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Guideline of Guidelines: Imaging of Localized Prostate Cancer

Guidelines Localised Prostate Cacner

 

Introduction

In the era before the widespread adoption of PSA screening for prostate cancer, most incident cases were already advanced stage. Because treatment options, such as surgery or radiation, are thought mainly to benefit patients with localised disease, prostate cancer imaging was necessary before treatment of almost all patients. However, in the PSA era >90% of incident cases are localised, making the need for routine imaging with CT, MRI, or bone scan obsolete [1]. Numerous studies show a relatively low rate of positive staging imaging in low- and intermediate-risk patients. Recognising these trends, several professional societies issued prostate cancer imaging guidelines in the mid-1990s in an effort to curb the overuse of imaging. However, despite these longstanding guidelines, a great number of patients undergo improper imaging [2]. Given how stubborn this problem has been to eradicate, there has been a renewed interest in finding ways to decrease unnecessary imaging, including a Physician Quality Reporting System (PQRS) quality measure and a highlighting of the problem in the ‘Choosing Wisely’ campaign [3-5]. In addition to the guidelines regarding the staging of incident prostate cancer, some groups have also presented guidelines on the use of imaging to follow men with advanced disease [6]. The purpose of the present article is to summarise the main points from multiple professional society guidelines on imaging in prostate cancer to help clarify when patients with prostate cancer should be imaged and with which modalities.

Prostate Cancer Key Points

Conjoint USANZ and UGSA Guidelines on the management of adult non-neurogenic overactive bladder

Guidelines

Abstract

Due to the myriad of treatment options available and the potential increase in the number of patients afflicted with overactive bladder (OAB) who will require treatment, the Female Urology Special Advisory Group (FUSAG) of the Urological Society of Australia and New Zealand (USANZ), in conjunction with the Urogynaecological Society of Australasia (UGSA), see the need to move forward and set up management guidelines for physicians who may encounter or have a special interest in the treatment of this condition. These guidelines, by utilising and recommending evidence-based data, will hopefully assist in the diagnosis, clinical assessment, and optimisation of treatment efficacy. They are divided into three sections: Diagnosis and Clinical Assessment, Conservative Management, and Surgical Management. These guidelines will also bring Australia and New Zealand in line with other regions of the world where guidelines have been established, such as the American Urological Association, European Association of Urology, International Consultation on Incontinence, and the National Institute for Health and Care Excellence guidelines of the UK.

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Article of the Week: Diagnosis and treatment of CBP and CP/CPPS – a consensus guideline

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Jon Rees discussing his paper. 

If you only have time to read one article this week, it should be this one.

Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline

Jon Rees, Mark Abrahams*, Andrew Doble† and Alison Cooper‡ for the Prostatitis Expert Reference Group (PERG) 

 

Backwell and Nailsea Medical Group, Bristol, *Department of Pain Medicine, Department of Urology, AddenbrookeHospital, Cambridge, and Evidence Team, Prostate Cancer UK, London, UK

 

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OBJECTIVES

To improve awareness and recognition of chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) among non-specialists and patients. To provide guidance to healthcare professionals treating patients with CBP and CP/CPPS, in both non-specialist and specialist settings. To promote efficient referral of care between non-specialists and specialists and the involvement of the multidisciplinary team (MDT).

PATIENTS AND METHODS

The guideline population were men with CBP or CP/CPPS (persistent or recurrent symptoms and no other urogenital pathology for ≥3 of the previous 6 months). Consensus recommendations for the guidelines were based on a search to identify literature on the diagnosis and management of CBP and CP/CPPS (published between 1999 and February 2014). A Delphi panel process was used where high-quality, published evidence was lacking.

RESULTS

CBP and CP/CPPS can present with a wide range of clinical manifestations. The four main symptom domains are urogenital pain, lower urinary tract symptoms (LUTS – voiding or storage symptoms), psychological issues and sexual dysfunction. Patients should be managed according to their individual symptom pattern. Options for first-line treatment include antibiotics, α-adrenergic antagonists (if voiding LUTS are present) and simple analgesics. Repeated use of antibiotics, such as quinolones, should be avoided if there is no obvious symptomatic benefit from infection control or cultures do not support an infectious cause. Early use of treatments targeting neuropathic pain and/or referral to specialist services should be considered for patients who do not respond to initial measures. An MDT approach (urologists, pain specialists, nurse specialists, specialist physiotherapists, general practitioners, cognitive behavioural therapists/psychologists, and sexual health specialists) is recommended. Patients should be fully informed about the possible underlying causes and treatment options, including an explanation of the chronic pain cycle.

CONCLUSION

Chronic prostatitis can present with a wide variety of signs and symptoms. Identification of individual symptom patterns and a symptom-based treatment approach are recommended. Further research is required to evaluate management options for CBP and CP/CPPS.

Read more articles of the week

Editorial: Chronic prostatitis – how to give our best without apposite vagueness

A patient with chronic prostatitis poses a significant challenge to the urologist in everyday practice. We are certain that all readers will be familiar with the effort required to manage a man with chronic prostatitis, not only in diagnostic and therapeutic interventions but also personal and psychological support. This is particularly true, when you consider that chronic prostatitis affects men of all ages and can significantly impair their quality of life and social functioning. Starting with medical considerations, the symptomatic, chronic forms of prostatitis, as defined by the USA National Institutes of Health (NIH) are chronic bacterial prostatitis (CBP; NIH category II) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS; NIH category III) [1]. These chronic conditions present with a wide range of clinical manifestations, but the four main primarily recognised symptoms are: urogenital pain, lower urinary tract symptoms (voiding or storage symptoms), alteration of the psychological status, and sexual dysfunction [2].

Prevalence rates are estimated at 2–10%, with some as high as 15–16% in Asian, European and North American samples [3]. Both CBP and CP/CPPS present with no one identified underlying cause, although infectious, genetic, anatomical, physiological, neurological, and immunological factors may be involved. For whatever reason, the underlying factor(s) of chronic prostatitis are likely to trigger tissue inflammation and immune responses which, in turn, induce bladder and pelvic pain leading to LUTS, ejaculatory pain, and pain in other regions, including the lower back and abdomen. The lack of a distinct aetiology has made making a specific diagnosis and effectively treating the disorder very arduous, presenting a serious challenge to urologists. In this respect, the difficulty for us is to do our best in trying to solve the problem, without apposite vagueness! [4]. In the obscurity of actual knowledge about the pathophysiology, diagnosis and treatment of CBP and CP/CPPS, it seems that recent insights can be favourably identified.

The consensus guideline on the diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome, published in BJUI by Rees et al. [5], indeed represents an important tool to provide guidance to urologists and healthcare professionals treating patients with CBP and CP/CPPS. Starting from a literature review of the most updated evidence-based information in the field of CBP and CP/CPPS, the consensus guideline provides new and useful recommendations in signs and symptoms evaluation, and clinical assessment and diagnosis of CBP and CP/CPPS. In this regard, reliable instruments, e.g. the NIH-Chronic Prostatitis Symptoms index (NIH-CPSI), IPSS and UPOINT (Urinary, Psychosocial, Organ-specific, Infection, Neurological/systemic, and Tenderness) scales [5], have been suggested to assess initial symptom severity, evaluate phenotypic differences, and monitor patients’ response to therapeutic intervention. In addition, psychological screening to evaluate the presence of psychological disorders, e.g. depression and anxiety, has been strongly recommended. What is most important is the detailed information about treatment approaches for each individual patient, according to history, physical examination, investigations, and stage of the disease. Specifically, levels of evidence and different recommendations are provided for α-blockers, antimicrobial therapy, phytotherapy, and pain management. This guideline also has the merit of being simple and easily understandable for non-specialists and patients in showing the most appropriate way in following a patient with CBP and CP/CPPS. We are sure that this consensus guideline represents a step forward to a more adequate approach in diagnosing and treating patients with chronic prostatitis. It can be a tool to improve awareness and recognition of these conditions, and for uniformity among different specialists involved in the field.

Read the full article
Antonella Giannantoni and Silvia Proietti*

 

Department of Surgical and Biomedical Sciences, Urolog y and Andrology Section, Ospedale S. Maria della Misericordia, University of Perugia, Perugia, and *Human itas Clinical and Research Centre, Department of Urology, Rozzano, MilanItaly

 

References

 

1 Murphy AB, Macejko A, Taylor A, Nadler RB. Chronic prostatitis: management strategies. Drugs 2009; 69: 7184

 

2 Krieger JN, Lee SW, Jeon J, Cheah PY, Liong ML, Riley DEEpidemiology of prostatitis. Int J Antimicrob Agents 2008; 31 (Suppl. 1): S8590

 

3 Habermacher GM, Chason JT, Schaeffer AJ. Prostatitis/chronic pelvic pain syndrome. Annu Rev Med 2006; 57: 195206

 

4 Twain M. My Late Senatorial Secretaryship (written about 1867). In: Sketches New and Old. Hartford, CT, and Chicago, IL: The American Publishing Company, 1882. Available at: https://www.gutenberg.org/les/ 3189/old/orig3189-h/p3.htm. Accessed May 2015.

 

5 Rees J, Abrahams M, Doble A, Cooper A. Prostatitis Expert Reference Group (PERG). Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int 2015; 116: 50925

 

Video: CP and CPPS – a consensus guideline

Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline

Jon Rees, Mark Abrahams*, Andrew Doble† and Alison Cooper‡ for the Prostatitis Expert Reference Group (PERG) 

 

Backwell and Nailsea Medical Group, Bristol, *Department of Pain Medicine, Department of Urology, AddenbrookeHospital, Cambridge, and Evidence Team, Prostate Cancer UK, London, UK

 

Read the full article
OBJECTIVES

To improve awareness and recognition of chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) among non-specialists and patients. To provide guidance to healthcare professionals treating patients with CBP and CP/CPPS, in both non-specialist and specialist settings. To promote efficient referral of care between non-specialists and specialists and the involvement of the multidisciplinary team (MDT).

PATIENTS AND METHODS

The guideline population were men with CBP or CP/CPPS (persistent or recurrent symptoms and no other urogenital pathology for ≥3 of the previous 6 months). Consensus recommendations for the guidelines were based on a search to identify literature on the diagnosis and management of CBP and CP/CPPS (published between 1999 and February 2014). A Delphi panel process was used where high-quality, published evidence was lacking.

RESULTS

CBP and CP/CPPS can present with a wide range of clinical manifestations. The four main symptom domains are urogenital pain, lower urinary tract symptoms (LUTS – voiding or storage symptoms), psychological issues and sexual dysfunction. Patients should be managed according to their individual symptom pattern. Options for first-line treatment include antibiotics, α-adrenergic antagonists (if voiding LUTS are present) and simple analgesics. Repeated use of antibiotics, such as quinolones, should be avoided if there is no obvious symptomatic benefit from infection control or cultures do not support an infectious cause. Early use of treatments targeting neuropathic pain and/or referral to specialist services should be considered for patients who do not respond to initial measures. An MDT approach (urologists, pain specialists, nurse specialists, specialist physiotherapists, general practitioners, cognitive behavioural therapists/psychologists, and sexual health specialists) is recommended. Patients should be fully informed about the possible underlying causes and treatment options, including an explanation of the chronic pain cycle.

CONCLUSION

Chronic prostatitis can present with a wide variety of signs and symptoms. Identification of individual symptom patterns and a symptom-based treatment approach are recommended. Further research is required to evaluate management options for CBP and CP/CPPS.

Read more articles of the week

SUSPEND Trial Poll Results

SUSPEND Trial Poll Results

 

The Lancet
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All Poll Results

 

Guideline of guidelines: kidney stones

GOG-KS

Abstract

Several professional organizations have developed evidence-based guidelines for the initial evaluation, diagnostic imaging selection, symptomatic management, surgical treatment, medical therapy, and prevention of recurrence for both ureteric and renal stones. The purpose of this article is to summarize these guidelines with reference to the strength of evidence. All guidelines endorse an initial evaluation to exclude concomitant infection, imaging with a non-contrast computed tomography scan, and consideration of medical expulsive therapy or surgical intervention depending on stone size and location. Recommends for metabolic evaluation vary by guideline, but all endorse increasing fluid intake to reduce the risk of recurrence.
GOG-KS key points
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The conservative management of renal trauma: a literature review and practical clinical guideline from Australia and New Zealand

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Guideline of Guidelines Poll Results

The recently published ‘guideline of guidelines’ attempts to bring together conflicting guidance from different authorities. But overall how often do you refer to AUA, EAU or other national urological guidelines in clinical practice?

At least weekly – 23%

At least once a month – 27%

Every 2-3 months – 15%

Less than 3 monthly – 23%

Never – 12 %

 

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