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The latter result may have been due to the small sample of the meta-analysis (Figure 31) symptoms kidney pain beloc 40mg with amex. Assessment of Publication Bias Funnel plots were generated to assess the extent of asymmetry for each meta-analysis. The following list shows the reference identifications for these trials and corresponding publications (each row). Hellstrom 2002, Hellstrom 2003, Hellstrom 2005, and Donatucci 2004 Overview of Trials 181-184,190,190,192,192,197,197-199,199,203 184,190, the trials were conducted in North America, Europe, 191,193-201,203,204 182,190,203 180,182,184,189,203,203,205,206 South America, and Asia. The total and mean numbers of patients randomly assigned to an intervention or placebo across the 22 trials were 8,621 and 392, 193 respectively, while the number of randomly assigned patients in each trial ranged from 21 to 190 1020. Interventions the patients in all 22 included trials were randomly assigned to receive monotherapy of oral 180-183,189,190,192-195,198,205 vardenafil at either a fixed or a flexible dose. In 12 trials, vardenafil was 189,192,194 193 administered at a fixed dose ranging from 5 mg/d to 40 mg/d, whereas in the remaining 10 trials a flexible dose with upward and downward titration was used, depending on the observed response in terms of efficacy and tolerability. In 10 trials patients were randomly assigned to receive two or more different fixed doses of 181,183,190,195,198,205 vardenafil in each arm: 10 mg/d versus 20 mg/d, 5 mg/d versus 10 mg/d versus 189,192,194 193 20 mg/d, and 20 mg versus 40 mg. In the majority of included trials, the duration of treatment with vardenafil was about 12 181-184,189,194,211 198,206 weeks. In one trial patients 203 were instructed to take the dose 8 hours before sexual activity for up to one dose a day. The Jadad total 206 191,197 score for the individual trials ranged from one to five. The methods for generating the 183,191,192,197 sequence of random assignment were described for four studies and were judged to 206 be appropriate. This section presents results derived from 21 placebo-controlled trials that compared the efficacy and harms profile of 180-184,189,191-201,203-206 190 vardenafil (any dose) to that of placebo. One trial that explored a doseresponse effect of vardenafil, without using a placebo arm, is reviewed in a later section (vardenafil dose 1 versus vardenafil dose 2). Therefore, this 181-184,189,191-201,203-206 section describes harms reported in 20 trials. The proportions of patients with one or more adverse event in vardenafil groups across the trials ranged from 182 189 about 27 percent (10 mg dose) to 74 percent (20 mg dose). The corresponding proportion 200 189 for the placebo groups ranged from about 17 percent to 52 percent. Most commonly, patients in the vardenafil arms experienced headache, flushing, rhinitis, and dyspepsia. Two of the 20 trials did not report the proportion of withdrawals due to adverse events. The withdrawal rate in vardenafil groups across the 18 181-184,189,191-199,201,203-205 193,195,198 192 trials ranged from 0 percent to 5 percent. The corresponding 193,195,203 189 rate for the placebo-treated patients ranged from 0 percent to 6 percent. Some of the reported specific events leading to the withdrawals were myocardial infarction, proctalgia, aortic 212 182,192 181,182 192 bifurcation graft, abnormal liver enzyme levels, myalgia, flushing, nausea, 181,191,192 192 181 headache, kidney calculus, abnormal vision, and rhinitis. The absence or occurrence of serious adverse events could not be 189,199,206 ascertained for three trials. The specific serious adverse events observed across the trials 198 198 in patients after random assignment to vardenafil therapy were: skin ulcer, reflux disease, 197 198,201 198 201 unstable angina, myocardial infarction, syncope and encephalitis aortic bifurcation, 182 facial palsy, and appendicitis. Serious adverse events that occurred in 10 trials were not 181,183,184,191,192,194,196,203-205 193,195,200 specified. In general, judging from the results of these trials, there were no obvious numerical or statistical differences in the occurrence of serious adverse events between patients randomly assigned to receive vardenafil and those assigned to placebo. In 11 trials vardenafil 180-183,189,192-195,198,205 was administered at a fixed dose (5 mg, 10 mg, 20 mg, and/or 40 mg). Ten trials administered 184,191,196,197,199-201,203,204,206 vardenafil with a flexible daily dose (5 mg, 10 mg, 20 mg). There were 10 trials with two or more dose181,183,189,190,192-195,198,205 specific arms of vardenafil. None of the trials were designed to compare flexible and fixed dosage regimens of vardenafil. In one multicenter North American study, for example, after 26 weeks of treatment with 5 mg, 10 mg, or 20 mg of vardenafil or placebo 19, 33, 42 and 7 percent of patients, 192 respectively, experienced at least one adverse event. The similar trend was observed in a trial that compared 20 mg and 40 mg doses of vardenafil (47. The most frequently observed adverse events in the 10 trials were 190 headache, flushing, dyspepsia, or rhinitis. In one trial, eight and 13 patients developed visual 189 disturbance(s) in the 10 mg and 20 mg groups, respectively. In another trial, two patients (one patient in each 5 mg and 20 mg groups) were observed to have visual disturbances (sensory, abnormal vision, and brightening). In three trials, none of the patients treated with 181,183,189,190,192,194, vardenafil withdrew because of adverse events. For the remaining seven trials, 205 the rate of withdrawals was numerically similar between treatment arms using 10 mg versus 181,183,189,190,192,194,205 20 mg of vardenafil. There was no apparent numerical or statistically significant difference in the occurrence of serious adverse events across the treatment arms of various doses of vardenafil. In another study, the corresponding proportions of patients with at least one serious adverse event were 5, 3, 192 190 and 4 percent. Four deaths were reported during one trial; one death resulted from suicide (10 mg group), while the other three (in the 20 mg group) occurred after myocardial infarction, coronary angioplasty, and ischemic cardiomyopathy. Results from two other trials demonstrated trends of a numerical increase in the rate of improved erections across 5 mg, 10 mg, and 20 mg doses of vardenafil. The highest proportion of patients with improved erections was observed in the 20 189,192 181 mg groups (range 80. In another trial, the proportion of participants with 49 improved erections was higher in participants who received 20 mg compared with those who received 10 mg of vardenafil (72 versus 57 percent, p < 0. Quantitative Synthesis Meta-Analysis of Trials Series of meta-analyses were performed using efficacy and harms data obtained from the 180-184,189,191-201,203-206 reports of 21 trials that were conducted in: 1) Clinically heterogenous groups of patients 2) Clinically homogenous groups of patients Clinically heterogenous groups of patients vardenafil (any dose: 5 mg, 10 mg, 20 mg, 40 mg) versus placebo. The analyses presented in this section did not include 10 trials for the following reasons: distinct clinical groups of patients. One of the 184 trials was restricted to patients who were nonresponders to previous treatment with sildenafil. This difference between the populations of the two trials might have led to the high degree of 2 statistical heterogeneity that was found (I = 61 percent) (Figure 39). The second meta-analysis, 184 which did not incorporate the trial of sildenafil nonresponders (see Figure 42), yielded a 2 substantially lower degree of heterogeneity (I = 3. This meta-analysis incorporated data from 10 182,184,189,191,192,194,197,198,201,203 trials. This meta-analysis incorporated the results of nine 182,191,192,194,197,198,200,203,213 trials. This meta-analysis included six trials, 192,194,197,198 184,189,200,201,203 the outcome of dyspepsia was not ascertainable for five trials. Only three trials including diabetic patients were potentially suitable for meta-analysis. Meta-analyses for efficacy outcomes in diabetes patients were not performed in view of missing qualitative or quantitative information. This meta-analysis included results from three 181,204,205 trials of patients with diabetes.

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Acute side effects included grade 3 dermatitis symptoms of high blood pressure purchase 20 mg beloc otc, mucositis, and dysphagia which occurred in 23, 29 and 12 patients respectively. Sixteen patients (32%) required evaluation in an emergency room during treatment with 10 subsequently requiring hospitalization primarily due to dehydration and pain from mucositis. It was noted that patients receiving a G-tube during radiotherapy had significantly longer history of smoking, greater comorbidity, more advanced disease, greater need for bilateral treatment, higher use of induction chemotherapy and concurrent chemotherapy, and a longer duration of treatment. With regards to toxicity, there were no differences in acute toxicity by technique. Sites of treatment included the larynx (1), nasopharynx (5), paranasal sinus (2) and oropharynx (1). At a median follow up of 27 months, four patients (44%) achieved a complete response, four achieved a partial response without disease progression and one developed local progression. With respect to toxicity, four patients experienced grade 3 acute toxicities and one developed a grade 4 toxicity (blindness in the treated eye). This heterogeneous group of patients included 19 receiving treatment at initial diagnosis and seven receiving treatment at recurrence (six of whom had prior radiation and three of whom had pulmonary metastases). Twenty were treated after surgery with 18 of these exhibiting positive margins or gross residual disease. Longer follow-up is needed to gauge the durability of disease control and to monitor for late toxicities of therapy. Sites of treatment included lacrimal gland or sac (5), paranasal sinus (4), parotid gland (4), submandibular gland (2) and buccal mucosa (1). Median dose delivered was 60 Gy with 12 patients receiving concurrent chemotherapy. Four patients developed acute grade 3 toxicity and one patient experienced a grade 4 toxicity (blindness). An additional patient developed asymptomatic frontal lobe necrosis 18 months after treatment completion with near resolution at 24 months. One additional patient refused radiation and chemotherapy after surgery but received stereotactic radiosurgery at the time of recurrence. Patients had stage T1N0 (1), T2N0 (6), T3N0 (1) or T4N0 (3), all without metastases. Primary sites included the lacrimal gland (7), lacrimal sac/nasolacrimal duct (10) or eyelid (3). Seven patients experienced acute grade 3 while 9 patients developed chronic grade 3 ocular or eyelid function toxicity. Bivariate analysis revealed that a dose of 36 Gy or less to the ipsilateral cornea was associated with grade 3 chronic ocular toxicity (p = 0. Additional data are needed to identify which patients are most likely to benefit from aggressive efforts to achieve local disease control and to evaluate the potential benefit of proton therapy relative to other modalities of reirradiation. Page 49 of 272 Lee et al. All plans were calculated to 55 Gy in 25 fractions with equivalent constraints and normalized to prescription dose. Protons also increased generalized equivalent uniform dose to duodenum and stomach, however these differences were small (< 5% and 10%, respectively; p < 0. Doses to other organs at risk were within institutional constraints and placed no obvious limitations on treatment planning. The authors concluded that protons are able to reduce the treated volume receiving low-intermediate doses, however the clinical significance of this remains to be determined. No patient demonstrated any grade 3 toxicity during treatment or during follow up. Chemotherapy was well-tolerated with a median of 99% of the prescribed doses delivered. Median follow up was 14 months for all patients and 23 months for surviving patients. No patient experienced a grade 3 or greater toxicity during treatment or follow up. Grade 2 toxicity was limited to a single patient Page 50 of 272 experiencing grade 2 fatigue. Of the remaining 50 patients, only 78% had surgery, with 16% found to be unresectable, 4% diagnosed with metastases prior to surgery, and 2% diagnosed with cholangiocarcinoma instead of pancreatic cancer. Six of 37 eligible resected patients (16%) experienced locoregional recurrence, while 73% developed distant metastases. The authors concluded that short-course proton-based chemoradiation is well tolerated and is associated with favorable local control in resectable pancreatic cancer (although 16% local failure after surgery and radiation, particularly with such limited follow up and early deaths, is not particularly favorable). Advanced immobilization techniques, such as the use of breath hold gating or targeting with implanted fiducial markers, were not used in this series, and the dose of 67. However, there was no statistical significance between the two groups regarding the median time to progression (15. This especially pertains to targets in the thorax and upper abdomen, including the pancreas, which move as a result of diaphragmatic excursion (Mori and Chen 2008; Mori, Wolfgang, and Lu et al. This could result in unanticipated overdose of normal tissues or under dose of target volumes. Therefore, direct comparative studies will be helpful to determine the relative safety and efficacy of protons relative to customary photon radiation. In addition, there are concerns about proton beam dose distributions in the setting of organ and respiratory motion and tissue differences and interfaces, as are seen in this location. Until such data is published and until there is clear data documenting the clinical outcomes of proton beam therapy in the treatment of cancer of the pancreas, proton beam therapy remains unproven. Seminoma the risks of radiation-induced second malignancy in seminoma are well documented. However, it must be recognized that use of anterior/posterior fields whether 2D or 3D are the very technique which has been the subject of these reports. They found a 19% increase in secondary primary malignancies in seminoma patients exposed to radiation therapy as compared to the general population including pancreas, non-bladder urothelial, bladder, thyroid, and others. An accompanying editorial in the journal noted an increased incidence of seminoma during the last 4 decades with improved survival, which makes the issue of radiation-induced malignancies of increasing concern. They identified risks of lung, bladder, pancreas, stomach, and other organs, noting that secondary primary cancers are a leading cause of death in men with a history of testicular cancer. Patients treated with radiation therapy had the highest risk of developing cancer especially when treated at a young age. Among organs treated in a radiation field, stomach, large bowel, pancreas, and bladder stood out for the development of a later cancer. Given these findings, radiation is no longer used in early seminoma but there remains a population of patients with more advanced disease that may benefit. Although this population of patients is relatively small as 80% of seminoma, totaling approximately 8600 cases a year, is diagnosed in Stage I, the relative doses of radiation and increased field sizes pose a problem. Page 53 of 272 the use of protons brings a distinct advantage in lowering radiation dosed to the population at risk. Therefore, there is concern that this patient population has a longer duration of survival, allowing sufficient time for very late side effects of radiation for curative treatment to emerge and affect quality of life. However, the doses of radiation that are typically delivered for lymphoma are low or moderate compared to most solid tumors, and these doses often do not approach the established tolerance doses for organs at risk in the treated volume. None of these studies has demonstrated a difference in clinical outcomes Page 54 of 272 related to this dosimetric reduction. Much of the experience has been in the pediatric population, and whether extrapolation of this to adult patients is appropriate is not clear. Three year relapse free survival was 93% and no late grade 3 or higher nonhematologic toxicities were noted.

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When selecting medications for treating rhinitis in preg573 sult in both bronchial and nasal infiammatory responses medications education plans generic beloc 20 mg without prescription. However, it is also beneficial to review human cositization to dust mites, a reduced forced expiratory fiow at 25% hort and case-control studies as well as birth registry data to 75% of forced vital capacity may be a marker of early bronbefore reaching a decision. Treatment with intranasal cortiX) were developed to guide the physician in choosing medications costeroids has been shown to prevent the seasonal increase in for which the benefit versus risk ratio can be weighed in an in577,578 formed manner. Treatment of allergic rhinitis with intranasal corticosteroids and birth registry as well as case-control and cohort studies when comcertain second-generation antihistamines may improve asthma paring the available medications and developing a treatment plan. Given the convincing relationship between allergic rhinitis and combined approach. The most critical time for concern about potential congenital who have asthma, it is also imperative that physicians who treat malformation because of medication use is the first trimespatients with asthma also consider aggressive treatment of ter, when organogenesis is occurring. A sufficient amount of human observational data has now Allergen specific subcutaneous immunotherapy has been asbeen accumulated to demonstrate safety for second-genersociated with a reduction in nonspecific bronchial hyperrespon990 ation as well as first-generation antihistamines. Several controlled studies have also reported a reduction in the incidence First-generation antihistamines, such as chlorpheniramine, of asthma in pediatric patients with allergic rhinitis treated with have previously been recommended as first-choice agents because 476,477,579 593 subcutaneous immunotherapy, and this effect appears of their observed safety and longevity of use. However, their to be sustained at least 2 years after discontinuing immunotherundesirable sedative qualities and possible effect on performance 473 475 apy. The American Academy of Pediatrics has not preference will all infiuence the final drug selection. Furthermore, the American Academy of Pediatrics consafety records and do not show a significant increase in congenital cludes that the use of antihistamines and decongestants are inefmalformations when used during the firsttrimester. Although diphenhydramine Rhinitis and otitis are both common childhood diseases, making is often used by pregnant patients and recent studies have not detected the casual association with viruses, bacteria, and allergens difficult any increased risk for congenital malformations, there is still some to establish at times. Eustachian tube dysfunction remains the concern over a case-control study suggesting an association with cleft most common etiology for otitis media. Hydroxyzine gic mediators released after allergen exposure resulting in nasal alshould be used cautiously during the first trimester based on animal lergic infiammation may contribute to the dysfunction of the 594 data. Although there are no reports of increased congenital malforeustachian tube by contributing to eustachian tube edema and inmations with the use of fexofenadine during pregnancy and animal 543,589,590 fiammation. Although under natural circumstances the studies are negative for teratogenicity, no epidemiologic studies in middle ear is not exposed to allergens, measurements of elevated 594 591 592 592 human pregnancy have been published. Oral decongestants should be avoided during the first triProspective studies examining the effect of allergy immunomester. As with all medication use malformations such as gastroschisis and small intestinal atrein pregnancy, intranasal corticosteroids should be tapered to the 594,600 lowest effective dose. The risks of such malformations were increased by combining a decongestant with acetaminophen or salicy600,601 105. Because of these findings, it is generally recommening pregnancy but without dose escalation. Likewise, the data on the safety of topical intranasal Specific allergy immunotherapy for allergic rhinitis may be decongestants during pregnancy have not been studied. Sodium cromolyn is a safe treatment for allergic rhinitis causing systemic reactions. C the patient receives when she becomes pregnant should not be increased and should be adjusted appropriately during pregnancy if For allergic rhinitis during pregnancy, nasal sodium cromolyn, necessary to minimize the chance of inducing a systemic reaction. Unfortunately the need for frequent 4 times a day dosing and reduced relative efficacy compared with other Rhinitis in the elderly agents limits its acceptance by patients. Montelukast is a safe treatment for allergic rhinitis during common in other age groups but may also be infiuenced pregnancy. Montelukast has been recommended for use in 991 pregnancy for asthma management only when there has been a part of the rhinitis practice. Many of the pathological changes 614 in connective tissue and vasculature associated with aging may uniquely favorable prepregnancy response. The same guide616,617 lines would be reasonable for the use of montelukast for rhinitis predispose to rhinitis complaints. These include atrophy in pregnancy management until additional information on efficacy of the collagen fibers and mucosal glands, loss of dermal elastic and safety becomes available. Intranasal corticosteroids may be used in the treatment of sult in drying and increased nasal congestion in some elderly nasal symptoms during pregnancy because of their safety patients. Nasal steClinical and epidemiologic studies on the safety of intranasal roids, however, may be safely used for treatment of allergic corticosteroids for rhinitis in pregnancy are limited. Although rhinitis, because they do not cause any clinical or histologic 618 animal gestational studies have shown risk for all inhaled cortiatrophic changes in the nasal mucosa. Pharmacologic studies show a much lower systemic exposure after intranasal than (orally) inmay be aggravated after eating (gustatory rhinitis), a-adrenergic haled corticosteroids. It is reasonable, therefore, to extrapolate hyperactivity (eg, congestion associated with therapy for hyperthe safety profile of inhaled corticosteroids to intranasal corticotension or benign prostatic hypertrophy), or chronic sinusitis. A recent meta-analysis concluded that the use of orally watery rhinorrhea syndrome frequently responds to intranasal 994 inhaled corticosteroids during pregnancy does not increase the ipratropium bromide. However, ipratropium bromide should risks of major malformations, preterm delivery, low birth weight, be used with caution with pre-existing glaucoma or prostatic 606 hypertrophy. Inhaled or intranasal corticosteroid use in pregnancy has demonstrated no convincing Elderly patients more commonly have more pronounced clear 11,602,607-609 rhinorrhea from cholinergic hyperactivity associated with the evidence of congenital defects using beclomethasone, 603,610 227,611 aging process. Medications taken for unrelated medical problems budesonide, or fiuticasone propionate. Selection safety data on triamcinolone, mometasone, and fiuniso611 of medications for rhinitis treatment should take into account that lide are extremely limited. No substantial difference in efficacy and safety has been shown among the available intranasal corticoelderly patients may be more susceptible to adverse effects of steroids. Thus it would be reasonable to continue any of the intrasome of these medications. If intranasal corticosteroids are begun during pregnancy, intranasal budesonide, which is in 107. Athletic performance can be affected by rhinorrhea and Pregnancy Category B largely on the basis of extensive human chronic or rebound nasal congestion. The decision which intranasal corticosteroid to prescribe often requires a discussion of the benapproved product and should be one that does not adefits and risks with the patient. In fact, the Patients with rhinitis under the care of primary care physicians of622 majority of all individuals, allergic and nonallergic, report nasal ten desire more education about their disease. Allergists/immusymptoms, especially rhinorrhea, with both outdoor (56%) and nologists have familiarity with the wide variety of aeroallergens 623,624 indoor (61%) exercise, but this rate is higher in patients with and have the expertise to provide avoidance education. Furthermore this They provide expertise in the interpretation of the clinical history exercise-induced rhinitis adversely affects athletic performance and diagnostic studies pertaining to upper and lower airway con69 623,624 in athletes with allergy (53%) and without allergy (28%). Allergen immunotherapy, as offered by allergists/ Among elite athletes, endurance athletes report a higher freimmunologists, effectively treats allergic rhinitis with clinical quency of physician-diagnosed allergic rhinitis and use of antialbenefits that may be sustained for years after discontinuation of 995 51,466,467,997 lergic medications. In normal exercise situations, nasal vasoconstriction ongoing allergist/immunologist treatment, others may require and decreased nasal resistance develop and persist for about only 1 or a few consultation visits, and/or cotreatment with the 1 hour. Athletes, especially long-distance runners, cyclists, or primary care physician with periodic follow-up care. A detailed listing of reasons Prescription of medication for the competitive athlete should be for consultation with an allergist/immunologist that may be 180 based on 2 important principles: no medication given to the athprovided as a guide for primary care physicians is detailed in lete should be on any list of doping products and should be apBox 6. Comorbid conditions nasal corticosteroids are allowed but that all decongestants are i. Recurrent sinusitis phenylephrine and imidazole preparations (ie, oxymetazoline iii. Ability to function on physical performance may occur in the athlete with rhinitis c. Associated with adverse reactions ation of these issues, the optimal therapy for the athlete with iii. Unacceptable for chronic use by patient choice, such symptomatic allergic rhinitis consists of aggressive allergen as cost or concern with long-term side effects avoidance frequently in combination with a second-generation H1-antihistamines and/or intranasal corticosteroids. Patients with allergic rhinitis, children, and possibly adults, cromolyn may be useful 30 minutes before commencing a being considered for allergy immunotherapy as a means of competition likely to be associated with high allergen exposure. Referral rationale and evidence level Allergist/immunologist consultation and referral guidelines 1. Direct evidence d Allergist/immunologist care for rhinitis is associated with 108. Consultation with an allergist/immunologist should be conclinical history and allergy diagnostic test results in upper sidered for patients with rhinitis who have inadequately 624 and lower airways conditions. Certain aspects of allergy in children: a critical review of the recent litin children with allergic rhinitis.

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The earlier (more than 50 years ago) history of the use of radiation therapy to treat noncancerous conditions is also very rich medicine expiration generic beloc 40mg without prescription, but precedes the overview below. Additional information regarding specific disorders may also be obtained from subscription services such as the Cochrane Review and UpToDate. No subsequent modern era radiation oncology review supports the use of ionizing radiation in the treatment of acne. Improved alternative treatments Page 163 of 272 and the risk of radiation-induced cancer render its use obsolete for the treatment of acne. Acoustic neuroma (vestibular schwannoma) these benign tumors of Schwann cell origin are relatively common and vary in presentation. Bulky, fast-growing tumors, especially those causing brainstem compression, most commonly are approached surgically. Factors that influence patient selection include symptoms such as hearing loss, status of hearing in the contralateral ear, age and life expectancy, tumor size and rate of growth, patient preference, comorbidities, and availability of therapeutic options. Adamantinoma (ameloblastoma) these rare, locally aggressive but usually histologically benign tumors are of epithelial origin and are most commonly of jaw or tibial location. The etiology of epithelial tissue in an unusual location is the subject of debate. The use of radiation is reported historically as beneficial, but with little evidence. The 2002 text by Order and Donaldson supplies several references, each with few cases to report, and mainly of mandible or maxillary origin. Amyloidosis There is only an occasional case report of the use of ionizing radiation therapy in the treatment of amyloidosis. Aneurysmal bone cyst these are relatively rare and benign osteolytic lesions of bone usually occurring in children or young adults. They are not true neoplasms, rather are a hyperplasia filled with blood-filled channels. Because of the availability of alternative therapy and the typically young age of patients, the use of ionizing radiation is a last resort. Radiation therapy is medically necessary only if accompanied by documentation that its use is considered essential by a multi-disciplinary team. Angiofibroma of nasopharynx (juvenile nasopharyngeal angiofibroma) While optimum management is controversial, there is general agreement that surgery is preferred if considered safe, as in cases when there is no extension into the orbital apex or base of skull. Since the typical patient is young, regard for the long-term hazard of radiation is important. When radiation is used, the radiation dose is lower than in malignant tumors of the same location. Policy: Radiation therapy is medically necessary in those cases with extension into the orbital apex or base of skull. Angiomatosis retinae (von Hippel Lindau syndrome) Capillary hemangiomas associated with von Hippel Lindau syndrome may be single or multiple, and can severely affect vision. Ankylosing spondylitis the use of radiation therapy in the treatment of ankylosing spondylitis is of historical interest. The risk of radiation-induced cancer and other morbidity contraindicates its use and is often cited as a common example of radiation carcinogenesis in radiobiological studies. Anovulation the use of radiation therapy in the treatment of anovulation is of historical interest only and is occasionally discussed in the treatment of functional pituitary adenomas. Arachnoiditis In the pre-antibiotic era the beneficial use of radiation for the treatment of arachnoiditis was described. Resolution is slow and may take years, during which the risk of hemorrhage is not eliminated. Arthritis (see total lymphoid irradiation for radioimmunosuppression) (see rheumatoid arthritis) (see osteoarthritis) N. Basalioma this synonym for basal cell carcinoma of the skin is sometimes included in lists of "benign" disorders of skin suitable for treatment with radiation therapy. It can be mistaken for other disorders because of the features it shares with psoriasis and eczema. Bronchial adenoma this term in the past has lumped together a variety of tumors arising from the mucous glands of the tracheobronchial tree including carcinoid, cylindroma, and mucoepidermoid carcinoma. The presentation and behavior ranges from truly benign to aggressive with metastatic potential. Surgical resection has historically been the treatment of choice with radiation reserved for technically or medically inoperable cases. Precise histologic classification may help discriminate those truly benign lesions that would not be expected to benefit from radiation therapy from lesions that would be best treated as invasive carcinomas. Bursitis, synovitis, and tendinitis Randomized studies in 1952, 1970, and 1975 cited in the Order and Donaldson review claimed "no benefit" to the use of radiation therapy for any of these, and the authors of the review recommend against its use. Department of Health, Education, and Welfare survey report of 1977 reporting the results of a survey of American radiation oncologists included these diagnoses as acceptable for treatment, as did the German survey of 2008. There is support in modern era texts, concluding that the use of radiation "may provide an alternative to conventional conservative treatment for patients who are not surgical candidates" (PerezBrady). Typical treatment is with photon beam therapy using, at most, complex treatment planning in five or fewer fractions. For those unresectable non-secretory lesions causing symptoms such as pain, radiation may be beneficial. For secreting tumors, radiation therapy is limited to those causing symptoms that are not controllable by medical means. The relationship to subsequent malignant lymphoma is unclear, with malignant lymphoma reported in as many as 30% of cases. Synonyms include giant follicular lymph node hyperplasia, follicular lymphoreticuloma, angiomatous lymphoid hamartoma, and giant benign lymphoma. Low dose radiation therapy has been reported as effective in refractory or relapsed cases if further use of steroids is contraindicated. Castration There is evidence that with sufficient dose radiation can effectively and permanently cease gamete production and hormone production in the testes and ovaries. Surveys reported by Order and Donaldson (1998) indicated 75% of surveyed radiation oncologists would use radiation for this purpose with the appropriate indication. Department of Health, Education, and Welfare survey report of 1977 included castration as an acceptable indication. The availability of drugs which achieve the same result has largely rendered this as obsolete. Policy: Cases will require medical review and documentation that no other reasonable alternative exists. Chemodectoma (carotid body, glomus jugulare, aortic body, glomus vagale, glomus tympanicum) (chromaffin negative) Chemodectoma is a general term that includes many specific types based on the location of the body in which they arise. These are chromaffin-negative, benign tumors that can arise in the chemoreceptor system, such as the aortic body; carotid body; glomus jugulare; and tympanic body. It is generally accepted that radiation therapy, with or without surgical resection, is medically necessary, with a significant probability of control. These tumors of notochord origin can be benign or malignant, but all tend to be locally invasive and tend to recur locally, some with the potential to metastasize. Surgery is the primary approach, but is often inadequate to control the primary tumor. Postoperative radiation therapy, and radiation therapy for inoperable lesions, is considered medically necessary. Adjuvant radiation is not indicated unless there is progression that cannot be dealt with surgically. Choroidal Hemangioma these are rare vascular tumors and may be circumscribed or diffuse, the latter associated with Sturge-Weber syndrome. Typically, radiation therapy is given using complex or three dimensional conformal external photon beam technique, or using low dose rate brachytherapy plaque. Corneal Vascularization Radiation therapy is not indicated in the treatment of corneal neovascularization. Corneal xanthogranuloma Corneal xanthogranulomas may develop in association with generalized juvenile xanthogranuloma and generalized histiocytosis.

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Signs of Infection Signs of wound infection include redness medicine checker buy 40 mg beloc overnight delivery, warmth, swelling, and tenderness in the tissues around the wound. A green, somewhat sweet-smelling, creamy material is a sign of colonization by Pseudomonas bacteria. You may start with a dressing regimen of antibiotic ointment covered with dry gauze. At this point you should change to a wet-to-dry dressing and observe how the wound progresses. Once the wound has improved in appearance, you can go back to the antibiotic ointment or continue with the wet-to-dry dressings. Duration of Wound Dressing the dressings should be continued until the wound heals. Often during the course of secondary healing, the wound develops a dry eschar (scab). If the wound is near a crease, encourage the patient to exercise the area to prevent formation of a tight scar. Whenever possible and practical, primary closure is the best way to close an acute open wound. Contraindications to Primary Wound Closure Concern about wound infection is the main reason not to close a wound primarily. If infection develops, the resultant deformity may be worse than that caused by the initial injury alone. Anesthetize the Area Before Suturing If local anesthetic was administered for wound cleansing, check to ensure that the anesthesia is still effective. Pinch the tissues with your forceps, or gently touch the skin edges with a needle. With adequate anesthesia, the patient may still feel a sensation of pressure when you pinch the tissues with the forceps, but it should not hurt. For wounds of the face or scalp, the addition of epinephrine decreases bleeding caused by the placement of sutures. The larger the number, the smaller the needle: a 25-gauge needle is much smaller than an 18-gauge needle. If the tissues are dirty, however, inject into the skin surrounding the wound to prevent foreign material from being pushed into the uninjured surrounding tissues. Primary Wound Closure 93 How to Suture the Wound Most wounds can be closed by suturing the skin edges together. Suture Size On the Face Small sutures such as 5-0 or 6-0 should be used to repair facial lacerations. Nonabsorbable Sutures For most skin suturing, nonabsorbable sutures are best because they are associated with less noticeable scarring. Exceptions include patients who cannot return for suture removal, children (because of the difficulty in removing sutures from a frightened, crying child), and some facial lacerations. Continuous Closure In an interrupted closure, you tie the suture once it has passed through each side of the wound. In a continuous closure, you place the sutures one right after the other without tying each suture individually. In a relatively simple laceration with smooth edges that line up easily, it makes no difference which method you choose. On the average, a continuous closure is faster to perform, but you should choose the method with which you are most comfortable. In a laceration with irregular edges, an interrupted closure is preferred because it allows better alignment of the tissues. If you have any concern that the wound may become infected, it is better to do an interrupted closure. If an area of the wound begins to look inflamed, the sutures in that area can be removed and the other sutures left in place. By removing a few sutures and placing the patient on oral antibiotics, you may be able to treat the infection adequately without having to reopen the entire wound. Simple Skin Closure Although most wounds require only skin closure, sometimes it is necessary to close the wound in layers. The layers may involve muscle, fascia (the layer of connective tissue that overlies the muscle and is actually quite strong), or dermis, depending on the particular wound. If the muscle or fascia is widely separated, a few absorbable sutures can be placed in a figure-of-eight fashion to bring the tissues together. Primary Wound Closure 95 If the wound is widely separated or the closure will be under some tension, a few buried dermal sutures are useful. Such sutures are placed in the skin layer just below the epidermis and should be made of an absorbable material. After suturing the wound closed, apply a small amount of antibiotic ointment over the suture line and cover the area with a dry gauze. The patient can wash the area with gentle soap and water the day after the repair. A shower is fine, but if the patient wants to take a bath, the injured area should not be allowed to soak in the water for more than a few minutes. A small amount of antibiotic ointment can be applied daily for the first few days; then leave the area open to air. If the injured area is on the hand, foot, or calf, have the patient elevate the affected extremity. To help maintain the wound closure, it is useful to place Steristrips (if available) across the scar once the sutures have been removed. These strips fall off on their own, and the patient can wash the area, even with the strips in place. What to Do if the Suture Line Becomes Red If the suture puncture sites start to become red and irritated-looking but the surrounding skin area is not tender or red, simply remove the sutures. This reaction probably represents nothing more than inflammation and irritation from the sutures. Try to express any underlying fluid or pus, and clean the area with saline or other antibacterial solution. If you cannot fully drain the underlying fluid or fully cleanse the area by taking out a few sutures, all of the sutures should be removed, the wound opened, and the area treated with wet-dry dressings. Delayed Primary Closure Delayed primary closure is a compromise between primary repair and allowing an acute wound to heal secondarily. This option may be considered for a wound with characteristics that require secondary closure. During the few days of dressing changes, the reasons for not closing the wound initially may resolve.

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The most common tumor in the parotid gland is benign and is a medicine norco buy beloc 20 mg on line. Treatment of most parotid tumors includes with 96 dissection and preservation of the facial nerve. They are most frequently benign and so common, particularly with advancing age, as to preclude biopsy and removal in every patient who presents with nodules. However, otolaryngologists ofen recommend and perform removal of nodules that have a reasonable risk of being cancerous, as determined by multiple factors that include those discussed below. Risk factors for malignant thyroid nodules are based on gender, age, early radiation exposure, and family history of thyroid cancer. While thyroid nodules are much more common in women than in men, a nodule in a male has a higher risk of being cancerous than a nodule in a female. In addition, larger nodules and nodules that demonstrate growth are more commonly malignant. This may be performed with or without ultrasound guidance, depending on the size and location of the lesion. While cytopathologic interpretation has improved, a clear diagnosis for malignancy is not always achieved. Certainly, any evidence of thyroid cancer in the neck nodes is an indication for total thyroidectomy and appropriate neck dissection. Remember, that absent any risk factors, there is a high degree of probability that the nodule is benign. When multiple nodules are found, the thyroid is classifed as a multinodular 99 thyroid or goiter, and only the dominant or largest nodules are biopsied. Radionuclide thyroid scans have become less essential to the diagnostic workup of nodules with the development and refnement of ultrasound and fne-needle aspiration techniques. Forms of Thyroid Cancer Tere are two essential classifcations of thyroid cancer: well diferentiated and other. Papillary Carcinoma Approximately 80 percent of thyroid cancers are papillary histologically. Tese may have a follicular component, but any amount of papillary component means the tumor will behave more like a papillary tumor. Tese tumors can be multifocal in the gland and ofen metastasize to neck lymph nodes. For unknown reasons, this disease follows a much more indolent course when discovered in people under age 40. However, while papillary carcinoma patients under 40 years of age ultimately live longer, they also experience a higher rate of recurrence. Historically, a total thyroid lobectomy and isthmectomy have been used to treat smaller papillary thyroid cancers (<1 cm). More recently, the trend has been toward total thyroidectomy in patients with nodules containing papillary thyroid cancers. Newer evidence from a study by Mazzaferri and colleagues suggests that total thyroidectomy, when compared to subtotal, may signifcantly decrease the local recurrence rate (18% versus 7%), and ultimately the number of deaths (from 1. However, 100 there was no diference in the number of deaths between these two groups. As mentioned earlier, if cervical metastatic thyroid cancer is present, a modifed or selective neck dissection is indicated, depending on the location of the disease. The greatest risks of thyroid surgery are hypoparathyroidism secondary to injury or removal of the parathyroid glands, and recurrent laryngeal nerve injury, which may result in hoarseness, shortness of breath, and reduced exercise tolerance. Follicular Carcinoma Approximately 15 percent of thyroid cancers is the follicular cell type. The surgical specimen of all thyroid cancers must be sectioned completely to determine if the tumor capsule and/or lymphatic and blood vessels are invaded. The fndings of capsular and/or lymphovascular invasion are essential for diagnosis and cannot be determined by a fne-needle aspirate. A variant is Hurthle cell carcinoma, which is a more aggressive form of follicular thyroid cancer and is marked by a high frequency (75% or more) of Hurthle cells. Like papillary carcinoma, follicular carcinoma has an afnity for radioactive iodine. Since iodine is concentrated in normal thyroid tissue, an attempt to remove all thyroid tissue allows a higher dose to be delivered to 1 Mazzaferri, E. A vision for the surgical management of papillary thyroid carcinoma: extensive lymph node compartmental dissections and selective use of radioiodine. Terefore, total thyroidectomy is the treatment of choice for follicular thyroid cancer. In either case, the parafollicular or C-cells are the cells of origin, and the tumor tends to be bilateral. All patients with medullary carcinoma should get a urinary metanephrine screen to determine whether there is an increase in circulating catecholamines. If this test is positive, the pheochromocytoma should be located and excised frst. All frst-degree relatives of patients with medullary carcinoma should be tested for calcitonin levels. However, most surgeons elect to perform a total thyroidectomy with paratracheal, central compartment neck dissections. In patients with a neck mass, a modifed neck dissection that encompasses all the involved levels of disease should be performed. In patients with the familial form, only abnormal parathyroid glands should be removed, but a total thyroidectomy is always indicated. Tyroid C-cells do not absorb radioactive iodine, so this common modality of adjuvant treatment in well-diferentiated thyroid cancers is seldom efective. Anaplastic Carcinoma Anaplastic thyroid cancer is a rare, aggressive cancer with a very poor prognosis. The role of the surgeon is ofen limited to establishing diagnosis through open biopsy and securing the airway, which usually involves a tracheotomy. Tese tumors are rarely resectable, and are ofen treated with external beam radiation and systemic chemotherapy, since 50 percent of patients will have pulmonary metastases at the time of diagnosis. A rapid diagnosis and institution of appropriate therapy are necessary to prevent airway obstruction. Treatment and cure are usually achieved by using a combination of chemotherapy and radiation. This brief discussion on thyroid cancer does not include a discourse on surgery of the thyroid gland. Tese conditions can also be treated medically using radioactive iodine-131, but further discussion is beyond the scope of this book. The frst step in the diagnostic evaluation of a thyroid nodule afer the history and physical is usually. In this chapter we will provide background information about the disease, informa105 tion on diagnosis and management, and a few case studies. Tese will help you understand how to integrate information and treatment modalities to afect a successful, modern approach to head and neck cancer.

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Foreign Material in the Depths of the Wound A foreign body in the depths of a wound may prevent healing 4 medications buy 20mg beloc with visa. Foreign material such as glass, wood, or metal fragments can cause an inflammatory reaction in the tissues that will not resolve until the foreign material is removed. The history often provides information that leads you to suspect that foreign materials may be the problem. Often foreign material is removed with overlying dead tissue during surgical debridement, allowing the wound to heal with dressing changes. Infection If signs of surrounding soft tissue infection (redness, warmth, pain, swelling) are present, oral or intravenous antibiotics should be given. The presence of an open wound, in and of itself, does not necessitate oral or intravenous antibiotic administration. Infection of the underlying bone (chronic osteomyelitis) may cause a chronic nonhealing wound. An x-ray may show irregularity in the periosteum (the thin layer of connective tissue around the bone), and signs of bone destruction may be seen. Chronic Wounds 175 Infection of the bone often requires at least 6 weeks of antibiotics. Tobacco Tobacco use interferes with wound healing through a combination of two mechanisms: 1. The vasoconstrictive effects of nicotine decrease local blood circulation to the skin. Thus, less blood and oxygen (and other factors that promote healing) reach the wound. The carbon monoxide present in tobacco smoke further decreases oxygen delivery to the tissues because carbon monoxide decreases the ability of hemoglobin to release oxygen to the tissues. All patients should be counseled not to smoke, especially patients with open wounds. Cancer In a long-standing wound that looks clean but still will not heal, the wound may be harboring an underlying cancer. The tissues around the wound edges may be raised and highly irregular, and irregular red patches may be seen in the surrounding skin. The concern about an underlying cancer is especially applicable in chronic wounds in elderly patients and on sun-exposed areas of the body. Cancer of the breast and soft tissue sarcomas can erode through the skin to create a chronic open wound. Usually, these two types of cancer are associated with a large soft tissue mass underlying the wound. In larger wounds, an incisional biopsy should be done to get a preliminary diagnosis, which helps to plan the definitive resection. An adequate diet supplying the proper amount of calories and protein on a daily basis is very important. The importance of nutritional factors in wound healing is illustrated by the fact that elective surgery often is contraindicated in patients without adequate protein stores. How to Assess Nutritional Status the liver produces various proteins that have been found to correlate well with nutritional status. Although albumin does not correlate with nutritional status as well as the other two, measurement of serum albumin is helpful if the more expensive tests for prealbumin and transferrin are unavailable. In adequately nourished patients, however, extra doses of these nutrients are not necessarily useful. As stated below in the discussion of radiation, vitamin E may be useful in a wound exposed to radiation. However, high doses of vitamin E interfere with normal wound healing in patients without a deficiency. Although nutritional supplements may be required in severely malnourished patients, nutritional counseling may be all that is needed for most patients. Nutritional supplements, such as high protein/calorie drinks/puddings, are often quite expensive and unnecessary. For this reason, patients with diabetes must watch their diet and regularly check glucose levels. High glucose levels should be treated with the appropriate medications (insulin or an oral agent) to maintain the best possible blood glucose control. Chronic Wounds 177 Medications Ask all patients about use of prescription and over-the-counter medications. Several classes of medications interfere with wound healing: Steroids Steroids significantly interfere with normal wound healing. Radiation Injury the patient may give a history of previous radiation therapy to the area around the wound. Radiation damages the ability of the tissues to promote new blood vessel growth as well as interferes with cellular functions necessary for wound healing. These effects are not reversible once the radiation exposure has been completed and in fact may worsen with time. Because of these effects, a seemingly minor injury in an area that previously received radiation may result in a chronic, open wound. Vitamin E has been shown to improve wound strength in areas exposed to radiation. Often the entire wound may need to be excised to remove the damaged, radiated tissue. Especially if no reconstructive specialists are available, try local wound care for a few weeks after excision to see whether the wound begins to heal. If this treatment is unsuccessful, a split-thickness skin graft or, more likely, a flap may be required for wound closure. Specific Problematic Wounds Leg Ulcers Leg ulcers usually are caused by problems in either the arterial circulation or the venous circulation (or sometimes a combination of the two). If you cannot feel the dorsalis pedis artery (on the top of the foot) or the posterior tibial artery (behind the medial malleolus), the patient probably has a problem in the arterial circulation. Even if you cannot feel a pulse in the foot vessels, blood flow to the foot may be sufficient to allow a properly treated wound to heal. Absence of a pulse, however, does indicate that the vessels are significantly diseased. There are many high-tech ways to examine the patency of the blood vessels of the legs. Measure the systolic blood pressure in the foot and divide this number by the systolic blood pressure in the arm (at the brachial artery, the usual place to check blood pressure). Healing probably will not occur unless a vascular bypass is done to bring more blood into the lower extremity. Venous Insufficiency Ulcers due to problems with the venous circulation tend to be on the lateral side of the ankle or lower calf. The foot, ankle, or calf around the wound is often chronically swollen, and obvious skin changes are present. Skin changes include woody induration (the skin feels very hard) and brawny discoloration. Chronic Wounds 179 Combination Arterial and Venous Insufficiency Unfortunately, many patients with leg ulcers do not have purely arterial or purely venous problems. Although we try to avoid amputation, sometimes it is the only successful treatment option. If no one with vascular surgical expertise is available, it is worth trying local wound care to see if the wound improves. If this attempt is unsuccessful, amputation may be the only way to obtain a closed wound. If the cause is venous insufficiency: An important component of treatment is to decrease the swelling in the foot or calf: 1. When the patient is seated, the foot should be propped on a stool so that it does not dangle dependently. The patient also should wrap the leg with Ace wraps or wear support stockings to improve blood flow through the veins and out the lower leg. It should be tighter at the toe than at the ankle and tighter at the ankle than at the calf.

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Lesions located in the inspection of the pelvic cavity has been used rather frepouch of Douglas may provoke firm adhesions between quently in recent years to verify the diagnosis and to the anterior wall of the rectum and the posterior vaginal evaluate the extent of the lesions medications herpes buy beloc paypal. Acute pain episodes in wall; this location may cause pain on defecation during the right iliac fossa due to endometriosis may be mismenstruation. Recurrent episodes of lower abfixed uterine retroversion due to endometriotic adhedominal pain, tenderness, and a slight fever may sions frequently cause deep dyspareunia. Endometriotic erroneously be taken for recurrent pelvic inflammatory foci that penetrate into or through the bladder wall may disease. Treatment Treatment of endometriosis will be hormonal or surgical Signs or combined. It will vary depending on age of the paOn pelvic examination a fixed painful retroversion may tient, stage of the disease, and the main presenting probbe found, or tender, enlarged, adherent adnexa on one or lem-pain or infertility or both. Small, tender nodular lesions, which are freconsists of cyclic estroprogestogens or in the continuous quently palpated either in a sacro-uterine ligament or on daily administration of oral progestogens, for example, the posterior surface of the uterus, are almost pathognoLynestrenol or norethisterone acetate. During recent years excellent results have been obtained by the continuous oral administration of Danazol, a strong antigoPage 168 nadotropin and mild androgenic drug. In these circumstances treatment with broad will, depending on the indication and the stage of the spectrum antibiotics and local heat is indicated. If the disease, consist of conservative surgery preferably by pain disappears, this confirms the diagnosis. If the pain microsurgical techniques, or semiradical or radical surand the parametrial tenderness persist, another cause of gery, i. Definition Main Features Pain with low grade infection of parametrial tissues, Prevalence: genital tuberculosis has become quite unespecially the posterior parametrium. Synonyms: pelvic common in most developed countries thanks to the lymphangitis, chronic parametrial cellulitis. It remains a problem in many less developed countries System where pulmonary tuberculosis is still widely prevalent. Symptoms: the most frequent symptoms are sterility, pelvic pain, poor general condition, and menstrual disMain Features turbances. Genital tuberculosis presents under two Site: Lower abdomen, sometimes the back also. In the silent lence: Because histological proof of the diagnosis is forms there are no particular symptoms; there is no pain usually missing, the prevalence is unknown, but the and no fever. It may be found soon general symptoms and signs of the tuberculous process, after a delivery, especially if the cervix has been torn menoor metrorrhagias, sometimes amenorrhea. In the active cases there is usually abdominal pain with or without low backache, and deep pyrexia, weight loss, and night sweats. The pain may occur during the premenstrual period and disappear durSigns ing menstruation, or it may be continuous, with premenOn pelvic examination a fixed retroversion with palpable strual exacerbation. Spontaneous pain and dysmenorrhea may be explained by a pyoor hySigns drosalpinx or by a tuberculous pelvioperitonitis. A more or less severely torn cervix is found and either Dyspareunia may be due to a fixed retroversion or to an acute or a chronic cervicitis. Usual Course Pathology the tuberculous process may become latent or may heal Posterior parametritis on chronic cervicitis is believed to spontaneously. It may, on the other hand, evolve towards be due to extension of a cervical infection along the a pyosalpinx or an ovarian abscess or to a tuberculous lymphatics of the parametrium. Diagnostic Criteria Diagnostic Criteria and Treatment In advanced cases general symptoms and signs of the Diagnosis of cervicitis depends on finding agglutinated tuberculous process, abdominal pain or discomfort, signs leukocytes in the cervical mucus during the periovulaof a pelvic infection, together with a positive tuberculin tory period. The presence of an infected cervical canal test and bacteriological evidence of tuberculosis constiand of a tender posterior parametrium and the absence of tute the basis of the diagnosis. Tubercle bacilli may be a history and of clinical findings suggestive of endomecultured either from menstrual blood or from an endotriosis make the diagnosis of posterior parametritis plaumetrial biopsy, taken preferably in the premenstrual Page 169 phase. Silent cases are usually diagnosed by the presence metriosis or posterior parametritis on a chronic cerof tubercular lesions in an endometrial biopsy taken durvicitis, and if the pain disappears after anterior reposition ing the evaluation of infertility cases. If a patient with a Treatment fixed retroversion complains of some symptoms, it is Treatment is essentially medical by means of a comusually impossible to prove which symptoms are due to bined drug regimen with Rifamycin, isoniazid, and the retroversion and which are not. It should last for a minimum of 18 months therefore be directed against the causal disorder, which to two years. Surgery will be resorted to only if pelvic may be either endometriosis or sequelae of acute pelvic masses persist or increase under medical treatment, if inflammatory disease or of a pelvioperitonitis, or a tuendometrial lesions persist, and if pain or other pelvic berculous salpingitis. If the patient complains of pain, reposition of the uterus will be tried and a pessary inReference serted. If it does, operative correction of the retroversion may be underDefinition taken. If the retroversion is fixed, treatment must be directed Main Features against the causal condition and a suspension operation Retroversion of the uterus is found in 15 to 20% of adult should be performed only when the retroversion itself is women, but only a small number of mobile retroversions probably the cause of the complaint, as in some cases of cause symptoms. In a few cases it may give rise to indyspareunia, or when there are other reasons for surgical termittent pain with or without deep dyspareunia. The pain usually Code is worse during the premenstrual period and mostly dis765. The symptomaexamination the retroverted uterus is tender and fretology of uterine retroversion and, in particular, pain in uterine quently slightly enlarged and softer than normal. Pathology It has repeatedly been observed that the size of a painful retroverted uterus diminishes and that it becomes firmer after anterior reposition. These circumstances seem to indicate that Lower abdominal pain due to an ovarian lesion. Main Features: lower abdominal pain due to recurrent painful functional cysts is sometimes, although rarely, Diagnostic Criteria seen in young women. If roversion is said to be fixed when adhesions bind the the result of this examination is compatible with a funcuterine corpus down in the pouch of Douglas. A mobile tional cyst, it is recommended to treat it conservatively retroversion should be considered the cause of the pain by means of oral contraceptives. There is a good chance only if no other causes of pain are found, such as endothat the cyst and the pain will disappear, whereas surgical exploration with wedge resection of the ovary is Page 170 likely to be followed by a recurrence of the cyst and of gynecological pain; and (3) if the syndrome is not due to the painful episode. The lower abdomiadhesions, active rests of ovarian tissue may cause a nal pain may be felt either in the whole lower abdomen painful condition called the ovarian remnant syndrome. The low Diagnostic Criteria: an ovarian remnant will be susback pain may be felt over the whole width of the sacropected when the patient presents evidence of estrogen gluteal zone or over a part of this zone. The pain is ususecretion that persists after a short course of corticoids ally more severe for several days before menstruation, prescribed to suppress adrenal androstenedione secretion and its intensity decreases on the first or second day of and its peripheral conversion to estrone. When a chronic pelvic pain syndrome has lasted for several months and Code has not been cured by medical treatment, it is useful to 764. X7b perform a laparoscopy in order to look for nonpalpable References lesions, such as endometriosis or sequelae of chronic Stone, S. Definition Chronic or recurrent pelvic pain that has apparently a Pathology gynecological origin but for which no definite lesion or Besides lower abdominal pain with or without sacrocause is found. During the last decades various conditions have been suspected as posMain Features sible causes. It has been thought that in a percentage of Chronic pelvic pain without obvious pathology is the cases the syndrome is due to traumatic laceration of a name given recently to a syndrome that has been known sacrouterine ligament or of a posterior leaf of one or and described for more than a century under many difboth broad ligaments. It seems, however, that the role of ferent names, some of them being: parametropathia those tears is negligible. Prevalence: There is good indirect evidence that circulatory factors this syndrome is rather uncommon. Until 20-30 years may give rise to chronic or intermittent lower abdominal ago, it was considered rather common, but the diagnosis pain. Pelvic varicosities are likely to be the that a total hysterectomy is not an effective treatment in major cause of the pain. All those who studied the psychological References characteristics of these patients found definite psychoBeard, R. Physiolplaints will, to a large extent, have a psychological exogic basis and history of the concept, Am. The rior parametrium and, less often, uterine cramps or a real clinical aspects of the congestion-fibrosis syndrome, Am. If the iliohypogastric nerve Testicular Pain is damaged, the lower abdominal skin reflex may be absent. Typically, with involvement of the genital Definition branch of the genito-femoral nerve in man, the cremaster Burning or lancinating or other pain syndrome due to reflex is absent on the affected side.