FP Essentials™ Female Pelvic Conditions PDF December 2024

FP Essentials ™ 547 Decembe...

FP Essentials ™ 547 December 2024 Female Pelvic Conditions Dyspareunia and Vulvodynia 8 Sexually Transmitted Infections 16 Urinary Incontinence 26 Interstitial Cystitis/Bladder Pain Syndrome 33 Downloaded from www.aafp.org/fpe. Copyright © 2024 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Editor-in-Chief Managing Editor Circulation Manager Sumi M. Sexton, MD Matthew Neff Susi Cordill Associate Medical Editors Senior Editors Senior Circulation Strategist Ryan D. Kauffman, MD, FAAFP, CCFP Monica Preboth Rebecca Harp Karl T. Rew, MD Amber Randel Circulation Specialist Kate Rowland, MD, FAAFP Genevieve W. Ressel Frances Spitsnogle Barry D. Weiss, MD, FAAFP Senior Associate Editors Production Director Medical Editor for Continuing Laurie Costlow Bret A. Taylor Medical Education Andrea Harden Aaron Saguil, MD, MPH, FAAFP S. Jane Thomas Production Design Manager Stacey Herrmann Editorial Board Members Associate Editors S. Lindsey Clarke, MD, FAAFP Eli Hoelscher Senior Production Designers Joel J. Heidelbaugh, MD, FAAFP, FACG Jennifer Wilkes Bryan Colley Robert C. Langan, MD, FAAFP Randy Knittel Editorial Coordinators Brian Z. Rayala, MD, FAAFP Senior Digital Production Elizabeth Kurfman Specialist Holly Messerschmidt Evan Palmer John Moessner Project Specialist Editorial Director Marilyn Harvey Leigh Ann Backer Vice President of Journal Media Darren Sextro Senior Vice President of Education, Inclusiveness, and Physician Well-Being Margot Savoy, MD, MPH, FAAFP Executive Vice President and Chief Executive Officer www.aafp.org/fpe R. Shawn Martin ISSN# 2159-3000 FP Essentials is indexed in MEDLINE and PubMed. Subscription Information American Academy of Family Physicians 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2680 Phone: 800-274-2237 Email: [email protected] Online: www.aafp.org/pubs/fpe/subscribe/subscription-management.html Other Contact Information Permission to reuse content: [email protected] Comments or suggestions for the editors: [email protected] Proposal submissions: www.aafp.org/pubs/fpe/authors.html Next Edition: Arthritis Cover illustration by Steve Oh  547 Female Pelvic Conditions Authors Estefan Beltran, MD Bonnie Brown, MD Kane Laks, MD Jessica Dalby, MD Estefan Beltran, MD,is an assistant professor in the Wisconsin. He completed his residency and academic fel- Department of Family Medicine and Community Health lowship training in the Department of Family Medicine at the University of Wisconsin–Madison School of Medi- and Community Health at the University of Wiscon- cine and Public Health. He completed his family medicine sin–Madison School of Medicine and Public Health. He residency training at the University of Wisconsin, where he graduated from the Rural Health Equity Track in residency earned a pathway certificate in pregnancy care. He contin- and his fellowship included emphases on rural training ues to practice full-spectrum family medicine. His interests curricula, teaching, and high-risk obstetrics. His interests are women’s health, including obstetric care, community include underserved rural populations and Native Ameri- medicine, and diversity, equity, and inclusion initiatives. can health. Bonnie Brown, MD, is an assistant professor in the Jessica Dalby, MD,is an associate professor in the Department of Family Medicine and Community Health Department of Family Medicine and Community Health at the University of Wisconsin–Madison School of Med- at the University of Wisconsin–Madison School of Medi- icine and Public Health. Before starting her current posi- cine and Public Health, where she directs the gynecologic tion, she completed a fellowship in advanced obstetrics health curriculum for the residency program. Since 2017, in Seattle, Washington, and practiced and taught in Mis- she has served as the medical consultant for sexual and soula, Montana. Her interests include obstetrics, women’s reproductive health for the City of Milwaukee Health health, and working with patients on lifestyle change. Department in Wisconsin. The Milwaukee area has high rates of sexually transmitted infections. She has published Kane Laks, MD,is a full-spectrum family medicine several articles and given more than 12 presentations on physician at the Menominee Tribal Clinic in Keshena, curbing the rise of sexually transmitted infections. Disclosure: It is the policy of the AAFP that all individuals in a position to control CME content disclose any relationships with ineligible companies upon nomination/invitation of participation. Disclosure documents are reviewed for potential relevant financial relationships. If relevant financial relationships are identified, mitigation strategies are agreed to prior to confirmation of participation. Only those participants who had no relevant financial relationships or who agreed to an identified mitigation process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. Beltran E, Brown B, Laks K, Dalby J. Female Pelvic Conditions. FP Essent. 2024;547:1-45. Brown B. Female Pelvic Conditions: Dyspareunia and Vulvodynia. FP Essent. 2024;547:8-15. Dalby J. Female Pelvic Conditions: Sexually Transmitted Infections. FP Essent. 2024;547:16-25. Laks K. Female Pelvic Conditions: Urinary Incontinence. FP Essent. 2024;547:26-32. Beltran E. Female Pelvic Conditions: Interstitial Cystitis/Bladder Pain Syndrome. FP Essent. 2024;547:33-39. Copyright © 2024 American Academy of Family Physicians. All rights reserved. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium. 1 Foreword This is a special edition of FP Essentials for several rea- have been so dedicated to their work, and with the incred- sons. For one, I worked with an excellent team of authors. ible and devoted editorial staff at the American Academy Dr. Dalby and her team were always on time with their of Family Physicians. It has been a great experience for work; they knew their topics well and were responsive me and hopefully helpful to our many thousands of FP when dealing with comments and suggestions from peer Essentials readers. reviewers and editors. I hope their discussions of dyspa- I will continue as an associate medical editor of Ameri- reunia and vulvodynia, sexually transmitted infections, can Family Physician and with my work in the Department urinary incontinence, and interstitial cystitis/bladder pain of Family and Community Medicine at the University of syndrome will be helpful in your practice and keep you up Arizona in Tucson. Dr. Sumi Sexton, editor-in-chief of to date. American Family Physician, will take over the editorship of It is also special because this is the last time I will work FP Essentials as the two publications merge under a single with FP Essentials, as I’m stepping down from my role as management team. Hopefully, you will continue to find editor. I joined the FP Essentials team nearly 25 years ago this publication useful in meeting your professional goals. and became the lead medical editor in 2007. Over those Barry D Weiss, MD, FAAP, Medical Editor many years, I’ve had the opportunity to work with some Professor, Department of Family and Community Medicine amazing authors from all over the world, with a wonderful University of Arizona College of Medicine, Tucson team of associate editors and editorial board members who Learning Objectives Diagnose women who experience pain with sexual intercourse. Treat chronic vulvar pain without a clear, identifiable cause. Screen patients for sexually transmitted infections using recommended guidelines. Determine the appropriate use of expedited partner therapy for sex partners of patients with sexually trans- mitted infections. Determine the most appropriate nonpharmacologic first-line therapies for urge and stress incontinence. Recognize potential adverse effects of anticholinergic drugs on cognitive function when treating urge incon- tinence in older adults. Monitor the effects of interstitial cystitis/bladder pain syndrome therapies with recommended symptom scales. Interpret initial and interval retinal examinations to prevent pigmented maculopathy when treating patients who have interstitial cystitis with pentosan polysulfate sodium. 2  Contents Authors........................................... 1 TABLES Foreword.......................................... 2 Section One Learning Objectives............................... 2 1. DSM-5 Criteria for Genito-Pelvic Pain/ Pretest Questions................................. 4 Penetration Disorder........................... 9 Pretest Answers................................... 5 2. Superficial Dyspareunia: Key Information........ 10 Key Practice Recommendations................... 6 3. Deep Dyspareunia: Key Information............. 12 Section Two SECTION ONE 1. Symptoms, Screening Recommendations, Dyspareunia and Vulvodynia....................... 8 and Recommended Testing for Common STIs... 19 Dyspareunia...................................... 8 2. Treatment Regimens for Common Vulvodynia....................................... 13 Sexually Transmitted Infections................. 22 References....................................... 14 Section Three 1. Urinary Incontinence Subtypes.................. 27 SECTION TWO 2. Indications for Referral to Incontinence Sexually Transmitted Infections.................... 16 Specialist...................................... 28 Background...................................... 16 3. Urinary Incontinence Treatments by Subtype.................................... 29 Epidemiology..................................... 16 Section Four Screening........................................ 17 1. Interstitial Cystitis/Bladder Pain Syndrome: Diagnosis and Treatment.......................... 20 Proposed Mechanisms and Treatments........ 34 References....................................... 24 2. Pharmacologic Management of Interstitial Cystitis/Bladder Pain Syndrome................ 37 SECTION THREE Urinary Incontinence.............................. 26 FIGURES Background...................................... 26 Section Two Epidemiology..................................... 26 1. US Congenital Syphilis Rates Definitions....................................... 26 by Race/Ethnicity.............................. 17 Diagnostic Evaluation............................. 27 2. US County-Level Syphilis Rates Treatment........................................ 28 Among Women and Screening References....................................... 31 Recommendations............................. 18 3. Traditional vs Reverse Sequence Algorithms SECTION FOUR for Syphilis Testing............................. 21 Interstitial Cystitis/Bladder Pain Syndrome........ 33 Section Three Background...................................... 33 1. Examples of Pessaries.......................... 30 Epidemiology..................................... 33 Section Four Pathophysiology.................................. 33 1. Female Genitourinary Pain Index................. 35 Evaluation........................................ 34 Treatment........................................ 36 Indications for Referral............................ 38 References....................................... 38 Resources......................................... 40 Posttest Questions................................ 41 Posttest Answers.................................. 44 3 Pretest Questions To assess your current knowledge of this FP Essentials topic, complete the pretest below and check your answers against the explanations provided at the end. Use the results to inform your study of this edition and prepare to com- plete the posttest, which appears later in the edition and online for CME credit. Each question has only one correct answer. 1. A 29-year-old patient has been experiencing 4. A sexually active woman comes to your office dyspareunia. She tells you that using vaginal reporting vaginal discharge and dysuria. On lubricants helps significantly and that she and examination, you note a mucopurulent discharge and her sex partner are using latex condoms for friability of the cervix. You have concerns that she contraception. Which one of the following lubricants may have an STI. Which one of the following is the is inappropriate to use with latex condoms? recommended testing for diagnosing STIs?  A. Silicone-based lubricants.  A. Nucleic acid amplification testing (NAAT) of a  B. Water-based lubricants. vaginal swab specimen.  C. Natural oil (coconut, almond, or olive)  B. Wet mount. lubricants.  C. NAAT of a urine sample.  D. None of these is inappropriate with latex  D. Culture and sensitivity testing of the vaginal condom use. discharge.  E. C ulture and sensitivity testing of a sample from 2. A 45-year-old patient has been experiencing vulvar the endocervical canal. pain for the past 6 months. After evaluation, you diagnose vulvodynia. Which one of the following is 5. A 54-year-old patient has been experiencing considered a first-line vulvodynia treatment? episodes of urinary incontinence during the day  A. Topical lidocaine. and at night. You tell the medical student working  B. Gabapentin. in your office about the DIAPERS mnemonic to help  C. Tricyclic antidepressants. identify potentially reversible causes of incontinence.  D. OnabotulinumtoxinA injections. The S in the mnemonic stands for which one of the  E. Pelvic floor physical therapy. following?  A. Syphilis. 3. A 22-year-old pregnant patient comes to your office  B. Sleep disorder. for her first prenatal visit. She is in a monogamous  C. Stress incontinence. relationship and has no particular risk factors for  D. Stool impaction. sexually transmitted infections (STIs). A physical  E. Sexual dysfunction. examination reveals no vulvar or other lesions. Which one of the following is recommended for syphilis 6. A patient in the second trimester of pregnancy screening in this patient? describes what sounds like stress urinary  A. Screen at this first prenatal visit. If negative, no incontinence that she experienced during a prior further screening is recommended. pregnancy. She asks if there are any exercises she  B. Screen at this first prenatal visit and again at can do to prevent this in the current pregnancy. delivery. Which one of the following statements is correct  C. Screen at this first prenatal visit, again in the about pelvic floor physical therapy during pregnancy? third trimester, and again at delivery.  A. It is contraindicated.  D. Screen only at delivery.  B. It decreases the risk of incontinence during  E. D o not screen because she is at low risk. pregnancy but not during the postpartum period.  C. It does not decrease the risk of incontinence during pregnancy but does reduce incontinence postpartum.  D. It decreases the risk of incontinence during pregnancy and postpartum.  E. It only has benefit for stress incontinence. 4  7. Which one of the following is the only US Food and 8. You refer a patient you suspect has IC/BPS to Drug Administration–approved oral drug for treating a urologist for further evaluation. The urologist IC/BPS? performs a cystoscopy and sends you a report that  A. Phenazopyridine. indicates Hunner lesions were seen during the  B. Pentosan polysulfate sodium. procedure. Based on this finding, which one of the  C. Amitriptyline. following statements is correct?  D. Hydroxyzine.  A. The patient does not have IC/BPS.  E. Cyclosporine A.  B. Intradetrusor onabotulinumA injections are the treatment of choice.  C. C yclosporine A may be an effective treatment with urogynecologist guidance.  D. Sacral neuromodulation is the treatment of choice. Pretest Answers Question 1: The correct answer is C. Question 5: The correct answer is D. Patients often use natural oils (including coconut, DIAPERS (delirium, infection, atrophic urethritis or almond, or olive) for inadequate lubrication during inter- vaginitis, pharmaceuticals, endocrine conditions causing course, but these should be avoided with use of latex excess urine output, restricted mobility, or stool impac- condoms because they can cause them to leak or break. tion) is a helpful mnemonic for remembering revers- See Section One, pages 12-13. ible causes of urinary incontinence. See Section Three, page 27. Question 2: The correct answer is E. Nonpharmacologic treatment options for vulvodynia Question 6: The correct answer is D. have the most evidence of effectiveness. Pelvic floor Pelvic floor physical therapy during pregnancy decreases physical therapy and cognitive behavior therapy are risk of incontinence in late pregnancy, postpartum, and first-line treatments for vulvodynia. For localized and up to 6 months postpartum. See Section Three, page 30. generalized pain, pelvic floor physical therapy has some of the strongest evidence for improving pain and sexual Question 7: The correct answer is B. function. See Section One, page 14. Pentosan polysulfate sodium is a heparin analog that is the only oral medication approved by the US Food and Question 3: The correct answer is C. Drug Administration for interstitial cystitis/bladder pain In 2024, the American College of Obstetricians and syndrome. See Section Four, page 36. Gynecologists recommended that all pregnant patients be screened for syphilis at the time of pregnancy diagno- Question 8: The correct answer is C. sis or prenatal intake, again in the third trimester, and at Cyclosporine A, an oral immunosuppressive calcineurin delivery. See Section Two, page 17. inhibitor, is commonly used for treating autoimmune diseases and has been studied for interstitial cystitis/ Question 4: The correct answer is A. bladder pain syndrome in patients with Hunner lesion Sexually active patients presenting with vaginal dis- disease. Patients report sustained improvement in pain, charge and dysuria, particularly with risk factors for sex- urinary frequency, and total daily voids. Given the side- ually transmitted infections, should have vaginal swabs effect profile of cyclosporine A, urogynecologic consulta- sent for nucleic acid amplification testing (NAAT) for tion should guide use. See Section Four, page 37. gonorrhea, chlamydia, and trichomoniasis and undergo testing for bacterial vaginosis. Cultures are not recom- mended as a first-choice test, neither are wet mounts or NAAT of urine. See Section Two, page 23. 5 Key Practice Recommendations These key learning points summarize the consensus- and evidence-based recommendations included in this edition. The sources listed here for each statement recommend that physicians perform or implement these actions directly in a clinical setting. 1. Recommend pelvic floor physical therapy and cogni- 3. S  creen all pregnant patients for syphilis at the begin- tive behavior therapy as first-line treatments for ning of pregnancy, again in the third trimester, and at vulvodynia. delivery. Evidence rating: SORT B Evidence rating: SORT B Sources: Section One, references 11, 19, 20, 21, and Source: Section Two, reference 12. 22 Website: https://www.acog.org/news/ Websites: https://obgyn.onlinelibrary.wiley.com/ news-releases/2024/04/acog-recommends- doi/10.1002/ijgo.14815 obstetrician-gynecologists-increase-syphilis-screen- https://www.nature.com/articles/s41572-020-0164-2 ing-for-pregnant-individuals https://www.dovepress.com/etiology-diagnosis- and-clinical-management-of-vulvodynia-peer- 4. Collaborate with local public health departments to reviewed-fulltext-article-IJWH coordinate contact tracing and facilitate the treatment https://www.frontiersin.org/journals/cellular- of patients with syphilis and their partners. and-infection-microbiology/articles/10.3389/ Evidence rating: SORT C fcimb.2021.678961/full Source: Section Two, reference 6 https://onlinelibrary.wiley.com/doi/10.1111/ Website: https://www.cdc.gov/mmwr/volumes/70/ jmwh.13456 rr/RR7004a1.htm?s_cid=RR7004a1_w 2. Screen for syphilis in all sexually active individuals 5. R  eport suspected gonorrhea treatment failure imme- ages 15 to 44 years living in communities with high diately to the Centers for Disease Control and Pre- syphilis rates, defined as a county rate of primary vention through local or state health departments. and secondary syphilis among women greater than Evidence rating: SORT C 4.6 cases/100,000 population. Source: Section Two, reference 6 Evidence rating: SORT B Website: https://www.cdc.gov/mmwr/volumes/70/ Sources: Section Two, references 5 and 10. rr/RR7004a1.htm?s_cid=RR7004a1_w Websites: https://www.acog.org/news/ news-releases/2024/04/acog-recommends- obstetrician-gynecologists-increase-syphilis-screen- ing-for-pregnant-individuals https://www.cdc.gov/mmwr/volumes/72/wr/ mm7246e1.htm?s_cid=mm7246e1_w Strength of Recommendation Taxonomy (SORT) Evidence Rating Definition A R  ecommendation based on consistent and good-quality patient-oriented evidence.* B R  ecommendation based on inconsistent or limited-quality patient-oriented evidence.* C R  ecommendation based on consensus, usual practice, opinion, disease-oriented evidence,* or case series for studies of diagnosis, treatment, prevention, or screening. *—Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life. Disease-oriented evidence measures intermediate, physiologic, or surrogate end points that may or may not reflect improvement in patient out- comes (eg, blood pressure, blood chemistry, physiologic function, pathologic findings). From Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medi- cal literature. Am Fam Physician. 2004;69(3):548-556. 6  SECTION ONE 6. For patients with stress incontinence, recommend 8.  Consider cystoscopy for patients with interstitial cys- pelvic floor physical therapy and use of intravaginal titis/bladder pain syndrome and suspected Hunner devices such as continence pessaries as the main lesions based on age older than 50 years, bladder- nonprocedural treatments. centric symptoms, presence of comorbid autoim- Evidence rating: SORT B mune or inflammatory conditions, or absence of other Source: Section Three, reference 10 systemic symptoms. Website: https://www.cochranelibrary.com/cdsr/ Evidence rating: SORT C doi/10.1002/14651858.CD012337.pub2/full Source: Section Four, reference 1 Website: https://www.auajournals.org/doi/10.1097/ 7. F  or patients with urge incontinence, recommend JU.0000000000002756 conservative treatments such as pelvic floor physical therapy and bladder training. 9. Treat patients with interstitial cystitis with a multi- Evidence rating: SORT B modal pain management approach. Source: Section Three, reference 10 Evidence rating: SORT B Website: https://www.cochranelibrary.com/cdsr/ Source: Section Four, reference 1 doi/10.1002/14651858.CD012337.pub2/full Website: https://www.auajournals.org/doi/10.1097/ JU.0000000000002756 Peer Reviewers All manuscripts published in FP Essentials undergo peer review by subject matter experts and our editorial board members, a process that helps ensure the quality and clinical usefulness of our content. Below we acknowledge the individuals who performed those reviews for editions published in 2024. We offer our sincere thanks for the time and effort they devoted to the peer review process. Natasha Ahmed, MD Doris Lin, MD Alexander Chang, MD, MS Ruikang (Kong Kong) Liu, MD, CAQSM, FAAP Terri Cheng, MD Juanita P. Moses, MD S. Lindsey Clarke, MD, FAAFP* Neil J. Murphy, MD Galen Toye Foulke, MD Eddie Needham, MD, FAAFP Joel J. Heidelbaugh, MD, FAAFP, FACG* Caitlin Nicholson, MD Madison Humerick, MD Brian Z. Rayala, MD, FAAFP* Daniel Ignell, MD Alexis Reedy-Cooper, MD David A. Johnson, MD, MACG, FASGE, MACP Tessa Rohrberg, MD, FAAFP Sachiko Kaizuka, MD George William Stone, MD Shubham Kalwani, DO Prashanthi Thota, MD C. Peony Khoo, MD, FAAFP Lara Carson Weinstein, MD, MPH, DrPH Rajan Krishnamani, MD Jay Winner, MD, FAAFP, DipABLM Robert C. Langan, MD, FAAFP* Lenny Lesser, MD, MSHS *Member of FP Essentials Editorial Board 7  SECTION ONE Dyspareunia and Vulvodynia Genito-pelvic pain/penetration disorder is a relatively new term encompassing both dyspareunia (recurrent pain with intercourse) and vaginismus (involuntary contraction of the pelvic floor with attempted penetration). Symp- toms are often multifactorial. Thus, a detailed history and sensitive patient-centered examination are essential to identify and treat the underlying cause(s). Additional laboratory or imaging studies are not routinely indicated but may be helpful to rule out infectious etiologies or evaluate pelvic organ pathology in cases of deep dyspareunia. Treatment may include patient education about the condition, avoidance or modifications of irritants or triggers, use of vaginal lubricants and moisturizers, hormone therapy, pelvic floor physical therapy, and psychosocial inter- ventions as indicated. Vulvodynia is a separate but related condition and is a diagnosis of exclusion. It is defined as vulvar pain for at least 3 months without another clearly identifiable cause. High-quality studies on the treatment of vulvodynia are limited. However, pelvic floor physical therapy and psychosocial interventions such as cognitive behavior therapy have the most consistent evidence of benefit. Case 1. TL is a 54-year-old patient with diabetes that is Despite its prevalence, genito-pelvic pain/penetration dis- well-controlled with metformin. She presents for a routine order is likely underrecognized in clinical practice because physical and cervical cancer screening. When asked about many patients do not report symptoms and clinicians may sexual health, she initially laughs and describes it as “nonexis- not ask about it.4 tent.” Asked for clarification, TL says she has not had vaginal Specific demographic risk factors include younger age sex for more than a year because it is too painful. She has tried (18-25 years), postpartum status, breastfeeding, and several over-the-counter products to relieve pain and vulvar peri- or postmenopausal status. Other risk factors include itching and burning without improvement. She says she has a history of operative vaginal delivery or pelvic surgery, difficulty discussing this with you or her partner, but it causes pelvic inflammatory disease, anxiety, depression, and a significant personal and relationship distress. history of sexual abuse.5,6 Low socioeconomic status and poor communication with a partner are associated with Dyspareunia worse outcomes.7 Regardless of the cause, genito-pelvic BACKGROUND pain/penetration disorder can cause significant physical, Dyspareunia (recurrent pain before, during, or after inter- psychological, and interpersonal distress. course) and vaginismus (involuntary contraction of the Symptoms of genito-pelvic pain/penetration disorder are pelvic floor muscles with attempted vaginal penetration) often multifactorial and associated with various biological, are common conditions that can cause significant distress psychological, and social risk factors that contribute to a and diminished quality of life. Genito-pelvic pain/penetra- patient’s pain experience. For example, vaginal atrophy tion disorder is a relatively new term encompassing both in postmenopausal patients (genitourinary syndrome of dyspareunia and vaginismus that recognizes the overlap in menopause [GSM]) can cause pain with penetrative inter- symptoms and etiologies between the two (Table 1).1 course, resulting in anxiety about intercourse. This may lead to a decrease in or avoidance of sexual activity. EPIDEMIOLOGY The reported prevalence of genito-pelvic pain/penetration EVALUATION disorder varies widely, likely reflecting variations across age Table 24,5,8-11 and Table 35,9,10,12 summarize the typical his- groups, regions, individual sexual practices, and study meth- tory, physical examination findings, and considerations for odologies. People with dyspareunia who avoid sexual activi- evaluating superficial and deep dyspareunia. ties, for example, may be underrepresented in study samples. Initial questions. Before the physical examination, Dyspareunia is estimated to affect between 10% and clinicians should take a history with the patient clothed, 28% of reproductive-aged patients,2 between 13% and asking permission to discuss sensitive or sexual topics. 84% of postmenopausal patients, and 40% and 20%, Use of nonjudgmental, neutral, and inclusive language respectively, of patients at 3 and 6 months postpartum.3 is important. Examples of broad-based initial questions 8  SECTION ONE during routine visits that can elicit sexual health concerns concerns. Also, some patients may not be emotionally or include “Are you satisfied with your current sexual func- physically prepared for a pelvic examination at the visit. tion?” or “Many people experience concerns about sex. However, patients may experience feelings of dismissal Are there any aspects of your sexual health you’d like to if evaluation is deferred to a future visit, so care should discuss?” An open-ended response to expressed concerns be taken to validate patient concerns when arranging (eg, “Tell me more”) can also be helpful. follow-up.8 Care should also be taken to describe the Once dyspareunia is identified, follow-up questions and examination and allow patients to control when and how a physical examination can often identify possible causes it is conducted, particularly for those who have previously and contributing factors. This may not be achievable at an experienced trauma. initial visit, given time constraints or competing medical History. Clinicians should ask about pain characteristics (location, duration, triggers, or alleviating or exacerbat- ing factors), symptom onset (gradual or abrupt, or events TABLE 1 associated with pain), and associated bowel, bladder, or DSM-5 Criteria for Genito-Pelvic Pain/ musculoskeletal symptoms.5,9,10,13 Superficial pain, or pain Penetration Disorder at vaginal entry, may suggest disorders of the vulva or ves- tibule, vaginal atrophy, inadequate lubrication, or pelvic A. Persistent or recurrent difficulties with one (or more) of floor dysfunction. Deeper pain may be myofascial or from the following: pelvic organ pathology.5,9,10,13 Several validated patient 1. Vaginal penetration during intercourse. symptom scores exist but may not be practical for use in 2. Marked vulvovaginal or pelvic pain during vaginal primary care settings.10 intercourse or penetration attempts. The history should include current medical conditions 3. Marked fear or anxiety about vulvovaginal or pelvic and medications, changes in hormonal status (menopause, pain in anticipation of, during, or as a result of vaginal pregnancy or breastfeeding status, or medical hormone penetration. therapy), trauma (including prior pelvic surgeries, vaginal 4. Marked tensing or tightening of the pelvic floor deliveries and lacerations, and assault or other injury), muscles during attempted vaginal penetration. other gynecologic history (including characteristics of B. The symptoms in Criterion A have persisted for a periods and history of infections), and prior prescribed or minimum duration of approximately 6 months. self-care treatments.5,9,10,13 C. The symptoms in Criterion A cause clinically significant It is also important to ask about psychological concerns, distress in the individual. given the interplay between dyspareunia and worsened D. The sexual dysfunction is not better explained by quality of life and mental health. Relationship concerns a nonsexual mental disorder or as a consequence of or social factors that may contribute to patient distress or severe relationship distress (eg, partner violence) or other significant stressors and is not attributable to the effects serve as protective factors (such as social support and a of a substance/medication or other medical condition. responsive partner) should also be explored because these may inform treatment. Specify whether: Physical examination. Patients with genito-pelvic pain/ Lifelong: The difficulty has been present since the penetration disorder may have anxiety about the physical individual became sexually active. examination. Yet, when done well, the examination can be Acquired: The difficulty began after a period of diagnostic and offer therapeutic feedback to the patient.3 relatively normal sexual function. Clinicians should inform patients that they are always in Specify current severity: control, and work with the patient to determine when and Mild: Evidence of mild distress over the symptoms in with whom (eg, a chaperone or support person, if desired) Criterion A. the examination should take place. Offering a mirror can Moderate: Evidence of moderate distress over the allow patients to follow along and pinpoint pain locations symptoms in Criterion A. and may be helpful in reviewing anatomy or findings. Severe: Evidence of severe or extreme distress over the Much of the examination, including inspection and symptoms in Criterion A. palpation, can be performed with the patient in the supine frog leg or hook lying position. The vulva and vestibule DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th ed. should be visually inspected for inflammatory, dermato- Reprinted with permission from Diagnostic and Statistical Manual of logic, or infectious conditions or anatomic changes (scar- Mental Disorders. 5th ed. American Psychiatric Association; 2013:437. ring or structural anomalies). 9  TABLE 2 Superficial Dyspareunia: Key Information Diagnosis History Examination/Evaluation Treatment Options Genitourinary Vaginal dryness May initially appear normal Moisturizers and lubricants syndrome of Tearing or burning Pale, dry vaginal mucosa Vaginal estrogen menopause, other low- Spotting after intercourse Loss of vaginal rugae Vaginal estrogen states dehydroepiandrosterone Urinary symptoms Friable tissue (prasterone [Intrarosa]) Small lacerations, petechiae Ospemifene (Osphena) Loss of vulvar architecture Inadequate Vaginal dryness or burning Dry vaginal mucosa Moisturizers and lubricants lubrication Difficulty with arousal Discontinuation of causative medication if possible Diabetes, chemotherapy, pelvic radiation, or use of certain medications* Infectious Burning, discharge, odor, Discharge Antibiotic, antiviral, antifungal vulvovaginitis pruritus therapy as indicated Vaginal erythema or lesions +/− deep pain Wet prep, Gram stain, yeast culture, nucleic acid amplification testing as indicated Vulvodynia Vulvar pain for at least Normal or erythematous mucosa Pelvic floor physical therapy 3 months without another Intense pain on contact with cotton swab Cognitive behavior therapy etiology Testing to rule out other causes of Topical lidocaine vaginitis Oral tricyclic antidepressants or gabapentin Vestibulectomy Vulvar dermatoses Lichen planus Less common Erythematous, well-demarcated erosions Possible referral Pain Possible scarring, introital stenosis High-potency topical steroids Spotting after intercourse May involve vagina Lichen Most common vulvar White/atrophic papules and plaques High-potency topical steroids sclerosus dystrophy Distorted vulvar anatomy Pruritus, pain Erosions, fissures Lichen simplex Burning, pruritus Biopsy may be necessary Vulvar hygiene chronicus Use of hygiene products or Leathery or erythematous vulva Avoidance of irritants prescribed medications* (lichenification) Topical steroids May have erosions, excoriations, or fissures continues *—Some contributing medications may include combined oral contraceptives, progestins, aromatase inhibitors, gonadotropin-releasing hormone antagonists, selective estrogen receptor modulators, antidepressants, and, less commonly, antihypertensives. †—Referred or positional pain from other locations (eg, hip, back) may be considered. 10  SECTION ONE TABLE 2 (continued) Superficial Dyspareunia: Key Information Diagnosis History Examination/Evaluation Treatment Options Myofascial pain† Pelvic floor Bowel/bladder dysfunction Pelvic floor tenderness Pelvic floor physical therapy dysfunction Pain radiates to thighs, back May have scar tissue Neuromodulation Prolonged (hours) pain after Gabapentin intercourse Trigger point injection Prior surgery, laceration Surgical repair Vaginismus May have more prominent Involuntary contraction of pelvic floor Pelvic floor physical therapy anxiety, history of trauma muscles with attempted insertion of Cognitive behavior therapy finger or speculum Sequential vaginal dilators OnabotulinumtoxinA injection *—Some contributing medications may include combined oral contraceptives, progestins, aromatase inhibitors, gonadotropin-releasing hormone antagonists, selective estrogen receptor modulators, antidepressants, and, less commonly, antihypertensives. †—Referred or positional pain from other locations (eg, hip, back) may be considered. Information from references 4, 5, and 8-11. Sensory testing should begin slowly from outside the Additional testing. Genito-pelvic pain/penetration pelvis (eg, starting on the inner thigh) with a light touch disorder is a clinical diagnosis;​thus, laboratory tests and from a cotton swab to assess for general guarding and imaging are not routinely indicated. However, they may be allodynia, and then progress inward. The swab can then be helpful in specific scenarios, such as evaluating for infec- used to assess the vestibule, or the area of smooth epithe- tious vulvovaginitis or obtaining a vulvar biopsy to evaluate lium from the labia minora to the hymenal ring, for areas a lesion. In patients with deep dyspareunia, imaging studies of allodynia and hyperalgesia. It is also important to note (pelvic ultrasonography or magnetic resonance imaging) any areas of hyperemia or visualized abnormality.3,5,10 are often indicated to evaluate for pelvic organ pathology. Next, the pelvic floor muscles should be palpated with a single lubricated digit through the vagina. For patients TREATMENT with vestibular sensitivity, this can be made more comfort- Clinicians should be aware that genito-pelvic pain/penetra- able by applying a topical analgesic before the examina- tion disorder is often multifactorial and should be treated tion, having the patient bear down to open the introitus, as such. For example, postmenopausal patients may have and avoiding pressure on the edge of the vestibule.3 Initial GSM and benefit from vaginal estrogen but also may have assessment should involve general tone and subsequent lichen simplex chronicus from using hyperosmolar lubri- palpation through 360° of the superficial pelvic floor mus- cants , hip arthritis contributing to positional pain during cles. Pain, tenderness, or bulkiness can suggest overactive intercourse, or subsequent relationship stress and decreased pelvic floor muscles or trigger points.14 libido from a previous painful experience. Postpartum Anteriorly, clinicians should also assess for pain in dyspareunia may also have multiple causes, including the urethra or bladder. The deeper pelvic floor muscles, decreased circulating estrogen and vaginal lubrication, pel- including the levator ani (posterolateral) and obturator vic floor dysfunction, and mood and relationship changes. internus (anterolateral), can be examined by gently moving Multimodal treatments addressing patient education, psy- the finger 2 to 4 cm deeper into the vagina.14 Deeper chosocial needs, pelvic floor function, and pharmacother- tissues can be assessed vaginally or rectally for nodularity apy may be indicated (Table 24,5,8-11 and Table 35,9,10,12). (suggesting endometriosis) or masses. Finally, if tolerated, Inadequate lubrication and low-estrogen states. the cervix and vagina can be examined by slowly inserting Low-estrogen states, whether physiologic (postpartum, a warmed, lubricated, small speculum.5,10 during breastfeeding, or menopausal), pathologic, or 11 iatrogenic, can cause vaginal atrophy and inadequate lubri- long-lasting and intended to be used to reduce sexual and cation during intercourse. Vaginal lubricants and mois- nonsexual symptoms. turizers are first-line therapy and may provide temporary Patients often use natural oils (including coconut, relief. Lubricants used at the time of intercourse provide almond, or olive), but these should be avoided with use a barrier and reduce friction, whereas moisturizers are of latex condoms because oil-based lubricants can cause TABLE 3 Deep Dyspareunia: Key Information Diagnosis History Examination/Evaluation Treatment Options Adenomyosis, Dysmenorrhea May have tender, enlarged NSAIDs leiomyomas uterus Heavy menstrual Combined OCs, progestins bleeding Pelvic US or MRI GnRH agonist + hormone therapy Levonorgestrel IUD Endometrial ablation, myomectomy, hysterectomy Adhesions History of pelvic May have localized Nonopioid analgesics inflammatory disease, tenderness, palpable scar Lysis of adhesions pelvic surgery (deep pain) tissue Endometriosis Dysmenorrhea, Generalized pelvic NSAIDs, acetaminophen +/− bowel or bladder tenderness, nodularity on Combined OCs, progestins dysfunction examination GnRH agonist + hormone therapy Pelvic US or MRI to rule out other pelvic pathology, Levonorgestrel IUD formal diagnosis through laparoscopy Surgical excision Interstitial Dysuria Tenderness to the anterior Patient education/lifestyle modifications cystitis vaginal wall Urgency, frequency Psychosocial support Urinalysis, cystoscopy Nocturia Pelvic floor physical therapy, bladder training Amitriptyline Hydroxyzine, cimetidine, pentosan Referral for cystoscopy, intravesicular therapy Ovarian Lateral pain Adnexal tenderness Observation masses Pelvic US Laparoscopy Pelvic floor Bowel/bladder Pelvic floor tenderness Pelvic floor physical therapy dysfunction dysfunction May have scar tissue Neuromodulation Pain radiates to thighs, Gabapentin back Trigger point injection Prolonged (hours) pain after intercourse Surgical repair Prior surgery, laceration GnRH = gonadotropin-releasing hormone; IUD = intrauterine device; MRI = magnetic resonance imaging; NSAIDs = nonsteroidal anti-inflammatory drugs; OCs = oral contraceptives; US = ultrasonography. Information from references 5, 9, 10, and 12. 12  SECTION ONE condoms to leak or break. Petroleum-based products can the scope of this edition, but the condition should be con- also cause irritation and predispose the patient to vaginal sidered when evaluating patients with genito-pelvic pain/ infection.15 Water-based lubricants tend to be sticky and penetration disorder, with biopsy as needed to confirm the require multiple applications. diagnosis or for concerning lesions. Patients should be counseled that many common com- Among the vulvar dermatoses, lichen sclerosus is the mercially available lubricants, such as KY Jelly and Astro- most common. It typically responds to high-potency ste- glide Gel, are hyperosmolar and can alter cell morphology, roids.4 However, due to the association of lichen sclerosus resulting in further irritation (especially with osmolality with a 4% to 7% risk of squamous cell carcinoma of the greater than 1,200 mOsm/kg).4,15 Products marketed as vulva, physicians should consider biopsy and referral to a flavored, scented, or “stimulating” should be avoided. dermatologist or gynecologist for these patients.4 Concerns have arisen about the safety or irritation poten- Lichen simplex chronicus is a cause of vulvar pruritus. tial of products with propylene glycol, chlorhexidine, or It may occur from contact dermatitis, the use of vulvar parabens.4,15 Silicone-based lubricants are often preferred irritants (including many feminine hygiene products), or because they are longer-lasting and less irritating, but they other dermatoses or infections leading to an itch-scratch may react with silicone-based devices if not washed off cycle. Treatment should focus on breaking this cycle with quickly after use.4 For product-specific information, see comfort-care measures and behavior modification, or treat- Resources. ment of any other underlying dermatologic disorder. For moderate to severe symptoms of GSM, vaginal Proximal/deep dyspareunia. This is often caused by estrogen improves dyspareunia, vaginal dryness, and pelvic organ pathology, such as endometriosis, leiomyoma, urogenital symptoms compared with placebo, without adenomyosis, chronic pelvic inflammatory disease, or ovar- significant differences noted between formulations.16,17 ian cysts or masses. Myofascial pain syndromes and pelvic Vaginal estrogen has not been shown to increase the risk of floor dysfunction can also cause it or contribute. Treatment cardiovascular disease or cancer (including breast cancer) is primarily directed at the underlying cause and at any in multiple large studies.4,16 The American College of other psychological or pelvic muscle dysfunction that has Obstetricians and Gynecologists and the North American subsequently occurred (Table 35,9,10,12). Referral for surgical Menopause Society support using low-dose vaginal estro- or procedural therapy may be indicated if symptoms persist. gen for GSM, even in patients with estrogen-dependent breast cancer, although patients should be encouraged to Vulvodynia discuss with their oncologist.4 BACKGROUND Oral ospemifene (Osphena) and vaginal dehydroepi- Vulvodynia is defined as vulvar pain of at least 3 months androsterone (prasterone [Intrarosa]) are also approved without a clearly identifiable cause.18 It is common, with by the US Food and Drug Administration for GSM and an estimated prevalence of 7% to 8%.11,19 Vulvodynia is dyspareunia caused by menopause, although ospemifene thought to be one of the most common causes of sexual is contraindicated in patients at risk for thromboembo- pain in reproductive-aged patients;​however, pain also com- lism.5,13 Fractional carbon dioxide laser treatments on vagi- monly occurs outside of insertional sexual contact.20 nal tissue have some evidence of effectiveness for decreasing Vulvodynia is characterized as localized, generalized, or dyspareunia and vaginal dryness due to menopause, but mixed and may be spontaneous, provoked (by touch such more high-quality, controlled studies are needed.4,13 as friction, inserting a tampon, or intercourse), or both. Pelvic floor dysfunction. Pelvic floor physical therapy Symptoms may vary in time of onset and may be immedi- with an experienced therapist is an option for patients ate, delayed, intermittent, or persistent.18 Although many with vaginismus or pelvic floor dysfunction contributing individuals with vulvodynia do not seek care, perhaps to genito-pelvic pain/penetration disorder.4,5,10 Patients because up to 50% have spontaneous resolution of symp- with vaginismus may also benefit from cognitive behavior toms, others have pain for years.20 therapy (CBT) or use of sequential vaginal dilators.4,10 The etiology of vulvodynia is likely multifactorial. A com- Less-studied treatments include trigger point and onabotu- mon hypothesis suggests that trigger events, such as infec- linumtoxinA injections, oral anticonvulsants (eg, gabapen- tion or injury, cause an inflammatory/neuroproliferative tin), and transcutaneous electrical nerve stimulation.5,10 response, leading to central sensitization and hyperalgesia/ Vulvar dermatoses. These (described in more detail in allodynia.11,21 Hormonal factors may also play a role;​some Table 24,5,8-11) can be primary or secondary causes of vulvar studies find an association between vulvodynia and oral irritation, itching, and genito-pelvic pain/penetration contraceptive use and other low-estrogen states.18,19 There disorder. A complete review of vulvar dermatoses is outside may be genetic predisposing polymorphisms as well.18,19 13  Common comorbidities and risk factors include pelvic strategies, have reduced pain and improved sexual func- floor dysfunction, other pain, and central sensitization tion in several studies.11,19-22 Unfortunately, access to these syndromes (eg, fibromyalgia, interstitial cystitis, irritable therapies can be limited in clinical practice. bowel syndrome), and psychosocial factors such as a his- Local and oral pharmacologic agents can also be tory of trauma, anxiety, or depression.20 considered, although evidence supporting their use is limited. Topical lidocaine 2% to 5% is a first-line medi- EVALUATION cation option, either at bedtime or as needed, with pain History. Patients may report chronic aching, tearing, reduction noted in some, but not all, small studies.11,19,22 stabbing, or burning pain, with further details characteriz- Topical steroids have not been found to be helpful con- ing their pain pattern as noted above. Some report recur- sistently.11,19,22,24 Further high-quality studies are needed rent vaginitis or dysuria with negative laboratory findings on other topical treatments, including vaginal diazepam, or symptoms that do not resolve after treatment of those compounded gabapentin, or amitriptyline.11,19,22 or other conditions.11,22 Clinicians should assess for and Oral options are often preferred by patients.24 Gabapen- address the comorbid conditions noted above, remem- tin, amitriptyline, desipramine, and venlafaxine have been bering that chronic vulvar pain can severely affect patient evaluated in small studies and case reports, also with mixed relationships, everyday function, and quality of life, and it results.11,19,22,25 OnabotulinumtoxinA injections have been may place an economic burden on patients due to health helpful in some studies, but outcomes in more recent care spending.11,18,20 randomized controlled trials have been less clear; further Physical examination. The vulva and vagina may appear studies are needed.11,19,26,27 normal or have areas of erythema, typically in the vestibule. Hormone therapy is controversial. Some clinicians con- Clinicians may assess for areas of tenderness or allodynia sider discontinuing oral combined contraceptives if symp- using a cotton swab on the vestibule. Application of lido- tom onset coincides with their use.10,11 Estrogen is not caine 2% to the vulva or vestibule can make the examina- routinely recommended for vulvodynia but is sometimes tion more tolerable.5,20,22 Physicians should also assess for used for the treatment of concurrent GSM.19 Patients have pelvic floor dysfunction that may contribute to pain.11,20,22 reported using cannabis for pain, but to date, there are no Additional testing. Vulvodynia is a diagnosis of exclu- studies of its use for vulvodynia.22 sion, typically made with a characteristic history and Referral to discuss vestibulectomy should be considered physical examination and after ruling out infectious or for patients with persistent provoked or localized vul- dermatologic causes.18 Laboratory testing or microscopy is vodynia. Recent studies show improved pain and sexual typically used to rule out vulvovaginal infection. A yeast function at 12 and 30 months posttreatment.11,19-21 culture may be helpful for patients with a history of or Case 1, cont’d. After further discussion and examination, self-reported yeast infections.11,19,20 Increased vaginal pH you diagnose lichen simplex chronicus and GSM. You discuss may be associated with infection or a low-estrogen state.19 vulvar hygiene, avoidance of irritants, and considerations for In one retrospective study, as many as 60% of patients with use of lubricants, and start a course of topical steroids and refractory vulvodynia (55 of 90 patients) referred to a ter- vaginal estrogen. TL also decides to join a weekly walking tiary center had clinically significant dermatoses.23 A derma- group with women her age for her mental and physical tologic cause should be considered in refractory cases with well-being. At follow-up 6 months later, she reports she has skin texture or anatomy changes;​biopsy may be needed. recently begun to engage in vaginal intercourse with her part- ner, with significant improvement in dyspareunia symptoms. TREATMENT Treatment recommendations are largely based on expert References opinion and limited small studies. Nonpharmacologic 1. Sexual dysfunctions. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association;​2013. options have the most evidence of effectiveness.11,22 2. Pukall CF, Goldstein AT, Bergeron S, et al. Vulvodynia:​definition, Supportive counseling about the condition, treatment prevalence, impact, and pathophysiological factors. J Sex Med. expectations, and strategies to minimize vulvar irritation 2016;​13(3):​291-304. may be a good place to start in the office.5,20,24 Pelvic floor 3. Weijmar Schultz W, Basson R, Binik Y, et al. Women’s sexual pain physical therapy and CBT are first-line treatments for and its management. J Sex Med. 2005;​2(3):​301-316. vulvodynia.11,19-22 For localized and generalized pain, pelvic 4. Streicher LF. Diagnosis, causes, and treatment of dyspareunia in floor physical therapy has some of the strongest evidence postmenopausal women. Menopause. 2023;​30(6):​635-649. for improving pain and sexual function.11,19-22 Psychosocial 5. Hill DA, Taylor CA. Dyspareunia in women. Am Fam Physician. interventions, particularly CBT and mindfulness-based 2021;​103(10):​597-604. 14  SECTION ONE 6. Latthe P, Mignini L, Gray R, et al. Factors predisposing women 18. Bornstein J, Goldstein AT, Stockdale CK, et al.;​Consensus Vulvar to chronic pelvic pain:​systematic review. BMJ. 2006;​332(7544):​ Pain Terminology Committee of the International Society for the 749-755. Study of Vulvovaginal Disease (ISSVD), the International Society for the Study of Women’s Sexual Health (ISSWSH), and the Inter- 7. Meana M, Binik YM. The biopsychosocial puzzle of painful sex. national Pelvic Pain Society (IPPS). 2015 ISSVD, ISSWSH and Annu Rev Clin Psychol. 2022;​18:​471-495. 1 IPPS consensus terminology and classification of persistent vulvar 8. Braksmajer A. Struggles for medical legitimacy among women pain and vulvodynia. Obstet Gynecol. 2016;​127(4):​745-751. experiencing sexual pain:​a qualitative study. Women Health. 2018;​ 19. Bergeron S, Reed BD, Wesselmann U, et al. Vulvodynia. Nat Rev 58(4):​419-433. Dis Primers. 2020;​6(1):​36. 9. Gross E, Brubaker L. Dyspareunia in women. JAMA. 2022;​327(18):​ 20. Sadownik LA. Etiology, diagnosis, and clinical management of vul- 1817-1818. vodynia. Int J Womens Health. 2014;​6:​437-449. 10. Uloko M, Rubin R. Managing female sexual pain. Urol Clin North 21. Paavonen J, Eschenbach DA. Localized provoked vulvodynia – an Am. 2021;​4 8(4):​4 87-497. ignored vulvar pain syndrome. Front Cell Infect Microbiol. 2021;​11:​ 11. Santangelo G, Ruggiero G, Murina F, et al. Vulvodynia:​a practical 678961. guide in treatment strategies. Int J Gynaecol Obstet. 2023;​163(2):​ 22. Schlaeger JM, Glayzer JE, Villegas-Downs M, et al. Evaluation and 510-520. treatment of vulvodynia:​state of the science. J Midwifery Womens 12. Clemens JQ, Erickson DR, Varela NP, et al. Diagnosis and treat- Health. 2023;​68(1):​9 -34. ment of interstitial cystitis/bladder pain syndrome. J Urol. 2022;​ 23. Bowen AR, Vester A, Marsden L, et al. The role of vulvar skin 208(1):​34-42. biopsy in the evaluation of chronic vulvar pain. Am J Obstet Gyne- 13. Buhling K. Evaluation of dyspareunia. BMJ Best Practice. Accessed col. 2008;​199(5):​4 67.e1-467.e6. September 1, 2024. https://bestpractice.bmj.com/topics/en-us/661 24. Committee Opinion No 673:​persistent vulvar pain. Obstet Gyne- 14. Harm-Ernandes I, Boyle V, Hartmann D, et al. Assessment of the col. 2016;​128(3):​e78-e84. pelvic floor and associated musculoskeletal system:​guide for med- 25. Loflin BJ, Westmoreland K, Williams NT. Vulvodynia:​a review of ical practitioners. Female Pelvic Med Reconstr Surg. 2021;​27(12):​ the literature. J Pharm Technol. 2019;​35(1):​11-24. 711-718. 26. Haraldson P, Mühlrad H, Heddini U, et al. Botulinum toxin A for 15. Potter N, Panay N. Vaginal lubricants and moisturizers:​a review provoked vestibulodynia:​12 months’ follow-up of a randomized into use, efficacy, and safety. Climacteric. 2021;​24(1):​19-24. controlled trial. J Sex Med. 2022;​19(11):​1670-1679. 16. Biehl C, Plotsker O, Mirkin S. A systematic review of the efficacy 27. Petersen CD, Giraldi A, Lundvall L, et al. Botulinum toxin type and safety of vaginal estrogen products for the treatment of A–a novel treatment for provoked vestibulodynia? Results from a genitourinary syndrome of menopause. Menopause. 2019;​26(4):​ randomized, placebo controlled, double blinded study. J Sex Med. 431-453. 2009;​6(9):​2523-2537. 17. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2016;​(8):​CD001500. 15  SECTION TWO Sexually Transmitted Infections Sexually transmitted infection rates are increasing in the United States, with significant increases in the rates of syphilis among patients of reproductive age and, subsequently, congenital syphilis. Syphilis screening is recom- mended in sexually active patients 15 to 44 years of age in communities with high syphilis rates and in all pregnant patients at the time of diagnosis or prenatal intake, in the third trimester, and at delivery. Screening for chlamydia and gonorrhea is currently recommended in asymptomatic, sexually active patients younger than 25 years, as well as in older patients with risk factors. When clinicians are diagnosing active infections, patients with anogenital ulcerations should be tested for syphilis and herpes and treated empirically while awaiting test results. Treatment of syphilis depends on the disease stage;​first-line regimens all involve penicillin G. Patients with vaginal discharge and dysuria should be tested for gonorrhea and chlamydia using nucleic acid amplification testing. Doxycycline should be used to treat chlamydia because it is more effective in rectal chlamydia, which often coexists with vagi- nal infection. Single-dose azithromycin is an alternative in populations at risk for poor medication adherence or confidentiality concerns. Ceftriaxone should be used to treat gonorrhea. Increasing drug resistance to gonorrhea is a growing public health threat, and clinicians must work with public health departments in cases of suspected treatment failure. Case 2. RS is a 29-year-old gravida 3, para 2 (G3P2) patient Syphilis predominantly affects men who have sex with who presents for prenatal care at 16 weeks’ gestation. A trepo- men, although data for recent years have shown marked nemal antibody screen is positive, and rapid plasma reagin increases in infections among women.3 Between 2018 and (RPR) is 1:​32. She reports having syphilis when she was 22 2022, syphilis rates in women increased 193%, whereas years old. You contact the local health department. They the rate in men increased 48%.1 Increased syphilis rates confirm her history and treatment and report her last known were most pronounced with the onset of the COVID-19 RPR titer 4 years ago was 1:​2. She reports that the father of pandemic, as resources from public health STI programs this child is different from the father of her last child. were diverted to COVID-19.4 As syphilis rates in women increased, so did cases of Background congenital syphilis.5 In 2022, there were 3,755 cases of Sexually transmitted infections (STIs) commonly affect congenital syphilis nationally, a 10-fold increase over the people of childbearing age, with implications for pregnancy past decade.1 Missed opportunities to prevent congenital and newborns.1 This review will focus on the leading causes syphilis are common. Approximately 40% of cases in 2022 of reportable bacterial STIs and common viral STIs caus- resulted from inadequate treatment of syphilis in the birth- ing symptomatic anogenital infection. ing parent despite timely testing.1 Although outcomes of infant death or stillbirth occurred Epidemiology in 8% of cases of congenital syphilis in 2022, more than The most recent national data from 2022 show an 80% half of infants during this time were born alive with no increase in syphilis rates, an 11% increase in gonorrhea documented signs or symptoms, and congenital syphilis rates, and a 6% decrease in chlamydia rates since 2018.1 was detected only because the birthing parent was tested at However, the COVID-19 pandemic led to less reliable the time of delivery.1,6 Undetected, congenital syphilis can surveillance data with interruptions in access to testing.2 lead to neurodevelopmental delay, blindness, deafness, and musculoskeletal deformity.7 SYPHILIS Case counts of congenital syphilis emphasize the racial Syphilis rates are highest in people 25 to 34 years of age disparities seen across all STIs. In 2022, rates of congen- (47 cases/100,000 individuals). Notably, the rate in those ital syphilis were highest among indigenous and Black 55 years and older more than doubled between 2018 and populations (Figure 1).1 Addressing comorbid substance 2022 (from 2.5-5.2/100,000), emphasizing the importance use disorders and removing barriers to pregnancy care are of taking a sexual history across the lifespan.1 necessary to address these disparities. 16  SECTION TWO GENITAL HERPES are not well established in non–high-risk, nonpregnant Genital herpes is not a reportable condition, so its true adults, but screening is recommended annually in high- incidence is unknown. Data from a large national survey of risk groups10 (Table 16,10,11). people 14 to 49 years of age found that the prevalence of In 2024, the American College of Obstetricians and herpes simplex virus-2 (HSV-2) decreased over time (18% Gynecologists recommended that all pregnant patients from 1999-2000 compared with 12% from 2015-2016).8 be screened for syphilis at the time of pregnancy diagno- The prevalence is higher in women than men (16% vs 8%) sis or prenatal intake, again in the third trimester, and at and significantly higher in Black than White populations delivery.13 (35% vs 8%).8 Screening for syphilis caused by Treponema pall- However, prevalence rates are underestimated because idum involves treponemal tests (detecting antibodies to many individuals with positive HSV-2 serology have no T pallidum proteins) and nontreponemal tests (RPR and symptoms, and herpes simplex virus-1 (HSV-1) can also Venereal Disease Research Laboratory [VDRL] test), cause genital herpes in previously unexposed individu- which detect antibodies to lipoidal antigens and damaged als. As HSV-1 prevalence has also decreased over time, host cells.14 Treponemal tests typically remain positive younger individuals have had less nonsexual exposure, over the lifespan, whereas RPR and VDRL decline after lack immunity, and are thus at increased risk for genital treatment and continue to decrease with time;​they may HSV-1.9 become nonreactive in prolonged latent infection. Syphilis testing is done with either traditional algorithms CHLAMYDIA AND GONORRHEA (starting with RPR or VDRL) or reverse-sequence algo- Chlamydia and gonorrhea are the first and second most rithms (starting with treponemal antibody assays). Many common reportable STIs in the United States. Chlamydia large laboratories use reverse sequencing because it allows is detected mainly through screening of asymptomatic for faster processing of large volumes of samples and earlier patients; rates in women are nearly double those in men disease detection. RPR and VDRL titers decrease with (621 vs 364 in 2022). Rates of gonorrhea, however, are time, rapidly following treatment and slowly even without higher in men than in women (263 vs 152 in 2022). Rates treatment.15,16 As a result, some late latent cases of syph- of both infections are highest among people 20 to 24 years ilis are detected only with treponemal antibody testing. of age.1 Nucleic acid amplification testing (NAAT) and darkfield However, stark racial disparities exist. Rates of infection microscopy can detect syphilis early in the course of infec- are highest among Black people. They account for 28% tion but are not widely available and do not detect late of chlamydia infections and 38% of gonorrhea infections, although Black people make up only about 13% of the US population.1 Screening Screening recommendations for com- mon STIs are listed in Table 1.6,10,11 SYPHILIS The Centers for Disease Control and Prevention (CDC) recommends syphilis screening for all sexually active individuals 15 to 44 years of age living in communities with high rates of syphilis, defined as a AI/AN = American Indian or Alaska Native;​Black/AA = Black or African American;​NH/PI = Native county rate of primary and sec- Hawaiian or other Pacific Islander. ondary syphilis in women greater *—Per 100,000. than 4.6/100,000 people5 (Figure Figure 1. US Congenital Syphilis Rates by Race/Ethnicity 212).The US Preventive Services Task Adapted from Centers for Disease Control and Prevention. Sexually Transmitted Infections Force (USPSTF) states that opti- Surveillance, 2022. US Department of Health and Human Services; 2024. Accessed November 19, 2024. mal screening intervals for syphilis https:​//www.cdc.gov/std/statistics/2022/slides/2022-STI-Surveillance-All-Slides.pptx 17 latent infection. Figure 3 shows an algorithm for interpret- Commonly used enzyme immunoassay tests for HSV-2 ing these tests.6 typically report an index value (ie, amount of antibody in the blood). Positive HSV-2 results with low index val- GENITAL HERPES ues (ie, less than 3.0) are often false positives. When this The USPSTF recommends against screening asymptomatic occurs, a secondary confirmatory test, typically by Western individuals for HSV-2 because of the potential for adverse blot, is required for accurate diagnosis.6 psychological effects of positive tests, no available cure, and risks of false-positive results.17 However, the CDC sup- GONORRHEA AND CHLAMYDIA ports shared decision-making for screening in some people. The CDC recommends screening at least annually for This includes those with multiple sex partners, especially if gonorrhea and chlamydia in asymptomatic, sexually active they or their partners have HIV infection because comor- patients younger than 25 years, as well as in older patients bid herpes is a risk factor for HIV transmission.6 with risk factors6 (Table 16,10,11). Continue to assess individual risk factors to determine screening needs.* Offer syphilis testing to all sexually active people aged 15-44 years.† Suppressed Figure 2. US County-Level Syphilis Rates Among Women and Screening Recommendations Living in a county of high syphilis disease burden is a major risk factor. The Centers for Disease Control and Prevention identified high- risk counties as those where the rate of primary and secondary syphilis among women aged 15 to 44 years is more than 4.6/100,000. This goal provides a threshold for geography-based syphilis screening efforts for all sexually active people. Map data are from 2023. *—In counties with a rate of primary and secondary syphilis among women aged 15–44 years at or below 4.6/100,000, clinicians should continue to assess individual risk factors to determine screening needs, as outlined in existing screening guidelines. †—Offer syphilis testing to all sexually active people aged 15–44 years in counties with a rate of primary and secondary syphilis among women aged 15–44 years that is greater than 4.6/100,000 people. Adapted from County-Level Syphilis Data. STI statistics. Centers for Disease Control and Prevention. Accessed November 20, 2024. https:​//www.cdc.gov/ sti-statistics/county-level-syphilis-data/index.html 18  SECTION TWO Due to its high sensitivity, NAAT is preferred when alternatives.18,19 Self-collected vaginal swabs offer an accu- screening for chlamydia and gonorrhea.18 Vaginal swabs rate alternative to clinician-collected swabs with higher are the optimal means of obtaining a testing specimen, patient acceptability and desirability.20,21 although endocervical and first-void urine are reasonable Screening for pharyngeal gonorrhea and rectal chlamydia TABLE 1 Symptoms, Screening Recommendations, and Recommended Testing for Common STIs Indications for Screen- Testing Recommendations Symptoms ing Asymptomatic (if present) Individuals Initial Follow-Up In Pregnancy Syphilis Chancre Residence in a community Serology:​ Obtain Test at the first with high rates of syphilis Treponemal and nontreponemal titers prenatal visit or time of Rash (Figure 2) nontreponemal every 6 months after pregnancy diagnosis Condyloma lata antibodies treatment Sex with multiple partners Retest at 28 weeks’ Mucous patches Only A fourfold decline gestation and at delivery HIV infection or diagnosis of another STI nontreponemal within 12-24 months Alopecia titers are indicated confirms treatment Otic and ocular History of incarceration in with a history of success symptoms patient or partner syphilis infection A fourfold titer Neurologic Transactional sex increase after symptoms treatment indi