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Actos Cancer : Radiation therapy for bladder cancer is commonly deliv­ered with a machine that focuses an invisible external beam on die area that requires treatment. The procedure is painless and similar to having an ordinary X-ray done. In the usual approach, your doctors will use your CT scan as a road map of your abdomen and pelvis to pinpoint your tumor and aim the beam at it. In another type of radiotherapy, doc­tors implant a small pellet or needle of radioactive material directly into your cancer. (This is rarely used for bladder cancer these days.)

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When radiation is used alone or with chemotherapy, there is an increased likelihood that your other organs, such as the prostate and uterus, will remain functional, as does your ability to void urine normally and have sex. The intention when chemotherapy ^¿radiotherapy are given is usually to improve the chances of curing the cancer while preserving the bladder and avoiding the need to remove it surgically. This area is still somewhat controversial; some physicians believe that this approach is nearly as effective as surgical removal of the bladder, but others feel that cystec­tomy is the best treatment. The decision of which treatment to pursue depends in part upon the physical fitness of the patient as well as upon the patients personal preferences.

Radiotherapy is not without side effects. Radiation can scar bladder tissue, and the scarring can reduce the amount of urine your bladder can hold as the bladder wall becomes less distensible. As a result you may experience an increase in the number of times you have to urinate, which can be irritating, especially at night. You also may experience an increase in bouts of cystitis.

There has been much discussion in the medical commu­nity about whether the results achieved by radiotherapy are the same as those from cystectomy with respect to achieving cure. We think that when one considers all types of blad­der cancer, in the hands of a highly experienced urologist who specializes in this operation, cystectomy gives better results than radiotherapy. However, there are some patients, particularly those with other significant medical conditions, who will benefit from radiotherapy, despite the possibility of a lower chance of permanent cure. In some centers, such as Massachusetts General Hospital, where the techniques of chemo radio therapy and bladder preservation have been piloted, a urologist will perform a cystoscopy about halfway through the planned course of radiotherapy. If the tumor is shrinking well, radiotherapy will be completed. However, if it appears that the cancer is not responding to radiother­apy, the plan will be abandoned and replaced with a radical cystectomy.

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There are no absolute guidelines for follow-up after cystec­tomy. What is right for you will depend on your situation: the type of urinary diversion system you have, whether you received chemotherapy and/or radiotherapy, and what, if any, side effects you are dealing with. A reasonable guide for follow-up, however, is to expect a physical exam, chest X-ray, urine test, and blood work every three months for the first year, every four months for the next two years, and then twice a year for life. We usually recom­mend an annual CT or MRI for the first five years at least.

Our use of the term or terms Actos Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Lawsuits : The stage is very important in determining the treatment that you will receive. There is a good barrier between the urothelium and the muscle of the bladder wall. If the tumor is kept within this barrier, the tumor can usually be completely removed with a transurethral resection of bladder tumor (TURBT) (Question 38). If the tumor has become more aggressive, it may figure out how to pass through this barrier. When the tumor has gotten through the protective layer, it becomes much more likely to spread outside of the bladder to other organs or lymph nodes. Once the tumor has gotten through the urothelium, simple scraping of the tumor is not likely to get all of the tumor out, and further therapy will be necessary—either surgery, chemotherapy, or radiation. The option that you and your doctor choose will depend on the extent of spread of the tumor and your overall health status.

Over the years, several different systems have been used to stage cancers. In an effort to ease confusion between different systems, doctors around the world met and decided to create a new staging system that would be relevant for all different types of cancer. This system is called TNM. The letters stand for Tumor size, lymph Node status, and the extent of Metastases.

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“Upper tract studies” are evaluations that your doctor does of your kidneys and ureters. The lining of the bladder is the urothelium. The same urothelium also lines the ureters and the inside of the kidneys. The kidneys and the ureters are then also potential locations of transitional cell cancer. The study that your doctor chooses depends on his or her personal opinion as well as the availability of each test at your hospital. Even if the upper tract study is negative, you will likely need to repeat the studies periodically. Patients with low-grade tumors have a low risk (approximately 2%) of developing upper tract tumors. The presence of a high-grade tumor or of diffuse carcinoma in situ, however, carries up to a 40% lifetime risk of developing an upper tract tumor.

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An ultrasound is often the easiest test to obtain and is therefore popular as a first study. Ultrasound technology generates sound waves and then measures their reflections off of internal structures to produce an image. The same imaging is used for obstetric ultrasounds to produce an image of the fetus. There is no radiation with an ultrasound. An ultrasound is very good for showing tumors and stones in the kidneys and for showing obstruction of the ureter causing hydronephrosis. It is not as good for showing small tumors inside the ureter or renal pelvis, and thus a second kind of study is usually needed in addition to the ultrasound.

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Actos Lawyer: Approximately twenty percent of patients with bladder cancer will complain of irritative voiding symptoms. These symptoms include urinary urgency (a need to rush to the bathroom), burning and urinary frequency. These same symptoms are present in other urologic conditions such as infection, bladder instability and prostatic enlargement in men. These symptoms are most commonly associated with a diffuse superficial form of transitional cell cancer of the bladder called CIS (carcinoma in situ). Unfortunately for some, their diagnosis may be delayed since these symptoms are present in so many other diseases.

Cystoscopy (examination of the bladder) is usually the first step in making the diagnosis of bladder cancer. Given the signs and symptoms suggesting bladder cancer, or an X ray or ultrasound revealing a possible bladder tumor, cystoscopy is a must. Cystoscopy can be accomplished with either a flexible cystoscope or a rigid scope. The flexible cystoscope is composed of small optical fibers encased by a plastic sheath. A rigid scope has glass lenses within a metal sheath. Both cystoscopes are passed directly through the urethra into the bladder to visualize the inside surface. Cystoscopy can be accomplished in both the urologist’s office or as an outpatient at a hospital or surgicenter.

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The flexible cystoscope is easier and less painful to pass, especially for males whose urethra is longer and more tortuous than in females. Flexible cystoscopy is readily accomplished in the doctor’s office. A lubricant is applied to the scope to ease passage. Local anesthesia can be squirted into the urethra prior to passing the scope. Discomfort from the cystoscope is usually well tolerated and short in duration. The discomfort usually lasts a few seconds as the scope is passed through the prostate. At that time, you may feel a pressure sensation. In females, passage of the scope is quick and relatively painless.

During the exam, your bladder will be filled with sterile water to allow complete visualization of all the surfaces. You may feel like you have to urinate. During flexible cystoscopy, small biopsies can be obtained. Any bleeding from the biopsy site is readily controlled. The biopsy and cauterization will cause pain for a few seconds. A mild oral sedative can be taken prior to an exam, but is generally not necessary. An entire examination may take only a few minutes. If biopsies are done, the exam will be a little longer. Flexible cystoscopy is very convenient. You can drive yourself to and from the office. After the exam, you can generally go right back to work. If a tumor is found that is too large to treat with a flexible cystoscope, you will be scheduled for an additional procedure at a hospital or surgicenter.

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The rigid cystoscope, although easy to pass in a female is difficult to pass without sedation in a male. The rigid cystoscope allows for generous biopsy specimens and removal of small tumors. Cystoscopy therefore can provide for both diagnosis and treatment at the same time. If a large cancer is found, removal with a resectoscope can be used to remove it at the same time. If multiple biopsies or resection of a cancer is done, spinal or general anesthesia may be required. Since rigid cystoscopy generally causes more discomfort than flexible cystoscopy and requires more anesthetic, you can expect to be out of work at least one day. In addition, someone will need to drive you home from the surgicenter or hospital.

If you are being initially screened for asymptomatic microscopic hematuria, a urologist will often choose flexible cystoscopy as the first step. He is not certain whether or not you have a bladder cancer or other condition causing the hematuria. Flexible cystoscopy will provide that answer in a less time consuming, less painful and more cost effective way than rigid cystoscopy. On the other hand, if there is a high likelihood a tumor is present, it makes sense to do rigid cystoscopy and if required, resection all at one setting. If you are experiencing gross hematuria, flexible cystoscopy does not provide adequate visualization, and rigid cystoscopy is warranted. Many urologists use both types of cystoscopes, but some do not have the flexible cystoscope in their office.

Our use of the term or terms Actos Lawyer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Litigation: A good starting point is your primary care physician. He will generally have a number of specialists to whom he generally refers his urology patients. If the primary care physician has been working with these urologists, he should have an appreciation of their skills and temperament. However, this does not mean he is referring you necessarily to the best available urologist in your area. His choices may be limited by insurance or hospital networks. An excellent source of information would be nurses who work in the operating room, recovery room or on the surgical floor where the urologist does his surgery. Asking friends or other individuals who have had experience with the urologist can also prove useful. After a little digging, you can often quickly learn what type of reputation the urologist has in the community. Generally, if an established urologist has a “good reputation” this is an indication that he has pleased many individuals with his care.

Given the litigious society we live in, most physicians can face at least one malpractice lawsuit during their careers. In urology, two of the most common causes of litigation would be a surgical mishap leading to a complication, or failure to diagnose cancer in a timely fashion.

Medicine is based on science, but also is an “art.” Individuals do not walk into their physicians offices with a diagnosis and treatment plan always readily apparent. Even the best intentioned, thorough physician will make mistakes. Most of these errors do not result in harm. On occasion they do, and a law suit may follow. If a physician develops a good working relationship with a patient, these bad outcomes more often than not are acknowledged and accepted without legal entanglement. Competent, busy physicians may be dealing with a higher mix of complicated patients, leading to a higher number of potential suits. Physicians who have poor “bed side manner” may find themselves dealing with more suits. If a physician has an inordinate number of suits, “red flags” should go up, as competency may be an issue.

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Medical information is scrutinized in journals and reviewed at conferences. The newest treatment regimens for advanced cancer are explored in clinical trials to determine their efficacy and safety. It is only after they are proven that they become adopted as standard practice by most physicians. For the vast majority of individuals with bladder cancer, excellent, comprehensive treatment can be obtained at the local level. For those requiring more specialized care or for those unfortunate individuals with advanced cancer who desire experimental therapy via a clinical trial for their cancer, a referral to the appropriate center may be appropriate.

Given the monetary pressures in today’s medical practice, some physicians are over booked and cannot see the allotted number of patients scheduled without delays. The theory behind this schedule is the expectation that a number of patients will not show for their appointment, allowing the physician to stay true to the schedule and not fall behind.

However, sometimes all of the patients do show, and the physician is delayed. Even with a carefully thought out schedule, emergencies may arise and some visits unexpectedly take longer than scheduled. The physician wants to devote the time and attention required for each individual. After all, you also expect the same time and attention during your visit. Even the most conscientious physician may find himself running behind in a busy medical practice. This lateness should be recognized by the physician who will often acknowledge it with an apology. If you find it distressing to wait more than fifteen minutes (a reasonable time to wait), you should discuss your feelings with your physician, who often can arrange an appointment at the beginning of the schedule when he will almost be guaranteed to be on time.

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You may need a second opinion if you are not doing well and your physician is unable to provide satisfactory explanations and solutions. Occasionally, your urologist may recommend a second opinion if your problem is unusual or particularly complicated. Having a physician you can trust is mandatory when dealing with cancer. Don’t let anyone pressure you into a second opinion if you feel confident in your physician’s abilities. On the other hand, if you are uncomfortable with your progress or a treatment recommendation, if you are not satisfied with the explanations given to you, don’t hesitate to seek out a second opinion. Your urologist should not feel threatened by this request as he wants you to feel comfortable with the plan of action. Only by partnering with your physician can he be most effective.

Cancer unfortunately is a common disease affecting almost all animals. People are equally susceptible; approximately one in three will be afflicted at some time in their life. In this chapter, we will review basic information regarding the bladder, bladder cancer, and cancer in general, including what causes it and some parameters used to determine how serious it is. A bladder stores urine and expels it at a convenient time. The bladder is a very useful organ, (tissues working together to accomplish a function), but an individual can live a normal life without one, if required, by surgical creation of a substitute. Bladder cancer can vary from the non serious, low grade superficial type (approximately 70%), to the invasive, aggressive type that can spread and prove to be fatal (approximately 30%). 5% of bladder cancer is accounted for by squamous cell carcinoma. This cancer is usually secondary to long term inflammation or infection of the bladder. Even rarer is adenocarcinoma, which accounts for less than 2% of all bladder cancers. More than 90% of bladder cancers arise from the lining bladder cells called transitional cells. Bladder cancer is almost always transitional cell cancer. These cells are also present in the urethra (the body tube which drains the bladder), as well as the renal pelvis (inner lining of the kidneys), and the ureters (the body tube draining the kidneys).

Our use of the term or terms Actos Litigation is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Mesothelioma Lawyer : Simian virus 40, or SV40, is a virus that has been asso­ciated with the development of malignant mesothe­lioma. This virus is found in rhesus monkeys and is now widespread among humans. The way this virus was transferred from monkeys to humans is uncertain, but it is postulated that some of the transfer occurred from 1954 to 1963 through SV40-contaminated polio vaccines administered worldwide. Those people who received the injectable form of the polio vaccine are believed to be those at greatest risk. This vaccine doesn’t folly explain the transfer of this virus, because many humans who could not have received the contaminated vaccines are now infected with the SV40 virus. One theory that has been proposed is that the SV40 virus continues to be transferred from monkeys to humans or that humans can pass the virus from person to per­son. Propecia Lawsuit

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The latter theory has been supported by data showing that SV40 can be excreted in human feces, breast milk, and semen. It is unlikely that this virus acts alone in the development of mesothelioma as most cancers have multiple risk factors associated with their development, and most mesotheliomas occur in asbestos exposed individuals. Instead, it is more likely that asbestos and SV40 may act together to develop into mesothelioma. Although rare, cases of mesothelioma have been found following radiation exposure to the chest and abdomen. These individuals were usually treated in the past with radiation therapy for a malignancy of the lymph glands known as lymphoma.

Lastly, there is an indication that a person’s own genes can play an important role in determining who is sus­ceptible, or vulnerable, to these mineral fibers and will then develop mesothelioma. It is hoped that doctors will be able to find the specific susceptibility gene in the future and that this may lead to the development of new prevention and treatment strategies to better control this disease. Exposure to asbestos is the link to the development of mesothelioma. People who end up with this disease usually have had some type of previous exposure to asbestos. How this works is not fully understood. It is thought that asbestos fibers are inhaled and first travel through the upper air passages, which include the throat, the trachea (windpipe), and the large bronchi (large breathing tubes of the lungs). These airways are lined with mucus, and therefore most of the fibers are cleared from these upper airways by sticking to this mucus and being coughed up or swallowed. When the fibers continue to travel and reach the small airways (the alveoli), the body’s immune system is able to sur­round, engulf, and remove the smaller fibers by a process known as phagocytosis. Actos Lawsuit

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The large, long, thin fibers cannot be cleared as easily and may eventually reach the pleura (the lining of the lung and the chest wall), where they may irritate and injure the cells and lead to the development of calcium containing plate­like structures on the pleural lining (pleural plaques), fibrosis (scar tissue formation), or mesothelioma. These same asbestos fibers can also damage cells in the lung itself, which can lead to asbestosis (scar tissue in the lung) and/or lung cancer. Patients with these pleu­ral plaques seem to be at highest risk for developing mesothelioma.

The best way to prevent mesothelioma is to decrease one’s exposure to asbestos in the workplace, at home, and in the environment. The federal government is responsible for developing regulations that deal with asbestos exposure in the workplace. The agency that issues these regulations is known as the Occupational Safety and Health Administration (OSHA). Employ­ers are required to follow these regulations, and there­fore workers who are concerned about asbestos exposure should be discussing these concerns with their employers or union. Also, employees should be using all protective equipment provided to them by their employers and following recommended safety procedures and practices while at work.

Our use of the term or terms Mesothelioma Lawyer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Multaq and Liver Damage: The most effective treatment of chronic HCV is antiviral ther- apy—that is, medication that targets a virus. Interferon, a widely known antiviral discussed earlier in this chapter, is the treatment of choice for chronic HCV. Pegylated interferon in combination with ribavirin-—-the most common treatment-—is the most effective treatment for chronic hepatitis C, but the side effects can be substantial. Flulike symp­toms (fever, chills, muscle and joint pain, fatigue, weakness) are common, and doctors will prescribe medications to combat these symptoms if they become debilitating. It is also important for patients to maintain their activity levels to build a little muscle and be able to muster the energy to get through the day. Adequate fluid intake is also essential. This is a simple and often overlooked strategy. Many patients report that substantially increasing their daily fluid intake is the most effective method in combating the fiulike side effects that plague pegylated interferon therapy.

Depression, insomnia, irritability, and even confusion are expe­rienced by more than half of patients undergoing interferon ther­apy. The depression is considered to be somewhat different from classic major depression, but afflicted patients may benefit from a course of antidepressants such as citalopram (brand name Celexa) or sertraline (brand name Zoloft).

Other side effects that don’t seem to follow any regular pattern include headaches, vision problems or dry eyes, weight changes, brictle nails, insomnia, changes in blood levels, a burning sen­sation in the mouth (known as stomatitis), decreased sex drive, and menstrual irregularities. To some degree, these symptoms are manageable. But in some patients, the side effects can be severe, and supportive medications are able only to “take the edge off” Although treatment may be difficult, physicians who regularly treat chronic hepatitis C are well versed in managing side effects. Key to successful outcome is maintaining the proper dose of medication to ensure that patients have the best possible chance to permanendy rid their bodies of the virus.

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Our use of the term or terms Multaq and Liver Damage is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Multaq Lawyer: Although no treatment exists for HAV, it is important to treat the symptoms. Patients experiencing fatigue should rest and not to push themselves. All HAV patients must drink plenty of fluids because dehydration can easily develop as a complication, espe­cially if the patient has had diarrhea. The good news about HAV is that if a person receives the proper vaccine series, the disease is almost always preventable. The HAV vaccine series has been used extensively worldwide and has proved to be a safe and extremely effective vaccine.

The first hepatitis virus to be discovered, hepatitis B (HBV), has infected an estimated 2 billion people worldwide. About 300 million are chronic carriers of the virus, including about 1.25 million Americans. HBV can be deadly; its complications kill about 1 million people every year, and it is the most prevalent cause of cirrhosis and liver cancer in the world, particularly in Africa and Southeast Asia. Yet most people infected with HBV lead fully normal lives.

The HBV virus can be found in body fluids, including saliva, blood, tears, and breast milk, though it is transferred between people only through blood and semen. Casual contact, such as hugging or shaking hands, does not spread the disease; in fact, not everyone infected with HBV is contagious. HBV can be con­tracted only through sexual contact, a blood exchange, or from a pregnant mother to her fetus—a method of transmission common in Africa and Asia.

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Before 1975, blood and platelets collected from blood donors (during blood drives, for example) were not screened for HBV so transfusions once accounted for many HBV infections in this country. Today, donated blood is tested for HBV, but the virus continues to be transferred through more subtle blood exchanges, such as when an infected person shares a razor or nail clippers, or exposes another person through a bleeding skin condition.

Needles used for tattooing and acupuncture can also be contaminated with blood infected with HBV. People diagnosed with hepatitis B need to take special care to cover any bleeding spots, and everyone should avoid contact with used needles. The HBV virus can live on an open surface, including needles, for up to a week.

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Acute hepatitis B, or HBV that lasts less than six months, is no longer prevalent in the United States, probably the result of early vaccinations. It does occasionally occur, however, and its flulike symptoms—fever, abdominal upset, nausea, decreased appetite, vomiting, and changes in the way things taste and smell—resem­ble symptoms associated with other hepatitis infections. In some cases, the individual experiences symptoms that make it clear the immune system is fighting off the HBV, such as muscle and joint aches, too much protein in the urine, or a rash.

Our use of the term or terms Multaq Lawyer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Trans Vaginal Mesh Lawsuit: Some women wear pads to protect their underwear and clothes from urine leakage. Your doctor will probably ask you about this during the office visit. The size and absorbency of pads vary, as does die frequency that women change them during the day. In order to accurately measure the amount of urine you may be losing during die day, some doctors ask you to do a pad count For a day or two before your appointment, you will be asked to keep all the pads you use in a sealed plastic bag and bring them, along with one dry pad, to the doctor’s office. This is not the most pleasant task, but it does tell the doctor exactly how much urine you are losing during the day. We weigh the wet pads, then the single dry one, and calcu­late how much urine you have lost. In addition to measuring the number of pads you use during a day, the test can also calculate if whatever treatment we prescribe actually decreases the amount of urine lost.

In order for us to understand what is causing your incontinence, we sometimes need to figure out if the bladder muscle is working properly. The test for this is known as urodynamics, or UDS for short. Despite the peculiar name, this has nothing to do with jet planes or aerodynamics. The term urodynamics implies that we are able to see the bladder (uro), in action (dynamic). The muscular sac we call the bladder is supposed to stay relaxed and then com­fortably expand while it collects and stores urine made by the kid­neys. The bladder is supposed to work without any effort, or even awareness, on your part. Then, when you are ready to urinate, it should contract and force the urine out. The urodynamic study allows us to measure the way the bladder works: Does it fill up without the contractions associated with overactivity? Does it con­tract properly and at the right time? Can the bladder hold a reason­able amount of urine? Does it hold too little urine? Too much? When it contracts, does it get all the urine out?

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UDS testing allows us to answer these questions. Some women may need to have UDS testing done, especially if the diagnosis is not clear to the doctor after the initial tests described above. UDS testing is performed in the office, takes about one hour, and is painless. Your doctor will ask you to undress from the waist down and wrap a sheet around your waist. First you will sit in a special chair that supports your back, buttocks, and legs in a comfortable position. This chair allows your doctor to tilt you back to a lying po­sition in order to perform the first part of the testing. Then, with­out your having to move, you can be tilted to a sitting position to see if your bladder functions any differently while you are up­right—as you are for most of the day. The first part of the testing involves urinating into a specialized basin that measures how fast or slowly the urine comes out of your bladder. If something is blocking the urine, such as scarring inside the urethra or a bladder muscle that isn’t working properly, the flow will be slow.

You should not be able to feel anything until your bladder gets filled to the point where you would normally have to urinate. Your doctor will ask you to tell us when this is. Then your doctor will ask you to cough (or bear down) after the addition of every 3 ounces of fluid from that point forward, to see if you leak. Leaking is a sign of having stress incontinence. Your doctor will continue to fill your bladder and ask you to say when you are really full—the point when, if you were driving, you might pull off the road to find a bathroom. Shortly thereafter you will feel that you cannot hold any more, and the test will be stopped. The computer measures how much fluid has been put into the bladder and what the pres­sure is in the bladder as it fills up.

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Normally, the bladder expands quietly as it fills, without any contractions at all, until you are ready to empty it. For some women, however, an overactive bladder contracts during the time it is filling. These contractions can be seen on the computer and are recorded for later analysis. An overactive bladder is usually treated nonsurgically.

The next part of the test is a repeat of the first part, but in a sit­ting position. Because most women with incontinence lose urine in the standing or sitting position, this part of th e test may reveal problems that were not apparent when you were lying down. Dur­ing this part of the UDS, a test called the abdominal leak point pres­sure test is also performed. After your bladder is partly filled, you will be asked to bear down as hard as you can. The pressure gener­ated by your abdominal muscles when you bear down pushes on the bladder and increases the pressure inside the bladder. Your doctor will look to see if you lose urine and then measure the pres­sure in the bladder when this happens. If the mechanisms that normally keep you from leaking are all working, you should not leak despite the increase in pressure. If you leak just as you start to bear down, it is called a low leak point pressure. A low leak point pressure usually means that scar tissue is holding the urethra.

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Vaginal Lawsuit : Ultrasonography of the urinary tract may be performed. This can be useful to visualize the upper tracts when looking for dilatation secondary to reflux, or to estimate bladder capacity or post-void residual. More recently, bladder wall thickness has been used to assess the probability of DO – a thickened hypertrophied detrusor being associated with abnormal detrusor activity. Ultrasound is a rapid, painless method of examining the pelvis and abdomen, and reveals a high number of incidental ultrasound findings, such as ovarian cysts or uterine fibroids. This is true regardless of the source of referral.²⁸ Such space-occupying lesions may profoundly affect lower urinary tract function. Ultrasound cannot yet, however, replace tests of dynamic function.

In isolation, a micturating cystogram is useful to diagnose fistulae and diverticula (Figure 3.8a,b). It is more useful to combine it with dual-channel subtracted cystometry at video- urodynamics. Magnetic resonance imaging (MRI) has improved the anatomical investigation of incontinence and prolapse because of the highly detailed images now available. Specifically, understanding of the normal pelvic anatomy and comparative studies after childbirth has advanced our knowledge of the mechanisms of incontinence and prolapse.^2g In the UK MRI remains predominantly a research (and tertiary centre) investigative technique because of cost and availability.

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The appropriate investigation of lower urinary tract symptoms is of paramount importance in order to secure an accurate diagnosis. Urinary symptoms alone are not sufficient to gain an accurate impression of the underlying pathology, and this may lead to inappropriate treatment being given and deterioration of the patient’s condition and quality of Life. The International Continence Society (ICS) classifies lower urinary tract dysfunction into disorders of the storage and voiding phases of the micturition cycle.^1,2 Adequate cognitive function, mobility, motivation and manuaL dexterity provide the means to perform the tasks of continence. It follows, therefore, that disruption of any of these functions can lead to incontinence.³Assuming the absence of inflammation, infection or neoplasm, lower urinary tract dysfunction can be caused by disturbances of neurological or psychological control and disorders of muscle function, structural abnormalities.

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Uodynamic stress incontinence (USI), detrusor overactivity (DO), mixed incontinence and overflow incontinence are by far the commonest causes of incontinence in the UK. Urodynamic stress incontinence accounts for approximately 50% of cases, DO for around 40% and overflow for most of the remaining 10%. Many women present with ‘mixed incontinence’, which is usually a combination of stress urinary incontinence with DO. Fistulae are rare in England and are usually secondary to gynaecological surgery, maLignancy or radiotherapy. A fistula is an abnormal connection between two epithelial surfaces.

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MY FAMILY WANTS ME TO GO FOR TREATMENT OF MY BLADDER CANCER TO THE “TEACHING HOSPITAL” IN THE CITY MY LOCAL UROLOGIST IS COMPETENT AND CARING AND I TRUST HIS JUDGEMENT SHOULD I LISTEN TO MY FAMILY AND SWITCH UROLOGISTS?

As we have discussed in the preceding questions, finding an excellent urologist to partner with is a must. A physician established at a “teaching hospital” (a hospital where physicians are trained in their respective fields of specialty) is at the minimum, competent. A large teaching or academic center would not risk its reputation on an individual who is sub par. Some individuals may be world class surgeons, but not all will be. An individual may be an average surgeon, but a gifted teacher or researcher, making them invaluable to their academic center. Your local community urologist will likely be an individual trained at one of these academic teaching hospitals. In addition, community hospitals also have credentialing and quality review programs to weed out incompetent physicians. In general, it is true the academic center will have more stringent standards and review of their staff. Nevertheless, excellent physicians can be found at the community hospital as well.

ISN’T IT TRUE THAT ACADEMIC OR TEACHING HOSPITALS WILL HAVE THE BEST TECHNOLOGY OR MOST UP TO DATE INFORMATION TO TREAT MY CANCER?

These hospitals generally are at the forefront of innovation regarding technological advances, testing and implementation of new surgical techniques and chemotherapeutic regimens. However, no one center can be excellent in all spheres of medicine. Each will have particular strengths and weaknesses. We are however, fortunate medical knowledge and innovation are shared openly via medical journals and conferences and other means of information exchange. New information and proven effective techniques are rapidly disseminated throughout the medical community. Some teaching hospitals may be “centers of excellence” for a particular procedure or innovative approach that is available at only a few sites in the country. There is naturally a lag time for some procedures to spread to the local level, and if in fact a new procedure carries substantial benefits compared to the standard, and is not available locally, then a referral may be appropriate.

Medical information is scrutinized in journals and reviewed at conferences. The newest treatment regimens for advanced cancer are explored in clinical trials to determine their efficacy and safety. It is only after they are proven that they become adopted as standard practice by most physicians. For the vast majority of individuals with bladder cancer, excellent, comprehensive treatment can be obtained at the local level. For those requiring more specialized care or for those unfortunate individuals with advanced cancer who desire experimental therapy via a clinical trial for their cancer, a referral to the appropriate center may be appropriate.

IF I HAVE MY MAJOR SURGERY PERFORMED AT A TEACHING HOSPITAL, WILL THE ATTENDING PHYSICIAN PERFORM MY SURGERY AND TAKE CARE OF ME AFTERWARDS?

At a teaching hospital, physicians are in training to master their skills before going out into “practice” in their respective fields. Interns are fresh out of medical school with limited practical training. Often they are referred to as PGY 1 (post graduate year 1). Years of training follow (PGY2, PGY3 etc.). Urology residents are required to generally have at least two years of training in a surgical program followed by four years in urology residency. It is the responsibility of the residency director to provide adequate training for these future urologists while assuring patient safety. Practically speaking, there are usually one or more attending physicians who supervise the work of the physicians in training. The attending physicians are board certified, experienced physicians who treat patients while simultaneously training physicians. The residents will be a key component in your care. They will be assessing you both pre- and post-operatively and will be writing orders directing your care. How much of the surgery they get to do is dependent on their years of training and their skills. They will be under the direct supervision of the attending physician. If you have concerns, you should address them with your attending physician.

MY UROLOGIST ALWAYS KEEPS ME WAITING, DOES THIS MEAN HE DOESN’T CARE?

Given the monetary pressures in today’s medical practice, some physicians are over booked and cannot see the allotted number of patients scheduled without delays. The theory behind this schedule is the expectation that a number of patients will not show for their appointment, allowing the physician to stay true to the schedule and not fall behind.

However, sometimes all of the patients do show, and the physician is delayed. Even with a carefully thought out schedule, emergencies may arise and some visits unexpectedly take longer than scheduled. The physician wants to devote the time and attention required for each individual. After all, you also expect the same time and attention during your visit. Even the most conscientious physician may find himself running behind in a busy medical practice. This lateness should be recognized by the physician who will often acknowledge it with an apology. If you find it distressing to wait more than fifteen minutes (a reasonable time to wait), you should discuss your feelings with your physician, who often can arrange an appointment at the beginning of the schedule when he will almost be guaranteed to be on time.

WILL THERE BE OTHER PHYSICIANS INVOLVED IN MY TREATMENT OF BLADDER CANCER?

You may need to be referred to an oncologist, a physician specialist in the medical therapy of cancer. At times, a referral to a radiation oncologist, a specialist who treats cancer with radiation, may be required. Other individuals may need to be consulted as well. It is important for your urologist to keep your primary care physician up to date so that he can coordinate your care and if required by your insurance plan, make the appropriate referrals.

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On a regular basis, magazine articles, books, and television shows implore those with major illnesses to seek out a second opinion. The general consensus is there is much to be gained and little to be lost, so why not seek out a second opinion? The issue certainly is more complicated than generally addressed, and deserves a review. The following chapter provides a second opinion on second opinions.

WHAT ABOUT SECOND OPINIONS?

In general, a competent physician will recommend a second opinion if there is uncertainty regarding your care. This uncertainty could involve the pathology report or debate regarding the most appropriate treatment options. Certainly if the pathology report is in question, a second opinion is mandatory! Your urologist should be able to spell out his treatment plans for you, what to expect and what alternatives may be required, depending on the seriousness of your disease. The plan may change over time as your disease improves or worsens.

You may need a second opinion if you are not doing well and your physician is unable to provide satisfactory explanations and solutions. Occasionally, your urologist may recommend a second opinion if your problem is unusual or particularly complicated. Having a physician you can trust is mandatory when dealing with cancer. Don’t let anyone pressure you into a second opinion if you feel confident in your physician’s abilities. On the other hand, if you are uncomfortable with your progress or a treatment recommendation, if you are not satisfied with the explanations given to you, don’t hesitate to seek out a second opinion. Your urologist should not feel threatened by this request as he wants you to feel comfortable with the plan of action. Only by partnering with your physician can he be most effective.

WILL MY UROLOGIST BE UPSET WHEN I REQUEST A SECOND OPINION?

Many physicians may feel slighted when a patient requests a second opinion. Your urologist may feel somehow you don’t trust his explanations, skill, or judgment. On the other hand, when a new patient faces a difficult or unexpected diagnosis, the urologist may find the request not at all unusual. It is important you explain to your urologist why you feel a second opinion is warranted. Urologists are professionals and will graciously facilitate your request. The experienced urologist comes to realize that despite his best efforts, some patients will seek a second opinion. If a patient is particularly concerned or nervous about a proposed treatment regimen, your urologist may welcome your request. Your urologist should facilitate your second opinion by sending appropriate records and telling you whether or not it is necessary for you to bring X rays or pathology slides with you. Your primary care physician may need to be contacted for the referral if your insurance requires it.

WHY DOESN’T MY UROLOGIST WANT ME TO GO FOR A SECOND OPINION?

Often, the urologist may believe the second opinion is unnecessary and will delay treatment. He may be concerned you will not only have a second opinion, but transfer your future care to the urologist providing the second opinion. He may believe that you may get bad advice. It is possible he may feel threatened the next urologist will not agree with his work up or care of you to date.

WHERE DO I FIND A SPECIALIST FOR A SECOND OPINION?

Start by asking your primary care physician. You may be able to see another urologist in your community. Do not see another urologist in the same group as a conflict of interest may deter a different opinion. If you are considering a different course of action, such as radiation or chemotherapy, a referral to the appropriate specialist should be made.

Many times your urologist will be highly supportive and suggest a second opinion. He will offer his recommendations and facilitate your visit to the appropriate physician. If there is an issue regarding the care given at your local hospital, you may wish a referral to a “tertiary” or teaching hospital. In most areas, a referral for this reason is unnecessary, as excellent care is obtainable in the community hospital.

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