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GUM BLEEDING 331
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form a painless, firm, indurated, shallow ulcer
with a clear base and a scant yellow serous discharge or, less commonly, a hard papule. This
lesion gradually involutes and disappears. Painless, unilateral regional lymphadenopathy is
also typical.
◆ Tinea cruris. Also called “jock itch,” this su-
perficial fungal infection usually causes sharply
defined, slightly raised, scaling patches on the
inner thigh or groin (often bilaterally) and, less
commonly, on the scrotum and penis. Pruritus
may be severe.
◆ Urticaria. This common allergic reaction is
characterized by intensely pruritic hives, which
may appear on the genitalia, especially on the
foreskin or shaft of the penis. These distinct,
raised, evanescent wheals are surrounded by an
erythematous flare.
O
THER CAUSES
◆ Drugs. Barbiturates and certain broad-spec-
trum antibiotics, such as tetracycline and sulfonamides, may cause a fixed drug eruption and
a genital lesion.
S
PECIAL CONSIDERATIONS
Many disorders produce penile lesions that resemble those of syphilis. Expect to screen every
patient with penile lesions for STDs, using the
dark-field examination and the Venereal Disease Research Laboratory test. In addition, you
may need to prepare the patient for a biopsy to
confirm or rule out penile cancer. Provide emotional support, especially if cancer is suspected.
To prevent cross-contamination, wash your
hands before and after every patient contact.
Wear gloves when handling urine or performing
catheter care. Dispose of all needles carefully,
and double-bag all material contaminated by
secretions.
P
EDIATRIC POINTERS
In infants, contact dermatitis (“diaper rash”)
may produce minor irritation or bright red,
weepy, excoriated lesions. Use of disposable diapers and careful cleaning of the penis and
scrotum can help reduce diaper rash.
In children, impetigo may cause pustules with
thick, yellow, weepy crusts. Like adults, children
may develop genital warts, but they’ll need more
reassurance that the treatment (excision) won’t
hurt or castrate them. Children with an STD
must be evaluated for signs of sexual abuse.
Adolescents ages 15 to 19 have a high incidence of STDs and related genital lesions. The
spirochete that causes syphilis can pass through
the human placenta, producing congenital
syphilis.
G
ERIATRIC POINTERS
Elderly adults who are sexually active with multiple partners have as high a risk of developing
STDs as do younger adults. However, because
of decreased immunity, poor hygiene, poor
symptom reporting and, possibly, several concurrent conditions, they may present with different symptoms. Seborrheic dermatitis lasts
longer and is more extensive in bedridden patients and those with Parkinson’s disease.
P
ATIENT COUNSELING
Explain to the patient how to use prescribed
ointments or creams. Advise him to use a heat
lamp to dry moist lesions or to take sitz baths to
relieve crusting and itching. Also, instruct him
to report any changes in the lesions.
Explain to male patients that condoms effectively prevent many STDs when used correctly.
Advise them to use a new condom for each
coitus; to avoid damaging the condom with a
sharp object, such as fingernails or teeth; to put
the condom on the erect penis before any genital
contact; to use only water-based lubricants; to
hold the condom firmly while withdrawing the
penis; to always withdraw the penis while it’s
still erect to avoid premature condom loss; and
to check the expiration date on the individual
condom packet. Teach the patient that hormonal contraceptives, diaphragms, foams, and jellies don’t protect against STDs.
Gum bleeding
[Gingival bleeding]
Bleeding gums usually result from dental disorders; less often, they may stem from blood
dyscrasias or the effects of certain drugs. Physiologic causes of this common sign include pregnancy, which can produce gum swelling in the
first or second trimester (pregnancy epulis); atmospheric pressure changes, which usually affect divers and aviators; and oral trauma. Bleeding ranges from slight oozing to life-threatening
hemorrhage. It may be spontaneous or may follow trauma. Occasionally, direct pressure can
control it.
EMERGENCY INTERVENTIONS If you
detect profuse, spontaneous bleeding in the
oral cavity, quickly check the patient’s airway
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and look for signs of cardiovascular collapse,
such as tachycardia and hypotension. Suction
the patient. Apply direct pressure to the bleeding
site. Expect to insert an airway, administer I.V.
fluids, and collect serum samples for diagnostic
evaluation.
H
ISTORY AND PHYSICAL
EXAMINATION
If gum bleeding isn’t an emergency, obtain a
history. Find out when the bleeding began. Has
it been continuous or intermittent? Does it occur spontaneously or when the patient brushes
his teeth or flosses? Have the patient show you
the site of the bleeding if possible.
Find out if the patient or any family members
have bleeding tendencies; for example, ask
about easy bruising and frequent nosebleeds.
How much does the patient bleed after a tooth
extraction? Does he have a history of liver or
spleen disease? Next, check the patient’s dental
history. Find out how often he brushes his teeth,
flosses, and goes to the dentist, and what kind
of toothbrush and floss he uses. Has he seen a
dentist recently? To evaluate nutritional status,
have the patient describe his normal diet and
intake of alcohol. Finally, note any prescription
and over-the-counter drugs he takes.
Next, perform a complete oral examination. If
the patient wears dentures, have him remove
them. Examine the gums to determine the site
and amount of bleeding. Gums normally appear
pink and rippled with their margins snugly
against the teeth. Check for inflammation, pockets around the teeth, swelling, retraction, hypertrophy, discoloration, and gum hyperplasia.
Note obvious decay, discoloration, foreign material such as food, and absence of any teeth.
M
EDICAL CAUSES
◆ Agranulocytosis. Spontaneous gum bleed-
ing and other systemic hemorrhages may occur
in this hematologic disorder, which typically
causes progressive fatigue and weakness, followed by signs of infection, such as fever and
chills. Inspection may reveal oral and perianal
lesions, which are usually rough edged with a
gray or black membrane.
◆ Aplastic anemia. In this disorder, profuse or
scant gum bleeding may follow trauma. Other
signs of bleeding, such as epistaxis and ecchymosis, are also characteristic. The patient exhibits progressive weakness and fatigue, shortness of breath, headache, pallor and, possibly,
fever. Eventually, tachycardia and signs of heart
failure, such as jugular vein distention and dyspnea, also develop.
◆ Cirrhosis. A late sign of cirrhosis, gum
bleeding occurs with epistaxis and other bleeding tendencies. Other late effects include ascites, hepatomegaly, pruritus, and jaundice.
◆ Ehlers-Danlos syndrome. In this congenital
syndrome, gums bleed easily after toothbrushing. Easy bruising and other signs of abnormal
bleeding are also typical. Skin is fragile and hyperelastic; joints are hyperextendible.
◆ Giant cell epulis. This pedunculated granu-
loma, which occurs on the gums or alveolar
process in front of the molars, is dark red and
vascular, resembling a surface ulcer. Gums
bleed easily with slight trauma.
◆ Gingivitis. Reddened and edematous gums
are characteristic of this disorder. The gingivae
between the teeth become bulbous and bleed
easily with slight trauma. However, with acute
necrotizing ulcerative gingivitis, bleeding is
spontaneous and the gums become so painful
that the patient may be unable to eat. A characteristic grayish yellow pseudomembrane develops over punched-out gum erosions. Halitosis is
typical and may be accompanied by headache,
malaise, fever, and cervical adenopathy.
◆ Hemophilia. Hemorrhage occurs from many
sites in the oral cavity, especially the gums. Mild
hemophilia causes easy bruising, hematomas,
epistaxis, bleeding gums, and prolonged bleeding during even minor surgery and for up to
8 days afterward. Moderate hemophilia produces
more frequent episodes of abnormal bleeding
and occasional bleeding into the joints, which
may cause swelling and pain. Severe hemophilia causes spontaneous or severe bleeding after
minor trauma, possibly resulting in large subcutaneous and intramuscular hematomas. Bleeding into joints and muscles causes pain,
swelling, extreme tenderness and, possibly, permanent deformity. Bleeding near peripheral
nerves causes peripheral neuropathies, pain,
paresthesia, and muscle atrophy. Signs of anemia and fever may follow bleeding. Severe
blood loss may lead to shock and death.
◆ Hereditary hemorrhagic telangiectasia.
This disorder is characterized by red to violet
spiderlike hemorrhagic areas on the gums,
which blanch on pressure and bleed spontaneously. These telangiectases may also occur
on the lips, buccal mucosa, and palate; on the
face, ears, scalp, hands, arms, and feet; and under the nails. Epistaxis commonly occurs early
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and is difficult to control. Hemoptysis and signs
of GI bleeding may develop.
◆ Hypofibrinogenemia. In this rare disorder,
the patient has frequent, spontaneous episodes
of severe gum bleeding. Hematomas, ecchymosis, and epistaxis are also common. Signs of GI
bleeding (such as hematemesis) and of central
nervous system bleeding (such as focal neurologic deficits) may also occur.
◆ Leukemia. An early sign of acute monocytic,
lymphocytic, or myelocytic leukemia, easy gum
bleeding is accompanied by gum swelling,
necrosis, and petechiae. The soft, tender gums
appear glossy and bluish. Acute leukemia causes severe prostration marked by high fever and
bleeding tendencies, such as epistaxis and prolonged menses. It may also cause dyspnea,
tachycardia, palpitations, and abdominal or
bone pain. Later effects may include confusion,
headaches, vomiting, seizures, papilledema,
and nuchal rigidity.
Chronic leukemia usually develops insidiously, producing less severe bleeding tendencies.
Other effects may include anorexia, weight loss,
low-grade fever, chills, skin eruptions, and enlarged spleen, tonsils, and lymph nodes. Signs
of anemia, such as fatigue and pallor, may occur.
◆ Pemphigoid (benign mucosal). Most com-
mon in women between ages 40 and 50, this
autoimmune disorder typically causes thickwalled gum lesions that rupture, desquamate,
and then bleed easily. Extensive scars form with
healing, and the gums remain red for months.
Lesions may also develop on other parts of the
oral mucosa, the conjunctivae and, less often,
the skin. Secondary fibrous bands may lead to
dysphagia, hoarseness, or blindness.
◆ Periodontal disease. Gum bleeding typical-
ly occurs after chewing, toothbrushing, or gum
probing but may also occur spontaneously. As
gingivae separate from the bone, pus-filled
pockets develop around the teeth; occasionally, pus can be expressed. Other findings include unpleasant taste with halitosis, facial
pain, loose teeth, and dental calculi and
plaque.
◆ Pernicious anemia. Gum bleeding and a
sore tongue can make eating painful in this disorder whose other cardinal symptoms are
weakness and paresthesia. The patient’s lips,
gums, and tongue appear markedly pale, and
his sclerae and skin are jaundiced. Other features are typically widespread, affecting the GI,
cardiovascular, and central nervous systems,
and include altered bowel and bladder habits,
personality changes, ataxia, tinnitus, dyspnea,
and tachycardia.
◆ Polycythemia vera. In this disorder, en-
gorged gums ooze blood after even a slight
trauma. Polycythemia vera usually turns the
oral mucosa—especially the gums and tongue—
a deep red-violet. Associated findings include
headache, dyspnea, dizziness, fatigue, paresthesia, tinnitus, diplopia or blurred vision, aquagenic pruritus, epigastric distress, weight loss,
increased blood pressure, ruddy cyanosis, ecchymosis, and hepatosplenomegaly.
◆ Pyogenic granuloma. Commonly affecting
the gums, lips, tongue, and buccal mucosa, this
granuloma may ulcerate and bleed spontaneously or with slight trauma. The lesion is pedunculated with a smooth or warty surface.
◆ Thrombasthenia (familial). This hereditary
blood platelet disorder causes spontaneous
bleeding from the oral cavity, especially the
gums. The patient commonly displays purpura,
epistaxis, hemarthrosis, and signs of GI bleeding, such as hematemesis and melena.
◆ Thrombocytopenia. In this disorder, blood
usually oozes between the teeth and gums;
however, severe bleeding may follow minor
trauma. Associated signs of hemorrhage include
large blood-filled bullae in the mouth, petechiae,
ecchymosis, epistaxis, and hematuria. Malaise,
fatigue, weakness, and lethargy eventually develop.
◆ Thrombocytopenic purpura (immune).
Profuse gum bleeding occurs in this disorder. Its
classic feature, though, is spontaneous hemorrhagic skin lesions that range from pinpoint petechiae to massive hemorrhages. The patient
has a tendency to bruise easily, develops petechiae on the oral mucosa, and may exhibit
melena, epistaxis, or hematuria.
◆ Vitamin C deficiency (scurvy). This defi-
ciency causes swollen, spongy, tender gums
that bleed easily. The gums between the teeth
are red or purple. The teeth themselves become
loose and may be surrounded by pockets filled
with clotted blood. Other findings include muscle and joint pain, petechiae, ecchymosis, splinter hemorrhages in the nail beds, and ocular hemorrhages. Associated effects are anorexia, dry
mouth, pallor, weakness, lethargy, insomnia,
scaly skin, and psychological disturbances, such
as depression or hysteria.
◆ Vitamin K deficiency. The first sign of this
deficiency is usually gums that bleed when the
teeth are brushed. Other signs of abnormal
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PATIENT-TEACHING AID
Preventing bleeding gums
Dear Patient:
Follow these tips to improve oral hygiene and
prevent your gums from bleeding:
◆ Eliminate between-meal snacks and reduce
carbohydrate intake to help prevent plaque
formation on your teeth.
◆ Visit the dentist once every 6 months for
thorough plaque removal.
◆ Avoid citrus fruits and juices, rough or spicy
food, alcohol, and tobacco if they irritate
mouth ulcers or sore gums and cause bleeding. Be sure to take vitamin C supplements if
you can’t consume citrus fruits and juices.
◆ Avoid using toothpicks, which may cause
gum injury and infection.
◆ Brush your teeth gently after every meal,
using a soft-bristled toothbrush held at a
45-degree angle to the gum line.
This patient-teaching aid may be reproduced by office copier for distribution to patients.
© 2011, Lippincott Williams & Wilkins.
bleeding, such as ecchymosis, epistaxis, and
hematuria, may also occur. GI bleeding may
produce hematemesis and melena; intracranial
bleeding may cause decreased level of consciousness and focal neurologic deficits.
O
THER CAUSES
◆ Chemical irritants. Occupational exposure
to benzene may irritate the gums, resulting in
bleeding. Other signs of abnormal bleeding may
accompany limb weakness and sensory
changes.
◆ Drugs. Warfarin and heparin interfere with
blood clotting and may cause prolonged gum
bleeding. Abuse of aspirin and nonsteroidal
anti-inflammatory drugs may alter platelets,
producing bleeding gums. Localized gum bleeding may also occur with mucosal “aspirin burn”
caused by dissolving aspirin near an aching
tooth.
S
PECIAL CONSIDERATIONS
Prepare the patient for diagnostic tests, such as
blood studies or facial X-rays. Prepare him for
the possibility of a blood or blood product
(platelets or fresh frozen plasma) transfusion if
necessary. When providing mouth care, avoid
using lemon-glycerin swabs, which may burn or
dry the gums.
◆ If dentures make your gums bleed, wear
them only during meals.
◆ If the dentist tells you not to brush your
teeth, rinse your mouth with salt water or hydrogen peroxide and water. Avoid using commercial mouthwashes, which contain irritating
alcohol.
◆ Floss your teeth daily to remove plaque, un-
less flossing causes pain or bleeding.
◆ Use a Water Pik on the low pressure setting
to massage your gums.
◆ Use aspirin sparlingly for toothaches or gen-
eral pain relief.
◆ Control gum bleeding by applying direct
pressure to the area with a gauze pad soaked
in ice water.
P
EDIATRIC POINTERS
In neonates, bleeding gums may result from vitamin K deficiency associated with a lack of normal intestinal flora or poor maternal nutrition.
In infants who primarily drink cow’s milk and
don’t receive vitamin supplements, bleeding
gums can result from vitamin C deficiency.
Encourage parents to teach proper oral hygiene early. Daily brushing in the morning and
before bedtime should begin with eruption of
the first tooth. When the child has all of his baby
teeth, he should begin receiving regular dental
checkups.
G
ERIATRIC POINTERS
In patients who have no teeth, constant gum
trauma and bleeding may result from using a
dental prosthesis.
P
ATIENT COUNSELING
Teach the patient proper mouth and gum care,
including proper brushing techniques using a
soft-bristled toothbrush. (See Preventing bleed-
ing gums.) Make sure patients with chronic disorders that predispose them to bleeding, such
as chronic leukemia, cirrhosis, or idiopathic
thrombocytopenic purpura, are aware that
bleeding gums may indicate a worsening of
their condition, requiring immediate medical
attention.
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Gum swelling
Gum swelling may result from one of two
mechanisms: an increase in the size of existing
gum cells (hypertrophy) or an increase in their
number (hyperplasia). This common sign may
involve one or many papillae—the triangular
bits of gum between adjacent teeth. Occasionally, the gums swell markedly, obscuring the teeth
altogether. Usually, the swelling is most prominent on the labia and bucca.
Gum swelling usually results from the effects
of phenytoin; less commonly, from nutritional
deficiency or certain systemic disorders. Physiologic gum swelling and bleeding may occur during the first and second trimesters of pregnancy
when hormonal changes make the gums highly
vascular; even slight irritation causes swelling
and gives the papillae a characteristic raspberry
hue (pregnancy epulis). Irritating dentures may
also cause swelling associated with red, soft,
movable masses on the gums.
H
ISTORY AND PHYSICAL
EXAMINATION
After ruling out pregnancy or the use of phenytoin or similar prescription drugs as the cause of
gum swelling, take a history. Have the patient
fully describe the swelling. Has he had it before?
Is it localized or generalized? Find out when the
swelling began, and ask about any aggravating
or alleviating factors. Is the swelling painful?
Then explore the patient’s medical history, focusing on major illnesses, bleeding disorders,
and pregnancies. Also check his dental history.
Does he wear dentures? If so, are they new?
Ask about use of alcohol and tobacco, which
are gum irritants. Then have the patient describe his diet to evaluate nutritional status. Ask
about his intake of citrus fruits and vegetables.
Next, inspect the patient’s mouth in a good
light. If he wears dentures, ask him to remove
them before you begin. As you examine the
gums, characterize their color and texture, and
note any ulcers, lesions, masses, lumps, or debris-filled pockets around the teeth. Then inspect the teeth for discoloration, obvious decay,
and looseness.
M
EDICAL CAUSES
◆ Crohn’s disease. Granular or cobblestone
gum swelling occurs in this disorder, which is
characterized by cramping abdominal pain and
diarrhea. In acute Crohn’s disease, the patient
may also have nausea, fever, tachycardia, ab-
dominal tenderness and guarding, hyperactive
bowel sounds, and abdominal distention.
Chronic effects include anorexia, weight loss, a
palpable lower quadrant mass, perianal lesions,
skin lesions (erythema nodosum), arthritis, and
occasionally constipation.
◆ Fibrous hyperplasia (idiopathic). In this
disorder, the gums become diffusely enlarged
and may even cover the teeth. Large, firm, painless masses of fibrous tissue that form on the
gums may prevent tooth eruption and cause lip
protrusion and difficulty chewing.
◆ Leukemia. Gum swelling is commonly an
early sign, especially in acute monocytic, lymphocytic, or myelocytic leukemia. Usually, the
swelling is localized and accompanied by
necrosis. The tender gums appear blue and
glossy and bleed easily.
Acute leukemia also causes severe prostration, high fever, and signs of abnormal bleeding,
such as ecchymosis and prolonged menses.
Sometimes it produces dyspnea, tachycardia,
palpitations, and abdominal or bone pain. Late
effects may include confusion, headache, vomiting, seizures, papilledema, and nuchal rigidity.
In chronic leukemia, signs and symptoms develop insidiously and may include malaise, pallor,
low-grade fever, chills, minor bleeding tendencies, and enlarged tonsils, lymph nodes, and
spleen.
◆ Vitamin C deficiency (scurvy). In this defi-
ciency, the gums are spongy, tender, and edematous, and the papillae appear red or purple.
The gums bleed easily, and inspection may reveal pockets filled with clotted blood around
loose teeth. Associated findings include anorexia, pallor, dry mouth, scaly dermatitis, weakness, lethargy, insomnia, and signs of abnormal
bleeding, such as myalgia and arthralgia (possibly with swelling), from hemorrhage into joints
and muscles. Occasionally, psychological
changes, such as depression and hysteria,
occur.
O
THER CAUSES
◆ Drugs. Gum swelling is a common side ef-
fect of the anticonvulsant phenytoin. Cyclosporine, a drug used to prevent rejection of
transplanted organs, also produces this sign in
about 15% of patients.
S
PECIAL CONSIDERATIONS
When performing mouth care, avoid using
lemon-glycerin swabs, which can irritate the
gums. Instead, use a soft-bristled toothbrush or
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one that’s padded with sponge or gauze. For
phenytoin-induced swelling, expect to substitute another anticonvulsant, such as carbamazepine, and prepare the patient for surgery.
Because gum swelling may affect the patient’s
appearance, offer emotional support and reassure him that swelling usually resolves with
treatment.
P
EDIATRIC POINTERS
Gum swelling in children commonly results
from nutritional deficiency. It may also accompany phenytoin therapy; in fact, drug-induced
gum swelling is more common in children than
in adults. Fortunately, this dramatic swelling is
usually painless and limited to one or two papillae. Gum swelling may also result from idiopathic fibrous hyperplasia and from inflammatory gum hyperplasia, which is especially
common in pubertal girls.
Good nutrition and oral hygiene help control
gum swelling in children, so encourage parents
to make brushing as much fun as possible.
G
ERIATRIC POINTERS
Always ask an elderly patient if he wears dentures and, if so, whether they’re new. Also ask
him when he last visited the dentist. If dentures
are causing gum inflammation, the patient may
require a new set. Always evaluate oral hygiene
in older patients, especially bedridden ones who
can’t perform self-care.
P
ATIENT COUNSELING
To prevent further swelling, teach the patient
the basics of good nutrition. Remind him to eat
foods high in vitamin C, such as fresh fruits and
vegetables, daily. Also, encourage him to avoid
gum irritants, such as commercial mouthwashes, alcohol, and tobacco. Advise him to see a
periodontist at least once every 6 months.
Gynecomastia
Occurring only in males, gynecomastia refers to
increased breast size due to excessive mammary gland development. This change in breast
size may be barely palpable or immediately obvious. Usually bilateral, gynecomastia may be
associated with breast tenderness and milk secretion.
Normally, several hormones regulate breast
development. Estrogens, growth hormone, and
corticosteroids stimulate ductal growth, while
progesterone and prolactin stimulate growth of
the alveolar lobules. Although the pathophysiology of gynecomastia isn’t fully understood, a
hormonal imbalance—particularly a change in
the estrogen-androgen ratio and an increase in
prolactin—is a likely contributing factor. This
explains why gynecomastia commonly results
from the effects of estrogens and other drugs. It
may also result from hormone-secreting tumors
and from endocrine, genetic, hepatic, or adrenal
disorders. Physiologic gynecomastia may occur
in neonatal, pubertal, and geriatric males because of normal fluctuations in hormone levels.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin the history by asking the patient when he
first noticed his breast enlargement. How old
was he at the time? Since then, have his breasts
gotten progressively larger, smaller, or stayed
the same? Does he also have breast tenderness
or discharge? Have him describe the discharge,
if any. Ask him if he ever had his nipples pierced
and, if so, if he developed any complications.
Next, take a thorough drug history, including
prescription, over-the-counter, herbal, and
street drugs. Then explore associated signs and
symptoms, such as testicular mass or pain, loss
of libido, decreased potency, and loss of chest,
axillary, or facial hair.
Focus the physical examination on the
breasts, testicles, and penis. As you examine
the breasts, note any asymmetry, dimpling, abnormal pigmentation, or ulceration. Observe the
testicles for size and symmetry. Then palpate
them to detect nodules, tenderness, or unusual
consistency. Look for normal penile development after puberty, and note hypospadias.
M
EDICAL CAUSES
◆ Adrenal carcinoma. Estrogen production by
an adrenal tumor may produce a feminizing
syndrome in males characterized by bilateral
gynecomastia, loss of libido, impotence, testicular atrophy, and reduced facial hair growth.
Cushingoid signs, such as moon face and purple
striae, may also occur.
◆ Breast cancer. Painful unilateral gyneco-
mastia develops rapidly in males with breast
cancer. Palpation may reveal a hard or stony
breast lump suggesting a malignant tumor.
Breast examination may also detect changes in
breast symmetry; skin changes, such as thickening, dimpling, peau d’orange, or ulceration; a
warm, reddened area; and nipple changes, such
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337
as itching, burning, erosion, deviation, flattening, retraction, and a watery, bloody, or purulent
discharge.
◆ Cirrhosis. A late sign of cirrhosis, bilateral
gynecomastia results from failure of the liver to
inactivate circulating estrogens. It’s often accompanied by testicular atrophy, decreased libido, impotence, and loss of facial, chest, and
axillary hair. Other late signs and symptoms include mental changes, bleeding tendencies, spider angiomas, palmar erythema, severe pruritus
and dry skin, fetor hepaticus, enlarged superficial abdominal veins and, possibly, jaundice and
hepatomegaly.
◆ Hermaphroditism. In true hermaphroditism,
ovarian and testicular tissues coexist, resulting
in external genitalia with both feminine and
masculine characteristics. At puberty, the patient typically develops marked bilateral gynecomastia. About 50% of hermaphrodites also
experience male menstruation in the form of
cyclic hematuria.
◆ Hypothyroidism. Typically, this disorder pro-
duces bilateral gynecomastia along with bradycardia, cold intolerance, weight gain despite
anorexia, and mental dullness. The patient may
display periorbital edema and puffiness in the
face, hands, and feet. His hair appears brittle
and sparse and his skin is dry, pale, cool, and
doughy.
◆ Klinefelter’s syndrome. Painless bilateral
gynecomastia first appears during adolescence
in this genetic disorder. Before puberty, symptoms also include abnormally small testicles
and slight mental deficiency; after puberty,
sparse facial hair, a small penis, decreased libido, and impotence.
◆ Liver cancer. This type of cancer may pro-
duce bilateral gynecomastia and other characteristics of feminization, such as testicular atrophy, impotence, and reduced facial hair growth.
The patient may complain of severe epigastric
or right-upper-quadrant pain associated with a
right-upper-quadrant mass. A large tumor may
also produce a bruit on auscultation. Related
findings may include anorexia, weight loss, dependent edema, fever, cachexia and, possibly,
jaundice or ascites.
◆ Lung cancer. Bronchogenic carcinoma or
metastasis to the lung from testicular choriocarcinoma may result in bilateral gynecomastia.
Other effects vary according to the tumor’s primary site but usually include anorexia, weight
loss, fatigue, chronic cough, hemoptysis, club-
bing, dyspnea, and diffuse chest pain. Fever and
wheezing may occur.
◆ Malnutrition. Painful unilateral gynecomas-
tia (known as refeeding gynecomastia) may occur when the malnourished patient begins to
take nourishment again. Other effects of malnutrition include apathy, muscle wasting, weakness, limb paresthesia, anorexia, nausea, vomiting, and diarrhea. Inspection may reveal dull,
sparse, dry hair; brittle nails; dark, swollen
cheeks and lips; dry, flaky skin; and, occasionally, edema and hepatomegaly.
◆ Pituitary tumor. This hormone-secreting tu-
mor causes bilateral gynecomastia accompanied by galactorrhea, impotence, and decreased
libido. Other hormonal effects may include enlarged hands and feet, coarse facial features
with prognathism, voice deepening, weight
gain, increased blood pressure, diaphoresis,
heat intolerance, hyperpigmentation, and thickened, oily skin. Paresthesia or sensory loss and
muscle weakness commonly affect the limbs. If
the tumor expands, it may cause blurred vision,
diplopia, headache, or partial bitemporal hemianopia that may progress to blindness.
◆ Reifenstein’s syndrome. This genetic disor-
der produces painless bilateral gynecomastia at
puberty. Associated signs may include hypospadias, testicular atrophy, and an underdeveloped
penis.
◆ Renal failure (chronic). This disorder may
produce bilateral gynecomastia accompanied by
decreased libido and impotence. Among its
more characteristic features, however, are ammonia breath odor, oliguria, fatigue, decreased
mental acuity, seizures, muscle cramps, and peripheral neuropathy. Common GI effects include
anorexia, nausea, vomiting, and constipation or
diarrhea. The patient also typically has bleeding
tendencies, pruritus, yellow-brown or bronze
skin and, occasionally, uremic frost and increased blood pressure.
◆ Testicular failure (secondary). Commonly
associated with mumps and other infectious
disorders, secondary testicular failure produces
bilateral gynecomastia that appears after normal puberty. This disorder may also cause
sparse facial hair, decreased libido, impotence,
and testicular atrophy.
◆ Testicular tumor. Choriocarcinomas, Ley-
dig’s cell tumors, and other testicular tumors
typically cause bilateral gynecomastia, nipple
tenderness, and decreased libido. Because these
tumors are usually painless, testicular swelling
may be the patient’s initial complaint. A firm
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mass and a heavy sensation in the scrotum may
occur.
◆ Thyrotoxicosis. Bilateral gynecomastia may
occur with loss of libido and impotence. Cardinal findings include an enlarged thyroid gland,
tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, dyspnea,
nervousness, diaphoresis, heat intolerance, and
possibly exophthalmos. An atrial or ventricular
gallop may also occur.
O
THER CAUSES
◆ Drugs. When gynecomastia is an effect of
drugs, it’s typically painful and unilateral. Estrogens used to treat prostate cancer, including estramustine, directly affect the estrogen-androgen ratio. Drugs that have an estrogen-like
effect, such as cardiac glycosides and human
chorionic gonadotropin, may do the same. Regular use of alcohol, marijuana, or heroin reduces plasma testosterone levels, causing gynecomastia. Other drugs—such as flutamide,
spironolactone, cimetidine, and ketoconazole—
produce this sign by interfering with androgen
production or action. Some common drugs, including phenothiazines, tricyclic antidepressants, and antihypertensives, produce gynecomastia in an unknown way.
◆ Treatments. Gynecomastia may develop
within weeks of starting hemodialysis for
chronic renal failure. It may also follow major
surgery or testicular irradiation.
around age 14. This gynecomastia is usually
asymmetrical and tender; it commonly resolves
within 2 years and rarely persists beyond age 20.
S
PECIAL CONSIDERATIONS
To make the patient as comfortable as possible,
apply cold compresses to his breasts and administer analgesics. Prepare him for diagnostic
tests, including chest and skull X-rays and
blood hormone levels.
Because gynecomastia may alter the patient’s
body image, provide emotional support. Reassure the patient that treatment can reduce gynecomastia. Some patients are helped by tamoxifen, an antiestrogen, or by testolactone, an
inhibitor of testosterone-to-estrogen conversion. Surgical removal of breast tissue may be
an option if drug treatment fails.
P
EDIATRIC POINTERS
In neonates, gynecomastia may be associated
with galactorrhea (“witch’s milk”). This sign
usually disappears within a few weeks but may
persist until age 2.
Most males have physiologic gynecomastia
at some time during adolescence, usually
Halitosis
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Halitosis describes any breath odor that’s unpleasant, disagreeable, or offensive. This common sign is usually easy to detect, but an embarrassed patient may take measures to hide it.
The patient may be unaware that he has halitosis, even though he may complain of a bad taste
in his mouth, or he may believe that he has halitosis but that no one else can detect it (psychogenic halitosis).
Certain types of halitosis characterize specific
disorders—for example, a fruity breath odor typifies ketoacidosis. (See “Breath with ammonia
odor,” page 120; “Breath with fecal odor,” page
121; “Breath with fruity odor,” page 123; and
“Fetor hepaticus,” page 297.) Other types of halitosis include putrid, foul, fetid, and musty
breath odors.
Halitosis may result from a disorder of the
oral cavity, nasal passages, sinuses, respiratory tract, or esophageal diverticula. It may also
stem from a GI disorder associated with
belching, regurgitation, or vomiting, or it may
be an adverse effect of an oral or inhaled
drug.
Other causes of halitosis include cigarette
smoking, ingestion of alcohol and certain
foods (such as garlic and onions), and poor
oral hygiene—especially in patients with an orthodontic device, dentures, or dental caries. In
addition, offensive skin odors—for example,
from foot perspiration—may be absorbed locally and later expelled by the lungs, resulting
in halitosis.
H
H
ISTORY AND PHYSICAL
EXAMINATION
If you detect halitosis, try to characterize the
odor. Does it smell fruity, fecal, or musty? If the
patient is aware of it, find out how long he has
had it. Does he also have a bad taste in his
mouth? Does he have difficulty swallowing or
chewing? Does he have reflux or regurgitation?
Does he have pain or tenderness? Ask the patient if he has a problem with flatus. Also ask
him to describe the frequency of his bowel
movements and the size and consistency of his
stools.
Find out if the patient smokes or chews tobacco. Have him describe his diet and daily oral
hygiene. Does he wear dentures? Complete the
history by asking about chronic disorders and
recent respiratory tract infection. If the patient
reports a cough, find out if it’s productive.
Begin the physical examination by examining
the patient’s mouth, throat, and nose. Look for
lesions, bleeding, drainage, obstruction, and
signs of infection, such as redness and swelling.
Check for tenderness by percussing and palpating over the sinuses. Then auscultate the lungs
for abnormal breath sounds. Auscultate the abdomen for bowel sounds, and percuss it, noting
any tympany. Finally, take vital signs.
M
EDICAL CAUSES
◆ Bowel obstruction. Halitosis is a late sign in
both small- and large-bowel obstructions, resulting from vomiting of bilious and later fecal
material. Other findings in a small-bowel
obstruction include constipation, abdominal
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distention, and intermittent periumbilical cramping pain. In a large-bowel obstruction, abdominal pain is milder and more constant than that
associated with a small-bowel obstruction and is
usually located lower in the abdomen.
◆ Bronchiectasis. Bronchiectasis usually pro-
duces foul or putrid halitosis, but some patients
may have a sickeningly sweet breath odor. The
patient typically also has a chronic productive
cough with copious, foul-smelling, mucopurulent sputum. The cough is aggravated by lying
down and is most productive in the morning.
Associated findings commonly include exertional dyspnea, fatigue, malaise, weakness, and
weight loss. Auscultation reveals coarse or
moist crackles over the affected lung areas during inspiration. Digital clubbing is a late sign.
◆ Common cold. A musty breath odor may ac-
company a common cold, which usually also
causes a dry, hacking cough with sore throat,
sneezing, nasal congestion, rhinorrhea,
headache, malaise, fatigue, arthralgia, and
myalgia.
◆ Esophageal cancer. In esophageal cancer,
halitosis may accompany classic findings of dysphagia, hoarseness, chest pain, and weight loss.
Nocturnal regurgitation and cachexia are late
signs.
◆ Gastric cancer. Halitosis is a late sign in gas-
tric cancer. Accompanying findings include
chronic dyspepsia unrelieved by antacids, a vague
feeling of fullness, nausea, anorexia, fatigue, pallor, weakness, altered bowel habits, weight loss,
and muscle wasting. Hematemesis and melena
are signs of associated gastric bleeding.
◆ Gastrocolic fistula. In this disorder, fecal
vomiting is responsible for fecal breath odor,
which is typically preceded by intermittent
diarrhea.
◆ Gingivitis. Characterized by red, edematous
gums, gingivitis may also cause halitosis. The
gingivae between the teeth become bulbous
and bleed easily with slight trauma.
Acute necrotizing ulcerative gingivitis also
causes fetid breath, a bad taste in the mouth,
and ulcers—especially between the teeth—that
may become covered with a gray exudate. Severe ulceration may occur with fever, cervical
adenopathy, headache, and malaise.
◆ Hepatic encephalopathy. A characteristic
late sign of hepatic encephalopathy is fetor hepaticus, a musty, sweet, or mousy (new-mown
hay) breath odor. Other late effects include
coma, asterixis (flapping tremor), and hyperactive deep tendon reflexes.
◆ Ketoacidosis. Alcohol-induced, diabetic, and
starvation forms of ketoacidosis produce a fruity
breath odor. Alcohol-induced ketoacidosis is usually seen in poorly nourished alcoholics who
have eaten very little over several days. Symptoms include sudden Kussmaul’s respirations
with vomiting for several days, light dehydration, abdominal pain and distention, and absent
bowel sounds. The patient is alert and has a
normal or slightly decreased blood glucose
level.
Life-threatening diabetic ketoacidosis pro-
duces a rapid, thready pulse; marked hypovolemia; nausea and vomiting; and, in its early
stages, the triad of polydipsia, polyphagia, and
polyuria.
Also life-threatening, starvation ketoacidosis
produces Kussmaul’s respirations; weight loss;
bradycardia; dry, scaly skin; sore tongue; muscle
and tissue wasting; abdominal distention; and
signs of dehydration, such as oliguria and poor
skin turgor.
Other common effects of diabetic and starvation ketoacidosis include orthostatic hypotension, generalized weakness, anorexia, abdominal pain, and altered level of consciousness.
◆ Lung abscess. Lung abscess typically causes
putrid halitosis, but its cardinal sign is a productive cough with copious, purulent, often bloody
sputum. Other findings include fever with chills,
dyspnea, headache, anorexia, weight loss,
malaise, pleuritic chest pain, asymmetrical
chest movement, and temporary clubbing.
◆ Necrotizing ulcerative mucositis (acute). A
strong, putrid breath odor is characteristic of
this uncommon disorder, which initially causes
slight cheek inflammation that’s rapidly followed by tooth loss and extensive bone sloughing in the mandible or maxilla.
◆ Ozena. This severe, chronic form of rhinitis
causes a musty or fetid breath odor as well as
thick green mucus and progressive anosmia.
◆ Periodontal disease. Periodontal disease
causes halitosis and an unpleasant taste. Typically, the patient’s gums bleed spontaneously or
with slight trauma and are marked by pus-filled
pockets around the teeth. Related findings include facial pain, headache, and loose teeth
covered by calculi and plaque.
◆ Pharyngitis (gangrenous). Halitosis is a
chief sign of gangrenous pharyngitis. The patient also complains of a foul taste in the
mouth, an extremely sore throat, and a choking
sensation. Examination reveals a swollen, red,
ulcerated pharynx, possibly with a grayish
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