This section discusses only general therapeutics; the specifics of individual therapeutic agents. Their use for a particular disorder are contained with the discussion of the diseases as they occur throughout this book.
One of the guiding principles of medical therapy is the recognition that a disease is occurring in an individual rather than existing as a separate, localized problem. This is particularly true for patients with genital disease where there are immense psychological, social, and sexual repercussions associated with every problem occurring in
this region of the body. For instance, patients are highly likely to have a perception that negligence on their part regarding something they were responsible for, such as sexual activity or hygiene, led to the development of their problem. This, of course, may or may not be actually true. Therefore, look for the presence of anxiety, depression, guilt, or other aspects of psychological dysfunction in all patients with anogenital disorders. Offer support and counseling to include assistance in obtaining help by other professionals where the magnitude of the problem warrants it. Failure to recognize the patient as a person is very likely to compromise the therapeutic outcome even when the disease itself is identified and treated correctly.
The anogenital area represents a very hostile environment for normal function of the mucocutaneous epithelial cells that make up the barrier between us and the outside world. Some of the detrimental factors that are involved include heat, sweat, vaginal secretion, urine, feces, clothing, friction, and excessive hygiene. These factors can cause disease, worsen minor problems, and retard normal healing.
Epithelial cells can generally withstand rather high temperatures but, unfortunately, with heat comes sweating. And sweat can be remarkably irritating as exemplified by the discomfort experienced when sweat gets in our eyes during exercise. The retention of sweat leads to maceration, and this in turn leads to damage and possibly death of epithelial cells. This damage to the epithelial barrier allows the exposure of cutaneous nerve endings and results in symptoms of pruritus and/or pain. The presence of this warmth and moisture also fosters colonization of, and sometimes infections due to, bacteria and Candida sp. Obesity, tight clothing, and prolonged sitting (especially on vinyl or plastic seats) are often responsible for such maceration. It is difficult, but worth trying, to ameliorate these conditions.
In women, vaginal discharge (whether physiologic or pathologic) and/or urinary incontinence can cause irritation with subsequent inflammation and damage to epithelial cells. The end result is similar to that described for sweat retention. To make matters worse, women with urinary incontinence or vaginal discharge often turn to the use of panty liners on a continual basis. The result is even worse maceration. The cause of vaginal secretions (see Chapter 15
) should be determined and treated appropriately. Incontinence may require urologic consultation. In both sexes, fecal soiling can lead to irritation. More careful cleaning after defecation is desirable so that sweat does not liquefy and spread irritating fecal material. Usually, careful use of ordinary toilet paper is sufficient but if that causes too much irritation, Cetaphil cleanser, mineral oil, or vegetable oil can be used for anal cleansing.
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