced OB-GYN Montgomery TX residents rely on the professional and caring staff at New Beginnings OB-GYN under the direction of Dr. In fact, a recent editorial in the Journal of Obstetrics and Gynecology called the vulva the “forgotten pelvic organ.” In addition, most health care providers have insufficient training in the diagnosis and treatment of sexual problems including pain during sex and decreased libido. However, it is also important that the medical staff managing the problem have a full understanding of normal physiology of the urogenital system as well as an understanding of female pelvic pathophysiology.

Unfortunately, many doctors—whether general practitioners or Ob-Gyns—have little familiarity with the disorder. Does vestibulectomy provide definitive treatment? How is vaginitis diagnosed? Genital warts and other infected areas turn white when exposed to vinegar. Therefore, the International Society for the Study of Vulvovaginal Disease (ISSVD), the International Society for the Study of Women’s Sexual Health (ISSWSH), and the International Pelvic Pain Society (IPPS) discussed a possible revision to the 2003 terminology, and organized an international meeting in order to reach a consensus on the terminology of vulvar pain, on April 8-9, 2015 in Annapolis, Maryland. Ranges from mild to severe. An x-ray of the chest shows no abnormalities.

Muscle spasm during intercourse is a very common pain reflex and can be overcome by treating the cause, and relaxation exercises. This is known as a Herxheimer reaction. Her skin is pale, warm, and dry. Melanoma is the second most common type of vulvar cancer, and accounts for 5% to 10% of the cases. In regard to infection, Candida albicans and bacterial vaginosis (BV) are usually the first conditions that are considered when a patient complains of vulvar pain, but they are not common causes of vulvar pain and are never causes of chronic vulvar pain. Edwards: I feel strongly that vestibulodynia and generalized vulvodynia are the same process. Examination A woman may need to have had several consultations before she is ready to be examined; she should always be reassured that she is in control and that you will stop immediately if she asks you to.[7] Patients with vaginismus may be extremely worried at the prospect of vaginal examination; gentle digital examination should be attempted before speculum examination.

The innermost border is the hymenal ring and the lateral border is Hart’s line on the inner aspect of the labia minora. Dr. Haefner: Several other infectious conditions or their treatments can cause vulvar pain. For example, herpes (particularly primary herpes infection) is classically associated with vulvar pain. Dr. “If the hymen is too tight, the vestibule shouldn’t hurt,” he says. Dr.
The Journal of Family Practice

Edwards: Skin diseases that affect the vulva are usually pruritic—pain is a later sign. UPDATE:  Just recently the AMA has suggested that physicians always use a steroid as the first treatment before suggesting the Immunomodulators and then only if a steroid doesn’t work. Lichen sclerosus manifests as white epithelium that has a crinkling, shiny, or waxy texture. It can produce pain, especially dyspareunia. It is extremely painful at times, particularly after intercourse. Comprehensive care of the patient who has vulvar pain, therefore, should include a thorough history, looking specifically for depression (including sleep disorders) and eliciting information on any suicidal thoughts or intentions. It involves introital redness and a clinically and microscopically purulent vaginal discharge that also reveals parabasal cells and absent lactobacilli.

Dr. Edwards: Pudendal neuralgia, diabetic neuropathy, and post-herpetic neuralgia are the most common specific neurologic causes of vulvar pain. In a series of asymptomatic multiparous patients undergoing sterilisation the prevalence was 26/ 3384 (3.7 %)5. If the doctor can’t identify any clear cause of the pain or if treating the apparent cause does not bring relief, your pain will probably be diagnosed as vulvodynia. Some studies suggest no association12–14 and others suggest a possible effect of OCs on vulvodynia.15–17 A study by Reed and colleagues found no association between taking OCs or hormone therapy at enrollment and incident vulvodynia only in the univariable analysis, but not when controlling for age at enrollment.18 This reflects the finding that younger age was associated with incident disease; younger age and use of OCs are similarly associated. Gunter: Given the misdiagnosis of many women, who are told they have chronic yeast infection, as I mentioned, it’s hard to know which vulvar pain syndromes are most prevalent. I suspect that lichen simplex chronicus is most common, followed by vulvodynia, with chronic yeast infection a distant third.

Stephanie grew up in South Jersey, and currently sees patients in our Los Angeles office. Other women adapt by finding sexual positions that make painful intercourse less likely. Physical examination shows hyperreflexia of the lower extremities and mild resting tremor of the upper extremities. Edwards: There is good evidence of marked overlap among subsets of vulvodynia. The vast majority of women who have vulvodynia experience primarily provoked vestibular pain, regardless of age. 5. Women who have had long-term suppression of their immune system caused by disease (such as certain cancers) or medication (such as those taken after organ transplantation) have an increased risk of developing vulvar cancer.

Localized clitoral pain and vulvar pain localized to one side of the vulva are extremely uncommon, but they do occur. As with shingles, a low threshold for starting a patient on gabapentin to control pain after herpes may be beneficial. Dr. They had noticed that during intravaginal digital palpation of the pelvic floor muscles of these women, there was considerable chronic tension and spasticity. My patients of African descent consult me primarily for itching or discharge. Dr. Lonky: Do your patients who have vulvodynia or another vulvar pain syndrome tend to have comorbidities?

Edwards: In my experience the most common age group is women 25 to 45 years old, probably because they are the most sexually active group old enough and tough enough to pursue this issue. Dr. Haefner: Women who have vulvodynia often have other medical problems as well. In my practice, when new patients who have vulvodynia complete their intake survey, they often report a history of headache, irritable bowel syndrome, interstitial cystitis, fibromyalgia,6 chronic fatigue syndrome, back pain, and temporomandibular joint (TMJ) disorder. These comorbidities are not particularly helpful in establishing the diagnosis of vulvodynia, but they are an important consideration when choosing therapy for the patient. Often, the medications chosen to treat one condition will also benefit another condition. However, it’s important to check for potential interactions between drugs before prescribing a new treatment.

You may also like

The Journal of Family Practice

The Journal of Family Practice

There are a number of different rashes that can develop on a woman’s body during pregnancy. Unfortunately you can’t get a definitive diagnoses unless the doctor takes a biopsy or a real close look at it, or gets a blood test to rule out syphilis. These events occur rarely.The use of any combined hormonal contraceptive (CHC) increases the risk of venous thromboembolism (VTE) compared with no use. See section 4.8 for how to report adverse reactions. Both patients achieved a good clinical response. Immunologic mechanisms, hormonal abnormalities, and abdominal skin distension have been suggested as etiologic mechanisms. Norethisterone mimics the effects of your natural progesterone and so can help regulate the healthy growth and normal shedding of the womb lining.

It is harmless, but the itchiness can be severe. Ruptured bullae left erythematous to beefy red eroded bases, and there were numerous smaller red papules with vesicular surface changes. The second case describes autoimmune progesterone urticaria in a 47-year-old woman with cyclical and recurrent skin eruption with variable morphology.[4] She tested strongly positive to intradermal progestin. PUPPP usually disappears a few days after the baby’s birth. Differential. Besides the rash, the itchiness lasts for at least one week, but it never really goes away completely. Oral antihistamines and highpotency topical corticosteroids were prescribed for this patient, whose relatively mild disease occurred intermittently throughout the remainder of her pregnancy.

The Journal of Family Practice
Patients may also complain that the rash is painful, particularly if bullae rupture, leading to superficial ulcerations. Fortunately, the patient’s quality of life can be dramatically improved with systemic corticosteroids—with no significant risk to the fetus. This extremely rare condition starts as a hive-like rash, which turns into large blistering lesions. At 40 weeks’ gestation, a healthy child was delivered; the neonate was free of lesions and continued to develop normally. This distribution helps to differentiate PUPPP from PG, where the lesions typically cluster around the umbilicus. It typically begins in either the second or third trimester. So why is this a problem if you have it?

Differential. Initially, PUPPP lesions can be difficult to differentiate from urticarial PG lesions. A further course of therapy may be employed if symptoms return. Additional non-hormonal methods of contraception (except the rhythm or temperature methods) should be used during the gastro-intestinal upset and for 7 days following the upset. In case of severe gastro-intestinal disturbances (e.g. PUPPP can only be diagnosed through clinical observation. vomiting or diarrhoea), absorption may not be complete and additional contraceptive measures should be taken.

• Hypersensitivity to the active substance(s) or to any of the excipients.Relevant UK clinical guidance should also be consulted. Prolonged immobilisation, major surgery, any surgery to the legs or pelvis, neurosurgery, or major trauma Note: temporary immobilisation including air travel >4 hours can also be a risk factor for VTE, particularly in women with other risk factors. • Hypersensitivity to the active substance(s) or to any of the excipients.Relevant UK clinical guidance should also be consulted. Consider hydroxyzine, although diphenhydramine has the more proven safety profile in pregnancy. Small vesicles started to appear in a circular ring on her left forearm surrounded by erythema with a fine scale and central clearing. If the condition appears classic for PUPPP, it can be managed symptomatically. Norgestrel is one of a group of substances called progestogens, which is similar to a hormone progesterone, that is produced naturally by women.

Intrahepatic cholestasis of pregnancy This condition is also called recurrent or idiopathic jaundice of pregnancy, obstetric cholestasis, and pruritus gravidarum. Primolut N must also be stopped at once if you become pregnant, or if you develop jaundice or other liver problems, or itching (pruritus), or if your doctor finds your blood pressure to be significantly raised. It has been recorded at a rate of approximately 10 to 150 per 10,000 pregnancies in Europe and 70 per 10,000 in the United States.12 In 80% of patients, the time of onset is after the 30th week.14 Although this disorder is not primarily a dermatosis of pregnancy, it is a pruritic condition that often presents with excoriations in pregnant women and is associated with fetal morbidity and mortality. It’s important to be able to identify this disease early to minimize sequelae.

You may also like

The Journal of Family Practice

The Journal of Family Practice

Herpes zoster is due to the reactivation of the virus causing varicella, called varicella-zoster virus. In a previous interim report we noted more prompt resolution of dermatomal signs and symptoms with acyclovir treatment. PHN is commonly defined as “dermatomal pain that persists 120 days or more after the onset of rash.”5 The pain of PHN has been characterized as a stimulus-dependent continuous burning, throbbing, or episodic sharp electric shock-like sensation6 and as a stimulus-dependent tactile allodynia (ie, pain after normally nonpainful stimulus) and hyperalgesia (exaggerated response to a painful stimulus). In addition, some patients experience myofascial pain secondary to excessive muscle guarding. However, there is currently no systematic collection of data concerning the effectiveness of antiviral drugs administered outside of clinical trials. While this acyclovir treatment regimen reduces the zoster-related pain during the acute phase of the disease, especially in patients treated within 72 hours of onset of skin lesions, it has no evident effect on either incidence, severity, or duration of post-herpetic neuralgia in the patients studied. Patients also feel spontaneous pain in areas where sensation is lost or impaired.

Antiviral agents suppress viral replication and have a beneficial effect on acute and chronic pain. But for others, there is no convincing evidence that antiviral drugs reduce the risk of painful complications. All 3 drugs have comparable efficacy and safety profiles. Based on this evidence, antiviral medications are strongly recommended for treating herpes zoster, especially for patients at increased risk of developing PHN. Antiviral treatment should be started within 72 hours of the onset of the rash. Analgesics are part of a practical approach for managing herpes zoster–associated pain that begins with a short-acting opioid in combination with acetaminophen or a nonsteroidal anti-inflammatory (NSAID) agent. Gabapentin or pregabalin, followed by a tricyclic antidepressant, can be added if conventional analgesics are not entirely effective.

The analgesic regimen should be tailored to the patient’s needs and tolerance of adverse effects. If pain control is inadequate or adverse effects are intolerable, consider referring the patient to a pain management center for possible interventional modalities. Calcium channel-blocking anticonvulsants gabapentin and pregabalin are safe and relatively well tolerated. They can be used as first-line agents for PHN, starting with a low dosage and titrating up, based on effectiveness and tolerability. Gabapentin is FDA approved for the treatment of PHN. The starting dosage is 100 to 300 mg taken at night, titrated as needed by 100 to 300 mg every 3 to 5 days, to as high a dosage as 1800 to 3600 mg/d in 3 or 4 divided doses. In 2 large, randomized controlled trials, gabapentin produced a statistically significant reduction in pain ratings and improved sleep and quality of life.14,15 Adverse effects include somnolence, dizziness, peripheral edema, visual adverse effects, and gait and balance problems.

The Journal of Family Practice
Because gabapentin is excreted by the kidneys, take care when using it in patients with renal insufficiency. Gabapentin clearance is linearly related to creatinine clearance and is decreased in the elderly and in individuals with impaired renal function. Hence, the gabapentin dose and the frequency of dosing must be adjusted in these patients. Extended-release gabapentin. The FDA recently approved an extended-release gabapentin formulation for PHN. Approval was based on a 12-week pivotal study and 2 adjunct studies. In a multicenter, randomized, double-blind, parallel-group, placebo-controlled, 12-week study evaluating the efficacy, safety, and dose response of 3 doses, extended-release gabapentin was effective at 1200 mg/d dosing.

The initial recommended dose is 600 mg, once daily for 3 days, followed by 600 mg, twice daily, beginning on Day 4.17 The premise is that the extended-release preparation improves bioavailability of the active drug and, therefore, reduces the incidence of adverse effects, compared with regular gabapentin. Pregabalin is also FDA approved for PHN. The effective dosage range is 150 to 600 mg/d. Pregabalin provided significantly superior pain relief and improved sleep scores compared with placebo in 776 patients with PHN.21 Adverse effects include weight gain, dizziness, and somnolence. Titrate the dosage slowly in the elderly. Sodium channel-blocking anticonvulsants topiramate, lamotrigine, carbamazepine, oxcarbazepine, levetriacetam, and valproic acid are not FDA approved for PHN. These agents may be a treatment option, however, for patients with PHN who do not respond to conventional therapy.

In an 8-week randomized controlled trial, patients treated with divalproex sodium (valproic acid and sodium valproate), 1000 mg/d, experienced significant pain relief compared with placebo-treated patients.22 Adverse effects included vertigo, hair loss, headache, nausea, and diarrhea. Nortriptyline and desipramine are preferred in frail and elderly patients. Start therapy with 10 to 25 mg nightly, titrating as tolerated every 2 weeks to 75 to 150 mg as a single daily dose. Adverse effects include dry mouth, fatigue, dizziness, sedation, urinary retention, orthostatic hypotension, weight gain, blurred vision, QT interval prolongation, constipation, and sexual dysfunction. Tramadol, an atypical opioid, has a weak μ-opioid receptor agonist effect and inhibits reuptake of serotonin and norepinephrine. Avoid using it in patients with a history of seizures. The maximum recommended dosage is 400 mg/d.

An extended-release formulation of tramadol is also available. Tapentadol has weak μ-opioid receptor agonist activity; norepinephrine reuptake inhibition is more predominant than serotonin reuptake inhibition. This drug is also available as an extended-release formulation. The maximum recommended dosage is 600 mg/d. Avoid using tapentadol in patients with a history of seizures. Note: Although there is no scientific evidence regarding the use of tapentadol in neuropathic pain, we use it often in our practice. Capsaicin topical cream is sold in 2 concentrations: 0.025% and 0.075%.

An extract of hot chili peppers, capsaicin acts as an agonist at the vanilloid receptors. The recommended dosage is 3 or 4 times a day. Initial application causes burning to become worse, but repeated use results in diminished pain and hyperalgesia.

You may also like