By O. Nafalem. Cornell University.
Progestins Two progestins can be employed to treat cancer: medroxyprogesterone acetate [Depo-Provera] and megestrol acetate [Megace] purchase celecoxib 100mg visa. In women with metastatic endometrial cancer buy celecoxib 200mg online, progestins promote palliation and tumor regression buy cheap celecoxib 100mg line. Benefits appear to derive from depriving these cancers of estrogen by inducing enzymes that metabolize estradiol, the primary endogenous estrogen. The principal adverse effects of progestins are fluid retention and nonfluid weight gain. The good news is that cancer pain can be relieved with simple interventions in 90% of patients. The bad news is that, despite the availability of effective treatments, pain goes unrelieved far too often. Important among these are inadequate prescriber training in pain management; unfounded fears of addiction (shared by prescribers, patients, and families); and a health care system that focuses more on treating disease than relieving suffering. Pain undermines quality of life for the patient and puts a heavy burden on the family. Furthermore, pain can impede recovery, hasten death from cancer, and possibly even create a risk for suicide. Every patient has the right to expect that pain management will be an integral part of treatment throughout the course of his or her disease. The goal is to minimize pain and thereby maintain a reasonable quality of life, including the ability to function at work and at play and within the family and society. In addition, if the cancer is incurable, treatment should permit the patient a relatively painless death when that time comes. The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Most important, we must appreciate that pain is inherently personal and subjective. Hence, when assessing pain, the most reliable method is to have the patient describe his or her experience. Neurophysiologic Basis of Painful Sensations The following discussion is a simplified version of how we perceive pain. Nonetheless, it should be adequate as a basis for understanding the interventions used for pain relief. Sensation of pain is the net result of activity in two opposing neuronal pathways. The first pathway carries pain impulses from their site of origin to the brain and thereby generates pain sensation. The second pathway, which originates in the brain, suppresses impulse conduction along the first pathway and thereby diminishes pain sensation. Pain impulses are initiated by activation of pain receptors, which are simply free nerve endings. In addition, prostaglandins and substance P can enhance the sensitivity of pain receptors to activation, although these compounds do not activate pain receptors directly. Conduction of pain impulses from the periphery to the brain occurs by way of a multineuron pathway. The first neuron carries impulses from the periphery to a synapse in the spinal cord, where it releases either glutamate or substance P as a transmitter. The brain is able to suppress pain conduction using endogenous opioid compounds, especially enkephalins and beta-endorphin. Release within the spinal cord is controlled by a descending neuronal pathway that originates in the brain. Nociceptive Pain Versus Neuropathic Pain In patients with cancer, pain has two major forms, referred to as nociceptive and neuropathic. Nociceptive pain results from injury to tissues, whereas neuropathic pain results from injury to peripheral nerves. In contrast, they describe visceral pain as vaguely localized with a diffuse, aching quality. Neuropathic pain produces different sensations than does nociceptive pain and responds to a different group of drugs. Patients describe neuropathic pain with such words as “burning,” “shooting,” “jabbing,” “tearing,” “numb,” “dead,” and “cold. Pain in Cancer Patients Among patients with cancer, pain can be caused by the cancer itself and by therapeutic interventions. Cancer can cause neuropathic pain through infiltration of nerves, and visceral pain through infiltration, obstruction, and compression of visceral structures. The incidence and intensity of cancer-induced pain is a function of cancer type and the stage of disease progression. Of these, 40% to 50% report moderate to severe pain, and 25% to 30% report very severe pain. Therapeutic interventions—especially chemotherapy, radiation, and surgery— cause significant pain in at least 25% of patients, and probably more. Chemotherapy can cause painful mucositis, diffuse neuropathies, and aseptic necrosis of joints. Radiation can cause osteonecrosis, chronic visceral pain, and peripheral neuropathy (secondary to causing fibrosis of nerves). Surgery can cause a variety of pain syndromes, including phantom limb syndrome and postmastectomy syndrome. Management Strategy Management of cancer pain is an ongoing process that involves repeating cycles of assessment, intervention, and reassessment. The goal is to create and implement a flexible treatment plan that can meet the changing needs of the individual patient. After the nature of the pain has been determined, a treatment modality is selected. When relief has been achieved, the effective intervention is continued, accompanied by frequent reassessments. If severe pain returns or new pain develops, a new comprehensive assessment should be performed—followed by appropriate interventions and reassessment. Throughout this process, the health care team should make every effort to ensure active involvement of the patient and his or her family. Assessment begins with a comprehensive evaluation and then continues with regular follow-up evaluations. Comprehensive Initial Assessment The initial assessment employs an extensive array of tests. Accordingly, if we want to assess pain, we must rely on the patient to tell us about it. Furthermore, we must act on what the patient says— even if we personally believe the patient may not be telling the truth. The best way to ensure an accurate report is to ask the right questions and listen carefully to the answers. The following information should be obtained: Onset and temporal pattern: When did your pain begin?
Accordingly buy genuine celecoxib on line, nicotinamide is often preferred to nicotinic acid for treating pellagra generic celecoxib 100mg otc. Therapeutic Uses In its capacity as a vitamin buy celecoxib 100 mg with visa, nicotinic acid is indicated only for the prevention or treatment of niacin deficiency. Preparations, Dosage, and Administration Nicotinic acid (niacin) is available in immediate-release tablets (50–500 mg), extended-release tablets (250–1000 mg), and extended-release capsules (250– 500 mg). For treatment of pellagra, daily doses may be as high as 500 mg/day; however, the usual dose is 50-100 mg every 6-8 hours. Once major signs and symptoms have resolved, dosing can be decreased to 10 mg every 8-12 hours until resolution of skin lesions. Unlike nicotinic acid, nicotinamide has no effect on plasma lipoproteins and hence is not used to treat hyperlipidemias. Riboflavin (Vitamin B ) 2 Actions Riboflavin participates in numerous enzymatic reactions. Sources and Requirements In the United States most dietary riboflavin comes from milk, yogurt, cheese, bread products, and fortified cereals. Use in Riboflavin Deficiency Riboflavin is indicated only for prevention and correction of riboflavin deficiency, which usually occurs in conjunction with deficiency of other B vitamins. In its early state, riboflavin deficiency manifests as sore throat and angular stomatitis (cracks in the skin at the corners of the mouth). Later symptoms include cheilosis (painful cracks in the lips), glossitis (inflammation of the tongue), vascularization of the cornea, and itchy dermatitis of the scrotum or vulva. Use in Migraine Headache As discussed in Chapter 23, riboflavin can help prevent migraine headaches; however, prophylactic effects do not develop until after 3 months of treatment. Thiamine (Vitamin B ) 1 Actions and Requirements The active form of thiamine (thiamine pyrophosphate) is an essential coenzyme for carbohydrate metabolism. Thiamine requirements are related to caloric intake and are greatest when carbohydrates are the primary source of calories. As indicated, thiamine requirements increase significantly during pregnancy and lactation. Sources In the United States the principal dietary sources of thiamine are enriched, fortified, or whole-grain products, especially breads and ready-to-eat cereals. Deficiency Severe thiamine deficiency produces beriberi, a disorder having two distinct forms: wet beriberi and dry beriberi. Wet beriberi is so named because its primary symptom is fluid accumulation in the legs. Cardiovascular complications (palpitations, electrocardiogram abnormalities, high-output heart failure) are common and may progress rapidly to circulatory collapse and death. In the United States thiamine deficiency occurs most commonly among people with chronic alcohol consumption. In this population, deficiency manifests as Wernicke-Korsakoff syndrome rather than frank beriberi. This syndrome is a serious disorder of the central nervous system, having neurologic and psychological manifestations. Symptoms include nystagmus, diplopia, ataxia, and an inability to remember the recent past. Accordingly, if Wernicke-Korsakoff syndrome is suspected, parenteral thiamine should be administered immediately. Therapeutic Use The only indication for thiamine is treatment and prevention of thiamine deficiency. Parenteral administration is reserved for severe deficiency states (wet or dry beriberi, Wernicke-Korsakoff syndrome). The dosage for beriberi is 5 to 30 mg/day orally in single or divided doses 3 times/day for 1 month. Pyridoxine (Vitamin B ) 6 Actions Pyridoxine functions as a coenzyme in the metabolism of amino acids and proteins. However, before it can do so, pyridoxine must first be converted to its active form: pyridoxal phosphate. Sources In the United States the principal dietary sources of pyridoxine are fortified, ready-to-eat cereals; meat, fish, and poultry; white potatoes and other starchy vegetables; and noncitrus fruits. Deficiency Pyridoxine deficiency may result from poor diet, isoniazid therapy for tuberculosis, and inborn errors of metabolism. Symptoms include seborrheic dermatitis, anemia, peripheral neuritis, convulsions, depression, and confusion. In the United States dietary deficiency of vitamin B is rare, except among6 people who abuse alcohol on a long-term basis. Within this population, vitamin B deficiency is estimated at 20% to 30% and occurs in combination with6 deficiency of other B vitamins. Isoniazid (a drug for tuberculosis) prevents conversion of vitamin B to its6 active form and may thereby induce symptoms of deficiency (peripheral neuritis). Inborn errors of metabolism can prevent efficient utilization of vitamin B,6 resulting in greatly increased pyridoxine requirements. Unless treatment with vitamin B is initiated early, permanent cognitive deficits may result. Drug Interactions Vitamin B interferes with the utilization of levodopa, a drug for Parkinson6 disease. Accordingly, patients receiving levodopa should be advised against taking the vitamin. Therapeutic Uses Pyridoxine is indicated for prevention and treatment of all vitamin B deficiency6 states (dietary deficiency, isoniazid-induced deficiency, pyridoxine dependency syndrome). Preparations, Dosage, and Administration Pyridoxine is available in solution (200 mg/5 mL), standard tablets (25, 50, 100, 250, and 500 mg), extended-release tablets (200 mg), and capsules (150 mg) for oral use. To correct dietary deficiency, the dosage is 10 to 20 mg/day for 3 weeks followed by 1. To protect against developing isoniazid- induced deficiency, the dosage is 25 to 50 mg/day. Pyridoxine dependency syndrome may require initial doses up to 600 mg/day followed by 25 to 50 mg/day for life. Because deficiency presents as anemia, folic acid and cyanocobalamin are discussed in Chapter 45. Because adults older than 50 years often have difficulty absorbing dietary vitamin B12, they should ingest at least 2. Food Folate Versus Synthetic Folate The form of folate that occurs naturally (food folate) has a different chemical structure than synthetic folate (pteroylglutamic acid). As a result of grain fortification, the incidence of folic acid deficiency in the United States has declined dramatically.
Many other vital vessels purchase cheap celecoxib line, nerves cheap celecoxib online american express, and structures are adjacent to the tonsils order celecoxib 100 mg free shipping, and care must be taken to avoid injury. Be able to identify vessels that supply the pharynx, especially branches that course through the tonsillar beds 5. Deep to the mucosa are several aggregations of lymphoid tissue that form a ring around the pharynx, priming the immune system for defense against pathogens (see Figure 49-1). The medial pterygoid plates support the lateral walls of the superior part of the pharynx. One opens to the nasal cavity, another to the oral cavity, and a third to the larynx. Therefore, the pharynx is divided into three corresponding regions: the nasopharynx, the oropharynx, and the laryngopharynx. The naso- and oropharynx are continuous but are separated by elevation of the soft palate during swallowing to prevent reflux of food and liquid into the nasopharynx. Depression of the epiglottis during swallowing separates the larynx from the laryngopharynx, preventing aspiration into the trachea and lungs. Frontal sinus Nasal cavity Nasopharynx Palatine tonsil Oropharynx Body of tongue Laryngopharynx Epiglottis Cricothyroid Figure 49-1. The inferior part of the inferior constrictor muscle thickens as it merges with the esophagus, forming a sphincter called the cricopharyngeus muscle. The gap between the superior constrictor and the occipital bone transmits the pharyngotympanic tube, the levator veli palatini muscle, and the ascending pala- tine artery. Between the superior and middle constrictors are the glossopharyngeal nerve and stylopharyngeus muscle. Between the middle and inferior constrictors course the internal laryngeal nerve and the superior laryngeal artery. The recur- rent laryngeal nerve and the inferior laryngeal artery ascend deep to the inferior constrictor. The lymphoid tissue surrounding the pharynx is commonly called the Waldeyer ring, which is composed of three masses of lymphoid tissue: the pharyngeal tonsils (also called “adenoids” when enlarged), the palatine tonsils, and the lingual tonsils. The pharyngeal tonsils are located in the roof and posterior wall of the nasopharynx. The opening of the pharyngotympanic tube into the nasopharynx is protected by a tonsil. The palatine tonsils are located in the anterior wall of the oropharynx between the palatoglossal and palatopharyngeal folds. The lingual tonsil is located under the mucosa of the posterior one-third of the tongue. The pharynx is supplied by arteries from several sources, most of which are branches of the external carotid artery, specifically the maxillary, facial, lingual, and superior thyroid arteries. The constrictor muscles are also supplied by branches from the deep cervical and inferior thyroid arteries. With respect to this case, the most important vessels are the ascending palatine and tonsillar branches of the facial artery. Surgery to remove the palatine tonsil can damage the tonsillar branch, resulting in excessive bleeding. In addition, there is an extensive pharyngeal venous plexus on the pos- terior surface of the constrictor muscles. The external palatine vein descends along the lateral surface of the palatine tonsil to drain into the venous plexus. Therefore, this vessel may be damaged during surgery to remove a palatine tonsil, also resulting in excessive bleeding. This nerve exits the cranium through the jugular foramen and descends with the stylopharyngeus muscle to pass through the gap between the superior and middle pharyngeal constrictor muscles. This nerve also exits the cranium through the jugular foramen but descends within the carotid sheath. As it descends, it gives off branches that form the pharyngeal plexus on the posterior surface of the pharynx. Her physician believes that the symptoms are due to postnasal drip brought on by allergy. The tonsillar branch of the facial artery lies in the bed of the palatine ton- sil and is susceptible to injury. Although the ascending palatine artery sends branches to the tonsil, it is unlikely to be affected in a routine procedure. Her medical problems include insulin-dependent diabetes melli- tus and sleep apnea. After the anesthesiologist has administered the paralyzing agent (succinylcholine), the patient experiences spasms of the airway and diffi- culty breathing with the bag and mask. The anesthesiologist attempts to place an endotracheal tube by direct visualization (direct laryngoscopy), without success due to swelling (laryngeal edema). Meanwhile, the oxygen saturation content of the blood has decreased to a very low range of 80 percent. The anesthesiologist remarks that an emergency airway needs to be surgically opened. After receiving the paralyzing agent, the patient develops laryngospasm and is difficult to ventilate. Direct laryngoscopy and intuba- tion attempts are unsuccessful, and oxygen saturation is low. This woman is probably obese and difficult to intubate because of her short neck, and her sleep apnea is a concern. When oxygen saturation decreases to dangerous levels (<90 percent), brain and/or heart ischemia may ensue. Immediate correction of oxygenation is critical, and, as in this case, emergency tracheostomy is indicated. One of the most expedient methods is to enter the cricothyroid membrane in the midline, between the cricoid and thyroid laryngeal cartilages. This interval is usually palpable and is approximately one-third the distance from the top of the manubrium to the tip of the chin (men- tum). Alternatively, a needle can be inserted into the same membrane, and oxygen can be administered through a jet ventilator. However, this procedure must be revised rapidly because there is insufficient flow to remove carbon dioxide from the lungs. Nonemergency tracheostomies are performed inferiorly to the cricoid cartilage and the isthmus of the thyroid gland. Be able to list the landmarks of the anterior neck and identify the muscles of the infrahyoid region 2. Be able to describe the cartilaginous skeleton of the larynx and the positions of the vocal cords in relation to palpable landmarks 3.
The registrar is on the way but you need to give something quickly to make the uterus contract purchase celecoxib without prescription. For each woman celecoxib 100mg mastercard, select the most appropriate initial investigation that will help you make a diagnosis cheap celecoxib 200 mg visa. She is complaining of a fronto-occipital headache that is so severe that she can hardly move and is associated with nau- sea. She had an epidural in labour that was initially ineffective and whilst it was being resited the dura was inadvertently punctured. She complains of pain at the top of her right leg near the hip joint and cannot stand up comfortably. Shortly after delivery she becomes progressively short of breath and complains of mild left-sided chest pain on inspiration. Her midwife brings the saturation probe from theatre and tells you that her oxygen levels are normal. She is thinking of embarking on another pregnancy in about a year’s time as her husband is keen to have another baby soon. The position of the baby’s head was occipito- anterior at the ischial spines with moulding++. A caesarean section was performed after three strong pulls during which there was no descent of the fetal head. You observe from the operation notes that there was a bicornuate uterus that might lead to another breech presentation next pregnancy. At her follow-up appointment the perineum has healed well and she has made a full recovery with no symptoms related to the anal sphincter. The labour was pro- gressing well up to that point but unfortunately the bradycardia turned out to be due to placental abruption and the baby did not survive. She does not feel strong enough to contemplate another pregnancy just yet, but is wondering about the mode of delivery next time. This will include knowledge of early pregnancy loss, including clinical features, investiga- tion, and management of disorders leading to early pregnancy loss such as miscarriage (including recurrent), ectopic pregnancy, and molar pregnancy. You will also be expected to know the basis of national screening programmes and their local implemen- tation through local care pathways. You will be expected to understand the indications and limitations of screening for premalignant and malig- nant disease. An understanding of the options available for palliative and terminal care, including relief of symptoms and community support, will be expected. This includes an understanding of the epidemiology, aetiology, management, and prognosis of male and female fertility problems. You will be expected to have a broad-based knowledge of investigation and management of the infertile couple in a primary care setting and appropriate knowledge of assisted reproductive techniques including the legal and ethical implications of these procedures. In ‘benign gynaecology’ areas of knowledge covered (many of which over- lap) are menstrual problems; endocrinology, for example, polycystic ovarian syndrome and the menopause; pelvic pain; pelvic infammatory disease and vaginal discharge; and paediatric/adolescent issues such as delayed puberty. There is also an area mysteriously called ‘issues relevant to a migrant popu- lation’ that involves subjects such as female genital mutilation, infectious dis- eases, and ethical problems. Questions are likely to concentrate on making a diag- nosis and knowing when to refer rather than detailed knowledge of the special- ised management once she reaches hospital, although the contents of national guidelines should be referred to in revision as they are likely to be relevant. She is healthy with no other medical problems and is using the withdrawal method for contraception. The practice nurse finds it very difficult to access the cer- vix because it is pushed backwards and sideways into the left fornix by a 10 cm diameter pelvic mass. Which of these investigations is the most relevant to make a diagnosis for her amenorrhoea? She is currently using barrier contraception but is worried about her age and wishes to become pregnant again as soon as possible. What advice should she be given about when it is safe to discontinue all methods of contraception? To prevent metabolic effects of polycystic ovarian syndrome, for example, diabetes E. She is very worried because she had her last pregnancy terminated at 10 weeks because of severe hyperemesis. Preemptive prescription of antiemetics has been shown to reduce the inci- dence of hyperemesis D. Which one of the following management options is most likely to amelio- rate her symptoms? In counselling her about the polyp, which one of the following statements is true? Histological proof that the uterus contained trophoblastic tissue will always exclude ectopic pregnancy C. Medical management is associated with an increased incidence of pelvic infection D. Perforation of the uterus during surgical evacuation is more likely in incomplete rather than missed miscarriage E. In this situation in which there is unex- plained recurrent miscarriage, which of the following interventions have been shown to be effective in reducing the risk of further miscarriage? The sac contains a fetus about 9 weeks’ size but there is no fetal heart pulsa- tion seen. She was not expecting this as she has not had any bleeding at all during the pregnancy, so is extremely upset and would like to deal with the problem as quickly as possible. She is due to have a hysterectomy for fibroids next week and is thinking of having her normal ovaries removed at the same time as the uterus. She wishes to discuss the possible benefits and problems associated with a surgi- cal menopause. Which one of her ideas about the bilateral oophorectomy operation is actually correct? It will completely prevent her from getting any gynaecological cancer in later life D. She has irregular periods with a cycle varying from 35 to 42 days, and the ovulation predictor kits she has purchased from the chemist indicate that she is not ovulating. Continue trying for six more months; then you will refer her to infertility clinic B. She is anxious because has suffered two previous early pregnancy losses; a miscarriage at 10 weeks followed by an ectopic pregnancy that was managed surgically. She has attended the surgery twice in the past for help with her menorrhagia and dysmenorrhoea. She brings with her the results of a private urodynamic study that she had done after surfing the Internet. This shows that she has a compli- ant bladder on filling in a sitting position, but when she stands up there is demonstrable leakage of urine associated with spikes of high detrusor pressure measurements >30 cm water. On examination she does have a moderate cystocoele and minor recto- coele but no uterine descent. Her symptoms are getting worse with frequent leakage despite intensive supervised pelvic floor physiotherapy. She presents with ‘something coming down’ and on exami- nation of the external genitalia you can see the vaginal vault protruding.
His vit a l sig n s a re n o rm a l discount 200 mg celecoxib otc, a n d h is ca rd io p u lm o n a r y a n d a b d o m in a l e xa m in a t io n is u n re m a rka b le buy generic celecoxib 100mg. Best initial therapy: Init ial t reat ment includes life st yle modificat ion and phar- macologic treatment with either an α -1-blocker or a 5-α reduct ase inh ibit or if the patient is bothered significantly by his symptoms generic celecoxib 100 mg overnight delivery. H ow often do you have the sensation of not completely emptying you bladder aft er you finished urinat ing? H ow often do you have to get up to urinate from the time you go to bed unt il the time you get up in the morning? These include prostate cancer, urethral stricture, bladder and or ureteral stones, bladder tumors, prostatitis, cystitis, and neurogenic bladder. The digital rectal examination is an important component of the workup because it gives us informat ion regarding the size, cont our, and consist ency of the prost at e. In clu ded in the wat ch fu l wait ing st rat egy are ser ial mon it or ing of symp- toms and serum creatinine, and education regarding life st yle modifications which include: (1) reducing fluid intake at specific times to reduce urinary frequency at inconvenient t imes, (2) using relaxed and double-voiding t echnique, (3) eliminat ing or limiting caffeine, alcohol, and/ or other foods that have diuretic and/ or irritat- ing effect s on t he bladder, (4) uret hral milking may help reduce or prevent post - vo id d r ib b le, ( 5 ) b lad d er r et r ain in g b y en co u r agin g m en t o d elay u r in at io n wh en having the urge may help gradually increase their bladder capacity, (6) treatment of constipation, (7) adjusting medications to replace or eliminate diuretics and other medications that may produce bladder symptoms. T his involves cont ract ion of t he detrusor (bladder muscle) followed by relaxation of the bladder neck and other urinary sphincters to allow for unrestricted and complete emptying of the bladder in a single sett ing. The normal prost at e has t he “feel” of the thenar eminence of the thumb (see Figure 57– 1). T his testing generally involves the placement of a manometry catheter into t he bladder and somet imes a second manomet er in t he rectum. T h e bladder is then slowly filled with warm water and patient is asked about sensation and asked to indicate when there is an urge to urinate. Specifically, the complaints may include urinary urgency, urinary frequency, nocturia, feelings related to incomplete bladder emptying, dif- ficu lt y/ p ain wit h u r in at ion, blad d er in fect ion s, or d ecr eased u r in ar y st r eam. T h e history and physical examinat ion is helpful to sort out the symptoms and possible cau ses. T h e d igit al r ect al exam in at ion h elp s ch ar act er ize pr ost at e size, con sist en cy, and ident ify abnormal nodularit ies or tenderness. Abnormal findings during digi- tal rectal examination may be further evaluated by transrectal ultrasonography. This type of medication generally will produce symptoms improvement within days after treatment initiation. Medications in this class include alfuzosin, doxa- zosin, tamsulosin, terazosin, and silodosin. Most common side-effects associated wit h α -blockers are weakness, abnormal ejaculation, and orthostatic hypotension. Patients’clinical responses to this class of medications generally are delayed by several months. M ajor side-effect s are reduct ion in libido, erect ile dys- fu n ct ion, an d abn or mal ejacu lat ion. Muscarinic-receptor antagonists: Muscarinic receptors are highly expressed in bladder smooth muscle cells, prostate, and bladder urothelial cells. Muscarinic- receptor blockade reduces bladder contraction and bladder sensory threshold (reduces urinary urgency). These drugs are mainly used for the treatment of over- act ive bladder in men and women. Side-effect s include dry mout h, const ipat ion, micturition difficulties, and dizziness. Vasopressin analogue (desmopressin): This drug controls urine production by binding to the V2 receptor in the renal collecting ducts. This medicat ion is h elpful for the management of patients with bothersome nocturia. Long-t erm com- plications associated with these procedures include urinary incontinence, bladder neck strictures, retrograde ejaculation, and erectile dysfunction. T h e pro- cedure produces cont rolled destruction of the prost ate and relief of bladder outlet obstruction. Open prostatectomy: This is the m o st in vasive su r gical o p t io n b u t is also m o r e effec- tive and more durable than the other surgical options. Transurethral laser vaporization of the prostate: Several laser energy deliver y devices can be int r odu ced by the t r an su r et h r al r out e wit h the d eliver y of en er gy t o the prost ate. The short-term result s are good; however, because these are newer treat- ments, long-term outcomes are not yet available. Referral to a general surgeon for the abdominal mass and a neurologist for the urin ar y in cont in en ce E. H e is cu r r en t ly t akin g an α -1 blocker for this prob- lem and h as recent ly present ed t o the emergency depart ment for dizziness that is affecting his ability to continue as a commercial pilot. Aft er det ailed discussions wit h t he pat ient, it appears t hat h is main complaint is noctural urinary frequency (2-3 t imes/ night ). H e has already reduced h is nighttime fluid intake with only minor improvement in symptoms. T his pat ient’s digit al rect al exami- nation reveals a normal-sized, smooth, prostate gland. T r an sr ect al u lt r aso n o gr ap h y an d b io p sy of the p r o st at e C. At this point, a t ransrect al ultrasound to evaluate the prostate and obtain biopsies of abnormal areas is indicated. This patient’s clinical presentation is compatible with overflow inconti- nence and bladder outlet obstruction. Therefore, when the person coughs, st ands, or increases t he abdominal pressure, urine leaks out s in a dribbling fash ion. T h e h ist ory and physical examinat ion are sufficient t o make the diagnosis, and placement of a urinary catheter is the best initial treatment. Alpha-1 Blockers cause smooth muscle relaxation but are associated wit h side effect s of dizziness and ort host at ic hypot ension. Desmopressin at bedtime may be helpful for this patient with a primary complaint of n oct u r ia an d ph ysical exam in at ion d emon st r at in g min imal prostate enlargement. It is likely that his symptoms are the result of an over- act ive bladder rat her t han bladder out let obst ruct ion. He d o e s n o t re ca ll t ra u m a t o the a re a a n d h a s n o u rin a ry comp laints. On examination, his b lood pressure is 110/70 mm Hg, his heart rate is 80 b e a t s/ m in u t e, a n d h e is a fe b rile. Th e e xt e rn a l genitalia examination reveals a 2-cm nontender mass in the right testis. Know that a non-tender, non-transilluminating testicular mass in a man under the age of 40 should be considered a testicular cancer until proven otherwise. Understand that knowledge of the correct pathological diagnosis or cell type(s) is crucial in direct ing t reat ment of test icular cancers. Know that a testicular carcinoma can be cured; however, patient compliance with t reatment and surveillance protocols is import ant. Co n s i d e r a t i o n s Test icular cancer is the most common malignancy in men bet ween the age of 15 and 35, with the incidence of 3-5/ 100,000 men.