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In the United States, sterilization is the most popular method of birth control for couples who want no more children Although sterilization is reversible in some instances, reversal surgery in both men and women is costly, complicated, and not always successful Therefore, patients should be counseled carefully before sterilization and should view the procedure as final Vasectomy is a safe, simple procedure in which the vas deferens is severed and sealed through a scrotal incision under local anesthesia Long-term follow-up studies on vasectomized men show no excess risk of cardiovascular disease Several studies have shown a possible association with prostate cancer, but the evidence is weak and inconsistent Female sterilization procedures include laparoscopic bipolar electrocoagulation, or plastic ring application on the uterine tubes, or minilaparotomy with Pomeroy tubal resection The advantages of laparoscopy are minimal postoperative pain, small incisions, and rapid recovery The advantages of minilaparotomy are that it can be performed with standard surgical instruments under local or general anesthesia However, there is more postoperative pain and a longer recovery period The cumulative 10-year failure rate for all methods combined is 185%, varying from 075% for postpartum partial salpingectomy and laparoscopic unipolar coagulation to 365% for spring clips; this fact should be discussed with women preoperatively Some studies have found an increased risk of menstrual irregularities as a long-term complication of tubal ligation, but findings in different studies have been inconsistent A new method of transcervical sterilization, Essure, is approved by the FDA The method involves the placement of an expanding microcoil of titanium into the proximal uterine tube under hysteroscopic guidance The efficacy rate at 1 year is 998%
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Refer to experienced clinicians for Implanon or other subcutaneous insertion, IUD insertion, tubal occlusion or ligation, vasectomy, or therapeutic abortion
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Abbott J Transcervical sterilization Best Pract Res Clin Obstet Gynaecol 2005 Aug;19(5):743 56 [PMID: 16023892]
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crisis centers whenever possible to provide ongoing support and counseling
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ESSENTIALS OF DIAGNOSIS
Women neither secretly want to be raped nor do they expect, encourage, or enjoy rape Rape is always a terrifying experience in which most victims fear for their lives The rapist is usually a hostile man who uses sexual intercourse to terrorize and humiliate a woman
General Considerations
Rape, or sexual assault, is legally defined in different ways in various jurisdictions Clinicians and emergency department personnel who deal with rape victims should be familiar with the laws pertaining to sexual assault in their own state From a medical and psychological viewpoint, it is essential that persons treating rape victims recognize the nonconsensual and violent nature of the crime About 95% of reported rape victims are women Penetration may be vaginal, anal, or oral and may be by the penis, hand, or a foreign object The absence of genital injury does not imply consent by the victim The assailant may be unknown to the victim or, more frequently, may be an acquaintance or even the spouse Unlawful sexual intercourse, or statutory rape, is intercourse with a female before the age of majority even with her consent Rape represents an expression of anger, power, and sexuality on the part of the rapist The rapist is usually a hostile man who uses sexual intercourse to terrorize and humiliate a woman Women neither secretly want to be raped nor do they expect, encourage, or enjoy rape Rape involves severe physical injury in 5 10% of cases and is always a terrifying experience in which most victims fear for their lives Consequently, all victims suffer some psychological aftermath Moreover, some rape victims may acquire sexually transmissible disease or become pregnant Because rape is a personal crisis, each patient will react differently The rape trauma syndrome comprises two principal phases (1) Immediate or acute: Shaking, sobbing, and restless activity may last from a few days to a few weeks The patient may experience anger, guilt, or shame or may repress these emotions Reactions vary depending on the victim s personality and the circumstances of the attack (2) Late or chronic: Problems related to the attack may develop weeks or months later The lifestyle and work patterns of the individual may change Sleep disorders or phobias often develop Loss of self-esteem can rarely lead to suicide Clinicians and emergency department personnel who deal with rape victims should work with community rape
The clinician who first sees the alleged rape victim should be empathetic Begin with a statement such as, This is a terrible thing that has happened to you I want to help 1 Secure written consent from the patient, guardian, or next of kin for gynecologic examination and for photographs if they are likely to be useful as evidence If police are to be notified, do so, and obtain advice on the preservation and transfer of evidence 2 Obtain and record the history in the patient s own words The sequence of events, ie, the time, place, and circumstances, must be included Note the date of the LMP, whether or not the woman is pregnant, and the time of the most recent coitus prior to the sexual assault Note the details of the assault such as body cavities penetrated, use of foreign objects, and number of assailants Note whether the victim is calm, agitated, or confused (drugs or alcohol may be involved) Record whether the patient came directly to the hospital or whether she bathed or changed her clothing Record findings but do not issue even a tentative diagnosis lest it be erroneous or incomplete 3 Have the patient disrobe while standing on a white sheet Hair, dirt, and leaves, underclothing, and any torn or stained clothing should be kept as evidence Scrape material from beneath fingernails and comb pubic hair for evidence Place all evidence in separate clean paper bags or envelopes and label carefully 4 Examine the patient, noting any traumatized areas that should be photographed Examine the body and genitals with a Wood light to identify semen, which fluoresces; positive areas should be swabbed with a premoistened swab and airdried in order to identify acid phosphatase Colposcopy can be used to identify small areas of trauma from forced entry especially at the posterior fourchette 5 Perform a pelvic examination, explaining all procedures and obtaining the patient s consent before proceeding gently with the examination Use a narrow speculum lubricated with water only Collect material with sterile cotton swabs from the vaginal walls and cervix and make two airdried smears on clean glass slides Wet and dry swabs of vaginal secretions should be collected and refrigerated for subsequent acid phosphatase and DNA evaluation Swab the mouth (around molars and cheeks) and anus in the same way, if appropriate Label all slides carefully Collect secretions from the vagina, anus, or mouth with a premoistened cotton swab, place at once on a slide with a drop of saline, and cover with a coverslip Look for motile or nonmotile sperm under high, dry magnification, and record the percentage of motile forms 6 Perform appropriate laboratory tests as follows Culture the vagina, anus, or mouth (as appropriate) for N gonorrhoeae and Chlamydia Perform a Papanicolaou smear of the cervix, a wet mount for T vaginalis, a baseline pregnancy test, and VDRL test A confidential test for HIV antibody can be obtained if desired by the patient and repeated in 2 4 months if initially negative Repeat the
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