FACTS ON FINGER TIPS

 1.ERECETILE DYSFUNCTION                                                                                      

       (Male Dysfunction)

   Salient Features (MIMS)

 Definition

 1.Erectile dysfunction (ED) is the liability to achieve and maintain an erection           

Epidemiology

1. ED affects up to 35% men in the 40-70 age group.                                                     

Aetiology

1.It was thought most causes were psychological; now it is known that most ED cases have an organic cause.

2.Organic causes include diabetes, hypertension, thyroid and vascular disorders, multiple sclerosis, paraplegia, and complications of prostatectomy.                                                 

 2. Drugs such as betablockers, anti-hypertensives, tricyclic antidepressants ,diuretics, phenothiazines can also be implicated.

Clinical features

1.Distingiush between primary ED (has never had an erection) and secondary ED. And ask about libido and ejaculation problems

2. A sudden onset of ED is associated with psychological or post-operative counselling. If the patient is experiencing inter-personal problems, anxiety or depression, treat this but avoid drugs that could worsen the ED.

3. Sildenafil or Tadalafil or apomorphine

4.Other treatments include vacuum constriction devices, intracavernosal injection therapy and the  intraurethral delivery of Prostaglandin E1.

5.Surgery is only indicated in a minority of cases                                                                                                                         

Key Points

1.Under-diagnosis is an important problem because men are reluctant to seek medical help

2.Drugs are a common cause of reversible ED, so ask about use of medicines. 

3. Psychological and social consequences of impotence can be significant, so the problem needs to be taken seriously                                               

6.DISORDERS AND /OR ADVERSE REACTIONS -  GENITO-URINARY SYSTEM -SUMMARY

 Refer - other information

Contents

1.Evidence Based Medicine                                                                                                 i. Management of Benign Prostatic Hypertrophy (BPH)

2.Facts on Finger Tips                                                                                                          i Erectile Dysfunction (Male Impotence)

3.Disorders and/or Adverse Drug  Reactions                                                                      Items 1- 19

                                     EVIDENCE BASED MEDICINE

6.DISORDERS AND /OR ADVERSE REACTIONS - GENITO-URINARY TRACT SYSTEM - SUMMARY

( Ref- Harrisons - Priniciples of Internal Medicine Ninth Edition )

1. Nephrotic syndrome ( 1315 )
2. Tubular necrosis ( 388 )
3. Acute nephritis (1284)
5. Proteinuria (214)
6. Hematuria (216)
7. Azotemia (217)
8.Oliguria (218)
9. Polyuria (219)
10.Nocturia (221)
11. Dysuria (222)
12.Impaired bladder emptying (222)
13. Incontinence (223)
14.Enuresis ( 223)
15. Analgesic Nephropathy (1334)
16. Renal tubular acidosis (446)
17.Gallstones (1490)
18. Urinary tract Obstruction (1286)
19. Cystitis (1330)

1. Nephrotic syndrome ( 1315 )

Nephrotic syndrome is characterized by albuminuria, hypoalbuminemia, hyperlipidemia, and edema.These abnormalites are direct or indirect consequences of excessive glomerular leakage of plasma proteins into the urine. Heavy proteinuria is the hallmark of the nephrotic state

  Adverse reactions- drugs ( 386 )
   1. Penicillamine
   2. Gold salts
   3. Phenindione
   4. Probenecid

2. Tubular necrosis ( 1293)

Acute renal failure is as a result of rapid deterioration of renal function sufficient to result in
accumulation of nitrogenous wastes in the body. The causes of such deterioration may be prerenal,postrenal or renal hypochymal origin which may include renal hypofusion, obstructive uropathy,and intrinsic renal diseases such as glomerulonenephritis. Acute reversible renal failure is a  condition commonly termed acute tubular necrosis.

  Adverse reactions- drugs
   1. Amphotericin B
   2. Aminoglycosides
   3. Polymixins
   4. Cephaloridine
   5. Tetracycline
   6. Colistin
   7. Sulfonamides
   8. Radionated contrast medium
   9. Methoxyflurane

3. Acute nephritis (1284)

A number of diseases invlove the glomueruli and to generally lesser extent, the tubules in an acute but transcient inflammatory process, manifested clinically by acute reduction of GFR , rapidly progressive azotemia, oliguria, and salt and water retention. The resulting expansion of extracellular volume , if marked , leads to hypertension, pulmonary vascular congestion and facial edema. Damage to the glomerular wall is usually  severe enough in almost all causes to gain urinary space.

   Intestinal nephritis (388)
  Adverse reactions- drugs
   1. Penicillins. particularly methicillin
   2. Sulfonamides
   3. Phenindione
   4. Furosemide
   5. Thiazides

5. Proteinuria (215)

Daily excretion of more than 150mg protein is properly termed pathological proteinuria, but in common usage the word proteinuria suffices. Protein excretion above 3.5g per 24 hour is termed massive proteinuria and usually occurs when glomeruli have been damaged enough to allow plasma proteins, especially albumin, to enter the urine. Urinary albumin loss lowers serum albumin concentration, and the consequent fall in intracapillary  oncotic pressure fosters accumulation of tissue edema; serum lipids rise.

6. Hematuria (216)

Urinary tract bleeding from the urethra to the renal pelvis produces isolated hematuria, without significant proteinuria cells or urinary casts. Total hematuria which occurs evenly throughout voiding, means that blood had the oppurtunity to mix freely with the bladder urine. When bleeding occurs mainly at the beginning or end of micturation, a prostatic or urethral origin is more likely.

Common causes of isolated hematuria are urinary tract stones, beingn  and malignant neoplasms of the urinary tract, tuberculosis, trauma, and prostatitis. Few primary renal disease cause it. Bacterial infection of the lower urinary tract or of the kidneys occassionally causes hematuria

7. Azotemia (217)

An increase in  serum concentration termed - azotemia- (azo - containing nitrogen) occurs as the GFR falls. Renal failure is reflected by a high blood nitrogen level. Of the two substances , creatinine is a more reliable index of GFR because of its low back diffusion from tubule lumen to peritubular blood. Althogh azotemia is a laboratory finding, rather than a symptom, it is almost universal clue to the presence of abnormal renal function and often of renal disease

8.Oliguria (218)

In this condition urine volume is insufficient to sustain life in a steady state, it is usually less than 400ml per  24hour(16.6ml/hr)  in an adult of average size. Daily urine volume is difficult to measure when flow rate is vert low, because small absolute errors of volume measurement, in the range of 50 to 100ml of urine each day, or timing of collection, may represent large percentage errors.

9. Polyuria (219)

When an individual is in water balance , urine volume is the difference between water intake and insensible water losses. Polyuria implies the production of more urine normal; if it is chronic, there also high water intake. A reasonable definition of polyuria is a urime volume above 3 litres per day, but should be qualified to exclude normal individuals who desire a large fluid intake and and therefore form large volume of urine.

Concentrating defect with polyuria ( or nephrogenic diabetes insipidus )  ( 388 )
  Adverse reactions- drugs
   1. Vitamin D
   2. Lithium
   3. Democlocycline
   4. Methoxyflurane

10.Nocturia (221)

Whether an individual sleeps through the night without urinating depends upon diuranal rhythm in which the volume of urine formed during sleep does not exceed bladder capacity. Nocturia results when nocturnal urine volume exceeds bladder capacity , or it results from reduced renal osmostic concentration, high sodium excretion , solute diuresis or low bladder capacity.

11. Dysuria (222)

Dysuria refers to anything abnormal having to do with urination, such as urinary frequency, nocturia,hesistancy in starting urination, straining to urinate , burning upon urination, urgency, decreased size of urinary stream, dribbling, at the end of urination, or combination of these symptoms. Some clinician restrict the term to burning or pain, but the broader definition is preferable

12.Impaired bladder emptying (222)

Increased ouflow resistence because of obstruction of the bladder neck, or urethra causes
hesistency, reduced caliber of the stream, and dribbling. Damage to the sacral nerves involved in vesical emptying, can produce a completely  autonomous bladder, or a sensory paralytic or motor paralytic neurogenic bladder.

Thus, the individual whose bladder has lost all sensory  and motor innervation must rely for emptying  upon distention of the organ leading to muscle stretching. Hesistency, incomplete emptying and even gross retention of urine can result and automatic contraction, because the sacral voiding refleux  is absent.

 Bladder dysfunction ( 388 )
  Adverse reactions - drugs
   1. Antichlonergics
   2. Monoamine oxidase inhibitors
   3. Tricyclic antidepressants
   4. Disopyramide

13. Incontinence (223)

Incontinence refers to the inability to retain urine in the bladder . The diagnostic approach to
the evaluation of the patient should be the same as dysuria.

Stress incontinence is common in postmenopausal parous women. The structures of the female  urerthra atrophy when deprived of estrogen and may become unable to resist the pasage of urine under stress of increased intraabdominal pressure during coughing, sneezing, climbing stairs,  and other physical activity.  

14.Enuresis ( 223)

Enuresis refers to the involuntary passage of urine at night or during sleep.- hence the synonyn bed wetting. Some clincians reserve the the term enuresis for those bed-wetters who have no gross urological abnormalities , but it should be used for bed wetting in general.

15. Analgesic Nephropathy (1334)

Numerous studies have established that individuals who ingest large quantities of analgesic drugs are particularly prone to develop tubuloinstestinal damage and papillary necrosis. In Australia, Switzerland and Swedan analgesic abuse ranks as one of most causes of chronic renal failure and it now recongnized as an important cause of renal insufficiency in the United States as well. Studies in animals have demonstrated that phenacetin and aspirin can induce papillary necrosis when either these drugs is given in quantities far excess of usual therapeutic doses

 Nephropathies due to analgesics (388)
   Adverse reactions- drug
    1. Phenacetin

 
16. Renal tubular acidosis (446)

Renal disease is the most common cause of chronic metabolic acidosis. In chronic renal failure, the principal  defect is decreased ability to excrete ammonium, but some patients also waste bicrabonate. Chronic metabolic acidosis is the hallmark of tubular dysfunction in renal tubular acidosis which may be a  primary renal disease. 

  Advere reactions - drugs
   1. Degraded tetracycline
   2. Amphotericin B
   3. Acetozolamide

17.Gallstones (1490)

The solubility of cholestrerol in bile depends on the relative molar concentration of cholesterol, bile acids, and lecithin. Saturated bile is secreted by the liver. Although not sufficient as a sole abnormality , cholestrol- sarurated bile is a prerequisite for cholesterol gallstone formation.

 Calculi ( 388 ) 
  Advere reactions - drugs
   1. Acetozolamide
   2. Vitamin D

18. Urinary tract Obstruction (1286)

Functional causes of urinary tract obstruction usually requires radological or surgical visualization.Causes for obstruction are numerous. Anuria in an adult is almost always due to obstruction of bladder outflow. Less common , blockage of upper urinary drainage from both the kidneys or a solitary  functioning kidney accounts for total or near-cesation of urine flow.

A large bladder after voiding is a sign of outlflow obstruction , usually due to urethral stricture, tumor, stone, neurogenic causes or prostatic hypertrophy. Nocturia , frequency, and overflow  incontinence, and slowing or micturation are also suggestive of outflow obstruction

Obstructive uropathy ( 388 )
  Advere reactions - drugs
   1. Intrarenal - cyctotoxics
   2.Extrarenal - methysergide

19. Cystitis (1330)

Many physicians refer to significant bacteriuria    associated with dysuria, frequency, urgency, and suprapubic pain  as cystitis. In actuality, both urethritis and cystitis are usually present. The urine often becomes grossly cloudy, malodorous, and in some cases, bloody. Pyuria without leukocyte casts, and bacteria should be present on examination of unspun urine.

Hemorrhagic cystitis ( 388 )
  Adverse reactions - drug
   1. Cyclophosphamide