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Chapter 28 Urologic Management of Women with Sexual Health Concerns

Chapter 28 Urologic Management of Women with Sexual Health Concerns. Carrie Fitzgerald Uro1 2/25/09. Classification Epidemiology Diagnosis Treatment Summary Questions. Sexual Medicine: Theory . Multidisciplinary groups/centers Holistic care Men, women, couples

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Chapter 28 Urologic Management of Women with Sexual Health Concerns

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  1. Chapter 28Urologic Management of Women with Sexual Health Concerns Carrie Fitzgerald Uro1 2/25/09

  2. Classification Epidemiology Diagnosis Treatment Summary Questions

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

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

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

  6. Epidemiology: Prevalance Sexual desire Lubrication/dryness Pain (after/during) Anorgasmic/difficulty Desire, arousal, orgasm OR pain Current 7% time of report, 31% lifetime 19-23% lifetime 17-19% lifetime 10-20% clinic 4-41% lifetime 33- 35% lifetime 45% (Weijmas Schultz 2005)

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

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

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

  10. Diagnosis: Labs pH (3.5-4.5) low (candidiasis) high vaginitis, vaginosis, atrophy Wet mount (>1 WBC per epithelial); cx: trichomonas, candida, gonorrhea, chlamydia, herpes, PID Increased parabasal cells: inflammation. Low estrogen Clue cells: bacterial vaginosis

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

  12. Diagnosis: Labs

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

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

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

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

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

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

  19. Peri/postmenopausal-Treatment • Low Androgens • Mm wasting • Sexual dysfunction • Osteoporosis • Decreased mood, energy, libido

  20. Peri/postmenopausal-Treatment DHEA Testosterone Baulieu et al (2000) DHEA (50 mg) or placebo N= 140 age 60-79 Increased skin hydration Increased bone density Increase libido 6 mo Increase sex satisfaction/ activity 12 mo Shifren et al (2000) s/p oophorectmy on estro Transdermal testosterone (150 UG, 300UG, placebo) Safety; 12 wk; lipids Simon et al (2004) Double blind, 24 weeks Transdermal testosterone (300 UG, placebo) Improved desire, arousal, pleasure, body image, freq

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

  22. Treatment- Vasodilators Phosphodiesterase type 5 inhibitors Phosphodiesterase type 5 inhibitors • 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 Psychotropic induced Salerian et al (2000) – SSRI less improvement Nunberg et al (1999) – treats anorgasmia Other vasodilator studies L-arginine, yohimbine, phentolamine, PG E1 Preliminary results

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

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

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

  26. Vestibulitis syndrome • 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

  27. Woodruff (1981) excised a semicircle perineal skin • Posterior hymenal ring • Post vulvar vestibule • Vaginal flap advancement

  28. 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

  29. Questions

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