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Am Fam Physician. 2001;63(5):974

Treatment of Anal Fissures

(Australia—Australian Family Physician, September 2000, p. 839.) Anal fissures are splits in the anal mucosa immediately within the anal verge. Severe pain during defecation is common and the pain may persist for several hours. Bright red bleeding is also common. Most fissures can be seen on inspection and the severe anal spasm can be appreciated on attempted digital examination. More than 80 percent of acute anal fissures will heal spontaneously with the use of dietary fiber to soften and bulk the stool. Recurrent or chronic fissures also benefit from the use of warm baths and suppositories. Surgical dilation or release of the internal sphincter has been the traditional treatment of chronic or severe fissures. Topical application of glyceryl trinitrate (0.2 percent) two to three times daily or injection of botulinum A toxin into the internal anal sphincter are controversial new therapies.

Tempering Enthusiasm for COX-2 Inhibitor Drugs

(Australia—Australian Family Physician, September 2000, p. 847.) The selective cyclo-oxygenase-2 (COX-2) inhibitor drugs were developed because COX-2 was believed to generate the prostaglandins that mediate inflammation, in contrast to cyclo-oxygenase-1 (COX-1) enzymes that are involved in gastrointestinal mucosal protection and thrombus formation. Researchers now believe that COX-2 has additional physiologic effects and may not be exclusively concerned with inflammation. This calls into question the major motivation for development of the COX-2 agents: control of inflammation and pain comparable to the nonsteroidal anti-inflammatory drugs (NSAIDs), but without gastrointestinal and other adverse effects. Studies comparing NSAIDs and COX-2 inhibitors have used different patient populations and outcome measures and have compared different drugs within the two groups. These and other factors make it difficult to draw conclusions. The two classes of drugs appear to be equally effective in relieving pain and inflammation, but studies differ on the occurrence of gastrointestinal damage. In one study, the cumulative incidence of dyspepsia over a six-month period was 23.5 percent in persons using a COX-2 inhibitor compared with 25.5 percent in persons using an NSAID, and this difference decreased with longer treatment periods. By one estimate, COX-2 inhibitors can reduce dyspepsia by up to 3.0 percent and more serious gastrointestinal complications by up to 1.0 percent compared with NSAIDs. These estimates suggest that the expensive COX-2 inhibitors may be useful only in selected patients at high risk of gastrointestinal complications from NSAID therapy.

Causes of Gynecomastia

(Great Britain—The Practitioner, September 2000, p. 785.) Enlargement of the male breasts commonly occurs in neonates, pubertal boys and older men because of excess estrogen or an estrogen/androgen imbalance. Patient complaints usually focus on embarrassment, concern about cancer, breast pain and tenderness. In approximately 20 percent of cases, gynecomastia is caused by medications such as cimetidine, spironolactone, nifedipine, verapamil and various chemotherapeutic agents. Drugs of abuse, such as anabolic steroids, heroin, marijuana and methadone, are well-recognized causes of breast enlargement and some bodybuilders take tamoxifen as a preventive measure. Inadvertent exposure to estrogen (e.g., from vaginal estrogen cream used by a sexual partner) has also been reported to cause gynecomastia. Pathologic causes include renal failure as well as a wide variety of conditions that disturb hormone balance, such as adrenal or testicular tumors, hyperthyroidism and production of ectopic hormone by tumors of the lung, stomach, liver or kidney.

Management of Patients with Priapism

(Great Britain—The Practitioner, September 2000, p. 764.) Patients with priapism develop a prolonged painful erection that is not associated with sexual desire. Although priapism can occur at any age, it is most common in men 20 to 50 years of age. Most painful cases are caused by “low-flow” conditions such as sickle cell disease, use of anticoagulants, hematologic malignancies, neuropathies and certain drugs. Low-flow priapism may also be idiopathic. Because the prolonged venous occlusion can result in ischemic necrosis, low-flow priapism is an emergency situation requiring prompt corporeal aspiration followed, if necessary, by instillation of an alpha-adrenergic agonist into the corpora. Potency may be preserved if the priapism is resolved within 12 to 24 hours. Penile or perineal trauma may result in “high-flow” priapism from shunting of blood and usually requires less urgent intervention.

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