Basic Facts About Prostate Cancer

Prostate cancer is an unusual growth of cells in a man's prostate gland that many older men in the St. Louis area are afflicted with. The prostate rests just below the bladder. It produces a portion of the liquid for semen. In young men, the prostate is about the size of a walnut. As men age, the prostate generally grows larger.

Prostate cancer is normal in men older than 65. It normally grows slowly and can take many years to grow big enough to bring about any problems. As with other cancers, treatment for prostate cancer works best when the cancer can be found early. Often, prostate cancer which has spread responds to treatment. Older men who've prostate cancer typically die from other causes.

Experts do not know what causes prostate cancer, but they believe that your age, family history (genetics), and ethnicity determine your chances of getting it. What you eat, such as foods loaded with fats, can also play a role.

Prostate cancer normally does not lead to symptoms in its early stages. Most men do not know they've got it until it's found during a regular medical exam.

When problems are noticed, they are most often problems urinating. But these same symptoms can also be attributed to an enlarged prostate (benign prostatic hyperplasia). An enlarged prostate is common in older men who live in St. Louis, Creve Couer, Florissant, and Kirkwood, Missouri.

See your physician for a checkup if:
•   You have urinary problems, such as:
      o   Not being able to urinate at all.
      o   Having difficulty starting or halting the flow of urine.
      o   Having to urinate many times, particularly at night.
      o   Having pain or burning during the course of urination.
•   You have difficulties having an erection.
•   You have blood in your urine or semen.
•   You have deep and recurring pain in your lower back, stomach, hip, or pelvis.

The most common way to test for prostate cancer is to have a prostate-specific antigen (PSA) blood test. An increased level of PSA could mean that you've got prostate cancer. But it could also mean that you've got an enlargement or infection of the prostate.

If your PSA is high, you might need a prostate biopsy to figure out the cause. A biopsy means that your physician takes tissue samples from your prostate gland and sends them to a lab for evaluation. Your treatment depends on what sort of cancer cells you've got, how far they have spread, your age and general health, and your preferences.

You and your doctor might choose to treat your cancer with surgery, radiation, hormone therapy, or a combination. Or if you have cancer that's low-risk and has not spread (early stage), you might be able to wait and watch with active monitoring to discover what happens. Throughout active surveillance, you will have regular checkups with your doctor to see if your cancer has changed.

Choosing treatment for prostate cancer can be complicated. Speak with a medical professional like those at Metropolitan Urological Specialists to determine the treatment that is right for you.

Your age and general health will make a big difference in how treatment may affect your quality of life. Any health issues you've got before you are treated, specifically urinary, bowel, or sexual function problems, will determine how you recover.

Both surgery and radiation may cause urinary incontinence (leaking urine) or impotence (being unable to have an erection). The level of urinary incontinence and the length of time it lasts and the quality of the erections a man has following procedures will depend on whether or not the tumor has spread. These also depend upon what treatment solutions are utilized.

Nerves that help a man have an erection are right next to the prostate. Surgery to remove the cancer could damage these nerves. Many times a special type of surgery, known as nerve-sparing surgery, can preserve the nerves. But if the cancer has spread to the nerves, they may need to be taken out during surgery. These same nerves can also be damaged by the X-rays that are used in radiation therapy.

Medicines and mechanical aids may help men who're impotent as a result of treatment. Some men recover a portion or a majority of their capability to have an erection months or even years after surgery.

If you live in St. Louis, Washington, Creve Couer, Crestwood, or Chesterfield, Missouri and you believe that you may be experiencing any of the symptoms of prostate cancer, contact Metropolitan Urological Specialists today and schedule an appointment.

Bladder Incontinence and the Percutaneous Nerve Evaluation

There's a lot of important matters that you need to think about prior to having a permanent bowel implant operation. Metropolitan Urological Specialists in St. Louis, Missouri wants to furnish you with an introduction to some of the symptoms that could lead to this kind of procedure and then let you know about a very important test that your physician may advise that you take before the procedure.

What are “bothersome” bladder symptoms?

•   Leakage of large or small amount of urine
•   Urinating often
•   Urinating urgently
•   Waking up at night to urinate
•   Inability to completely empty the bladder, or may be not able to urinate at all

What are “bothersome” bowel symptoms?

•   Fecal leakage
•   Fecal smearing
•   Diarrhea
•   Constipation

How common are bladder control problems?

•   Over thirty-three million people (1 in 6 adults) suffer from urinary control issues in the United States alone.
•   These issues may affect both males and females.
•   It may affect people of all ages; it isn't just a normal part of the aging process.
How common are bowel control issues?
•   Over 18 million individuals or 8.3% of adults suffer from symptoms of bowel control.
•   Likely more prevalent than reported due to the embarrassing nature of condition.

What are the causes of “bothersome” bladder and bowel symptoms?

•   There could be multiple causes; including, injury, side effects from particular medications, neurologic diseases, infection, bearing children, pelvic pain, and others.
•   Dr. Naughton, one of Metropolitan Urological Specialists’ top doctors makes it a priority to rule out medical causes of “bothersome” bladder and bowel symptoms.  Then, based on how these symptoms affect quality-of-life of the person, she will make suggestions on treatments.

Before placement of the permanent implant, your doctor may recommend a Percutaneous Nerve Evaluation. A Percutaneous Nerve Evaluation (PNE) is a simple office test which allows you a chance to test two temporary leads (or wires) into the pelvic nerves.  Under local anesthesia in an office setting, two temporary leads are positioned on each side of the pelvic nerves.  The leads are fixed to the back and connected to an external battery the size of a beeper.  The patient will have the opportunity to test both leads over the next 3-5 days to determine if there are any changes to the bladder and/or bowel symptoms.  We look at a fifty percent improvement in symptoms a positive test, which makes the patient a prospect for implantation of the permanent device.

What to know about the Percutaneous Nerve Evaluation (PNE) Procedure

1.   Please show up thirty minutes before your scheduled appointment time.
2.   You might drive yourself to the procedure; however, it is considerably better to have somebody drive you both to and from the procedure.
3.   This procedure is completed in the office under local anesthesia.
4.   Don't eat 2 hours prior to your procedure.  A light snack or meal is acceptable 2 hours before your procedure.
5.   Give up aspirin and ibupfren products (Motrin, Alleve, etc.) no less than five days before your procedure.
6.   Let our scheduler know whether you're taking blood thinners, such as Coumadin (warfarin), Xaralto, etc.
7.   No baths or showers during the test period.
8.   Abstain from heavy lifting or excessive bending during the trial.

What you should expect on the day of the PNE procedure:

1.   You will meet a medical assistant and agent(s) from Medtronic; the product company.
2.   You're going to be told to lie on your stomach.  The medical assistant will wash off your back and buttocks.
3.   Dr. Naughton will perform the procedure with the help of the Medtronic agent.
4.   The Medtronic agent and the medical assistant will secure the leads to your back, wipe off the cleaning solution on your back and buttocks before you get dressed.
5.   Following the process, you will talk with the Medtronic representative to review voiding and bowel diary instructions and set up contact plans with the representative to go over changes in your urinary and bowel function during the trial period.
6.   You will make an appointment to see Dr. Naughton in 3 to 5 days in the office before you leave to remove the leads and talk about the results of your trial.

If you have any questions before the procedure, call the procedure scheduler at the offices of Metropolitan Urological Specialists at 314-315-9933 during regular business hours. If you have questions about this procedure or anything else associated with bladder problems, schedule an appointment with one of our offices in the St. Louis area, including Washington, Florissant, and Creve Couer, Missouri.

More Info On Impotency (Erectile Dysfunction)

Impotence is the lack of ability to have and maintain an erection adequate for sexual activity. As a result of the unfavorable associations and misunderstandings surrounding the term impotence, the issue is usually referred to as erectile dysfunction, or just ED.

According to many specialists, erectile dysfunction is the most common sexual problem among American men. Nearly all males suffer from occasional short episodes of ED due to routine or short-term causes such as tiredness, emotional stress, or illness. For some erectile problems become chronic. While ED might be associated with decreased sexual interest, typically it isn't connected to libido (the emotional or psychic element of sexual interest), nor does it impact the capacity to experience an orgasm.

Male impotence can take place at any age, but it’s more common as men grow older. An estimated five percent of American men are impotent at age forty; among those over age sixty-five, the percentage rises to 15 to 25 percent. However, the issue is not an inevitable result of aging. The causes are complex, combining physical and psychological factors. While the the vast majority of men with erectile dysfunction can be helped, many experts feel that as many as 90 percent don't look for medical help due to fear of embarrassment and a belief that nothing can be done medically. This is unfortunate, because once underlying medical conditions and psychological factors are addressed, the regularity and duration of erections usually improves. Most males with erection problems don’t need to settle for them.

Signs and Symptoms of Male Impotence

• Chronic difficulty getting and sustaining an erection for a period of time long enough to take part in sexual intercourse
• Fewer nighttime erections

What Can Cause Erectile Dysfunction?

In the past, over 90 percent of all cases of ED were associated with emotional factors. However, experts currently calculate that only about ten percent of cases are strictly psychological in origin.
An erection depends upon many physical factors, such as the blood flow and nerve tissue within the penis, as well as hormones. Circulatory problems, nerve disorders, cardiovascular disease, diabetes, and the negative side effects of specific medications (tranquilizers, blood pressure medications, antidepressants, and anti-inflammatory medications) can contribute to impotence. Smoking, unnecessary use of alcohol, and lower levels of the hormone testosterone may also come into play. Impotence may also be caused by prostate surgery or radiation treatment for cancer.

Psychological factors, such as stress, depression, and performance anxiety, believed to play a limited role in cases of erectile dysfunction. When such factors are involved, it's mainly in males under age forty. However even in older men, emotions and sexual history could complicate physical factors.

What If You Do Nothing?

Frequent or chronic erectile troubles are not going to improve without some kind of intervention, particularly among men over the age of fifty. There are proven treatments for ED, but out of embarrassment or a lack of knowledge about medical solutions, a lot of men choose to do absolutely nothing about their ED, which often leads to emotional distress.

Home Remedies for Impotence Problems

If you're having erectile problems, it’s a great idea to seek a medical assessment. If you've got an underlying illness, early treatment may restore sexual potency.

Getting more informed about sexual matters, undergoing treatment for physical problems, giving up tobacco use, and reducing excessive alcohol consumption can all contribute to restoring potency. If erectile dysfunction takes place only from time to time, some of the below measures may help address—and solve—the issue.

•   Exercise regularly. Along with increasing blood circulation, regular moderate exercise—for example, walking, swimming, jogging, bicycling, or resistance training—helps raise energy levels, increases physical awareness, and stimulates sexuality. Don't forget that bicycle riding has with it a threat of seat or crossbar injuries to the perineal nerves (situated just behind the scrotum) that may lead to ED.
•   Consume a healthy balanced diet.
•   Restrict alcohol ingestion. ED among men in their late 40s and 50s is associated more regularly with excessive alcohol consumption than with any other single factor. There are numerous other health-related reasons to avoid excessive drinking, so if it appears to be dampening your sex life, scale back or avoid alcohol completely.
•   Minimize stress in your life. Stress and other emotional problems can affect the brain and thus reduce libido and the ability to achieve or maintain a suitable erection.
•   Give up smoking. Smoking has not been found to be an immediate cause for ED. Nevertheless, studies have found that when smoking is coupled with other risk factors, such as heart disease, high blood pressure, and untreated arthritis, erectile dysfunction levels are constant and very high.
•   Lose weight. Obesity is not necessarily a direct cause of erectile dysfunction, but researchers know that being obese is associated with the onset of diabetes and the buildup of fatty deposits on the interior walls of arteries, and these two problems are certainly related to erectile dysfunction.
•   Relieve your anxieties. Don't assume each sexual experience has to end with orgasm. Thinking that you need to have a climax can make you nervous, which might lead to erectile dysfunction. As an alternative, your partner and you can agree to focus on caressing and kissing instead of having an orgasm. This might alleviate performance anxiety.

Medical Treatments for Erectile Dysfunction

A number of methods have been designed to treat erectile dysfunction that's caused chiefly by physical factors. If you decide to try any, speak to your doctor from a trustworthy office like Metropolitan Urological Specialist in St. Louis, Missouri about beginning with the least invasive—the oral prescription drug Viagra (sildenafil citrate). Viagra improves the flow of blood to your penis to allow for an erection, and it is effective for the majority of men: In one study, it alleviated impotence in nearly 70 percent of males. It might not be safe for some adult males with cardiovascular disease.

For these males, there are some other treatment options for erectile dysfunction, though they're more invasive or cumbersome. One choice is a penile suppository, which is placed into the urethra 10 to 30 minutes before intercourse; a drug is dispensed that widens arteries in the penis, causing an erection which lasts 30 to 60 minutes in about two thirds of men in most cases. The drug, known as alprostadil, can also be administered by injection with an ultrathin needle into the base of the penis (which could produce infection or scarring as side effects).

A third option is a vacuum erection device (VED)—a pump that draws blood into the penis. It may seem awkward, but it has a really low failure rate and no significant side effects.

By comparison, a penile implant, consisting of a bendable rod or an inflatable cylinder connected to a little pump, has downsides that make it the very least popular option. Not only does an implant necessitate surgery, but implants may fail or become infected, and then need to be eliminated. Be sure to get a second, or even third, opinion before getting an implant.

Beyond Home Remedies: When You Should Contact Your Doctor

Contact your health care provider if you are consistently unable to achieve or maintain an erection. Also get hold of your doctor if new medications you are taking have caused a change in erectile function, or if work-related stress or other psychological factors are impacting your sexual abilities. (The side effect of numerous prescription drugs for depression, allergies, and cardiovascular disease is erectile dysfunction.) Over 200 medications currently on the market can significantly affect sexual performance. Physicians at the Center For Sexual Health in St. Louis, MO including Dr. Cathy Naughton have a lot of experience helping men with their ED issues.

What Your Doctor Will Do

The first thing your doctor should do is take a comprehensive medical and sexual history. If mild to moderate erectile dysfunction is identified, your doctor might suggest an experienced urology specialist, who can perform tests to find out if blood flow to the penis is adequate. The medical specialist might also find out whether spinal cord problems may be involved or if blood testosterone levels are low.

If your issue is basically psychological, a physician should give you advice or refer you and your partner to a therapist. (If you're waking up at night or in the morning with a full, firm erection, then the cause of the dysfunction is most likely psychological.) Sex therapy delivers a cure rate of 60 to 80 percent for erectile problems brought on by psychological causes. If counseling is needed, a referral from your physician or from a psychologist is probably the best way to find a properly certified sex therapist, however some family practitioners might have training in sexual therapy.

If the problem is associated with medicine you're taking, your doctor will discuss with you about alternative medicines that will not impact your ability to have an erection.

For impotence that can't be treated by some other means, some medical solutions are available. Be certain to try all nonsurgical choices before thinking about a penile implant. If you've got any other queries, contact Metropolitan Urological Specialists at 314-315-9911.

The Many Effects of Male Impotence

Regardless of whether the reason behind your erectile dysfunction is physiological or psychological, both the patient and his partner commonly experience a variety of intense feelings and emotions. Any of these feelings can result in a sense of hopelessness and reduced self-esteem. Men in St. Louis, Florissant, Creve Couer, and Kirkwood can go to the Center For Sexual Health, a location of Metropolitan Urological Services, to obtain answers pertaining to their impotence problems.
Naturally, feelings of sexual anxiety can reinforce any performance anxiety a man experiences and produce a vicious cycle of repeated failures and increasingly negative feelings.

Step one to surmounting these feelings is to recognize the issue and speak truthfully and freely with each other.

ED Effect on Self-confidence

Because sexual performance is generally a big part of a person's self-confidence, experiencing erectile dysfunction (ED) can be damaging not only to a man's sexual life, but to his whole sense of being. Men with erectile dysfunction can become uncertain of themselves and avoid intimate situations with their partners; this just escalates the pressure and anxiety associated with a condition that is often treatable.

Additionally, erectile dysfunction may cause men to feel inadequate in their roles. Men suffering from male impotence commonly isolate themselves from their relationships and withdraw from their partners.

The psychological results of erectile dysfunction can interfere with every aspect of a man's everyday life, from his relationship with his partner, to his communications on a social level, to his job performance. Therefore, it is crucial for a man who is experiencing ED to feel as secure as possible speaking about his condition with his companion, and with his physician, in order to discover the treatment strategy that can best help get over this condition.

Male Erectile Dysfunction Effect on Sexual Partners

Erectile dysfunction can be awkward to discuss not just with a doctor but also with a partner. It often causes men to withdraw from those people that care about them, which places a significant stress on relationships.

Partners of men with erectile dysfunction assume that starting a conversation regarding the situation will cause embarrassment and humiliation. They also may develop a sense of inadequacy, thinking the reason for male impotence is their fault and that they are not physically attractive to their partner.

In most cases, erectile dysfunction is a result of physical causes (though it could easily be worsened by psychological factors), and can often be addressed. Nevertheless, silence, embarrassment, and feelings of inadequacy and humiliation only result in additional withdrawal on the part of both partners, boosting the distance and tension within the relationship. The stress and anxiety which results can easily make a case of ED worse, resulting in a vicious cycle of failure and anxiety about failure.

Both partners and males with erectile dysfunction should try to keep in mind that erectile dysfunction is often times a treatable physical condition. The first step to treatment, however, is trust and a readiness on the part of both people to go over the situation with each other, and with a health care provider. Physicians at the Center For Sexual Health like Dr. Cathy Naughton have many years of experience helping men feel relaxed about finding the answer to their erectile dysfunction. Give them a call today and set up an appointment.

An Overview Of Erectile Dysfunction

The Center For Sexual Health, a division of Metropolitan Urological Specialists in St. Louis, MO, and Dr. Cathy Naughton, head of the Center, are pleased to provide you with some of the basic information regarding one of the most prevalent sexual problems facing men today. Erectile dysfunction (ED) is the inability of a guy to attain or maintain an erection sufficient for his sexual needs or the needs of his partner. Many men suffer from this at some point in their lives, in most cases by age 40, and aren't mentally affected by it.

A few men, nevertheless, experience persistent, complete male impotence, and others experience partial or brief erections. Frequent erectile dysfunction causes emotional and relationship problems, and often results in decreased self-esteem. Male impotence has several causes,—most of which are treatable. Impotence is not an inevitable outcome of the aging process.

Incidence of ED

The phrase "erectile dysfunction" could mean the inability to get an erection, an inconsistent ability to do this, or the ability to reach only brief erections. These various definitions make estimating the frequency of male impotence tough.

According to the National Institutes of Health (NIH), around 30 million men across the nation encounter chronic erectile dysfunction and incidence of the condition increases with age.

Chronic erectile dysfunction affects around 4 percent of men in their 50s, almost 17 percent of males in their 60s, and about 47 percent of men older than 75. Transient erectile dysfunction and inadequate erection affect up to half of men between the ages of 40 and 70.

Ailments (for example., diabetes, kidney disease, alcoholism, atherosclerosis) account for up to seventy percent of persistent ED cases and psychological factors (e.g., stress, anxiety, depression) may account for 10–20 percent of cases. Between 35 and 50 percent of males with diabetes experience ED.

If you believe you've got chronic or partial erectile dysfunction, it is vital that you contact a physician at the earliest opportunity. The Center For Sexual Health and Metropolitan Urological Services in St. Louis, Creve Couer, Florissant, and Kirkwood, Missouri would be pleased to meet with you anytime you like to help you to find a solution.

Risk Factors for Stress Incontinence

Risk factors that Metropolitan Urological Specialists in St. Louis, Missouri specialize in include childbirth, menopause, and pelvic surgery (such as a prostatectomy or hysterectomy).

Having A Baby

Pregnancy and childbirth can flatten, stretch, and weaken the pelvic floor muscles which support the bladder neck and urethra. The position of the bladder and urethra might change, bladder control nerves can be damaged, or an episiotomy (incision of the perineum and vagina) may be performed to prevent tearing during vaginal delivery. These kinds of issues will damage the pelvic floor muscle groups.

If urinary control is lost right after giving birth, the pelvic floor muscles may recover within about 6 weeks. If continency isn't restored, treatment may be required. Sometimes incontinency develops months or years after the birth. Ladies who work out the pelvic floor muscle groups (Kegel exercises) are less likely to develop incontinence.
 
Menopause

At menopause, the ovaries quit producing estrogen. Insufficient estrogen brings about thinned tissues that line the urethra, a weakened sphincter mechanism that opens up and closes the urethra, and weak bladder muscles. These factors can cause the urethral sphincter to open during physical exercise.

Pelvic surgery

Pelvic surgery can weaken and damage the pelvic floor muscles, causing the bladder neck and urethra to drop when abdominal pressure is applied (hypermobility) during the course of physical exercise.

Surgical operations which can affect the pelvic floor muscles include the following:
Abdominal resection for colorectal cancer
Total or partial hysterectomy (removal of the uterus)
Failed surgery to correct stress incontinence

Causes of Stress Incontinence

Stress incontinence is a result of the following:
Thinning of the urethral lining
Vaginal prolapse (e.g., cystocele, enterocele, rectocele, uterine prolapse, vaginal vault prolapse)
Weakened bladder and/or pelvic floor muscle groups
Damaged urethral sphincter

Sign and Symptom of Stress Incontinence

Urine leaks throughout strenuous physical activity are a symptom of stress incontinence.

If you are living in St. Louis, Washington, Creve Couer, Florissant, or Kirkwood, Missouri and think that you may have stress urinary incontinence, give a call to Metropolitan Urological Specialists at 314-315-9911.

What are Bladder Stones?

Metropolitan Urological Specialists, serving Washington, Creve Couer, Florissant, and St. Louis, MO want to offer a couple of tips on identifying and treating bladder stones. Bladder stones develop whenever substances (like calcium oxalate) in the urine concentrate and coalesce into hard, solid lumps that lodge in the bladder. Often, several stones form at once. Generally, they're pretty small and are excreted in the urine without complications, but on occasion stones become trapped in the neck of the bladder and—as residues in the urine continue to accumulate—grow large enough to cause discomfort, urinary blockage, or infections, thus necessitating surgical intervention. Bladder stones almost exclusively impact middle-aged and older men, but, for unknown reasons, are becoming progressively more rare.

What Causes Bladder Stones?

Most commonly, stones come to be problematic whenever the neck of the bladder is hindered due to prostate growth, a benign growth (adenoma) inside the prostate, or unnatural contraction or stricture of the bladder neck. Stones often arise elsewhere in the urinary tract (such as the kidneys), or perhaps in the bladder itself. Hereditary factors may be involved.

Other causes include the long-term usage of a urinary catheter, chronic urinary tract infections, or a nerve injury that impairs bladder function.

Moderate, chronic dehydration concentrates the urine, which could promote stone formation.
A diet high in oxalic acid (found in rhubarb, leafy vegetables, and coffee) may lead to stones.
Weakened area of the bladder caused by a bulging pouch within the organ (called bladder diverticulum)

Damage to the nerves that carry signals to the bladder muscles from the brain (known as neurogenic bladder)

Symptoms of Bladder Stones

• Disruption of the urine stream, lack of ability to urinate except in specific positions, frequent urge to urinate but with only small amounts of urine passed
• Blood in the urine, often only apparent within the last few drops
• Dark urine
• Pain—sometimes severe—in the pelvic region, genitals, lower abdomen, or lower back
• Low-grade fever (under 102°F)

Bladder Stones Avoidance

• Drink no less than eight glasses of water a day.
• Get prompt treatment for urinary tract infections.
• Potassium citrate can increase urine levels of citrate, which is a substance that suppresses calcium stone formation.
• Avoid meat, eggs, and animal fats, as well as processed and fried foods.
• Dietary changes and treatment for any underlying condition may be helpful.

Bladder Stones Diagnosis

• A thorough medical record and physical examination (including a rectal exam) and lower abdominal check to look for bladder distention are performed.
• Urine samples are taken and analyzed (urinalysis).
• Stones can be found with x-rays or ultrasound.
• Bladder stones diagnosis may be confirmed with x-rays, ultrasound, computerized tomography (CT) scan, cystoscopy (inspection of the inside of the bladder using a scope) and intravenous pyelogram (x-rays are taken after dye is used to highlight the urinary organs).

How to Deal with Bladder Stones

Your physician may prescribe narcotic analgesics to relieve pain and antibiotics to treat an infection.
Smaller stones can be removed with a cystoscope, a tube inserted through the urethra that allows the physician to view the stones. The scope can also be outfitted with a device that crushes the stones, after which the fragments are washed away.

Larger stones are treatable with extracorporeal shock-wave lithotripsy, which aims focused bursts of sound waves that powderize the stones.

In rare occasions, very large stones may necessitate surgical removal (suprapubic lithotomy).
The root problem (such as prostate enlargement) causing stones to be caught in the bladder must be identified and treated to avoid recurrence.

For additional information about identifying and treating bladder stones, contact Metropolitan Urological Specialists in St. Louis, Missouri.