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911DOC, Board Certified Dr.
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Experience:  Emergency Medicine Physician
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Diagnosed with possible perineal shingles

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I have been diagnosed with possible perineal shingles, so I don't know whether to address a gastroenterologist,dermatologist or gynecologist! I saw that you had responded to a person with perineal shingles, so I decided to ask you.

I have seen the GYN (on July 1) and have a follow-up appointment with her next Wednesday, so I don't want to keep running to more doctors if this is something that just runs a certain course and I have to wait it out - but if I should do something right away, I need to know that too. Having the weekend come up is scary. I am also a student in the middle of summer finals.

First: it did start with mid-low-back pain, but I have disc problems so that is not new, just worse. Then a burning sensation started along the back of the buttock into the perineum. Have had that before with the disc issue, not a big deal, just uncomfortable. However, I developed an abrased-feeling area in the perineum (neither vaginal nor rectal, but in between) that was bleeding slightly, which is when I went to urgent care. This doctor said he just saw a red area, no pus or drainage, but remarked that the inside of the buttock was tender to touch. He put me on Bactrim and said that if it did not get better, I should see GI.

After a few days it seemed much worse, but I could not get in to GI. (Of note, I had a colonoscopy in January 2013 that was normal). I saw my GYN. She said it looked like shingles, with possibly a touch of candidiasis. She said the area was very blistered along the left side of the perineum. She put me on Acyclovir, and said if it was not better next week she will need to biopsy. She told me not to use anything on it except zinc oxide and a little Lotrimin cream, but that has turned out to be impossible. I would not even be able to go to the bathroom if I did not put something on it. I have to mix a very small amount of Lidocaine solution in A&D or mild steroid cream around the area so that having a BM does not make me feel I am going to split apart. It would be far worse if I did not go at all, because of the pressure on the skin.

It does NOT hurt internally (either anal or vaginal), and the red and tender area isn't really the rectum or vagina as much as it is the perineal area, and up the inside of the left cheek, but each time it is stretched or touched it will flare up. It still looks red and blistered, some areas look like blackheads, from what I can see. I do use a little Lotrimin cream which does not really help or hurt. It's just that NOTHING I am doing or using is giving any great relief, and the pain has turned into an awful itch as well. The tender spot inside the left buttock is still tender and has sort of a dried-up blister appearance. But there is still NO drainage, discharge or pus either vaginally or anally.

If this sounds like the normal course of shingles, then I will wait it out. But of course I read too much on-line about abcesses, etc, so then I get worried. Again, getting into the GI is impossible and, where I live, no other GI doctor will accept you if you have seen any other GI in the area. My primary doctor can't get me in right away. And because the nature of this is humiliating to me, and I seem to have to explain it over the phone again and again to non-medical people trying to get an appointment with someone . . . . well, I'd just as soon stick with one doctor and I love my GYN.

Being uncomfortable is one thing, and that's pretty bad. I just need your thoughts on whether this is the normal course for shingles, or any other thoughts about what it could be - AND, if there is anything it's safe to use then I would love to know that too! Oh - I have been using Domeboro soaks which seems to help temporarily.

This is a pretty good story for shingles.

It does not sound like a bacterial infection or abscess, especially if it is not rapidly spreading and you do not have fever

Have you noticed improvement on the acyclovir?
OH, thank you so very much, that is extremely reassuring. I just needed a qualified doctor to tell me if it sounded like shingles so that I do not worry all weekend. No, I do not have a fever, just had an upset stomach and slight fever a few weeks ago before this started. What I know of shingles, that goes with it too.

911DOC :
Yes, it does. Glad you don't have fever. Are you any better with the acyclovir?
I don't know that i have had an improvement on Acyclovir, but started so late in the course, I wasn't expecting much (and my GYN said this too)

911DOC :
Yes, that's true. And you have an appointment with gyn coming up soon correct?
Next Wednesday. My GYN told me there was not a lot of point in getting a herpes zoster culture since they are not always reliable if not taken from the exact right spot.

911DOC :
That is correct. Are you able to urinate now with the local anesthetic?
You are very reassuring. Yes, I can, even though I know she told me not to use anything but zinc oxide. But it's solution-based and I really mix it in with water or A&D or witch hazel so that it's not so irritating. Anything else you think is safe to use? Is the Domeboro okay? Should I stop the Lotrimin?

911DOC :
Domeboro would be fine. The lotrimin is fine but if you have used it for 5 days as directed then you have taken a full course. And do not need to continue unless you think that you do have a yeast infection and are still having discharge
Okay, I will stop it then. I also finished the antibiotic. I never had a discharge at all.

911DOC :
Good. Things to consider over the weekend. You should be seen right away if you can not urinate, if you develop fever, or if you develop a spreading rash. But i think that's unlikely to happen at this point. Does this make sense?
Yes, it does. If none of that happens - and you are very reassuring that it probably won't - then safe to just wait until Wednesday when I see GYN, correct?

911DOC :
Yes, i think so. And i hope you get quite a bit better between now and then
Oh, thank you very much. You don't know how much better I feel about it after talking to you!

911DOC :
Great. Here is a good link for you.

Thank you so much for your question. It was a pleasure talking with you.

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