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Foods to improve sex drive in males

When it comes to herbal remedies, saw palmetto's properties make it a popular choice for treating a number of ailments. Saw palmetto has long been considered an aphrodisiac and sexual rejuvenator, although little research supports the claim. The action of saw palmetto has been well studied, and the herb is popular in the treatment of prostate enlargement. Research has shown that saw palmetto inhibits one of the active forms of testosterone in the body (dihydrotestosterone) from stimulating cellular reproduction in the prostate gland.
Saw palmetto is recommended to treat weakening urinary organs and the resulting incontinence that may occur in elderly people or women after menopause. Saw palmetto has also been touted as a steroid substitute for athletes who wish to increase muscle mass, though little documentation supports this claim. In the next section, you will learn how to prepare saw palmetto for herbal remedies and some of the potentially dangerous side effects. 2.1The Licensed Material may not be used in any final materials distributed inside of your company or any materials distributed outside of your company or to the public, including, but not limited to, advertising and marketing materials or in any online or other electronic distribution system (except that you may transmit comps digitally or electronically to your clients for their review) and may not be distributed, sublicensed or made available for use or distribution separately or individually and no rights may be granted to the Licensed Material. 2.2One copy of the Licensed Material may be made for backup purposes only but may only be used if the original Licensed Material becomes defective, destroyed or otherwise irretrievably lost. According to the American Cancer Society, 1 in 6 men will suffer from prostate cancer at some point in their life causing approximately 29,720 prostate cancer deaths annually.
The really serious, life threatening problems with prostate cancer don’t usually kick in until the naively, unsuspecting succumb to toxic, invasive, allopathic, Big Pharma interventions like: radiation, chemo and surgery.
Sadly, early stage, aggressive allopathic, prostate cancer “treatment” can and does cause permanent damage including: impotence, heart attacks, incontinence, and even death. The standard PSA test was approved by the FDA in 1994 and each year millions of men are screened with a blood test for PSA, which is manufactured exclusively by the prostate gland.
A PSA test will only tell you how much PSA is in your blood, and although elevated levels can be detected, that information is useless. Men with high PSA readings can be cancer free, while those with low readings can actually have cancer. The good news is that whole Ginger root (Zingiber officinale Roscoe) is a promising inexpensive, readily available, non-toxic spice-medicine that can be utilized by almost anyone for preventing, treating and reversing prostate cancer. The researchers discovered that whole ginger root extract interrupts cancer cell progression, impairs the ability of cancer cells to reproduce, and induces cancer cell apoptosis (self destruction). The 2011 was conducted at the Department of Biology at Georgia State University to explore ginger’s potential for prostate cancer treatment, based on ginger’s previous scientifically established anti-inflammatory, antioxidant, and anti-tumor properties. The results were impressive, whole ginger extract was shrinking tumors by 50 % after only eight weeks.
Maintain a well-rounded exercise plan, handle your stress, and optimize your vitamin D3 levels. UCLA lab tests showed that lutein reduces prostate cancer cell growth by 25 percent, while lycopene from tomatoes reduces cell growth by 20 percent.
Keep in mind only the whole avocado in all its innate richness delivers an “entourage effect” medicinally and nutritionally. For most of the 20th century, from 1909 until the late 1990s, the premier treatment for symptomatic benign prostatic hypertrophy (BPH) was transurethral resection of the prostate (TURP).
Since the advent of medical therapy for symptomatic prostatic hypertrophy with 5-alpha reductase inhibitors and alpha-adrenergic blockers, the need for immediate surgical intervention in symptomatic prostatic obstruction has been reduced substantially. Less common uses of TURP include intractable prostatitis or for tissue sampling when standard biopsy techniques cannot be used. The relative frequency of TURP compared to open prostatectomy in surgical patients varies from country to country. The average age of patients currently undergoing TURP is approximately 69 years, and the average amount of prostate tissue resected is 22 g. African Americans more typically present for TURP surgery with urinary retention or urinary infections and have a higher incidence of preexisting medical problems compared to the general population. Go to Prostate Cancer, Prostate-Specific Antigen, and Benign Prostatic Hypertrophy for complete information on these topics. Most men who present for surgical correction of their urinary outlet obstruction are those in whom medical therapy or alternative procedures have failed or are inappropriate for some reason.
A study by Blanchard et al showed that patients in whom alpha-blocker therapy is ineffective or those in whom it has failed tend to have poorer outcomes after TURP than men who proceed directly to a transurethral resection.[3] This is presumably from preoperative bladder damage and other risk factors that affect voiding rather than the size of the prostate. Although persistent, progressive, or bothersome symptoms of urinary obstruction due to prostatic hypertrophy that are refractory to medical therapy constitute the most common indication for TURP, 70% of men undergoing the procedure have multiple indications. Surgical treatment of BPH is also indicated in cases of renal failure or insufficiency secondary to prostatic obstruction. The only absolute indication for an open prostatectomy over a TURP is the need for an additional open procedure on the bladder that must be performed at the same time as the prostatectomy.
A relative indication for the selection of an open prostate surgery over a TURP is generally based on prostatic volume and the ability of the surgeon to complete the TURP in less than 90 minutes of actual operating time (although < 60 min is considered optimal).
In general, open prostatectomy can be justified in a patient with a prostate of 45 g or larger, but this is totally dependent on the skill and experience of the endoscopic urological surgeon. The new availability of reasonable alternative medical and surgical treatment options means that TURP, once one of the most commonly practiced urological procedures, is now performed much less frequently.
The 1985 Veterans Administration Normative Aging Study estimated the lifetime probability of surgical intervention for prostatic enlargement at 29%, and the 1986 National Health Survey estimated that 350,000 patients in the Medicare age group had a TURP that year, compared to fewer than 200,000 in that same age group by 1998.
These numbers should be considered within the context that the median age of the typical patient is rising (the number of older men with BPH-related symptoms in the United States is expected to increase from 5 million to 9 million persons by 2025), the size of the average resected prostate gland is increasing, and the typical patient has more comorbidities and is generally less healthy than surgical patients of the past.
Another factor that must be considered when evaluating the general decline in the number of TURP procedures performed is the significant reduction in financial reimbursement to urologists for TURP surgeries in the United States.
Physician reimbursement from Medicare for a TURP has dropped from a high of $2000-$3000 in the past to approximately $650 today, with a 90-day global period that covers all postoperative care by the surgeon for 3 months. Alternative surgical procedures, such as microwave therapy and prostatic laser surgery, are reimbursed at much higher levels, even though they may not be as durable or effective.
In a large Canadian series reported by Borth et al, the number of TURP procedures dropped by 60% between 1988 and 1998, presumably because of medical therapy, despite an increase of 16% in the male population older than 50 years.[6] While the number of patients presenting with urinary retention was significantly higher in the 1998 group than in the 1988 cohort (55% vs 23%), no significant difference was noted in their average age, medical comorbidities, operative parameters, average size of prostate tissue resected, or complication rates.
The transition zone is usually the smallest of the 3: it occupies only 5% of the prostate volume in men younger than 30 years.
As the transition zone expands, it can comprise up to 95% of the prostate volume, compressing the other zones. The periurethral glands are less commonly involved with BPH, but when they do become enlarged, they can form what is termed a median lobe, which appears as a teardrop-shaped midline structure at the posterior bladder neck. In some earlier jargon, the transition zone and periurethral region were called the central gland or inner gland, and the peripheral and central zones were called the outer gland.
Prostatic calculi are formed from calcification of the corpora amylacea and precipitation of prostatic secretions. Although prostatic calculi may arise spontaneously, they also may be formed in response to an inflammatory reaction or as a consequence of another pathological process that produces acinar obstruction.
If a channel is opened during surgery that allows these calculi to be expressed, they often flow out by themselves if the opening is large enough. The prostate is thinnest and most narrow anteriorly (the 12-oa€™clock position when viewed through a cystoscope).
The external sphincter muscle tends to be slightly tilted, with the most proximal portion located anteriorly, opposite the verumontanum. The verumontanum is the single most important anatomical landmark in TURP (see the image below).
The orifices to the ejaculatory ducts emerge in the verumontanum (see the first image below). The proximity of the ureteral orifices to the cephalad margin of the hypertrophied prostate varies, particularly in patients with an enlarged median lobe. The vascular anatomy of the prostate was accurately described in detail by Rubin Flocks in 1937.[7] The blood supply of the prostate comes primarily from branches of the inferior vesical artery, which is a branch of the internal iliac artery (see the image below). When the inferior vesical artery reaches the prostate just at the vesicoprostatic border, it branches into 2 groups of arteries (see the image below). Vessels that parallel the prostatic urethra supply most of the blood to the hypertrophied lateral lobes. The prostate has been described as the organ of the body most likely to be involved with disease of some sort in men older than 60 years.
As the hyperplastic process increases the volume of the prostate, the urethral lumen is compressed, causing outlet obstruction.
It has been known for many years, however, that prostate size alone is not a reliable or accurate predictor of the presence or degree of urinary outlet obstruction. Thus, at the same time as the occurrence of mechanical obstruction, a dynamic component involving the stromal prostatic tissue and bladder is present, which is often more significant in causing urinary symptoms than simple mechanical obstruction from an enlarged prostate. When a bladder is trying to empty through a blocked outlet from an obstructing prostate gland, the intravesical pressure required to open the bladder neck is increased.
Isolated muscle bundles hypertrophy in response to the need for a higher intravesical pressure to overcome the increased resistance to voiding, and bladder trabeculation often follows. Evidence indicates that obstruction causes partial denervation of bladder smooth muscle, which results in further bladder irritability and involuntary detrusor contractions. Overall bladder mass increases because of detrusor muscle hypertrophy, but collagen deposition is also increased, which eventually contributes to decompensation, urinary retention, and permanent loss of detrusor contractile ability.
BPH is thought to be caused by aging and by long-term testosterone and dihydrotestosterone (DHT) production, although their precise roles are not completely clear. Histopathologic evidence of BPH is present in approximately 8% of men in their fourth decade and in 90% of men by their ninth decade. A 5-year longitudinal study by Rhodes and colleagues of 631 community men aged 40-79 years from Olmsted County, Minnesota demonstrated an average annual prostate growth rate of 1.6%. The average prostate weighs approximately 20 g by the third decade and remains relatively constant in size and weight unless BPH develops. DHT has an affinity for prostate cell androgen receptors that is 5 times greater than that of testosterone.
The success of 5-alpha reductase blockers, such as finasteride and dutasteride, in reducing prostatic size and relieving symptoms seems to confirm this, although it does not explain the relative lack of symptom relief in those with smaller prostate glands treated with these agents. Upon physical examination, the bladder may be palpable during the abdominal examination and the prostate may be enlarged during the digital rectal examination.
Alpha-adrenergic receptors are present and functional in the stromal smooth muscle of the prostate and especially at the bladder neck. Spinal anesthesia is generally preferred for transurethral resections for a number of reasons, not the least of which is the ability to converse with the patient and to evaluate him for symptoms of an early dilutional hyponatremia (ie, transurethral resection [TUR] syndrome) during surgery. A 1998 study by Fredman et al compared general versus spinal anesthesia in patients older than 60 years undergoing short transurethral prostate surgery. Several studies have failed to show any significant differences in complication rates, operative mortality and morbidity, or blood loss between regional and general anesthesia. The obturator nerve runs near the prostate and can be electrically stimulated during transurethral prostate surgery, causing a violent thrusting of the leg, which is called the obturator nerve reflex.
The obturator reflex most often occurs while resecting bladder tumors on the lateral walls of the bladder. If the electrosurgery (cautery) unit does not appear to be functional, inadvertent use of normal saline (isotonic sodium chloride) irrigation is one of the first things to check besides the grounding pad, power switch, and cord connections. Sterile water is rarely used because, when absorbed in large quantities during the procedure, it causes hyponatremia, intravascular hemolysis, and hyperkalemia. Glycine inhibits neurotransmission and may rarely cause visual disturbances if absorbed in large amounts. Most experts, however, believe that these effects are relatively insignificant during routine TURP procedures. A new bipolar resectoscope, with a redesigned generator that can operate safely with normal saline (isotonic sodium chloride solution) irrigation, is now available (see below). Demonstration of the Iglesias resectoscope, with the free hand allowing a finger in the rectum to elevate the floor of the prostate. The main advantage of a resectoscope that allows the resection to be performed with a single hand, as in the Iglesias design and the earlier Nesbit design, is that it leaves the second hand free to place a finger in the rectum to help raise the apex and floor of the prostate. The Iglesias working element uses the thumb and the spring to do the actual cutting, while the older Stern-McCarthy model allows the resection to be controlled by the thumb and first two fingers using a rack-and-pinion mechanism, which provides finer motor control and excellent tactile sensory feedback. Continuous-flow resectoscopes like the Iglesias model are designed to eliminate the need for intermittent bladder evacuations, which interrupt the resection and waste time while the surgeon needs to become reoriented. Bipolar technology, which allows normal saline to be used as an irrigation fluid to reduce hyponatremia, is just the latest in a long line of technological innovations in TURP.
The current generated by a bipolar instrument tends to remain superficial, which generally prevents the potentially dangerous obturator reflex often associated with transurethral resection of bladder tumors. This type of technological improvement permits transurethral endoscopic surgeries to be performed more safely, especially in high-risk patients and those at particular risk for dilutional hyponatremia or iatrogenic trauma from an inadvertent obturator reflex.
Modern coaxial continuous-flow bipolar resectoscopes are currently the overwhelming first choice of urologists for TURP instrumentation. A third advantage is that the suprapubic trocar can keep the bladder fluid pressure at or below only 8 cm water, which is well below the 10-15 cm water pressure of the pelvic veins and periprostatic venous system; this keeps fluid absorption down.
We prefer to use a suprapubic trocar for establishing continuous flow when trying to resect larger prostates (>80 g), following the technique of Dr. The trocar is placed into the stab wound, with the sharpened obturator tip angling slightly superiorly toward the patienta€™s head. The sharpened obturator tip is then replaced with the fenestrated drainage insert attached to suction tubing. The key to placement of the suprapubic trocar is to have the bladder completely filled before attempting to place the trocar. No significant extravasation occurs unless the trocar is removed too early and the resectoscope must be reintroduced.
A modified cutting system designed to decrease blood loss and hematuria has been developed for TURP. Make sure the patient is positioned with the buttocks flush with the end of the cystoscopy table. Hypothermia, defined as a core body temperature of 36A°C or less, induces shivering, which has been shown to increase oxygen demands by as much as 500%.
Room-temperature irrigation can result in a substantial decrease in the patienta€™s core body temperature, particularly if continuous-flow irrigation is used.
Consequently, irrigating fluid warmed to body temperature is strongly recommended, along with the use of warming blankets and other appropriate thermal modalities.
For patients on clopidogrel, 14 days off the medication prior to TURP surgery is recommended, but 10 days may be sufficient. In selected patients subject to an unusually high medical risk, short-term heparinization can be used while other anticoagulants are discontinued. However, the heparinized group required more inpatient hospital days because of prolonged hematuria and a longer period of catheterization that averaged approximately 2 days more than the group who received the standard therapy.
Therefore, we recommend that aspirin be stopped at least 10 days prior to surgery and, preferably, 14 days before. We generally wait until the urine is grossly clear for 24 hours before resuming warfarin, but we recommend confirming that the urine is grossly clear for at least 48 hours before restarting clopidogrel or aspirin because of the longer half-life of these agents and the inability to easily reverse them, if needed. Some controversy exists regarding the use of systemic antibiotics prior to the initiation of prostate surgery. Patients with indwelling Foley catheters are presumed to be infected regardless of culture results and should be routinely given broad-spectrum antibiotic coverage before surgery.
The issue of how long to maintain the antibiotics and whether to use them postoperatively is even less clear, although some evidence indicates that 2 weeks of postoperative antibiotic coverage can help reduce urethral stricture formation. A 2002 meta-analysis by Berry and Barratt suggested that the type of antibiotic was relatively unimportant when used prophylactically in low-risk individuals.[16] They found that prophylaxis significantly decreased bacteriuria and septicemia, even in men with sterile urine preoperatively.
After postoperative catheter removal, we generally use doxycycline, TMP-SMZ, or a nonsystemic urinary antiseptic such as nitrofurantoin. A complete blood count (CBC) is needed to establish preoperative hemoglobin and hematocrit levels and platelet counts. Creatinine, blood urea nitrogen (BUN), and electrolyte levels are used to establish the presence of a new azotemia, which may prompt the physician to request appropriate studies, such as renal ultrasound examinations, to determine if bilateral hydronephrosis is present.
In regard to coagulation studies, several studies have indicated that PT and aPTT are not generally necessary or cost effective without a history of unusual bleeding or use of an anticoagulant medication.
Performing bleeding time studies should be considered in patients with renal insufficiency or those taking platelet-inactivating drugs such as aspirin, clopidogrel, or ibuprofen.
A high prostate-specific antigen (PSA) level suggests an active urinary or prostatic infection, a markedly enlarged prostate, or possible prostatic carcinoma. The increase in intravascular fluid absorption that happens during a TURP can quickly cause congestive heart failure (CHF) in susceptible patients; therefore, a preoperative chest radiograph is useful for comparison.
Early use of furosemide (Lasix) intraoperatively should be considered in patients at increased risk for CHF or hyponatremia and in patients in whom blood loss is excessive. Intravenous pyelograms and computed tomography (CT) scans also may be used selectively to evaluate associated conditions, such as hematuria, but they are not part of the routine evaluation for prostatic obstruction or hyperplasia. Ultrasonographic examinations of the kidneys, bladder, and prostate, although not routinely recommended, are performed in some centers to help exclude other pathologies in the urinary system and to help estimate prostatic volume.
Renal ultrasonography is not recommended as a routine preoperative study, although it can be useful for helping detect hydronephrosis in cases of azotemia or pathological sources of hematuria not related to prostatic disease. Electrocardiograms are usually performed because most patients are elderly and occasionally a patient demonstrates a silent myocardial infarct or other cardiac problem that affects the timing of the surgery.
Preoperative urodynamic studies are indicated in patients who may have underlying neurologic disease or potentially nonfunctioning bladders. The Urodynamics Subcommittee of the ISC recommends filling cystometry in addition to pressure-flow studies. A study by Van Venrooij et al that evaluated patients urodynamically before and after TURP found that 50% of patients with a urodynamically unstable bladder preoperatively developed stable bladder function by 6 months after their TURP procedures.[18] This suggests that urodynamics may not always be highly predictive of outcome success after TURP, particularly when dealing with unstable bladders. Uroflowmetry provides information about the force of the patienta€™s urinary stream and the volume of urine voided. Sonographic measurement of postvoid residual urine volume is useful for helping differentiate patients with overflow incontinence from those with purely irritative problems.
Whereas a postvoid residual urine volume of less than 50 mL is generally recognized as normal, no absolute quantity exists that represents an abnormal postvoid residual urine volume.
Cystoscopy is another optional test that is not specifically required or recommended as part of the routine TURP workup.

BPH occurs primarily as two histological types: stromal hyperplasia (fibromuscular) and glandular hyperplasia (nodular, epithelial). As the name implies, stromal hyperplasia results from proliferation of the fibromuscular stromal fibers that separate the acini of prostate glands. Glandular hyperplasia appears as nodules of redundant glandular acini, which are mainly epithelial in nature.
Prostate resections of 50 g or less are predominantly stromal, with the glandular (nodular) component averaging only approximately 22% of the total.
Prostatic tissue growth from the relatively small transitional zone, which is located just lateral and distal to the internal sphincter, is the primary site of origin of the majority of BPH glandular tissue. The goal of prostate surgery for BPH is to remove the obstructing tissue while minimizing damage to surrounding structures, with as little discomfort to the patient as possible. Electrosurgical TURP remains the standard for endoscopic removal of obstructive BPH tissue and is the primary focus of this review. TURP is a surprisingly challenging procedure technically, with a protracted learning curve. Open prostatectomy is more appropriate for larger prostates, in which endoscopic resection would be so lengthy that dangerous fluid shifts and other complications are more likely to occur. If the transurethral resection will take longer than 90 minutes of operating time to complete, then an open prostatectomy, referral to a more experienced colleague, or some alternative therapy is recommended. Confirm that the cutting loop of the resectoscope fits perfectly into the sheath without any gaps.
A spare telescope and sheath, extra cutting loops, a backup electrosurgical unit, instruments for a perineal urethrostomy, and a small (24F) resectoscope set should be immediately available in case they are needed.
Use of a plastic barrier sheath (eg, Lingeman sheath, Oa€™Connor sheath) helps maintain sterility and protects the operative field, while allowing digital manipulation of the prostate through the rectum. If the patient has been catheterized, gentle irrigation of the urethra with a Toomey or bulb syringe rinses mucus, blood clots, and other debris into the bladder, where these materials will not interfere with vision. As noted (see Preparation), an isotonic solution should be used for intraoperative irrigation. Irrigating fluid should be kept at the lowest height (pressure) level possible to maintain an adequate flow. The procedure always begins with a careful cystoscopic inspection of the anterior urethra, external urinary sphincter, verumontanum, prostatic urethra, bladder neck, prostatic median lobe, trigone, ureteral orifices, and the rest of the bladder using a small-caliber cystoscope (see the image below). The initial cystoscopy should be performed gently, avoiding contact with the superficial surface of the enlarged lateral and medial lobes of the prostatic urethra as much as possible.
After careful inspection and orientation, the bladder is distended with approximately 100 mL of fluid, which helps to improve anatomical identification and better visualize the prostate, bladder neck, median lobe, and bladder wall.
The relative distance between the ejaculatory ducts of the verumontanum and the proximal edge of the external sphincter muscle should be carefully noted in order to better judge the absolute distal limits of resection.
In very large prostates, some expert and experienced resectionists remove apical and lateral lobe tissue located adjacent or slightly distal to the verumontanum, arguing that failure to remove this tissue results in an incomplete resection and postoperative voiding difficulties in some patients.
The external sphincter muscle is identified by (1) its wrinkling and constricting action as the resectoscope is withdrawn and (2) the bunching-up of the superficial mucosa just in front of the telescope as it is reinserted.
The resectoscope sheath should be well-lubricated and placed with the aid of an obturator to prevent trauma to the urethral mucosa or false passage formation.
If there is any doubt as to whether the urethra is of adequate size to easily accommodate the resectoscope sheath that will be used, the urethra should first be calibrated. A smaller-sized resectoscope sheath (24F) should be used if the urethra appears too narrow for easy access with larger instruments; therefore, a 24F resectoscope sheath and appropriately sized cutting loops should always be immediately available.
If the patient has an extremely small urethra, an internal urethrotomy (preferred) or gentle dilation of the urethra with sequential Van Buren sounds may be needed. Beware of resecting folds of tissue that may build up in front of the edge of the beak of the resectoscope because this may cause a perforation. A perineal urethrostomy can be performed to create temporary access into the bulbous urethra to avoid any additional trauma to the rest of the urethra (see the image below). Always keep in mind and follow an orderly resection plan, regardless of which technique is used.
Once the resection has been started in a particular area, that portion of the resection should be finished completely before moving on to another location. The surgeon should always be prepared to terminate the procedure with relatively little notice if the patient develops complications. Resect tissue only when pulling or withdrawing the cutting loop toward the resectoscope, never when pushing it forward. If a very large and obstructing median lobe is present, it should be resected first, regardless of the method chosen for the rest of the transurethral resection.
A modification designed to reduce bleeding from an enlarged median lobe involves making several small, short cuts in the cleft between each lateral lobe and the median lobe. The bulk tissue of the median lobe is resected from the top down, while the end of the resectoscope is at the bladder neck to avoid subtrigonal tunneling and bladder neck injury, which can lead to extravasation and increased fluid absorption (see the image below).
When the resection approaches the bladder floor, the cutting loop can be used, without any electrical current, to gently lift the lip of the remaining median lobe tissue up and away from the bladder floor and trigone (see the image below). The bladder should be reinspected to identify the ureteral orifices, which should be visible.
Blood in urine and pain in men is also known as Hematuria and this is a very common condition in men. This condition generally gets detected in a urine test or it might also be noticed while urinating. It is necessary to consult a doctor if you find blood in your urine which is accompanied by some kind of pain.
Some of the most common causes of blood in urine and pain include tumors, stones and infections. Doctors also resort to the method of prescribing antibiotics that help in treating urinary tract infections, which might result in blood in the urine and pain as well.
Doctors might also try shock wave therapy for haematuria caused due to kidney or bladder stones.
A surgery might be one of the most effective methods of treating blood in urine and pain in men. The effective use of some natural remedies like cranberry can always help in treating the condition of blood in urine accompanied with pain while urinating.
The excessive intake of fluids, especially water helps in releasing the harmful toxins and the bacteria that result in blood in urine conditions along with pain while urinating. From penile dysfunction to incontinence, saw palmetto can help relieve discomfort and some male performance issues.
Saw palmetto does act on the sexual organs, and many herbalists value it as a treatment for impotence.
Enlargement of the prostate gland affects millions of men older than 50 years of age, causing difficulty with urination and a sensation of swelling in the low pelvis or rectal area.
Saw palmetto does affect testosterone, one of the hormones responsible for promoting muscle mass, as described above, but the precise hormonal activities on tissues other than the prostate are not yet understood. Many plant steroids, for example, enhance hormonal activity in one type of tissue and inhibit it in others.
Shows the typical appearance of hydroneophrosis of the left kidney secondary to bladder outlet obstruction as a result of the prostate enlargement. Except as specifically provided in this Agreement, the Licensed Material may not be shared or copied for example by including it in a disc library, image storage jukebox, network configuration or other similar arrangement. In fact, prostate cancer is the #2 cause of cancer death among men just behind lung cancer.
Ironically, prostate cancer death statistics don’t reveal that those who die from prostate cancer are in many cases actually killed by AMA approved “treatment” protocols, not by prostate cancer.
Ablin, who in 1970 discovered PSA (prostate specific antigen) speaks out in a March 2010, N.Y. I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. Researchers concluded that humans taking 100 grams (about 3.5 ounces) of fresh ginger daily would likely experience the same anti-cancer benefits. Heber’s findings also indicate that our avocados contain a biochemical called lutein, a carotenoid recently discovered in avocados and found in green vegetables, which can help protect against various forms of cancer, including prostate cancer. When lutein and lycopene were combined, prostate cancer cell growth was reduced by 32 percent.
His pet peeves are the Medical Mafia’s control over health and the food industry and government regulatory agencies’ corruption.
However, alpha-blockers do not modify prostate growth, and even the use of prostatic growth inhibitors such as finasteride or dutasteride often fails to prevent recurrent urinary symptoms of BPH and retention. In 1990, the relative frequency rate of TURPs in surgical patients with BPH in the United States was 97%, with similar rates in Denmark and Sweden. Risk factors associated with increased morbidity include prostate glands larger than 45 g, operative time longer than 90 minutes, and acute urinary retention as the presenting symptom. Operating time and weight of resected tissue have been documented as the same between the 2 groups; therefore, prostatic size alone does not account for the difference in outcomes. Patients with prostates larger than 45 g, who present with acute urinary retention, or who require operating times in excess of 90 minutes, are at increased risk for postoperative complications. Such indications include open surgical resection of a large bladder diverticulum or removal of a bladder stone that cannot be easily fragmented by intracorporeal lithotripsy.
Most experienced urologists use a prostatic volume of 60-100 g as the upper limit amenable to endoscopic removal, but some highly skilled resectionists are capable of safely treating a 200-g prostate with TURP in less than 90 minutes. In 1962, TURP operations accounted for more than 50% of all major surgical procedures performed by urologists in the United States. In many instances, performing a TURP is simply not profitable for the urologist when office overhead, billing and malpractice costs are considered, especially when complications occur. This creates a strong financial disincentive for urologists to perform TURP procedures, except when no reasonable alternatives exist.
The peripheral zone is the largest of the zones, encompassing approximately 75% of the total prostate glandular tissue in men without BPH. Intraoperatively, the 2 enlarged lobes of the transition zone can be seen obstructing the prostatic urethra on either side.
This terminology should be avoided both because it is vague and because it creates confusion with the now-standard anatomical label of the central zone. They occur between the transition zone and the compressed peripheral zone; in fact, they can be used as a marker for this border.
Some practitioners believe that calcifications that form in response to bacterial prostatitis may harbor bacteria that periodically flourish, causing recurrent prostatitis. They can be milked out by using the end of the cutting loop without current to gently press around the opening where the prostatic stones are seen and can be pushed into the opened prostatic fossa.
Care should be taken when operating in this area to avoid perforating the prostatic capsule, especially if this portion of the prostate is resected early in the operation. The external sphincter can be identified cystoscopically by its wrinkling and constricting action as the resectoscope is withdrawn. It is a midline structure located on the floor of the distal prostatic urethra just proximal to the external sphincter muscle.
Its importance lies in its position immediately proximal to the external sphincter muscle (see the second image below), which allows it to be used as the distal landmark for prostate resection. One penetrating group passes directly into the prostate toward the interior of the bladder neck.
The second large group of arteries follows the exterior of the prostatic capsule posterolaterally, periodically giving rise to perforating vessels, and supplies the area around the verumontanum.
This statement characterizes any histological evidence of BPH as a disease, which is certainly debatable, but there is no argument that BPH is an extremely common clinical entity. An enlarged median lobe may cause relatively more severe symptoms than lateral lobe hyperplasia of similar magnitude because it can act as a valve at which increased bladder pressure may actually cause further obstruction. The failure of several purely obstructive therapies, such as prostatic balloon dilatation, and the obvious success of alpha-adrenergic blockers eventually led to the description of BPH as having both a dynamic (neurogenic) and a mechanical (obstructive) component. The precise interaction of these two mechanisms, mechanical and dynamic, is not well understood. The bladder is initially able to produce a higher transitory voiding pressure when required, but loses muscle tone over time. The spaces between these hypertrophied bundles tend to become thinner, with less functional muscle.
When seen on cystoscopy images, it is a relative indicator of the degree and duration of any bladder outlet obstruction (eg, BPH), although any detrusor hyperactivity problem can possibly produce bladder trabeculations, even without an identifiable obstruction. Fortunately, most of these hyperactive symptoms resolve over time with removal of the prostatic obstruction or with a response to appropriate medications. Cross-sectional studies based on cadaver autopsies or consecutive patients seen in urology clinics suggest that the growth rate decreases with age. This remained essentially constant regardless of age, although men with larger prostates tended to have higher growth rates. The levels of 5-alpha reductase are increased in the stromal tissue of men with BPH compared to controls. Patients may also present with acute or chronic urinary retention, urinary tract infections, gross hematuria, renal insufficiency, bladder pain, a palpable abdominal mass, or overflow incontinence. Symptoms are not necessarily proportional to the size of the prostate on digital rectal examination or transrectal ultrasound findings. Many studies have documented the success of various alpha-adrenergic blockers in relieving symptoms of BPH. Patients recovering from a general anesthetic often cough heavily, which tends to increase hematuria. The study demonstrated that general anesthesia with propofol and desflurane facilitated shorter induction and recovery times without adversely affecting patient comfort. Transurethral resections have even been performed with local anesthesia and sedation, although these have only been performed on relatively small prostates averaging just 11 g of resected tissue. In these cases, the reflex may be prevented by injecting a local anesthetic into the sensitive area through a special needle passed through the resectoscope. Saline cannot be used because it conducts electricity, which diffuses the current and prevents it from cutting or cauterizing tissue.
Complaints of prickling sensations, increased nausea, hypotension, bradycardia, and confusion have been reported when more than 1000 mL of glycine has been absorbed. The advantages of such a system include the total elimination of hyponatremia (TUR syndrome) because normal saline is used as the irrigant. The primary disadvantage is that some of the sensory perception from cutting the tissue is lost. Most urologists today use the Iglesias model, but a few prefer the original Stern-McCarthy design for these reasons (see the image below). They also help maintain low fluid pressure in the prostatic fossa and bladder, which should reduce fluid absorption.
Nevertheless, most urologists find continuous-flow instrumentation convenient and beneficial.
In a bipolar system, instead of a grounding pad on the patient, the ground electrode is placed inside the sheath of a modified continuous-flow resectoscope, allowing the cutting current to pass directly between the wire loop and the sheath, or is built into the electrode itself, where the more proximal of the dual adjacent, parallel wire loops acts as the ground. The wire loop may be slightly smaller than a conventional resectoscope, but it otherwise looks and operates the same.
These instruments require a small skin incision and create a small cystostomy wound in the bladder, but they offer several distinct advantages over the more popular single coaxial continuous-flow instruments.
When compared directly to a coaxial continuous-flow system, the suprapubic trocar technique has been found to allow shorter operating times with lower intravesical pressures and less fluid absorption.
The placement technique is to fill the bladder to capacity (or with at least 200-300 mL) while the resectoscope is in place and then make a small suprapubic stab wound approximately 1 cm above the pubic symphysis. This is performed in such a manner that the final intravesical trocar position is angled toward the posterior bladder wall and away from the resection site.
Therefore, wait until just before the patient is ready to be transferred from the cystoscopy table before removing the suprapubic trocar. This new coagulating intermittent cutting (CIC) device uses a constant voltage pulse current with controlled pulse intervals to help reduce bleeding.
Resection of the anterior prostate opposite the bladder neck can be impaired when deflection of the resectoscope is restricted by the edge of the cystoscopy table. Aside from chilling and shivering, bodily cooling produces a number of cardiovascular changes such as bradycardia, reduced cardiac output, higher mean arterial pressure, increased cardiac stress, and greater vascular resistance.
Other factors that may increase the risk of hypothermia include longer resection times, larger amounts of irrigating fluid absorbed, increased prostate size, small body habitus, and low body weight. No significant increase in blood loss has been found with the use of irrigating fluid warmed to body temperature. A high-flow, low-pressure fluid warmer specifically designed for TURP irrigation is commercially available from Smiths Medical. Unlike other surgeries, TURP relies more heavily on normal coagulation to help control postoperative bleeding. This study suggests that low molecular weight heparin substitution may be a reasonable alternative to oral anticoagulant discontinuation for selected patients.
The timing is highly variable and depends on many factors, such as the original reason for anticoagulation, the patienta€™s overall clinical situation, the size and difficulty of the transurethral surgery, and the degree and length of postoperative bleeding, among others. The majority of studies have demonstrated a benefit, and most urologists use them routinely.
Effective agents included quinolones, aminoglycoside, trimethoprim-sulfamethoxazole (TMP-SMZ), and cephalosporins. The partially devascularized and necrotic prostatic tissue tags and any remaining tissue remnants are perfect breeding grounds for bacteria; therefore, some antibacterial prophylaxis should probably be maintained for at least the first 15 days after a TURP. These findings are helpful in determining blood loss and deciding on possible transfusions postoperatively.
However, because of the substantial risk of hemorrhage during TURP, many surgeons assess coagulation status preoperatively in higher-risk patients, patients on anticoagulants, and those with larger prostate glands.
Obtaining information about bleeding time just prior to surgery is particularly useful and recommended in patients who normally take clopidogrel because PT and aPTT are not affected by this particular anticoagulant medication.
It should also be considered in patients with a history of chronic or recurrent urinary tract infections, previous urinary tract surgery, or urolithiasis.

Poor postoperative results in terms of bladder emptying can occur in patients with associated neurological abnormalities affecting the urinary bladder. They argue that patients who clearly demonstrate obstruction tend to fare better with surgery. Although it is not necessary in all patients planning to undergo TURP, many surgeons find the information useful. Although this test is not specifically required before BPH therapy, postvoid residual volume findings can be helpful for assessing a patienta€™s ability to completely empty his bladder and his response to both medical and surgical interventions. However, it is useful for helping establish the size and shape of the prostate and for checking for intravesical prostatic extension, bladder tumors, and other pathology. Transurethral resection can be performed on a prostate gland of any size or shape, depending on the skill and experience of the operating surgeon (see image below). TURP may limit the treatment options and timing for definitive prostate cancer therapy and may be unnecessary once a definitive prostate cancer treatment is initiated.
Histologically, the appearance is identical to the stromal hyperplasia observed in uterine fibroids. The cells have clear cytoplasm, and the prostatic ducts or lumens may be dilated or characterized by complexed folds.
The average size of the nodules in these small- to medium-sized prostates is 4 mm or less in diameter. The accessibility of the obstructing prostate via transurethral endoscopy affords the opportunity to remove the obstruction without open surgery. If in the middle of the case and unable to complete the entire resection in 90 minutes, at least finish one lateral lobe, the median lobe (if enlarged), and the bladder neck. Various regions of the country and specific teaching institutions use slightly different techniques to perform the procedure. In particular, check that any insulating pieces, attachments, parts, or tips are firmly secured. This helps avoid tags of tissue that interfere with vision and would have to be cut again, wasting valuable time. The smaller resectoscope set should be used if the urethra proves to be narrower than expected. This debris can then be easily rinsed out when the bladder is drained through the cystoscope.
Raising the irrigating fluid level from 60 cm to 70 cm height has been shown to dramatically affect fluid absorption. This inspection is important not only to verify the absence of associated pathologies (eg, bladder tumors, urethral strictures, vesical stones) but also to help the surgeon obtain a clear 3-dimensional mental image of the patienta€™s specific anatomical features and relationships. Their surface is often hyperemic and they bleed easily, which interferes with vision during the cystoscopy and resection. The external urinary sphincter is located just distal to the verumontanum, which is specifically used as the distal resection border and landmark to prevent any injury to the sphincter.
Despite the fact that 10-20% of the prostate may extend distally beyond the verumontanum, especially in larger prostate glands, the verumontanum remains the distal margin of resection in most circumstances.
However, the risk of inadvertent and permanent injury to the external sphincter muscle is quite high when resecting in this area, so caution is advised. The fibers of the external sphincter are embedded within the urogenital diaphragm, which is relatively fixed in position, while the prostate has some limited mobility. We use a 28F resectoscope sheath only on the largest prostates and prefer a 24-26F sheath for routine use. This commonly results in a urethral stricture at the fossa navicularis and possibly elsewhere in the urethra (see the image below). Additional urethral dilation or use of a smaller resectoscope sheath can help prevent this from occurring. The perineal urethrostomy is especially important if obtaining easy passage of the resectoscope sheath proves difficult, if patients have contractures or penile prostheses, or if the urethral length proves to be too long for the standard instruments. Performing a partial or incomplete resection in several lobes at once is discouraged because of the resultant increased bleeding and fluid absorption. This cleanly separates the resected tissue from the rest of the prostate gland and prevents tunneling, perforation, bladder injury, and extravasation. An attempt should be made to identify the ureteral orifices, but this may be impossible in some cases until the markedly enlarged median lobe has been at least partially removed. This resection cuts off much of the blood supply to the bulk of the median lobe, which comes from the penetrating periurethral prostatic branches of the inferior vesical artery at the bladder neck.
Loop without current is used to gently lift the posterior flap of the median lobe tissue now lying on the bladder surface.
Once lifted free, current can be applied to the cutting loop and the elevated median lobe tissue can be resected.
With a finger in the rectum for guidance, the loop without current can be used to lift a flap of prostatic tissue prior to cutting. Cystitis or bladder infection, blood thinning medicine, diseases of blood, prostate enlargement, strenuous exercise and kidney injury are the other causes of blood in urine.
The shock wave therapy helps in breaking down the kidney or the bladder stones that cause haematuria.
However, a surgery is recommended only for severe cases of blood in the urine and pain while urinating. Water is considered one of the best treatments for urinary tract problems which might have an individual suffering great difficulty in urinating.
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The jury is out on whether saw palmetto will pump you up, but many herbalists agree that it may benefit cases of tissue wasting, weakness, debility, weight loss, and chronic emaciating diseases. Neither the Editors of Consumer Guide (R), Publications International, Ltd., the author nor publisher take responsibility for any possible consequences from any treatment, procedure, exercise, dietary modification, action or application of medication which results from reading or following the information contained in this information. Upon download of any film Licensed Material, you will be invoiced a non-refundable access service fee of one hundred fifty dollars ($150) USD or such other local currency amount as Getty Images may apply from time to time. By age 50 most men have some non-life threatening, cancerous prostate cells, although they are asymptomatic and many never know it until they are medically screened. The medical community must confront reality and stop the inappropriate use of PSA screening. Because common over-the-counter medications like ibuprofen, benign prostate enlargement, an inevitable part of aging and infections also elevate PSA levels. This indicates that both nutrients together help protect against prostate cancer better than either nutrient alone. Paul’s valiant contributions to the health movement and global paradigm shift are world renowned. Decisions you make about your family's healthcare are important and should be made in consultation with a competent medical professional.
To this day, it remains the criterion standard therapy for obstructive prostatic hypertrophy and is both the surgical treatment of choice and the standard of care when other methods fail. The transition zone consists of two separate lobes on either side of the urethra and usually involves a small grouping of ductal tissue near the central portion of the prostatic urethra near the internal sphincter.
Thus, the term lateral lobes is often used intraoperatively for this tissue to distinguish it from any hyperplastic periurethral gland tissue. Any significant intravesical extension of prostatic tissue can act as a valve when the detrusor pressure increases and presses this tissue against the bladder neck or across the outlet to the urethra, creating a functional obstruction (see the image below). Prostatic calculi are generally composed of calcium phosphate and are not considered clinically significant. Proponents of this theory advocate TURP to liberalize these calcifications as a treatment for recurrent prostatitis. They can be rinsed into the bladder and evacuated with the rest of the resected prostatic chips. Abundant venous blood vessels are located in the area just anterior to the prostatic capsule, which can cause significant bleeding that cannot be easily controlled if the vessels are damaged during resection. It appears as a small, rounded hump that is best seen when withdrawing the telescope through the prostate while visualizing the prostatic floor at the 6-oa€™clock position.
The precise distance between the verumontanum and the external sphincter demonstrates some slight individual variation and should be verified visually before starting the resection and periodically during the surgery.
Upon reaching the prostatic interior near the urethra, most of these branches turn distally and parallel the prostatic urethra, while others supply the median lobe. Eventually, this can progress to the point at which the bladder becomes almost nonfunctional. Initial symptomatic changes include increased bladder instability and irritability, which can eventually progress to muscular decompensation with permanent loss of detrusor contractile ability. The detrusor becomes less able to maintain a constant voiding pressure over time, which leads to early termination of voiding, intermittency of the urinary stream, and higher residual urine volume, accompanied by loss of bladder compliance. The similarities in presentation, pathological examination findings, and symptoms of BPH among identical twins suggest a hereditary influence.
This and other data indicate that DHT is much more important in the development of prostatic hypertrophy than testosterone is. Evidence from the Medical Therapy of Prostate Symptoms Trial indicates that combination therapy with both an alpha-blocker and a 5-alpha reductase inhibitor can delay the progression of symptoms and is more effective over time than either medication alone for reducing symptom scores and improving peak urinary flow rates. Laryngeal mask anesthesia (LMA) tends to minimize many of the negative aspects of general anesthetic and is now used for many TURP cases. The problem of unintentional obturator nerve stimulation can be corrected under general anesthesia by paralyzing the patient.
In addition, the current can possibly be transmitted down the shaft of the resectoscope and affect the surgeon.
These relatively isotonic agents protect against hemolysis but cannot prevent dilutional hyponatremia because their intravascular absorption increases fluid volume without adding any sodium. The metabolism of glycine into glycolic acid and ammonia has been postulated as a contributing factor to TUR syndrome. Progressively increasing adverse effects occur as the amount of absorbed glycine increases.
Glycine toxicity has been linked to the rare fatality, but this is considered an extremely rare event. One advantage is that chips and irrigation flow away from the telescope toward the drainage tube in the bladder, which improves visualization. Madsen of Madison, Wisconsin, who extensively studied fluid absorption during TURP and routinely used temporary suprapubic trocar cystostomies for continuous flow in his TURP procedures.[13] The technique proved especially useful in larger prostates, or even in moderate-sized prostates when only a 24F sheath can be used, allowing a full-thickness cut of tissue to be made without compromising irrigant flow. At the end of the case, when the Foley catheter is in place and the irrigation fluid is clear, the suprapubic trocar is removed and the stab wound site is covered with a small compression dressing using gauze pads and an elastic adhesive bandage (eg, a large Band-Aid). Varying patient height to a comfortable level and using the Trendelenburg position appropriately should make the resection easier and more comfortable and can facilitate visualization. Hypothermia is particularly worrisome as core body temperature approaches 35A°C or less, which is sufficient to induce angina, cardiac arrhythmias, and myocardial infarctions. The prothrombin time (PT) and the activated partial thromboplastin time (aPTT) should be checked just prior to the surgical procedure. Only a bleeding time can help determine if any lingering anticoagulant effects from the clopidogrel are present.
With these issues in mind, administering a preoperative systemic antibiotic seems reasonable and prudent.
Short-course therapy was found to be more effective than single-dose regimens, regardless of the agent chosen.
The overall risk rate of blood loss following TURP sufficient to justify transfusion is approximately 2.5%. This would allow physicians to direct invasive therapy only to those patients most likely to benefit from it. This modality also allows for objectively tracking response to medical or surgical therapies for BPH. The rest is divided among gland elements, acinar lumens, and epithelial elements as determined by morphometric studies. This type of hyperplasia is theorized to respond better to medical management with alpha-blockers, which relax the tone of the muscle fibers. BPH that is primarily nodules of glandular hyperplasia is likely to be larger and more likely to respond to hormonal therapy such as finasteride and dutasteride than BPH that is primarily stromal and fibromuscular. Prostates heavier than 50 g in resected weight typically demonstrate glandular or nodular tissue constituting more than 50% of the total prostate, with the average nodule measuring 8 mm or more in diameter. It also protects the surrounding organs from injury by removing the tissue from the intraluminal surface of the prostate.
Continuing improvements in instrumentation and technique allow accomplishment of this procedure more easily for the surgeon and less dangerously for the patient. Surgeons need to know their own resecting capability and should not attempt a TURP in a prostate that is clearly too large. This often results in very good clinical outcomes and offers essentially the same symptom relief as the completed TURP.
However, a number of general principles are applicable to all variations of TURP and are outlined below.
Some continuous flow systems use a plastic insulating beak at the end of the inner sheath, which can come loose and break off in the bladder during surgery. Although they prevent hemolysis, these solutions can still cause hyponatremia, confusion, and visual disturbances if large volumes are absorbed. Without this landmark, one can easily lose orientation and risk damaging the external sphincter muscle, causing permanent incontinence.
To prevent postoperative urethral strictures, do not to use a resectoscope that is much larger than the patienta€™s urethra, fossa navicularis, or urethral meatus. While most surgeons normally perform a ventral meatotomy, Winston Mebust and others have suggested making a dorsal internal urethrotomy, arguing that large ventral meatotomies often result in a split or diverse stream with splattering and splaying.
One of the most common mistakes made in TURP surgery is the failure to use a perineal urethrostomy appropriately.
In these cases, good results have generally been reported when at least one complete lobe has been resected. Intravenous (IV) methylene blue dye can be used to help find the ureteral orifices and prevent their inadvertent resection. This portion of the median lobe resection requires relatively thin superficial cuts of tissue. However, this may be from improved digestion and absorption, rather than from any hormonal effect. The publication of this information does not constitute the practice of medicine, and this information does not replace the advice of your physician or other health care provider.
The Licensed Material may only be used in materials for personal, noncommercial use and test or sample use, including comps and layouts. If Licensed Material featuring a person is used (i) in a manner that implies endorsement, use of or a connection to a product or service by that model; or (ii) in connection with a potentially unflattering or controversial subject, you must print a statement that indicates that the person is a model and is used for illustrative purposes only. Create your slideshowBy using the code above and embedding this image, you consent to Getty Images' Terms of Use. Plastics contain endocrine (hormonal) disruptors that can lead to cancer – especially breast and prostate cancers. This is because the external sphincter muscle is imbedded within the urogenital diaphragm, which is relatively fixed in position, while the prostate has some limited mobility.
In men aged 51-70 years, the prostatic doubling time is approximately 10 years, while in men older than 70 years, the doubling time increases to more than 100 years. Studies performed on rats given intravenous (IV) and retroperitoneal glycine found toxic effects from the glycine on the liver, kidneys, and pancreas. This can be cauterized with the resectoscope before the case is completed and the trocar is removed. Platelet transfusion is the only way to correct the anticoagulant effects of clopidogrel but should be used only as a last resort when absolutely necessary. In such situations, careful consideration should be given to alternative treatments for BPH, such as medical therapy, photoselective vaporization of the prostate (PVP), intermittent catheterization, suprapubic tube placement, permanent Foley catheterization, or a urethral stent. Patients who do not demonstrate significant obstruction based on findings from these studies or those with equivocal results may only need less-invasive and less-expensive therapies.
The growth rate of the epithelium, and particularly the stroma, in BPH is much faster than the growth rate of these same tissue types in normal prostates. Hyperplastic prostate tissue that arises primarily from the periurethral zone tends to be mainly stromal and fibromuscular. Aspects of particular technical approaches (eg, those of Nesbit and Milner) will be noted where appropriate. The fluid should be warmed to body temperature to avoid chilling the patient, and adequate fluid should be available. If, during the case you are not absolutely certain of your exact location, orientation, or position relative to the verumontanum, stop resecting immediately and reorient by finding a stable landmark (eg, bladder neck or verumontanum). In some very high-risk patients, it may be reasonable to intentionally complete only the median lobe and one lateral lobe so as to reduce the total anesthesia and operating times. Meanwhile, the patient is most likely actively bleeding, absorbing additional irrigating fluid, and delaying the completion of the surgery. Surprisingly large volumes of fluid may be needed if continuous-flow instrumentation is used. Each state and each discipline has its own rules about whether practitioners are required to be professionally licensed.
If you plan to visit a practitioner, it is recommended that you choose one who is licensed by a recognized national organization and who abides by the organization's standards. It is always best to speak with your primary health care provider before starting any new therapeutic technique.

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