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A survey of erectile dysfunction in Taiwan: use of the erection hardness score and quality of erection questionnaire generic 500 mg glycomet. Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk? Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial buy glycomet 500 mg. Phosphodiesterase type 5 inhibitors in postprostatectomy erectile dysfunction: a critical analysis of the basic science rationale and clinical application buy 500 mg glycomet with visa. Is there any evidence of superiority between retropubic, laparoscopic or robot-assisted radical prostatectomy? Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of medicare-age men. Cancer control and functional outcomes after radical prostatectomy as markers of surgical quality: analysis of heterogeneity between surgeons at a single cancer center. Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function. Anatomy and preservation of accessory pudendal arteries in laparoscopic radical prostatectomy. Erectile dysfunction after radiotherapy for prostate cancer and radiation dose to the penile structures: a critical review. The concept of erectile function preservation (penile rehabilitation) in the patient after brachytherapy for prostate cancer. Often it is not possible to include the partner on the patients first visit, but an effort should be made to include the partner at the second visit. This will make it easier to ask questions about erectile function and other aspects of sexual history. A relaxed atmosphere will also make it easier to explain the diagnosis and therapeutic approach to the patient and his partner. A detailed description should be made of the rigidity and duration of both sexually stimulated and morning erections and of problems with arousal, ejaculation, and orgasm. Psychometric analysis also supports the use of erectile hardness score as a simple, reliable and valid tool for the assessment of penile rigidity in practice and in clinical trials research (5). In cases of clinical depression, the use of a 2-question scale for depression is recommended: During the past month have you often been bothered by feeling down, depressed or hopeless? Where indicated, screening questionnaires, such as the International Prostate Symptom Score may be utilised. Particular attention must be given to patients with cardiovascular disease (Section 2. Patients may need a fasting glucose or HbA1c and lipid profile if not recently assessed. If indicated bioavailable or calculated-free testosterone may be needed to corroborate total testosterone measurements. For levels > 8 nmol/l the relationship between circulating testosterone and sexual function is very low (7,8). If any abnormality is observed, referral to an endocrinologist may be indicated (10,11). Epidemiological surveys have emphasised the association between cardiovascular and metabolic risk factors and sexual dysfunction in men and women (13). The Princeton Consensus (Expert Panel) Conference is dedicated to optimizing sexual function and preserving cardiovascular health. The second objective focused on re-evaluation and modification of previous recommendations for evaluation of cardiac risk associated with sexual activity in men with known cardiovascular disease. It is also possible for the clinician to estimate the risk of sexual activity in most patients from their level of exercise tolerance, which can be determined when taking the patients history. A functional erectile mechanism is indicated by an erectile event of at least 60% rigidity recorded on the tip of the penis that lasts for > 10 min (20). A positive test is a rigid erectile response (unable to bend the penis) that appears within 10 min after the intracavernous injection and lasts for 30 min (21). This response indicates a functional, but not necessarily normal, erection, and the erection may coexist with arterial insufficiency and/or veno-occlusive dysfunction (22). A positive test shows that a patient will respond to the intracavernous injection programme. The test is inconclusive as a diagnostic procedure and duplex Doppler study of the penis should be requested, if clinically warranted. Young patients with a history of pelvic or perineal trauma who could benefit from potentially curative vascular surgery. Association of specific symptoms and metabolic risks with serum testosterone in older men. The relationship between sex hormones and sexual function in middle-age and older European men. Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel. Arterial and corporeal veno-occlusive function in patients with a positive intracavernosal injection test. Psychologically based treatment for male erectile disorder: a cognitive-interpersonal model. Clinical evaluation and management strategy for sexual dysfunction in men and women. This results in a structured treatment strategy that depends on efficacy, safety, invasiveness and cost, as well as patient preference (1). The assessment of treatment options must consider patient and partner satisfaction and other QoL factors as well as efficacy and safety. A significant improvement can be expected as soon as after 3 months of initiating lifestyle changes (8). However, these results have yet to be confirmed in well-controlled, long-term studies. Early compared with delayed erectile rehabilitation brings forward the natural healing time of potency (9). Intracavernous injections and penile implants are still suggested as second- and third-line treatments, respectively, when oral compounds are not adequately effective or contraindicated for postoperative patients (Sections 3. Erectile function was improved in 71% of patients treated with 20 mg tadalafil versus 24% of those treated with placebo, while the rate of successful intercourse attempts was 52% with 20 mg tadalafil versus 26% with placebo (22). Penile prosthesis remains a satisfactory approach for patients who do not respond to either oral or intracavernous pharmacotherapy or to a vacuum device (29). Testosterone deficiency is either a result of primary testicular failure or secondary to pituitary/hypothalamic causes, including a functional pituitary tumour resulting in hyperprolactinaemia. Testosterone replacement therapy (intramuscular, oral, or transdermal) is effective, but should only be used after other endocrinological causes for testicular failure have been excluded (30). There is limited evidence suggesting that such treatment may not pose an undue risk of prostate cancer recurrence or progression (32). Patients given androgen therapy should be monitored for clinical response, elevated hematocrit and development of hepatic or prostatic disease. Testosterone therapy is contraindicated in patients with untreated prostate cancer or unstable cardiac disease. The lesion must be demonstrated by duplex Doppler study of the penis and confirmed by penile pharmacoarteriography. Vascular surgery for veno-occlusive dysfunction is no longer recommended because of poor long-term results (35). Psychosexual therapy requires ongoing follow-up and has had variable results (36). The recommended starting dose is 50 mg and should be adapted according to the patients response and side effects. Adverse events (Table 8) are generally mild in nature and self-limited by continuous use. The recommended starting dose is 10 mg and should be adapted according to the patients response and side effects. Nevertheless diabetic patients remain poor responders to tadalafil on demand, with a successful intercourse rates incresing from 21.

Stopping treatment altogether is likely to cause a relapse Doses by severity: Stable: inhaled steroid bd discount 500mg glycomet amex, agonist prn purchase 500mg glycomet with amex. If well controlled can take total steroid dose once a day at night rather than bd better compliance Unstable: inhaled steroid qid generic glycomet 500mg with visa, agonist prn. If still not controlled then oral theophylline at night or long acting agonist Severe: systemic steroids, high dose agonist, O2, medical review. Bronchodilators and inhaled steroids dont work so well in severe asthma as the major cause of obstruction is mucus plugging and the drugs dont get through. Use as needed not regularly then becomes a guide to severity Salbutamol and terbutaline sulphate common. Single dose good for prevention of exercise induced asthma Respiratory 79 Anti-leukotrienes: Leukotrienes vascular permeability, mucus production, mucus transport, etc. If not using spacer, need to rinse, gargle and spit otherwise risk of thrush and croaky voice. Lower level of suck needed than powder inhalers but still require good suck to get lower airways deposition. Instructions for use: Shake an inhaler between each puff Remove cap Hold it upright and pointed backwards Breath out st Fire during 1 25% of long slow inhalation Hold breath Breath out after removing inhaler from mouth Inhalers through a spacer: As effective as a nebuliser. Need smaller spacer as they have a small tidal volume Volumatic without facemask. Need to be able to mouth breath well (ie try from age 2 3 onwards) Need to inhale within 30 seconds of a puff into the space One puff at a time But plastic spacer static charge particles stick. So wash in detergent once a week and do not rinse bubbles off ( microfilm of detergent) If using a new space without washing, need to prime it (10 puffs). Disadvantages: cost, require high respiratory flow Accuhaler: 60 doses, easy to use, has dose meter Disk haler: 6 doses Turbohaler: easier to use than disk haler. Commonly H Influenzae or M Catarrhalis Steroids: 30 40 mg/day, stepping down over around 2 weeks Chronic Bronchitis = Persistent cough with sputum for at least 3 months in 2 consecutive years Follows prolonged exposure of the tracheobronchial trees to non-specific irritants hypersecretion of mucus and structural changes Types: Simple chronic bronchitis: no airway obstruction Chronic asthmatic bronchitis: intermittent bronchospasm and wheezing Chronic obstructive bronchitis: heavy smokers with chronic airways obstruction, usually with emphysema. Sputum will be clear/white, only occasionally will be infected (yellow/green) [Cf Chronic infective bronchitis with green sputum bronchiectasis] Pathogenesis: Chronic irritation (eg inhaled substances such as smoking) and microbiological infections hyper-secretion of mucus obstructing airways. Hypertrophy of submucosal glands in larger bronchi and hyperplasia of goblet cells in small airways. Reid index (ratio of mucous gland layer to thickness of epithelium to cartilage) greater than 0. If severe luminal obliteration Emphysema Enlargement of air-spaces distal to terminal bronchioles and destruction of alveolar walls without fibrosis Respiratory 81 Moderate to severe emphysema is rare in non-smokers Aetiology: Cigarettes: usually had a 20-pack year history. Neutrophils also release free radicals that inhibit 1-antitrypsin Types: Centriacinar (Centrilobular): enlargement of respiratory bronchioles, distal alveoli are spared. Seen in smokers and coal workers pneumoconiosis Panacinar (Panlobular): acinus is uniformly involved from respiratory bronchiole to terminal alveoli. Treatment same as for smoking induced Paraseptal (distal acinar): proximal acinus is normal, distal part affected. Often seen in cases of spontaneous pneumothorax in young people Irregular emphysema: acinus irregularly involved. Associated with scarring Macroscopic appearance: voluminous lungs Microscopic appearance: large abnormal airspaces, blebs and bullae. Bronchitis and bronchiolitis Clinical features: 60 years or older Prolonged history of exertional dyspnoea Minimal non-productive cough Usually have lost weight Use accessory muscles for respiration Prolonged expiration period (lungs collapse due to elastin) Pink puffers: respiratory rate maintains O2. Dangerous to give O2 ventilatory drive Medical management: Bronchodilators and inhaled corticosteroids: only if reversible obstruction Smoking cessation (nicotine replacement doubles quit rate) Antibiotics O2 with care Exercise/physio Attention to nutrition Bronchiectasis Chronic necrotising infection of bronchi and bronchioles (ie a pneumonia that doesnt clear) abnormal airway dilation and destruction of bronchial walls obstruction due to inflammation, ulceration and distortion = Chronic infective bronchitis Pathogenesis: Obstruction (especially during growth) due to tumour, foreign bodies, mucous impaction (eg in cystic fibrosis and immotile cilia) Infection with bronchial wall weakening and atelectesis (eg in necrotising pneumonia). Airways may be cylindrical, fusiform or saccular Microscopic appearance: Acute inflammatory exudate with desquamation and ulceration of the epithelium. Chronic peribronchial fibrosis th th 82 4 and 5 Year Notes Clinical course: foul, bloody sputum, especially in the morning. Rarely cor pulmonale, metastatic brain abscesses and amyloidosis Restrictive/Interstitial Pulmonary Disease = Reduced expansion of the lung parenchyma British and Americans give them different names Over 150 different disease processes primarily affecting alveoli epithelium, interstitium and capillary endothelium, not airways Restrictive Lung Diseases Affecting chest wall or Interstitial or infiltrative diseases pleural space bellows function. Heavy lungs due to fluid accumulation (interstitial and later alveolar) Microscopic appearance: Early change: interstitial oedema, few cell infiltrates Acute exudative stage: microvascular injury breakdown of basement membrane leakage of plasma proteins into alveoli. Fibroblasts lay down collagen in interstitium and alveolar spaces interstitial and intra-alveolar fibrosis Prognosis: 50% mortality. Filling of alveolar with alveolar macrophages (not desquamated as originally thought). See Types of Lung Cancer, page 88 Laryngeal and perhaps extrapulmonary neoplasms When asking about occupational exposure, need to go back a long time. Serpentine crysotile form (curly, flexible) is more common, less dangerous, cleared more easily from bronchi and more soluble so dont persist in the alveoli. Monocytes recruited granuloma formation Macroscopic appearance: Chest X-ray shows bilateral hilar lymphadenopathy and/or diffuse interstitial disease. Tightly clustered epithelioid histiocytes, multiple giant cells, and a few peripheral lymphocytes Clinical course: Treat with steroids. Contain lots of cholesterol Pharyngeal pouch: Mucosa herniates out through triangle between the cricopharyngeus and thyropharyngeal muscles under pressure from swallowing when upper oesophageal sphincter doesnt relax properly. Treatment: radiotherapy unless spread through cartilage Supraglottic: 30%, above chords, involves false chord. Quitline 0800 778 778 Epidemiology of Lung Cancer Commonest cancer in the world In New Zealand, leading cause of cancer death in men (23%, bowel 15%, prostate 14%) and third most common in women. Maori women have the highest death rate from lung cancer of any female population in the world Males predominate. Females catching up Respiratory 87 60% not resectable at the time of diagnosis 23% of all lung cancers are mixed Smoking: > 90% are caused by smoking and are therefore preventable 25% of lung cancer in non-smokers is due to passive smoking Types according to smoking status: % Smokers % Non-smokers Squamous Cell 98 2 Small Cell 99 1 Large Cell 93 7 Adenocarcinoma 82 18 Bronchioalveolar 70 30 Presentation and Survival: Smokers Non-smokers Distant disease at presentation > 50% 10% Endocrine disorders 10 25% 5% 5 year survival 5% 17% Relative incidence changing rapidly: Squamous cell Adenocarcinoma (now more common than squamous cell in most countries) Bronchioalveolar carcinoma Large cell constant Presentation Fatigue 84% Cough 71% Dyspnoea 59% Anorexia 57% Pain 48% Haemoptysis 25% Diagnosis Cytology necessary for management. Fragile crushed causing blue streaks Complications: metastatic disease to lymph nodes, brain, liver and adrenals Two year survival 25% Treatment: chemotherapy. Grows by expansion rather than infiltration Mesothelioma: Primary pleural tumours, including benign and malignant (also tumours of the peritoneum, tunica vaginalis and pericardium) Benign mesothelioma does not produce pleural effusion and has no relationship to asbestos Malignant mesotheliomas arise in either visceral or parietal pleura, produce pleural effusion (can be unilateral) and are related to asbestos. Aggressive, bulky, peripheral tumour Pancoast tumour/syndrome: lung cancer (usually squamous) in the apex extending to supraclavicular th st nd nodes and involving 8 cervical and 1 and 2 thoracic nerves shoulder pain radiating in ulnar distribution. Surgical studies are highly selected and not representative of the general population Majority will require radiotherapy. Can be used prior to surgery/radiotherapy to control micro-metastases/improve operability, or palliatively. Cisplatin and Etoposide are the gold standards amongst the older agents Small Cell: 70 80% have metastasised at diagnosis Very rapid doubling time No place for surgery Mainly managed with chemo +/- radiotherapy (makes a dismal outlook a bit better) Sleep Apnoea See also: Treatment of Insomnia, page 534 for Treatment of Insomnia See also Tiredness, page 6 Sleepiness Varies according to circadian cycle: two sleep gates each day, 2 3 pm and 10 11 pm (correlates with melatoin) Obstructive sleep apnoea is the most common cause of excessive sleepiness. Variety of causes including neuromuscular and chest wall deformities Cheyne-Stokes Respiration: usually with advanced heart failure. Treatment: codeine or anti-Parkinson drugs Narcolepsy: Normal sleep at night and frequently going to sleep during the day. Can also be complicated by cataplexy (sudden loss of muscle tone in response to emotional stimuli). Need to titrate pressure Treat allergic rhinitis Medication: Sleeping pills make it worse stop them Dental devices Surgery: Kids tonsils and adenoids. Prone to infection so steroids worsen the condition by depressing the immune system. Bronchial lavage effective in acute episodes A number of vasculitis affect the lung. Usually found as incidental findings on X-ray Primary Pulmonary Hypertension: rare, usually in young women. A large histiocyte with one bland folded nucleus, abundant eosinophilic cytoplasm with indistinct cell borders. X-rays show multiple nodules scattered through both lungs Langhans giant cell: (not the same as Langerhans cell) multinucleated giant cell in granulomas, with nuclei arranged around the periphery of the cell in a horseshoe pattern Sequestration: Extralobular: Congenital. Mass of lung tissue not connected to bronchial tree and outside the visceral pleura Intralobar sequestration: usually acquired. Within the visceral pleura but not connected to the bronchial tree Differential of Solitary lung nodule: Tumour: benign (bronchial adenoma or pulmonary hamartoma) or malignant Tb Sarcoidosis Other granuloma: eg fungal Haematoma (ie blood clot, eg in cavity following lung contusion) th th 92 4 and 5 Year Notes Endocrine and Electrolytes History. Ketoacidosis will develop unless insulin given (if any endogenous insulin then no ketones) Incidence up to 20 yrs: 10 15/100,000 Prevalence: 0. So when start insulin replacement back titrate (after stabilised) type 1 may have honeymoon period until no endogenous insulin Currently being investigated for prevention in high risk individuals (ie have antibodies but not frank disease): Cows milk avoidance until 6 months of age Early oral insulin therapy autoimmune modulation Nicotinamide (vitamin B) supplementation Treatment goals: stable blood sugar, prevent/monitor complications, promote normal growth and development, maintenance of normal weight Investigations for both Type 1 and Type 2 Diabetes Glucose testing HbA1C. Dipsticks detect > 150 g/l (ie insensitive) Microalbuminuria hard to test (needs 24 hr urine). After 30 years 80% have background retinopathy and 7 8% are blind (see Focal Ischaemic Retinal Disease, page 145).

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Shaffer 524 There is still some controversy regarding the use of albumin post-paracentesis buy glycomet 500mg cheap, as patients who do not receive albumin have not been shown definitively to have greater mortality discount 500 mg glycomet. Other plasma expanders glycomet 500 mg with amex, such as Hemaccel, Dextran 70 and Pentaspan, have also been used and have been shown to be equally effective. However, a group in Barcelona has suggested that albumin is superior to all the other volume expanders in the prevention of post-paracentesis circulatory dysfunction and the development of renal failure. A recent study from Toronto has shown that as long as the ascitic volume removed is less than 8 litres and the standard dose of albumin of 6-8 gm per litre of ascitic fluid removed is given, the development of post-paracentesis circulatory dysfunction is not associated with any renal dysfunction. Vasopressin receptor antagonists, which are pure aquaretic agents, have been tried in combination with diuretics and large volume paracentesis in the management of ascites, whether the patient is still diuretic-responsive or diuretic-resistant. Vasopressin receptor antagonists are able to reduce the volume of ascites accumulated, and hence the frequency of large volume paracentesis in these patients. A communication is created between a branch of the portal vein and a branch of the hepatic vein, and this communication is held open by a metal stent. This stenting reduces the sinusoidal portal pressure, and allows a slow but effective elimination of ascites. Without the use of diuretics, sodium excretion begins after the first month, and slowly increases thereafter. Within 6 months, complete resolution of ascites eventually occurs in approximately two-thirds of patients, and a partial response in the other third. Therefore, regular assessments of shunt patency with doppler ultrasound and/or angiography are required. In recent years, the use of covered stents has significantly reduced the rate of shunt stenosis. Survival of patients according to patient characteristics following the insertion of a transjugular intrahepatic portosystemic stent shunt for treatment of refractory ascites. It is a condition in which the ascites becomes infected in the absence of a recognisable cause of peritonitis (other than cirrhosis itself). Curiously, in most cases, the infection occurs after the patients admission into hospital. More often, the presentation is atypical, with worsening of hepatic encephalopathy or renal function. Positive culture results may take 48 hours, and Gram stains of ascitic fluid are only positive in 10-50% of infected patients. A five-day course of Cefotaxime 2 g intravenously every 8- 12 hours is effective as a ten-day course. Micro-organisms that can cause spontaneous bacterial peritonitis Gram negative bacilli Gram positive organisms Anaerobes E. These options explore the possibility of giving part of the treatment course as outpatients, thereby shortening the duration of hospital stay. However, monitoring patient compliance becomes mandatory if this course of action is to be followed. One study has shown that the First Principles of Gastroenterology and Hepatology A. Shaffer 528 concomitant use of albumin can reduce the risk of renal impairment in these patients. However, further studies have shown that only patients with a baseline serum creatinine of >88. The response to treatment should be assessed by both evaluating the symptoms and signs of infection, and performing at least one follow-up paracentesis after 48 hours of antibiotic therapy. A reduction of less than 25% in relation to the pre-treatment value is often considered to represent failure of antibiotic treatment. If secondary bacterial peritonitis is suspected, antibiotic coverage should be broadened with the addition of metronidazole and ampicillin. Radiographic examinations are required to exclude perforation of the gastrointestinal tract, with emergency surgery only where gut perforation is confirmed. Routine selective intestinal decontamination with oral non-absorbable antibiotics has proved to be effective in reducing recurrence. Norfloxacin 400 mg daily, Trimethoprim/sulfamethoxazole 160/800mg daily, or Ciprofloxacin 750 mg weekly are the drugs of choice, as they rarely cause bacterial resistance and have a low incidence of side effects when administered chronically. Trimethoprim/sulfamethoxazole 160/800mg daily may confer greater gram-positive coverage. Antibiotic prophylaxis is effective in improving survival in cirrhotic patients with gastrointestinal hemorrhage. The optimal dose and the duration of treatment in this setting have not yet been established. There are no studies to date to determine whether these patients require antibiotic prophylaxis. The recommended dose of albumin is 1 g/kg of body weight per day up to a maximum of 100 g/day. The splanchnic arterial vasodilation that results from severe portal hypertension is a key initiating event. Cirrhotic cardiomyopathy results in an inappropriately low compensatory increase in cardiac output, further compromising renal perfusion. A number of soluble circulating vasoactive mediators have also been implicated in decreasing renal perfusion and the glomerular microcirculation. Parenchymal kidney disease can result from many different First Principles of Gastroenterology and Hepatology A. A renal biopsy is occasionally required to discriminate between causes of parenchymal kidney disease. An assessment of liver function and investigations to rule in or out the presence of sepsis are indicated. Urine microscopy and studies for electrolytes and protein can help rule in or out parenchymal renal disease. Daily serum electrolytes and creatinine help follow responses to therapy and to screen for the development serious electrolyte disturbances (such as severe hyponatremia and hyperkalemia). Treatment with agents thought to be directly vasodilatory for the renal arterial supply (such as non-pressor doses of dopamine) are ineffective (Angeli 1999). Terlipressin, which is not currently available in North America, is the most comprehensively studied pressor (Table 2). Contraindications to terlipressin include ischemic cardiovascular disease, and patients should be observed for the development of ischemic heart disease, arrhythmias, mesenteric and digital ischemia and volume overload. Clinical Presentation Patients with this condition will present in a variety of ways (Table 1). Patients with chronic disease often have other manifestations of their liver disease including jaundice, ascites and gastrointestinal bleeding. The usual physical signs and laboratory abnormalities associated with advanced liver disease may be present. These physical findings include muscle wasting, jaundice, peripheral edema, and ascites. Occasionally fetor hepaticus, a sickly-sweet smell from the mercaptanes in the breath, will be present. Hepatic encephalopathy is characterized by changes in personality, consciousness, behavior and neuromuscular function. West Haven Criteria for Hepatic Encephalopathy Stage Consciousness Intellect and Behaviour Neurological findings 0 - Normal - Normal - Normal exam 1 - Mild lack of - Shortened attention span - Mild asterixis or tremor awareness Impaired attention or subtraction 2 - Lethargic - Disoriented - Obvious asterixis - Inappropriate behavior - Slurred speech 3 - Somnolent but - Gross disorientation - Muscular rigidity and clonus arousable - Bizarre behaviour - Hyperreflexia 4 - Coma - Coma - Decerebrate posturing First Principles of Gastroenterology and Hepatology A. The earliest feature is often reversal of the diurnal sleep pattern or subtle personality changes and irritability. Asterixis (asymmetric flapping motions of the outstretched, dorsiflexed hands) can be easily checked in a routine clinical exam. Hepatic encephalopathy associated with acute liver failure has a rapid onset and progression. It is usually complicated with cerebral edema, which can lead to seizures and lateralizing neurologic signs. Occasionally, a refractory pattern emerges leading to debilitating syndromes such as dementia, spastic paresis, cerebellar degeneration and extrapyramidal movement disorders. When approaching a patient with severe liver disease who has an altered level of consciousness or other neurological features, it is important to rule out other causes of changes in mental status and neurologic disease. One may need to distinguish the neurologic changes commonly seen in patients with alcoholic liver disease and Wilson disease. It may reflect either a reversible metabolic encephalopathy, brain atrophy, brain edema or any combination of these conditions. The mechanisms of brain dysfunction in liver failure are not clearly known (Table 3).

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Later glycomet 500 mg,pain order glycomet 500mg with visa,haema- Nausea and vomiting are common associated symp- turia and impaired renal function discount glycomet 500 mg without a prescription. There may be history of previous self-resolving episodes of pain, particularly at night in young boys Investigations (can be associated with nocturnal sexual arousal that As for urinary stones. If <10% renal function the kid- veals a red hemiscrotum, with an asymmetrically high, ney should be removed. If there is >25% function in a swollen testis (pulled up by the shortened, twisted sper- younger patient many would probably try to preserve matic cord). The cremasteric response is absent in tor- sion (stroking or pinching the inside of the thigh should Management cause the ipsilateral testis to rise), but this response is not Open surgery, or very slow gradual breaking up of reliable below the age of 30 months or over 12 years. Nephrectomy is advised for a can be difcult to distinguish particularly as the testis symptomatic stag horn calculus in a poorly functioning can also swell in this condition. Complications If surgery is delayed beyond 1218 hours the blood sup- Disorders of the male genital ply is compromised and infarction occurs requiring sur- system gical orchidectomy. Investigations Torsion of the testis Diagnosis is clinical and surgery should not be delayed. Age Most occur in young children and peri-pubertally, less Management common over 25 years. The scrotum is explored, the twist is reversed and if the testis is viable both testes are xed in position as the Sex condition is a bilateral defect. Aetiology Torsion occurs if the testis is insufciently xed by its Hydrocele lower pole to the tunica vaginalis by the gubernaculum testis, so allowing it to twist. Pathophysiology Twisting of the testis on the spermatic cord leads to ve- Incidence/prevalence nous/haemorrhagic infarction. Aetiology Most hydroceles are idiopathic but may occur secondary Incidence/prevalence to trauma, infection or neoplasm. Pathophysiology Fluid accumulates between the two layers (parietal and Aetiology/pathophysiology visceral) of the tunica vaginalis. It is thought to occur Thesearetheequivalentofvaricoseveins,duetothevalve due to imbalance of secretion/reabsorption of peritoneal leaets becoming incompetent, blood ows back down uid from these layers. Varicoceles occur more commonly on by the persistence of the processus vaginalis and can be the left side due to the perpendicular drainage of the left associated with herniation of abdominal contents into spermatic vein into the renal vein, which is compressed the sac. Usually the hydrocele covers the testis, tile, but many also have normal sperm counts. Testicular atrophy is thought to swelling, a normal spermatic cord should be palpable occur due to the slightly raised temperature triggering (this differentiates a hydrocele from an inguinal hernia). A simple hydrocele transilluminates well, but if there is blood (a haematocele) or it is chronic and the wall is Clinical features thickened, it does not. Patients may complain of a dragging sensation or aching pain in the scrotum, particularly on standing. On palpation there is a soft If there is any doubt an ultrasound scan conrms the swelling like a bag of worms along the spermatic cord, diagnosisandisusefultoexcludeanunderlyingtesticular which is compressible and disappears on lying at. Management Management Surgery is indicated in boys and young males with asym- 1 Anysecondary cause should be identied and treated. Aspiration should not be attempted as there is a tile men with a varicocele, surgery has not been shown risk of infection and bleeding. Ligation of the spermatic 3 If the hydrocele uid becomes infected or contains vein can be either by open or laparoscopic surgery. In blood, incision and drainage of pus are necessary, and older males who no longer wish to have more children, examination of the scrotal contents to exclude an un- treatment with scrotal support and analgesia may be derlying tumour may be performed at that time. Aetiology/pathophysiology Clinical features Normally the foreskin does not retract at birth and it Aswelling in the scrotum located above and behind the may be months to years before it becomes retractile. In testes, thus some patients attend saying they have devel- congenital phimosis, the orice is too small from birth oped a third testis. Surgery to remove the cyst(s) risks damaging the sper- Clinical features matic pathway, such that bilateral operations can cause r Ayoung child with congenital phymosis may have dif- sterility, and more conservative removal often leads to culty with micturition, with ballooning of the pre- recurrence. Denition Inability to achieve or sustain a sufciently rigid erection Complications r in order to have sexual intercourse. Occasional episodes Recurrent balanitis may occur due to secretions col- of impotence are considered normal, but if erectile dys- lecting under a poorly retractile foreskin. Balanitis function precludes more than 75% of attempted inter- causes pain and a purulent discharge. Also called male If apoorly retracting foreskin remains retracted after sexual dysfunction. Incidence/prevalence r Phimosis increases the rate of penile cancer by at least This has been underestimated in the past, due to the 10-fold. With Management greater understanding, increased availability of treat- Symptomatic phimosis is treated by elective circum- ment and more widespread discussion of the problem, cision. Circumcision is not required in asymptomatic 40% of men aged 40 are recognised to have some degree young children, unless for religious reasons. In cases of of sexual dysfunction, increasing by approximately 10% acute paraphimosis, the band is excised under general with each decade. Aetiology The cause is pyschogenic in 25% of cases, drugs (25%) and endocrine abnormalities (25%). The other 25% are Epididymal cysts caused by diabetes, neurological and urological/pelvic Denition disease. Epididymalcystsareuidlledswellingsconnectedwith Psychogenic causes can be divided into following: the epididymis that occur in males. If the uid contains r Depression, causing loss of libido and erectile dys- sperm, it is called a spermatocele. Barbiturates, corticosteroids, phenothiazines 5phosphodiesterase), so increasing the ability to gen- and spironolactone may reduce libido. Recreational drugs such as co- 1 hour before sex, and its effects last for 4 hours. Its caine and hallucinogenic drugs can cause impotence vasodilation effects can cause headache, dizziness, a with long-term use. Auto- r Penile self-injection with vasoactive drugs such as pa- nomic neuropathy is also an important factor. There r Vacuum devices can be used to suck blood into the isalsoareexarcatS2S4whichmeansthatgenitalstim- penis and then a ring is applied at its base to main- ulation increases vascular ow. Ejaculation is not possible with these any level can therefore interfere with sexual function. Clinical features r Psychological counselling is useful for those with a Some features in the sexual history, medical history or psychological cause. Completelossof erections, including nocturnal erections, suggests a neu- rological or vascular cause. Sudden loss of sexual func- Genitourinary oncology tion without any previous history of problems, or major genital surgery, suggests performance anxiety, stress or Kidney tumours loss of interest in the sexual partner. Ability to generate an erection, but then inability to sustain it may be due Benign tumours are commonly found incidentally at to anxiety or to a problem with vascular supply, or nitric post-mortems or on imaging. It is important to r Renal adenomas are derived from renal tubular ep- take a drug history and enquire about possible features ithelium. Tumours less than 3 cm in diameter are ar- of depression, smoking, alcohol or drug abuse. Microscopically they giomyolipomas, but there is also an increased risk of contain only large well-differentiated cells with papillary renal cell carcinoma. Malignant tumours r Clinical features The most common is renal cell carcinoma (8590% Presenting symptoms may include haematuria, fever, in adults). These share the same pathology as in dromes are relatively common: bladder cancer. Adenocarcinoma of the kidney, which arises from the r Polymyalgia-like symptoms with aching proximal renal tubular epithelium. Many patients remain asymptomatic until advanced lo- Prevalence cal disease or metastases develop, so may present with 2% of all visceral tumours; 8590% of primary renal the symptoms of complications and increasingly lesions malignancies in adults. On examination, occasionally a palpable loin mass Age may be found and lymphadenopathy, hepatospleno- Increases with age, most over age 50 years.

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