Urologist Vasectomy Reversal

Overview

Bladder cancer accounts for approximately 90% of cancers of the urinary tract (renal pelvis, ureters, bladder, urethra). The bladder is an organ located in the pelvic cavity that stores and discharges urine. Urine is produced by the kidneys, carried to the bladder by the ureters, and discharged from the bladder through the urethra.

Types
Bladder cancer usually originates in the bladder lining, which consists of a mucous layer of surface cells that expand and deflate (transitional epithelial cells), smooth muscle, and a fibrous layer. Tumors are categorized as low-stage (superficial) or high-stage (muscle invasive).

In industrialized countries (e.g., United States, Canada, France), more than 90% of cases originate in the transitional epithelial cells (called transitional cell carcinoma; TCC). In developing countries, 75% of cases are squamous cell carcinomas caused by Schistosoma haematobium (parasitic organism) infection. Rare types of bladder cancer include small cell carcinoma, carcinosarcoma, primary lymphoma, and sarcoma.

Incidence and Prevalence
According to the National Cancer Institute, the highest incidence of bladder cancer occurs in industrialized countries such as the United States, Canada, and France. Incidence is lowest in Asia and South America, where it is about 70% lower than in the United States.

Incidence of bladder cancer increases with age. People over the age of 70 develop the disease 2 to 3 times more often than those aged 55–69 and 15 to 20 times more often than those aged 30–54.
Bladder cancer is 2 to 3 times more common in men. In the United States, approximately 38,000 men and 15,000 women are diagnosed with the disease each year. Bladder cancer is the fourth most common type of cancer in men and the eighth most common type in women. The disease is more prevalent in Caucasians than in African Americans and Hispanics.

Causes and Risk Factors
Cancer-causing agents (carcinogens) in the urine may lead to the development of bladder cancer. Cigarette smoking contributes to more than 50% of cases, and smoking cigars or pipes also increases the risk. Other risk factors include the following:

Exposure to carcinogens in the workplace also increases the risk for bladder cancer. Medical workers exposed during the preparation, storage, administration, or disposal of antineoplastic drugs (used in chemotherapy) are at increased risk. Occupational risk factors include recurrent and early exposure to hair dye, and exposure to dye containing aniline, a chemical used in medical and industrial dyes. Workers at increased risk include the following:

Signs and Symptoms
The primary symptom of bladder cancer is blood in the urine (hematuria). Hematuria may be visible to the naked eye (gross) or visible only under a microscope (microscopic) and is usually painless. Other symptoms include frequent urination and pain upon urination (dysuria).

Diagnosis
Diagnosis of bladder cancer includes urological tests and imaging tests. A complete medical history is used to identify potential risk factors (e.g., smoking, exposure to dyes). Laboratory tests may include the following:

NMP22®BladderChek® is a urine test used to detect elevated levels of a nuclear matrix protein (called NMP22®). Bladder cancer increases levels of this protein in the urine, even during early stages of the disease.

Results of this test, which is noninvasive and is performed in a physician's office, are available during the patient's office visit. Studies have shown that when used with cystoscopy, NMP22®BladderChek® may be more effective than other diagnostic tests (e.g., urine tests or cystoscopy alone).

Various imaging tests may also be performed. Intravenous pyelogram (IVP) is the standard imaging test for bladder cancer. In this procedure, a contrast agent (radiopaque dye) is administered through a vein (intravenously) and x-rays are taken as the dye moves through the urinary tract. IVP provides information about the structure and function of the kidneys, ureters, and bladder. Other imaging tests include CT scan, MRI scan, bone scan, and ultrasound.

If bladder cancer is suspected, cystoscopy and biopsy are performed. Local anesthesia is administered and a cystoscope (thin, telescope-like tube with a tiny camera attached) is inserted into the bladder through the urethra to allow the physician to detect abnormalities. In biopsy, tissue samples are taken from the lesion(s) and examined for cancer cells. If the sample is positive, the cancer is staged using the tumor, node, metastases (TNM) system.

Staging
Once the physician has determined that a tumor exists, the next step is to clarify the tumor's status. Several questions will have to be answered: Is the tumor large or small? Does it lie within the lining of the bladder or has it extended into the surrounding tissue? Has the tumor spread to nearby lymph nodes? Has the tumor metastasized to distant sites within the body?

Fortunately, a number of systems have been developed to answer these questions. The most common of these — the TNM (tumor, node, metastasis) system — allows tumors to be classified, or "staged," according to their overall characteristics. A biopsy is removed and sent to a histopathologist for examination under a microscope. The pathologist then assigns a stage and a grade to the tissue sample.

The stage refers to the physical location of the tumor within the bladder or, more specifically, the tumor's depth of penetration. In general, tumor stage is confined to one of two categories: (1) superficial, surface tumors, or (2) invasive, deep-spreading tumors. Superficial tumors affect only the bladder lining. They grow up and out from the lining tissue and extend into the bladder's hollow cavity. Invasive tumors grow down into the deeper layers of bladder tissue, and they may involve surrounding muscle, fat, and/or nearby organs. Invasive tumors are more dangerous than superficial tumors, since they are more likely to metastasize.

The grade is an estimate of the speed of tumor growth as suggested by cell features seen under a microscope. Most systems are based upon the degree of tumor cell anaplasia - that is, the loss of cellular "differentiation," the distinguishing characteristics of a cell. The World Health Organization (WHO) grading system groups transitional cell carcinomas (TCCs) into three grades that correspond to well-, moderately, and poorly differentiated cells. The International Union Against Cancer (UICC) has devised a four-grade system that considers Grade 1 tumors to be well-differentiated, Grade 2 to be moderately differentiated, and Grades 3 or 4 to be poorly differentiated. Both systems are widely used and can be summarized as follows:

There is a continuing debate about the classification of benign bladder lesions known as papillomas. The WHO defines papilloma as a single papillary (wart-like) growth with 8 or less cell layers in normal-looking surface tissue. By contrast, many pathologists and urologists classify papilloma as a Grade 1 TCC because of its tendency to recur and not to invade muscle.

There is a strong correlation between tumor stage and tumor grade. Nearly all superficial tumors are low grade; that is, they are Grade 1 tumors, with cells that are distinctly specialized and well-differentiated, whereas nearly all muscle-invasive tumors are high grade; that is, they are Grade 3 or 4 tumors, with cells that are nonspecialized and poorly differentiated. More importantly, there is a strong correlation between tumor stage and prognosis (the probable outcome of a disease), with superficial tumors having the most chance of a favorable result.

The latest TNM system for staging bladder cancer was developed by the UICC in 1997
(see Table 2).

Table 2: TNM Classification of Urinary Bladder Cancer

T - Tumor
N - Regional Lymph Nodes	M - Distant Metastasis
TX - Primary tumor cannot be evaluated T0 - No primary tumor Ta - Noninvasive papillary carcinoma TIS - Carcinoma in situ ("flat tumor") T1 - Tumor invades connective tissue under the epithelium (surface layer) T2 - Tumor invades muscle T2a - Superficial muscle affected (inner half) T2b - Deep muscle affected (outer half) T3 - Tumor invades perivesical (around the bladder) fatty tissue T3a - microscopically T3b - macroscopically (e.g., visible tumor mass on the outer bladder tissue) T4 - Tumor invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall	NX - Regional lymph nodes cannot be evaluated N0 - No regional lymph node metastasis N1 - Metastasis in a single lymph node < 2 cm in size N2 - Metastasis in a single lymph node > 2 cm, but < 5 cm in size, or Multiple lymph nodes < 5 cm in size N3 - Metastasis in a lymph node > 5 cm in size	MX - Distant metastasis cannot be evaluated M0 - No distant metastasis M1 - Distant metastasis

According to recent consensus decisions of the American Joint Committee on Cancer (AJCC), the stage groupings of bladder cancers are as follows:

Individuals with Grade 1, Stage 0 tumors usually do not need any additional workup for staging, because there is little risk of metastasis. By contrast, individuals with more advanced tumors, for example, Grade 2, Stage 2 tumors, require a routine staging assessment. Such an assessment should include basic blood work, chest X-ray, lower body imaging by either computed tomography (CT scan) or magnetic resonance imaging, and a bone scan.

Ta (papillary, noninvasive carcinoma)
"Ta" tumors are papillary (wart-like) in nature. They often look like pink cabbages, and they may be present in groups. Ta tumors are confined to the inner surface of the bladder wall and are distinguished from T1 tumors because they have not broken through the basement (supporting) membrane.

TIS (carcinoma in situ; flat, pre-invasive tumor)
Carcinoma in situ (CIS) of the transitional epithelium — otherwise known as TIS — is very rare. In the past, TIS tumors were associated with high death rates because they often were undiagnosed. Unlike papillary tumors, TIS tumors are flat. The cancerous cells in TIS tumors are pre-invasive (confined to the basement membrane). When detected in the urine by Pap staining, TIS cells appear anaplastic (lacking cellular differentiation - the distinguishing characteristics of a cell). In middle-aged men, TIS may resemble cystitis without hematuria. Accurate diagnosis depends upon biopsy of the mucosa in any patients with unexplained cystitis or sterile pyuria (no microorganisms are present but there is "pus-like" matter in the urine).

T1 (tumor invasion of connective tissue)
During clinical inspection, T1 tumors often look like Ta tumors. These cancers may appear as an isolated mass, or they may be present in groups. But the distinctive feature of the T1 tumor is that—although it has broken through the basement membrane into the connective tissue of the bladder-lining mucous membrane (lamina propria)—the stalk of the tumor has not invaded the muscle below. Some physicians believe that T1 tumors should not be considered "superficial TCC," because they have the potential to be invasive and to progress. T1 tumors have a progression rate of roughly 30%. In T1 lesions of Grade 3 or Grade 4, nearly half of all tumors progress.

T2 (tumor invasion of muscle)
T2 tumors are characterized by the invasion of the muscle surrounding the bladder. If only the inner half of "superficial" muscle is affected (T2a tumor) and tumor cells are well-differentiated, the tumor may not have gained access to the lymphatic system. However, if the tumor has penetrated the outer half of "deep" muscle (T2b tumor) and cells are poorly differentiated, then the patient's prognosis usually is worse.

T3 (tumor invasion of perivesical tissue)
When a tumor has broken through the surrounding muscle and begins to invade the perivesical tissue (fatty tissue around the bladder) or peritoneum (membrane lining the abdominal cavity) outside of the bladder, it is classified as a T3 tumor. If the process of invasion has just begun and only can be seen by microscopy, then the tumor is classified as T3a. However, if the tumor is visibly massed on the outer bladder tissue, then it is classified as T3b.

T4 (tumor invasion of surrounding organs)
If a tumor has progressed to invade nearby organs—such as the prostate (a male gland that surrounds the bladder neck and urethra and adds a secretion to the semen), uterus (womb), vagina (female reproductive canal), or walls of the abdomen or pelvis (hip bone)—it is classified as T4. T4 tumors are, by and large, inoperable, meaning they can/should not be surgically removed. They may cause painful symptoms, hematuria, frequent urination, and sleeplessness. In addition, the necrotic (dead) tissue within the bladder often becomes infected. Surgery may be performed not as a cure, but as a method to reduce suffering in patients with T4 tumors.

Treatment
Treatment for bladder cancer depends on the stage of the disease, the type of cancer, and the patient's age and overall health. Options include surgery, chemotherapy, radiation, and immunotherapy. In some cases, treatments are combined (e.g., surgery or radiation and chemotherapy, preoperative radiation).

Surgery
The type of surgery depends on the stage of the disease. In early bladder cancer, the tumor may be removed (resected) using instruments inserted through the urethra (transurethral resection).

Bladder cancer that has spread to surrounding tissue (e.g., Stage T2 tumors, Stage T3a tumors) usually requires partial or radical removal of the bladder (cystectomy). Radical cystectomy also involves the removal of nearby lymph nodes and may require a urostomy (opening in the abdomen created for the discharge of urine). Complications include infection, urinary stones, and urine blockages. Newer surgical methods may eliminate the need for an external urinary appliance.

In men, the standard surgical procedure is a cystoprostatectomy (removal of the bladder and prostate) with pelvic lymphadenectomy (removal of the lymph nodes within the hip cavity). The seminal vesicles (semen-conducting tubes) also may be removed. In some cases, this can be performed in a manner that preserves sexual function.

In women with T2 to T3a tumors, the standard surgical procedure is radical cystectomy (removal of the bladder and surrounding organs) with pelvic lymphadenectomy. Radical cystectomy in women also involves removal of the uterus (womb), ovaries, fallopian tubes, anterior vaginal wall (front of the birth canal), and urethra (tube that carries urine from the bladder out of the body).

Segmental cystectomy (partial removal of the bladder), which is a bladder-preserving procedure, may be used in some cases (e.g., patients with squamous cell carcinomas or adenocarcinomas that arise high in the bladder dome). When segmental cystectomy is performed, it may be preceded by radiation therapy.

Urinary Tract Diversion
Until recently, most bladder cancer patients who underwent cystectomy (bladder removal) required an ostomy (surgical creation of an artificial opening) and an external bag to collect urine. Newer reconstructive surgical methods include the continent urinary reservoir, the neobladder, and the ileal conduit.

The continent urinary reservoir is a urinary diversion technique that involves using a piece of the colon (large intestine) to form an internal pouch to store urine. The pouch is specially refashioned to prevent back-up of urine into the ureters (tubes that carry urine out of the kidneys and into the bladder) and kidneys. The patient drains the pouch with a catheter several times a day, and the stoma site is easily concealed by a band aid.

The neobladder procedure involves suturing a similar intestinal pouch to the urethra so the patient is able to urinate as before, without the need for a stoma. In many cases, there is no sensation to void, but some patients experience abdominal cramping as the neobladder fills.

Complications of the continent urinary reservoir and neobladder include bowel (intestine) obstruction, blood clots, pneumonia (lung inflammation), ureteral reflux (back-flow), and ureteral blockage.

The ileal conduit is a urinary channel that is surgically created from a small piece of the patient's bowel. During this procedure, the ureters are attached to one end of the bowel segment and the other end is brought out of the surface of the body to make a stoma. An external, urine-collecting bag is attached to the stoma and is worn at all times.

Complications of the ileal conduit procedure include bowel obstruction, urinary tract infection (UTI), blood clots, pneumonia, upper urinary tract damage, and skin breakdown around the stoma.

Chemotherapy
Chemotherapy is a systemic treatment (i.e., affects the entiry body) that uses drugs to destroy cancer cells. It is administered orally or intravenously (through a vein) and in early bladder cancer, may be infused into the bladder through the urethra (called intravesical chemotherapy). Chemotherapy also may be administered before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy).
Drugs commonly used to treat bladder cancer include valrubicin (Valstar®), thiotepa (Thioplex®), mitomycin, and doxorubicin (Rubex®). Side effects can be severe and include the following:

Radiation
Radiation uses high-energy x-rays to destroy cancer cells. External beam radiation is emitted from a machine outside the body and internal radiation is emitted from radioactive "seeds" implanted into the tumor. Either type of radiation therapy may be used after surgery to destroy cancer cells that may remain. Radiation therapy is also used to relieve symptoms (called palliative treatment) of advanced bladder.

Side effects include inflammation of the rectum (proctitis), incontinence, skin irritation, hematuria, fibrosis (buildup of fibrous tissue), and impotence (erectile dysfunction).

Immunotherapy
Immunotherapy, also called biological therapy, may be used in some cases of superficial bladder cancer. This treatment is used to enhance the immune system's ability to fight disease. A vaccine derived from the bacteria that causes tuberculosis (BCG) is infused through the urethra into the bladder, once a week for 6 weeks to stimulate the immune system to destroy cancer cells. Sometimes BCG is used with interferon.

Side effects include inflammation of the bladder (cystitis), inflammation of the prostate (prostatitis), and flu-like symptoms. High fever (over 101.5°F) may indicate that the bacteria have entered the bloodstream (called bacteremia). This condition is life threatening and requires antibiotic treatment. Immunotherapy is not used in patients with gross hematuria (blood in urine).

Photodynamic therapy is a new treatment for early bladder cancer. It involves administering drugs to make cancer cells more sensitive to light and then shining a special light onto the bladder. This treatment is being studied in clinical trials.

Follow-Up
Bladder cancer has a high rate of recurrence. Urine cytology and cystoscopy are performed every 3 months for 2 years, every 6 months for the next 2 years, and then yearly.

Prognosis
Superficial bladder cancer has a 5-year survival rate of about 85%. Invasive bladder cancer has a less favorable prognosis. Approximately 5% of patients with metastasized bladder cancer live 2 years after diagnosis. Cases of recurrent bladder cancer indicate an aggressive tumor and a poor prognosis.

Prevention
Bladder cancer cannot be prevented. The best way to lower the risk is not to smoke. Studies have shown that drinking plenty of fluids daily also lowers the risk for bladder cancer.

Bladder Control Problems/ Overactive Bladder

In people with an overactive bladder (OAB), the layered, smooth muscle that surrounds the bladder (detrusor muscle) contracts spastically, sometimes without a known cause, which results in sustained, high bladder pressure and the urgent need to urinate (called urgency). Normally, the detrusor muscle contracts and relaxes in response to the volume of urine in the bladder and the initiation of urination.

People with OAB often experience urgency at inconvenient and unpredictable times and sometimes lose control before reaching a toilet. Thus, overactive bladder interferes with work, daily routine, intimacy and sexual function; causes embarrassment; and can diminish self-esteem and quality of life.

Urination
Urination (micturition) involves processes within the urinary tract and the brain. The slight need to urinate is sensed when urine volume reaches about one-half of the bladder's capacity. The brain suppresses this need until a person initiates urination.

Once urination has been initiated, the nervous system signals the detrusor muscle to contract into a funnel shape and expel urine. Pressure in the bladder increases and the detrusor muscle remains contracted until the bladder empties. Once empty, pressure falls and the bladder relaxes and resumes its normal shape.
The Sudden Urge to Go: Is It Overactive Bladder?

Incidence and Prevalence
Overactive bladder affects men and women equally. The U.S. Department of Health and Human Services has reported that approximately 13 million people in the United States suffer from OAB and other forms of incontinence.

Signs and Symptoms
Three symptoms are associated with an overactive bladder:

Causes
A malfunctioning detrusor muscle causes overactive bladder. Identifiable underlying causes include the following:

Other conditions can produce symptoms similar to overactive bladder, including urinary tract infection (UTI) and normal pressure hydrocephalus.

Diagnosis
The Sudden Urge to Go: Is It Overactive Bladder?
A complete medical history, including a voiding diary; a physical examination; and one or more diagnostic procedures help the physician determine an appropriate treatment plan for overactive bladder.

Medical history
The medical history includes information about bowel habits, patterns of urination and leakage (when, how often, how severe), and whether there is pain, discomfort, or straining when voiding. The patient's history of illnesses, pelvic surgeries, pregnancies, and medications currently used also supply the physician with information relevant to making a diagnosis. In the elderly, a mental status evaluation and assessment of social and environmental factors may be performed.

Physical examination
A physical examination includes a neurologic status evaluation and examination of the abdomen, rectum, genitals, and pelvis. The cough stress test, in which the patient coughs forcefully while the physician observes the urethra, allows observation of urine loss. Instantaneous leakage with coughing indicates a diagnosis of stress incontinence. Leakage that is delayed or persistent after the cough indicates urge incontinence.

The physical examination also helps the physician identify medical conditions that may be the cause of overactive bladder. For instance, poor reflexes or sensory responses may indicate a neurological disorder.

Urinalysis
Examination of the urine may identify medical conditions associated with overactive bladder, such as the following:

Specialized Testing
If overactive bladder persists after diagnosis and treatment, additional testing may be needed. Urologists perform urodynamic, endoscopic, and imaging tests to obtain a more extensive evaluation of the lower urinary tract to determine a new treatment plan.

Postvoid residual volume (PRV)
This procedure requires catheterization or pelvic ultrasound. The patient voids just before the PRV is measured. This initial void should be observed for hesitancy, straining, or interrupted flow. A PRV less than 50 mL indicates adequate bladder emptying. Repeated measurements of 100 to 200 mL or higher represent inadequate bladder emptying. The clinical setting and the patient's readiness to void may affect the test result; therefore, repeated measurements may be necessary.

Urodynamic Testing
Cystometry may be used to measure the anatomic and functional status of the bladder and urethra. The cystometer is an instrument that measures the pressure and capacity of the bladder; thus evaluating the function of the detrusor muscle. Simple cystometry detects abnormal detrusor compliance, but abdominal pressure is not included and the results must be evaluated with caution.

The multichannel, or subtracted, cystometrogram simultaneously measures intra-abdominal, total bladder, and true detrusor pressures. This allows involuntary detrusor contractions to be distinguished from increased intra-abdominal pressure. The voiding cystometrogram detects outlet obstruction in patients who are able to void.

Uroflowmetry identifies abnormal voiding patterns. Urethral pressure profilometry measures the resting and dynamic pressures in the urethra.

Endoscopic Tests
Cystoscopy may be performed when urodynamic testing fails to duplicate symptoms, when the patient experiences new symptoms (e.g., cystitis, pain), or when urinalysis reveals a disease process (e.g., menaturia, pyuria). Cystoscopy identifies the presence of bladder lesions (e.g., cysts) and foreign bodies.

Imaging Tests
X-rays and ultrasound may be used to evaluate anatomic conditions associated with overactive bladder. Imaging of the lower urinary tract before, during, and after voiding is helpful in examining the anatomy of the urinary bladder and urethra.

Treatment
Treatment may include one or more of the following:

Bladder Training with Timed Voiding
This treatment is used for urge and overflow incontinence. The patient keeps a voiding diary of all episodes of urination and leaking, and the physician analyzes the chart and identifies the pattern of urination. The patient uses this timetable to plan when to empty the bladder to avoid accidental leakage. In bladder training, biofeedback and Kegel exercise help the patient resist the sensation of urgency, postpone urination, and urinate according to the timetable.

Medication
Drugs such as oxybutynin chloride (Ditropan XL®) and tolterodine (Detrusitol®, Detrol LA®) are taken orally, once a day, for overactive bladder. These medications are antimuscarinics, which affect the central nervous system and muscarinic receptors in smooth muscle. They relax the smooth muscle of the bladder, reducing detrusor contraction and subsequent wetting accidents, usually within 2 weeks. Newer drugs indicated for OAB include trospium chloride (Sanctura®), derifenacin (Enablex®), and solifenacin (Vesicare®).

Side effects, including dry mouth, constipation, headache, blurred vision, dry eyes, hypertension, drowsiness, and urinary retention occur in approximately 50% of those who use these medications. They should be used with caution in patients with narrow-angle glaucoma or certain types of kidney, liver, stomach, and urinary problems. Women who are pregnant should not take these medications without consulting a physician.

Oxybutynin Transdermal System
The oxybutynin transdermal system (Oxytrol®) is a thin, flexible, clear patch that is applied to the skin of the abdomen or hip, twice weekly, to treat overactive bladder. This treatment delivers oxybutynin continuously through the skin into the bloodstream and relieves symptoms for up to 4 days allowing twice a week dosing.

Patients who have urinary or gastric retention, uncontrolled narrow-angle glaucoma, and those with hypersensitivity to oxybutynin should not use the oxybutynin transdermal system.

Side effects are usually mild and include adverse reactions at the site of application, dry mouth, and constipation.

Sacral Nerve Stimulation
InterStim® therapy is a reversible treatment for people with urge incontinence caused by overactive bladder who do not respond to behavioral treatments or medication. InterStim is an implanted neurostimulation system that sends mild electrical pulses to the sacral nerve, the nerve near the tailbone that influences bladder control muscles. Stimulation of this nerve may relieve the symptoms related to urge incontinence.

Prior to implantation, the effectiveness of the therapy is tested on an outpatient basis with an external InterStim device. For a period of 3 to 5 days, the patient records voiding patterns that occur with stimulation. The record is compared to recorded voiding patterns without stimulation. The comparison demonstrates whether the device effectively reduces symptoms. If the test is successful, the patient may choose to have the device implanted.

The procedure requires general anesthesia. A lead (a special wire with electrical contacts) is placed near the sacral nerve and is passed under the skin to a neurostimulator, which is about the size of a stopwatch. The neurostimulator is placed under the skin in the upper buttock.
Adjustments can be made at the doctor's office with a programming device that sends a radio signal through the skin to the neurostimulator. Another programming device is given to the patient to further adjust the level of stimulation, if necessary. The system can be turned off at any time.
Possible adverse effects include the following:

Surgery
Surgical augmentation of the bladder is reserved for people who do not benefit from bladder retraining or medication.

Those who cannot take medication due to medical conditions or intolerance may find incontinence management devices helpful.
DEPEND® Adult Incontinence Products. Encouragement and information for people with incontinence, and those who care for them.

Elimination and Challenge Diet
Bladder control problems that are not the result of neurological damage, poor muscle tone, or hormone deficiencies may result from irritability within the bladder or urethral tissues caused by chronic inflammation and/or food sensitivities. An elimination and challenge diet can help determine a food sensitivity. Symptoms that can occur on a food challenge include the following:

Symptoms associated with food challenges may not be the same symptoms experienced before the elimination process. For example, before the elimination and challenge diet began, a patient's symptom was chronic sinus pain, but a stomachache occurred during the challenge. This does not mean that the food group being challenged was not causing the sinus pain. It is just that the body and immune system react differently when the offending agent is removed and then reintroduced.

Option 1

For 2 to 6 weeks, eliminate all suspect foods and focus diet on fresh fruits, vegetables, potatoes, yams, animal protein (fish, poultry, lamb), and nonglutenous grains (rice, buckwheat). Eat organic foods whenever possible.
After 2 to 6 weeks of maintaining a strict elimination diet, there should be relief from symptoms. Weight may also be lost. Now begin the challenge. Start with the food group that is least problematic. Challenge a specific food group for one day only. Eat several servings of that food group throughout the day. Then do not eat that food again for at least 48 hours while continuing to eat only elimination diet foods. If symptoms do not return after 48 hours, go on to the next suspected food group. However, feel free to wait more than 48 hours. Waiting a week between food group challenges is optimal. This increases the accuracy of the diagnosis. Remember to challenge only one food group at a time.

Continue this process until the problematic food group is determined. In most cases, reactions occur within 48 hours. Rarely do symptoms appear several days or weeks later.

Option 2

Maintain a regular diet and eliminate only the food group that is believed to be causing the symptoms. Eliminate all items in that food group for at least 1 month. If the symptoms disappear before the end of the month, continue to abstain from that food group for another week before starting the challenge.
To do the challenge, eat several servings of the suspect food group during a 24-hour period. Then return to the elimination diet and do not eat the suspect food group for at least 48 hours. More often than not, immediate reactions occur if there is a sensitivity.

Herbal Support
Soothing urinary tract tonics may help heal the bladder and related nervous irritation. Also drink 2 - 3 quarts of water daily.
Herbs to use as tea:

Homeopathic Support
A trained homeopathic practitioner is needed to diagnose and prescribe a deep acting, constitutional remedy. For acute, symptomatic relief, the following remedies may relieve some of the symptoms associated with incontinence.

Standard dosage for acute symptom relief is 12c to 30c, 3 to 5 pellets taken 3 times a day until symptoms resolve. If you have chosen the right remedy, you should experience improvement shortly after the first or second dose.

Benign Prostatic Hyperplasia (BPH)

Overview
Benign prostatic hyperplasia (BPH) is not simply a case of too many prostate cells. Prostate growth involves hormones, occurs in different types of tissue (e.g., muscular, glandular), and affects men differently. As a result of these differences, treatment varies in each case. There is no cure for BPH and once prostate growth starts, it often continues, unless medical therapy is started.
The prostate grows in two different ways. In one type of growth, cells multiply around the urethra and squeeze it, much like you can squeeze a straw. The second type of growth is middle-lobe prostate growth in which cells grow into the urethra and the bladder outlet area. This type of growth typically requires surgery.
Anatomy

The prostate is a walnut-sized gland located beneath the bladder and in front of the rectum. It is surrounded by a capsule of fibrous tissue called the prostate capsule. The urethra (tube that transports urine and sperm out of the body) passes through the prostate to the bladder neck. Prostate tissue produces prostate specific antigen and prostatic acid phosphatase, an enzyme found in seminal fluid (the milky substance that combines with sperm to form semen).

Incidence and Prevalence
It is difficult to establish incidence and prevalence of BPH because research groups often use different criteria to define the condition. According to the National Institutes of Health (NIH), BPH affects more than 50% of men over age 60 and as many as 90% of men over the age of 70.

Risk Factor
BPH is a condition of aging. Nearly all men over the age of 50 have an enlarged prostate.

Causes
The cause of benign prostatic hyperplasia is unknown. It is possible that the condition is associated with hormonal changes that occur as men age. The testes produce the hormone testosterone, which is converted to dihydrotestosterone (DHT) and estradiol (estrogen) in certain tissues. High levels of dihydrotestosterone, a testosterone derivative involved in prostate growth, may accumulate and cause hyperplasia. How and why levels of DHT increase remains a subject of research.

Signs and Symptoms
Common symptoms of benign prostatic hyperplasia include the following:

In severe cases of BPH, another symptom, acute urinary retention (the inability to urinate), can result from holding urine for a long time, alcohol consumption, long period of inactivity, cold temperatures, allergy or cold medications containing decongestants or antihistamines, and some prescription drugs (e.g., ipratropium bromide, albuterol, epinephrine). Any of these factors can prevent the urinary sphincter from relaxing and allowing urine to flow out of the bladder. Acute urinary retention causes severe pain and discomfort. Catheterization may be necessary to drain urine from the bladder and obtain relief.

Diagnosis
A physical examination, patient history, and evaluation of symptoms provide the basis for a diagnosis of benign prostatic hyperplasia. The physical examination includes a digital rectal examination (DRE), and symptom evaluation is obtained from the results of the AUA Symptom Index.

Digital rectal examination (DRE)
DRE typically takes less than a minute to perform. The doctor inserts a lubricated, gloved finger into the patient's rectum to feel the surface of the prostate gland through the rectal wall to assess its size, shape, and consistency. Healthy prostate tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the nose. If the examination reveals the presence of unhealthy tissue, additional tests are performed to determine the nature of the abnormality.

AUA Symptom Index
The AUA (American Urological Association) Prostate Symptom Index is a questionnaire designed to determine the seriousness of a man's urinary problems and to help diagnose BPH. The patient answers seven questions related to common symptoms of benign prostatic hyperplasia. How frequently the patient experiences each symptom is rated on a scale of 1 to 5. These numbers added together provide a score that is used to evaluate the condition. An AUA score of 0 to 7 means the condition is mild; 8 to 19, moderate; and 20 to 35, severe.

PSA and PAP Tests
Blood tests taken to check the levels of prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) in a patient who may have benign prostatic hyperplasia helps the physician eliminate a diagnosis of prostate cancer.

Prostate-specific antigen (PSA) is a specific antigen produced by the cells of the prostate capsule (membrane covering the prostate) and periurethral glands. Patients with benign prostatic hyperplasia (BPH) or prostatitis produce larger amounts of PSA. The PSA level also is determined in part by the size and weight of the prostate.

The test measures the amount of PSA in the blood in nanograms per milliliter (ng/mL). A PSA of 4 ng/mL or lower is normal; 4–10 ng/mL is slightly elevated; 10–20 is moderately elevated; and 20–35 is highly elevated. Most men with slightly elevated PSA levels do not have prostate cancer, and many men with prostate cancer have normal PSA levels. A highly elevated level may indicate the presence of cancer.

The PSA test can produce false results. A false positive result occurs when the PSA level is elevated and there is no cancer. A false negative result occurs when the PSA level is normal and there is cancer. Because of this, a biopsy is usually performed to confirm or rule out cancer when the PSA level is high.

Free and total PSA (also known as PSA II) PSA in the blood may be bound molecularly to one of several proteins or may exist in a free, or unbound, state. Total PSA is the sum of the levels of both forms; free PSA measures the level of unbound PSA only. Studies suggest that malignant prostate cells produce more bound PSA; therefore, a low level of free PSA in relation to total PSA might indicate a cancerous prostate, and a high level of free PSA compared to total PSA might indicate a normal prostate, BPH, or prostatitis.

Age-specific PSA Evidence suggests that the PSA level increases with age. A PSA of up to 2.5 ng/mL for men age 40–49 is considered normal, as is 3.5 ng/mL for men age 50–59, 4.5 ng/mL for men age 60–69, and 6.5 ng/mL for men 70 and older. The use of age-specific PSA levels is not endorsed by all medical professionals.
Use the PSA Age/Race Quiz or the PSA Velocity Quiz to deterimine your risk of prostate cancer.

Urodynamic Testing
Urodynamic tests, usually performed in a physician's office, are used to measure the volume and pressure of urine in the bladder and to evaluate the flow of urine. They are particularly useful for the diagnosis of Intrinsic sphincter deficiency and uncertain cases of mixed, overflow, urgency, or total incontinence. Additional tests may be conducted if symptoms indicate that blockage is caused by a condition other than BPH.

Uroflowmetry is a simple test performed to record urine flow, to determine how quickly and completely the bladder can be emptied, and to evaluate obstruction. With a full bladder, the patient urinates into a device that measures the amount of urine, the time it takes for urination, and the rate of urine flow. Patients with stress or urge incontinence usually have a normal or increased urinary flow rate, unless there is an obstruction in the urinary tract. A reduced flow rate may indicate BPH.

A pressure flow study measures pressure in the bladder during urination and is designed to detect a blockage of flow. It is the most accurate way to evaluate urinary blockage. This test requires the insertion of a catheter through the urethra in the penis and into the bladder. The procedure is uncomfortable and rarely may cause urinary tract infection (UTI).

Post-void residual (PVR) test measures the amount of urine that remains in the bladder after urination. The patient is asked to urinate immediately prior to the test and the residual urine is determined by ultrasound or catheterization. PRV less than 50 mL generally indicates adequate bladder emptying and measurements of 100 to 200 mL or higher often indicate blockage. Nervousness and other types of stress may affect the result; therefore, the test is often repeated.

Treatment Options
Treatment options for enlarged prostate, or benign prostatic hyperplasia (BPH), may include the following:

Medical Treatment
There are several treatment options for men with benign prostate hyperplasia, depending on the severity of symptoms. If symptoms do not threaten the man's health, he may choose not to be treated. If symptoms are severe enough to cause discomfort, interfere with daily activities, or threaten health, treatment is usually recommended.

Watchful waiting
Men with mild symptoms may choose to return for annual examinations. The physician will perform an examination that includes a DRE, PSA tests, and a urinary flow rate. The patient will be asked to describe symptoms in order to determine if the condition is worsening.

Medication
5-Alpha reductase inhibitors such as finasteride (Proscar®) and dutasteride (Avodart®) prevent the conversion of testosterone to the hormone dihydrotestosterone (DHT). In many cases, a treatment period of 6-month is necessary to see if the therapy is going to work. These drugs are taken orally, once a day. Finasteride is available in tablet form and dutasteride is available as soft gelatin capsules. Patients should see their physician regularly to monitor side effects and adjust the dosage, if necessary.

Side effects include reduced libido, impotence, breast tenderness and enlargement, and reduced sperm count. Long-term risks and benefits have not been studied.
Women who may be pregnant must avoid handling dutasteride capsules and broken or crushed finasteride tablets because exposure to the drugs may cause serious side effects to the fetus. Intact tablets are coated to prevent absorption through the skin during normal handling. Patients should wait at least 6 months after dutasteride treatment to donate blood to prevent pregnant women from being exposed to the drug through blood transfusion.

Alpha blockers relax smooth muscle tissue in the bladder neck and prostate, which increases urinary flow. They typically are taken orally, once or twice a day.
Commonly prescribed alpha blockers include the following:

Patients taking an alpha blocker require follow-up during the first 3 or 4 weeks to evaluate the effect on symptoms and adjust the dosage, if necessary. Side effects include headache, dizziness, low blood pressure, fatigue, weakness, and difficulty breathing. Long-term risks and benefits have not been studied.

Prostatic stents
Although a prostatic stent is not a medical treatment, neither does it fall under the classification of a surgical procedure. Prostatic stents are used most often for patients with significant medical problems that prohibit medication or surgery. It is a tiny, springlike device inserted into the urethra. When expanded, it pushes back the surrounding tissue and widens the urethra. Prostatic stents have several

advantages:

Minimally Invasive Treatment
Minimally invasive BPH treatments use state-of-the-art tools and techniques to reduce or eliminate symptoms. Men are treated on an outpatient basis in a urologist's office or the hospital. Other advantages of minimally invasive treatments are

Usually, heat is used to destroy excess prostate tissue. Techniques differ in heat source, heat delivery method, side effects, and number of treatments. Delivery methods include:
Laser (e.g., non-contact, contact, interstitial)

Patients who want to stop taking medication or whose medication no longer improves symptoms may elect to have one of these procedures. However, patients with severely enlarged prostates and whose bladders do not work properly may not be good candidates.
Prior to diagnosis and treatment of BPH, a prostate-specific antigen (PSA) test and digital rectal examination (DRE) are performed to rule out prostate cancer. A transrectal ultrasound and cystoscopy also may be performed to determine if prostatectomy or TURP is indicated.

Surgical Treatment
Surgery involves removing the enlarged part of the prostate that constricts the urethra. It is recommended for patients who experience serious complications, such as the following:

TURP
Transurethral resection of the prostate (TURP) is the gold standard to which other surgeries for BPH are compared. This procedure is performed under general or regional anesthesia and takes less than 90 minutes.

The surgeon inserts an instrument called a resectoscope into the penis through the urethra. The resectoscope is about 12 inches long and 3/8 of an inch in diameter. It contains a light, valves for controlling irrigating fluid, and an electrical loop to remove the obstructing tissue and seal blood vessels. The surgeon removes the obstructing tissue and the irrigating fluids carry the tissue to the bladder. This debris is removed by irrigation and any remaining debris is eliminated in the urine over time.

Patients usually stay in the hospital for about 3 days, during which time a catheter is used to drain urine. Most men are able to return to work within a month. During the recovery period, patients are advised to

Complications
Blood in the urine (hematuria) is common after TURP surgery and usually resolves by the time the patient is discharged. Bleeding also may result from straining or activity. Postsurgical bleeding should be reported to the urologist immediately.

Some patients have initial discomfort, a sense of urgency to urinate, or short-term difficulty controlling urination. These conditions slowly improve as recovery progresses, but it is important to remember that the longer the urinary problems existed before surgery, the longer it takes to regain full and normal bladder function after surgery.

Up to 30% of men who undergo TURP experience problems with sexual function. Complete recovery of sexual function may take up to 1 year. The most common, long-term side effect of prostate surgery is retrograde ejaculation (dry climax), which results when the muscle that closes the bladder neck during ejaculation is removed along with the obstructing prostate tissue. Semen enters the wider opening to the bladder instead of being expelled through the penis, causing sterility but not affecting the man's ability to experience sexual pleasure. This complication is not an issue for most men requiring prostate surgery.

HoLEP
Holmium laser enucleation of the prostate (HoLEP) produces results that are similar to TURP with fewer complications (e.g., less intraoperative bleeding). In this procedure, a holmium laser is used to remove obstructive prostatic tissue and seal blood vessels. HoLEP is usually performed as a day procedure in the hospital. Benefits of HoLEP over traditional surgery include the following:

Approximately 10–15% of patients with large prostates (>100 gm) experience stress incontinence after undergoing HoLEP. In most cases, incontinence resolves within 6 weeks.

Prostatectomy
If the prostate is greatly enlarged, if the bladder has been damaged, or if the patient has complications prohibiting transurethral surgery, prostatectomy (removal of the obstructing prostate) may be necessary. This procedure is sometimes the best and safest approach.

Prostatectomy is performed under general or regional anesthesia. The surgeon makes an external incision in the lower abdomen or in the perineum (area between the rectum and the scrotum). If the surgeon accesses the prostate from the abdomen, the procedure is called suprapubic or retropubic prostatectomy; surgery through the perineum is called perineal prostatectomy. Once access is gained, the prostate is removed.

After prostate surgery, a urinary catheter is inserted to ensure bladder emptying. Urine output and color and continuous bladder irrigation (CBI), if present, are monitored. Blood in the urine is an expected side effect of prostate surgery. CBI is used to maintain the effectiveness of the urinary catheter, remove blood clots, and cleanse the surgical area. If bladder spasms occur, the surgeon should be notified.

Once they have been discharged from the hospital, patients should abstain from sexual intercourse for 6 weeks after surgery. Strenuous activity and lifting is to be avoided throughout the recovery period, which can take up to 8 weeks.

Potential complications include incontinence and impotence. Depending on the procedure, stress urinary incontinence may result when pressure is put on abdominal muscles. Urge incontinence and involuntary passing of urine while asleep also may occur. Patients are encouraged to use Kegel exercises to strengthen pelvic floor muscles and to increase their water intake. Ejaculatory dysfunction and erectile dysfunction (impotence) may occur, depending on the procedure.

TUIP
Transurethral incision of the prostate (TUIP) may be recommended to treat a prostate that is not greatly enlarged. The surgeon makes one or more cuts in the bladder neck where the urethra joins the bladder, extending into the prostate. This reduces the prostate's pressure on the urethra and makes urination easier. TUIP may provide relief with a lower incidence of retrograde ejaculation than TURP. However, its long-term benefits and risks compared to TURP have not been established.

TULIP
Transurethral ultrasound-guided laser incision of the prostate (TULIP) is a new procedure that is similar to TUIP, except that the cuts are made with a laser.

Naturopathic Treatment
The goal of benign prostatic hyperplasia (BPH) treatment is to reduce excessive cell growth by inhibiting the conversion of testosterone into the more potent hormone dihydrotestosterone (DHT) and by preventing estrogen from attaching to receptors in prostate tissue. From a naturopathic viewpoint, this is accomplished through nutrition and the use of supplements and herbs.

Nutrition

Supplements
Supplements are intended to provide nutritional support. Because a supplement or a recommended dose may not be appropriate for all persons, a physician (i.e., a licensed naturopathic physician or holistic MD or DO) should be consulted before using any product. Recommended doses follow:

Herbal Medicine
Herbal medicines usually do not have side effects when used appropriately and at suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset or headache. This may reflect the purity of the preparation or added ingredients, such as synthetic binders or fillers. For this reason, it is recommended that only high-quality products be used. As with all medications, more is not better and overdosing can lead to serious illness and death.
These herbs may be used to treat BPH:

Epididymitis/Orchitis

Overview

Epididymitis is inflammation of the epididymis, which is a structure located on top of each testicle (testis). The epididymes are an important part of the sperm development process and are more prone to infection than the testicles.

Orchitis, inflammation of the testicles, usually results from the spread of infection from the epididymis. Most cases of isolated orchitis (i.e., orchitis that develops without epididymitis) are a symptom of the mumps (a viral infection that usually begins in the salivary glands). When epididymitis and orchitis occur together, it is called epididymo-orchitis.

These conditions cause inflammation and pain that is often limited to one, but can involve both sides of the scrotum.

Acute epididymitis, orchitis, and epididymo-orchitis cause sudden pain that usually responds well to treatment. Chronic conditions cause pain that develops gradually and can be more difficult to treat. Acute and chronic cases may result in male fertility problems or testosterone deficiency.

Incidence and Prevalence
Acute epididymitis is common in young men, and can affect males of any age. Orchitis and chronic conditions are less common. According to the U.S. Centers for Disease Control and Prevention (CDC), epididymitis is especially common in young sexually-active men and is the most common cause of acute (severe) scrotal pain in adolescent males.

In 2004, the CDC noted that approximately one-third of postpubertal (sexually mature) males with mumps develop mumps orchitis, which is the primary cause of isolated orchitis. However, in a 2006 outbreak of mumps in the United States, about 50% of infected postpubertal males developed mumps orchitis, according to the CDC. Mumps is rare in the United States, due to a widely available vaccine, but occasional outbreaks do occur. It is a common disease outside of the United States.

Causes and Risk Factors
The most common cause for acute epididymitis and epididymo-orchitis is a bacterial infection that spreads from another area, usually the urinary tract (e.g., urethra, bladder). Sometimes, pain in the testicular area is the first sign of infection.

According to the CDC, approximately two-thirds of acute epididymitis cases in men under age 35 are complications of gonorrhea or chlamydia/NGU, which are sexually transmitted infections (also called as STIs or STDs).

Gonorrhea and chlamydia, which often occur together, may cause symptomatic urethral infections (urethritis). In some cases, the first symptom of gonorrhea or chlamydia infection is epididymitis.
Other than sexually transmitted infection, the most common cause for epididymitis is another type of bacteria, such as E. coli. Rare causes include systemic tuberculosis (TB), sarcoidosis, brucellosis (a rare bacterial infection), fungal infection, and infected hydrocele (an abnormal fluid-filled sac around the testicles). Systemic TB usually only occurs in people who have a compromised immunity, such as with AIDS, or in communities where TB is widespread.

Inflammation of the epididymes and testicles also may have noninfectious causes, such as trauma, recent urinary catheterization, or reflux (backwards flow) of urine caused by a bladder outlet obstruction (e.g., a result of enlarged prostate or urinary tract abnormalities). The drug amiodarone (Cordarone®), used to treat severe cases of irregular heart rhythms, also can cause inflammation of the epididymis.

Chronic epididymitis and epididymo-orchitis also can develop as a result of multiple episodes of acute cases. In some chronic cases, the cause is unknown.
Risk factors for epididymitis include the following:

The most common cause for acute orchitis is epididymitis, and the condition is then more accurately called epididymo-orchitis. Orchitis that occurs by itself usually is a secondary symptom of the mumps (a viral infection that usually begins in the salivary glands). This condition, which is called mumps orchitis, only occurs in males after puberty.

Female Sexual Dysfunction

Overview

Concepts of female sexual dysfunction are controversial, particularly those based on biological causes. The American Psychological Association (APA) classifies female sexual problems as mental disorders: loss of sexual desire or arousal, discomfort during intercourse, diminished blood flow to the vagina, trauma-related aversion to sex, and the inability to achieve orgasm. Historically, psychiatrists and sex therapists have diagnosed and treated these disorders, perhaps, in many cases, according to limited perspectives maintained by psychiatric literature. Urologists and gynecologists now treat female sexual problems that result from medical conditions causing diminished pelvic and vaginal blood flow and nerve damage.

Currently, urologists, behavioral scientists, and psychologists are looking at medical, cultural, psychological, and relational reasons for women's sexual dysfunction, perhaps more accurately termed sexual dissatisfaction. They are emphasizing education and communication between partners. Surveys of women suggest that therapy should focus on women's physiological needs to experience enjoyable sex instead of medical conditions. Under this view, sexual dissatisfaction is symptomatic of an intimacy problem in which one or both partners fail to communicate their needs.
A useful model for exploring disturbances in female sexual response considers traditional and innovative, psychiatric and medical, and psychological and physiological perspectives. For some women, dysfunction or dissatisfaction is defined by a loss of interest in sex (low libido) and the inability to become aroused or to achieve orgasm when participating in sex. Many are dissatisfied because their partners are uneducated or inattentive and do not understand female arousal and its anatomical basis. For others, a medical evaluation uncovers a physiological problem that impairs sensitivity. The concept of female sexual dysfunction, or dissatisfaction, remains poorly defined.

Incidence and Prevalence
The absence of dependable empirical data combined with varying definitions about sexual dysfunction, and even normal sexual practices, prevents a clear understanding of the prevalence of women's sexual problems. While some studies document a prevalence of sexual dysfunction among non-Caucasian women and women of lower socioeconomic status, opponents of these studies point to a lack of diversity in these test populations.

A survey conducted by the American Medical Association in 1999 indicates that sexual dysfunction affects approximately 43% of women in the United States. Age may not be a significant factor, as women under 20 and over 50 experience problems with arousal, orgasm, and satisfaction. However, there is evidence that the majority of female sexual dysfunction happens after menopause, when hormone production drops and vascular conditions are more common.
Female Sexual Response Cycle

The clinical definition of the female sexual response cycle consists of four stages of arousal, marked by physiological and psychological changes. The first stage is excitement, which can be triggered by psychological or physical stimulation, and is marked by emotional changes, and increased heart rate, respiration, and vaginal swelling and lubrication due to increased blood flow. Sustained excitement is called the plateau, the second stage. Vaginal swelling, heart rate, and muscle tension may increase as long as stimulation continues. The breasts enlarge, the nipples become erect, and the uterus dips. The third stage is orgasm, which involves synchronized vaginal, anal, and abdominal muscle contractions, the loss of involuntary muscle control, and intense pleasure. The final phase, resolution, involves a rush of blood away from the vagina, shrinking breasts and nipples, and a reduction in heart rate, respiration, and blood pressure.

Hematuria

Overview
Hematuria is the presence of blood, specifically red blood cells, in the urine. Whether the blood is visible only under a microscope or visible to the naked eye, hematuria is a sign that something is causing bleeding in the genitourinary tract: the kidneys, the tubes that carry urine from the kidneys to the bladder (ureters), the prostate gland (in men), the bladder, or the tube that carries urine from the bladder out of the body (urethra).
Bleeding may happen once or it may be recurrent. It can indicate different problems in men and women. Causes of this condition range from non-life threatening (e.g., urinary tract infection) to serious (e.g., cancer, kidney disease). Therefore, a physician should be consulted as soon as possible.

Types
There are two types of hematuria, microscopic and gross (or macroscopic). In microscopic hematuria, the amount of blood in the urine is so small that it can be seen only under a microscope. A small number of people experience microscopic hematuria that has no discernible cause (idiopathic hematuria). These people normally excrete a higher number of red blood cells.

In gross hematuria the urine is pink, red, or dark brown and may contain small blood clots. The amount of blood in the urine does not necessarily indicate the seriousness of the underlying problem. As little as 1 milliliter (0.03 ounces) of blood will turn the urine red.

"Joggers hematuria" results from repeated jarring of the bladder during jogging or long-distance running.

Reddish urine that is not caused by blood in the urine is called pseudohematuria. Excessive consumption of beets, berries, or rhubarb; food coloring; and certain laxatives and pain medications can produce pink or reddish urine.

HIV/AIDS

Overview

Human immunodeficiency virus (HIV) attacks the body's immune system, multiplying and spreading from cell to cell at incredible speed, damaging and destroying cells. At first, the immune system fights back by producing new cells, but eventually, HIV causes so much damage that the immune system can no longer keep up. When this happens, T-cells drop below 200 and AIDS develops.

Incidence and Prevalence
According to the Centers for Disease Control and Prevention (CDC), approximately 40 million people worldwide were living with HIV infection in 2004, and an estimated 14,000 new infections occur each day. Of these new infections, more than 90% occur in sub-Saharan Africa and in Asia.
In the United States, HIV infection rates remain high in urban minority populations, in men who have sex with men (MSM), and in people who use injection drugs.

The Immune System
The immune system is the body's defense against disease and illness. It is a complex network of organs, cells, and proteins that

The immune system readily recognizes and identifies disease-causing bacteria, viruses, fungi, and other abnormal cells. When an abnormality is detected, messages are sent from cell to cell to invoke an "attack" to destroy the abnormal cells. Afterwards, the immune system "remembers" the ordeal so that, if the same pathogen (disease-causing organism) invades the body again, it can quickly and readily come to the body's defense. This remarkable ability to remember a foreing substance and how to attack it is the basis of vaccination.

The immune system is made up of a variety of different types of cells (e.g., leuckocytes, lymphocytes, phagocytes, B cells, CD8+ cells). HIV targets CD4+ cells, also called helper T-cells. Health care professionals often use the terms "CD4+ cell" and "T-cell" interchangeably. Helper T-cells are immune system managers. They "instruct" other cells when to start and stop carrying out their various duties.
HIV and the Immune System
HIV interferes with the immune response in the following ways:

The immune system can replace as many as 10 billion CD4+ cells a day; but, after years of fending off the virus, it begins to wear down. The gap between the number of cells destroyed and the number that can be replaced grows wider over time and eventually leads to AIDS.

Incontinence

Overview
Urinary control relies on the finely coordinated activities of the smooth muscle tissue of the urethra and bladder, skeletal muscle, voluntary inhibition, and the autonomic nervous system.
Urinary incontinence can result from anatomic, physiologic, or pathologic (disease) factors. Congenital and acquired disorders of muscle innervation (e.g., ALS, spina bifida, multiple sclerosis) eventually cause inadequate urinary storage or control.
Acute and temporary incontinence are commonly caused by the following:

Urinary Incontinence: Why Does It Happen?

Types
Of the several types of urinary incontinence, stress, urge, and mixed incontinence account for more than 90% of cases. Overflow incontinence is more common in people with disorders that affect the nerve supply originating in the upper portion of the spinal cord and older men with benign prostate hyperplasia (BPH). The primary characteristics of these types are as follows:

Symptoms Quiz: What type of incontinence do you have?

Incidence and Prevalence
The U.S. Department of Health and Human Services reported in 1996 that approximately 13 million people in the United States suffer from urinary incontinence. The condition is far more prevalent in women than men. In the general population aged 15 to 64 years old, 10-30% of women versus 1.5-5% of men are affected. At least 50% of nursing home residents are affected. Of that number, 70% are women.

Treatment Options
Treatment options for urinary incontinence depend on the type of incontinence as outlined below.
Stress incontinence is urine loss during physical activity that increases abdominal pressure (e.g., coughing, sneezing, laughing). Treatment options include:

Urge incontinence is urine loss with urgent need to void and involuntary bladder contraction (also called detrusor instability). Treatment options include:

Overflow incontinence is constant dribbling of urine; bladder never completely empties. Treatment options include:

Management
There are several things patients can do to help improve continence.

A number of protective devices are available to help manage accidental urination, including the following:

Early reliance on absorbent pads may cause the wearer to accept incontinence rather than seek diagnosis and treatment. These products should be applied correctly and changed often to prevent skin irritation and urinary tract infection.

Naturopathic Treatment of Incontinence
Natural medicine may be used to treat urinary incontinence caused by poor muscle tone, hormonal deficiency, or food allergy.
Kegel exercises are the standard and most effective treatment for incontinence caused by poor muscle tone.

In women, lower estrogen levels during menopause can cause urethral tissue to become thinner, less resilient, and less elastic, leading to reduced sphincter control. The addition of phytoestrogens (plant estrogens) to the diet can be helpful for women who experience menopause-related tissue atrophy. Phytoestrogens are compounds found in plants that produce an estrogen-like effect in the body. In most cases, adding phytoestrogens to the diet is safe and easy and the following items may be suggested:

Soy isoflavones, which are the components of soy with the strongest estrogenic properties, are available in capsule form in health food stores and supermarket nutrition sections. A typical dose is 50–150 mg daily. There are also several phytoestrogenic and progesterone creams that can be applied directly to the genital tissue to support the elasticity as well as reduce vaginal dryness.
From a naturopathic standpoint, incontinence problems that are not the result of neurological damage, poor muscle tone, or hormone deficiencies are may result from irritability or chronic inflammation within the bladder or urethral tissues caused by food sensitivities. Naturopathic physicians and holistic medical doctors often can treat this uncomfortable condition with changes in the diet and the elimination of sensitive and/or inflammatory foods.
Nutrition

Supplements
The following supplements can provide anti-inflammatory support.

Herbal Medicine
Herbal medicines usually do not have side effects when used appropriately and at suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset or a headache. This may reflect the purity of the preparation or added ingredients, such as synthetic binders or fillers. For this reason, it is recommended that only high-quality products be used. As with all medications, more is not better and overdosing can lead to serious illness and death.
The following herbs may be used to soothe and heal the urinary tract:

Homeopathy
A trained homeopathic practitioner is needed to diagnose and prescribe a deep-acting, constitutional remedy. The standard dosage for acute symptom relief is 3 pellets of 30C every 4 hours until symptoms resolve. Lower potencies, such as 6X, 6C, 30X, may be given every 2 to 4 hours. If the right remedy is chosen, symptoms should improve shortly after the second dose. If there is no improvement after 3 doses, a different remedy is given.
The following remedies have been used to treat incontinence:

Interstitial Cystitis

Interstitial cystitis (IC) is a chronic inflammatory condition of the bladder that causes frequent, urgent, and painful urination and pelvic discomfort. The natural lining of the bladder (epithelium) is protected from toxins in the urine by a layer of protein called glycoaminoglycan (GAG). In IC this protective layer has broken down, allowing toxins to irritate the bladder wall. The bladder then becomes inflamed and tender and does not store urine well.
Unlike inflammation of the bladder caused by bacterial infection (cystitis), which is associated with urinary tract infections (UTI) and usually treated with antibiotics, no infectious agent has been found in IC. Though not curable, IC is treatable and most patients find some relief with treatment and lifestyle changes.

Kidney Cancer

Renal Cell Carcinoma (RCC)
Several types of cancer can develop in the kidneys. Renal cell carcinoma (RCC), the most common form, accounts for approximately 85% of all cases. In RCC, cancerous (malignant) cells develop in the lining of the kidney's tubules and grow into a mass called a tumor. In most cases, a single tumor develops, although more than one tumor can develop within one or both kidneys.

Early diagnosis of kidney cancer is important. As with most types of cancer, the earlier the tumor is discovered, the better a patient's chances for survival. Tumors discovered at an early stage often respond well to treatment. Survival rates in such cases are high. Tumors that have grown large or spread (metastasized) through the bloodstream or lymphatic system to other parts of the body are more difficult to treat and present an increased risk for mortality.

Incidence and Prevalence
According to the National Cancer Institute, the highest incidence of kidney cancer occurs in the United States, Canada, Northern Europe, Australia, and New Zealand. The lowest incidence is found in Thailand, China, and the Philippines.

In the United States, kidney cancer accounts for approximately 3% of all adult cancers. According to the American Cancer Society, about 32,000 new cases are diagnosed and about 12,000 people die from the disease annually. Kidney cancer occurs most often in people between the ages of 50 and 70, and affects men almost twice as often as women.

Smokers develop renal cell carcinoma about twice as often as nonsmokers and develop cancer of the renal pelvis about 4 times as often. Not smoking is the most effective way to prevent kidney cancer and it is estimated that the elimination of smoking would reduce the rate of renal pelvis cancer by one-half and the rate of renal cell carcinoma by one-third.
Wilms' tumor accounts for about 6% of childhood cancers and is the most common type of kidney cancer in children. Incidence of Wilms' tumor is higher in girls younger than the age of 5 and in African Americans.

The Kidneys
The kidneys are an essential part of the body's urinary system. Each kidney is composed of about one million microscopic "filtering packets" called glomeruli. The glomeruli remove uremic waste products from the blood. Each glomerulus connects to a long tube, called the tubule. Urine made by the glomerulus moves down the tubule. Together, the glomerulus and the tubule form a unit called a nephron. Each nephron connects to progressively larger tubular branches, until it reaches a large collection area called the calyx. The calices form the funnel-shaped portion of the upper ureter (renal pelvis). Urine moves from the renal pelvis to the ureters, the large tubes that connect the kidney to the bladder.

Kidney Stones

Overview
Physician developed and monitored.
Original source: www.urologychannel.com
Kidney stones (calculi) are hardened mineral deposits that form in the kidney. They originate as microscopic particles and develop into stones over time. The medical term for this condition is nephrolithiasis, or renal stone disease.
The kidneys filter waste products from the blood and add them to the urine that the kidneys produce. When waste materials in the urine do not dissolve completely, crystals and kidney stones are likely to form.

Small stones can cause some discomfort as they pass out of the body. Regardless of size, stones may pass out of the kidney, become lodged in the tube that carries urine from the kidney to the bladder (ureter), and cause severe pain that begins in the lower back and radiates to the side or groin. A lodged stone can block the flow of urine, causing pressure to build in the affected ureter and kidney. Increased pressure results in stretching and spasm, which cause severe pain.

Stone Formation
Kidney stones form when there is a high level of calcium (hypercalciuria), oxalate (hyperoxaluria), or uric acid (hyperuricosuria) in the urine; a lack of citrate in the urine; or insufficient water in the kidneys to dissolve waste products. The kidneys must maintain an adequate amount of water in the body to remove wa