APP

Diagnostic Criteria

Manning Rome IV

• Pain relieved by defecation • Recurrent abdominal pain at
• More frequent stools at onset of least 1day/wk in last 3 months
associated with ≥ 2 of following
pain criteria
• Looser stools at onset of pain
• Visible abdominal distention • Related to defecation
• Passage of mucus > 25% of time
• Sensation of incomplete • Association with change in stool
frequency
evacuation > 25% of time
• Associated with change in stool
form

Pathophysiology - Theories

• Motility
• Visceral hypersensitivity
• Intestinal inflammation
• Post infectious
• Alteration in microflora
• Bacterial overgrowth
• Food sensitivity
• Genetic
• Psychosocial dysfunction

Patient Evaluation

• History & Exam
• Bowel history

• Frequency
• Consistency
• Evacuation/Straining
• Incontinence
• Family history of bowel disorders

• Bowel Diary
• Physical exam – typically normal

138

Bowel Diary

Patient Evaluation

• Labs

• CBC
• Patients with diarrhea

• C-reactive protein
• Serologic testing for celiac disease

• Testing

• Age appropriate colorectal cancer screening
• Anorectal manometry in refractory severe constipation

Alarm Features

• Age of onset after 50
• Rectal bleeding/melena
• Nocturnal diarrhea
• Progressive/severe abdominal pain
• Unexplained weight loss
• Lab abnormalities
• Family history of IBD or colon cancer

139

Differential Diagnosis

Constipation Diarrhea

• Organic disease • Celiac disease
• Dyssynergic defecation • Microscopic colitis
• Slow transit • Small intestine bacterial

overgrowth

• Inflammatory bowel disease

Treatment: All Types

Treatment - Initial Therapy

• Education
• Dietary modification

140

Treatment: Dietary Modification

• Exclude gas-producing foods

• beans, onion, celery carrots, raisin, banana, wheat germ, alcohol and caffeine

• Lactose avoidance

• Consider empiric trial

• Low FODMAP diet

• Fructose, honey, wheat, apples, pears, mango, cherries
• 8 week trial then reintroduce
• Dietician assistance beneficial

• Gluten avoidance (?fructans)
• Fiber (psyllium)

Treatment

• Food allergy testing

• Not recommended

• Physical activity

• May improve symptoms
• General health benefit

Treatment: Constipation Focused

141

Constipation Treatment – Pharmacologic
Polyethylene Glycol (PEG)

• Miralax ®
• 17 g daily, titrate up to 34 g daily if needed
• Treats constipation not pain
• Side effects: bloating and abdominal discomfort

Constipation Treatment – Pharmacologic
Lubiprostone

• Amitiza ®
• Chloride channel activator
• IBS-C dose*: 8 mcg BID

• Lower than idiopathic and opioid-induced constipation (24 mcg BID)

• Side effects: nausea

* Approved for women only

Constipation Treatment – Pharmacologic
Linaclotide & Plecanatide

• Linzess ® and Trulance ®
• Stimulates cGMP production

• Increases intestinal fluid secretion and motility

• IBS-C/CIC dosing

• Linaclotide: 290 mcg daily
• Plecanatide: 3 mg daily

• Side effects: diarrhea

• ~ 2 weeks
• (6% discontinuation)

142

Treatment: Diarrhea Focused

Diarrhea Treatment – Pharmacologic
Loperamide

• Imodium ®
• 2mg 45 minutes prior to meals

• Scheduled dosing
• Max dose 16 mg/d

• Avoid in IBS-C patients . . . . . . . . . . . . . . . . . . . . . . . . .
• Stool frequency and consistency improved

• Not: bloating, abdominal pain, global IBS symptoms

Diarrhea Treatment – Pharmacologic
Atropine/Diphenoxylate

• Lomotil ®
• Short-term use
• Not best option for long-term

• May develop dependence

143

Diarrhea Treatment – Pharmacologic
Eluxadoline

• Viberzi ®

• Mu-opioid receptor agonist/delta-opioid receptor antagonist

• CI: h/o biliary disorder, pancreatitis, liver disease, heavy alcohol use
•  CI if prior cholecystectomy

• High risk of pancreatitis

• SE: nausea, constipation, abdominal pain

Diarrhea Treatment – Pharmacologic
Bile Acid Sequestrants

• Cholestyramine, colestipol, colesevelam
• Up to 50% of IBS-D have bile acid malabsorption
• Bile acids stimulate colonic secretion and motility
• SE: bloating, flatus, abdominal pain, constipation

Diarrhea Treatment – Pharmacologic
5-hydroxytryptamine (serotonin) receptor
antagonist

• Alosetron (Lotronex ®), Ondansetron (Zofran ®)

• Restricted use

• Approved: Severe IBS-D in females
• Global improvement in IBS symptoms
• Relief abdominal pain/discomfort

144

Treatment: Abdominal Pain/Bloating

Abdominal Pain & Bloating Pharmacologic
Treatment: Probiotics

• Cannot routinely recommend
• Species, Strain and Dosing not known
• Limited negative effects
• I encourage my patients to use

Abdominal Pain & Bloating Pharmacologic
Treatment: Antispasmotics

• As needed
• Dicyclomine 20mg QID
• Hyoscyamine 0.125 – 0.25mg oral/sublingual TID

145

Abdominal Pain & Bloating Pharmacologic
Treatment: Antidepressants

• Tricyclics

• Anticholinergic properties – slow transit
• Avoid in constipation patients
• Start at low doses

• SSRI/SNRI

• Less data
• Inconsistent
• Use primarily in those where depression is a cofactor

Abdominal Pain & Bloating Pharmacologic
Treatment: Antibiotics

• Not routinely used
• In refractory patients who failed other therapies
• Rifaximin – 2 week treatment

• 550mg TID
• Beneficial effect on bloating/pain

Key Points

• IBS is common in women (14%)
• Initial therapy focuses on education and dietary modification
• Alarm features suggesting immediate referral:

• Onset after 50, rectal bleeding, nocturnal diarrhea, severe pain, weight loss, lab
abnormalities, family history of IBD/colon cancer

• Subtype diagnosis should guide treatment

146

Irritable Bowel Syndrome

John A. Occhino, MD, MS

147

Notes

Fecal Incontinence: Where 
are Now with Treatment? 

Christina Lewicky‐Gaupp, MD

Associate Professor
Director, Resident Surgical Skills Curriculum
Medical Director, PEAPOD Peripartum Clinic
Department of Obstetrics and Gynecology
Division of Female Pelvic Medicine & Reconstructive 

Surgery 
Northwestern University Feinberg School of Medicine

Karen Weeks, PT, MPT, WCS, CLT

Division of Female Pelvic Medicine & Reconstructive 
Surgery 

Northwestern University Feinberg School of Medicine

148

“Like the kid’s book says, 
‘everyone poops’. And at 
some point, some us feel 
like we’re going to poop in 

our pants.”
‐from hopkinsmedicine.org

“Fecal Incontinence in 
Women: a Q&A with an 

Expert”

Objectives

• Discuss pathophysiology of fecal incontinence
• Describe treatment options for fecal incontinence

Bowel Incontinence

Fecal incontinence: involuntary loss of solid or liquid
stool 
Anal incontinence: involuntary loss of solid or liquid 
feces or flatus

Often more bothersome than FI

149

Prevalence

• 2‐21% of population
• Non‐institutionalized people >65 (% adjusted for sex and age)

• 29.3% mucus
• 76% loose stool
• 29.2% solid stool
• 74.9% flatal (of those who had FI)

‐National Center for Health Statistics “Prevalence of Incontinence Among Older Americans” 2014

Impact “I’d never stay at my friend’s house. She has 
white furniture. Like her whole house is white. 
• Social impact What if I have an accident?!”

‐Isolation “There’s nothing like being in a meeting, 
‐Depression  presenting in front of my entire staff and 
‐ Institutionalization passing gas. They knew it was me.”

Impact 2010 average cost for FI:
$4,110 per patient for pts with more 
• Economic impact than one year of at least 1 episode 
of FI/month
• Cost of pads, supplies
• Institutionalization $2,353 direct medical + nonmedical 
expenses

$1,549 indirect costs associated with 
productivity loss 

150

Pathophysiology • Functional bowel disorders

• Weakened PFMs • IBS
• Pregnancy • Constipation/Obstruction
• Delivery • Outlet Obstruction/Dyssynergia
• Disuse atrophy
• Nerve injury/denervation • Impaired Rectal Sensation 
• Sarcopenia
‐Hyper (UC, Crohn’s), Hypo
• IAS defects

• EAS defects
• Trauma (obstetric, surgical)
• Surgery
• Radiation
• Non‐traumatic (scleroderma)

Case 

• 68 ♀ presents with 6‐year history of fecal urgency & incontinence

• 5 vaginal deliveries, one with forceps; OASIS; largest infant 10 pounds
• Worsening incontinence of solid, liquid, and gas 
• Psyllium fiber daily and pelvic floor physical therapy with minimal impact

• PMH:  obesity
• PSH:  cholecystectomy

Physical Examination and Diagnostic Testing

• Examination: decreased anal tone, intact 
reflexes

• Dove tail appearance, 1 cm thickness pb

• Surface Electrode EMG: reasonable isolation 
with decreased squeeze pressure activity, good 
relaxation, no evidence of dyssynergia

• Anal Manometry: anal resting tone of 25 mm 
Hg, squeeze to 55 mmHg, normal sensation, 
compliance 200 cc, normal RAIR

• Endoanal Ultrasound:

151

First Line Therapies

• 1st line treatment is

• Education 
• Pelvic Floor Physical Therapy
• Medications
• Normalization Of Stool Consistency 
• Bowel Habits
• Devices

• Surgery helpful for many women
• Need to be able to discuss all options with patients and individualize 

care

First Line Therapies: Medications

• Reduce stool frequency and improve consistency 

• Bulking agents: psyllium or methylcellulose
• Loperamide if diarrhea

• Bismuth subsalicylate 
• Cholestyramine

152

First Line Therapies: Devices

• Vaginal insert
• In‐office fitting

First Line Therapies: Pelvic Floor Physical 
Therapy

Fecal Continence

• Feel that you need to go
• Have a place to go
• Be able to get to that place
• Hold until you get to that place
• Be able to actually go when you get there

153

Feel Need To Go

• Awareness
‐Are you just going because 
you think you should?

• Stool consistency
• Sensation

‐Hypersensitivity
‐Hyposensitivity

Have a Place to Go and Be Able to Get There 

• Access to bathroom • Mobility
‐Create easier  ‐Hip motion/strength
access to  ‐Assistive devices
bathrooms
‐Have a plan
‐Bathroom locators

Keep Holding Until You Get There

• Use barriers • EAS “close the 
‐ Plugs circle”
‐ Pads
‐Imagery
‐Self 
biofeedback

• PFM strength
• LE strength

154

Keep Holding Until You Get There

• sEMG
• Balloon catheter retention

Actually Go When You Get There

• Abdominal bracing
• Splinting
• Stimulation

• Visceral motility
• Digital stimulation

• Positioning techniques
• Coordination training

Other Therapies: Perianal Injectable Agents

• First described in 1993
• Passive fecal incontinence
• 2011  non‐animal stabilized hyaluronic 

acid/dextranomer approved by FDA for 
treatment of FI refractory to conservative 
therapy
• Administered via anoscopy as outpatient
• No anesthesia
• 4 ‐ 1ml blebs

155

Hyaluronate Sodium: Clinical Review

• Four trials reported in the literature

• 367 patients*

• Hyaluronate sodium demonstrated consistent efficacy for all 
types of FI

• No safety issues

• Majority of AE’s were mild and self limited

*1.Graf et al Lancet 2011, 2.Dodi et al Gastroenterology Research and Practice 2010, 3.Schwandner et al Surgical Innovations
2011, 4.Danielson et al DC&R 2009.

Most Common Related AEs ‐ Patients Through 18 months

Preferred term Events % patients
Proctalgia 41 17.3
Injection site hemorrhage 18 8.1

Rectal hemorrhage 15 7.6
Pyrexia 14 6.6
Injection site pain 10 5.1
Diarrhea 10 4.1
Anal hemorrhage 9 4.1
Anorectal discomfort 8 4.1
Rectal discharge 7 3.6
Proctitis 5 2.5

Majority of AE’s were mild and self limited

What About Surgery?

156

Sphincteroplasty
Sphincteroplasty
Sphincteroplasty

157

Sphincteroplasty

Outcome Data

• Effective short‐term: 

• 70‐80% of patients report symptom improvement 

• Long‐term success deteriorates over time

• 20‐67% by 5 years
• 0‐40% at 10 years

Anandam, 2014; Sung et al, 2007; Tjandra et al, 2003; Garcia et al, 2005

Cochrane Review 2013: Surgery for Fecal Incontinence

• Lack of high quality RCT on FI
• Small number of trials, small sample sizes, and methodological 

weaknesses limit usefulness
• Unable to identify or refute clinically important differences 

between the alternative surgical procedures
• Larger rigorous trials needed
• Optimal treatment regime may be combination of surgical and non‐

surgical therapies

158

Case 2

• 67 yo female with a 7‐year history of FI
• FI of liquid/solid stool, 3‐times per week necessitating constant pad use and 

scared to leave her home
• Has had a sphincter repair, tried behavioral therapy including pelvic muscle 

exercises, other PT strategies, attention to diet, and use of medications with 
some improvement, but still room for improvement
• Recent 2 week diary revealed nearly daily bowel movements with leakage 2 
times the first week and 3 times week 2
• PMH:  hypertension
• PSH:  hysterectomy

Physical Examination & Diagnostic Testing

• Examination: decreased rectal tone, intact reflexes
• Surface Electrode EMG: reasonable isolation with good squeeze 

pressure activity, good relaxation, no evidence of dyssynergia
• Anal Manometry: anal resting tone of 40 mm Hg, squeeze to 70 

mmHg, normal sensation, compliance 100 cc, normal RAIR
• Endoanal Ultrasound: intact external and internal anal sphincters

She is considering colostomy‐
what surgical options are available?

Sacroneural Modulation/Stimulation

• Many potential neurologic targets

• Voluntary somatic
• Afferent sensory
• Efferent autonomic

• Rectal blood flow increased with stimulation as 
measured by doppler flowmetry

• Decreased episodes of spontaneous sphincter 
relaxation

• Electrical stimulation of the sacral nerves causes: 

• Modulation of neural reflexes
• Interrupts constant sensory input from rectum

1 Kenefick J, Br J Surg, 2003   2 Vaizey C, Gut, 1999

159

How Does It Work?

• Staged testing
• Simple outpatient procedure 

done under local anesthesia with 
IV sedation
• 2‐4 week bowel diary prior to 
placement, then 2‐4 week 
stimulation trial with diary
• Sustained benefit of up to 14 
years demonstrated in >80% of 
subjects

Matzel et al, 2009

SNS Adverse Events

• Most occur within 1st year of implantation

• Device pain (28%) 
• Paresthesia (15%)

• Infection rate 3‐11%
• Advancements in lead design and techniques 

explantation rarely necessary (3‐4%)

Tan et al, 2011; Wexner et al, 2010, Mellgren et al, 2011

Severe Refractory Fecal Incontinence

Artificial Bowel Sphincter (ABS) Anal Sling
‐ 50‐70% success rate • Investigational
‐ High morbidity – explantation • Similar to transvaginal or 
required in upwards of 1/3 of 
patients transobturator sling for UI
• Wound infections, sinus 

tract, ulcer
• Treated with antibiotics or 

removal
• Small sized inadequate 

studies to date

160

Severe Refractory Fecal Incontinence

PTNS Targeting Sacral Plexus
• Investigational
• Peripheral 

neuromodulation
directed to L4‐S3 nerve 
roots
• RCT with sham effective 
for OAB/Urge UI

• RCTs pending for FI

• 63‐84% reported ≥50% reduction 
of FI episodes/wk (bowel diary)  
in observational studies

Final Consideration

• Fecal Diversion

Key Points

• Fecal incontinence can be multifactorial
• Initial treatments involve medications, dietary modifications, stool 

bulking, physical therapy and devices
• Surgery can be successful in many women
• Sacralneuromodulation is a very promising treatment
• New treatments are on the horizon

161

Notes

Vulvar dermatoses

Amy Park, MD
Associate Professor
Departments of Ob/Gyn and Urology
Georgetown University School of Medicine
Section of Female Pelvic Medicine & Reconstructive

Surgery
MedStar Washington Hospital Center

Amy Park, MD

• @dramypark
• Associate Professor
• Associate Fellowship Director
• Education

• BA, Brown University
• MD, University of Rochester School of Medicine
• Residency, Obstetrics & Gynecology, University of Pittsburgh Magee Womens

Hospital
• Fellowship, Female Pelvic Medicine & Reconstructive Surgery, Cleveland Clinic

• Board certified

• Obstetrics & Gynecology
• Female Pelvic Medicine & Reconstructive Surgery

Disclosures

• none

162

Learning objectives

• Review signs, symptoms of common conditions affecting the
vulva

• Review signs, symptoms of common conditions affecting the
vagina

• Review diagnosis and treatment options

Why cover this topic?

• Very common
• Many women delay seeking care, causing anxiety,

embarrassment, fear of STIs or hygiene concerns
• With the right diagnosis, can significantly improve quality of life

with the appropriate treatment
• Worst case scenario – vulvar cancer = bad to miss

Symptoms

• Vulvar pruritus
• Burning
• Pain
• Irritation
• Dyspareunia
• Apareunia

163

Important questions to ask on history

• Urinary or fecal incontinence • Lubricants
• Use of pads • Use of hormone therapy –
• Soaps
• Douches either topical or systemic
• Baby wipes • Thorough medication history
• Powders • Ask if any other autoimmune
• Lotions
diseases, skin conditions
present
• History of STIs, sexual abuse

Look for

• Erythema
• Edema
• Lichenification (thickening of skin)
• Erosions
• Synechiae
• Tumors
• Atrophy
• Scarring
• Abnormal pigmentation

Differential Diagnosis

• Cutaneous disease • Vaginitis, vaginosis

• Atopic or eczematous • Atrophic vaginitis
dermatitis • Desquamative inflammatory

• Psoriasis vaginitis
• Lichen simplex chronicus • Candida
• Contact dermatitis • BV
• Lichen sclerosus
• Lichen planus
• Plasma cell vulvitis
• acanthosis

164

Differential Diagnosis

• Infectious • Neoplasm

• Bacterial: Gonorrhea, • VIN/vulvar cancer (squamous)
Chlamydia, Trichomonas • Paget’s
• Basal cell
• Fungal: Candida, tinea cruritis • Melanoma
• Viral: HSV, HPV, herpes zoster,

molluscum
• Scabies, lice, threadworm

Differential Diagnosis

• Systemic • Idiopathic
• Crohn’s • Vulvodynia
• Behcet’s • Drug eruption
• Pemphigoid • Dermatographism
• Systemic lupus

165

Vulvar biopsy

• Gather supplies in the underbuttock pull out drawer

• Betadine
• 1 or 2% lidocaine drawn up in syringe, 25 gauge needle
• Suture removal kit – forceps/pick up, scissors, 4 x 4
• 3 or 4 mm punch biopsy
• Silver nitrate stick

• Assistant should have formalin and silver nitrate ready, have
suture and needle driver available if necessary

Take biopsy at border of lesion,
incorporating normal and abnormal tissue

166

Atopic or eczematous dermatitis

• Symmetric erythematous
patches

• Histology: spongiotic
• Avoid humidity, tight pants
• Treatment: steroids

(triamcinolone 0.1% for
moderate, clobetasol 0.05%
for more severe cases) bid
then taper, topical tacrolimus
0.03% or 0.1% qd-bid

Contact dermatitis

• Erythematous, edematous
• Allergic or irritant (e.g. urine)
• Histology: spongiotic
• Indicates prior sensitization
• Diagnosis: patch testing or by

history or elimination
• Treatment: avoidance of

irritants, steroids

167

Lichen simplex chronicus

• Bilateral erythematous,
lichenified plaques with
excoriation

• Localized plaque caused by
chronic rubbing or scratching in
response to pruritus

• “itch/scratch/itch cycle”
• Hallmark: intractable pruritus
• Caused by vulvar irritation
• Treatment: steroids

Lichen sclerosus

• Autoimmune condition
• Causes itching, burning
• Whitening of vulva in keyhole

pattern
• Cigarette paper appearance
• Figure of eight pattern
• Obliteration of normal architecture
• Fusion of clitoral hood to clitoris,

labia minora to labia majora
• Diagnosis by punch biopsy
• Treatment: topical clobetasol

0.05%, tacrolimus
• Does not involve vaginal

epithelium

More lichen sclerosus

168

Lichen sclerosus

Surveillance necessary – 5% risk of vulvar cancer
can be prevented with compliance with topical steroid use
(Lee A, et al. JAMA Dermatology, 2015)

+ Squamous cell + VIN

In African-Americans, VIN appearance like “angry pink
lesions”

Vulvar intraepithelial neoplasia

169

VIN
Paget’s
Vulvar melanoma

170

Vulvar basal cell carcinoma

Lichen planus

• Autoimmune condition
• Causes pain, burning,

dyspareunia, vaginal d/c
• Scarring of loss of normal

architecture
• Stenosis of vagina, scarring
• Presence of well demarcated

erosions or glazed erythema at
introitus
• Hyperkeratotic white border to
erythematous areas or erosions
• Diagnosis by punch biopsy

171

Three morphologies LP – can co-exist

• Erosive

• Erythematous
• Glazed
• Agglutination
• Adhesions
• Vaginal stenosis
• Often associated with

inflammatory vaginal discharge

Lichen planus cont’d

• Classic
• Erythematous to violaceous

papules
• Lacy white reticular striae

Lichen planus cont’d

• Uniformly white,
hyperkeratotic plaques

172

Lichen planus

• Unlike LS, affects vaginal epithelium
• Affects 1% of women
• Also can affect mucous membranes of conjunctiva, esophagus,

urethra, anus
• Look at the mouth – findings can include erosions, reticulate striae,

gingival inflammation
• +/- copious vaginal discharge (lymphocytes, parabasal cells)
• Harder to treat than LS
• Treatment: topical clobetasol 0.05%, vaginal hydrocortisone 25 mg

supp (available for per rectum but rx for vagina), topical tacrolimus

Wickham’s striae
glassy erythematous plaques with white
striae

Gingival involvement

173

Psoriasis

• Autoimmune skin condition
• Characterized by rapid epithelial turnover
• Well-demarcated, erythematous silvery plaques
• Look for other lesions in typical locations: elbows, knees, scalp
• Can also affect skin folds, gluteal folds, umbilicus, axilla
• Moisture, friction can lead to poorly demarcated erythematous

plaque with minimal scale/shiny texture
• May need to biopsy
• Treatment: topical steroids, tacrolimus, salicylic acid, retinoids, coal

tar

Psoriasis

174

Pemphigus vulgaris

• Autoimmune
• Affects mucous membranes:

eyes, mouth, esophagus,
vagina, nose, lungs
• Can be caused by ACE-I,
penicillinase
• Blistering lesions
• Treatment: topical or
intralesional steroids

Cicatricial pemphigoid

175

Behcet’s disease

• Autoimmune • Inflammation of digestive
• Oral, genital ulcers systems (diarrhea), brain (MS
• Inflammation of eyes (uveitis, changes, aseptic meningitis,
HA, personality changes)
retinitis, iritis)
• Arthritis • Rarely kidney involvement
• Vasculitis • More common in Far East,

Middle East descent

Behcet’s

Behcet’s

• Diagnosis: by rheumatology
• recurrent oral ulcers ≥3 x/yr

plus 2 of following:

• Recurrent genital ulcers
• Skin lesions
• Eye inflammation
• “pathergy” test

• Treatment: topical steroids

176

Crohn’s vulvar involvement
Crohn’s
Crohn’s

177

Treatment

• Manage expectations
• Education re: chronic nature
• Avoid irritants/triggers, exacerbating factors

• Includes incontinence, diabetes management, obesity

• Restore skin barrier
• Decrease skin inflammation
• Symptom relief
• Prevent and treat secondary infection
• Treatment with vaginal dilators if necessary for stenosis

Restore skin integrity

• Wash with lukewarm water
• Do not use: washcloths, baby wipes, wet wipes, medicated

wipes, douches, powders, deodorant sprays, scented pads,
harsh detergents, perfumes, tight clothes
• Avoid hot water, bubble baths, deodorant soaps, spermicides,
condoms
• Use petroleum barrier ointment if necessary
• Consider going commando at night

Jen Gunter: @DrJenGunter
The vagina is a self-cleaning oven.

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Decrease skin inflammation

• Topical steroids – decrease inflammation, pruritus, autoimmune reaction
• Triamcinolone 0.1% for mild cases or clobetasol or halobetasol 0.05%:

• Depending on severity, apply bid then titrate to qd then 3-4x/week
• Educate that exacerbating factors (e.g. stress, humidity) may require increasing

frequency again

• Causes skin thinning so need to monitor
• Prefer ointment as cream has more additives
• May need adjunctive oral steroid taper 40-60 mg or triamcinolone 1 mg

diluted in 10 mg saline
• For lichen planus, may need intravaginal (rectal) hydrocortisone 25 mg

suppositories

Decrease skin inflammation

• Topical tacrolimus 0.03% or 0.1%, pimecrolimus 1%

• Inhibits T-cell activation, mast cell cytokine release
• Need to develop tachyphylaxis (2 wks) – intense burning and pruritus –

I advise pts to use topical lidocaine and ice or gel packs
• Use in addition to steroids if symptoms refractory
• Black box warning on lymphomas and skin cancer development

• American Academy of Dermatology & American Academy of Allergy, Asthma,
Immunology have protested this warning

Symptom relief

• Topical lidocaine 2-4%
• Cool gel packs
• Cut nails and keep short
• Try to avoid scratching or rubbing, even with towels or

washcloths
• Avoid scratching at night: amitriptyline 10 mg or hydroxyzine 10

– 25 mg

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Treat skin infection

• Keflex 500 mg bid x 7-10 days if superinfection present

Vaginal stenosis

• Causes dyspareunia
• Pelvic floor PT +/- vaginal

dilators, e.g. SoulSource

Vulvodynia

• Vulvar burning, itching, sharp pain
• Entry dyspareunia
• History of “never being able to use tampons”, vulvar burning,

pain with tight clothing, prolonged sitting, biking
• 3-15% prevalence in self-report studies
• 20-60 yo, mostly premenopausal
• If post-menopausal, I always start vaginal estrogen first!

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Vulvodynia

• Location: Generalized or localized or mixed
• Provocation: provoked, spontaneous, or mixed
• Onset: primary or secondary
• Often coexists with fibromyalgia, interstitial cystitis, irritable

bowel syndrome

Localized vulvodynia

• Most common
• Pain localized to vulvar vestibule, with or w/o clitoris
• Absence of identifiable cause
• Duration of at least 3 mo
• Pain elicited with pressure-point testing
• Diagnosis by Q-tip test

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Vulvodynia treatment

• Avoidance of soap, fragrance, douches, wipes
• Cotton underwear
• Compunded topical gabapentin 4 or 6% tid
• Topical lidocaine 2 or 5% to cotton ball nightly and before sex
• Amitriptyline 10-25 mg nightly
• Gabapentin 100-300 mg nightly
• Pelvic floor physical therapy +/- dilators
• Referral for vestibulectomy if refractory to above
• Patient education: nva.org

Take home points

• Avoidance of irritants
• Practice good vulvar hygiene
• Low threshold to biopsy
• Most dermatologic conditions treated with immunosuppressant

therapies
• Anti-histamines for pruritus
• Encourage careful follow up and compliance

References

• Stockdale CK, Boardman L. Diagnosis and Treatment of Vulvar
Dermatoses. Obstetrics & Gynecology, 2018; 131(2): 371-386.

• Stewart KMA. Vulvar Dermatoses: A practical approach to evaluation
and management. Jcomjournal.com

• https://medicine.umich.edu/sites/default/files/content/downloads/The
%20Latest%20in%20Vulvar%20dermatoses%20PPT.pdf

• Boardman LA, et al. Topical gabapentin in the treatment of localized
and generalized vulvodynia. Obstet Gynecol, 2008; 112(3): 579-85.

• Burrows LJ, et al. The Vulvar Dermatoses. J Sex Med:
http://www.cvvd.org/assets/files/vulvar_dermatoses-_JSM.pdf

• Edwards L and Lynch PJ. Genital Dermatology Atlas.

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Notes

Compounded Medications for
Pelvic Floor Dysfunction

Cara R. King, DO, MS
Section Chief of Minimally Invasive Gynecologic Surgery

Assistant Professor, University of Wisconsin-Madison

Disclosures

• I have no conflicts of interest

Objectives

• 1. Review definition of pelvic floor dysfunction, risk factors, and
types of dysfunction

• 2. Discuss various compounded medications to consider in your
pelvic floor dysfunction treatment plan

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Pelvic Floor Muscles

Pelvic Floor Functions

Pregnancy Pelvic
and child organ
support
birth
Bladder
Breathing and
bowel

control

Sexual Passing of
function urine and

feces

Pelvic Floor Dysfunction

• Often result of pelvic floor muscles being:

Too tight Too relaxed

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