Reinke's Edema

In Brief

Voice disorders can result from the swelling of the non-muscle part of the vocal fold that is right underneath its surface lining (i.e., in the superficial lamina propria, also known as Reinke's space). This condition is called Reinke's edema, which literally means "swelling in Reinke's space" or "build-up of fluid in Reinke's space."

A change in a vocal fold causes change in vocal fold vibration. The vocal fold swelling makes the superficial lamina propria (Reinke's space) stiff, thus reducing vocal fold vibration – hence voice changes and/or problems. (For more information, see Anatomy & Physiology of Voice Production.)

Common Complaints

Patients usually have a low, raspy, or rough voice. A low voice is particularly striking in women – a male-quality voice in a female.

Common Causes

Reinke's edema is caused by vocal fold irritation from voice misuse, smoking, and/or conditions that irritate the vocal folds, such as backflow of stomach fluids to the voice box (laryngopharyngeal reflux). Reinke's edema typically occurs in middle-aged/post-menopausal women who have a long-term history of smoking cigarettes.

Treatment Strategies

Reinke's edema does not go away on its own.

The cause of Reinke's edema needs to be identified and treated before treatments directed at the voice disorder (such as voice therapy or surgery) are considered.

Elements of Successful Treatment

Long-term success in the treatment of Reinke's edema requires two, sometimes three approaches.

Fixing the underlying cause (e.g., stop smoking, treat reflux, eliminate voice overuse or abuse)
Voice therapy

In some cases, vocal fold phonomicrosurgery (For more information, see Phonomicrosurgery.)

Typical Course

Although Reinke's edema usually develops slowly over the course of many years, the condition can worsen to the point of causing problems with breathing (airway problems).

What is Reinke's edema?

Swelling from Fluid Accumulation in Reinke's Space
Reinke's edema is the build-up of a gelatinous substance in the layer right underneath the surface lining of the vocal folds (superficial lamina propria or Reinke's space. It may occur in one or both vocal folds.

Reinke's Space Is Not an "Empty Space"

The superficial lamina propria, or Reinke's space, is not an empty space. It has a defined structure made up of cells, special fibers, and substances made by cells. (For more information, see Anatomy & Physiology of Voice Production.)

The superficial lamina propria (Reinke's space) plays an important role in the vibration of vocal folds, which is a key element in sound production.

Voiceproblem

Extremity Edema During Pregnancy

Why are my ankles and toes so swollen?

What you're experiencing is called edema — that's the medical term for when excess fluid collects in your tissue. It's normal to have a certain amount of this swelling during pregnancy because you retain more water while you're pregnant, and certain changes in your blood chemistry cause some fluid to shift into your tissue.

Why does it collect in the legs and feet? When you're pregnant, your growing uterus puts pressure on your pelvic veins and on your vena cava (a large vein on the right side of your body that receives blood from your lower limbs and carries it back to the heart). The pressure slows down circulation and causes blood to pool in your legs, forcing fluid from your veins into the tissues of your feet and ankles. This increased pressure is relieved when you lie on your side. And since the vena cava is on the right side of your body, left-sided rest works best.

Edema is most likely to be an issue during your third trimester, particularly at the end of the day, and it may be worse during the summer. After you have your baby, the swelling will disappear fairly rapidly as your body eliminates the excess fluid. As a result, you may find yourself urinating frequently and sweating a lot in the first days after childbirth.

When should I be concerned about swelling?

A certain amount of edema is normal in the ankles and feet during pregnancy. You may also have some mild swelling in your hands. However, call your midwife or doctor if you notice swelling in your face or puffiness around your eyes, more than slight swelling of your hands, or excessive or sudden swelling of your feet or ankles. It could be a sign of preeclampsia, a serious condition. Also call your caregiver if you notice that one leg is significantly more swollen than the other, especially if you have any pain or tenderness in your calf or thigh.

Can I do anything to minimize the puffiness?

Here are a few tips:

• Put your feet up whenever possible. At work, it helps to keep a stool or pile of books under your desk; at home, lie on your left side when possible. Don't cross your legs or ankles while sitting.

• Stretch your legs frequently while sitting: Stretch your leg out, heel first, and gently flex your foot to stretch your calf muscles. Rotate your ankles and wiggle your toes.

• Take breaks from sitting or standing. Take a short walk every so often to keep your blood circulating.

• Wear comfortable shoes that stretch to accommodate the swelling. Don't wear socks or stockings with tight bands around your ankles or calves.

• Try waist-high maternity support stockings. Put them on before you get out of bed in the morning, so blood has no chance to pool around your ankles.

• Drink plenty of water. Surprisingly, this helps your body retain less water.

• Exercise regularly, especially by walking, swimming, or riding an exercise bike. Or try a water-aerobics class — immersion in water can help reduce swelling, particularly if the water level is up near your shoulders.

• Eat well, and avoid junk food.And try not to let it get you down. Although the sight of your swollen ankles will probably add to your feelings of ungainliness, edema is a temporary condition that will pass soon after you give birth.

Baby Center.com

Foot Edema

Alternative names Return to top

Swelling of the ankles - feet - legs; Ankle swelling; Foot swelling; Leg swelling; Edema - peripheral, Peripheral edema

Definition Return to top

Abnormal buildup of fluid in the ankles, feet, and legs is called peripheral edema.

Considerations Return to top

Painless swelling of the feet and ankles is a common problem, particularly in older people. It may affect both legs and may include the calves or even the thighs. Because of the effect of gravity, swelling is particularly noticeable in these locations.

Common Causes Return to top

Foot, leg, and ankle swelling is common with the following situations:

Prolonged standing
Long airplane flights or automobile rides
Menstrual periods (for some women)
Pregnancy -- excessive swelling may be a sign of pre-eclampsia, a serious condition sometimes called toxemia, that includes high blood pressure and swelling
Being overweight
Increased age
Injury or trauma to your ankle or foot

Swollen legs may be a sign of heart failure, kidney failure, or liver failure.

In these conditions, there is too much fluid in the body.

Other conditions that can cause swelling to one or both legs include:

Blood clot Leg infection Venous insufficiency (when the veins in your legs are unable to adequately pump blood back to the heart)
Varicose veins
Burns (including sunburn)
Insect bite or sting
Starvation or malnutrition
Surgery to your leg or foot

Certain medications may also cause your feet to swell:

Hormones like estrogen (in birth control pills or hormone replacement therapy) and testosterone
A group of blood pressure lowering drugs called calcium channel blockers (such as nifedipine, amlodipine, diltiazem, felodipine, and verapamil)
Steroids
Antidepressants, including MAO inhibitors (such as phenelzine and tranylcypromine) and tricyclics (such as nortriptyline, desipramine, and amitriptyline)

Home Care Return to top

Elevate your legs above your heart while lying down.
Exercise your legs. This helps pump fluid from your legs back to your heart.
Wear support stockings (sold at most drug and medical supply stores).
Try to follow a low-salt diet, which may reduce fluid retention and swelling.

Call your health care provider if Return to top

Call 911 if:

You feel short of breath.
You have chest pain, especially if it feels like pressure or tightness.

Call your doctor right away if:

You have decreased urine output.
You have a history of liver disease and now have swelling in your legs or abdomen.
Your swollen foot or leg is red or warm to the touch.
You have a fever.
You are pregnant and have more than just mild swelling or have a sudden increase in swelling.

Also call your doctor if self care measures do not help or swelling worsens.

What to expect at your health care provider's office Return to top

Your doctor will take a medical history and conduct a thorough physical examination, with special attention to your heart, lungs, abdomen, legs, and feet.

Your doctor will ask questions like the following:

What specific body parts swell? Your ankles, feet, legs?
Above the knee or below?
Do you have swelling at all times or is it worse in the morning or the evening?
What makes your swelling better?
What makes your swelling worse? Does the swelling get better when you elevate your legs?
What other symptoms do you have?

Diagnostic tests that may be performed include the following:

Blood tests such as a CBC or blood chemistry
ECG
Chest x-ray or extremity x-ray
Urinalysis

The specific treatment will be directed at whatever underlying cause is found. Diuretics may be prescribed. These are effective in reducing the swelling but have some side effects.

Home treatment for benign causes of leg swelling should be tried before drug therapy under medical supervision.

Prevention Return to top

Avoid sitting or standing without moving for prolonged periods of time.
When flying, stretch your legs often and get up to walk when possible.
When driving, stop to stretch and walk every hour or so.
Avoid wearing restrictive clothing or garters around your thighs.
Exercise regularly.
Lose weight if you need to.

References Return to top

Cho S. Peripheral edema. Am J Med. 2002; 113(7): 580-586.Schroeder BM. ACOG practice bulletin on diagnosing and managing preeclampsia and eclampsia. American College of Obstetricians and Gynecologists. Am Fam Physician. 2002; 66(2): 330-331.Update Date: 6/3/2005

Updated by: Thomas A. Owens, M.D., Departments of Internal Medicine and Pediatrics, Duke University Medical Center, Durham, NC. Review provided by VeriMed Healthcare

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Foot Edema

Why You Have Foot Swelling

You may hear your doctor refer to leg and foot swelling as edema, the term used to describe an abundance of fluid found between tissue cells. Edema typically causes lower leg, ankle and foot swelling, but can really impact any area of the body.

Many factors contribute to your likeliness to develop foot swelling. Some causes of foot swelling can be quite serious, so please take note of any body or foot swelling and talk to your doctor about it.

The causes of foot swelling, according to The Podiatry Institute, include:

Serious conditions of the kidney, heart, liver or blood vessels can contribute to foot swelling and edema in other parts of the body.
Eating a poor diet high in salt and carbohydrates can cause foot swelling.
Abusing laxatives can contribute to foot swelling. Abusing diuretics may cause you to develop foot swelling.
Abusing drugs can lead to foot swelling.
Taking birth control or hormone replacement therapy pills may cause foot swelling.
Pregnancy and PMS can lead to foot swelling.
Sodium retention may contribute to foot swelling.
Varicose veins and a history of phlebitis (inflammation of a vein’s wall) can lead to foot swelling.
Allergic reactions may cause foot swelling.
Neuromuscular disorders could lead to the development of foot swelling.
Any kind of trauma may contribute to foot swelling.

How to Determine If You Have Foot Swelling or Edema

If you have foot swelling or edema, your may first notice that your foot is swelling up more and more as the day goes on. But after a period of time, the foot swelling will set in first thing in the morning and continue to worsen throughout the day.

Long-term foot swelling or edema causes pitting:
When you press on the swollen area for a few seconds, you will notice an indentation in that area. Continued foot swelling or swelling in other parts of the body can also cause skin ulcerations (sores on the skin).

Over time, other symptoms of foot swelling and edema will develop:

High blood pressure is a symptom of edema/ foot swelling.
Headaches can go along with edema/ foot swelling.
Increased urination is a symptom of edema/ foot swelling.
Palpitations can go along with edema/ foot swelling. Puffy eyes can go along with edema/ foot swelling.
Weight gain is a symptom of edema/ foot swelling.
Swollen hands and/or wrists can go along with edema/ foot swelling.

Tips on How to Relieve Your Foot Swelling and Related Symptoms

The best way to reduce leg and foot swelling is to elevate your legs above the level of the heart, which puts minimal pressure on knees, thighs and lower back. Just sitting in a reclining chair in front of the TV is a great way to elevate your legs to reduce foot swelling. Many products, for use at home or at work, can also help reduce leg and foot swelling.

Other aids to ease leg and foot swelling include:

Leg cushions , including leg and bed wedges and leg elevators, raise the feet while sleeping and/or resting to help ease foot swelling.
Support socks and graduated compression hosiery – which come in various gradients (light, moderate, firm) depending on the pressure you need, and various lengths depending on the level of the edema – can help ease your foot swelling.
Proper fitting shoes and socks can help relieve foot swelling.

Shopping Tip: Remember to buy new shoes in the afternoon to get the best fit, since foot swelling can get worse as the day continues. If you buy new shoes in the morning, and your foot is swelling by the afternoon, your shoes will feel too tight.

The Podiatry Institute recommends the following techniques to help decrease foot swelling and other symptoms of edema:

Increase muscle activity with walking to help reduce foot swelling and other symptoms of edema.
Avoid standing in place for long period of time to ease foot swelling and other symptoms of edema.
Avoid sitting with the feet dependent to relieve foot swelling and other symptoms of edema.
Limit salt intake to help alleviate foot swelling and other symptoms of edema.
Do not abuse diuretics, but a short-term course may be helpful to help reduce foot swelling and other symptoms of edema.
Do not abuse laxatives if you want to reduce foot swelling and other symptoms of edema.
Drink plenty of water to alleviate foot swelling and other symptoms of edema.
Avoid contraceptive pills and hormone replacement therapy – if possible – if you want to help reduce foot swelling and other symptoms of edema.
Use a compression pump to help fluid return to the blood vessels to help ease foot swelling and other symptoms of edema.

If foot swelling or other swelling continues to worsen, please consult your doctor. You may need more specific treatment for your case of edema/ foot swelling.

Information on foot, leg and lower body health conditions like foot swelling provided by The Podiatry Institute, dedicated to advancing the standard of care in podiatric medicine and its effects on muscoskeletal health.

Footsmart

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What Causes Foot Edema (Swelling) During Air Travel?

Swelling (edema) of the feet and ankles is common during long flights. It's usually caused by inactivity. As a passenger on a plane, you spend most of your time seated with your feet on the floor. This allows blood to pool in your leg veins. When you walk, the muscles in your legs contract and compress the veins, forcing blood back to your heart.

Also, the position of your legs when seated increases pressure in the veins. This contributes to leg swelling by causing fluid to leave the blood and move into the surrounding soft tissues. Another cause of swelling may be certain medications, such as calcium channel blockers.

You can usually relieve swelling after a flight by elevating your legs and feet and walking.

To help reduce swelling during a flight, you can:

Get up and walk around the plane once an hour
Rotate your ankles while seated

Swelling of the feet isn't a serious problem if it lasts only a short time. But excessive swelling that persists for several hours after you resume activity may be due to a more serious condition, such as a blood clot in the leg (deep vein thrombosis, or DVT) — especially if the swelling occurs in only one leg and is accompanied by pain. These symptoms require prompt medical attention.

On flights lasting six hours or more, consider taking these additional precautions to reduce the risk of DVT:

Avoid wearing tight clothing around your waist
Drink plenty of fluids to avoid dehydration
Stretch your calves once an hour

If you're at increased risk of blood clots, talk to your doctor before flying. He or she may recommend:

Compression stockings
Low-molecular-weight heparin given two to four hours before departure.

Aspirin is not recommended.

Tissue Edema and Principles of Transcapillary Fluid Echange

Richard E. Klabunde, Ph.D.

Edema refers to the swelling of tissues that result from excessive accumulation of fluid within the tissue. Edema can be highly localized, for example, a small region of the skin subjected to a bee sting. Edema, however, can also comprise an entire limb, specific organs such as the lungs (e.g., pulmonary edema) or the whole body.

General principles

To understand how edema occurs, it is first necessary to explain the concept of tissue compartments. There are two primary fluid compartments in the body between which fluid is exchanged - the intravascular and extravascular compartments. The intravascular compartment contains fluid (i.e., blood) within the cardiac chambers and vascular system of the body. The extravascular system is everything outside of the intravascular compartment. Fluid and electrolytes readily move between these two compartments. The extravascular compartment is made up of many subcompartments such as the cellular, interstitial, and lymphatic subcompartments, and a specialized system containing cerebrospinal fluid.

The movement of fluid and accompanying solutes between compartments (mostly water, electrolytes, and smaller molecular weight solutes) is governed by physical factors such as hydrostatic and oncotic forces. These forces are normally balanced in such a manner the fluid volume remains relatively constant between the compartments. If the physical forces or barriers to fluid movement are altered, the volume of fluid may increase in one compartment and decrease in another. In some cases, total fluid volume increases in the body so that both intravascular and extravascular compartments increase in volume. This can occur, for example, when the kidneys fail to excrete sufficient amounts of sodium and water. When the fluid volume within the interstitial compartment increases, this compartment will increase in size leading to tissue swelling (i.e., edema). When excess fluid accumulates within the peritoneal space, this is termed "ascites." Pulmonary congestion, which can occur in heart failure as the left atrial pressure increases and blood backs up in the pulmonary circuit, causes pulmonary edema.

A model that helps us to understand what causes edema is shown to the right. In most capillary systems of the body, there is a net filtration of fluid from the intravascular to the extravascular compartment. In other words, capillary fluid filtration exceeds reabsorption. This would cause fluid to accumulate within the interstitium if it were not for the lymphatic system that removes excess fluid from the interstitium and returns it back to the intravascular compartment. Circumstances, however, can arise where net capillary filtration exceeds the capacity of the lymphatics to carry away the fluid (i.e., net filtration > lymph flow). When this occurs, the interstitium will swell with fluid, thereby become edematous.

Factors Precipitating Edema

Increased capillary hydrostatic pressure (as occurs when venous pressures become elevated by gravitational forces, in heart failure or with venous obstruction)

Decreased plasma oncotic pressure (as occurs with hypoproteinemia)

Increased capillary permeability caused by proinflammatory mediators (e.g., histamine, bradykinin) or by damage to the structural integrity of capillaries so that they become more "leaky" (as occurs in tissue trauma, burns, and severe inflammation)

Lymphatic obstruction (as occurs in filariasis)

Prevention and Treatment of Edema

The treatment for edema involves altering one or more of the physical factors that regulate fluid movement. For example, in edema (pulmonary or systemic) secondary to heart failure, diuretics are given to reduce blood volume and venous pressure. If a patient suffers from ankle edema, that person will be instructed to keep their feet elevated whenever possible (to diminish the effects of gravity on capillary pressure), use tight fitting elastic hose (to increase tissue hydrostatic pressure), and possibly be prescribed a diuretic drug to enhance fluid removal by the kidneys.

Revised 09/14/2005

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Lymphedema People

Edema - Pathophysiology and Treatment

Donald E. Kohan, M.D., Ph.D.

General Concepts

Edema is defined as soft tissue swelling due to expansion of the interstitial volume. Edema can be localized or generalized. The normal distribution of body water is illustrated below.

1. Generalized edema involves an increase in extracellular fluid only (18% of body weight). Some extracellular fluid compartments, termed transcellular fluids (cerebrospinal fluid, intraocular fluid and joint fluid) do not communicate freely with the rest of the body.

EXAMPLE: A 70 kg adult has an ECF volume of 12.6 L (18% of body weight). If 2.5 L of fluid is added to this compartment alone, there is a 20% increase in interstitial fluid, but only a 3.5% increase in body weight. This amount could result in detectable edema.

2. Generalized edema is due to increases in both total body water and sodium. If just water is retained, it distributes throughout the total body water compartment (60% of body weight) and edema will not usually form. However, if sodium is retained as well, it is confined to the extracellular spaces. The increased osmolality due to sodium retains water in the ECF.

3. Generalized edema can occur with low, normal, or high serum sodium concentration. Serum sodium concentration, per se, does not reflect total body sodium. Increased total body sodium can occur with a low, normal or high serum sodium concentration.

Mechanisms maintaining interstitial fluid volume

The volume of interstitial fluid is determined by Starling's Law: Hydrostatic Pressure (capillary - tissue) - Oncotic pressure (capillary - tissue) = net fluid movement out of capillary into interstitium.

Oncotic pressure = osmotic pressure created by plasma protein molecules that are impermeable across the capillary membrane.

Causes of generalized edema

I. Decreased oncotic pressure
Nephrotic syndrome
Cirrhosis
Malnutrition

II. Increased vascular permeability to proteins
Angioneurotic edema (usually allergic)

III. Increased hydrostatic pressure
Congestive heart failure
Cirrhosis

IV. Obstruction of lymph flow
Congestive heart failure

V. Inappropriate renal sodium and water retention
Renal failure
Nephrotic syndrome

Except for increased vascular permeability to proteins, virtually every clinical situation in which edema is manifest requires the kidneys to reabsorb supranormal amounts of sodium and water.

Effective arterial blood volume (EABV)

The concept of EABV is crucial in understanding why the kidney retains sodium and water. EABV is an abstract term that refers to the adequacy of the arterial blood volume to "fill" the capacity of the arterial vasculature. Normal EABV exists when the ratio of cardiac output to peripheral resistance maintains venous return and cardiac output at normal levels. EABV can be reduced, therefore, by factors which reduce actual arterial blood volume (hemorrhage, dehydration), increase arterial vascular capacitance (cirrhosis, sepsis) or reduce cardiac output (congestive heart failure). EABV can be reduced in the setting of low, normal, or high actual blood volume. Whenever EABV falls, the kidney is triggered to retain sodium and water. The mechanisms involved are:

1. Reduced renal blood flow. When EABV is reduced, renal blood flow is reduced. In addition, volume receptors in large arterial vessels are activated, leading to increased renal sympathetic tone and decreased renal blood flow. When renal blood flow is reduced, the kidney retains sodium and water by the following mechanisms (see figure below):

a. An increase in proximal tubule salt and water reabsorption. Reduced renal blood flow is perceived by the kidney as a fall in blood pressure. To compensate, renin is produced by the juxtaglomerular apparatus, leading to increased angiotensin II formation. Angiotensin II causes predominantly efferent arteriole constriction which increases filtration fraction (ratio of GFR to renal blood flow) and elevates oncotic pressure at the end of the glomerular capillary. The increased oncotic pressure enhances proximal tubule fluid reabsorption.

b. Enhanced distal sodium and water reabsorption. The increase in angiotensin II stimulates the adrenal gland to release aldosterone. Aldosterone stimulates sodium retention by the collecting duct.

2. Antidiuretic hormone (ADH). Volume receptors in the arterial tree

Edema formation in congestive heart failure (CHF)

CHF implies a primary failure of the pumping ability of the heart. When the heart begins to fail, blood backs up in the venous system, while arterial volume is initially reduced. This reduction in arterial filling (or, in effect, EABV) is detected by arterial volume receptors, triggering sympathetic nerve-mediated vasoconstriction in an attempt to restore the ratio of cardiac output to vascular capacitance. The net result of this vasoconstriction is that the brain, heart and lungs continue to receive as much blood flow as possible. In contrast, blood flow to the kidney and other organs is reduced, having been shunted to the organs necessary for immediate survival. Thus, EABV is reduced and the kidney begins to retain sodium and water.

In more severe degrees of CHF, the patients can become hyponatremic. This occurs because more water is retained by the kidney than is sodium. In this setting, serum ADH levels are markedly elevated, resulting in a very concentrated urine. Additionally, proximal tubule sodium and water reabsorption are very high, permitting relatively little water to reach the urine. Finally, ADH stimulates thirst, resulting in increased water intake.

Edema formation in cirrhosis

Cirrhosis of the liver is defined as increased fibrous tissue in the liver associated with regeneration of focal areas of damaged liver parenchyma. If severe, scarring and distortion of normal liver architecture can lead to marked hepatic dysfunction. This, in turn, can cause sodium retention and edema formation by the following mechanisms which lower EABV (see figure):

1. Decreased total peripheral resistance may be the most important causative factor for renal sodium retention in cirrhosis. Total blood volume is usually increased in cirrhotics, even before obvious edema formation. It appears that the damaged liver fails to degrade or overproduces vasodilating factors. These factors lead primarily to a marked fall in mesenteric (splanchnic) vascular resistance and blood pooling. This lowers EABV, activating compensatory mechanisms such as sympathetic nerves and the renin-angiotensin-aldosterone system.

2. Increased portal pressure (portal hypertension) is due to obstruction of blood flow in the portal vein. This causes increased hydrostatic pressure in the splanchnic circulation and accumulation of fluid in the peritoneal space, a condition known as ascites.

3. Decreased hepatic albumin synthesis causes hypoalbuminemia and decreased plasma oncotic pressure, enhancing movement of fluid into the interstitium.

Edema formation in nephrotic syndrome

The nephrotic syndrome is defined as a glomerular disease which results in proteinuria (urinary protein losses of ≥ 3.5 gm/day), hypoproteinemia, edema, and hyperlipidemia. Most patients with nephrotic syndrome have an expanded plasma volume due to an intrinsic, as yet unidentified, defect in renal sodium and water excretion. Hypoalbuminemia due to urinary protein losses favors fluid movement from the intravascular to the interstitial compartment and exacerbates edema formation in the nephrotic syndrome. In some patients, urinary protein loss and hypoalbuminemia can be so severe that plasma volume becomes reduced, leading to renal hypoperfusion and further stimulating sodium and water retention (see figure).

- Diagnosis and management

Rationale for treatment

Excessive fluid in the extracellular space can markedly impair normal organ function. Edema of the skin, particularly in the lower extremities can be painful, interferes with normal blood circulation, impairs wound healing, increases the likelihood of infection, and is unattractive. Ascites can impair normal respiration, decrease venous blood return to the heart, and promotes intraperitoneal infection. Pulmonary edema interferes with respiratory gas exchange and is a major cause of morbidity and mortality. Most importantly, edema is a sign of an underlying disease process which needs to be treated.

Differential diagnosis

FENa (fractional excretion of sodium) = Urine/Plasma sodium concentration
Urine/Plasma creatinine concentration

FENa <> 1.0 can be seen in volume expanded states, such as too much intravenous or oral sodium and water, and reduced renal mass. It is also seen in patients taking diuretics.

The treatment of edema should neither begin nor end with the administration of diuretics. The basic approaches to treatment are as follows.

1. First, treat the underlying disease.
2. Decrease sodium and water intake, either dietary or intravenous.
3. Increase excretion of sodium and water
a. Diuretics - remember, these are palliative, not curative.
b. Bed rest, local pressure

4. Do not make the disease worse. Other than treatment of severe pulmonary edema, treatment of edema is not usually an emergency. The use of all diuretics entails one major risk: excessive diuresis. Overdiuresis causes volume depletion, hypotension, inadequate organ perfusion and a host of complications. USE CAUTION!

Fluid restriction

An edema forming patient typically loses little sodium from his/her body - about 15 mEq/day in urine, sweat and stool combined. Placing a patient on a low salt diet (about 1 gm per day) gives an intake of sodium of about 17 mEq/day. Thus restricting dietary salt often does not decrease edema, it only prevents edema from becoming worse.

A major problem in hospitalized patients is those receiving intravenous fluids. In many patients, an intravenous line containing some sodium chloride is kept running continuously. Typically, the lowest rate that keeps a vein patent is 500 ml/day. Even using the a low sodium concentration (l/4 normal saline), the patient is given 19 mEq sodium/day. Thus, intravenous fluids can be a major cause of edema in hospitalized patients with problems excreting sodium.

Diuretics

Diuretics inhibit sodium and water reabsorption in the nephron. Several classes of diuretics are available that have different sites of action, potencies and side effects. Diuretics will be discussed in detail after the lectures on edema, water metabolism, and potassium homeostasis.

See the Complete Article

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Lymphedema People

Joint Edema

Joint Swelling

Alternative names

Swelling of a joint; Knee swelling; Toe swelling; Finger swelling; Hip swelling

Definition

Swelling occurs in the joints when fluid accumulates in the soft tissue, such as "water on the knee."

Considerations

Joint swelling may occur along with joint pain.

Common Causes

Osteoarthritis
Trauma
Acute gouty arthritis (gout)
Chronic gouty arthritis
Rheumatoid arthritis
Ankylosing spondylitis
Enteropathic arthropathy
Infection
Ludwig's angina
Pseudogout
Psoriatic arthritis
Reiter's syndrome
Systemic lupus erythematosus
Hemarthrosis

Home Care

For unexplained soft tissue joint swelling, contact your health care provider. Follow prescribed therapy to treat the underlying cause.

Call your health care provider if

Call your health care provider if any of the following occurs:

Severe, unexplained joint pain
Severe, unexplained stiffness or swelling, especially if accompanied by other unexplained symptoms

What to expect at your health care provider's office

Your health care provider will obtain your medical history and will perform a physical examination.

Medical history questions documenting joint swelling may include the following:

Location

Which joint is swollen?
Is it the big toe?
Is the jaw or neck swollen?
Are multiple joints swollen?

Time pattern

When did the joint swelling develop?
Is it always present or off and on?
Is this the first time you have had swollen joints?

Quality

How swollen is the area?
If you press over the swollen area with a finger, does it leave a dent after you take the finger away?

Aggravating factors

What makes the swelling worse?
Is it any worse in the morning or at night?
Does exercise make it worse?

Relieving factors

What make the swelling better?
Does elevating the affected body part make the swelling go down?
Is it better if you use an elastic wrap?
What home treatment have you tried? How effective was it?

Other

What other symptoms are also present?
Is there joint pain?
Is there fever?
Is there a rash?

The physical examination will include a detailed examination of the affected joint(s).

Diagnostic tests that may be performed include the following:

Blood studies (such as a CBC or blood differential)
Joint X-rays Physical therapy for muscle and joint rehabilitation may be recommended.

Update Date: 7/4/2004
Updated by: Andrew L. Chen, M.D., M.S., Steadman-Hawkins Sports Medicine Foundation, Vail, CO. Review provided by VeriMed Healthcare Network.

Medline Plus

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Lymphedema People

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Joint Symptoms - Joint Swelling

A complete history and physical examination are important in a patient with joint symptoms, which may be part of localized or systemic disease. Laboratory and x-ray data are usually of only supplementary help.

Physical Examination

Each involved joint should be inspected and palpated, and the range of motion measured. This usually determines the presence of joint disease and establishes whether the joint, the adjacent structures, or both are involved. Involved joints should be compared with their uninvolved opposites or with those of the examiner. Information is recorded objectively and quantitatively (eg, using a numbered grading system, measuring the range of motion in degrees).

Joint motion, generally painful in joint disease, may not be painful in periarticular, bone, or soft tissue disease. Swelling is an important finding. Palpation of swollen joints helps to (1) elicit the presence of fluid; (2) differentiate among simple effusion, synovial thickening, and capsule or bony enlargement; and (3) determine whether the swelling is confined to the joint or is periarticular. Tenderness or swelling at only one side of a joint may actually arise in adjacent ligaments, tendons, or bursae; findings from several approaches to the joint substantiate articular involvement. Monarthritis always suggests infection, crystal-induced arthritis, trauma, or rarely, tumor.

Increased heat over the joint should be carefully localized. Many normal joints are actually cooler than adjacent skin. Crepitus may arise from intra-articular structures or from tendons; the crepitus-producing motions should be determined (eg, knee crepitus may arise from patellofemoral grinding or from femorotibial motion).

Small joints (eg, the acromioclavicular near the shoulder, the tibiofibular at the lateral aspect of the knee, the radioulnar at the elbow) can be the source of pain that was initially believed to arise from the major joint.

Hand: The main differential features of the hand in osteoarthritis and RA are outlined in Table 49-1. Subluxations producing swan-neck or boutonnière deformities (see Ch. 61) occur in chronic RA. In psoriatic arthritis, the distal interphalangeal (DIP) joints are commonly affected, psoriasis often is evident around the adjacent nail, and other joint involvement is more asymmetric than in RA. In Reiter's syndrome, synovial, periarticular, and periosteal changes can be present in a few DIP, proximal interphalangeal, or metacarpophalangeal joints, and there is asymmetric finger joint involvement. Asymmetric DIP joint involvement also occurs in chronic gout, in which irregular joint or extra-articular tophaceous deposits occur, some of which can be seen under the skin as cream-colored aggregates.

Changes in the hand are generalized in the shoulder-hand syndrome (reflex sympathetic dystrophy), with diffuse edema and mottled, mildly cyanotic skin. In progressive systemic sclerosis, there may be initial diffuse puffiness, but with time the skin thickens, and flexion contractures often develop; Raynaud's phenomenon may be noted. Findings in hypertrophic pulmonary osteoarthropathy include clubbing of the fingertips and bony tenderness of the distal radius and ulna caused by underlying periostitis. Joint synovitis similar to that in RA occurs in SLE and, less often, in dermatomyositis, although arthralgias and sore, painful hands lacking objective joint swelling are more typical of both these disorders. Finger deformities resembling RA can occur in SLE but are caused by soft tissue disease, not advanced erosive arthritis. Raynaud's phenomenon can be present in SLE, and scaling erythema may be found over the extensor joint surfaces in dermatomyositis.

Elbow: Synovial swelling and thickening caused by joint disease occur in the lateral area between the radial head and olecranon, producing a bulge. Fluid or thickening in the olecranon bursa, rheumatoid nodules, and epitrochlear nodes should also be sought. Full 180° extension of the joint should be attempted. Although full extension is possible with nonarthritic or extra-articular lesions, its loss is an early change in arthritis. In tennis elbow, sharply localized pain is elicited by placing firm pressure over the lateral epicondyle.

Shoulder: Limited motion, weakness, pain, and disturbed mobility can be tested by having the patient attempt to raise both arms above the head. Muscle atrophy and neurologic changes should be sought. Although swelling is not common, a bulge in the anterior area of the shoulder is occasionally present in RA as a result of forward dissection of glenohumeral synovitis. Careful palpation of the relaxed shoulder may identify tenderness caused by inflammation of bursae or tendons, with common conditions occurring primarily in the subacromial area or in the long head of the biceps tendon. Localization may permit aspiration and injection of a corticosteroid-lidocaine solution to relieve acute tendinitis and to confirm the diagnosis.

Foot and ankle: Because weight bearing may elucidate certain abnormalities, the patient should stand for part of the examination. In the normal ankle joint, 15° dorsiflexion and 40° plantar flexion are possible. Swelling just below and in front of the malleoli is characteristic of synovial or intra-articular disease. Palpation of such tender soft swelling, with pain elicited on extension and flexion of the foot, demonstrates synovitis of the ankle joint. Pain on inversion or eversion suggests subtalar or ligament disease. Ankle edema, which is associated with normal ankle joint motion, can be differentiated from true joint swelling by its diffuse, superficial, pitting, nontender character. Metatarsophalangeal joints are commonly swollen and tender in RA. Interphalangeal synovitis, not as common in the feet in RA, may indicate Reiter's syndrome, other reactive arthritis, psoriatic arthritis, or gout. In gout, the first metatarsophalangeal (MTP) or bunion joint is most commonly affected, but the midtarsal or ankle areas can also be involved. Diffuse erythema is striking in an acute attack of gout. First metatarsophalangeal pain on motion with crepitus suggests osteoarthritis.

Knee: Gross deformities such as swelling (eg, popliteal cysts), quadriceps muscle atrophy, and joint instability may be more obvious when the patient stands and walks. Careful palpation of the knee in a supine patient, especially noting the presence of joint fluid, synovial thickening, and local tenderness, helps detect arthritis. Tender extra-articular bursae and true intra-articular disturbances should be differentiated.

Detection of small knee effusions is commonly problematic and is best accomplished using the "bulge sign." The knee is extended and the leg is slightly externally rotated while the patient is supine with muscles relaxed. The medial aspect of the knee is stroked to express any fluid away from this area. Placement of one hand on the suprapatellar pouch and gentle stroking or pressing on the lateral aspect of the knee can create a fluid wave or bulge, visible medially when an effusion is present.

Full 180° extension of the knee should be attempted to detect knee flexion contractures. With meniscus tears or collateral ligament injuries, forceful lateral or medial bending on leg extension produces pain by compressing the meniscus and simultaneously stretching the opposite collateral ligament. The joint line can be located by medial and lateral palpation while slowly flexing and extending the knee. A displaced meniscus is painful on firm pressure; a collateral ligament injury is tender longitudinally. The intactness of the cruciate ligaments can be determined by grasping the leg with the knee flexed at 90° (best performed with the patient sitting on a table with legs dangling) and estimating the amount of posterior-anterior movement (which should be minimal). The patella should be tested for free, painless motion. To gauge excess knee mobility, especially lateral instability, the thigh is firmly fixed and an attempt is made to rock the relaxed, almost extended knee from side to side.

Hip: A limp is common in patients with significant hip arthritis or disease in other joints of the leg. It may be caused by pain, shortening of the leg, flexion contracture, or muscle weakness. Loss of internal rotation (often the earliest change), flexion, extension, or abduction can usually be demonstrated. Placement of one hand on the patient's iliac crest detects pelvic movement that might be mistaken for hip movement. Flexion contracture can be identified by attempting leg extension with the opposite hip maximally flexed to stabilize the pelvis. Tenderness over the femoral greater trochanter indicates local bursitis rather than arthritis.

Vertebral column: Cervical and lumbar motion should be measured. Inability to reverse the normal lumbar lordosis on flexion occurs in degenerative arthritis; limited lumbar flexion is also characteristic of ankylosing spondylitis. Degenerative arthritis or ankylosing spondylitis also limits neck motion. Either soft tissue disease or arthritis may cause pain and limited movement. The effect of movement on pain should be noted. Palpation and firm percussion over each vertebra and sacroiliac joint may elicit superficial or deep bone tenderness that should be distinguished from muscle spasm lateral to the spine. Localized bone pain suggests osteomyelitis, leukemia, primary or metastatic cancer, compression fracture, or herniated disk. Psychogenic ("touch-me-not") reactions should be noted, as should muscular tender points typical of fibromyalgia. Chest expansion should be measured because it is typically impaired in ankylosing spondylitis.

Diagnosis

Conditions easily misinterpreted as arthritis by the patient include phlebitis, arteriosclerosis obliterans, cellulitis, edema, neuropathy, vascular compression syndromes, the stiffness of Parkinson's disease, periarticular stress fractures, spinal stenosis, myositis, polymyalgia rheumatica, and fibromyositis. These can each be distinguished by their typical features (described elsewhere in The Manual) and by the absence or paucity of joint findings. Popliteal cysts resulting from knee arthritis can cause local popliteal pain, venous compression, or rupture into the calf and can be confused with phlebitis.

Extra-articular findings can be significant in helping to identify the type of arthritis (eg, tophi in gout, nodules in RA, pustular rash in gonococcemia). Coexisting periarticular disease also may facilitate diagnosis. For example, tendinitis commonly coexists with gonococcal arthritis, RA, and other systemic diseases; prominent tenderness of bones adjacent to joints and joint effusions occur in sickle cell disease and hypertrophic pulmonary osteoarthropathy; and enthesitis with tenderness and swelling at tendon insertions suggests reactive arthritis.

Often, arthritis is transient and resolves without diagnosis. Arthritis also may not fulfill the criteria for any defined rheumatic disease (see Table 49-2). A tentative diagnosis is made for treatment, with other possibilities kept in mind. Systemic disease should be considered in all atypical and undiagnosed conditions. Lyme disease and other infections should always be considered early because they may respond to specific treatment.

Certain problems require immediate attention and prompt treatment. Acute monarthritis is one example, and joint fluid examination is essential (see below). Hemorrhagic joint fluid suggests fracture, bleeding diathesis, or malignancy. Intensely inflammatory effusions suggest pyogenic infection, requiring immediate antibiotic therapy and aspiration or other drainage to establish the diagnosis and to prevent joint destruction.

Blood tests are useful in diagnosing some specific types of arthritis (for specific tests, see the chapters for each disease). Elevated ESR or C-reactive protein suggests inflammatory disease. Serum uric acid levels are elevated by diuretics, low doses of aspirin, other drugs, diet, or alcohol and in gout. Latex fixation tests for rheumatoid factor are often highly positive in RA but may also be positive in hepatitis, cirrhosis, sarcoidosis, subacute bacterial endocarditis, TB, and other infections and collagen diseases. Antinuclear factors may be positive in RA, Sjögren's syndrome, progressive systemic sclerosis, SLE, hepatitis, and other diseases. If SLE is suspected, anti-double-stranded DNA, anti-Sm, and complement levels may also provide further support. Serum CK and AST are elevated in muscle disease, including certain forms of muscular dystrophy, crush injury, and polymyositis or dermatomyositis. CK can also be elevated in hypothyroidism.

X-rays are important in the initial evaluation of relatively localized, unexplained joint complaints to detect possible primary or metastatic tumors, osteomyelitis, bone infarctions, periarticular calcifications, or other changes in deep structures that may escape physical examination. Erosions, cysts, and joint space narrowing can occur in chronic RA, gout, and osteoarthritis. X-rays also are especially useful in examination of the spine but are usually not needed if the problem seems to be simple acute back strain. CT and MRI can help define puzzling persistent lesions.

Other useful studies may include needle or surgical synovial biopsy, ultrasound, arthroscopy, arthrography, bone scanning, electromyography, nerve conduction times, thermography, and muscle or bone biopsy. Evaluation of synovial fluid is discussed below.

Differentiating Inflammatory and Noninflammatory Joint Disease

Once joint involvement is established, inflammatory and noninflammatory processes must be differentiated. Among the typical local signs of inflammation, increased heat and erythema are most helpful in this differentiation. Erythema should not be expected over chronically inflamed joints in RA. ESR and C-reactive protein tend to elevate and fever often occurs with severe inflammatory arthritis, but these may also be caused by an inflammatory process elsewhere in the body. Soft-tissue swelling tends to favor an inflammatory process, but aspiration of an effusion is essential to determine its nature. Osteoarthritis of the knee, although primarily degenerative, often causes knee effusions. Preparation for handling the fluid obtained is critical. It is not necessary to perform all tests on each fluid.

Synovial fluid measurements allow most effusions to be classified as normal, noninflammatory, inflammatory, or septic (see Table 49-3). Effusions can also be hemorrhagic. Each type of effusion suggests certain joint diseases (see Table 49-4). So-called noninflammatory effusions are actually mildly inflammatory but tend to suggest diseases with less inflammatory mechanisms. If infection is suspected, a portion of the synovial fluid sample should be sent to the laboratory for bacteriologic assessment.

Microscopic examination of a wet synovial fluid smear for crystals (only a few drops of fluid or washings from a joint are needed), using polarized light, is essential for definitive diagnosis of gout, pseudogout, and other crystal-induced arthropathies (see Ch. 55). Use of an inexpensive polarizer over the light source and another between the specimen and the examiner's eye will visualize crystals with a shiny white birefringence. Compensated polarized light is provided by inserting a first-order red plate, as is found in commercially available microscopes. The effects of a compensator can be reproduced by placing two strips of clear adhesive tape on a glass slide and placing this slide over the lower polarizer. Any such homemade system should be tested against a commercial polarizing microscope before diagnostic use. If the crystals seen are not typical, several less common crystals (cholesterol, liquid lipid crystals, cryoglobulins) or artifacts (eg, depot corticosteroid crystals) should be considered.

Other synovial fluid findings that may occasionally make or suggest a specific diagnosis include specific organisms (identifiable by Gram or acid-fast stain); spontaneous in vivo-developed LE cells; marrow spicules (caused by fracture); Reiter's cells (monocytes that have phagocytized PMN), seen most often in reactive arthritis; amyloid fragments (identifiable by Congo red stain); sickled RBCs (caused by sickle cell hemoglobinopathies); and iron in large mononuclear synovial cells (identifiable by Prussian blue stain and present especially in hemochromatosis or pigmented villonodular synovitis).

Comparing synovial fluid and serum complement levels may only occasionally help evaluate inflammatory fluids. The synovial fluid complement level tends to be <>

Measurements of rheumatoid factor in synovial fluid can give false-positive or false-negative results and, thus, should not be performed. Extremely low synovial fluid glucose levels in carefully handled specimens in fluoride tubes may favor the presence of infection.

Merck Manual

Diuretics, Loop (Systemic)

Description

Loop diuretics are given to help reduce the amount of water in the body. They work by acting on the kidneys to increase the flow of urine.

Furosemide is also used to treat high blood pressure (hypertension) in those patients who are not helped by other medicines or in those patients who have kidney problems.

High blood pressure adds to the work load of the heart and arteries. If it continues for a long time, the heart and arteries may not function properly. This can damage the blood vessels of the brain, heart, and kidneys, resulting in a stroke, heart failure, or kidney failure. High blood pressure may also increase the risk of heart attacks. These problems may be less likely to occur if blood pressure is controlled.

Loop diuretics may also be used for other conditions as determined by your doctor.

This medicine is available only with your doctor's prescription, in the following dosage forms:

Oral

Bumetanide

Tablets (U.S.)
Ethacrynic Acid

Oral solution (U.S. and Canada)
Tablets (U.S. and Canada)

Furosemide

Oral solution (U.S. and Canada)
Tablets (U.S. and Canada)

Parenteral

Bumetanide
Injection (U.S.)
Ethacrynic Acid
Injection (U.S. and Canada)
Furosemide
Injection (U.S. and Canada)

Before Using This Medicine

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For loop diuretics, the following should be considered:

Allergies—Tell your doctor if you have ever had any unusual or allergic reaction to bumetanide, ethacrynic acid, furosemide, sulfonamides (sulfa drugs), or thiazide diuretics (water pills). Also tell your health care professional if you are allergic to any other substances, such as foods, preservatives, or dyes.

Pregnancy—Studies have not been done in pregnant women. However, studies in animals have shown this medicine to cause harmful effects.

In general, diuretics are not useful for normal swelling of feet and hands that occurs during pregnancy. Diuretics should not be taken during pregnancy unless recommended by your doctor.

Breast-feeding—These medicines have not been reported to cause problems in nursing babies. Furosemide passes into breast milk; it is not known whether bumetanide or ethacrynic acid passes into breast milk.

Children—Although there is no specific information comparing the use of loop diuretics in children with use in any other age group, these medicines are not expected to cause different side effects in children than they do in adults.

Older adults—Dizziness, lightheadedness, or signs of too much potassium loss may be more likely to occur in the elderly, who are more sensitive to the effects of this medicine. Elderly patients may also be more likely to develop blood clots.

Other medicines—Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking loop diuretics, it is especially important that your health care professional know if you are taking any other medicines.

Other medical problems—The presence of other medical problems may affect the use of loop diuretics. Make sure you tell your doctor if you have any other medical problems, especially:

Diabetes mellitus (sugar diabetes)—Loop diuretics may increase the amount of sugar in the blood

Gout or

Hearing problems or

Pancreatitis (inflammation of the pancreas)—Loop diuretics may make these conditions worse

Heart attack, recent—Use of loop diuretics after a recent heart attack may increase the chance of side effects

Kidney disease (severe) or

Liver disease—Higher blood levels of the loop diuretic may occur, which may increase the chance of side effects

Lupus erythematosus (history of)—Ethacrynic acid and furosemide may make this condition worse

Proper Use of This Medicine:

This medicine may cause you to have an unusual feeling of tiredness when you begin to take it. You may also notice an increase in the amount of urine or in your frequency of urination. After you have taken the medicine for a while, these effects should lessen. In general, to keep the increase in urine from affecting your sleep:

If you are to take a single dose a day, take it in the morning after breakfast.
If you are to take more than one dose a day, take the last dose no later than 6 p.m., unless otherwise directed by your doctor.

However, it is best to plan your dose or doses according to a schedule that will least affect your personal activities and sleep. Ask your health care professional to help you plan the best time to take this medicine.

To help you remember to take your medicine, try to get into the habit of taking it at the same time each day.

For patients taking the oral liquid form of furosemide:

This medicine is to be taken by mouth even if it comes in a dropper bottle. If this medicine does not come in a dropper bottle, use a specially marked measuring spoon or other device to measure each dose accurately, since the average household teaspoon may not hold the right amount of liquid.

For patients taking this medicine for high blood pressure :

In addition to the use of the medicine your doctor has prescribed, appropriate treatment for your high blood pressure may include weight control and care in the types of foods you eat, especially foods high in sodium. Your doctor will tell you which factors are most important for you. You should check with your doctor before changing your diet.

Many patients who have high blood pressure will not notice any signs of the problem. In fact, many may feel normal. It is very important that you take your medicine exactly as directed and that you keep your appointments with your doctor even if you feel well.

Remember that this medicine will not cure your high blood pressure but it does help control it. Therefore, you must continue to take it as directed if you expect to lower your blood pressure and keep it down. You may have to take high blood pressure medicine for the rest of your life . If high blood pressure is not treated, it can cause serious problems such as heart failure, blood vessel disease, stroke, or kidney disease.

If this medicine upsets your stomach, it may be taken with meals or milk. If stomach upset (nausea, vomiting, or stomach pain) continues or gets worse, or if you suddenly get severe diarrhea, check with your doctor.

Dosing:

The dose of loop diuretics will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of loop diuretics. If your dose is different, do not change it unless your doctor tells you to do so.

The number of tablets or teaspoonfuls of solution that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are taking loop diuretics.

For bumetanide

For oral dosage form (tablets):

To lower the amount of water in the body:

Adults—0.5 to 2 milligrams (mg) once a day. Your doctor may increase your dose if needed.

Children—Dose must be determined by your doctor.

For injection dosage form:

To lower the amount of water in the body:

Adults—0.5 to 1 mg injected into a muscle or a vein every two to three hours as needed.

Children—Dose must be determined by your doctor.

For ethacrynic acid

For oral dosage form (oral solution or tablets):

To lower the amount of water in the body:

Adults—50 to 200 milligrams (mg) a day. This may be taken as a single dose or divided into smaller doses.

Children—At first, 25 mg a day. Your doctor may increase your dose as needed.

For injection dosage form:

To lower the amount of water in the body:

Adults—50 mg injected into a vein every two to six hours as needed.

Children—Dose is based on body weight and must be determined by your doctor. The usual dose is 1 mg per kilogram (kg) (0.45 mg per pound) of body weight injected into a vein.

For furosemide

For oral dosage form (oral solution or tablets):

To lower the amount of water in the body:

Adults—At first, 20 to 80 milligrams (mg) once a day. Then, your doctor may increase your dose as needed. Your doctor may tell you to take a dose once a day, two or three times a day, or every other day.

Children—Dose is based on body weight and must be determined by your doctor. The usual dose is 2 mg per kilogram (kg) (0.91 mg per pound) of body weight for one dose. Then, your doctor may increase your dose every six to eight hours as needed.

For high blood pressure:

Adults—40 mg two times a day. Your doctor may increase your dose.

For injection dosage form:

To lower the amount of water in the body:

Adults—At first, 20 to 40 mg injected into a muscle or a vein for one dose. Then, your doctor may increase your dose every two hours as needed. Once the medicine is working, the dose is injected into a muscle or a vein one or two times a day.

Children—Dose is based on body weight and must be determined by your doctor. The usual dose is 1 mg per kg (0.45 mg per pound) of body weight injected into a muscle or a vein for one dose. Your doctor may increase your dose every two hours as needed.

For very high blood pressure:

Adults—40 to 200 mg injected into a vein.

Missed Dose:

If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Storage:

To store this medicine:

Keep out of the reach of children.
Store away from heat and direct light.
Do not store in the bathroom, near the kitchen sink, or in other damp places. Heat or moisture may cause the medicine to break down.
Keep the oral liquid form of this medicine from freezing.
Do not keep outdated medicine or medicine no longer needed. Be sure that any discarded medicine is out of the reach of children.

Precautions While Using This Medicine:

It is important that your doctor check your progress at regular visits to make sure that this medicine is working properly.

This medicine may cause a loss of potassium from your body:

To help prevent this, your doctor may want you to:

eat or drink foods that have a high potassium content (for example, orange or other citrus fruit juices), or
take a potassium supplement, or
take another medicine to help prevent the loss of the potassium in the first place.

It is very important to follow these directions. Also, it is important not to change your diet on your own. This is more important if you are already on a special diet (as for diabetes), or if you are taking a potassium supplement or a medicine to reduce potassium loss. Extra potassium may not be necessary and, in some cases, too much potassium could be harmful.

To prevent the loss of too much water and potassium, tell your doctor if you become sick, especially with severe or continuing nausea and vomiting or diarrhea.

Before having any kind of surgery (including dental surgery) or emergency treatment, make sure the medical doctor or dentist in charge knows that you are taking this medicine.

Dizziness, lightheadedness, or fainting may occur, especially when you get up from a lying or sitting position. This is more likely to occur in the morning. Getting up slowly may help. When you get up from lying down, sit on the edge of the bed with your feet dangling for 1 or 2 minutes. Then stand up slowly. If the problem continues or gets worse, check with your doctor.

The dizziness, lightheadedness, or fainting is also more likely to occur if you drink alcohol, stand for long periods of time, exercise, or if the weather is hot. While you are taking this medicine, be careful to limit the amount of alcohol you drink. Also, use extra care during exercise or hot weather or if you must stand for long periods of time.

For diabetic patients:

This medicine may affect blood sugar levels. While you are using this medicine, be especially careful in testing for sugar in your blood or urine.

For patients taking this medicine for high blood pressure :

Do not take other medicines unless they have been discussed with your doctor. This especially includes over-the-counter (nonprescription) medicines for appetite control, asthma, colds, cough, hay fever, or sinus problems, since they may tend to increase your blood pressure.

For patients taking furosemide:

Furosemide may cause your skin to be more sensitive to sunlight than it is normally. Exposure to sunlight, even for brief periods of time, may cause a skin rash, itching, redness or other discoloration of the skin, or a severe sunburn.

When you begin taking this medicine:

Stay out of direct sunlight, especially between the hours of 10:00 a.m. and 3:00 p.m., if possible. Wear protective clothing, including a hat. Also, wear sunglasses.
Apply a sun block product that has a skin protection factor (SPF) of at least 15. Some patients may require a product with a higher SPF number, especially if they have a fair complexion. If you have any questions about this, check with your health care professional.

Apply a sun block lipstick that has an SPF of at least 15 to protect your lips.
Do not use a sunlamp or tanning bed or booth. If you have a severe reaction from the sun, check with your doctor.

If you have a severe reaction from the sun, checek with your doctor.

Side Effects of This Medicine:

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor as soon as possible if any of the following side effects occur:

Rare

Black, tarry stools; blood in urine or stools; cough or hoarseness; fever or chills; joint pain; lower back or side pain; painful or difficult urination ; pinpoint red spots on skin; ringing or buzzing in ears or any loss of hearing—more common with ethacrynic acid; skin rash or hives; stomach pain (severe) with nausea and vomiting; unusual bleeding or bruising; yellow eyes or skin ; yellow vision—for furosemide only

Signs and symptoms of too much potassium loss

Dryness of mouth; increased thirst; irregular heartbeat; mood or mental changes; muscle cramps or pain; nausea or vomiting; unusual tiredness or weakness ; weak pulse

Other side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. However, check with your doctor if any of the following side effects continue or are bothersome:

More common

Dizziness or lightheadedness when getting up from a lying or sitting position

Less common or rare

Blurred vision; chest pain—with bumetanide only; confusion—with ethacrynic acid only; diarrhea—more common with ethacrynic acid; headache; increased sensitivity of skin to sunlight—with furosemide only; loss of appetite—more common with ethacrynic acid; nervousness—with ethacrynic acid only; premature ejaculation or difficulty in keeping an erection—with bumetanide only ; redness or pain at place of injection; stomach cramps or pain

Other side effects not listed above may also occur in some patients. If you notice any other effects, check with your doctor.

Additional Information:

Once a medicine has been approved for marketing for a certain use, experience may show that it is also useful for other medical problems. Although these uses are not included in product labeling, loop diuretics are used in certain patients with the following medical conditions:

Hypercalcemia (too much calcium in the blood)
Diagnostic aid for kidney disease

Other than the above information, there is no additional information relating to proper use, precautions, or side effects for these uses.

Medline Plus

See Also:

Lymphedema People