TREATMENT GPPPD

1. TREATMENT GPPPD t.Eftekhar tums

2. Treatment of Vulvodynia • However in practice,a multidisciplinary approach is recommended, withtherapy based on presenting symptoms, • side effect profile ofrecommended treatments, cost, and patient preference

3. Treatment of Vulvodynia • vulvar care • i.e., eliminating pads allergens fabric softeners, soaps ,other potentially irritating chemicals. • Initial management • will depend on findings but usually includes physical therapy,relaxation therapy, , topical medications. • Oral medication and injections may follow and surgery • may be considered if other approaches fail

4. Vestibulectomy • Surgical removal of the painful vulvar vestibular tissue • Isthe most widely investigated approach for dyspareunia in womenwith vestibulodynia • overall success rates are high (85–90%) success refers toimprovement of at least 50% and need not include painlessintercourse.Surgery has risks, side effects, and some lessthan optimal outcomes

5. use of dilators and sex therapy has been associated with improved outcome of vestibulectomy

6. they had poorer outcome. • Higher pretreatment pain • psychosocialcomplaints • negative attitude towards sex

7. Pharmacological Treatment • Tricyclic antidepressants modulate pain in the central nervoussystem at the level of the dorsal horn of the spinal cordand brain . • are an excellent medication for generalizedvulvodyniaand may be effective for localized provoked. • CBT, physical, ,sex therapy to low-dose oral amitriptyline (10–20 mg daily)with or without topical triamcinolone • desipramine and topical lidocaine

8. Desipramine • had the highest drop out ratesside effects of • dry mouth, tachycardia, hotflashes, dizziness • Topical amitriptyline avoids systemic side effects. • topical amitriptyline 2% cream • 56% response rate ,10% pain free • 30%reporting a moderate improvement

9. Injections with lidocaine and methyl prednisone aim todecrease the local inflammatory reaction • sodium channel blocking effects of lidocaine. • complete relief of persistent vulvarvestibular pain

10. oral tricyclicantidepressants • gabapentin • a low-oxalate diet withcalcium supplementation followed by biofeedback • Corticosteroid creams are not effective

11. Botulinum toxin A reduces muscle .hypertonicity and hasantinociceptive effects in studies of neuropathic pain. • . Cromolyn sodium blocks mast cell degranulation andinhibits the release of inflammatory mediators. • Capsaicinis an agonist of vanilloid receptors , • located onthe peripheral terminals of sensitive nociceptorsIt has been recommended for treatment of post-herpetic neuralgia or • peripheral neuropathy

12. Physical therapy techniques for managementinclude internal and external tissue mobilization myofascialtrigger point release manipulation, biofeedback,electrical stimulation • use of dilators Transcutaneous Electrical Nerve Stimulation(TENS) • Psychological Interventions

13. Vaginismus and vestibulodynia overlap and can pose achallenge to differentiate the two diagnoses based solely onexam. • Fear and vaginal muscle tension were greater in thevaginismus group as compared the dyspareunia/PVD

14. Patients require instructions on how to use • the dilators, how to overcome the anxiety • education on sexual positionsthat allowrelaxation of the pelvic floor. • Psychological, sexualbehavioral therapy in conjunction with The use of dilators, also called vaginal trainers leads to thebest outcome.

15. Treatment of Vaginismus • Desensitization • The use of dilators, also called vaginal trainers (VTs), ofgradually increasing sizes is one of the most commonly recommendedtreatments for vaginismus, despite lack of systematicresearch VTs may help overcome thephysical aspects of vaginismus, as well as the fear of penetration

16. Vaginal dilators

17. Pharmacological Interventions • Anxiolytic medicationantidepressantssuch • diazepam amitriptyline • alone has not shown to resolvevaginismus • with psychotherapy theycan be used for patients with high levels of anxiety

18. Botulinum toxin A was injected into puborectalis muscles • symptoms on the post-injection visit 1 week later witheffects lasting up to 12 months

19. Psychological Interventions • Sensate focus consists of • non-penetrative,touching exercises that aim to increase the participant’sawareness of their senses • Gradual exposure to intercourse using CBT can decreasefear of penetration and avoidance behavior

20. Including the Partner in Treatment • Treating the couple and not just the affected woman is recommended. • Partners of women with vaginismus can develop • sexual dysfunction secondarily to their partner’s complaint.5–45% of men have reported • erection disorders or prematureEjaculation

21. Specific Causes of Vulvar Painand Superficial Dyspareunia • Burning and aching inthe Sacral 2–4 nerve dermatomal distribution can also be • caused by • dermatoses, dermatitis, infections • referred visceralpain from the bladder or the rectum, or levatoranisyndrome.

22. The Nantes criteria for pudendal neuralgia related toentrapment include essential, complementary, and exclusioncritera • Essential criteria: (1) pain in the territory ofthe pudendal nerve (anal-rectal, vulvo-vaginal, and distalurethral tissues) (2) pain mostly while sitting which maybecome continuous over time, (3) pain does not wake thepatient at night, (4) pain without sensory deficit, and (5)relief by diagnostic pudendal nerve block. • .

24. (A) ilioinguina ln(L1) • ; (B) genitofemoraln (L1-2); and • (C, D) branches of the pudendaln (S2-4). • (C) the dorsal nerve of the clitoris (shown deeper as dashed lines in muscles of the urogenital diaphragm) • , (D) the perineal nerve, which innervates the labia majora and perinuem, • (E) the inferior rectal nerve, which innervates the perianal area. The pudendalnerve also innervates the external anal sphincter and deep muscles of the urogenital • The triangle

25. Complementary diagnostic criteria shooting, stabbing pain and numbness, allodynia or hyperalgesia in the pudendal nerve territory, rectal or vaginal foreign body sensation worsening of the pain during the day, predominately unilateral pain pain triggered by defecation, and exquisite tenderness on palpation of the ischial spine

26. Management of Pudendal Neuropathy • neural blockade, using local anesthetic± corticosteroid. • Tricyclic antidepressants, such as nortriptyline, desipramineor amitriptyline, beginning with 10 mg at night and increasingto 50–150 mg are useful. • Selective serotonin and norepinephrine reuptake inhibitors • have also been used to treat pudendal neuropathy, • duloxetine 30–60 mg, one to two times per day, or venlafaxine • gabapentin, in doses of 300 mg atnight up to 600–900 mg three times daily, pregabalin 75 mgper day up to 300 mg twice daily, topiramate 50–100 mgtwice daily are in the armamentarium. • Topical lidocaine 5%or other compounded preparations of the above medicationscan be used off label. Muscle relaxants orally or vaginally • may be helpful.

27. Physical Therapy • PT is an important part of treatment and pelvic floor disordersoften accompany pudendal nerve pain. All the musclesbetween ribs and knees should be examined; • myofascial triggerpoints (hyperirritable spots within a taut band of muscleor fascia) should be treated. • Common trigger points arelocated in the rectus abdominis, obturator internus, piriformis,gluteal muscles, quadratuslumborumabductus; thesewill respond to manual therapy • , dry needling or trigger pointinjections.

28. Vulvar Dermatoses • Lichen Sclereous • Vulvar/introital pain with sexual activity can also result fromchronic inflammatory autoimmune conditions lichen sclerosus(LS) or lichen planus (LP). • LS is a chronic inflammatoryautoimmune disorder which may be associated with LP • perniciousanemia, alopecia areata, and autoimmune thyroiddisease.

30. Treatment of Lichen PlanusUltra- and mid-potent corticoid steroids ointments • clobetasol0.05% bd /1 m and then tailoring the medication over 3 months the used once or twice a week as needed with exams every4–6 months • mometasonefuraote cream, hydrocortisonesuppositories • tacrolimusslight increased risk of squamous cell • Carcinoma • topical estradiol and testosterone are helpful, applied once or twice daily.

31. vulvar granuloma fissuratum • may be atrophy,such as with menopause or estrogen suppression related tohormonal contraceptives, lichen planus or lichen sclerosus,vulvar intraepithelial neoplasia, hypertonic pelvic floor

32. Lichen Planus (LP) . Symptoms include pain,burning, dyspareunia, andpostciotalbleeding. LP affects thevestibule and inner labia minora and majora, vagina, andmouth. Signs include erosions in 74%, redness 65%, scarring and lacy changes with white overlyingred epithelium in 63%, and in 56% vestibule

33. vagina are Abnormal vaginal discharge consists of yellow non • odorous discharge; under the microscope reveals multiple • white blood cells and immature vaginal epithelial cells

34. Vulvovaginal atrophy or thinning is a common cause of dyspareunia • occurring in the setting of prolonged estrogen deficiency,typically with menopause.