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    Chronic sexual pain: a layered guide to evaluation

     

    Overall treatment principles

    Share with patients a written individualized treatment plan addressing each layer. The vulvar surface must be protected and strengthened, abnormal peripheral and central nerve activity suppressed, and the PF normalized with PT. Musculoskeletal abnormalities and pelvic organ pain require focused therapies, and underlying systemic conditions must be appreciated and treated. Depression, anxiety, and hopelessness are improved by supportive and cognitive behavioral therapy. Develop a relationship with a therapist who is knowledgeable about chronic pain and mind-body practices, which calm the ANS and physical consequences of pain and stress. 

    Anticipate pain flares and have a plan in place before they occur. Re-evaluate persistent or recurrent pain often, layer by layer. Address the side effects of medications preemptively and quickly. Avoid opioid pain relievers, which do not relieve chronic pain, but may cause bowel and bladder symptoms, endocrinopathies, sexual dysfunction, and mood and cognitive disturbances that may lead to overdose.28

    Patients trust ob/gyns with the care of chronic sexual pain. Our committed partnership with patients will improve their quality of life and provide an essential component of healing: hope for the real possibility of cure. 

     

    References    

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    8. Nguyen RH, Turner RM, Rydell SA, et al. Perceived stereotyping and seeking care for chronic vulvar pain. Pain Med. 2013;10:1461–1467.

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    13. Piper CK, Legocki LJ, Moravek MB, et al. Experience of symptoms, sexual function, and attitudes toward counseling of women newly diagnosed with vulvodynia. J Low Gen Tract Dis. 2012;16(4):447–453.

    14. Tang YY, Ma Y, Fan Y, et al. Central and autonomic nervous system interaction is altered by short-term meditation. Proc Natl Acad Sci USA. 2009;106(22):8865–8870. 

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    17. Leclair CM, Goetsch MF, Korcheva VB et al. Differences in primary compared with secondary vestibulodynia by immunohistochemistry. Obstet Gynecol. 2011;117:1307–1313.

    18. Goldstein AT, Belkin ZR, Krapf JM, et al. Polymorphisms of the androgen receptor gene and hormonal contraceptive induced provoked vestibulodynia. J Sex Med. 2014;11:2764–2771.

    19. Dellon AL, Coady D, Harris D. Pelvic pain of pudendal nerve origin: surgical outcomes and learning curve lessons. J Reconstr Microsurg. 2015;31(4):283–290.

    20. Furtmüller GJ, McKenna CA, Ebmer J, Dellon AL. Pudendal nerve 3-dimensional illustration gives insight into surgical approaches. Ann Plast Surg. 2014;73:670–678.

    21. Weiss PM, Rich J, Swisher E. Pelvic floor spasm: the missing link in chronic pelvic pain. Contemporary OB/GYN. October 1, 2102.

    22. Hartmann D, Sarton J. Chronic pelvic floor dysfunction. Best Pract Res Clin Obstet Gynaecol. 2014; doi.org/10.1016/j.bpobgyn.

    23. Prather H, Dugan S, Fitzgerald C, Hunt D. Review of anatomy, evaluation, and treatment of musculoskeletal pelvic floor pain in women. PMR. 2009;1:346-358.

    24. Goetsch MF, Lim JY, Caughey AB. Locating pain in breast cancer survivors experiencing dyspareunia: a randomized controlled trial. Obstet Gynecol. 2014; 123(6):1231-6.

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    28. Reuben DB, Alvanzo AAH, Ashikaga T, et al. National Institutes of Health pathways to prevention workshop: the role of opioids in the treatment of chronic pain. Ann Int Med. 2015; DOI: 10.7326/M14-2775.

    Deborah Coady, MD, FACOG
    Dr Coady is Clinical Assistant Professor of Obstetrics and Gynecology at NYU Langone Medical Center, New York.

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