Pelvic Floor and Other Pelvic Disorders

Vulvodynia

Definition

Vulvar discomfort occuring in the absence of relevant visible findings or a specfici, clinically-identifiable, neurological disorder.

Symptoms

• Burning
  
• Stabbing
  
• Stinging
  
• Itching
  
• Allodynia (light touch perceived as pain)
  
• Hyperalgesia (mildly noxious stimulus perceived as severely noxious)
  
• Functional limitation (e.g. pain during intercourse, using tampons, sitting)
  

Diagnosis

Symptoms should be present for 3-6 months before this diagnosis is considered.

Other conditions that should be ruled out include;

• Vulvovaginal candidiasis
  
• Bacterial vaginosis
  
• Trichomoniasis
  
• Genital herpes
  
• Neuropathic viruses (e.g. Herpes zoster)
  
• HPV
  
• Lichens simples chronicus
  
• Lichens simples sclerosus
  
• Lichens planus
  
• Contact dermatitis
  
• Atrophic vaginitis
  
• Squamous cell carcinoma
  
• Pudendal nerve injury
  
• Referred pain from sacral nerve roots after disc injury
  
• Neurologic disease (e.g. MS)
  

Classifications

Generalized vulvodynia;

• Almost constant, typically burning pain
  
• Affects the entire vulva
  
• Provoked (sexual, non-sexual or both)
  
• Unprovoked
  
• Mixed (provoked and unprovoked)
  

Localized vulvodynia / vestibulodynia;

• Localized to vulvar vestibule
  
• Burning / cutting pain at entrance of vagina
  
• Provoked (sexual, non-sexual or both)
  
• Unprovoked
  
• Mixed (provoked and unprovoked)
  

Co-Morbidities

• Interstitial cystitis
• Fibromyalgia
• Irritable Bowel Syndrome
• Depression
• Dyspareunia
• TMJ or facial pain
• Overactive pelvic floor

Dyspareunia / Vaginismus

Definition

Dyspareunia: Painful vaginal penetration in the absence of disease

Vaginismus: Inability to penetrate due to spasm of the muscles

Causes

• Painful scar / episotomy
• Vulvodynia - Interstitital cystitis
• Protective response to infection, inflammation, injury or decreased estrogen or fear

Lichens Simplex

• Chronic irritation of the vulva
• Leads to itching, scratching and thickening of the skin
• Vulva can be weepy, causing moisture

Lichens Sclerosis

• Auto-immune disorder
• Itching or burning
• Skin with white patches
• Scars and adhesions of the vulva
• Easily bruised and torn

Lichens Planus

• Chronic mucocutaneous disease
• Itching or burning
• Scar adhesions
• On the vulva and in the vagina
• Affects other mucosal membranes e.g. oral, genital, esophageal - oral rash typically occurs first
• Significant pain

Desquamative Inflammatory Vaginitis

Definition

• Profuse discharge with irritation of the vulva and vagina
• Inflammation causes the vaginal wall to peel or shed (desquamation)
• No cancerous, contagious or bacterial origin known

Signs and Symptoms

• Pus-like yellow/green discharge
• May be vulvar burning and itching
• Usually no odour
• PAP smear may be abnormal
• No improvement with anti-biotics or anti-fungals

Atrophic Vaginitis

• Decreased estrogen causes thinning of the vaginal epithelium leading to inflammation
• Can cause vaginal soreness, itching and dyspareunia
• Sores and cracks can occur spontaneously
• Can have an odours discharge

Interstitial Cystitis / Painful Bladder Syndrome

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Dysmenorrhea

Definition

Painful menstrual periods

Classification

Primary: Menstrual pain without pelvic pathology, onset shortly after menarche

Secondary: Pain associated with secondary pathology, onset may be years after menarche

Risk Factors

• Low BMI and low consumption of fruit, eggs and fish (for primary dysmenorrhea)
• Poor mental health
• Primary co-morbidities: irritable bowel syndrome, interstitial cystitis, vulvodynia, dyspareunia, TMJ and migraines
• Secondary co-morbidities: endometrioses, presence of intra-uterine device, pelvic inflammatory disease, uterine myomas and adhesions
• Smoking

Endometriosis

Definition

The abnormal presence of endometrial tissue outside of the uterus. This tissue implants and can behave in a similar manner to the uterus, shedding tissue and inflammatory molecules into the abdominal/pelvic cavity.

Symptoms

• Subfertility
• Pelvic pain including dysmenorrhea

Co-morbidities

• Irritable bowel syndrome
• Interstitial cystitis
• TMJ disorders
• Migraines
• Fibromyalgia
• Auto-immune disorders

Anal Fissures

Definition

Tears in the mucosal membrane of the anal canal, usually extending from anal opening. Can become chronic and deep.

Signs and Symptoms

• Pain after bowel movement
• May notice bright red bleeding on toilet paper

Causes

• Stretching of anal mucosa beyond its capacity
• Constipation or prolonged diarrhea
• Trauma during childbirth
• Crohn's disease
• Anal sex
• Poor toileting in young children