Insertional Dyspareunia

Educational Objectives

The goals of this program are to improve diagnosis and management of insertional dyspareunia. After hearing and assimilating this program, the clinician will be better able to:

1. Use history and physical examination to diagnose the cause of insertional dyspareunia.

Summary

Prevalence: ≈8% of women seeing gynecologist and one-third of those presenting with sexual problem

Vulvodynia: burns but does not itch; vulva appears normal; patient may have history of yeast infections; use 75 to 100 mg amitriptyline (eg, Elavil, Tryptizol, Tryptomer), beginning with 25 mg at dinnertime; increase by 12.5 mg every 10 to 14 days; taper after ≥1 yr, but 50% require long-term therapy; other treatments — gabapentin (Gralise, Neurontin); sertraline (Lustral, Zoloft); carbamazepine (Carbatrol, Equetro, Tegretol)

Vestibular adenitis: woman with no previous complaints develops pain over ≈3 wk; unable to have intercourse, use tampon, or wear tight clothes due to severe pain; 1- to 2-mm vestibular glands analogous to prostate; use colposcope to view tiny red ulcerations; ulcers, but not surrounding tissue, painful to touch and usually around hymenal ring; excise surgically

Lichen sclerosus (LS): mostly in postmenopausal women; presents with loss of labia minora and phimosis of clitoris; vulva pale, thin, and tears with stretching; introital stenosis can develop; thin mucosa, keratin, and inflammation seen on biopsy (not needed for diagnosis, but biopsy if ulcers present); only ≈5% of LS progresses to malignancy; treatment — 0.5% clobetasol (Cormax, Temovate); show patient where to apply cream (between labia, around clitoris and urethra, and on perineal body); use twice daily until controlled, then daily; effective in 3 wk; continue use but decrease frequency, if possible; for introital stenosis, perform midline episiotomy and close transversely

Lichen planus: rare; presents with heavy discharge, raw vulva and vagina, superficial ulcers, scarring, vaginal stenosis, and oral ulcers; easily recognizable; use 1% hydrocortisone foam for hemorrhoids (Cortifoam, Proctofoam) in vagina daily; use dilator for vaginal stenosis; tacrolimus (Protopic) also effective; lifelong treatment needed

Rigid hymen: patients report pain since first intercourse; treat surgically; inject with bupivacaine (Marcaine, Sensorcaine) with epinephrine and cut at 2, 4, and 5 o’clock; suture open to prevent recurrence; use same technique for VA

Transverse vaginal band: pain with partial insertion; palpable band forms where embryonic vestibular bulbs meet mullerian ducts; cut band and sew open, or remove band if tight

Urethral diverticulum: pain with partial insertion; palpating tender lump on anterior vaginal wall may expel pus from urethra; distinguish from urethrocele by inserting urethral catheter (catheter can traverse urethrocele, but not diverticulum); open anterior vaginal wall and dissect around cyst; communication with urethra not always in midline, so dissect halfway, then open cyst to see urethral communication and complete dissection; catheterize for 10 days and give antibiotics

Anterior and posterior repairs: avoid making vagina too small; bivalve vagina at 3 and 9 o’clock and place skin graft; if bands present, cut vertically and reapproximate transversely

Vaginismus: possibly not true entity; most women have pathology

Posterior fourchette: for older woman with tears after intercourse, excise affected area of vestibule, then undermine vagina and pull it downward

Readings

ACOG Committee on Gynecologic Practice: ACOG Committee Opinion: Number 345, October 2006: Vulvodynia. Obstet Gynecol. 2006;108(4):1049-52; Alazzam M et al: First-line chemotherapy in low-risk gestational trophoblastic neoplasia. Cochrane Database Syst Rev. 2012;7:CD007102; Alazzam M et al: Chemotherapy for resistant or recurrent gestational trophoblastic neoplasia. Cochrane Database Syst Rev. 2012;12:CD008891; Antosh DD and Gutman RE: Diagnosis and management of female urethral diverticulum. Female Pelvic Med Reconstr Surg. 2011;17(6):264-71; Berkowitz RS and Goldstein DP: Current management of gestational trophoblastic diseases. Gynecol Oncol. 2009;112(3):654-62; Bradford J and Fischer G: Surgical division of labial adhesions in vulvar lichen sclerosus and lichen planus. J Low Genit Tract Dis. 2013;17(1):48-50; Fylstra DL: Ectopic pregnancy not within the (distal) fallopian tube: etiology, diagnosis, and treatment. Am J Obstet Gynecol. 2012;206(4):289-99; Fylstra DL: Ectopic pregnancy after hysterectomy: a review and insight into etiology and prevention. Fertil Steril. 2010;94(2):431-5; Groysman V: Vulvodynia: new concepts and review of the literature. Dermatol Clin. 2010 Oct;28(4):681-96; Cai Z et al: The value of laparoscopy alone or combined with hysteroscopy in the treatment of interstitial pregnancy: analysis of 22 cases. Arch Gynecol Obstet. 2012;285(3):727-32; Chi CC et al: Systematic review and meta-analysis of randomized controlled trials on topical interventions for genital lichen sclerosus. J Am Acad Dermatol. 2012;67(2):305-12; Gayer G: Images in clinical medicine. Abdominal ectopic pregnancy. N Engl J Med. 2012;367(24):2334; Lurain JR et al: Actinomycin D for methotrexate-failed low-risk gestational trophoblastic neoplasia. J Reprod Med. 2012;57(7-8):283-7; Osborne RJ et al: Phase III trial of weekly methotrexate or pulsed dactinomycin for low-risk gestational trophoblastic neoplasia: a gynecologic oncology group study. J Clin Oncol. 2011;29(7):825-31; Simões M et al: Early abdominal pregnancy with an unexpected and misleading location. The ultrasonographic interpretation. Clin Exp Obstet Gynecol. 2012;39(1):115-7; Tommola P et al: Long-term well-being after surgical or conservative treatment of severe vulvar vestibulitis. Acta Obstet Gynecol Scand. 2012;91(9):1086-93; Verma U et al: Conservative management of nontubal ectopic pregnancies. Fertil Steril. 2011;96(6):1391-1395; van Trommel NE et al: The curative effect of a second curettage in persistent trophoblastic disease: a retrospective cohort survey. Gynecol Oncol. 2005;99(1):6-13.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Underwood was recorded at the 43rd Annual OB/GYN Spring Symposium, sponsored by Medical University of South Carolina, Department of Obstetrics and Gynecology, College of Medicine, co-sponsored by Lowcountry AHEC, and held April 16-18, 2012, in Charleston, SC. For information on upcoming CME programs presented by Medical University of South Carolina, call 843-876-1925 or visit their website at academicdepartments.musc.edu/cme. The Audio-Digest Foundation thanks the speaker and the sponsors for their cooperation in the production of this issue.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OB600503

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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