Brief Answer:
The urologist will go over everything at your pre-procedure visit.

Detailed Answer:
Hello, and I hope I can help you today.

The reason that your GYN doctor referred you for cystoscopy is that you may have been having pelvic pain and/or bladder pain that is not due to infection. The urologist's job will be to make a diagnosis, and if the problem is something completely urologic, to treat you as well.

A cystoscopy is performed after sedation (normally not general anesthesia) by the urologist inserting a catheter-sized camera into your bladder for look inside. Depending on the diagnosis, biopsies may be done. They instrument is them removed from the bladder and tha procedure is done.

The doctor will talk to you before the procedure, and that would be a good time to ask him questions about what to expect after the procedure; if you will be prescribed any medication, what symptoms to expect, and when you will get your results. Some may be able to tell you right away after the procedure but, because you will be sedated, they may discuss the results with you at a follow-up visit. In addition, the anesthetist will discuss the anesthesia with you as well before the procedure.

So I hope I was able to give you a guideline for discussion with your doctor and I hope the procedure goes well and that you are able to get a diagnosis and treatment plan. If you need anything further, do not hesitate to contact me.

Best wishes,

Dr. Brown

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Brief Answer:
I would ask the urologist that question at your procedure

Detailed Answer:
The best person to ask that question to is your urologist; because the description of your bladder as "feathery" does not give a lot of information and is not a standard medical term. Bladder ultrasound is a good test to rule out stones and tumors but not very good at imaging things that are diffuse and small.

However, regarding bladder cancer, I doubt you have to worry about that as it is usually painless and presents itself as a lump in the bladder rather than a diffuse process.

So i don't think there are any life-threatening conditions you need to worry about and I hope the cystoscopy helps your GYN doctor make a good treatment plan for you.

I'm sorry about your endometriosis and adenomyosis. They really are the same condition just that endometriosis is in the pelvis and adenomyosis is in the uterus. I am sure you have endometriosis because I reviewed your medical history and I know it was diagnosed by laparoscopy. The only way to know for sure if you have adenomyosis, and the only way to cure it. is by removing the uterus.

Either way, menopause (either natural or by removal of the uterus and ovaries) will cure any hormone-dependent condition like endometriosis. It is very important if you do decide to have a hysterectomy that you have your ovaries removed as well, because if you do have endometriosis outside in your pelvis, bladder, or other organs just removal of the uterus will not be enough to control all your symptoms.

So in summary- there is no reason to be afraid of cancer or anything life-threatening in your bladder, and I hope your procedure will help make an accurate diagnosis.

Oh and regarding your grade 2 prolapse- that really has no significance unless it is causing incontinence. If you didn't even notice it, it doesn't need any treatment.

I hope this information was helpful and I am always available if you need anything else.

Sincerely, Dr. Brown

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Brief Answer:
Bladder prolapse does not cause pain with sex- it can cause incontinence

Detailed Answer:
Hello again,

I'm sorry that you've had such a difficult time with your chronic pain.

Firstly, bladder prolapse is not cause any symptoms of pain and most people do not even notice it until a GYN examines them. Bladder prolapse is just a loosening of the skin in the upper wall the vagina which makes the bladder bulge down. If the skin becomes loose enough sometimes women experience incontinence when they cough and sneeze or lift heavy objects. If you have none of those symptoms, your bladder prolapse does not need to be treated and definitely does not cause pain with intercourse. Grade 2 is actually not even noticeable except to a doctor except on a pelvic exam.

I know that you've lived with these problems for very long time, and is normal to be impatient when you are in chronic pain. However, all your doctors are trying to do is to make sure that surgical treatment (i.e. a hysterectomy) will be curative for your condition and not put your health at risk. This is why they're trying to rule out any other non-gynecologic causes for your pain. You already have a pain syndrome (fibromyalgia) so no one wants you to have surgery and not be cured of the problem. In addition, you have a history of certain psychological conditions such as depression and PTSD which can exacerbate chronic pain. Also you have nausea- which is a completely different symptom altogether and can be caused by both GI, GYN and psychological factors. So it is not easy for any one doctor to figure out the best treatment for you.

Regarding your pain with intercourse, any pelvic pain related disease like endometriosis, interstitial cystitis, diverticulitis, or other pelvic inflammatory processes can cause pain with penetration. It is not unusual when you have pelvic pain also have pain with intercourse. When you're able to get an accurate diagnosis, this will also be able to be treated as well.

Regarding the appointment with urologist, it is possible that the doctor will discuss all the things with you on the day of the procedure rather than in a separate appointment. Normally, if you are having procedure the doctor's office will contact you by phone one or two days before to give you instructions on how to proceed. Cystoscopy is not an operation, just a procedure, so there is nothing that you need to do to prepare for it other than they may ask you to not eat or drink after midnight the night before. It is similar to an endoscopy or colonoscopy if you have had either of those before. So there is a possibility that you will be taken care of with the procedure and all the instructions on the same day. You can call the urologist's office ask ask them as well.

The way I see your situation so far is that the only gynecologic pain related diagnosis you actually have been proven to have his endometriosis. Endometriosis is a chronic lifelong condition that can affect the bladder, bowel and other pelvic organs, and the treatment is hormonal rather than surgical. You may benefit from treatment with Lupron or similar drug which temporarily stops your period which decreases the inflammation from the endometriosis.

I really think your needs will be best served by seeing a specialist in chronic pelvic pain or chronic pain. There are certainly many specialists such as these in major medical centers, and working with one physician who oversees numerous organ systems and specializes in treating pain I believe will get you the best relief of all your symptoms. There many stronger medications you could be taking for pain rather than Tylenol 3, which is not a very strong pain reliever and causes nausea as a side effect. The Zofran prescription you were given may help with the nausea; I don't know if you've tried it already, but it is a medication that is commonly prescribed to patients on chemotherapy. But anyway, certainly there are many stronger pain medications that you could be prescribed. Also certain antidepressants can also help chronic pain, and these may be an option for you, but you will need to discuss those issues with your rheumatologist to see if there is a risk of interaction with your other medications.

You have a very long complicated medical history and is impossible for me, over the Internet, without reviewing all of your medical records and previous doctors diagnoses, to speculate on what is really wrong with you. It will take a series of tests and evaluations, which take time, to come up with an accurate diagnosis and treatment plan. I do believe that a specialist in this area will get you the fastest comprehensive evaluation and treatment plan.

I know this is all frustrating and you want to feel better and I am sorry it isn't easier to find a simple answer. Most university-affiliated medical centers in the US have specialists in pelvic pain. Also there are pelvic physical therapists that can work with you to help desensitize to pelvic pain. Again, these types of specialists exist near teaching hospitals. I do not know if you are in or near an urban area, but I would consider getting an opinion from a multidisciplinary pain specialist. You can google "pelvic pain specialist" for your local area and see what doctors might be good candidates to see you.

I hope that this information was helpful, and I really wish you and improvement of your symptoms. If I can be of any additional help, please do not hesitate to contact me.

Sincerely,

Dr. Brown

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Brief Answer:
You probably for the best long-term relief will be served best by surgery

Detailed Answer:
I am not familiar with vasospastic angina, though Lupron and similar classes of medications are contraindicated in atherosclerotic heart disease. You would have to discuss this with your cardiologist.

However, given the long history of problems with medications that you've had over the years, I do think that as long as the other doctors consulted do not find any other diseases outside of endometriosis/adenomyosis can be causing your symptoms, I believe that ultimately total hysterectomy (meaning removal of your uterus, tubes and both ovaries) will give you the greatest chance of permanent relief of your symptoms. It is very important that both of your ovaries be completely removed, as any hormonal activity from your ovaries will still continue to give you endometriosis symptoms. If you have menopausal symptoms afterwards, there are different medications both hormonal and nonhormonal that can be used to help treat hot flashes and other unpleasant side effects. It is also important also that you choose your surgeon wisely; as people with long-term endometriosis and previous surgery frequently have severe internal scarring that can make performance of a hysterectomy surgically difficult so you want to make sure that the person taking care of you is skilled and experienced.

I know that most narcotic pain relievers do cause nausea as a side effect, however with a pain specialist you have access to other types of medication for example narcotic patches and other non-oral formulations. In addition, as I discussed before there also is types of antidepressants that help with chronic pain that may not be as sedating and some other medications you've tried.

But it is true that these types of specialists usually concentrate around academic medical centers. Sometimes it is true that you need to travel great distance to find appropriate specialist to take care of you, but in the end that might end up enabling you to finally get the proper care that you need more quickly and comprehensively than what you have experienced previously.

Regardless, if you do see a specialist, please bring specialist copies of all your medical records from all your different doctors that they can completely be aware of the problems all your different organ systems to best come up with a treatment plan.

In any case, it may take some time, but I hope you find the proper solution for your situation and that you ultimately do get relief from this debilitating, difficult disease.

I've hope everything works out and feel free to get back to me after the cystoscopy if there is anything else that you want to go over at that time.

Sincerely, Dr. Brown

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