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SURGERY FOR CANCER OF THE PROSTATE

The second type of prostate operation is done when a man has cancer of the prostate. Called a radical prostatectomy, this procedure involves the removal of the entire prostate and the seminal vesicles, always through an incision in the body. It’s much more common for crucial nerves to be injured during this type of procedure. Because surgeons have now identified the exact location of these nerves, however, new methods have been developed to save them, and the odds that potency will be maintained are much better. Using these new techniques, popularized by Patrick C. Walsh, M.D., Chairman of the Department of Urology at Johns Hopkins University, the surgeon can preserve the nerves next to the prostate that control erection. The results are striking: One year after having their prostates removed, 86 percent of men who were potent before surgery retained their ability to get an erection. Previously, the vast majority of men who had such surgery were physically incapable of getting an erection. It does take some time to regain potency following prostate surgery; less than a third of the men were potent after just three months, but after nine months about 60 percent had regained potency. Younger patients were faster to recover their erectile abilities, and the smaller the cancer, the better the odds for preserving the nerves and the ability to get an erection. The nerve-sparing technique is now widely known, and any man contemplating prostate surgery should discuss the methods to be used with his doctor.

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MEDICATION CAN CAUSE POTENCY PROBLEMS

Always ask your doctor or pharmacist if a medication can cause potency problems—even if the problem occurs after you’ve been taking the drug for a while. And remember to ask about how drugs interact with each other and with alcohol. Doctors differ in their approach to the drug/erection problem. Some believe that volunteering the information that a medication may cause impotence just sets the patient up for performance anxiety. Others strongly assert that a well-informed patient is in a much better position to report any difficulties, and that patients can be saved needless anxiety by knowing what might happen. We favor the second approach. In any case, you can protect yourself by always asking if a medication can affect your potency. If you ask directly for the information, the physician should provide it.

Many patients do not connect medications with potency, and neither do their wives. Think how differently William and Sharon would have felt if, when the first erection problem occurred, William said, “Well, it might be the blood pressure pills. I’ll call the doctor in the morning. Maybe he can switch me to a different medication, or change the dosage.” A lot of pain and anguish might have been avoided.

Recreational drugs, like marijuana, amphetamines and narcotics can also cause erection problems. As with medications, responses to these drugs vary: Some men find that even small doses leave them unable to get an erection, or maintain one, while others have a higher tolerance.

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INTESTINAL GAS

Intestinal gas includes a number of problems, such as burping, belching, swelling and bloating of the abdomen, and an increase in the passage of “wind” (flatus). These symptoms can be so disturbing that some individuals change their social life in order to avoid the embarrassment that comes with “too much gas.”

There are two ways in which gas can enter the digestive system. The most common way is by swallowing air. This occurs unconsciously during eating and drinking and is normal for everyone. Some people, however, swallow too much air, especially when anxious or under stress. It is common for some people to swallow air and then immediately burp or belch to relieve certain kinds of abdominal discomfort. People with acid indigestion often develop this habit, and they may even drink carbonated beverages such as soda water to increase the amount of air in their belches.

The other source of intestinal gas is the fermentation and digestion of food by bacteria that normally inhabit the large intestine. These bacteria break down nutrients, and one of the by-products is intestinal gas. Everyone produces some gas normally, and for the most part this is passed without problem, either during a bowel movement or discreetly throughout the day.

Some people are plagued by abdominal swelling and bloating as well as pain. Studies have shown that the amount of gas in the intestine is about the same in all individuals but some people become more sensitive to normal amounts of gas, and when the bowel is stretched by the gas, it becomes uncomfortable and results in a bloating sensation.

Since almost all gas entering the esophagus and stomach comes from what you swallow, the most important step in decreasing burping and belching is to learn how to swallow less air. You can begin by avoiding carbonated beverages, which contain excess amounts of gas. Eat meals slowly, and never gulp liquids. Avoid chewing gum and smoking, which can lead to increased amounts of swallowed air. If you suffer from acid indigestion, relieve it with antacids.

The passing of malodorous wind is very disquieting to some people. All of us have to pass a certain amount of flatus as part of our normal bodily functions. If, however, you tend to swallow air, the amount of flatus will increase. In addition, certain foods produce excessive amounts of gas and increase the undesirable odor. Therefore, after your physician has determined that no illnesses are affecting your bowel, a change of diet is often helpful.

You should try to eat smaller meals more frequently rather than one or two large meals a day. If you take liquids with your meals, they should be in smaller amounts, and you should drink them slowly rather than using them to “wash down” the food. You should also try to eat slowly. Avoid chewing gum or sucking candies, and stop smoking. If you have a lactose intolerance, a decrease in milk products will be helpful.

Some foods, such as beans, nuts, cauliflower, cabbage, broccoli, radishes, turnips, apples and other raw fruits and vegetables, may lead to an increase in gas. However, rather than discontinuing these foods simultaneously, it might be necessary only to decrease or omit a few of them. Try one at a time and see the result. Many of these foods also supply important amounts of fiber, vitamins, and minerals, and stopping them altogether could lead to serious nutritional problems.

Medications such as antacids decrease the amount of gas. Simethicone, which is often combined with antacids, allows swallowed air to be belched, rather than having it pass through the intestine and leave the body as flatus. Some laxatives increase gas. No medication can completely cure excess flatus.

Although many medications, such as chlorophyllin, have been used to decrease the objectionable odor that is associated with excess flatus, none has proven to be successful in all people. Some people benefit from certain medications if changes in their diet and eating habits have not been beneficial. Chlorophyllin can be taken if you feel that the odor of your flatus and stool is so objectionable that it is interfering with your emotional and social life. Although chlorophyllin is not readily available, your physician can arrange to have your pharmacist order it for you. It will make your stool green, but it does not appear to have any other negative effects.

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WEIGHT GAIN

Once we reach adulthood, we usually maintain a fairly steady weight. Weight can go up during the middle years, especially if your exercise and physical activity are minimal. Beyond middle age your weight may drop slightly because your skeleton mass and the bulk of your muscles gradually decrease. In Western countries excess weight is a common problem, and it may become exaggerated with age. But obesity is not normal or healthy.

The most common cause of weight gain is a decrease in activity compared to the number of calories eaten. Since eating habits rarely change, and as the inclination to exercise often lessens with age, many older people tend to gain weight. This may be exaggerated by economic factors, which force people to rely on cheaper foods such as sugars, starches (carbohydrates), and fats when good sources of protein become prohibitively expensive. Besides decreasing your energy level, excess weight has serious consequences on your ability to function well: it steps up the work of the heart, exaggerates the symptoms of arthritic conditions and back pain, increases the risks in surgery, and makes diabetes mellitus more difficult to control.

The most effective way to deal with weight gain is to maintain a reasonable degree of activity and carefully limit your food intake. The best way to assure adequate physical activity is to prepare in advance for your senior years by developing good exercise habits. Even if you have never been used to physical exertion, it is never too late to start on a program of gradually increasing exercise. This will also improve your sense of well-being.

If you are overweight, you should try to reduce, even though it is difficult to change eating patterns that were developed over many years. Group sessions such as those given by senior-citizen organizations, weight-reduction associations, or by dietitians and physicians may be helpful in guiding your eating habits. It is important to avoid fats (especially animal fats), sugars, and simple starches, and to substitute protein, complex carbohydrates, and high-fiber vegetables, which have low caloric value.

Far too often an older person becomes aware of the disability resulting from obesity only after having suffered from a serious illness or surgery. It should not be necessary to learn the hard way that being overweight can endanger your health and even your life.

Some causes of weight gain may be the result of illnesses rather than an imbalance between food intake and physical activity. Whenever your pattern of weight changes unexpectedly or if you have other symptoms in addition to weight gain, consult your physician.

Elderly persons with heart disease may gain weight because water tends to accumulate throughout the body. You may become aware of swelling of your legs and abdomen, which may vary throughout the day, with a tendency to worsen in the evening and improve after a night’s sleep. You may feel short of breath or experience other heart symptoms. Because the weight gain can be gradual, the connection between heart disease and fluid accumulation may be overlooked.

People with an underactive thyroid gland (hypothyroidism) may also experience weight gain. This illness may be very gradual in its onset. You may or may not be aware of a generalized slowing of your physical and mental condition, or you experience weight gain despite a limited food intake.

Heart disease, an underactive thyroid gland, and other causes of fluid retention should be investigated and proper treatment sought whenever there is unexpected weight gain.

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BRONCHOSCOPY, CYSTOSCOPY, AND ARTHROSCOPY

Bronchoscopy

To diagnose diseases of the bronchi and lungs, it is sometimes necessary to look into the respiratory system rather than rely on X-rays alone. A bronchoscope is a thin, flexible instrument that can be passed through the nose or mouth into the trachea and down the bronchi. During the examination you will probably receive a local anesthetic and a mild tranquilizer to alleviate the discomfort of the procedure. Samples of sputum can be obtained during the test, and tumors or other abnormalities can be seen and samples or biopsies taken.

Cystoscopy

The urinary tract can be investigated through intravenous pyelogram (IVP) X-rays and echograms and by urine tests. A cystoscopy may be done when there is bleeding from the urinary tract or difficulty with the passage of urine. It is more commonly necessary for men because of disorders of the prostate gland. A local anesthetic is usually used, although a cystoscopic examination is sometimes carried out under a general anesthetic. The procedure, which is somewhat uncomfortable, takes only ten or fifteen minutes and may have to be repeated. It is often possible to remove small tumors that grow in the bladder through the cystoscope, which means that surgery may be avoided.

Arthroscopy

Arthroscopy allows a physician to look inside a joint (such as the knee) and assess damage and diagnose certain rheumatic conditions and injuries. Sometimes surgical procedures and removal of damaged material can be done through the ar-throscope, thereby in some instances avoiding the need for surgery. The instrument (arthroscope) is inserted with little discomfort after preparation of the insertion site with local anesthetic.

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BARIUM X-RAYS, GASTROINTESTINAL SERIES, AND BARIUM ENEMA

Barium, a white, sticky substance, is often used to investigate disorders of the gastrointestinal (GI) tract, such as ulcer disease, hiatus hernia, benign and malignant tumors, and inflammatory disorders of the bowel. When barium is swallowed the substance outlines the esophagus, stomach, and small intestine. Barium is given as an enema when the lower intestine is to be examined.

The upper gastrointestinal series, or barium swallow, is used to diagnose diseases of the esophagus, stomach, and small intestine. The barium, which tastes chalky but is usually flavored to make it palatable, can cause some constipation, and you will probably be given a laxative to help you expel it.

The test is usually done with a fluoroscope or video device, which allows the physician to watch the barium flow into the esophagus and stomach. A barium swallow is done in the fasting state. Any food or fluid that has been taken in the eight or ten hours before the study may interfere with an accurate interpretation of the X-rays.

A barium enema uses the same substance, but it is inserted into the rectum. This X-ray displays the lower intestine (large bowel). The test and the preparation for it are somewhat uncomfortable. Usually it is necessary to take laxatives for a day or two before the X-ray to clear the bowel. I sometimes recommend a more gradual preparation with a fluid diet for a day or two before. This often avoids the need for strong laxatives.

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BLOOD TESTS

Usually, your physician will request blood tests because almost all illnesses cause some abnormality in the constituents of the blood. Blood tests are often the easiest way to determine that you have a disorder. They are easy to do, pose very little danger, and if done carefully, usually cause little discomfort. They can be repeated readily to obtain diagnostic information and measure the results of treatment.

Blood consists of a fluid called plasma, which carries red and white blood cells. Red cells, or erythrocytes, carry oxygen and carbon dioxide. They contain a special chemical substance called hemoglobin, which allows oxygen and carbon dioxide to enter or leave the cell. In many diseases the ability of the body to keep up the normal level of red cells and hemoglobin is disturbed. This disturbance is determined by a blood count, which tells the physician whether the red cells and hemoglobin are normal. If they are too low, the condition is called anemia.

There are a number of varieties of white blood cells, or leucocytes, which help the body fight infection. In certain illnesses there may be either too many or too few white blood cells, or the ones produced may be abnormal. If you have too many white blood cells, you may have an infection, which stimulates the body to fight the germs. On the other hand, a disorder of the white blood cells may make you more susceptible to infection.

Platelets are small cell-like particles that induce blood clotting when an artery or vein is injured. There may be too many or too few platelets in certain disorders. This can make the blood too sticky, which causes blood clots to form within blood vessels, or it can keep the blood from clotting normally and increase your tendency to bleed.

All the blood cells and platelets are produced in the bone marrow, found within the bones of the body. Bone marrow manufactures blood cells and allows them to enter the bloodstream according to the needs of the body. Sometimes the bone marrow becomes diseased and produces excess amounts of blood cells or too few of its components. This results in various blood diseases.

The blood cells are carried in the plasma, which also contains many other components that are vital for the normal, healthy function of the body. Hormones, produced by glands, are also transported by the plasma, as are salts, which keep the body environment normal. All nutrients from food pass into the plasma from the gastrointestinal tract and are circulated throughout the body. Antibodies, which are produced to fight disease, all medications, and the by-products of metabolism are contained in the plasma.

As medicine progresses, we learn more and more about changes that occur within the components of the blood. Therefore, the number and complexity of blood tests has grown enormously in the past few years. The elements in the blood that can be affected by medications, either by design or unintentionally as side effects, can also be determined.

Ask your physician what tests are being done. He may tell you their chemical name or that he is examining your “kidneys” or “liver.” Sometimes blood tests are repeated, and you may wonder why. Many older people complain that their blood is being taken too often, but it is often advisable to repeat blood tests in order to make a diagnosis and to monitor the outcome of treatment. If tests are reordered, ask your physician why. In many instances it is more important for the physician to know about the changes that occur in the blood than to see the results of a single measurement.

The following is a summary of the most common blood tests, but new tests are always being developed. Tests are done by commercial and hospital laboratories, but ones that require special equipment or expertise may be sent elsewhere. Before you leave your physician’s office, ask how you will find out about the results of the tests. Ask whether he will want to see you again to discuss the tests or whether he can tell you the results over the telephone. A physician may tell you that if the tests are normal, you will not hear from him and know that “no news is good news.” If you have gone to a specialist for the tests, he may tell your physician the results. Make sure that you know what tests will be done and who has the answers so that unnecessary duplication is avoided.

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BACTERIAL VAGINOSIS (ANAEROBIC VAGINOSIS) – INVESTIGATION AND DIAGNOSIS; MANAGEMENT

The presence of N gonorrhoeae, yeasts or trichomonads should be excluded. G vaginalis can be isolated by culture. Microscopy of vaginal smears may reveal numerous small gram-negative coccobacilli with no inflammatory cells and an absence of lactobacilli. The ‘clue cell’ with its numerous adherent bacteria is a feature of bacterial vaginosis.

The pH of vaginal secretions on the tip of the speculum can be measured using indicator paper; in bacterial vaginosis the pH is usually between 5 and 6. The presence of semen, a cervical discharge or menstrual blood can raise the pH of vaginal secretions.

Vaginal fluid can be tested for amine using the ‘whiff test; vaginal discharge on a swab is mixed with a drop of potassium hydroxide with production of a putrescent odour.

The nitroimidazoles (e.g. metronidazole 400 mg twice daily for 5 days or

2 g per day for two days) produce a short term cure and are currently the treatment of choice. The nitroimidazoles should not be used in pregnancy and lactation; ampicillin 500 g four times each day for 5 days can be used.

Recurrence is common; treatment of male partners is of no proven value.

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HUMAN IMMUNODEFICIENCY VIRUS INFECTION – MANAGEMENT

Detailed information on management is not covered in this handbook. Patients with HIV infection require considerable support, counselling and regular assessment. There is no effective therapy for the immunodeficiency. Several drugs inhibit HIV viral replication in vitro. For patients with AIDS, zidovudine (azidothymidine — AZT) has been shown to decrease mortality, reduce the incidence of opportunistic infections, decrease viraemia and increase the number of T4 lymphocytes. Severe adverse reactions occur with this drug including anaemia and neutropaenia in up to 25% of patients.

Some opportunistic infections can be successfully treated. Treatment of others such as the atypical mycobacteria is usually ineffective. Chemotherapy may be effective in malignancies such as KS and lymphoma particularly if immune function is good.

Hospitalisation and nursing

Patients with HIV infection may be cared for in any hospital and strict isolation is unnecessary. Detailed recommendations can be obtained from publications such as the Infection control guidelines published by the AIDS Task Force.

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SYPHILIS – JARISCH-HERXHEIMER REACTION; RETREATMENT

This reaction is a consequence of treponemal destruction. It occurs 6 to 12 hours after commencing treatment and is a mild reaction with fever, headache, malaise, rigors and joint pain. The reaction lasts for several hours and does not recur. Symptoms are controlled by paracetamol and rest.

Retreatment

Only one course of treatment is normally necessary. Further treatment is indicated in the following circumstances:

where clinical symptoms or signs of syphilis persist or recur,

where initially high titres in the reagin test (e.g. VDRL 1/8 or greater or RPR 1/16 or greater) persist for a year or more after treatment; or

where there is a sustained four-fold increase in the titre of the reagin test (as may occur with reinfection in a successfully treated patient).

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