Wounds - home health advice

Overview
Definition

A wound is any injury causing an interruption of the normal continuity of affected structures or tissues, most often the skin. The skin, the outer integument, is the first line of defense against microorganisms; its loss facilitates entry of microorganisms into wounds. Wounds are classified as incised (made with a sharp object that creates a clean cut, such as bites, knives, scalpel), contused (made by a blunt object that may not break the skin but may cause significant damage, such as bumping the head when falling); lacerated (made by an object such as barbed wired that creates a jagged, irregular cut); puncture (made by a pointed object such as an ice pick or bullet), or thermal and chemical burns (made by scalds, fires, flammable liquids, gases, electricity, and chemicals), and decubitus ulcers (bed sores or diabetic ulcers).
Etiology

* Blunt or penetrating trauma
* Surgery
* Chemical injury
* Thermal injury
* Temperature extremes (e.g., burns, frostbite)
* Ionizing radiation
* Tissue breakdown due to malnutrition or diabetes

Risk Factors

* Age (e.g., elderly)
* Malnourishment, especially protein depletion
* Trace element deficiencies, especially zinc
* Vitamin deficiencies, especially vitamin C
* Compromised general health
* Location and severity of the wound
* Steroid use
* Radiation and chemotherapy
* Diabetes mellitus
* Smoking
* Weight loss or obesity

Signs and Symptoms

* Erythema
* Edema
* Pain and tenderness
* Heat
* Possible fever with infection
* Serous, sanguineous, serosanguineous, or purulent exudate
* Loss of function (or mobility)
* Foul smell (in infected wounds only)

Diagnosis
Physical Examination

A complete assessment, with a history of the insult event, is essential to determine the extent and severity of the injury, possible contamination, and conditions that might complicate the clinical course and treatment. Wound healing is often divided into three types: (1) first intention healing in which the edges of a wound are approximated and closed with sutures (e.g., laceration), thus scarring is usually minimal; (2) second intention healing in which the edges of a wound are not approximated and the wound is left open to granulate (e.g., burns, ulcers), thus scarring is often wide and deep; and (3) third intention healing in which a wound is left open initially because of contamination and then subsequently closed surgically. Astute clinical observation is essential to diagnose possible wound infection, particularly with human bites.
Laboratory Tests

* Complete blood count, to monitor leukocytosis (white blood count should stay between 5,000 and 10,000/mm3), which may herald the development of sepsis
* Urinalysis, blood urea nitrogen (BUN), and serum creatinine, to monitor renal function
* Wound cultures, to measure the number of bacteria (<105 organisms per gram of tissue)
* Sedimentation rate
* Electrolytes

Pathology/Pathophysiology

There are generally four stages of wound healing: (1) vascular response (immediately for about 10 minutes) characterized by blood vessel constriction, smooth muscle contraction, platelet aggregation, blood coagulation, followed by vasodilation, processes that are mediated by histamine release; (2) inflammatory response (days 1 to 5) characterized by infiltration by neutrophils, monocytes, macrophages, and lymphocytes to protect against invasion by microorganisms; (3) proliferative phase (days 5 to 20, depending on the amount of necrotic material and infection) characterized by formation of granulation tissue, collagen synthesis, angiogenesis, and wound contraction, processes that are mediated by cytokines and growth factors; (4) maturation stage (day 20 to resolution, which could take months or years) characterized by remodeling of scar tissue, the basic component of which is collagen, a sturdy structural protein found throughout the body. Scar tissue is only 80% as strong as normal tissue.
Treatment Options
Treatment Strategy

Treatment depends on the type and severity of the wound. Some wounds are characterized by a loss of tissue, requiring grafting to repair, and others, including clean lacerations, result in no tissue loss. It is important to determine at the outset, based on the history and physical, whether or not the wound can be closed immediately either by suturing or grafting, or delayed because of contamination. A contaminated wound can be cleaned sufficiently so that it can be closed, but infected wounds are never closed until the infection has been successfully treated. Wounds must be protected from additional physical, chemical, or bacteriologic complications.
Drug Therapies

* Analgesics, for comfort especially before wound closure or dressing changes
* Antiseptics (e.g., povidone iodine), to clean contaminated wounds
* Systemic antibiotics for wound infections; broad-spectrum antibiotics for sepsis
* Amoxicillin/clavulanic acid (250 to 500 mg orally tid) or ampicillin/sulbactam (1.5 to 3.0 g intravenously every six hours) for animal bites (clindamycin or ciprofloxacin can be substituted for penicillin-allergic patients)
* Medicated dressings (e.g., gauze impregnated with topical antimicrobial agents such as silver sulfadiazine cream, mafenide cream, silver nitrate), to aid healing and make dressing changes less disruptive to epithelialization
* Triamcinolone (10 mg/mm3), to ameliorate hypertrophic scar formation (keloid)
* Tetanus immune globulin, for tetanus prophylaxis; penicillin (10 to 12 million units intravenously for 10 days); metronidazole (500 mg every 6 hours or 1 g every 12 hours) for tetanus infection
* Exogenous growth factors (e.g., epidermal growth factor [EGF], transforming growth factor-beta [TGF-beta], platelet-derived growth factor [PDGF]), to accelerate normal healing (experimental)

Surgical Procedures

* Surgical excision of burned tissue and wound debridement (removal of devitalized or contaminated tissue or foreign bodies)
* Skin grafting
* Excision and drainage, for wound abscesses
* Intubation or tracheostomy, for hypoventilation associated with severe tetanus or pneumonia associated with burn patients
* Splinting, to inhibit contraction, the movement of adjacent skin to close an open wound; in some parts of the body contraction can cause deformity and immobility

Complementary and Alternative Therapies

Homeopathic remedies may provide excellent relief of acute trauma. In addition, nutrients and herbs can help reduce inflammation, speed healing, and minimize the risk of secondary infection.
Nutrition

These supplements can also be taken before surgery to reduce healing time. Lower dose or discontinue when wound has healed.

* Beta-carotene (250,000 IU/day) or vitamin A (50,000 IU/day) promote healthy scar tissue. These are high doses and should not be taken for longer than one to two weeks without physician supervision. Reduce dose to 50,000 IU of beta-carotene and 15,000 to 25,000 IU of vitamin A daily after two weeks. Vitamin A should be avoided by women who are pregnant or trying to conceive.
* Vitamin C (500 to 1,000 mg tid) enhances tissue formation and strength.
* Vitamin E (400 to 800 IU/day) promotes healing when taken internally. May also be used externally once the acute phase has passed and new skin has formed. Higher doses may be beneficial for burn victims.
* Zinc (10 to 30 mg/day) stimulates wound healing.
* Bromelain (250 mg tid between meals) is a proteolytic enzyme and an anti-inflammatory that has been shown to reduce postsurgical swelling, bruising, healing time, and pain.
* Seacure (3 capsules bid to tid) is hydrolized whitefish protein that provides absorbable protein necessary for wound healing.

Herbs

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

* Turmeric (Curcuma longa) is an anti-inflammatory that potentiates bromelain. Use the dried extract 250 to 500 mg tid.
* Gotu kola (Centella asiatica) promotes connective tissue repair, supports normal wound healing, and prevents scar hypertrophy and keloid formation. For best results, use a standardized extract 60 mg one to two times daily. For tincture, take 60 drops tid to qid. Gotu kola may also be used topically as a wash for burns to minimize skin shrinking. Note: in some patients gotu kola can cause insomnia, agitation, or overstimulation of the sympathetic nervous system. Reduce dose accordingly.
* Coneflower (Echinacea purpurea) increases macrophage activity. Goldenseal (Hydrastis canadensis) is an antimicrobial that enhances healing. Use them together to protect against secondary infection. Equal parts of tincture may be taken 30 to 60 drops tid to qid.
* Powders of goldenseal, comfrey (Symphytum officinale), and marshmallow root (Althea officinalis) may be applied topically to enhance healing and minimize infection. Washes or compresses of cooled tea containing these herbs may also be used.
* St. John's wort (Hypericum perforatum) oil applied topically helps prevent postsurgical adhesions and may relieve nerve pain.
* Aloe vera gel applied to burns and wounds provides excellent pain relief and speeds healing.
* Marigold (Calendula officinalis) and plantain (Plantago major) aid in healing and can be used topically as salves or creams. These should only be used in incisional or "clean" wounds. Due to their fast action, they could encapsulate an infection.
* Granulated or confectioner's sugar applied topically to decubitus ulcers speeds wound healing. Safe for diabetic ulcers.

Homeopathy

Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

* Arnica for bruised feeling and grief and/or shock from trauma
* Staphysagria for pain from laceration or surgical incisions
* Symphytum for wounds which penetrate to and involve bone
* Ledum for puncture wounds
* Urtica for burns
* Hypericum for injuries and trauma to nerves
* Keloid gel (Wala) for keloids

Patient Monitoring

Patients must be monitored for signs of bleeding, discoloration, or swelling in and around the wound. Fever, increasing pain, and the development of purulent drainage all indicate the presence of local infection and possible sepsis. Attention to nutritional status and positioning (to avoid undue pressure on the wound) are critical to healing.
Other Considerations
Prevention

Most wounds are accidental and often preventable. Wound infection and other complications can be prevented by careful aseptic technique and prophylactic antibiotics.
Complications/Sequelae

* Keloid scar tissue formation is an overgrowth of scar tissue that can be deforming. A keloid scar often returns even if excised.
* Wound contamination (10% if wounds), for example by Clostridia, Staphylococcus, Pseudomonas, Proteus, and Klebsiella, can occur in three stages: simple contamination, cellulitis, and myonecrosis (gas gangrene). Treatment consists of drainage, surgical debridement, and in severe cases, amputation. Fungal infections (e.g., Candida, Aspergillus) and herpes simplex can also compromise wound healing.
* Wound hemorrhage, usually a result of poor technique.
* Burn wound sepsis occurs when microorganisms invade subeschar tissue. Because most burn wounds are avascular, antibiotics do not adequately suppress microbial growth. Pneumonia is one of the most common infectious complications in burn patients.
* Tetanus (Clostridium tetani) occurs most often in mild penetrating injuries as a result of splinters, thorns, rusty nails, or dirty abrasions and lacerations, often because these mild injuries are ignored. Trismus (lockjaw) is pathognomonic. The mortality rates are as high as 30%, but for patients who recover, recovery is total. Human tetanus immune globulin (TIG) can prevent tetanus.

Prognosis

Prognosis is dependent on the extent and severity of the initial wound, as well as of any subsequent infection.
References

Black JM, Matassarin-Jacobs E. Medical-Surgical Nursing: Clinical Management for Continuity of Care. 5th ed. Philadelphia, Pa: W.B. Saunders Co; 1997.

Blumenthal M, ed. The Complete German Commission E Monographs. Boston, Mass: Integrative Medicine Communications; 1998:432.

Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:837, 839, 902-905, 947, 968.

Hardy JD, et al. Hardy's Textbook of Surgery. 2nd ed. Philadelphia, Pa: J.B. Lippincott; 1988.

Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North Atlantic Books; 1992:312, 314, 316.

Murray MT. The Healing Power of Herbs. Rocklin, Calif: Prima Publishing; 1991:184, 185, 207.

Nettina SM. The Lippincott Manual of Nursing Practice. 6th ed. Philadelphia, PA: J.B. Lippincott; 1996:90-91.

Reeves CJ, et al. Medical-Surgical Nursing. New York, NY: McGraw-Hill; 1999:535, 542-546, 551-553, 567-568.

Schwartz SI, et al. Principles of Surgery. 5th ed. New York, NY: McGraw-Hill; 1989:201-205, 301-302, 320-323, 470-473.

Thompson JM, et al. Mosby's Clinical Nursing. 4th ed. St. Louis, Mo: Mosby; 1997:461-462, 1099-1100, 1160, 1441.

Warts - home health advice

Overview
Definition

Warts (verrucae) are small, benign, usually painless, and sometimes self-limiting growths on the skin caused by human papillomaviruses (HPV).

* Common warts (Verruca vulgare)
* Flat warts (Verruca plana)
* Genital warts (Condyloma acuminatum)
* Plantar warts (Verruca plantaris)

Although prevalence is highest in children and lowest in the elderly, warts affect all age groups. Genital warts are contagious; common, flat, and plantar warts generally are not. All warts can spread from one part of the body to another. Warts can disappear without treatment, and reappear.
Etiology

Human papillomaviruses (HPV)
Risk Factors

* Contact with affected persons or shed skin with HPV (particularly for genital warts)
* Trauma
* Immunosuppressive diseases (e.g., AIDS) and drugs
* Atopic dermatitis
* Communal facilities (locker rooms)

Signs and Symptoms

General characteristics:

* Appear singularly, clustered
* Sometimes painful

Common warts:

* Round and asymmetric
* Can grow from tiny (1 mm), smooth, flesh-tone papules to large (5 to 10 mm), thick, rough plaques
* May form mosaics (1 to 3 cm in diameter)
* Found anywhere, but generally on the hands

Flat warts:

* Small (1 to 3 mm) papules with flat tops
* Usually flesh-tone or pink
* Sometimes itchy
* Generally found on the face and back of hands

Genital warts (venereal warts):

* Tiny flat papules that grow to resemble common warts
* Generally found on external genitalia, pubic, and perineal regions
* May be found intravaginally and in the anal canal

Plantar warts:

* Rough, thickened, scarcely elevated papules
* Sometimes exhibiting black dots, indicating thrombosed capillaries
* Often quite tender, possible leg/back pain from disrupted posture
* Found on the sole of the foot, sometimes completely covering the heel or plantar region

Differential Diagnosis

* Corns or clavi Scar tissue
* Skin tags Molluscum contagiosum
* Moles Condyloma latum
* Calluses Seborrheic keratoses
* Skin cancer

Diagnosis
Physical Examination

General clinical characteristics of warts include:

* Disturbed skin lines
* Tiny black dots (thrombosed capillaries)
* Previous trauma to sites (e.g., fingers, nails, knees, face, scalp)

Other Diagnostic Procedures

* Warts usually can be diagnosed by location, appearance, and, if necessary, paring or debridement.
* Genital warts: Check intravaginally and in the anal canal.
* Plantar warts: To confirm diagnosis (vs. corns or clavi), pare lesion and look for characteristic black dots (thrombosed capillaries).
* Electron microscopy
* Immunohistochemistry
* Nucleic acid hybridization

Treatment Options
Treatment Strategy

Although asymptomatic warts can be ignored (with some risk of spreading), treatment may be desirable because warts can be embarrassing and disfiguring.

A number of treatments are available, including drug therapy (usually the initial therapy), cryosurgery (minimal scarring), electrosurgery, laser vaporization, curette and desiccation (scarring possible), and excision (scarring possible). Actual treatment depends on the location, type, and severity of warts. Because warts are benign, avoid treatments that could be harmful or could result in scarring.

Advise patients not to self-treat warts on mucous membranes or genitals and to be aware of scarring when treating warts on the face. Also, advise patients to keep warts covered during treatment.
Drug Therapies

Common, flat, and plantar warts: 12% to 40% salicylic acid, sometimes paired with lactic acid, qid (OTC). To optimize treatment, review guidelines with patients:

* Soak wart in warm water or bathe before treatment.
* Dry wart area.
* Apply medication per manufacturer's instructions.
* Keep area dry during treatment.

Some practitioners advise filing (pumice stone) before application.

Less common drugs include trichloroacetic acid or cantharidin (common warts), tretinoin (retinoic acid, Retin-A) (flat warts, notably on the face), benzoyl peroxide, bleomycin (intradermal injection), and cimetidine.

Genital warts: physician-applied podophyllin 25% in tincture of benzoin weekly or patient-applied podofilox 0.5 bid three days/rest four days, repeat up to four cycles. U.S. FDA-approved intralesional interferon alfa-n3 can be effective for persistent and recurring external genital warts. Covering warts for a week at a time with waterproof tape can cure warts by preventing viral growth. Plantar warts sometimes respond to hot-water soaks, 113?F water for 30 to 45 minutes, two to three times/week for six to eight weeks.
Complementary and Alternative Therapies

Nutritional and herbal support may enhance immune function and minimize recurrence of HPV. Some cases of HPV may respond to alternative therapies alone.
Nutrition

* Eliminate caffeine, alcohol, refined foods, and sugar.
* Avoid saturated fats, which increase inflammation (animal protein and dairy products).
* Increase whole grains, fresh vegetables, fruits, legumes, and essential fatty acids (nuts, seeds, and cold-water fish).
* Vitamin C (1,000 to 1,500 mg tid), beta-carotene (100,000 IU/day), vitamin E (400 IU/day), and zinc (15 to 30 mg/day) support immune function. Vitamin E may also be used topically to treat warts.
* B complex (50 to 100 mg/day) helps to reduce the effects of stress, which can weaken the immune system. Folic acid (800 mcg/day) is especially recommended for cervical HPV.
* Selenium (200 mcg/day) has antioxidant activity and supports immune function.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. of herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Antiviral herbs that support the immune system. Combine tinctures of 1 part of goldenseal (Hydrastis canadensis) with 2 parts each of the following: lomatium (Lomatium dissectum), licorice root (Glycyrrhiza glabra), coneflower (Echinacea purpurea), osha (Ligusticum porteri), thuja leaf (Thuja occidentalis). Take 30 drops bid.

Topical applications are most effective for eradicating warts. Discontinue any topical application if irritation should develop in the surrounding skin.

For plantar, flat, and common warts use one or more of the following applications. The application may need to be repeated nightly for up to three weeks. Wart will turn black as it begins to die.

* Peel patch. Cut a piece of banana peel and place over wart before going to bed. Tape in place.
* Raw garlic patch. Cover wart and surrounding skin with a thin layer of castor or olive oil. Apply a thin slice of fresh garlic; tape in place.

To maximize benefit, place 2 to 4 drops of tincture of thuja or greater celandine (Chelidonium majus) on the wart before application.

For genital HPV, paint the warts with vitamin A or beta-carotene once or twice daily. Add 3 to 4 drops each of thuja, echinacea, and lomatium for best results. Cervical involvement may need to be treated under the supervision of a physician. A retention douche with 1 tsp. each of thuja, echinacea, and lomatium in 2 cups of water may be helpful in resolving superficial warts.
Homeopathy

Thuja is the classic remedy for warts, although by no means the only remedy that expresses warts. For the greatest benefit, an experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency.
Acupuncture

May be helpful in stimulating immune system.
Patient Monitoring

Monitor patients with diabetes or poor circulation for infections.
Other Considerations
Prevention

* Avoid contact with warts, particularly genital warts.
* Cover warts during treatment and avoid wound fluid.
* Use footwear in public areas.
* Do not scratch, pick, or bite warts.
* Do not share towels and washcloths with affected persons.

Complications/Sequelae

All warts: auto inoculation, scars

Common warts: nail deformity

Plantar warts: chronic pain from plantar wart removal

Genital warts: intraepithelial neoplasms
Prognosis

Although some warts will disappear without treatment, usually within 6 to 24 months, resolution without remission cannot be guaranteed.

With treatment, resolution for common, flat, and plantar warts can be six weeks or more; for genital warts, 20 weeks or more. If treatments are unsuccessful, first consider cryosurgery (multiple treatments may be needed) and then consider electrosurgery, laser vaporization, curette and desiccation, or excision.
Pregnancy

High doses of vitamins and herbs are contraindicated in pregnancy. Topical applications are safe. Pregnant women should not use podophyllin.
References

Barker LR, et al., eds. Principles of Ambulatory Medicine. 4th ed. Baltimore, Md: Williams & Wilkins; 1995:1467-1469.

Berkow R, Beers MH. The Merck Manual of Medical Information. Whitehouse Station, NJ: Merck Research Laboratories; 1997:984-985.

Brodell RT. Infect Med. SCP Communications, Inc.; 1996:13:56-60, 66.

Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md: Lippincott Williams & Wilkins; 1999:1166-1169.

Duke JA. The Green Pharmacy. Emmaus, Pa: Rodale Press; 1997: 452-455.

Ewald GA, McKenzie CR, eds. Manual of Medical Therapeutics. 28th ed. Boston, Mass: Little, Brown and Company; 1995:20-21.

Lockie A, Deddes N. The Complete Guide to Homeopathy. New York, NY: DK Publishing Inc; 1995:187, 189, 227.

Ody P. The Complete Medicinal Herbal. New York, NY: DK Publishing Inc; 1993:160-161.

Pray WS. Nonprescription Product Therapeutics. Baltimore, Md: Lippincott Willliams & Wilkins, in press.

Scalzo R. Naturopathic Handbook of Herbal Formulas. 2nd ed. Durango, Colo: Kivaki Press; 1994:73.

Walker LP, Brown EH. The Alternative Pharmacy. Paramus, NJ: Prentice Hall Press; 1998:353-354.

Varicose Veins - home health advice

Overview
Definition

Varicose veins are large, dilated, tortuous, elongated superficial veins exhibiting reflux or retrograde flow as a result of valvular incompetence, weakness of the venous walls, or increased intraluminal pressure. They occur in 10% to 20% of the population, most commonly in the greater and lesser saphenous veins and their tributaries in the legs. Varicose veins may appear at any age, but the peak incidence is between 50 and 60 years of age. Varicose veins must be distinguished from spider veins or telangiectases, which are tiny, dilated, superficial veins visible on the skin surface.
Etiology

Primary varicose veins result from intrinsic weakness in the walls of the veins coupled with incompetent, perforating veins; 50% of these cases are familial (genetic). Secondary varicose veins are most often caused by post-thrombotic deep venous insufficiency and the resulting diversion of flow into superficial collateral vessels. They may also arise from superficial thrombosis. Less often, they are caused by arteriovenous fistulas.
Risk Factors

* Primary varicose veins
* Family history of varicose veins (50%)
* Female gender (three times more common in women)
* Pregnancy
* Occupations requiring prolonged standing
* Obesity
* Secondary varicose veins
* Proximal obstructing lesions (e.g., tumor)
* Conditions predisposing to deep venous thrombosis, such as surgery or immobilization, hereditary thrombophilia (e.g., protein C or S deficiency, factor V Leiden), acquired thrombophilia (e.g., malignancy), trauma, and arteriovenous fistulas

Signs and Symptoms

Primary varicose veins are often asymptomatic, causing only cosmetic concerns. Secondary varicose veins are more likely than primary varicose veins to be accompanied by the following.

* Chronic pain or heaviness or aching in the legs, relieved by elevation
* Ankle edema
* Skin ulcerations
* Superficial thrombosis
* Rupture with bleeding after minor trauma (rare)

Differential Diagnosis

Differentiating between primary and secondary varicose veins is critical before invasive therapy is attempted. Chronic venous insufficiency may develop if varicose veins are ablated when the deep venous system is obstructed. Chronic leg pain may not be due to the varicose veins themselves but to superficial or deep venous thrombosis. Additional causes of leg pain that must be considered include the following.

* Sciatica
* Peripheral neuropathy
* Arthritis of hip or knee
* Baker's cyst

Diagnosis
Physical Examination

The physician must conduct the examination while the patient is standing position so that the veins distend and are therefore easily seen and palpated. The following three tests may be helpful to distinguish primary and secondary varicosities.

* Brodie-Trendelenberg test to determine valvular incompetence in the saphenofemoral system
* Percussion test to determine valvular competence in the great saphenous vein
* Perthes test to determine valvular competence in the deep femoral vein

Imaging

* Doppler ultrasound to determine the relationship of varicosities to the saphenous system; to assess competence of the greater and lesser saphenous systems; to rule out deep venous obstruction and arterial occlusive disease
* Duplex ultrasound scanning with color-flow imaging used for the same purpose as Doppler ultrasound but may also permit more complete and accurate diagnosis, especially in obese patients.
* Venography to visualize veins filled with a contrast medium; most commonly used to detect thrombophlebitis
* Photoplethysmography to quantitatively measure venous function; to assess the severity of chronic venous insufficiency

Treatment Options
Treatment Strategy

Conservative (noninvasive) therapy is the initial treatment of choice for all patients and may be the only treatment ever needed for all but the most severe cases. These measures include the following.

* Avoidance of prolonged sitting, standing, or walking
* Regular exercise since action of the calf and other leg muscles increases venous return
* Periodic elevation of the legs
* Graduated compression stockings
* Ablative (invasive) procedures, including sclerotherapy and surgery, are indicated for superficial varicose veins accompanied by chronic pain; chronic venous insufficiency with edema, ulceration or other skin changes; and recurrent superficial vein thrombosis.
* Such treatment may also be indicated purely for cosmesis.

Surgical Procedures

Sclerotherapy involves injection of a sclerosing solution (e.g., sodium tetradecyl sulfate) into a varicosity, followed by application of a compression dressing. This produces inflammation in the vessel wall, which leads to fibrosis with obliteration of the vessel lumen. It is used most often for spider veins (telangiectases) and smaller, nonsaphenous varicose veins. Use of sclerotherapy alone and in combination with surgery to treat larger, more extensive varicosities of the greater and lesser saphenous veins is controversial in the U.S.

Phototherapy employs laser or high-intensity pulsed light to destroy telangiectases. It is not used to treat varicose veins per se. Radiofrequency ablation uses a catheter threaded into the varicose vein to heat the vein wall either to obliterate the lumen or shrink it enough to restore valve competence. It is suitable for treating large varicosities in the saphenous system, yet it is a relatively new technique where long-term results are unknown.

Surgical therapy involves removal of varicose veins by various techniques including classic stripping and ligation and the more recently developed stab-avulsion technique, which uses smaller incisions.
Complementary and Alternative Therapies

Nutritional supplements and herbs may be beneficial in enhancing the integrity of the vasculature, stimulating circulation, and relieving discomfort.
Nutrition

* Include dietary fiber in the form of complex carbohydrates (e.g., whole grains) to avoid constipation, which may contribute to venous congestion. Include foods rich in bioflavonoids, such as dark berries, dark leafy greens, garlic, and onions, which strengthen collagen tissues. Drinking fluids and getting regular exercise also help prevent constipation.
* Vitamin C (500 to 1,000 mg tid), vitamin E (200 to 600 IU/day), and zinc (15 to 30 mg/day) are essential for vascular health.

Herbs

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes). Commercial preparations often contain a combination of the following herbs. They may also be taken individually, as noted.

* Horse chestnut (Aesculus hippocastanum) 500 mg tid or standardized Aescin 10 mg tid
* Butcher's broom (Ruscus aculeatus) standardized extract (9% to 11% ruscogenin) 100 mg tid
* Gotu kola (Centella asiatica) 1,000 mg bid to qid or standardized extract (asiaticoside 40%, Asiatic acid 30%, madecassoside 1% to 2%) 60 mg once to twice daily
* Bilberry (Vaccinium myrtillus) standardized extract (25% anthocyanoside) 80 to 160 mg tid

Combine the following in equal parts to support the vasculature and tone the circulatory system: yarrow (Achillea millefolium), hawthorn (Crataegus monogyna), ginkgo (Ginkgo biloba), marigold (Calendula officinalis), horse chestnut (Aesculus hippocastanum), and ginger (Zingiber officinalis). Take 30 to 60 drops tincture bid to tid or drink three to four cups of tea daily.
Homeopathy

An experienced homeopath would consider the individual's constitution. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

* Aesculus for generalized venous congestion, especially with hemorrhoids and constipation
* Fluoricum acidum for painful varicose veins and sensation of heat
* Hamamelis for weak veins and easy bruising or bleeding; varicose veins with stinging pains
* Secale for varicosities with burning, constricting pains that are worse with exertion

Physical Medicine

Cold compresses of witch hazel (Hamamelis virginiana) and yarrow (Achillea millefolium) tea may provide temporary relief.
Acupuncture

May be helpful in improving the overall circulatory system and reducing venous congestion.
Massage

May be beneficial in alleviating venous congestion and mechanically stimulating circulation.
Patient Monitoring

Varicose veins, while treatable, will eventually recur and progress regardless of the treatment chosen. Recurrences may develop in residual varicose veins not completely removed by surgery or obliterated by sclerotherapy or in veins not previously affected. This may be assessed by periodic monitoring.
Other Considerations
Prevention

Regular exercise increases venous return. Both weight loss and exercise decrease the likelihood of thrombosis.
Complications/Sequelae

Both primary and secondary varicose veins develop progressively. Once a vein segment dilates, valvular incompetence develops and blood refluxes distally. This increases hydrostatic pressure distally, causing further vein dilation and elongation. Eventually this process may propagate throughout the length of the vein and into peripheral branches and perforating veins. Varicose veins are not thought to lead to venous ulceration unless accompanied by deep venous or greater or lesser saphenous vein insufficiency. Thus, varicose veins may account for only 20% to 30% of venous ulcers.

Complications of sclerotherapy include cutaneous hyperpigmentation; allergic reactions to sclerosing agents; thrombus formation; edema; telangiectatic matting; cutaneous necrosis; and ulceration. Arterial injection with sclerosing agents may lead to limb amputation; pulmonary embolism; deep venous thrombosis; and nerve damage.
Prognosis

Varicose vein disease is a chronic condition. New varicosities often occur after treatment, such as residual varicosities from incomplete surgery or sclerotherapy.
Pregnancy

The incidence of varicose veins during pregnancy varies from 8% to 20% and is most common in multiparous women. These varicosities may be caused by compression of the iliac veins by the uterus, which results in increased pressure in the lower veins, or by the effects or estrogen and progesterone, which make the walls of the veins more pliable. Elevation of legs may be particularly effective.
References

Bergan JJ, Yao JST. Venous Disorders. Philadelphia, PA: Saunders; 1991: 201 215.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:99, 149, 432.

Branch WT Jr. Office Practice of Medicine. 3rd ed. Philadelphia, PA: Saunders; 1994: 144 146.

Fauci AS. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998: 1405.

Goldman MP, Weiss RA, Bergan JJ. Varicose Veins and Telangectasias: Diagnosis and Treatment. 2nd ed. St. Louis, MO: Quality Medical; 1999: 3 41, 110 124, 164 174, 175 264, 414 424, 470 497.

Gruenwald J, Brendler T, et al, eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Company; 1998:729-730.

Hoffman D. The New Holistic Herbal. New York, NY: Barnes & Noble Books;1995: 31.

Morrison, R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993.

Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. Rocklin, Calif: Prima Publishing; 1998: 540.

Rosen P, et al. Emergency Medicine: Concepts and Clinical Practice. 4th ed. Vol 2. St. Louis, MO: Mosby; 1998: 1862 1863.

Vaginitis - home health advice

Overview
Definition

Vaginitis is the inflammation of the femal vagina, of which there are various types. Some are caused by an increase in abnormal organisms (e.g., trichomonads) and others by an increase in normal flora (e.g., Candida, Gardnerella vaginalis, anaerobes). Candidiasis in the vaginal tract is called vulvovaginitis and is the most common cause of vaginal discharge in women. The Candida yeast-like fungus causes approximately 40% of all vaginitis, and about 75% of women get Candida vaginitis at some time.
Etiology

Candida vaginitis is primarily caused by Candida albicans but may be caused by C. tropicalis or C. glabrata. Yeast is a part of the normal flora of the vaginal tract in nearly one-third of women; infection occurs when there are changes in host resistance or bacterial flora. A small amount of vaginal discharge is normal at midcycle and should not be confused with vaginitis.
Risk Factors

* Antibiotic therapy especially with broad spectrum types
* Pregnancy from increased heat and moisture and hormonal shifts
* Diabetes
* Corticosteroid use
* Immunosuppressive drugs and conditions
* Human immunodeficiency virus (HIV) infection frequent candidiasis can be an early sign of HIV in women
* Anemia
* Hypothyroidism
* Oral contraception controversial, predominately for recurrence
* Being overweight
* High sugar intake
* Use of panty hose, constrictive clothing, or underwear that is not cotton

Signs and Symptoms

* Vaginal and vulvar pruritus (proportional to the number of organisms)
* Thin, creamy, or curd-like vaginal discharge; more copious during pregnancy; nonodorous
* Red, swollen, painful vaginal mucous membranes and external genitalia
* Satellite lesions (tender, red, discrete pustules that spread to thighs and anus)

Differential Diagnosis

* Trichomoniasis
* Gardnerella vaginalis
* Anaerobes
* Vaginal foreign bodies (retained tampons)
* Allergic reaction to douching or vaginal contraception
* Gonorrhea (especially in prepubertal girls)
* Contact dermatitis/vaginitis, including latex in condoms

Diagnosis
Physical Examination

* Vagina may appear hyperemic, bright red, with dry, white, and curd-like plaques or may have no erythema
* Vulva may have fissures, edema, and erythema
* Discharge appears creamy or curd-like

Laboratory Tests

* Microscopic wet mount scraping of vaginal plaque, discharge, or vulva scraping mixed with 10% potassium hydroxide (KOH) shows yeast, spores, and/or pseudohyphae; 50% to 70% accuracy rate.
* Gram's stain is more sensitive; identifies both mycelial and blastospore forms.
* pH
* Wet prep for trichomonas.

For recurrent infections (vaginal pH <4.5):

* Culture's findings on Nickerson's or Sabouraud's media
* Glucose tolerance test rules out diabetes
* HIV testing
* Possibly obtain endocervical swabs for chlamydia and gonorrhea detection assays

Pathology/Pathophysiology

* Pustule lesion dissects horizontally under the stratum corneum and peels it away; may appear like hyperplastic indurated plaques, atrophic inflamed plaques, or a leukoplakic area
* Accumulation of scale and inflammatory cells
* The pH of discharge is normal

Treatment Options
Treatment Strategy

Topical treatment is initiated before systemic, but patient preference may influence choice. Length of treatment and dose are both typically increased for chronic infection. Patients should avoid excessive exertion and sweating, keep vaginal area as dry as possible during infection, avoid sexual relations until symptoms clear, take showers instead of baths, and use unscented soap. Use proper hygiene when cleansing after bowel movement by wiping from front to back. Wear cotton underwear and avoid pantyhose and tight-fitting pants.
Drug Therapies

Topical and oral therapies are considered to be almost equally effective.

* Topical therapies may initially cause burning from inflammation: polyenes (nystatin) one tablet bid for two weeks placed high in the vagina with applicator; 70% to 80% effective; no systemic side effects. Azole derivatives such as imidazole (e.g., miconazole, butoconazole) and triazole (e.g., fluconazole, terconazole) intravaginal cream one to five days, also may be used externally for satellite lesions; 85% to 90% effective; no systemic side effects.
* Oral therapies: fluconazole 75% to 92% effective; 150 mg once; often considered the treatment of choice; contraindicated during pregnancy; appears to help HIV infected women. Ketoconazole 83% effective, but higher rate of recurrence with cessation of short- and long-term therapy; 400 mg/day for five days, or for two weeks with recurrent infection. Oral nystatin helps reduce intestinal colonization.

Complementary and Alternative Therapies

With the exception of pelvic inflammatory disease, gonoccocal, and chlamydia infections, alternative therapies for acute and chronic vaginitis can be effective for treating both symptoms and causes. Begin with a douche and an acidophilus supplement. For chronic or recurrent vaginitis, also incorporate vitamins, minerals, and herbs into the treatment plan.

Topical Applications: Use only one of the following douches at one time. Do not douche during menstrual flow. For first time or acute infection try the vinegar douche or boric acid capsules. For chronic vaginitis, use the herbal combination douche. For recurrent vaginitis, use the Betadine douche. Discontinue douching immediately if there is pain or exacerbation of symptoms.

* White vinegar: 1 to 2 tbsp. white vinegar to 1 pint of water. Douche daily for 10 to 14 days.
* Boric acid: One capsule (600 mg) inserted daily for 10 to 14 days. May cause irritation or problems from systemic absorption.
* Herbal combination: Mix equal parts of oregano leaf (Oreganum vulgare), goldenseal root (Hydrastis canadensis), and coneflower (Echinacea purpurea). Steep 1 heaping tbsp. of herbal mixture in one pint of water. Cool and douche daily for 10 to 14 days.
* Povidone iodine (Betadine): Douche with one part iodine to 100 parts water twice daily for 10 to 14 days. Prolonged use can suppress thyroid function.

Nutrition

* Avoid simple and refined sugars (breads, pasta, baked goods, sweets), dairy products, alcoholic beverages, peanuts, fresh or dried fruit, fruit juice, and all known food allergens. Eat whole foods with plenty of protein, fresh vegetables, and grains.
* Lactobacillus acidophilus reestablishes normal flora in the body and prevents the overgrowth of Candida. Take one capsule orally bid to tid, and insert one capsule into the vagina nightly (not to exceed 14 nights).
* Vitamin A (10,000 IU/day) or beta-carotene (50,000 IU/day) enhances the integrity of the vaginal mucosa. Required for proper immune functioning. Avoid high doses of vitamin A in pregnant patients or those who plan to get pregnant within three months.
* Zinc (30 mg/day) and vitamin E (400 to 800 IU/day) are essential for immune function.
* Vitamin C (1,000 mg tid to qid) optimizes immunity and helps to restore the integrity of vaginal mucosa.

Herbs

Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

* Pau d'arco tea has antifungal effects. Drink 2 to 4 cups/day.
* Garlic (Allium sativum) has antimicrobial, antifungal, and immune stimulating properties. Prepare a tea with two cloves of garlic. Drink 2 to 4 cups/day. May add lemon and honey for flavor.

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

* Calcarea carbonica for intense itching with thick white or yellowish discharge that is worse before menses.
* Borax for burning pains with egg-white colored discharge that occurs midcycle.
* Sepia for burning pains with milky white discharge and pressure in vaginal area. Depression and irritability are usually present.
* Graphites for backache with thin white discharge that is worse in the morning and when walking.
* Arsenicum album for burning, offensive discharge in a patient who is easily chilled.
* Homeopathic combinations are also available as creams to apply intravaginally.

Acupuncture

Acupuncture may relieve pelvic congestion and improve immune function.
Patient Monitoring

Patients should be educated about the various risks for infection. Strict diabetic control is essential for diabetic patients. There is no specific follow-up unless infection persists. Repeat pelvic examination and a culture is then warranted. Treating the partner will minimize the possibility of reinfection.
Other Considerations
Prevention

* Avoid risks (see above).
* Avoid sweating, overheating, and sexual relations until symptoms clear.
* Use unscented soap, take showers instead of baths, and follow proper hygiene.

Complications/Sequelae

* Chronic candida vaginitis no definitive cure
* Often a result of persistent yeast in vagina, not recurrent infection
* Use oral and topical therapies together in higher doses for two to three weeks; maintenance therapy with azoles.
* Additional risk factors include oral contraception, vaginal douching, increased frequency of sexual intercourse.
* Fifteen percent of men have symptomatic balanitis and should be treated to prevent recurrent female infection.
* Antifungal therapy or acidophilus supplementation is started prophylactically with known antibiotic-associated candida vaginitis.
* HIV infection and diabetes predispose patients to chronic infections.
* Secondary bacterial infections

Prognosis

Some cases of candida vaginitis resolve spontaneously while others progress or become chronic. Recurrence is common. Chronic cases should be evaluated for systemic infections.
Pregnancy

Treatment should only be conducted under the supervision of a physician.
References

Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md: Lippincott Williams & Wilkins; 1999:358-361.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.

Habif TP. Clinical Dermatology. 3rd ed. St. Louis, Mo: Mosby-Year Book; 1996.

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:43, 69, 85, 171, 346.

Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998:530-535.

Uveitis - home health advice

Overview
Definition

Uveitis is characterized by inflammation of one or all parts of the uveal tract (iris, ciliary body, choroids). The most common form is anterior uveitis (iritis, iridocyclitis); posterior uveitis (choroiditis, chorioretinitis) is uncommon and found mostly in persons with AIDS who have cytomegalovirus (CMV) infection. Uveitis occurs in acute (<6 weeks) and chronic forms. The cause is often unknown but may result from either ocular trauma (e.g., chemical exposure) or an underlying systemic disease; the latter accounts for 40% of all cases (see section entitled Etiology for more details). Rate of incidence in both the U.S. and worldwide is 8 to 15 cases per 100,000. Uveitis occurs in men and women of all ages, with most patients presenting between 20 and 50 years of age; peak incidence is during the third decade of life.
Etiology

* Infection, including viral, bacterial, spirochetal, parasitic, and fungal infections (e.g., syphilis, tuberculosis, CMV, Lyme disease, histoplasmosis); toxoplasmosis is common cause of congenital posterior uveitis
* Masquerade syndromes (syndromes that simulate uveitis) include leukemia, lymphoma, retinitis pigmentosa, retinoblastoma, and malignant melanoma of the choroid
* Systemic disease, including suspected immune-mediated disorders (e.g., Behcet's and Crohn's disease, juvenile rheumatoid arthritis, multiple sclerosis, Reiter's syndrome, sarcoidosis); HLA-B27 genotype on chromosome 6 is present in some patients with acute anterior uveitis associated with ankylosing spondylitis, Reiter's syndrome, inflammatory bowel disease, psoriatic arthritis, and recurrent anterior uveitis
* Ocular trauma
* Idiopathic and/or confined to the eye, as in the case of acute retinal necrosis, birdshot choroidopathy, multifocal choroiditis, pars planitis, and Fuchs' heterochromic iridocyclitis
* Some drugs may cause uveitis; rifabutin, for example, has been identified in at least 113 cases by the FDA. Other drugs associated with uveitis include cidofovir, pamidronic acid, and sulfonamides.

Risk Factors

Forms of uveitis are geographically endemic (e.g., histoplasmosis in Ohio and Mississippi Valleys and Lyme disease in the northeastern, north central, and western U.S.). Uveitis due to toxoplasmosis is sometimes associated with pets. General risk factors include the following:

* History of autoimmune disease
* Infections
* Other eye diseases

Signs and Symptoms

* Painful eye(s)
* Conjunctival redness
* Photophobia
* Blurred or decreased vision
* Tearing
* Redness
* Floaters (posterior)

Differential Diagnosis

* Corneal abrasion or ulceration
* Ulcerative or ultraviolet keratitis
* Glaucoma
* Scleritis
* Conjunctivitis

Diagnosis
Physical Examination

Complete history and physical exam are required to identify possible underlying systemic disease. Signs of systemic disease include joint deformities (arthritis), oral or genital lesions (Reiter's and Behcet's syndromes), low back pain (ankylosing spondylitis), breathing problems (sarcoidosis), rash, and nail pitting (psoriasis). An ophthalmologic examination may reveal the following:

Anterior:

* Pupil contraction
* Inflammatory cells visible via slit-lamp examination
* Keratic precipitates on posterior corneal surfaces

Posterior:

* Inflammatory cells
* Fuzzy white retinal lesions
* Retinal and/or choroid inflammation (may be localized, diffuse, or multifocal)

Laboratory Tests

Laboratory tests should be tailored toward specific signs and symptoms when an underlying etiology is suspected.

* Angiotensin-converting enzyme (sarcoidosis)
* Antinuclear antibody testing (autoimmune diseases)
* Complete blood count (bacterial or viral etiology)
* Enzyme-linked immunosorbent assay (Lyme disease)
* Erythrocyte sedimentation rate (systemic disease)
* Human leukocyte antigen-B27 (HLA-B27)
* Syphilis serology; RPR and VDRL may also be associated with granulomatous uveitis; FTA-ABS and microhemagglutination assay for antibodies to Treponema pallidum are more specific for syphilis
* Purified-protein derivative skin test (tuberculosis)
* Skin test for anergy

Pathology/Pathophysiology

Although specific pathophysiology is unknown, the most common cause is an immune reaction against foreign molecules or antigens, which may also cause direct injury to uveal vessels and cells. In the case of autoimmune disorders, immune complexes may deposit in the uveal tract. Findings may include the following:

* Inflammation of ocular structures
* Small, white (not mutton-fat) keratic precipitates without iris nodules (nongranulomatous anterior uveitis)
* Large mutton-fat keratic precipitates and iris nodules (granulomatous anterior uveitis)

Imaging

* Chest X ray (tuberculosis and sarcoidosis)
* Joint X rays (juvenile rheumatoid arthritis and ankylosing spondylitis)
* Fluorescein angiography (may reveal late hyperfluorescence associated with cystoid macular edema)

Other Diagnostic Procedures

* Slit-lamp examination helps confirm diagnosis by revealing leukocytes and increased protein (flare) in aqueous humor
* Gonioscopy determines the presence of progressive peripheral anterior synechia?
* Tonometry measured intraocular pressure

Treatment Options
Treatment Strategy

Prompt treatment is required to preserve vision. Conventional practitioners recommend warm compresses to help relieve symptoms; naturopathic doctors may recommend the addition of herbs, such as eyebright, goldenseal, or marigold (Calendula officinalis) to the water used to make the compress. Sunglasses can protect for light sensitivity. In posterior uveitis, the goals are to determine and treat the systemic cause of the inflammation.
Drug Therapies

* Corticosteroids (topical or systemic) (e.g., prednisone, 0.125% to 1%; fluorometholone; 0.1% to 0.25%) to reduce inflammation and pain, stabilize cell membranes, inhibit release of lysozyme by granulocytes, and suppress lymphocyte circulation; oral prednisone or intraocular injections may be used in recalcitrant cases; contraindicated in patients with viral, fungal, and tubercular infections; can lead to increased intraocular pressure; posterior subcapsular cataracts associated with chronic topical use
* Cyclopegics (e.g., cyclopentolate, 0.5% to 2%; homatropine, 2% to 5%) block neurotransmission to the ciliary muscle, reduce pain, prevent adhesion of the iris to anterior lens capsule, stabilize blood-aqueous barrier, and help prevent continued protein leakage (flare); contraindicated in patients with narrow-angle glaucoma; toxic anticholinergic side effects are rare and occur most often in children; side effects include loss of accommodation (difficulty reading closeup)
* Antimicrobials
* Anti-inflammatories
* Oral immunosuppressants require close monitoring of side effects
* Humanized anti-Tac monoclonal antibody (daclizumab; approved now for immunosuppression in the case of kidney transplantation) phase I/II clinical trial conducted by the National Eye Institute (NEI) of the NIH suggests that this treatment, given IV one time per month, controlled uveitis as effectively as standard treatment with a marked decrease in side effects for the small group of patients studied; the next phase of research for daclizumab is to test the treatment on patients with Behcet's disease followed by a large, multicenter trial

Surgical Procedures

Surgery is used to repair ocular damage, such as glaucoma, cataracts, or detached retina.
Complementary and Alternative Therapies

CAM therapies may be beneficial in reducing the severity of systemic diseases whose sequelae include uveitis. Reducing free radical damage with herbs and nutrients may prevent or slow the progression of uveitis.
Nutrition

Flavonoids are highly concentrated in the eye. They inhibit neutrophil respiratory burst and superoxide production, both of which can create free radical damage in ocular tissues. In one study, the flavonoid, quercetin, decreased intraocular inflammation, reduced hemorrhagic changes, and minimized choroidal thickening in rats with S-antigen-induced uveoretinitis (Romero et al. 1989). High concentrations of flavonoids are found in red grapes, blueberries, cherries, and onions. Quercetin, 200-400 mg tid with meals, may also be taken as a supplement, often with bromelain to enhance function. Carotenoids are also thought to have antioxidant activity, particularly in the eye. Orange, yellow, and dark green vegetables contain a lot of dietary carotenoids. Supplement forms include mixed natural carotenoids (50,000 IU/day) and the carotenoid lutein (5 mg/day); the latter is considered to have a particular affinity for the eyes. Food to avoid that may be pro-inflammatory include saturated fats, fried foods, dairy products, and refined foods; anti-inflammatory foods include flaxseed, fatty fish, and other forms of essential fatty acids.

A randomized, double-blind, placebo-controlled trial evaluated the effects of vitamins C (1,000 mg/day) and E (200 IU/day) in patients with a first or recurrent episode of acute anterior uveitis. A total of 130 patients completed the study. Patients were evaluated for changes in anterior segment inflammation, measured by a laser cell flare meter. Clinical assessments included best-corrected visual acuity (VA), scores on the Hogan-Kimura scale for uveitis, and the number of drops of prednisolone and mydriatic administered (van Rooij et al. 1999).

Upon completion of the study, no significant differences in laser flare and cell measurements were detected between the vitamin and placebo groups, possibly because all patients were also treated with steroids. However, average visual acuity was better on all points in the vitamin group as compared to the placebo group. The investigators suggest that oral vitamins C and E protect photoreceptors from free radical damage and, in this manner, help preserve visual acuity. In addition, vitamin E may play a role in protecting against cystoid macular edema. CME can lead to loss of visual acuity in uveitis patients (van Rooij et al. 1999).
Herbs

Curcumin, the primary active substance in turmeric, has been reported to have anti-inflammatory effects including inhibition of prostaglandin synthesis and stabilization of lysosomal membranes. Specific application for uveitis is not definitive but results of a recent preliminary study are intriguing. In a three-year study following 32 patients with chronic anterior uveitis, researchers report that curcumin (Curcuma longa) showed effects comparable to those of corticosteroid therapy but had none of the adverse effects associated with steroid use. Patients received curcumin, along with topical mydriatics and warm compresses for spasm and pain relief. Antitubercular drugs were added to the regimen if the person had a strongly positive PPD (Purified Protein Derivative, a substance used to measure reactivity to tuberculosis). Curcumin 375 mg po tid was administered to patients for 12 weeks. Antitubercular therapy was continued for one year. Although patients in both groups had recurrences of anterior uveitis (55% in those receiving curcumin alone and 36% in those with the addition of anti-TB drugs), each group showed noticeable improvement. In addition, according to the authors, the rates of both recurrence and complications secondary to the uveitis for all 32 patients on curcumin, with or without anti-TB medications, were similar to these figures for patients taking corticosteroids to treat uveitis. Finally, none of the participants complained of side effects from the curcumin (i.e., any side effects experienced were in the anti-TB drug group and were attributable to those medications) (Lal et al. 1999).

Similar to particular foods (see Nutrition section), herbs with concentrated amounts of flavonoids, such as ginkgo (Ginkgo biloba) and bilberry (Vaccinium myrtillus), have a long tradition of use in treating diseases of the eye. However, their use in the treatment of uveitis specifically has not yet been validated by scientific studies (Blumenthal et al. 2000).
Homeopathy

Homeopathic treatment can address both constitutional?and acute aspects of disease in general. In homeopathic terminology, the constitutional state reflects a pattern of underlying vulnerability or weakness that is unique to the individual and persists throughout that person's life. Symptoms tend to alternate over time and treatment consists of selecting the appropriate remedy specific for the patient's constitutional type. By contrast, in acute conditions a remedy can be administered without reference to any particular constitutional state (Ullman 1995). Although there are no known scientific studies evaluating the utility of specific homeopathic remedies for treating uveitis, acute homeopathic remedies may be beneficial in providing symptomatic relief.
Acupuncture

Acupuncture has been shown to be effective in the treatment of other ocular diseases (see Macular Degeneration monograph, for example) but has not been fully assessed in the treatment of uveitis.
Massage

N/A
Patient Monitoring

Slit-lamp and intraocular pressure measurements every 1 to 7 days in acute phase, with follow up every 1 to 6 months.
Other Considerations
Prevention

There are no known preventive measures for uveitis. However, regular eye exams can screen for chronic asymptomatic uveitis. Treatment of causative disorders may help prevent onset.
Complications/Sequelae

* Glaucoma
* Cataracts due to neovascularization
* Permanent partial vision loss
* Retinal detachment
* Band keratopathy
* Cystoid macular edema
* Macula scarring impairs central vision

Prognosis

* Prognosis is good with early diagnosis and treatment; anterior uveitis tends to respond to treatment in days to weeks
* Outcome may be dependent on underlying condition
* Chronic uveitis (defined as presence of inflammation >6 weeks) may require long-term low-dose topical steroid use and can lead to ocular scarring and vision loss

Pregnancy

Safety of topical steroid use in pregnant women has not been established.
References

Alexander KL, Dul MW, Lalle PA, Magnus DE, Onofrey B. Optometric Clinical Practice Guideline: Care of the Patient with Anterior Uveitis. 2nd edition. American Optometric Association; 1997. Accessed at: www.aoanet.org/cpg-7-au.html on February 8, 2000.

Berkow R, Fletcher AJ, Beers MH, eds. The Merck Manual. Rahway, NJ: Merck & Co.; 1992:2380-2382.

Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, Mass: Integrative Medicine Communications; 2000:18, 165-166.

Dunn JP, Nozik RA. Uveitis: role of the physician in treating systemic causes. Geriatrics. 1994;49(8):27-32.

Fraunfelder FW, Rosenbaum JT. Drug-induced uveitis. Incidence, prevention and treatment. Drug Saf. 1997;17(3):197-207.

Gordon K III. Iritis and uveitis. In: Adler J, Brenner B, Dronen S, et al. Emergency medicine: An On-line Medical Reference. Accessed at http://emedicine.com/cgi-bin/foxweb.exe/showsection@d:/em/ga?book=emerg&topicid=276 on August 17, 2000.

Lal B, Kapoor AK, Asthana OP, et al. Efficacy of curcumin in the management of chronic anterior uveitis. Phytother Res. 1999;13(4):318-322.

No author listed. Drug-induced uveitis can usually be easily managed. Drugs Ther Perspect. 1998;11(10):11-14.

Nussenblatt RB, Fortin E, Schiffman R, et al. Treatment of noninfectious intermediate and posterior uveitis with the humanized anti-Tac mAb: a phase I/II clinical trial. Proc Natl Acad Sci USA 1999;96(13):7462-7466.

Romero J, Marak GE Jr, Rao NA. Pharmacologic modulation of acute ocular inflammation with quercetin. Ophthalmic Res. 1989;21(2):112-117.

Sowka JW, Gurwood AS, Kabat AG. Anterior Uveitis. In: Handbook of Ocular Disease Management. Review of Optometry Online. Accessed at www.revoptom.com/handbook/sect4e.htm on February 8, 2000.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Tarcher/Putnam; 1995.

van Rooij J, Schwartzenberg SG, Mulder PG, Baarsma SG. Oral vitamins C and E as additional treatment in patients with acute anterior uveitis: a randomised double masked study in 145 patients. Br J Ophthalmol. 1999;83(11):1277-1282.

Urolithiasis - home health advice

Overview
Definition

Also called nephrolithiasis or kidney stones, urolithiasis is the presence of calculi in the urinary tract. The male-to-female incidence ratio is 4:1, with 240,000 to 720,000 Americans affected yearly. Eighty percent of calculi are composed of calcium (either oxalate or phosphate), with others composed of struvite, uric acid, or cystine.
Etiology

Type of stone indicates cause.

* Calcium type I increased small bowel absorption of calcium unrelated to intake
* Calcium type II increased dietary calcium intake
* Calcium type III increased vitamin D synthesis (secondary to renal phosphate loss)
* Calcium oxalate idiopathic in origin, or through primary intestinal disorders, chronic diarrhea with inflammatory bowel disease or steatorrhea
* Struvite (magnesium ammonium phosphate) mainly in women and can be large, stag's horn shape; secondary to infection with urease-producing organisms (Proteus, Pseudomonas, Providencia, and less commonly Klebsiella)
* Uric acid metabolic defects or dietary excess of uric acid; bowel disease or chemotherapy
* Cystine secondary to chronic diarrhea, type I renal tubular acidosis, chronic hydrochlorothiazide treatment, idiopathic

Risk Factors

* Excess intake of calcium, oxalate, or purines in predisposed individuals
* Inadequate fluid intake
* Sedentary occupation
* Area of high humidity, elevated temperatures (summer)
* Hyperparathyroidism
* Renal tubule defects (renal tubule acidosis)
* Bowel disease
* Ileal bypass for obesity
* Genetics cystinuria is an autosomal recessive disorder and homozygous type has markedly increased cystine excretion
* Excessive intake of certain vitamins and minerals
* Gout
* Use of certain diuretics

Signs and Symptoms

May be asymptomatic, but the following are usually seen.

* Sudden onset of severe flank pain
* Nausea and vomiting
* Patient in constant motion in attempt to lessen the pain
* Pain referred to testes or labium as the stone moves
* Fever and chills (infection)
* Pain radiating anteriorly over the abdomen

Differential Diagnosis

* Urinary tract infection
* Pyelonephritis
* Diverticulitis
* Pelvic inflammatory disease
* Ovarian pathology
* Drug addiction
* Appendicitis
* Small bowel obstruction
* Ectopic pregnancy
* Cadmium toxicity

Diagnosis
Physical Examination

Patient is in extreme pain and constantly moving. Pain occurs episodically as the stone moves down the ureter and may be referred. Severity of symptoms does not reflect stone size. Patient may be asymptomatic, with stone found incidentally on plain film.
Laboratory Tests

* Urinalysis Possibly microscopic or gross hematuria, but absence does not exclude stones. Exclude infection.
* Urine pH Persistent urinary pH <5.0>7.5 indicates struvite stone.
* Urine culture and sensitivity tests
* Serum chemistries for calcium, electrolytes, phosphate, and uric acid
* 24-hour urine collection for calcium, uric acid, phosphate, oxalate, citrate excretion (recurrent cases only), and to collect stones for analysis

Pathology/Pathophysiology

Analysis of stone to determine type 60% to 80% are calcium, 15% to 20% struvite, 5% uric acid, and 1% to 3% cystine.
Imaging

* Plain abdominal film and renal ultrasound radiopaque stones
* Ultrasound with a full bladder to confirm stone in the ureterovesical junction
* Intravenous urography to confirm diagnosis
* Intravenous pyelogram to determine size and location of stone and degree of obstruction
* Unenhanced helical CT scan rim sign or halo of the calculus

Other Diagnostic Procedures

Metabolic evaluation for recurrent stone formation:

* 24-hour urine collection to check volume, urinary pH, calcium, uric acid, oxalate, and citrate excretion
* Second collection on restricted calcium (400 mg/day), sodium (100 mEq/day), and oxalate diet
* Serum parathyroid hormone and calcium load tests at third visit

Treatment Options
Treatment Strategy

Usually conservative management eventually results in stone passage. Treatment depends on type of stone, ability or inability to pass, and presence of complications. All patients should drink at least six to eight glasses of water daily plus one at bedtime and one during the night. For calcium type II stones, follow a low-calcium diet, restrict sodium to 1 g/kg daily, and increase bran intake.
Surgical Procedures

Surgery is recommended for patients with severe pain unresponsive to medications, serious bleeding, and persistent fever, nausea, or significant urinary obstruction. If no medical treatment is provided after surgery, stones recur in 50% of patients within five years.

* Extracorporeal shock wave lithotripsy (ESWL) outpatient procedure that shatters stones under 2 cm and without complications
* Urethroscopy for stones in lower third of ureter
* Percutaneous nephrolithotomy when in upper two-thirds of ureter and greater than 2 cm in size

Drug Therapies

* Narcotics as needed to control acute severe pain
* Allopurinol for uric acid calculi; 100 to 300 mg/day to control hyperuricemia
* Potassium citrate for uric acid calculi; 100 mEq tablets bid to raise urinary pH
* Hydrochlorothiazide for calcium type I stones; 25 to 50 mg/day.
* Cellulose phosphate for calcium type I stones; 10 g/day to decrease bowel absorption
* Orthophosphates for calcium type III stones; to inhibit vitamin B synthesis

Complementary and Alternative Therapies

Symptomatic urolithiasis requires medical attention. Alternative therapies aid in preventing recurrent episodes and increasing the overall vitality of the urogenital system. Start with nutritional guidelines for prevention of recurrence. Herbs and homeopathics can be used for acute pain relief and long-term tonification of the urinary tract.
Nutrition

* Reduce intake of sugar, refined foods, animal products (meats and dairy), caffeine, alcohol, soft drinks, and salt.
* Increase intake of water, fiber, vegetables, whole grains, and vegetable proteins.
* Minimize oxalate-containing foods such as spinach, rhubarb, beets, nuts, chocolate, black tea, wheat bran, strawberries, and beans.
* Include foods rich in magnesium and low in calcium, such as barley, bran, corn, rye, oats, soy, brown rice, avocado, banana, and potato.
* Magnesium citrate (200 to 400 mg/day) may increase the solubility of calcium oxalate and calcium phosphate.
* Pyridoxine (B6, 10 to 100 mg/day) is essential for the metabolism of oxalic acid.
* Folic acid (5 mg/day) for uric acid stones.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites, or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 10 to 20 minutes and drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

* For acute pain relief, combine tinctures of wild yam (Dioscorea villosa), cramp bark (Viburnum opulus), kava (Piper methysticum), and Jamaica dogwood (Piscidia piscipula). Take 15 drops every 15 minutes for up to 8 doses.
* Drink an infusion of equal parts of gravel root (Eupatorium purpureum), corn silk (Zea mays), pipissewa (Chimaphila umbellata), and kava 1 tsp./cup, 3 to 4 cups/day.

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

Remedies that may be considered for acute pain relief include the following.

* Berberis for sharp, stitching pains that radiate to groin
* Colocynthis for restlessness with pains that feel better bending forward
* Ocimum for nausea and vomiting from the pain

Physical Medicine

Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory. Apply oil directly to skin, cover with a clean soft cloth (e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or heating pad) over the pack and let sit for 30 to 60 minutes. For best results, use for three consecutive days.
Patient Monitoring

Fifty percent of patients pass the stone within 48 hours. For complications or recurrences, refer patient to a urologist. Admit patients to the hospital when they have persistent vomiting, suspected urinary tract infection, pain unresponsive to oral analgesics, or obstructing calculus with a solitary kidney.
Other Considerations
Prevention

Maintain proper hydration and dietary restrictions to avoid future development of stones. Determine and treat underlying cause. Alkalinize urine (maintain pH >7.5 with cautious use of penicillamine) in patients with recurrent cystine stones.
Complications/Sequelae

Urinary tract infection and obstruction can result in extensive kidney damage.
Prognosis

Annual rate of recurrence after first stone is 3%, after second stone 6%. This condition is painful but usually produces no permanent damage. Majority of patients will pass the stone within 48 to 72 hours of onset of symptoms.
Pregnancy

Do not perform ESWL on women of childbearing age who have a stone in the lower ureter; the effect on the ovary is not known. Rule out ectopic pregnancy and/or ruptured ovarian cyst.
References

The Burton Goldberg Group, compilers. Alternative medicine: The Definitive Guide. Tiburon, Calif: Future Medicine Publishing; 1997.

Ferri FF. Ferri's Clinical Advisor: Instant Diagnosis and Treatment. St Louis, Mo: Mosby-Year Book; 1999.

Grases F, et al. Urolithiasis and phytotherapy. Int Urol Nephrol. 1994;26:507-511.

Larson DE, ed. Mayo Clinic Family Health Book. 2nd ed. New York, NY: William Morrow and Company; 1996.

Scalzo R. Naturopathic Handbook of Herbal Formulas. Durango, Colo: 2nd ed. Kivaki Press; 1994.

Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment 1994. Norwalk, Conn: Appleton & Lange; 1994.

Urinary Incontinence - home health advice

Overview
Definition

Urinary incontinence (inability to control urination or the involuntary loss of urine from the bladder) afflicts more than 13 million people in the United States of both sexes and all age groups. Incidence is higher in the elderly and twofold greater in women. Exercise and behavioral therapies have a high degree of success; medication and surgery are effective in a select group over the short-term. Many drugs have unwanted and/or serious side effects. Surgery should be considered only when other treatment options fail. Diagnostic categories are:

* Stress incontinence (SUI): Most common form among women primarily due to pregnancy, childbirth, menopause. Weakened pelvic floor muscles fail to support bladder and resultant pressure interferes with muscles that close the urethra. Leakage occurs with physical stress (e.g., coughing, sneezing).
* Urge (or reflex) incontinence (UI): Leakage accompanied by sudden unexplained need to urinate (e.g., when touching water). May be due to nerve damage (e.g., from Alzheimer's disease, stroke, brain tumor, injury, surgery).
* Overflow incontinence (OI): Rare in women. Bladder overextension due to blocked urethra or inability of bladder muscles to expel urine. Caused by neurological damage (e.g., from diabetes), tumors, urinary stones, enlarged prostate.
* Mixed incontinence (MI): SUI/UI in combination.
* Functional incontinence (FI): Impaired cognitive abilities and/or restricted movement (e.g., confined to a wheelchair) prevents timely access to toilet.
* Transient incontinence (TI): Triggered by medication, UTIs, restricted mobility, stool impaction.

Etiology

* Neurological damage/disorders (dementia, spinal cord injury, multiple sclerosis, stroke)
* Low estrogen levels in women
* Physical changes (from pregnancy or enlarged prostate, stool impaction, tumor)
* Medications
* Urinary tract infections (UTIs)
* Weak urethral sphincter
* Weak pelvic floor muscle

Risk Factors

* Overweight
* Hysterectomy before age 45
* At least one live birth
* Labor exceeding 24 hours
* Prostate disease or hypertrophy in males
* Physical problems associated with age/debility
* Neurologic damage or disorders

Signs and Symptoms

* Involuntary urination Perineal irritation
* Frequent and unusual urinary urge

Differential Diagnosis

* Vaginal discharge in women UTIs
* Urethral discharge in men Medication effects (diuretics)

Diagnosis
Physical Examination

* Urine leakage
* Findings specific to risk factors

Laboratory Tests

Urinalysis to determine urinary tract/bladder infection, urinary stones, diabetes, glomerular disease, tumor.
Pathology/Pathophysiology

* Urethral sphincter incompetence Prostatic hypertrophy
* Bladder tumor UTI

Imaging

* Pelvic ultrasound Renal ultrasound
* Transrectal ultrasound (prostate)

Other Diagnostic Procedures

* Physical examination
* Neurological assessment
* Medical history
* Interview for pattern of voiding/leakage, straining/discomfort associated with urination
* Test for stress incontinence (e.g., vigorous coughing to detect urine loss)
* Urodynamics
* Voidin cystourethrogram

Treatment Options
Treatment Strategy

Along with the drug therapies and surgical procedures listed below, the following may be necessary.

* Catheters Urethral plugs
* Condom catheters Absorbent pads, undergarments, diapers

Drug Therapies

* Antibiotics: For UTIs or sexually transmitted diseases
* Anticholinergics: For UI, reduce detrusor muscle contractions/increase urethral resistance (imipramine [Tofranil] 10 to 25 mg up to tid; oxybutinin [Ditropan] 2.5 to 5 mg up to tid; hyoscyamine [Cystospaz], hyoscyamine sulfate [Levsin/Levsinex, Cystospaz-M], and flavoxate [Urispas] all 100 to 200 mg tid or qid). High instance of undesirable/intolerable side effects
* Antimuscarinic/ganglionic-blockers: Propantheline (Pro-Banthine) 15 to 30 mg every four to six hours. High incidence of side effects including confusion, agitation, coronary artery disease, especially in the elderly.
* Cholinergics: For underactive detrusor, bethanechol (Duvoid, Myotonachol, Urecholine); contraindicated with asthma, bradycardia, Parkinson's disease. Can produce intolerable sweating/excessive salivation.
* Sympathomimetics: For SUI, phenylpropanolamine (found in Ornade) 25 to 100 mg bid; or pseudoephedrine (found in Sudafed) 15 to 30 mg tid; caution with hypertension, angina, hyperthyroidism, diabetes
* Hormones: SUI in women, increase urethral resistance (conjugated estrogens [Premarin] 1.25 to 2.5 mg/day in cream; 0.3 to 0.625 mg/day orally with estradiol [Estrace]); increased risk of endometrial cancer, particularly with unopposed estrogen

Surgical Procedures

Success rate higher in younger patients; effectiveness deteriorates over time; long-term success rate estimated at 75% to 90% for five years.

* Artificial sphincter: Inflatable cuff surrounding bladder neck activated by mechanism implanted in scrotum or labia.
* Supportive devices: String secured to the bladder and attached to muscle, bone, or ligament; in severe SUI, a wide sling elevates bladder.

Complementary and Alternative Therapies

The main thrust of alternative therapies is Kegel exercises, biofeedback, and preventing any exacerbating conditions. Underlying conditions (e.g., malnutrition, dementia, prostatitis, and UTIs) need to be addressed. Yoga may be beneficial. Habit training (establishing toilet times to increase regularity of voiding) may also help treat this condition.
Nutrition

* Eliminate caffeine, alcohol, sweetener substitutes, simple sugars.
* Cranberries and blueberries contain substances which inhibit the adhesion of bacteria to bladder tissue. This may be useful in preventing infections which can exacerbate incontinence. Also helps to deodorize urine.
* Vitamin C (1,000 mg tid) acidifies urine, which inhibits bacterial growth.
* Beta-carotene (25,000t to 50,000 IU/day) is necessary for immune function and mucous membrane integrity.
* Zinc (30 mg/day) supports immune function, often deficient in the elderly.
* Calcium (1,000 mg/day) and magnesium (500 mg/day) together may help to improve sphincter control.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Urinary astringents have been used historically for sphincter tone and connective tissue integrity. Demulcents soothe irritated tissue and may decrease spasm of the bladder.

These urinary astringents tone and heal the urinary tract and can be taken long term at 1 cup/day or 30 drops tincture/day.

* Horsetail (Equisetum arvense) also helps with connective tissue integrity.
* Plantain (Plantago major) is an astringent and demulcent.

Marshmallow root (Althaea officinalis) is a urinary demulcent, best used alone in a cold infusion. Soak 1 heaping tbsp. of marshmallow root in 1 quart of cold water overnight. Strain and drink during the day in addition to other teas.
Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

* Causticum for SUI, especially with retention from holding the urine and frequent urges to urinate
* Natrum muriaticum for SUI, vaginal dryness, painful coitus, especially with a history of grief
* Pareira for retention of urine from an enlarged prostate
* Sepia for SUI with sudden urging, especially with prolapsed uterus and vaginitis
* Zincum for SUI, urinary retention from prostate problems, unable to urinate standing, must sit

Acupuncture

May be of help, depending on cause.
Patient Monitoring

Compliance with behavioral techniques is essential and may require close monitoring and reinforcement. Physician must be alert to and monitor side effects of medications, or for infections following implants/surgery.
Other Considerations

Early treatment is most beneficial; embarrassment often causes delay in seeking help.
Prevention

* Pelvic muscle strengthening (Kegel) exercises during and after pregnancy
* Maintenance of healthy prostate in men; maintenance of healthy pelvis in women
* Maintenance of optimal body weight for height/age

Complications/Sequelae

* Drugs: Considerable risk of unwanted, intolerable and/or serious side effects; contraindication with other medications
* Surgery: Possible complications
* Catheters: UTIs

Prognosis

Most cases can be vastly improved with appropriate management; effectiveness may deteriorate with age.
Pregnancy

Pregnancy increases risk of incontinence; effect of drugs upon fetus must be determined before being administered during pregnancy.
References

Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers; 1995:247.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:432.

Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md: Williams & Wilkins; 1998.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:1466-1468.

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:111-113, 258-261, 286, 402.

Olshevsky M, Noy S, Zwang M, et al. Manual of Natural Therapy. New York, NY: Facts on File Inc; 1989.

Thom DH, Van den Eeden SK, Brown JS. Evaluation of parturition and other reproductive variable as risk factors for urinary incontinence. Obstet Gynecol. 1997;90:983-989.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: The Putnam Publishing Group; 1995.

Urethritis - home health advice

Overview
Definition

Urethritis is infection and inflammation of the urethral lining caused by bacterial infections, and may involve the bladder, prostate, and reproductive organs. Urethritis can affect males and females of all ages; however, females are at higher risk due to proximity of urethral opening to anus and vagina, increasing the likelihood of bacterial contamination.

Sexually transmitted pathogens Chlamydia trachomatis, Neisseria gonorrhoeae (co-infection common), and herpes simplex are primary causes of urethritis, particularly in men; however, often no infection can be documented. Vaginitis triggered by Candida albicans or Trichomonas vaginalis, and bacterial vaginosis, are also contributing causes for women. In bacteria-negative cultures, urethritis and vaginitis account for most urinary disorders in women.

Of the organisms which cause nongonococcal urethritis (NGU), chlamydia is the most common and most serious, with 75% of infected women and 50% of infected men remaining asymptomatic. Left untreated, it can lead to permanent damage of reproductive organs in both men and women. Implications tend to be more severe in women due to the internal nature of the infection, which often goes without notice until complications arise.
Etiology

* Bacteria and other organisms entering the urethra, including Chlamydia trachomatis, Neisseria gonorrhoeae, Ureaplasma urealyticum, Mycoplasma hominis, Candida albicans, Trichomonas vaginalis, and herpes viruses
* Bruising during sexual intercourse (women)
* Infection reaching the urethra via venous system from prostate gland or through the penis opening; in older men, classic urinary tract pathogens are a more common cause than STDs
* Bacterial infection following course of antibiotics
* Reiter's syndrome

Risk Factors

* Unprotected sex
* History of sexually transmitted diseases
* Multiple sex partners, or sexual relations with individual who has multiple sex partners
* Urinary catheter or instrumentation
* Bacteria-resistant drugs
* Prior history of kidney stones, prostatitis, epididymitis, genital injury
* Reiter's syndrome, which has a genetic predisposition
* Increased caffeine intake

Signs and Symptoms

In both sexes but particularly women, the disease may be asymptomatic.

In men:

* Burning during urination
* Purulent or whitish-mucus urethral discharge
* Burning or itching around the penile opening

In women:

* Painful urination and/or unusual vaginal discharge
* Cervicitis
* Salpingitis
* Pelvic inflammatory disease

Differential Diagnosis

* Reiter's syndrome
* Gonorrhea
* Allergic reactions
* Other urinary tract infections

Diagnosis
Physical Examination

* Watery and thin discharge (Chl. trachomatis)
* Purulent discharge (N. gonorrhoeae)
* Inflammation of penile opening

Laboratory Tests

* Presence of white blood cells in urine specimen
* Gram's stain of urethral discharge which shows >4 WBCs per HPF
* Intracellular gram-negative diplococci strongly suggests gonorrhea
* Absence of gram-negative cocci strongly suggests NGU (Gram's stains are less than 100% sensitive for chlamydial infections)
* Syphilis and HIV serology to rule out other STDs

Pathology/Pathophysiology

* Unusual urethral/vaginal discharge in 50% to 75% of cases
* In males, possible inflammation and irritation at penis opening
* Urethral strictures

Other Diagnostic Procedures

* Thorough medical and sexual history, including date of symptom onset and prior history of STDs
* Genital examination
* Evaluation of laboratory evidence for infection (Chl. trachomatis requires specimen of intracellular and urethral cellular material; collect specimen with calcium alginate swab inserted two to three cm into urethra)
* Evaluation of sexual partners may aid diagnosis in asymptomatic disease

Chl. trachomatis:

* Immunofluorescent testing
* Enzyme-linked immunoassay
* DNA probing of cervical samples

Treatment Options
Treatment Strategy

* Therapy must often be administered presumptively.
* Antimicrobial therapy directed against etiologies.
* Chlamydial disease may persist even after successful treatment of gonococcal component.
* Impress upon patient importance of treatment compliance.
* All sex partners should be treated.
* Sexual abstinence recommended until treatment regimen is completed, as disease can remain active even after symptoms have disappeared.

Drug Therapies

Urethritis:

* Tetracycline (500 mg qid for seven days)
* Erythromycin (500 mg qid for seven days; preferred in pregnancy)

N. gonorrhoeae:

* Ceftriaxone (250 mg IM once a day)
* Ofloxacin (400 mg once a day)
* Ciprofloxacin (500 mg once a day)

Chl. trachomatis:

* Doxycycline (100 mg bid for 10 days)
* Ofloxacin (300 mg orally bid for 10 days)

Trichomonas urethritis/vaginitis:

* Metronidazole (2 g orally once a day; contraindicated in pregnancy)
* Clindamycin (300 mg orally bid for seven days)

Herpes simplex:

* Acyclovir (400 mg orally tid for 10 days)
* Famciclovir (250 to 500 mg orally bid for 10 days)
* Valacyclovir (1,000 mg orally bid for 10 days)

Persistent/recurrent disease:

* Retreatment with antimicrobials

Complementary and Alternative Therapies

Nutrition, herbs, and homeopathic remedies are useful in fighting infection, relieving pain, and tonifying the urinary system.
Nutrition

* Eliminate any known food allergens. Food allergies can be tested for using an IgG ELISA food allergy panel, or by an elimination diet.
* Eliminate refined foods, fruit juices, caffeine, alcohol, and sugar, which may compromise immune function and irritate the urinary tract.
* Cranberries and blueberries contain substances that inhibit the adhesion of bacteria to the urinary tract.
* Vitamin C (1,000 mg tid) stimulates immune system and acidifies urine, which inhibits bacterial growth.
* Beta-carotene (25,000 to 50,000 IU/day) is necessary for immune function and mucous membrane integrity.
* Zinc (30 to 50 mg/day) supports immune function.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Herbal therapy should be instituted at the first sign of symptoms and continued for three days beyond resolution of symptoms. Treatment of infectious urethritis is best accomplished through teas because of the flushing action of the additional fluid intake. Combine two herbs from each of the following categories and drink 4 to 6 cups/day.

Urinary antiseptics are antimicrobial and include the following.

* Uva ursi (Arctostaphylos uva ursi)
* Buchu (Agathosma betulina)
* Thyme leaf (Thymus vulgaris)
* Pipissewa (Chimaphila umbellata)

Urinary astringents tone and heal the urinary tract and include the following.

* Horsetail (Equisetum arvense)
* Plantain (Plantago major)
* Cleavers (Galium aparine)

Urinary demulcents soothe the inflamed urinary tract and include the following.

* Corn silk (Zea mays)
* Couch grass (Agropyron repens)
* Marshmallow root (Althaea officinalis) is best used alone in a cold infusion. Soak 1 heaping tbsp. of marshmallow root in one quart of cold water overnight. Strain and drink during the day in addition to the other urinary tea.

For advanced or recurrent infections, prepare a tincture of equal parts of goldenseal (Hydrastis canadensis) and coneflower (Echinacea purpurea). Take 30 drops four to six times/day in addition to the urinary tea.

For noninfectious urethritis or for urethritis with severe pain and spasm, add kava kava (Piper methysticum) to any of the above formulas.

A periwash may be helpful in reducing pain with urination. Place 1 tsp. of the coneflower/goldenseal tincture in an 8-oz. peri bottle. Fill with water. Rinse off after each urination.
Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

* Staphysagria for urinary infections associated with sexual intercourse
* Apis mellifica for stinging pains that are exacerbated by warmth
* Cantharis for intolerable urging with "scalding" urine
* Sarsaparilla for needing to stand to urinate, with burning after urination

Acupuncture

May be helpful in enhancing immune function.
Patient Monitoring

* Recurrent or persistent symptoms require careful reevaluation and re-treatment with antimicrobials when urethral discharge tests positive or demonstrates increased numbers of polymorphonuclear leukocytes.
* Monitor general condition/medications.
* Encourage patient self-care.
* Monitor closely for treatment compliance, particularly for STD-related urethritis.

Other Considerations

Treat patient's sexual partner(s) if STD-related.
Prevention

* Wipe from front to back following bowel movement, wash genitalia with soapy water, shower rather than bath (for women only).
* Drink eight glasses of water daily.
* Protected sex with latex condom when outside of a monogamous relationship

Complications/Sequelae

* When left untreated, gonococcal urethritis common in men may cause urethral stricture with increased risk of periurethral abscess; may perforate the peritoneal scrotum, causing urethral fistula.
* Untreated chlamydia increases risk of acquisition/transmission of HIV, causes pelvic inflammatory disease (PID) in women, and in men affects the testicles, which leads to complications and possible infertility.
* Infection spread to ureters/kidneys

Prognosis

* When associated with low-grade infection and treated appropriately, seldom produces long-term illness; however, recurrence is common.
* STDs or NGU can be effectively treated with antibiotic medication. When asymptomatic or left untreated, complications including infertility may result, and disease transmission to sex partners is inevitable.

Pregnancy

NGU:

* Permanent damage to reproductive organs/infertility in both sexes.
* Difficulties during pregnancy, premature delivery, low birth weight.
* Ear, eye, and lung infections in newborns. (Resultant neonatal conjunctivitis can permanently damage eyesight.)
* Nutritional guidelines are safe to follow in pregnancy. Herbal therapies should be used only with physician supervision.
* Avoid tetracyclines.

References

Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers; 1995:436-437.

Berkow R, Beers MH. The Merck Manual of Diagnosis and Therapy. Rahway, NJ: Merck and Company; 1992.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:432.

Bowie WR. Approach to men with urethritis and urologic complications of sexually transmitted diseases. Med Clin North Am. 1990;74:1543-1557. Accessed at www.thriveonline.com.

Hoffman D. The New Holistic Herbal. New York, NY: Barnes & Noble Books; 1995:109-110.

Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North Atlantic Books; 1992:98-102.

Shealy CN. The Illustrated Encyclopedia of Healing Remedies. Boston, Mass: Element Books Limited; 1998.

Tierney LM Jr, et al., ed. Current Medical Diagnosis & Treatment 1999. 38th ed. Stamford, Conn: Appleton & Lange; 1999.

Virtual Hospital: University of Iowa Family Practice Handbook. 3rd ed. Available at www.vh.org.