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Disorders of the GI tract

–Constipation

–Crohn disease

–Diverticular disease

–Fistulas

–Hemorrhoids

–Inflammatory bowel disease

Disorders of the urinary tract

–Interstitial cystitis

–Ureteral or vesical lesions

–Urethritis

Chronic disease

–Behçet syndrome

–Diabetes

–Sjögren syndrome

Male

–Cancer of penis

–Genital muscle spasm

–Infection or irritation of penile skin

–Infection of seminal vesicles

–Lichen sclerosus

–Musculoskeletal disorders of pelvis and lower back

–Penile anatomy disorders

–Phimosis

–Prostate infections and enlargement

–Testicular disease

–Torsion of spermatic cord

–Urethritis

Psychological disorders

–Anxiety

–Conversion reactions

–Depression

–Fear

–Hostility toward partner

–Phobic reactions

–Psychological trauma

RISK FACTORS

Fatigue

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Stress

Depression

Diabetes

Estrogen deficiency

–Menopause

–Lactation

Previous PID

Vaginal surgery

Alcohol/marijuana consumption

Medication side effects (antihistamines, tamoxifen, bromocriptine, lowestrogen oral contraceptives, SSRIs, depo-medroxyprogesterone, desipramine)

Pregnancy Considerations

Pregnancy is a potent influence on sexuality; dyspareunia is common in late pregnancy and postpartum.

–Breastfeeding, perineal pain, fatigue, and stress can be risk factors in postpartum period.

Episiotomies do not have a protective effect.

–Women who experience delivery interventions including episiotomy are at greater risk than women who deliver over an intact perineum or have an unsutured tear.

COMMONLYASSOCIATED CONDITIONS

Vaginismus

DIAGNOSIS

HISTORY

Identify pain characteristics:

–Onset

–Duration

–Location: entry versus deep, single versus multiple sites; positional

–Intensity/quality: varying degrees of pelvic/genital pressure, aching, tearing, and/or burning

–Pattern (precipitating or aggravating factors): when pain occurs (at entry, during, or after intercourse)

–Relief measures: Avoid intercourse, change positions, and have intercourse

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only at certain times of the month.

Include menstrual, obstetric, reproductive, sexual, domestic violence, and rape histories with medical, surgical, and psychosocial history.

PHYSICALEXAM

Acomplete exam, including a focused pelvic exam, to identify pathology

–Exam must include inspection and palpation of urethra, vulva, and vaginal areas; palpation of the uterine, bladder, and adnexal structures; and a rectovaginal exam.

–Sensory mapping with a cotton-tipped applicator to identify sensitive and

painful areas

Because examination often reproduces the pain, examiner should be cautious and sensitive to patient’s anxiety.

DIFFERENTIALDIAGNOSIS

Vaginismus (genito-pelvic pain penetration disorder)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Based on history and exam findings

Wet mount

Gonorrhea and chlamydia cultures

Herpes culture

Urinalysis and urine culture

Pap smear

Follow-Up Tests & Special Considerations

Serum estradiol if vulvodynia or atrophic vaginitis

Voiding cystourethrogram if urinary tract involvement

GI contrast studies if GI symptoms

Ultrasound and CT scan are of limited value; perform if clinically indicated.

Diagnostic Procedures/Other

Based on history and exam findings

Colposcopy and biopsy if vaginal/vulvar lesions

Laparoscopy if complex deep-penetration pain

Cystoscopy if urinary tract involvement Endoscopy if GI involvement

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Test Interpretation

Depends on etiology

TREATMENT

Potential relationships exists between primary dyspareunia and vaginismus, low libido, and arousal disorders.

Endocrine factors, such as primary amenorrhea, might reduce the biologic basis of sexual response.

If pain prevents penetration, severe vaginismus may be present.

GENERALMEASURES

Educate the patient and partner regarding the nature of the problem. Reassure both that there are solutions to the problem.

Initiate specific treatment when initial evaluation identifies an organic cause. Once organic causes are ruled out, treatment is a multidimensional and multidisciplinary approach (1)[C].

–Individual behavioral therapy

Indicated to help the patient deal with intrapersonal issues and assess the role of the partner

–Couple behavioral therapy

Indicated to help resolve interpersonal problems

May involve short-term structured intervention or sexual counseling

Designed to desensitize systemically uncomfortable sexual responses and intercourse through a series of interventions over a period of weeks

Interventions range from muscle relaxation and mutual body massage to sexual fantasies and erotic massage.

MEDICATION

First Line

Depends on the etiology

Antibiotics, antifungals, or antivirals, as indicated, for infection

Vaginal moisturizers and lubricants for dryness

Analgesics and topical anesthetics for pain

Topical estrogen for vaginal and vulvar atrophy

Neuropathic pain associated with vulvar vestibulitis/vulvodynia may respond

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to tricyclic antidepressants (amitriptyline or nortriptyline) or gabapentin.

Second Line

Ospemifene for moderate to severe symptoms due to menopause-related vulvar and vaginal atrophy (2)[B]

Intravaginal DHEA(prasterone) for moderate to severe symptoms due to menopause-related vulvar and vaginal atrophy

ISSUES FOR REFERRAL

Referral for long-term therapy may be necessary.

ADDITIONALTHERAPIES

Physical therapy for pelvic floor muscle pain

SURGERY/OTHER PROCEDURES

Laparoscopic excision of endometriotic lesions has shown benefit (3)[C].

Surgical vestibulectomy can be considered if medical measures fail with vulvar vestibulitis (4)[B].

COMPLEMENTARY& ALTERNATIVE MEDICINE

Sitz baths may relieve painful inflammation.

Perineal massage

Antioxidants may improve symptoms associated with endometriosis.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Outpatient follow-up depends on therapy.

Every 6 to 12 months once resolved

DIET

Ahigh-fiber diet may help if constipation is a contributing cause.

PATIENT EDUCATION

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Boston Women’s Health Book Collective. Our Bodies, Ourselves. New York,

NY: Touchstone; 2001.

Kegel exercise information

Provide couples with information about sexual arousal techniques.

PROGNOSIS

Depends on underlying cause but most patients will respond to treatment

REFERENCES

1.Crowley T, Richardson D, Goldmeier D. Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction. Int J STD AIDS. 2006;17(1):14–18.

2.Portman DJ, Bachmann GA, Simon JA. Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vular and vaginal atrophy. Menopause. 2013;20(6):623–630.

3.Ferrero S, Abbamonte LH, Giordano M, et al. Deep dyspareunia and sex life after laparoscopic excision of endometriosis. Hum Reprod. 2007;22(4):1142– 1148.

4.Steege JF, Zolnoun DA. Evaluation and treatment of dyspareunia. Obstet Gynecol. 2009;113(5):1124–1136.

ADDITIONALREADING

Seehusen DA, Baird DC, Bode DV. Dyspareunia in women. Am Fam Physician. 2014;90(7):465–470.

Sung SC, Jeng CJ, Lin YC. Sexual health care for women with dyspareunia.

Taiwan J Obstet Gynecol. 2011;50(3):268–274.

SEE ALSO

Balanitis, Phimosis, and Paraphimosis; Endometriosis; Genito-Pelvic

Pain/Penetration Disorder (Vaginismus); Pelvic Inflammatory Disease (PID);

Sexual Dysfunction in Women; Vulvovaginitis, Estrogen Deficient;

Vulvovaginitis, Prepubescent

Algorithms: Discharge, Vaginal; Dyspareunia

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CODES

ICD10

N94.1 Dyspareunia

F52.6 Dyspareunia not due to a substance or known physiol cond

CLINICALPEARLS

Careful history to determine if patient feels pain before, during, or after intercourse will help identify cause.

–Pain before intercourse suggests a phobic attitude toward penetration and/or the presence of vestibulitis.

–Pain during intercourse combined with the location of the pain is most predictive of the causes of pain.

–Introital pain after intercourse suggests vestibulitis in women of childbearing age, hypertonic pelvic floor, or vulvovaginal dystrophia.

Potential relationship exists between primary dyspareunia and vaginismus, low libido, and arousal disorders.

Episiotomy does not offer any benefit in the prevention of dyspareunia; an episiotomy in fact may cause more future discomfort.

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DYSPEPSIA, FUNCTIONAL

Briana Lindberg, MD Kristina Burgers, MD

BASICS

DESCRIPTION

Agroup of epigastric symptoms classified based on presenting symptoms

The presence of bothersome postprandial fullness, early satiety, or epigastric pain/burning in the absence of causative structural disease (to include normal upper endoscopy) for at least 1 to 3 days per week for the preceding 3 months, with initial symptom onset at least 6 months prior to diagnosis (Rome IV criteria)

Rome IV criteria divide patients into two subtypes:

–Postprandial distress syndrome (PDS)

–Epigastric pain syndrome (EPS)

System(s) affected: GI

Synonym(s): idiopathic dyspepsia; nonulcer dyspepsia; nonorganic dyspepsia; PDS; and EPS

EPIDEMIOLOGY

Incidence

Unknown; accounts for 70% of patients with dyspepsia, and ~5% of primary care visits

Prevalence

10–30% prevalence worldwide

Typically more common in Western cultures. PDS may be more common in Eastern cultures than originally recognized.

Predominant age: adults but can be seen in children

Predominant gender: female > male

ETIOLOGYAND PATHOPHYSIOLOGY

Unknown but proposed mechanisms or associations include gastric motility disorders, visceral pain hypersensitivity, Helicobacter pylori infection, alteration in upper GI microbiome, postinfectious complications, immune activation, inflammation, and gut-brain axis disorders

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Genetics

Possible link to G-protein β3 subunit 825 CC genotype, serotonin transport genes, and/or cholecystokinin-A-receptor gene polymorphisms

Geriatric Considerations

Patients ≥60 years with new-onset dyspepsia should undergo endoscopy.

Pediatric Considerations

Be alert for family system dysfunction.

Pregnancy Considerations

Pregnancy may exacerbate symptoms.

RISK FACTORS

Other functional disorders: fibromyalgia, temporomandibular joint pain, chronic fatigue syndrome

Anxiety/depression, psychosocial stressors (e.g., divorce, unemployment)

Smoking

Female gender

GENERALPREVENTION

Avoid foods and habits known to exacerbate symptoms.

COMMONLYASSOCIATED CONDITIONS

Other functional bowel disorders

DIAGNOSIS

HISTORY

Postprandial fullness (1)[B]

Early satiety (1)[B]

Epigastric pain (1)[B]

Epigastric burning (1)[B]

Symptoms for 3 months (1)[C]

Alarm features that may necessitate endoscopy include (2–4)[C]:

– Unintended weight loss

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–Progressive dysphagia

–Odynophagia

–Persistent vomiting

–GI bleeding

–Family history of upper GI cancer

–Age ≥60 years

PHYSICALEXAM

Document weight status and vital signs.

Examine for signs of systemic illness.

–Murphy sign for cholecystitis

–Rebound and guarding for ulcer perforation

–Palpation during muscle contraction for abdominal wall pain

–Jaundice

–Thyromegaly

DIFFERENTIALDIAGNOSIS

Peptic ulcer disease; gastroesophageal reflux disease

Cholecystitis; choledocholithiasis

Gastric or esophageal cancer; esophageal spasm

Malabsorption syndromes; celiac disease

Pancreatic cancer; pancreatitis

Inflammatory bowel disease; carbohydrate malabsorption; gastroparesis

Ischemic bowel disease

Intestinal parasites

Irritable bowel syndrome

Ischemic heart disease

Diabetes mellitus; thyroid disease

Connective tissue disorders

Conversion disorder

Medication effects

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Functional dyspepsia is a diagnosis of exclusion. Order labs based on clinical suspicion (3)[C].

Test for H. pylori (stool antigen or urea breath test) in areas of high H. pylori prevalence (3,4)[A].

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