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7.A urethral diverticula is usually identified as a distal
bulge under the urethra. Gentle massage of the area
will frequently produce a purulent discharge from the
urethral meatus.
8.Testing for stress incontinence is performed by
asking the patient to cough vigorously while the
examiner watches for leakage of urine.
9.While performing the bimanual examination, levator
ani muscle function can be evaluated by asking the
patient to tighten her  vaginal muscles and hold the
contraction as long as possible. It is normal for a
woman to be able to hold such a contraction for five to
10 seconds. The bimanual examination should also
include a rectal examination to assess anal sphincter
tone, fecal impaction, occult blood, or rectal lesions.
III.Treatment of urinary incontinence
A.Rehabilitation of the pelvic floor muscles is the common
goal of treatments through the use of pelvic muscle
exercises (Kegel's exercises), weighted vaginal cones and
pelvic floor electrical stimulation.
B.A set of specially designed vaginal weights can be used
as mechanical biofeedback to augment pelvic muscle
exercises. The weights are held inside the vagina by
contracting the pelvic muscles for 15 minutes at a time.
C.Pelvic floor electrical stimulation with a vaginal or anal
probe produces a contraction of the levator ani muscle.
Cure or improvement in 48 percent of treated patients,
compared with 13 percent of control subjects.
D.Occlusive devices, such as pessaries, can mimic the
effects of a retropubic urethropexy. A properly fitted
pessary prevents urine loss during vigorous coughing in
the standing position with a full bladder.
E.Medications such as estrogens and alpha-adrenergic
drugs may also be effective in treating women with stress
incontinence. Stress incontinence may be treated with
localized estrogen replacement therapy (ERT). Localized
ERT can be given in the form of estrogen cream or an
estradiol-impregnated vaginal ring (Estring).
Medications Used to Treat Urinary Incontinence
Drug Dosage
Stress Incontinence
Pseudoephedrine (Sudafed) 15 to 30 mg, three times
daily
Vaginal estrogen ring Insert into vagina every
(Estring) three months.
Vaginal estrogen cream 0.5 g, apply in vagina every
night
Overactive bladder
Oxybutynin transdermal 39 cm2 patch 2 times/week
(Oxytrol)
Oxybutynin ER (Ditropan 5 to 15 mg, every morning
XL)
Tolterodine LA (Detrol LA) 2-4 mg qd
Generic oxybutynin 2.5 to 10 mg, two to four
times daily
Tolterodine (Detrol) 1 to 2 mg, two times daily
Imipramine (Tofranil) 10 to 75 mg, every night
Dicyclomine (Bentyl) 10 to 20 mg, four times daily
Hyoscyamine (Cystospaz) 0.375 mg, two times daily
F.Alpha-adrenergic drugs such as pseudoephedrine
improve stress incontinence by increase resting urethral
tone. These drugs cause subjective improvement in 20 to
60 percent of patients.
G.Surgery to correct genuine stress incontinence is a
viable option for most patients. Retropubic urethropexies
(ie, Burch laparoscopic and Marshall-Marchetti-Krantz
[MMK] procedures) and suburethral slings have long-term
success rates consistently reported in the 80 to 96 percent
range.
H.Another minimally invasive procedure for the treatment
of stress incontinence caused by intrinsic sphincter
deficiency is periurethral injection.
I.Overactive bladder
1.Behavioral therapy, in the form of bladder retraining
and biofeedback, seeks to reestablish cortical control
of the bladder by having the patient ignore urgency and
void only in response to cortical signals during waking
hours.
2.Pharmacologic agents may be given empirically to
women with symptoms of overactive bladder.
Tolterodine (Detrol) and extended-release oxybutynin
chloride (Ditropan XL) have largely replaced generic
oxybutynin as a first-line treatment option for overactive
bladder because of favorable side effect profiles.
Oxybutynin transdermal may cause less dry mouth than
the oral formulation.
3.ERT is also an effective treatment for women with
overactive bladder. Even in patients taking systemic
estrogen, localized ERT (ie, estradiol-impregnated
vaginal ring) may increase inadequate estrogen levels
and decrease the symptoms associated with overactive
bladder.
4.Pelvic floor electrical stimulation is also effective in
treating women with overactive bladder. Pelvic floor
electrical stimulation results in a 50 percent cure rate
of detrusor instability.
5.Neuromodulation of the sacral nerve roots through
electrodes implanted in the sacral foramina is a
promising new surgical treatment that has been found
to be effective in the treatment of urge incontinence.
6.The FDA has recently approved extracorporeal
magnetic innervation, a noninvasive procedure for the
treatment of incontinence caused by pelvic floor
weakness. Extracorporeal magnetic innervation may
have a place in the treatment of women with both stress
and urge incontinence.
References: See page 255.
Genital Warts
Genital warts or condyloma acuminata are caused by infection
with human papillomavirus (HPV). Types 16, 18, 31, and 45
have been associated strongly with premalignant and
malignant cervical carcinoma. About 18% to 33% of sexually
active female adolescents test positive for HPV DNA.
Common warts are associated with different HPV types than
those that cause genital warts.
I.Symptoms and Signs
A.The lesions of condylomata acuminata are usually flesh-
to gray-colored papillomatous growths. They range in size
from less than 1 millimeter in diameter to several square
centimeters. The presence of koilocytotic cells on
Papanicolaou smears from the cervix suggest condyloma.
B.Among adolescent and adult males, venereal warts
usually are localized to the penis. Lesions present as
brown to slate blue pigmented macules and papules.
II.Treatment
A.Cryotherapy with liquid nitrogen or a cryoprobe is the
most effective method of treating single or multiple small [ Pobierz całość w formacie PDF ]