A recipe for a great IC- friendly casserole:

It’s that time of the year again. There’s a nip in the air. This is a time to start thinking of getting cozy near a fire and spending more time inside. The foods of the cooler months often remind us of those homey feelings from childhood. Casseroles—hearty foods that warm you inside, and stay with you—are just the thing in the fall.

Here is a recipe for a great IC- friendly casserole:
Mushroom Lasagna (Vegetarian, no tomato sauce)

Sauce ingredients: 3 T butter 1 ½ lb. fresh mushroom halves or pieces 1 t. grated lemon zest ¼ c. flour 1 tsp. salt 2 ½ c. milk ½ c. minced fresh parsley 2 T white wine (optional)	Cheese: 1 lb. cottage cheese 8 oz. grated packaged mozzarella
	Pasta: 8 oz. lasagna noodles

Sauce preparation:
Melt butter in large saucepan. Add mushrooms and lemon zest. Sauté until mushrooms are wilted. Blend in flour and salt. Gradually stir in milk, followed by parsley and wine. Cook and stir until sauce thickens, making sure to boil off the alcohol from the wine. Makes 1 quart.
Put it together:

• Mix the two cheeses together in a small bowl. Build this dish in a 13" X 9" flat pan as you would a lasagna: noodle layer, sauce layer and cheese layer. Be sure to save a little sauce to cover the top layer of noodles so they will not dry out.
• Cook for 45 minutes at 325°. If desired, cover with foil for first half of cooking time to make it juicier.
• Let dish stand for 20 minutes before serving.

You can enjoy this dish any time. It can be made ahead of time, covered with foil, and reheated in the oven at 325° until hot and bubbly. It can even be frozen and put in the refrigerator the night before to thaw, then reheated for a delicious quick meal.
Enjoy!

Stop Pelvic Pain

It depends on what is causing the pelvic pain.

You first need to know how is classified pelvic pain:

1. Pelvic pain that has nothing to do with the bladder. For example, pelvic pain can come from endometriosis, tumors or infection, of the pelvis, uterus, prostate, rectum, etc. We have to exclude these major problems in the beginning.

2. Neuropathic pain. In this instance, the nerves themselves are malfunctioning. They send inappropriate pain messages to the brain, which incorrectly tells the patient that there's a problem in the bladder. The nerve problem can exist anywhere from the nerves of the pelvis to the spinal cord to the brain. This problem could be due to factors such as previous surgery, trauma, lower back disc disease, or tumors of the spine. In most instances, medical evaluation fails to demonstrate a cause. As you can imagine, any treatment that you apply directly to the bladder, such as DMSO, may have no effect on those patients. I find that patients having this type of pain are the most difficult to treat.

3. Bladder hypersensitivity/Interstitial Cystitis. A good history and physical examination will often help the physician hone in on the bladder as a central problem. For example, most patients with bladder specific pain will have one or more of the following problems:

• Urinary frequency and urgency
• Pain relieved somewhat by bladder emptying
• Discomfort on physical examination when the bladder is pressed

I find a helpful technique to identify the bladder as a source of pain is simply to instill an "anesthetic cocktail" into the bladder. A mixture of different anesthetics that will hopefully numb the bladder. If significant pain relief occurs, the pain is most likely related to the bladder. To further evaluate the bladder as a potential source of pain, we can perform a bladder hydrodistention (a stretch of the bladder with water and under anesthesia) to see if the bladder capacity is low, to see if the bladder bleeds easily, etc.

4. Pelvic floor dysfunction (PFD). The fourth site of pain is often the pelvic floor muscles. As you probably already know, the bladder and the rest of the pelvic organs rest upon these muscles. The muscles of the pelvic floor are very complex and serve very important roles for us on a moment-to-moment basis. For example, they need to relax when one urinates, has a bowel movement or, in the case of females, has sexual intercourse. I often see patients who complain of a very poor urinary stream. The urine flow may even start and stop. Many of these patients feel that they need to "push" in order to completely empty themselves. These patients are having a normal bladder contraction, however, instead of pelvic floor muscle relaxation occurring, they are actually tightening up and preventing urine from being released. The act of pushing urine out may be counterproductive since it often worsens the muscle "spasticity." On physical examination, pushing into this muscle group often elicits significant pain. The muscles are frequently "bulky" and in some instances very taught, having the characteristics of a violin string (as opposed to being soft and non-tender). Muscle problems such as this often give rise to vague complaints of pelvic discomfort. PFD is often associated with painful sexual intercourse (the pain is usually most severe "the day after"), irritable bowel syndrome and/or chronic constipation. Stress seems to be a very important factor in symptom worsening.
Overall, those are the broad reasons that patients will develop a pelvic pain syndrome. The big question is how to deal with it. This can be particularly complicated since patients often have several associated problems. For example, many of IC patients will have accompanying PFD. If both problems aren't addressed, patients generally have a suboptimal response to treatment.
If the patient's main problem is the bladder, then we will treat the bladder. As you know, dietary changes, oral medications,  will often improve symptoms. These medications have specific qualities that target the bladder. Sometimes medications instilled directly into the bladder may help. If the pain and discomfort appear to be coming from the muscles of the pelvic floor, then the therapy is not going to be the same. We want therapy aimed at relaxing the muscles. Teach patients how to deal with those pelvic floor muscles appropriately.

The basic principles are as follows:

1. Every patient has to stop pushing. Some patients don't feel like they are emptying their bladders, so they try to empty out the bladder completely by trying to get every drop out. That type of behavior can potentiate even more muscle spasticity. It becomes a vicious cycle. It is better that a patient go back to the bathroom 10-20 minutes later (called double voiding) than to try to push it out at one time.

2. Patients cannot be constipated. If you are constipated, you will never get better unless that problem is dealt with aggressively.  You may have to go to a gastroenterologist to make sure there is no other associated problem.

3. The third thing patients should do is to get into the bathtub twice a day. It should be a warm bath which facilitates muscle relaxation. You can use two moist heating pads, sitting on one and placing the other on the lower abdomen if you don't have access to a bathtub. Keep in mind that baths usually work better.

4. Put patients on a muscle relaxant. Patients are usually weaned down on their dosage as symptoms improve. This is not given as a medication for stress, (although stress can play a role in PFD), but to get the muscles relaxed. It tends not to make patients sleepy as opposed to other muscle relaxants.
There are other things that can be done for PFD. For example, biofeedback can be helpful. If in-office therapy is helpful, small, portable home units are often prescribed.
More and more physical therapists are now being trained to manage these problems. Some physical therapists are experienced in pelvic floor biofeedback, but be careful. Biofeedback is a method that is also used to treat urinary leakage. The therapist may be trained to deal with leakage but has no experience when dealing with pain derived from the muscles of the pelvic floor. Physical therapists who specialize in this area are able to perform "internal massage" to identify the trigger points to smooth this area out. Again, PFD can be a problem associated with IC, or it can be a separate entity.

Interstitial cystitis (IC) Surgery

General Information

Surgery is generally considered the treatment of last resort by IC patients and their doctors. The obvious reasons are that surgery is invasive and irreversible, but in addition, many patients who choose to have surgery may not improve, and some may, in fact, do worse. Potential complications from these procedures also need to be considered. Researchers have pointed out that with an ever-enlarging array of treatment options available to the IC patient, surgery should be considered only when all other choices have failed. This Fact Sheet is intended to be a brief overview of the most common methods available. Only a urologist experienced in treating IC can advise you as to the appropriateness of surgery for your particular situation.
 

Types of Surgery

    There are two basic types of surgery used in IC patients: augmentation cystoplasty and urinary diversion.
    In augmentation cystoplasty, part or most of the bladder is surgically removed and replaced with a section of the patient's bowel, thus forming a "new bladder." Urine continues to be stored in the bladder and evacuated through the urethra.
    Urinary diversion is performed in several ways: With the bladder either removed or left in place, a tube or conduit is fashioned from a short section of bowel and the ureters are placed in this conduit. The urine is then diverted to an opening in the abdomen called a stoma, through which urine is allowed to drain constantly into a collection bag.
    In a second type of procedure, also with the bladder either removed or left in place, an internal pouch (known as a Koch, Florida, or Indiana pouch) is constructed from a bowel segment and placed inside the abdomen. The urine is emptied from the pouch by self-catheterization four to six times each day.
 

Clincal Studies

Little data is available on the long-term outcome of these surgical procedures. A small study done at Duke University  reviewed the cases of IC surgery patients. Many augmentation patients continued to have urgency and frequency, and some were unable to void on their own, necessitating self-catheterization, which was often difficult. IC has also been reported to recur in the augmented bowel segment of bladders. Some patients who undergo total cystectomies (bladder removal) still experience pelvic pain, indicating that neurologic mechanisms are an important aspect of IC that needs to be researched further.
 

Who Can Benefit

    Most of the current available literature concludes that surgery should be reserved as the treatment of last resort, and used primarily in patients for whom decreased bladder capacity (less than 250cc under general anesthesia) is the primary problem.
    Patients who have only bladder pain related to filling seem to benefit more than those who have more generalized pelvic, urethral, vaginal or labial pain and those with larger capacities.
 

Some Questions to Ask Your Doctor

•     What are the known complications of the procedure?
•     What is the specific condition of my bladder: capacity, presence of ulcers, fibrosis?
•     Are there other treatments I should try, including pain management techniques, before I consider surgery?
•     Should I have psychological counseling before I decide on surgery? How do I prepare myself for surgery?
•     What are the chances I will still have IC pain after this surgery? If I continue to have pain, how can it be treated?
•     How will my bowel function be affected by this surgery? Will my kidneys be affected after the surgery?
•     Who long will the surgery take, how long will my hospital stay be, and how long is the recovery period?
•     How will my activities be restricted after surgery?
•     What conditions require further surgery and what are the chances I will need it?
•     How many patients have you operated on and how are they doing?

Interstitial Cystitis - Finding the Right Physician for You

Patient Goals

    Patient goals include finding a physician 1) who is knowledgeable of and interested in treating IC, 2) who will provide an accurate diagnosis, appropriate treatments and ongoing care, and 3) who will educate you about treatment options, take time to listen, work collaboratively with you and respect the knowledge you have to share about your IC experience.


Why is this important?

    This is important because successfully managing a chronic illness like IC depends, in part, on your choice of physician and the attributes that physician brings to the process. Effective treatments are enhanced by a knowledgeable, compassionate physician. A urologist is a physician who specializes in treating urinary conditions.


How to go about finding the right physician

    Gather names of physicians from IC patients, Interstitial Cystitis Association (ICA) volunteers and the Physician Registry, a national list, available from the ICA, of physicians who have indicated an interest in treating IC. Check board certification through the American Board of Medical Specialties at 800-776-CERT ( http://www.certifieddoctor.org ) or consult your local library. Be aware that some highly recommended physicians may not have an expertise in treating IC. Make an appointment to meet the doctor. Ask some of the general questions listed below. You don't have to agree to an exam or medical tests during the first visit. Ask yourself how you feel about this initial meeting and trust your feelings.

 

Suggested questions to ask your doctor

    General questions to ask at an initial appointment:

•     Would you tell me what Interstitial Cystitis is and what symptoms patients experience?
•     What medical tests are used to diagnose IC? What findings support the diagnosis?
•     What are the treatment options for IC? What determines which ones you recommend?
•     Are there lifestyle changes that might be important in managing the symptoms of IC?

    Specific questions to ask regarding diagnostic testing, treatment and management of IC:

•     Why are these tests necessary? What are the risks, discomforts and costs of these tests? When will the results be available? May I have a written copy of the test results?
•     What are my test results? What do they indicate? What is my exact diagnosis? What is that based on?
•     What are the benefits, possible side effects and risks of the treatment you are recommending?
•     How long do I need to follow this/these treatment(s) before I might expect to see some improvement?
•     If this treatment plan is not helpful, or only partially helpful, what other treatments would you consider? Ask your physician if it would be possible for him or her to provide you with a list of possible treatment options so that if one treatment does not work, you will be reassured that there are other options available to you.

    Also, remember to ask about possible side effects and instructions for taking prescribed medications.


You have the right as a patient to...

•     Change physicians, consult other physicians, and get other medical opinions.
•     Obtain your medical records.
•     Be given adequate information to make informed decisions and give informed consent.
•     Decline or refuse suggested diagnostic procedures and/or treatment options.
•     Seek information about your medical condition from other sources.
•     Seek other kinds of care and/or support, which may include nutritional advice, group support, participation in the ICA, psychological support, pain management, stress management, or more.
•     Receive supporting documentation required by agencies with which you may file disability claims.
•     Receive supporting documentation required by your insurance provider when care is denied.
•     Receive a timely response to telephone contacts.

    Exercising these rights should not subject you to disrespectful treatment, threats or denial of care.

Alternative Medicine and Interstitial Cystitis

Most IC patients, have tried, or have considered trying, some form of alternative therapy to help relieve IC symptoms. 

Known as alternative, complementary, nutriceutical, holistic, integrative, and various other titles, this form of treatment, a shift away from allopathic medicine (most Western medicine is based on the allopathic principle that a disease is treated by creating an environment in which the disease can no longer survive), is sweeping the country. Various types of alternative therapies have existed for centuries, and have been practiced in the US for many years. But within the past few years, many of these therapies have become "mainstream," and it is not uncommon to find rows of herbal remedies in pharmacies as well as supermarkets. Some physicians are now incorporating many of these treatments into their practices, and practitioners of alternative medicine are setting up shop in even the smallest of towns. Considered standard forms of medical treatment in most of Europe for many years, alternative therapies in the US marketplace are now booming.

Dietary Supplement Health and Education Act

One reason for this boom is that in 1993, when the US Food and Drug Administration (FDA) began legislation to impose stricter regulations on the herbal and supplement industry, a massive consumer letter-writing campaign pressured the FDA to tone down their legislation. This resulted in the Dietary Supplement Health and Education Act (DSHEA), signed in 1994. This guideline for supplements, which includes vitamins, minerals and herbs, requires no proof of efficacy, no proof of safety, and sets no standards for quality control of products labeled as supplements. Manufacturers cannot make claims that their products affect (cure, alleviate, diagnose, prevent) a disease (if a product did, it would have to undergo standard FDA clinical testing to determine its safety and effectiveness), but they can cleverly word the product packaging to grab the consumer's attention.

For example, typical wording differences between an over-the-counter (OTC) laxative medication and an alternative herbal treatment that is purported to help relieve constipation would be the following: the OTC, FDA-approved medication can call itself a laxative; the alternative preparation cannot. The OTC medication can state that the medication helps to relieve constipation; the alternative preparation can use phrases such as, "promotes regularity," or "promotes healthy bowel function." Also, should questions arise about a product, the burden of proving negative claims lies with the FDA, not the manufacturer of the product. In other countries with regulation of supplement products, the burden of proof lies in the hands of the manufacturer, and standards of herb quality and safety assessment are enforced by the government, similar to the way in which the FDA controls the quality of prescription and over-the-counter medications in this country. Since there is no quality control, supplements can vary in quality and strength from bottle to bottle, and batch to batch. The FDA is currently working to redefine the DSHEA.

How Safe are These Products for IC Patients?

The enactment of the DSHEA has not helped the FDA in its attempts to ban questionable alternative treatments, even ones like the herb ephedra (a natural form of ephedrine, that can cause IC symptoms to flare) which has been linked to serious medical complications, such as heart failure. In many cases, healthy people are using alternative therapies to promote health, not to cure disease. Alternative therapies may turn out to play an important role in preventive medicine. Since the cause or causes of IC are unknown, and since IC has a yet unexplained relationship to other conditions such as allergies, fibromyalgia, irritable bowel syndrome, and/or vulvodynia, caution should be used when considering any treatment, including alternative treatments.

Not enough is understood yet about the nature of interstitial cystitis. Many IC patients have been told by various practitioners of alternative therapies to boost their immune systems with preparations like echinacea and ginseng, yet many of these practitioners have never heard of IC. Since IC researchers are still debating the possible link between IC and an autoimmune response, it would be unwise for anyone with autoimmune symptoms to try to "boost", their immune systems even further. Scientifically defined categories for the various causes of IC have not been established, and most IC patients (and physicians) don't know the actual cause or effect of IC in their bodies. This becomes territory that is potentially dangerous to your health.

Urothelial cancer

Bladder cancer accounts for just under 5% of all cancers and just over 3% of cancer deaths. Risk factors include cigarette smoking, occupational exposure to the class of chemicals known as aromatic amines, bladder infestation with the parasite Schistosoma haematobium, especially common in Egypt and Tanzania, and the immunosuppressant drug cyclophosphamide. The sensitivity of the bladder to toxicity from a variety of chemicals is explained by concentration of toxins within the urinary tract.

Kidney cancer accounts for 1.6% of all cancers and nearly 2% of cancer deaths. Kidney cancers are of three types: nephroblastomas (Wilms' tumours), adenocarcinomas (hypernephromas) and transitional and squamous cell carcinomas of the renal pelvis. The first category are limited to childhood and are of unknown aetiology, with the exception of a few of genetic origin. The second type constitute the majority of cases, are commoner in Western Europe and North America than in Africa and Asia, and are slowly increasing in incidence. There is a weak association with cigarette smoking. The third type constitutes around 10% of cases. Risk factors include occupational exposure to the chemicals causing bladder cancer, phenacetin ingestion (in sufficient quantities to cause analgesic nephropathy) and smoking. The increased risk is small. However, Balkan nephropathy, a form of chronic interstitial renal disease endemic in villages in parts of Romania, Bulgaria, Bosnia, Croatia and Serbia, increases the risk of carcinoma of the renal pelvis several hundredfold. Toxins in the River Danube and genetic factors have been implicated as possible contributory factors.

Urothelial tumours affect 11000 men and women annually in England and Wales, and cause the death of 5300 people. Treatment with radiotherapy will cure 30% of patients but causes significant toxicity in 30%. We have developed non toxic chemotherapy programmes that are as effective as radiotherapy but without toxicity.

In a new study we will be examining the efficacy of a new gemcitabine based treatment programme.

In patients with relapsed bladder cancer we are about to start an investigation of liposomal packaged adriamycin, a treatment that we hope will have efficacy with minimal toxicity.

Urethra

The bladder empties via the urethra. 

There are differences between the male and female urethras both on the gross level and histologically. Both have a proximal transitional, an intermediate pseudostratified and a distal stratified squamous epithelium.

Female 

In the female, the urethra runs a short course (4-5 cm) from the bladder to its termination.
 
 The lining epithelium changes over its course from transitional to pseudostratified columnar and finally to stratified squamous. Small collections of mucus-secreting cells can be found. These are called glands of Littré, which are much more well-developed in the male. 
Also, at about the midpoint, a voluntary muscular sphincter is present. 
Between the skeletal muscle and the mucosa, there is an inner longitudinal and an outer circular layer of smooth muscle.

Male 

The male urethra consists of three segments, The prostatic urethra, the membranous urethra and the penile urethra. 
As the urethra leaves the bladder, it enters and traverses the prostate, where it is called the prostatic urethra. 
About midway through, there is an elevation on the posterior wall of the urethra. 
This is the verumontanum or colliculus seminalis. There are three openings on the verumontanum, a central blind ending prostatic utricle and two lateral ejaculatory ducts. 
This portion of the urethra is lined with transitional epithelium and is easily identified due to the presence of the prostate.

Beyond the prostatic urethra, the membranous urethra spans only about one cm. 
This is where the external sphincter is present. 
This skeletal muscle provides voluntary control to the otherwise involuntary urethral sphincter. 
This segment of the urethra is lined with pseudostratified columnar epithelium. 
The urethra continues as the penile, or spongy, urethra. 
The penile portion is located within the corpus spongiosum of the penis. 
The epithelium here is mostly pseudostratified columnar and many glands of Littré are present. 
The luminal lining changes to stratified squamous near the urethral terminus.

Urethroplasty is a surgical procedure dealing with the repair of a defect or injury over the walls of the urethra. 
This surgery is carried out simply to fix the scar tissue blockage pertaining to the urethra known as urethral stricture.