A - B - C - D - E - F - G - H - I - J - K - L - M - N - O - P - Q - R - S - T - U - V - W - X - Y - Z

A

Alpha Adrenergic Agonists - Alpha-adrenergic agonists are drugs, which stimulate sites in the nervous system that respond to the chemical norepinephrine. Therefore, patients suffering from forms of incontinence requiring increased muscle tone and urethral resistance -- for example, stress incontinence -- may benefit from the use of alpha-adrenergic agonists.

Alpha-1 Adrenergic Blocking Agents (Alpha Blockers) - Benign prostatic hyperplasia -- noncancerous enlargement of the prostate -- can encroach upon the urinary tract, leading to overflow or urge incontinence. Alpha-1 adrenergic receptor blocking agents --known as alpha-1 blockers or alpha blockers -- are used to treat BPH, because they reduce the tone of striated and smooth muscle, thereby decreasing urethral resistance and relieving symptoms of obstruction. Alpha-blockers should not be used in people who are hypersensitive (have an exaggerated reaction) to such medication or who experience postural hypotension (extremely low blood pressure when standing up or standing still).

Alternative Treatment Devices - In addition to standard methods such as biofeedback, drug therapy and surgery, a number of treatment devices are available to help patients achieve bladder control.

Interstim is a new therapy, which may be effective in treating urge incontinence in some patients. It consists of a device, about the size of a pacemaker that is implanted into the sacral nerves of the lower spine, where it delivers electrical impulses that help regulate bladder function.

In this way, Interstim reduces the likelihood and severity of accidental urination or leakage. The surgery required for implantation is minimal, and the device can be adjusted to meet the bladder control needs of each patient.

Prosthetic occluding devices can be used to block the flow of urine by squeezing the urethra shut. For men, such mechanical devices include penile clamps (for example, the Cunningham clamp) and compression rings. The penile clamp is a V-shaped casing with a foam cushion that fits over and under the penis. When closed, the penile clamp should stop the flow of urine without causing discomfort. Compression devices are adjustable rings that surround the penis and, when inflated with air, pinch off the urine flow. Individuals usually reserve occluding devices for temporary use with stress incontinence. These devices must be removed at regular 2- to 3-hour intervals to empty the bladder. Therefore, only mentally competent individuals who are able to adjust them by hand and who are able to remember the bladder-emptying schedule should use them. Improper use of penile clamps and compression devices can result in penile and urethral erosion, penile edema (swelling), pain and obstruction.

Vaginal pessaries -- ring, cube or doughnut-shaped devices made of rubber or silicone -- are inserted into the vagina to support the bladder neck in female patients with stress incontinence. Vaginal pessaries are available in different sizes, and they are generally put in place by a gynecologist. The major side effects of pessary use are wearing away have the vaginal skin and vaginal infection. Therefore, people who use pessaries need frequent examinations to ensure vaginal health. Erosion problems usually can be managed by removal of the pessary until the skin heals, and vaginal infections are treatable by douching and/or antibiotic therapy. Pessaries may be an alternative form of treatment for frail elderly women who cannot undergo other forms of incontinence therapy.

Introl is a pessary-like vaginal prosthesis that also works to support the bladder neck. A woman can insert and remove the device, which should not be worn continuously for more than 24hours without proper cleaning. The manufacturer recommends removing the prosthesis at night before going to bed.

A number of additional treatment devices recently have become available for women. The first device--the Reliance urinary control insert--also is known as a urethral plug. The Reliance insert is a single-use, balloon-tipped tube that is about one-fifth the size of a tampon. The insert can be placed in the urethra by means of a special applicator. When in place, the small balloon (which extends into the bladder) can be inflated with air to prevent leakage. If the wearer wishes to urinate, she just pulls a string to deflate the balloon and then removes the insert. Unfortunately, fairly high infection rates are seen with this device, because it is placed directly into the urethra. The manufacturer reports that urinary tract infections are most common during the first month of use and decrease as women become more familiar with its proper use.

Amitriptyline (Elavil) and doxepin (Sinequan) act as antidepressants when given in large doses. In smaller doses, they can help IC symptoms by blocking pain, calming bladder spasms, and decreasing inflammation.

Too much histamine in the bladder may cause some cases of IC. Antihistamine drugs such as hydroxyzine (Vistaril and Atarax) and cimetidine (Tagamet) relieve symptoms in some IC patients. If taken at bedtime, hydroxyzine may also help patients sleep.

Antibiotics - Antibiotics frequently are prescribed to eliminate infections that could impair fertility, such as infections of the urinary tract and prostate. The physician will be especially inclined to prescribe an antibiotic if leukocytes (white blood cells) are detected in the man's semen sample. Strong antibiotic medications - like double- strength trimethoprim plus sulfamethoxazole (Bactrim DS) and doxycycline hyclate (Vibramycin) - often are the drugs of choice. They usually are administered for intervals of 1 to 3 months. Nitrofuran antibiotics are avoided, since they may impair sperm maturation. STDs, such as gonorrhea or ureaplasma, commonly are treated with ceftriaxone sodium or doxycycline.

Arterial Embolization - This procedure usually is reserved for patients whose overall health does not permit surgery, such as those with heart or lung problems. In arterial embolization, a very small tube called a catheter is inserted through a blood vessel in the groin and passed up to the kidney. There it is used to inject a small piece of gelatin sponge into the artery that supplies blood to the cancerous kidney. This cuts off the flow of blood to the kidney and the cancerous tumor, which die. The kidney usually is surgically removed at a later date, if and when the patient's overall condition permits.

Artificial Insemination - Artificial insemination (AI) is a process in which a relatively large number of healthy sperm are deposited in a woman by artificial means. The sperm are placed either at the entrance to the cervix or directly into the uterus (womb) near the fallopian tubes (intrauterine insemination or IUI). Artificial insemination is particularly useful when the male partner's sperm count is low or when sperm quality is below average (e.g., in cases of spinal cord injury, ejaculation disorder or impotence). The sperm can be prepared by washing, concentration, or other methods to ensure the best chance of conception (see also Sperm Retrieval). Artificial insemination also is commonly performed using sperm from a donor.

Artificial Sphincter - An Artificial Sphincter sometimes complicated cases of incontinence require implantation of a device known as an artificial urinary sphincter. People who might benefit from this treatment include those who are incontinent after surgery for prostate cancer or stress incontinence, trauma victims and people with congenital (present at birth) defects in the urinary system.

The artificial sphincter has three components, including a pump, balloon reservoir, and a cuff that encircles the urethra and prevents urine from leaking out. The cuff is connected to the pump, which is surgically implanted in the scrotum (in men) or labia (in women). The pump can be activated (usually by squeezing or pressing a button) to deflate the cuff and permit the bladder to empty. After a brief interval, the cuff refills itself and the urethra is again pressed closed.

Because the artificial sphincter is an implant, it is subject to the risks common to implants, such as infection, erosion (breaking down of tissue) and mechanical malfunction. Yet with appropriate presurgical evaluation, operative techniques and postoperative follow-up, many problems can be avoided and incontinent patients can experience an improved quality of life with this device.

B

Bacillus Calmette-GuÈrin (BCG)

BALLOON DILATION - Balloon dilation has been used clinically as an alternative to prostatectomy. It is very similar to the angioplasties done for coronary artery disease. Basically, a balloon is placed into the prostatic channel, either by finger guidance or telescopic guidance, and the balloon is then inflated to stretch the prostate channel. This has the apparent end result of tearing the prostate gland and creating a wider opening in the urinary channel. No prostate tissue is removed and the procedure does not work well for very large prostates. Recent numerous studies have demonstrated that most of the patients after balloon dilation have recurrence of their symptoms relatively soon and require repeat treatments within two years. With today's wider and more efficaceous variety of BPH treatments, balloons are less accepted as a viable alternative treatment.

Biofeedback/Electrical Stimulation - Biofeedback is practiced to help people gain awareness and control of their urinary tract muscles. The principle of biofeedback is simple: a variety of instruments are used to record small electrical signals that are given off when specific muscles are squeezed during contraction. These contraction-related signals are instantly converted into audio and/or visual signs that patients can recognize and learn from, in order to control muscular activity. With biofeeback, weak muscles can be better activated on demand, overly tense muscles can be relaxed, and overall muscle activity can be coordinated.

Biofeedback usually is performed in conjunction with Kegel exercises, since it helps to reinforce correct Kegel techniques. Biofeedback lets patients visualize and identify the pelvic floor and/or abdominal muscles that are appropriate for their exercise programs.

Neuromuscular electrical stimulation (NMES) also is employed to "reeducate" and strengthen weak urinary muscles. In NMES, electrical stimulation of the pudendal nerve causes contraction of the pelvic floor and periurethral (urethra-encircling) muscles. A probe is inserted into either the vagina (female reproductive canal) or anus (outside opening of the large intestine), and NMES is applied at an intensity that is below the threshold of pain. Most NMES devices are biphasic: that is, they produce a current that stimulates contraction, followed by a rest period of 5 to 10 seconds.

Patients are instructed to join in with the NMES-stimulated contraction. Such assisted exercise eventually strengthens the pelvic floor muscles and improves bladder control. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence. NMES treatment programs usually last 20 to 30 minutes. NMES devices are available for both home and hospital use.

Bladder Augmentation - Individuals who suffer from a low-capacity bladder -- for example, a bladder that is small, hyperactive or nonresilient -- may benefit from surgery that increases the fluid-holding potential of the bladder. Surgery that increases bladder capacity, otherwise known as bladder augmentation or augmentation cystoplasty, is conducted using either the bladder itself (autoaugmentation) or bowel (intestine) segments. Such surgery is not recommended for patients who are unable to perform self-catheterization (self-placement of a urinary tube) or who have kidney disorders, bowel disease or urethral disease.

Autoaugmentation is a novel method of bladder augmentation. It increases the capacity of the bladder without using bowel or stomach segments, which may result in complications after other augmentation procedures. During autoaugmentation, the detrusor (the smooth muscle in the wall of the bladder that contracts and expels urine) is cut out of the dome of the bladder, leaving the mucosa (mucous membrane tissue) intact. This procedure creates a bladder with reduced muscle squeezing ability and improved function; however, long-term findings in some subjects suggest that contraction of the mucosa eventually can occur.

Bowel augmentation makes use of segments from the ileum (the last part of the small intestine), cecum (the first part of the large intestine) or ileocecum (junction between the small and large intestines) to increase the capacity of the bladder. In all bowel augmentation procedures, the bowel segments are changed in shape from a cylinder to a sphere to produce a flexible, low-pressure vessel. The bladder is opened at the dome and is cut at right angles on each side to create a clam-like shape. The open bowel segment then is joined to the "clammed" bladder with sutures.

Bowel augmentation is associated with post-operative complications, such as leakage of urine, continued incontinence, and kidney problems. Long-term risk factors include the development of bladder stones, increased risk of bladder cancer and increased risk of incontinence during and after pregnancy.

Bladder Distension - Because some patients have noted an improvement in symptoms after a Bladder Distension done to diagnose IC, the procedure is often thought of as one of the first treatment attempts.

Researchers are not sure why distension helps, but some believe that the procedure may increase bladder capacity and interfere with pain signals transmitted by nerves in the bladder. Symptoms may temporarily worsen 24 to 48 hours after distension, but should then return to predistension levels or improve after 2 to 4 weeks.

Bladder Instillation - This procedure may also be called a bladder wash or bath. During a Bladder Instillation, the bladder is filled with a solution that is held for varying periods of time, from a few seconds to 15 minutes, before being drained through a narrow tube called a catheter.

The only drug approved by the U.S. Food and Drug Administration (FDA) for bladder instillation is dimethyl sulfoxide (DMSO, RIMSO-50). With DMSO treatments a narrow tube (catheter) is guided up the urethra into the bladder. A measured amount of DMSO is passed through the catheter into the bladder, where it is retained for about 15 minutes before being expelled. Treatments are given every week or two for 6 to 8 weeks, and repeated as needed. Most people with IC who respond to DMSO notice improvement of symptoms 3 or 4 weeks after the first 6- to 8-week cycle of treatments. Highly motivated patients who are willing to catheterize themselves may, after consultation with their doctor, be able to have DMSO treatments at home. Self-administration of DMSO is less expensive and more convenient than going to the doctor's office.

Doctors think DMSO works in several ways. Because it passes into the bladder wall, DMSO may more effectively reach tissue to reduce inflammation and block pain. It may also prevent muscle contractions that may cause pain, frequency, and urgency.

A bothersome but relatively insignificant side effect of DMSO treatments is a garlic-like taste and odor from the breath and skin. This may last up to 72 hours after a treatment. Long-term DMSO treatments have caused cataracts in animal studies, but this side effect has not appeared in humans. Blood tests, including a complete blood count and kidney and liver function tests, should be done about every 6 months.

A variety of other drugs have been used experimentally for bladder washes, including silver nitrate, sodium oxychlorosene (Clorpactin WCS-90), heparin, and pentosanpolysulfate (Elmiron).

Silver nitrate and oxychlorosene sodium are thought to work by first attacking the bladder lining. This triggers the body's immune system to step in and start the healing process. Some patients have been successfully treated with these drugs, but the frequent, painful treatments usually must be done under general anesthesia. Neither drug can be used in people who have urinary reflux, a condition in which urine flows backward up the ureters into the kidneys.

Heparin and pentosanpolysulfate are thought to work by replacing or repairing the "leaky" bladder lining.

Bladder Removal (Cystectomy) - Different methods can be used to reroute urine once the bladder has been removed. In most cases, the ureters are attached to a piece of bowel that opens onto the skin of the abdomen, called a stoma. Urine empties through the stoma into a bag outside the body. This procedure is called a urostomy. Some urologists are using a technique that also requires a stoma but allows urine to be stored in a pouch inside the abdomen. At intervals throughout the day, the patient puts a catheter into the stoma and empties the pouch. Patients with either type of urostomy must use very clean, or sterile, steps to prevent infections in and around the stoma.

With a third method, a new bladder is made from a piece of the patient's bowel (large intestine) and attached to the urethra in place of the removed bladder. After a time of healing, the patient may be able to empty the bladder by voiding at scheduled times or may insert a catheter into the urethra. Few surgeons have the special training and expertise needed to perform this procedure.

Even after total bladder removal, some patients still experience variable symptoms of IC. Therefore, the decision to undergo a cystectomy should only be undertaken after serious deliberation on the potential outcome.

Bladder Training - People who have found some relief from pain may be able to reduce frequency using Bladder Training techniques. Methods vary, but basically the patient decides to void at designated times and use relaxation techniques and distractions to help keep to the schedule. Gradually, the patient tries to lengthen the time between the scheduled voids. A diary of voids is usually helpful in keeping track of progress.

Brachytherapy - Technically, brachytherapy is more a form of therapy than a surgical procedure, but it does involves a surgical element - the implantation of tiny, radioactive implants into a cancerous prostate gland. Radiation emitted by the implants kills the malignant tumor. Men whose cancers are small and confined to the prostate (Stage 1 or 2) are candidates for brachytherapy.

The physician first uses an ultrasound device (TRUS) to create a three-dimensional grid map of the prostate. A computer then is used to calculate the volume of the gland, the number of radioactive implants (called "seeds") that will be needed and where they should be placed.

The procedure, performed on an outpatient basis, takes 45 to 60 minutes and is done under local (spinal) anesthesia. From 50 to 100 rice-sized seeds are then inserted by a special needle through the perineum and into the prostate in a preplanned pattern, guided by the TRUS and grid map. The seeds contain a radioactive isotope, usually Palladium 103 or Iodine 125, which emit radiation for about three months before decaying to an inert state.

Brachytherapy patients can be discharged the same day and usually resume normal activity within a day or two. A small proportion, generally those over 70, experience incontinence or impotence problems. But brachytherapy has been found to deliver a higher and better-focused dose of radiation with fewer side effects and at substantially lower cost than external beam therapy. In a recent study of 111 brachytherapy patients, 100% were prostate cancer free after five years.

Bromocriptine - Bromocriptine is a drug that is classified as a dopamine agonist. This means that bromocriptine acts like dopamine, a catecholamine (sympathetic nervous system chemical) that stops the release of prolactin hormone from the pituitary gland. Bromocriptine therapy is useful for men in whom impaired sperm production is due to hyperprolactinemia (high blood level of prolactin) (see also Hyperprolactinemia). The customary daily dose of bromocriptine is 5-10 mg. The side effects of bromocriptine therapy include high blood pressure, headache, dizziness, nausea, and vomiting.

C

Clomiphene Citrate - Clomiphene citrate, a synthetic steroid drug related to estrogen (female sex hormone), has both anti-estrogenic and estrogenic effects. In men with oligospermia (low sperm count), clomiphene has been used to increase gonadotropin secretion, which, in turn, may stimulate testosterone release and improve sperm output (see also Endocrine Disorders). Yet the male response to the drug is not as pronounced as that seen in women. Clomiphene usually is given in oral daily doses of 25-50 mg for a 3- to 6-month period. However, the results from clomiphene trials are extremely variable, with differing success rates for conception. Therefore, more clinical data are needed to confirm the effectiveness of this drug.

Combined Estrogen/Alpha-Adrenergic Agonist Therapy - Since estrogen therapy appears to heighten the response of nerve receptors in the urethra (that is, the alpha-adrenergic receptors, which increase the tone of striated and smooth muscle), it is believed that a combination of estrogen and alpha-adrenergic agonists (drugs specific for the alpha-adrenergic receptors) may be beneficial in women who have undergone menopause and who lose bladder control because of insufficiency (malfunction) of the urinary sphincter muscles.

A common estrogen/alpha-adrenergic agonist combination is phenylpropanolamine (PPA, 25-100 mg twice a day) plus intravaginal or oral conjugated estrogen (1.25 mg/day orally or 2 g/day vaginally). Phenylpropanolamine is found in many over-the-counter cough/cold preparations, such as Tavist-D, Comtrex, Dimetapp, Triaminic, and Robitussin-CF.

Cryotherapy - This treatment alternative uses a TRUS-guided probe to deliver freezing temperatures to the cancerous tumor. Intermittent freezing and thawing kills the cancer cells. Long-term results of cryosurgery are still unknown. Reported side effects include urinary incontinence, rectal injury and impotence.

D

Diet - There is no scientific evidence linking diet to IC, but some doctors and patients believe that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inflammation. Some patients also notice a worsening of symptoms after eating or drinking products containing artificial sweeteners. Patients may try eliminating such products from their diet and reintroduce them one at a time to determine which, if any, affect symptoms. It is important, however, to maintain a well-balanced and varied diet.

Ditropan® XL - Extended-release tablets contain oxybutynin chloride. Ditropan® XL is a once-a-day medication for overactive bladder. One tablet releases medication into your system continuously for relief that lasts up to 24 hours with one dose. In many patients, once-a-day Ditropan® XL has been shown to help effectively treat urgency, frequency, and wetting accidents. Some patients use far fewer pads. Some patients experienced relief after taking Ditropan® XL after 1 week. In a clinical study with Ditropan® XL, patients experienced a 90% reduction (from 16 to 2) in the number of wetting accidents per week versus patients taking a sugar pill who experienced a 51% reduction (from 21 to 11). The typical dosage is 5-15 mg to be taken orally 1 time/day. In clinical studies, the most common side effect was dry mouth. However, only 1% of patients discontinued therapy for this reason. Other common side effects included constipation, drowsiness, diarrhea, blurred vision, dry eyes, dizziness, and runny nose. Only 7% of patients in clinical studies discontinued therapy due to side effects.

Done on an outpatient basis, this cost effective and informative test stimulation procedure:

• Locates and identifies the integrity of the sacral nerves

• Demonstrates the effect of sacral nerve stimulation on patient symptoms

• Allows the patient to experience the sensation of stimulation

Dormia basket is, as the name implies, a small basket made of thin metal wire. Especially smaller stones, that are located in the 'lower' ureter can be reached through urethra and bladder, picked up in the basket and pulled out. General anesthesia is necessary, because such a treatment can be quite painful. It is an easy a quick method, although sometimes the stones do not get 'grabbed' by the basket.

Doxazosin mesylate (Cardura) - Doxazosin mesylate is a drug that acts by blocking the alpha-1 adrenergic r receptor sites within the body. Doxazosin is prescribed for the treatment of urinary outflow obstruction in BPH and for hypertension. The typical dose is 1-8 mg, taken once daily.

E

Electrical Nerve Stimulation - This surgical treatment is a variation of TENS, described previously, but involves permanent implantation of electrodes and a unit that emits continuous electrical pulses. This relatively new procedure has variable short-term results; unknown long-term effects and, therefore, is not widely used.

Electrical Stimulation - Electrical stimulation of the sacral autonomic and somatic nerves has been used with varying degrees of success to treat stress and urge urinary incontinence as well as urgency and frequency syndromes. Most of the studies documenting use of the technology have been uncontrolled. Stimulation with electric current causes initial contraction of the bladder that is followed by a prolonged relaxation and gradual fatigue of the contractile response. In addition, stimulation results in reflex inhibition that may "calm" the detrusor and improve storage; however, the ultimate role of this treatment modality is not yet known.

ELECTROEJACULATION - Electroejaculation - ejaculation that is stimulated by an electrode - is a successful form of therapy for men who have normal testes but who cannot emit semen or ejaculate because of a fault in the sympathetic nervous system. Candidates for electroejaculation include men who have undergone orchiectomy (testis removal), retroperitoneal lymph node dissection (RPLND) or spinal cord injury (see also Neurogenic Causes).

The technique of electroejaculation involves the placement of a probe in the rectum (end of the large intestine). Electrical current from the probe then causes the emission of semen due to direct stimulation of nerve fibers within the male reproductive tract. Forceful ejaculation generally does not occur during this procedure, and semen may be released in an antegrade/retrograde manner - that is, semen may dribble out through the urethra, or it may be released backward into the bladder (see also Retrograde Ejaculation). Because semen may need to be retrieved from the urine, the urine will be made alkaline (nonacidic) by having the patient take sodium bicarbonate tablets (600 mg) during the day before the procedure.

Exercise - Many IC patients feel that regular exercise helps relieve symptoms and, in some cases, hastens remission.

External Radiation Treatment (XRT) - This, too, is more a form of therapy than surgery. It usually is prescribed for patients with localized cancer, that is, those whose tumors have spread outside the prostate capsule, but are still likely confined to the immediate surrounding tissues. Treatment involves projecting a high-energy beam of X-rays onto the prostate tissues from a machine outside the body. The radiation kills cancer cells and shrinks tumors. Radiation treatment usually is done on an outpatient basis over a period of 7 to 8 weeks. Common side effects include impotence, particularly in older men, discomfort with urination, urinary urgency and diarrhea, especially during the later stages of treatment.

Survival rates for external radiation therapy patients are comparable to those experienced by patients who under surgical removal of the prostate (radical prostatectomy). One study of 999 patients found 79% of Stage 1, 66% of Stage 2, 55% of Stage 3 and 22% of Stage 4 prostate cancer patients were still living 10 years after treatment.

For instructions on the proper technique for intermittent catheterization click here.

G

Gamete Intrafallopian Transfer - Gamete intrafallopian transfer (GIFT) is an ART procedure in which the egg and sperm (gametes) are placed together within the fallopian tubes. Like IVF, GIFT requires prior, hormone-induced "super stimulation" of the woman's ovaries to produce mature eggs. The eggs then are retrieved from the woman by laparotomy, a surgical incision through the abdomen. After a number of mature eggs have been collected, they are combined with sperm, which, as in IVF, has been treated to concentrate the most healthy and active cells. Finally, the gametes are transferred back into the fallopian tubes, where fertilization should take place. Any embryos that result from this procedure will naturally descend into the uterus for implantation.

Gonadotropins  - Gonadotropins are gonad-stimulating hormones. The gonadotropins human chorionic gonadotropin (HCG), human menopausal gonadotropin (HMG), and their combinations very successfully treat men with hypogonadotropic hypogonadism (delayed sexual maturity due to sex hormone deficiency) (see also Hypogonadotropic Hypogonadism). Both HCG and HMG stimulate testosterone synthesis, which, in turn, improves sperm production and pregnancy rates.

Gonadotropin therapy also has been tested in men with oligospermia (low sperm count) due to unknown causes. For these men, HCG and/or HMG therapy may or may not improve fertility. Given the expense of such therapy and potential difficulty of administration (HMG requires injection), most specialists do not recommend gonadotropin therapy for oligospermic patients.

H

Hormonal Replacement/Estrogen Therapy ( hormonal therapy ) - Estrogen therapy helps to maintain and restore the health of urethral tissues in women who have undergone menopause (the end of monthly menstrual periods). In particular, estrogen appears to reduce stress incontinence and heighten bladder outlet resistance by increasing blood flow, tone and nerve response in the urethral muscle. Yet the exact mechanism of estrogen is still unknown.

Studies suggest that estrogen replacement therapy, by oral or vaginal administration, may benefit patients with stress incontinence or mixed incontinence. To prevent an abnormal build-up of the endometrium (lining of the uterus), estrogen replacement should be given with the pregnancy hormone progesterone (Premphase).

Medications such as Introl and Suctimpro should only be used if the patient's uterus is present --that is, only if the patient has not had a hysterectomy (operation to remove the uterus).

Various doses of estrogen and progesterone are available. Oral conjugated estrogen usually is given at doses of 0.3-1.25mg per day, and vaginal estrogen is given at 0.5-2.0g per day.

In addition, estradiol --the most potent naturally occurring estrogen in humans --is available as a skin-patch (Alora, Climara, Fempatch, Vivelle, Estraderm) and as a vaginal ring (Estring). All of the sepreparations release estrogen slowly.

Estrogen therapy is not recommended for patients with diagnosed or suspected cancer of the breast, cervixoruterus, or for patients with undiagnosed vaginal bleeding or blood clotting disorders such as thrombophlebitis (inflammation and clotting of the veins) or thromboembolism (blood clot |plugging2 of a blood vessel).

Hyoscyamine sulfate (Levbid; Cytospaz) - Hyoscyamine sulfate, like oxybutynin chloride, is an anticholinergic and antispasmotic drug. It is prescribed for the treatment of urge incontinence. Hyoscyamine sulfate is specifically contraindicated (improper) for patients with obstructive urinary tract disorders (for example, bladder neck obstruction due to an enlarged prostate) and for those with glaucoma or ulcerative colitis (severe inflammation of the large intestine). - The usual dosage of hyoscyamine sulfate is one to two 0.375 mg tablets every 12 hours.

I

Ileal Conduit - The Ileal Conduit is a small urine reservoir 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 piece; the other end is brought out onto the surface of the body to make a stoma. The patient then attaches an external, urine-collecting bag to the stoma. This bag needs to be 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.

In Vitro Fertilization - In vitro fertilization (IVF) is, by definition, the fertilization of an egg in the laboratory. Using a variety of hormonal drugs, the woman's ovaries are "super stimulated" to produce eggs. Then, many mature eggs are gathered from the ovaries, and they are fertilized in the laboratory using the man's sperm. Two methods used to collect the eggs. Transvaginal aspiration is an ultrasound-guided technique in which the eggs are aspirated (drawn out) via the vagina; this procedure also is known as TV collection. Laparoscopy involves an incision through the abdomen to extract the eggs.

Once the eggs have been collected, they are placed in a special fluid and are incubated (kept warm) with a prepared sample of the man's semen. The semen sample will have been processed to separate out the most active, healthy sperm. After the eggs are fertilized (roughly 48 hours after collection), they are replaced inside the woman's uterus.

Inflatable artificial sphincter -

Injectables - Other alternatives to invasive, stress incontinence surgery include injectable agents that increase the bulk around the urethra. These agents compress the urethra near the bladder outlet and can greatly improve the function of the urethral sphincter muscle. Injectable materials include collagen (a naturally occurring protein found in skin, bone and connective tissues), polytetrafluoro-ethylene (PTFE, a synthetic compound known as Teflon, Polyte for Urethrin) and fat.

In women, injectable agents are a good choice if the patient is older, is not a good candidate for surgery, and has persistent intrinsic sphincter deficiency without urethral hypermobility (distinguished by leak point pressures less than 90 cm of water). In men, injectable agents may be beneficial for patients with intrinsic sphincter deficiency that has lasted longer than one year.

The Contigen Bard implant is a new collagen-based form of injection therapy for leakage caused by stress incontinence. Contigen uses a highly purified form of collagen made from cowhide; therefore, all potential Contigen recipients should receive a skin test 28 days before scheduled injection to determine whether or not they are allergic to bovine collagen.

The Contigen implant is injected around the top of the urethra using prefilled syringes. The procedure generally is conducted on an outpatient basis with a local anesthetic (painkiller). Most patients need one to three Contigen treatments (up to 28 cc) to achieve bladder control.

Polytetrafluoroethylene (PTFE, a synthetic compound known as Teflon, Polytef or Urethrin), in the form of a micro polymer paste, can be injected into the upper urethra. The PTFE particles spur the growth off ibroblasts (fiber-making cells), which help to fix the PTFE in the urethral tissue and assist in urethral closure. PTFE is not approved in the United States for treatment of incontinence, because questions remain regarding the potential for PTFE particles to migrate to other regions of the body, such as the lungs, brain and lymph nodes.

Fat injections also have been used to treat intrinsic sphincter deficiency. Autologous fat (fat from the patient's own body) is gathered by liposuction from the abdominal wall and is then injected around the urethra. Like collagen and PTFE injection, fat injection is a simple technique that can take place under local anesthesia. The results of this procedure appear favorable and cost-effective, although long-term findings are lacking.

Intermittent Catheterization - Intermittent Catheterization involves inserting a catheter thru the urethra into to bladder to empty it of urine. Once the bladder is empty the catheter is removed. Intermittent catheterization should be performed every 3 to 8 hours or as recommended by your physician.

Interstitial Laser Coagulation - This new procedure uses a device called a cystoscope in the urethra to introduce a special fiberoptic probe directly into the prostate. The probe focuses a beam of low-power laser energy to vaporize a controlled amount of obstructing prostate tissue, resulting in prostate shrinkage and improvement of BPH symptoms. The process is repeated as needed, and takes about 30 to 60 minutes to perform on an out-patient basis.

INTERSTITIAL LASER COAGULATION OF THE PROSTATE (ILC) - Similar to transurethral needle ablation of the prostate, a thin laser fiber is inserted into the prostatic adenoma via a tranurethral or transrectal route under ultrasound guidance. Laser energy is then utilized to induce tissue destruction by local tissue heating with the laser light energy. Preliminary data on small series of patients suggest it has potential as a viable minimally invasive surgical alternative for the treatment of BPH. This device is currently not FDA approved.

Intracytoplasmic Sperm Injection - Intracytoplasmic sperm injection (ICSI) is an IVF procedure in which a single healthy sperm is injected directly into the egg. ICSI is especially useful when the man's sperm count is very low or many sperm are abnormal or immotile (see also Sperm Retrieval). A tiny injection pipette is used to pass the sperm through the zona pellucida (outside layer) of the egg into its ooplasm (central substance). In general, ICSI is performed on several eggs. Once they have been fertilized, they are replaced inside the woman's uterus after a period of about 48 hours.

K

Kegels - The Kegels exercises are one of the most common treatments for stress urinary incontinence. Exercises to strengthen the pelvic floor muscles were originally described by Kegel in 1948. Such exercises, which are now known as Kegel exercises, can be used to regain bladder control, especially if the levator ani (pelvic floor muscle) and/or sphincter muscles have been weakened by childbirth or other factors.

To identify these muscles, you can perform a contraction (muscle squeeze) to stop the flow of urine in midstream. If the urine flow stops, you've located the correct muscles. The next step is to repeat the exercise frequently throughout the day. Programs of 10 Kegels (for 30 seconds each) every hour, or twice-daily Kegels (4 seconds each for 5 minutes) have proven effective. The benefits of Kegel exercises are not immediate, so you should continue the program for at least 8 to 12 weeks before expecting to experience any results. After you identify the muscles, Kegels should not be performed during voiding, since urine could be retained.

In women, weighted vaginal cones sometimes are used to help patients find the proper muscles to squeeze during Kegel exercise. When the cone is held in place, the exercise is being performed correctly. Weighted cones should be worn for 15 minutes twice daily while walking or standing.

Kegel exercises improve the urethral support and closure mechanisms, particularly during activities such as coughing or bending. Therefore, Kegel exercises are notably helpful for stress incontinence due to the effects of pregnancy in women or Prostatectomy (surgical removal of the prostate) in men.

L

Laser surgery

Lasers - In recent years, science has adapted the use of high-energy light beams called lasers to a variety of surgical applications. Prostate surgery involving the use of lasers is becoming increasingly common. Some studies suggest it offers advantages over conventional prostate surgery, particularly in men with smaller prostates, for whom such procedures as TURP might be considered unsuitable. The following are the main laser treatments.

Lithotripsy

Lithotryptor (litho=stone, tryptor=cruncher). Using high energy shockwaves stones can be crushed into small pieces. For the shockwaves to be able to reach the stone the patient used to be partly immersed in water - a kind of bathtub - in the early days of external lithotripsy; water is a good conductor of these shockwaves (the body itself is composed mainly of water). Nowadays, a small water bath or a watery gel is sufficient for treatment. During treatment, the patient is positioned on a large table, in which the shockwave machine is inbuilt. An X-ray and/or ultrasound device is also built into the table and is used to pinpoint the stone in the patient and target the focus of the shockwaves. During the treatment session, a couple of thousand shockwaves are fired at the stone in rapid succession. Because it is possible to target the shockwave focus very precisely (the focal width is only a few millimeters), only the stone is really hit, although still quite some of the shocks hit the surrounding tissue instead because with every breath the kidney moves up and down. The treatment takes 30-45 minutes and is tolerated well, although some pain can result from the bouncing of the stone. After treatment, there is often some numb feeling of the skin due to the tiny shockwaves that have been bombarding it. The treatment is generally quite effective, although in some cases (big stones) several sessions may be needed to fully disintegrate the stone.

M

Methylprednisolone - Methylprednisolone is a corticosteroid medication that has been prescribed as a treatment for immunologic infertility. In particular, methylprednisone is used to suppress blood levels of antisperm antibodies (see also Other Sperm Function Tests). In men, the drug is given a specific number of days before the female partner's time of ovulation (fertile period).

Methylprednisolone therapy is very controversial, since, with the high doses required (96 mg daily), it can produce many side effects that are associated with other forms of steroid therapy - that is, worsened peptic ulcer disease, skin disorders, glucose intolerance (inability to metabolize the sugar glucose) and mental disorders. Success rates are varied, but very few studies have shown much benefit.

MICROWAVE HYPERTHERMIA OF THE PROSTATE -Similar to the laser ablation procedure, transurethral microwave hypertermia of the prostate utilizes heat to remove prostatic tissue. A microwave probe is placed into the prostatic channel; microwave energy is utilized to heat the prostate tissue to temperatures above 50 degree Celcius. This causes destruction to the prostate tissue and shrinkage of the gland. No prostate tissue is removed for pathologic diagnosis. The new generation microwave machines use a catheter that cools the lining of the prostatic urethra while the prostate tissue deep inside is heated. This allows patients to recover with less irritation after the procedure. These new generation machines also control the delivery of microwave energy and the heat level they produce more accurately with the advance computer technology that is employed. The newest machines are available at Columbia Presbyterian Medical Center as part of several clinical trials across the USA and their results are promising as an intermediate modality between medical therapy and more invasive surgical approaches.

N

Needle Suspension - Needle suspension procedures are simpler than abdominal suspension procedures and are less invasive (because they require smaller/fewer incisions and punctures). A surgeon named Pereyra first described transvaginal (through the vagina) needle suspension in 1959. Since that time, numerous surgical adaptations have been developed, each named after its creator (Stamey, Raz, Gittes, etc.); however, the principles of needle suspension remain the same.

In essence, sutures are placed blindly through the pubic skin or via vaginal incision into the anchoring tissues on each side of the bladder neck. The bladder neck then is supported by the sutures, which are threaded on a needle and tied to the fascia (fibrous tissue) or the pubic bone. Operative times and recovery periods are shorter for needle suspension versus other suspension techniques. Some healthcare facilities even conduct needle suspensions as outpatient procedures.

The Stamey technique can be performed both vaginally and through a small incision above the pubic bone. A nylon suture is used to suspend the urethra on each side. Cystoscopy is employed to ensure that the urethra and bladder are not injured during the procedure. (Note: When endoscopy -- visual examination of the bladder by means of a tiny, telescope-like device connected to a video camera -- is used to examine the organs of the abdominal cavity, the procedure is called laparoscopy.)

The Raz procedure often is chosen for patients who are incontinent due to urethral and bladder neck hypermobility (dropping down) and who have minimal or no cystocele (herniation of the bladder into the vagina). An inverted U-shaped incision is made at the base of the anterior (front) vaginal wall, and adhesions (fibrous tissue bands) around the bladder neck and urethra are released. A needle is passed through the surgical incision, and the suspending sutures are pulled up, lifting the front of the vagina and urethra. The Raz procedure is very similar to the Stamey procedure, but the sutures are not placed near the urethra; instead, they are placed in the front of the vaginal wall.

The Gittes procedure is a transvaginal technique that does not require an incision. Instead, a small puncture is made above the pubic fat pad. A suture is then transferred by a needle through the rectus (muscle of the pubic crest) and down toward the vaginal wall, where it is looped and drawn back and out through the puncture. A second pass is made through the same incision (1 or 2 cm beside the first pass) to create a strong support for the suspension. The process is repeated through another puncture hole, which is made 1.5 to 2.0 cm away from the first site. Both suspending sutures are tied down within their respective puncture sites.

Bone anchors are new additions to the techniques for needle suspension of the bladder neck. When needle suspension was first developed, surgeons questioned the amount of tension that was suitable for the suspension sutures. They wanted to avoid the complications of bladder outlet obstruction and suture breakdown that could because by too much tension or sutures pulling out of the anchoring tissue.

Recent innovations, such as the vesica® bladder suspension kit and Intac/Infast kits, employ bone anchoring devices to improve the needle suspension procedures.

With vesica®, a disposable suture carrier creates a large Z-stitch that is used move pubic fascia beside the bladder neck and urethra. Next, the suspension sutures are fixed to an anchor that is inserted into the pubic bone and they are tied without tension by means of a removable spacer. Bone anchoring is not a very painful procedure and can be performed on an outpatient basis.

Patients with severe stress incontinence and intrinsic sphincter deficiency (Type III SUI or weakening of the urethra muscle) may not be helped by simple suspension procedures. Yet such individuals are good candidates for the pubovaginal sling procedure, which can create the urethral compression necessary to achieve bladder control.

This technique involves the creation of an autologous sling -- that is, a sling made out of a strip of tissue from the patient's own abdominal fascia (fibrous tissue). Occasionally, surgeons use a synthetic (artificial, man-made) sling for this procedure, although urethral erosion (breakdown) appears to be more common when synthetic slings are used.

Nifedipine (Procardia) is a treatment for heart disease and high blood pressure, but it has reduced bladder pain and urgency in some IC patients. Recent studies have suggested that heart disease patients may have more heart or other problems if treated with nifedipine than with other heart medications. It is not known whether these findings would apply to IC patients without heart disease.

Noninvasive/External Devices - Several noninvasive, or external, devices are among the newer promising treatments for stress incontinence.

The Miniguard Patch and Impress (Uromed) are single-use foam pads that are slightly larger than a postage stamp. One surface of the patch is covered with gel-like glue that adheres to the region around the opening of the urethra. The patch fits between the labial folds and provides opposing pressure on the urethra to prevent leakage. When the wearer wants to urinate, she simply removes the patch and applies a new one afterward. The patch is less bulky than cumbersome pads and provides a neater alternative for leakage.

FemAssist and Bard Cap Sure Continence Shields are external devices that function like foam pads, but can be reused used for about one week before being replaced. Both are small, circular, silicone rubber devices that are positioned over the flat area surrounding the urethra. Using suction, they support and reinforce the muscle that naturally control urine output and help prevent accidental urine loss in women who suffer from stress incontinence. An ointment is used to create a mild vacuum seal that holds the device in place. When a woman wants to urinate, she removes the device, which can then be cleaned and reapplied. Because they are used externally, FemAssit and CapSure have lower rates of associated infection than internal devices, though some woman report discomfort or mild irritation when using these products.

O

Open Prostatectomy - If the prostate is greatly enlarged, if the bladder has been damaged and must be repaired, or if the patient has other complications prohibiting transurethral surgery, an open surgical procedure called a prostatectomy (removal of the prostate) may be necessary.

With this procedure, the patient is anesthetized and the surgeon makes an external incision, either in the lower abdomen or in the perineum (the area between the rectum and the scrotum), depending upon the location of the enlarged portion of the prostate. The surgeon then removes the enlarged prostate tissue from inside the gland. An open prostatectomy in which the surgeon accesses the prostate from the abdomen is called suprapubic (surgery from on top or above); surgery through the perineum is called retropubic (surgery from the back or from behind).

Open Abdominal Surgery - Sometimes incontinence surgery takes place via an incision through the abdomen. Two standard suspension procedures that require abdominal incisions are the Marshall Marchetti Krantz procedure and the Burch procedure.

The Marshall Marchetti Krantz (MMK) procedure is still offered in many medical centers throughout the United States, but it is no longer a favored technique. This is because the sutures (stitches) in the procedure are placed around the urethra, creating the potential for obstruction; in addition, the surgical entryway limits the physician's ability to correct cystocele (herniation of the bladder into the vagina). During the MMK procedure, the bladder neck and urethra are separated from the back surface of the pubic bone. Sutures are placed on either side of the urethra and bladder neck, which are then elevated to a higher position. The free ends of the sutures are anchored to the surrounding cartilage and pubic bone.

The Burch procedure, also known as Burch colposuspension (vaginal suspension), often is performed when the abdomen is already open for another purpose, such as abdominal hysterectomy (removal of the uterus). During the suspension procedure, the sutures are placed laterally (sideways), which avoids urethral obstruction and allows the physician to repair any small cystoceles that may be present. The bladder neck and urethra are separated from the back surface of the pubic bone. The bladder neck then is elevated by means of lateral sutures that pass through the vagina and Cooper's (pubic) ligaments. The vaginal wall and ligaments are brought together without tension, and the sutures are tied.

Oral Drugs - All drugs--even those sold over-the-counter--have side effects. Patients should always consult a doctor before using any drug for an extended time.

Aspirin and ibuprofen are easy to obtain and may be a first line of defense against mild discomfort. However, they may make symptoms worse in some patients. Over-the-counter forms of phenazopyridine hydrochloride (Azo-Standard, Prodium, and Uristat) may provide some relief from urinary pain, urgency, frequency, and burning. Higher doses of the drug are available by prescription as Prodium and Pyridium.

Other Alpha Adrenergic Agonists  - Other Alpha Adrenergic Agonists include ephedrine and epinephrine and norepinephrine. Since the actions of these drugs are so widespread within the body, they are not specifically indicated for incontinence and should be prescribed with caution. The significant side effects of these drugs are hypertension, tachycardia (fast heartbeat) and arrhythmia (irregular heartbeat).

Oxybutynin chloride (Ditropan) - Oxybutynin is an anticholinergic drug medication that also directly relaxes bladder smooth muscle. It is prescribed for neurogenic bladder patients, and patients who have symptoms of bladder instability with voiding: that is, patients with urge incontinence, frequency, urinary leakage, or painful urination. The typical dosage is 2.5-5.0 mg to be taken orally 3 to 4 times/day). Oxybutynin's notable side effects are dry mouth, dry skin, visual blurring, nausea and constipation.

P

Partial Nephrectomy - In some cases it may be possible to remove only the cancerous tissue and part of the kidney, particularly if the tumor is small and confined to the very top or bottom of the kidney. A partial nephrectomy also may be the procedure of choice for patients with RCC in both kidneys and those who have only one functioning kidney.

Pelvic Muscle Rehabilitation - Pelvic muscle rehabilitation involves implementation of a comprehensive group of progressive exercises aimed at strengthening the levator muscle. These exercises have been used to treat several types of urinary incontinence but are most frequently employed in patients diagnosed with stress incontinence. The use of biofeedback during exercise allows patients to observe the duration and strength of contractions. It has been estimated that pelvic muscle rehabilitation produces complete resolution of symptoms in 20% of patients and that improvements in incontinence are observed in 50% to 75% in most of those treated.

Pelvic Surgery - Like pregnancy and childbirth, pelvic surgery can weaken and damage the pelvic floor muscles. As a result, the pelvic floor muscles may no longer be able to provide the necessary support to the bladder neck and urethra, and these structures may drop freely when downward pressure is applied. This condition, which is known as hypermobility, causes incontinence during physical activity, when the urethra cannot close tightly enough to resist increased abdominal pressure on the bladder.

Urinary incontinence can result from common forms of pelvic surgery, including abdominal resection for colorectal (intestinal) cancer, gynecologic (female genital tract) surgery such as radical hysterectomy (complete removal of the uterus) or hysterectomy for benign (noncancerous) disease, and failed prolapse (restabilization) surgery for stress urinary incontinence.

Most patients with postoperative incontinence have either detrusor instability (DI or unstable bladder: an involuntary, downward-pushing contraction of the bladder) or urethral/bladder neck incontinence (abnormal function) due to nerve damage. Successful management of DI incontinence usually can be achieved by drug therapy and urinary catheterization (passage of a tube through the urethra into the bladder to drain urine into a bag outside the body); patients with bladder neck incontinence may require additional surgical measures.

Penile Implant - A penile implant

Pentosan polysulfate sodium (Elmiron) reduces bladder discomfort and pain in some people with IC. Doctors don't know exactly how the drug works, but they believe it may repair leaks in the bladder lining. Elmiron is the first oral drug developed for IC and was approved by FDA in the Fall of 1996.

Percutaneous lithotripsy (per=through, cutis=skin) the stone in the kidney is reached with a scope through a small wound in the skin and through the tissues of the kidney. The exact location of the stone is monitored with the ultrasound device. Like in the transurethral lithotripsy the stone is then disintegrated with an oscillating device. This technique is used in cases of large stones, when a treatment with the external lithotryptor would take too much time and too many sessions and/or in cases of obstruction of the outlet of the kidney in which the kidney could be damaged if it takes too long to treat the stone. General anesthesia is necessary, although patient and kidney generally very well tolerate the treatment.

Percutaneous Slings - The pubovaginal sling involves the creation of an autologous sling -- that is, a sling made out of a strip of tissue from the patient's own abdominal fascia (fibrous tissue). Occasionally, surgeons use a synthetic (artificial) sling for this procedure, although urethral erosion (breakdown) appears to be more common when synthetic slings are used.

During the pubovaginal sling procedure, a strip of fascia is obtained via an incision above the pubic bone. This strip of fascia becomes the sling. Another incision is made in the front of the vaginal wall, through which the surgeon can grasp the sling and adjust its tension around the bladder neck. The sling itself has sutures attached to it.

The sling is secured in place when the two sutures are loosely tied to each other above the incision in the pubic fascia, providing a hammock for the bladder neck to rest on.

The pubovaginal sling procedure generally results in high success rates, with bladder control lasting more than 10 years. Some of the possible complications of pubovaginal sling procedures are accidental bladder injury, wound infections and prolonged urinary retention.

Vesica® sling procedure, a minimally invasive (reduced operative risk and a shorter recovery phase) surgery, involves the placement of a sling to support the bladder neck, urethra and sphincter.

Through the opening created by the incision(s), your surgeon will place two small anchors into the pubic bone in order to provide stable fixation for the bladder neck. He/she will then take one end of the suture and guide it through the tissue on one side of the bladder neck then the other side.

Depending on your diagnosis your physician may elect to use a sling made of either a biocompatible synthetic material or of your own tissue. This sling (like a hammock) is secured to the anchor placed in the bone and serves as additional support for the urethra, bladder neck and sphincter.

To help with the healing process, a catheter may be placed into your bladder. The catheter will be connected to a drainage bag, which will collect your urine.

Routine physical activity may be restricted for a short time after the procedure and strenuous activity for 8-12 weeks. Your doctor or nurse will provide you with specific guidelines.

Phenylpropanolamine hydrochloride - Phenylpropanolamine hydrochloride is found in many prescription and nonprescription cough/cold preparations and antihistamines (anti-allergy drugs). A typical dosage for bladder control is 25-75 mg in sustained- released form, twice a day. Individuals should not use phenylpropanolamine, like all other alpha adrenergic agonists, with obstructive forms of incontinence; it should be used with caution by individuals with hypertension (high blood pressure), hyperthyroidism (overactive thyroid gland), arrhythmia (irregular heartbeat), and angina (heart pain caused by decreased oxygen supply to the heart muscle).

Preoperative Radiation Therapy - Preoperative Radiation Therapy is another strategy that has been used for bladder cancer treatment. The theory is that radiation exposure will "sterilize" tumor outgrowths, regional lymph node metastases, and any tumor cells that are spread during the process of cystectomy (bladder removal). Radiation therapy also is used to shrink the tumor before surgery. Preoperative radiation sometimes is given in a short-course schedule of 2,000 CGy over a 1-week period. But survival results from clinical studies have been conflicting. In addition, preoperative radiation may cause a significant delay in the performance of cystectomy. Therefore, there is a tendency for American physicians to omit radiotherapy prior to cystectomy in patients with invasive bladder cancer. Exceptions to this include patients with invasive squamous cell carcinoma (SCC) or bilharzial bladder cancer.

Propantheline bromide (Pro-Banthine) - Although bladder spasm is not an FDA-approved indication for this drug, propantheline has been widely prescribed over the years for the treatment of urge incontinence (typical dosage: 7.5-30 to be taken without food 3 to 5 times/day). It is a classic anticholinergic medication that stops muscle contractions in the normal bladder. Some of the unwanted side effects of propantheline include dry mouth, visual blurring, nausea, constipation, tachycardia (fast heartbeat), drowsiness and confusion. Propantheline is specifically contraindicated (improper) for patients with obstructive urinary tract disorders and for those with narrow-angle glaucoma (eye disease characterized by high pressure within the eye).

Prostatic Stents - A prostatic stent is a tiny, spring like device inserted into the urethra. When expanded, it pushes back the surrounding tissue and widens the urethra to permit an increased flow of urine. Prostatic stents are most often used for patients who have other medical problems that prohibit medication or surgery. Prostatic stents have several advantages:

·         They can be placed in less than 15 minutes under regional anesthesia.

·         Bleeding during and after surgery is minimal.

·         The patient can be discharged the same day or next morning.

The disadvantages of stents are:

·         Prepositioning them can be difficult.

·         They may cause irritation and frequent urination.

·         They may move and cause pain or incontinence.

·         Removing them-necessary in one-third of patients-can be difficult.

Prostatron - Transurethral microwave thermotherapy (TUMT) does not cure BPH; it reduces its symptoms. TUMT uses a special catheter with a tip containing an antenna-called a Prostatron-to deliver high-temperature (41°- 44°C) microwave energy to the prostate without affecting adjacent structures. Depending on the elasticity of the urethra, the therapeutic deep heat will improve urine flow. A fiberoptic thermosensor monitors temperatures throughout the procedure, and a cooling system circulates water within the catheter applicator to protect the urinary tract. The procedure takes about an hour and is performed on an outpatient basis without anesthetic.

Prostatron therapy does not solve the problem of incomplete emptying of the bladder, but its benefits are achieved without causing incontinence or impotence. Most patients resume normal activity immediately after treatment.

Prosthetic occluding devices - Prosthetic occluding devices can be used to block the flow of urine by squeezing the urethra shut. For men, such mechanical devices include penile clamps (for example, the Cunningham clamp) and compression rings. The penile clamp is a V-shaped casing with a foam cushion that fits over and under the penis. When closed, the penile clamp should stop the flow of urine without causing discomfort. Compression devices are adjustable rings that surround the penis and, when inflated with air, pinch off the urine flow. Individuals usually reserve occluding devices for temporary use with intrinsic sphincter deficiency. These devices must be removed at regular 2- to 3-hour intervals to empty the bladder. Therefore, only mentally competent individuals who are able to adjust them by hand and who are able to remember the bladder-emptying schedule should use them. Improper use of penile clamps and compression devices can result in penile and urethral erosion, penile edema (swelling), pain and obstruction.

Pseudoephedrine Hydrochloride - Pseudoephedrine Hydrochloride is found in many prescription and nonprescription cough/cold preparations and antihistamines. A typical dosage for bladder control is 15-30 mg, three times a day.

R

Radiation Therapy - Outside of the United States, Radiation Therapy (also known as radiotherapy) often is used as a primary (singular) treatment for invasive bladder cancer. Yet, in America, primary radiation therapy usually is reserved for people who may not be good candidates for bladder surgery because of age or certain medical problems. Primary therapy generally involves a radiation dose of 6,000 to 7,000 rad to the bladder, with or without corresponding lymph node treatment. High-dose, external beam radiation therapy may be an alternative to bladder surgery in patients with stage T2 to T3 muscle-invading cancers. Radiation therapy has no role in the management of carcinoma in situ (CIS, TIS). However, 5-year survival rates are much lower in radiation-treated patients versus patients who undergo surgical therapy. And, unfortunately, local reappearance of bladder cancer occurs in up to one-half of all individuals who receive radiation therapy. Yet people who experience complete tumor regression after radiation therapy tend to do well. There can be significant side effects from high-dose external beam radiation therapy, including radiation cystitis (symptoms of irritation, incontinence, bloody urine, and fibrosis, a buildup of fibrous tissue), proctitis (inflammation of the rectum), impotence, and skin reactions.

Radical Cystectomy - In women with T2 to T3a tumors, a standard surgical procedure is Radical Cystectomy (cutting away of the entire bladder and associated tissues) with pelvic lymphadenectomy. Radical cystectomy in women includes removal of the uterus (womb), tubes, ovaries, anterior vaginal wall (front of the birth canal), and urethra (the tube that passes urine from the bladder out of the body). Preoperative radiation therapy may have some merit when combined with bladder surgery, although radiation therapy alone usually is unsuccessful.

Radical Nephrectomy - The most common form of surgery for RCC, radical nephrectomy involves removal of the entire kidney, often along with the attached adrenal gland, surrounding fatty tissues and nearby lymph nodes (regional lymphadenectomy), depending upon how far the cancer has spread.

S

Sacral Nerve Stimulation-InterStim - InterStim® Continence Control Therapy is a reversible treatment alternative for people with urinary urge incontinence who have found behavioral and pharmacological treatments ineffective or not well tolerated. InterStim® Continence Control Therapy uses a small stimulation system, about the size of a pacemaker that is surgically placed under the skin in the lower abdomen and lower back. The therapy uses mild electric pulses to stimulate a sacral nerve in the lower spine. This nerve influences the bladder and surrounding muscles that control urinary function.

Clinical studies have shown that nearly half of all urge incontinent patients using the therapy are completely dry and many others have had their symptoms reduced significantly. The exceptional success rate of InterStim® Therapy is linked to the test stimulation procedure. This unique feature allows patients and their physicians determine the effect of InterStim® Therapy prior to consideration of a surgical implant procedure.

During the test stimulation procedure patients are asked to keep a voiding diary to record voiding patterns with the stimulation. The voiding diary is then compared to diaries from before the test stimulation procedure and after the test stimulation procedure to determine the effect of the treatment on their symptoms.

The test stimulation allows the clinician to evaluate the therapy as an option for the patient without significant cost or delay. It also provides patients with realistic expectations about the results of InterStim Therapy. Usually within three to five days both the patient and clinician can determine if InterStim® Therapy is a viable treatment option.

After successful evaluation of the test stimulation, the InterStim® System may be implanted for long-term therapy. The procedure is performed under general anesthesia, and the InterStim® System can generally be activated on the first day after surgery.

Potential side effects of the InterStim® Continence Control Therapy include: pain at the implant sites, lead migration, infection, change in bowel function, and undesirable stimulation or sensations.

Segmental Cystectomy - Segmental Cystectomy (partial removal of the bladder)—a bladder-preserving or "salvage" form of surgery—is appropriate only in a limited selection of male or female patients (for example, 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.

Simple prostatectomy

Sling Procedures - Patients with severe stress incontinence and Intrinsic Sphincer Deficiency (Type III SUI or weakening of the urethra muscle) may not be helped by simple suspension procedures. Yet such individuals are good candidates for a sling procedure, which can create the urethral compression necessary to achieve bladder control.

Sperm Retrieval - Sperm retrieval is not limited to ejaculated semen. With today's technology, sperm can be obtained from men with azoospermia (lack of sperm) that is caused by an obstructive lesion, failed vasectomy reversal, inherited absence of the vas deferens, or other uncorrectable blockage.

For example, applying microsurgical methods in a process known as micro epididymal sperm aspiration (MESA), sperm can be gathered close to the blocked portion of the epididymis, the elongated, coiled duct that provides for the maturation, storage, and passage of sperm from each testis. Similarly, percutaneous epididymal sperm aspiration (PESA) uses a small needle to penetrate the testicular skin and draw sperm from the area near the epididymal obstruction. Testicular sperm extraction (TESE), the removal of a small amount of testicular tissue under local anesthesia, also can be a source of sperm (see also Testis Biopsy).

Sperm retrieval methods usually are scheduled to coincide with the female partner's time of ovulation, so that they may be used for in vitro fertilization (IVF) of a retrieved egg. Sperm that is retrieved by MESA, PESA or TESE then can be processed for use in procedures such as intracytoplasmic sperm injection (ICSI) (see also Intracytoplasmic Sperm Injection). While excess sperm from MESA or PESA usually can be frozen for future use, most TESE-derived sperm are not of sufficient quality or quantity for frozen storage (cryopreservation). Multiple MESA or PESA procedures are not recommended, since repeated surgery can lead to scarring around the site of incision.

Most patients are advised to wear scrotal supports for 1 week following MESA, PESA or TESE. Side effects are rare, although postoperative pain and swelling may persist for up to 2 weeks.

Sperm Washing - Sperm washing is a procedure that is used extensively for the treatment of semen with low sperm counts, abnormal sperm forms, antibodies, and other fertility-impairing features (see also Other Tests of Sperm Function). The "washing" is accomplished by adding culture medium (a fluid containing nutrients and buffers) to the semen and spinning the entire sample in a centrifuge (a machine that uses centrifugal force to separate heavier and lighter elements in a solution). The heavy sperm "pellet" is then rewashed in culture medium. If the physician needs a "rise" or "swim-up" fraction of the most active sperm, the concentrated sperm sample is incubated (kept warm) for about 1 hour, and the swimming sperm are extracted from the top of the test tube. If the physician wants to enhance the fertile potential of the sperm, TEST-yolk buffer (a special solution containing buffers, chicken egg yolk, glucose and antibiotics) may be used during the washing and pellet dilution procedures. The sperm that are gathered from such washing methods are subsequently used for artificial insemination and in vitro fertilization procedures.

STANDARD TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) -Transurethral resection of the prostate (TURP) has been the standard choice for the past 50 years of treatment for urinary symptoms attributed to a large prostate condition commonly known as BPH that causes obstruction of the bladder outlet and voiding symptoms such as urinary frequency, voiding at night and a slow urinary stream.

About 400,000 TURPs are performed each year in the United States. TURP is a safe procedure with 80% of patients experiencing resolution of their voiding symptoms and improvement of urinary flow measurements. A TURP involves the removal of the obstructing portions of the prostate with a telescopic hot wire loop that cuts like an electric knife. The TURP requires an anesthetic and takes about 30-60 minutes to perform. A tube or catheter is inserted into the bladder and is left in place for 2 to 3 days. The hospitalization lasts from 2-5 days and requires two weeks of severe activity restrictions and another two weeks of modest restrictions. The long term effectiveness of TURP in alleviating obstruction and symptoms caused by BPH has made the TURP the gold standard to which new procedures are compared.

However, the TURP is a surgical procedure with potential risks and complications such as bleeding, impotence and incontinence. To decrease hospitalization costs and recuperation time from work, alternative therapies are being developed and introduced by the urologic community. These include medical treatments and alternative surgical treatments that have the potential to decrease complications and be as effective as the gold standard TURP.

Surgery - This option is considered only if an IC patient has failed all available treatments and the pain is severe. Most doctors are reluctant to operate because the outcome is unpredictable in individual patients-some people have Surgery and still have symptoms.

Anyone considering surgery should discuss the potential risks and benefits, side effects, and long- and short-term complications with a surgeon and family, as well as with people who already have had the procedure. Surgery requires anesthesia, hospitalization, and weeks or months of recovery, and as the complexity of the procedure increases, so do the chances for complications and failure.

To locate a surgeon experienced in performing specific procedures, check with your doctor.

Systemic Chemotherapy - Many individuals with late-stage bladder tumor(s) and/or metastases have a poor prognosis. Therefore, researchers have begun a number of clinical trials to test the effectiveness of Systemic Chemotherapy with multiple drugs. In particular, combinations of agents such as cisplatin, methotrexate, and vinblastine, with or without doxorubicin (CMV or M-VAC), have produced some encouraging responses in late-stage patients. In addition, the combination of cisplatin, cyclophosphamide, and doxorubicin (CISCA) has shown some activity, although the responses have not been as great as those reported for CMV or M-VAC treatments. In metastatic bladder cancer, other chemotherapeutic agents that have produced some benefits are: paclitaxel, ifosfamide, gallium nitrate, and gemcitabine. Whenever possible, individuals should be encouraged to participate in such trials. Multi-agent chemotherapeutic trials for metastatic bladder cancer have produced response rates of up to 70%, and survival times may be increased.

In persons with inoperable bladder cancer, the focus of care is palliation (relief) of symptoms. Large, late-stage tumors may cause frequent, painful, and bloody urination during the night and day. Decaying tissue within the tumor also may be a constant source of infection. Therefore, urinary tract diversion in such individuals may spare them the suffering and sleeplessness of persistent, agonizing urination.

T

Tamoxifen - Tamoxifen, like clomiphene citrate, is an oral anti-estrogen compound that has been used to treat male infertility. But, unlike clomiphene, tamoxifen has no estrogenic activity. Tamoxifen stimulates sperm output by increasing the release of gonadotropins. In current studies, the most common oral dosage is 20 mg daily. As with clomiphene, some men respond favorably to tamoxifen and show improved semen quality and increased rates of conception; however, there are still questions regarding which patient groups are most likely to be helped by tamoxifen therapy. Recent findings suggest that pregnancy may occur in up to one-third of couples in which the male partner has received tamoxifen therapy.

Tamsulosin hydrochloride (Flomax) - Tamsulosin hydrochloride blocks only the alpha-1a adrenergic receptors in the prostate. Tamsulosin is used to treat the signs and symptoms of BPH; however, because of its prostate-specificity, tamsulosin is not a recommended treatment for hypertension. The usual oral dose of tamsulosin is 0.4-0.8 mg, once daily.

Targis - The TargisTM System is an advanced form of microwave therapy. It uses advanced microwave technology to deliver energy through a flexible catheter. TargisTM therapy destroys the diseased tissue, while protecting the pain-sensitive, healthy urethral tissue. The procedure is anesthesia-free, with no need for IV sedation, spinal or general anesthesia. Most patients can return home the same day as the treatment and quickly resume everyday activities.

• The catheter (also known as the Microwave Delivery System) is inserted into the urethra. The balloon, located at the very end of the catheter, is inflated to position the microwave antenna in the prostate.

• Chilled water is circulated through the catheter to protect healthy urethral tissue.

• While the chilled water is being circulated, the microwave power is started and the diseased tissue in the prostate is heated.

• Heating is continued for one hour in order to destroy the diseased tissue.

• After one hour, the microwave energy is turned off, while the chilled water continues to circulate to protect the healthy urethral tissue from any residual heat.

• At the completion of cooling, the procedure is finished and the catheter is removed.

TENS (Transcutaneous Electrical Nerve Stimulation) - With TENS, mild electric pulses enter the body for minutes to hours two or more times a day either through wires placed on the lower back or the suprapubic region, between the navel and the pubic hair, or through special devices inserted into the vagina in women or into the rectum in men. Although scientists don't know exactly how it works, it has been suggested that the electric pulses may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, and trigger the release of hormones that block pain.

TENS is relatively inexpensive and allows the patient to take an active part in treatment. Within some guidelines, the patient decides when, how long, and at what intensity TENS will be used. TENS has been most helpful in relieving pain and decreasing frequency in IC patients who have Hunner's ulcers. Smokers do not respond as well as nonsmokers. If TENS is going to help, change usually occurs in 3 to 4 months.

Terazosin hydrochloride (Hytrin) - Terazosin hydrochloride also blocks the alpha-1 adrenergic receptor sites in the body. Like doxazosin, terazosin is prescribed for the treatment of urinary outflow obstruction in BPH, as well as for hypertension. The typical dose is 1-10 mg, taken once daily.

Testosterone - Testosterone, an androgenic (male) sex hormone required for sperm manufacture, has been employed as a form of "rebound" therapy in men who suffer from inadequate sperm production. In brief, testosterone - in the form of 200 mg testosterone cypionate or enanthate, administered by weekly intramuscular injection for up to 12 weeks - is used to stop sperm production and cause azoospermia (no sperm in the semen). When testosterone is discontinued, sperm production may recover, or "rebound," and lead to significantly increased sperm counts in a proportion of patients. Such rebound usually occurs 4 to 6 months after stopping testosterone treatment. Unfortunately, success rates from this therapy are poor, and some men run the risk of permanent azoospermia after treatment.

Tolterodine Tartrate (Detrol) - Tolterodine tartrate is a new drug that is classified as a muscarinic receptor antagonist: that is, it blocks nerve receptors that respond to the chemical muscarine. Both bladder contraction and salivation (formation of saliva) are controlled by muscarinic receptors. By blocking muscarinic nerve receptors, tolterodine tartrate can reduce symptoms of urinary frequency or urgency, and it is able to treat bladder over activity and urge incontinence.

The typical dose of tolterodine tartrate is 1-2 mg, twice a day. Tolterodine tartrate should not be used in people who are hypersensitive (have an exaggerated reaction) to the drug or who have urinary retention, gastric (stomach) retention, or uncontrolled narrow-angle glaucoma (eye disease characterized by high pressure within the eye).

TRANSURETHRAL ELECTROVAPORIZATION OF THE PROSTATE (TVP) - A new modification on the TURP technology, termed transurethral electrovaporization of the prostate, (TVP), applies electrical energy to electrosurgically vaporize or remove the obstructive enlarged prostatic tissue. The technique involves the application of a simple, specially designed grooved rollerball electrode that allows the surgeon to channel open the urethra that is blocked by the prostate tissue. Compared to the standard TURP, the procedure is safer and has minimal side effects. There is less bleeding, shorter hospitalization and catheter times and faster recovery period.

The procedure allows the grooved rollerbar electrode to rapidly heats the tissue cells so that they turn into steam, leaving a space where the prostate tissue was previously present. The majority of heat that is turned into steam is then washed away by a constant flow of water. As the electrode moves to fresh tissue, new cells are removed creating an incision or vaporized space. The resulting pathway does not bleed because it is coagulated and sealed by the electrically heated rolling action of the rollerball electrode. Technically, this is a new way to do a TURP and TVP can also be utilized to perform a TUIP.

Our experience has demonstrated significant improvement in symptoms and urine flow that parallel that reported for either conventional TURP or laser assisted prostatectomy. Anesthesia utilized included general, regional, and intravenous sedation with local intraurethral xylocaine. Patients had their urethral catheters removed within 24 hours after surgery and were able to void spontaneously, unlike patients who were treated with TURP. There was minimal blood loss during the surgery. Patients, who reported adequate sexual erectile function before surgery, reported no change in their sexual abilities after surgery. There was no incidence of incontinence from sphincter damage.

Our current experience numbers over 170 patients with similar results to our earlier published series. Long term data on its efficacy as well as multicenter trials are currently underway to compare it to other procedures to treat BPH such as the standard TURP and laser TURP. The major potential advantage of TVP compared to the conventional TURP and laser assisted prostatectomy is cost, few side effects, rapid convalescence time and short hospital stay overnight as well as the simplicity of the procedure. This makes TVP or transurethral electrovaporization a useful, safe and versatile tool in the treatment of the enlarged prostate disease that cause urinary outflow obstruction or BPH.

Transurethral fulguration and resection of ulcers - Fulguration involves burning Hunner's ulcers using electricity or a laser. When the area heals, the dead tissue and the ulcer fall off, leaving new, healthy tissue behind. Resection involves cutting around and removing the ulcers. Both treatments, done under anesthesia, use special instruments inserted into the bladder through a cystoscope. Laser surgery in the urinary tract should only be done by doctors who have the special training and expertise needed to perform the procedure.

Denervation is a complicated procedure done by surgeons who have special training and expertise. Rarely used in the treatment of IC, it involves cutting some of the nerves to the bladder, interfering with pain signals. Many approaches and techniques are used, each of which has its own advantages and complications that should be discussed with the surgeon.

Augmentation makes the bladder larger, most often by adding a section of the patient's small intestine, a tube-like structure that absorbs and transports nutrients from food for use by the body. With this treatment, scarred, ulcerated and inflamed sections of the patient's bladder are removed, leaving only healthy tissue and the base of the bladder. A piece of the patient's small intestine is removed, reshaped, and attached to what remains of the bladder. After the incisions heal, the patient may be able to void normally.

Even in carefully selected patients-those with small, contracted bladders-the pain, frequency, and urgency may remain or return after surgery and the patient may have additional problems with infections in the new bladder and difficulty absorbing nutrients from the shortened intestine. Some patients are incontinent while others cannot void at all and must insert a catheter into the urethra to empty urine from the bladder.

TRANSURETHRAL INCISION OF THE PROSTATE (TUIP) - A transurethral incision of the prostate (TUIP) is a simplified alternative to TURP that simulates its results in both symptom relief and flow rates improvements. Making a simple deep cut or incision along the entire length of the prostate to split it open performs the procedure. This allows the circular muscle fibers running around the prostate to spring open and increase urinary flow by opening the prostatic urinary channel. TUIP is ideally suited for smaller prostates and has a lower incidence of ejaculation abnormalities. In appropriately selected patients with relatively small and anatomically appropriate prostates, the success rates for TUIP are similar to TURP with the advantage that hospital stays and recovery are much shorter.

TRANSURETHRAL LASER VAPORIZATION / ABLATION OF THE PROSTATE (VLAP) - The laser is a high energy source that has gained much attention as a unique surgical tool in the surgical treatment of many diseases. In urology, the light energy is converted to heat on contact to tissue to produce its surgical effect. It is an energy modality utilized in breaking stones, treating bladder tumors and removing prostate tissue.

With laser prostatectomy, a laser fiber is passed into the prostatic channel under telescopic guidance. The laser is then used to destroy the obstructing portions of the prostate by heating it up. The two techniques to remove tissue are laser vaporization and laser ablation. With vaporization, high instantaneous heat is created to vaporize or steam away prostate tissue. With ablation, a lower laser energy is applied which heats up the tissue enough to dry it out, and let it shrink and slough away with time. Compared to standard transurethral resection or TURP, the advantages of these laser procedures are: no significant bleeding, shorter hospitalization and reduced operating time. The laser albation or VLAP has not been optimum in large prostate because of the necessity for multiple treatments. Laser vaporization, on the other hand, has been able to remove more tissue at one treatment. With these laser procedures; there has been a greater amount of swelling around the prostate channel after the procedure (3-10 days) which requires temporary catheter drainage (tube into the bladder to drain urine). In addition, patients can experience a few weeks of urinary frequency and irritation while the prostatic channel is healing. Its significant advantages are no bleeding and a short hospital stay.

One concern of this procedure among the urological commiunity is that no prostate tissue is removed. Therefore, one cannot be certain that cancer does not exist. However, with the excellent diagnostic techniques available today with PSA and Ultrasound, appropriate assessments can be performed and biopsies taken if indicated.

Transurethral lithotripsy (trans=by way of, so via the urethra) the stones are reached with a very slim tube-formed scope through the urethra, bladder and ureter and cab be disintegrated with the use of an oscillating probe. General anesthesia is necessary, because treatment can be painful while it is of eminent importance that the patient and the stone does not move.

TRANSURETHRAL NEEDLE ABLATION OF THE PROSTATE (TUNA) -Applying the heat ablation principle to coagulate and necrose prostatic tissue, this technique utilizes electrical radiofrequency current through small needles place bilaterally into the prostate gland via a transurethral approach to induce tissue destruction by local heating. This technique can be performed with minimal anesthisia and as an outpatient procedure. Preliminary data on small series of patients suggest it has potential a viable minimally invasive surgical alternative for the treatment of BPH. This device is currently not FDA approved.

Transurethral Resection of the Prostate or TURP

Transvaginal Slings - Precision Tack™ Transvaginal Anchor System is a device that allows your physician to perform a minimally invasive procedure to restore urinary function by returning your anatomy to its original position.

The transvaginal approach means no abdominal incision is made, therefore eliminating any visible scars on the body surface. With Precision Tack two tiny anchors are placed in the back side of the pubic bone to provide long-term support of the bladder neck and urethra.

To begin with, your physician will make a small incision in the vaginal area. This incision is necessary in order to create an area for a sling to be inserted. Your physician will determine the size and shape of the incision, based on whether there is a need for additional repairs. Once the incision is made your physician will place two small tacks in the pubic bone, one on each side. These tacks provide a stable fixation for the bladder neck.

After the tacks are in place, your physician will insert a sling into the vagina. A sling is a small piece of material that attaches to the tacks with sutures. The sling will remain in the body providing support, like a hammock, holding the anatomy in its original position.

With the tacks and sling in place, the vaginal incision is closed. The Transvaginal Sling procedure is complete and normal urinary function should be restored.

To help with the healing process, a catheter may be placed in your bladder. It will be connected to a drainage bag, which will collect your urine. The catheter will be removed within a short time. After the procedure is complete, specialized nurses will monitor you. You will probably be discharged within 24 hours.

Routine physical activity may be restricted after the procedure. Strenuous activity may be restricted for 8 ‚ 12 weeks and physical activity for 6 ‚ 8 weeks. Your doctor or nurse will provide you with specific guidelines.

Tricyclic Antidepressants (TCAs) - Tricyclic antidepressants -- such as imipramine pamoate (Tofranil-PM) -- are often prescribed as part of incontinence treatment programs, but they are not FDA-approved for incontinence. Tricyclic antidepressants have anticholergenic effects. Many experts believe that tricyclic antidepressants are beneficial because they decrease nighttime incontinence and are useful for the management of urge incontinence. The usual oral dose of imipramine is 10-25 mg, 1 to 3 times/day, for a total daily dose of 25-100 mg).

TUIP - Your doctor may recommend transurethral incision of the prostate (TUIP) if your prostate requires surgery, but isn't greatly enlarged. This procedure widens the urethra by making several small cuts in the neck of the bladder, the point where the urethra joins the bladder, and in the prostate itself. This reduces the prostate's pressure on the urethra and makes urination easier. Some experts believe TUIP gives relief with fewer side effects than TURP, particularly a lower incidence of retrograde ejaculation. However, others say its long-term benefits and risks have yet to be established conclusively.

TUNA -Transurethral needle ablation of the prostate (TUNA), procedure delivers low level radio frequency (RF) energy to the prostate, relieving obstruction without causing damage to the urethra. A small probe is inserted through the urethra and into the prostate. Two small electrodes are deployed into the prostate and a low level of radio frequency energy is applied. The energy heats the prostate tissue and shrinks it, relieving the obstruction while protecting the urethra and surrounding areas.

The TUNA procedure can be performed in an office or hospital outpatient center in less than 1 hour using minimal anesthesia. Clinical studies have demonstrated that TUNA provides significant improvements in urine flow and other symptoms of BPH. Its long-term side effects are minor compared with those of such conventional procedures as TURP. Most patients are able to return to their normal activities within 24 hours.

TURP - About 90% of all surgeries for BPH involve transurethral resection of the prostate (TURP). This procedure requires no external incision and takes about 90 minutes.

After giving anesthesia, the doctor inserts an instrument called a resectoscope into the penis through the urethra. The resectoscope is about 12 inches long and half an inch in diameter. It contains a light, valves for controlling irrigating fluid and an electrical loop to cut tissue and seal blood vessels. The doctor uses this loop to remove the enlarged tissue one piece at a time. The irrigating fluids carry this tissue to the bladder where they are flushed out after the operation.

Patients usually must remain in the hospital for about 3 days after TURP surgery, during which a catheter must be used to drain their urine. After that, recovery usually is quick. Most men find their BPH symptoms improve rapidly and are able to return to work within a month. During the recovery period, doctors generally advise you to:

·         Drink plenty of water to flush the bladder

·         Eat a balanced diet and use a laxative if necessary to prevent constipation and straining when moving the bowels

·         Avoid heavy lifting, driving or operating machinery

U

Urethrolysis - Urethrolysis is an anti-incontinence operation that involves the cutting of obstructive adhesions (fibrous tissue bands) that fix the urethra to the pubic bone. Urethral obstruction is a well-recognized complication of surgical procedures for disorders such as stress incontinence. The symptoms of post surgical urethral obstruction include urinary retention, incomplete bladder emptying, irritation or pain when urinating, decreased force of the urine stream, hesitancy, and recurrent urinary tract infections.

Urethrolysis that is performed via an incision through the vagina (female reproductive canal) is known as transvaginal urethrolysis. Transvaginal urethrolysis is associated with fewer complications than other methods of urethrolysis, and it permits the correction of coexisting vaginal abnormalities. Transvaginal urethrolysis is the most effective procedure to mend urethral obstruction after surgical repair of stress incontinence.

Urinary catheters

Urinary Tract Diversion - Until recently, most bladder cancer patients who underwent cystectomy (bladder removal) needed an ostomy (surgical creation of an artificial opening) and an external bag to collect their urine. Now, reconstructive surgical methods have been developed to replace the cancerous bladder. The continent urinary reservoir is the newest form of Urinary Tract Diversion . With this technique, a piece of colon (large intestine) is removed and used to form an internal pouch to store urine. The pouch is specially refashioned to prevent back-up of urine into the ureters (one of two tubes that pass urine out of the kidneys and into the bladder) and kidneys. The patient—whether male or female—can urinate as before, without the need for an external bag or collection device. The urinary reservoir procedure is associated with some complications, such as bowel (intestine) obstruction, blood clots, pneumonia (lung inflammation), ureteral reflux (back-flow), and ureteral blockage.

V

Vacuum Therapy - Vacuum therapy

Vaportrode - Transurethral vaporization of the prostate (TUVP), also known as vaportrode, is a new technique that involves direct application of high heat (less than 100 degrees) to the prostate tissue by means of a grooved roller-bar that vaporizes tissue instead of burning it with a laser. The immediate tissue loss leads to quick improvement in BPH symptoms and urinary flow, comparable to TURP. The procedure takes from 20 to 65 minutes. Most patients can have their catheters removed within 24 hours and can go home on the second day after treatment.

Varicocele Embolization - Varicocele embolization is an alternative to surgery for men with varicocele. Embolization is an outpatient procedure in which the varicocele is closed off (occluded) by means of a balloon catheter (flexible tube with a tiny detachable balloon), steel coil, and/or sclerosing (vessel-hardening) solution.

First, the patient is catheterized (a flexible tube is inserted into a blood vessel) at a few venous sites (e.g., right femoral vein, left renal vein, left internal spermatic vein). The patient then performs a Valsalva maneuver (a forced "exhale" with a closed nose and mouth) and undergoes venography (X-ray of a vein filled with contrast medium) to identify the location of the varicocele. Next, the balloon catheter is drawn through the vessel and usually is inflated at the level of the pubic ramus (e.g., pubic branch of the internal spermatic vein), below the insertion of most collateral (parallel) veins. Careful attention is paid to the level of occlusion to avoid varicocele recurrence. If follow-up venography shows that residual collateral veins remain, further occlusion may be performed by using a steel coil or another balloon with or without a sclerosing agent such as glucose. After the catheter materials are withdrawn and no venous bleeding is observed, the patient is sent home to resume normal activities the next day.

Since venography is used to visualize and "target" the veins during embolization, varicocele theoretically should not recur in most men, but there is still a high rate of technical failure and/or recurrence. On very rare occasions, balloons have moved from the scrotal venous system into the general circulation and caused embolism (clots) in the lung and other sites.

Varicocelectomy - Varicocelectomy - the cutting away of a varicocele - is usually performed with regional or general anesthesia. The surgeon makes an incision into the groin, and the problematic venous system then is repaired. The venous channels are divided to prevent varicocele recurrence, and the external cremasteric vessels (the veins associated with the testis-elevating muscle) also are tied off and divided. Varicocele repair often dramatically increases semen quality and pregnancy rates in infertile couples. The major complications of varicocelectomy are varicocele recurrence and formation of hydrocele (collection of fluid in a contained area). However, newer microsurgical techniques have substantially limited these complications.

Vascular Surgery - Vascular surgery

Vasoepididymostomy - Vasoepididymostomoy is a microsurgical procedure that uses a microscopic camera and very small operative tools to correct obstructions in the genital tract (see also Vasography). The procedure requires removal of the blockage in the epididymis (the coiled tube that extends the length of each testis and connects with a larger duct - the vas deferens) and re-attachment of the epididymis to the vas deferens. Vasoepididymostomy may improve pregnancy rates by up to one-third of all patients; however, the success of vasoepididymostomy is dependent upon the experience and technical expertise of the microsurgeon.

Classic signs of epididymal "blockage" are a swollen top of the epididymis, the presence of sperm in semen drawn from the obstructed segment, and otherwise normal testes. Blockages frequently arise in the epididymis because of inflammation due to sexually transmitted diseases (STDs). Gonorrhea is an STD that, if left untreated, is likely to damage the epididymis and produce obstruction. Other, rarer causes of obstruction include cysts, inherited atresia (tubal closure), and genital tuberculosis. Vasectomy (a contraceptive procedure involving surgical removal of a portion of the vas deferens) currently is the leading cause of infertility secondary to genital tract obstruction (see also Vasovasostomy). There is an increased likelihood of epididymal blockage among men who have had vasectomies of more than 10 years' duration.

Vasovasostomy - Vasovasostomy, otherwise known as vasectomy reversal, is the re-connection of the severed ends of the vas deferens. This procedure, like vasoepididymostomy, commonly is conducted using microsurgical methods. However, nonmicroscopic, "macrosurgical" techniques also are successfully employed. Most vasectomy reversal procedures are conducted on an outpatient basis.

During microsurgical vasovasostomy, most surgeons use a "two-layer" technique in which both the inside and outside layers of the severed tubules is reconnected with tiny sutures. Close attention is paid to the character of the fluid that is obtained from the testicular end of the vas: if the fluid is clear and colorless and if sperm are present, the results of vasovasostomy usually are favorable. By contrast, if the fluid is thick or creamy and if sperm are absent, a vasoepididymostomy usually is performed rather than a vasovasostomy (see also Vasoepididymostomy).

The complications experienced after vasovasostomy are infrequent and minor. After vasovasostomy some men are found to produce antisperm antibodies - immune system molecules that lessen the fertilizing potential of sperm (see also Other Sperm Function Tests). The antibody production is a result of the vasectomy. Some physicians recommend the collection and freezing of sperm from the site of vasectomy reversal in the event that sperm are abnormal or sperm output is inadequate after successful reconnection of the vas.

The new forms of fertility treatment - collectively known as Assisted Reproductive Technologies (ART) - incorporate many methods of sperm retrieval and preparation. Once the sperm have been processed to ensure optimal fertilizing potential, they are used in a variety of procedures that aid the process of conception. These procedures include artificial insemination (AI), in vitro fertilization (IVF), and sperm microinjection techniques.

W

Water-Induced Thermotherapy (WIT) - Water-induced thermotherapy (WIT) is the most recent development in the treatment of noncancerous, enlarged prostate. This innovative procedure was developed during the 1990s and received FDA approval in 1999. WIT is a minimally invasive outpatient procedure that is less complicated than other treatments for BPH.

WIT effectively destroys excess prostatic tissue, which presses on the urethra and compromises urinary flow, and thus reopens the urethra. WIT has its advantages: it can be performed in ambulatory surgery, outpatient surgery, or a physician's office; it takes only 45 minutes and does not require general anesthesia, and therefore does not carry the risks associated with inpatient surgery; and it does not produce incontinence or impotence, common effects of surgical treatments for BPH.

The Procedure
Before the day of the procedure, the urologist measures the size of patient's prostate in order to select the size of the catheter. The catheter is made up of four contiguous sections: the urinary drainage lumen, the positioning balloon, the treatment balloon, and the insulated shaft.

On the day of the procedure, the urologist inserts Lidocaine gel, an anesthetic, into the urethra to control pain. Next, the computer console, to which the catheter is attached, heats the water to 60° C (140° F). The urologist inserts the catheter through the urethra, through the center of the prostate, and into the bladder. Once the urinary drainage lumen and the positioning balloon reach the bladder, the positioning balloon inflates, thereby securing the catheter. Urine is allowed to pass by means of the urinary drainage lumen for the duration of the procedure.

The treatment balloon, resting in the prostatic urethra (located directly below the bladder), inflates and then fills with water, during which time the patient will likely feel some pressure. The temperature-controlled water then circulates through the insulated shaft into the treatment balloon. The catheter conducts heat through the insulated shaft to the prostate gland, raises the temperature of the gland, and then destroys the obstructive tissue to a depth of approximately 11 mm.

Throughout the procedure, the computer console precisely maintains the temperature of the water at 60° C. After 45 minutes of treatment, the catheter is removed. Over the next few weeks, the body either sloughs off or absorbs the destroyed tissues.

Following the procedure, the patient will likely experience swelling. A urethral catheter will ease the constricted flow of urine caused by the swelling. The catheter will remain in place for approximately 4 to 17 days, or until the swelling is reduced and normal urinary flow is restored. Patients also experience transient hematuria, or temporary blood in the urine, after the procedure. Studies indicate that some patients experienced treatable urinary tract infection or urinary urgency after the procedure.