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By U. Jose. Westminster Theological Seminary.

The root of the penis expands posteriorly to form the bulb of the penis and the crus Objective 13 Describe the structure and function of the penis buy cheap extra super avana 260mg on-line. The penis and scrotum buy discount extra super avana 260 mg, which are suspended from the perineum buy extra super avana 260mg overnight delivery, constitute the external genitalia of the male order 260mg extra super avana free shipping. Male Reproductive © The McGraw−Hill Anatomy purchase 260mg extra super avana otc, Sixth Edition Development System Companies, 2001 Chapter 20 Male Reproductive System 711 FIGURE 20. Red, yellow, and purple indicate the warmest portions; blue and green indicate the coolest. The crus, which is superior to the bulb, is enveloped monly removed from an infant on the third or fourth day after by the ischiocavernosus muscle. This The body of the penis is composed of three cylindrical procedure is called a circumcision. The paired dorsally posi- because the glans penis is easier to clean if exposed. The fibrous tissue between the two corpora accumulate along the border of the corona glandis if good hygiene is forms a septum penis. Smegma can foster bacteria that may cause infec- tions, and therefore should be removed through washing. Cleaning penis is ventral to the other two and surrounds the spongy urethra. Occasionally, a child is born with a prepuce that is too tight with blood. In the sexually aroused male, it becomes firm and erect to permit retraction. Trauma to the penis, testes, and scrotum is common be- The penis is supplied with blood on each side through the cause of their pendent (hanging) position. Because the penis and superficial external pudendal branch of the femoral artery and testes are extremely sensitive to pain, a male will respond reflex- the internal pudendal branch of the internal iliac artery. Urethral injuries are more com- nous return is through a superficial median dorsal vein, which mon in men than in women because of the position of the empties into the great saphenous vein in the thigh, and through urethra in the penis. In addition, The glans penis is the cone-shaped terminal portion of the the penis has extensive motor innervation from both sympa- penis, which is formed from the expanded corpus spongiosum. The opening of the urethra at the tip of the glans penis is called the urethral orifice. The corona glandis is the prominent poste- Knowledge Check rior ridge of the glans penis. Describe the position of the penis relative to the scrotum attaches the skin covering the penis to the glans penis. Describe the external structure of the penis and the inter- is generally more darkly pigmented than the rest of the body nal arrangement of the erectile tissue. Define circumcision and explain why this procedure is com- monly performed. Male Reproductive © The McGraw−Hill Anatomy, Sixth Edition Development System Companies, 2001 712 Unit 7 Reproduction and Development Sexual excitement; stimulation Reduction of venous flow from Increase in parasympathetic Inhibition of sympathetic penis; increased cardiac output impulses causes vasodilation of impulses to penis through sympathetic impulses arterioles within penis to heart Accumulation of blood within erectile tissue of penis Penis becomes turgid and erect FIGURE 20. Erection of the Penis MECHANISMS OF ERECTION, EMISSION, AND EJACULATION Erection of the penis depends on the volume of blood that enters the arteries of the penis as compared to the volume that exits Erection of the penis results from parasympathetic impulses that through venous drainage (fig. Normally, constant sympa- cause vasodilation of arteries within the penis and a decrease in thetic stimuli to the arterioles of the penis maintain a partial venous drainage. Emission and ejaculation are stimulated by constriction of smooth muscles within the arteriole walls, so that sympathetic impulses, which result in the forceful expulsion of there is an even flow of blood throughout the penis. Also, during parasympathetic stimulation there is inhibition of sympathetic Objective 15 Describe the events that result in erection of impulses to arterioles of the penis. These combined events cause the Objective 16 Explain the physiological process of spongy tissue of the corpora cavernosa and the corpus spongio- ejaculation. In this condition, the penis can be inserted into the vagina of the female and function as a copulatory organ to dis- charge semen. Erection, emission, and ejaculation are a series of interrelated Erection is controlled by two portions of the central ner- events by which semen from the male is deposited into the fe- vous system—the hypothalamus in the brain and the sacral male vagina during coitus (sexual intercourse). The hypothalamus controls con- occurs as a male becomes sexually aroused and the erectile tissue scious sexual thoughts that originate in the cerebral cortex.

REGIONAL BLOCKS Claims resulting from anesthesia provided by regional blocks buy 260 mg extra super avana visa, including epidural buy extra super avana 260mg line, spinal anesthetics purchase extra super avana 260 mg without a prescription, and brachial plexus blocks purchase extra super avana 260mg fast delivery, often allege injuries different from claims involving general anes- thesia buy extra super avana 260mg on-line. Panel reviews of these claims have found that the main alle- gations include nerve damage, inadequate volume replacement, informed consent, and patient communication problems. Nerve damage injuries include allegations of pain, numbness, and palsies. Often in obstetrical/gynecology claims, subsequent neurological consulta- tion finds that the injuries are more consistent with saphenous or pero- neal nerve damage from lithotomy stirrups or obturator nerve damage from compression against the pelvic bone during delivery. Still, a patient with weak or numb legs who has had an epidural is likely to assume that it is the cause. Similarly, when patients develop neuro- logical symptoms after arm surgeries performed under brachial plexus blocks, it can be difficult to determine whether the cause is the surgery itself or the anesthetic. Therefore, anesthesiologists are advised to seek prompt neurological consultation for patients with persistent neurological complaints after regional blocks. Anesthesiologists should always be cognizant of the risk of epidu- ral hematoma formation after epidural blocks. Because the window for regaining function after cord compression from an epidural hematoma may be as small as 6–8 hours, often at issue in these claims is how promptly the hematoma was suspected and diagnosed, usually through magnetic resonance imaging scanning. Although plaintiffs often must concede that epidural hematomas are within the risks of the procedure, 130 Lofsky a failure to diagnose them in a reasonable time frame might not be. Because the risks of hematoma formation are higher when epidural catheters are used in combination with anticoagulants like heparin, warfarin, and enoxaparin (Lovenox®), anesthesiologists should communicate with surgeons and primary care physicians who could be writing anticoagulation orders for these drugs on their patients. The issue of whether regional blocks should be placed in patients who are already under general anesthesia remains controversial. A number of claims have occurred related to placement of interscalene and supraclavicular brachial plexus blocks for postoperative pain relief in shoulder surgeries performed under general anesthesia. Injuries have included total arm paralysis and direct trauma to the spinal cord. The allegation is always that if the patient had been awake when the block was performed, pain and paresthesias would have alerted the anesthe- siologist to improper needle placement and avoided the severe neuro- logical injury. Anesthesiologists should also carefully weigh the risks of performing thoracic and cervical epidural blocks on patients under general anesthesia or heavy sedation. These patients might not be com- pletely cooperative or able to communicate uncomfortable sensations to their physicians. Epidural and spinal blocks performed for surgical anesthesia often result in relative hypovolemia because of vasodilatation. Some anesthe- sia claims allege inappropriate use of these blocks in severely hypov- olemic patients or inadequate replacement of the resulting intraoperative fluid shifts. Line placement may become an issue, because central venous catheters or Swan-Ganz catheter lines can help clarify patients’ volume status if it is uncertain, although other factors such as blood pressure, heart rate, and urine output are also useful guides (4). Informed consent can become an issue in claims involving regional blocks simply because the alternative of general anesthesia usually exists. An anesthesiologist should provide some documentation that the more common risks of regional blockade were discussed with the patient and, ideally, that the alternatives to a block were also pre- sented. If there are particular reasons why an anesthesiologist prefers a regional block, such as poor patient respiratory status or anticipated airway difficulties, then it is also helpful if this is recorded. Blocks performed solely for postoperative pain relief should be explained as such, and the alternatives should be presented to the patient. Although considered well within the risks of epidural and spinal anesthetics, postsubdural puncture headaches remain a common cause Chapter 10 / Anesthesiology 131 of malpractice claims. As this is one of the more common complica- tions, it should likely be mentioned in the informed consent for all planned epidurals and spinals. Should an accidental dural puncture occur in a planned epidural anesthetic or should a patient complain of a classic positional headache afterward, the anesthesiologist should evaluate the patient and explain alternatives to treatment, such as pain medication and blood patching. Many of these claims seem to arise when the patient has felt ignored or has had to endure a time-consum- ing and expensive process to be evaluated and treated by a physician for a headache complaint. OPERATING ROOM FIRES Historically, operating room fires were associated with flammable anesthetics and static electricity.

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The extraocular muscles move the vision is clear buy extra super avana 260 mg line, but the eye cannot focus on distant objects buy discount extra super avana 260mg line. These six muscles purchase extra super avana 260mg without a prescription, which originate on the bone of the A negative (diverging) lens corrects this defect buy extra super avana 260 mg otc. If the cur- orbit (the eye socket) and insert on the sclera 260mg extra super avana fast delivery, are arranged vature of the cornea is not symmetric, astigmatism results. They are under visually Objects with different orientations in the field of view will compensated feedback control and produce several types have different focal positions. Vertical lines may appear of movement: sharp, while horizontal structures are blurred. This condi- • Continuous activation of a small number of motor units tion is corrected with the use of a cylindrical lens, which produces a small tremor at a rate of 30 to 80 cycles per has different radii of curvature at the proper orientations second. Especially in older adults, there may be a progressive and large, slow movements, used in following moving increase in its opacity, to the extent that vision is obscured. This condition, called a cataract, is treated by surgical re- Organized movements of the eyes include: moval of the defective lens. An artificial lens may be im- • Fixation, the training of the eyes on a stationary object planted in its place, or eyeglasses may be used to replace • Tracking movements, used to follow the course of a the refractive power of the lens. The peak spectral sensitivity ward to fix on near objects for the red-sensitive pigment is 560 nm; for the green-sen- • Nystagmus, a series of slow and saccadic movements sitive pigment, it is about 530 nm; and for the blue-sensi- (part of a vestibular reflex) that serves to keep the retinal tive pigment, it is about 420 nm. At wavelengths away from the optimum, the receives a slightly different image of the same object. Be- property, binocular vision, along with information about cause of the interplay between light intensity and wave- the different positions of the two eyes, allows stereoscopic length, a retina with only one class of cones would not be vision and its associated depth perception, abilities that are able to detect colors unambiguously. Many ab- of the three pigments in each cone removes this uncer- normalities of eye movement are types of strabismus tainty. Colorblind individuals, who have a genetic lack of (“squinting”), in which the two eyes do not work together one or more of the pigments or lack an associated trans- properly. Other defects include diplopia (double vision), duction mechanism, cannot distinguish between the af- when the convergence mechanisms are impaired, and am- blyopia, when one eye assumes improper dominance over the other. Failure to correct this latter condition can lead to loss of visual function in the subordinate eye. The retina is a multi- B layered structure containing the photoreceptor cells and a complex web of several types of nerve cells (Fig. There are 10 layers in the retina, but this discussion em- ploys a simpler four-layer scheme: pigment epithelium, photoreceptor layer, neural network layer, and ganglion cell layer. These four layers are discussed in order, begin- ning with the deepest layer (pigment epithelium) and mov- ing toward the layer nearest to the inner surface of the eye C (ganglion cell layer). Note that this is the direction in which visual signal processing takes place, but it is opposite to the path taken by the light entering the retina. This opaque material, which also extends between portions of individual rods and cones, prevents the scattering of stray light, thereby greatly sharpening the resolving power of the retina. Its presence ensures that a tiny spot of light (or a tiny portion of an image) will excite only those receptors on which it falls directly. People with albinism lack this pig- ment and have blurred vision that cannot be corrected ef- D fectively with external lenses. The pigment epithelial cells also phagocytose bits of cell membrane that are constantly shed from the outer segments of the photoreceptors. Because of the eye’s mode of embryologic development, the photore- E ceptor cells occupy a deep layer of the retina, and light must pass through several overlying layers to reach them. The cones are responsible for photopic (daytime) vision, which is in color (chromatic), and the rods are responsible for scotopic FIGURE 4. C, Photore- are basically similar, although they have important struc- ceptor layer. CHAPTER 4 Sensory Physiology 75 retinal is isomerized back to the 11-cis form, and the rhodopsin is reconstituted. All of these reactions take place in the highly folded membranes comprising the outer seg- ment of the rod cell.

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It is the measurement of the rate of urination and force of the bladder’s expulsive ability cheap extra super avana 260mg overnight delivery. Pressure flow parameters in the study include bladder pressure discount extra super avana 260mg mastercard, rectal pressure effective 260 mg extra super avana, differential pressure purchase 260mg extra super avana with visa, urethral pressure order extra super avana 260mg free shipping, flow rate, volume, and electromyogram (EMG) sphincter activity. Both needle and surface EMG and CMG (filling cystometro- gram) are helpful in diagnosing detrusor-sphincter dyssynergia. Bladder training consists of education, scheduled voiding, and positive reinforcement. This requires that the participant resist or inhibit the sensation of urgency to postpone voiding, and urinate according to a timetable rather than according to the urge to void. Bladder training may also involve tactics to allow the bladder to hold a greater volume: 1. Drinking an adequate amount of fluid at one sitting will gener- ally result in an urge to void within the retraining time frame. Avoiding fluids with caffeine, artificial sweeteners, and alcohol will reduce bladder irritability. Medications that are beneficial for failure to store and DSD include: anticholinergics (oxybutynin) antimuscarinics (tolterodine tartrate, hyoscyamine sulfate) tricyclic antidepressants (imipramine) antidiuretic hormone analog (desmopressin acetate), particularly for nocturia C. Crede method is contraindicated because of the potential to create increased pressure and damage the upper tract. Allows an individual to empty the bladder at regular intervals, thereby reducing the risk of UTI, structural damage, and other distressing bladder symptoms. Teaching guides are available 74 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM E. An indwelling catheter may be needed for either short- or long-term use and allows for continual drainage by gravity. Its use is suggested for those individuals who cannot be managed with ISC and/or medications, or who have chronic decubiti and cannot perform ISC. Long-term use of indwelling catheters is a significant source of bacteruria and UTI. Management varies but the usual practice is to change the catheter after a minimum of 30 days or prn. If the patient has a symptomatic UTI, the entire system must be changed and a urine culture obtained. A person with MS may still experience urinary incontinence with an indwelling catheter. In this instance, the indication is not to increase the size of the catheter or balloon, but rather to use anticholinergic/antimuscarinic medications to decrease urinary tract spasticity. Suprapubic catheters are sometimes an alternative to long-term urethral catheters. These may be helpful in male patients and in women who have developed severe urethral irritation secondary to an indwelling Foley catheter. Sphincterectomy may be recommended for very disabled male patients who experience intractable hesitancy and retention. Anticholinergic medications and an external condom catheter can be combined to manage bladder activity. Some female patients with small-capacity bladder may benefit from a laparoscopic procedure that includes bladder augmenta- tion with a continent diversion. Diversion procedures including cystostomy or transurethral resection, which provides a clear passageway for the urine to flow freely. Chapter 14 Bowel Elimination and Continence Objectives: Upon completion of this chapter, the learner will identify: The common pathophysiology of upper motor neuron bowel, lower motor neuron bowel, uninhibited neurogenic bowel, and motor paralytic bowel as seen in MS Goals for establishing bowel control with MS Common nursing interventions in managing a neurogenic bowel A comprehensive care plan for gastrointestinal complications The long-term implications of neurogenic bowel dysfunction Altered bowel function may occur whenever the central nervous system (CNS) has been impaired. When disease or disability results in altered bowel control, incontinence may become as devastating a problem as the disease itself. Control of incontinence and prevention of constipation and diarrhea are possible through an effective bowel program, which requires a knowledge of normal and altered bowel physiology as well as an in-depth assessment of bowel function. The lower bowel acts under voluntary control to store and eliminate feces. Inability to store fecal matter causes problems with involuntary bowel or incontinence. The bowel consists of three separate parts: the ileum, the cecum, and the colon. It is approximately 12 feet long and extends from the jejunum to the ileocecal opening. Almost all absorption and digestion is accomplished in the small intestine.

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