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Hunger due to a low blood sugar level can also occur in thyrotoxicosis impotence beavis and butthead order generic himcolin on line, and in diabetes mellitus when an incorrect balance between insulin and carbohydrate intake causes hypoglycaemia erectile dysfunction pills thailand order 30 gm himcolin with visa. The disease is due to a defective gene and is inherited in an autosomal dominant manner (see genetic disorders) erectile dysfunction doctor calgary order himcolin overnight. The chorea usually affects the face erectile dysfunction young adults treatment order himcolin overnight delivery, arms, and trunk, resulting in random grimaces and twitches, and clumsiness. Dementia takes the form of irritability, personality and behavioural changes, memory loss, and apathy. If the condition is diagnosed in early infancy, a bone marrow transplant may be curative. Larvae mostly settle in the liver, lungs, or muscle, causing the development of cysts. The infestation is generally confined to dogs and sheep, but may be passed on to humans through accidental ingestion of worm eggs from materials contaminated with dog faeces. Cysts in the liver may cause a tender lump or lead to bile duct obstruction and jaundice. Cysts in the lungs may press on an airway and cause inflammation; rupture of a lung cyst may cause chest pain, the coughing up of blood, and wheezing. The mole, which resembles a bunch of grapes, is caused by degeneration of the chorionic villi. In a small number of affected pregnancies, the mole develops into a choriocarcinoma. Urine and blood tests detect excessive amounts of human chorionic gonadotrophin (see gonadotrophin, human chorionic), which 288 is produced by the tumour. The tumour can be removed by suction, a D and C, or, less commonly, a hysterectomy. Hydralazine may cause nausea, headache, dizziness, irregular heartbeat, loss of appetite, rash, and joint pain. A hydrocele may be caused by inflammation, infection, or injury to the testis; occasionally, the cause is a tumour. If the swelling is uncomfortable or painful, however, the fluid may be withdrawn through a needle. The condition may be present at birth, when it is often associated with other abnormalities, such as spina bifida, or it may develop as a result of major head injury, brain haemorrhage, infection (such as meningitis), or a tumour. With congenital hydrocephalus, the main feature is an enlarged head that continues to grow rapidly. If it is not treated, hydrocephalus progresses to severe brain damage, which may result in death within weeks. When the condition occurs later in life, symptoms include headache, vomiting, loss of coordination, and the deterioration of mental function. In most cases, treatment of hydrocephalus is by draining the fluid from the brain to another part of the body, such as the abdominal cavity, where it can be absorbed. Synthetic hydrocortisone is used as a corticosteroid drug to treat inflammatory or allergic conditions, such as ulcerative colitis or dermatitis. The obstruction of a ureter may be caused by a stone (see calculus, urinary tract), a kidney tumour, or a blood clot. Occasionally, hydronephrosis is caused by obstruction to the outflow of urine from the bladder by an enlarged prostate gland (see prostate, enlarged). Acute hydronephrosis, with sudden blockage of the ureter, causes severe pain in the loin. Chronic hydronephrosis, in which the obstruction develops slowly, may cause no symptoms until total blockage results in kidney failure. If the blockage can be removed surgically, 289 the kidney is likely to function normally again. Occasionally, however, a kidney is so badly damaged that it requires removal (see nephrectomy). Hydrops fetalis is often the result of Rhesus incompatibility (see haemolytic disease of the newborn). The word hygiene is commonly equated with cleanliness, but it can also refer to public health. Cystic hygromas are usually present from birth and disappear naturally from the age of about 2. The hymen has a central perforation which is usually stretched or torn by the use of tampons or during sexual intercourse for the 1st time. Imperforate hymen is a rare condition in which the hymen has no perforation; at the onset of menstruation, menstrual blood collects in the vagina, causing lower abdominal pain. It is not joined to any other bone but is suspended by ligaments from the base of the skull. It provides an anchor point for the muscles of the tongue and of the upper front part of the neck. It is also used in eye-drops to dilate the pupil before an eye examination or surgery. An injection of hyoscine hydrobromide is often given as part of a premedication because it dries secretions in the mouth and lungs. Possible adverse effects of both forms include dry mouth, blurred vision, drowsiness, and constipation. The occasional occurrence of such behaviour in small children is considered normal.
This is usually accompanied by nausea erectile dysfunction daily pill discount himcolin 30 gm with amex, vomiting erectile dysfunction and diabetes type 1 buy generic himcolin pills, nystagmus erectile dysfunction medication for high blood pressure discount himcolin uk, 362 and deafness laptop causes erectile dysfunction buy himcolin 30gm cheap, tinnitus, and a feeling of pressure or pain in the affected ear. Diagnosis is usually made with audiometry (see hearing tests) or other hearing tests, and a caloric test. Treatment with certain antihistamine drugs, such as cinnarizine, or with betahistine usually relieves the symptoms, although prochlorperazine may be given, either rectally or by injection, for severe attacks. The outer membrane, the dura mater, is tough and fibrous; it lines the inside of the skull and forms a loose sheath around the spinal cord. It is separated from the arachnoid mater by the subarachnoid space, which contains cerebrospinal fluid. If the tumour invades the skull bone, there may be thickening and bulging of the skull. Viral meningitis tends to occur in epidemics in the winter; it is relatively mild. The infection usually reaches the meninges via the bloodstream from an infection elsewhere in the body. Less commonly, it passes through skull cavities from an infected ear or sinus, or from the air following a skull fracture. The main symptoms are fever, severe headache, nausea and vomiting, dislike of light, and a stiff neck. In bacterial meningitis, the main symptoms may develop over only a few hours, followed by drowsiness and, occasionally, loss of consciousness. In about half the cases of meningococcal meningitis, there is also a rash under the skin that does not fade with pressure (see glass test). The rash starts as pin-prick spots that can join to give a bruise-like appearance. Viral meningitis needs no treatment and usually clears up within a week or two with no after-effects. For other types of bacterial meningitis, antibiotic drugs are given as a protective measure to 363 people who have come into contact with the infection. Meniscectomy may be carried out when damage to the meniscus causes the knee to lock or to give way repeatedly. The procedure cures these symptoms and reduces the likelihood of premature osteoarthritis in the joint. Arthroscopy may be carried out to confirm and locate the damage, and the damaged area removed by instruments passed through the arthroscope. Alternatively, the meniscus may be removed through an incision at the side of the patella (kneecap). In either case, there may be an increased risk of osteoarthritis in later life, but this is less than if the damaged meniscus had been left in place. The knee joint has 2 menisci, and the wrist joints, and the temporomandibular joints of the jaw, have one each. The menisci are held in position by ligaments and help to reduce friction during joint movement. The term is usually used to refer to a period of physical and psychological changes that occur as a result of reduced oestrogen production. Symptoms of menopause include hot flushes and night sweats; vaginal dryness caused by thinning of the vaginal skin; and a decrease in vaginal secretions. Vaginal dryness may also make sexual intercourse more difficult and painful (see vaginitis). The neck of the bladder and urethra undergo similar changes, which can result in a feeling of needing to urinate frequently. Changes in metabolism occur during the menopause but may not cause symptoms until later. There is also an increased level of fats in the blood, which may cause an increase in atherosclerosis and a higher incidence of coronary artery disease and stroke. Menorrhagia may be caused by an imbalance of oestrogen hormones and progesterone hormone, which control menstruation. Disorders that affect the uterus, such as fibroids, polyps, or a pelvic infection, can also cause menorrhagia. It is used as a treatment for certain types of male and female infertility, as it prepares the ovary for ovulation and may help stimulate sperm production. It is used along with human chorionic gonadotrophin (see gonadotrophin, human chorionic). In women, menotrophin may cause multiple pregnancy, abdominal pain, bloating, and weight gain. At the beginning of the cycle, a hormone from the pituitary gland stimulates an egg follicle in an ovary to mature. Ovulation (release of an egg from the follicle) usually occurs in the middle of the menstrual cycle. The empty follicle also produces progesterone hormone, which makes the endometrium become swollen and thick with retained fluid. If pregnancy fails to occur, the production of oestrogens and progesterone diminishes. Menstrual disorders may be a sign of a problem in the pelvic area, such as fibroids, endometriosis, or pelvic inflammatory disease, but the cause is often unknown. Other types of menstrual disorder are amenorrhoea (absence of menstruation), polymenorrhoea (too frequent menstruation), oligomenorrhoea (infrequent periods or scanty blood loss), and menorrhagia (excessive bleeding). Some women have extreme variations in the length of menstrual cycles or menstrual periods, or in the amount of blood lost (see menstruation, irregular).
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The extent o the surgery depends on the severity o the condition and erectile dysfunction and diabetes medications purchase 30 gm himcolin, in general erectile dysfunction surgery buy himcolin line, requires bilateral salpingectomy and o ten oophorectomy erectile dysfunction treatment options-pumps cheap himcolin 30gm free shipping, although som e ovarian tissue m ay be saved erectile dysfunction protocol amino acids buy generic himcolin on-line. This occurs in the acute phase o the in ection, and exudate accum ulates, distending the oviduct to a greater or lesser degree. The distension o the oviduct attens the endosalpinx and the wall o the oviduct is thickened by the in am m atory process. Because the in am m atory process extends through the wall o the oviduct, adhesions to surrounding structures are com m on. The distended oviduct has a thin wall, which is translucent and usually retort-shaped. Hydrosalpinx m ay be sym ptom less, but i sym ptom s are present they are m any and variable. They include general ill-health, lassitude, disturbances o m enstruation and chronic aching in the lower abdom en, which is worse 280 Chapter 3 3 In ections o the genital tract. The m ost com m on com plaint is a chronic deep pelvic ache, o ten localized to one side, and backache. Deep dyspareunia is requent, and m ay be so severe as to prevent sexual intercourse. Vaginal exam ination shows a tender uterus drawn to one side and relatively f xed in position. Treatm ent is unsatis actory; som e patients respond to pelvic short-wave diathermy, and hysterectomy is another option. Tu b e rcu lo u s in f e ct io n o f the g e n it a l t r a ct In the developed countries genital tract tuberculosis is very uncom m on, accounting or <0. In regions where Mycobacterium tuberculosis is endem ic the incidence is m uch higher. I this happens to coincide with puberty, when increased growth both o the internal genital organs and o the supply o blood thereto occurs, in ection m ay also occur. The disease m ay be lim ited to the oviducts, but spread to the endom etrium is com m on. Sym ptom s are m inim al, and the condition is detected when investigations or in ertility are m ade. Treatm ent is that or pulm onary tuberculosis, surgery only being used when there are large adnexal m asses and a ter m edical treatm ent has been tried. Vaginal exam ination m ay reveal generalized tenderness or a sm ooth cystic enlargem ent. Because o these nonspecif c com plaints, laparoscopy is o ten required to m ake a diagnosis. Chro nic pe lvic ce llulitis Chronic pelvic cellulitis is less com m on today but still occurs. It is usually the sequela o acute pelvic cellulitis and results in thickening and f brosis o the connective 281 Chapter 34 Atrophic and dystrophic conditions occur if the wom an develops an endom etrial or cervical carcinom a. The wom an m ay com plain of lower abdom inal pain, and an exam ination shows that the uterus is larger than expected for her age. The diagnosis is conrm ed by ultrasound scanning, which shows that the uterine cavity is enlarged and lled with uid. If carcinom a is detected it is treated appropriately; if it is not present, the cervix is dilated and a drain inserted for a few days. The super cial cells dim inish in num ber, and interm ediate and parabasal cells predom inate. These changes show clinically as vaginal discom fort and burning, and painful intercourse. In the years after the m enopause the internal genital organs becom e sm aller and atrophic. These changes occur because the am ount of circulating oestrogen falls to a very low level. The pe lvic f o o r Deprived of oestrogen, the blood supply to the m uscles of the pelvic oor dim inishes. The pelvic oor m uscles lose their tone and the connective tissue loses its elasticity, with the result that pelvic oor tissues dam aged during childbirth are likely to relax, with varying degrees of prolapse (see Chapter 38). In the uterus, the endom etrium has becom e atrophic and the m uscle bres of the myom etrium have been progressively replaced by brous tissue. If the wom an develops uterine infection the pus m ight not escape, leading to a pyom etra. In very old wom en, only a narrow cleft indicates the presence of the vaginal introitus. These changes m ay lead to vulval irritation, although this m ay occur at earlier ages. Vu lv a l a t ro p h y in y o u n g e r w o m e n Vulval atrophy m ay occur in a few younger wom en. It can cause considerable distress, not only because it is uncom fortable but because it prevents sexual intercourse, or m akes it painful. The wom an should be investigated for the presence of im paired glucose tolerance, and allergic conditions sought. The wom an should be advised not to wear garm ents that prevent ventilation and increase vulval m oisture. The reason m ay be infection, general skin or m edical disease, and can be associated with psychological, relationship or sexual problem s. Whatever the cause, the itch, m ediated by a release of histam ines, leads to scratching, which aggravates the itch.
Malform ations of the genital tract occur when the pro cess described above does not occur erectile dysfunction code red 7 cheap 30 gm himcolin visa. Fa ilu re o f re ca n a liza t io n the m ost com m on defect is an im perforate hym en or transverse septum erectile dysfunction natural order himcolin canada, which should be detectable during the exam ination of the neonate impotence after prostate surgery himcolin 30 gm with mastercard. If it is not detected until after puberty impotence and age order himcolin us, m enstrual discharge m ay collect in the vagina and, in long term cases, m ay distend the uterus and tubes. Treatm ent is to m ake a cruciate incision in the hym en septum and perm it the inspissated uid to escape slowly. Benign tum ours occur m ost often in the uterus and m ost benign cysts occur in the ovaries. A subseptate uterus m ay lead to recurrent abortion, and can be treated by excising the septum by surgery or laser. If the wom an has a bicornuate uterus and becom es pregnant, the fetus m ay present as a transverse lie in late pregnancy. A few wom en develop vulval varicosities, which m ay cause discom fort and are m ore m arked in pregnancy. A cystic swelling m ay occur in the anterior wall of the vagina, directly below the urethra: this is a urethral diverticulum. If it becom es infected, the wom an com plains of dysuria and frequency of urination. The colum nar epithelium covering the polyp m ay undergo squam ous m etaplasia, or ulcerate. The m ain sym ptom s are interm ittent or postcoital bleed ing, although m any cervical polyps are sym ptom less. The polyp can be rem oved by twisting the pedicle, and the tissue should be sent for histopathology. As there is frequently a vessel in the pedicle this should only be done where there is the appropriate equipm ent to arrest any bleeding. Other tum ours that m ay be detected occasionally are genital pap illom ata and broids. Encapsulated smooth muscle f bres interspersed with strands o connective tissue usually developing in the myometrium. Regress a ter menopause Examination and conf rmatory ultrasound Depend on size and position and are requently symptomless. Ut e r in e b ro id s (le io m y o m a t a, b ro m y o m a s) these are the m ost com m on tum ours of the genital tract. A uterine broid is com posed of sm ooth m uscle bundles interspersed with strands of connective tissue, surrounded by a thin capsule (Box 36. They grow slowly and m ay only be detect able clinically in the fourth decade of life, when the incidence increases to about 20%. They are m ore com m on in nulliparous wom en or wom en who have had only one child. They m ay arise from norm al m uscle cells, from im m ature m uscle cells in the myo m etrium, or from em bryonal cells in the walls of uterine blood vessels. Whatever their origin, the tum ours begin as tiny m ultiple seedlings which are scattered through the myom etrium. The seedlings grow very slowly but pro gressively (over years rather than m onths), under the 297 Fundam entals of Obstetrics and Gynaecology Pedunculated subserous Submucous Subserous Broad ligament Pedunculated Cervical 70% Intramural. At rst the tum our is intram ural, but as it grows it m ay develop in several directions. After the m enopause, as oestrogen is no longer secreted in any great quantity, broids tend to atrophy. The bundles o spindle-shaped muscle cells run in several directions and tend to orm a whorl-like pattern. Patho lo g y If the tum our is cut, it pouts above the surrounding myo m etrium as its capsule contracts. Whitish grey in colour, it is com posed of whorled intertwining bundles of m uscles in a m atrix of connective tissue. At its periphery the m uscle bres are arranged in concentric layers, and the norm al m uscle bres surrounding the tum our are sim i larly oriented. Between the tum our and the norm al myo m etrium a thin layer of areolar tissue form s a pseudocapsule, through which the blood vessels enter the broid. On m icroscopy, groups of spindle shaped m uscle cells, with elongated nuclei, are separated into bundles by con nective tissue. As the entire blood supply of the broid is derived from the few vessels entering from the pseudocapsule, the growth of the tum our m eans that it often outstrips its blood supply. This follows extravasation of blood through the tum our, giving it a raw beef appearance. If the broid is associated with m enstrual disturbances a hysteroscopy is advisable to exclude intra uterine pathology. Image enhanced by in usion o saline through transcervical catheter seen in upper left on scan. Myomectomy If the wom an wishes to preserve her reproductive function, myom ectomy m ay be chosen.