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A thrombolytic can be instilled into the catheter and allowed to dwell; if this fails to restore blood flow after multiple attempts topiramate 200mg low cost symptoms copd, the catheter likely needs to be replaced purchase topiramate 100mg amex symptoms 8 weeks pregnant. Severe reductions in blood pressure during dialysis limit ultrafiltration purchase topiramate online pills symptoms 89 nissan pickup pcv valve bad, perpetuate renal injury, and compromise perfusion to other vital organs. Ronco C, Bellomo R, Homel P, et al: Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Saudan P, Niederberger M, De Seigneux S, et al: Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Bellomo R, Cass A, Cole L, et al: Intensity of continuous renal- replacementt herapy in critically ill patients. John S: Effects of continuous haemofiltration vs intermittent haemodialysis on systemic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospective, randomized clinical trial. Uchino S, Bellomo R, Kellum J: Patient and kidney survival by dialysis modality in criticall ill patients with acute kidney injury. Vinsonneau C, Camus C, Combes A, et al: Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Pannu N, Klarenbach S, Wiebe N, et al: Renal replacement therapy in patients with acute renal failure. Bell M, Granath F, Schön S, et al: Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure. Parienti J, Thirion M: Femoral vs jugular venous catheterization and risk of nosocomial events in adults. Demirkiliç U, Kuralay E, Yenicesu M, et al: Timing of replacement therapy for acute renal failure after cardiac surgery. As many as 45% of patients with an estimated creatinine clearance less than 40 mL per minute receive medications that are dosed as much as 2. In addition, adverse drug reactions occur in approximately 9% of patients with blood urea nitrogen less than 20 mg per dL versus 24% of patients with blood urea nitrogen greater than 40 mg per dL . Adverse drug events not only place patients at increased risk for morbidity and mortality but also have a tremendous impact financially. It has been estimated that each adverse drug event increases hospital costs by $2,000 to $4,600 [8–10]. For all of these reasons, appropriate drug dosing for critically ill patients with kidney or liver injury is essential. The following review uses pharmacokinetic principles to discuss key concepts of drug dosing in critically ill patients with renal and hepatic dysfunction. Pharmacokinetics relates to the principles of drug absorption, distribution, metabolism, and excretion, whereas pharmacodynamics describes the pharmacologic response resulting from the drug at the site of action (receptor). Clinical pharmacokinetics is the application of knowledge of drug absorption, distribution, metabolism, and excretion to design patient-specific drug regimens with the goal of maximizing therapeutic outcomes and minimizing toxicity. As the plasma concentration increases or decreases, the amount of drug eliminated increases or decreases in a directly proportional relationship. Clinically, if a drug dose is increased, the plasma concentration increases proportionally, as does the amount eliminated. If a drug’s plasma concentration is plotted versus time using a logarithmic scale, two different slopes are evident. When monitoring serum drug concentrations, it is important to sample after the distribution phase is complete to avoid making decisions based on falsely elevated drug levels. The elimination rate constant (K ) is obtainedel by calculating the slope of the line during the elimination phase, and it can be used to calculate a drug’s half-life (t1/2). The effect of increasing daily dose on average steady-state drug concentrations for drugs undergoing linear or first-order pharmacokinetic modeling (dotted line). Zero-order, or Michaelis–Menten pharmacokinetics, refers to removal of a constant quantity of drug per unit of time. As the plasma concentration of the drug decreases or increases, the amount eliminated remains the same. This is the result of metabolism by a saturated enzyme system capable of eliminating drug only at a constant rate, regardless of the serum concentration. Clinically, this means small increases in the drug’s dose can lead to large increases in the plasma concentration; hence, the term nonlinear pharmacokinetics. The half-life of a specific drug remains constant provided that the metabolizing and eliminating processes remain constant. If a patient’s renal or hepatic function declines, the half- life of the drug can be significantly prolonged. The half-life of a medication can be used to determine the time required for a drug to reach steady state. Steady state is achieved when the amount of drug entering the body equals the amount eliminated, so plasma drug levels no longer increase. A clinician should generally wait for steady state to be achieved before obtaining a drug serum concentration or changing medication dose. Knowledge of a drug’s half-life may help estimate how long it should take for a pharmacologic or toxic effect to clear. With first-order elimination, a constant percentage of drug is removed from −1 the plasma per unit of time and is often expressed as minutes or hours −1. A drug’s Kel and half-life are constants and do not change unless the metabolizing or eliminating processes (or both) change. Volume of distribution is not a physiologic volume but rather a theoretical volume that relates the plasma concentration to the administered dose. If a 700-mg dose of a drug administered as an intravenous bolus to a 70-kg patient results in a calculated maximum plasma concentration of 7 mg per L, it appears as if the drug is dissolved in 100 L of fluid. A large volume of distribution means that the amount of drug available to be measured in the plasma is reduced owing to distribution among peripheral compartments or binding to plasma proteins. Medications that are hydrophilic and remain in the central (vascular) compartment, and without high affinity for plasma protein binding, tend to have a lower volume of distribution with a value that is closer to the intravascular volume. Drugs that are highly lipophilic and distribute to peripheral tissues, or are highly plasma protein bound, tend to have a very large volume of distribution. Clearance through an organ is determined by the product of blood flow to the organ and the extraction ratio for the organ. The extraction ratio is the percentage of medication removed from the blood as it passes through the eliminating organ: It depends not only on the blood flow rate but also on the free fraction of drug and the intrinsic ability of the organ to eliminate drug. Changes in blood flow to the organ responsible for clearing the drug or any factor altering the extraction ratio of a drug can alter a drug’s clearance. For example, a patient experiencing septic or cardiogenic shock may have impaired blood flow to the liver or the kidneys, hampering the clearance of a particular drug. In addition, if a pharmacologic vasopressor is added to the therapy, blood flow to the gastrointestinal tract may be compromised, resulting in a decreased absorption and transport of drug to the site of action.
It has been conception is performed topiramate 200 mg without prescription medications similar buspar, but also reduce the chance of available for many years purchase topiramate 200mg otc medicine 627, but one of the first recorded and any diagnosis being missed before multiple cycles are possibly best‐known instances of assisted conception was embarked on with the subsequent emotional and finan that performed by the eminent surgeon John Hunter in cial cost to the patient if they are unsuccessful purchase 100 mg topiramate with mastercard medicine app. The husband, in this infertile couple, had hypospadias and artificial insemination of ejaculated Female sperm was performed on the wife. This basic Tests of ovarian reserve have been utilized for many assisted conception continued until scientific techniques years; previously an early follicular phase follicle‐ stimu improved in the middle of the twentieth century. Most forms of assisted conception, excluding egg donation, require normal ovarian reserve to have any significant chance of success. Even though the diagnosis may have been made and the If the patient is undergoing a licensed form of assisted con most appropriate form of treatment decided upon, there ception under the 1990 Human Fertilisation and Embryology are a few essential investigations that should be per Act, then both the male and female partner have to be formed prior to any form of assisted conception. Uterine cavity and tubal patency Both the uterine cavity and the fallopian tubes should be Acronym Definition examined prior to all forms of assisted conception. If a significant problem is noted in the uterine cavity, this would nor mally be corrected prior to the assisted conception cycles is positive for the above conditions this does not preclude being performed. The uterine cavity and the fallopian them from being treated but unless specific embryo cryo tubes can be investigated using the following methods. With newer techniques, and in particular the advent of suction Ultrasound caps and small balloon catheters, the need for unneces Virtually all ultrasound scanning in assisted conception sary trauma is obviated. The initial scan assesses sev uterine cavity and the fallopian tubes and it is an eral areas. In most an echogenic fluid is ● the ovaries are assessed for accessibility, not just for instilled inside the uterine cavity and into the fallopian the monitoring itself but also if transvaginal oocyte tubes, which can be tracked by transvaginal ultrasound. This can be avoided by initially sure can be applied during the screening ultrasound to using sterile saline to outline the endometrial cavity ensure that the ovary can be moved down to a more before using ultrasound contrast medium, which by accessible position for egg collection. These are commonly performed infertility investiga ● the rest of the pelvis is also screened in a systematic tions, particularly if the patient has other presenting fashion to exclude other pathology. Therefore, any patient who has the lesion is removed, for example intrauterine adhe fibroids larger than 3 cm, and in particular who has sions can be divided hysteroscopically, or submucus recurrent implantation failures, should be considered for fibroids can be extracted by transcervical resection. Although treatment of these fibroids does appear to have an impact on implantation rates, in a randomized trial Male partner Surrey et al. Salpingectomy used to be the routine recommendation but more units are now coagulating the proximal portion Important coexistent pathologies because of the worry that salpingectomy may compro There are several other coexistent pathologies that can mise ovarian vasculature and reduce subsequent significantly reduce the successful outcome of assisted response to stimulation [7 6]. Most practitioners would conception or increase the complication rates associated individualize the treatment of hydrosalpinges and take with it. It has always been difficult to ascertain the causality between these Polycystic ovaries fibroids and the patient’s infertile status, but the pres Polycystic ovaries as seen by ultrasound are an extremely ence of fibroids does not necessarily mean there is a common finding in women of childbearing age and can direct causal link between fibroids and infertility. It degree of resistance at lower doses but then a very nar was previously thought that fibroids only significantly row therapeutic window before the patient hyperstimu reduced implantation rates if the uterine cavity was dis lates, and this can quite often lead to cycle cancellation. In the first one should always start with a low dose and then increase of these, Eldar‐Geva  showed that intramural fibroids in small increments until the appropriate therapeutic significantly reduced implantation rates; this was then window is achieved. There is now evidence that metformin does not improve the success rate but can improve the safety of the cycle. Although there inseminated into the uterine cavity at the appropriate is little evidence that the routine treatment of peritoneal time of the patient’s menstrual cycle. Approximately 2 endometriosis results in a significant improvement in weeks later a pregnancy test is performed to see if the assisted conception cycles, there can be benefit in treat cycle has been successful. Pre‐cycle drainage hours prior to the insemination to ensure optimal timing by needle aspiration can also be a cause of ovarian with ovulation. If any form of ovulation induction has been logues can shrink the cysts and also improve the overall used, then it is recommended that more accurate moni success rates. It is therefore recommended that the can be used for mild male factor problems, it is not rec female partner should be encouraged to lose weight. Although success rates of 35% have been There are many types of assisted conception available quoted in literature, these tend to be highly selective in the modern unit. Most centres cycles such as pre‐implantation genetic diagnosis would expect a twinning rate of 10–15% and a triplet rate 708 Reproductive Problems of less than 1%. If the triplet rate is higher than 1%, and in Indications particular if there are even higher numbers than this, ● Severe tubal disease: tubal blockages. Although there are other short protocols using agonists, Advantages these are now less used due to poorer success rates. It also requires at least one If this continuous administration is maintained, then healthy fallopian tube and reasonable sperm parameters. As long as the ago nists are continued then the ovary is suppressed unless Indications exogenous gonadotrophins are given. In a mid‐luteal start (normally around day 21), the ● To optimize the use of donor sperm. A scan and often a blood estradiol level are performed to ensure the In vitro fertilization patient is adequately suppressed. If this is the case, then In vitro fertilization is where the mature oocyte is surgi gonadotrophins are started the following day and contin cally removed from the ovary and then fertilized with ued until an adequate ovarian response is gained. The injec nists, does not need several days to achieve menopausal tion is normally given around midnight to allow for levels of the pituitary‐derived gonadotrophins. Virtually all oocyte retrievals are per during stimulation of the ovaries with exogenous gon formed by this transvaginal ultrasound‐directed route. Serial transvaginal ultrasound to assess fol the laparoscopic route is still occasionally used if the licular growth should be used. This can occa units continue to use serial estradiol levels to add to the sionally occur in frozen pelvises or when the ovaries have information obtained from the ultrasound. An more commonly, local anaesthesia or some form of intra under‐response can sometimes be anticipated in the venous sedation. An over‐response can sometimes be anticipated if a single‐use disposable needle is used or a double‐ there has been a previous over‐response or if the patient channel needle that allows ‘flushing’ of the follicle if the has polycystic ovarian morphology on her initial diag egg is not obtained on simple aspiration. There seems to be no value in routine inserted under ultrasound control directly into the folli estradiol monitoring. If sound probe is removed, the vaginal vault is checked for 710 Reproductive Problems. Evidence from elective single embryo trans occasionally an absorbable suture has to be inserted fer programmes in Scandinavia and Belgium has shown under direct vision for a specific bleeding point. Most that twin rates can be virtually eliminated whilst main patients go home a few hours after the procedure has taining acceptable overall pregnancy rates . The potential benefits of a day 2 transfer are that a sin gle‐stage culture medium can be used and also that the Embryo transfer majority of normal embryos survive to this stage. The potential downside of a day 2 are incubated in a commercially prepared culture transfer is that in a normal menstrual cycle, the day 2 medium under strict laboratory conditions. The temper embryo is still in the fallopian tube and not in the uterine ature within the incubators is carefully controlled, as are cavity. Also it is much more difficult to accurately grade the gas content, humidity and pH. The benefit of a day 5, or blastocyst, Traditionally, most embryos were transferred at day 2 transfer is that the embryo has been replaced when it or 3 following egg collection.
Antivenom A specific discount generic topiramate uk medicine chest, equine purchase topiramate on line medicine of the prophet, whole-immunoglobulin widow spider antivenom available in the United States discount topiramate online mastercard medicine app, Antivenin (Latrodectus mactans) (Black Widow Spider Antivenin) (manufactured by Merck & Co. Indications for antivenom use in Latrodectus envenomations remain controversial, however, given recent evidence that questions its efficacy in relieving pain or reversing systemic toxicity  as well as its small but real risk of adverse reactions (see below). Antivenom might be considered in patients who are severely envenomated, pregnant, or in labor, or in those who have a history of cardiovascular disease or other major medical problems and evidence of significant envenomation despite benzodiazepine and opioid therapy [58,61,62]. Assistance from an expert toxicologist or poison center is helpful in making the decision about whether to administer antivenom. If antivenom is to be given, informed consent should be obtained, and the patient should be in a monitored setting with epinephrine available at the bedside. One vial is generally given initially, but a second vial can be administered if deemed necessary [60,62]. The types of adverse drug events seen with widow spider antivenom are the same as for snake antivenoms, with acute reactions occurring in approximately 2% and serum sickness in approximately 10% . Deaths due to acute reactions have occurred following administration of widow spider antivenom [65,70]; this, plus questions of efficacy should limit its use to cases that are truly severe and potentially life threatening. It is hoped that ongoing research into a new F(ab′) widow spider antivenom2 might demonstrate improved efficacy with less risk, resulting in a safe, clearly effective antivenom use for widow spider bites in North America . The clinical course of most patients with widow spider envenomation is benign [58,72], but significant pain and spasms can persist for 2 to 3 days . Most healthy adults do well with supportive measures and adequate administration of parenteral benzodiazepines and opioids . Disposition and Outcome Patients can be discharged from the hospital when signs or symptoms of envenomation have been significantly controlled, although it may be best to admit and observe younger children. Patients should be given analgesics and muscle relaxants, prescribed bed rest, and instructed to return if they worsen. The mortality rate from widow spider envenomation in the United States is much less than 1% [55,58], and it is debatable if there are truly deaths from envenomation. Recovery from widow spider envenomation may sometimes be slow, with weakness, fatigue, paresthesias, headache, and insomnia persisting for several months . All species are characterized by a violin-shaped marking on the dorsal aspect of the cephalothorax (though this may be hard to see in some specimens) and three pairs of eyes, in contrast to the four pairs found in most spiders. The brown recluse is found throughout the southern, south-central, and midwestern United States; other species are found in the western part of the country . While recluse spiders may cause severe dermonecrosis (necrotic arachnidism), the majority of bites actually result in insignificant lesions . Venom activation of the complement cascade induces a series of autopharmacologic changes that amplify toxicity to a variable degree in victims . The cutaneous changes seen after a recluse spider bite are initiated by venom-induced endothelial damage in small dermal vessels that become occluded with microthrombi, producing vascular stasis and infarction . Polymorphonuclear leukocytes are attracted to the site via a chemotactic response and propagate the inflammatory, necrotic reaction [81,82]. Accumulation of polymorphonuclear leukocytes at the site appears to be a vital component of the dermonecrotic response and is related to complement activation . Clinical Manifestations the clinical course of recluse spider envenomation varies from a mild temporary irritation at the bite site to a rare, severe, potentially fatal outcome . During the next several hours, there may be pruritus, tingling, mild swelling, and redness or blanching at the bite site . Variable degrees of local pain and tenderness due to local vasospasm and ischemia occur within 2 to 8 hours [83,84]. At 12 to 18 hours, a small central vesicle (clear or hemorrhagic) often develops at the site and is surrounded by an irregular zone of erythema or ecchymosis and edema, which may have a distinct gravitational distribution around the central lesion . Bites to fatty regions of the body tend to be more severe, with undermining of the skin and more extensive scarring . Lesions destined to develop significant necrosis usually demonstrate early evidence of local ischemia . Systemic (viscerocutaneous) loxoscelism is rare, but can be rapidly progressive and severe, particularly in children . Systemic symptoms generally start 24 to 72 hours after the bite and occasionally occur before cutaneous findings become impressive . Symptoms are often flulike, with fever, chills, headache, malaise, weakness, nausea and vomiting, myalgias, and arthralgias . Hemolytic anemia with hemoglobinemia, hemoglobinuria, jaundice, thrombocytopenia, disseminated intravascular coagulation, acute renal failure, seizures, and coma have been reported . The severity of systemic symptoms is directly related to the quantity of venom deposited, but does not necessarily correlate with the severity of cutaneous changes . Diagnostic Evaluation It is uncommon for a victim of a Loxosceles bite to see the offending spider because the bite is relatively painless, and, given that the spider is nocturnal, a large percentage of bites occur while the victim is asleep . As the spider is rarely available for identification, determining the cause of early lesions is difficult , and the diagnosis of spider bite is usually presumptive. The working diagnosis should be cutaneous necrosis if the precise cause is unknown and necrotic arachnidism if a biting spider was seen but not identified. In patients with severe envenomation, laboratory studies should include a complete blood cell count and urinalysis . If there is any evidence of consumptive coagulopathy, hemolysis, or hemoglobinuria, further studies should include prothrombin time and partial thromboplastin time, electrolytes, blood urea nitrogen, and creatinine, and a specimen should be sent for blood typing and screening. The white blood cell count may be 3 as high as 20,000 to 30,000 per mm, and the hemoglobin may fall to as low as 4 g per dL [57,62,84]. Serial complete blood cell counts and urinalyses should be obtained in patients with significant lesions or systemic loxoscelism . The differential diagnosis for Loxosceles envenomation includes bites or stings by other arthropods (e. The majority of cases require only local wound care, including cleansing of the bite site, application of a sterile dressing, immobilization with a well-padded splint, and tetanus prophylaxis as necessary . Frequent local application of ice or cold packs during the first 72 hours to reduce sphingomyelinase D activity may be beneficial . If an ulcer develops, it should be cleaned several times each day with hydrogen peroxide or povidone–iodine solution . Antibiotics to prevent secondary cellulitis can be considered  and should include coverage for methicillin-resistant S. It is important to emphasize to patients that nothing has been proven to decrease the extent of dermonecrosis after these bites and that most lesions heal quite satisfactorily with conservative management alone [57,84]. Controversial modalities for managing the wound include the use of steroids, dapsone, colchicine, surgery, hyperbaric oxygen therapy, and topical nitroglycerine application [77,89–92]. Routine use of these agents should be avoided until prospective controlled studies prove that benefits outweigh risks. Early excision of the wound site is contraindicated because it is impossible to predict the ultimate extent and severity of the lesion . Surgical procedures that might be required, such as skin grafting, should be postponed at least 6 to 8 weeks to ensure that the necrotic process has been completed and to improve chances of healing .
The perineal urethra is embedded in the anterior offered the same clinical care as any women whilst rec- vaginal wall and is surrounded by erectile tissue in all ognizing there will be some differences in clinical needs directions 200mg topiramate with mastercard symptoms 3 weeks pregnant, except posterior where it relates to the vagi- during the post‐perioperative care period and in the nal wall  buy cheap topiramate 100 mg on-line chi infra treatment. The clitoris and where necessary purchase genuine topiramate on-line medicine in spanish, liaison with the surgeon involved appears to exist solely for the purpose of sexual pleasure. On orgasm and whether the presence of a G‐spot exists to some occasions, the gynaecologist may be the first per- bring about sexual pleasure. In recent years a number of son with whom a patient may raise the issue of a desire papers have been published with regard to the possible for gender transition (which if towards the male role isolation of tissue identified to be the G‐spot and the would be as a trans man). An overview of guidelines for evidence and arguments are summarized in a recent clinical care for trans people is available . Sexual dysfunction Sexual diversity It is important to remember that there will be some the gynaecologist should strive to offer a non‐judgemental women who do not openly share the details of their sex- approach when exploring a woman’s sexual identity ual life or sexual preference, even when asked about it. The principle hears about a particular preference or practice, especially issues involve sexual orientation, gender identity and the any that may be outside their own experience. It is difficult to be cer- toire for arousal and sexual pleasure, is considered next. Thus, some same‐sex attraction or of the conditions historically described as ‘sexual per- experience was reported by 15. This may not there is an attempt to clearly distinguish between the always be as a binary female. Clinicians should desire for sexual behaviours involving unwilling persons attempt to ascertain whether any anxiety or depression or persons unable to give legal consent’ . To take the is a consequence or a cause of the sexual complaint, and example of fetishism, a fetish is an object or body part treatment should be administered accordingly. The monly occur in later life should be included as part of the reliance on some non‐living object as a stimulus for initial evaluation in middle‐aged and older persons pre- arousal and sexual gratification may arise for a number senting with sexual complaints . For many people there is experimentation dations are to assess multiple aspects of sexual with fetishistic behaviour, which is not a fetish by defini- functioning, including, but not limited to, subjective tion. Numerous sexual aids and ‘toys’ are easily available aspects such as sexual self‐esteem and sexual satisfac- from high‐street shops and mail order. A developmental require no inanimate objects but merely non‐genital approach to assessing the onset of sexual activity is rec- parts of the body. Preference for the feet or toes (such as ommended, including self‐focused as well as partnered sucking the toes of the partner and/or having their own activity ranging from non‐genital to genital expressions, toes or feet licked or rubbed) was the most prevalent fetish the context around those experiences, as well as any by a considerable margin in one recent large study . Likewise, in a study to try to identify ‘what exactly is an Crucially, there should be an attempt to explore their unusual sexual fantasy’, the themes that were most possible role in the individual’s current sexual function reported by women included an exotic or unusual private and behaviour. Around one‐sixth ences including sexual abuse and, if this occurred, its of women mentioned involvement of a stranger and characteristics regarding frequency, duration and around 8% mentioned either homosexual activities or whether the perpetrator was known or not. The themes were very different from those In addition, a number of life‐stage stressors are evi- mentioned by men, where voyeurism and fetishism were dent for women, including infertility, postpartum expe- the highest reported. Clearly, this matter may lead to some riences, ageing and menopause, and these can have a difficulties for partners if they were to declare these openly specific impact on psychosocial and psychosexual expe- or try to enforce these into the sexual repertoire, especially riences. The prevalence of sexual dysfunction in women if they were not negotiated or discussed in advance . The recommendation to clinicians is that during all brevity reference to a partner may be made whilst recog- phases of infertility diagnosis, investigation and man- nizing that many women may be without a partner at a agement the clinician, whenever possible, assess sexual certain time through preference or otherwise or may function and satisfaction. Approximately half (52%) of women resume sexual activity by 5–6 weeks post partum. However, it is less clear the extent of sexual dysfunction at 2–6 months post partum, with various studies suggesting this affects Psychosocial and psychosexual 22–86% of women (see Brotto et al. Women were the fourth International Consultation on Sexual much less likely to report being sexually active than men. The Half of the women (and half of the men) reported at least committee reviewing psychological and interpersonal one bothersome sexual problem and were concerned dimensions of sexual function and dysfunction made a about the impact of ageing changes on their sexuality. Exploration were low desire (43%), difficulty with vaginal lubrication of the attachment style of the woman, her personality, her (39%), and inability to orgasm (34%) . Assessment of depres- ual function and satisfaction include sexual experience sion, anxiety, stress, substance use and post‐traumatic throughout life, attitudes toward sex, dysfunctional sex- stress (and their medical treatments) should be carried ual partner, death of partner, sexual performance issues, Sexual Dysfunction 959 impaired self‐image, physical or mental fatigue, disturbed Physical factors contributing family relationships, divorce, physical illnesses and disa- to sexual well‐being bilities, need for special care, changes in employment and financial status . A drop in testosterone levels, and A substantial number of factors can interrupt the normal increase in cognitive and depression issues with older age process of sexual activity and can be considered as endo- may also impact on sexuality. Clinicians should be aware crine factors (typically androgens and oestrogens), neuro- of the relationship between symptoms of ageing and logical factors, vascular factors and iatrogenic factors. Dermatological conditions such as lichen sclerosus tance of including social, health and relationship factors and eczematous rash can cause a number of sexual prob- in the context of menopause and sexual functioning. Indeed, any life event may bring about a change in These factors and, in particular, feelings toward one’s mood and well‐being that in turn interrupt the opportu- partner or starting a new relationship have also been nity for usual sexual activity and opportunity for pleasure. There are a number of practices with Overview of psychosocial complex ethical issues (e. The clinician should always try to give the patient the opportunity to talk about her own sexuality and to listen actively so that the woman feels accepted and understood and there may follow some emotional Summary box 66. During this stage assess the woman’s and her part- ner’s concepts and knowledge of sexuality, passion, inti- ● There are a number of aetiological factors that may pre- macy, commitment and love. Take the opportunity to inform her monly associated with all the sexual problems trouble- about the reality of human sexuality and to put the vari- some for women. Give ● Encouraging women to speak about their problems information about the usual frequency of problems and during consultations may be helpful and in many cases about differences between female and male sexuality. Encourage communication about her sexual needs with 960 Sexual Health the doctor and the partner. Whilst all of these can be contributory to empowerment and self‐confidence around sexuality. Some offer a number of explanations for a problem and so offers common myths are that a healthy woman always has an a number of treatment options and interventions that may orgasm, that sex must lead to orgasm and that masturba- include some couples’ therapy together. Time can also be used to On some occasions, there may be sexual problems include suggestions about use of specific sexual posi- within the partner. In certain cir- may include erectile dysfunction or early or delayed ejac- cumstances suggestions about the use of erotica and the ulation. Depending on the aetiology, these problems may use of specific bibliotherapy may be helpful. Typically, these therapies include body awareness onto work with a partner if both parties are in agreement. The ability to ing, sensate focus and, less frequently, psychodynamic receive and also to give pleasure will open the opportunity individual therapy. These can be provided in both verbal and writ- intimacy and to be able to say to each other that they love ten format with the opportunity to answer any questions each other. Typically, these include looking at helpful than just providing a sheet of instructions that are the naked body from all sides in a large mirror (and to com- often read briefly and forgotten between sessions as the pare it with drawings or other photographs); looking at the detail fails to appreciate the specific circumstances and genitalia using a small hand mirror and exploring the genita- needs of the women (and her partner). For this latter exercise the clinician can provide addi- attraction, boredom and lack of pleasure. When there is tional guidance such as to try manual stimulation (where, evidence of concurrent depression, body image issues, how and how intensive), to increase intensity and duration, sequelae of sexual abuse, personality or relationship fac- to think about using a vibrator and to try manual stimulation tors, then these matters are often better addressed first in the presence of the partner and then involving the partner. Relaxation work includes making suggestions about how to manage stress, advice on how to relax the body Summary box 66.
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