Case Series: Redefining Severe Grade 5 Vaginismus.

INTRODUCTION: Vaginismus is poorly understood and relatively unknown among health care providers. For those who understand and treat vaginismus, few make an assessment of the severity of this condition. The importance of classifying the severity of vaginismus impacts the clinician's ability to diagnose and treat vaginismus, and understanding of the patient's experience. AIM: The aims of this paper are to identify the distinguishing features of severe grade 5 vaginismus, determine if vaginal spasm is present in severe grade vaginismus, and to establish qualifications for the Pacik grade 5 classification. METHODS: Assessment of 553 referred or self-referred women who were unable to tolerate intercourse completed a comprehensive pretreatment questionnaire. Of those women, 391 underwent a vaginal examination in a certified surgicenter using sedation and anesthesia as needed. MAIN OUTCOME MEASURE: The main outcome measures were to detect the presence of a visceral reaction with an intended or actual gynecologic examination in Grade 5 patients, and to identify vaginal spasm on examination. RESULTS: A visceral response reaction to routine gynecologic examinations, as well as spasm of the bulbocavernosum, occurred in patients with severe vaginismus. CONCLUSION: Severe vaginismus with visceral response manifestations to routine gynecologic examinations, inability to have intercourse, and spasm of the bulbocavernosum is newly defined as severe grade 5 vaginismus. Pacik PT, Babb CR, Polio A, et al. CASE SERIES: Redefining Severe Grade 5 Vaginismus. Sex Med 2019;7:489-497.

Vaginismus Treatment: Clinical Trials Follow Up 241 Patients.

INTRODUCTION: Vaginismus is mostly unknown among clinicians and women. Vaginismus causes women to have fear, anxiety, and pain with penetration attempts. AIM: To present a large cohort of patients based on prior published studies approved by an institutional review board and the Food and Drug Administration using a comprehensive multimodal vaginismus treatment program to treat the physical and psychologic manifestations of women with vaginismus and to record successes, failures, and untoward effects of this treatment approach. METHODS: Assessment of vaginismus included a comprehensive pretreatment questionnaire, the Female Sexual Function Index (FSFI), and consultation. All patients signed a detailed informed consent. Treatment consisted of a multimodal approach including intravaginal injections of onabotulinumtoxinA (Botox) and bupivacaine, progressive dilation under conscious sedation, indwelling dilator, follow-up and support with office visits, phone calls, e-mails, dilation logs, and FSFI reports. MAIN OUTCOME MEASURES: Logs noting dilation progression, pain and anxiety scores, time to achieve intercourse, setbacks, and untoward effects. Post-treatment FSFI scores were compared with preprocedure scores. RESULTS: One hundred seventy-one patients (71%) reported having pain-free intercourse at a mean of 5.1 weeks (median = 2.5). Six patients (2.5%) were unable to achieve intercourse within a 1-year period after treatment and 64 patients (26.6%) were lost to follow-up. The change in the overall FSFI score measured at baseline, 3 months, 6 months, and 1 year was statistically significant at the 0.05 level. Three patients developed mild temporary stress incontinence, two patients developed a short period of temporary blurred vision, and one patient developed temporary excessive vaginal dryness. All adverse events resolved by approximately 4 months. One patient required retreatment followed by successful coitus. CONCLUSION: A multimodal program that treated the physical and psychologic aspects of vaginismus enabled women to achieve pain-free intercourse as noted by patient communications and serial female sexual function studies. Further studies are indicated to better understand the individual components of this multimodal treatment program. Pacik PT, Geletta S. Vaginismus Treatment: Clinical Trials Follow Up 241 Patients. Sex Med 2017;5:e114-e123.

Understanding and treating vaginismus: a multimodal approach.

INTRODUCTION AND HYPOTHESIS: This clinical opinion was written to bring attention to the understanding and treatment of vaginismus, a condition that is often under diagnosed and therefore inadequately treated, yet affects millions of women worldwide. Despite its description more than a century ago, vaginismus is rarely taught in medical school, residency training, and medical meetings. The DSM 5 classification stresses that vaginismus is a penetration disorder in that any form of vaginal penetration such as tampons, finger, vaginal dilators, gynecological examinations, and intercourse is often painful or impossible. Compared with other sexual pain disorders such as vulvodynia and vestibulodynia, the treatment of vaginismus has the potential for a high rate of success. Stratifying the severity of vaginismus allows the clinician to choose among numerous treatment options and to better understand what the patient is experiencing. Vaginismus is both a physical and an emotional disorder. In the more severe cases of vaginismus women (and men) complain that attempted intercourse is like "hitting a wall" suggestive of spasm at the level of the introitus. The emotional fallout resulting from this needs to be addressed in any form of treatment applied. METHODS: This article is based on lessons learned in the treatment of more than 250 patients and evaluation of more than 400 inquiries, and was written to make vaginismus more widely understood, to aid in the differential diagnosis of sexual pain, suggest a variety of effective treatments, and explain how Botox can be used as part of a multimodal treatment program to treat vaginismus. CONCLUSIONS: With greater awareness among clinicians it is hoped that medical schools, residency programs, and medical meetings will begin teaching the understanding and treatment of vaginismus.

Vaginismus: review of current concepts and treatment using botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia.

Vaginismus is a poorly understood condition affecting approximately 1-7% of females worldwide. This article aims to bring attention to this disorder and to review the use of Botox injections to treat these patients. Vaginismus, also known as vaginal penetration disorder, is an aversion to any form of vaginal penetration as a result of painful attempts and a fear of anticipated pain. It is involuntary and uncontrolled and functions much the same as any reflex to avoid injury. It is the most common reason for unconsummated marriages. The etiology is thought to be unknown. Numerous papers note a history of religious or strict sexual upbringing or aversion to penetration because of perceived pain and bleeding with first-time intercourse. Sexual molestation may be more prevalent in this group of patients. The Lamont classification is very helpful in stratifying these patients for treatment. Lamont grade 5 vaginismus is introduced. Vaginal Botox injections for the treatment of vaginismus has received increasing attention since the technique was first described in a 1997 case report. Plastic surgeons worldwide with their experience using Botox are well positioned to learn more about this relatively unknown entity and render treatment.

Pain control in augmentation mammaplasty: safety and efficacy of indwelling catheters in 644 consecutive patients.

BACKGROUND: In an effort to give patients an additional effective form of analgesia, indwelling catheters for the instillation of a long-acting local anesthetic have been used to alleviate postoperative pain in patients undergoing augmentation mammaplasty. OBJECTIVE: This prospective study analyzes the safety and efficacy of this form of pain control in a consecutive series of 644 patients. METHODS: Patients were given a choice of intermittent bolus or continuous flow catheters for pain control. Prior to discharge, 20 mL of 0.25% bupivicaine with 1:400,000 epinephrine was instilled by a nurse into catheters for those patients receiving bolus self-administration. Pain scores for each side were recorded both before and 30 minutes after instillation. Patients then instilled 1 to 2 additional doses of bupivicaine during the first 24 hours and continued to record pain scores in the evening and following morning. For patients using continuous flow catheters, 0.25% bupivicaine without epinephrine was used to fill pumps that allowed up to 2 days of continuous flow at a rate of 2 mL per hour per side. Patients recorded pain at time intervals similar to those of patients using bolus self-administration. Questionnaires were given to all patients to determine the extent of pain reduction following the instillation of local anesthesia. More than 200 complete questionnaires were gathered, and pain scores from each of these were analyzed to gauge the efficacy of the instillation regimen. RESULTS: Eighty-nine percent of the patients who self-administered a bolus of bupivacaine reported pain reduction on the evening of surgery, and 78% reported a reduction on the following morning, before implant mobility exercises. Catheters were maintained for 1 day postoperatively by 544 patients (84%) and for 2 days by 100 patients (16%). One patient developed an infection of unknown etiology that ultimately resulted in the loss of a unilateral implant. CONCLUSIONS: A prospective study of 644 consecutive augmentation mammaplasty patients shows that indwelling catheters for the postoperative instillation of bupivacaine are both safe and effective in the management of postoperative pain. This gives the patient an additional form of analgesia, limited to the operative site, which is helpful in a multimodal pain management program. Both continuous flow and intermittent bolus self-administration systems are effective and their patient ratings are indistinguishable.

Pain control in augmentation mammaplasty using indwelling catheters in 687 consecutive patients: data analysis.

BACKGROUND: Postoperative pain following augmentation mammaplasty can cause significant disability. In the authors' previously published prospective study of 644 consecutive augmentation mammaplasty patients, it was shown that the use of indwelling catheters for the postoperative instillation of bupivacaine is both safe and effective in postoperative pain management. OBJECTIVE: This study analyzes a large population of augmentation mammaplasty patients to not only compare the effectiveness of catheter control with systemic analgesics but also to delineate sites of pain and determine if any of a variety of factors influence postoperative pain. METHODS: Questionnaires were given to all patients to record the extent of pain reduction following the instillation of local anesthesia, patient preference for a variety of analgesics, and the locations of postoperative pain. Potential correlations to pain-including the number of children, age, handedness, preoperative fear, pain tolerance, and length of narcotic use-were investigated using statistical analysis. Operative aspects, such as the size of implants, use of asymmetrical implants, intraoperative expansion, duration of surgery, and sharp versus blunt dissection were also studied to determine if these factors influenced postoperative pain. RESULTS: Self-administration of bupivacaine the evening after surgery achieved pain reduction in 89% of patients. Patients gave high preference scores for the instillation of local anesthesia, comparable to rates achieved with the systemic narcotics Vicodin (Abbott Laboratories, Abbott Park, IL) and Percocet (Endo Pharmaceuticals, Chadds Ford, PA). Lower patient ratings were given to ibuprofen and methocarbamol. Patients identified multiple sites of postoperative pain, including the sternum, armpits, outer ribs, top of the breast (infraclavicular), interscapular region, and shoulders. Older patients experienced less pain. Patients who reported more pain, higher levels of fear, and sternal pain used narcotics for a longer period of time. Duration of surgery, blunt versus sharp dissection, and intraoperative expansion were not significantly related to pain. Combined implant size did not correlate with pain, though in the case of asymmetrical implants, greater pain (not statistically significant) on the larger side was reported. CONCLUSIONS: Postoperative pain following augmentation mammaplasty may be influenced by several factors, but these appear unrelated to implant size, specific operative techniques (blunt versus sharp dissection), or duration of surgery. Pain may involve not only the breasts, but also the sternum, sides of the chest, armpits, and infraclavicular and interscapular areas. The use of indwelling catheters for the instillation of a long-acting anesthetic is rated comparable in efficacy to the systemic narcotics Vicodin and Percocet. Sternal pain can be severe and may require narcotics for effective pain control.

Augmentation mammaplasty: enhancing inferomedial cleavage.

BACKGROUND: Typically, symmetrical markings are made to lower the inframammary fold (IMF) according to the surgeon's judgment. Because inferomedial fascial attachments of the IMF may at times compromise the proper seating of the implant in this area, causing excessive superior projection, asymmetrical lowering of the IMF is performed to allow for increased lowering of the inferomedial aspect of the fold. OBJECTIVE: A technique for enhancing inferomedial cleavage in augmentation mammaplasty is presented, and the frequency and value of the procedure in a series of patients is assessed. METHODS: A retrospective chart review was performed of 267 patients who underwent subpectoral augmentation mammaplasty using inflatable implants between November 2001 and March 2005. In cases involving lowering of the IMF, a combination of blunt and sharp dissection was performed to release the IMF in the inferomedial area and lower the inferomedial aspect of the fold, tapering to less lowering centrally and minimal to no change laterally. RESULTS: Among the 267 cases reviewed, 225 patients (84%) underwent some form of IMF lowering, of whom 191 (71%) underwent asymmetric lowering of the IMF to enhance inferomedial cleavage. Complications included 4 patients who required revision to correct bottoming out and 1 case of hematoma. CONCLUSIONS: Increased lowering of the inferomedial portion of the inframammary fold is helpful in correction of constriction of the inferior pole and/or lateral flare of the breasts. This technique is also suitable for patients who desire to enhance the inferomedial cleavage area and is of value for patients requesting larger implants.

Pain management in augmentation mammaplasty: a randomized, comparative study of the use of a continuous infusion versus self-administration intermittent bolus of a local anesthetic.

BACKGROUND: Indwelling catheters for pain control after augmentation mammaplasty appear to be safe and effective. However, little is known regarding the comparison of continuous flow to intermittent bolus anesthetics. OBJECTIVE: A prospective, randomized study was developed to compare these 2 systems. METHODS: Forty-one patients were divided into 2 groups. All patients used the On-Q (I-Flow Corp, Lake Forest, CA) continuous infusion pump system (2 mL per hour) in 1 breast. Group 1 consisted of 20 patients who, in the opposite breast, were permitted to bolus themselves with 20 mL of 0.25% bupivacaine HCl with 1:400,000 epinephrine (Sensorcaine; Astra Zeneca, Wilmington, DE) as needed, every 6 hours for a maximum of 2 doses. Group 2 consisted of 21 patients who were requested to instill 10 mL of 0.25% bupivacaine with 1:400,000 epinephrine every 4 hours (total 4 instillations) regardless of need (except during sleep). Results with regard to effectiveness and patient preference in both groups were assessed. All patients were asked to avoid any additional analgesics or narcotics for 30 to 60 minutes after self-administration in order to record an unbiased self-assessment response to the instillation of local anesthesia. All patients were seen the day after surgery and given an additional 20 mL of bupivacaine on the self-administration side before implant mobility exercises. RESULTS: In group 1, 10 patients preferred the continuous On-Q infusion, 9 patients preferred the self-administration bolus, and 1 patient who had no pain on either side was undecided. Among patients in this group, 24-hour pain scores were similar. In group 2, 13 patients preferred the continuous On-Q infusion, 5 patients preferred self-administration, and 3 patients were undecided. Pain scores in group 2 were lower for On-Q. An unexpected finding was that after unilateral self-administration, 20 of 41 patients (42%) noted bilateral reduction of pain. By day 3, 33 of 41 patients (80%) used no narcotics. There were no complications associated with either device. CONCLUSIONS: After augmentation mammaplasty, both indwelling catheters using continuous flow and intermittent bolus anesthesia as needed are effective in controlling postoperative pain. Continuous flow maintains a steady state of pain control without patient intervention. Self-administration allows patients to have a more active role if they have pain and is an effective low-cost alternative to a commercial pain pump. These conclusions are supported by a review of the literature and by our own experience with more than 380 consecutive patients.