Thank you, Dr. Lipinsaiah. Welcome, and I thank the Educational Committee of AUGS for inviting me to give this talk. So, Integrated Medicine Meets FPMRS. And these are my disclosures. And I know you guys have objectives, but essentially just I'm going to define the basics of integrated medicine relevant to our field, and then a basic understanding of some of the diets, the botanicals, herbs, minerals, and supplements that can be utilized in the patient, and then some cases and things that make you go, hmm. So greater than 30% of adults and over 12% of children actually use complementary alternative medicine. And I want to define the terms. So if it's a non-stream practice used together with conventional medicine, it's called complementary, and now that's integrative. If it's non-mainstream and it's used in the place of conventional medicine, it's contended alternative, but true alternative medicine is not really common. My definition I really like is from the Arizona Center for Integrative Medicine, which is essentially a healing-oriented medicine that takes account of the whole person, including body, mind, and spirit. And it includes all aspects of lifestyle, emphasizing therapeutic relationships, and it makes use of all appropriate therapies, including conventional and alternative. So in 2012, actually this was reported in 2015, but they looked at the 10 most complementary health approaches among adults. And of course, natural products being the most. Again, nowadays is deep breathing, yoga, and meditation, and don't forget your osteopathic manipulation. In 2012, Americans spent almost $30 billion on complementary alternative medicine. For outpatient visits, it's almost $15 billion, and natural products is almost $13 billion. And the most common things that were bought were fish oil, probiotics, and melatonin. The projection is close to $200 billion by 2025. Between 2012 and 2017, this looks at the National Health Interview Survey, and essentially adults aged 18 or over from 2012 to 2017, the use of yoga, meditation, and chiropractors during the past 12 months. And so as you see, there's a significant increase in all of these. And so we're going to see more and more of this, and definitely more and more studies and research are going to be coming out there. Now in general, I just want to talk about some of the things that potentially, because we all have a lot of time in our offices, right? And some of the little things that we can do that patients can go home with. High fructose corn syrup has been linked with cancer, increased cholesterol levels, diabetes, hypertension, heart disease, leaky gut. And so definitely avoiding some of the, actually avoiding the foods and reading the labels that have HFCS, so high fructose corn syrup in them, can potentially help some of their issues. Carrageenan is extracted from seaweed, and it's used as a filler for thickening and stabilizing foods or drinks, especially milks, some meats. The National Organic Standards Board actually voted in November of 2016 to remove that as a, it's a potent inflammatory agent and carcinogen from the National List for Use in Organics. It's linked to inflammation and cancer. And so that's one of the things to take a look at as far as reading labels. Acroline, of course, we all love our barbecue. And essentially, there's limited evidence that it's teratogenic in animals. It's not classified as carcinogenic yet, but it's coming down the pike. They're actually doing some studies. And the Cornucopia Institute, which is a nonprofit food and farm policy research group, actually further exposes the leading natural organic brands for including cheap conventional ingredients instead of creating nutritive products. And so they keep doing a lot of the tests on foods. So essentially, when they look up, and you look at the labels on the foods, you want to see USP or United States Pharmacopeia, or GMP, Good Manufacturing Practices. Now you have your endocrine or hormonal disruptors. And essentially, what happens is these disruptors, it's located in plastics, receipts, even some foods. And essentially, it can cause reproductive neurologic, developmental or immune defects. This is kind of the dirty dozen, I'm not going to belabor the point, the EWD.org actually has a nice description of each of these. But the things that I just want to point to are BPA, of course, plastics, canned foods and beverages, receipts contain bisphenol, mercury, as far as canned tuna, sushi, don't forget your leads, organic produce. And then of course, the things that we're exposed to in the hospital, triclosan, which is in Purell. So nutraceuticals or natural products, often sold as dietary supplements or teas or tinctures, essential oils include vitamins, minerals, supplements, such as probiotics or herbs or botanicals, which is essentially is made from plants. As far as that's concerned, you may be getting more or less than what you bargained for. So definitely, what you want to do is do your homework. Buy supplements with the labels with Consumer Lab or USP. Again, NSF International, because they do their homework and they actually do tests on these products. Consumer Labs actually has their own website. And they conduct rigorous third party testing before giving a seal of approval. Those patients who are extremely sensitive and have allergies, you have to be careful in the supplements as well. And price does not necessarily equal quality just because the supplement costs more, it doesn't mean it's more effective. So I'm going to go into more specifics, vitamin D. So vitamin D, of course, is for bone health, it prevents muscle weakness, it protects against fractures and falls. It can help with nonspecific musculoskeletal pain. And deficiency can be in patients who have bowel, prostate or breast cancers, even diabetes. Essentially, what I do, and because I do integrative urogan, is I do send levels to define insufficiency versus deficiency. And if you look at some of the studies out there, some of the most recent studies, vitamin D deficiency increased urinary incontinence by 170%. And they looked at incontinence in community dwelling older adults. There's another study that looked at patients post menopausal and vitamin D level deficiencies were associated with pelvic organ prolapse and stress urinary incontinence. So these are the patients that we see. And so replacing some of these vitamin D levels, especially if it's insufficient and deficient, or especially if they're in the Northeast, where we don't have a lot of sun, especially in the wintertime. And we also because of UVA lights, we use a lot of sunblock. To define insufficiency, it's between 21 to 29 nanograms per ml, and deficiency is less than 20. And so really those patients with osteoporosis, the perimenopausal, the naturally melanin rich, melanin rich people, total skin covering, obesity, gastric bypass, 10% of the US is deficient. So this is an important vitamin. There are no adverse effects with vitamin levels less than 140 nanomoles per liter, or what we measure is nanograms per ml, so less than 100. And they actually looked at levels above that and below that, and there's no increase in risk for kidney stones. There is with deficiency, mortality risk. And with replacing it, you can actually decrease that mortality risk. And there's a few studies that are listed there. And some of the foods that contain vitamin D are fortified milk, orange juice, cereal, and some of the canned fishes. Now almost 50% of the population consumes less than the recommended daily allowance of magnesium. It's associated with metabolic syndrome, asthma, hypertension, muscle spasms. And in 2011, the FDA actually issued a MedWatch warning of when patients are on long-term use of proton pump inhibitors, their magnesium levels potentially could be low. Magnesium is an intracellular supplement, metal essentially, and the red blood cell magnesium level is what you would get to actually get the level. A lot of times you just send a regular magnesium. If that's low, then we know that the RBC magnesium is low. If they have normal kidney function, they don't have any issues, any muscular dystrophies, I would start them on 300 to 600 milligrams daily. Magnesium glycinate is very easy on the GI tract. And so we have those patients with chronic pain syndromes and constipation. This may be a benefit. Omega-3 soil, the EPA to DHA, and that's ecopentatoic acid and decohexatoic acid is important. Alpha-linolenic acid is in flaxseed. It can lower triglycerides. It's actually a natural anti-inflammatory. And really you don't increase bleeding until you get above 25, but some of the literature says above 10. Really, one gram is the recommended daily allowance, but if they have issues, four grams daily can help. Turmeric is also another anti-inflammatory and antioxidant. Turmeric contains two other curcumins, the methoxycurcumin and bisdemethoxycurcumin. So essentially, and those two also have some of the nice anti-inflammatory properties. So the difference is pure curcumin versus turmeric, and the studies actually look at both. It helps in arthritis and depression, 500 milligrams to 1500 daily in divided doses, or one teaspoon contains 200 milligrams of fresh curcumin. You want to actually use black pepper or fatty foods for digestion to make it bioactive. Probiotics is another thing that's studied. It's used in irritable bowel syndrome, ulcerative colitis, urinary tract infections and vaginal infections. Elderberry is an anthocyanin, and essentially when cranberry is a pro-anthocyanin, which is the precursor to the anthocyanin, so this could potentially be helpful. And this is one area that we're getting ready to study as far as urinary tract infections and prophylaxis. Manual therapy. So of course, we know a lot about, there's a lot of literature on physical therapy, so I won't belabor that, but there's chiropractic manipulation, osteopathy, as well as reflexology as well. Don't forget your mind-body practices. A lot of studies include yoga and meditation, mindfulness, relaxation techniques such as acupuncture, breathing exercises to help with stress. Tai chi and Qigong actually has been used in lowering blood pressure, and then there's also hypnotherapy. There's movement therapies such as the Feldenkrais, which helps in muscle sclerosis. The Alexander technique, which helps with posture. Pilates helps with core, and some of the physical therapists that do pelvic floor therapy actually use some of these methods. There are some studies on rolfing that show that neurological impairments such as either carpal tunnel syndrome and the things that we see like piriformis syndrome can benefit from this realignment. Dr. Trager was also a medical doctor who created the psychophysical integration movement, and he treated his own back pain, and so this is some of the mind-body practices and movement therapies that are used. Some of the other things in integrated medicine include Ayurveda, traditional Chinese medicine, and then you have homeopathy, which essentially uses, pretty much, it's basically you use poisons at significantly dilute solutions to cure disease, and essentially I'd say to help disease go away. Naturopathy is the only kind of type of integrated medicine that is pure alternative medicine, and then for stress you have animal therapy and music therapy, stress reduction. So let's go into the cases. So you have a 30-year-old, frequent urinary tract infections for the past three years. She gets burning with urination after intercourse, which lasts until she's treated. She worries about taking so many antibiotics, and it seems like she has sex with her boyfriend when she goes home and gets another urinary tract infection. She then takes the antibiotics and gets a yeast infection, and she wants to know what she can do to prevent these infections. So I'm not going to belabor this point, but recurrence versus reinfection versus relapse. The majority is reinfection, where it's recurrence caused by different strain and microorganism after two weeks of treatment. The risk factors are previous history of urinary tract infections, congenital or acquired obstruction, diabetes, and the most common organisms, of course, is E. coli, which is up to 90%. Don't forget your Enterobacteri, Staphylophyticus, which is second. Then there's Klebsiella, Proteus, Pseudomonas. Pseudomonas is secondary to instrumentation, and then don't forget your yeast or other fungal organizations in diabetics or immunocompromised. Your standard treatment includes either prophylactic with antibiotics, patient-initiated antimicrobial treatment. Sometimes you get inappropriate choice of antibiotics, and then you have resistance. And the antibiotics aren't benign. Ciprofloxacin has been linked to acute tendonitis and ruptured tendons. You've got neuropathies and macrodantin. So probiotics would be the first thing to consider. Lactobacilli actually secretes hydrogen peroxide, which kills E. coli. The ones that studied, 2008, looked at lactobacilli rhamnosus and routeri, and essentially it's effective in the treatment of urinary tract infection. The randomized double-blinded trial in 2006 looked at postmenopausal women and pitted lactobacilli against Bactrim, or trimethoprim sulfomethoxyl. The intent to treat showed difference of 0.4 UTIs per year. I'm not sure if it's clinically significant, but I do use it in my patients and I have seen it, and we are actually getting ready to come out with a couple of abstracts. Antibiotic resistance for the Bactrim actually occurred as early as one month. And looking at these patients, 71% had clinical improvement or resolution of their symptoms. CRISPATAS is the one that was studied recently in 2012, a randomized placebo-controlled trial in premenopausal women. They received intravaginal suppositories and recurrence rate was lower than placebo. In 2006, it was one of the earlier studies that measured assays with L-CRISPATAS in premenopausal women without UTIs, and it showed it was highly adherent to the vaginal epithelial cells, blocking E. coli. So, the vagina maintained a low pH and it produces hydrogen peroxide, which of course kills the E. coli. There's two products in the U.S., but there are several more coming out. There's femdophilus, which I think is a little more expensive, and then there's women's proflora that has both rhamnosus and muteri. Vitamin C, there's a role in prevention of urinary tract infections, but high doses may cause diarrhea. If they have good kidney function, they'll be able to excrete the extra vitamin C. There was only a single blind randomized trial of pregnant women which decreased UTI rates by giving them 100 milligrams daily by half, and there's only one case study. D-mannose is another one. Simple sugar found in fruits. It's not really broken in the bloodstream, so you can give it to diabetics. It concentrates in the bladder. It binds to E. coli and blocks adherence to the uroepithelium. The TAM horsefowl protein essentially is effective against protease, and it was shown in mice in the Journal of Urology in 2010. It's produced by the renal cells, and it actually plays a role in the body's defense against UTIs. In 2014, there was a randomized controlled trial, 308 women with a history of recurrent urinary tract infection, and essentially, D-mannose versus nitrofurantone, they were essentially equivocal. It was a little bit more than equivocal, but essentially, between the D-mannose and the nitrofurantone versus nothing, it was significant. High doses cause loose stools and abdominal bloating, and prolonged high doses may be nephrotoxic. So, you just want to make sure that if you're going to give them the D-mannose, you give them to it for, say, five days to treat a urinary tract infection, and if it's prophylactics, it's once a day as opposed to four times a day. Cranberry, we all know, has some good things in the literature. Regarding prophylactic treatment for urinary tract infections, it's a proanthocyanidins, or proanthocyanins, it's the same thing, that inhibit bacterial adherence to the uroepithelium. You want to watch the products on the market, because some of them do contain sugar, and 500 milligrams daily, you can go up to 800 milligrams twice a day. Then your biofilm disruptors, which are now being studied, the fact that they're studied, the feeling is with recurrent urinary tract infections, you have the microorganisms underneath this biofilm, and then what happens is the matrix gets disrupted, and then the patient gets a urinary tract infection. There are enzymes that can disrupt the matrix. The ones that I start patients off with are Interface and loricidin, and I test out their urine as well, of course. You definitely don't want to give them a significant amount, because it can cause bloating, but other than that, it doesn't have any of the other really bad side effects. Now, the German Commission E is kind of similar to our United States Pharmacopeia in Germany, and 75% of what's in there is mostly supplements, botanicals, nutraceuticals. Uva Ursi is an approved treatment over there for urinary tract infection, and the active compound turns into hydroquinone, which then can help treat the urinary tract infection. You only want to use it for one to two weeks at a time, and less than five times annually, and it actually, as far as the trial is concerned, when combined with dandelion when combined with dandelion root, it prevented urinary tract infection versus placebo, 18 versus zero. If you use it with antibiotics, it decreases the bacterial action of the ciprofloxacin or ampicillin. It's not safe in children or pregnancy, and it is hepatotoxic when used for long periods of time. Berberine is another. It's from traditional Chinese medicine. It's another botanical in 2008, where in vitro studies, it causes inhibition of E. coli, and essentially, I'm going over all this because sometimes we get desperate, and we cannot, I mean, we use these antibiotics, and we try to treat these patients, and it's just not working, and so some of these things actually really do work. Marshmallow root is mostly used for the GI tract, but it can acidify the urine, and it coats the mucous membrane, so with those patients who may have interstitial cystitis, this can help as well. Echinacea is mostly used to decrease the interval for colds, but it is immune stimulator, and then slippery elm works similarly like marshmallow root, and there's no side effects. Case two, essentially, speaking of IC, a 26-year-old who presented with bladder pain six weeks prior, it gets better with emptying the bladder, and worse with a full bladder, has pressure and burning in the urethra, and it's associated with her bladder pain, as well as urinary frequency. She has no past medical history, denies any surgery, and is in a monogamous relationship, which is compromised. She's already seen her primary doctor, which ruled a urinary tract infection, and she has irritable bowel constipation. She denies any tobacco, alcohol, or drugs, and has a great support system, and has essentially been on all of the conventional therapies, essentially first, second, and third line for interstitial cystitis. She's had a cystoscopy bladder over distention, has tried Elmeron physical therapy, has a little bit of improvement after some dietary changes but none after the pharmacotherapy and she didn't want any surgical options. So their comorbidities include fibromyalgia, irritable bowel. It's a suggestion that there's a dysregulation centrally and so vulvodynia can be involved as well and it's associated with depression, anxiety, or panic disorder. And here's the AUA guidelines which you have less than six weeks of duration, I mean more than six weeks of duration of unpleasant sensation including pain, pressure, or discomfort. Treatment then begins quickly. So your pain catastrophic score which was developed in 95, really important because it actually asked the person taking the questionnaire on how they relate to pain and their experience. If they score above a 35, they would benefit from mindfulness and meditation and or guided imagery even therapeutic guidance or psychological guidance first before treatment because then their attitude does change towards pain and treatment. This is what it looks like. There's 10 questions. Once they do that and say if they score less than a 35, they score over and you actually refer them for psychologic guidance. Then of course diet and behavior modifications as far as first-line therapy. Meditation does help, stress management practices, pelvic floor relaxation, bladder retraining, education. Your alternative treatments include the IC diet or elimination diet where there's two ways to do the elimination diet either eliminating all the bladder irritants and then adding them back or if the patient can't do that, add them back one by one. Gluten-free, dairy-free diet has been associated with decreased symptoms for irritable bowel and so if that's associated with the symptoms of IC or if they have that, this can potentially help. They've been looking at low oxalate diets as well especially with the patient with a history of kidney stones and irritable interstitial cystitis. FODMAP is really with small intestinal bacterial overgrowth but SIBO has been associated with IC in some patients and so a low FODMAP diet could potentially help them. Then you have the general diets like the anti-inflammatory or Mediterranean diet and then vegan, vegetarian or raw. So here are your bladder irritants and just I wanted to point to nitrites which some people eat cold cuts and they really need to look at the labels because nitrites can affect the batter significantly as well as MSG. Your Mediterranean diet has been shown in a lot of studies to decrease anti-inflammatory markers. The anti-inflammatory diet is just another Mediterranean diet and just named by Dr. Weil. So reduction in C-reactive protein has been seen, triglycerides, interleukin-6, all these are inflammatory markers. It takes a good eight months for you to see some significant differences but even starting these patients on this diet at least could be an adjunctive to therapy. Cherries has been looked at. It reduces C-reactive protein in healthy men and women. Fiber also decreases interleukin-6. Flaxseed flour as well. In a four-year prospective study of 10,000 individuals for the Mediterranean diet, it was associated with a 42% reduction in the risk of depression, which in these patients with pain, depression and anxiety is present. Bladder ease, the two ingredients I'd like to point to are L-arginine which can actually turn into nitric oxide, which can relax the urethral sphincter cell. It modulates the bladder afferent neurons as well. The thing with that is those patients who have initial cystitis but have a typical urethral pain, this could potentially help and it's in a small enough dose that it's not toxic. Quercetin is a bioflavonoid. In high doses, you can lose protein function but in this particular product, it doesn't cause that. Magnesium reduces bladder spasms because it's alkalinizing. It does help with sleep and constipation and it is a treatment for migraines and migraines can be associated with patients who have interstitial cystitis. Of course, you don't want to forget your kidney function in patients to make sure their kidney function is normal. It's actually a cofactor for protein synthesis, which then makes collagen. The probiotics of course, lactobacilli, rhamnosus, ruteria and crispatus like I discussed earlier, the bifidobacteria which can help with the GI tract and then your turmeric and omega-3 fish oil are the natural anti-inflammatories and these can be all adjunctive. Aloe, we've seen the research on aloe and essentially it's a natural antimicrobial anti-inflammatory. Only a small double blind placebo controlled crossover trial showed symptomatic relief but I have a few patients that are on it and are doing well. Kava Kava really helps with stress. It's from the plant Piper Mephisticum and it's prepared from the plant's root. It can be hepatotoxic long-term but the tea is safe. Marshmallow root, which I discussed earlier is mucilaginous to mucous membranes. It's a diuretic. It can decrease absorption. It can lower sugar in diabetics. Some of the other alternative treatments include gotu kola, which is grown in areas of the Himalayas. It's an Indian herb that's been shown to help with Alzheimer's or brain issues but it stimulates the glycosaminoglycan layer. Pumpkin seed also has been shown to be beneficial. There was one study looking at a Chinese herbal tea which combined some of these and reported significant relief in approximately 60% of patients after four weeks. Then you have your mindfulness-based therapy, which I think is like placebo. Your stress reduction exercises, acupuncture, and evidence on reflexology. Mindfulness, there's guided imagery, which is the therapy that uses music, words, or images to attain that response. In 2008, there was a randomized controlled trial, just 30 women, but there was a trend towards improvement in IC symptoms with Tysodate guided imagery after eight weeks. Stress reduction does stimulate the anti-inflammatory cascade and so it's really essential to achieving patients with chronic pain. With yoga, there's limited evidence but in 2002, there was 90% of participants who took this Hatha yoga class reported a reduction in their symptoms and stress levels. There are quite a few studies supporting yoga therapy and it's extremely important for coping and functioning with this chronic pain syndrome. Acupuncture, there's a few ways to do acupuncture. There's electrical acupuncture, there's moxibustion, which uses heat, but that has been shown in some studies to decrease IC symptoms and there's improvement in 38% of patients. The visual analog score has been decreased in this particular study in 2013. And then there's one that came out just looking at 14 patients, but six to eight weeks of acupuncture applied to the bladder meridian reduced IC pain. It works by neuromodulation, which establishes the balance between yin and yang, or positive and negative. Battlefield acupuncture is auricular acupuncture actually used for pain. So, they mostly use it to decrease opioid use in patients in pain management and actually in some states like Maryland, it's covered by insurance. There's five points and what happens is their ASP or tiny needles where they would walk around after placing one needle in one of the points for 30 seconds to activate the needles. And you want to get them down to from a 10 down And you want to get them down to from a 10 down to a level of one or zero, and you don't want to go past that. Otherwise, it can actually increase pain. Reflexology maps the body to the feet or the hand or the ears. This is something that can be adjunctive. And basically, this is in general, the head is close to the toes, the chest is the next level, the bladder where we are, the GU organs are in that area. When you break the foot into fourths, so the three quarter area of the foot, and then the heel is a pelvic area. So, essentially, you want to use your thumb or index finger press for five seconds, and this would potentially help any areas that they may have pain, especially stimulating the urinary symptoms, the system. Next is low dose naltrexone. So low dose naltrexone, they use naltrexone for decreasing or stopping opioids. And it can enhance immune function. It can improve Crohn's disease. It improves in the inflammatory reaction. It reduces inflammation in the brain. It blocks opioid growth factor and its receptor. And it's used and studied in fibromyalgia, autoimmune disease, which some people think, and there's some theory behind IC and autoimmunity, rheumatoid arthritis, irritable bowel. And you start with 1.5 milligrams, it can cause insomnia. So I advise the patient to take it in the morning, you can increase to three, then 4.5, and then six. That's pretty much, they have vivid dreams. But that's pretty much the side effect profile of low dose naltrexone. And it's made in a compounding pharmacy. Don't forget cannabis. So THC is a hallucinogen, but CBD or cannabidiol or hemp is not. And they're starting to study that for interstitial cystitis, for myofascial pain syndromes. And so far, they've had success. But they need to, there's, Jefferson actually has the Lambert Center, and they're starting to conduct some trials. Small intestinal bacterial overgrowth has been seen in patients with interstitial cystitis with GI symptoms. And so those patients who come in with IC and have the bloating, even the constipation, the potential irritable bowel, and have not been tested, there could be benefit from treating SIBO and helping them with their pain. I see a cocktail of supplements that recommend for recurrent, is it UTI patients? I do. I'm going to go over my cocktail in a few minutes. I have it all lined out for you. So SIBO, you have an increase in neural bacteria. The symptoms are gas, flatulence, bloating, malabsorption. And of course, you want to look at that in patients with chronic proton pump inhibitor use, poor diet, diabetes, hydrogen or methane gas. The conventional therapies are afaximin, metronidazole. The integrative approach is herbal preparations. But after that, they need to be, if you can, actually the GI can try to get them off proton pump inhibitors and antacids. That's where marshmallow root, diglycerolized licorice could potentially help control the diet, increase gastric emptying as well. Bifidobacterium-based probiotics reduce inflammation and can be helpful. And acupuncture and behavioral therapy can help as well. For overactive bladder, the studies are out on physical therapy, of course, manual therapy. Bromelain is a protein enzyme. One case report looking at bromelain, pumpkin seeds as well. I do not recommend Spanish pie, but I put that there because patients do come in as a recommendation from the homeopathic practitioner. Acupuncture and acupressure works well and yoga. For stress urinary incontinence, there's manual therapy. There's a few studies on acupuncture. The recent one in 2017 looked at 500 women, was multi-centered. Was multi-centered and they did an hour pad test at baseline two in six weeks and the effects persisted for 24 weeks. Another study in 2014 looked at 20 women in a six-week program and it decreased episodes from 66 to 13%. There's myofascial pain and high tone. Vaginismus. Massage therapy, osteopathic medicine, cannabis, they're starting to look at yoga. And the one thing is regenerative medicine. There was one abstract in 2017 by Jarnagan et al. It's FDA approved. It's FDA regulated to use from amniotic fluid and it regulates gene expression. And so he found a 60% relief of symptoms and 30% improvement that was in six weeks, but now he's looking at two to three year data. And of course, there's some regenerative medicine like stem cells, but that would be off label. So I'm coming to my cocktail for regimen. So for recurrent urinary tract infections, of course, they need to find out what antibiotics they've been on and asked if they have ever been on a course of probiotics because with all those antibiotics, they've eradicated the normal bacteria. So first I start them on probiotics, at least five days worth to get that normalized. If they continue with recurrent urinary tract infections, I do like using lactobacilli crispatus, the rhamnosus and roteri. If they can tolerate cranberry with the proanthocyanidins, I will start them on the cranberry. If they cannot tolerate cranberry pills, 100% cranberry juice, a shot of it is beneficial. I add D-mannose, especially if they continue to have E. coli. And then I may add interphase depending if they keep coming back. Actually, if they have interstitial cystitis associated with pain and GI, then I may add bladder ease and marshmallow root. I definitely check their vitamin D levels. And it all depends on some of the extra, some of the other symptoms that they may have, such as constipation. Magnesium, glycinate, starting off with 400 milligrams, I'd increase to 600 milligrams. It can help with constipation. It can alkalinize the urine as well. Your natural anti-inflammatories like omega-3 fish oil, I'll automatically put them on if they can tolerate it. And turmeric, as long as they don't have the GI upset and heartburn, it needs to be standardized to curcumin. There's a difference between the root and the powder because there's less curcumin in turmeric root versus the extract, which has more curcumin, of course. I do check vitamin D levels and replace as needed. And then if those UTIs, it may be urinary tract infections with microbials versus interstitial cystitis, I may send them to manual therapy. If they can do yoga and mindfulness and they're open to it, I will. Actually, we have a mindfulness program at Jefferson. You have to still consider your conventional along with some of this integrative medicine. I don't have a lot of referrals for acupuncture. I'm still looking for some in the area that really work on as far as bladder is concerned, but I would love to find some because acupuncture has been well-studied. Same thing with yoga too. We are looking at cannabis. If there's any pain associated with all this, I do low-dose naltrexone and then reassess in six weeks. That's my gist. I know it's a lot of information. I was trying to go over all of the regimens to consider, especially with this difficult patients that we potentially could have. These are some of the references. With the product claims, patients come in with a whole lot of herbal remedies. Instead of looking all of them up, which sometimes I will, but there's product claims. You look at Quack Watch, of course, Snopes, Quality Assurance. You have consumerlab.com and Emerson Ecologics. I'll leave this up for you. There's the natural database.com. Of course, I guess I need to put up my email. You can email me if you have any questions. This is the general gist. If you all have any questions, I wanted to leave time because I know that sometimes you have these patients and you may have some specific patient questions or any other questions that you have about what we went over. Well, thank you, Dr. Eccles, for your presentation. We have a few minutes for questions. You can submit your questions on the question block on the left-hand side of the window. Our first question about the UTI, surprise, surprise. Do you have a cocktail of supplements that you recommend for current UTI patients? Are we talking brands or just in general? I think it's in general and maybe they can go into brands later. Okay. So I do send vitamin D levels or I check vitamin D levels on patients because that's associated with bladder disorders. I will replace it if I need to. Sometimes what happens is they're not replaced properly. And so it's usually if they're deficient, it's 50,000 units a week for at least eight to 12 weeks. I will use probiotics. And with probiotics, either if they have GI issues, I'll make sure the probiotic has bifidobacterium in it, but lactobacilli, rhamnosus, and ritori have been studied. It's crispostas as well. So there's a few preparations. Femdophilus is one of them. Women's ultraflora is another that I start them on. If they have any GI issues though, I would definitely send them for SIBO, but if not, and it's just E. coli, of course, cranberry, if they can tolerate it. And I usually use either Theracran or Allura. If they can't tolerate pills, then I would have them get 100% cranberry because a lot of the regular cranberry juice has sugar. Thank you. And the next question kind of about the cocktails as well. What is your typical starters cocktail for IC patients? So for IC, I do check, of course, vitamin D levels. I will start in the natural anti-inflammatories, fish oil, four grams. I'll do turmeric, 500 milligrams, and increase it to 500, three times a day, as long as they're able to tolerate it. I want to make sure that they take you a pepper. I'll talk to them about the elimination diet because I want to see if there's any irritants that could potentially be causing their symptoms. I then will start bladder E's, which I love L-Arginine, especially if they have urethral spasms. And then I take it from there. I mean, I'll add some conventional therapies. I do tend to assist my patients a little bit more often to see if there's any mast cells in the biopsy, but that's what I start off with. Hello? Next question is about the crisp pellets. How do you use it vaginally? I don't use it vaginally, actually. The study was vaginal, but I use it orally, and I've been finding that it does help. Vaginally, the problem is what they were using is kind of this yogurt preparation. I'm not sure how to get it, and it was in Europe. There are a couple of preparations, probiotics by mouth, and so I use it orally.

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stress reduction

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