Dear Dr. Roach: I am a 73-year-old active lady. I recently noticed a wrinkle in my palm near my ring finger. I had a consultation with a nearby doctor, and he diagnosed Dupuytrens contracture. He said I should come back when the finger is curved down. I was surprised! Wouldnt it be better to have it taken care of before it gets to be a serious problem? I dont understand why I should put this off. Would surgery done promptly have a shorter recovery time? H.B.
Answer: Dupuytrens contracture is a condition of unknown cause characterized by progressive fibrosis of the deep connective tissue of the hand, called the palmar fascia. It often starts with a nodule in the hand, and progresses over years or decades to flexion of the finger joints a permanent curve toward the palm. It most commonly affects the fourth finger, and the joints on either side of that ring finger become difficult to straighten, then finally impossible to straighten completely. It is usually painless. The condition is most common in people of Northern European ancestry.
Because progression is variable in timing, and because people can have no bothersome symptoms for years (and the condition goes away in about 10%), there is no consensus on when the optimal time for intervention. Most experts recommend treatment when the degree of flexion is at least 20 degrees. A fixed bend of more than 60 degrees is less likely to respond to treatment.
Open surgery has long been the standard treatment, but there are options, including needle surgery, injection of an enzyme that dissolves the connective tissue (collagenase, brand name Xiaflex), and radiation. Injection of collagenase is typically done at an earlier stage than surgery.
Following surgery, most people need to wear a splint and do hand physical/occupational therapy for months. The condition recurs after treatment in about half of patients. Its not clear that early surgery has a faster recovery time, even though it seems to make sense.
Given the multiple treatment options, the variable nature of disease progression, possibility of recurrence and significant recovery time, the decision of how and when to treat absolutely requires an expert to go over the different options and timing.
DEAR DR. ROACH: I recently had to give a urine sample for microalbumin. Does it matter if I use the first part of the void or midstream? — N.F.
ANSWER: Urine microalbumin is a test for small amounts of protein in the urine. It is most commonly used as a screening test for kidney damage due to diabetes. Very small amounts of the protein albumin — far less than what shows up on a typical urine dipstick — predict the onset of the kidney disease that can ultimately lead to dialysis. Positive microalbumin means that the diabetes may not have been under optimal control, and this is often treated with medications like ACE inhibitors, which greatly slow kidney damage due to diabetes.
The very first few drops of urine often contain some cells of the lining of the urethra, and in the case of women, of the vulva around the urethra. Allowing that urine to void uncollected reduces contamination of those cells. This is particularly important when looking for infection, but is usually recommended for microalbumin as well. Hence, midstream is preferred.
One study showed that the very first urine made in the morning is the most accurate way of looking for urine microalbumin.
