Denniz Zolnoun | University of North Carolina at Chapel Hill (original) (raw)
Papers by Denniz Zolnoun
Journal of The American Association of Gynecologic Laparoscopists, 2003
American Journal of Obstetrics and Gynecology, 2004
Objective: The purpose of this report was to describe the evidence for the benefits of laparoscop... more Objective: The purpose of this report was to describe the evidence for the benefits of laparoscopic surgery in obese patients, to review the physiologic abnormalities that are associated with obesity, and to explore surgical techniques that will enable surgeons to perform laparoscopy successfully in obese patients. Study design: This article is a review of the available literature on obesity, the
Obstetrics and Gynecology, 2003
ObjectiveTo assess the effectiveness of nightly application of 5% lidocaine ointment for treatmen... more ObjectiveTo assess the effectiveness of nightly application of 5% lidocaine ointment for treatment of vulvar vestibulitis.
The Journal of reproductive medicine, 2009
Chronic pelvic pain (CPP) affects 15% of women and has a high rate of psychiatric comorbidity. Vu... more Chronic pelvic pain (CPP) affects 15% of women and has a high rate of psychiatric comorbidity. Vulvodynia, a vulvar pain syndrome that includes vulvar vestibulitis, is the most common subtype of CPP. This study examined the efficacy of lamotrigine for the treatment of CPP using an open-label design. Forty-three women with CPP were recruited from a specialty pelvic pain clinic. Of these, 31 completed 8 weeks of active treatment. Outcome variables included the McGill Pain Rating Index and subscales of pain intensity and the Hamilton Depression and Anxiety Rating Scales. We found significant reductions in all pain and mood measures at the 8-week visit compared to baseline. In particular, women with vulvodynia-type CPP (N = 17) had robust reductions in pain and mood symptoms. CPP is a heterogeneous disorder, with psychiatric comorbidity and poor treatment response. This open-label study suggests that treatment with lamotrigine in women with the vulvodynia subtype of CPP may be helpful i...
Obstetrical & Gynecological Survey, 2006
Vulvar vestibulitis syndrome (vestibulitis), the most common type of chronic vulvovaginal pain, i... more Vulvar vestibulitis syndrome (vestibulitis), the most common type of chronic vulvovaginal pain, impairs the psychologic, physical, and reproductive health of approximately 10% of women at some point in their lives. Research on the pathophysiology of vestibulitis suggests abnormalities in 3 interdependent systems: vestibular mucosa, pelvic floor muscles, and central nervous system pain regulatory pathways. To date, causes and relative contributions of these abnormalities to the development and maintenance of vestibulitis remain poorly understood. Research consistently supports the conceptualization of vestibulitis as a chronic pain disorder-akin to fibromyalgia, irritable bowel disorder, and temporomandibular disorder (TMD)-that is far more complex than vestibular hypersensitivity alone. Nevertheless, the clinical diagnosis of vestibulitis continues to rely on subjective report of pain during intercourse and vestibular sensitivity on clinical examination after exclusion of other gynecologic disorders. We propose that current diagnostic criteria, which are based on highly subjective patient and clinician measures, are not sufficient to describe and properly classify the heterogeneous clinical presentations of this disorder. To inform clinical care or research, we must be able to objectively characterize women with vestibulitis. This narrative review critically appraises current conceptualization of vestibulitis and presents a context for studying vestibulitis as a chronic pain disorder, emphasizing the need for objective assessment of clinical features.
Midurethral slings successfully treat stress urinary incontinence through a minimally invasive va... more Midurethral slings successfully treat stress urinary incontinence through a minimally invasive vaginal approach. Postoperative pain related to sling placement can occur and poses both diagnostic and treatment dilemmas. Four years after transobturator midurethral sling placement, the patient presented with complaints of left labial pain and dyspareunia since surgery. Using sensory mapping and a nerve stimulator, the problem was identified in the distribution of the genitofemoral nerve. Conservative therapy with a centrally acting neuromodulatory drug and nerve block relieved the pain. Postsling neuralgia diagnosis using sensory mapping and a nerve stimulator aids in indentifying the nerve involved and in successful conservative treatment with a nerve block.
Sexual and Relationship Therapy, 2008
The objective of this study was to describe acceptability of vulvar vibration therapy (VVT), a no... more The objective of this study was to describe acceptability of vulvar vibration therapy (VVT), a novel treatment approach to vulvodynia. We included women with vulvodynia who attended the Pelvic Pain Clinic and had used VVT for at least two weeks. Participants completed a three-page, 65-item, questionnaire assessing demographics, VVT usage and responses to Likert statements regarding accessibility, comfort and symptom response to VVT. Of 69 qualifying patients, results from 49 (72%) were eligible for analysis. Participants were primarily white, married and welleducated, with a median age of 30 (range 19-68 years). Median duration of vulvar pain and dyspareunia was two years (0-23) and three years (0-30), respectively. Median duration of VVT was five months (1-18) and three days per week (0.5-7). Fully, 83% said that, "vibrator treatment is an acceptable treatment", 83% said that they were "satisfied with vibrator treatment", 76% endorsed vibrator as comfortable to use, 73% indicated that sex is less painful since starting vibration treatment and 88% would recommend VVT to others. We conclude that the therapeutic rationale for VVT is based on the anti-nocioceptive properties of vibration and on the favorable response of vulvodynia to physical therapy. Vulvar vibration therapy is safe, inexpensive and, in this survey, acceptable to most patients, many of whom described improvement in symptoms.
Obstetrics and Gynecology Clinics of North America, 2004
Laparoscopy is a useful tool for the diagnosis and treatment of conditions associated with chroni... more Laparoscopy is a useful tool for the diagnosis and treatment of conditions associated with chronic pelvic pain. In the evaluation of chronic pelvic pain, laparoscopic techniques vary from conservative procedures, such as pain mapping, excision, and nerve ablation, to more extensive procedures like oophorectomy and hysterectomy. Although useful for diagnosis, laparoscopy continues to have a controversial role in the treatment of chronic pelvic pain.
Obstetrics & Gynecology, 2004
Vaginal apex pain is a subset of chronic pelvic pain commonly treated with surgical excision of t... more Vaginal apex pain is a subset of chronic pelvic pain commonly treated with surgical excision of the vaginal apex. Our objective was to estimate long-term postoperative pain levels, recovery time, and return to sexual function in women who have undergone vaginal apex repair for chronic vaginal apex pain.
Obstetrics & Gynecology, 2009
Dyspareunia affects 8 -22% of women at some point during their lives, making it one of the most c... more Dyspareunia affects 8 -22% of women at some point during their lives, making it one of the most common pain problems in gynecologic practice. A mixture of anatomic, endocrine, pathologic, and emotional factors combine to challenge the diagnostic, therapeutic, and empathetic skills of the physician. New understandings of pain in general require new interpretations concerning the origins of pain during intercourse, but also provide new avenues of treatment. The outcomes of medical and surgical treatments for common gynecologic problems should routinely go beyond measures of coital possibility, to include assessment of coital comfort, pleasure, and facilitation of intimacy. This review will discuss aspects of dyspareunia, including anatomy and neurophysiology, sexual physiology, functional changes, pain in response to disease states, and pain after gynecologic surgical procedures.
Obstetrics & Gynecology, 2003
To assess the effectiveness of nightly application of 5% lidocaine ointment for treatment of vulv... more To assess the effectiveness of nightly application of 5% lidocaine ointment for treatment of vulvar vestibulitis.
Obstetrics & Gynecology, 2007
The Journal of the American Association of Gynecologic Laparoscopists, 2003
International Journal of Gynecology & Obstetrics, 2008
Objective-To investigate the distribution of psychological characteristics and pain reporting amo... more Objective-To investigate the distribution of psychological characteristics and pain reporting among women with vulvar vestibulitis syndrome (VVS).
International Journal of Gynecology & Obstetrics, 2011
Objective: To examine long-term reports of pain and psychologic correlates of pain in women after... more Objective: To examine long-term reports of pain and psychologic correlates of pain in women after vestibulectomy. Methods: In a retrospective cross-sectional exploratory study, 37 women who had undergone vestibulectomy between January 1989 and January 2008 completed questionnaires assessing demographic information, self-reported levels of pain, anxiety, somatization, psychologic distress, and sexual function. Results: Eight women reported being completely pain free after surgery. The remaining 29 women reported various levels of pain during intercourse (as measured by the Gracely pain scale) and decreased sexual function (as measured by a sexual functioning questionnaire). Various measures of psychologic distress were associated with average intercourse-related pain, including brief symptom inventory (P = 0.002), Pennebaker inventory of limbic languidness (P = 0.002), perceived stress scale (P = 0.04), and Spielberger trait-anxiety inventory (P = 0.01). These same measures of psychological distress were similarly associated with general, unprovoked vaginal pain. Conclusion: The present data suggest that the pathophysiology of localized vulvodynia may be more complex in some women, leading to a suboptimal response to surgical treatment.
International Journal of Gynecology & Obstetrics, 2014
Patients: 193 patients with pathologically confirmed bowel endometriosis. Intervention: Laparosco... more Patients: 193 patients with pathologically confirmed bowel endometriosis. Intervention: Laparoscopic treatment of bowel endometriosis. Measurements and Main Results: Predictors of higher stage endometriosis include a history of previous laparoscopic surgery (P = 0.04) and a presenting complaint of abnormal uterine bleeding (P = 0.01). The higher the stage of endometriosis, the more likely there would be coexistent urinary tract endometriosis (P = 0.02), a need for enterolysis (P = 0.002), ovarian cystectomy (P\0.001), and bowel resection (P = 0.01) performed during laparoscopy. Obesity was associated with higher rate of recurrence of endometriosis (P = 0.002). Within our cohort, 87% of our patients achieved amelioration of symptoms by the end of the first postoperative month. Disc excision and segmental bowel resection were performed on 73% and 1.6% of patients, respectively. Conclusion: Our study confirms that laparoscopic management of bowel endometriosis is safe and effective. Disc excision, as opposed to segmental bowel resection appears equally effective, safer and advisable in all but the most severe cases. We found two statistically significant predictors of higher stage disease that should prompt careful surgical planning.
The Clinical Journal of Pain, 2014
We evaluated the stability of the comorbidity between vulvodynia and orofacial pain (OFP) and its... more We evaluated the stability of the comorbidity between vulvodynia and orofacial pain (OFP) and its associated clinical characteristics over a 2-year follow-up period. In an earlier study of vestibulodynia patients, we administered questionnaires assessing demographic data, self-reported pain, anxiety, somatic awareness, and presence of signs and symptoms suggestive of clinical and subclinical OFP. The present study readministered the same surveys to a subset of the original cohort after a 2-year follow-up period. Of the 138 women in the previous study, 71 (51%) agreed to participate in the present study. We confirmed our earlier findings that (1) OFP is a highly prevalent (66%) condition among women with vestibulodynia, and (2) compared with women with no OFP symptoms, those with OFP symptoms experience higher levels of anxiety (P=0.005) and somatic awareness (P<0.001). Although OFP symptoms showed improvement in many of the vestibulodynia patients (33%) with OFP symptoms at baseline, 13% had either developed new symptoms or transitioned from subclinical to clinical OFP classification. Intercourse-related pain decreased in 69% of patients and increased in 24% of patients. Consistent with our earlier report, we did not observe significant differences with respect to demographics or severity of pain during intercourse among the subgroups. OFP is a common comorbidity among women with vestibulodynia, although the presence of OFP can vary over time. The comorbidity between vestibulodynia and OFP suggests that common underlying mechanisms may mediate both conditions.
The Clinical Journal of Pain, 2008
Objectives-To explore the prevalence of Orofacial Pain (OFP) among patients with Vulvar Vestibuli... more Objectives-To explore the prevalence of Orofacial Pain (OFP) among patients with Vulvar Vestibulitis Syndrome (VVS) and to examine the relationship between signs and symptoms of OFP and clinical characteristics of women with VVS; we specifically sought to investigate differences in psychological characteristics and self-reported severity of painful intercourse.
American Journal of Obstetrics and Gynecology, 2006
Journal of The American Association of Gynecologic Laparoscopists, 2003
American Journal of Obstetrics and Gynecology, 2004
Objective: The purpose of this report was to describe the evidence for the benefits of laparoscop... more Objective: The purpose of this report was to describe the evidence for the benefits of laparoscopic surgery in obese patients, to review the physiologic abnormalities that are associated with obesity, and to explore surgical techniques that will enable surgeons to perform laparoscopy successfully in obese patients. Study design: This article is a review of the available literature on obesity, the
Obstetrics and Gynecology, 2003
ObjectiveTo assess the effectiveness of nightly application of 5% lidocaine ointment for treatmen... more ObjectiveTo assess the effectiveness of nightly application of 5% lidocaine ointment for treatment of vulvar vestibulitis.
The Journal of reproductive medicine, 2009
Chronic pelvic pain (CPP) affects 15% of women and has a high rate of psychiatric comorbidity. Vu... more Chronic pelvic pain (CPP) affects 15% of women and has a high rate of psychiatric comorbidity. Vulvodynia, a vulvar pain syndrome that includes vulvar vestibulitis, is the most common subtype of CPP. This study examined the efficacy of lamotrigine for the treatment of CPP using an open-label design. Forty-three women with CPP were recruited from a specialty pelvic pain clinic. Of these, 31 completed 8 weeks of active treatment. Outcome variables included the McGill Pain Rating Index and subscales of pain intensity and the Hamilton Depression and Anxiety Rating Scales. We found significant reductions in all pain and mood measures at the 8-week visit compared to baseline. In particular, women with vulvodynia-type CPP (N = 17) had robust reductions in pain and mood symptoms. CPP is a heterogeneous disorder, with psychiatric comorbidity and poor treatment response. This open-label study suggests that treatment with lamotrigine in women with the vulvodynia subtype of CPP may be helpful i...
Obstetrical & Gynecological Survey, 2006
Vulvar vestibulitis syndrome (vestibulitis), the most common type of chronic vulvovaginal pain, i... more Vulvar vestibulitis syndrome (vestibulitis), the most common type of chronic vulvovaginal pain, impairs the psychologic, physical, and reproductive health of approximately 10% of women at some point in their lives. Research on the pathophysiology of vestibulitis suggests abnormalities in 3 interdependent systems: vestibular mucosa, pelvic floor muscles, and central nervous system pain regulatory pathways. To date, causes and relative contributions of these abnormalities to the development and maintenance of vestibulitis remain poorly understood. Research consistently supports the conceptualization of vestibulitis as a chronic pain disorder-akin to fibromyalgia, irritable bowel disorder, and temporomandibular disorder (TMD)-that is far more complex than vestibular hypersensitivity alone. Nevertheless, the clinical diagnosis of vestibulitis continues to rely on subjective report of pain during intercourse and vestibular sensitivity on clinical examination after exclusion of other gynecologic disorders. We propose that current diagnostic criteria, which are based on highly subjective patient and clinician measures, are not sufficient to describe and properly classify the heterogeneous clinical presentations of this disorder. To inform clinical care or research, we must be able to objectively characterize women with vestibulitis. This narrative review critically appraises current conceptualization of vestibulitis and presents a context for studying vestibulitis as a chronic pain disorder, emphasizing the need for objective assessment of clinical features.
Midurethral slings successfully treat stress urinary incontinence through a minimally invasive va... more Midurethral slings successfully treat stress urinary incontinence through a minimally invasive vaginal approach. Postoperative pain related to sling placement can occur and poses both diagnostic and treatment dilemmas. Four years after transobturator midurethral sling placement, the patient presented with complaints of left labial pain and dyspareunia since surgery. Using sensory mapping and a nerve stimulator, the problem was identified in the distribution of the genitofemoral nerve. Conservative therapy with a centrally acting neuromodulatory drug and nerve block relieved the pain. Postsling neuralgia diagnosis using sensory mapping and a nerve stimulator aids in indentifying the nerve involved and in successful conservative treatment with a nerve block.
Sexual and Relationship Therapy, 2008
The objective of this study was to describe acceptability of vulvar vibration therapy (VVT), a no... more The objective of this study was to describe acceptability of vulvar vibration therapy (VVT), a novel treatment approach to vulvodynia. We included women with vulvodynia who attended the Pelvic Pain Clinic and had used VVT for at least two weeks. Participants completed a three-page, 65-item, questionnaire assessing demographics, VVT usage and responses to Likert statements regarding accessibility, comfort and symptom response to VVT. Of 69 qualifying patients, results from 49 (72%) were eligible for analysis. Participants were primarily white, married and welleducated, with a median age of 30 (range 19-68 years). Median duration of vulvar pain and dyspareunia was two years (0-23) and three years (0-30), respectively. Median duration of VVT was five months (1-18) and three days per week (0.5-7). Fully, 83% said that, "vibrator treatment is an acceptable treatment", 83% said that they were "satisfied with vibrator treatment", 76% endorsed vibrator as comfortable to use, 73% indicated that sex is less painful since starting vibration treatment and 88% would recommend VVT to others. We conclude that the therapeutic rationale for VVT is based on the anti-nocioceptive properties of vibration and on the favorable response of vulvodynia to physical therapy. Vulvar vibration therapy is safe, inexpensive and, in this survey, acceptable to most patients, many of whom described improvement in symptoms.
Obstetrics and Gynecology Clinics of North America, 2004
Laparoscopy is a useful tool for the diagnosis and treatment of conditions associated with chroni... more Laparoscopy is a useful tool for the diagnosis and treatment of conditions associated with chronic pelvic pain. In the evaluation of chronic pelvic pain, laparoscopic techniques vary from conservative procedures, such as pain mapping, excision, and nerve ablation, to more extensive procedures like oophorectomy and hysterectomy. Although useful for diagnosis, laparoscopy continues to have a controversial role in the treatment of chronic pelvic pain.
Obstetrics & Gynecology, 2004
Vaginal apex pain is a subset of chronic pelvic pain commonly treated with surgical excision of t... more Vaginal apex pain is a subset of chronic pelvic pain commonly treated with surgical excision of the vaginal apex. Our objective was to estimate long-term postoperative pain levels, recovery time, and return to sexual function in women who have undergone vaginal apex repair for chronic vaginal apex pain.
Obstetrics & Gynecology, 2009
Dyspareunia affects 8 -22% of women at some point during their lives, making it one of the most c... more Dyspareunia affects 8 -22% of women at some point during their lives, making it one of the most common pain problems in gynecologic practice. A mixture of anatomic, endocrine, pathologic, and emotional factors combine to challenge the diagnostic, therapeutic, and empathetic skills of the physician. New understandings of pain in general require new interpretations concerning the origins of pain during intercourse, but also provide new avenues of treatment. The outcomes of medical and surgical treatments for common gynecologic problems should routinely go beyond measures of coital possibility, to include assessment of coital comfort, pleasure, and facilitation of intimacy. This review will discuss aspects of dyspareunia, including anatomy and neurophysiology, sexual physiology, functional changes, pain in response to disease states, and pain after gynecologic surgical procedures.
Obstetrics & Gynecology, 2003
To assess the effectiveness of nightly application of 5% lidocaine ointment for treatment of vulv... more To assess the effectiveness of nightly application of 5% lidocaine ointment for treatment of vulvar vestibulitis.
Obstetrics & Gynecology, 2007
The Journal of the American Association of Gynecologic Laparoscopists, 2003
International Journal of Gynecology & Obstetrics, 2008
Objective-To investigate the distribution of psychological characteristics and pain reporting amo... more Objective-To investigate the distribution of psychological characteristics and pain reporting among women with vulvar vestibulitis syndrome (VVS).
International Journal of Gynecology & Obstetrics, 2011
Objective: To examine long-term reports of pain and psychologic correlates of pain in women after... more Objective: To examine long-term reports of pain and psychologic correlates of pain in women after vestibulectomy. Methods: In a retrospective cross-sectional exploratory study, 37 women who had undergone vestibulectomy between January 1989 and January 2008 completed questionnaires assessing demographic information, self-reported levels of pain, anxiety, somatization, psychologic distress, and sexual function. Results: Eight women reported being completely pain free after surgery. The remaining 29 women reported various levels of pain during intercourse (as measured by the Gracely pain scale) and decreased sexual function (as measured by a sexual functioning questionnaire). Various measures of psychologic distress were associated with average intercourse-related pain, including brief symptom inventory (P = 0.002), Pennebaker inventory of limbic languidness (P = 0.002), perceived stress scale (P = 0.04), and Spielberger trait-anxiety inventory (P = 0.01). These same measures of psychological distress were similarly associated with general, unprovoked vaginal pain. Conclusion: The present data suggest that the pathophysiology of localized vulvodynia may be more complex in some women, leading to a suboptimal response to surgical treatment.
International Journal of Gynecology & Obstetrics, 2014
Patients: 193 patients with pathologically confirmed bowel endometriosis. Intervention: Laparosco... more Patients: 193 patients with pathologically confirmed bowel endometriosis. Intervention: Laparoscopic treatment of bowel endometriosis. Measurements and Main Results: Predictors of higher stage endometriosis include a history of previous laparoscopic surgery (P = 0.04) and a presenting complaint of abnormal uterine bleeding (P = 0.01). The higher the stage of endometriosis, the more likely there would be coexistent urinary tract endometriosis (P = 0.02), a need for enterolysis (P = 0.002), ovarian cystectomy (P\0.001), and bowel resection (P = 0.01) performed during laparoscopy. Obesity was associated with higher rate of recurrence of endometriosis (P = 0.002). Within our cohort, 87% of our patients achieved amelioration of symptoms by the end of the first postoperative month. Disc excision and segmental bowel resection were performed on 73% and 1.6% of patients, respectively. Conclusion: Our study confirms that laparoscopic management of bowel endometriosis is safe and effective. Disc excision, as opposed to segmental bowel resection appears equally effective, safer and advisable in all but the most severe cases. We found two statistically significant predictors of higher stage disease that should prompt careful surgical planning.
The Clinical Journal of Pain, 2014
We evaluated the stability of the comorbidity between vulvodynia and orofacial pain (OFP) and its... more We evaluated the stability of the comorbidity between vulvodynia and orofacial pain (OFP) and its associated clinical characteristics over a 2-year follow-up period. In an earlier study of vestibulodynia patients, we administered questionnaires assessing demographic data, self-reported pain, anxiety, somatic awareness, and presence of signs and symptoms suggestive of clinical and subclinical OFP. The present study readministered the same surveys to a subset of the original cohort after a 2-year follow-up period. Of the 138 women in the previous study, 71 (51%) agreed to participate in the present study. We confirmed our earlier findings that (1) OFP is a highly prevalent (66%) condition among women with vestibulodynia, and (2) compared with women with no OFP symptoms, those with OFP symptoms experience higher levels of anxiety (P=0.005) and somatic awareness (P<0.001). Although OFP symptoms showed improvement in many of the vestibulodynia patients (33%) with OFP symptoms at baseline, 13% had either developed new symptoms or transitioned from subclinical to clinical OFP classification. Intercourse-related pain decreased in 69% of patients and increased in 24% of patients. Consistent with our earlier report, we did not observe significant differences with respect to demographics or severity of pain during intercourse among the subgroups. OFP is a common comorbidity among women with vestibulodynia, although the presence of OFP can vary over time. The comorbidity between vestibulodynia and OFP suggests that common underlying mechanisms may mediate both conditions.
The Clinical Journal of Pain, 2008
Objectives-To explore the prevalence of Orofacial Pain (OFP) among patients with Vulvar Vestibuli... more Objectives-To explore the prevalence of Orofacial Pain (OFP) among patients with Vulvar Vestibulitis Syndrome (VVS) and to examine the relationship between signs and symptoms of OFP and clinical characteristics of women with VVS; we specifically sought to investigate differences in psychological characteristics and self-reported severity of painful intercourse.
American Journal of Obstetrics and Gynecology, 2006