Nosebleeds Definition

When one or two of the small veins in the nose erupt, the resulting condition is nosebleed or epistaxis. Nosebleeds can be caused by a myriad of events; it could be due to trauma as a result from picking the nose, temperature changes or a symptom of another disease. Nosebleeds can also be harmless or it could be a predictor of a serious disease.

Nosebleeds in children is a common case, in fact; almost 30% of children from 0 to 5 years old have episodes of nosebleeds, 56% for 6 to 10 year old children, and 64% of 11 to 15 year old children.

Most cases of nosebleeds are dealt with simple treatment or management; however we still cannot discount the fact that this could be a sign of an underlying condition. To better help us determine what conditions prompt medical attention, we must first know more about nosebleeds in children.

Types (Terminology)

Recurrent Nosebleeds

In recurrent nosebleeds the episode of bleeding happens only at certain periods of time. The bleeding may happen today, and then happen again after a week or so. Recurrent nosebleeds can be due to seasonal patterns, this can be observed in most cases where the bleeding episode only happens when the weather gets hot and dry, and ceases when during the cold months. Medical attention must be done if the recurrent nosebleed presents the following:

1. Nosebleeds that recurs frequently
2. Does not assume a seasonal pattern,
3. When other symptoms such as bleeding of the gums and easy bruising is noted.

These conditions can signify the child has a bleeding problem and that the nosebleeds might be a symptom of an underlying disease.

Constant Nosebleeds

This is the type of nosebleed that happens for a longer period of time. Oftentimes nosebleeds happen as a single incidence, but in constant nosebleed, the bleeding is continuously. The bleeding may last to up to 45 minutes (common nosebleeds only occur within 15 minutes).Constant epistaxis is always a sign of alarm, especially if the bleeding is heavy.

Sudden or spontaneous Nosebleeds

These are nosebleeds which could happen anytime of the day, regardless of the activity of the child, whether the child is resting or playing. This is the most common type of bleeding episode, where the child suddenly experiences bleeding from the nose.

Chronic Nosebleeds

Chronic conditions are defined as conditions that are continually experienced for more than six months. Nosebleeds are considered chronic if the child continuously experiences the same condition for more than six months. Chronic nosebleeds happen as result of a chronic underlying disease, these include:

• Chronic liver or kidney disease
• Blood dyscratias
• Long term use of medications that cause bleeding
• Vascular malformations

Children with this type of bleeding episode has to deal with the nosebleeds for life, treatment for this usually focus on the underlying disease condition.

Heavy Nosebleeds

Heavy nosebleeds pertain to episodes where there is a significant amount of blood coming out of the nose. Heavy nosebleeds describe bleeding that is severe, profuse and continuous. Once this type is seen, immediate first aid treatment must be employed and the child must be rushed to a nearest medical facility for evaluation.

What Causes Nosebleeds in Children?

• Trauma – from picking or inserting a foreign object to the nose. Such activity can cause the small sensitive blood vessels in the nose to burst.
• Sudden temperature changes- this event causes blood vessels to constrict and dilate. The sudden constriction and dilation can put a significant stress on the blood vessel; this then causes some of them to rupture.
• Problems in blood clotting– conditions in which the body lacks the ability to initiate blood clotting, this makes the child prone to nose bleeds. Vitamin K deficiency is one of the causes of blood clotting problems. Vitamin K helps in the process of clot formation, without it blood cannot clot properly.
• Infections – infectious agents such as viruses and bacteria release certain chemicals that can destroy the blood and blood vessels. This then cause bleeding tendencies (such as in the case of dengue fever).
• Valsalva maneuver or excessive straining-excessive pressure from straining causes blood vessels to rupture. In children this happens when they are constipated.
• Medications– certain medications can cause changes in the blood and their normal behavior. Aspirin for example, is a drug that has an anticoagulant effect. This means it prevents the blood from coagulating; this makes the blood free flowing and unable to clot or aggregate in cases of trauma, stress or temperature changes.
• Blood disorders– nose bleeds can also be caused by certain disease conditions. Anemia, Von Willebrand’s disease, and Osler-Weber-Rendu syndrome are just some blood disorders that cause nosebleeds in children.

Associated Symptoms of Nosebleeds

In some cases, nosebleeds in children are accompanied by other associated symptoms. Other symptoms are very helpful in knowing the true condition of the child. It helps the clinician determine if the nosebleed is a part of a myriad of symptoms that suggest a disease. Significant associated symptoms of nosebleeds are as follows:

• Gum Bleeding
• Bruising especially in the upper extremities
• Facial swelling or pain
• Nasal blockage or presence of nasal discharges
• Pain in the head or neck
• Presence of allergies

Diagnosis of Nosebleeds

Diagnosis that evaluates the source of the bleeding is done by determining the following:

1. Presence of crusting on the nasal septum- this usually indicates infection and inflammation
2. Presence of Visible blood vessels present on the anterior septum- this is observed in almost 50% of the cases, and it was also observed that bleeding occurs on the side where the vessels are visible.
3. Presence of pyogenic granulomas and tumors

To rule out other underlying conditions that may cause the bleeding episode, the following are done:

• Complete blood count – This determines deficiencies such as anemia or lack of platelets responsible for clotting.
• Coagulation studies – This determines if the child has normal blood clotting.
• MRI – To view the inner structures of the nose
• Angiography – To view the structure of the blood vessels and if there are obstructions
• Endoscopy and biopsy – To determine if there are tumors or other abnormal growths

Treatment of Nosebleeds

• Employ first aid measures– during episodes of nosebleeds, whether that is mild or severe case, first aid measures must be done initially until medical help is available
• Let the child sit, with upper body tilted forward
• Keep his/her mouth open to prevent the child from swallowing the blood
• Pinch the upper part of the nostrils just below the bony prominence (or the fleshy part of the nose) with the thumb and index finger
• Apply an icepack to the nose and cheek area

Continue the procedure until the bleeding stops, when the bleeding does not stop, the child must be sent to the nearest medical facility. Severe bleeding episodes can be treated with the following interventions:

• Intravenous fluid therapy to prevent blood loss
• Silver nitrate cautery if visible vessels are found
• Naseptin antiseptic cream if infection is present
• Hemostatic agent such as Kaltostat
• Possible surgery in the case of tumors

Complications

The primary complication of untreated nosebleeds is severe bleeding and shock. This is not directly due to the loss of blood from the nose. Since nosebleeds can be a sign of a bleeding disorder, disregarding them could lead to the worsening of the underlying condition. The child might go undiagnosed or untreated if the episode of epistaxis is taken for granted. That is why it is important to know when the child’s nosebleed needs medical attention.

What is Chronic Pain Syndrome?

Pain is defined as a sensory which is unpleasant and which yields an experience of the emotional state which can be associated to the potential or actual tissue or organ damage that the person’s body undergoes. The Chronic Pain Syndrome, meanwhile, is an expected symptom that doesn’t have a good feedback to medical treatment and this kind of syndrome imposes a great challenge to the persons who are inclined to the health care system. It imposes a challenge to the persons inclined in the health care system because the cause is unclear and the patient who has this syndrome yields a poor response to the therapy done. Researchers says that for a person to experience such syndrome, the pain should last for 6 months and others used 3 months as the minimum diagnostic standards while others use the basis of the normal recuperation period for a disease condition. In a general form, it is a persisting pain that last longer compared to acute pain that are only last for less than a month.

Symptoms and Characteristics

When a person is undergoing Chronic Pain Syndrome, he or she will manifest the some or most of the following signs, symptoms and characteristics such as:

• Discomfort
• Pain which can be described as burning, shooting, electrical, or aching
• Pain that doesn’t go away directly as it is expected after injury or illness
• Soreness
• Tightness
• Fatigue
• Immune system which is weak
• Mood changes such as irritable, hopelessness, fear and stress
• Disability
• Stiffness
• Disturbed sleeping pattern
• Withdrawn from normal day to day activity
• Depression
• Somatisation

Causes and Risk Factors

The exact cause of why Chronic Pain Syndrome happens is still unclear, up to this point. As mentioned, chronic pain the pain persists for weeks to months to years even after the recuperation period. It can develop after one sustain an illness or an injury or perhaps develop idiopathic or having an unknown cause. There is also a possibility that brain chemicals, which normally suppresses the pain, doesn’t properly work. Some of the most common causes that attribute to experiencing this kind of syndromes are the following common cases:

• Fibromyalgia
• Shingles
• Nerve damage
• Multiple sclerosis
• Lower back pain
• Arthritis
• Headache

The factors that increase your risk into experiencing the Chronic Pain syndrome may be attributed to:

• Smoking
• Aging
• Existing health problems such as the cases mentioned above
• Health problems encountered in the past which have recurred
• The general overall health condition
• Health conditions which are hard to treat
• Lifestyle
• Stress
• History of sexual, physical or emotional abuse
• Relationship problems

Diagnosis

In evaluating and diagnosing if the person is experiencing the Chronic Pain syndrome, the physician will require test or examination prior to diagnosing the patient himself or herself. Such of the examinations that the physician conducts are as follows:

• Medical History Examination which should be detailed
• Physical Examination using the IPPA or Inspection, Percussion, Palpation, Auscultation
• Neurological Examination
• Mental Health Examination or Assessment Examination
• Blood Examination
• X-Ray Examinations
• Electromyography Examination
• Angiogram
• Nerve Block Diagnostic Examination

Treatment of Chronic Pain Syndrome

There are various ways or method to treat Chronic Pain Syndrome. Prior to treatment the physician or the health care team will usually assess the patient by using the pain scale method to determine the scale and intensity of the pain experienced by the patient himself or herself. They will use this rate to determine the effectivity of the treatment that the patient has undergone. Such treatment therapies that patients can undergo to treat this kind of syndrome are as follows:

Natural Treatment

Cognitive Behavior Treatment – There is a need to step back and evaluate one’s feelings and to recognize this feeling and initiate a change in behavior or attitude.

Eat healthy and balanced diet – It includes diet that is high in essential nutrients and vitamins

Follow Regular Exercise regimen – It is best way in pain reduction. It is through exercise that one produces endorphins which are known to be hormones that elevates the persons mood and which are also known to be useful in pain reduction.

Getting an ample enough of sleep – This is good way to manage the pain that one is experiencing in chronic pain syndrome

Pharmacological Pain Medications

• Analgesics such as NSAIDs
• Opioid

Both are commonly prescribed various pain medications to alleviate the pain that the person experiences during the Chronic Pain syndrome episodes

Holistic Treatment

• Occupational and Physical Therapy
• Acupuncture
• Massage
• Chiropractic Therapy
• Herbal Medicines
• Hypnosis
• Visualization Therapies
• Meditation
• TENS
• Heat and Cold Therapies
• Humor
• Jaw Relaxation
• Slow Rhythmic Breathing Therapy

Prognosis

When it comes to the prognosis of persons with Chronic Pain Syndrome, the prognosis varies from one person to another but it is most often poor and leads to failure to thrive and death. Yet, there are is a possibility for a considerate improvement that is suitable for management and support.

Complications

The complications which are associated with the Chronic Pain Syndrome are as follows:

• Disturbance of the sleep pattern
• Employment is loss
• Disability
• The physical suffering is prolonged (compared to acute pain)
• Marital problems
• Family problems
• Financial problems
• Side effects of medications due to long term treatment therapy

Prevention

The fact is that you can never prevent chronic pain. However if you are adapting a healthy lifestyle which possess good mental and physical health, you can be able to at least prevent chronic pain syndrome or be able to cope with the constant and persisting pain. Other ways that can be of help in the prevention of this syndrome consist of:

• Adequate sleep
• Exercise
• Balanced and healthy diet
• Stress reduction
• Early treatment
• Activity and Rest periods

What is Balanoposthitis?

Balanoposthitis is a condition seen in uncircumcised males where the glans penis and the prepuce are inflamed due to several infections related to the non-removal of the foreskin. This is frequently due to unretractility of the foreskin and very poor personal hygiene, which results to too much bacterial and fungal growth around the area. This condition is only exclusive to males. Most of the affected group comes from children 0-5 years old and in adult males who actively engage in sexual intercourse. Other medical conditions may also precipitate to balanoposthitis, which can be more severe. This can become the point of onset of bacteraemia and fever in men with very low levels of neutrophils. Patients with diabetes mellitus are also susceptible to candidal balanitis. This can also become an entry way for acquiring infections. Morbidity of this condition is only limited to its associated symptoms. Death is at hand only to those patients who are immunocompromised and those who develop balanoposthitis consequential to septicaemia caused by fungi. Intermittent balanoposthitis caused by candida albicans results to mondor phlebitis. Severe balanoposthitis enhance the probability of balanitis xerotica obliterans, tightening of the foreskin or phimosis, cancer and paraphimosis.

Balanoposthitis Symptoms, Signs

Upon physical examination, the following signs and symptoms can be noted:

• Red, damp unelevated lesion on the glans and foreskin
• Soreness
• Irritation
• Redness of the penis
• Painful penis and prepuce
• Rashes around the penis
• Presence of discharge beneath the prepuce
• Tightening of the foreskin or phimosis
• Foul smelling discharge
• Apparent ulcerations
• Unusual enlargement of the lymph nodes over the groin area
• Fatige
• Low back pain
• Anxiety

Balanoposthitis Causes

In nearly all cases of balanoposthitis results from the existence of the foreskin or prepuce, which may be unnecessary and tightened, making it more susceptible to different infections. The foreskin façade provides under the commonly peeling off of epithelial cells and secretions from the glands provide an inviting warm, damp culture environment for organisms. Therefore, proper personal hygiene is very important in the prevention of balanoposthitis.

Other notable causes include:

• Usage of harsh soaps for genital wash
• Staphylococcus aureus infection
• Candida albicans infection
• Uncontrolled diabetes
• Improperly rinsing soap off during bathing
• Diseases like lichen sclerosis and reactive arthritis.

Balanoposthitis Diagnosis

For the diagnosis of this condition, physician will do a physical assessment, which will reveal the symptoms most commonly associated with balanoposthitis. Aside from physical examination, proper history is also taken. Other tests include:

• Laboratory studies
• Potassium hydroxide Test: This is done to check presence of candidial infections. This is also cultured to know the specific antifungal medication to which the organism is sensitive.
• Serologic Test: This test may be prescribed for candidial infections, especially in cases where the infection is unclear.
• Skin Biopsy: This procedure is done if the recommended antifungal therapy does not produce a good result. This is also done to check for the malignancy of the affected area and to rule out other conditions.

Balanoposthitis Treatment

The management and handling for this condition concentrates on clearing the onset of infection and inhibiting the periodic irritation or infection by way of enhanced hygiene.

The treatment regimen for balanoposthitis is also dependent on the cause. If the infection is caused by a bacteria, then treatment will antibiotics. Treatment may also include steroid based creams to reduce the inflammation.

Supportive Care: Proper personal hygiene and washing your hands regularly Exposure of the affected part to air will help stop the growth of anaerobic microorgasims.

Medical Care: Applying topical creams are the treatment that is widely used for this condition. The aim of this therapy is to eradicate the different microorganisms and to arrest inflammation.

Antifungal Therapy: The means by which this class of drugs act includes slowing down the conduits of substances essential for the production of the organisms’ cell membrane or changing the capacity of cell membrane to let substance pass through the cell membrane of the fungal cells.

Cotrimazole (Lotrimin, Fomisol 7, Mycelex, Gyne-Lotrimin): These are drugs with broad spectrum antifungal action. These are used to remedy infections of the skin, which results from different varieties of microorganisms causing skin disorders and yeasts. It slows down the growth of yeasts by changing the capacity of the cell membrane to let substance pass through, which results to demise of fungal cells. 1% cream is usually prescribed.

Antimicrobial Therapy: The mechanisms by which these drugs function tend to obliterate the microbes causing the infection, to arrest their reproduction or development, or to stop their illness causing actions.

Metronidazole (0.75% MetroGel Cream or lotion, 1% Noritate cream): This in imidazole with the capability to reduce the multiplication of anaerobic bacteris, protozoa, and fungi. It also provides an inflammatory effect, which involve inflection of white blood cells action.

Steroid Creams: This acts by inhibiting the inflammation of the glans penis and the foreskin.

Surgery: This is indicated in severe cases where the foreskin can no longer be retracted for cleaning. Circumcision is probably the best choice in treating this condition.

Balanoposthitis Prognosis

The expected outcome for balanoposthitis is high. Most patients who suffer from this condition have good prognosis since in most instances; the condition can be restricted with the use of specially medicated creams and with proper and improved personal hygiene. Circumcision is generally not needed especially if the balanoposthitis is not that severe and foreskin is still retractile and smegma can still be removed.

Complications

Normally, balanoposthitis do not exhibit any kind of complications especially if the patient has good compliance to treatment regimen. Again, early detection and treatment is very important. But, if the condition is left untreated or the inflammation or infection has been prolonged, it can lead to several complications such as:

• Scarring of the penis’
• Narrowing of the penile orifice, a condition known as meatal stricture
• Phimosis or severe tightening of the prepuce making it hard to bare the head of the penis
• Paraphimosis or the difficulty pushing the foreskin on top of the end of the penis
• Deacreased blood supply to the end of the penis as a result of the narrowed penile orifice

Prevention

The best prevention of Balanoposthitis and any other condition is having a proper and good hygiene. Being free from any kind of infections or disease all comes down to personal hygiene. Bathing regularly will help reduce the incidence of contracting balanoposthitis. During bath time, gently drag down the foreskin to reveal the end of the penis and clean it with water and soap. Remember to rinse off the soap properly and pat dry the part beneath it. Regular hand washing is also recommended to reduce the likely of infection. If you see changes around scrotal and penile areas, consult a doctor and avoid self diagnosis and self medication.

Balanoposthitis Pictures

Picture 1 – Observe unretractility of the foreskin

picture 2 – surgical procedure for Balanoposthitis