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Either the patient can return to the clinic where the circumcision was performed, or go to another clinic for postoperative follow-up and removal of the dressing. If the dressing has dried out, it should be gently dabbed with antiseptic solution (aqueous cetrimide) until it softens. It is important not to disrupt the wound by pulling at a dressing that has dried to the wound. C: appearance of a wound healing normally 48 hours after the operation Surgical procedures for adults and adolescents Chapter 5-31 Male circumcision under local anaesthesia Version 3. However, clinic-based circumcision can be undertaken in the presence of minor abnormalities, if the circumcision team has sufficient experience. Any abnormalities should be detected in the preoperative examination of the penis, which should include full retraction of the foreskin. Two abnormalities – both of which are common indications for circumcision – require a slight variation in technique. Phimosis Phimosis is scarring of the aperture of the foreskin to the extent that the foreskin cannot be retracted. If the scar tissue is extensive, then the man is not suitable for clinic-based circumcision and should be referred to a higher level of care. The first step in all circumcision operations is to mark the foreskin with the line of the incision. If the sleeve resection method is used, the phimosis will prevent retraction of the foreskin and the line of incision near the corona cannot be marked. In this case, a small dorsal slit should be made, which is just long enough to allow the foreskin to be retracted. Once retracted, any adhesions can be divided and any debris under the foreskin cleaned with a swab soaked in povidone iodine or cetrimide. Once all adhesions have been divided, the second line of incision on the foreskin near the corona can be marked and the circumcision operation can proceed as usual. In the forceps-guided or dorsal slit methods, the line of incision is marked on the outer aspect of the foreskin in the normal manner. However, with minor degrees of phimosis, it may be necessary to make a small dorsal slit to allow full retraction and cleaning under the foreskin before proceeding with the operation. The forceps-guided method should not be used if there is evidence of extensive scarring. Tight or scarred frenulum All males have a band of tissue (the frenulum) on the ventral side of the penis, just below the glans. During early sexual experiences, the frenulum may be stretched as the foreskin is retracted, and minor tears are a frequent problem. Such tears can heal, leaving inelastic scar tissue, which tightens and makes further tearing and scarring more likely. The problem can be seen when the foreskin is retracted during physical examination. Spread open the foreskin and retract it ventrally to put the frenular band under tension. Using dissection scissors, snip the band at its centre, taking care not to injure the urethra, which is just under the frenulum. Any bleeding from the frenular artery should be controlled by careful tying or under-running. In this case, however, do not suture the penile skin up to the edge of the foreskin defect, since this will cause increased tension on the ventral side. This tension may cause curvature of the penis or possibly make erection or Surgical procedures for adults and adolescents Chapter 5-33 Male circumcision under local anaesthesia Version 3. Instead, close the V-shaped defect by placing the frenular suture 1–2 cm (depending on age and penis size) back from the apex of the V, taking both sides of the defect (Fig. Four surgical techniques are described: • the dorsal slit method; • the Plastibell method; • the Mogen clamp method; • the Gomco clamp method. Four widely-used surgical techniques for paediatric circumcision are described in this chapter. The recommended techniques are shown in detail so that they can be referred to in the context of a training course. Surgeons should become expert in the technique most suited to the circumstances of their practice. It is not recommended that a nursing, clinical or medical officer learn all the techniques. Circumcision of infants and pre-pubertal boys is simpler than circumcision of older boys and adults, because the penis is relatively underdeveloped and the foreskin less vascular. Circumcision can be delayed to an older age, when the boy can understand the risks and benefits of circumcision and consent to the procedure himself. Programmes that promote circumcision of young children are likely to have lower morbidity rates and lower cost than programmes targeting adolescents and adults. If there is any doubt, surgery should be deferred or the client Infant and paediatric circumcision Chapter 6 - 1 Male circumcision under local anaesthesia Version 3. Neonatal circumcision (within the first 28 days of life) should be undertaken only if the birth was a full-term delivery and the baby has had no significant medical problems. Known haematological disorders and jaundice are contraindications to circumcision. Thus any baby with yellow sclera or purpuric skin lesions should not be accepted for clinic-based circumcision. Any congenital abnormality of the genitalia is a contraindication to circumcision. Only babies with a normal physical examination and an intact, completely normal appearing penis and foreskin should be considered for male circumcision. This is because the foreskin may be needed for plastic surgical repair of the abnormality. The parent or legal guardian should be fully informed about how the procedure will be done, what type of anaesthetic will be used, what complications are possible, and what type of postoperative care should be provided. The consent of the child should also be obtained, if he is able to give it (Chapter 3 addresses this issue in more detail). Because mothers may need to travel some distance to the clinic, any clinic offering infant circumcision should have facilities for washing babies and changing nappies. Many studies have shown that babies react to pain, and that an effective method of providing local anaesthesia is with a dorsal penile nerve block. Infant and paediatric circumcision Chapter 6 - 2 Male circumcision under local anaesthesia Version 3. It is important to verify that the anaesthetic is clear and that there are no visible particles, which may suggest that the vial is contaminated. Before injecting any local anaesthetic, the surgeon should gently aspirate to make sure that no blood enters the syringe. This safety precaution should be repeated each time the needle is moved and before any additional local anaesthetic is injected. B: Diagram of an infant penis, to show the anatomy of the dorsal nerve as it passes under the pubic arch, and the position of the anaesthetic in relation to the dorsal penile nerve and pubic symphysis. It can also be used for boys who are old enough to cooperate during the procedure. For children between the ages of about 1 and 12 years, use of local anaesthetic alone is more problematic, since the boy may not remain still during the operation. Sedation may be required in addition to local anaesthesia, but there are risks, particularly of air-way obstruction and anoxia. If sedation is necessary to perform the procedure safely the patient should be referred to an appropriate facility. It must be applied with care in neonates, because of the potential risk of methaemoglobinaemia from prilocaine metabolites, which can oxidize haemoglobin and dangerously reduce the oxygen-carrying capacity of the blood. Care must be taken to ensure that the cream is not accidentally rubbed onto a large area of the baby’s body, as a result of the hands and feet wriggling during the procedure. This can be done by covering the penis with a small piece of polythene held in place with a sticking plaster. Possible minor adverse events include transient local skin reactions, such as blanching and redness.
Diseases
- Diomedi Bernardi Placidi syndrome
- Glomerulonephritis
- Myopathy tubular aggregates
- Rombo syndrome
- Porencephaly
- Optic atrophy polyneuropathy deafness
It should tion menstruation blood loss order female cialis master card, following treatment with midodrine 30–120 min be remembered women's health center greenville nc order female cialis 10 mg on-line, also women's health care policy issues order generic female cialis canada, that schistosomiasis and tu-- before a new stimulation breast cancer 7 mm tumor buy female cialis 20mg. Percutaneous tory ducts, which may be associated with obstruction aspiration of semen from the vas deferens has also and dilatation of the seminal vesicles. Such stones been reported as a means of harvesting semen for usually pass spontaneously. Unlike erectile capacity, the ability to prolonged sitting, and stasis of prostatic luid. Testic-- ejaculate increases with descending levels of spinal ular biopsies in spinal cord injured men demonstrate injury. Less than 5% of patients with complete upper a wide range of testicular dysfunction including hypo-- motor neuron lesions retain the ability to ejaculate. Approximately 22% prostatitis secondary to prolonged catheterization, of patients with an incomplete upper motor neuron epididymitis, and epididymo-orchitis can precipitate lesion and almost all men with incomplete lower mo-- obstructive ductal lesions and testicular damage. In et al reported that sperm density and motility were those patients capable of successful ejaculation, the higher in those with incomplete lesions [402]. In a sensation of orgasm may be absent and retrograde recent collective analysis of 40 paraplegic patients, ejaculation often occurs. Early studies showed that up to ing in particular have become very important in the three quarters of patients lost antegrade ejaculation well being of cancer patients. Due to modern sur-- after full bilateral retroperitoneal lymph node dissec-- gical techniques, improved quality of drugs for che-- tion. As a result of careful anatomical studies, the tech-- motherapy, and modern radiation techniques, more nique of retroperitoneal lymph node dissection has patients can be successfully treated without largely been modiied with nerve sparing so that antegrade compromising sexual functioning. Nevertheless, such was related to the size of the excised mass (<4 cm instruments are highly variable and largely unvali-- 4%; 4 8 cm 19%; >8 cm 60%). These questionnaires elicit limited informa-- It is important to anticipate this complication in young tion about aspects of sexuality other than erectile men with testicular tumors who may need chemother-- function. Although a deterioration of sexual activity apy or node dissection, and arrangements should be has been associated with the severity of ejaculatory made for sperm storage before treatment commenc-- dysfunction, particularly a decrease in volume or es. Excellent results can be obtained with artiicial in-- absence of semen [410], only a few questionnaires semination using cryopreserved spermatozoa [407]. Pathological dilatation of the seminal vesicles Herr [414] reported already in 1979 on 51 patients in the absence of obstruction has been described treated with retropubic Iodium-125 seeds, with loss previously, although the etiology remains obscure of ejaculate experienced by 6% of the patients. Caffo et al testesareverysensitivetoradiation,spermatogenesis evaluated toxicity and qoL of 143 patients treated is more easily affected than androgen productions. However, exit bilaterally at the inferior pole of the superior numbers were too small to draw inal conclusion. Damage of the young men in their sexual and fertile life, sexual sympathetic nerves could be caused by radiation, functioning and ejaculatory disorders are particularly but the dose does not seem enough to completely important. It is important and fear have been hypothesized, including fear of to anticipate this complication in young men with death and castration, fear of loss of self resulting testicular tumors who may need chemotherapy or from loss of semen, fear of castration by the female node dissection. Arrangements should be made genitals, fear that ejaculation would hurt the female, for sperm collection and storage at the earliest fear of being hurt by the female, performance anxiety, opportunity before treatment commences. Excellent unwillingness to give of oneself as an expression of results can be obtained with artiicial insemination love, fear of impregnating the female, and guilt sec-- using cryopreserved spermatozoa [407]. Appropriate necessary for learning to ejaculate or may result assessment requires an appreciation of how these in an inhibition of normal function. Regardless of factors combine to determine the inhibited ejaculatory speciic religion involved (Muslim, Hindu, Jewish, response for any particular individual. Some of these men Among those factors that are psychogenic and/or masturbated for a period of years like their secular behavioral, a number of possibilities have been counterparts, but guilt and anxiety about “spilling proposed. These men explanations have received more support than oth-- often had little contact with women prior to marriage ers, and some appear more plausible than others. Many different manifestations of anxiety women often relected a «Madonna-whore» split. And inally, the evaluative/performance aspect a relative absence of subjective arousal [367]. This same process is the likely cause of in-- cues that normally serve to enhance arousal [433]. These men confused their a man has dificulty with ejaculation, or has a small erect state as an indication of sexual arousal when volume or absent ejaculate, it must irst be estab-- it merely indicated vasocongestive success [2, 431]. The course of the problem is documented, pressure,duration,andintensitynecessarytoproduce and variables that improve or worsen performance an orgasm, yet dissimilar to what they experienced are noted. If orgasmic attainment had been between the reality of sex with the partner and the possible previously, the life events/circumstances use of sexual fantasy (whether unconventional or temporarily related to orgasmic cessation are re-- not) during masturbation is another potential cause viewed. This disparity may take any number of forms: cal, congenital problems, illness, trauma, or a variety body type, orientation, and sex activity performed. This assessment in conjunction b) Imaging in ejaculatory duct obstruction with appropriate physical examination and laborato-- A lesion or obstruction may be suspected by inding ry results will provide understanding and determine distended seminal vesicles on transrectal ultrasound an appropriate treatment path. However,theexactsiteofobstructionshould be deined radiologically by vasography or percuta-- 2. Next, occasionally of use in the evaluation of delayed ejacu-- it is essential to establish whether there is retrograde lation or anejaculation. The presence d)PudendalSomatosensoryEvokedPotentials of spermatozoa indicates retrograde ejaculation. They provide objective If the etiology is unclear, organic factors such as information concerning the afferent volley from the haemospermia may require full investigation. The technique of expressed prostatic secretion and urine will deine consists of electrical stimulation of the dorsal nerve the nature of an infective process such as prostatitis of penis with recording of the evoked responses over [440] and urine cytology and serum prostate speciic the spine and the scalp (2 cm behind the central antigen should be assayed to exclude bladder or vertex). Ultrasound scan of the testicles By deinition, the sensibility threshold is the lowest and epididymes should deine any local disease. The latency of the response is prostate or seminal vesicles, or may show up a stone measured both at the onset of the response and the in the ejaculatory duct or even a Mullerian duct cyst. Seminal analysis may simply spine), and a central transit time (which is obtained by be reported as showing azospermia or oligospermia, subtracting the peripheral from the total transit time). The total transit time is approximately 34 msec entire component of the ejaculate that comes from (onset) and 43 msec (top of P1 delection) [443, 444]. This technique consists of stimulating the motor cortex and sacral When there is absence of the vasa, it is important roots by means of a magne to electric stimulator. For to establish whether the condition is unilateral or brain stimulation, the coil is applied 2 cm behind the bilateral. For sacral root stimulation, the coil is applied the urinary system must also be checked by laterally to the spine. Brain stimulation is performed, malformation of the vasa, it is essential to consider irst at rest, and then during a voluntary contraction whether the anomaly may be part of a genetic defect of the pelvic loor (facilitation procedure). Sacral root associated with carriage of the potentially harmful stimulation is performed only at rest. They should, for ex-- 2 levels, 3 different transit times will be obtained: ample, be alert to various medical conditions as well a total transit time (from brain to target muscle), a as medications that might delay ejaculation and, in peripheral transit time (from sacral roots to target the case of antidepressants, consider a reduction in muscle) and a central transit time (obtained by sub-- dose or use of antidote [449]. Whether a clear patho-- physiological cause is present or absent, patients f) Sacral Relex Arc Testing: the Somatic might be counseled to consider lifestyle changes, in-- somatic Relex Arc cluding enjoying more time together to achieve great-- er intimacy, minimizing alcohol consumption, mak-- This test allows the investigation of the sensory and ing love when not tired, and practicing techniques motor branch of the pudendal nerve and of the sacral that maximize penile stimulation such as pelvic loor segments S2, S3, S4. Patient education regarding existing ulating the dorsal nerve of the penis and recording the factors that can exacerbate their delayed ejacula-- response from the bulbocavernosus muscles. The tion is an important irst step and may represent a response consists usually of 2 delections. The test allows evaluation of only effective treatment, as effective drug treatment is the sympathetic efferent outlow to the skin of the limited and poorly tested. The dorsal nerve of the penis is stimulated been eliminated, requires thorough psychosexual using 2 ring electrodes wrapped around the penile assessment. Numerous tion consists of single electrical pulses applied at psychotherapeutic processes are described for the a rate of 0. Sympathetic skin responses are management of delayed or inhibited ejaculation [224, recorded from hand, foot, and perineum using disc 225, 367, 450] and some appear to be effective, but electrodes afixed to the skin. Two tracings are su-- none has been properly evaluated in large scale perimposed to check the reproducibility of the re-- samples [451].
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This can be for a variety of reasons; the man may have been out of practice for a while or may need a higher dose or an alternative treatment. Once correct use is established and advised on, it will be important to understand what his situation is. W to try the product on his own to get used to the efects before proceeding to sexual intercourse. If after a few attempts the product is still not providing a satisfactory response, Mr. R should be taken through the Checklist to establish his symptoms and to look at the underlying issues. You know he is a smoker and there is a possibility that he is not in the best of health. The Checklist is designed to help you explore these issues and ascertain his suitability for the product. R should be advised to see his doctor to get a thorough assessment of his physical and mental health. The decision to supply the product will depend on the answers he gives you and this guide will help you with determining this for the wide range of men you may need to talk to. The most commonly reported adverse reactions in clinical studies among sildenafl treated patients were headache, fushing, dyspepsia, nasal congestion, dizziness, nausea, hot fush, visual disturbance, cyanopsia and vision blurred. Adverse reactions from post marketing surveillance has been gathered covering an estimated period >10 years. Because not all adverse reactions are reported to the Marketing Authorisation Holder and included in the safety database, the frequencies of these reactions cannot be reliably determined. Common (?1/100 and <1/10): Dizziness, Visual colour distortions (Chloropsia, Chromatopsia, Cyanopsia, Erythropsia and Xanthopsia), Visual disturbance, Vision blurred, Flushing, hot fush, nasal congestion, nausea, dyspepsia. Uncommon (?1/1,000 and <1/100): Rhinitis, hypersensitivity; somnolence; hypoaesthesia, Lacrimation disorders ( Dry eye, Lacrimal disorder and Lacrimation increased) Eye pain, Photophobia, Photopsia, Ocular hyperaemia, Visual brightness, Conjunctivitis, vertigo, tinnitus, tachycardia, palpitations, hypertension, hypotension, epistaxis, sinus congestion, Gastro oesophagael refux disease, Vomiting, Abdominal pain upper, Dry mouth, rash, myalgia, pain in extremity, haematuria, chest pain, fatigue, feeling hot, heart rate increased. Cardiovascular risk factors: Since there is a degree of cardiac risk associated with sexual activity, the cardiovascular status of men should be considered prior to initiation of therapy. Agents for the treatment of erectile dysfunction, including sildenafl, are not recommended to be used by those men who with light or moderate physical activity, such as walking briskly for 20 minutes or climbing 2 fights of stairs, feel very breathless or experience chest pain. The following patients are considered at low cardiovascular risk from sexual activity: patients who have been successfully revascularised (e. These patients may be suitable for treatment but should consult a doctor before resuming sexual activity. Patients previously diagnosed with the following must be advised to consult with their doctor before resuming sexual activity: uncontrolled hypertension, moderate to severe valvular disease, left ventricular dysfunction, hypertrophic obstructive and other cardiomyopathies, or signifcant arrhythmias. Sildenafl has vasodilator properties, resulting in mild and transient decreases in blood pressure (see section 5. Patients with increased susceptibility to vasodilators include those with left ventricular outfow obstruction (e. Serious cardiovascular events, including myocardial infarction, unstable angina, sudden cardiac death, ventricular arrhythmia, cerebrovascular haemorrhage, transient ischaemic attack, hypertension and hypotension have been reported post-marketing in temporal association with the use of sildenafl. Most, but not all, of these patients had pre-existing cardiovascular risk factors. Many events were reported to occur during or shortly after sexual intercourse and a few were reported to occur shortly after the use of sildenafl without sexual activity. It is not possible to determine whether these events are related 37 directly to these factors or to other factors. Priapism: Patients who have conditions which may predispose them to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia), should consult a doctor before using agents for the treatment of erectile dysfunction, including sildenafl. Prolonged erections and priapism have been occasionally reported with sildenafl in post-marketing experience. In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance. Concomitant use with other treatments for erectile dysfunction: the safety and efcacy of combinations of sildenafl with other treatments for erectile dysfunction have not been studied. Concomitant use with alpha-blockers: Caution is advised when sildenafl is administered to patients taking an alpha-blocker, as the co-administration may lead to symptomatic hypotension in a few susceptible individuals (see section 4. In order to minimise the potential for developing postural hypotension, patients should be hemodynamically stable on alpha-blocker therapy prior to initiating sildenafl treatment. Treatment should be stopped if symptoms of postural hypotension occur, and patients should seek advice from their doctor on what to do. Efect on bleeding: Studies with human platelets indicate that sildenafl potentiates the antiaggregatory efect of sodium nitroprusside in vitro. There is no safety information on the administration of sildenafl to patients with bleeding disorders or active peptic ulceration. Therefore the use of sildenafl is not recommended in those patients with history of bleeding disorders or active peptic ulceration, and should only be administered after consultation with a doctor. Use with alcohol: Drinking excessive alcohol can temporarily reduce a man’s ability to get an erection. Men should be advised not to drink large amounts of alcohol before sexual activity. Contra-indications: Hypersensitivity to the active substance or to any of the excipients listed in section 6. Agents for the treatment of erectile dysfunction, including sildenafl, should not be used by those men for whom sexual activity may be inadvisable, and these patients should be referred to their doctor. Sildenafl should not be used in patients with severe hepatic impairment, hypotension (blood pressure < 90/50 mmHg) and known hereditary degenerative retinal disorders such as retinitis pigmentosa (a minority of these patients have genetic disorders of retinal phosphodiesterases). This is because the safety of sildenafl has not been studied in these sub-groups of patients, and its use is therefore contraindicated. If after several attempts on diferent dosing occasions patients are still not able to achieve a penile erection sufcient for satisfactory sexual activity, they should be advised to consult a doctor. Elderly: Dosage adjustments are not required in elderly patients (? 65 years old). Renal Impairment: No dosage adjustments are required for patients with mild to moderate renal impairment. Hepatic Impairment: Sildenafl clearance is reduced in individuals with hepatic impairment (e. The safety of sildenafl has not been studied in patients with severe hepatic impairment, and its use is therefore contraindicated (see section 4. With the exception of ritonavir, for which co- administration with sildenafl is contraindicated (see section 4. In order to minimise the potential of developing postural hypotension in patients receiving alpha blocker treatment (e. Erectile dysfunction: a harbinger or consequence: does its detection lead to a window of curability? Clinically meaningful improvement on the self-esteem and relationship questionnaire in men with erectile dysfunction. Efects of sildenafl on the relaxation of human corpus cavernosum tissue in vitro and on the activities of cyclic nucleotide phosphodiesterase isozymes. The European Commission does not guarantee the accuracy of the data included in this report. Neither European Commission nor any person acting on its behalf is responsible for any use that might be made of the information in the report. Europe Direct is a service to help you fnd answers to your questions about the European Union Freephone number (*): 00 800 6 7 8 9 10 11 (*) Certain mobile telephone operators do not allow access to 00 800 numbers or these calls may be billed. More information on the European Union is available on the Internet (http://europa. For reproduction or use of the artistic material contained therein and identifed as being the property of a third-party copyright holder, permission must be sought directly from the copyright holder. The State of Men’s Health in Europe Extended Report Professor Alan White Centre for Men’s Health Leeds Metropolitan University 1 List of contributors Writers Prof. Alan White Leeds Metropolitan University, England Dr Bruno de Sousa Instituto de Higiene e Medicina Tropical, Portug al Dr Richard de Visser University of Sussex, England Prof. Richard Hogston Leeds Metropolitan University, England Dr Svend Aage Madsen Copenhagen University Hospital, Denmark Prof. Witold Zatonski Centrum Onkologii-Instytut, Poland With thanks to: Dr Gary Raine, Nick Clarke Management advisory group Prof. Wolfgang Rutz Academic University Hospital Uppsala, Sweden Dr Luciano Vittozzi National Centre for Rare Diseases, ItalyProf. Martin McKee London School of Hygiene & Tropical Medicine, England Dr Ineke Klinge Maastricht University, the Netherlands Dr Alfons Romero University of Girona, Spain Dr Elisabeth Zemp Stutz Basel University, Switzerland Prof.
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