|Robert J. Echenberg, M.D.|
Dr. Robert J. Echenberg is a board certified obstetrician-gynecologist, who completed his residency training at the University of Michigan in 1972, practiced privately in Bethlehem,Pennsylvania
for more than 20 years, and has worked for hospital based systems since
1994 in New Mexico and more recently back in Bethlehem with St. Luke's
Hospital. In 2006, he has returned once again to private practice in
Bethlehem , PA.
In years past he had a full obstetric and
gynecological surgical program with emphasis on team approach,
education, family participation and holistic management. He has had extensive experience with sexual counseling, grief counseling, and provided special programs for premenstrual syndrome, infertility, pre-conceptual and renatal education, and has provided a caring approach to women throughout the life cycles from adolescence through the menopausal years.
He has spoken at local, regional and national levels concerning women's health care issues. He was most influential in helping to establish many of the family-centered and technologic changes in obstetric and gynecological practice at St. Luke's Hospital in Bethlehem, PA for over twenty years, and was instrumental in helping to allow families to participate in and fully appreciate their birthing experiences. Dr. Echenberg has demonstrated his technical expertise and skills in both basic
gynecologic surgery and in all aspects of obstetrics as he maintained at least 15-20 births
per month and a comparable number of surgical procedures throughout most of his career.
Even while maintaining a busy practice of clinical medicine throughout those years, Dr. Echenberg's administrative skills and management activities focused on patient centered issues. All of the committees, programs, and organizations that he either helped to establish or that he participated in required a high degree of organizational skills as well as a deep commitment of time and energy. He was recognized throughout the Lehigh Valley in Southeast Pennsylvania as one of the key forces and influences in fighting for the best interests of the women and children of his community for over two decades.
His foresight and vision paved the way for many of the changes that took place in the routine medical care of women, both in the various community hospitals in the region as
well as in the private offices and clinics throughout that community in
Pennsylvania. Upon moving to New Mexico in 1995, Dr. Echenberg was part
of a multi-specialty hospital-based group in Las Cruces, New
Mexico. Working for the "First Step Women's Health Center", Dr. Echenberg practiced in professional collaboration with other physicians and Certified Nurse-midwives, caring for a large population of indigent women in the Southern New Mexico region. The physicians within the group were responsible for all of the high risk Ob and operative births.
Dr. Echenberg took great satisfaction in working within collaborative groups and took pride in helping to maintain an excellent record of quality outcomes of mothers and babies in these programs. There were approximately 120-130 births per month in this high risk population among almost exclusively uninsured and mostly indigent families in this economically poor region of Southern New Mexico. The C-section rate of about 11% was only one example of the quality care provided by this multi-disciplined group sponsored by Memorial Medical Center in Las Cruces.
Dr. Echenberg's teaching skills and experience can be appreciated by the fact that throughout all the years in Bethlehem, Pennsylvania, St. Luke's Hospital maintained an accredited Ob/Gyn Residency program and he was on the teaching faculty for that program. He was also affiliated with Temple University as an associate faculty member, working with Temple University medical students who rotated through that service. For one year before coming to New Mexico, Dr. Echenberg was on the faculty of the Ob/Gyn Residency program at Lehigh Valley Hospital Center in Allentown,
Pennsylvania.. He remained actively teaching in New Mexico in their Family Practice Residency program. In 1999, he was appointed Clinical Instructor by the Health Sciences Center of the West Virginia University School of Medicine.
In addition, for the past 25 years, Dr. Echenberg has guest lectured at many courses in local colleges and universities in both Pennsylvania and New Mexico.
Finally, for about the past 18 years, Dr. Echenberg's biggest professional interest outside of women's healthcare has been in the area of medical ethics. Once again, his managerial and executive skills have been utilized in creating and chairing various ethics committees and programs both in Pennsylvania and New Mexico, including one of the first Perinatal Ethics Committees in the country in 1984. It should be mentioned that without him, the ethics program at Memorial Medical Center in Las Cruces, NM would probably not have been established in its current form, and that he was commended for his work after JCAHO gave the hospital high marks in this complex area of ethics-related programming. Additionally, in 1999, he sat on the ethics committee of St. Joseph?s Hospital in Buckhannon, WV, and is currently back on the Ethics Consultation Committee at St.
Luke?s Hospital in Bethlehem, PA. He was also reappointed Chair of the Perinatal Ethics Committee at that institution.
During the last 2 years of his stay in New Mexico, Dr. Echenberg was Chairman of the Ob/Gyn Department at Memorial Medical Center. He ran regular administrative meetings in this capacity and sat in on numerous other decision-making meetings for his department. In his position on the Medical Executive Committee, he was sent to several management training seminars by the hospital. In addition to all of these hospital-related professional activities, Dr. Echenberg has
devoted extensive volunteer time to the local community sexual assault crises centers, both in Pennsylvania and in New Mexico, as a member of the Board of Directors. He was on the personnel committee in New Mexico, and spent extensive time participating in the recruiting and hiring of an executive director for this organization. He was also medical director of the "SANE" program in which nurses were trained to perform sexual assault physical exams and collect forensic evidence, and then testify in court when needed.
It should be noted that virtually all of the professional and community activities that Dr. Echenberg has participated in outside of his regular clinical duties required a great deal of managerial and leadership skills. This has been the case for many years, and he has been recognized in numerous ways for his vision, depth of interest and accomplishments in these endeavors.
|Chronic Pelvic Pain |
|Description of Overall Program|
following is a descripton of the program for chronic pelvic pain that
has been developed by Dr. Echenberg. This program is unique in the
Lehigh Valley and is based on sound principles of evidenced based
medicine. Chronic pelvic pain and lower genital tract disorders
including painful bladder syndrome (interstitial cystitis), irritable
bowel syndrome, low back disorders, vulvar burning/pain and sexual pain
disorders, are among the most common reasons for women seeking help
from their gynecologists or other primary health care providers.
Special hours are set aside for Dr. Echenberg to be able to spend the
time necessary to sort out, diagnose, and provide appropriate therapies
for these varied disorders.
WHAT IS THE CHRONIC PELVIC PAIN PROGRAM?
Chronic Pelvic Pain Program is a special program for women who have a
history of pain in the lower abdomen, pelvis, lower back, or in the
lower genital tract for a period of at least 3 - 6 months. Chronic
female pelvic pain also involves many women with long term histories of
bladder irritability (urinary frequency, urgency, and night time
voiding), vaginal irritation, and increasingly difficult discomfort
with sexual relations, all of which may have been unresponsive to many
different attempts at therapy.
There is only a limited amount
of appointment times available due to the amount of time spent with
each patient. Dr.Echenberg works in association with health care
psychologists and physical therapists, in Bethlehem, Allentown, and
WHAT TESTS SHOULD BE DONE BEFORE BEING SEEN?
recognize that you may already have had various tests, including urine
tests, blood tests, ultrasound and x-ray examinations, and even
surgical procedures such as laparoscopy (surgery done to view the
pelvic organs). There is no need to get any further testing before
entering our program, but it is very important that you make
arrangements to get your previous medical records to us. Please contact
your doctor?s office to sign the necessary releases to send us these
records. (We will send you the necessary release forms when you make an
These forms as well as other health
questionnaires and registration and insurance forms for our office can
be mailed or E-mailed to you depending on your preference.
WILL MY INSURANCE COVER THESE VISITS?
Appropriate coding of your visits will be submitted to insurance in
order to maximize coverage of your specific problems.
WHAT HAPPENS AT THE FIRST VISIT?
detailed history of your problem will be assessed by the doctor and his
nurse. This first visit usually concentrates on a great deal of
education and offering you many resources in the form of handouts, both
published and Internet sites. Usually a comprehensive physical
examination, concentrating on the areas of greatest concern, is carried
out as well. If you feel that it would be helpful for you to have a
significant other person with you at any visit it would be acceptable
for you to do so. These first visits will range from 60-120 minutes.
WHAT ABOUT SUBSEQUENT VISITS?
We feel strongly that mind and body
are very closely linked in anyone having chronic pelvic pain. Everyone
entering our program will likely be asked to see a health psychologist
and/or a physical therapist as part of their therapeutic program. An
overall assessment and plan of treatment will then be implemented on an
WHAT ARE THE GOALS OF THE PROGRAM?
major goal is to help you regain control of your life. Chronic pain
affects every part of your life - work, family, and social
relationships. Stressful times in your life can also make pain worse.
Therefore, we use a holistic approach in helping you learn to manage
your pain - things like stress management, exercise, nutrition, and
relaxation techniques. We also treat specific causes of pain. This will
include various medications and treatments for your specific problems.
DO WE THINK THAT YOUR PAIN IS ALL IN YOUR HEAD??
We know that your pain and its impact on your life are very real. That
does not mean that there is a major disease causing your pain that has
been missed. We often find treatable conditions which are not dangerous
but which can trigger very serious chronic pain. The model of therapy
for these chronic pelvic pain issues is very similar to the model of
treatment used in many established chronic pain management centers.
Also, very few of our patients are found to have dangerous illness, and
surgery is rarely indicated.
WHAT DO WE FEEL ARE SOME ?NO ? No?s??
are some things that we do not recommend in the Pelvic Pain Program,
since they do not seem to help and may make pain or disability worse.
We do not routinely prescribe long term narcotics. (Research shows that
these drugs can make chronic pain worse over time). (Opiates may be
used as rescue medication for severe pain flares).
2. We do not sign permanent disability papers. (Our goal is to help you get back to work!)
3. We rarely recommend surgery. (We do not think surgery helps in the vast majority of cases of chronic pelvic pain.)
Program for Female Lower Genital Tract Disorders and Chronic Pelvic Pain
A Therapeutic Program offered by
Robert J. Echenberg MD
variety of common symptoms in many women may result from disorders of
the various organ systems in the female pelvic area. Some of these
disorders are quite common but are often not diagnosed routinely or
easily. Combinations of these disorders may sometimes be present for
months or even years, and may lead to varying degrees of physical and
emotional disabilities if they remain undiagnosed or treated
Lower genital tract disorders may include any combination of the following symptoms complexes:
Symptoms of Recurrent Urinary Tract Infections: Recurrent episodes of
increased urinary frequency, urgency, and night time awakening for
urination ? often with negative urinalysis and cultures.
Symptoms of Recurrent Vaginal Infections: Recurrent episodes of vaginal
burning, itching, redness, irritation, and variable vaginal discharges
? often with inconclusive vaginal smears and cultures.
or Recurrent Vulvar Pain: burning, itching, redness, and unexplained
hypersensitive painful areas on the vulva or the vaginal opening.
- Chronic Dyspareunia: increasingly difficult and painful sexual intercourse.
such as Interstitial Cystitis and Vulvodynia are examples of disorders
that may cause any or all of the above symptoms and often go
undiagnosed for many years.
Chronic pelvic pain may also
co-exist with any or all of the above symptom complexes. The presence
of unexplained non-cyclic persistent or recurrent lower abdominal pain,
back pain, hip or even inner thigh pain may alert one to this
Any of these symptoms, especially if associated
with variations of chronic pelvic pain for 3-6 months or longer, may
represent a diagnosis of a Central Regional Pain Syndrome. Other
examples of central regional pain syndromes include Fibromyalgia,
Reflex Sympathetic Dystrophy (RSD), Irritable Bowel Syndrome (IBS),
Migraine Headaches, Chronic Fatigue Syndrome, and Trigeminal Neuralgia.
Severe Seasonal Allergies may also be associated with these syndromes.
of life can be greatly impaired with these symptoms and syndromes, and
many women suffer for years without being adequately diagnosed. Many
have seen multiple specialists and often are treated both medically and
surgically without significant reduction of their symptoms.
program offers a careful assessment of these diverse problems and
symptoms, and focuses on diagnostic accuracy. Individualized treatment
plans are initiated early, and often include multidisciplinary
Dr. Robert Echenberg is the primary
medical provider of these services. Dr. Echenberg has over 30 years of
experience as a practicing Board Certified Obstetrician and
Gynecologist, and he has developed special interest and expertise in
the diagnosis and management of chronic pelvic pain and lower genital
tract disorders over the past several years - since 2001.
major goal of this therapeutic program is to aid patients with these
debilitating problems regain control of their lives. With a combination
of medical therapies, physical therapy of the pelvic floor musculature,
psychological counseling and acupuncture and relaxation techniques when
indicated, this holistic approach has proven itself by regularly
contributing to improved quality of life of those women cared for in
We know that your chronic symptoms and pain have
had a significant impact on your life. You will not be treated as
though your problems are only ?in your head?. However very few of our
patients are found to have serious diseases and seldom are surgical
interventions required. Painful symptoms that have been present for
prolonged periods of time may show no current acute tissue damage. We
believe that these chronic problems need to be addressed entirely
differently than acute pain and discomfort.
Please fill out
the questionnaire and bring it with you to your first appointment. We
will go over the questions with you at the time of your visit. We have
a limited number of new appointment spaces due to the amount of time
spent with each patient.
A large part of recovery in this
therapeutic program depends on positive patient motivation. We
encourage each patient to learn as much as possible about her specific
condition and participate actively in her own treatment. Time will be
spent for education, and reading materials and web sites will be
|Bladder Issues and Pelvic Pain|
|Painful Bladder Syndrom/Interstitial Cystitis|
cystitis can be a chronic, debilitating disease. Since there is no
known cause or cure, our approach has been one of active patient
participation and patient education. We welcome the opportunity to
assist those in need of attention and understanding as our practice
grows with an increasing number of interstitial cystitis patients.
cystitis (IC), also known as "painful bladder syndrome" or "frequency-
pain syndrome," is a complex, chronic disorder that has baffled doctors
for as long as it has been recognized. Patients with interstitial
cystitis may have an inflamed bladder wall that can lead to scarring,
decreased bladder capacity, glomerulations (pinpoint bleeding) and, in
rare cases, ulceration. In other cases, the bladder wall can appear
normal without any evidence of disease process.
Estimates of the
number of people who have been diagnosed with IC vary. Studies have
indicated that up to 20 to 25% of all reproductive age women have some
degree of this disorder. It is likely that millions who suffer this
disease have yet to be diagnosed. About 90 percent of IC patients are
women. While people of any age can be affected, about two-thirds of the
patients are in their twenties, thirties, or forties. IC is rare in
children. In a few cases, IC has afflicted both mother and daughter,
but there is no evidence that the disorder is hereditary, or
genetically passed from parent to child.
Because IC varies so
much in symptoms and severity, many researchers have considered that it
may actually be not one, but several diseases. In the past, cases were
mainly categorized as ulcerative IC or non-ulcerative IC, based on
whether ulcers had formed on the bladder wall. But many clinicians have
questioned the usefulness of this classification, since the vast
majority of cases do not involve ulcers, and their presence or absence
does not influence treatment options or response to treatment as much
as other factors do.
The cause of IC is unknown, but
the disorder is believed to be a real, physical phenomenon, not a
result, symptom, or sign of an emotional problem. Research has focused
on the glycocalyx (mucus) lining of the bladder made up primarily of
mucins and glycosaminoglycans (GAGs). This layer normally protects the
bladder wall from toxic effects of urine and its contents. Researchers
at the University of California, San Diego, found that this protective
layer of the bladder was "leaky" in about 70 percent of IC patients
they examined and may allow substances in urine to pass through the
bladder wall mucosa and trigger IC symptoms. The researchers also found
that patients with bladder wall ulcers had "leakier" bladders than
patients without the ulcers.
An allergic reaction that causes
specialized mast cells to release histamine is considered another
possible cause, however these changes are seen in a minority of biopsy
specimens. Infection, drug reactions and autoimmunity are other causes
under investigation, however no significant advances have been
The symptoms of IC vary greatly from
one person to another but typically have similarities to those of a
urinary tract infection:
* Decreased bladder capacity
* Severe urinary frequency, day and night
* Feelings of pressure, pain, and tenderness around the bladder, pelvis
and perineum that may increase as the bladder fills and decrease as it
* Painful sexual intercourse
* In men, discomfort of pain in the penis and scrotum
* In most women, symptoms usually worsen around the menstrual cycle
* As with many other illnesses, stress may also intensify symptoms.
symptoms are similar to those of other disorders of the urinary system,
and because there is no definitive test to identify IC, other
conditions must be ruled out before considering a diagnosis of IC.
Among these disorders is a urinary tract or vaginal infection, bladder
cancer, radiation cystitis, kidney stones, endometriosis, neurological
disorders, sexually transmitted diseases, and in men, prostatitis.
Spasm of the muscular pelvic floor must also be considered.
may also be associated with diseases such as vulvodynia (vulvar/vaginal
pain), fibromyalgia (musculoskeletal pain) and irritable bowel disease.
evaluation may include a urinalysis, urine culture, urodynamic (bladder
pressure) study, cystoscopy (looking into the bladder using a miniature
telescope with anesthesia), biopsy of the bladder wall, and, in men,
laboratory examination of prostate secretions.
distension is painful in IC patients, cystoscopy must be performed with
either regional or general anesthesia. The diagnostic finding is
pinpoint hemorrhage, known as "glomerulations" which appear only after
the bladder is distended. A small bladder capacity under anesthesia
also helps to support the diagnosis of IC.
In review, the diagnosis of IC is based on:
* Presence of frequency, urgency, with pelvic/bladder pain (PUFF Scale questionairre)
* Cystoscopy sometimes indicated - Cystoscopic evidence (under
anesthesia) of bladder wall inflammation and pinpoint bleeding
(glomerulations) or Hunner's ulcers
* Absence of other diseases that may cause the symptoms
have not yet found a cure for IC, nor can we predict who will respond
best to which treatment. Symptoms may disappear without explanation or
coincide with an event such as a change in diet or treatment. Even when
symptoms disappear, however, they may return after weeks, months, or
years. This is known as IC FLAIR and it is important to understand that
the symptoms of IC can recur or "flair" up at any time without cause or
Because we do not know the cause of IC, treatments are
aimed at symptomatic relief. One or a combination of treatments, many
of which are described below, helps most people for variable periods of
is a treatment procedure that is done in the office. A tiny soft
catheter is placed into the bladder. Medication is then poured into the
bladder and the catheter is removed. The patient then leaves the office
and is instructed to empty her bladder about 1 1/2 to 2 hours later.
* "Rescue Solution" is now becoming first line treatment for initial
severe pain and symptoms of flair. This is a mixture of lidocaine, (a
topical anesthetic), heparin and Sodium Bicarbonate. It is very
soothing and quickly reduces pain levels by "breaking the pain cycle".
This results in dramatic reduction of anxiety and allows more time for
office assessment to determine long term treatment options. Treatments
are usually needed over the course of about 6 weeks to gain durable
* Heparin or pentosanpolysulfate (Elmiron) can also be
instilled as a single agent and are thought to work by replacing or
repairing the "leaky" bladder lining.
* A variety of other
drugs have been used experimentally for bladder washes, but have not
been shown to be beneficial and in many cases can be extremely
irritating. These include silver nitrate, sodium oxychlorosene
(Clorpactin WCS-90) and BCG.
polysulfate sodium (Elmiron) and amitriptyine are two medications that
have been shown to be effective in randomized, placebo-controlled
* Elmiron is an FDA approved medication which helps
restore the damaged lining of the bladder. Results are evident by the
third month of use and there appears to be a 40 % to 50% response rate.
It is taken three times a day and is generally well tolerated.. The
most common side effect is gastric upset and about four percent have
hair loss that is completely reversible when medication is stopped.
* Amitriptyline (Elavil) is an antidepressant that has the ability to
block pain and reduce bladder spasms. Studies have now documented
statistically significant improvement in pain and urgency when compared
to placebo. Most people who respond to this drug show improvement 3 or
4 weeks after starting treatment. Side effects include drowsiness and
* Hyoscyamine (Levsin) and oxybutynin (Ditropan,
Ditropan-XL) and tolterodine (Detrol, Detrol LA) have excellent
properties to reduce bladder spasms and are well tolerated. Dry mouth
is the most common side effect of this class of medication.
* Hydroxyzine (Vistaril, Atarax) is an antihistamine that has been reported to be effective in limited studies.
supplements are also under investigation and some have been shown to
benefit some patients in limited, uncontrolled studies.
L-Arginine is an amino acid (protein building blocks) that breaks down
into nitrous oxide, (a neurotransmitter) that can reduce pain and
frequency in some patients.
* Kava Kava is an herbal
preparation that has anti-anxiety effects. Even though this is a plant
extract and is not under FDA control, it can produce serious side
effects and a physician's supervision is needed if it is taken for more
than 3 months.
* Quercitin is one kind of several substances
called bioflavonoids that are found in onions, red wine, green tea and
other plants. In limited and preliminary clinical reports, a
non-standardized preparation seems to have improved symptoms in about
half of the patients. Quercitin has strong anti-oxidant and
anti-inflammatory properties that may explain its beneficial effects,
but further well-controlled studies are needed to determine its
There is no scientific evidence linking
diet to IC, however many patients obtain considerable relief by
limiting intake of alcohol, tomatoes, spices, chocolate, caffeinated
beverages, citrus and high-acid foods. Some patients also notice a
worsening of symptoms after eating or drinking products containing
artificial sweeteners. An "elimination diet" can be used to pinpoint
specific food irritants and is recommended for all IC patients. For
those who are sensitive to food acidity, "Prelief" is available locally
as tablets or granules that reduce the acidity of food and helps to
reduce pain. Their toll-free hotline is 1-800-994-4711.
PAIN CONTROL: A different kind of pain.
of us are familiar with typical pain of a sprained ankle or a cut
finger. This is called "somatic" pain and is easily localized to the
area of injury, is easy to describe (sharp, dull or aching) and heals
in a short period of time. The pain of IC is called "visceral" pain and
is very different because it arises from the bladder, an internal organ
located deep in the pelvis. This kind of pain is difficult localize,
can be very difficult to describe and occurs on a long-term, chronic
basis. One reason why IC is so frustrating is because a patient may
have difficulty telling a doctor where the pain is located and be
unable to describe its character. A typical patient will point to
several areas including the back thighs abdomen and pelvis calling the
pain "pressure-like" or "cramping". This is not the typical description
of distinct and localized somatic pain that most doctors are familiar
with and feel comfortable treating. One of the most important aspects
of receiving good care is to choose a physician who is experienced in
treating IC and is comfortable assessing and treating visceral pain.
some IC patients the most effective control of long-term pain is
obtained with the use of opioid narcotics. They are derived from the
opium poppy and are excellent at providing pain relief, Vicodin and
oxycodone are the most commonly prescribed oral preparations. Side
effects include sedation, respiratory depression and constipation.
These can be very significant and require careful dose adjustment and
Unfortunately, all opioids have the potential for
tolerance, physical dependence, and addiction. These characteristics
have lead to many misconceptions about narcotic use and prevent many
health care providers from considering prescribing them for long-term
Tolerance to opioid medication is common. It refers to the
progressive decrease in pain control and the need of higher doses to
provide the same level of pain relief.
always occurs. with long-term use of opioids. If the medication is
abruptly withdrawn or the dose is markedly reduced patients will
experience a withdrawal syndrome that includes abdominal cramping,
sweating, nausea, diarrhea and irritability. It is strictly a medical
condition and should not be taken as a sign of psychological weakness.
Addiction is a behavioral disorder that results in psychological
dependence of a substance. It refers to compulsive drug use and
continuing drug use despite harm. Unfortunately, addiction is all too
often incorrectly equated with physical dependence and withdrawal
syndrome. To provide proper chronic pain management it is crucial for
physicians to recognize this critical difference.
Objectives of Pain Control
The patient and physician should have realistic expectations regarding the use of opioids.
an excellent Quality of Life should be the main goal by adequate
control of pain, not the complete elimination of pain. Outcomes should
focus on developing a daily routine schedule involving work,
participation in social functions, and family needs.
long-term medication controls but does not cure diabetes or high blood
pressure, long term medication is required to adequately control
Because of the abuse potential of narcotic pain
medication many physicians require patients to agree to an Opioid
contract. This is a reasonable approach that creates the obligation of
both parties to effectively communicate dose requirements, dose
changes, reports of side effects and refill authorization.
Anxiety and IC
is a significant component of IC that tends to be misunderstood.
Patients coping with chronic pain often restrict activities for fear of
increased pain or further injury. Withdrawal from normal activities
such as work, family responsibilities and social events can result in a
high degree of anxiety, worry, frustration and fear of loss. Research
has shown that individuals with a high disposition to become anxious
report significantly higher pain levels than those with low levels of
anxiety. It is also known that as anxiety increases, the intensity of
reported pain increases. This results in a vicious cycle that needs to
Pain and Anxiety Cycle
many situations the pain-anxiety cycle is not treated because the
physician or patient does not recognize or refuses to accept the
presence of anxiety. The impact that psychological factors have on the
perception of pain does not mean that the pain is "in the persons head"
or not real. Those with IC who report pain are really experiencing it,
even if a physical cause cannot be identified.
Relief of anxiety can be obtained by two approaches:
* Behavioral changes include relaxation techniques and stress
management. There are many options available that can be individualized
according to personal preference. These include:
o Progressive muscle relaxation
o Breathing techniques
* Medication can relieve symptoms quickly and safely. The most
effective and most prescribed class of medication is benzodiazepines
(Valium, Xanax, Klonopin). The most common side effect is drowsiness
and tolerance (see above) can develop so short-term use is recommended.
Because these drugs are often used in combination with antidepressants
such as amitriptyline, the lowest possible dose should be prescribed to
minimize side effects.
No one should ever be denied treatment
for pain. But because of the reluctance of certain physicians to treat
chronic pain, there is an alternative to help obtain proper pain
Pain Management Programs
Pain clinics are now
becoming popular for patients who continue to have difficulty obtaining
adequate pain control. These are specialized, integrative pain
management programs that are available at many community and academic
hospitals. Dr. Echenberg's practice offers such a comprehensive pain
management program for chronic pelvic pain in women. Therapies offered
typically include conventional pain medications, interventional
pudendal nerve blocks, trigger point injections, referral for
acupuncture, neural therapies (i.e. Neurontin, Lyrica, Topomax),
massage therapy, physical therapy, deep tissue and spinal manipulation,
dietary recommendations and counseling.
Sacral Nerve Stimulation
can be used to relieve severe frequency when all other options have
failed. Our program can refer you for this procedure though it is
rarely needed. The InterStim device is an implanted stimulation system
that sends electrical impulses to the nerve near the tailbone that
influences bladder control. Stimulation of this nerve may relieve the
symptoms related to urge incontinence.
The effectiveness of the
therapy is first tested on an outpatient basis. If the test is
successful, the patient may choose to have the device implanted.
final procedure requires general anesthesia, A small wire is placed
near the sacral nerve through an incision and is passed under the skin
to a silver dollar sized neurostimulator. The neurostimulator is then
placed under the skin in the upper buttock.
Adjustments can be
made with a wireless programming device that sends a radio signal
through the skin to the neurostimulator. The patient can make further
adjustments at the doctor's office or at home.
This treatment is
about 50% effective. Complications such as infection are frequent,
permanent nerve damage have been reported and migration of the
implanted wires can render the system ineffective. However, it is an
excellent alternative to any major surgical procedure.
emotional support of family, friends, and other people with IC is very
important in helping patients cope with the disorder. Studies have
found that IC patients who learn about the disorder and become involved
in their own care do better than patients who do not. We encourage our
patients to visit the superbly designed web site: www.ic-network.com
which has a wealth of information regarding all aspects of IC including
chat groups. We also suggest our patients visit www.ichelp.com which
provides access to professional publications, support groups and
ICN Patient Handbook. This is an on-line manual available at www.ic-network.com . Very accessible and pertinent information.
Interstitial Cystitis Survival Guide. Moldwin, New Harbinger, 2000. The
most comprehensive review of IC available. Easy to read. Highly
Overcoming Bladder Disorders. Chalker and Whitmore,
HarperPerennial, 1990. An excellent comprehensive manual including
self-help strategies. A bit outdated but still extremely useful.
Bladder and Prostate Problems. Blaivas, Plenum Trade, 1998. Somewhat
technical chapters covering all aspects of the urinary system.
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Interstitial Cystitis Updates
an attempt to further understand this disease and to discover new
treatment options and research discoveries, we will post reviews of
recent articles and other significant matters that relate to
Antiproliferative activity is present in bladder but not renal pelvic urine from interstitial cystitis patients.
S, Warren JW, Zhang CO, Tu LM, Gordon DA, Whitmore KE Department of
Medicine' University of Maryland School of Medicine' the Research
Service' Baltimore Veterans Affairs Maryland Health Care System ë21201'
USA.; J Urol; 1999 Oct; 162(4):1487-9
PURPOSE: To determine
whether an antiproliferative urine factor that we previously discovered
to be specific for urine from interstitial cystitis (IC) patients
originated in the lower urinary tract or a more proximal site.
AND Methods: Sequential catheterized urine specimens were collected
under sterile conditions from the bladder and renal pelvis of 20 IC
patients and one control patient (with stress incontinence).
Antiproliferative activity was determined by 3H-thymidine incorporation
of primary normal adult bladder epithelial cells cultured with pH- and
osmolality-corrected bladder or ureteral urine specimens; significant
inhibition was defined as a change in 3H-thymidine incorporation
greater than 2 standard deviations from the mean of control cells.
Bladder urine specimens from 19 of 20 IC patients significantly
inhibited 3H-thymidine incorporation as compared to cell medium alone
(mean change for bladder specimens = -68.7+/-7.5%)' while a renal
pelvic specimen from only 1 of 20 IC patients inhibited proliferation
significantly (mean change for renal pelvic specimens = 3.2+/-3.4%)
(p<.001 by Fisher's exact test). The one inhibitory IC renal pelvic
specimen inhibited by 31% while a bladder specimen obtained during the
same procedure inhibited by 94%. In comparison neither bladder nor
renal pelvic urine from the control patient had inhibitory activity.
The antiproliferative factor previously found in the urine of IC
patients appears to be made and/or activated in the distal ureter or
New Clinical Marker for Interstitial Cysitis
cause of interstitial cystitis is thought to be a deficiency in the
protective mucous layer of the bladder. More specifically, it is
thought that potassium diffusion becomes more prominent and potassium
acts as an irritant to the superficial and muscle layers of the
bladder, producing symptoms of interstitial cystitis.
GP 51 is a
urinary glycoprotein that functions as a protective barrier to the
bladder wall. A recent study at Thomas Jefferson University evaluated
urinary GP 51 levels in patients with and without interstitial
cystitis. It was found that these levels are significantly reduced in
patients with the disease. Although, it does not explain why levels
were lower, it certainly raises the possibility of using GP 51 as a
clinical marker for diagnosing interstitial cystitis using a
non-invasive urinary test. It may also become an excellent way of
monitoring treatment and the ongoing effects of drug therapy.
Reduce Acid Content in Foods
patients with interstitial cystitis have difficulty tolerating acidic
foods such as pizza, tomato sauces, coffee and juices. It is thought
that the bladder pain is caused by high levels of potassium that leaks
through the bladder wall. A product called Prelief, which reduces acid
content in food, is available over the counter as tablets and granules
and may be of value in the diets of interstitial cystitis patients who
are sensitive to acidic foods. Check out their website at
Echenberg may have prescribed Lidocaine Ointment for you for your
persistant irritation at the vaginal opening. 5% Lidocaine Ointment is
a local topical anesthetic ointment that has been shown to gradually
diminish the senstivity of the nerve fibers that supply the vaginal
opening (the "vestibule" of the vagina). The instruction for use of
this ointment is as follows: Apply a small portion of the Lidocaine
Ointment to a cotton ball each evening at bedtime and place it in the
vaginal opening overnight and throw it away in the morning or if you
have to get up to the bathroom during the night. Some patients find
that the Lidocaine provides a soothing comfortable feeling when it is
there overnight while it gradually is desensitizing the nerve endings
that cause the burning and pain during intercourse. Please call for an
appointment with Dr. Echenberg if you wish to be evaluated for this all
too common problem.
Guidelines for Vulvar Skin Care
NOTE: The goal is to promote healthy vulvar skin. This is done by decreasing and/or removing any chemicals, moisture, or rubbing (friction). Any products listed below have been suggested for use because of their past success in helping to decrease or relieve vulvar/vaginal itching and burning.
Use a detergent free of dyes, enzymes and perfumes (such as ALL-Free and Clear or Earth-Rite) on any clothing that comes in contact with your vulva such as your underwear, exercise clothes, towels, or pajama bottoms. Use 1/3 to 1/2 the suggested amount per load. Other clothing may be washed in the laundry soap of your choice. Do not use a fabric softener in the washer or dryer on these articles of clothing. If you do use dryer sheets with the rest of your clothes, for any loads, you must hang dry your underwear, towels, and any other clothing that comes in contact with
your vulva. Stain Removing Products. Soak and rinse in clear water all underwear and towels on
which you have used a stain removing product. Then wash in your regular washing cycle. This removes as much of the product as possible.
Wear white all cotton underwear, not nylon with a cotton crotch. Cotton allows air in and moisture out. Avoid pantyhose. If you must wear them, either cut out the diamond crotch (if you cut out the crotch be sure to leave about 1/4 to 1/2 inch of fabric from the seam to prevent running) or wear thigh high hose. Many stores now carry thigh high nylons. Avoid tight clothing, especially clothing made of synthetic fabrics. Remove wet bathing and exercise clothing as soon as you can.
BATHING AND HYGIENE
Avoid bath soaps, lotions, gels, etc. which contain perfumes. These may smell nice but can be irritating. This includes many baby products and feminine hygiena products marked "gentle" or "mild". Dove-Hypoallergenic, Neutrogena, Basis, or Pears are the soaps we suggest. Do not use soap directly on the vulvar skin just warm water and your hand will keep the vulvar area clean without irritating the skin. Avoid all bubble baths, bath salts and scented oils. You may apply a neutral
(unscented, non-perfumed) oil such as Keri Oil to damp skin after getting out of the tub or shower. Do not apply oils directly to the vulva. Do not scrub vulvar skin with a washcloth, washing with your hand and warm water is enough for good cleaning. Pat dry rather than rubbing with a towel. Or use a hairdryer on a cool setting to dry the vulva. Baking Soda soaks. Soak in lukewarm (not hot) bath water with 4-5 tablespoons of baking soda to help soothe vulvar itching and burning. Soak 1 to 3 times a day for 10-15 minutes. Use white, unscented toilet paper. If paper has a perfumed scent or lotion, avoid using it. Avoid all feminine hygiene sprays, perfumes, adult, or baby wipes. Pour
lukewarm water over the vulva after urinating if urine causes burning of the skin. Pat dry rather than rubbing with a towel. Avoid the use of deodorized pads and tampons. Tampons should be used when the blood flow is heavy enough to soak one tampon in four hours or less. Tampons are safe for most women, but wearing them too long or when the blood flow is light may result in vaginal infection, increased discharge, odor, or toxic shock syndrome. Also, use only pads that have a cotton liner that comes in contact with your skin. Avoid all over the counter creams or ointments, except A&D Ointment. Ask your health care provider first. Small amounts of A&D Ointment may be applied to your vulva as often as needed to protect the skin. It may also help to decrease skin irritation during your period and when you urinate. Brands that have been helpful are the Fougera brand, Toys R Us
brand, Rugby brand, or NMC brand.
DO NOT DOUCHE. Baking soda soaks will help rinse away extra discharge and help with odor.
DO NOT SHAVE the vulvar area.
Some women may have problems with chronic dampness. Keeping dry is important. Choose cotton fabrics whenever you can. Keep an extra pair of underwear with you in a small bag and change if you become damp during the day at work/school. Gold Bond Powder or Zeosorb Powder may be applied to the vulva and groin area one to two times per day to help absorb moisture. Dryness and irritation during intercourse may be helped by using a lubricant. Use a small amount of a pure vegetable oil such as Crisco (solid or oil). The vegetable oils contain no chemicals to irritate vulvar/vaginal skin. Vegetable oils will rinse away with water and will not increase your chances of infection. Water-based products like K-Y Jelly are helpful, but may tend to dry before intercourse is over and also contain chemicals that can irritate your vulvar skin. It may be helpful to use a non-lubricated, non-spermicidal condom, and use vegetable oil as the lubricant. This will help keep the semen off the skin which can decrease burning and irritation after intercourse.
BIRTH CONTROL OPTIONS
The new low-dose oral birth control pills do not increase your chances of getting a yeast infection.
Lubricated condoms, contraceptive jellies, creams, or sponges may cause itching and burning. Ask your health care provider for help. The use of latex condoms with a vegetable oil as a lubricant (#14 above) is suggested to protect your skin. Oil based lubricants may affect the integrity of condoms when used for birth control or prevention of sexually transmitted diseases. Our experience has not found this to be a problem with vegetable based oils. However,the Centers for Disease Control recommends that condoms not be used with any oil based lubricants for birth control or prevention of sexually transmitted disease.
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The Vulvar Self-Exam
as you would examine your breasts or skin for changes, you should
examine your vulva. Many diseases of the vulva have similar symptoms.
The vulvar self-exam will help you to be aware of any changes in the
vulvar area that may need ongoing evaluation. Some changes in the vulva
may mean cancer. Tell your physician if you see any changes or have
symptoms that don?t go away, such as itching, bleeding or discomfort.
If a problem does occur, catching it at an early stage--when treatment
is most successful--is in your best interest. Learning how to do a
vulvar self-exam can best accomplish this.
1. Wash your hands carefully before you begin.
or sit up in a comfortable position with good lighting and a hand
mirror (a magnifying mirror may work best). It may help to prop up your
back with pillows, or you can squat or kneel. Finding a comfortable
position is important so you can clearly see the vulvar area, perineum,
and anus. First, just look and learn. Things may appear different from
what you expect, and that does not necessarily mean they are abnormal.
Gently separate the outer lips of the vulva. Look for any redness,
swelling, dark or light spots, blisters, bumps or other unusual colors.
3. Next, separate the inner lips and look carefully at the area
between them for the same changes. Also, look at the entrance of the
4. Gently pull back the skin covering the clitoris and examine the area under the hood at the tip of the clitoris.
Be sure also to inspect the area around the urethra, the perineum, the
anus, the outside of the labia majora and the mons pubis.
SOME SUGGESTED VULVAR PAIN & ITCHING MEASURES
vulva is the external genitalia in the female. The skin of the vulva
can be quite sensitive. Because it is moist and frequently subjected to
friction while sitting and moving, this area can be easily injured.
There are various strategies that can be used to prevent irritation and
allow the vulva to heal. Keeping this area dry can accelerate healing.
Chemicals found in toilet tissues, laundry soaps and detergents that
come in contact with the vulva can cause irritation. Avoiding contact
with potential irritants that contain chemicals is important. Fabric
softeners in undergarments, chemicals in deodorant soaps, bubble baths,
feminine hygiene spray and panty liners etc., can all cause irritation
to the vulva. The following recommendations are specific measures that
can help minimize vulvar irritation.
Wear white 100%
cotton underwear, and do not wear pantyhose, tights, or other
close-fitting clothes. Enclosing this area with synthetic fibers holds
both heat and moisture in the skin, conditions which potentiate the
development of secondary infections. Tight-fitting clothes may also
increase your symptoms of discomfort.
underwear, put it through at least one whole cycle with water only.
Some women have suffered needlessly from irritants in detergents whose
residue was left in clothes by incomplete rinsing. Rinsing clothes
thoroughly is more important than which detergent is used although to
be on the safe side, the milder the soap, the better. Wash new
underwear before wearing. Fabric softeners and dryer sheets should not
Rinse skin off with plain water frequently.
Use tap water, distilled water, sitz baths, squirt bottles, or bidets.
Pat the skin gently dry, or dry with a cool setting on a hair dryer if
Use very mild soap for bathing. It is best
not to use any soaps on the vulva. The vulva should be rinsed with warm
water. Bars of soap such as Neutrogena unscented face soap, Basis,
Pears (made in England), and castile soap with olive oil (Conti) are
gentle to the other skin areas. They are found at pharmacies or health
food stores. Remember that frequent baths with soaps may increase the
irritation. You cannot wash away your symptoms.
compress of oiled Aveeno (a powdered oatmeal bath treatment) has been
recommended by some. It is placed over the vulva three to four times a
day. Put two tablespoons of Aveeno in one quart of water. Mix in a jar
and refrigerate. This is often helpful after intercourse or when
symptoms of burning and itching are present.
lubricants suggested by your physician to make intercourse more
comfortable. Astroglide is a product with a natural lubricating action.
Other water-soluable lubricants include Lubrin, Moisturel, Replens and
KY Jelly. Vegetable oils such as olive oil also provide lubrication.
100% cotton menstrual pads and tampons. Many women with vulvar pain
experience a significant increase in irritation and pain every month
when they use commercial paper pads or tampons. This monthly increase
in pain can often be reduced by using 100% washable and reusable cotton
menstrual pads. Some disposable cotton pads are available. Pure cotton
tampons are also available.
Don?t sit or remain in a wet bathing suit for prolonged periods.
Avoid condom and spermicidal creams or gels if they cause increased irritation of sensitive tissues.
it is often recommended that the vulva is left uncovered at night (i.e.
no underwear) to allow adequate exposure to the air.
of the disease processes will require a biopsy to diagnose your
condition. If a biopsy is performed during your visit, after care is
important. Keep the area clean and dry. Avoid application of creams or
ointments to the biopsy site. Sitz baths twice a day for three or four
days following the biopsy will aid in healing. If increase redness,
severe pain, heavy discharge, or heavy bleeding occurs at the biopsy
site, call for further instrucitons. Avoid intercourse until the biopsy
site is healed.
The Vulvar Pain Foundation, "Natural and Prophylactic Measures Suggested", Vulvar Pain Newsletter 1993: Spring: 5-6
The Interstitial Cystitis Association Vulvar Pain handout
large proportion of the patients seen at the University of Michigan
Center for Vulvar Diseases have vulvar pain. The following information
is a comprehensive review of the different aspects of vulvar pain.
Throughout history many different terms have been used to describe
vulvar pain. Vestibulodynia (previously called vulvar vestibulitis)
consists of pain at the entranceway to the vagina. Vulvar dysesthesia
(previously called dysesthetic vulvodynia) consists of a burning or
pain on the vulva present in areas outside of the vestibule. Patients
with dysesthetic vulvodynia may also have burning or pain at the
vestibule. Symptoms consist of burning, stinging, irritation or
rawness. Other terms used to describe the vulvar discomfort include:
itching, stretching and throbbing.
Causes: Vulvar pain
can be divided into two major categories: those with a known cause and
those where a cause cannot be identified.
Pain with a known cause
pain can be associated with simple chemical irritation, so-called
contact dermatitis. Common irritants include soaps, shampoos, scented
toilet paper, douches, fabric softeners and scented menstrual pads. It
can also be caused by certain medications which have been used to treat
vulvar problems. Various infections can also be causes of vulvodynia.
Women with chronic vulvar and vaginal yeast infection can frequently
have vulvar itching and burning. Often symptoms worsen before menses as
the changes in ovarian hormone production and the local vaginal
environment can favor yeast growth during that time. Recurrent herpes
simplex virus infection can also cause vulvar pain. These infections
wax and wane, often starting at stressful times and lasting anywhere
from a couple of days to a week or more. Irritation of the nerves which
supply the vulva can also cause vulvar pain. This type of vulvar pain
may radiate from the vulva to the perineum and into the groin and
thigh. Some patients have lower back problems which may be associated
with this pain also. Vulvar pain also results from injury (i.e.
childbirth, vaginal/vulvar trauma).
Pain without a known cause
examination of this group of patients does not demonstrate any visible
abnormalities. It is important to understand that vulvar pain with a
normal appearing vulva does not mean that there is not a cause of the
vulvar discomfort, rather a cause cannot be identified. Despite the
fact that a cause of vulvar pain cannot be established in all cases,
two things are important to keep in mind: 1) frequently the discomfort
associated with vulvar pain can be controlled, and 2) it is clear that
there is generally no relationship between vulvar pain and the
subsequent development of vulvar cancer.
Pain on the
Vestibule of the Vulva: Some women present with distinct tenderness and
at times erythema (redness) in the vestibule. Intercourse is painful
and, in some cases, impossible due to the severe pain. Typically, women
with pain on the vulvar vestibule present with a varying duration of
symptoms from weeks to several years. Symptoms often begin after
experiencing some type of infection or trauma followed by difficulty
with intercourse. Burning, stinging, irritation or rawness at the
vaginal opening with intercourse are the most common complaints. This
same sensation may also be experienced when placing tampons or touching
in the area of the vestibule. Women with severe symptoms may also feel
this same sensation when riding a bicycle, horseback riding or jogging.
In more extensive cases, some patients experience these symptoms while
sitting, walking or even without any movement. Typically, these women
have seen a number of health care practitioners and have had numerous
attempts at therapy with topical or oral antifungals, topical steroids,
and antibiotics. Usually, these provide no long term relief.
cause(s) of pain on the vestibule is not known. Early studies
implicated the human papilloma virus as a cause, but this is no longer
considered to be associated with vulvar vestibulitis. There appears to
be a small subset of women who have chronic yeast infection as a cause
of their vestibular pain, and long-term yeast suppression has met with
promising results in these women. There is also another group of women
who appear to have both pain at the vulvar vestibule and interstitial
cystitis (a condition of the bladder which causes urinary frequency and
burning). Because the vestibule and a portion of the bladder are the
only two tissues in the body derived from the same embryologic tissue,
investigators have begun to look for an irritant which might affect
both of these structures. To date, no causative agent has been proven.
Some patients relate the onset of their pain to a gynecological or
obstetric event. It is important to recognize that there is absolutely
no evidence that vestibular pain is a sexually transmitted disease,
therefore, it cannot be contracted from or given to your sexual
Treatment: Treatment of vulvar pain
conditions is confounded by the fact that the cause is unknown in a
great majority of cases, and the best treatment will likely come only
when the cause has been identified. Where chronic yeast infection can
be identified, suppression of yeast growth can be gratifying. Other
topical therapies such as steroids and antibiotics have not met with
success. Topical anesthetic agents (e.g., viscous or liquid xylocaine)
can sometimes help with temporary relief. The greatest success in
treating vulvar pain conditions comes from using a group of medications
called antidepressants. This group of drugs (e.g., Elavil?, Pamelor?,
Norpramin?) has been used to treat many chronic pain conditions where a
cause cannot be found. The TCA (tricyclic antidepressant) may work by
inhibiting certain pain fibers which supply (innervate) the vulva. This
in turn can prevent these specific nerves from transmitting the message
to the brain where it is processed and pain is perceived. Another group
of drugs, anticonvulsants, are used as treatment for other chronic pain
conditions and may be used for vulvar pain. The use of the CO2 laser
has not been successful, and in some cases, the results of treating
vestibulitis with the CO2 laser have worsened the pain.
has been suggested burning on the vestibule may be associated with
elevated levels of oxalates in the urine. A group of investigators have
described patients whose symptoms improve while on a low oxalate diet
combined with taking a mineral called calcium citrate. Calcium citrate
may decrease calcium oxalate formation in the urine, which is proposed
to cause vulvar pain. (See page 21) Surgical excision of the vulvar
vestibule may be offered as treatment for pain on the vestibule if
conservative measures have failed.
There is no standard
treatment for patients with vulvar pain since there are likely multiple
causes. Treatment suggested will depend on your individual case.
Modifications of treatments and medication dosages may need to be
altered if your symptoms vary. The doctors and nurses at the Center for
Vulvar Diseases will discuss your individual case with you and develop
an individual treatment plan based on your history, prior treatments
and severity of symptoms.
Vulvar pain can be a
difficult process to treat. Improvement may take weeks to months (even
years) of long-term treatment. Spontaneous remission of symptoms has
occurred in some women, while with others multiple attempts with
medical management has proven unsuccessful in relieving 100% of
IMPORTANT THINGS TO REMEMBER
ABOUT VULVAR PAIN