Dr. Buttrick, I'll pay you later. Thank you. I appreciate your talk. In full disclosure, he and I do not work together. We do not work in the same place, but you're going to hear a lot of the same things. There's a lot of redundancy in the slides. I'll skip over those and hopefully we can talk about some other things. There are some things that he has suggested that I will talk about and there's some things that he has suggested that I'll talk maybe on the other side of just a little bit, but that's okay too. I certainly have no relevant financial relationships. You know, never will. PTs, we don't get that, you know. My goals and objectives are really pretty simple. I want to talk a little bit about the updated nomenclature, but I'll give you the old stuff first and then the new. Dr. Buttrick went through this, so we'll not spend a lot of time with it. We've also seen a lot of anatomy. I'll add a little bit to that. Then I'll talk a little bit about what PTs do. My job here, how many PTs do we have in the audience? One. Okay. Woohoo. Thank you for being here. How many nursing professionals? Wonderful. And how many physicians? So primarily physicians. So my goal here isn't really, excuse me, isn't really to tell you what I do and how to do it, because obviously you're not going to do that. But I will tell just a little bit about what I do and a little bit about how vulvar pain might be treated. But I always like to start with this disclaimer, because just like every lecture that you've ever heard about treating anything, there are different ideas for all sorts of things. What I'm going to share with you certainly isn't the only way for a physical therapist to treat women with chronic vulvar pain. It's just what I have found to be very helpful for me in 27 plus years dealing with women with chronic vulvar pain. It's been a pretty cool place to be. So this is that nomenclature. This is the old stuff, and it's vulvar discomfort. This is prior to 2004. Vulvar discomfort, most often described as burning pain occurring in the absence of relevant visible findings or specific clinically identifiable neurologic disorder based on the site of pain, localized or generalized, and we'll talk about that when it comes up a little bit different. This is again those first four categories that Dr. Butcher referred to. This was again in 2004. Then they had this meeting with the ISSVD, International Society for the Study of Vulvar Vaginal Diseases, ISWSH, International Society for the Study of Women's Sexual Health, and IPPS, International Pelvic Pain Society, with observers from ACOG and the National Vulvodynia Association to try to say, look, what we had before really isn't really true. We need to look at everything that's happened since that was published, and we've seen a lot. We've seen that tricyclics actually have some impact, so perhaps there may be a neuropathic etiology. They found that doing some nerve excisions seemed to suggest, made a difference, so they were successful, suggesting that perhaps there's some neurological involvement that we can actually surgically do. Others, we've added primary and secondary, which Dr. Butcher talked a little bit about, and we found that there's more variation in symptoms. It can be intermittent. It can be persistent. I've been in the ISSVD meetings since 1995 and heard these arguments for years and years and years, so it's interestingly that this, it's very interesting that this came and went without arguments at ISSVD, so we're very happy to see that. The new definition is a little bit different. Vulvar pain of at least three months duration without clear identifiable cause, which may have potential associated factors. As a physical therapist, I can suggest to you that all the things that Dr. Butcher talked about, as a physical therapist, I have treated in patients and found that they get better. So as a PT, it was always interesting to see that it, what the diagnosis was, or what the description was and how it's changed. We've added these things on the bottom. We kept the first four. Trauma was added. Anything iatrogenic, hormonal deficiencies were added as additional possible triggers. We know that the pain can either be localized or generalized. The localized pain is typically now referred to as vestibulodynia in the literature, provoked vestibulodynia or PVD. Generalized and provoked or, the localized pain is just within the vestibule, whereas generalized pain is that pain that can be throughout the vulva. It's not restricted just to the vestibule and they can be mixed or both or one or the other. They can be provoked or spontaneous. Typically provoked vestibulodynia only hurts when you poke it. Spontaneous vulvodynia is what generalized vulvodynia used to be. It just bloody hurts. You might wake up with pain and burning in the morning. You live with it all day. You go to bed with it at night. Women who have generalized vulvodynia are miserable. I haven't seen that in a very long time. The biggest part of, the biggest proportion of women with chronic vulvar pain have provoked vestibulodynia. The onset can be primary or secondary. Again, that primary is that they have pain with first intercourse, pain, first use of tampon, first exam, or it can be secondary. They've had great sex and then it gets bad. Intermittent, constant, immediate or delayed. We've talked about that twice. This is just a table to give you the breakdown of some of those factors that can be included in the diagnosis now. We won't go over that. This is all, you can find this all online. We've talked a lot about comorbidities. Those with IC had positive bladder testing but suggested that it was the bladder that was causing the vulvar pain, which comes first, right? Patients with IC and painful bladder syndrome, you can see two-thirds of them had vulvar pain, over half of them had pain with sex, and nearly three-quarters of them had pain in the last year with sex. However, only 23 percent had been diagnosed with vulvodynia. What I've seen in my practice is it depends, the diagnosis that patients would come to me with depended on what kind of physician they saw, what their specialty was. Typically those coming from gynecologists came with the diagnosis of vulvodynia, those from urologists, painful bladder syndrome, and that's fine. What physicians do and the job of physicians is that they take history, they look at all the tests, they take a look at all the history, they take a look at all the symptoms, and their job, at least in our country, is to come to a diagnosis, right? So they get that one diagnosis that they can bill for and they can call it something. They then send it to physical therapy and we, as PTs, get to go the other way. We get to do this. We get that diagnosis and from whatever, did that just go away? Whatever that is, we call it chronic vulvar pain, but we're able to look at all of the muscle systems, all of the body symptoms, and try to figure out what it is that creates that chronic vulvar pain. I've always said we're really lucky in our world because we get to look at everything in the body. We get to look at all the systems. We're also really lucky that we typically get to see patients once a week, oftentimes for an hour, so we're really the lucky ones. Those with chronic pelvic pain, you can see the results here, retrospective chart review, all sorts of things were going on with these chronic pelvic pain patients, voiding dysfunction, dyspareunia, urethral issues. They were treated, as Dr. Buttrick talked about, with that therapeutic anesthetic cocktail. Fifty percent of the vulvar pain went away. Sixty-seven percent of the chronic pelvic pain went away. The IC or the painful bladder, 73 percent. Seventy percent with other disorders got better, whatever those were, right? We've heard this over and over again. I'm not, by the way, going to talk about central sensitization. Dr. Buttrick did a great job. I'm going to be very simple. I'm going to talk about the physical things that we can deal with, that we can treat as PTs, that I have found has helped, but I certainly understand and know all of the research and the literature that's looked at central sensitization. For years, I've kind of talked about redoing that reflex pain cycle in women with chronic vulvar pain, so that's something that we've talked about for a long time. But those comorbidities, fibromyalgia, IC, painful bladder, irritable bowel, so bladder and bowel dysfunction, looking at all of these almost 2,000 women, women with chronic vulvar pain or vulvodynia are more than likely than those without vulvodynia to have at least one, if not three, one or more of three chronic pain conditions. Okay, so we know that those comorbidities exist, and again, how are they diagnosed? What are they talking about? Myofascial pain. What the heck is myofascial pain? I got asked that question so many times. This slide's been in my presentation for a long time, because what the heck is that myofascial system? What do you PTs do? You put your hands on there and you affect the myofascial system. How the heck do you do that? Well, the myofascial system is a system of connective tissue that goes from the brain all the way down to the toes and the fingers. It's a system that covers the brain, it covers the nerves, it covers the blood vessels, it covers the muscles, the bones. It's a continuous sheath of tissue that goes throughout the body, traverses the body. It has all sorts of ways it can get mucked up. It can get tight, it can get restricted, it can cause problems. And we can, as PTs, as manual therapists, key in to that myofascial system and help release tension and improve mobility of all of the structures in the body. This was the question that I got asked forever and ever. I started seeing women with chronic vulvar pain in 1991, and there was only one physician in the city of Chicago who was seeing patients and referring them. And they would come to me after he said to them, well, there's nothing else that I can do. There's this physical therapist, I'm not really sure what she does, and I'm not really sure she can help, but go try her. Right? So, you know, you have these patients, even then and even forever, who come and they sit down in your office and they sit down at your desk and they cross their legs and they cross their arms and they look at you, like with a scowl, and say, I didn't, you know, I don't have a sprained ankle, I didn't have a stroke, why am I here? So that's where we always got to give them a good education of what was going on. You've already seen most of this. Who should be referred to PT? Women with chronic vulvar pain, certainly we've seen that, dyspareunia, bowel bladder dysfunction, chronic Easter vaginal infections, because of what happens, the sequelae of what happens with that, right? But it's really interesting that we need to get these people, too. We're still PTs. We don't just deal with the pelvic floor, which is what women's health PTs had the, we needed to have shirts. We do treat more than just the pelvic floor, we really do. Because a lot of the body can impact what's going on in the pelvis. So low back pain, hip pain, any other orthopedic problems can also contribute to what's going on in the pelvis. Chronic dysmenorrhea, history of endo, all of those things we've already talked about. So again, this is that clock, this 12 o'clock is at the clitoris, 6 o'clock is at the anus, posterior frechette, that infamous 6 o'clock spot. That spot that hurts all the time, that we hear it all the time. I'll suggest in a little bit why I think there's a lot of problems there. We've all seen this, this is pretty familiar, we know that we've got muscle there, we've got bone there. I started working with Howard Glazer, I don't know if any of you remember Howard Glazer, did a lot of research with biofeedback, published papers on biofeedback. He's really the one who really put forth the ideology that the elevated pelvic floor muscle tension or pelvic floor muscle hyperactivity was what was causing vulvar pain. He had a hellacious protocol of pelvic floor biofeedback with sensors for 20 minutes twice a day. It was really, really amazing. But he had great results. So how can you go against that? As a physical therapist, I had a little bit of a problem just treating the pelvic floor, so he and I kind of split ways after that. But it really was from his research that the idea of pelvic floor hypertensity really got out there. We know there's a whole lot more that's going on down there. We have the muscles, right? I'm sorry, we're going to talk about the muscles. We have the muscles here, but we also have their bony attachments that we can't forget. We have the pubic symphysis in the front, we have the ischial tuberosity, these are the sits bones on either side, and we have the coccyx in the back. Pelvic floor muscles all come and attach to these bony structures on the periphery, in the superficial pelvic floor. If we look at more of a cartoon, we can see that this is a superficial pelvic floor. Superficial pelvic floor muscles almost forming a triangle of support around the vaginal opening on the top, continuing almost in a figure-eight pattern to form the external anal sphincter, and then coming back and attaching to the coccyx. Deep pelvic floor is a lot bigger and broader, goes from the front to the back in some sort of sling-like representation, going from just lateral to the pubic symphysis in the front, coming back, and attaching to the sacrum and the coccyx in the back. The function of the pelvic floor is to support the pelvic organs so they don't fall out. They're not very pretty when they fall out. They work to help control mituration and defecation. They contract and relax with the orgasmic response, which is kind of important. And they're also the base of the core. They're very important in core support with transverse abdominis in multifidus. So we really need the pelvic floor muscles to function. In women who have chronic vulvar pain, who have that hypertonicity, they're not very functional. Just looking at that pelvic floor hypertonicity, there are a couple of studies published not too long ago looking at what's really happening there. The first was done with actually an internal biofeedback probe, which you think might have had a little bit of impact on what was happening with pelvic floor tension. But their suggestion, their conclusion was that perhaps prior to insertion of anything into the vaginal canal, there's a reflexive splinting. Or the woman remembers, you know, the last time you tried to put that in there, it really hurt. I don't want you there. I'm going to squeeze so you can't get in there. The second study that was done four years later, both of these are by Canadian researchers, physical therapists in their groups, used a transvaginal ultrasound. So she didn't actually put a sensor in, but she wanted to know what was happening in women with vulvodynia, vestibulodynia as compared to those without it. What was going on with that pelvic floor resting tone? And she found that there appeared to be elevated resting tone regardless of provocation. So at this point, who knows? It's certainly one or the other. I'm here to suggest again that it's not just the pelvic floor. You know, Dr. Bedford talked about all the things that can impact the pelvic floor, and I couldn't agree with him more. Everything below the parietal peritoneum, you have the bladder and the ureters. We also have this uracus coming off of the bladder here in the middle. You have the uterus and the fallopian tubes. We know that the ovaries are up in the abdomen, so they're not below the peritoneum. We also have a lot of ligamentous structures throughout the pelvis, and this certainly isn't all of them. These are just some of the main ligamentous structures that we see. We have the arcus tendineus that comes across, the broad round ligament that comes down through the inguinal canal down to the labia majora on either side, the puboscervical ligament, that huge broad uterus sacral ligament that comes back supporting the uterus all the way back to either side of the sacroiliac joint. We also have the bones with the pubic symphysis in the front, that bony structure support, the sacroiliac joint, the sacrum and the coccyx in the back. And then we have the pelvic floor muscles on the bottom. We certainly don't forget them, but we know that there's a whole lot of anatomy going on right there that can impact what's happening with their tone. We also can't forget about all of this. You know, as physical therapists, traditionally we've treated muscles and joints, but we can also now take a look at what's happening in the viscera. If you take a look at it from a physical perspective, what do you think is going on in the bowel in somebody with chronic diarrhea or chronic IBS? Any spasm or tension in these structures? What about in the large bowel, as the ascens transverse and descens comes down into the sigmoid into the rectum? If you've got colon issues, you've got a colitis, is there any tension or spasm? Again, from a physical perspective, I'm not talking about from a diagnostic perspective, but more from a physical perspective. Bladder. What about a bladder that we know doesn't really have the inflammation of IC, but there's still urgency and frequency? Could it be that there's tension in those muscles that doesn't go away as it relates to pelvic floor muscle tension or as, you know, which comes first the chicken or the egg, or the urethra as far as that goes? So what do I do on my first visit? It's not a whole lot different than what Dr. Patrick talked about. I do, in my history, include, you know, I want to get the comorbid conditions and talk to them a little bit about what's going on in their bowel, their bladder, their obstetric history. We talk a lot about sex. By the time my patients would leave my office they'd say, you know, I've told you more than I've ever told anybody else. Now, mind you, I get an hour with them, so it's not uncommon with new patients for me to spend, you know, half an hour, 45 minutes just going through this history. So we're really able to develop, and this is just dressed and seated at my table, by the end their legs are usually uncrossed and their arms are usually uncrossed and they're, you know, they're a little happier. It's really important to let her get all of this out and for me to say, you know, that's not uncommon, that's not uncommon. We see that a lot. That validation, I think, is so important. Again, I was always going to do a, you know, a perceived pain index as they walked through the door and do it again after we do this history to see if it would change. After I go through the history and when she's still sitting with me, I pull out, like I said, my favorite friend. This is one of the, other than my hands, the best tool I had in my clinic. I could show this to her. I could describe the muscles. I could describe where the organs are so that when we went on to my exam table she had a really good idea of what I was looking for. She's not just crazy that she hurts and she burns. There may be something there. There are muscles there. Who knew? Who knew? So she knows physically that I'm going towards something and that really makes a big difference in how she perceives what's going on. You know, we've already gone through why is this happening, what did I do, why did this happen to me, that kind of stuff, but my goal is to try to show her some real physical things. So once I get her on the table and we've talked through all these things, I found that there are a number of things that I could do prior to even doing an internal exam that would make her feel better. One of them was talk to her about breathing strategies. We know that the respiratory diaphragm up here, down to the pelvic diaphragm down here, is a pressurized cavity. The guts don't, the organs don't just hang out in there. They're held, actually they have attachments to the backside of the abdominal wall, but it's a pressurized system that keeps them in place. The pressure is the greatest, that pulling up pressure is the greatest at the respiratory diaphragm and is the least at the pelvic floor diaphragm, which is one of the reasons why we have so much prolapse because we don't have that upward pull, so that's what happens. I talk to my patients about doing a lower lateral diaphragmatic breathing technique. What I want you all to do for me if you could, since we've been all sitting here, sit up straight in your chair for me, put your feet flat on the floor. I know this is really hard, I promise I won't do anything silly. Close your eyes and I want you to take a really, really good deep breath for me, all the way in. Breathe in, breathe in, breathe in, breathe in, and now blow it out. Okay? I want you to keep your eyes closed and do that for me a second time and when you do it this time, I want you to figure out and think where is your breath going? So now take another really big breath in for me. Breathe in, breathe in, breathe in, breathe in, and now blow it out. Where did your breath go? Shout it out. Where did your breath go? Into your ribcage? Wonderful. In your abdomen? Hello? Anybody else? Anybody have it go into their upper chest? Right? Yeah? It's not at all uncommon for people who have chronic pelvic pain, who have vulvodynia, who have IC, who have IBS, any of those things, to adopt an upper chest breathing pattern. Because we know from functional MRIs that if you take it to take a breath in, right, in the normal circumstance, your diaphragm has to go down. As your diaphragm goes down in that pressurized system, that pressure translates all the way down through the viscera to the pelvic floor. But if you've got some dysfunction going on there, your body says, yeah, no, I don't want that diaphragm to come down. I want you to use the accessory muscles up top to bring the air in because I don't want you to mess with what's going on below the respiratory diaphragm. It's really, really typical when you ask patients with chronic pelvic pain or vulvodynia or any of these things to take a deep breath that you see that upper chest breathing. What I'm going to suggest to you is I want you to put your hands on either side of your ribcage. Put a little bit of pressure. Your ribs are actually very flexible. Put a little bit of pressure into your ribs. You can see how they move. And now when you take a deep breath, I don't want that air to go into your belly like a yoga breath. I don't want it to go into your upper chest because I don't want to see your boobs move. I only want to see your ribcage go out. So take a breath in and try to push your hands out to the side and blow it out. You might feel your back go back. It's almost like your ribcage opening up like an umbrella. What we know is that that's the best way to translate pressure down through the viscera into the pelvic floor. So that if we can get women to do that and do this really nice diaphragmatic breathing, not only does it bring down her blood pressure and her heart rate and calm her anxiety, right, all the things that deep breathing does, we know from a physical perspective that that can help to relax the pelvic floor. Not such a bad thing to know. I suggest it's like the dance of the diaphragm. When the pelvic floor muscles, when you take a really deep breath in and the diaphragm, respiratory diaphragm, descends, the pelvic floor diaphragm goes down or stretches a little bit. When you exhale, the respiratory diaphragm comes up and the pelvic floor returns. They go in unison. So that in your offices you're teaching somebody to do a pelvic floor muscle exercise, which would be wonderful if you all did that, contrary to what Dr. Patrick said, that when you inhale, your diaphragm goes down, both diaphragms go down, and when you exhale, they come up. So if you're teaching somebody to do a pelvic floor muscle exercise, you want them to contract on the exhale. Not unlike any other exercise. You blow out like when you work. You blow out or you exhale to contract. It seems totally backwards. When you try it, it'll seem really weird. We also worry about this visceral tension and what's happening on top of the pelvis from a physical perspective. Anatomically, this is the backside of the abdominal wall. The viscera is gone here. This is the umbilicus here. We can see the umbilical folds on either side and the middle fold coming down forming the uracus. The two lateral bands come down and go on either side of the bladder. The middle one goes down and attaches into the top of the bladder. Now what's really cool about this is that if you look at the pelvis going down into the pelvis, this is the bladder, this is the cervix, this is the rectum, this is the abdominal wall, and here are those three structures coming down on the backside of the abdominal wall. What's really, really cool is that as those lateral bands come down, they help to support the periurethral fascia. They come down and help to support the bladder. It then comes back and attaches to the ischial tuberosity in the back of the pelvis. This is that arcus tendineus. What we know is anatomically, it comes all the way up to the umbilicus. So what I have found with this, you'll see in a video that I'm going to show you in just a minute, that with a little bit of pressure right here externally, we can have an impact on these support structures of the urethra and the bladder. We also know that there's a lot of input from the deep hip muscles. That's not just the piriformis. Everybody talks about the piriformis syndrome. It's not just the piriformis. There are five deep little rotators in there that wreak havoc with pelvic floor muscle function, including the obturator internus. We also know that the giant psoas muscles that attach to the lumbar vertebrae and come underneath the inguinal canal are the major hip flexors, also contribute to a lot of pelvic floor and chronic pelvic pain. Interestingly, those ladies with ovarian pain, oftentimes it's psoas problems. We can go down and we can find the psoas and they say, oh yeah, that's my psoas pain, or that's my ovary pain, and you have them contract the psoas. Oh yeah, that really hurts. Well, oftentimes that's the case. When I do my vulvar assessment, and the reason I'm showing this to you now is because my next slide is actually a video. It's a video that I made for ISSVD last year. I presented it in Mendoza, Argentina, for those of you who might be interested in ISSVD. I wanted to do this because in the video, I check for each of the three women's vulvar pain before we do any of these techniques that I've just talked to you about. So I wanted to just show you this. And typically, the gold standard for diagnosing provoked vestibular dandruff is the Q-tip test, right? Pain with palpation at 3, 6, and 9. I don't use Q-tips in my office. I use my finger. So I use a lubricated gloved finger to, I call it a modified Q-tip test, that I go to the right. I go to 3, 6, and 9 to assess 0 to 10 pain. This is how I assess anybody before or after, but this is, I wanted to show you this before I show you the video because in the video, I leave my finger right at 6 o'clock. I don't keep pressure there, but I leave it there throughout the video. When we're talking about, I lied, it's not the next slide. When we're talking about pelvic floor muscle hypertonicity, what does it physically look like? Pressure and tension with the superficial pelvic floor close in to decrease the size of the vaginal opening. Deep pelvic floor muscles do the same thing. So what does that tension do when you're just looking at a woman and an orthotomy? We know if you put it, if you, this green line represents the plane across the ischial tuberosities. Normal pelvic floor location with normal tone sits just above that plane. Somebody with pelvic floor underactivity, the perineal body sits below that plane. Somebody with pelvic floor muscle overactivity or hypertonicity, that pelvic floor, that opening, the perineal body is sucked way up and inside. So that as you go to diagnose, if you go to evaluate somebody and you've not gotten her history and you really don't know what's happening or you really don't know if it's pelvic floor muscle, when you look at it and if her perineum is hanging out, maybe not pelvic floor muscle hypertonicity, but if you look and it's like, where, you know, where is it? You have to go and find it. And when you get there, it's so teeny, you couldn't get your finger through it. It's really hard to get just one digit, one assessing digit through there. That's pelvic floor muscle dysfunction, pelvic floor hypertonicity. So it's really easy to see. There are not a lot of tests. It doesn't do any good to pat her on the leg and say, just relax. She has no clue. No clue what you're talking about. You know, it's like you could tell her to relax her earlobes. It's kind of the same thing. If you can identify it with palpation, with using this, with education, you can actually give her the best tool she knows how to use. I'll talk about that in a minute. Don't die. So before we go inside, these are the cues that I give my patients. It's breathe, stretch, and mobilize. I want you to take a deep breath all the way down. Fill up your lungs. Push your ribcage out to the side and breathe all the way down to my finger where it's sitting at 6 o'clock. I want you to pull up on your belly to stretch that uracus. And then have you stretch both hips to get to those deep rotators. And I'm going to ask you to do a bridge to bring your hips up towards the ceiling. Hold it there and then come back down because we're going to mobilize all of those extensors. Pelvic floor goes along and it relaxes. It has a tendency to relax when you come down. And then I want you to squeeze inside like you're holding back gas and pee and then just let it go. Though pelvic floor muscle dysfunction appears to be a primary driver of chronic vulvar pain, it is possible that the muscular dysfunction is secondary to abnormal tension in the surrounding abdominal and pelvic viscera, fascia, and muscle. Together, these abnormal physical findings make internal assessment, whether digital or with a speculum, painful, difficult at best, or oftentimes impossible. This video will introduce five simple patient activities that can be used prior to intervaginal examination. Those activities include deep lateral diaphragmatic breathing, self-stretching of the lower abdominal wall, bilateral stretching of the deep hip muscles, active bridging, and active pelvic floor muscle mobilization. Three women with chronic vulvar pain, Kathy, Holly, and Lisa, were assessed prior to and following instruction and completion of these activities. Zero to ten. If zero is no pain, ten is the worst pain ever. What does this feel like? Give me a number. Like a six or seven. Six or seven. And this is right at the bottom. This is right at the posterior crochet. I'm going to turn my finger to the left three o'clock and give me a number there. Ten. Ten. And over here on the right? Nine ten. Nine ten. So not very good today. Using a gentle digital palpation prior to those activities, each woman's vulvar pain was assessed at three, six, and nine o'clock at the introitus. My assessment digit remained at the posterior crochet throughout the completion of the activities, allowing me to reassess changes as they occur. Now, I want you to put your hands on either side of your rib cage for me. Low down. And I want you to put a little bit of pressure. And I want you to take a really deep breath for me. As you do that, I want you to push your rib cage out. Wonderful. I don't want your belly to go up. I don't want your chest to go up. When you get to the end, go ahead and breathe out. I want you to do this five or six times for me. And as you do that, your diaphragm goes down to pull the air in. And physiologically, as that happens, that transfers pressure down from the respiratory diaphragm all the way down to where my finger is. My finger's still where it was. I'm going to move it just a little bit. I'm still at that six o'clock spot. How does it feel now? Awesome. Can you give me a number? Seven. How about here on the left side? Eight. Eight. How about here on the right side? Seven. Yeah. Now, I want you to take your hands below your belly button. And I'm going to have you scoop in and pull up for me. And I want you to hold it there. There's a ligament on the backside of the abdominal wall that goes down behind the pubic bone and into the pelvis. And relax and let go. Now, I want you to do that again. And lift and pull. Clinically, what seems to happen is that bit of fascial pull releases tension all the way down through the bladders, through the urethra, and into the pelvic floor muscles. And relax. Let's go back to six o'clock. How does it feel there now? Give me a number. There's barely any pain. Barely any pain. How about here on the left? Two. And here on the right? Three. Okay. Now, I'm going to have you stretch your hip muscles. I want you to bring this right knee and take it up to your left shoulder, grapple with it, and give it a good stretch. There are five deep rotators that lie right adjacent to the pelvic floor muscles. I found clinically that a stretch of these muscles really help to relax pelvic floor muscle tension. So bring this knee up to the opposite shoulder and back down again. I'm at six o'clock again. Give me a number. Three. How about here on the left? Four. And here on the right? Three or four. Three or four. Okay. Now, I'm going to keep my finger here back at six o'clock again, and I want you to lift your hips up towards the ceiling. Go all the way up, and I want you to hold it for ten counts. This is an extensor activity, trunk extension, hip extension. All of those muscles tighten to hold. Oftentimes, the adductors will squeeze. Pelvic floor is such a follower. It goes along, and it holds tight, too. After ten seconds, you come down and relax all of those muscles. And now, give me a number at six. Two. And at three. One. And at nine. Two. Now, we're going to do pelvic mobilization. I just want you to pull your pelvic floor muscles in like you're holding back gas and pee. Squeeze and hold for five. One, two, three, four, five. And let go all the way down. And then five quick lifts. Two, three, four, five. And let go. Now, I'm ready. Six o'clock, how does it feel? No pain. How about here on the left side? None. And over here on the right side? None. Fantastic. And now give me a number at 6. 2. And at 3, 1. And at 9, 2. 6 o'clock, how does it feel here now? A 2. A 2. How about over here? 2. And over here? 2, 3. Do you feel like you have any more space down there? Yeah, it feels looser. It feels looser and more relaxed? Less burning? Yeah. Wonderful. When assessing women with chronic vulvar pain, please consider using these strategies to decrease tissue tension, reduce anxiety, and lessen the palpated vulvar pain prior to performing intervaginal examinations. Our internal assessment should not cause more pain. Rather, we should start by giving women hope that they are not crazy, that this pain is not all in their heads, and that there may possibly be some very simple things that they can do to begin to help themselves regain control of their bodies. Thank you for your attention. Okay, so I go through all of those activities, and what I find, 8 times out of 10, is that that palpated vulvar pain has decreased. So right away, on initial evaluation, I've given these women some hope that maybe there's something physical, more than one thing, physical things going on that could be contributing specifically to that pain. They're asked to do these exercises every night before they go to bed and in the morning when they wake up. If they have urgency-frequency, I suggest that they do the uracus pull. If they're sitting in a meeting, they've just gone to the bathroom, they continue to have urgency-frequency, I suggest that they pull up on that uracus. They can do it in meetings. They can do it in their car. They can do it wherever they want to go. It seems to just relax the urethra and the bladder and ease urgency just a little bit. I ask them to do the lateral and lower lateral diaphragmatic breathing throughout the course of the day. If they're sitting in work, if they're sitting at work and they feel like they have some discomfort, they can do the breathing. They can do the uracus pull. I also suggest that they contract and relax their pelvic floor during the course of the day because if their pain is worse, for whatever reason, they may have a boss who's yelling at them. They may have worn tight jeans pants that day. They may have had sex the day before, the night before. Check the pelvic floor and see what's going on. Since they've learned from the very beginning how to contract and relax their pelvic floor muscles, it becomes the greatest tool that they can use. Now, what's causing that pelvic floor muscle tension? I wish I knew and I wish I had my PhD and I wish I could do research because I'm going to suggest to you that just like Dr. Buttrick suggested, there are all sorts of things that can contribute to that. And we can't just address the pelvic floor and we can't just address the bladder. We can't just address the bowel. We have to take a look at everything all together. I'll suggest to you that from when I first evaluate them and I ask them to contract and relax their pelvic floor, till after they do this, that the pelvic floor range of motion has increased every single time. So, I then go on to my internal exam. I take my finger in. You saw this with Dr. Buttrick's slides as well. Taking, going up into the side to get to the obturator internist to see what's happening there. I then want to take a look at what's happening with all of the viscera. I'm going to turn my examining finger, my hand, up and I'm going to go right to the urethra. A normal urethra feels like a mound of tissue, kind of soft and mushy. A urethra that has tension and spasm feels like a pencil or a straw. And you palpate it and it feels round, those circumferential and longitudinal muscles are tight as can be. Oftentimes it can cause symptoms. It can cause pain. It can cause urgency. That's a positive finding. That's an abnormal urethra. When I go up to the bladder, it's the same. A normal bladder feels like a cotton ball. A bladder with tension feels like a racquetball roll, like a racquetball. It too, with a little bit of palpation, can cause urgency, frequency, or pain if that's tension that's going on there. I'm then going to take a look at the uterus to see what's happening there. I'm going to put my fingers on either side of the cervix to move the uterus to see and check what the uterine mobility is doing. I've found in so many cases that in treatment, mobilizing the uterus because it's at the peak of the arch, mobilizing the uterus and releasing tension at the trigone, at the bladder, typically the pelvic floor muscles drop. I'll then turn my hand over, my examining finger over, and I'll take a look at the rectum. Rectum have a tendency, if they're full, obviously they're really bumpy and gooky. But if there's tension there, there's also going to be that problem, and it oftentimes creates that urgency to defecate or feeling like they're going to pass gas. Personally, I think the pain at posterior frechette at 6 o'clock oftentimes, a lot of times, is from bowel tension because of the attachment right there pulling on those myofascial tissues at the vaginal opening, the posterior frechette. So my goal, my number one priority, is to give my patients tools that they can use to take care of themselves. I really like them in my office and all, but I really don't want them forever. They need to be able to take care of themselves. I can't tell you how many people have said, could you just come home with me? Well, I can't. And I can't give them my finger because that doesn't work either. So I really work to give them what they can do to help themselves. My goal isn't to go through all of this treatment. I am going to take a few minutes to go through what I do with vaginal dilators. You know, I hear all the time and I see all the time that, well, my patients use dilators and they use the first one, it's okay, they get to the second one and they leave it in, but it hurts so much, it hurts so much, they just quit. Right? Ever heard that story before? I'm going to suggest that you start with the smallest dilator. It's okay if it goes in and out okay and there's no pain. If they can contract and relax their pelvic floor muscles and there's no pain, move to the next one. If you move to the next side and as they put it in, it's like, oh, that hurts just a little bit. Okay? Squeeze and contract your pelvic floor. Oh, yeah, that hurts more. Now let go. How does it feel? Oh, that feels better. So I suggest that when they use the dilators, they use them at night because, as you see, I give all of my patients pelvic floor muscle exercises to do twice a day from their first visit along with all of these other self-releases. I'll have them use the dilators at night before they go to bed because I don't want them to be uncomfortable after they do it. I want them to be able to go right to sleep. Typically they aren't, but I just want them and I don't want them to have to do it in the morning. If they can use whichever step you are in the dilators, they can put it in, they can contract and relax around it without pain, they move on to the next dilator. And the reason that I do that is because we want it to be functional. Last I checked, I may be wrong, sex usually isn't with a penis that just goes in and sits there. It's really not very functional. If we can teach women that they can control their pelvic floor and that burning and tension at the opening by contracting and relaxing when something is there, it's a great tool for being able to allow less pain with penetration and eventually pain-free penetration. It works like a champ. You saw in the studies, we work and we work and we work and we work and we work and they still don't have sex like, gosh darn it, we think they should. It's really, really, really, really, really hard to have desire and what is desire. First and foremost, if you've got somebody with primary vestibulodynia, I'll suggest to you, they're going to have no desire because they have no idea what it feels like to be aroused. They've never had arousal. So what are you getting excited about? Until we really teach women what it feels like to have that sensual arousal, sensate focus is one of the things that you can use, it's really easy to get there. Until we can show them how good it can feel with sex, why are they going to want to do it? If they have a history of pain with sex and they come to your office and say, I just have no desire. Say, well, yeah. It's hard to get excited about putting a hot stick in your eye. That's totally normal. We have to get you past that. We have to figure out how to get that pain down, but we have to teach you to learn to accept what feels good because if you won't have something, you don't know what feels good, you can jump into bed and do it and have sex and grit your teeth and burn for three days, use ice, tear, but you're not going to have desire and arousal. So we can do that. Some people suggest that you use lidocaine before you have sex, which I just think is a travesty. Anyway, that's it for another lecture. Everyone who I see in my clinic would see in my clinic got pelvic floor muscle exercises to work up to five minutes twice a day, not to cause pain. I gave them exercises as indicated, but all of the five every time. So I just want to suggest, as you've seen in both Dr. Buttrick's lecture and here, there are all sorts of ways for women to come to you complaining of chronic vulvar pain. Don't be singularly focused. Take it out a little bit. Many or most with chronic vulvar pain can learn to manage their symptoms. I'm going to suggest to you that it's muscle, fascia, and viscera tension that can possibly contribute to what's going on with provoked vestibulodynia. Physical therapy and that multimodal treatment approach typically works pretty darn well. I would like to encourage everybody to take a look. Our next meeting with the ISSVD, our international group, meets every other year. We're going to be in Torino next year, northern Italy. It's a great group to belong to just for the trips. I said we were in Mendoza two years ago last year. So it's pretty darn cool. I'm actually the North American chapter president for the ISSVD. We're also doing a two-day educational course in Montreal for anybody who's interested on vulvodynia. We'll have a day on vulvodynia and a day on other lectures. There's my plug. Thanks so much for your attention. I really appreciate it. We're kind of tight for time, so we're going to get started. I'm Jan Baker. I am the chair of the APTA SIG group. That's the one that says A-P-P-T-H-A. And just so you know, that is a collection of nurse practitioners, physicians, physicians' assistants, physical therapists, and allied health, which would be all the other people that help you in your office. I wanted to let you know that we're having a meeting tomorrow at 5 to 6 in the room next door. Everyone is invited. Sometimes it's kind of hard to sort out where those meetings are in your book. And it is on page 7 in the program. This vulvar workshop is directed by one of our advanced practice nurses, Deb Ritchie. Deb is a family nurse practitioner and a gerontological nurse practitioner with 25 years of experience. She is currently practicing at the Center for Female Continence and Advanced Pelvic Surgery at the University of Missouri-Columbia, which is actually my alma mater. So I am really excited to introduce her. Come on up, Deb. We have quite an exciting day ahead of you all. We're really impressed by all of our speakers. So to move along, we're going to have four speakers. They're going to be back-to-back. They've got 50 minutes each. We're not going to have a break in between, so if you need to go to the restroom or go get a drink, feel free to leave. We're going to try, if they have time at the end of their lectures for questions, we'll hold the questions until then, or we have got 10 minutes at the very end. The first speaker is Dr. Naz Siddiqui, and she actually works at Duke University Medical Center. She got her medical degree from the University of Michigan, and she did her residency at Cleveland Clinic in Cleveland, Ohio, then Duke for her fellowship. She's been in practice at Duke for 11 years. She's one of a large group of urogynecology providers that includes seven faculty, two nurse practitioners, and three fellows. So please welcome Dr. Siddiqui. Okay. Welcome, everybody. Can you hear me? Okay. Excellent. Well, first of all, before I start, I want to give a little bit of thanks to Amy Kawasaki. She's one of my partners who actually did this talk last year. So I cannot take much credit for the slides because she literally handed me her presentation. I have to give kudos for her. She put a lot of work into this. So I am going to be going over vulvar pathology with you today. And I was tasked with just talking about diagnosis, so the process of diagnosing a lesion or something that you see on the vulva. The beauty is that I have the easy part of the presentations today because I just get to do some show and tell. You know, I'm going to talk about the terminology, some definitions, and things like that. And then, you know, the next speaker is going to come up and talk about the difficulty that we all face, which is the treatment. So in terms of vulvar pathology and diagnosis, you know, as a urogynecology provider, I do end up seeing a lot of these issues, partially because we have transitioned to be, in a way, the sort of post-menopausal provider of many, many women. Before I get into the talk, I do have to go through my disclosures. There are none relevant to the talk, but these are my funding sources. And in terms of the objectives for the next 40 minutes or so, this is what we're going to go through. We're going to talk a bit about the anatomy and physiology of the vulva, some concepts that maybe, you know, back at some time we've gone through but probably haven't refreshed our minds recently. Talk about some of the risk factors for vulvar conditions. Talk about the evaluation and diagnosis of common vulvar dermatoses. A few considerations for biopsy, and then also a small discussion about precancerous lesions. And before I move on, how many of you in the room, just give me a show of hands, are providers that are seeing and treating women with vulvar issues? How many of you would be in a position where you'd have to do a biopsy, for example? Okay, great, perfect. So this is right up your alley. So to begin, we are going to go through some of the anatomy of the vulva. I will just give you a little bit of forewarning. I think this whole morning you're going to see lots of pictures and videos of vulva, and some of them are quite disfigured vulvar anatomy. So the first few slides will just be kind of normal cartoons, but then we'll get into some pictures in a while. So in terms of the components of the vulva, we're going to go through everything on this slide in just a moment. We're going to start with the superficial anatomy of the vulva. And just as a refresher, I'm going to use the mouse here. Let's see, can you see it? Apparently the recording doesn't prefer a pointer. So I'm going to try to use the mouse. But, you know, raise your hands and kind of speak up if you can't see what I'm pointing to, and I will switch over. But, of course, we're going to just go through some basic anatomy here for a moment. When we talk about the vulva, we are including the mons, which is overlying the pubic bone area. This is stratified squamous epithelium. Ooh, there's a downside of using the pointers, that we get links. Or the mouse. Well, maybe I will use a pointer at some point in time. Thank you, Debbie. Or not Debbie, I'm sorry. Thank you, Deb. Okay. So when it comes to the mons, this is the area overlying the pubic bone. There is stratified squamous epithelium and hair-bearing skin and adipose tissue. So this is the area that we're talking about. In women, this is sort of the equivalent of what in men can also develop infectious processes, abscesses, especially in the hair-bearing sites. I say the equivalent in men because Fournier's gangrene is a condition that comes up in the urologic population. And so the equivalent in women would be having some sort of infectious process with necrotic tissue here. Hopefully, we won't get into that too much today. In terms of the labia, the next structure, labia majora, is coming down here. It's composed of adipose tissue, again, covered with stratified squamous epithelium. Laterally, there are hair-bearing units, the pile of sebaceous units. And medially, the labia majora are hair-less. Then moving further inward, we have the labia minora. The labia minora have no hair follicles but do have small yellow papules that occasionally you can see on exam. And the labia minora are variable in length, generally not very thick, about 5 millimeters. But they can be variable in size. So moving on to some more just terminology and definitions, the vestibule of the vagina is sort of the opening of the vagina. And there are some boundaries that we sort of keep in mind. And that's partially because this is where the skin transitions to slightly different characteristics. But the boundaries include the hymen laterally, so the hymenal tissue on both sides laterally, the clitoris superiorly, the posterior foreshadow inferiorly. And collectively, all of this is considered the heart line as sort of the boundary of the vestibule of the vagina. Within that area, within the vestibule, we also find a couple of glandular openings. We have the dartholins glands, or also sometimes termed the vestibular glands. And these are the posterolateral glands that are down in these areas. And there are ducts that open up generally around 5 and 7 o'clock on the vagina. So there can be instances of abscesses or masses in these areas. And then there are also the skeins glands. The skeins glands are homologous to the prostate in women. They are found posterolateral to the urethra. With the urethra being right there in the center. The skeins glands are often not easy to visualize, but in some women they really are. And there are some instances where you can see these small openings, and that would be the normal variant, the normal skeins duct opening. So moving on finally to the end of the superficial anatomy of the vulva, then as we all know, the clitoris. The clitoral hood and tip of the clitoris is here. The clitoral structure itself is actually quite large and goes much deeper, so we're only seeing literally the tip of the iceberg. But that's the clitoral structures, which are often involved in some of the dermatoses that we see of the vulva. And then also the external urethral orifice right here. And then some other relevant anatomy. We've already spoken about the hymen, the hymenal remnant that tends to be sometimes a jagged or smooth appearance in women. And the perineum is another structure that's relevant because you can also have vulvar dermatoses occurring along the perineal skin, but the perineum is the area between the posterior foreshort and the anus, and then obviously the anal opening is the opening of the rectum. So that's just the relevant superficial anatomy. When we get a little bit further, a little bit deeper into the tissue, I'm going to just briefly review the blood supply to the vulva. This is mainly relevant because the blood supply moving in and the lymphatic drainage moving out are sort of relevant for how vulvar malignancies may spread. Since we're not really going into depth about malignancies today, I just want to generally review the anatomy and make sure you're aware of where things are coming in and going out. The majority of the blood supply to the vulva is from the internal pudendal artery. That is really the main supply. And the internal pudendal is sort of wrapping around here. It comes with the pudendal neurovascular bundle through an area called Alcox canal and then literally comes up and fans out like fingers, and you can see lots of these blood vessels fanning out all across the vulva. Now there are some anastomoses or some other collateral blood vessels that come in, typically from the superior locations, and these are the external pudendal arteries, superficial and deep, that also bring blood supply towards the area. The dorsal and deep arteries of the clitoris are also very much involved in sexual function. The artery of the bulb, which is essentially this artery that kind of spreads out all along, all these little fingers going out, is also very involved in engorgement with sexual function. So all of these arteries are involved in bringing blood flow to the area and also involved in stimulating lubrication. And then finally, in terms of anatomy, the nerve supply, I should say finally, second to last, the nerve supply to the vulva is similar in that you see main branches of nerves coming out in certain locations and then just really fanning out all across, and you see a lot of anastomoses where we have different nerves coming across to meet in the vulvar area. So essentially, the main nerve function of the vulva comes from the pudendal nerve again. Similar to the artery, you have the pudendal nerve coming up through Alcock's canal and essentially coming up and fanning out and leaving lots of, kind of extending lots of branches all around. And you also have some additional nerve branches coming from the posterior cutaneous nerve of the thigh, similarly fanning lots of nerve branches around. Superiorly, there can be some branches coming down to the mons from the ilioinguinal nerve, as well as the genital branch of the genitofemoral nerve. So I think the main take-home here is that both for the arteries and nerves, we see just lots of anastomoses, lots of fanning out. So let's say, theoretically speaking, you had to do a biopsy or there was a laceration or something that happens in the vaginal vulvar area, you tend to get a lot of compensation from the nearby blood vessels and nerves. And it's pretty rare with most of those kinds of events, like a biopsy or an obstetric laceration, to have sensory disorders simply because of, you know, one nerve branch is involved. You tend to have a lot of other things that are around to help compensate. So final slide about anatomy. We're going to talk about the lymphatic drainage of the vulva. This is mainly relevant for cancerous lesions in terms of where things may spread. But essentially, the vulva drains first to the superficial inguinal nodes. So this is the vulva here. We see superficial inguinal nodes here depicted on these two sides. And these are palpable nodes that you can feel in the groin. So generally speaking, if you have a vulvar issue and you're a little bit worried about it, you know, the first place you might want to check are groin nodes to see if there's anything that feels like a pea or a lima bean or even larger in that area because that would be the first place that something that is a cancer would theoretically spread in terms of the drainage pattern. Thereafter, we have drainage that goes to the deep inguinal and femoral nodes. So essentially, it kind of goes deep to the tissue into the inguinal and femoral node bundle. And then from there, we have lymphatic drainage extending up to the external iliac nodes and the para-aortic nodes. When women undergo more radical surgeries for cancer, these are the different nodal packets that are removed in order to assess for spread. So I'm going to just segue now away from anatomy and talk a little bit about evaluating the vulva. When you have a woman who comes in who has a vulvar issue, you know, typically people will come in and talk about pain or itching or discomfort, and you'll have to do some evaluation of that. It is helpful to first of all characterize just the stage of life that the woman is in because depending on the stage of life, that may make certain disorders more or less relevant. Certainly understanding, you know, the menarchal status, whether a woman is menstruating, pregnant. Even if they're not pregnant, lactation is another time where we can have some changes in sort of the relative hormone abundance in the vulva where sometimes vulvar issues can come up. And then the postmenopausal life phase is a time where we typically will see a lot of vulvar disorders present. That's the majority of the time that I'm interfacing with these issues in my clinical practice. There are other medical historical details that may be relevant for you to capture. So thinking about whether or not a woman has diabetes. Other inflammatory medical conditions. And although this is rare, this can be quite relevant. I've had two instances now where I would see an unusual vulvar lesion. One was an ulcerated lesion. And then the woman is telling me about this magic mouthwash she has to use for ulcers in her mouth. And as I start to explore a little further and we get a negative herpes, you know, viral culture on this ulcer, all of a sudden we start to connect the dots and think, oh, are we thinking about Bichette's, which we'll talk about a little bit more, but another vulvar, you know, another related vulvar condition to what's happening in her mouth. So another instance where that can come up is oral lichen planus. So another vulvar issue that I'll show you some pictures of in a little bit. But a dermatosis of the vulva, which can also have some oral manifestations. And so in some instances when people are coming in with vulvar issues, the medical history can be helpful. I will say to be, you know, full disclosure, often this is a little bit of backtracking for me. You know, I see something in the vulva and then I'm going back and asking questions because I have some heightened suspicion. A medical history of psoriasis is also potentially relevant to vulvar disorders. Gynecologic dysplasia can be relevant. So people who have had HPV exposure at some point in their life, that can come up again in the vulva. And so that can be quite relevant later on. A history of sexually transmitted infections. And then other disorders that may cause secondary changes to the vulva. Urinary incontinence and chronic diarrhea. Sometimes the urine or stool soiling that is chronically in contact with sensitive skin can cause some secondary changes that are, you know, not necessarily originating in the vulva but are happening because of the irritant. So in terms of further history, when it comes to vulvar issues, you know, it certainly helps to understand what are women doing or what's touching the vulva. And many times this is not, these are not items that will typically just be, you know, women are not always very forthcoming until queried. And so asking about use of tampons, pads, deodorants, other agents, you know, many products are marketed directly to women in the drugstores to apply to the vulvar skin. And so some of those items can actually have contact irritants or allergens that may be relevant to ask about. Understanding if symptoms change with coitus, menses, certain clothing, activity, diet, or, you know, kind of doing your sort of thorough history and understanding what are the eliciting factors, things that aggravate the condition and what alleviates the condition may be helpful. Getting some history from the woman, especially if she's postmenopausal, about whether or not she has used estrogen of any sort, either orally or topically, and what the result was with that. Sometimes that history, you have to be a little bit careful about that because in my clinical experience there are women who will tell me, oh, yeah, I've used estrogen, but then when you ask the follow-up questions of how did you use it, how long did you use it, where were you applying it, that becomes much more relevant if it did or did not work. You know, in some instances people think that it's a cream and it should work immediately, and if it doesn't work after two applications, then I stop. So, you know, certainly if you're asking about estrogen, I have found that sometimes it helps to ask some follow-up questions about how long that was used. In terms of vulvar hygiene products, I've sort of mentioned this before, I think we all in this room probably know that some of the vulvar hygiene products can actually be irritants as well. Douches generally can affect what we would consider the vaginal microbiome, the sort of healthy carpet of bacteria that live in that area, and so can be related to certain vaginitis and vulvar issues. Hot tubs, spas, the temperature of the water, laundry products, underwear, fabric. In some instances, eliciting whether or not other family members or a spouse have similar symptoms could be relevant. This is probably more relevant for infectious disorders than many of the things I'm going to talk about in my slides today. And then recent antibiotic usage and whether or not any symptoms are associated with vaginal symptoms or discharge. So generally speaking, I think when we take a history, we do like to focus in on the main symptom. And when we're talking about vulvar disorders, vulvar dermatoses, often that main symptom will be something like pruritus, pain, or perhaps a mass or a nodule. And so those are the things that you may want to focus in about and obtain some more historical details. And then next you'll be doing an exam. And I think that when it comes to vulvar disorders, the exam is really telling and often in many instances helps to really clarify what's going on. You'll want to do a thorough inspection. You can consider magnification, a fluorescent lamp. I never use a fluorescent lamp, so yes, you can consider it. But full disclosure again, I have not used that. Culposcopy is not routinely used on the vulvar skin unless you're evaluating for dysplasia. So there are instances where you have a person with a history of dysplasia, cervical or vulvar, where you may want to use acetic acid or perform a culposcopic type of evaluation. Now generally speaking, we're talking about a thorough inspection. And having a heightened awareness of some of the things you're looking for. Sometimes when we do an exam, we just do it so quickly, it's kind of rote that you can kind of just quickly glance over. But when you're actually evaluating somebody with a vulvar complaint, taking a moment and doing that thorough inspection, really kind of cataloging what you're seeing can be very helpful. If you're going to use photography, I'll talk about this in a moment. Photography can be very helpful when you're tracking a vulvar lesion. You'll probably want to ensure that in this day and age, you have the woman's consent and make sure she understands why you're taking pictures and putting them in the chart. A speculum exam and a bimanual exam can also be helpful. So we're going to start to talk about some of the various vulvar lesions. And I'm just going to take a moment to talk about some of the terminology. And a lot of this is very relevant when you're communicating with a dermatologist or a dermatopathologist because we want to use the same language and ensure that we're all describing things in the way that we would all think of. So macules are flat lesions. Often when you look in dermatologic texts, they will talk about flat hypopigmented. So like whitish, if you think about atopic skin or eczema patches, those are often called macules as well. But here is a hyperpigmented flat lesion that is a macule. Papules, on the other hand, are well-defined and elevated. So this picture, and I'm not sure how well it's projecting, but you can see a whole series of these little dot-like elevations that are called papules. And occasionally, again, in the dermatologic world, people will talk about a maculopapular rash, which is essentially a rash that has features of macules and papules but in slightly distinct areas. A plaque is an elevated lesion that's elevated off the skin but still flat. So this here is a picture of a plaque. So psoriasis, we'll often talk about plaque-like lesions. A verruca is, we think about verruca as a wart, and that's probably true to think about it that way. A warty texture, elevated and horny textured appearance is a verruca. An ulcer is a depressed defect, often with some desquamation. So here you can see a trio of ulcers with that lack of the overlying skin. And a tumor is a growth within the skin or subcuticular tissue. Here you see a very large tumor depicted along that whole left side of the vulva. So these are some of the terms you may think about using when you're trying to describe a lesion in your notes, partially because if other providers are looking at your notation, that will help to use the same common language. Other things to comment on in your notes are the size. I will frequently measure things if I need to, but I had obstetrics as part of my training, so I still remember my finger gauge of what's one centimeter and three centimeters and things like that. But often when we're talking about vulvar lesions, we're talking about millimeters. It helps to also describe the color, whether it's hyper, hypopigmented, white, red, purple, black, dusky, necrotic. Those kinds of words can help to describe a lesion for other people. Whether there's tenderness associated with the lesion. In many instances there may not be, but if there is, that can help to point you down different differential diagnosis. The location, right, left. I just had to go over this with one of our residents to be careful that we're talking about the right and left side of the patient, not you. And so when you're talking about a lesion, it is the patient's right or the patient's left when you're documenting in the chart and biopsying a lesion. We just had to go through a whole correction process because we had a lesion that was sent in as left when it's really the patient's right. And that becomes relevant when you're trying to track something into the future. If you have a biopsy that comes back with an indeterminate diagnosis or something where a border, where you want to follow up on it later, you want to remember where that came from. Also, stating in terms of the location, whether something is on the labia minora, majora, the mons. Some people use the clock face and kind of talk about which location on a clock a lesion would be. That tends to be, I think, very helpful for other GYN providers because we tend to use that common language. Whether the surrounding tissue has any associated findings may be relevant. So if you see erythema, if there's a hair-bearing unit around the area where you think you're dealing with something that's really in the pile of sebaceous gland, like a folliculitis or an impacted hair follicle, those things may be relevant. And then the distribution of the lesion. We're going to talk a little bit about this figure of eight, which comes up with some of the lichens. But in terms of where you see changes, whether or not it's purely in one location or whether it's extending to other places on the vulva and whether there's involvement of the perianal region. Finally, in terms of description, photographic documentation can be really, really helpful. You know, this is one of the examples where a picture may be worth, you know, a thousand words. But I do think that if you're going to use photographic documentation, again, having a conversation with the patient about why you're using these photographs and then documenting the progress with therapy sometimes can be very, very helpful. And in some institutions, in some places, there is actually a consent form that patients will sign to make sure that they're on the same understanding of why you're taking pictures of their vulva. So, we're going to now move on to some of the diagnostic tests that you may perform. And I will say that I did a dermatology rotation once in medical school, so I have, because of that rotation, I've done a lot of these diagnostic tests. But you know, many times in my clinical practice, we don't necessarily always have every piece of instrumentation around for every single one of these tests. So, it's helpful for you to understand what's available, and then depending on, you know, how many women you're seeing with vulvar disorders, you may choose to obtain some additional materials in your clinical world. So, generally speaking, when it comes to diagnostic tests for vulvar issues, a biopsy is really one of the things that we rely on quite a bit. And we'll talk about some of the nuts and bolts of biopsy in just a moment, just to refresh for people. There are some other tests that can be helpful, especially when you're dealing with non-classic disorders. A Zank smear is something that has been done in the past. Nowadays, we have these, you know, great herpes PCR tests where you can take a swab and just, you know, put it against a lesion, and a few days later you get some information. But prior to the advent of PCR, a Zank smear was essentially taking a scraping of the base of a lesion and looking under a microscope at what looks like multi-nucleated giant cells. I have a picture of it later for you. But that's a simple, quick and dirty thing you can do in the office that doesn't necessarily require, you know, sending off a test. But a Zank smear is something you can do to assess an ulcerated lesion. Mineral oil is something that the lore, you know, will tell you that when you have critters, mites or lice in the vulvar area, mineral oil will impede the respiratory process. And so sometimes placing mineral oil on a hair-bearing unit can help. And then in some instances you can actually find, you know, do a scraping in oil and look at it under the microscope and find, for lack of a better word, critters. So essentially these are, you know, things like mites and lice that can inhabit the area. When I say mites, scabies is one of the things that is, you know, a relevant thing to consider. I have never diagnosed vulvar scabies, and hopefully I will not, you know, be in that situation, but scabies can be associated with really intense itching. And if you see sort of reddish areas, especially with a linear sort of appearance, it's kind of, the classic description is like track marks essentially, but like tracks or linear tracks because scabies would be burrowing under the skin, you can actually do a scraping of that and look under the microscope and see. And again, I have some pictures, oh, I don't know if I have pictures, but you can actually Google it and find some pretty disturbing pictures out there. But there's some really interesting pictures of scabies suspended in mineral oil. So mineral oil can be a useful thing when you're looking under a microscope to do a scraping and suspend it in oil. Potassium hydroxide is helpful for your dematophytes, so these are fungal issues, things like candida and tinea. When you place the potassium hydroxide on a slide, the cellular material gets lysed and you get to see what is in between, living in between the cells, and that's where you can often see candida that look like hyphae or tinea that looks like spaghetti meatballs where you have essentially spore-like circular elements and then the hyphae spreading around. A saline wet prep is often used for vaginal, you know, vaginitis, but there are instances where, you know, if you're thinking that candida might be spreading out to the vulvar area, may be relevant to do that. Saline wet prep is classically used for things like candida to look for clue cells if you're thinking about bacterial vaginosis and trichomonads. So again, those are things that are more classically involving the intravaginal space, but occasionally can have some sequelae more on the vulvar skin. And then finally, patch tests. So if you have somebody that you're suspecting has a contact dermatitis, if you were to send that patient to an allergist, they may do a patch test where they basically take a whole series of patches of different allergens and place it on the skin and mark it and then, you know, later you'll look and see if there are reactions on the skin to different allergens. And you can request patch testing for certain allergens. There are actually some allergens in very, very common vaginal products that are available over-the-counter that, you know, that often are offenders in terms of contact dermatitis. And so that's something you can do. Certainly you can just have women start to stop, basically stop using products, but if you really want to get some diagnosis out of it, this is something you could do. Okay. So now I'm going to move on a bit towards biopsy. By the raising of the hands earlier, I see that a lot of you are having to do this in your clinical practice, so I apologize if these slides are remedial, but I just wanted to go through the steps one more time because I know that there are a range of providers in the room and just review, you know, what we would do with a biopsy. But essentially, a biopsy is really valuable. The slide says especially valuable if hyperpigmented, and I think that's true, but even the hypopigmented lesions, if you want to convince yourself and the patient that you're dealing with what you think you're dealing with, then a biopsy can be very helpful. It's a pretty benign thing to do to take a biopsy. Sure it can be uncomfortable, but if you have a woman who's faced with having a long, you know, period of time of symptoms, this can be really helpful for diagnosis and treatment. Generally speaking, when it comes to a biopsy, you want to use clean conditions and sterile instrumentation. We're not dealing with a sterile area, but you want to keep things as clean as possible. I have very rarely seen infections in vulvar biopsies, you know, so we talk about that as a potential risk of a biopsy, but I think that area is not a clean and sterile area, and so it generally has a lot of properties that minimize from infection. So generally speaking, when we're talking about a biopsy, most people are using a keys punch biopsy, which the instruments come in a range of sizes, but generally the three to four millimeter size is the one that tends to be selected the most. And when we're talking about a biopsy, we want to first apply some antiseptic solution to the skin. You could use Hibiclens or Betadine. I tend to prefer Hibiclens because sometimes when you put Betadine on an area, it obscures the color and the demarcation of what you're looking for. And when I'm biopsying, many times if I see a well demarcated lesion, I'm going to try to biopsy right across that demarcation because I might want to get some normal skin plus some of the lesion. And if I'm painting a solution on there that obscures my view, that can be a downside. So I generally use Hibiclens just because it's clear and easy to see through. In terms of local anesthesia, some people use benzocaine spray. I tend to use an injection, 1% lidocaine injection using a 27 gauge or smaller needle. I tell patients this is going to feel like a bee sting, yes it's going to hurt, but thankfully after that you won't feel the rest. I feel that when I inject a lesion that gives me a lot of range of ability to take a biopsy for what I need and not have to worry as much about the discomfort to the patient. So obviously it's going to be uncomfortable at some point, but the numbing with lidocaine provides you some flexibility to really get a biopsy of what you need. If you explain it to a woman in that way, you know we're going to want to do this once and be done with it, then they usually understand quite well. And then also if you happen to have to place a stitch later or do something other than your typical hemostatic agent, then having injected with lidocaine can be very helpful. So I generally will inject with lidocaine. I've had unfortunately a biopsy of the inferior part of my foot. So having had that done personally, I appreciate having a nice wide bed of lidocaine. And so I tend to just inject that lidocaine in a nice wide area so I have some flexibility with what I can do. And then use the Keys Punch biopsy. So you'll usually insert it down into the skin and get some depth. It doesn't have to be hubbed per se, but you want to get some depth of the tissue so you're getting beyond just the superficial epidermis. And if you can see here, you would want to elevate the tissue. Usually I'll use a hemostat to grab the cone of tissue that you're excising and elevate it and then use a pair of scissors to cut down at the base. So that would be a punch biopsy. You can also do an excisional biopsy, and this can be relevant if you have a lesion where you want to really excise the whole lesion and have clean margins. And so that's where you would want to perhaps do an ellipse. We often do an ellipse because that's easier to close afterwards and really excise the whole lesion with a scalpel. In terms of closure of the wound, there are a range of options. I rarely have to suture in this area, especially with a Keys Punch, but if you're doing an elliptical excision, then often I will place a few stitches. If you're placing stitches, I tend to just use an absorbable Vicryl polygalactin suture. You could use chromic or plain gut. I will give you some caution, though, because some people actually do react to chromic in particular, that suture material. And so if you're dealing with somebody who has some sort of cell sensitivity on their vulva already that you're biopsying, you know, having that reaction to the suture material can be quite uncomfortable. So I tend to just use Vicryl. If there's tension on the area where you feel like the edges aren't coming together naturally, then you can consider putting in a permanent suture and having the patient return in seven to ten days for removal. Remember that often when we're doing a biopsy, the patient's in a lithotomy position where their legs are up and separated, and as soon as the legs come down, things tend to actually come back together a little bit more naturally, so just keep that in mind. In terms of the materials that are listed here, this is mainly more for your slide set, essentially, you know, needle driver, having a hemostat available, maybe helpful, scissors, and some sort of grasp or tissue forcep. Those are the things that are really the basics of what you would need for a biopsy. And in terms of hemostatic agents, these are the things that I would typically use for most of my biopsies. Using silver nitrate is quite effective. Moncell solution is another medical cautery agent that you can use in the clinic. So now we're going to go through a little tour of the types of lesions in my final ten minutes that I have, and I'm going to go through a series of pictures that just shows you what are the different things that you might, you know, come across. And we're going to sort of categorize them by the white lesions, the red lesions, ulcers, and then there are also small tumors and VIN, vaginal intrapithelial neoplasia. Moving on to the white lesions, which are the lichens, so lichens are found in nature as, you know, rough textured appearing growths on a smooth surface. And in the body, there are a couple of different ways that lichens can present. The top three, the most common is lichen simplex chronicus, and then there's lichen planus and lichen sclerosis. And although lichen simplex chronicus and lichen sclerosis come up quite frequently in clinical practice, I've now treated a number of patients with lichen planus as well, just being a urogynecology provider, so it does certainly come up. As I mentioned, lichen simplex chronicus is the most common of the lichens. Often clinically, these lesions will present with pruritus, in many instances preceded by a trigger. So this is almost like a chronic irritation, itch scratch situation, and some instances this has just come on out of the blue, but in some instances there can be a lesion at the center that's caused somebody to start itching, and then they get lichen simplex chronicus around, you know, something that's more relevant, perhaps in the middle. So it's important when you have an edge or an area where you see some lichen simplex chronicus to really look and see if there's something else, another type of lesion that's somewhere embedded in there. On exam, you may see some thickened skin, hyperpigmented areas, you could see some markings or excoriations from scratching, because typically patients do find, we find that there are these itch scratch cycles with this condition. And histologically, if you take a biopsy, you see hyper and parakeratosis, so this sort of thickening of the squamous epithelium on the top. Now lichen sclerosis is a common condition that we tend to treat a lot in the clinic. I'm not going to go into a lot of the treatment, because I know, I think that's for Dr. Buttrick to go over a little bit later, but this occurs in about 1 in 60 patients in GYN specialty practices, so generally we tend to come across it. It's bimodal in its prevalence, so it comes up in pre-pubertal girls, as well as post-menopausal women. And clinically, it often presents with pruritus, many times at night, though not always. And it can be progressive in severity, so can occur with pain, dyspareunia, you can have some dysuria or burning with urination in the absence of an infection, can also cause fissuring and scarring. However, one-third of the time it's asymptomatic. I see this all the time. I'm doing an exam and I see an area, especially anteriorly up towards the clitoral area that looks like lichen, but the patient has no symptoms of it, so that can certainly happen. In terms of lichen sclerosis, in some instances it's misdiagnosed as atrophy, but there are some, and part of that is because it can present in different ways, so sometimes it can look a little bit more reddish. Here this almost looks like some lichen simplex chronicus on top, on this labia majora, whereas over here you see some sort of reddish appearance on the inside. But then, you know, the classic appearance is this white appearing lesion that we talk about as cigarette or parchment paper lesions. So you can see, both in this picture and this picture, you see this sort of wrinkled or whitened, thin, almost shiny appearing texture to the skin. Lichen sclerosis tends to affect the skin in a keyhole, or it can affect the keyhole configuration, or a figure of eight is another place. So if you think about drawing a figure of eight on the vulva, those are the areas that lichen sclerosis tend to affect. So a lot up here and a fair amount over here as well. Generally speaking, the clitoris prepuse are very common areas for lichen sclerosis to affect. Periurethral area is, being a urogynecology provider, I will say a couple times a year I see somebody who's having urethral discomfort and I diagnose periurethral lichen sclerosis. I treat with clobetasol and they think I'm like their hero, so that's pretty awesome. But basically the clitoris, prepuse, periurethral area, the labia minora, the labia majora often are spared, not always, but often, and the perineal body. So again, the figure of eight area is what typically tends to get affected. With lichen sclerosis, as it advances, you can have resorption of the skin and of the folds and agglutination and you can start to see some of that here where you really are losing the architecture and the contour of the labia minora and they're sort of resorbing and becoming agglutinated with the surrounding skin. And there is a progression from early to late disease. So early on you start to see maybe some architectural asymmetry in the beginning where one labia might look different from the other. Over time you see some resorption and fusion. Here you can see fusion completely anteriorly from the clitoris down. And this is a very common way that lichen can present. And then later on you see sort of this keyhole formation and fissure appearance that can be a pretty drastic change. In terms of the histology, we see epidermal atrophy, loss of the reedy ridges, these sort of ridges that come down between the epidermis and the dermis. We see collagen homogenization, hyperkeratosis, basically a bunch of things that the pathologist will look for to give you that kind of diagnosis of lichen sclerosis. It's helpful to have a biopsy prior to treatment. And this is one of the dermatologic conditions that is associated with an increased risk of genital cancer. So lichen sclerosis, especially in the more advanced stages, has about a 3 to 5 percent chance of having a squamous cell cancer embedded within it. The relative risk of squamous cell malignancies is greater than 260 when you have lichen sclerosis. And looking at some existing data, 60 percent of all of our squamous cell carcinomas arise from tissue affected by lichen sclerosis. So that's something that you just want to be surveilling for and you want to look and see if you have a new lesion in your existing patient who's had lichen sclerosis, that may be a time to re-biopsy. Again, watch for new lesions, ulcers, or nodules. Follow-up regularly, I mean annually, is probably a reasonable time to follow-up unless you're having a flare of symptoms or having to adjust their therapy. Biopsy, re-biopsy if the patient's refractory. And because you have squamous cell carcinomas arising within an existing change in the vulva, sometimes it makes early detection difficult and the progression can be quite fast. So this is just something to just have a heightened awareness about when you're treating patients with lichen sclerosis. And I do tend to discuss with patients the risk of vulvar cancers and just having somebody eyeball, kind of look at the vulvar area once a year. So now I'm going to move on to the third lichen, lichen planus. So this tends to be more of an erosive condition of the mucosal surfaces, the five Ps, purple, polygonal, pepules, and plaques that are pruritic, so intensely itchy pruritic. And this is one of the vulvar conditions that can have extragenital disease, so can also present in the mouth as well as other areas of the skin. In the mouth there are some prototypical signs, they call them wicumstria, but basically whitish linear lines on the buccal mucosa. So if you have a patient that has sort of an erosive, irritated condition in the vulva or vagina, and then you look in their mouth and you see something like that, that can be a pretty helpful way of diagnosing lichen planus. Lichen planus has a band-like chronic inflammatory infiltrate of lymphocytes, and I don't know if you remember the pictures from the other slides, but you didn't tend to see all these black dots right underneath. And in some instances this can be a very difficult condition to deal with because of the erosion of different layers of skin, so you can also get superinfection because we lose our normal skin barrier. You know, our skin has a big barrier function in many places of the body, and certainly in the vulva, that skin, the barrier function is very helpful. So in some instances because of the itching you can also get superimposed lichen simplex chronicus, that first condition that I mentioned that's very common, so it can coexist due to the itch-scratch cycle and the pruritus that's involved with this. And again, I'm going to leave treatment for another talk, some of these can be challenging to treat. We're going to move on to other types of lesions, so we're now going to talk a little bit about the red lesions, so things that look a little bit different in appearance. One of the most common is contact dermatitis. So this is an inflammation of the skin that's often due to some irritant, something touching the skin. It can be a chemical irritant that's in a soap, a lotion, or something that the woman is applying to the vulva. It can be a chemical irritant in wet napkins. So many women nowadays are using these moist towelettes or wipes, and there are some allergens within those wipes that are well described in the dermatologic literature. Urine is another irritant to the skin, and so chronically having urine around the vulvar area can result in what looks like a contact dermatitis, as you can see here. Also physical, mechanical factors, having tight clothing, obesity, pads rubbing against the skin, you can have contact issues with that. In this picture here, when I first looked at it, there is some contact dermatitis here, but you see these dots all around that almost look to me like satellite lesions that would come up with yeast, so that's another thing that I think about when you have contact dermatitis. Again, as soon as you're having something that's evading the barrier function of the skin, you have an opportunity for yeast or other things to grow as well. So contact dermatitis, the damage occurring exceeds the skin's normal repair mechanism. You can see some sharply demarcated areas, papules, plaques, sometimes a weeping appearance, the classic quote diaper rash that can appear anywhere that the irritant contacts. So, you know, before I move on, I will say that there's a fair amount of what we deal with that probably is related to contact dermatitis, and especially when you see confluent lesions or lesions that appear to be kissing, things like that, that's when I have a heightened sense of awareness of contact issues. Moving on to psoriasis, comes up less frequently but can be relevant. This would be red plaques with scaling on the edges. Again, in a patient with a medical history of psoriasis, this can come up again in the vulva. You can have gray and white fissuring with cracks, especially in the intertrigonus areas and the groin folds, and typically this would also have extra genital symptoms. They tend to be chronic, relapsing, recurring, and so need to have periodic treatment. A lot of these vulvar disorders, you know, one of the things, one of the messages to women is that these are relapsing and recurring conditions that tend to need chronic treatment. The histology, you will see hyperplasia of the reedy ridges. These ridges get really pronounced and elongated. Then moving on to vulvovaginal atrophy, another very common condition in the postmenopausal population, but it can happen any time that the woman is hypoestrogenic. So postpartum, when women are lactating, is another time where they can have a relatively hypoestrogenic vulva and can have some atrophic-type symptoms. Menopause, however, is the most common time, and usually it's a few years after the onset of menopause, when you've had some time for the estrogen to not be there. We have a decrease in estrogen and progesterone, which results in less blood flow, thinning of the epithelium, less exfoliation of the skin, and there's fewer lactobacilli, that healthy carpet of bacteria, there's fewer of those around as well. And so when we look at vaginal atrophy, we actually see these physical changes in the skin. You see the elasticity decreases that is related to vaginal dryness as well, and you can see a shortening or constriction of the vaginal canal. When you look histologically, you can certainly see some changes. I will frequently in my clinic, when I'm doing a wet mount, if I happen to see parabasal cells, again this is something you can Google and see some nice pictures of what parabasal cells look like, but I think many of us have, if you've done any saline microscopy in the clinic, you'll see your healthy appearing squamous cells that are these large cells with dots, and then you can see these more circumscribed, circular parabasal cells. So that's a quick and easy way in the clinic, again, of sort of understanding if somebody with vaginitis, if their symptoms are due to atrophy. Again, that's getting more into the vagina as opposed to the vulva, but that's something I'll frequently do with our residents in clinic. So coming back out to the vulvar area, in terms of vulvovaginal atrophy, the vulva also tends to lose subcutaneous fat and can be thinner in appearance, and the entroitis can be more exposed. And essentially, you have the symptoms that we all know, lack of lubrication, superficial tearing, and dyspareunia. So I'm going to finally just quickly wrap up with a few other types of lesions, because I think my time is up. When it comes to ulcers, these come up much less frequently, but can occur. Herpes is the most typical ulcerated lesion that is an infectious etiology. Genital herpes, you know, is something that can be caused by either herpes 1 or 2 different viral strains. And so that's helpful to keep in mind, because if you're doing a blood test and just getting a certain viral strain, it's not always diagnostic for what you're seeing in the vulvar area. But this is a sexually transmitted infection where the primary infection presents with flu-like symptoms and painful vesicles, and then recurrent herpes can be asymptomatic but can present months or years later. Testing from the lesions can involve a viral culture or PCR, which is probably most frequently what is done in most centers these days. You can also do a direct fluorescence antibody. From the blood, you can look at the type-specific serology. And then again, as I mentioned before, the zinc smear, the sort of quick and dirty thing you can do in the office where you scrape a lesion and look for multi-nucleated giant cells under your microscope. These are some pictures of herpetic lesions, classically fluid-filled vesicles, but sometimes can be ulcerated or fissured when they're presenting to you, and these are painful. So when pain is a presenting symptom with ulcers, you have to think about herpes first. The Schatz disease I mentioned before is another non-infectious ulcer that can occur in the vulvar area and is associated with other systemic symptoms, joint pain, but also mucocutaneous lesions. And these are also painful, so ulcers tend to be painful. They can be persistent and deep, and the labia minora are the most common site. So finally, moving on to small tumors, condyloma, these are genital warts associated with human papilloma virus. Women get exposed to the virus with sexual exposure, but there can also be vertical transmission during childbirth. And in many instances, if there's a warty appearance, this can be asymptomatic but can have periods of time where they grow a little bit more, to be more pronounced. And whenever you're dealing with something that's associated with HPV, the other thing we have to think about is VIN, vulvar intrapithelial neoplasia, which is the precursor lesion to other vulvar cancers. And so VIN is the final thing I'm just going to wrap up with here. I have gotten sort of shocked and amazed by this in my clinical practice where I saw a woman that had patchy, whitish things that I thought might have been lichen sclerosis. I biopsied it and it came back VIN. So I think that this is another area where if you see whitish lesions, especially if they're more patchy and not as sort of confluent in the typical areas, that figure of eight that I mentioned before, this is an instance where you may want to biopsy. These are typically, VIN is related to a prior exposure to HPV, and there's no really routine screening other than looking for visual lesions, but these can present with pruritus, pain, burning, and then also a lesion or a bump. They can be multifocal and mimic other conditions, and this is where biopsy is really, really helpful. So there is some terminology that's out there in terms of how to classify and grade VIN, but it's important to understand and diagnose VIN if it's present because that is another condition that can certainly turn into a vulvar malignancy, and so you'd want to be, you know, you'd want to start treating that if you've diagnosed it. So just to conclude, there are a lot of conditions that can affect the vulva, and this is in your slide set, and this is a website that's out there, but really the message is sort of stay calm when you're looking at the vulva and start to just describe, you know, describe what you're seeing. You can take a biopsy, and that can help to start to allow you to figure out where down the diagnostic algorithm you should go, but you have, you know, we have inflammatory conditions, non-infectious conditions. There are also ulcers, erosions, but ultimately stay calm, carry on, and algorithms can really help in terms of diagnosis. So that's all I have for you in summary. I hope you have a general understanding of vulvar anatomy, how to take a comprehensive history to assist your diagnosis, examination and using photography and proper terminology is really, really helpful, how to biopsy, we've done a quick tour of some of the lesions that we'll see in the vulva, and that there are algorithms out there that can really help you to identify, type, and classify the lesions that you're seeing. And there are a whole bunch of references and other things you can look up in your packet. Thank you very much. Dr. Chip Buttrick, he's a urogynecologist in Kansas City. He's moderated the American College of Gynecology courses on chronic pelvic pain for over ten years. He's also the past president of the International Pelvic Pain Society and founder of that society, and he's also authored many books on pelvic pain disorders, especially interstitial cystitis and pelvic pain and dysfunction. Thank you. Well, we just had a wonderful review on what those lesions look like and the differential diagnosis, but from the show of hands I saw earlier, we're all in the trenches. I want to emphasize, 40 percent of my practice is pain, and I think that there are certain types of pain disorders I've got a pretty good handle on. I know about IC, I know about pelvic floor muscle pain, I know a lot about mesh-related pain, but I'll tell you, vulvodynia is the challenge, and that's my challenge today. I want you guys to pat yourself on the back because you're here to learn how to take care of some of the pain disorders that we see on a regular basis. I'm going to emphasize what vulvodynia is. I'm going to talk about the differential diagnosis and how to treat some of those other lesions we just heard about, and then we'll talk a lot about vulvodynia and its associated pain disorders. And that's really the key. There is a significant differential diagnosis that needs to occur when a patient presents to your office with complaints of pain and discomfort, like in sclerosis, chronic vaginal infectious problems. Again, vulvar pain disorders are seen in 7 to 8% of all women by the age of 40. And there are many different etiologies and triggers, and understanding what the trigger is to a patient's individual pain disorder is extremely important. Is it infectious? Does she have other pain disorders like IC, pelvic floor disorder? And in fact, our surgeries as urogynecologists, we can trigger these pain disorders that these patients have in the vulvar region. That's why we need to learn how to take care of those problems. You want to carefully evaluate the patient, go through that differential diagnosis. You want to identify each trigger and potentiator. A potentiator is something that keeps the problem present. For example, when I teach courses on IC, it's hard to relax the muscles if you constantly feel like you need to urinate because you're constantly holding urine. The pelvic floor muscles becomes a potentiator or something that allows that problem, IC, pelvic floor pain, to continue. And vulvodynia is certainly a good example of that. Vulvodynia is certainly a complex pain disorder, and it therefore requires multimodal therapy. You can't just treat the burning at the vaginal opening. You got to downregulate the pelvic floor. You got to turn off the central upregulation that's occurred within their spinal cord and their CNS. And sexual therapy is oftentimes required. And again, I emphasize, pat yourself on the back because you're here to help your patients. This is the first reference I want to make sure you have a copy of in your office. Again, the International Pelvic Pain Society, two other societies, put together a very nice consensus terminology. The whole concept of vulvar pain disorders can be confusing. The terminology keeps changing. Step number one, there are specific disorders that make people have pain. We heard about some in the last talk. Again, infectious problems, inflammatory problems, neoplastic, neurologic disorders, pudendal neuralgia, postherpetic neuralgia, and nerve compression disorders. I see a lot of those kind of disorders. Trauma, again, surgical, obstetrical, iatrogenic, again, we can cause problems with our radiation therapies and again with our surgeries. And hormone deficiencies, and the classic example I'm going to show in a few moments, some birth control pill problems that sometimes will trigger these pain disorders. Vulvodynia, then, is the term used for what's left over. I've ruled out these other potential causes of vulvar pain, but the patient still has pain. And the terminology might be that it's localized, just to the vestibule, just to the clitoris, for example. It can be provoked, meaning it's only there with light touch, with the use of a tampon, or with intercourse, or with your pelvic exam. Or it can be generalized, meaning it's there all the time. I'm sitting in the kitchen and I have burning. Onset can be primary. I've had it even as a little girl. I was treated at the age of four for repeated yeast infections and bladder infections. And I still have those problems now at the age of 25. Or it can be secondary. I never had these problems until I had the diagnosis of spinal stenosis, until I got interstitial cystitis. Now about two years after my IC problems, I have burning at the vaginal opening. And so it's important to get that history. What triggered it? What was the onset? When did it start? But down at the bottom, I just put in yellow probably the most important thing that really makes these patients difficult. That is, you can have two different problems. For example, if I have lichen sclerosis, I'm going to have a lot of itching and burning and irritation. But what's that going to make me do? It's going to make me tense up my muscles really tight. And when my muscles are tight, I might develop a neuroproliferative hypersensitivity. So now I've got two disorders. I've got lichen sclerosis as well as a neuropathic pain disorder that we would normally call vulvodynia. And that's why when we look at patients with vulvodynia, we see all these comorbidities. These patients have fibromyalgia. They have genetic predispositions and hormonal factors. And there's lots of evidence to point out a genetic component to these issues, neurologic upregulation, again, peripheral as well as central nerve injuries. There's psychosocial issues. Yeah, the patient that's anxious and burns all the time, yeah, of course her muscles are going to be tight. And then certain of our anatomic problems. If a patient feels like her pelvic organs are going to fall out, many patients will quickly learn to squeeze to hold those muscles up inside. And that will trigger their pelvic floor muscles to hurt and their vaginal opening to burn. This is not new information. Foster, again, one of our leading researchers in 2003, very nicely demonstrates his model that kind of explains this neuroinflammatory cascade of events. In an individual patient, for example, there might be an inflammatory or a painful insult to the vulva. It could be a laser treatment. Remember we used to do HPV treatment with this brushing with the CO2? What a mistake. Vaginal deliveries, yeah, we can get trauma. How many times do we see the postpartum patient that can't have sex? And of course chronic yeast infections. But the bottom line is all this inflammation at the introitus will cause a localized peripheral sensitization. We can do biopsies and we can see inflammatory cytokines. We can see changes within the vulvar tissue themselves, again, peripheral sensitization. And those nerves become upregulated. And again, when that occurs, there's this barrage of noxious stimuli that goes to the spinal cord. If you originally, and of course these numbers are totally arbitrary just to make a point, if you have a hundred nerves in the vulvar area and then we upregulate it because of chronic yeast infections for two years, because she's on tetracycline for acne, what's going to happen? Well, those nerves suddenly are 1,000 or 2,000 nerves. So the barrage of noxious stimuli upregulates the spinal cord. And that's called central sensitization. Some people are more prone to that than others. So while we see a patient with vulvar symptoms, and we call that vulvodynia, they also have this central sensitization. Several studies have shown through multiple tests that patients with vulvodynia have central sensitization. And the reason that's important is when the spinal cord upregulates, there's a process called antidromic neurogenic inflammation, which means these abnormal reflexes coming out of the spinal cord actually sends neurotransmitters in the opposite direction down a sensory nerve, goes to the vestibule and it releases these cytokinins and these other bad things that make the vulvar area get further upregulated and cause pain. The other thing that's bad is when a patient with vulvodynia upregulates their spinal cord, those same neuropathic changes within the dorsal horn causes other pain disorders. Patients will develop IC, they'll develop IBS, especially chronic constipation, and pelvic floor disorders where the muscles are too tight, and those are just more pain generators that keep the spinal cord upregulated, and there's more neurogenic inflammation. As I said, multiple studies demonstrate that patients with vulvodynia have this centralized pain disorder as a component, and these again are some references that point out the data. And again, if that is a term that you're not comfortable or not familiar with, again, just remember, anything that hurts for a long time, especially in a patient at risk, will develop this sensitization within the dorsal horn, this upregulation. And now, things that shouldn't hurt start hurting. The clothing, the blouse against the lower abdomen, a tampon in their vagina. In addition, the spinal cord causes these neuropathic responses that are abnormal. These again trigger the muscles to get tighter, the nerves to be hypersensitive. Now I feel like I need to urinate every 20 minutes, and sure enough I develop other pain generators, but they go back to the same segments within the spinal cord, S2, 3, and 4. So it's a self-perpetuating pain disorder. You've got to turn down the centralized pain disorder, and especially in the area of neurogenic-induced inflammatory changes like chronic vulvodynia. It's this antidromic stimulation that triggers many of these persistent pain disorders. You've got to turn off the nerves. This again is an article written by Goldstein. Goldstein is truly, I consider, a true expert in the area of vulvodynia. This is another article you need to make a copy of and put in your office. It very nicely demonstrates in a stepwise fashion the differential diagnosis. This article is filled with little clinical pearls, and I'm going to share with you some of those pearls as we go through this. I fully understand the print's too small, and that's again why I say get this article and put it in your office. But first, before we jump into vulvodynia, we want to rule out other causes of vulvar pain, so we're going to touch upon some of the things that we just heard about. We're going to evaluate for infectious etiologies, and in fact patients come to us and say, I've got this chronic yeast infection. Just a few pearls. Wet preps are wrong 50% of the time. Sorry. We don't do wet preps to understand what's in the vagina. Your wet prep again will be wrong half the time. DNA probes or cultures are the way to go. Remember yeast infections can sometimes be non-albacan species. We use diflucan all the time, and patients are developing resistances to that. Therefore, appropriate evaluation, at least in my practice when patients are having chronic repeated treatments, is let's know what we're dealing with. DNA probe or culture. Bacterial vaginosis. Here's the bad news about DNA probes is that yeah, you can pick up one or two little gardenella and they'll turn positive for nonspecific vaginitis or bacterial vaginosis. Remember that diagnosis requires a yellow discharge with an odor. If the patient doesn't have that symptom and all she has is gardenella in the vagina, remember 20% of women have gardenella in the vagina and it's totally asymptomatic, but it will show up on your testing. So it's a positive test plus it's the findings of your history. Desclamated inflammatory vaginitis, another unusual infectious process. Again, a yellow purulent discharge is typically seen. Your testing, however, will show a reduced or even total absence of lactobacillus, oftentimes an overgrowth of strep and staph. Again, make sure you evaluate these patients carefully. Oh gosh, a patient comes in and says, boy, the estrogen cream just doesn't work for my atrophy. I have pain with intercourse and the estrogen, in fact, when I apply it, makes me burn. Remember, primarine also has alcohol in it. That's why it makes you burn. So again, this patient, of course, has lichen sclerosis and lichen sclerosis is something that's actually increasing in prevalence in our population. It's something that occurs very commonly. The data I would share would be 1 in 30, especially in the older women. Again, patients that don't have to be postmenopausal. I have premenopausal women with this problem all the time. Extragenital lesions are certainly seen, oral as well as rectal. And again, it's oftentimes presenting with this repeated bladder infection that just won't go away. Again, you give a clean voided sample, the urine strikes against the skin. You might have a few germs in the urine, a few white cells, et cetera. It's not a bladder infection. It's external burning. And so again, I see these patients a lot that go undiagnosed except for with the burning they get, they think it's a bladder infection. As I said earlier, a lot of these patients have secondary hypertonic dysfunction and voiding dysfunction. Remember, if you can't void right, you do tend to get bladder infections. So you'll see these patients, again, with true culture positive UTIs as well as misdiagnosed UTIs where they have external. A little pearl is that the patients will say, oh no, I don't have itching or burning. And then you say, well, do you feel dry? Oh, I feel dry all the time. In general, dryness is an adjective that they're using simply to say I'm irritated down there. And yes, the lack of estrogen can cause a person to be irritated. But I would call dryness with intercourse a more typical symptom of lack of estrogen. If a patient is feeling dry just sitting in the living room, they're probably using dryness as a description of irritation. So be on the lookout for these lesions. Again, the lack of normal anatomy, the white fissuring, the agglutination, the parchment skin we've heard about. Again, it's real easy to treat these things, but the one little caveat, the pain with intercourse that occurs on the posterior foreshed is because, and you can get this historically, every time I have sex, I tear. I get a paper cut. I'm bleeding. And Mother Nature heals that. And the next time I have sex, I tear it again. It's a dotted line. And to develop a hypertrophic band of scar tissue, you have to fix that surgically in a sexually active woman with complaints. Two fingers in the vagina spread. Other hand is this where it hurts with intercourse. It's an easy diagnosis to make in the office. Sometimes the treatment of lichen sclerosis will soften that skin. It will start stretching. But if not, you in essence do a transverse incision, a rotational flap, bring the vagina down. You get rid of that band. Makes a big difference in the pain with intercourse. Careful exam to know if that's really the source. And then a little pearl, the loss of anatomy can also be seen in those patients that present your office on tamoxifen, aromatase inhibitors, etc. An aggressive anti-estrogen, again, environment will also cause resorption, but usually not as severe as you see with lichen sclerosis, such as in this particular diagram or image. So how do we treat lichen sclerosis? Well, we start off with aggressive therapy. I tell patients we want to turn off this disorder. And it usually takes six to eight weeks. We use a high-potency steroid, again, for decades. We've used clobetazole. I do it BID for four weeks and then just at night for four weeks. It's a real important concept and the patients just don't hear it. I give it to them in handouts. I write it on a piece of paper and I tell them you've got to come back. Because they think once my symptoms go away I can stop my cream. And you'll see them back a month or two later and it all comes back. I make a big deal, guaranteed it will come back if you stop your topical steroids. It's like high blood pressure, right? You treat the high blood pressure with pills. The blood pressure is great. You stop your pills. Your blood pressure gets bad again. We always worry about steroid dermatitis. It can happen, but it's actually relatively rare. In the more severe cases, I tell patients it's easy to remember. Do the clobetazole just on the weekend and do the hydrocortisone for maintenance the rest of the time. That's over the counter, 1% hydrocortisone. Always the big debate is do we treat the asymptomatic lichen sclerosis. But as we've already heard, there is a malignant degeneration process that can occur even in relatively asymptomatic patients. So I generally do treat symptoms, especially in asymptomatic patients without symptoms, obviously. And then finally, and that should be a PRP, platelet-rich plasma has been shown to be beneficial. You inject it in the subcutaneous tissues, probably better for localized areas. You do it one time per month for two separate treatments, originally reported just as a case report. And then more recently, 28 patients, 15 out of 28 with symptom resolution, again off-label use, of course. There's no label for that. And then fractional CO2, you have the Mona Lisa touch, for example. You make an application to the involved tissues one time per month. You do that three or four times. Again, word of warning, boy, these patients are hypersensitive and you laser their vagina. They'll be good for the first two or three days. And about day four or five, they light up and it hurts bad. And again, lots of topical lidocaine and other things to control that post-procedure flare in their pain as the tissues try to heal. Some very good reports, again, have been described. I emphasize we have no published data. Mickey Cram has led some of that research. Again, with conversations with him, he's very impressed with his therapy in that. But it's not published yet. We talked earlier about lichen planus. It's a much more severe form of lichen sclerosis. It's still that same autoimmune disease, except for much worse with ulcers, et cetera. More likely to have extra genital involvement. And these patients typically will get not only entroidal stenosis, but it's up in the vaginal vault. And so the vaginal vault will scar close. About three times a year, I take a patient to the operating room. We have to open up the vagina where it literally is agglutinating her entire vaginal canal and she loses any functional vagina. Most patients have a pretty good response, but of course, it tends to come back. I work with a couple dermatologists in the Kansas City area. Systemic therapy is actually very good. For example, methotrexate for those patients. I'm not comfortable using that drug. That's why I get my dermatology colleagues involved. Not all dermatologists understand about lichen sclerosis and lichen planus. Do your homework well. And then the lichen simplex, again, there's no loss of anatomy. But you have that same white kind of weird looking skin. Here's a little pearl, though. When you look at the patient, oftentimes it's unilateral or it is worse on one side than the other. A little trick is when I see this, I say, are you left-handed or right-handed? Because in fact, if they're right-handed, they tend to have more problems on the right side, because that's the side they're itching. These are the patients that describe, I use a dry washcloth and scratch myself. And of course, the more they scratch, the more they are bothered by this. Again, a topical steroid to decrease some of the inflammation I consider a good starting point. I like amitriptyline or doxepin, things to sedate them a little bit, because they tend to do it at night when they go to bed. So again, do things to try to decrease that itch, scratch reflex that is occurring. So now we've ruled out the pathology, but they still have that burning problem. So why do they burn? And again, as we said earlier, that would be the more typical vulvodynia. Evaluate the patient's history. When did this start? Why do you have this problem? What makes it worse? What makes it better? Again, are the pelvic muscles involved? And in fact, 90 percent of the time it is. Is the bladder involved in these symptoms? And 50 percent of the time it is. And does the patient have other centralized pain disorders? Remember I said comorbidities are very common. Fibromyalgia, IBS, endometriosis. I had a hysterectomy at the age of 25 because my endometriosis was so bad. And you get the PATH report and there was no endometriosis in her pelvis, right? So that's chronic pain. ACOG has very nicely written out some guidelines for us. Wear the cotton underwear and avoid douching, avoid irritants, you know, keep the area clean, use lubricants, very important. Rinse and pat the vulva after urinating, et cetera. Patients right now are using a lot of coconut oil. I do not like coconut oil. It tends to cause vaginal infections, especially if it's in the vagina. I prefer sesame seed oil that is preservative free and you can get that at Whole Foods or some of the health food store, groceries, et cetera. Keep the area dry and when you're really burning, if all else fails, yeah, ice is your friend. When people have burning at the vaginal opening, we want to get rid of the burn. So when you examine the patient, if there's a lot of erythema, remember neurogenic inflammation causing vasodilation, those patients will call, oh, I got the mirror out, I'm all red, I must have an infection. People are red for reasons other than infections. So a topical steroid I will use, BID, clobetazole or triamcinolone, you do that for a few weeks, see if you can turn that off. Usually it makes them feel a little bit better but it won't turn it off all the way. Lidocaine, very good, it numbs those nerves completely. But here's the pearl. The standard Lidocaine we get at the standard pharmacy has all these preservatives and when patients are really upregulated and their nerves are so hypersensitive, they've quadrupled in number in the vestibule, yeah, you don't want to use preservatives against the entroitis. You have to compound that Lidocaine. It tends to be much better tolerated. And how often do you use it? As long and as often as you need to because you want to get rid of the burning because what happens if you burn? You tense up your muscles. You don't want to tense up. I've been using ABG cream for 20 years. I was the guy that invented that stuff. It really does work 60 to 80 percent of the time. I use it in a pleuroderm base. That is the same base they use for transdermal hormones. It sucks the drug through the skin and into the subcutaneous tissues. Again, apply it BID to TID. And generally, again, we're trying to downregulate that neuroprolifitive disorder so you want to really use a lot of it for a long time. Again, they've come to you having burning usually for five years. So again, you need to downregulate them for several months. The local anesthetic combined with a steroid injection, I do that only for localized areas. You know, Buttrick, I've gotten better except for this one spot right here. You get at your Q-tip, you identify that spot, inject it. And do it two or three times if you need to. Intramuscular Botox is wonderful primarily in the muscles to get the muscles to relax. And when you relax those muscles, then a lot of the burning will go away. I emphasize it's usually not going to be paid for by the insurance companies. We don't do this very often. Jennifer Gunter did the original study back probably in about 1990 where she injected Botox in the subcutaneous tissues in vulvodynia patients. That did not work. You put it in the muscles, you'll get some benefit. But again, the data is very soft there and there are certainly no randomized controlled trials. But why are the muscles the problem? Why do we have to even treat the muscles? They have this burning problem on the outside. And again, 90% of patients with vulvodynia have this problem with tight muscles. There's three theories as to why those muscles are important and why they're so tight. Again, as I said before, if a person has burning at the vaginal opening, they're going to tense up their muscles. And if their muscles are really tight with intercourse, they won't be able to relax their muscles, especially if they've experienced pain in the past. They'll be apprehensive and so therefore they have increased friction. Maybe. Option two, if the vulvar area is quite inflamed and irritated, they get that central upregulation we talked about. As a reflex, the spinal cord makes the muscles hypertonic. The patient can't get them to relax. And also the central sensitization causes more neurogenic inflammation. And then pelvic floor hypertonic disorders and the muscles are hurting, that's the first symptom. And then they later on develop that centralized pain disorder with the neurogenic inflammation. Again, we see that a lot in our IC patients. My bladder's inflamed, I feel like I need to urinate all the time, I tighten my muscles. My muscles are now tight and a year or two later I start having burning at the vaginal opening all the time. That just makes me tighten my muscles more. See how it's all linked. Get a good history, figure out where it's coming from, what came first, the burning, the muscle problem, the bladder problem. This slide just depicts it. There's lots of different things that can make your muscles tight and uncomfortable. And it might start off in that four year old who never learned how to relax their muscles. I think we all know if a four year old has repeated bladder infections, they're ten times more likely to have IC. They're ten times more likely to have a chronic pain disorder the rest of their life. Pick up for those childhood problems of chronic constipation. That's again, one third of chronic constipation is caused by hypertonic muscle dysfunction. So if your muscles are tight and you can't pass stool at the age of four and no one teaches you how to relax your muscles, your muscles are still too tight. Again, an insult to the pelvic floor. I delivered a baby, I had forceps. Yeah, a lot of patients will develop prolapse and incontinence with those forceps, but a lot of patients end up with chronic pain disorders. Anything that hurts in the pelvis makes you tense up, especially inflammatory disorders. For example, Crohn's disease, chronic diarrhea, I rusted the toilet, I got to hold in my muscles in order to get to the toilet so I don't stain my clothing. Yeah, your muscles will be tight. Pain with intercourse, I'm apprehensive, my bladder feels like I need to go to the bathroom all the time. There's lots of things. What are the symptoms of muscle dysfunction? It's an achy pelvic pressure. It's discomfort. As a urogyne, and again, I'm sure you're aware of the Adams data that shows that 20% of patients that come to a urogyne practice are found to have pelvic floor tension myalgia. Again, 20%. If your muscles are tight and you can't pass stool and you can't pass urine, what are you going to do? Push. So what do you do if you push all the time? Develop prolapse. Urinary hesitancy, voiding dysfunction. Again, common symptoms of muscles that are too tight. I have intercourse and I have trouble urinating after I have sex. That's a classic muscle symptom. Often worse with prolonged sitting. Often worse with standing for a long time. Dyspareunia, but the real pearl here is I hurt not only with sex, but I hurt after sex. It goes on for hours. That's a classic muscle symptom. Okay, so when we examine patients, what do we want to do? Well, we want to look at their muscles. Ask the patient to squeeze and relax their muscles and see if they have the normal lift of the perineum or do they see what's called an S2 or a bulbocaprinosis wink, where the posterior foreshad lifts straight up, not towards the head, but towards the urethra. Again, that's abnormal. There's no movement at all because the muscles are so tight they can't contract at all, or they can relax momentarily and then it tightens back up afterwards. Single digit exams, not both fingers. Palpation of the muscles. Find the tender spot. Oh, I have ovarian cysts all the time. Yeah, feel the obturator muscles. That's usually the source of what patients call ovarian pain. It's really coming from the obturators because it hurts right here in the groin. That's again why our trans-obturator mesh procedures make people have groin discomfort. Again, use your finger and it's very easy to identify that. And again, levator muscles, white line, obturator muscles. You can do a very careful muscle examination and isolate areas of pain that the patient oftentimes has had for years. So for example, the patient that presents with symptoms that you think are vulvodynia and you examine them and their introitus is extremely hypersensitive, especially the six o'clock position. That's a pearl. Six o'clock position. That almost always is going to be associated with hypertonic muscle dysfunction. If it's above the urethra and below the anterior foreshad, that's usually bladder pain. That's where the bladder pain patients will be severely allodentic. They usually have poor pelvic floor muscle awareness, like I just said, and they can't relax it. This is a classic example of an elevated baseline at rest. We have a patient squeeze and they sometimes demonstrate a squeeze. We say relax. See how it comes down and then it goes back up? Again, I'll say squeeze and I'll just look at the perineum and you can watch it tighten back up. And again, that's that rebound hypertonic dysfunction. Again, the resting tone should be low. When people do their teagles, it's squeeze and relax. And again, on surface EMG, you can see that. We see it on urodynamics. There's multiple articles that demonstrate that when people have urethral pressures that are elevated, this is an old slide I used 20 years ago, but the scale here is 0 to 20 and that's a urethral pressure profile. Anything that's kind of age-related, but anything above 120 to 130 is abnormal. This patient's up around 200. The pelvic floor, again, is producing that elevated urethral pressure. You can do a bilateral pudendal block and you'll see the urethral pressures drop to normal because that all comes from the pelvic floor. That's not the sphincter mechanism that's doing that. That's the pelvic floor that does that. So how do we treat the muscles when they're hypertonic? We don't tell them to do teagles. We tell them to do reverse teagles. And you can do biofeedback and teach patients to do it at home and learn how to relax their muscles. And again, usually a manual therapy approach is extremely important to elongate the muscle fibers. I know we're going to be talking about that in just a few minutes, but again, I don't want to steal the thunder. But yeah, a feel massage was done back in 37. I used to do it in my office in the 80s. Again, it works great to get the muscles to relax. You've got to get in there and stretch those muscles out. Heat, relaxation therapy, protective cushions, you know, these are all things. If I sit a long time, it makes me hurt. We'll give the patient a special pad that they can sit on. But you've got to cut out the pad in order to give room. I tell patients, sit on the coffee table and figure out where your tuberosities are. And that's how wide the hole needs to be. And then you take that everywhere you go. Yeah, Botox works quite nicely. Lots of different articles written. I usually start with 100 units. I tend to do it in the area of greatest tenderness. I like to do local anesthetic first to make sure I can get rid of the muscle pain with just Lidocaine. That's a trigger point injection. Your insurance company pays for it. If the patient said, boy, I felt better, like it was totally gone for six hours and it felt better for two or three days, that's a good response. Now let's put Botox in the exact same spot and you'll about 80% of the time get the response that will last about four to six months. Again, duration, again, Botox is not forever so it has to be repeated. And again, usually insurance companies will not pay for that. Neuromodulation has been described, S3 nerve roots, again probably a 50% response rate. Pudendal nerve stimulation, as Ken Peters has done it, also shows a very nice success rate for myofascial pain involving the pelvic floor. I'm going to talk more about neuromodulation in a moment. I emphasize the patients, you know. Physical therapists around the Midwest send me their patients when the physical therapy alone hasn't worked because I think adding drugs to the physical therapy is an important part that most patients require. So what are the drugs? Well, the drug we've used for IC for years because remember 80 to 90% of patients with IC have muscle hypertonus is amitriptyline or Elevil. It decreases the urge to urinate and also relaxes muscles. Tizanidine or Xanaflex has been a favorite of mine for years. We all talk about Valium suppositories. Emphasize, a lot of patients use five milligram suppositories. Those don't work very well in my opinion. Ten milligrams are those that works. You do absorb some of that. I don't like using Benzos. Again for 20 years I've been doing Baclofen suppositories. The pediatricians have data concerning children with voiding dysfunction. Remember we were talking a moment ago, pediatric elimination disorders involves the stool. It also involves the bladder. And in fact Baclofen works very nicely in children to help them void better. So why not use it in women and again I use a suppository. This of course is compounded. About two years ago I shifted from the Baclofen 30 milligram suppository to combining that with Ketamine 15 milligrams. That has been magic. Patients that found the Baclofen to be beneficial but didn't knock it out totally, you add 15 milligrams of Ketamine to that and patients being in their own control says, oh I like these new suppositories better. I like that especially in patients that are describing burning. A lot of these patients will have burning at the introitus but they'll say I also have burning in my vagina. Again Baclofen plus Ketamine. The Ketamine that causes IC, remember that's abuse, that's a higher dose, that's oral or IV. Neurolytics again for the burning symptoms especially. Gabapentin or Neurontin, Pregabalin as well or Lyrica. I think the biggest problem with these drugs is it causes a lot of side effects and patients don't tolerate it. I do think it's an important part and I'm going to show you some data and we're going to start off with data just in 2018. This is a randomized double blind placebo controlled crossover trial. What a wonderful study. 66 patients and it showed it didn't work. But they had the primary outcome I think wrong in this study and in that they tested patients with tampons. Many of them had such bad vulvodynia. They'd had it for over five years. They couldn't have sex so they just were asked to try to use tampon and see if you could get it in and out without pain. So a lot of patients failed that outcome measure. The authors themselves, and again one of those is that expert I talked about, Dr. Foster, he actually commented that it probably needs, these drugs probably need to be part of a multimodal therapeutic approach. And this study was monotherapy where the only thing you did was to give them that drug. And in fact this is another article which is a retrospective observational study where they had 241 patients went through a chart review and they just captured the patients that had been given amitriptyline, gabapentin, or Lyrica pregabalin. 60% had long lasting pain relief. 10% had short term relief and then escaped from therapy. And again you got to push the drugs high enough to where you get some side effects. And so 30% of the patients didn't tolerate it. So again I emphasize as Dr. Foster's article in his discussion would describe, as part of a multimodal therapy in patients with this upregulated centralized pain disorder we've talked about, this probably plays a role. As monotherapy it probably doesn't work. Because remember you can't relax your muscles if you have burning at the opening. You can't relax your muscles if you feel like you need to urinate every 20 minutes. And you can't relax your muscles if you feel like your pelvic organs are falling out. So what happens when the muscles are really tight? Yeah, in Alcox canal we tend to pinch the pudental nerve. That's why a lot of these patients will show up in my office and say, I've got pudental neuralgia. But in practicality these patients actually have a pelvic floor disorder that then secondarily gives them pudental nerve pain. And that's why in the trenches what do we all do with patients that think they have pudental nerve pain? We treat the muscle component first. And most of the time we'll have a pretty good response, but not always. Now we're going to come back to vulvodynia. So certainly there are patients that despite everything that I've just outlined for you, they still have persistent pain. And in those patients that have localized, provoked, not general, it burns all the time. It's just when I have sex, just when someone examines me, just when I use tampons. We need to relax the muscles and you're still having problems. Then a vestibulectomy would be the right thing to do in my opinion. Again, I probably see a hundred new patients a year with vulvodynia. I probably do one of these procedures per year. If I'm going to operate on someone with pain though, I'm certainly going to do a lot of perioperative techniques to make sure my surgery doesn't worsen their problem. And when you do a literature review on vulvodynia and vestibulectomies, you will upregulate and make some patients worse with your surgery. For pre-gablin in the holding area, ketamine IV, both intraoperative is when I usually do it. I put epidurals in these patients and continue the epidurals overnight to keep them from tightening up their muscles in the recovery room and going home with muscle pain. And postoperative pain control is real important. Lots of tricks, local anesthetics, ice, etc. And again, visual analog scales from baseline will drop very nicely at two months. And again, you maintain that multimodal approach and the visual analog scale will drop all the way down to 2.48. Does it go to zero? No, it doesn't go to zero. But it certainly makes patients a lot better. And certainly long term, if you don't maintain those multimodal therapies, a lot of people will start flaring up again. The spinal cord is upregulated, the muscles have a muscle memory and they'll tend to tense up more later on. And that's why when you look at long term follow-ups, and this was a randomized study done in 2012, patients randomized to surgery versus continued multimodal therapy, in the long run, the visual analog scales were about the same. And again, a vestibulectomy is a very easy procedure to do. Again, epidural anesthesia, I provide then marcaine with epinephrine, I undermine those tissues, I make an incision after I've pain mapped them very carefully in the office and have drawn diagrams. But basically, it's a horseshoe resection of the tissues. Make sure you remove all the areas that hurt. And then you undermine the vagina, sort of like a posterior repair, so that you can then advance that posterior vagina out onto the vestibule. And then again, like I say, lots of tender loving care to make them better and you'll have a pretty good outcome. But it's got to be the right patient. Don't do it when their muscles are still hypertonic, don't do it if they have generalized or that continuous burning unrelated to per vote. Now I saw a couple people nod their head, but this is one of the pearls that's important. The patient that calls you and said, every cream you've given me makes me burn. Well, the first question is why? And the answer is because they're upregulated, their nerves are hypersensitive both at the periphery and centrally, okay? So they're telling you, I have allodynia, right? So everything you put on them hurts. But you've got to get the therapeutic creams there. So what do you do? Well, you put ice first, 20 minutes of ice, and then you apply whatever topical, ABG, lidocaine, etc., whatever you want to do. As I said before, the compounded lidocaine works better than the standard lidocaine. And you can put on the lidocaine first, and then put on what you consider a therapeutic. Pramazone is a trick that was taught to me by a dermatologist. It's 2.5 percent hydrocortisone, but it also has pramoxine. Pramoxine is a very unique narcotic that has anesthetic qualities. It tends to be less irritating than your standard steroid cream. It's also more expensive. I'll fall to that only if I need to. And then you can do a compounded topical called, well, GKL. We love our initials. Gabapentin, ketamine, and lidocaine. But this is unique, and again, I have no financial arrangement with them. Innovation Compounding is a compounding facility that works out of Georgia. And it actually has, as a consultant, Dr. Goldstein, who I consider an expert. This is his recipe. And the company, Innovative Compounding, has a special vaginal foam application that really tends to be much more soothing than any of the other applications or bases or creams that I can get from my local compounding pharmacies. So, again, something to think about. Innovationcompounding.com. Go to their website. You'll see it. Again, no financial arrangement there. Okay, case number two. I'm going to look at a couple of cases and then we're done. 25-year-old white female. And she's had pain with intercourse ever since she first became sexually active. And she says that tampons are always uncomfortable. Even when she was 12 and 14 years old, she could never tolerate them. In fact, she says that now when she has intercourse, she has burning that goes on for 18 to 24 hours after sex. She describes it as a course, as they oftentimes do. I have a yeast infection that won't respond to monastad every time I have sex. And then she goes on to say, and I've used birth control pills because I have had really bad dysmenorrhea since I was a teenager. And in fact, for three years prior to that, I used Depo-Madroxipogesterone just to turn off my periods. And when you examine the patient, you see what appears to be a relatively normal introitus. She's not really lost her labia minora. She has erythema along the perimeter here. She's sure enough has had some fissuring go on, so she's got that transverse band we've talked about. And she does say, oh yeah, I get paper cuts sometimes within her course. So, of course, the patient, because she had childhood problems, yeah, tampons hurt. There's only one thing that makes tampons hurt, and that's tight muscles, right? So again, she gave you that history. You know her muscles have been tight for years. And in fact, she has a history of dysmenorrhea. What do you do when you're 14 years old and you have really intense menstrual cramps? I miss school. I lay on the ground and cramp. I tighten up in a ball. That's her muscles tightening. She's been doing it since she was a little girl. And so her muscles are hypertonic, and she's never learned how to relax them all the way. And then the second insult was that she actually suppressed all of her hormones. Not only estrogen, not only did she get the progesterone, kind of the anti-estrogen from the Depo-Provera she used, but then she used birth control pills for several years as well. So how are we going to treat this patient? Well, we want to teach her about what's causing her problems. It's not in her head. Remember, her chief complaint is pain with intercourse. And so we're going to get her into physical therapy. We're going to get her muscles to relax. I'm going to use a little amitriptyline to try to help her relax her muscles. Baclofen suppository, remember I taught you about that? Have her put that in her vagina an hour before she has sex. She'll be able to relax her muscles much better. She'll be more successful with intercourse, and then she'll be less apprehensive every time. You can use the Valium if you want to. But you have to stop the hormone suppression that's going on. And in fact, not only do you need to stop her birth control pills, but you probably need to supplement with estrogen and testosterone. Usually about three months will do the trick, and you'll regain those receptors. A big pearl here, and it's been written about in two different authors, and that is low-dose birth control pills, and in particular, those with the third-generation progestins, the classic example being Yaz. Not only does it cause the lowering of the estrogen, but it also lowers the androgenic environment. It turns off your estrogen receptors. And remember, it's good for the acne. It's bad for the vagina. So those pills, especially with the history of Depo-Provera prior to that, is this patient's real trigger, and that's what made her pain start going on for 18 to 24 hours after intercourse. Again, the big red flags would be the hypoplastic entroitis, punctate areas of erythema, sometimes submucosal hemorrhage. Again, the big red flag is, I started birth control pills or suppression, very low-dose pills before the age of 16. That tends to really increase your risk of that problem at all. The third-generation cephalosporins again, or third-generation progestins are the really bad ones. And you can actually do it in laboratory animals and see that the tissues become hyper-innervated in the face of this synthetic progesterone environment. And again, not only get rid of the suppressive agents, but also supplement with estrogen. It's real quick, about three months and it all goes away. It goes from this red, irritated vaginal opening to a nice, healthy, pink-looking vaginal opening very rapidly. Case number three, a 45-year-old with burning at the vaginal opening. The burning's present all the time. I'm just sitting in the living room and I'm burning. But it's especially bad during and after intercourse for the last two years. And her review of systems is otherwise totally negative. She doesn't have any problems at all. But then she says, yeah, but I do get bladder infections, but I've been that way for years. I get three or five per year. You start talking to her more about bladder infections, about half the time the cultures are negative or they don't respond to antibiotics and I need a second course of antibiotics. But no other problems with her bladder. Everyone that comes to my office does a bladder diary. So what does her bladder diary show? Well, she doesn't have urinary frequency. She only voids six times a day. But that's because she's only drinking 28 ounces. She's figured out that if she drinks a normal amount of fluid, she has to go to the bathroom all the time. But when you look at the diary, she's voiding two to four ounces. That's her functional volume while she's awake. Look what happens when she falls asleep. Her muscles relax and suddenly she can hold ten ounces. Boy, is that classic for pelvic floor dysfunction? Look at the diary. It tells you if the muscle or the bladder is what's screaming at you. And again, in her case, it's obviously the muscles. So let's examine the vestibule. Lots of aledinia. And the aledinia is present in the supramietal area as well as the posterior foreshad. Remember, we talked about that. That sounds like muscles. That sounds like bladder. And sure enough, her muscles are hypertonic. She has trouble relaxing them. You touch the pubococcygeus muscles. That's where she has pain with intercourse. And the bladder base is mildly tender. So in this third case, I'm trying to figure out, well, is it primarily a muscle problem or primarily a bladder problem that's keeping her so irritated? So how can I figure that out? Well, we can do a bladder rescue challenge. That's where we put a local anesthetic in the bladder and we take the bladder out of the picture. And so if you put a local anesthetic in the bladder in some patients, that would be option number one. The burning totally resolves for two hours. The patient's main irritation is gone. And that tells you that the bladder is causing this referral pattern pain. Again, emphasize, 50% of patients with IC also have vulvodynia. And so if they feel a lot better after the cocktail, that means one of your targets has to be the bladder in a multimodal approach. Option two is, oh, I did the bladder cocktail and the burning didn't get any better at the vaginal opening. Remember, she has it all the time. It didn't help, but boy, the catheter was horrible. And you're never doing that again. Patients that have pain after an analgesic cocktail, right, you just put local anesthetic in their bladder. Their bladder is numb. So why would they hurt? Of course, we call that urethral syndrome. The urethra is allodentic. Why is the urethra uncomfortable? Shlomo Ross described it back in the 70s. Skeletal muscle spasticity around the urethra is the cause of that problem of urethral allodentia or what used to be called urethral syndrome. And therefore, when the patient says the catheter made me worse and the local anesthetic didn't help my burning, her pelvic floor muscles are obviously the main problem. So we've got to treat the muscles as one of our therapeutic targets. So we can turn off those nerves and muscles sometimes with neuromodulation. This is an article that nicely summarizes, I believe it's a meta-analysis of the use of sacral neuromodulation or interstem for the treatment of that. Some patients have gone through dorsal column stimulation, although the results there are relatively poor. This is exciting in the area of pelvic pain, however, and that is they've developed in the last six months to a year a technique called dorsal root ganglion stimulation for pain disorders. And this Dr. Hunter actually presented just literally a few days ago the bilateral stimulation at both S1 and lumbar 1, L1, and had marked improvement in patients with vulvodynia and other chronic pain disorders. This is a new technology of they developed a special little implant, a lead, that has a slight curve to it and you can drop it right over the top of the dorsal root itself. Again, I won't do that, but there are pain interventionalists that will do that. And again, I've got one in my area in Kansas City who is just starting to do this and I've already sent him three patients. We'll see what the end result is. Be on the lookout. Google that every six months or so and see if we see some more data concerning the benefit. Hunter, as I said, was the only one that's reported this technique in the area of pelvic pain, but it's used for many other sources of chronic pain. But here's a real-world article written by a friend of mine, Georgine Lambeau, and what this is is a very nice vulvodynia registry where experts in the area of vulvodynia did all the things that I just taught you about. They used topical therapies and a lot of compounded stuff and they did physical therapy and they did oral medicines, Elevil and Gabapentin, and most patients had more than one intervention, multimodal therapy. So what was the outcome in this registry at six months follow-up? Improved general pain, sexual pain, anxiety, and quality of life. The bad news, the FSFI still showed poor sexual function. And that's the final thing is if you've had pain with intercourse for most of your life or certainly the last five to ten years, there are other things we need to do to get the couple, man and woman, back to being able to have a normal intimacy. We must treat the pain disorder first and then complement your therapy for the pain disorder with the skills of a sex therapist. And again, hopefully you can find one in your community. I know some will work over the phone long distance if you don't have that. So the bottom line is, gosh, vulvodynias and vulvar pain disorder is a tough group. But again, pat yourself on the back because now you have some tools hopefully that will help you. Seven to eight percent of patients have vulvodynia and they're coming to your office on a regular basis because they're coming to your office because they also have prolapse, they have incontinence, plus they have the pain disorder possibly as their chief complaint, possibly in their history. And you don't want your surgeries to make their problem worse. Remember it's a pain disorder. If it's been going on for a long time, they've got centralized upregulation. You want to treat this pain disorder before you do surgery on patients. If you know anything about persistent post-operative pain disorders, one of the big risk factors is pre-existing pain that you don't down-regulate before you take them to the OR to fix their prolapse. So treat the vulvodynia and the pelvic floor dysfunction before they go. They might have more than one trigger to their symptoms, so you always have to look out. What am I missing? There's something else going on. Why can't I get her better? Identify the triggers. Identify the things that are keeping her hurting. Treat the periphery, but also treat the central. And then remember to treat the whole patient. That's after all why we're providers. The chase away the devil. Okay, you guys, you drained me for everything I'm worth. There's a question back there. Vaginal dilators for tight muscles are good, and quite honestly, the woman can trust the dilator more than her husband or significant other. So again, the vaginal dilators are very good. I like them. And physical therapists are excellent about helping get patients plugged into them. Good question. Malia is a woman's health nurse practitioner in the Division of Urogynecology and Reconstructive Pelvic Surgery. She has a bachelor's degree in biology from Rhodes College and a master's of science degree in nursing from Vanderbilt University School of Nursing. She's been working in urogynecology since 2000. She's an active member of the American Urogynecologic Society, and she sees all types of urogynecology patients, including women with prolapse, urinary incontinence, fecal incontinence, bladder infections and pelvic pain. Thank you. All right, so I'm going to go back for a moment. No, I'm good. Okay. So thank you all for allowing me to present here today. I have no relevant financial disclosures. So all of these cases that I'm going to present are either specific patients that I've seen and sort of things are changed to protect their rights. And all of them generally have more than one issue going on. So our first case is a 71-year-old female with a history of urinary incontinence who is new to your office. She also has a long history of vulvar itching, but of course that wasn't what brought her to you. She has tried many over-the-counter creams like Vagisil and Cordaid, and she has been treated over the phone by her gynecologist for yeast. She is not sexually active due to partner issues. The last time she was was about 10 years ago, and it was very painful. She wears pads, and she washes her vulva with soap and water several times a day due to the odor from the urinary incontinence. So this is what you see when you examine her. So I want to look at that for a moment, and then I want you to, in your mind, just let me know or hold it to yourself, what is your diagnosis? So more than one of these things is obviously possible, but there's one that's sort of most correct here, and that is, of course, lichen sclerosis. So as we have discussed earlier today, there's a whitened, shiny, thickened appearance to her skin. There's loss of her architecture, meaning she sort of no longer has the labia minora. This is the common sort of figure of eight or keyhole pattern. It's all the way down, and you can't see here, but all the way down around her perineum. The diagnosis, as we've discussed, is based not only on appearance, but on biopsy if necessary. In my practice, I don't typically biopsy someone like this if there's nothing that looks suspicious. I think there is some debate in the vulvar community about whether you have to or you don't. If you don't biopsy and you treat, and then she doesn't get better, I think wash her out for two weeks and then do your biopsy. So we've talked about treatment with one of three super potent topical corticosteroids. In my area of the country, clobetazole, which is sort of the gold standard treatment, has become very, very expensive. If that is the case for you, you can try either halobetazole or the betamethazone in augmented vehicle. It's a long name, but it's really important to get the augmented vehicle, because the non-augmented is lower potency. I went to the ISVVD conference in Boston and learned a great pearl there, which is that a 15-gram tube should really last for about six months. So if you're like me and you're giving the 45-gram tube and she's asking for a refill in a month or two, she's using way too much. So just a thin layer is really all she needs. All right, so a few other treatment pearls. We talked about biopsy, in my opinion. Abnormal appearance can resolve with treatment, and so as we talked about, either documenting with words or with a drawing or with a picture is important. I just learned I use Epic, and there is a way, if you have Epic on your phone, to take a photograph with your phone, and it will load directly into Epic. So that's a fun thing. You can probably need to get patient permission, either verbal or written, for that. So treatment is indefinite. Dr. Buttrick talked about how everyone stops their treatment because even though you told them 12 times that they have to continue it indefinitely, it got to feeling better, they lost their tube, whatever, and they stop and it comes back. So patient education is really, really important. It is also very important when you first start someone on treatment to not just do it daily for a week and then twice a week. You really need that once-daily or twice-daily treatment for a longer course, two or three months until things look normal. Dr. Buttrick spoke about how the vulva is pretty resistant and that steroid dermatitis. Not terribly common, the thinning, the warnings that come on the steroid tube, not to use it for more than a week or whatever. The vulva skin regenerates pretty quickly. All right. Stop the irritants. I think we've talked a lot about that. And vaginal estrogen. In my practice, I typically, if they need both, I'll get their skin feeling better, stop the itching, and then, if needed, we can start estrogen at that point. All right. Any questions on that case? My talk is not terribly long, so if you have questions, please feel free to raise your hands. All right. So 21-year-old with complaint of pain with sex for three months. She started her periods at 14, started birth control pills at 18, only uses pads, cannot tolerate tampons. She's now having vulvar burning all the time. Her skin feels raw, worse when she urinates. Sometimes she has discharge. She wears liners when that happens. Urine cultures are negative, but antibiotics do seem to help her pain. On exam, she is tender to Q-tip at between 5 and 7 o'clock on the introitus. Her pelvic floor is tight and tender, and her vulva is mildly erythematous. So this is what she looks like. All right. So what is your diagnosis? Again, more than one of these things may be correct, but one of them is sort of the most correct. All right. So vulvodynia. So as we've talked about for most of the morning, vulvar pain is typically burning, not caused by infection. In my experience and reading from the ISVBD, vestibulitis is an old term. It's not truly inflammation, although I'm interested to read more about what Dr. Buttrick said this morning about sort of being a local inflammatory response. Erythema may be present. We talked about how it's classified and how other pain syndromes are common. So this is a slide that's very small for you to read, but it's from Debra Bierenbaum, who spoke at ISVBD, talks about all the various things sort of broken down in algorithm for treatment. All right. So case three is a woman, 54-year-old, postmenopausal, urge incontinence for five years at least. She was last seen in your office about two years ago. Her incontinence is so bad that she puts trash bags on top of her mattress and also wears diapers. She was two hours late for this visit and for every visit after this visit. She mentions having a bump down there for two months. She tried to pop it, of course. She accidentally shaved it, and now it will not heal. And by the way, she has to leave soon, so this is reality in our world. All right. So on exam, she has an ulcer-like lesion. It's about one centimeter. It's raised. It's painless. No palpable lymphadenopathy. So what is your diagnosis? This was a big surprise to me. So she has vulvar cancer. So when I, you know, in my mind thought, okay, painless raised lesion, I thought, well, maybe it's syphilis. So I did test her for syphilis. That was negative. I did a biopsy, and I used, I usually use a three millimeter punch. In this case, I used five because I wanted to be sure to get a good sample, and it showed cancer. So I referred her to Gynonc, and she had a vulvectomy late every single visit, and there's comments all, you know, multiple social issues with this patient, which she is lucky that she had urinary incontinence. That's all I can say. She did actually have Botox as well, but anyway, so, and she was late for that appointment too. I actually told her to come an hour early, so it was, it was less bad. She was offered radiation, but declined. So sadly, she now has throat cancer, so, all right, so case four is an 85 year old with Alzheimer's who presents with her daughter for a complaint of vulvar and vaginal pain, itching, burning, and it's pretty much all the time, although it's episodic. So it comes, and it's really terrible, and she's so bad that, and she can't pee, and they take her to the ER, and then, you know, so that. She has been treated with all the things you would expect, fluconazole, antibiotics, triamcinolone. She leaks urine with urge, but that really is not an issue with her daughter. She has 24-hour sort of aids that help and change her diapers. She wears a pull-up all the time. She is assisted with showers three times a week, only uses water, vulvar. Hygiene is actually quite good in this patient. She also has a history of both recurrent and very resistant UTIs in the past. So all of this history has come from her daughter, because I walk in the room, and the patient's awake, and then she falls asleep for the rest of the visit. On exam, she has very mild erythema of her labia, no skin breakdown, perineum is dry. The vulvar is tender, although the patient can't really tell me. She's angry that I'm examining her. She doesn't know what I'm doing, doesn't know why she's there. Nothing sort of screams, you know, what the diagnosis is, though. Her urethra is non-tender. She was uncomfortable with catheterization. Her PBR was slightly elevated. Her vagina, you know, unremarkable, what you would expect for an 85-year-old. So I don't have a picture here for obvious reasons, but it's pretty normal. So this was sort of a big thing, like I couldn't get an answer all at once, and so I went back and I reviewed her records, and these problems, these episodes of vulvar pain and itching and burning began after she was treated with multiple courses of antibiotics for UTIs, which then led to C. diff. She was found to have retention when she was hospitalized for C. diff. That was managed with a Foley, and then she was started on Flomax, which did wonders for her leakage. She was also put on Fluconazole, based purely on the vulvar itching, no cultures or anything done. So everyone's trying to be helpful. There's multiple providers, different hospitals, but it has become a muddled mess. So what is your diagnosis here? And yes, it's all of the above, that's not a surprise, right? So this lady has a little bit of everything. So the first thing that I tried to prioritize in this visit is to manage the chaos. So stop the Fluconazole, because there's no reason to think she has yeast. I did culture her and it was negative, and that was in the middle of a flare. Stop the Flomax. Her PBR was relatively normal for an 85-year-old. I did recheck it later and it was okay. I prescribed gabapentin cream twice daily to the vulva. I wasn't quite sure what was going on in terms of the vulvar pain. I gave her some hydroxyzine after I got permission from her primary. I didn't want to over-sedate her, but she was literally waking in the night, scratching and screaming and having to be taken to the ER. I also started Keflex at 2.50 at bedtime for UTI suppression. So after multiple visits, I finally figured out that the UTI was actually the cause of her vulvar symptoms, so that was how she was manifesting. So UTI symptoms in the elderly can be very different, and I'm going to plug my pre-conference tomorrow. I'm doing care of the geriatric urogynecology patient, and we're going to talk about UTIs in that conference. So she is now on a rotating antibiotic suppression. So Keflex one month, I think Bactrim single-strength the following month. We did talk about D-mannose and high-potency cranberry, so this is not that conference, so I'll go on. All right. Any questions on that patient? Yeah, sure. So it's not the cranberry dosage, it's the pro-anthocyanidins, and I think it has to be PAC. It has to be 35. So there's two on the market. One is Allura, and the other is by Theralogix, and it's called Theracran. So my understanding is that the sort of over-the-counter CVS cranberry supplements don't have enough of that PAC. There have been clinical trials showing some improvement, I think, with the higher-dose cranberry supplements. How many of them? 35. And that's not something that's on the label. I have found, I actually looked at CVS myself, and it doesn't say. It's just like 300 milligrams of cranberry, so. All right. You will see a lot of products that are on the label that say, standardized PACs. Yeah. If you call and ask them. What does that mean? They say, well, we don't pay this into the market. Right. Yeah. So I have no affiliation with either Allura or Theracran, but I feel like perhaps they're under, they're expensive. That's the baseline. That's the problem. They're not prescription. They're not covered by insurance, so. All right. Next case is a 35-year-old nullip with a complaint of vulvar itching for six months. She also has urgent continence. The itching and scratching wakes her from sleep. She does have a history of lichen planus of her scalp. She's wearing menstrual pads because they're more affordable. She has treated with over-the-counter yeast creams, like myconazole. And she also washes, it's actually, I wrote soap, but it's just cool water to just sort of soothe the irritation. So this is what it looks like, and she's left-handed. So what's your diagnosis? So if you said lichen simplex chronicus, you are correct. It's a variant of eczema. We've talked about it sort of being an autoimmune issue. And in her case, the pads and the urine were the thing that triggered all of this. But as Dr. Buttrick said, eliminating triggers alone is not enough. So you do need a high-potency steroid ointment again. And then at last year's vulvar conference, we had a speaker who talked about this treatment called soak and seal. So soak is soaking in a sitz bath or a tub for five minutes, you know, cool water, nothing hot, and then sealing that moisture in with the steroid ointment. And I'm not sure anyone has said here, but ointments are really better than creams for these vulvar conditions. They don't have alcohol in them. They stay on the skin better. So, all right. So case six, 17-year-old Nalep with burning with urination since age 13. She also has pain with the full bladder. Symptoms started after she was diagnosed with Crohn's and started mezalamine. She is now in remission. She was diagnosed before she came to your office with vulvodynia. She is not sexually active, no history of abuse. Her symptoms are daily, so she hurts a little every day, but it waxes and wanes in intensity. So on exam, she has some erythema at 6 o'clock. It's mild. Urethral meatus is normal in appearance. Her vulva is normal in appearance. It is tender to Q-tip in the periurethral area. Her bladder is relatively non-tender, no masses. Her pelvic floor is soft and non-tender. She has done physical therapy before she came to your office. Bimanual is normal. Urethra, vaginal, urine cultures are all negative. So, rather than a diagnosis, because I think you know what this is, what treatment would you recommend first line? And more than one of these answers is probably correct. I will tell you that many providers will treat this as a sort of non-infectious urethritis, or they'll treat it as an infectious urethritis despite negative cultures and give an antibiotic. I don't think that's helpful in most cases. If they get better, I think it's placebo. PT, absolutely. Amitriptyline, absolutely. In my practice, I would not start someone with, this is Elmeron, pentosin, polysulfate, sodium. Cystoscopy with hydrodissension scares the crap out of this girl, and I don't blame her. Not necessary. So, she has mixed symptoms of painful bladder, vulvodynia. She did try PT first line and did improve. We added amitriptyline and topical lidocaine. She is now following an anti-inflammatory diet that she found online, and she is skin and bones. I always joke with my patient, if you eliminate everything from the icy diet list, you will end up eating peanut butter and hot dogs. So, I caution you to counsel your patients. Google doesn't have an MD. All right. Case 7. An 82-year-old with known lichen sclerosis. She calls with acute vulvar pain. She regularly uses clobetazole and Aquaphor. No new products. I wrote Aquaphor here to trigger a memory, which is that Aquaphor has lanolin in it. So, if your patients are sensitive to lanolin or wool products, Aquaphor is probably not a good idea as a barrier. Just plain Vaseline is cheap and easy. This patient has some dysuria and burning vulvar pain. No prior STIs. She is not sexually active currently. So, on exam, this is what you see. All right. So, what is your diagnosis? So, this is herpes. So, in her case, this was probably not a primary outbreak. It didn't have all the features of a primary outbreak. She also had not had sex in a very long time. She did use high-potency topical steroids, which actually can increase the risk of yeast infections and herpes outbreaks. Herpes culture that day was negative, and that's always a tough conversation to have. It's usually by phone, which makes it even harder. She did have serology, which was positive. I always treat for herpes while waiting for the result. It just looked, you know, very much like herpes. So, this, you know, of course triggered all kinds of, oh, my God, you know, she literally thought God was punishing her. So, tough conversation for older patients with herpes. All right. So, last case. 85-year-old who is seeing you for a pessary check. You have not seen her in the past. She has incontinence all the time and wears diapers. She has dementia and cannot provide any history. She comes from a skilled nursing facility, and they have given you a med list and recent labs, all of which was normal. The aide that is with her mentioned seeing spots of blood in her adult diaper that morning. Thank God she had a hysterectomy, so you don't have to do an endometrial biopsy on this poor woman. So, on exam, it is clear why she is having blood in her diaper. So, all right. So, what is your diagnosis in this lady? Yes. This is irritant dermatitis. In her case, this has probably been going on for a while. This is your first time seeing her. Leakage is the most common cause of irritant dermatitis in her case. Incontinence products like pads can also contribute. There are many treatment challenges in patients with dementia. She happens to live in a skilled nursing facility that can provide peri-care instructions and pray that they are followed. If she's at home, a relative may be able to help. A visiting nurse may be able to come in, at least in the beginning. Obviously, you want to discontinue irritants. If the leakage is treatable, good. If it's not, that may not be something you can fix. Improve the skin barrier function with the barriers that we talked about, like Vaseline. And then consider vaginal estrogen. So, the other things you can do besides the ointments and things for barriers. I talked about sitz baths earlier, pat dry, apply ointments. All right, so this is a list of a couple of resources that I think can be really helpful for you in your daily practice. The ISSVD, there's a vulvovaginal disorders algorithm, which is amazing. You do have to sign in, but it's free. They have pictures. The ISSVD has handouts, which I use and tailor for my patient population. And then the National Vulvodynia Association also has both patient and provider resources. All right, any other questions? All right, thank you so much. Applause

vulvar pathology

anatomy

diagnostic process

vulva

blood supply

nerve supply

lymphatic drainage

diagnosis

treatment

vulvar malignancies

vulvodynia

pain disorder

triggers

potentiators

evaluation