Table 7.

Frequently Asked Questions

Who needs a pelvic and rectal exam to rule out tumor?We recommend a pelvic/rectal exam in patients who present with findings suspicious for tumor, such as unilateral edema, pelvic symptoms, or weight loss. We were unable to find evidence or published opinions on when the pelvic or rectal exam is indicated in patients with edema The pelvic exam has poor sensitivity compared with computed tomography (CT) scan for detection of pelvic tumors that cause leg edema. However, information gained from this part of the exam may complement subsequent radiologic studies.
Who needs an abdominal/pelvic CT scan to rule out tumor?An abdominal/pelvic CT scan should be considered in patients over 40 without an apparent cause for edema and in younger patients with suspicious findings (unilateral edema, pelvic signs or symptoms, weight loss). Patients over age 35 with undiagnosed lymphedema should have a CT scan.11 Tumors commonly associated with leg edema include prostate cancer, ovarian cancer, and lymphoma.11,12
Who needs to be evaluated for a systemic cause, and what tests should be done?It is reasonable to obtain a few basic tests in all patients with bilateral leg edema over age 45 because the tests are relatively few and inexpensive. The basic tests include a complete blood count, urinalysis, electrolytes, creatinine, blood sugar, thyroid-stimulating hormone, and serum albumin. An echocardiogram should be considered in patients over age 45, because pulmonary hypertension is a common cause of leg edema and is commonly missed.4 Unilateral edema generally does not require a search for a systemic cause. A search for liver disease is unnecessary in the absence of ascites because leg edema is a late finding in patients with cirrhosis.
When should diuretics be used and when should they be avoided?Loop diuretics (eg, furosemide, 40 mg daily) should be used in patients with edema secondary to heart failure or renal failure.62 Patients with ascites and leg edema due to cirrhosis should be treated with spironolactone (starting with 50 mg daily) combined with furosemide (starting with 40 mg daily).63,64 In patients with chronic venous insufficiency, diuretics should be used only after leg elevation and compression stockings have failed. At that point, they should be used sparingly and for brief periods. In patients with idiopathic edema who are taking diuretics, a 3 to 4 week trial off diuretics is indicated. In patients with idiopathic edema who are not already taking diuretics or those who fail to improve off diuretics, spironolactone and thiazides can be used. Long-term furosemide use in patients with idiopathic edema has been associated with impaired renal function.65 Diuretics should be used rarely if at all in patients with lipidema, lymphedema, and deep vein thrombosis.