Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + ACTIVE SURVEILLANCE (AS) FOR THE MANAGEMENT OF LOCALIZED PROSTATE CANCER Download Section PDF Listen +++ +++ 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) Download Section PDF Listen +++ +++ 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. + ++ aAlfa-blockers: alfuzosin, doxazosin, tamsulosin, and terazosin. All have equal clinical effectiveness. ++ b5-Alfa-reductase inhibitors: dutasteride and finasteride. + ERECTILE DYSFUNCTION (ED) Download Section PDF Listen +++ +++ 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: Sildenafil. Tadalafil. Vardenafil. Avoid nitrates and use α-blockers with caution when prescribing a selective PDE5 inhibitor. + ++ aProstate CA, breast CA, signs of prostatism, men who intend fertility in short term, PSA >4 ng/mL or >3 ng/mL and high-risk, or comorbidities that would be a contraindication. + HEMATURIA Download Section PDF Listen +++ +++ 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 Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 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. 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: Stage I: 86% alive at 5 y. Stage II: 68%. Stage III: 38%. Stage IV: 19%. Relapsed ovarian cancer is rarely curable, but sequential treatments and intraperitoneal chemotherapy have extended survival to 50–60 mo. + PAP SMEAR, ABNORMAL Download Section PDF Listen +++ ++ FIGURE 32-2 Abnormal Pap Smear Algorithm Graphic Jump LocationView Full Size||Download Slide (.ppt) + ++ Source: Modified from the ASCCP 2013 Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and Cancer Precursors at http://www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx. + POLYCYSTIC OVARY SYNDROME Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Population ++ –Adult women. +++ Recommendations ++ AUA 2017 ++ FIGURE 32-3 Aua Sui Algorithm 2017 Graphic Jump LocationView Full Size||Download Slide (.ppt) 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 Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 32-5 Initial Management of Urinary Incontinence in Women: Eau 2011 Graphic Jump LocationView Full Size||Download Slide (.ppt) + URINARY TRACT SYMPTOMS, LOWER Download Section PDF Listen +++ +++ 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 ++ –http://www.nice.org.uk/nicemedia/live/12984/48557/48557.pdf –http://www.uroweb.org/gls/pdf/12_Male_LUTS.pdf + ++ aAlfuzosin, doxazosin, tamsulosin, or terazosin.