Metformin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anamarija Morovic?, MD

• Clinical Instructor, Department of Pathology and Laboratory Medicine, University of Cincinnati College of
• Medicine, Cincinnati, Ohio

Gluteus Maximus: Trigger points Site in this muscle may refer pain to any part of the buttock Buttock from sacrum to greater femoral trochanter with or coccyx areas diabetes mellitus patient education purchase metformin canada. Gluteus Medius: Trigger points in this or without posterior thigh blood sugar 105 discount metformin 850mg with visa, leg diabetes mellitus hyperlipidemia order metformin 500 mg without prescription, foot diabetes hereditary order metformin online pills, groin, or perineum. Those in the or in which the piriformis prevents excessive medial posterior portion refer pain downward into the lower rotation by acting as a lateral rotator of the thigh during part of the buttock, the posterior part of the thigh, and twisting and bending movements. The knee joint is not aware of the injury until hours or days after the incispared in this distribution. Symptoms are particularly aggravated by sitting to that of sciatica and also of other low back pain condi(which places pressure on the piriformis muscle) and by tions involving the gluteal musculature. Placing the hip in external rotation may delocated in the anterior portion refer pain similarly except crease pain. Course: without appropriate intervention, that it is distributed along the lateral rather than posterior persistent pain. Aggravating Factors A foot with a long second and short first metatarsal Associated Symptoms bone. It can act as a perpetuating factor for all the gluteal Paresthesias in the same distribution as the pain; other muscles, especially the gluteus medius. Straight leg raising is usually dyspareunia, pain on passing constipated stool, imporestricted because of tightness in the hamstring and glutence. Signs Pathology On external palpation through a relaxed gluteus maxiSee myofascial pain syndromes. On Trigger points of the gluteal musculature very often internal palpation during rectal or vaginal examination: function as satellite trigger points of those located in the piriformis muscle tenderness and firmness (medial trigquadratus lumborum muscle. Reproduction of buttock Differential Diagnosis pain with stretching the piriformis muscle during hip Sacroiliac joint dysfunction, sciatic neuritis, piriformis flexion, abduction, and internal rotation while lying susyndrome. Painful hip abduction against resistance while sitCode ting (Pace Abduction Test). Pain in the buttock and posterior thigh due to myofascial Bone scan (Tc-99m methylene diphosphonate) is usually injury of the piriformis muscle itself or dysfunction of normal but has been reported to show increased piriPage 201 formis muscle uptake acutely. Selected nerve conduction studies Essential Features may demonstrate nerve entrapment. Buttock pain with or without thigh pain, which is aggravated by sitting or activity. Posterolateral tensponds well to appropriate interventions, particularly in derness and firmness on rectal or vaginal examination. Relief Correction of biomechanical factors (leg length discrepDifferential Diagnosis ancy, hip abductor or lateral rotator weakness, etc. ProLumbosacral radiculopathy, lumbar plexopathy, proxilonged stretching of piriformis muscle using hip flexion, mal hamstring tendinitis, ischial bursitis, trochanteric abduction, and internal rotation. Facilitation of stretchbursitis, sacroiliitis, facet syndrome, spinal stenosis (if ing by: reciprocal inhibition and postisometric relaxation bilateral symptoms). May occur concurrently with lumtechniques; massage; acupressure (ischemic compresbar spine, sacroiliac, and/or hip joint pathology. Xlf procaine/Xylocaine) to region of lateral attachment of piriformis on femoral greater trochanter (lateral trigger References point), or to tender areas medial to sciatic nerve near Travell, J. The lower extremities, pirisacrum (medial trigger point) with rectal/vaginal moniformis, and other short lateral rotators. If previous measures fail, surgical transection of & Wilkins, Baltimore, 1992, pp. Social and Physical Disabilities Difficulty sitting for prolonged periods and difficulty with physical activities such as prolonged walking, standing, bending, lifting, or twisting compromise both sedentary and physically demanding occupations. Main Features Metastases to the hip joint region produce continuous System aching or throbbing pain in the groin with radiation Nervous system. In some cases peripheral causes have through to the buttock and down the medial thigh to the been described; the spinal cord is probably also inknee. A metastatic deposit to the femoral shaft produces local pain, Main Features which is also aggravated by weight-bearing. Sometimes rePain at rest due to tumor infiltration of bone usually relieved by activity, though it may be worse following sponds reasonably well to nonsteroidal antiexercise. Pain due to ments may be florid or almost imperceptible, and in the hip movement or weight-bearing responds poorly to latter case, the patient may never have noticed them. They consist of irregular, involuntary, and sometimes writhing movement of the toes, and they cannot be imiSigns and Laboratory Findings tated voluntarily. They can be suppressed for a minute or There may be tenderness in the groin and in the region two by voluntary effort and then return when the patient of the greater trochanter. There is not usually a relation between the formity unless a pathological fracture has occurred. Complications the major complication is a pathological fracture of the Relief femoral neck or the femoral shaft. Pathology Precise pathology unknown, but nerve root lesions have Summary of Essential Features and Diagnostic been described, and spinal cord damage. There is usually tenderness in the groin and increased pain on internal and external rotaReferences tion. Differential Diagnosis the differential diagnosis includes upper lumbar plexoNathan, P. Psychiatry, 41 (1978) pathy, avascular necrosis of the femoral head, and septic 934-939. Definition Usual Course Pain in the limbs, usually constant and aching in the feet, Unremitting. Pathology Site Degenerative changes appear in the dorsal root ganglion the distal portion of the limbs, more often in the feet cells or motor neurons of the spinal cord with resulting than in the hands, and across the joint spaces. Cold, damp, and changes in the weather appear to cause an increase in the symptom. Rest, simple analgesics the pain arises in association with peroneal muscular such as paracetamol (acetaminophen) and nonsteroidal atrophy. Age anti-inflammatory drugs, and transcutaneous electrical of Onset: the illness normally appears in childhood and stimulation help to ease the pain. Relief is also associadolescence, with a reported age range for prevalence ated with warmth, massage, lying down, sleep, and disfrom 10-84 years. The sex linked form is less common than the other Conduction velocities in motor nerves may be detypes. Pain Quality: pain is relatively rare in the disease, creased, or denervation may be evident. It may be continuous or intermittent but is aggraEssential Features vated by activity, stress, cold, and damp. This aching Pain in the relevant distribution in patients affected by pain appears most often as a complication of surgical the typical muscle disorder. Anxiety and Pain affecting joints only fatigue appear in association with the pain. Definition System Severe, sharp, or aching pain syndrome arising from Musculoskeletal system. The patient characteristically finds it impossible to sleep on the affected side. Cases are often secondary to systemic Aggravated by climbing stairs, extension of the back inflammatory disease, such as ankylosing spondylitis, from flexion with knees straight. Relief Usual Course Injection into the ischial bursa with local anesthetic and Usually of sudden onset. Local infiltration of local anesthetic and steroid into the area of the greatest tenderness produces excellent pain Pathology relief. Essential Features Recurring pain in ischial region aggravated by sitting or Pathology lying, relieved by injection. Inflammatory process of bursa caused by repeated trauma or generalized inflammation such as rheumatoid Differential Diagnosis arthritis. X3 Local pain aggravated by climbing stairs, extension of the back from flexion with knees straight.

Syndromes

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Use can quickly become chronic can you reverse diabetes in dogs metformin 850mg sale, with escalating dosages blood sugar formula cheap 500mg metformin free shipping, diminishing therapeutic effects ketenzorg diabetes mellitus type 2 metformin 850mg, and increasing demands on the physician diabetes response dogs 850 mg metformin visa. When admitted to the hospital, they may suffer unrecognized withdrawal symptoms, complicating their treatment, or may continue to take medications from a personal supply without informing the medical staff (150). There are many patients who could benefit from anxiolytics but who are inordinately worried about becoming dependent or addicted. A patient with no history of addictive behaviors is unlikely to get into trouble with a standard dose of medication (156,157). Many patients and their families are anxious because of misinformation or misunderstanding about a medical problem or treatment. Few patients can absorb all the information about significant gynecologic conditions at a single visit, but many feel that asking questions will burden the physician or make the patient appear stupid. Patients suffer anxiety when there is disagreement among family members or medical staff about the diagnosis or recommended treatment. Many patients dread certain aspects of care, sometimes on the basis of past experience or outdated information (157). For example, a reassuring family member or friend can be allowed to stay with the patient during a diagnostic test, sedation can be administered orally or by inhalation before an intravenous line is inserted, or the patient can be allowed control over her own analgesia. Behavioral interventions are extremely useful in managing anxiety disorders without problematic side effects. Specialists in behavioral medicine, usually psychologists, are expert in these techniques. A local medical school department of psychiatry or behavioral medicine is a good source for referrals. Faced with an obsessive or anxious, talkative, and needy patient in the midst of bedside rounds, clinic, or office hours, the clinician can develop a pattern of avoidance, sometimes alternating with overindulgence stemming from feelings of guilt. Gynecologists tend to underrate the power of their personal interactions with patients and their own ability to structure and limit those interactions appropriately. A patient with a long list of symptoms can be informed at the beginning of the visit how much time is available and asked to focus on her most important problem, with other problems to be discussed at future, scheduled appointments (162). Instead of scheduling appointments and returning telephone calls grudgingly in response to patient demands, the gynecologist should inform the patient that her condition requires brief regular scheduled visits. If she is contacting the office more often than visits can reasonably be scheduled, she should be asked to call between visits, at prearranged times, to advise the staff of her progress. There are useful self-help groups for patients with various psychiatric conditions and their families. Benzodiazepines are effective when taken for acute anxiety or during relatively brief, time-limited (several days) stressful situations. The specific agent should be chosen on the basis of onset of action and half-life. The patient must be admonished to avoid concomitant use of alcohol and to exercise extreme care about driving or engaging in other activities requiring attention, concentration, and coordination. Patients who fail to respond to a trial of office counseling or medication, who are unable to fulfill their responsibilities, who exhaust the patience and resources of significant others, who pose a diagnostic dilemma, who consume inordinate quantities of medical resources, or whose symptoms are becoming increasingly worse should be evaluated by a psychiatrist (166). Somatizing Disorders Diagnosis Somatizing disorders are those in which psychological conflicts are expressed in the form of physical symptoms. There is a spectrum of somatizing disorders based on the degree to which the patient is aware of or responsible for the onset of the symptoms. The spectrum ranges from the deliberate malingerer to the so-called hysteric, who is completely unaware of the link between her psyche and her physical symptom (167). Malingering Malingering is the deliberate mimicking of signs and symptoms of physical or mental illness to achieve a tangible personal gain, such as exemption from dangerous military duties or exoneration from criminal responsibility. Factitious disorder, or Munchausen syndrome, is a poorly understood condition in which the patient actively causes physical damage to herself or feigns somatic symptoms that result in repeated hospital admissions and painful, dangerous, invasive diagnostic and therapeutic procedures (167). These patients may introduce feces or purulent material into wounds or intravenous lines, inject themselves with insulin, or produce hemorrhages. Given enough diagnostic and therapeutic interventions, significant iatrogenic conditions, such as adhesions from surgery or Cushing syndrome from the administration of steroids, may develop in these patients (167). Most people want attention, but very few are willing to go to these lengths to get it. When staff members become suspicious, they will be tempted to validate their suspicions by spying on the patient or sending her out of her hospital room on a pretext and then searching her belongings. The latter is illegal, and either action, followed by a confrontation, will end the therapeutic relationship and provoke the patient to flee rather than addressing the problem. Calls for a psychiatric consultation may provoke resentment in the patient and family. As a result, there are few data about the etiology, incidence, and management of this condition. Often these patients are medically sophisticated because they or their family members had some kind of medical training or they gained knowledge during previous hospitalizations. The diagnosis requires symptoms of pain related to at least four different anatomic sites or physiologic functions: two gastrointestinal symptoms, one sexual or reproductive symptom, and one pseudoneurologic symptom or deficit other than pain (seizures, paresis). She responds accurately to questions about her past symptoms and treatments but may not volunteer information about them unless she is asked. Conversion Disorder Conversion disorder is the condition formerly called hysteria. Other Somatizing Disorders Pain disorder is a conversion condition with pain as the only symptom. Body dysmorphic disorder is preoccupation with a trivial or imagined defect in bodily appearance, a preoccupation that is not alleviated by the many medical and surgical treatments that the patient pursues (167,173). The gynecologist should hesitate to refer such a patient to a plastic or cosmetic surgeon, although specialists tend to be familiar with the condition and should hesitate to perform procedures on these patients. When one disease is ruled out, the patient is either convinced that the diagnosis was overlooked or switches her concerns to some other disease. Epidemiology Somatization is believed to be among the most common and most difficult psychological conditions in office practice. It is estimated that 60% to 80% of the general population experiences one or more somatic symptoms in a given week, providing an ample substrate for the patient preoccupied with her health (167). Somatization disorder occurs almost exclusively in women; menstrual symptoms may be an early sign. Conversion disorder occurs 2 to 10 times more frequently in women than in men (there is no difference for gender in children), and it is more common in rural and disadvantaged populations with little medical sophistication (167). Hypochondriasis is equally distributed between men and women; prevalence in general medical practice is estimated to be 4% to 9%. There are few statistics about body dysmorphic disorder, but it seems to be equally distributed between men and women, with an average age of onset of about 30 years (167). The goal of treatment in primary care is not to eliminate all the somatic symptoms but to help the patient cope with them and minimize their effect on her relationships and responsibilities (167). Because patients often seek care simultaneously or sequentially from several physicians, it is crucial to ask about all past and current diagnostic procedures, diagnoses, treatments, and responses. The impact on the lives of patients and their families can be mitigated even if the condition is not entirely eliminated.

Data from 48 reporting areas blood glucose watch purchase 850 mg metformin with amex, excludes California diabetes type 1 bedtime snacks buy generic metformin 500mg, Florida diabetes mellitus early symptoms purchase metformin 500mg amex, Louisiana diabetes meaning buy metformin 850mg with amex, and New Hampshire. Contraception failure in the first two years of use: differences across socioeconomic subgroups. From puberty until menopause, women are faced with concerns about childbearing or its avoidance: the only options are sexual abstinence, contraception, or pregnancy. The contraceptive choices made by couples in the United States in 2008 are shown in Table 10. Although use of contraception is high, a significant proportion of sexually active couples (7. Abortion ratios by age group indicate that the use of abortion is greatest for the youngest women and least for women in their late 20s and early 30s who are most likely to continue pregnancies (Fig. Young women are much more likely to experience unplanned pregnancy because they are more fertile than older women and because they are more likely to have intercourse without contraception. The effect of age on pregnancy rates with different contraceptive methods is shown in Figure 10. Efficacy Factors affecting whether pregnancy will occur include the fecundity of both partners, the timing of intercourse in relation to the time of ovulation, the method of contraception used, the intrinsic effectiveness of the contraceptive method, and the correct use of the method. It is impossible to assess the effectiveness of a contraceptive method in isolation from the other factors. The best way to assess effectiveness is long-term evaluation of a group of sexually active women using a particular method for a specified period to observe how frequently pregnancy occurs. A pregnancy rate per 100 women per year can be calculated using the Pearl formula (dividing the number of pregnancies by the total number of months contributed by all couples, and then multiplying the quotient by 1,200). With most methods, pregnancy rates decrease with time as the more fertile or less careful couples become pregnant and drop out of the calculations. This method calculates the probability of pregnancy in successive months, which are then added over a given interval. Problems relate to which pregnancies are counted: those occurring among all couples or those in women the investigators deem to have used the method correctly. Because of this complexity, rates of pregnancy with different methods are best calculated by reporting two different rates derived from multiple studies. Safety Some contraceptive methods have associated health risks; areas of concern are listed in Table 10. All of the methods are safer than the alternative (pregnancy with birth), with the possible exception of estrogen-containing hormonal contraceptives (pills, patches and ring) used by women older than 35 years of age who smoke (6). Most methods provide noncontraceptive health benefits in addition to contraception. Oral contraceptives reduce the risk of ovarian and endometrial cancers and ectopic pregnancy. These recommendations are based on the best evidence available supplemented by expert opinion. All present methods of contraception are assigned to one of four categories of suitability of use by women with more than 60 characteristics or conditions. The categories are: A condition for which there is no restriction for the use of the contraceptive method; A condition for which the advantages of using the method generally outweigh the theoretical or proven risks; A condition for which the theoretical or proven risks usually outweigh the advantages of using method; A condition that represents an unacceptable health risk if the contraceptive method is used. Cost effectiveness of levonorgestrel subdermal implants: comparison with other contraceptive methods available in the United States. A complex cost analysis based on the cost of the method plus the cost of pregnancy if the method fails concludes that sterilization and the long-acting methods are the least expensive over the long term (8) (Table 10. Long-Acting Reversible Contraceptives Several contraceptive methods are as effective as sterilization, but are completely reversible. These forgettable methods have pregnancy rates in typical use of less than 2 per 100 woman-years, are effective for at least 3 months without attention from the user, and are among the safest methods. Nonhormonal Methods Coitus Interruptus Coitus interruptus is withdrawal of the penis from the vagina before ejaculation. This method, along with induced abortion and late marriage, is believed to account for most of the decline in fertility of preindustrial Europe (11). Coitus interruptus remains a very important means of fertility control in many countries. Eighty-five million couples are estimated to use the method worldwide, yet it has received little recent formal study. The penis must be completely withdrawn both from the vagina and from the external genitalia. Pregnancy has occurred from ejaculation on the female external genitalia without penetration. Efficacy is estimated to range from 4 pregnancies per 100 women in the first year with perfect use to 27 per 100 with typical use (Table 10. Jones and colleagues offer a modern review of this practice and conclude that it likely is as effective as the condom (13). Breastfeeding Breastfeeding can be used as a form of contraception and can be effective depending on individual variables. Even with continued nursing, ovulation eventually returns but is unlikely before 6 months, especially if the woman is amenorrheic and is fully breastfeeding with no supplemental foods given to the infant (15). For maximum contraceptive reliability, feeding intervals should not exceed 4 hours during the day and 6 hours at night, and supplemental feeding should not exceed 5% to 10% of the total amount of feeding (16). To prevent pregnancy, another method of contraception should be used from 6 months after birth or sooner if menstruation resumes. Combination hormonal methods can be used after 6 weeks, once milk production is established. These recommendations are not based on any observed adverse effect of early administration, and many maternity programs begin injectable contraception with progestin at the time of hospital discharge. A variety of methods are used: the calendar method, the mucous method (Billings or ovulation method), and the symptothermal method, which is a combination of the first two methods. With the mucous method, the woman attempts to predict the fertile period by feeling the cervical mucus with her fingers. Under estrogen influence, the mucus increases in quantity and becomes progressively more slippery and elastic until a peak day is reached. The mucus then becomes scant and dry under the influence of progesterone until onset of the next menses. In the symptothermal method, the first day of abstinence is predicted either from the calendar, by subtracting 21 from the length of the shortest menstrual cycle in the preceding 6 months, or the first day mucus is detected, whichever comes first. The woman takes her temperature every morning and resumes intercourse 3 days after the thermal shift, the rise in body temperature that signals that the corpus luteum is producing progesterone and that ovulation occurred. The postovulatory method is a variation in which the couple has intercourse only after ovulation is detected. A correct use pregnancy rate of 2% and a typical use pregnancy rate of 12% were reported (21). Efficacy the ovulation method was evaluated by the World Health Organization in a five-country study. Women who successfully completed three monthly cycles of teaching were enrolled in a 13-cycle efficacy study. A review of 15 national surveys from developing countries estimated a 12-month gross failure rate of 24 pregnancies per 100 (23). Risks Conceptions resulting from intercourse remote from the time of ovulation more often lead to spontaneous abortion than conceptions from midcycle intercourse (24). Condoms In the 1700s, condoms made of animal intestine were used by the aristocracy of Europe, but condoms were not widely available until the vulcanization of rubber in the 1840s (1). Modern condoms usually are made of latex rubber, although condoms made from animal intestine are still sold and are preferred by some who feel they afford better sensation. Although the nonlatex condoms may break more easily than the latex varieties, substantial numbers of study participants preferred them and would recommend them to others (25).

Clearly blood sugar testing buy metformin 850 mg with visa, and for some diabetes mellitus urine specific gravity buy 850 mg metformin visa, more importantly diabetes mellitus birth defects purchase line metformin, surgery has an impact on intimate sexual relationships diabetes insipidus care plan order metformin from india. Trans, non-binary and non-gender people seeking surgery, may have intimate relationships with other people who are also planning surgery, or who have already undergone such surgery. So, as a background to your decisions about surgery, you may also be trying to negotiate the emotional destabilisation of your family, the grief and, possibly, anger of your partner. Many families do weather the storm; children, especially younger ones, become accepting of the change; partners may be willing to enter into discussions about how your intimate lives may continue, or how you can remain friends in a loving but largely platonic relationship. You may consider some counselling, separately and/or together, to help you deal with the inevitable stress. Talking to other couples who have successfully navigated the transition pathway can be helpful. You should not attempt to meet the expectations of doctors or other trans friends, nor should you feel as though you are disappointing others and that you are somehow failing to match up to their expectations. The crucial question is, is this surgery essential for you to be a whole, integrated personfi This was often associated with the loss of support from their families although a few were disappointed with their surgical results. However, where surgical results fall below expectations, this factor plays a part in undermining overall satisfaction. The possible risks and disadvantages of various approaches to surgery are discussed later in the text. Make sure that you have learned as much as possible about the various approaches to surgery, and that you have the opportunity to ask your lead surgeon anything you are not sure about. This is necessary, as it is extremely important that the surgeon does not find some unexpected difficulties that affect what can be done. Seeing the surgeon well before surgery also gives you time to consider alternatives, and to think about the opinion of the surgeon regarding likely outcomes in light of the examination undertaken and your personal health history. Each surgical team has its own technique but some surgical teams may be flexible about what surgery they will provide, and may, in any case, have to adapt their technique in individual cases, depending, for instance, on the tissue available. The lead surgeon 3 Landen, M, Walinder, J, Hambert, G, Lundstrom, B (1999) Factors predictive of regret in sex reassignment. You should also be made aware of the length of time which you will need to convalesce (section 8), any specific post-operative care (section 14). You should also understand the impact of surgery on reproductive options (see section 6). If possible you should see a copy of this form a few weeks ahead of surgery so that you have time to ask the surgeon further questions. Obviously, once you come off hormones, the emergence of male characteristics such as facial hair and male pattern baldness will resume. Most surgeons insist that you stop taking oestrogen about four weeks before your operation as this reduces the likelihood of deep vein thrombosis. Operation Operation time Hospital stay Recovery complete genital reconstruction five hours seven to eight days six weeks 9 What does surgery aim to achievefi This surgery aims to provide you with a genital appearance that is virtually indistinguishable from other women. It is worth bearing in mind that there is no uniformity of appearance in non-trans women. The following is a list of procedures that may be undertaken in gender confirmation surgery. This will emerge within the labia minora so will not be immediately visible from the outside. Also, you may need less oestrogen than before but hormones must be taken to preserve bone density (see section 16) and general wellbeing; fi although you will still have a prostate gland, the chances of developing cancer of it are significantly reduced (but it can happen and the symptoms may be harder to spot); fi social and leisure pursuits which involve changing rooms or wearing a swimming costume become much easier; and fi most importantly, you may feel better about yourself. For example less skin will be available in a circumcised person and one who has been taking female hormones for some time. The penis is disassembled into its various parts but most of these will remain attached to the body so that nerve and blood vessel connections are preserved. However, the erectile tissue is removed from the shaft of the penis and either side of its base. A wide, deep pocket is created in the area behind the root of the penis, projecting up into the pelvic cavity between the urethra and bladder in front, and the bowel behind. Where the pedicle flap is used, the upper aspect of the penile skin remains attached to the lowest part of the abdomen; two holes will be made in the front of this flap, to allow the clitoris to emerge through the skin, and the urethra to have an opening (meatus) through which to pee. The skin of the penis is turned inside-out so that the outside surface of the penis becomes the inside surface of the vagina and the base of the tube will lie between the urethral and bowel openings. It is recommended that you have pre-operative electrolysis to the area around the base of the penis to avoid subsequent problems with hair adjacent to the clitoris. Creating the vagina using penile and scrotal tissue: To overcome the shrinkage of scar tissue at the entrance to the vagina, and to provide extra tissue where penile tissue is insufficient, a combination of penile and scrotal tissue may be used. A section of scrotal tissue, continuous with the underside of the penile skin, is used to supplement the tissue available for creating the vagina. In both this technique and the one described above, the clitoris may be too exposed and therefore cause discomfort. In addition to removing hair around the base of the penis, this area of the scrotum also must have all hair removed prior to surgery, otherwise it will regrow within the vagina. Disadvantages: fi Scrotal skin is hair-bearing, so careful removal of the hair around the base of the penis and underneath the scrotum should be undertaken before the operation, otherwise it will continue to grow inside the vagina and this can cause ongoing difficulties. This technique may include using the lower part of the glans to form a cervix (see below) Advantages the urethral tissue remains sensate and moist. More complicated procedures have greater potential to develop post-operative complications, but these are rare with an experienced team. The scrotal tissue has all hair removed during the operation; this is done by punching out the hair follicles. The tissue is a free flap (not attached to the body) that is shaped and stretched over a mould. However, if insufficient tissue is available from the options mentioned above or, earlier surgery has not succeeded in providing a vagina of adequate length and breadth, then bowel tissue may be used to augment to available tissue. The glans is divided from side to side; the front/upper part is refashioned and made smaller, usually retaining a small amount of corpus spongiosum (see diagram below) and is positioned superficially just in front of, and slightly below, the pubic bone; it will be accessible through an opening made in the penile flap (where that technique is used to make the front wall of the vagina). As shown in the diagram below, some surgeons also use the back/lower part of the glans (which is at the end of the bundle of nerves and blood vessels that supply the urethra and this part of the glans) to form a cervix at the upper end of the vagina. The clitoris is made by removing some of the central tissue from the top half of the glans and the glans of the penis folding the outer wings forwards is divided into upper and inwards, and joining them and lower halves. The tissue used to create the inner lips (labia minora) is often taken from the scrotum and sometimes from the lower part of the penis as well. As mentioned above, a clitoral hood may be made from the foreskin; this will be positioned at the upper end of the labia minora, and will be partially covered by them. The outer lips, the labia majora, are usually made from scrotal tissue, as in this image. Post-operative complications, which are specific to this surgery that may arise, are: fi scar tissue at the entrance to the vagina shrinks, and/or the vagina itself loses depth and width.

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