Oral desipramine and topical lidocaine for vulvodynia: a randomized controlled trial.

OBJECTIVE: To estimate the efficacy of common treatments for vulvodynia: topical lidocaine monotherapy, oral desipramine monotherapy, and lidocaine-desipramine combined therapy. METHODS: A 12-week randomized, double-blinded, placebo-controlled trial was conducted on 133 vulvodynia-afflicted women assigned to four treatment arms: placebo tablets-placebo cream, desipramine tablets-placebo cream, placebo tablets-lidocaine cream, and desipramine tablets-lidocaine cream. The tampon test was selected as primary end point using a modified intention-to-treat analysis. Twelve secondary end points were also examined. At completion of the 12-week randomized phase, women were examined "open label" through 52 weeks postrandomization. RESULTS: All treatment arms reported substantial tampon-test pain reduction: 33% reduction placebo cream-placebo tablet, 20% reduction lidocaine cream-placebo tablet, 24% reduction placebo cream-desipramine tablet, and 36% reduction lidocaine cream-desipramine tablet. Compared with placebo, we found no significant difference in tampon-test pain reduction with desipramine (t=0.90; P=.37) or lidocaine (t=1.27; P=.21). Of the remaining 12 outcome measures, only the Index of Sexual Satisfaction, improved with desipramine compared with placebo (t=-2.81; P=.006). During the open-label phase, women undergoing vestibulectomy surgery reported significantly improved pain as measured by cotton swab test and the McGill Pain Scale compared with nonsurgical alternatives. CONCLUSION: Oral desipramine and topical lidocaine, as monotherapy or in combination, failed to reduce vulvodynia pain more than placebo. Placebo or placebo-independent effects are behind the substantial pain improvement seen in all treatment allocations. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00276068. LEVEL OF EVIDENCE: I.

A multidisciplinary approach to total joint replacement.

A multidisciplinary team was formed to look at consolidating and improving patient education for patients preparing to undergo total knee replacement or total hip replacement. The objective was to encompass disciplines from across the continuum of care, beginning with the surgeon's office through postdischarge rehabilitation. Project goals for the team were to develop the "ideal" pre and postoperative orders for total joint patients, review and revise current clinical and patient pathways for the total knee replacement patient and the total hip replacement patient, add rehabilitation services to clinical pathways, and develop a patient education class and patient education booklet. This article describes how working together with all disciplines involved resulted in a consolidated order set, clinical and patient pathways that reflected actual care and processes, a user-friendly patient education book, and a multidisciplinary patient education class. The end products led to consistency in the quality of care across the continuum from preadmission through postdischarge rehabilitation for total joint replacement patients.