After Great Pain
David Elpern, M.D., Williamstown, MA, USA
on October 20, 2001
The patient is a 30-year-old man who presents for evaluation of a painful area around the glans and shaft of the penis. The problem has been present for about three years. It waxes and wanes somewhat. He says that the symptoms are almost always there. He complains of burning and pain on the glans penis and ventral portion of the shaft of the penis. The problem is particularly severe after intercourse which he avoids because of discomfort.
He saw me in 1998 and then after that consulted another local dermatologist. At our 1998 visit I thought he might have scrotodynia since the symptoms were located on the scrotum at that time.
He has continued to have problems and has seen Dr. A. on a number of occasions. He has been treated with Dome Boro Solution wet dressings, Betamethasone valerate 0.1% Cream, betamethasone butyrate 0.2% cream, Lotrisone (clotrimazole + betamethasone diproiprionate) , terbinafine cream, Bacitracin, and Aquaphor. None of has helped. He consulted me again a few months back.
The patient, a professional administrator at an institution of higher education, also suffers from depression. He was on Zoloft (sertralazine) in 1998 when his symptoms began and and is now taking Celexa (citalopram). He feels his depression is doing well. He is single but has had significant others and hopes to marry soon. The genital pain severely affects his relationships and has caused a number of breakups.
EXAMINATION: He points to some erythema on the glans penis. This is very subtle and may be a normal finding. Although he had a small ulcer on the scrotum in 1998, this is not present any longer.
IMPRESSION: I still think we are dealing with a genital pain syndrome that is probably related to scrotodynia. I suppose this could be some very unusual form of herpes simplex sine herpes, but I doubt it. I think his depression is related and that this may be a monosymptomatic hypochondriasis.
The patient is anxious to "be cured."
PLAN and DISCUSSION:
1. I asked him to stop all of his topical medications and use cold water compresses when the area is symptomatic.
2. I tried him on pimozide for a few weeks. At one mg per day he was symptom-free, but developed disabling akathesia (severe anxiety and agitation) and had to stop. Risperadol was not effective.
3. The dynias are poorly understood and difficult to treat. many of these patients have underlying psychiatric disease.
4. I do not know how whether insight-oriented therapy will help.
The patient is being presented for discussion and suggestions. This may be a group of disorders with different etiologies and responses to treatment. An interesting illness narrative was reviewed in the Sunday, October 14, New York Times Book Review (see below).
1) de Belilovsky [Vulvodynia]. C.Presse Med 2000 Jun 17;29(21):1191-6
[Article in French]
2) Wesselmann U. Neurogenic inflammation and chronic pelvic pain. World J Urol 2001 Jun;19(3):180-5
3) Wesselmann U, Burnett AL, Heinberg LJ. The urogenital and rectal pain syndromes. Pain 1997 Dec;73(3):269-94
4) Susanna Kaysen 'The Camera My Mother Gave Me': A Medical Detective Story Book Review from Sunday, October 14, 2001 New York Times
From Siew Eng Choon, 10/20/01:
Thank you for sharing the case. I have a female patient with similar problem i.e. almost daily burning sensation/pain affecting the vulva for 2 years. She has seen many dermatologists and gynaecologists in Malaysia and Singapore. She has been on all kinds of pain killers and is currently on a trial of suppressive acyclovir. Her husband surprisingly has similar problem although STD screening was negative for both. This is her second marriage and her problem started with the second marriage. She was given amitrptyline by a gynaecologist but stopped the medication the moment they found out it is an antidepressant. She flatly refused psychiatric referral. Vulvodynia is certainly a "heartsink problem" for the carer and it is worse when both partners have the same problem. Can psychiatrists really help out here? Will value suggestions for further management?
This topic, is always important, there is not a week, that we dont see a patient like this. Hard to treat. Psycosomatics areas are very important to help them. They usually has more than a problem. The patient need to be understanding and listening. They are some psychopharmacos to help them. I usually work with a psychiatric colleague in those cases, and help me very much. improve: That is a very good presentation, with a lot of material to read and more understanding.
The most important question is "How does this pain interfere with you life?" The answer is obvious. I think the patient would be helped by psychotherapy.