What you need to know about the HPV (Human Papillomavirus Vaccine)

shutterstock_167922080One of the most controversial topics in medicine recently has been the HPV vaccine.  It can save lives by helping prevent cervical cancer but must be given at an early age.

What is HPV?  Genital human papillomavirus (HPV) is the most common sexually transmitted virus in the United States.  More than half of sexually active men and women are infected with HPV at some time sin their lives.

About 20 million American are currently infected, and about 6 million more get infected each year.  HPV is usually spread through sexual contact.

Most HPV infections don’t cause any symptoms, and go away on their own.  HPV can cause cervical cancer in women.  Cervical cancer is the 2nd leading cause of cancer deaths among women around the world.  In the United States, about 12,000 women get cervical cancer every year about 4,000 are expected to die from it.

HPV is also associated with several less common cancers, such as vaginal and vulvar cancers in women, and anal and oropharyngeal (back of the throat, including base of the tongue and tonsils) cancers in both men and women.  HPV can also cause genital warts and warts in the throat.

There is no cure for HPV infection, but some of the problems it causes can be treated.

HPV vaccine: Why get vaccinated?  The HPV vaccine is one of two vaccines that can be given to prevent HPV.  It may be given to both males and females. This vaccine can prevent most cases of cervical cancer in females, if it is given before exposure to the virus.  In addition, it can prevent vaginal and vulvar cancer in females, genital warts and anal cancer in both males and females.  Protection from HPV vaccine is expected to be long-lasting.  Vaccination however is not a substitute for cervical cancer screening.  Women should still get regular Pap tests.

Who should get the HPV vaccine and when?  HPV vaccine is given as a 3-dose series.  The first dose is initially given, with the second dose 1-2 months after the first dose and the final third dose is given 6 months after dose 1. Additional (booster) doses are not recommended.  The HPV vaccine is recommended for girls and boys 11 or 12 years of age.  It may be given starting at age 9.

Why is HPV vaccine recommended at 11 or 12 years of age?  HPV infection is easily acquired, even with only one sex partner.  That is why it is important to get HPV vaccine before any sexual contact takes place.  Also, response to the vaccine is better at this age than at older ages.

Catch-Up Vaccination:  This vaccine is recommended for females ages 13-26 years of age who have not completed the 3-dose series or males 13-21 years old who have not completed the 3-dose series.  This vaccine maybe given to men 22 through 26 years of age who have not completed the 3-dose series. It is recommended for men through age 26 who have sex with men or whose immune system is weakened because of HIV infection, illness or medications.   It may be given at the same time as other vaccines.

Some people should not get HPV vaccine or should wait:  Anyone who has ever had a life-threatening allergic reaction to any component of the HPV vaccine, or to a previous dose of HPV vaccine, should not get the vaccine.  Tell your doctor if the patient has any severe allergies, including an allergy to yeast. HPV vaccine is not recommended for pregnant women, however receiving the vaccine when pregnant is not a reason to consider terminating the pregnancy.  Women who are breast feeding may get the vaccine.  Any woman who learns that she is pregnant when she got the vaccine is encourage to contact the manufacturer’s HPV-in-pregnancy registry at 800-986-8999.  This will help us learn more about how pregnant women respond to the vaccine.

What are the risks from this vaccine?  The HPV vaccine has been used in the U.S. and around the world for about six years and has been very safe.  Any medication however could possibly cause a serious problem or severe allergic reaction.  The risk of vaccines causing serious injury or death however is very small.  Life-threatening allergic reactions from vaccines are very rare.  If they do occur, it would happen within a few minutes to hours after the vaccination.  Several mild to moderate problems are known to occur with this vaccine.  These symptoms do not last long and go away on their own.

1)      Reactions in the arm where the shot was given

2)     Pain around the injection site

3)     Redness or swelling around the injection site

4)     Mild fever up to 100 degrees F

5)     Moderate fever up to 102 degrees F

6)     Headache

7)     Fainting during the procedure – usually caused from being nervous

What if there is a moderate or severe reaction – what should I look for?  Any unusual condition such as high fever or behavior changes of the person who received the vaccination.  Signs of a serious allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, fast heart rate or dizziness.  If any of these occur, call a medical provider or 911 immediately.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

This information comes from the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC).

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Sexually Transmitted Infections – “So you want to be tested for everything…”

shutterstock_36483805I frequently have patients come into the office and ask for STI (sexually transmitted infections) screening.  This is often done when they start a new relationship, when they find out that a partner has been unfaithful or if they have unprotected sex with someone that they don’t know well.  Patients often have no understanding of which sexually transmitted infections (formerly referred to as sexually transmitted diseases) they should be checked for and rely on their health care providers to order the proper tests and discuss the results with them.  Patient’s often will refer to being “clean” or “clear” when referring to their screening results.  When I ask them which infections they would like to be screened for, I usually hear something like “check me for everything.”

I think it’s important for patients to know which infections are most common, what the symptoms might be and know what to ask for when going to your doctor to be checked for sexually transmitted infections.  It’s also important to understand that some infections can be cured (with antibiotics), some infections can be controlled but never eradicated completely, and some infections can be present and not have any symptoms for years before becoming apparent.  Checking for “everything” might mean different things to different patients or medical providers, so my advice is to be very specific with what tests you request your medical provider order and keep track of the results so that when you think about “being clean” or “clear” of infection, you know exactly which infections you are clear of.

Types of infections:

1)  Chlamydia:  The most common sexually transmitted infection in the U.S.  This infection can cause pain and inflammation of the urethra (opening where urine comes out), the testicular area, the cervix and anus.  If untreated chlamydia can lead to infertility, chronic pelvic pain, prostatitis, and even severe infections of the fallopian tubes or tubal pregnancy.  Most men and women who are infected with chlamydia do not have symptoms.  Testing can be done with a urine sample from the patient or a swab.

2)  Herpes simplex virus:  It is estimated that about ¼ of the US population has herpes type 1 or 2 and many infected patients are unaware that they have the virus.  Skin ulcers are a result of the infection and increase the risk spreading or acquiring HIV.  Many patients with herpes are not screened because unless patient’s give a description of an ulcer in the genital area, a blood test for the antibodies to the viruses is usually not ordered.  If an ulcer is present, a swab may be collected by touching an open ulceration and sent for viral culture.  If you are concerned that you may have genital herpes, make sure you tell your medical provider and discuss testing with them because routine testing for herpes is usually not done unless there is some suspicion of infection.

3)  Gonorrhea:  The highest rates of infection are in sexually active 15-19yo women and 20-24yo men.  Rates are 20x higher in African-Americans than in whites.  Infection can lead to pain and inflammation of the urethra (opening where the urine comes out), sore throat and anal infection.  If untreated it can lead to serious complications in women including pelvic inflammatory disease and infertility.  Testing is frequently done from a urine sample or a swab.  Because of high rates of reinfection, patients diagnosed with gonorrhea should be advised to retest in 3 months.

4)  Trichomoniasis:  Infection with trichomonas produces symptoms similar to a urinary tract infection including pain and inflammation of the urethra (where the urine comes out), and/or vaginal discharge.  It can be present and men or women.  Most men who are infected do not have symptoms.  Testing is done by examination of a urine specimen.  Testing for trichomonas is not generally done on routine screening for STDs unless the patient asks for it or has symptoms.

5)  Syphilis:  Testing for syphilis is done with a standard blood test normally.  Symptoms of syphilis vary depending on the stage of infection.  Initially there is the appearance of a single sore mark, but there may be multiple sores.  The sore is usually firm, round and painless.  Because the sore is painless, it can easily go unnoticed.  It lasts 3-6 weeks and heals regardless of whether or not the person is treated.  If the infected person does not get treatment, the infection will progress to the second stage.  Skin rashes and/or sores in the mouth, vagina and anus (also called mucous membrane lesions) are typical of the second stage of symptoms.  The rash usually does not cause itching and may appear as rough, red or reddish brown spots both on the palms of the hands and/or the bottoms of the feet.  Sometimes rashes associated with secondary syphilis are so faint that they are not noticed.  Other symptoms of secondary syphilis include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.  The symptoms of secondary syphilis will go away with or without treatment.  Without appropriate treatment, the infection will progress to the latent and possibly late stages of disease.  The latent (hidden) stage can last for years.  About 15% of people who have not been treated for syphilis develop the late stage of the disease.  This stage can occur 10-30 years after the infection began and symptoms can include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia.  Damage to the internal organs, including the brain, nerves, eyes, heart, liver, bone and joints can occur and result in death.

6)  Hepatitis A, B and C:  Hepatitis that is transmitted by sexual contact is caused one of several different viruses (A, B or C).  All types of hepatitis virus infections can cause liver inflammation.  Hepatitis B and C can cause severe infection and lead to liver failure and death.  Hepatitis A is more commonly a cause of food-borne outbreaks.  Because there are vaccinations available for hepatitis A and B, we are seeing more patients recently developing hepatitis C because we currently do not have a protective immunization.  Hepatitis testing can be done through a simple blood test similar to HIV testing.  The initial test for hepatitis is usually done by trying to detect the antibody to the virus.  It can take your body several months after being infected with the hepatitis virus to develop the antibody and therefore there is a period of time called the “window period” when the test result may be negative even though the infection is present.  A repeat test is usually offered 3-6 months after the initial negative test for confirmation that the patient is negative after “high risk sexual contact.”

7)  Human Immunodeficiency virus (HIV):  It is important to recognize that patients who have been infected with other sexually transmitted infections may also be infected with HIV.  Recent recommendations from the Centers for Disease Control (CDC) recommend opt-out screening and annual screening for those at high risk for HIV infection.  The test for HIV is an antibody test.  Similar to hepatitis, it can take your body several months after being infected with HIV to develop the antibodies, and therefore there is a period of time called the “window period” when the test result may be negative even though infection is present.  Repeat testing 3-6 months after a previously negative result after “high risk sexual contact” is recommended.  HIV causes suppression of your natural immune system and can lead to a constellation of problems associated with immune suppression (infections, cancer) and AIDS related syndrome.

8)  Human papillomavirus (HPV):  This virus is the main cause of cervical cancer.  There are routine screening guidelines that have been established for pap smears which are the main way of detecting this virus and treating it before the development of cervical cancer.  All sexually active women should have a screening pap test by age 21.  Women between the ages of 9 and 26 years old are recommended to receive the HPV vaccine to prevent cervical dysplasia and cervical cancer.  Routine vaccination is recommended for female between 11 and 12 years, but the vaccination series may be started as early as 9 years and females aged 13-26 years can benefit as well.  The quadrivalent HPV vaccine can also be used in males and females aged 9-26 years of age to prevent genital warts and anogenital cancers.

Recommendations for screening for sexually transmitted infections in pregnant women, men who have sex with men, women who have sex with women and HIV infected patients vary depending on the risk group.

State health department notification:  Medical providers are required to notify the local and state public health departments in the case of chancroid, chlamydia, gonorrhea, acute hepatitis b, acute hepatitis c, HIV and syphilis.

Partner notification:  In the event that a patient has been diagnosed with a sexually transmitted infection, partners should be notified, examined and treated.  In some cases, the patient directly provides their sexual contact with medications and prescriptions to be filled (Partner Delivered Patient Medication (PDPM) although this is not legal in all states.  Patients and their partners should not have sexual relations until seven days after a single dose treatment or upon completion of a seven day regimen in cases of bacterial infections.  Discussion with sexual partners can be difficult but is very important for the partner’s safety and to prevent re-infection of the patient who tested positive initially.

2010 treatment/screening guidelines as outlined by the Centers for Disease Control in 2010:

  1. All patients being evaluated for STIs should be offered counseling and testing for HIV.
  2. Hepatitis B screening should be offered to men who have sex with men (MSM), injection drug users (IDU), persons attending an STI clinic or seeking STI treatment, and persons with history of multiple sex partners.  Patients who are not immune should be offered vaccination.
  3. Hepatitis A screening should be offered to MSM and injection drug users.  Those who are not immune should be offered vaccination.
  4. Asymptomatic women with risk factors for STIs should be screened for gonorrhea and chlamydia infection each year.
  5. Males and female between the ages of 9 and 26 years old should be offered the human papillomavirus vaccination (HPV vaccination).
  6. The following screening tests for active MSM are recommended on at least an annual basis:  HIV, gonorrhea, chlamydia, and syphilis.
  7. Syphilis screening is recommended for commercial sex workers, persons who exchange sex for drugs and persons in correctional facilities.
  8. Pregnant women should be screened for gonorrhea, chlamydia, HIV, hepatitis B, and syphilis infections.
  9. HIV-infected patients should be screened annually for gonorrhea, chlamydia, syphilis, hepatitis B and hepatitis C.  Vaccination against hepatitis A and B is recommended for nonimmune patients.  HIV-infected patients who actively use injection drugs or intranasal cocaine, engage in unprotected sex, are men who have sex with men, or are undergoing dialysis should have ongoing screening for hepatitis C.
  10. Local and state public health departments should be kept informed of notifiable infections, which include chancroid, chlamydia, gonorrhea, acute hepatitis A and acute hepatitis B, acute hepatitis C, HIV and syphilis.
  11. Partners should be notified, examined, and treated for the STI identified in the index patient.  Patients and their sex partners should abstain from sexual intercourse until therapy is completed.

References:  http://www.cdc.gov/std/treatment/2010/default/htm

Centers for Disease Control and Prevention.  Sexually Transmitted Disease Surveillance, 2008. US Department of Health and Human Services, Atlanta, GA 2009

US Preventative Services Task Force. Screening for gonorrhea.  Agency for Healthcare Research and Quality, Rockville, MD. Revised January 2006.

US Preventative Services Task Force. Screening for syphilis.  Agency for Healthcare Research and Quality, Rockville, MD. Revised January 2006.

US Preventative Services Task Force. Screening for herpes.  Agency for Healthcare Research and Quality, Rockville, MD. Revised January 2005.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Sexual Dysfunction in Men – Erectile Dysfunction and Beyond

shutterstock_136970978Purchasing medications for erectile dysfunction:  I first want to comment the issue of purchasing medication on the internet, through mail order , magazine articles or television ads that claim to sell medications such as Viagra, Cialis or Levitra or some herbal supplement for erectile dysfunction without the need for a prescription and at a low cost.  I highly recommend that you do not purchase these products this way because the sources are not known to be safe or reliable.  Would you purchase your blood pressure or diabetes medicine from someone you don’t know but who claims to be legit?  I sure wouldn’t!  It is not known if these drugs sold without prescription through ads like this are counterfeit or contain toxic chemicals which could be damaging to your health.

Men often come to talk with me about medications that may help with sexual problems such as inability to acquire or maintain an erection for sexual intercourse.  Since this is a popular topic in the primary care office, I thought I might discuss male sexual dysfunction, possible causes and some treatment options.

Some male sexual complaints may include:

1)     Premature ejaculation

2)     Delayed or inhibited ejaculation

3)     Lack of interest in sex (decreased sex drive)

4)     Unable to become erect or maintain an erection for satisfactory sexual intercourse (we also call this impotence or erectile dysfunction)

Erectile Dysfunction (ED):   Your doctor may diagnose erectile dysfunction if the man cannot acquire or maintain an erection during 75% of attempts to have sexual intercourse.  If a man has only occasional inability to have an erection and this improves later, they do not have erectile dysfunction (ED) as defined by the American Urological Association.

Possible causes of male sexual dysfunction:

1)      Limited blood flow to the penis can be caused by:

  1. Cigarette smoking
  2. Uncontrolled diabetes (high blood sugars)
  3. High blood pressure (hypertension)
  4. Alcoholism
  5. Illicit drug use
  6. Aging
  7. Depression
  8. Common medications prescribed by your doctor

2)     Psychological causes:  Performance anxiety, stress or decreased mood can lead to impotence.  Many patients explain that they accept a decrease in sexual function as being normal due to aging.  Often times there are reasons for decreased sexual function in men that once addressed can improve sexual function and increase the satisfaction with their sexual health.  One of the possible reasons such as performance anxiety is when the focus of the sexual act shifts from a romantic experience to one filled with anxiety about the ability to acquire or maintain an erection.  It’s also true in some men that as they mature, their interests and concerns may expand.  If he’s preoccupied with concerns about money or business matters, he may lose the sexual focus needed to maintain an erection.

How to determine the cause of male sexual dysfunction:   When a man expresses concern about sexual dysfunction, I usually start off by trying to determine the cause by asking some questions, performing an exam and then ordering some laboratory tests.  If you will be visiting your doctor and have concerns about sexual dysfunction, I recommend that you think about the following and be ready to discuss these items with your doctor:

1)      Do you get erections at night or in the morning when you first wake up?

2)     Are you having any personal problems with your sexual partner?

3)     Did the sexual dysfunction come on gradually or all the sudden?

4)     Do you have medical problems such as diabetes, high blood pressure, tobacco use, alcohol or illicit drug use or other psychological factors that could contribute to the dysfunction?

What to expect during a physical examination:  Some men may be resistant to come to their doctor to discuss sexual dysfunction because they’re not sure what to expect during the physical exam.  Your doctor may do the following:

1)     Check your blood pressure – it’s very important to get your blood pressure at goal

2)     Examine the penis, testicles and blood vessels in the groin

3)     Examine the chest for signs of abnormal breast swelling in men

Laboratory testing:  Your medical provider will often check several lab tests that can influence a man’s sexual ability.

1)     Testosterone (hormone) level – hormone

2)     Blood sugar tests – a fasting blood glucose or an A1c

3)     Thyroid hormone test (TSH)

4)     Prolactin (hormone) level

5)     Home nocturnal penile tumescence (NPT) is a test that measures how many erections the man is getting during the night when sleeping.  Men who have damage to the blood vessels or nerves involving the sexual organs usually have decreased nocturnal erections and we call this “organic” impotence.  Men with normal night-time erections are more likely to have psychologically related impotence although there may be a combination of the two factors involved.

6)     If the nocturnal penile tumescence test is abnormal, your doctor may ask you to have some special tests such as a ultrasound test to examine the deep arteries of the penis and groin to make sure they are getting enough blood flow.

Treatments for male sexual dysfunction:  Men often come in to the clinic and ask for medication without understanding that medication may not help if the cause of the problem is not discovered.  It’s very important to determine the cause of the sexual dysfunction because the improper use of medications can have serious side effects and may not actually cure or help the problem.

Medications to treat erectile dysfunction:

Testosterone therapy:  If your testosterone level is too low, correcting this by taking testosterone medication can improve sex drive, erectile dysfunction, increase muscle mass and reduce the risk of osteoporosis.  Men who do not have low testosterone levels do not benefit from additional testosterone and may actually have unhealthy side effects if they take testosterone inappropriately.  Treatment options may include testosterone injections that may be given every 1-2 weeks, testosterone gels (Androgel is a commonly prescribed example), a testosterone skin patch (Andoderm is a popular example) or a testosterone lozenge that remains in the mouth for 12 hours are the most common treatment options for low testosterone.

Counseling:  We realize that depression, anxiety and increased social stresses can cause erectile dysfunction. Sexual therapy is often helpful in these cases.  The great thing about counseling is that there are no medical side effects because this does not involve taking a medication.  Counseling can actually fix the problem which is often more desirable than relying on a medication which must be used repeatedly.  Some examples of where psychotherapy can be useful are:

1)      Performance anxiety, when a man suddenly experiences one or more failures during sex.   Often this is not due to the inability to perform but more related to anxiety about failure.

2)     Men who have depression or anxiety often have a lowered sex drive.  Counseling can help improve both while improving sex drive and function without the need for medication.

3)     Couples where one partner has a serious medical condition might be worried about possible the safety of sexual activity.  It is often helpful to discuss this with a medical professional or counselor who can help with these concerns.

Phosphodiesterase-5 inhibitors (PDE-5) – Viagra, Levitra and Cialis:  These medications work by increasing the natural chemicals in the body that allow the penis to become erect.  The do not increase sexual desire.  These medications are effective in restoring the ability to have an erection in about 70% of men and work best in men with psychological erectile dysfunction problems (in combination with treating the underlying psychological component).  In men with damage to the blood vessels or nerves of the pelvis/penis due to high blood pressure or diabetes, these medications help about 55-60% of the time.  For men who have sexual dysfunction after prostate surgery, these medications help in only 25%.   The main difference between Viagra, Levitra and Cialis is the cost of the medication and amount of time that the medication takes to begin working and how long the effects last.  Some people may find the one particular medication works better for them than another but all three work in a medically similar way.

Possible side effects:  PDE-5 medications such as Viagra can cause headache, dizziness, indigestion and flushed (red colored) skin or blurred vision.  Most side effects only last a short time, but because Cialis has a longer duration than the others, the side effects may also last longer.  There is also a possibility of drug interaction with nitroglycerin if a patient uses that for chest pain or blood pressure.  Using PDE-5 medications and nitroglycerin can cause dangerously low blood pressure.  If a man is taking nitrate medications we generally do not recommend Viagra, Levitra or Cialis.

Drug interactions:  In addition to nitroglycerin, patients who take doxazosin or terazosin (which are used to treat enlarged prostate and hypertension) should not take PDE-5 medications because the combination can cause a dangerously low blood pressure.   Other medications such as erythromycin, ketoconazole, rifampin, phenytoin and grapefruit juice can alter the time that these erectile dysfunction drugs remain in the body and subsequently can cause more side effects.

Safety:  We are unsure if Viagra is safe for patients who have had a heart attack, stroke or life-threatening heartbeats (arrhythmia) within 6 months.  We are also not sure if it is safe for men who have had untreated high or low blood pressure or a condition called retinitis pigmentosa which is a medical condition of the eye that can lead to blindness.

Penile self-injection:  Patients may inject a medication into an area of the penis called the corpora cavernosa and this causes an erection by allowing the blood vessels within the penis to expand.  No sexual stimulation is needed to create the erection.  The common medications used are alprostadil or papaverine.

Possible side effects:  many men stop doing penile self-injections because of pain at the injection site.  There is also a risk that the penis may remain erect after intercourse.  Prolonged erection is called priapism.  If it lasts longer than 4-6 hours it may be a medical emergency and those patients should be seen in an emergency room.  If blood stays inside the penis for more than 48 hours permant scarring of the tissue inside of the penis may result.

Insertion of a pellet into the urethra:  MUSE (Intraurethral alprostadil):  The same medication used for penile self-injection can be inserted into the urethra (opening where the urine comes out) and the medicine is absorbed and causes an erection.

Possible side effects:  There can be some pain in the penis as the blood vessels enlarge to create the erection.  There is less chance of prolonged erection with this than with self-injection.

Vacuum-assisted erection devices:  A rigid ring is placed at the base of the penis (near the body) to hold the blood in the penis and then vacuum pressure is used to draw blood into the penis to create an erection.  About 67% of patients are able to achieve and erection with a vacuum assisted device but only about 25-50% of people who use them are satisfied with them.

Possible side effects:  Although the man will be able to have an orgasm, he is usually not able to ejaculate with a vacuum-assisted device because the ring that holds blood in the penis also compresses the urethra and that prevents semen from exiting.

Inflatable implant:  With an inflatable implant, an erection is produced by squeezing a small pump that has been implanted surgically in the scrotum.  The pump causes fluid to flow from a reservoir (also implanted surgically) in the lower pelvis to two cylinders residing inside the penis.  The cylinders expand to create the erection.

As you can see, there any many possible reasons that can lead to male sexual dysfunction and multiple treatment options.

For more information, you may check out the web resources below:

American Urological Association

The Hormone Foundation

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

All About Kidney Stones – A Cause of Pain Similar in Intensity to Childbirth

shutterstock_116071294shutterstock_77325922I’ve had quite a few female patients who’ve told me that the pain of having a kidney stone is similar to the intensity of pain during childbirth.  A patient came in the other night with intense abdominal/side pain associated with nausea and vomiting.  At first I thought he might have had appendicitis but after we were able to give him enough fluid by IV to rehydrate him and get a urine sample I saw he had blood in his urine and the CT scan showed a 3mm stone in his kidney.

Kidney stones (also called nephrolithiasis or urolithiasis) are small solid fragments or crystals with sharp barbs on them that form within the urinary tract.  They can be made up of calcium, oxalate, cysteine, uric acid or a combination of these and other substances.  When these crystals form within the kidney or urinary tract they can become anchored or stuck and get larger.  Sometimes additional kidney stones are also formed while one is already lodged within the kidney or ureter.  The ureter is a small tube that drains the urine from the kidney down to the bladder. When a kidney stone travels down the ureter it can cause pain that radiates from the kidney all the way down the side and abdomen to the urinary bladder.

Risks for Developing Kidney Stones:  Certain factors can increase your chances of developing a kidney stone including:

1)   Dehydration

2)   Diet with high level of sugars

3)   High sodium diet

4)   Low calcium in your diet

5)   Diet with lots of animal protein

6)   Diet with low levels of phytate (phosphorus that we get mostly from plants)

7)   Patients with gout

8)   Obesity

9)   Crohn’s disease

10)  History of bariatric surgery such as gastric or intestinal bypass surgery

11)  Diabetes

12)  Hyperparathyroidism

Symptoms:

1)  Pain – most patients complain of pain either in the back, flank or abdomen.  The pain seems to come on in waves (called renal colic) and sometimes it may be barely noticeable and then become so intense that it requires treatment in the hospital.

2)  Bloody urine

3)  Pass small stones in the urine

4)  Nausea

5)  Vomiting

6)  Pain with urination

Diagnosis:  Sometimes the patient’s symptoms and history can be very suggestive of kidney stones and making the diagnosis is easy.  Other times it can be more challenging to diagnose kidney stones and imaging studies such as a CT scan or ultrasound.  Plain x-rays can also sometimes show kidney stones.

Treatment:  For patients who come to the medical clinic we try to ensure that they are well hydrated to prevent the formation of more stones and help the current stones to pass.  Some patients need IV fluids to help with the hydration process, especially if they have been vomiting and aren’t keeping fluids down.  Depending on the size of the stone and location, the patient may be able to treat their symptoms at home with over the counter pain medications such as Advil or Aleve.  In addition, we may prescribe medications that help the stone to pass more easily.  If the pain becomes severe, the patient may need to be treated with stronger pain medications and sometimes hospitalization is necessary.  If the stones are larger than 5mm, they don’t pass on their own very easily and generally require a procedure to break them up or remove them.  Some treatments to remove the stones may include:

1)   Shock wave lithotripsy (SWL):  Ultrasonic energy is used to break up the larger stone so that it can be passed more easily

2)   Percutaneous nephrolithotomy (PNL):  A surgical procedure that is minimally invasive may be required to remove a stone that is extremely large or complex, especially if SWL is not effective.  Small instruments are inserted through the skin in the operating room to remove the stone.

3)   Ureteroscopy:  A small scope is passed through the urethra up into the bladder and then up into the ureter.  This scope has a small camera and instruments that are used to remove the stone or break it up into small pieces.  This procedure is used more often if a stone is blocking the ureter and causing swelling of the kidney.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

The Most Common Cause of Vaginal Discharge in Women – Bacterial Vaginosis

Bacterial Vaginosis (BV) is not a sexually transmitted infection.  It is the most frequent cause of vaginal discharge in women, but it can be difficult to know if the discharge is caused by BV or other types of vaginal infections.

Definition:  Discharge caused by a large change in the number and types of bacteria in the vagina.  For some reason, the number Lactobacilli (which is a normal bacteria found in the vagina) are actually decreased while other bacteria are increased.

Risk factors:  Multiple or new sexual partners, douching, cigarette smoking.  Again, BV is not a sexually transmitted infection, as it can occur in women who are not sexually active.

Symptoms:  50-75% of women with BV do not have symptoms.  Those with symptoms may note an unpleasant, “fishy smelling” vaginal discharge that is more noticeable after vaginal intercourse.  The discharge is usually a thin, yellow-white color.  Most of the time it does not cause pain with urination or sex, vaginal itching or intercourse.  Self-treatment with over-the-counter medications such as yeast creams or deodorants are not recommended.

Diagnosis:  Physical examination, which usually includes pelvic examination and laboratory testing may be used to test the vaginal secretions to determine if BV is present.

Complications:  Bacterial vaginosis is usually not considered harmful but has been associated with some health problems such as:

1)   Increases risks for becoming infected with HIV, genital herpes, gonorrhea or chlamydia

2)   Pregnant women with BV are at higher risk of preterm delivery

3)   Untreated BV in woman who have had hysterectomy or abortion can lead to infection at the surgery site

Treatment:  We commonly use one of two different treatment options for treating BV.  Either Metronidazole or Clindamycin can be taken in pill form or with a gel or cream that is inserted into the vagina.   There are more side effects possible if taken orally, but it is more convenient.

Sexual partners:  There is no need to treat sexual partners of those infected with BV as it doesn’t decrease the risk of infection coming back.  BV is not a sexually transmitted infection, remember?

Relapse:  Within 3 months after resolution of symptoms, 30% of women have recurrence.  More than 50% have recurrence after 12 months.  The reasons for recurrence are unknown.  Relapse may be treated with a more prolonged course of antibiotics and the CDC suggests a treatment regimen different from the initial treatment if recurrence occurs.

Some patients use a preventative treatment with metronidazole vaginal gel twice weekly for 3-6 months if they get more than 3 episodes in 12 months.

Prevention:  Some recommendations may include the following:

1)   Finish the entire course of antibiotics for the treatment of BV even if symptoms resolve rapidly

2)   Limit the number of sexual partners

3)   Do not douche.  There is no proven benefit to douching and the solution used to rinse the vagina may upset the balance of bacteria and actually flush other bacteria up into the uterus or fallopian tubes and cause other types of infections

If you have vaginal discharge or questions, please contact your medical provider.  Do not attempt to treat yourself as this can actually make the situation worse.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

All about Vaginal Yeast Infections

shutterstock_128350532Patients frequently present to their health care provider with complaints of yeast infection symptoms.  Other terms that are used to describe yeast infections include yeast vaginitis or vaginal candidiasis.  The symptoms of this type of infection usually include itching and irritation to the vulva around the opening of the vagina.

Yeast infections are more common during times of menstruation (having monthly periods) and also after taking antibiotics.

There is no evidence that vaginal yeast infections are related to poor hygiene or tight synthetic clothing.

Other symptoms of yeast infections:

1)   Pain with urination – can be confused with a urinary tract infection

2)   Itching or irritation around the opening of the vagina

3)   Pain with intercourse

4)   Watery or white colored vaginal discharge

5)   Red or swollen vaginal tissues

The symptoms of yeast infection can be confusing because they can be similar to a number of other disorders such as a bacterial infection of the vagina, urinary tract infection, trichomoniasis, or common dermatitis (inflammation of the skin).  Most of the time the patient may not know if the itching or irritation is caused from yeast or another cause and this leads them to see a medical provider.

Causes of yeast infection:  Candida is the name of the yeast that causes the infection and it normally lives in the intestines and vagina.  Most of the time Candida causes no symptoms.  If it grows out of control (which can be due to increased stress, antibiotic use, or stress to the immune system), it can overgrow and cause symptoms.

Risk factors for yeast infection:  Often there are no underlying health problems that lead to yeast infections in women, but several factors may increase the chances of developing an infection including:

1)   Antibiotics – most antibiotics kill lots of bacteria including those that normally live in the vaginal area.  The bacteria that are normally found in the vagina help protect this area from being overgrown with yeast.  Antibiotics can kill off these bacteria and lead to an increase of the normal flora of yeast in the vagina

2)   Pregnancy can increase the chances of yeast infection because there is a normal increase in the amount of vaginal discharge.

3)   Diabetes causes an elevation of blood sugars which can lead to an increase in the likelihood of a yeast infection

4)   Hormonal contraceptives such as birth control pills, vaginal rings or patches that contain estrogen can sometimes increase the chance of yeast infection in some people.

5)   Contraceptive devices such as diaphragms, vaginal sponges and IUDs can also increase the chance of a yeast infection.  Spermicides usually don’t cause yeast infections, but can lead to vaginal irritation.

6)   Increased sexual activity can lead to a yeast infection.  The reason for this may be related to changes in the concentration of bacteria within the vagina that happen with sexual intercourse.  Yeast infections are not considered a sexually transmitted infection.

Diagnosis:  Sometimes women who have symptoms of a yeast infection will diagnose themselves and seek treatment with over the counter medications.  One study showed that only 11% of women accurately diagnosed their infection.  Women who previously had a yeast infection were slightly more accurate (35% correct).  The general recommendation is for women who have symptoms consistent with yeast infection be be evaluated by a medical provider.  The exam usually consists of examination of the vulva and vagina and sometimes a swab is used to collect a sample of the discharge to look for yeast.

Treatment:  You may be treated with oral or vaginal medication for yeast infection (or both).

Vaginal treatment:  Most of the time the treatment includes a cream or tablet that is placed into the vagina at bedtime with an applicator. There are several different treatment options some of which are 1, 3 or 7 days in duration.  The vaginal treatment seems to be more effective in reducing the vaginal irritation quicker than the oral medications.

Oral treatment:  Diflucan is a very common oral medication for treating yeast infections.  Most of the time only one dose is needed, however a second dose given 3 days or so after the first dose may be recommended for some patients.

If you’re not feeling better within a few days after starting the treatment, make sure you call the office of your medical provider to let them know.

Recurrent vaginal yeast infections:  There are about 5-8% of women who have vaginal yeast infections that come back repeatedly.  If the patient has more than 4 infections in one year, we call this recurrent vaginal yeast infection.

There is no evidence that eating yogurt or other products containing live lactobacillus acidophilus or applying these products vaginally will benefit women with recurrent vaginal yeast infections.

A persistent infection can be cause from a less common species of Candida called Candida glabrata or Candida krusei and in these less common species, we use different medications to treat them.

Treatment of recurrent vaginal yeast infections:  Most of the time we use a longer course of anti-yeast medication in patients who have recurrent infections, often between 7 and 14 days for a topical cream or suppository or if the oral medication is used, it is taken with a 2nd dose 3 days later and possibly a 3rd dose 6 days later.  Some patients are started on preventative treatment with oral or vaginal creams once per week.

Treatment of a sexual partner:  Vaginal yeast infections are not a sexually transmitted infection and most experts do not recommend treating a sexual partner.

Prevention:

1)   Diabetes:  Keep blood sugars under good control in diabetic patients

2)   Antibiotics:  For patients who frequently get yeast infections after taking antibiotics, we often will prescribe a dose of fluconazole at the start and end of antibiotic therapy to prevent post-antibiotic vulvovaginitis.

3)   Patient awareness:  Patients who are using hormone birth control products or contraceptive devices should be aware of the increased risk of yeast infections with these products.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

I’m having abdominal pain, what’s causing it? The million dollar question…

shutterstock_152569646Patients who present to the clinic or urgent care with abdominal pain can be some of the most challenging, because of the many different causes.  The job of your primary care or urgent care provider is to determine whether the pain is requiring immediate surgical evaluation.

Medical providers must try to determine which patients can safely be observed and their symptoms treated and which patients require further investigation by a specialist such as a surgeon.  This is difficult because abdominal pain is often non-specific and presents with other symptoms very commonly.

Triage:  We must urgently investigate abdominal pain in many patients.  Some patients require assessment of their airway, breathing and circulation followed by appropriate resuscitation.   Patients who may need surgery must be transferred to a facility where they can receive that care where appropriate nursing care, laboratory, surgical consultation, and radiology facilities are available. Patients who are having less severe pain or signs on exam may require consultation or referral for further management.

Helpful information from patients:

1)   Time course of pain

2)   Location of pain

3)   Radiation of pain

4)   Factors that make the pain worse or better (such as foods or antacids)

5)   Associated symptoms including fever, chills, weight loss, nausea, vomiting, diarrhea, constipation, blood in the stools, jaundice, change in stool or urine color or diameter of the stools.

6)   Past medical history, including history of abdominal surgeries

7)   Family history of bowl disorders

8)   Alcohol intake

9)   Medications – including Tylenol, aspirin, and ibuprofen/aleve

10)  Menstral and contraceptive history in women

Surgical abdomen:  Usually defined as a condition with rapidly worsening course without surgical intervention.  Obstructions of the intestines and peritonitis (inflammation/irritation of the inner wall of the abdomen that covers most abdominal organs) are reasons for referral to a surgeon.

Sometimes tests will be ordered such as an abdominal radiograph,  CBC, comprehensive metabolic panel with liver enzymes, lipase, a urine analysis and pregnancy test (in women of childbearing potential).

Other things we consider in determining the cause of the abdominal pain are the location of the pain and changes in where the pain radiates as well as how rapidly the pain gets worse.

Some possible causes of abdominal pain are many – gallstones or gallbladder dysfunction, peptic ulcer, hiatal hernia, pneumonia, heart attack,  pancreatitis, heartburn, lactose intolerance, celiac sprue, pregnancy (including ectopic), endometriosis, sickle cell disease,  appendicitis, ovarian cyst or torsion, UTI, kidney stones, constipation, colitis, diverticulitis, pelvic inflammatory disease, gastroenteritis, intestinal ischemia (decreased blood flow to the intestines), diabetic ketoacidosis, kidney infection, abdominal aortic aneurism, or even trauma.

Treatment:  Is tailored to address the cause of the pain.  If no cause can be found at your doctor’s office, the goal is to determine whether it is safe for you to go home with medications to help with the pain, and testing done as an outpatient or whether you need to be transferred to the hospital where further workup can be done immediately.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com