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CURRENT Practice Guidelines in Primary Care 2019

Chapter 32: Genitourinary Disorders

ACTIVE SURVEILLANCE (AS) FOR THE MANAGEMENT OF LOCALIZED PROSTATE CANCER

Population

–Men with early clinically localized prostate cancer (Stages T₁ and T₂ and Gleason score less than or equal to 7).

Recommendations

CCO 2016, ASCO 2016

–For most patients with low-risk (Gleason score 6 or less) localized prostate cancer with a PSA <10, active surveillance (AS) is the recommended disease management strategy.
–Younger age, high-volume Gleason 6 cancer, patient preference, and/or African American ethnicity should be taken into account since definitive therapy may be warranted for select patients.
–For patients with limited life expectancy (<5 y) and low-risk cancer, watchful waiting may be more appropriate than active surveillance.
–Active treatment (radical prostatectomy (RP) or radiation therapy (RT)) is recommended for most patients with intermediate-risk (Gleason score 7) localized prostate cancer. For select patients with low-volume, intermediate-risk (Gleason score 3 + 4 =7) localized prostate cancer, AS may be offered.
–The AS protocol should include the following tests:
- PSA test every 3–6 mo.
- Direct rectal exam at least once a year.
- At least a 12-core confirmatory transrectal ultrasound-guided biopsy (including anterior-directed cores) within 6–12 mo and then serial biopsy every 2–5 y thereafter or more frequently if clinically warranted. Men with limited life expectancy may transition to watchful waiting and avoid further biopsies.
–For patients undergoing AS who are reclassified to a high-risk category (Gleason score now 7 or greater and/or significant increase in volume of Gleason 6 tumor consideration) should be given active therapy (RP or RT).

Comments

There are other ancillary tests that may make a difference in deciding when definitive therapy is indicated. The multiparametric MRI (mpMRI) and genomic testing of the malignant prostate cancer may reveal larger tumor size or unfavorable mutations that put the patient in a higher risk category which will need definitive therapy.
Data at 10-y follow-up from both observational and randomized trials show a very similar survival, although patients on surveillance had an increase in frequency of metastatic disease and clinical progression. (N Engl J Med. 2016;375:1415)
This approach is especially beneficial to patients older than 65 who have comorbidities and higher risk of complications. Active surveillance also significantly avoids over-treatment and therapy-related morbidity. A recent 10-y follow-up comparing monitoring, surgery, and radiation therapy treatment outcomes resulted in very similar overall survival.

Sources

–ASCO. J Clin Oncol. 2016;34:2182-2190.
–N Engl J Med. 2016;375:1415.
–N Engl J Med. 2014;370:932.
–Eur Urol. 2015;67:233.

BENIGN PROSTATIC HYPERPLASIA (BPH)

Population

–Adult men age >45 with lower urinary tract symptoms (LUTS) from prostatic enlargement.

Recommendations

AUA 2010

–Routine measurement of serum creatinine is not indicated in men with BPH.
–Do not recommend dietary supplements or phytotherapeutic agents for LUTS management.
–Patients with LUTS and no signs of bladder outlet obstruction by flow study should be treated for detrusor overactivity.
- Alter fluid intake.
- Behavioral modification.
- Anticholinergic medications.
–Options for moderate-to-severe LUTS from BPH (AUA symptom index score ≥8).
- Watchful waiting.
- Medical therapies.
  - Alfa-blockers.^a
  - 5-Alfa-reductase inhibitors.^b
  - Anticholinergic agents.
  - Combination therapy.
- Transurethral needle ablation.
- Transurethral microwave thermotherapy.
- Transurethral laser ablation or enucleation of the prostate.
- Transurethral incision of the prostate.
- Transurethral vaporization of the prostate.
- Transurethral resection of the prostate.
- Laser resection of the prostate.
- Photoselective vaporization of the prostate.
- Prostatectomy.
–Surgery is recommended for BPH causing renal insufficiency, recurrent urinary tract infections (UTIs), bladder stones, gross hematuria, or refractory LUTS.

Source

–http://www.guidelines.gov/content.aspx?id=25635&search=aua+2010+bph

Comments

Combination therapy with alfa-blocker and 5-alfa-reductase inhibitor is effective for moderate-to-severe LUTS with significant prostate enlargement.
Men with planned cataract surgery should have cataract surgery before initiating alfa-blockers.
5-Alfa-reductase inhibitors should not be used for men with LUTS from BPH without prostate enlargement.
Anticholinergic agents are appropriate for LUTS that are primarily irritative symptoms, and if patient does not have an elevated postvoid residual (>250 mL).
The choice of surgical method should be based on the patient’s presentation, anatomy, surgeon’s experience, and patient’s preference.

ERECTILE DYSFUNCTION (ED)

Population

–Adult men.

Recommendations

EAU 2009, An Endocrine Society Clinical Practice Guideline 2018

–Recommends a medical and psychosexual history on all patients.
–Recommends a focused physical examination to assess CV status, neurologic status, prostate disease, penile abnormalities, and signs of hypogonadism.
–Recommends checking a fasting glucose, lipid profile, and morning fasting total testosterone levels.
–Recommends psychosexual therapy for psychogenic ED.
–Recommends testosterone therapy for androgen deficiency if no contraindications are present.^a
–Selective phosphodiesterase 5 (PDE5) inhibitors are first-line therapy for idiopathic ED.

Sources

–J Clin Endocrinol Metab. 2018,103(5):1-30.
–http://www.uroweb.org/gls/EU/2010%20Male%20Sex%20Dysfunction.pdf

Comments

Selective PDE5 inhibitors:
1. Sildenafil.
2. Tadalafil.
3. Vardenafil.
Avoid nitrates and use α-blockers with caution when prescribing a selective PDE5 inhibitor.

HEMATURIA

Population

–Adults with microscopic hematuria.

Recommendations

AUA 2012

–Workup and management of microscopic hematuria.

FIGURE 32-1

Algorithm for the Diagnosis and Management of Incidentally Discovered Microscopic Hematuria

Perform microscopic urinalysis with dipstick testing positive for blood. If less than three red blood cells per high-power field, repeat urinalysis 3 times at 6-week intervals. If negative, no additional workup. If the positive result and the initial urinalysis has three or more red blood cells per high-power field, assess for urinary tract infection and other benign causes, example, vigorous exercise, menstruation, recent urologic procedure. Repeat urinalysis 6-week after treatment or discontinuation of contributing factor. If negative, no additional workup. If positive, proceed with renal function testing to assess for medical renal disease, example, dysmorphic red blood cells, cellular casts, and proteinuria. If negative, go to A. If positive, proceed with concurrent nephrologic referral. A. Assess for risk factors for malignancy, contraindications to radiation, contrast media allergies, and renal insufficiency. If there is low risk of malignancy or renal insufficiency, radiation sensitivity, and contrast media allergy, proceed with less optimal imaging option, example, magnetic resonance urography, renal ultrasonography, noncontrast computed tomography, magnetic resonance imaging, retrograde pyelography, and urologic referral. If there is high risk of malignancy and or good renal function, no contrast media allergy, and no contraindications to radiation, procced with computed tomography urography and urologic referral. After imaging, proceed with cystoscopy. If positive, treat. If negative, proceed with annual urinalysis for 2 years. If negative, release from care. If positive, annual repeat urinalysis positive; repeat anatomic evaluation within 3 to 5 years.

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Source

–Davis R, Jones JS, Barocas DA, et al. Diagnosis, Evaluation and Follow-up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. American Urological Association Education and Research, Inc., 2012:1-30.

INDWELLING URINARY CATHETERS OR INTERMITTENT CATHETERIZATION

Recommendation

AUA 2015

–Recommends against empiric antibiotics unless the patient has symptoms of a urinary tract infection.

Source

–http://www.choosingwisely.org/clinician-lists/american-urological-association-antimicrobials-indwelling-or-intermittent-bladder-catheterization/

INFERTILITY, MALE

Population

–Adults.

Recommendations

EAU 2012

–Assessment of male infertility includes:
- Semen analysis.
- Checking FSH, LH, and testosterone levels.
- Screening for gonorrhea and Chlamydia.
- Substance abuse screening.
–Refer patients with abnormal screens to a specialist in male infertility for potential treatments that may include clomiphene citrate, tamoxifen, human chorionic gonadotropin (hCG), dopamine agonists, or surgical treatments depending on the underlying etiology.

Source

–http://www.uroweb.org/gls/pdf/15_Male_Infertility_LR%20II.pdf

Comment

Infertility is defined as the inability of a sexually active couple not using contraception to conceive in 1 y.

OVARIAN CANCER FOLLOW-UP CARE

Population

–Women treated for ovarian cancer with complete response (Stage I–IV).

Recommendation

NCCN 2015

–Follow-up plan
- Office visits every 2–4 mo for 2 y, then 3–6 mo for 3 y, then annually after 5 y.
- Physical exam including pelvic exam and measurement of CA-125 with each visit.
- Refer for genetic risk evaluation if not previously done.
- Chest/abdominal/pelvic CT, MRI, PET-CT, or PET as clinically indicated due to symptoms or rising CA-125.

Source

–https://www/nccn.org/professionals/physician_gls/pdf/ovarian/pdf

Comment

–Clinical Points
1. All patients with ovarian cancer should be screened for BRCA 1 and 2 mutations. Ten percent of patients with Lynch syndrome will develop ovarian cancer.
2. Around 23,000 new cases of ovarian cancer are reported in the United States, with 14,000 deaths; 5-y survival is related to stage:
  1. Stage I: 86% alive at 5 y.
  2. Stage II: 68%.
  3. Stage III: 38%.
  4. Stage IV: 19%.
3. Relapsed ovarian cancer is rarely curable, but sequential treatments and intraperitoneal chemotherapy have extended survival to 50–60 mo.

PAP SMEAR, ABNORMAL

FIGURE 32-2

Abnormal Pap Smear Algorithm

If the cervical cytology is not abnormal, there are multiple pathways. In the presence of benign endometrial cells, is there postmenopausal, irregular bleeding, or risk factors for endometrial CA? If yes, perform endometrial biopsy, otherwise resume regular screening. In the presence of atypical squamous cells of undetermined significance or ASCUS, if high-risk HPV DNA test is positive, perform colposcopy, if the test is not positive, repeat co-testing at 1 year, and if the cytology and HPV are negative, repeating co-testing at 3 years. If the testing cannot be performed, repeat cytology at 1 year and proceed with colposcopy for persistent ASCUS. In the presence of Atypical squamous cells that cannot exclude high grade intraepithelial lesion or ASCUS-H, perform colposcopy. In the presence of low-grade squamous intraepithelial lesion or LSIL, if there is a high risk of HPV positive, perform colposcopy, else repeat co-testing at 1 year, and if ASCUS or HPV is positive, perform colposcopy. In the presence of high-grade squamous intraepithelial lesion or HSIL, proceed with colposcopy with endocervical curettage. In the presence of any malignant cells, refer to Ob/Gyn. In the presence of HPV high-risk DNA positive with normal cytology and woman greater than or equal to 30 years old, and if there is high risk of HPV positive, perform colposcopy, otherwise repeat co-testing at 12 months. Proceed with colposcopy for abnormal cytology or HPV test positive, and with routine screening every 3 years if both is negative. If the cervical cytology is abnormal for 21 to 24 years, there are two pathways. In the presence of HSIL, AGC, or malignant cells, treat as in greater than or equal to 25 years algorithm as above. In the presence of ASCUS or LSIL, is there a high-risk of HPV positive? If no, repeat co-testing in 3 years. If yes, repeat cytology every year. In the presence of HSIL, AGC, or malignant cells, treat as in greater than or equal to 25 years algorithm as above. In the presence of ASCUS or LSIL times 2, perform colposcopy. Note: pregnant patients should never have endocervical sampling and treatment during pregnancy is indicated only if invasive cancer is suspected.

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POLYCYSTIC OVARY SYNDROME

Population

–Adolescent and adult women.

Recommendations

Endocrine Society 2013

–Diagnosis if 2 of 3 criteria are met:
- Androgen excess.
- Ovulatory dysfunction.
- Polycystic ovaries.
–Treatment
- Hormonal contraceptives for menstrual irregularities, acne, and hirsutism.
- Exercise and diet for weight management.
- Clomiphene citrate recommended for infertility.
- Recommends against the use of metformin, inositols, or thiazolidinediones.

Source

–http://www.guideline.gov/content.aspx?id=47899

PROSTATE CANCER FOLLOW-UP CARE

Population

–Prostate cancer survivors.

Recommendations

ASCO 2015

–Surveillance for prostate cancer patient recurrence
- Measure serum PSA (prostate-specific antigen) every 4–12 mo (depending on recurrence risk) for the first 5 y then recheck annually thereafter.
- Survivors with elevated or rising PSA levels should be evaluated as soon as possible by their primary treating specialist.
- Perform an annual direct rectal examination.
- Adhere to ASCO screening and early detection guidelines for 2nd cancers (increased risk of bladder and colon cancer after pelvic radiation).
–Assessment and management of physical and psychosocial effects of PC and treatment
- Anemia related to androgen deprivation therapy (ADT).
- Bowel dysfunction and symptoms especially rectal bleeding.
- Cardiovascular and metabolic effects for men receiving ADT—follow USPSTF guidelines for evaluation and screening for cardiovascular risk factors.
- Assess for distress and depression and refer to appropriate specialist.
- Osteoporosis and fracture risk in men on ADT—do baseline DEXA (dual energy x-ray absorptiometry) scan and support with calcium, vitamin D, and bisphosphonates as indicated.
- Sexual dysfunction—phosphodiesterase type 5 inhibitors may help—refer to appropriate specialist.
- Urinary dysfunction (incontinence and leakage)—refer to urology specialist.
- Vasomotor symptoms (hot flushes) in men receiving ADT—selective serotonin or noradrenergic reuptake inhibitors or gabapentin may be helpful. Low-dose progesterone may be helpful in refractory patients.

Source

–Prostate cancer survivorship care guidelines. J Clin Oncol. 2015;33:1078-1085.

Comments

General health promotion can be helpful
- Counsel survivors to achieve and maintain a healthy weight by limiting consumption of high-caloric food and beverages.
- Counsel survivors to engage in at least 150 min/wk of physical activity.
- Improve dietary pattern with more fruits and vegetables and whole grains.
- Encourage intake of at least 600 IU of vitamin D per day as well as sources of calcium not to exceed 1200 mg/d.
- Counsel survivors to avoid or limit alcohol consumption to no more than 2 drinks/d.
- Counsel survivors to avoid tobacco products.
Rising PSA in patients with nonmetastatic PC
- A PSA ≥ 0.2 ng/mL on 2 consecutive tests is reflective of recurrent prostate cancer. These patients are treated with pelvic radiation with improvement in 10-y survival and freedom from recurrence. The earlier radiation is started after a PSA rise, the better the outcome. Patients who have had previous radiation to the prostate occasionally undergo surgery but most are treated with ADT or cryoablation (JCO. 2009;27:4300-4305). A recent trial adding ADT to radiation in this setting increased disease-free progression. (Eur Urol. 2016;69:802)
- Routine CT or bone scanning is not indicated but evaluate new symptoms even if PSA is not rising (transformation to small cell carcinoma in 5% of patients).
- In newly relapsed patients with visceral metastasis and/or more than 4 separate bone lesions, a combination of concurrent androgen deprivation and taxotere chemotherapy is associated with a 15%–20% increased survival at 5 y vs. sequential therapy. (N Engl J Med. 2015;373:737. Lancet. 2016;387:1163)

URINARY INCONTINENCE, OVERACTIVE BLADDER

Population

–Adults.

Recommendations

American Urologic Association 2014

–Rule out a urinary tract infection.
–Recommend checking a post-void residual to rule out overflow incontinence.
–First-line treatments:
- Bladder training.
- Bladder control strategies.
- Pelvic floor muscle training.
–Second-line treatments:
- Antimuscarinic meds.
–Darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium.
–Contraindicated with narrow-angle glaucoma or gastroparesis.
–Third-line treatments:
- Sacral neuromodulation.
- Peripheral tibial nerve stimulation.
- Intradetrusor botulinum toxin A.
–Recommend against indwelling urinary catheters.

Source

–http://www.guideline.gov/content.aspx?id=48226

URINARY INCONTINENCE, STRESS

Population

–Adult women.

Recommendations

AUA 2017

FIGURE 32-3

Aua Sui Algorithm 2017

There are four steps under evaluation or indications. Initial evaluation: The initial evaluation of patients desiring to undergo surgical intervention should include the following components: history, physical exam, demonstration of SUI, PVR assessment, and urinalysis. Cystoscopy: Should not be performed unless there is a concern for lower urinary tract abnormalities. Urodynamics: May be omitted when SUI is clearly demonstrated. Initial evaluation leads to additional evaluation. Additional evaluation should be performed in the following scenarios: lack of definitive diagnosis; inability to demonstrate SUI; known or suspected NLUTD; abnormal urinalysis; urgency-predominant MUI; elevated PVR; high-grade POP, if SUI not demonstrated with POP reduction; evidence of significant voiding dysfunction. Additional evaluation may be performed in the following scenarios: Concomitant OAB symptoms; failure of prior anti-incontinence surgery; and prior POP surgery. In patients who wish to undergo treatment, physicians should counsel regarding the availability of observation, pelvic floor muscle training, other non-surgical options, and surgical interventions. Physicians should counsel patients on potential complications specific to the treatment options. There are two stages under treatment. Non-Surgical: continence pessary, vaginal inserts, and pelvic floor muscle exercises. Surgical: bulking agents, midurethral sling and synthetic, autologous fascia pubovaginal sling, and burch colposuspension. If a midurethral sling surgery is selected, either the retropubic or transobturator midurethral sling may be offered. A single-incision sling may be offered to index patients if they are informed as to the immaturity of evidence regarding their efficacy and safety. Physicians must discuss the specific risks and benefits of mesh as well as alternatives to a mesh sling. There are four special cases. 1. Fixed immobile urethra: pubovaginal sling, retropubic midurethral sling, and urethral bulking agents. 2. Concomitant surgery for POP repair and SUI: Any incontinence procedure. 3. Concomitant NLUTD: Surgical treatment following appropriate evaluation and counseling. 4. Child-bearing, diabetes, obesity, geriatric: Surgical treatment following appropriate evaluation and counseling. MUI is mixed urinary incontinence; NLUTD is neurogenic lower urinary tract dysfunction; OAB is overactive bladder; POP is pelvic organ prolapse; PVR is post-void residual; SUI is stress urinary incontinence.

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Source: http://www.auanet.org/guidelines/stress-urinary-incontinence.

ACP 2014

–Recommends pelvic floor muscle training and bladder training for urinary incontinence in women.

Source

–http://www.guideline.gov/content.aspx?id=48543

FIGURE 32-4

Initial Management of Urinary Incontinence in Men: Eau 2011

History: post-micturition dribble; incontinence on physical activity usually post-prostatectomy; incontinence with mixed symptoms; urgency or frequency; with or without incontinence; and complicated incontinence such as recurrent or total incontinence and incontinence associated with pain, hematuria, recurrent infection, voiding symptoms, prostate irradiation, and radical pelvic surgery. Clinical assessment of the second, third, and fourth cases of history are as follows. General assessment. Urinary symptom assessment and symptom score, including frequency-volume chart and questionnaire. Assess quality of life and desire for treatment. Physical examination: abdominal, rectal, sacral neurological. Urinalysis plus or minus urine culture if infected, treat and reassess. Assessment of pelvic floor muscle function. Assess post-void residual, PVR, urine. Presumed diagnosis from the clinical assessment is as follows. Stress incontinence, presumed due to sphincteric incompetence. Mixed incontinence, treat most bothersome symptom first. Urge incontinence, presumed due to detrusor overactivity. Presumed diagnosis for the clinical assessment and the fifth case of history is as follows: any other abnormality detected, example, significant PVR. Management for the first case of history is urethral milking and pelvic floor muscle contraction. Management for the different diagnoses of incontinence are as follows. Discuss treatment options with the patient. Lifestyle interventions. Pelvic floor muscle training plus or minus biofeedback. Scheduled voiding or bladder training. Incontinence products. Antimuscarinics, overactive bladder plus or minus urgency incontinence, and alpha-adrenergic antagonists, if also bladder outlet obstruction. Failure of this management and the diagnosis of the fifth case of history leads to specialized management.

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FIGURE 32-5

Initial Management of Urinary Incontinence in Women: Eau 2011

History: incontinence on physical activity; incontinence with mixed symptoms; incontinence or frequency, with or without urgency incontinence; and complicated incontinence such as recurrent incontinence and incontinence associated with pain, hematuria, recurrent infection, significant voiding symptoms, pelvic irradiation, radical pelvic surgery, and suspected fistula. Clinical assessment of the first three cases of history are as follows. General assessment. Urinary symptom assessment, including frequency volume chart and questionnaire. Assess quality of life and desire for treatment. Physical examination: abdominal, pelvic and perineal. Cough test to demonstrate stress incontinence if appropriate. Urinalysis plus or minus urine culture if infected, treat and reassess if appropriate. Assess oestrogen status and treat as appropriate. Assess voluntary pelvic floor muscle contraction. Assess post-void residual urine. Presumed diagnosis from the assessment is as follows. Stress incontinence, presumed due to sphincteric incompetence. Mixed incontinence, treat most bothersome symptom first. Overactive bladder, OAB, with or without urgency incontinence, presumed due to detrusor overactivity. The diagnosis for the fourth case of history is as follows. If other abnormality found, example, significant post void residual, significant pelvic organ prolapse, and pelvic mass. The management for the diagnosis from the clinical assessment is as follows. Lifestyle interventions. Pelvic floor muscle training for SUI or OAB. Bladder retraining for OAB. Duloxetine, subject to local regulatory approval, SUI or antimuscarinic, OAB plus or minus urgency incontinence. This leads to other adjuncts, such as electrical stimulation and vaginal devices, urethral inserts. Failure of management and the diagnosis of the fourth case of history leads to specialized management.

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URINARY TRACT SYMPTOMS, LOWER

Population

–Adult men.

Recommendations

NICE 2010, EAU 2011

–All men with LUTS should have a thorough history and exam, including a prostate examination, and a review of current medications.
–Recommends supervised bladder training exercises and consider anticholinergic medications for symptoms suggestive of an overactive bladder.
–Recommends an α-blocker for men with moderate-to-severe LUTS.^a
–Consider a 5-α-reductase inhibitor for men with LUTS and prostate size larger than 30 g.
–For men with refractory obstructive urinary symptoms despite medical therapy, offer 1 of 3 surgeries: transurethral resection, transurethral vaporization, or laser enucleation of the prostate.

Sources

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