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Urology - Major articles

New developments in metastatic prostate cancer therapy

23 Apr 2015Paid-up subscribers

Advanced prostate cancer remains an incurable and lethal disease. Innovation continues to provide new hope for patients with advanced disease, with improved survival while maintaining quality of life. As patients live longer with increasing treatment options, education of all healthcare professionals involved in their care is crucial in ensuring holistic care for this complex disease.

Careful assessment key in managing prostatitis

23 Apr 2015

Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis. Clinical assessment includes a thorough history and examination. A digital rectal examination should be performed after a midstream urine sample has been collected for urine dipstick, microscopy and culture. The prostate should be checked for nodules.

GPs could play key role in prostate cancer survivorship programmes

24 Nov 2014Paid-up subscribers

More than 80% of men diagnosed with prostate cancer can expect to survive for at least five years. Up to 87% of men with prostate cancer may have unmet supportive care needs. Patients regularly cite psychological and sexual issues as the most significant. Poor functional outcomes after treatment such as incontinence and erectile dysfunction have a major impact on quality of life. The key elements of a survivorship programme are: education, intervention, surveillance and co-ordination of care. Interventions which may improve immediate care include: structured holistic needs assessment and care planning, treatment summaries and cancer care reviews, patient education and support events and advice about, and access to, physical activity schemes. [With external links to the evidence base]

Improving the management of urinary incontinence

20 Mar 2014Paid-up subscribers

Urinary incontinence is a common condition that is likely to be under-reported. Its frequency increases with age, parity, high BMI, and associated comorbidities. The history should include the circumstances in which the incontinence occurs, the duration and how it affects the patient’s quality of life. The initial assessment should include enquiring for symptoms of urinary tract infection and carrying out a urine dipstick test. [With external links to the current evidence base]

Prompt diagnosis key in bladder cancer

22 Jan 2014Registered users

Bladder cancer is the most frequently diagnosed cancer involving the urinary tract. Delayed diagnosis is associated with high-grade muscle invasive disease which has the potential to progress rapidly, metastasise and is often fatal. Haematuria which is typically intermittent, frank, painless and at times present throughout micturition is the classical and most common presentation of bladder cancer. However, irritative symptoms such as dysuria, urgency, urge incontinence and frequency as well as obstructive symptoms i.e. feeling of incomplete voiding, intermittent stream and straining can also be experienced. [With external links to the current evidence base]

Advances in the treatment of metastatic prostate cancer

25 Apr 2013Paid-up subscribers

Prostate cancer is the most common cancer in men in the UK. It accounts for nearly a quarter of all male cancer diagnoses and is the second most common cause of male cancer death. Most patients present with localised disease, but there are still many who present with metastatic disease. Medical castration using LHRH analogues has become the gold standard in managing both locally advanced prostate cancer, in combination with radiotherapy, and metastatic disease. Eventually most men with advanced prostate cancer become resistant to androgen deprivation therapy. This is called castrate refractory prostate cancer, and is associated with a poor prognosis. There is now hope for patients who progress after chemotherapy with the emergence of several new agents that have been shown to benefit patients. [With external links to the current evidence base]

Is there a link between BPH and prostate cancer?

25 Apr 2012Paid-up subscribers

GPs are playing an increasing role in managing both prostate cancer and benign prostatic hyperplasia (BPH). More than 70% of men over 70 years are affected by BPH, and prostate cancer is the most common cancer in men in the UK. GPs play an important part in the initial management of men presenting with lower urinary tract symptoms and in addressing concerns regarding prostate cancer and the significance of the patient’s symptoms. While there is no proven causal link between prostate cancer and BPH, associations have been found. BPH may increase the chance of an incidental prostate cancer being diagnosed through PSA testing and other investigations.  [With external links to current evidence and summaries]

Treating nocturnal enuresis in children in primary care

21 Jun 2011Paid-up subscribers

Nocturnal enuresis is a common condition that can cause much distress to sufferers and their families. It is defined as involuntary wetting while asleep at least twice a week in children over the age of five. Less frequent wetting can be described simply as bedwetting. Primary nocturnal enuresis describes those children who have always been wet. Secondary nocturnal enuresis is defined as a relapse after a child has been completely dry for at least six months. Bedwetting is a very common, and often distressing, condition which can be treated very effectively. Contrary to previous belief, many children do not grow out of it, particularly children with frequent wetting or coexisting bladder dysfunction. Treatment should be instituted in all children over the age of seven years, where desired by the child or parents. Treatment should be considered in children aged five to seven years, especially when wetting is frequent or causing severe family stresses. The NICE quick reference guide for nocturnal enuresis gives more detailed information on treating the condition. [With external links to the evidence base]

Improving lower urinary tract symptoms in BPH

19 Apr 2011Paid-up subscribers

Benign prostatic hyperplasia (BPH) is one of the most common diseases to affect older men.Histological (microscopic) BPH, which is characterised by both stromal and glandular hyperplasia, is present in more than 60% of men beyond their sixties. More than 40% of men in this age group have lower urinary tract symptoms (LUTS) and about half this group have impaired quality of life. The prevalence increases with age, and the overall number of patients affected is rising worldwide as populations age. At current intervention rates, about one-fifth of patients with symptomatic disease who present to a doctor will eventually be treated surgically, although this may be falling. The remainder will often be managed initially by watchful waiting. However, the majority of these individuals suffer gradual progression of symptoms and the bother associated with them, and increasingly require treatment either with medication or surgery. [With external links to the evidence base]

Managing patients with acute urinary retention

18 Apr 2011Paid-up subscribers

Acute urinary retention (AUR) is a common urological emergency. AUR is more than ten times more common in men than women. AUR in men tends to occur in the elderly and the risk of AUR is higher in men > 70 years. Those in this age group have a 10% risk of developing AUR over a five-year period. The incidence of AUR is low in the general male population of 45 years or older.  However, in almost 50% of AUR patients with benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS), AUR was their first symptom. GPs can play a major role in identifying patients who need assessment for BPH/LUTS and starting early treatment with pharmacotherapy. Health education should address the importance of compliance with medication and patients should be followed up to reduce the risk of AUR and surgical intervention. Urological intervention may only be required in cases where specialised assessment or treatment is needed and in patients where catheter insertion has failed during an episode of AUR.

Nice Evidence

Acute urinary retention

https://www.evidence.nhs.uk/search?q=Urinary+retention

PubMed

Acute urinary retention

http://www.ncbi.nlm.nih.gov/pubmed/?term=acute+urinary+retention

Urinary incontinence in women: diagnosis and management

21 Mar 2010Registered users

Urinary incontinence can affect women of all ages. Incontinence may seriously influence the physical, psychological and social wellbeing of affected individuals, and the impact on the families and carers may also be profound. There are more than 3.5 million sufferers in the UK. [With external links to the current evidence base]

Advances in the diagnosis and treatment of prostate cancer

15 Feb 2010Paid-up subscribers

GPs are increasingly becoming involved in the care of patients with prostate cancer. Prostate cancer is currently diagnosed in more than 34,000 men every year. It claims more than 10,000 lives per annum in the UK, and many more than that internationally. Men dying from advanced disease often suffer intractable bone pain and debilitating lower urinary tract symptoms which have a considerable impact on their quality of life. In the absence of a breakthrough [ time of writing 2010] in the treatment of metastatic disease, earlier diagnosis and more effective eradication of clinically significant disease currently seem to afford the best opportunity of stemming the tide.  [With external links to current evidence and summaries]

Diagnosing urological disorders in ageing men

14 Feb 2010Registered users

Urology practice includes large numbers of ageing men presenting with urinary symptoms, haematuria, urogenital cancer and sexual dysfunction. As with women, hormonal changes in men may be associated with significant health-related problems. Often symptoms are misleading in older patients and may be related to different pathology. [ With external links to the evidence base]

 

Editorials

Androgen deprivation therapy and cardiovascular risk

24 Sep 2015Registered users

An awareness of CVD risk allows GPs to look proactively at modifiable risk factors in these men, to encourage smoking cessation, weight loss and increased exercise – all of which have been independently associated with improved prostate cancer outcomes in their own right – and to consider medical treatment for risk factors such as dyslipidaemia.

Medical therapy ineffective for aiding passage of ureteric stones

22 Jun 2015Registered users

The findings from this large, well designed randomised controlled trial which showed no benefit for medical expulsive therapy in expectant management, together with the fact that both alpha-blockers and calcium channel blockers have a significant side-effect profile, make a case for changing clinical practice.

DRE has vital role in early detection of prostate cancer

22 Jan 2015Registered users

Digital rectal examination is important, not just for reducing concern in men with urinary symptoms, large prostates and borderline PSA levels, but also because it is recognised that a significant number of men have clinically significant prostate cancer despite a normal PSA. [With external links to the evidence base]

Obesity, metformin and prostate cancer risk

15 Dec 2014Registered users

A total of 104 global studies were reviewed, examining nearly 10 million (9,855,000) men and 191,000 cases of prostate cancer. The analysis concluded that being overweight or obese significantly increases the risk of advanced prostate cancer. The link between obesity and advanced prostate cancer is important for primary care. In order to maximise the benefit from PSA testing of asymptomatic men, we should be trying to target higher-risk men and should now think of adding obesity to that list. [With external links to the evidence base]

Urgency urinary incontinence the most bothersome LUTS

25 Jul 2014Registered users

This study, from Finland, compared the impact of different lower urinary tract symptoms (LUTS). A total of 3,727 individuals took part, just over half were women. On an individual level, urgency urinary incontinence was the most likely symptom to be rated as bothersome by both men and women, with 30.7% reporting at least moderate bother. It is not the presence of symptoms but the bother they cause the patient that is vital to understand when assessing and managing LUTS. Storage symptoms, particularly urgency and urgency urinary incontinence, are the most likely to cause significant impairment of quality of life. [With external links to the current evidence base]

Weighing up the risks and benefits of androgen deprivation therapy

22 May 2014Registered users

The cardiovascular risks of androgen deprivation therapy (ADT) mean that a definite decision should be made regarding risk versus benefit for all men receiving this treatment. For men with high-risk prostate cancer, however, the oncological benefits of ADT are likely to outweigh the cardiovascular risks. Men receiving ADT should be 'medically optimised' in terms of cardiovascular risk and advice from their GP on exercise and diet is essential. [With external links to the current evidence base]

The prostatic urethral lift: a new treatment for LUTS

22 Jan 2014Registered users

The search continues for treatments for lower urinary tract symptoms (LUTS) to match the long-term effectiveness of surgical intervention but without the peri- and post-operative complications associated with these procedures. The first multicentre, blinded, randomised controlled study of the prostatic urethral lift has shown promising results.  [With external links to the current evidence base]

Are 5-ARIs suitable for prevention of prostate cancer?

23 Oct 2013Registered users

As with the original Prostate Cancer Prevention Trial, the use of a 5-ARI, in this case finasteride, was seen to reduce the incidence of prostate cancer by about a third. Although high-grade cancer was more common in the 5-ARI group, after 18 years of follow-up there was no significant difference in rates of prostate cancer specific survival or overall survival between the two groups. Prescription of finasteride or dutasteride as a chemopreventive agent against prostate cancer cannot be justified on the available evidence. [With external links to current evidence and summaries]

PSA in men in their 40s predicts risk of prostate cancer death

23 Sep 2013Registered users

For many men, three lifetime PSA tests (mid to late 40s, early 50s and at age 60 years) would be sufficient screening to identify the small number of men developing clinically significant prostate cancer, allowing resources to be concentrated on those at higher risk, a study in the BMJ concludes. The European Association of Urology recommends that all men aged 40-45 years should be offered a baseline PSA to ‘initiate a risk-adapted follow-up approach with the purpose of reducing prostate cancer mortality and the incidence of advanced and metastatic cancer’.

Do 5-ARIs have a role in preventing BPH?

21 Aug 2012Paid-up subscribers

Treating asymptomatic older men with 5-alpha reductase inhibitors may reduce their risk of developing benign prostatic hyperplasia (BPH). However, the case for prophylactic use of these drugs is still unproven. Dr Jonathan Rees, GPwSI Urology, Bristol, considers the implications of new data from the long-running Prostate Cancer Prevention Trial.

PSA at 60 may predict risk of death from prostate cancer

20 Oct 2010Paid-up subscribers

The debate on PSA screening to detect prostate cancer is ongoing. Two large studies published in 2009 gave an unclear message. The European ERSPC trial showed a significant reduction in prostate cancer mortality as a result of screening but with a significant risk of overtreatment in order to save lives (48 additional patients requiring treatment for each life saved). The American PLCO study showed no benefit from screening, but has been criticised for the large amount of PSA testing outside the study in the control arm, contaminating the results and potentially diluting any benefit.A meta-analysis incorporating these two studies and four other randomised controlled trials (a total of 387,286 men), published in the BMJ, has examined the overall evidence for PSA screening. [With external links to current evidence and summaries]

 

Clinical reviews: Urology

Fracture admissions higher in men on ADT

23 Jun 2016Paid-up subscribers

Androgen deprivation therapy (ADT) in men with prostate cancer is associated with a small but significant increase in fracture risk, a UK study has shown. Using the Hospital Episodes Statistics database for 2004-2008, the authors identified 8,902 men with prostate cancer who had been admitted to hospital with a fracture. Of these, 3,372 (37.8%) had been treated with ADT and 5,530 (62.2%) had not. There were 228,852 admissions in the background population.

What are the benefits of testosterone treatment in older men?

28 Apr 2016Paid-up subscribers

Testosterone therapy in men 65 and over with low testosterone levels produced moderate improvements in sexual function and some improvement in mood but had no effect on vitality or walking. All men enrolled were randomised to either testosterone gel or a placebo gel for one year.

Chemotherapy with hormone therapy boosts survival in advanced prostate cancer

21 Mar 2016Registered users

The addition of docetaxel at the time of hormone therapy initiation for advanced prostate cancer improved overall survival by 10 months, in a large  randomised controlled trial. The STAMPEDE study commenced in 2005, and has recruited men with metastatic, high-risk localised or node-positive prostate cancer who were newly diagnosed or had high-risk recurrence following previous local therapy. STAMPEDE utilises a multi-arm approach to test whether addition of other agents at the time of hormone therapy initiation improves overall survival.

Can NSAIDs reduce the need for antibiotics in UTI in women?

25 Jan 2016Paid-up subscribers

Although initial treatment of urinary tract infection (UTI) with ibuprofen reduced the use of antibiotics, women had a greater symptom burden and a higher risk of pyelonephritis than those treated with antibiotics from the outset, a primary care study from Germany has found.

Prostate specific alpha blockers increase risk of falls

25 Nov 2015Paid-up subscribers

The newer prostate-specific alpha blockers produce a small but significant increase in the risk of falls in older men with lower urinary tract symptoms (LUTS), a study from Canada has shown. The alpha blocker cohort consisted of 147,084 men aged 66 years and over, starting a selective alpha blocker (84% tamsulosin). An equal cohort of matched men, not taking alpha blockers was created on a 1:1 basis. The primary outcome measures were falls and fractures 90 days after initiation of therapy. Secondary outcomes were major osteoporotic fractures, hip fractures, hypotension and head trauma.

Exercise is associated with lower prostate cancer risk

21 Oct 2015Paid-up subscribers

Regular physical activity reduces the risk of prostate cancer in older men, a single-centre study from Italy has shown.

Add-on therapy for overactive bladder shows promise

22 Jun 2015Paid-up subscribers

Mirabegron in combination with solifenacin significantly reduced overactive bladder (OAB) symptoms, in a small preliminary study from Japan. This was an open label study with no placebo arm, over a relatively short time period of 16 weeks of treatment. So the results must therefore be interpreted with caution. Clearly, combination therapy represents a promising development in the medical treatment of the symptoms of overactive bladder. Formal, double blind, randomised controlled trials are shortly due to report and it will be interesting to see if these findings are replicated in a more rigorous trial setting. More importantly, the results will need to be analysed to see if improvements in symptoms are clinically significant to patients in order to justify the addition of a further long-term therapy, and a significant increase in the cost of medical treatment.

Ethnic groups differ in their attitudes to testing for suspected prostate cancer

23 Apr 2015Paid-up subscribers

Black men are less likely to choose investigation for symptoms that may herald prostate cancer, at all levels of risk, a UK study has found. A total of 555 men (286 black, 269 white), aged = 40, were approached while awaiting a GP appointment and recruited to the study from four GP surgeries in Bristol. This study emphasises ethnic differences in attitudes towards prostate cancer diagnosis, and a different approach to risk. It is important therefore to be aware of these differences when discussing investigations with Afro-Caribbean men. Better targeting of PSA testing in higher risk black men is vital if we are to lessen the disparate burden this disease has on the Afro-Caribbean population.

Ultrasound vs CT in suspected renal colic

24 Nov 2014Paid-up subscribers

Ultrasound may be a viable alternative to CT scanning as an initial investigation for suspected nephrolithiasis, the findings from a study in the United States suggest. A total of 2,759 patients aged 18-76, presenting to an emergency department with suspected renal colic were randomly assigned to either initial diagnostic ultrasound carried out by an emergency physician (908), ultrasound by a radiologist (893), or abdominal CT scan (985).

 

Current evidence - prostate cancer

UPDATED EVIDENCE
US: National Cancer Institute

PDQ® (Physician Data Query) is NCI's cancer database of  peer-reviewed, regularly updated evidence-based, referenced summaries

Prostate prevention 
Prostate screening  
Prostate treatment

UK: NICE- evidence search results
Prostate cancer   
Metastatic
Cancer survivorship
Cancer prostate survivorship

Cochrane Reviews 
Prostate cancer

PubMed

PubMed is a database of the US National Library of Medicine/National Institutes of Health

Metastatic prostate cancer 
Benign prostatic hyperplasia and prostate cancer 
BPH relation to prostate cancer 
Palliative care at home 
Causes of prostate cancer - reviews   
Early prostate cancer - reviews
Prostate cancer survivorship - reviews

National Cancer Survivorship Initiative

www.ncsi.org.uk

Macmillan Cancer Support

Survivorship

The Urology Foundation

Prostate Cancer UK

British National Formulary
Malignant disease and immunosuppression

Cancer Research UK
Prostate cancer statistics

Early diagnosis in primary care
UK Risk Assessment Tools
QCancer 
Qcancer men

UK Early diagnosis programmes
UK NCAT   
Macmillan - early diagnosis