27 September 1999

1. Hip Pain
2. Oxandrin as a Medication to Stimulate Growth?
3. Longterm Effcts After Vasectomy
4. Bleeding After Coitus, Fertile Period
5. Persistent Diarrhea
6. Should DTP Be Repeated After a Severe Reaction?
7. Decreased BM Frequency
8. Infant Refuses Medicine
9. Disclaimer

• Read Questions & Answers in Another Column

Hip Pain

About one month later, the same thing happened with a slightly higher fever (102-103F) and joint discomfort in the opposite knee (not hip this time). Blood work was again done with similar results and again we were told to wait it out for 2 days.

Assuming no septic arthritis, what are the possible causes or relatively severe joint pain accompanying her fever/cold? I don't like be told to just wait it out to see if it goes away without a "real" explanation of the problem.

Thank you for any information.

-AH

Dear AH: Inflammation of the hip following upper respiratory viruses is known as toxic synovitis of the hip. It is fairly common in children and the pain may be severe. Knee pain may be referred pain from the hip, but two bouts of toxic synovitis in a month is unusual. Should there be additional recurrences, you should consult a pediatric rheumatologist. For persistent hip pain with limp you should consult an orthopedist to be sure you are not dealing with Perthe's Disease.

Sincerely,
Dr. Warren

-DP

Dear DP: The PDR lists the following indications for Oxandrin:

Oxandrin is indicated as adjunctive therapy to promote weight gain after weight loss following extensive surgery, chronic infections, or severe trauma, and in some patients who without definite pathophysiologic reasons fail to gain or to maintain normal weight, to offset the protein catabolism associated with prolonged administration of corticosteroids, and for the relief of the bone pain frequently accompanying osteoporosis.

In children, androgen therapy may accelerate bone maturation without producing compensatory gain in linear growth. This adverse effect results in compromised adult height. The younger the child, the greater the risk of compromising final mature height. The effect on bone maturation should be monitored by assessing bone age of the left wrist and hand every 6 months.

Anabolic agents may accelerate epiphyseal maturation more rapidly than linear growth in children and the effect may continue for 6 months after the drug has been stopped. Therefore, therapy should be monitored by x-ray studies at 6- month intervals in order to avoid the risk of compromising adult height. Androgenic anabolic steroid therapy should be used very cautiously in children and only by specialists who are aware of the effects on bone maturation.

• Hepatic: Cholestatic jaundice with, rarely, hepatic necrosis and death. Hepatocellular neoplasms and peliosis hepatis with long-term therapy. Reversible changes in liver function tests also occur including increased bromsulfophthalein (BSP) retention, and increases in serum bilirubin, aspartate aminotransferase (AST, SGOT) and alkaline phosphatase.
• Prepubertal: Phallic enlargement and increased frequency or persistence of erections.
• Postpubertal: Inhibition of testicular function, testicular atrophy and oligospermia, impotence, chronic priapism, epididymitis, and bladder irritability.
• CNS: Habituation, excitation, insomnia, depression, and changes in libido. Hematologic: Bleeding in patients on concomitant anticoagulant therapy.
• Breast: Gynecomastia.
• Skin: Acne (especially in females and prepubertal males).
• Skeletal: Premature closure of epiphyses in children .
• Fluid and electrolytes: Edema, retention of serum electrolytes (sodium, chloride, potassium, phosphate, calcium).
• Metabolic/Endocrine: Decreased glucose tolerance, increased creatinine excretion, increased serum levels of creatinine phosphokinase (CPK). Inhibition of gonadotropin secretion.

Sincerely,
Dr. Warren

Thanks in advance

-LW

Dear LW: To answer your question I am quoting an article abstract.

"Vasectomy review: sequelae in the human epididymis and ductus deferens.", Author: McDonald SW, Laboratory of Human Anatomy, University of Glasgow, Scotland. , Clin Anat 1996;9(5):337-42

"Abstract: Following vasectomy, spermatogenesis continues, the human epididymis and ductus deferens may distend and leak, and the extravasated spermatozoa stimulate formation of a sperm granuloma. Granulomas may occur at 60% of vasectomy sites and are usually asymptomatic and relieve intraluminal pressure. About 3-5% of patients experience pain. Intraluminal phagocytosis may explain why some reproductive tracts become depleted of spermatozoa. Distension of the epididymis is common after vasectomy and may lead to granuloma formation there. Up to 6% of patients have symptoms, but many with epididymal changes have no discomfort. Most episodes of painful epididymitis and granulomas resolve with conservative treatment, but < 1% require vasectomy reversal or, if this is ineffective, excision of the epididymis and obstructed ductus deferens."

Sincerely,
Dr. Warren

Something else that I want to ask you. When is that a woman can get pregnant? Is it 5 days after and before the period, or when? I think a woman has to know that and unfortunately I did not receive enough information about that.

On December 23th. we had relations again it was not as painful as the first, but I started bleeding again. As before he did not stay for more than 5 sec. and did not ejaculate., but my concern is the bleeding, please help me.

Thank you.

-LZ

Dear LZ: I do not think the bleeding you experienced from intercourse had anything to do with the surgery you had to remove an ovarian cyst; however, I may not have all the necessary facts since removal of an ovarian cyst doesn't generally require removal of the ovary. Since you had pain on intercourse, the bleeding was probably secondary to tearing the hymen especially if the pain you felt was primarily at the vaginal entrance. If you continue to have bleeding and pain, you will have to consult a gynecologist.

A woman's peak fertility is at ovulation which occurs 14 days before the start of menstruation. That means if you have a 21 day cycle it would be day 7. For a typical 28 day cycle it would be day 14. And for a 40 day cycle it would be day 26. Whatever the length of your usual cycle, subtract 14 to approximate the day of ovulation. The day is counted from the first day of menstruation. Remember that even if you are very regular, some cycles may not be regular so you can't always depend on it.

Sincerely,
Dr. Warren

Thank you for your assistance

-MH

Dear MH: Why is your doctor continuing to give your child antibiotics? Since I don't know what he is treating, I can't advise you to stop the antibiotics, but if your child has persisting diarrhea, unless there is a very good reason for your son to be on antibiotics, the antibiotics should be stopped. Your son should also have a stool culture and a stool test for clostridium difficile toxin, since the antibiotics may have caused or aggravated a problem.

There are no medications which alter the course of diarrhea. Medicines like Kaopectate, Imodium, Lomotil, attapulgate, and narcotics which provide symptomatic relief for older children and adults do not alter the course of the illness and are not appropriate for your son. Just make sure your son gets plenty of fluids including some salts as found in Pedialyte. The BRAT diet is fine for diarrhea management, but it has no protein. If your son cannot tolerate milk or soy, you must offer him some chicken or turkey. Even if he has an increase in his diarrhea he cannot be without protein in his diet for months or he will develop protein malnutrition which will make it harder for him to get better.

Sincerely,
Dr. Warren

Sincerely,
-Jenny

Dear Jenny: Pallor (turning pale) is listed as a reaction to DTP. Such a reaction is not a contraindication to giving future Pertussis vaccines, but it indicates a need for caution. The contraindications and precautions to further DTP vaccination can be found at http://aepo-xdv-www.epo.cdc.gov/wonder/prevguid/m0041645/00001675.htm#Table_4.

The DTaP has been approved for the primary series of DTP as well as the boosters. The acellular vaccine is more effective and causes less reaction than the whole cell vaccine. Under the circumstances, I can't see any reason to continue using the whole cell vaccine.

The decision to give a vaccine to which a child has reacted badly is always difficult. The general rule is that the benefits should outweigh the risks. The problem is that even though your baby reacted badly to DTP, his risk is not fully known. Whooping cough is still around. The younger a baby is when he contracts whooping cough, the more serious an illness it is, which is why we start Pertussis immunization in young infants. You should review your child's reaction to the DTP in detail with your physician so that he can help you explore the benefits and risks and come to a decision.

Sincerely,
Dr. Warren

Thank you in advance.

-H & T

Dear H & T: Many nursing babies have bowel movements as infrequently as every 4 to 5 days. As long as the BMs remain soft and the baby remains comfortable with a good appetite there is no cause for concern. If the baby has hard stools, abdominal distention (swelling), loss of appetite, or appears to have significant pain associated with the lack of bowel movements, then you will need to look into what might relieve the problem.

Sincerely,
Dr. Warren

Thanks in advance.

-TH

Dear TH: Amoxicillin can be mixed with other liquids, but if your son dislikes the taste, he may detect it. If you put it in a large volume of liquid to disguise it, you have to be sure he finishes it all. Most kids don't mind the taste of amoxicillin, so you might succeed if you just change the way you give it to your son. Experiment a little to see what works. One enterprising mother tried giving her child medicine by dipping a lollipop into it. Good luck.

Sincerely,
Dr. Warren

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