Ingredient in Botanicals Tied to Urinary Cancer

New research links a carcinogen known as aristolochic acid, which is found in some Chinese herbal products, including guan mu-tong, to a higher risk of urinary tract cancer.

The findings were reported online Dec. 21 in the Journal of the National Cancer Institute.

The study involved 4,594 people in Taiwan who had just been diagnosed with urinary tract cancer, as well as a random sample of 174,701 people from the country.

The cancer rate was higher among those who had been prescribed more than 60 grams of mu-tong (which the researchers said might have had guan mu-tong in it) and among people who had consumed an estimated 150 milligrams or more of aristolochic acid.

"In addition to a ban on products that contain any amount of aristolochic acid, we also recommend continued surveillance of herbs or Chinese herbal products that might be adulterated with aristolochic-acid-containing herbs," the researchers wrote. "Finally, patients with a history of aristolochic acid nephropathy or consumption of mu-tong or fangchi before they were banned should be monitored regularly for urinary cancer."

Many countries, including Taiwan, have banned products, including botanicals, that contain aristolochic acid, according to a news release from the journal's publisher.

The researchers acknowledged that their finding came with caveats — including that participants in the study might have taken other herbs that were not prescribed and that the analysis did not take smoking into account.

Women's Health

Bladder Cancer

Bladder cancer is extremely rare in children. The most common carcinoma to involve the bladder is transitional cell carcinoma, which generally presents with blood in the urine. The diagnosis and treatment of bladder cancer are the same for children, adolescents, and adults. Adolescents who develop this tumor are often prone to the development of other cancers. Bladder cancer in adolescents may develop as a late effect of certain chemotherapy Bladder Cancer Treatment drugs given for other childhood tumors or leukemia.

National Cancer Institute

Cystoscopy and Ureteroscopy

Cystoscopy and Ureteroscopy

What is a cystoscopy?

A cystoscopy is an examination of the inside of the bladder and urethra, the tube that carries urine from the bladder to the outside of the body. In men, the urethra is the tube that runs through the penis. The doctor performing the examination uses a cystoscope—a long, thin instrument with an eyepiece on the external end and a tiny lens and a light on the end that is inserted into the bladder. The doctor inserts the cystoscope into the patient’s urethra, and the small lens magnifies the inner lining of the urethra and bladder, allowing the doctor to see inside the hollow bladder. Many cystoscopes have extra channels within the sheath to insert other small instruments that can be used to treat or diagnose urinary problems.

A doctor may perform a cystoscopy to find the cause of many urinary conditions, including

• frequent urinary tract infections
• blood in the urine, which is called hematuria
• a frequent and urgent need to urinate
• unusual cells found in a urine sample
• painful urination, chronic pelvic pain, or interstitial cystitis/painful bladder syndrome
• urinary blockage caused by prostate enlargement or some other abnormal narrowing of the urinary tract
• a stone in the urinary tract, such as a kidney stone
• an unusual growth, polyp, tumor, or cancer in the urinary tract

What is a ureteroscopy?

A ureteroscopy is an examination or procedure using a ureteroscope. A ureteroscope, like a cystoscope, is an instrument for examining the inside of the urinary tract. A ureteroscope is longer and thinner than a cystoscope and is used to see beyond the bladder into the ureters, the tubes that carry urine from the kidneys to the bladder. Some ureteroscopes are flexible like a thin, long straw. Others are more rigid and firm. Through the ureteroscope, the doctor can see a stone in the ureter and then remove it with a small basket at the end of a wire inserted through an extra channel in the ureteroscope. Another way to treat a stone through a ureteroscope is to extend a flexible fiber through the scope up to the stone and then, with a laser beam shone through the fiber, break the stone into smaller pieces that can then pass out of the body in the urine. How and what the doctor will do is determined by the location, size, and composition of the stone.

The reasons for a ureteroscopy include the following conditions:

• frequent urinary tract infections
• hematuria
• unusual cells found in a urine sample
• urinary blockage caused by an abnormal narrowing of the ureter
• a kidney stone in the ureter
• an unusual growth, polyp, tumor, or cancer in the ureter

What are the preparations for a cystoscopy or ureteroscopy?

People scheduled for a cystoscopy or ureteroscopy should ask their doctor about any special instructions. In most cases, for cystoscopy, people will be able to eat normally in the hours before the test. For ureteroscopy, people may be told not to eat before the test.

Because any medical procedure has a small risk of injury, patients must sign a consent form before the test. They should not hesitate to ask their doctor about any concerns they might have.

Patients may be asked to give a urine sample before the test to check for infection. They should avoid urinating for an hour before this part of the test.

Usually, patients lie on their back with knees raised and apart. A nurse or technician cleans the area around the urethral opening and applies a local anesthetic so the patient will not experience any discomfort during the test.

People having a ureteroscopy may receive a spinal or general anesthetic. They should arrange for a ride home after the test.

How is a cystoscopy or ureteroscopy performed?

After a local anesthetic is used to take away sensation in the ureter, the doctor gently inserts the tip of the cystoscope or ureteroscope into the urethra and slowly glides it up into the bladder. A sterile liquid—water or salt water, called saline—flows through the scope to slowly fill the bladder and stretch it so the doctor has a better view of the bladder wall.

As the bladder is filled with liquid, patients feel some discomfort and the urge to urinate. The doctor may then release some of the fluid, or the patient may empty the bladder as soon as the examination is over.

The time from insertion of the scope to removal may be only a few minutes, or it may be longer if the doctor finds a stone and decides to treat it. Taking a biopsy—a small tissue sample for examination with a microscope—will also make the procedure last longer. In most cases, the entire examination, including preparation, takes 15 to 30 minutes.

What happens after a cystoscopy or ureteroscopy?

Patients may have a mild burning feeling when they urinate, and they may see small amounts of blood in their urine. These problems should not last more than 24 hours. Patients should tell their doctor if bleeding or pain is severe or if problems last more than a day.

To relieve discomfort, patients should drink two 8-ounce glasses of water each hour for 2 hours after the procedure. They may ask their doctor if they can take a warm bath to relieve the burning feeling. If not, they may be able to hold a warm, damp washcloth over the urethral opening.

The doctor may prescribe an antibiotic to take for 1 or 2 days to prevent an infection. Any signs of infection—including severe pain, chills, or fever—should be reported to a doctor.

Points to Remember

• Cystoscopy and ureteroscopy are procedures used to view the inside of the bladder, urethra, and possibly the ureters.
• A cystoscope is an instrument used to examine the urethra and bladder.
• A ureteroscope is an instrument used to examine the ureters.
• Before a cystoscopy or ureteroscopy, patients should
  • talk with their doctor to ask questions and receive instructions
  • sign a consent form
  • avoid urinating for about an hour before giving a urine sample if one is required
  • arrange for a ride home if general or spinal anesthetic will be used
• After a cystoscopy or ureteroscopy, patients should
  • drink two 8-ounce glasses of water each hour for 2 hours
  • ask about taking a bath or using a warm, damp washcloth to relieve the burning feeling
  • report any problems, such as
    • bloody urine that lasts more than 24 hours after the test
    • severe pain
    • chills
    • fever

Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has many research programs aimed at understanding kidney and urologic disorders, including urinary stones, enlarged prostate, urinary incontinence, and kidney failure. The NIDDK sponsors researchers developing advanced diagnostic equipment, such as cystoscopes that can examine bladder tissue at the microscopic level. This technology may in some cases eliminate the need for biopsy.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research.

Medlineplus

Leigh’s Disease

What is Leigh’s Disease?

Leigh’s disease is a rare inherited neurometabolic disorder that affects the central nervous system. This progressive disorder begins in infants between the ages of three months and two years. Rarely, it occurs in teenagers and adults. Leigh’s disease can be caused by mutations in mitochondrial DNA or by deficiencies of an enzyme called pyruvate dehydrogenase. Symptoms of Leigh’s disease usually progress rapidly. The earliest signs may be poor sucking ability,and the loss of head control and motor skills.These symptoms may be accompanied by loss of appetite, vomiting, irritability, continuous crying, and seizures. As the disorder progresses, symptoms may also include generalized weakness, lack of muscle tone, and episodes of lactic acidosis, which can lead to impairment of respiratory and kidney function.

In Leigh’s disease, genetic mutations in mitochondrial DNA interfere with the energy sources that run cells in an area of the brain that plays a role in motor movements. The primary function of mitochondria is to convert the energy in glucose and fatty acids into a substance called adenosine triphosphate ( ATP). The energy in ATP drives virtually all of a cell’s metabolic functions. Genetic mutations in mitochondrial DNA, therefore, result in a chronic lack of energy in these cells, which in turn affects the central nervous system and causes progressive degeneration of motor functions.

There is also a form of Leigh’s disease (called X-linked Leigh’s disease) which is the result of mutations in a gene that produces another group of substances that are important for cell metabolism. This gene is only found on the X chromosome.

Is there any treatment?

The most common treatment for Leigh’s disease is thiamine or Vitamin B1. Oral sodium bicarbonate or sodium citrate may also be prescribed to manage lactic acidosis. Researchers are currently testing dichloroacetate to establish its effectiveness in treating  lactic acidosis. In individuals who have the X-linked form of Leigh’s disease, a high-fat, low-carbohydrate diet may be recommended.

What is the prognosis?

The prognosis for individuals with Leigh’s disease is poor. Individuals who lack mitochondrial complex IV activity and those with pyruvate dehydrogenase deficiency tend to have the worst prognosis and die within a few years. Those with partial deficiencies have a better prognosis, and may live to be 6 or 7 years of age. Some have survived to their mid-teenage years.

NINDS

Cystocele (Fallen Bladder)

What is a cystocele?

A cystocele occurs when the wall between a woman’s bladder and her vagina weakens and allows the bladder to droop into the vagina. This condition may cause discomfort and problems with emptying the bladder.

A bladder that has dropped from its normal position may cause two kinds of problems—unwanted urine leakage and incomplete emptying of the bladder. In some women, a fallen bladder stretches the opening into the urethra, causing urine leakage when the woman coughs, sneezes, laughs, or moves in any way that puts pressure on the bladder.

A cystocele is mild—grade 1—when the bladder droops only a short way into the vagina. With a more severe—grade 2—cystocele, the bladder sinks far enough to reach the opening of the vagina. The most advanced—grade 3—cystocele occurs when the bladder bulges out through the opening of the vagina.

What causes a cystocele?

A cystocele may result from muscle straining while giving birth. Other kinds of straining—such as heavy lifting or repeated straining during bowel movements—may also cause the bladder to fall. The hormone estrogen helps keep the muscles around the vagina strong. When women go through menopause—that is, when they stop having menstrual periods—their bodies stop making estrogen, so the muscles around the vagina and bladder may grow weak.

How is a cystocele diagnosed?

A doctor may be able to diagnose a grade 2 or grade 3 cystocele from a description of symptoms and from physical examination of the vagina because the fallen part of the bladder will be visible. A voiding cystourethrogram is a test that involves taking x rays of the bladder during urination. This x ray shows the shape of the bladder and lets the doctor see any problems that might block the normal flow of urine. Other tests may be needed to find or rule out problems in other parts of the urinary system.

How is a cystocele treated?

Treatment options range from no treatment for a mild cystocele to surgery for a serious cystocele. If a cystocele is not bothersome, the doctor may only recommend avoiding heavy lifting or straining that could cause the cystocele to worsen. If symptoms are moderately bothersome, the doctor may recommend a pessary—a device placed in the vagina to hold the bladder in place. Pessaries come in a variety of shapes and sizes to allow the doctor to find the most comfortable fit for the patient. Pessaries must be removed regularly to avoid infection or ulcers.

Large cystoceles may require surgery to move and keep the bladder in a more normal position. This operation may be performed by a gynecologist, a urologist, or a urogynecologist. The most common procedure for cystocele repair is for the surgeon to make an incision in the wall of the vagina and repair the area to tighten the layers of tissue that separate the organs, creating more support for the bladder. The patient may stay in the hospital for several days and take 4 to 6 weeks to recover fully.

Prostate Enlargement: Benign Prostatic Hyperplasia

The Prostate Gland

The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. As the diagrams show, the prostate is located in front of the rectum and just below the bladder, where urine is stored. The prostate also surrounds the urethra, the canal through which urine passes out of the body.

Scientists do not know all the prostate's functions. One of its main roles, though, is to squeeze fluid into the urethra as sperm move through during sexual climax. This fluid, which helps make up semen, energizes the sperm and makes the vaginal canal less acidic.

Benign Prostatic Hyperplasia: A Common Part of Aging

It is common for the prostate gland to become enlarged as a man ages. Doctors call this condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH.

Though the prostate continues to grow during most of a man's life, the enlargement doesn't usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH.

As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so some of the urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.

Many people feel uncomfortable talking about the prostate, since the gland plays a role in both sex and urination. Still, prostate enlargement is as common a part of aging as gray hair. As life expectancy rises, so does the occurrence of BPH. In the United States in 2000, there were 4.5 million visits to physicians for BPH.

Why BPH Occurs

The cause of BPH is not well understood. No definite information on risk factors exists. For centuries, it has been known that BPH occurs mainly in older men and that it doesn't develop in men whose testes were removed before puberty. For this reason, some researchers believe that factors related to aging and the testes may spur the development of BPH.

Throughout their lives, men produce both testosterone, an important male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. Studies done on animals have suggested that BPH may occur because the higher amount of estrogen within the gland increases the activity of substances that promote cell growth.

Another theory focuses on dihydrotestosterone (DHT), a substance derived from testosterone in the prostate, which may help control its growth. Most animals lose their ability to produce DHT as they age. However, some research has indicated that even with a drop in the blood's testosterone level, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of cells. Scientists have also noted that men who do not produce DHT do not develop BPH.

Some researchers suggest that BPH may develop as a result of “instructions” given to cells early in life. According to this theory, BPH occurs because cells in one section of the gland follow these instructions and “reawaken” later in life. These “reawakened” cells then deliver signals to other cells in the gland, instructing them to grow or making them more sensitive to hormones that influence growth.

Symptoms

Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but the most common ones involve changes or problems with urination, such as

a hesitant, interrupted, weak stream
urgency and leaking or dribbling
more frequent urination, especially at night
The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms while others, whose glands are less enlarged, have more blockage and greater problems.

Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking over-the-counter cold or allergy medicines. Such medicines contain a decongestant drug, known as a sympathomimetic. A potential side effect of this drug may prevent the bladder opening from relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temperatures, or a long period of immobility.

It is important to tell your doctor about urinary problems such as those described above. In eight out of 10 cases, these symptoms suggest BPH, but they also can signal other, more serious conditions that require prompt treatment. These conditions, including prostate cancer, can be ruled out only by a doctor's examination.

Severe BPH can cause serious problems over time. Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence—the inability to control urination. If the bladder is permanently damaged, treatment for BPH may be ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such complications.

Diagnosis

You may first notice symptoms of BPH yourself, or your doctor may find that your prostate is enlarged during a routine checkup. When BPH is suspected, you may be referred to a urologist, a doctor who specializes in problems of the urinary tract and the male reproductive system. Several tests help the doctor identify the problem and decide whether surgery is needed. The tests vary from patient to patient, but the following are the most common.

Digital Rectal Examination (DRE)

This examination is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This examination gives the doctor a general idea of the size and condition of the gland.

Prostate-Specific Antigen (PSA) Blood Test

To rule out cancer as a cause of urinary symptoms, your doctor may recommend a PSA blood test. PSA, a protein produced by prostate cells, is frequently present at elevated levels in the blood of men who have prostate cancer. The U.S. Food and Drug Administration (FDA) has approved a PSA test for use in conjunction with a digital rectal examination to help detect prostate cancer in men who are age 50 or older and for monitoring men with prostate cancer after treatment. However, much remains unknown about the interpretation of PSA levels, the test's ability to discriminate cancer from benign prostate conditions, and the best course of action following a finding of elevated PSA.

A fact sheet titled “The Prostate-Specific Antigen (PSA) Test: Questions and Answers” can be found on the National Cancer Institute website at www.cancer.gov/cancertopics/factsheet/Detection/PSA.

Rectal Ultrasound and Prostate Biopsy

If there is a suspicion of prostate cancer, your doctor may recommend a test with rectal ultrasound. In this procedure, a probe inserted in the rectum directs sound waves at the prostate. The echo patterns of the sound waves form an image of the prostate gland on a display screen. To determine whether an abnormal-looking area is indeed a tumor, the doctor can use the probe and the ultrasound images to guide a biopsy needle to the suspected tumor. The needle collects a few pieces of prostate tissue for examination with a microscope.

Urine Flow Study

Your doctor may ask you to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH.

Cystoscopy

In this examination, the doctor inserts a small tube through the opening of the urethra in the penis. This procedure is done after a solution numbs the inside of the penis so all sensation is lost. The tube, called a cystoscope, contains a lens and a light system that help the doctor see the inside of the urethra and the bladder. This test allows the doctor to determine the size of the gland and identify the location and degree of the obstruction.

Treatment

Men who have BPH with symptoms usually need some kind of treatment at some time. However, a number of researchers have questioned the need for early treatment when the gland is just mildly enlarged. The results of their studies indicate that early treatment may not be needed because the symptoms of BPH clear up without treatment in as many as one-third of all mild cases. Instead of immediate treatment, they suggest regular checkups to watch for early problems. If the condition begins to pose a danger to the patient's health or causes a major inconvenience to him, treatment is usually recommended.

Since BPH can cause urinary tract infections, a doctor will usually clear up any infection with antibiotics before treating the BPH itself. Although the need for treatment is not usually urgent, doctors generally advise going ahead with treatment once the problems become bothersome or present a health risk.

The following section describes the types of treatment that are most commonly used for BPH.

Drug Treatment

Over the years, researchers have tried to find a way to shrink or at least stop the growth of the prostate without using surgery. The FDA has approved six drugs to relieve common symptoms associated with an enlarged prostate.

Finasteride (Proscar), FDA-approved in 1992, and dutasteride (Avodart), FDA-approved in 2001, inhibit production of the hormone DHT, which is involved with prostate enlargement. The use of either of these drugs can either prevent progression of growth of the prostate or actually shrink the prostate in some men.

The FDA also approved the drugs terazosin (Hytrin) in 1993, doxazosin (Cardura) in 1995, tamsulosin (Flomax) in 1997, and alfuzosin (Uroxatral) in 2003 for the treatment of BPH. All four drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction. The four drugs belong to the class known as alpha blockers. Terazosin and doxazosin were developed first to treat high blood pressure. Tamsulosin and alfuzosin were developed specifically to treat BPH.

The Medical Therapy of Prostatic Symptoms (MTOPS) Trial, supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), recently found that using finasteride and doxazosin together is more effective than using either drug alone to relieve symptoms and prevent BPH progression. The two-drug regimen reduced the risk of BPH progression by 67 percent, compared with 39 percent for doxazosin alone and 34 percent for finasteride alone.

Minimally Invasive Therapy

Because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms but are less invasive than conventional surgery.

Transurethral microwave procedures. In 1996, the FDA approved a device that uses microwaves to heat and destroy excess prostate tissue. In the procedure called transurethral microwave thermotherapy (TUMT), the device sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. A cooling system protects the urinary tract during the procedure.

The procedure takes about 1 hour and can be performed on an outpatient basis without general anesthesia. TUMT has not been reported to lead to erectile dysfunction or incontinence.

Although microwave therapy does not cure BPH, it reduces urinary frequency, urgency, straining, and intermittent flow. It does not correct the problem of incomplete emptying of the bladder. Ongoing research will determine any long-term effects of microwave therapy and who might benefit most from this therapy.

Transurethral needle ablation. Also in 1996, the FDA approved the minimally invasive transurethral needle ablation (TUNA) system for the treatment of BPH.

The TUNA system delivers low-level radiofrequency energy through twin needles to burn away a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage. The TUNA system improves urine flow and relieves symptoms with fewer side effects when compared with transurethral resection of the prostate (TURP). No incontinence or impotence has been observed.

Water-induced thermotherapy. This therapy uses heated water to destroy excess tissue in the prostate. A catheter containing multiple shafts is positioned in the urethra so that a treatment balloon rests in the middle of the prostate. A computer controls the temperature of the water, which flows into the balloon and heats the surrounding prostate tissue. The system focuses the heat in a precise region of the prostate. Surrounding tissues in the urethra and bladder are protected. Destroyed tissue either escapes with urine through the urethra or is reabsorbed by the body.

High-intensity focused ultrasound. The use of ultrasound waves to destroy prostate tissue is still undergoing clinical trials in the United States. The FDA has not yet approved high-intensity focused ultrasound.

Surgical Treatment

Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following section describes the types of surgery that are used.

Transurethral surgery. In this type of surgery, no external incision is needed. After giving anesthesia, the surgeon reaches the prostate by inserting an instrument through the urethra.

A procedure called transurethral resection of the prostate (TURP) is used for 90 percent of all prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is inserted through the penis. The resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels.

During the 90-minute operation, the surgeon uses the resectoscope's wire loop to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the bladder and then flushed out at the end of the operation.

Most doctors suggest using TURP whenever possible. Transurethral procedures are less traumatic than open forms of surgery and require a shorter recovery period. One possible side effect of TURP is retrograde, or backward, ejaculation. In this condition, semen flows backward into the bladder during climax instead of out the urethra.

Another surgical procedure is called transurethral incision of the prostate (TUIP). Instead of removing tissue, as with TURP, this procedure widens the urethra by making a few small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate gland itself. Although some people believe that TUIP gives the same relief as TURP with less risk of side effects such as retrograde ejaculation, its advantages and long-term side effects have not been clearly established.

Open surgery. In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient's general health help the surgeon decide which of the three open procedures to use.

With all the open procedures, anesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he or she scoops out the enlarged tissue from inside the gland.

Laser surgery. In March 1996, the FDA approved a surgical procedure that employs side-firing laser fibers and Nd: YAG lasers to vaporize obstructing prostate tissue. The doctor passes the laser fiber through the urethra into the prostate using a cystoscope and then delivers several bursts of energy lasting 30 to 60 seconds. The laser energy destroys prostate tissue and causes shrinkage. As with TURP, laser surgery requires anesthesia and a hospital stay. One advantage of laser surgery over TURP is that laser surgery causes little blood loss. Laser surgery also allows for a quicker recovery time. But laser surgery may not be effective on larger prostates. The long-term effectiveness of laser surgery is not known.

Newer procedures that use laser technology can be performed on an outpatient basis.

Photoselective vaporization of the prostate (PVP). PVP uses a high-energy laser to destroy prostate tissue and seal the treated area.

Interstitial laser coagulation. Unlike other laser procedures, interstitial laser coagulation places the tip of the fiberoptic probe directly into the prostate tissue to destroy it.

Your Recovery After Surgery in the Hospital

The amount of time you will stay in the hospital depends on the type of surgery you had and how quickly you recover.

Foley catheter

At the end of surgery, a special catheter is inserted through the opening of the penis to drain urine from the bladder into a collection bag. Called a Foley catheter, this device has a water-filled balloon on the end that is put in the bladder, which keeps it in place.

This catheter is usually left in place for several days. Sometimes, the catheter causes recurring painful bladder spasms the day after surgery. These spasms may be difficult to control, but they will eventually disappear.

You may also be given antibiotics while you are in the hospital. Many doctors start giving this medicine before or soon after surgery to prevent infection. However, some recent studies suggest that antibiotics may not be needed in every case, and your doctor may prefer to wait until an infection is present to give them.

After surgery, you will probably notice some blood or clots in your urine as the wound starts to heal. If your bladder is being irrigated (flushed with water), you may notice that your urine becomes red once the irrigation is stopped. Some bleeding is normal, and it should clear up by the time you leave the hospital. During your recovery, it is important to drink a lot of water (up to 8 cups a day) to help flush out the bladder and speed healing.

Do's and Don'ts

Take it easy the first few weeks after you get home. You may not have any pain, but you still have an incision that is healing—even with transurethral surgery, where the incision can't be seen. Since many people try to do too much at the beginning and then have a setback, it is a good idea to talk with your doctor before resuming your normal routine. During this initial period of recovery at home, avoid any straining or sudden movements that could tear the incision. Here are some guidelines:

Continue drinking a lot of water to flush the bladder.
Avoid straining when having a bowel movement.
Eat a balanced diet to prevent constipation. If constipation occurs, ask your doctor if you can take a laxative.
Don't do any heavy lifting.
Don't drive or operate machinery.

Getting Back to Normal After Surgery

Even though you should feel much better by the time you leave the hospital, it will probably take a couple of months for you to heal completely. During the recovery period, the following are some common problems that can occur.

Problems Urinating

You may notice that your urinary stream is stronger right after surgery, but it may take awhile before you can urinate completely normally again. After the catheter is removed, urine will pass over the surgical wound on the prostate, and you may initially have some discomfort or feel a sense of urgency when you urinate. This problem will gradually lessen, and after a couple of months you should be able to urinate less frequently and more easily.

Incontinence

As the bladder returns to normal, you may have some temporary problems controlling urination, but long-term incontinence rarely occurs. Doctors find that the longer problems existed before surgery, the longer it takes for the bladder to regain its full function after the operation.

Bleeding

In the first few weeks after transurethral surgery, the scab inside the bladder may loosen, and blood may suddenly appear in the urine. Although this can be alarming, the bleeding usually stops with a short period of resting in bed and drinking fluids. However, if your urine is so red that it is difficult to see through or if it contains clots or if you feel any discomfort, be sure to contact your doctor.

Sexual Function After Surgery

Many men worry about whether surgery for BPH will affect their ability to enjoy sex. Some sources state that sexual function is rarely affected, while others claim that it can cause problems in up to 30 percent of cases. However, most doctors say that even though it takes awhile for sexual function to return fully, with time, most men are able to enjoy sex again.

Complete recovery of sexual function may take up to 1 year, lagging behind a person's general recovery. The exact length of time depends on how long after symptoms appeared that BPH surgery was done and on the type of surgery. Following is a summary of how surgery is likely to affect the following aspects of sexual function.

Erections

Most doctors agree that if you were able to maintain an erection shortly before surgery, you will probably be able to have erections afterward. Surgery rarely causes a loss of erectile function. However, surgery cannot usually restore function that was lost before the operation.

Ejaculation

Although most men are able to continue having erections after surgery, a prostate procedure frequently makes them sterile (unable to father children) by causing a condition called retrograde ejaculation or dry climax.

During sexual activity, sperm from the testes enters the urethra near the opening of the bladder. Normally, a muscle blocks off the entrance to the bladder, and the semen is expelled through the penis. However, the coring action of prostate surgery cuts this muscle as it widens the neck of the bladder. Following surgery, the semen takes the path of least resistance and enters the wider opening to the bladder rather than being expelled through the penis. Later it is harmlessly flushed out with urine. In some cases, this condition can be treated with a drug called pseudoephedrine, found in many cold medicines, or imipramine. These drugs improve muscle tone at the bladder neck and keep semen from entering the bladder.

Orgasm

Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. Although it may take some time to get used to retrograde ejaculation, you should eventually find sex as pleasurable after surgery as before.

Many people have found that concerns about sexual function can interfere with sex as much as the operation itself. Understanding the surgical procedure and talking over any worries with the doctor before surgery often help men regain sexual function earlier. Many men also find it helpful to talk with a counselor during the adjustment period after surgery.

Is Further Treatment Needed?

In the years after your surgery, it is important to continue having a rectal examination once a year and to have any symptoms checked by your doctor.

Since surgery for BPH leaves behind a good part of the gland, it is still possible for prostate problems, including BPH, to develop again. However, surgery usually offers relief from BPH for at least 15 years. Only 10 percent of the men who have surgery for BPH eventually need a second operation for enlargement. Usually these are men who had the first surgery at an early age.

Sometimes, scar tissue resulting from surgery requires treatment in the year after surgery. Rarely, the opening of the bladder becomes scarred and shrinks, causing obstruction. This problem may require a surgical procedure similar to transurethral incision (see section on Surgical Treatment). More often, scar tissue may form in the urethra and cause narrowing. The doctor can solve this problem during an office visit by stretching the urethra.

Prostatic Stents

A stent is a small device that is inserted through the urethra to the narrowed area and allowed to expand, like a spring. The stent pushes back the prostatic tissue, widening the urethra. It is designed to relieve urinary obstruction in men and improve the ability to urinate. The device is approved for use in men for whom other standard surgical procedures to correct urinary obstruction have failed.

BPH and Prostate Cancer: No Apparent Relation

Although some of the signs of BPH and prostate cancer are the same, having BPH does not seem to increase the chances of getting prostate cancer. Nevertheless, a man who has BPH may have undetected prostate cancer at the same time or may develop prostate cancer in the future. For this reason, the National Cancer Institute and the American Cancer Society recommend that all men over 40 have a rectal examination once a year to screen for prostate cancer.

After BPH surgery, the tissue removed is routinely checked for hidden cancer cells. In about one out of 10 cases, some cancer tissue is found, but often it is limited to a few cells of a nonaggressive type of cancer, and no treatment is needed.

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Hematuria (Blood in the Urine)

What is hematuria?

Hematuria is the presence of red blood cells (RBCs) in the urine. In microscopic hematuria, the urine appears normal to the naked eye, but examination with a microscope shows a high number of RBCs. Gross hematuria can be seen with the naked eye—the urine is red or the color of cola.

What causes hematuria?

Several conditions can cause hematuria, most of them not serious. For example, exercise may cause hematuria that goes away in 24 hours. Many people have hematuria without any other related problems. Often no specific cause can be found. But because hematuria may be the result of a tumor or other serious problem, a doctor should be consulted.

How is hematuria diagnosed?

To find the cause of hematuria, or to rule out certain causes, the doctor may order a series of tests, including urinalysis, blood tests, kidney imaging studies, and cystoscopic examination.

Urinalysis is the examination of urine for various cells and chemicals. In addition to finding RBCs, the doctor may find white blood cells that signal a urinary tract infection or casts, which are groups of cells molded together in the shape of the kidneys' tiny filtering tubes, that signal kidney disease. Excessive protein in the urine also signals kidney disease.

Blood tests may reveal kidney disease if the blood contains high levels of wastes that the kidneys are supposed to remove.

Kidney imaging studies include ultrasound, computerized tomography (CT) scan, or intravenous pyelogram (IVP). An IVP is an x ray of the urinary tract. Imaging studies may reveal a tumor, a kidney or bladder stone, an enlarged prostate, or other blockage to the normal flow of urine.

A cystoscope can be used to take pictures of the inside of the bladder. It has a tiny camera at the end of a thin tube, which is inserted through the urethra. A cystoscope may provide a better view of a tumor or bladder stone than can be seen in an IVP.

How is hematuria treated?

Treatment for hematuria depends on the cause. If no serious condition is causing the hematuria, no treatment is necessary.

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How the Urinary System Works

The organs, tubes, muscles, and nerves that work together to create, store, and carry urine are the urinary system. The urinary system includes two kidneys, two ureters, the bladder, two sphincter muscles, and the urethra.

How does the urinary system work?

Your body takes nutrients from food and uses them to maintain all bodily functions including energy and self-repair. After your body has taken what it needs from the food, waste products are left behind in the blood and in the bowel. The urinary system works with the lungs, skin, and intestines—all of which also excrete wastes—to keep the chemicals and water in your body balanced. Adults eliminate about a quart and a half of urine each day. The amount depends on many factors, especially the amounts of fluid and food a person consumes and how much fluid is lost through sweat and breathing. Certain types of medications can also affect the amount of urine eliminated.

The urinary system removes a type of waste called urea from your blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys.

The kidneys are bean-shaped organs about the size of your fists. They are near the middle of the back, just below the rib cage. The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.

From the kidneys, urine travels down two thin tubes called ureters to the bladder. The ureters are about 8 to 10 inches long. Muscles in the ureter walls constantly tighten and relax to force urine downward away from the kidneys. If urine is allowed to stand still, or back up, a kidney infection can develop. Small amounts of urine are emptied into the bladder from the ureters about every 10 to 15 seconds.

The bladder is a hollow muscular organ shaped like a balloon. It sits in your pelvis and is held in place by ligaments attached to other organs and the pelvic bones. The bladder stores urine until you are ready to go to the bathroom to empty it. It swells into a round shape when it is full and gets smaller when empty. If the urinary system is healthy, the bladder can hold up to 16 ounces (2 cups) of urine comfortably for 2 to 5 hours.

Circular muscles called sphincters help keep urine from leaking. The sphincter muscles close tightly like a rubber band around the opening of the bladder into the urethra, the tube that allows urine to pass outside the body.

Nerves in the bladder tell you when it is time to urinate, or empty your bladder. As the bladder first fills with urine, you may notice a feeling that you need to urinate. The sensation to urinate becomes stronger as the bladder continues to fill and reaches its limit. At that point, nerves from the bladder send a message to the brain that the bladder is full, and your urge to empty your bladder intensifies.

When you urinate, the brain signals the bladder muscles to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax. As these muscles relax, urine exits the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.

What causes problems in the urinary system?

Problems in the urinary system can be caused by aging, illness, or injury. As you get older, changes in the kidneys’ structure cause them to lose some of their ability to remove wastes from the blood. Also, the muscles in your ureters, bladder, and urethra tend to lose some of their strength. You may have more urinary infections because the bladder muscles do not tighten enough to empty your bladder completely. A decrease in strength of muscles of the sphincters and the pelvis can also cause incontinence, the unwanted leakage of urine. Illness or injury can also prevent the kidneys from filtering the blood completely or block the passage of urine.

How are problems in the urinary system detected?

Urinalysis is a test that studies the content of urine for abnormal substances such as protein or signs of infection. This test involves urinating into a special container and leaving the sample to be studied.

Urodynamic tests evaluate the storage of urine in the bladder and the flow of urine from the bladder through the urethra. Your doctor may want to do a urodynamic test if you are having symptoms that suggest problems with the muscles or nerves of your lower urinary system and pelvis—ureters, bladder, urethra, and sphincter muscles.

Urodynamic tests measure the contraction of the bladder muscle as it fills and empties. The test is done by inserting a small tube called a catheter through your urethra into your bladder to fill it either with water or a gas. Another small tube is inserted into your rectum or vagina to measure the pressure put on your bladder when you strain or cough. Other bladder tests use x-ray dye instead of water so that x-ray pictures can be taken when the bladder fills and empties to detect any abnormalities in the shape and function of the bladder. These tests take about an hour.

What are some disorders of the urinary system?

Disorders of the urinary system range in severity from easy to treat to life threatening.

Benign prostatic hyperplasia (BPH) is a condition in men that affects the prostate gland, which is part of the male reproductive system. The prostate is located at the bottom of the bladder and surrounds the urethra. BPH is an enlargement of the prostate gland that can interfere with urinary function in older men. It causes blockage by squeezing the urethra, which can make it difficult to urinate. Men with BPH frequently have other bladder symptoms including an increase in frequency of bladder emptying both during the day and at night. Most men over age 60 have some BPH, but not all have problems with blockage. There are many different treatment options for BPH.

Painful bladder syndrome/Interstitial cystitis (PBS/IC) is a chronic bladder disorder also known as frequency-urgency-dysuria syndrome. In this disorder, the bladder wall can become inflamed and irritated. The inflammation can lead to scarring and stiffening of the bladder, decreased bladder capacity, pinpoint bleeding, and, in rare cases, ulcers in the bladder lining. The cause of IC is unknown at this time.

Kidney stones is the term commonly used to refer to stones, or calculi, in the urinary system. Stones form in the kidneys and may be found anywhere in the urinary system. They vary in size. Some stones cause great pain while others cause very little. The aim of treatment is to remove the stones, prevent infection, and prevent recurrence. Both nonsurgical and surgical treatments are used. Kidney stones affect men more often than women.

Prostatitis is inflammation of the prostate gland that results in urinary frequency and urgency, burning or painful urination, a condition called dysuria, and pain in the lower back and genital area, among other symptoms. In some cases, prostatitis is caused by bacterial infection and can be treated with antibiotics. But the more common forms of prostatitis are not associated with any known infecting organism. Antibiotics are often ineffective in treating the nonbacterial forms of prostatitis.

Proteinuria is the presence of abnormal amounts of protein in the urine. Healthy kidneys take wastes out of the blood but leave in protein. Protein in the urine does not cause a problem by itself. But it may be a sign that your kidneys are not working properly.

Renal (kidney) failure results when the kidneys are not able to regulate water and chemicals in the body or remove waste products from your blood. Acute renal failure (ARF) is the sudden onset of kidney failure. This condition can be caused by an accident that injures the kidneys, loss of a lot of blood, or some drugs or poisons. ARF may lead to permanent loss of kidney function. But if the kidneys are not seriously damaged, they may recover. Chronic kidney disease (CKD) is the gradual reduction of kidney function that may lead to permanent kidney failure, or end-stage renal disease (ESRD). You may go several years without knowing you have CKD.

Urinary tract infections (UTIs) are caused by bacteria in the urinary tract. Women get UTIs more often than men. UTIs are treated with antibiotics. Drinking lots of fluids also helps by flushing out the bacteria.

The name of the UTI depends on its location in the urinary tract. An infection in the bladder is called cystitis. If the infection is in one or both of the kidneys, the infection is called pyelonephritis. This type of UTI can cause serious damage to the kidneys if it is not adequately treated.

Urinary incontinence, loss of bladder control, is the involuntary passage of urine. There are many causes and types of incontinence, and many treatment options. Treatments range from simple exercises to surgery. Women are affected by urinary incontinence more often than men.

Urinary retention, or bladder-emptying problems, is a common urological problem with many possible causes. Normally, urination can be initiated voluntarily and the bladder empties completely. Urinary retention is the abnormal holding of urine in the bladder. Acute urinary retention is the sudden inability to urinate, causing pain and discomfort. Causes can include an obstruction in the urinary system, stress, or neurologic problems. Chronic urinary retention refers to the persistent presence of urine left in the bladder after incomplete emptying. Common causes of chronic urinary retention are bladder muscle failure, nerve damage, or obstructions in the urinary tract. Treatment for urinary retention depends on the cause.

Who can help me with a urinary problem?

Your primary doctor can help you with some urinary problems. Your pediatrician may be able to treat some of your child’s urinary problems. But some problems may require the attention of a urologist, a doctor who specializes in treating problems of the urinary system and the male reproductive system. A gynecologist is a doctor who specializes in the female reproductive system and may be able to help with some urinary problems. A urogynecologist is a gynecologist who specializes in the female urinary system. A nephrologist specializes in treating diseases of the kidney.

Points to Remember

Your urinary system filters waste and extra fluid from your blood.

Problems in the urinary system include kidney failure, urinary tract infections, kidney stones, prostate enlargement, and bladder control problems.

Health professionals who treat urinary problems include general practitioners (your primary doctor), pediatricians, urologists, gynecologists, urogynecologists, and nephrologists.

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Kidney Stones

Kidney Stones
Also called: Nephrolithiasis
A kidney stone is a solid piece of material that forms in the kidney from substances in the urine. It may be as small as a grain of sand or as large as a pearl. Most kidney stones pass out of the body without help from a doctor. But sometimes a stone will not go away. It may get stuck in the urinary tract, block the flow of urine and cause great pain.
The following may be signs of kidney stones that need a doctor's help:
Extreme pain in your back or side that will not go away
Blood in your urine
Fever and chills
Vomiting
Urine that smells bad or looks cloudy
A burning feeling when you urinate

National Institute of Diabetes and Digestive and Kidney Diseases

Phthiriasis

Adult pubic lice are 1.1-1.8 mm in length. Pubic lice typically are found attached to hair in the pubic area but sometimes are found on coarse hair elsewhere on the body (for example, eyebrows, eyelashes, beard, mustache, chest, armpits, etc.).

Pubic lice infestations are usually spread through sexual contact. Dogs, cats, and other pets do not play a role in the transmission of human lice.

Both over-the-counter and prescription medications are available for treatment of pubic lice infestations.

CDC

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