Chapters Transcript Not all that Itches is Yeast: Vulvovaginitis in the Pediatric & Adolescent Patient Dr. Maggie Dwiggins, MD, MS share techniques for a proper exam, how to diagnose common vulvar disorders and how to adequately treat vulvovaginitis. And now for our first presenter, we have Maggie De Wiggins. She earned her medical degree at University of Illinois, Rockford, Illinois. Then she did her residency at the University of Illinois in Peoria and her fellowship at Medstar Georgetown Hospital Center in Washington DC. Doctor De Wiggins is currently an assistant professor in the division of obgyn pediatric and adolescent gynecology with the washi physicians and sees patients at Barnes Stewart Hospital, Missouri Baptist and the Washington University pediatric specialty care at Memorial Hospital in Shiloh. She sees patients for congenital anomalies of the reproductive tract ad nexal. How do you pronounce that? Doctor Gilligan, anal and all mas mentally invasive surgery and fertility preservation. So, thank you so much for joining us today and we look forward to talk. All right. Well, thank you for having me because this is clearly my favorite topic is pediatric and adolescent gynecology. Um And it's something that I love to talk about and I feel like we don't have that many lectures about. So, yeah, so I'm happy to be here today. Um So today, what I would like to do and so that you can see this is my title and I have no, um, there we are, I have no commercial or financial disclosures. But by the end of the lecture today, I really hope that you will gain an understanding of how to examine the vulva of somebody who's prepubertal as it is different from somebody who's already gone through puberty. Uh And then also just like the diagnosis of probably what I compiled is the most common referrals that I get for vulgar complaints in that pediatric population. And then just for you to kind of re reflect internally and understand what you feel like. Oh, hey, I could treat this or do you want to refer them and then kind of how to refer them to us? So um on the agenda today, it'll be that introduction, this evaluation and then I'll just talk about the three topics that I get the most uh conditions that itch bleed and hurt. I guess another disclosure is I'm not really going to talk about um sexual trauma and abuse today, but I will talk like a little bit about trauma as it relates to the Volva. But, but not that that's like a whole different topic. So for the introduction, um any time that I see a patient before me, I'm clearly going to do a history and a physical exam for the very young patients or for those who might be very, very nervous in the history, I really ask that the patient participates. So I make eye contact with the patient. I really want to know it names that they use for their own body parts, use those names and then say, oh, hey, I say this for this body part and this is where it's located and sometimes show them pictures and just actively engage them in the conversation from the get go. And then before I do a physical exam, we always always talk about good touch, bad touch. I make sure that they understand that the only reason that even a doctor should be examined in a private area is because they have a guardian present with them and that if they're ever alone with somebody, they shouldn't be looking in this area. And I always ask permission of my patients too. And if they say no, then we talk about it. And on an on occasion, I don't do the exam during that first visit unless I think that it's really an emergency, but usually the patient will, will eventually give ascent to, to go. Um And then a lot of times I'll also start out, this is just kind of like pearls. What I've noticed helps. I will start out with my hands behind my back and say now you just let your legs fall to the side and show me yourself no touching. And then I'll start out just by saying, ok, well, I think I need to touch with one hand here or one hand there. Um And it works usually pretty well during the teaching exam. This is what I do with the patients almost exclusively. They don't want the mirror, but that's OK. I still offer it. Um but I make sure to teach them what all the structures are so that they know that the, they understand the words that I am using to describe their anatomy. And so for the exam, there are differences in the appearance of the prepubertal, un estrogenized Bulba and vagina that are different in the post pubertal or estrogenized vagina. And I think that these are key differences. First of all, the labia minora are minuscule and sometimes you can't even appreciate them or they're just like this tiny little puff of structure around the urethra. They are clearly more prominent than somebody who is post pubertal and they do tend to grow with estrogenization. And so they will grow kind of around the same time that breasts start to grow. And so it's really typical. I get a lot of consults about um A B our mass around the time of breast budding. Um the structure would be the hymen. You can see the hymen looks totally different in the post pubertal patient. It's very squishy redundant um pink and then the prepubertal patient, it is very vascular and bright red. And I also get a lot of consults about redness in this area. And I should just say like a beefy red appearance of a Hyman is actually very, very typical. Um you can see here the tissue is a lot more prominent and that's of the posterior for she. And so there's really no give right there. And so where in the postpubertal patient, that area of the body, the poster for she is very stretchy and you can just spread it. This area of the prepubertal patient is incredibly delicate and could, could tear pretty easily. And the maa um are usually very, very fat and plump and especially in a very young person may be contiguous with the folds of the growing or bottom as well. Um But they also will start to grow with estrogen. And then last is the mos um this is the area that will eventually grow hair and sometimes there can be hair present in the pre feral patient as well. Um I guess last is just the, the clitoral hood as you can see there. All right. So as far as the exams go, this exam is what I would do for somebody who is pubertal. So you can see I can really spread the tissue apart, stretch it, you can push down, you can push up, you can push directly to the sides like at uh three and nine o'clock. But in the pre pubertal patient, this is the stretch technique. And so I just pinch the labia and pull out instead of pulling or pull, pull towards myself and start pulling outward. Because if you could see if you pour, pull outward that area of the posterior for she can absolutely rip and we don't want that trauma to the patient. Um So usually I will push on the actual the buttocks. If I want to see clearly, just to kind of spread the lady, I'll push down kind of at like five and seven o'clock position. And if I need to put to see into the vagina, I do as I pinch Alaa pull them shut, ask the patient to cough and as the patients cough and then I pull out towards myself. Uh and I can even do that a couple of times while they're coughing and that puts air into the vagina and opens up the hymen. So I can see into this distal portion of the vagina. Um and that works really quite well and it is really low discomfort to the patient. And I just wanted to include what is normal for the post pubertal patient. I get a lot of questions about symmetry and quote unquote labial hypertrophy. And I have to say I have actually myself never seen labial hypertrophy. Uh There's no real consensus what is abnormal and sizes do vary. But I would say that a five centimeter, Lavia still is considered normal. And really, it's not until you can see the picture on the left. That's where the Lavia is being spread and they actually touch the, the legs when they're in frog leg position to measure the labia, you start the measurement by just folding over, not stretching, but just folding over the Labia Minora and where they meet the Labia Madura, that's where the measurement starts. And then you can see like the patient on the right, the labia mi minor is about 1.5 centimeters in width on one side. Um So this is just some statistics, 90% of labia will be around three centimeters or smaller. And I would say that kind of checks out with what I see, more than half of patients will be able to see labia minora without spreading the labia at all. So it's very, very normal. Uh and then just kind of note, so that if you guys see these patients, they come to you wanting uh labiaplasties, there is actually a federal law. Um that kind of criminalizes labiaplasties in a minor for normal anatomy. And it's part of the female genital mutilation law. Um And so really, if they're normal, they could come to us for a second opinion, but just kind of set the expectation that normal labia should not be operated on in a minor, really. All right. And now just to kind of get into the presentation, I will start out with v vaginal itching because it is probably the main complaint that I get. And this is just kind of a tongue in cheek slide. Um but in a prepubertal patient, vaginal itching is not yeast. Uh So yeast cannot live in the prepubertal vagina because the condition is too basic. It's not until estrogen is involved in the process of the vagina becomes more acidic and that's when the yeast can survive. So, yeast, it's like a natural defense against yeast. So there's really if it's itchy, it's not yeast, let's not treat the blue. Can I have seen some pretty good chemical burns and contact dermatitis from nice statin. And so I really would recommend trying to avoid treatment for yeast. Now, the caveats are if the patient is still in diapers and it looks like an external skin yeast infection. If they are um poorly controlled diabetic or otherwise immunocompromised, then it could be yeast. But again, just use your kind of best judgment. All the itches is not yeast. So the three things that I want to talk about the most would be non-specific b vaginitis pathogens associated B vaginas and then lichen sclerosis. And this is what really itches the most. So non specific vaginitis. That is the most common cause of itching that I see. So it's about 75% of all patients who complain of vulva, vaginal itching and redness have just non-specific vulva vaginitis. These don't need to have cultures and really it's just hygiene and emollient will, will really help these patients. Uh The presentation is usually that it's been persistent two or three weeks, they haven't gone away. That's usually when I see them. Um I will sometimes get a vaginal culture but they typically don't grow anything or they're like normal flora. Um do not test for BV in these patients either because the BV test will come back positive since the flora of the prepubertal vagina is different than the post pubertal vagina. And BV is specifically testing for that flora in the postpubertal patient. Uh All these pictures here, those are examples of non-specific v vaginitis. So nothing to do except for like conservative management. See on the far left, those secretions, the insulated secretions can be very, very irritating to this delicate skin. And so this one would be just like hygiene. Changes are probably some vain or aqua form. That would be really quite curative. I think in the middle there most likely there's gonna be some urinary dribbling that's contributing to her symptoms uh because you could see some skin down from persistent moisture. And then on the far right, this redness is super, super typical um of of poor hygiene as well. It's just the areas of the skin that touch or uh are opposing, that become red and inflamed and sometimes get these like little blisters or little ulcers there. So these are all just non-specific and the treatment is really improve hygiene. I find that most of these happen around the time of potty training and there's another influx around kindergarten when, when uh these patients are really more independent with their bathroom hygiene. So there's usually area of improvement there again, that's just like wiping, to be making sure to actually wipe too. Um I do like sits baths, so plain water baths for 1015 minutes and then stand up to shower. I don't like them to sit in the bubbles or sit in shampoo or anything like that. Um But I do of just plain water baths for vulva vaginitis, uh white cotton underwear. We used to say that but now it's not quite as important. If the color though is rubbing off on the skin, then that could be contributing. So they can always try different brands of underwear and see what helps them. Um I like unscented dove, the best kind of for the body of a small girl anyway, but no soap in the velvet is absolutely appropriate. Just water is fine. Um And then when urinating, I asked them to spread their legs really far apart, so knees really far apart and then put their elbows on their knees to kind of lean forward to direct the urine into the toilet um as opposed to sitting with legs closed. And so that the dribble kind of goes into the vagina and that's what's called vaginal voiding. Uh patients like to sit backwards on the toilet and that really helps to spread the legs too and direct the urine forward. And then the emollient that I like. Um for my derm colleagues are Vaseline deci and A and D. Uh They say that really nobody is allergic to those things. And so those are really good resources for the boba. Now, pa oops sorry pathogen associated v vaginitis, the way that this differs is there, it is sedative. And so what you can see is that white purulent discharge is kind of on the hymen itself. So this pulse is coming from the vagina. It's not just like secretions caught in the labial folds and it's usually quite sticky and maybe a little malodorous that erythema of the hymen and the vagina is very impressive, like this beefy flaming red appearance. I would always culture these uh most commonly it's gonna be skin or upper respiratory that has caused this. And I really, really often see these after like an upper respiratory infection. So somebody was sent home from daycare because they had a fever or they now have a cough and runny nose and they can get bone vaginitis. Most common causes would be h flu uh group, a strep or, or strep pyogenes. And then you guys probably know even better than I do how to treat any of these. Um But really just a pic on uh family, I usually use amoxicillin for almost everybody and it works pretty well. I just wanted to highlight one thing that causes itching too that we can treat is pinworms. And so a lot of times um if I have culture negative excruciating itching, that's just not getting better. I will just treat empirically for pinworms and I don't know, maybe half the time the parents say maybe they saw some penguins and half the time they don't. Um but it doesn't typically cause harm. So those are the two Volvo vaginitis side by v vaginitis is and the next lichen sclerosis. And this is something I also see pretty commonly. I have at least one or two patients every single day with this. Uh So the the cause is the hypo estrogenic state. So that's like the cause. But is this also partly autoimmune? Is it partly chronic skin injury? We don't necessarily fully understand the mechanism of action here. But really what happens is one of the skin layers starts to be attacked by the body and that causes itching and then disruption of the skin. This happens in a bimodal distribution. So somebody who is usually earlier in life, usually before age 10. Um and then post menopausal women, also the findings or the presentations like relapsing, remitting, intense, intense pitti uh lots of scratching, especially at nighttime, maybe some explorations and vaginal bleeding. There's often once as it progresses there, vulva peral pain that can lead to dysuria, holding patient. Um this kind of touching, pressing in that area as well on exams. Papa mic is the texture change in the skin. And so the kind of old term was a cigarette paper. Now we're saying just crinkling of the skin. Uh and it's usually hypopigmented and figure of a pattern and you can see that pretty clearly. In the second picture there. You can see the hypopigmented pigmentation of the labia majora, the clitoral hood, the perineum and the perianal region. Um This can also be associated with telling petit and fissures as well. And I've had a couple of consults that look like the, the third picture there in the middle um for somebody who had supposedly beal trauma and then has for the past seven weeks, has not had a resolution of their bruise. And really, that's just a finding of like and um and then treating with steroids um makes them go away the farthest picture on the right there. I would consider this the most extensive version of lichen and kind of more, I'd be more concerned about this one. But you can see there is complete loss of architecture of the labia Madura to minor to clitoral hood. So the whole top area has just scarred together, the skin is so, so thin and so so shiny and white and this is action pretty aggressively to, to try to salvage some of the architecture. You can also see that area of the perineum um looks like it's starting to structure clothes too around the vagina and this can be permanent if we don't treat it. So this is kind of a proposed treatment algorithm. Um But basically anything that looks likely in sclerosis will treat it likely in sclerosis. And I like using clobetasol B ID. Uh If there is disease improvement and then I would taper and I would say I almost always treat for three months before I will taper persistent disease. After that, we could consider a biopsy, but that's usually less, less recommended. Um Because there's not really much else that it could be except for lichen and it doesn't progress as it does in the adult. Uh So usually if there's persistent disease, that's when I will engage the services of my dermatology colleagues and start a Calci an inhibitor for these patients. Uh So the follow up, I will see them in my, in my office every single month. So every four weeks, I'll bring them back until there's remission. And like I said, that usually takes three months of B ID dosing of clobetasol recurrence rate is very, very high though. So about 80% will recur. So I have them returned one month after treatment, then three months after that, then six months after that. And then I do a skin exam every 12 months. Unless there's like a lot of recurrence, then I might do it every six months. We also used to think that after puberty that this was cured. Uh But we see that that does not actually happen anymore. Uh So we used to say that 10% of these, but now we're saying it could be much, much higher. So really, we do need a skin exam every single year for recurrence. Um And then there's a question always about vver squamous cell carcinoma. This really has only been shown in the post menopausal population that happens in about 4 to 5%. There's one case report of a 37 year old who had lichen who was a, as a preverbal patient. Um But she also had a lot of other risk factors for squamous cell carcinoma. So it's hard to say was there a correlation, but she's the youngest patient so far. Ok. So on to bleeding. So the differential, the most common differential for bleeding would be mini puberty, foreign body or urethral prolapse. Um And then of course, a trauma uh and I have this asterisk that non-specific pathogen associate of vaginitis, non specific and pathogens associated can also be associated with bleeding, especially their skin breakdown. So the many actually interestingly enough just saw consult about this in the in the hospital this morning. Uh But it's this phenomenon that happens from birth up to two years old. And it's really when the the female babies are withdrawing from the maternal estrogen that they had during uh while they were in utero and it most sharply declined immediately after birth. So I'd say in the week or two after birth is when it's most likely to happen. And then there's this reflex uh brain stimulation of the ovaries that causes estrogen to rise again and then it will fall and then it'll just kind of like wax and wane over time. And so some patients will have just spotting here and there. Some will have spotting for two or three weeks. Some have periods like spotting once a month for six months. Um But usually the bleeding is no more than like a half dollar size every so often throughout the day. I would, I'd be very concerned if they were filling up a diaper with blood. Um And the bleeding itself usually improves around six months. But breast budding is really common with this too. And the breast budding is what's usually more persistent for about two years. A foreign body. This this I usually know when I walk into the room. So a foreign body has bleeding and copious, very malodorous discharge like it smells kind of like a road kill and that's, I guess to be expected because there's a foreign body that's irritating the skin and the skin is starting to break down and it's persistently just in there and causing breakdown and scar formation and stuff like that. Um So it's a very, you look at the perineum, it's got slimy sticky green, red brown smelly discharge and that's usually foreign body. Most commonly, it's toilet paper, especially again from kids who are just recently in school or toilet training who are using those terrible thin toilet papers and rubbing vigorously. And so then they just rub so much at little pieces of tissue paper, get caught inside the vagina. Oops, I'm sorry. Um, and over time will kind of build up. Uh, there are other things, you know, I take out toys all the time. Batteries, screws, beads, you know, you name it. Play, do like all kinds of stuff out of the vagina. Uh, if it's something like hair or toilet paper, then a vaginal lavage in the office is actually really quite successful, but any heavier item will need a sedated exam. Um, and removal. Uh, of note, if we're gonna do a vaginal lavage, then be very careful to avoid the Hyman because it's exquisitely sensitive in a prepuberal patient. Um, and then urethral prolapse. So this one I'm usually consulted because of a vaginal mass or a lot of times it'll be for possible uterine prolapse, uh because it could get pretty big and just fill up the entire space between the Lavia. This usually presents with bleeding and dysuria, but it can be just asymptomatic bleeding as well. There will sometimes be a history of increased pressures. This is usually not in a small child unless they have significant constipation, but more around the ages of like 4 to 8. Um And this could be a child with, again, constipation, obesity, uncontrolled asthma, that those sorts of things. Uh But really, there's no real cause I think this is just like risk factors that would increase the likelihood of it. Um The findings on exam will be this doughnut mass. So it's just this mass with a hole in the middle, sometimes bleeding around the edges. And then if you do that exam where you pinch the baby and pull towards yourself, you can see this little crescent of a lower vagina inferior to the mass. And the treatment for this is topical estrogen twice a day for two weeks as well as a bath every single day. And they respond very, very well. They didnt do tend to recur um and a mild recurrence without any bleeding or symptoms can be safely watched with just the sits bath. But if they have recurrence of symptoms as well, then I would retreat them and then last for the bleeding would be vulgar trauma. Um So, like I said, trauma of, so this would be unintentional, non accidental trauma versus accidental trauma. So, non accidental trauma is a completely different topic. And so I'm not really gonna go into that here. Um But just in like how you can differentiate. So the trauma that I really want to talk about is a straddle injury and they can be pretty profound. Uh So what happens is just like when a kid can fall on their knee and the skin of the knee breaks apart because of the pressure of the bony surface, um the pressure of the tissue against the bony pelvis. So, so, so often it's anterior around the clitoral hood or posterior by the, the sacrum in the pelvis. Um and that causes a shearing force and splitting of the skin. Uh This type of injury almost never involves the hymen or the vagina. And so the most important thing for this exam would be to determine if the hymen is intact or not. If the hymen is intact, then there's never a penetrating injury. And even if you see bleeding coming from the vagina, it's probably pooled blood that's coming out. But if the hymen is damaged and there might be some, some vaginal damage as well. Uh I would say I almost always treat these conservatively. Um I find that these heal like magic in about five days and somebody who is young, um and stitches will often cause more discomfort than just the open incision. And so I usually will treat them with six baths and Vaseline also. Um But if there's somebody who has acute bleeding, a deeper defect, you could see this picture here, there's a hematoma of the clitoral hood and a defect that extends up the right labia, majora and kind of like a second degree obstetric laceration as well. So this patient would need to have an exam under anesthesia and probably be repaired in the or um for anybody who has damage to the hymen, I would also take them to the or just to get to evaluate the rest of the vagina and see if there's any bleeding. The hematoma is, I probably should have put this in here too, but a hematoma also is usually managed conservatively with pressure. Uh they are not drained unless the skin itself is being compromised and is necros because the bleeding vessels tend to retract back into the tissue. This area is extremely vascular. So you can't hardly ever find the vessel. And then removal of the clot make releases the pressure that's kind of tampon in itself. And so then there's like clot reformation, he would have a reformation and continued bleeding. So travel injuries, they will treat conservatively. Now how to differentiate that between non accidental trauma. Um I would s so on history if they're telling me something and I'm looking at the injury and I don't think that this matches, that would be my first red flag, especially if they say there's a history of falling on the monkey bars or the teeter totter or on a bicycle and there's hymenal damage. So get none of those things unless they fall, sit on something sharp. I've had like spigots of the bathtub then post those sorts of things. Yeah, that's gonna go into the vagina probably and cause some damage. But really anything else that they sit on is not gonna go into the vagina. And so if the hymen is damaged and the history does not seem like it should have damaged the hymen, then that would be very, very suspicious. Um This usually will require multi, multidisciplinary involvement. So if there is trauma, we don't delay necessary procedures for a same exam, but I would want a certified provider to be with me in the room so that we could take some pictures and get whatever swab or like collect whatever we can possibly collect because we don't want to miss out on an opportunity. Um, but that's really it. I think you are probably hopefully well versed at being a, a responder, a responder. Um, and just keep that in, in mind, but bruises otherwise bruises the labia at daycare. I I don't often get worried about. All right. So that's trauma and then last will be vocal vaginal pain. So for this one, I've kind of chosen to, to talk about and that would be the apus ulcer and pelvic floor dysfunction. As I discussed earlier, trauma causes pain, a history of trauma causes pain in the pelvis a lot of times. And so we need to always keep this on our differential and I will still do an exam. But if there's nothing there, there's a history of trauma, then I very strongly recommend multidisciplinary treatment as well as mental health provider. Um And so that's, that's kind of all I'll say about that. Uh Now on an abscess ulcer, uh this I also see very, very commonly, I see this about once a week too. Uh And it's usually from a provider who said that they've never seen anything so terrible looking ever in their career. So these usually happen in kind of the perry adolescence. And so 8 to 13 is like real prime time to get these. They are extremely painful, extremely acute. So they've happened from nothing to this huge ulcer in two or three days and usually from a viral Pro Dome prodrome. And so oftentimes these patients will come to me and say that they've had this upper respiratory infection, they had strep throat, they had mono COVID is a big one. And then like two or three days after they started feeling terrible from an upper respiratory standpoint, and then they started noticing these really super painful ulcers. Uh These patients also, I don't know why, but they're usually never sexually active either. And I guess they're just unlucky because they form like that. The etiology is unclear but it's not an infection. So it's really just the way that the body is responding to some specific viruses or some specific condition that they cause ulceration of the opposing tissue of the vulva. Um Usually with biopsies, it just shows inflammation and I've never seen an only biopsy. There is a hand handful of times that I've never seen it come back from growing any microbe. Um So, uh the findings, these are usually sharply, sharply demarcated and what I would describe as punched out ulcers usually pretty big like two or three centimeters in size. Uh There's this dark necrotic base. They can't, they can be exed. I'll get um consulted for a volar abscess that has like whiteness and they're like, oh, it's a draining volar abscess, but it's actually this abscess ulcer just with exit on the top. Um And then they can form this like little necrotic exo of caps on that. That's what that middle picture is. So, so, so painful. Um, the treatment for them, definitely supportive. And so I'll do topical. Lidocaine sits baths, um, topical emollient again, especially with urinate and have them get a peri bottle, which is a sport bottle that we use. Um, postpartum. So, per bottle to pee or pee in the shower or the bathtub, apply Vaseline or lidocaine before pee. And those sorts of things, usually they'll have to stay home from school and then I find some pretty good success with steroids um for I like the Medrol dose pack. Um even though the patients often feel terrible, but it seems to shorten the course by about five days. And if you're talking about two weeks, a week, little over a week, then that can be pretty significant. Um If they're very, very painful or very, very big, then I also might add topical clob is all there to just help with the healing. Um But a lot of my patients say that the clob is all stings and you can't place it after the Vaseline or it's not, it's defeated the purpose. You can't place it after the lidocaine. So I kind of leave it up to the patient. They think they want to put something on it topically, but I have really good success with the Medrol dose pack. So as far as the proposed algorithm, so for these vulgar ulcers, um I usually do not do HSV testing, but I think that almost always when I have gotten the patient, they have already had this sort of testing because it looks like herbs, you know, and it's super painful just like herbie. So I don't think it's wrong to rule that out. Um If it is the first episode and you would talk about associated symptoms, like fevers, chills like bad, not those sorts of things. Pro drones. Um If this is and then kind of go with the work up from there, if, if you feel like this could be a virus that is important like EBV or MONO or influenza or COVID for that matter. Um Then I would test for those things. I've actually started asking all those patients who presented to me with upper respiratory infections to also get COVID test just in case because it does happen so frequently with that. But if there's really just a non-specific pro no other symptoms that it could just be like, I don't know, I don't know why this happened and just treat them both the same. If this is recurrent, I often will refer them to rheumatology. Um They have G I ocular or oral symptoms. So that's when I think about be she and I would also probably send them to rheumatology. I have on occasion biopsied these because they wanted to know if it was bets versus an aus ulcer. And percent of the time says inflammation could be bets versus api ulcers. So, again, I have found that to be very unhelpful, um, a biopsy and it's very painful. So it would have to be a sedated procedure for that. But rheumatology, if it's beets or if it's just recurrent apus, ulcers treat them the same, that's often with colchicine. Uh So at least here they don't mind the referrals. Um If what I'm doing does not seem to be helping. Mhm. And then last would be pelvic floor dysfunction. And this one is probably the hardest to treat for me because there's really nothing to treat except for behavior and desensitization, desensitization of the patient. And so a lot of times these people will come to me with burning cramping, tender feeling of the vulva, kind of painful to sit on feeling wet all the time. They usually have a history of significant constipation or urinary holding. You think your muscles are so, so tight down there that there might be this muscle spasm component to your pain. Um The etiology is just a hyperactive nerve response to those sustained contractions of the muscles and that's what needs to be treated as those hyperactive, tight, tight, tight muscles on exam. It'll be mostly normal except for like really seems to be like out of like more than you would expect discomfort with the exam, especially even just like palpate in the buttocks or like around the elevators can be very, very tender. Even just like a bladder exam, like pushing on the bones or at the p pubic synthesis can be pretty uncomfortable. So for these, I would do pelvic floor physical therapy and I actually have good success even in three and four year olds. Um because we just, we really need to learn how to react, relax that pelvic floor in somebody who's younger physical therapy will address muscle tightening of the pelvis in in the older patient who also wants to use tampons or be sexually active. That's usually when internal vaginal therapy is, is initiated. But in somebody who's younger, you can feel confident that they will do age appropriate sort of therapy. Uh I can also consider tricyclic antidepressants as an adjuvant. And this is kind of the similar thought as if we are treating migraines, abdominal chronic abdominal pain, endometriosis pain, those sorts of things. Um I start with a low dose at bedtime and kind of lean off as soon as possible. But I have found that it's helpful, um especially in early physical therapies, we're addressing this. So. Ok, well, that is it. Um this is, you know, this is a book that I love, I might be a little bit biased. Uh But we wrote this protocol book really specifically for like emergency rooms and primary care providers to be able to reference and see what you think you can, can gain from it. Uh, but the contributors were amazing and this is our little team and this is how had a little team. Um, we have, we see people everywhere. So here at the center for outpatient health, uh South County Missouri Baptist, Shiloh and Tele. All right. Thank you so much, Doctor De Wiggins. Does anyone have any questions that they'd like to put in the chat or in the Q and me? It looks like there's some checks. You can also just go, I think emails I just checked and it looks like 11 person had trouble also logging on. Um, don't see any yet. Oh, wait here Q and A. How do you get the book? Oh, it's on Amazon. There you go. Yeah, you can just, I guess you could just search for my name or pediatric gynecology. Anyone does have any questions, um, that come up later. I'm more than happy to, you know, you can email them to me or um, actually just email to me and I'll get them to Doctor De Wiggins. Unless Doctor Do Wiggins, you mind sharing your email with me and I can send it out in a follow up email. Yeah, you can definitely share my email and if anybody has Epic, I also respond usually pretty well to Epic Secure message chats. So, yeah, great. Thank you so much. I really appreciate it. Enjoy the rest of your day. Yeah. Well, thank you for having me. All right, thanks so much. Created by Presenters Maggie Dwiggins, MD, MS Pediatric & Adolescent Gynecology, LGBTQIA+ Health Obstetrics & Gynecology, Washington University Transgender Center View full profile
