Presentation is loading. Please wait.

Presentation is loading. Please wait.

Chapter 28 Urologic Management of Women with Sexual Health Concerns Carrie Fitzgerald Uro12/25/09.

Similar presentations


Presentation on theme: "Chapter 28 Urologic Management of Women with Sexual Health Concerns Carrie Fitzgerald Uro12/25/09."— Presentation transcript:

1 Chapter 28 Urologic Management of Women with Sexual Health Concerns Carrie Fitzgerald Uro12/25/09

2

3 Classification Classification Epidemiology Epidemiology Diagnosis Diagnosis Treatment Treatment Summary Summary Questions Questions

4 Sexual Medicine: Theory Multidisciplinary groups/centers Multidisciplinary groups/centers Holistic care Holistic care Men, women, couples Men, women, couples Urologist have a unique understanding pelvic floor Urologist have a unique understanding pelvic floor Improved evidence based management of biologic-based pathophysiologic processes Improved evidence based management of biologic-based pathophysiologic processes

5

6 Classification Women's Sexual Interest/Desire Disorder Women's Sexual Interest/Desire Disorder Subjective Sexual Arousal Disorder Subjective Sexual Arousal Disorder Genital Sexual Arousal Disorder Genital Sexual Arousal Disorder Combined Genital and Subjective Arousal Disorder Combined Genital and Subjective Arousal Disorder Persistent Sexual Arousal Disorder Persistent Sexual Arousal Disorder Women's Orgasmic Disorder Women's Orgasmic Disorder Dyspareunia Dyspareunia Vaginismus Vaginismus Sexual Aversion Disorder Sexual Aversion Disorder

7 Classification No accepted screening tool No accepted screening tool Definition Female Sexual Dysfunction (FSD) not universal Definition Female Sexual Dysfunction (FSD) not universal Few population-based epidemiologic studies Few population-based epidemiologic studies

8 Epidemiology: Prevalance Sexual desire Sexual desire Lubrication/dryness Lubrication/dryness Pain (after/during) Pain (after/during) Anorgasmic/difficulty Anorgasmic/difficulty Desire, arousal, orgasm OR pain Desire, arousal, orgasm OR pain Current Current 7% time of report, 31% lifetime 7% time of report, 31% lifetime 19-23% lifetime 19-23% lifetime 17-19% lifetime 10-20% clinic 17-19% lifetime 10-20% clinic 4-41% lifetime 4-41% lifetime % lifetime % lifetime 45% (Weijmas Schultz 2005) 45% (Weijmas Schultz 2005)

9 Diagnosis Hx; medical Hx; medical –Neurologic, urologic, gyn –Medications ie SSRI and hormones Hx; psychologic Hx; psychologic –Abuse, beliefs, trauma, psych hx, substance abuse Questionnaires; Female Sexual Function and Sexual Function Questionnaire Questionnaires; Female Sexual Function and Sexual Function Questionnaire

10

11

12

13 Diagnosis: Physical exam Pt directed, anatomy, pain, trauma Pt directed, anatomy, pain, trauma External genital External genital Glands; ie: minor vestibular adenitis Glands; ie: minor vestibular adenitis Anal tone, bulbocavernosal reflex Anal tone, bulbocavernosal reflex Pelvic floor hypertonicity Pelvic floor hypertonicity Organ prolapse Organ prolapse +/- speculum exam +/- speculum exam

14 Diagnosis Work up continued Work up continued Endocrine disorders ie: thyroid disease, prolactinoma, Addisons disease Endocrine disorders ie: thyroid disease, prolactinoma, Addisons disease Skin ie herpes, psoriasis, spider veins Skin ie herpes, psoriasis, spider veins

15 Diagnosis: Labs pH ( ) low (candidiasis) high vaginitis, vaginosis, atrophy pH ( ) low (candidiasis) high vaginitis, vaginosis, atrophy Wet mount (>1 WBC per epithelial); cx: trichomonas, candida, gonorrhea, chlamydia, herpes, PID Wet mount (>1 WBC per epithelial); cx: trichomonas, candida, gonorrhea, chlamydia, herpes, PID Increased parabasal cells: inflammation. Low estrogen Increased parabasal cells: inflammation. Low estrogen Clue cells: bacterial vaginosis Clue cells: bacterial vaginosis

16 Diagnosis: Labs Androgens ie DHEAS or calculated free testosterone Androgens ie DHEAS or calculated free testosterone Estrogens Estrogens LH, FSH, prolactin, TSH LH, FSH, prolactin, TSH +/- SHBG +/- SHBG

17 Diagnosis: Labs Diagnosis: Labs

18 Diagnosis: Con’t Vascular duplex Doppler ultrasonography duplex Doppler ultrasonography MRI pelvic/brain MRI pelvic/brain Neurologic Motor innervation Motor innervation Sensory innervation Sensory innervation Quantitative Sensory Testing ie thermal/vibratory Quantitative Sensory Testing ie thermal/vibratory Clinical research: bulbocavernosal reflex test, somatosensory, electromyography, nerve conduction Clinical research: bulbocavernosal reflex test, somatosensory, electromyography, nerve conduction

19 Treatment: premenopausal Estrogen and progesterone ie. OCP or dysmenorrhea treatment Estrogen and progesterone ie. OCP or dysmenorrhea treatment –Decrease LH, FSH –Increase SHBG –Therefore decrease testosterone –Monitor levels in sexual dysfunction (SHBG, androgens)

20 Treatment: premenopausal DHEA- dietary supplement DHEA- dietary supplement limited evidence (arousal, interest, thoughts) limited evidence (arousal, interest, thoughts) Monitor LFT’s, HDL, estradiol, estrone, acne, hirsurtism Monitor LFT’s, HDL, estradiol, estrone, acne, hirsurtism

21

22 Treatment: premenopausal Low testosterone Low testosterone –Hyperprolactinemia –Adrenal insufficiency –OCP –Aging (slow progessive) Limited basic science studies Limited basic science studies Limited clinical studies Limited clinical studies Limited longterm safety data (esp preg) Limited longterm safety data (esp preg)

23

24

25 Peri/postmenopausal Cessation of estradiol Cessation of estradiol Androstenedione  estrone or testosterone  estradiol Androstenedione  estrone or testosterone  estradiol Glycogen  glucose  lactic acid Glycogen  glucose  lactic acid Tissue atrophy, loss of rugae, decreased lubrication/sensation Tissue atrophy, loss of rugae, decreased lubrication/sensation LUTS, incontinence LUTS, incontinence Increase vaginal pH promotes growth yeast Increase vaginal pH promotes growth yeast

26 Peri/postmenopausal- treatment Local Estrogen therapy Tablets (25-hydroxy-17B- estradiol) Tablets (25-hydroxy-17B- estradiol) Ring (2mg estradiol) Ring (2mg estradiol) Cream (conjugated equine estrogen, estradiol, estrone) Cream (conjugated equine estrogen, estradiol, estrone) Systemic estro/progest therapy Dennerstein et al 1980 Dennerstein et al 1980 Ethinyl estradiol 50 microgr Ethinyl estradiol 50 microgr Improved vaginal atrophy, dryness, orgasmic freq, desire, enjoyment, mood Improved vaginal atrophy, dryness, orgasmic freq, desire, enjoyment, mood

27

28 Peri/postmenopausal-Treatment Low Androgens Low Androgens –Mm wasting –Sexual dysfunction –Osteoporosis –Decreased mood, energy, libido

29

30 Peri/postmenopausal-Treatment DHEA Baulieu et al (2000) Baulieu et al (2000) DHEA (50 mg) or placebo DHEA (50 mg) or placebo N= 140 age N= 140 age Increased skin hydration Increased skin hydration Increased bone density Increased bone density Increase libido 6 mo Increase libido 6 mo Increase sex satisfaction/ activity 12 mo Increase sex satisfaction/ activity 12 mo Testosterone Shifren et al (2000) Shifren et al (2000) s/p oophorectmy on estro s/p oophorectmy on estro Transdermal testosterone (150 UG, 300UG, placebo) Transdermal testosterone (150 UG, 300UG, placebo) Safety; 12 wk; lipids Safety; 12 wk; lipids Simon et al (2004) Simon et al (2004) Double blind, 24 weeks Double blind, 24 weeks Transdermal testosterone (300 UG, placebo) Transdermal testosterone (300 UG, placebo) Improved desire, arousal, pleasure, body image, freq Improved desire, arousal, pleasure, body image, freq

31 Dopamine Agonists –Premenopausal studies –Caruso (2004) Apomorphine/Placebo control study; enhanced frequency, orgasm, enjoyment –SE: headache

32 Treatment- Vasodilators Phosphodiesterase type 5 inhibitors Double blind, crossover safety/efficacy; enhanced arousal, frequency, orgasm, enjoyment Double blind, crossover safety/efficacy; enhanced arousal, frequency, orgasm, enjoyment –Caruso et al (2001) - premenopausal –Bermann et al (2003)- post menopausal;, benefit in sexual arousal disorder; No benefit in hypoactive desire –SE: headache, nausea, visual changes Phosphodiesterase type 5 inhibitors Psychotropic induced Psychotropic induced Salerian et al (2000) – SSRI less improvement Salerian et al (2000) – SSRI less improvement Nunberg et al (1999) – treats anorgasmia Nunberg et al (1999) – treats anorgasmia Other vasodilator studies Other vasodilator studies L-arginine, yohimbine, phentolamine, PG E1 L-arginine, yohimbine, phentolamine, PG E1 Preliminary results Preliminary results

33 Gential Sexual Pain disorders Phimosis/balantitis Conservative; topical estrogen and/or testosteron Conservative; topical estrogen and/or testosteron Antifungal (po/topical), anti viral, clobetasol if assc with lichen planus/sclerosis Antifungal (po/topical), anti viral, clobetasol if assc with lichen planus/sclerosis Preputial infxtn Sebaceous cysts; abx, sitz bathes and/or I and D Sebaceous cysts; abx, sitz bathes and/or I and DVulvodynia Vulvar hygiene, holistic, amitryptyline/gabapentiv

34 Genital sexual pain disorders Traumatic neuropathy Childbirth Childbirth Pelvic fractures Pelvic fractures Saddle injuries Saddle injuries Treatment: amitryptyline or gabapentin Treatment: amitryptyline or gabapentin Irritative voiding symptoms Urethral prolapse/skenes adenitis Urethral prolapse/skenes adenitis Hypoestrogen state Hypoestrogen state Dysuria & perineal burning Dysuria & perineal burning Urethritis/UTI Urethritis/UTI Cystocele/rectocele Cystocele/rectocele Inflammatory gyn condtns Inflammatory gyn condtns Interstitial cystitis Interstitial cystitis

35 Pelvic floor disorders Pelvic exam Pelvic exam Hypotonus ie. Childbirth/radiation Hypotonus ie. Childbirth/radiation Tx Pelvic floor strengthening, TVT, sling Tx Pelvic floor strengthening, TVT, sling Hypertonus ie. Hypersensitivity disorders Hypertonus ie. Hypersensitivity disorders –Chr bacterial cystitis –Pain disorders –Urg/freg syndrome –Interstitial cystitis Tx Pelvic floor rehab, massage

36 Vestibulitis syndrome Vestibular adenitis  dysparunia (<50 yo) Vestibular adenitis  dysparunia (<50 yo) –Dysparunia –Conservative: education, top estrogens/lidocaine, TCA, gabapentin –Surgical options »Vulvar vestibulectomy »Complete vulvar vestibulectomy »Modified vulvar vestibulectomy »Vestibuloplasty »Excision of vestibular adenitis

37 –Woodruff (1981) excised a semicircle perineal skin »Posterior hymenal ring »Post vulvar vestibule »Vaginal flap advancement

38 Other surgical procedures Other surgical procedures –Dorsal slit for phimosis –Incision/drainage/ mass resection –Vestibulectomy for introital stenosis –Resection of urethral prolapse –Marsupialization of Bartholin cyst –Labioplasty for pain/persistent fungal infections

39 Questions Questions


Download ppt "Chapter 28 Urologic Management of Women with Sexual Health Concerns Carrie Fitzgerald Uro12/25/09."

Similar presentations


Ads by Google