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What recommendation should you make regarding how frequently she should undergo Pap smear testing She had three vaginal deliveries hiv symptoms two weeks after infection order famciclovir paypal, the last of which was complicated by gestational diabetes and preeclampsia hiv and hcv co infection symptoms purchase famciclovir pills in toronto. Her family history is significant for coronary artery disease in her dad and a maternal aunt who developed ovarian cancer at the age of 67 antiviral brandon cronenberg trailer discount famciclovir 250 mg line. A 30-year-woman presents to antivirus windows 8 discount famciclovir line your office with the fear of developing ovarian cancer. Currently she and her husband use condoms, but they hate the hassle of a coital-dependent method. She is interested in a more effective contraception because they do not want any more children. She reports occasional migraine headaches and had a serious allergic reaction to anesthesia as a child when she underwent a tonsillectomy. During her office visit, you counsel the patient at length regarding birth control methods. Which of the following is the most appropriate contraceptive method for this patient Her family history is significant for stroke, dia betes, and high blood pressure. Her blood pressure is 150/92 mm Hg, pulse 70 beats per minute, respiratory rate 14 breaths per minute, and tem perature 37C (98. The next appropriate step in the management of this patients blood pressure is which of the following Nicotine replacement in the form of chewing gum or transdermal patches has not been shown to be effective in smoking cessation programs. No matter how long one has been smoking, smoking cessation appears to improve the health of the lungs. Alternatively, flexible sigmoidoscopy can be performed every 5 years along with a yearly fecal occult blood test. After a woman has had three or more con secutive normal Pap smears, the Pap test may be performed less frequently in a low-risk woman. A hepatitis B vaccine would be indicated only in individuals at high risk (ie, international travelers, intravenous drug users, and their sexual contacts, those who have occupational exposure to blood or blood products, persons with chronic liver or renal disease, or residents of institutions for the devel opmentally disabled, and inmates of correctional institutions). Parabasal cells on a Pap smear indicate lack of estrogen and are a normal finding in postmenopausal women. Hepatitis C virus testing is indicated only in persons with a history of injecting illegal drugs, those who have received blood transfusions before 1992, those with occupational exposure to blood products, or those undergoing chronic hemodialysis. She is not a candidate for the varicella Preventive Care and Health Maintenance Answers 193 vaccine since she has had chicken pox. The hepatitis A vaccine is indicated for international travelers, illegal drug users, and health care workers. The pneumococcal vaccine is indicated in immunocompromised persons, those with chronic illnesses, and individuals more than 65 years old. The influenza vaccine is especially indicated in pregnant women, individuals with chronic diseases, and those in long-term-care facilities. It is best to perform the breast examina tion in both the erect and supine positions. Asymmetry of the breasts is common in most women, but any recent changes need to be reported. Any nipple discharge should be reported immediately to a physician, because it can be associated with an underlying tumor. The Pederson speculum works best for nulliparous women and menopausal women with atrophic vaginas; the blades are flat and narrow and barely curve on the sides. The blades of the Graves speculum are wider, higher, and curved on the sides; they work better for parous women with looser vaginal walls. A childs vagina can best be examined using an instrument called a vaginoscope or some type of endoscope such as a hysteroscope. The Graves and Pederson speculums come in pediatric sizes to be used in virginal adults or young chil dren. Nasal specula are too short to be used to examine the vagina in adults and children. More specifically, the parity is further subclassified into number of term deliveries, preterm deliveries, abortions (spontaneous or induced) or ectopics, and number of living children. Since this patient is a G6P3215, she has been pregnant six times and has had three term deliveries, two preterm deliveries, one abortion, and has five liv ing children. Pederson specula have nar rower blades and are most appropriate for nulliparous patients and post menopausal patients with atrophic vaginas. Pediatric specula, vaginoscopes, and hysteroscopes are all used to examine infants or prepubertal children. These are usually small and asymptomatic and are found inci dentally during a pelvic examination. They can be followed conservatively unless the patient becomes symptomatic, at which time excision is recom mended. Inclusion cysts are the most common vaginal cysts and result from birth trauma or previous gynecologic surgery. Bartholin ducts open into a groove between the hymen and labia minora on the posterior lateral vaginal open ing. Lipomas are benign, encapsulated tumors of fat cells; they are most commonly discovered in the labia majora and are superficial in location. Hematomas of the vulva usually occur as a result of blunt trauma or strad dle injury. Spontaneous hematomas can occur as a result of rupture of a varicose vein in pregnancy or the postpartum period. This patient is not considered to be a low-risk patient since she Preventive Care and Health Maintenance Answers 195 has a history of previous cervical pathology. This patient is at an increased risk of developing diabetes because she experienced ges tational diabetes during pregnancy. With her previous history of treatment for cervical dysplasia, yearly Pap smear is recommended. The use of combination oral contraceptives decreases the risk of developing ovarian cancer by about 40%. Nulliparity, increasing age, and fertility drugs all increase ovulatory cycles and therefore are risk factors for developing ovarian cancer. In the general population, the risk of developing ovarian cancer is about 1% to 1. This risk increases to about 5% if a woman has one first-degree relative with ovarian cancer and to about 7% if she has two or more first degree relatives with ovarian cancer. A bilateral tubal ligation would be another option; how ever, the patient had a serious allergic reaction to anesthesia as a child, and general anesthesia is required for female laparoscopic sterilization. The patients smoking and age contraindicate the use of combination oral contra ceptives. Migraine headaches accompanied by neurologic symptoms such as loss of vision, paresthesias, and numbness are generally considered to be a contraindication to combination oral contraceptive use. However, there are no studies that show a statistically significant increased risk of stroke in pill users who have migraine headaches. Use of a diaphragm is a coital-dependent action and the patient relates that that is not something she desires. A single ele vated diastolic blood pressure less than 100 mm Hg should be treated, but should be rechecked within 2 months. The first line of treatment for women with hypertension should be lifestyle changes: smoking cessation, weight loss, diet modification, stress management, and exercise. If after 3 months these measures have failed to lower blood pressure, then pharmacologic therapy should be instituted. There are studies that demonstrate that smoking cessation is of ben efit to pulmonary health regardless of how long one has smoked. Doctors should repeatedly counsel their patients to stop smoking, and follow-up visits to achieve these goals are effective. Nicotine replacement therapy and transdermal nicotine patches have increased the effectiveness of smoking cessation programs. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus Ultrasound confirms a com plex left adnexal mass with solid components that appear to contain bone and teeth.

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However antiviral natural factors generic famciclovir 250mg with amex, it is fairly com sis of collagen obtained from the skin hiv infection rash discount famciclovir 250 mg otc, white mon in hospitals and extended care facili connective tissue hiv infection rates miami purchase famciclovir with amex, and bones of animals hiv infection unprotected penetration purchase famciclovir 250 mg free shipping. In ties for a caregiver to open capsules or crush commerce, it is available in the form of a fine tablets to mix with food or drink, especially powder, a coarse powder, shreds, flakes, or for children or other patients unable to swal sheets. This should be done Gelatin is stable in air when dry but is sub only with the concurrence of the pharmacist, ject to microbial decomposition when it be since the drug-release characteristics of cer comes moist. Normally, hard gelatin capsules tain dosage forms can be altered and can ad contain 13% to 16% of moisture (2). In an environment of Hard gelatin capsule shells are used in most extreme dryness, some of the moisture nor commercial medicated capsules. They are mally present in the gelatin capsules is lost, also commonly employed in clinical drug and the capsules may become brittle and trials to compare the effects of an investi crumble when handled. Therefore, it is desir gational drug with those of another drug able to maintain hard gelatin capsules in an product or placebo. The community phar environment free from excessive humidity or macist also uses hard gelatin capsules in the dryness. The empty capsule shells are made of gelatin capsules and may affect hygroscopic gelatin, sugar, and water (Fig. As such, agents within, many capsules are packaged they can be clear, colorless, and essentially along with a small packet or cylinder of a des tasteless. Because such changes the Heidelberg capsule, the approximate size could forewarn of possible changes in bio of a No. As discussed in Chapter 5, drug absorp Most capsules are designed for oral admin tion from the gastrointestinal tract depends istration. Some patients prefer to swallow a capsule wetted with water or saliva because a wetted the Manufacture of Hard Gelatin capsule slides down the throat more read Capsule shells ily than a dry capsule. Gelatin is soluble in hot water and in warm gastric fluid; a gela Hard gelatin capsule shells are manufac tin capsule rapidly dissolves and exposes its tured in two sections, the capsule body and contents. Some capsule oped to track the passage of capsules and shells are designed to lock in place when tablets through the gastrointestinal tract to closed. The shells are produced industrially map their transit time and drug-release pat by the mechanical dipping of pins or pegs terns. Among these is gamma scintigraphy, a of the desired shape and diameter into a noninvasive procedure that entails the use temperature-controlled reservoir of melted of a gamma rayemitting radiotracer incor gelatin mixture (Figs. The pegs, porated into the formulation with a gamma made of manganese bronze, are affixed to camera coupled to a data recording system plates, each capable of holding up to about (4, 5). Each plate is mechanically lowered gamma scintigraphy is small and does not to the gelatin bath and the pegs submerged compromise the usual in vivo characteristics to the desired depth and maintained for the of the dosage form being studied. When scin desired period to achieve the proper length tigraphy is combined with pharmacokinetic and thickness of coating. Then the plate and studies, the resultant pharmacoscintographic the pegs are slowly lifted from the bath, and evaluation provides information about the the gelatin is dried by a gentle flow of tem transit and drug-release patterns of the dos perature and humidity-controlled air. When age form as well as the rate of drug absorption dried, each capsule part is trimmed mechani from the various regions of the gastrointesti cally to the proper length and removed from nal tract (4). This method is particularly useful the pegs, and the capsule bodies and caps are in (a) determining whether a correlation exists joined together. A manufacturer also may prepare distinctive-looking capsules by altering the usual rounded shape of the capsule-making pegs. By tapering the end of the body producing peg while leaving the cap-making peg rounded, one manufacturer prepares capsules differentiated from those of other manufacturers (Pulvules, Eli Lilly). Another manufacturer uses capsules with the ends of both the bodies and caps highly tapered (Spansule Capsules, SmithKline Beecham). Each machine is capable of producing 30, 000 sign is the Snap-fit, Coni-snap, and Coni capsules per hour. It takes a 40-minute cycle to produce snap Supro hard gelatin capsules depicted a capsule. The original Snap-fit construction enables the two halves of the to prevent disengagement. The pegs on capsule shells to be positively joined through which the caps are formed are slightly larger locking grooves in the shell walls. The two in diameter than the pegs on which the bod grooves fit into each other and thus ensure re ies are formed, allowing the telescoping of liable closing of the filled capsule. In capsule shell pro closing process, the capsule body is inserted duction, there is a continuous dipping, dry into the cap. With the high-capacity filling ing, removing, and joining of capsules as the rates of the modern capsule-filling machines peg-containing plates rotate in and out of the (more than 180, 000 capsules per hour), split gelatin bath. As noted earlier, capsule shells ting (telescoping) and denting of the capsule shell occur with the slightest contact between the two rims when they are joined. This prob lem, which exists primarily with straight walled capsule shells, led to the development of the Coni-snap capsule, in which the rim of the capsule body is not straight but tapered slightly (Fig. This reduces the risk of the capsule rims touching on joining and es sentially eliminates the problem of splitting during large-scale filling operations. In the Coni-snap Supro capsules, the upper capsule part extends so far over the lower part that only the rounded edge of the latter is visible (Fig. Opening of such a filled capsule is difficult because the lower surface offers less gripping surface to pull the two halves apart. After filling, some manufacturers ren der their capsules tamper evident through various sealing techniques. This makes separation of the two parts more difficult and Capsule sizes contributes to capsule integrity. For prescriptions requiring extempora the size selected for use is determined by the neous compounding, hard gelatin capsules amount of fill material to be encapsulated. The pharmacist may compound largely determine to what extent it may be capsules of a single medicinal agent or com packed into a capsule shell (7) (Fig. For bination of agents at the precise dosage pre estimation, a comparison may be made with scribed for the individual patient. However, the final deter the large-scale or small-scale preparation of mination may be largely the result of trial and filled hard gelatin capsules is divided into error. For human use, empty capsules ranging the following general steps: in size from 000 (the largest) to 5 (the smallest) are commercially available (Fig. A diluent or filler may be added to the formulation to produce the proper capsule fill volume. Lactose, microcrystalline cel lulose, and starch are commonly used for this purpose. In addition to providing bulk, these materials often provide cohesion to the powders, which is beneficial in the transfer of the powder blend into capsule shells (2). This is particularly important when a drug of low dosage is blended with other drugs or nondrug fill (8). When necessary, developing the formulation and particle size may be reduced by milling to pro selecting the Capsule size duce particles ranging from about 50 to 1, 000 In developing a capsule formulation, the goal mm. For drugs of lower dose or when In dry formulations, the active and inac smaller particles are required, micronization is tive components must be blended thoroughly employed. The addition of a lubricant or glidant agent, or some other pharmaceutical excipi such as fumed silicon dioxide, magnesium ent, formulation can influence the bioavail stearate, calcium stearate, stearic acid, or talc ability of a drug substance and can account (about 0. Pharmacists must be aware of this lubricant, the waterproofing characteristics possibility when product interchange, for of this water-insoluble material can retard example, generic substitution, is considered. Even if a water-insoluble lubricant separate chemically incompatible agents or is used, after the gelatin capsule shell dis to add premeasured amounts of potent drug solves, gastrointestinal fluids must displace substances. Rather than weighing a potent the air that surrounds the dry powder and drug, a pharmacist may choose to insert a penetrate the drug before it can be dispersed prefabricated tablet of the desired strength in and dissolved. Other less potent agents and di drugs have a tendency to resist such pen luents may then be weighed and added. The choice is determined ous liquids because water softens gelatin and by requirements of the formulation, includ distorts the capsules, resulting in leakage of ing the dose of the active ingredient and the the contents. However, some liquids, such density and compaction characteristics of as fixed or volatile oils, that do not interfere the drug and other components. If the dose with the stability of the gelatin shells may of the drug is inadequate to fill the volume be placed in locking gelatin capsules (or the of the capsule body, a diluent is added.

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However boots anti viral order discount famciclovir online, consultation with the prescriber indicates that the patient is frail and requires a lower than norm al dose of codeine to hiv infection mouth ulcers cheap famciclovir 250mg line achieve pain control antiviral krem purchase famciclovir cheap. An excess is made to how long after hiv infection do symptoms show buy famciclovir 250mg line allow w hich is below the m inim um w eighable for losses during preparation. As 100 m g cannot be accurately w eighed, the quantities in m ix X need to be adjusted. Flavouring w hen appropriate Oral pow ders are sw allow ed w ith a draught of w ater and, as such, do not require avouring. M ethod for preparing Codeine Phosphate 10 m g unit dose powders using the above form ula 1. Choice of container Once m anufactured, the pow ders should be packaged ap to ap and enclosed w ith a rubber band. Title the product is unof cial, therefore the follow ing title w ould be suitable: Codeine Phosphate 10 m g pow ders. Product-speci c cautions (or additional labelling requirem ents) Store in a dry place w ill need to be added to the label as the products are individual dose pow ders. The British National Form ulary (51st edn, p 226) recom m ends the follow ing caution: Label 2 Warning: may cause drowsiness. Discard date the products are individual unit dose pow ders and so w ill attract a 3-m onth discard date. Advice to patient the patient w ould be advised to take the contents of one pow der w ith a glass of w ater w hen required. In addition, the discard date, the need to store the product in a dry place and the additional British National Form ulary w arning w ould be highlighted. W hich of the follow ing directions should alw ays be included on the label of single unit dose pow ders W hich of the follow ing reference books contains an appendix advising on cautionary and advisory labelling requirem ents W hat labelling instruction is needed on single dose pow ders but not on capsules How m any capsules w ould you provide on a prescription w ith instructions 1 tds 5/7 How m any capsules w ould you supply if the directions on the prescription read 2 qqh 1/52 W hat quantity of capsules w ould you dispense if a prescription gave the directions 1 tds increasing to 1 qds after a fortnight. W hich size capsule w ould be the capsule of choice w hen dispensing 200 m g of pow der Bulk oral pow ders are suitable for the adm inistration of relatively non-potent m edicam ents. Assum ing you m ake 10 pow ders, each w eighing 200 m g, to allow a suitable excess, w hich of the follow ing w ould be the m ost suitable form ula for your concentrated pow der m ix X You receive a prescription in your pharm acy w ith the follow ing details: Patient: Mrs Grace Browning, 47 Bridgeport Street, Astonbury Age: 34 Prescription: Bendro umethiazide 2. You receive a prescription in your pharm acy w ith the follow ing details: Patient: Miss Jessica Felsham, 4 Farnham Place, Astonbury Age: 10 Prescription: Imipramine Caps 50 mg Directions: 1 nocte M itte: 6 Answers to self-assessment Chapter 2: Solutions 1. Therefore a 20% w/v solution will contain 2 g per 10 m l, 1 g per 5 m l and 500 m g per 2. If sodium bicarbonate is soluble 1 in 11, that m eans that 1 g is soluble in 11 m l. Used to treat chronic acidotic states (British National Form ulary 51st edn, p 477). This patient has been recently discharged from hospital and the hospital states that the recom m ended dose for a child 1 m onth2 years is 12 m m ol/kg daily in 12 divided doses. In order to con rm the dose on the prescription is safe and suitable, the w eight of the child w ould be required. The parent w ould be able to provide this inform ation: this w ould be m ore accurate than the average w eight listed in the British National Form ulary. In this case the child w eighs 5 kg, therefore the dose that w ould be safe is 510 m m ol daily in divided doses and the am ount ordered on the prescription concurs w ith this. Freshly boiled and cooled puri ed w ater w ould be used as the solution is intended to be adm inistered to a baby w ith renal problem s. M easure approxim ately 100 m l of freshly boiled and cooled puri ed water and transfer to a beaker. Transfer to a 200 m l am ber at m edical bottle with a child-resistant closure and label. A plain am ber bottle w ith a child-resistant closure w ould be m ost suitable as the preparation is a solution for internal use. The product is unof cial, therefore it is necessary to put the quantitative particulars on the label. As the product is intended for internal use, the quantitative particulars w ould be expressed per dose. The parent/guardian w ould be show n how to use the oral syringe and instructed to give 10 m l using the oral syringe tw ice daily w ith feeds. In order to prepare this product w e need to dilute a concentrate that is com m ercially available. The Hibitane concentrate is m iscible w ith both w ater and alcohol (British National Form ulary 51st edn, p 607). Freshly boiled and cooled puri ed w ater w ould be the vehicle of choice as the preparation is being used as a skin disinfectant. Transfer to a 150 m l uted am ber m edical bottle with a child-resistant closure and label. A uted am ber bottle w ith a child-resistant closure w ould be m ost suitable as the preparation is a solution for external use. The product is unof cial, therefore the follow ing title w ould be suitable: Hibitane Solution 0. For external use only Do not use after (2 weeks) Each 150 ml contains: Hibitane Concentrate 5% 1. The patient would be advised to use the solution for cleansing the affected area as directed by her doctor. In addition, the discard date and the fact that the product is for external use only would be highlighted to the patient. They m ix readily with water and on shaking diffuse evenly through the liquid and rem ain in suspension long enough for a dose to be accurately m easured. Indiffusible solids are insoluble powders which will not rem ain evenly distributed in a vehicle long enough to ensure uniform ity of dose. This m ay be corrected by increasing the viscosity by adding a thickening/suspending agent. The patient is required to take each dose four tim es a day and a 2-week supply has been requested. Freshly boiled and cooled puri ed water would be chosen as the vehicle as the suspension does not contain a preservative. Answer: b (The am ount of suspending agent used depends on the am ount of powder to be suspended. The dose of 10 m l three tim es a day is consistent w ith the recom m ended dosage (British Pharm aceutical Codex 1973, p 746). Using the m aster form ula from the British Pharm aceutical Codex for 1000 m l of nal product, calculate the quantity of ingredients required to produce the nal volum e needed (150 m l). Noting that sodium bicarbonate is soluble 1 in 11 with water, a m inim um of 11 m l of water would be required to dissolve 1 g of sodium bicarbonate. As 1 g of sodium bicarbonate is soluble in 11 m l, 12 g is soluble in 132 m l (12 11 = 132 m l). Therefore a m inim um of 132 m l of vehicle would be required to dissolve the 12 g of sodium bicarbonate in this exam ple. For ease of com pounding choose a convenient volum e of vehicle, say 135 m l, in which to dissolve the solute initially. When choosing the am ount of vehicle to use for Answers to self-assessment 175 dissolution, it is im portant to consider the total am ount of each liquid ingredient in the preparation to ensure that only the correct am ounts are added or the nal product does not go over volum.

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In fact anti viral herb purchase 250mg famciclovir with visa, at times these patients may need to hiv infection first symptoms order discount famciclovir on line reduce the prolapse in order to hiv infection rates by continent order famciclovir 250mg online void antiviral interferon famciclovir 250 mg. Following surgical repair, if the urethrovesical junction is not properly elevated, stress urinary incontinence may result. This incontinence may present within the first few days to weeks following surgery. Vesicovaginal fistula would present with continuous leakage of urine from the vagina. In patients diagnosed with a urinary tract infection, treatment should be initiated and then the patient should be reevaluated. It is not uncommon for symptoms of urinary leakage to resolve after appropriate therapy. After obtaining the history and physical examination and evaluating a urinalysis (including urine culture), initial evaluation of the incontinent patient includes a cystometrogram, check for residual urine volume, stress test, and urinary diary. A cystometrogram is a test that determines urethral and bladder pres sures as a function of bladder volume; also noted are the volumes and pres sures when the patient first has the sensation of need to void, when maximal bladder capacity is reached, and so on. Residual urine volume is determined by bladder catheterization after the patient has voided; when urine remains after voiding, infection and incontinence may result. The rectal sphincter can be completely lacerated, but as long as the patient retains a functional puborectalis sling, a high degree of continence will be main tained. Therapy for fecal incontinence includes bulk-forming and antispasmodic agents, especially in those patients presenting with diarrhea. Biofeedback and electrical stimulation of the rectal sphincter are other possible conserva tive treatments. Surgical repair of a defect is indicated when conservative 290 Obstetrics and Gynecology measures fail, when the defect is large, or when symptoms warrant a more aggressive treatment approach. The technique involves partial denudation of opposing surfaces of the vaginal mucosa followed by surgi cal apposition, thereby resulting in partial obliteration of the vagina. Patients who are candidates for this procedure must have no evidence of cer vical dysplasia or endometrial hyperplasia, have an atrophic endometrium, and no longer desire sexual function since the vagina is essentially obliter ated and there is no longer access to the cervix or uterus via the vagina. Urinary incontinence can be a side effect of this procedure, so care must be exercised in the denudation of vaginal mucosa near the bladder. In a patient who already has urinary incontinence, the Le Fort operation would be relatively contraindicated. An A&P repair essentially involves excision of redundant mucosa along the anterior and posterior walls of the vagina, at the same time strengthening the vaginal walls by suturing the lateral par avaginal fascia together in the midline. Undoubtedly, the most important fac tor is the actual quality of the tissue itself. There is a much lower incidence of uterine prolapse and enterocele formation in black and Asian patients in comparison with whites. Any factors that increase abdominal pressure can aggravate or further deteriorate the prolapse. Although the actual number of deliveries is probably not important, traumatic deliveries, especially those in which the rectal sphincter is lacerated or improperly repaired, have been associated with pelvic relaxation. In approximately 1% to 2% of patients undergoing the procedure, the painfully debilitating condi tion of osteitis pubis will develop. Treatment of this aseptic inflammation of the symphysis is suboptimal, and the course is usually chronic. Short-term intermittent or indwelling catheteri zation is the treatment for urinary retention. In addition to the surgery, the patient in question will require medical treatment for her incontinence as her preoperative cystometrics showed evidence of detrusor instability. The typical symptoms include urinary frequency, urgency, dysuria, hematuria, and dyspareunia. A urethral diverticu lum is often palpable as a mass on the anterior vaginal wall under the ure thra. Although urethral polyps, eversion, fistula, and stricture may present with similar symptoms, there is no suburethral mass present. A noninvasive renal ultrasound is fast, inexpensive, and accurate way to make the diag nosis. Intravenous antibiotics are not indicated at this time since there is not clear evidence of an infection (normal white blood cell count). The patient has a normal drop in hemoglobin for the surgical blood loss and does not have signs of hemodynamic instability to warrant a blood trans fusion at this time. During the cystometrogram, a normal first sensation is of fullness felt at 292 Obstetrics and Gynecology 100 mL. The primary reason to perform a cystometrogram is to rule out uninhibited detrusor contractions. The urethral pressure profile is normal in women with genuine stress urinary incontinence. Genuine stress incontinence is a condition of immediate involuntary loss of urine when intravesical pressure exceeds the maximum urethral pressure in the absence of detrusor activity. Patients with this con dition complain of bursts of urine loss with physical activity or a cough, laugh, or sneeze. The cause of stress incontinence is structural, attributed to a cystocele or urethrocele. In cases of overflow incontinence, patients experience a continuous loss of a small amount of urine and associated symptoms of fullness and pressure. Overflow incontinence is usually caused by obstruction or loss of neurologic control. Women with detrusor instability/dyssynergia have a loss of bladder inhibition and complain of urgency, frequency, and nocturia. Vesicovaginal fistulas are uncommon and usually occur as a complication of benign gynecologic procedures. Women with this complication usually present with a painless and continuous loss of urine from the vagina. Sometimes the uncontrolled loss of urine is not continuous but related to a change in position or posture. In the case of uri nary tract infections, women usually present with symptoms of frequency, urgency, nocturia, dysuria, and hematuria. A urine cul ture, cystoscopy, and cystometrics may also be part of the workup for this patients chief complaint, but the physical examination should be the very next step. Placement of a pessary is one of the treatments for a cystocele, once the diagnosis has been made. Placement of a pessary is an option to relieve a cys tocele, but is not ideal in this patient, who is sexually active. Antibiotics such as Bactrim would be used to treat a urinary tract infection, but would not affect stress incontinence. A Le Fort procedure is performed in patients with vaginal vault prolapse and pelvic relaxation who are poor surgical candidates and not sexually active. The procedure involves obliterating the vaginal canal to provide support to the pelvic structures. Anticholinergic drugs such as Ditropan (oxybutynin chloride) are used to relax the bladder in the treatment of detrusor instability. The use of vaginal estrogen cream may relieve vaginal atrophy and improve patient comfort in postmenopausal patients, but it will not correct the cystocele or treat incontinence. Natural aging of the tissue, intrinsic weak nesses caused by genetics, birth trauma, hypoestrogenism, and chronic ele vation of intraabdominal pressure because of obesity, cough, or heavy lifting are all factors that contribute to pelvic relaxation. Diabetes can result in neu ropathy, which can affect the neurologic control of the bladder, but this medical condition is not a cause of pelvic relaxation. Kelly plication is an older procedure used to suspend the ure thra and has a lower cure rate for stress incontinence than the Burch procedure. The Burch procedure suspends the bladder neck to Cooper lig ament of the pubic bone using an abdominal approach. Anterior and poste rior colporrhaphy are procedures used to correct cystoceles and rectoceles and are not indicated in this patient. Sacral colpopexy is a procedure to repair prolapse of the vagina by suspending the vaginal vault from the sacrum. Seventy-five percent of fistulas occur after abdominal hysterectomies and 25% occur as a result of vaginal operations.

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