Current Clinical Strategies, Outpatient and Primary Care Medicine (2005); BM OCR 7.0 2.5

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therapies. Lesions should be frozen until a 2 mm margin
of freeze appears, then allowed to thaw, then refrozen.
Repeat freeze several times. Side effects include burning,
which resolves within a few hours, and ulceration, which
heals in 7 to 10 days with little or no scarring.
B.Repeated weekly application of podophyllin as a 10%
solution in benzoin has been the principal mode of therapy
for many years. Podophyllin can cause chemical burns
and neurologic, hematologic, and febrile complications.
Podophyllotoxin (podofilox) is more efficacious and less
toxic than podophyllin.
C.Other treatment modalities include 5-fluorouracil as a
5% cream and a solution of trichloroacetic acid, both of
which are painful and can cause ulcers.
D.Imiquimod (Aldara) induces interferon. A cream
formulation containing 5% imiquimod has resulted in good
total clearance rates and tolerable side effects (erythema).
The cream is applied three times a week prior to normal
sleeping hours and is washed off after 6 to 10 hours with
mild soap and water.
E.Surgical techniques include conventional surgery,
electrocautery, and laser therapy. Intralesional or systemic
administration of interferon is effective for recalcitrant
disease.
F.Sexual transmission of HPV can be decreased by using
condoms. Examination of sex partners is unnecessary;
most probably are infected with HPV already, and no test
for asymptomatic infection is available.
References: See page 255.
Pubic Infections
I.Molluscum contagiosum
A.This disease is produced by a virus of the pox virus
family and is spread by sexual or close personal contact.
Lesions are usually asymptomatic and multiple, with a
central umbilication. Lesions can be spread by
autoinoculation and last from 6 months to many years.
B.Diagnosis. The characteristic appearance is adequate
for diagnosis, but biopsy may be used to confirm the
diagnosis.
C.Treatment. Lesions are removed by sharp dermal
curette, liquid nitrogen cryosurgery, or electrodesiccation.
II.Pediculosis pubis (crabs)
A.Phthirus pubis is a blood sucking louse that is unable to
survive more than 24 hours off the body. It is often
transmitted sexually and is principally found on the pubic
hairs. Diagnosis is confirmed by locating nits or adult lice
on the hair shafts.
B.Treatment
1.Permethrin cream (Elimite), 5% is the most effective
treatment; it is applied for 10 minutes and washed off.
2.Kwell shampoo, lathered for at least 4 minutes, can
also be used, but it is contraindicated in pregnancy or
lactation.
3.All contaminated clothing and linen should be
laundered.
III.Pubic scabies
A.This highly contagious infestation is caused by the
Sarcoptes scabiei (0.2-0.4 mm in length). The infestation
is transmitted by intimate contact or by contact with
infested clothing. The female mite burrows into the skin,
and after 1 month, severe pruritus develops. A multiform
eruption may develop, characterized by papules, vesicles,
pustules, urticarial wheals, and secondary infections on the
hands, wrists, elbows, belt line, buttocks, genitalia, and
outer feet.
B.Diagnosis is confirmed by visualization of burrows and
observation of parasites, eggs, larvae, or red fecal
compactions under microscopy.
C.Treatment. Permethrin 5% cream (Elimite) is massaged
in from the neck down and remove by washing after 8
hours.
References: See page 255.
Urologic Disorders
Benign Prostatic Hyperplasia
More than 80 percent of men older than 80 years have benign
prostatic hyperplasia (BPH). When symptoms of urinary
obstruction interfere with quality of life, treatment is warranted.
Sequelae of BPH include urinary retention, detrusor instability,
infection, stone formation, bladder diverticula, and upper tract
dilation with renal insufficiency.
I.Clinical evaluation
A.Obstructive symptoms, such as nocturia, a slow urine
stream, intermittency, and double voiding, are generally
evaluated through focused history taking, and a digital rectal
examination, with or without serum PSA testing.
B.Symptoms of BPH may be obstructive, which are
secondary to bladder outlet obstruction or impaired bladder
contractility, or irritative, which result from decreased vesicle
compliance and increased bladder instability. Obstructive
symptoms include a weak stream, hesitancy, abdominal
straining, terminal dribbling, an intermittent stream, and
retention; irritative symptoms are frequency, nocturia,
urgency, and pain during urination.
C.Physical examination should include a digital rectal
examination, and a focused neurologic examination to rule
out a neurologic cause of symptoms.
BPH Symptom Score
For each question, circle the answer that best describes your situation.
Add the circled number together to get your total score. See the key at the
bottom of this form to determine the overall rating of your symptoms.
Less Less More
than than Abou than Al-
one in half of t half half of most
Not at five the of the the al-
all times time time time ways
In the past
month, how
often have you
had a sensa-
tion of not
emptying your
bladder com-
pletely after
you finished
voiding? 0 1 2 3 4 5
In the past
month, how
often have you
had to urinate
again less
than 2 hours
after you fin-
ished urinating
before? 0 1 2 3 4 5
In the past
month, how
often have you
found you
stopped and
started again
several times
when you uri-
nated? 0 1 2 3 4 5
In the past
month, how
often have you
found it diffi-
cult to post-
pone urina-
tion? 0 1 2 3 4 5
In the past
month, how
often have you
had a weak
urinary
stream? 0 1 2 3 4 5
In the past
month, how
often have you
had to push or
strain to begin
urination? 0 1 2 3 4 5
In the past
month, how
many times
did you typi-
cally get up to
urinate from
the time you
went to bed
until you arose
in the morn-
ing? 0 1 2 3 4 5
D.Laboratory assessment
1.Urinalysis and a serum creatinine assay are useful
to ascertain there is no infection, hematuria, or de-
creased renal function. [ Pobierz całość w formacie PDF ]

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