POP!!

NewFNP has previously discussed the lady scourge of urinary incontinence. Kegels, ladies, kegels!! But what newFNP hasn't talked about is the sister scourge of pelvic organ prolapse.

NewFNP is super content to leave her lady-junk all up in there, where it's supposed to be. Except the parts that are supposed to be outside. They can stay there. NewFNP is just saying this -- a reasonable expectation for aging is to keep all yo junk in its O.G. spot. Let's get Suzanne Somers to work on this one with her team of experts!

Because when innies become outties, that is not so good.

What makes newFNP think of this on a lovely Sunday is a patient who came in with a chief complaint of feeling something falling out of her vagina. This is the second CC of this nature, but as this patient was in her 50's and was not in the post-partum period, newFNP was certain that she would not find any form of placental treasure upon examination.

What newFNP did see was a fairly obvious cystocele-rectocele combination platter. As newFNP's patient had mentioned that the sensation of fullness was more pronounced when she was using force, newFNP went ahead and had her patient give her a little Valsalva while in the lithotomy position.

Had newFNP been wearing 3D glasses, she might have had a heart attack. "Okay, stop!" she told her patient, fearful that she would deliver her uterus into newFNP's hands.

NewFNP quickly completed the OB/GYN referral and was ready to end the visit when her patient asked her, "Is that happening because I'm not having any sexercise?"

"Did you say 'sexercise'?" newFNP replied.

She had indeed.

Not so much a lack of sexercise, no, but her four >8 pound babies delivered vaginally might perhaps be a more likely culprit. (Or, in other cases, family history. Or obesity. Or hysterectomy.)

Dis-gusting!

No Monday could be worse than last Monday when newFNP took one to the kisser.

But newFNP had a close second in terms of building her case against Mondays. (And this Monday is in the shadow of a three-day weekend and a newFNP cumpleaños so bitches better start coming correct!!)

NewFNP was going about the same old business of performing a pap. Using her gentle touch, of course, she grabbed an endocervical sample with the cytobrush and, upon removal, noted a viscous, gloopy, stringy mucous hanger-on. Not wanting it to drop, newFNP began an attempt to loop it around the brush using a circular motion.

No luck. A glob of it was hell bent on attack and launched itself Pyongyang style, landing directly on newFNP's forehead.

Fucking. Disgusting.

But newFNP felt like she lucked out by not having that shit land in her eye. She brushed off the attack, literally and figuratively, and went about her day.

Thanks, but no thanks

It was placenta. The patient is fine albeit somewhat peeved.

In her follow up visit, she told newFNP that when she first felt something falling out of her lady business, she called her husband into the bathroom to survey the scene as she was unable to see beneath her newly post-partum abdomen. He confirmed that there was, indeed, something gone quite awry and that there was most certainly something alien in her nether regions.

"Pull it out!" she instructed him.

He declined and, instead, brought her into the clinic.

For those who are interested, the AAFP has a decent article about how to evaluate whether one has actually accounted for the whole thing. The article is a bit old, but newFNP doesn't think that the placenta has changed much in the past twelve years.

Contingency management

NewFNP deals with a lot of vaginal complaints. They generally run along the lines of itch, olfactory woes or a forgotten objet causing distress and/or one of the aforementioned concerns.

What is exceedingly uncommon (n=1 in five years) is for a woman, three days post-partum, to present to clinic with a chief complaint of "something is coming out of my vagina." NewFNP had two differentials: retained products or prolapsed uterus.

As newFNP and her patient assumed their respective positions, newFNP briefly thought, "Holy mother, is that an umbilical cord??" before coming to her senses. What she saw was a shiny, slimy, veiny mess with a decent sized clot in the middle of it, discovered only by digital exploration of said mess. NewFNP admits that she was surprised at the absolute lack of vaginal bleeding given the situation.

"Placenta," she thought. "Now what?"

NewFNP gave the protruding mass a gentle tug. Nothing moving and no pain on the patient's end. A slightly more forceful tug elicited movement but nothing spectacular. At this point, newFNP brought in Dr. Dual-Ivy-League-Degrees for assistance. While newFNP maneuvered the speculum around the protruding mass, Dr. Dual-Ivy-League-Degrees tugged with the ring forceps. Again, nothing. Not wanting to cause a hemorrhage and noting increased vaginal bleeding and that the patient's pulse was 120, newFNP and Dr. Dual-Ivy-League-Degrees stopped their efforts and called for an ambulance.

NewFNP probably could have handled the entire situation alone, but was just too uncertain. If the patient had been hemorrhaging and had something protruding from her vagina, that is an entirely different call: get whatever is causing the problem OUT. But this was different and newFNP just hasn't managed post-partum complications such as this in the past.

What a great learning experience for newFNP, both in learning about the actual care of this patient and of trusting her knowledge and feeling confident in her care.

The Freshmaker

To many of newFNP's patients, the human body is a big mystery. Perhaps because her patients have had limited access to medical care, they have fashioned DIY treatments for various ailments. Rubbing alcohol, of course, is the big savior, dematologically speaking. It's got a "cure for what ails ya" mystique amongst newFNP's patients. Tincture of violet is another go-to topical.

But mere derm problems are not the only health concerns for which patients fashion their own treatments.

Throw menopause into the body mystery equation and it's like one big clusterfuck of a mystery to many of newFNP's patients. The uncomfortably itchy atrophic vag, the non-existent sex drive, the beard, the emotional upheaval. Honestly, newFNP isn't looking so forward to it. But she will have options when she gets there. Maybe she'll hook up with Suzanne Somers a la Samantha from SATC, maybe she'll do acupuncture -- who knows!

But what she most certainly will not do it dutifully apply Vicks Vapo-Rub to her atrophic downstairs in other to refresh herself, which is precisely what her patient told her she was doing. Granted, new FNP is nowhere near her menopause (knock wood), but there are a few places in which newFNP would not apply Vicks no matter what and her Lady Gaga is one of them. Talk about a bad romance!

Pole Position

NewFNP really enjoys IUD placements. She finds procedures fun - a little break from the assessment of DP pulses and the futile attempts to palpate hepatosplenomegaly in her generally overweight patient population.

Today, newFNP had a gregarious patient present for an IUD insertion. NewFNP asked her patient if a colleague who is learning how to place IUDs could observe the procedure.

"Yeah, sure," she replied. "I mean, I used to be a stripper so it's all good."

NewFNP replied, "Oh wow - what was that like for you?"

Some people might be amazed to learn that newFNP had never met a stripper before! She wanted to ask her all the details. How does one learn to pole dance? Do pasties hurt upon removal? What was it like?? Hell, newFNP doesn't even like to walk around the Korean day spa naked, but the rub-n-scrub is worth the lady nakedness. Dollar bills in g-strings would not be worth it to newFNP.

Her patient told newFNP that, not unlike health care, the location of the practice played a significant role in how well one was treated. In ghetto areas, her patient explained, her treatment was not so good. But in nice areas - "with lots of white guys" - it was a pretty good gig.

NewFNP didn't go into it any further, but she would actually really like to learn what it was like for her patient. What was it like the first time she performed? Did she feel hesitation about considering exotic dancing as a job? Was it worth it? Did she feel exploited? Alas, it seemed inappropriate to ask such questions while seated at the business end of the lithotomy position looking past the pierced clitoral hood to the perfectly centered cervical os.

It was the most seamless insertion of newFNP's career. Her patient was completely comfortable and pain-free, talking to newFNP and laughing the entire time.

It's quite nice to have appointments like that during a generally hum drum clinic day.

Rx: vibrator

NewFNP is aware that it is wholly within the boundaries of acceptability to discuss one's sex life with one's provider.  In newFNP's clinic, however, this discussion generally consists of women telling newFNP that they are tired of having sex with their partners and are stupefied at the amount of sex a man wants.  In a 25-patient day, it is exceedingly difficult to suss out if that is because intercourse is physically painful or if it is because their partners are content to sit around and watch TV while the women clean the house & bathe the kids, etc. or if it is because their partners are just sort of remedial when it comes to doing it.

If the aversion stems from physical discomfort, newFNP feels like she can easily manage that discussion.  Not enough lubricant?  Try some Astroglide! 

If the discussion involves a selfish lover/partner, then what is newFNP to do?  There are no Dr. Ruths in newFNP's clinic and there are probably no Dra. Ruths on Telemundo.  Sadly, there is no wonder female sexuality duo a la Berman & Berman. 

But mostly, there is no time.

So what is newFNP to do when her 40-something year old first time patient, all undressed in anticipation for her pap, lets newFNP know that she just never has orgasms.  For all her life, no orgasm.  Sex feels good, but there is just something missing.

And how!!!

Now, newFNP knows that this woman is looking for direction but - hell - newFNP is not her best girlfriend.  She is newFNP!  Can newFNP just say, "Listen.  Seriously listen.  You must teach your man how to perform oral sex.  Period.  At the very least, you guys should watch some Sex and The City reruns for inspiration."

It's a delicate topic, is it not?  How does newFNP know if her patient is open to, say, the cowgirl position or assisted orgasm technology?  They simply do not teach that kind of shit in multiculturalism workshops!

NewFNP didn't say what she may have said to a member of her grad school girl gang, but did bring up some options: communicate with your partner about what feels good; explore for yourself what feels good; maybe try a new position or two; and if all else fails, follow Charlotte York's lead and buy the Rabbit and call it a day.

A very good day.

Now boarding

There are several ways in which patients can endear themselves to newFNP.

For instance, they might express heartfelt thanks for the care they've received. They might tell newFNP how young she looks when, in fact, she is not.

Most endearing of all, they might be funny as shit in the exam room.

NewFNP's first patient of the day hit the ball out of the park when she did all three and started newFNP's first post-move work day off right!

Now, newFNP knows that it is through the magic of Nars that she looked so youthful this morning. Who the fuck wouldn't look youthful with a fresh sweeping of Sin blush across the apples of one's cheeks? However, beyond her welcome flattery, this patient was truly grateful for the care she received and expressed her gratitude freely.

It was not, however, the flattery or the gratitude which endeared this patient so profoundly to newFNP. No, it was the fact that she was the funniest historian newFNP has encountered, hands down.

This patient, a woman in her fifties, came in with a chief complaint of vaginal discharge - already one can appreciate the potential for humor in the face of a not-so-humorous condition if you are the patient. This discharge, according to newFNP's patient, had "set her back." NewFNP had never heard that turn of phrase in this context before. She is more familiar with its use in the context of something along the lines of "That new Miu Miu purse set newFNP back a car payment!" So, when evaluated in that context, newFNP understood that the discharge was significant.

NewFNP's patient went on to give newFNP details of the discharge, such as the fact that it was malodorous enough to warrant "a hell of a scrub" before coming to the clinic. In addition, it was copious enough to require the use of feminine protection.

Now, newFNP's patient had a hysterectomy some years ago and, as a result, was unfamiliar with the decades-old advances in pantyliner technology. She stated that she had purchased some pantyliners but, upon running out, could not afford another box and borrowed some pantyliners from her daughter.

"Those damn things look like an airplane! I ain't never seen a pantyliner like that - it had wings!"

Superfluous information? Sure. Welcome? Fuck yeah.

Wings.

Bathtub safety

NewFNP has a hunch that it is going to be a grand day at work when, driving to work at 8AM, she sees no less than five commercial sex workers standing on consecutive corners, white patent faux leather thigh-high boots, Daisy Dukes and Huggy Bear caps-a-plenty. Is there no vice squad in newFNP's major metropolitan area? Can the lady walking down the street in a tee-shirt and no pants or underwear find it within herself to cover her huge ass? What the fuck?

Seriously people. Can't we all agree that there are certain things that newFNP, as well as the majority of the rest of the world, do not need to see except at the movie theater or on C*O*P*S? There is only so much vice that newFNP can tolerate so early in the morning. This morning exceeded newFNP's quota.

So, hours passed with no obvious prostitution, leading newFNP to think that her day was normailzing, when newFNP was saw the chief complaint of "hurt her vagina." Now, newFNP is no stranger to curiously worded CC's, such as "little ball on the peanuts, " "soap in the right eye x 9 days" and "cough and flames x 2 days." What does newFNP have, a dragon for a patient? So, clearly, "hurt her vagina" isn't the oddest CC, but it's no "med refill" either.

Apparently, newFNP's 200-pound patient had slipped while exiting the tub. Her fall was broken by the tub wall, with her labia bearing the brunt of the force. Her left labia majora to be exact.

NewFNP uttered the words "oh shit" upon seeing her patient's horribly swollen purple labia. It was the size of newFNP's fist. It looked like a seashell. NewFNP imagines that she felt what all men feel when they see another man take a hit to the testes. Youch! Again, newFNP did screen for abuse - none. All of the pelvic bony structures were intact and the patient had full ROM at the hip, thus no x-ray for this uninsured patient.

Ice. Ice. Ice. Ice. Ice. Frozen peas baby. Mold 'em to your downstairs. Motrin 800mg TID with food. NewFNP thinks that pelvic rest is an obvious plan, but said it nonetheless. A little prayer that this will resolve quickly for the patient.

Man, oh man. What a day.

The three D's

NewFNP apologizes for the recent silence, but she has moved (homes, not clinics) and is just settling in to her new place. Ahhhh.... home sweet apartment home.

Anyway.

NewFNP must have previously noted how patients' chief complaints come in waves. One day it's nothing but pap smears - one vag after another. The only difference is the amount of hair. You might be surprised to know that a 250-pound woman has the flexibility to get a Brazilian but they do! The next day, one might be swimming in abscesses and chalazions. Frankly, it's uncanny - do newFNP's patients all know each other and coordinate their visits? Perhaps they figure that newFNP will really be on her game if they all come for the same thing on the same day. Suckers!

So newFNP just had the diabetes and depression day. Some patients even had both. Now, newFNP is no expert on either, but can manage each effectively in the primary care setting. NewFNP admits that she is a little dodgy when it comes to changing for oral hypoglycemics to insulin, but she has no fear regarding starting an adult patient with depression on an SSRI. But one after the frigging other for eight hours? Fucking hell. NewFNP thinks of her mental health colleagues and is so thankful that there are people in this world who can address these sometimes debilitating depression cases. Because newFNP sure as hell cannot during her 15 minutes. The diabetes/depression day is not a rewarding one for newFNP. It just doesn't make for a fun clinic day.

That is until newFNP was rewarded for her diabetes/depression diligence with The Third D: Dookie. Now, newFNP is no stranger to euphemisms for the act of moving one's bowels. She generally, however, reserves 'dookie' for elementary school students and not for 38-year old men. NewFNP truly attempts to be professional during her visits with patients, but then someone says something like this, "Yeah, I used to dookie like 3 or 4 times a day, but now I maybe dook once. Maybe twice, but I used to dookie a lot." All that newFNP heard was "dookie, dook, dook, dookie, dook." Oh, it was awesome. NewFNP was biting the inside of her lip in order not to start laughing.

The Dook. NewFNP will never forget him.

You can't keep a good newFNP down

Since newFNP last exposed herself to a patient's aromatic purulent discharge in a not-altogether successful attempt, newFNP has incised and drained not one, but two further patient lesions.

Lesion one: lady business abscess. OK, not exactly lady business but suprapubic in locale and wholly a result of picking at one's ingrown hair. Hands. Off. Ingrowns. I restate my case initially argued in "Picky Evolution."

Lesion two: epidermoid cyst. NewFNP has been waiting for this since she first became acquainted with one during her independent study in derm.

NewFNP is floating in her derm dreamworld. Oh, how newFNP loves derm. Bring on the Retin-A, kiss that acne and those wrinkles good-bye. NewFNP would love to scrapy-scrape your big fat plantar's wart, just as she would love to inject your inflamed acne lesion with kenalog. NewFNP loves to draw pics of derm lesions. NewFNP simply loves derm. It's a pure, unadulterated love.

OK, back from dreamworld. So, an epidermoid cyst. Not pretty. It forces one to utilize culinary analogies when describing cyst contents: cheesy. Soft cheese. Soft white cheese. Rondele, anyone? The I&D is exactly the same, except that you want to get the sac which contains the contents out in order to prevent recurrence and numbing the patient is so much more difficult. The contents of the cyst are firmer and therefore require a larger bored syringe in order to introduce the lidocaine. Ouch, big fat needle.

What can ruin a perfect I&D is another provider's student attempting to horn in on the I&D action. And by horning in, newFNP means asking not once, not twice, but five times to either perform or observe the I&D. At each query, newFNP replied 'no,' each response becoming progressively more firm and annoyed, the last of which being, "You can stare at me all you want; the answer is no." Is the student six years old? No, no she isn't. Yet newFNP found herself speaking to her as though she were. There is a reason that newFNP does not have a student: because newFNP needs the experience herself. NewFNP still is gaining comfort in her role as pus-expressor.

Note to all students: when your preceptor says 'no,' there is a reason. Don't push it. Should newFNP even have to tell anyone that? NewFNP is certain that her readership is already savvy enough to realize the non-kosher maneuver by our student.

In the end, not even pushy student could spoil the supremely successful I&D. NewFNP was even able to disrupt and express the sac. You can imagine my happiness - bordering on beatitude.

A Cure for the Obesity Epidemic

I've got it. It's a plan that will never come to fruition, but one I think has the potential to be quite effective. No, it's not the removal of sodas and Taco Bell, Golden Arches,Burger King and vending machines from schools. It's not more exercise or daily P.E. in schools. It's not 'you'll get Type 2 diabetes and have hypertension and dyslipidemia, all predisposing you to a big old MI.' Those are good ideas, by the way, great ideas even, but my proposed campaign is meant to have a visceral response, striking at the very core of insecurities all over the world.

(I love hyperbole.)

It's fair to say that all people have some degree of interest in their genitals, right? I mean, we have penis pumps, Brazilian waxes thanks to those evil J Sisters, circumcision, female circumcision as well as various nether-region accoutrement. Men can't stop touching their goods from infanthood until, well, until they die I guess. This obsession is the basis for my campaign.

My idea is this: let's raise the awareness of the 'hidden penis' and the 'fat vagina.'

I mean, does any guy want to exchange his average penis for a huge pannus? It's not even a fair trade!

And ladies have labiaplasty in order to have a perfect genital portrait. Not my patients, but I've seen the advertisements and if plastic surgeons can play off vag insecurity, then so can public health. So don't get a huge vag!

And after this awareness raising campaign, we can transition back to the more traditional interventions. It's worth a shot. The other methods sure as hell aren't working very well.

This just in....

There are few things that newFNP likes to ponder less than pelvic floor disorders and urinary incontinence. I was, however, at a conference recently and found myself desperately and vigorously performing Kegel after Kegel in order to stave off a sad, sad future. In fact, I'm doing my Kegels now and you should be too. We should all have the lactic acid build-up normally associated with leg presses, 10-mile runs and push-ups. Because, baby, I do not want my uterus heading south for the winter. Nor am I relishing the thought a future with rubber mattress pads.

The reason I am exercising my vagina 100 times more than my abs or glutes is that the keynote speaker at the conference presented data from the WHI that stated that a full forty-frigging-one percent of women had some form of prolapse. Hey, maybe your bladder is just sneaking posteriorly into your vag, but maybe your cervix is at your knees. I don't want either. Kegel, Kegel, Kegel... feel the burn.

Sure, childbirth makes a difference in the likelihood of anatomical slippage, but guess what? It's the first kid that makes the most difference and, I hate to say it, but nulliparous women may share the prolapse experience with their more fertile sisters. Thinking of scheduling a c-section like your gal-pal Britney S.? Well, that's not gonna save you either. So go ahead and have your babies in whichever way you choose, but Kegel it up, ladies. And do your best to lose the pregnancy weight, because overweight (waist circumference >88cm) isn't going to help matters.

The same goes for incontinence. Parity, obesity, hysterectomy... they all will have you running to bathroom, stifling your laughs and hoping that your little cough goes away quickly. Apparently, 50% of us will have incontinence. Son of a bitch, does that ever suck. Kegels. 30-35 exercises per day. I don't want vaginal hypertrophy, but I'm thinking the more, the merrier when it comes to incontinence prevention.

Diabetes also plays a role in incontinence due to the nerve damage. So, let's see what sucks about uncontrolled diabetes. It's not the death so much, in my opinion, as all the horrible effects of the disease. Blindness, kidney dysfunction, erectile dysfunction, amputations, thick toenails, heart disease and incontinence. None of those are my idea of a good time.

In other news, updated CDC guidlelines, due to come out next year, state that we should no longer be prescribing 2g of Flagyl PO for BV. It's just not efficacious. It's all about the 500mg PO BID x 7, 5 nights of Metro-Gel or 7 nights of Clindamycin cream. So give your ladies a break and treat their BV effectively, OK?