Vaginal:
Vaginismus
Injections with 22 gauge spinal needle, total of 60mg Toradol and 40ml Bupivicaine. Injections into pelvic floor muscularture
Procedure: Palpate pubococcygeus, illiococcygeus, obturator internus, ischiococcygeus bilaterally. Hold needle against index finger with bevel pointed away from finger. As you palapate each muscle, inject a small wheel beneath the epithelium
Bennett's Pelvic Floor muscle injections:
- 0.25% sensorcaine with epinephrine (20ml) combined with 30mg toradol.
- Pelvic nerve injections: 0.25% sensorcaine without epinephrine and kenalog
- After injections, place a tampon. For consider putting 2% lidocaine gel on tampon for pain control.
*Monthly injections x3, then add Elavil for other medication to help with maintenance.
Myofascial Pain Syndrome/Trigger Point Injections: (Try pelvic PT/E-stim first, if fails, then TPI, if fails, then botox injections).
- 1 to 3 mL doses of 0.25 percent bupivacaine (maximum total volume 30 to 40 mL, depending on patient’s weight) throughout the pelvic floor using a pudendal kit. Trigger points in the abdomen may also be injected, as needed, using a long (at least 1 inch) small gauge (27 g) needle.
- 10 mL of 2% lidocaine, 10 mL of 0.25% bupivacaine, and 1 mL (40 mg) of triamcinolone.
Vaginal apex pain Injections:
Lawrence: 40mg Kenalog with 2% Lidocaine for total of 10ml. Inject 5ml into each vaginal apex. Needle should only be a few millimeters deep.
Pudendal nerve block: 0.5% bupivicaine 10ml. 4mg dexamethasone.
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Vulvar/Introitus:
Introitus/perineal pain:
- Topical lidocaine and silvadine 50/50, applied 2-3x daily to the perineum/introitus. Then topical lidocaine alone before intercourse.
- If using lidocaine, then the male should use olive oil for lubrication to prevent numbness from lidocaine.
- Lidocaine gel 5% BID, and Emla cream (lidocaine/prilocaine) 30 minutes before intercourse.
- If pain is unresolved, then consider injections.
- Elavil and lidocaine formulary by pharmacy for vulvadynia.
*For pain during exam, or for pelvic floor muscles in spasm, have patient to valsalva, which is usually releases spasm.
Hart's Line Injection:
- 3ml dexamethasone with 6ml 0.25% bupivacaine. Inject 1-2ml at 3 and 9 o'clock, just distal to the hymen (enough to create a wheel). Then inject at 4,5,7, and 8 o'clock positions.
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Bladder:
Kegel's (per Bennett's office):
- Hold for 10 sec, then relax for 10 sec for 10 reps. Repeat 4 times daily.
- Change to 20 reps twice daily with increased pelvic floor strength.
- Add quick kegels (hold, relax for 1 sec each) 10 reps, 4 times daily after patient is used to regular kegels.
*Patient needs to continue for 15-20 weeks (per UpToDate -
Bladder Instillation:
Barkett:
- 20 ml of 1% lidocaine, 5 ml of 8.4% sodium bicarbonate, and 40,000 units of heparin.
Bennett: 10,000u heparin, 30ml bupivicaine
*Bennett will do bladder instillations up to 3x/week initially for significant IC pain, then space out the instillations. Some patients give themselves instillations if it is covered by insurance.
UpToDate:
- 1% lidocaine 20 cc, 125 mg Solu-Medrol (2 cc solution), 10,000 units heparin (1000 u/ml, 10 ml vial to total 10,000 units), and 8.4%sodium bicarbonate 20 cc.
- 40,000 units of heparin, 8 mL of 2% of lidocaine, and 3 mL of 8.4% of sodium bicarbonate to reach a total fluid volume of 15 mL.
*For significant IC flairs consider steroid (kenalog, solumedrol with heparin and local) for 4 weekly instills, then switch to instill without steroids.
*For women with recurrent UTIs include 80mg gentamicin in instillation.
www.ichelp.org for more bladder instillation cocktails and other resources.
Hydrodistention:
Barkett:
- Insert cystoscope, and fill with water until fluid begins leaking around scope.Then allow water to flow out scope into measuring container and record amount of fluid that was in bladder.
Bennett:
- 3L bag 60-80cm above bladder, hold finger around urethra to prevent leaking, hold until flow stops from bag. Empty and measure capacity. Repeat for total of 3 distensions, measuring capacity at first and last distension.
Vandermark, same setup as Bennett, but only do one distention, holding for 5 minutes, then empty.
Chronic Urinary Retention:
- Start with straight Catheterization q6hr and followup in 1 week to review postpaid residuals from catheterizations. If low PVR, then decrease straight Cath frequency.
- Annual US for hydronephrosis, and at least annual Creatinine to monitor for kidney function.
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GI Problems:
Constipation:
- Increase water intake and dietary fiber intake.
- 250mg magnesium citrate tabs a bedtime until regular, then space out as needed.
- Start with one tab at bedtime, increase by one tab every 3 days up to 5 tabs (or 1000mg) daily.
- Patient to titrate dose until regular, soft BMs.
- Short-term: Colace 100mg BID, then add Miralax daily as needed.
*if patients have mixed constipation and occasional loose stools (or even fecal incontinence), then treat constipation first.
- Loose stools may be from liquid stool leaking around constipated stool.
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Misc:
Iliohypogastric nerve block:
Barkett: Bilateral injection of 0.5% bupivacaine, or .25% marcaine (6ml each side) approx. 2cm medial to ASIS. Inject at depth of fascia where nerve passes. Move needle around at level of fascia to ensure anesthesia reaches nerve.
*This can be used in patients with pelvic pain who have notable tenderness when pressing 2cm medial to ASIS. Patients should have relief within minutes of injection, but it will not last long.
Referred Pelvic Pain
Pelvic Pain: Diagnosis and Management by Fred M. Howard