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–Low humidity, nasal oxygen use, CPAP

–Tumors: benign, malignant

–Vascular malformations

Trauma

–Epistaxis digitorum (nose picking)

–Foreign bodies

–Septal perforation

–Nasal fracture

–Nasal surgery

Systemic

–Thrombocytopenia

–Congenital or acquired coagulopathies

–Liver or renal disease

–Chronic alcohol abuse

–Leukemia

–Anticoagulant drug use

–CHF

–Hereditary hemorrhagic telangiectasia (HHT)

–Collagen abnormalities

–Mitral valve stenosis

–Multiple myeloma

–Polycythemia vera

–HIV

RISK FACTORS

Local irritation from multiple causes

Medications/supplements including aspirin, clopidogrel, ginseng, garlic, ginkgo biloba, sildenafil, warfarin, and other anticoagulant

Prior septoplasty/turbinate procedures, anemia, and thrombocytopenia are risk factors for recurrent epistaxis.

GENERALPREVENTION

Humidification at night

Cut fingernails and minimize picking.

For topical-nasal medication users, direct spray laterally away from septum. Use opposite hand to spray (i.e., right hand to spray in left nostril).

Petroleum jelly to prevent anterior mucosal drying

Control hypertension (HTN) (controversial association with increased risk for recurrent epistaxis).

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COMMONLYASSOCIATED CONDITIONS

Vascular malformation/telangiectasia (HHT)

Neoplasm (rare; consider if persistent and unilateral) Systemic

–Coagulopathy: primary or iatrogenic

–Thrombocytopenia

–Cirrhosis

–Renal failure

–Alcoholism

No proven association with HTN but may make control of bleeding more difficult

DIAGNOSIS

HISTORY

Assess airway patency and cardiovascular stability.

Determine on which side bleeding began, anterior or posterior, duration.

Define trauma (including nose picking) or other precipitating events.

Previous episodes

Comorbid conditions (cardiovascular compromise symptoms)

Current medications including over-the-counter and supplements

Nausea, hematemesis, or hemoptysis may indicate a posterior and more severe bleed.

PHYSICALEXAM

Blood loss through one or both nostrils in most cases is due to anterior nasal septal bleeding and can often be directly visualized.

Focus on localizing site of bleeding to anterior versus posterior nasal cavity.

Patient is seated, head forward, to avoid blood going down the posterior pharynx.

Use of nasal speculum improves visualization.

DIFFERENTIALDIAGNOSIS

Diagnosis usually apparent; the differential for the etiology is key. Posterior bleeding must be included in the differential for any chronic blood loss.

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DIAGNOSTIC TESTS & INTERPRETATION

Lab testing is not indicated in most uncomplicated cases in which bleeding is easily controlled.

Initial Tests (lab, imaging)

Mild cases, responsive to pressure: no labs

For recurrent or intractable cases

– CBC, PT/PTT, BMP

PT/PTT if on warfarin or other medications affecting coagulation

Cross-match when appropriate.

Toxicology screen when nasal use of illicit drugs is suspected

For most cases, imaging is not indicated.

Follow-Up Tests & Special Considerations

Consider neoplasm if recurrent unilateral epistaxis, especially if not responding to treatment.

Diagnostic Procedures/Other

Nasal endoscopy

Pediatric Considerations

More likely anterior, idiopathic, and recurrent

Geriatric Considerations

More likely to be posterior bleed

TREATMENT

Most cases are managed as outpatient (1)[B].

Home use—Nosebleed QR: a nonprescription powder of hydrophilic polymer with potassium salt; induces scab formation

Patient applies direct pressure by pinching the lower part of the nose (nasal ala) for 5 to 20 minutes without a break. This stops bleeding in most patients.

Cleanse nasal cavity of blood clots by blowing nose.

An ice pack placed over the dorsum of the nose may help with hemostasis. Inspect the nasal septum for the bleeding site.

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GENERALMEASURES

Resuscitation, as indicated. Use universal “airway/breathing/circulation (ABC)” approach.

MEDICATION

First Line

If general measures fail, affected naris may be sprayed with topical vasoconstrictor, such as:

Phenylephrine: 0.5–1%

Oxymetazoline: 0.05%

Epinephrine: 1:1,000

Cocaine: 4%

Second Line

Chemical (silver nitrate) or electrical cautery

Nasal packing: ribbon gauze, nasal tampons, nasal balloon catheter

For intractable/refractory: Consider surgical ligation, endoscopic ligation/cautery, endovascular embolization.

ISSUES FOR REFERRAL

Posterior bleeding frequently requires an otolaryngology consultation.

Anterior bleeding that fails conservative measures, packing, and cauterization

Recurrent episodes

HHT patients should establish care with ENT. Concurrent anticoagulation

–If bleeding stops with packing, may continue same dose of warfarin if INR therapeutic; decrease dose if supratherapeutic INR.

–If bleeding persists despite packing, stop anticoagulation and administer vitamin K 10 mg IV ×1, recheck INR in 30 minutes, if still >1.5, give PCC.

–Novel anticoagulation may be associated with lower rates of epistaxis than warfarin. When epistaxis occurs, it may be harder to control.

ADDITIONALTHERAPIES

Nasal packing: either with ribbon gauze or preformed nasal tampons. Systemic prophylactic antibiotics are unnecessary in the majority of patients with nasal packs; topical antibiotics may be as effective and cheaper (2)[B]. FloSeal: Abiodegradable hemostatic sealant (a thrombin-type gel) in one

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study is more effective and better tolerated than packing (3)[B].

Local application of tranexamic acid may reduce bleeding time as compared to anterior packing (4).

If an actively bleeding anterior septal site is visualized, this may be treated with gentle silver nitrate cautery for ~10 seconds for definitive treatment. 75% silver nitrate is preferred. Apply in a spiral fashion, starting around the bleeding vessel, moving inward.

Limit cautery (silver nitrate) to one side of septum, or wait 4 to 6 weeks in between treatments to reduce risk of perforation.

Posterior: Posterior packing or tamponade with balloon devices (Foley catheter has been used). Inpatient monitoring is generally required. Recurrent epistaxis: Cochrane review in children shows no difference in effectiveness between antiseptic nasal cream, petroleum jelly, silver nitrate cautery, or no treatment.

–Silver nitrate cautery followed by 4 weeks of antiseptic cream may be better than antiseptic cream alone (5).

SURGERY/OTHER PROCEDURES

Packing

–Layering of Vaseline ribbon gauze (1/2 inch)

For gauze packing, be certain that both ends of the ribbon gauze protrude from the nostril.

Packing is layered from the floor upward.

Secure packing with gauze across the outside of the nostril.

–Nasal tampon may be used after lubricating the tip with KYJelly or antibiotic cream or ointment.

–Additional saline may be needed to expand the tampon if the bleeding has slowed.

–Merocel and Rapid Rhino packs are easier to use than gauze packing and

are usually well tolerated. Posterior bleed

–In the emergent setting, this may be attempted utilizing a Foley catheter or a specific posterior packing balloon.

–With both methods, the tubing is introduced through the nose similar to the passage of a nasogastric tube. Once it reaches the posterior oral pharynx, the balloon is inflated and the tubing is pulled back outward to tamponade the posterior bleeding source.

If using a Foley catheter (10 to 14F catheter), the balloon can be inflated with 10 mLof saline.

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Traction is maintained with an umbilical cord clamp with adequate padding between the clip and the nose to avoid injury.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Consider hospitalization for elderly or for patients with posterior bleeding or coagulopathy; may also consider if significant comorbidities

Admission criteria/initial stabilization

–Posterior bleed

–Hemodynamic changes

–Clotting dysfunction

–Universal ABC approach. Stop blood loss.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Hemodynamic monitoring if severe blood loss

24-Hour minimum for leaving packing in place; some recommend 3 to 5 days. Rebleed usually occurs between 24 and 48 hours. Longer durations of packing have increased risk of mucosal injury and toxic shock syndrome.

PATIENT EDUCATION

Demonstrate proper pinching pressure techniques.

Avoidance of trauma or irritants is key.

Management of systemic illness and proper use of medication

PROGNOSIS

Most are self-limited.

Good results with proper treatment

COMPLICATIONS

Septal perforation

Pressure-induced tissue necrosis of the nasal mucosa

Toxic shock syndrome with packing

Arrhythmias triggered by packing (particularly posterior)

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REFERENCES

1.Melia L, McGarry GW. Epistaxis: update on management. Curr Opin Otolaryngol Head Neck Surg. 2011;19(1):30–35.

2.Biggs TC, Nightingale K, Patel NN, et al. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl. 2013;95(1):40–42.

3.Escabasse V, Bequignon E, Vérillaud B, et al. Guidelines of the French Society of Otorhinolaryngology (SFORL). Managing epistaxis under coagulation disorder due to antithrombotic therapy. Eur Ann Otorhinolaryngol Head Neck Dis. 2017;134(3):195–199.

4.Clinkard D, Barbic D. Tranexamic acid for epistaxis—a promising treatment that deserves further study. CJEM. 2016;18(1):72–73.

5.Calder N, Kang S, Fraser L, et al. Adouble-blind randomized controlled trial of management of recurrent nosebleeds in children. Otolaryngol Head Neck Surg. 2009;140(5):670–674.

ADDITIONALREADING

Manes RP. Evaluating and managing the patient with nosebleeds. Med Clin North Am. 2010;94(5):903–912.

Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009;360(8):784– 789.

CODES

ICD10

R04.0 Epistaxis

CLINICALPEARLS

Most epistaxis is anterior and responds well to timed pressure over the anterior nares for 5 to 20 minutes.

Most nosebleeds are idiopathic or as a result of nose picking.

Posterior nosebleeds can be asymptomatic or present with nausea, hematemesis, or heme-positive stool.

Consider evaluation for neoplasm in cases of recurrent unilateral epistaxis.

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ERECTILE DYSFUNCTION

James G. Nee, MD, FAAFP

BASICS

DESCRIPTION

Erectile dysfunction (ED): the consistent or recurrent inability to acquire or sustain an erection of sufficient rigidity and duration for sexual intercourse

In the past, ED was assumed to be a symptom of the aging process in men, but it is more often the result of concurrent medical conditions of the patient or from medications that patients may be taking to treat those conditions.

Sexual problems are frequent among older men and have a detrimental effect on their quality of life but are infrequently discussed with their physicians

Synonym(s): impotence

EPIDEMIOLOGY

Incidence

It is estimated that >600,000 new cases of ED will be diagnosed annually in the United States, although this may be an underestimation of the true incidence, as ED is vastly underreported.

Prevalence

Overall prevalence for some degree of ED:

52% in men age 40 to 70 years

Age-related increase ranging from 12.4% in men age 40 to 49 years up to 46.6% in men age 50 to 69 years

ETIOLOGYAND PATHOPHYSIOLOGY

ED is a neurovascular event.

–With stimulation, there is release of nitrous oxide, which increases production of cyclic guanosine 3′,5′-monophosphate (cGMP).

–This leads to relaxation of cavernous smooth muscle, leading to increased blood flow to penis.

–As cavernosal sinusoids distend with blood, there is passive compression of subtunical veins, which decreases venous outflow, and this leads to an

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erection.

Alterations in any of these events lead to ED.

ED may result from problems with systems required for normal penile erection.

–Vascular: diseases that compromise blood flow

Peripheral vascular disease, arteriosclerosis, essential hypertension

–Neurologic: diseases that impair nerve conduction to brain or penile vasculature

Spinal cord injury, stroke, diabetes

–Endocrine: diseases associated with changes in testosterone, luteinizing hormone, prolactin levels

–Structural: phimosis, lichen sclerosis, congenital curvature

–Psychological: patients suffering from malaise, depression, performance

anxiety

Social habits such as smoking or excessive alcohol intake

Medications may cause ED.

Prostate cancer treatment

Structural injury or trauma (bicycling accident)

Genetics

Rarely related to chromosomal disorders

RISK FACTORS

Advancing age

Cardiovascular disease

Diabetes mellitus

Metabolic syndrome

Sedentary lifestyle

Cigarette smoking

Urologic surgery, radiation, trauma/injury to pelvic area or spinal cord

Medications that induce ED

SSRIs, β-blockers, clonidine, digoxin, spironolactone, antiandrogens, corticosteroids, H2 blockers, anticonvulsants

Central neurologic and endocrinologic conditions

Substance abuse (alcohol, cocaine, opioids, marijuana) Psychological conditions: stress, anxiety, or depression, sexual abuse, relationship problems

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GENERALPREVENTION

The two best ways to prevent ED are by the following:

Making healthy lifestyle choices by exercising regularly, eating well-balanced meals, limiting alcohol, and avoiding smoking

Treating existing health problems and working with your patients to manage diabetes, heart disease, and other chronic problems

ALERT

Aging alone is not a cause.

COMMONLYASSOCIATED CONDITIONS

Cardiovascular disease:

–Men with ED have a greater likelihood of having angina, myocardial infarction, stroke, transient ischemic attack, congestive heart failure, or

cardiac arrhythmia compared to men without ED (1). Diabetes

Neurologic conditions

Metabolic syndrome Psychiatric disorders

DIAGNOSIS

Inability to achieve or maintain erection satisfactory for intercourse

HISTORY

Identify concurrent medical illnesses or surgical procedures, history of trauma, and a list of current medications (e.g., antihypertensive meds).

Psychosocial history: smoking, ethanol intake, recreational drug use, anxiety and depression, satisfaction with current relationship

Presence or absence of morning erections

Speed of onset and duration of symptoms

Relationship of symptoms to libido

Detailed sexual history important to rule out premature ejaculation, as this is frequently confused with ED

Five-question International Index of Erectile Function (IIEF-5) is useful in rapid clinical assessment and measurement of effectiveness of ED treatments (1).

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