Community UrologyPlenary Education Meeting

December 2011

Christof Kastner Consultant Urologist Addenbrooke’s Hospital

Mark Brookes GP Nuffield Road Surgery, Cambridge

Co-chairsUrology Community Partnership, Cambs

Aaron Horner Coordinator

Urology 2010: Designed around the Patient

Outpatient Innovation

Community Urology

One-StopSpecialist

Clinics Follow-up Clinics

PSAFollow-up

Continence

Male LUTS

ProtecT (UK)

Results expected 2018

ERSPC (Europe)

screening reduces CaP death by 20%

BUT: screen 1400 + treat 48 to prevent 1 death

PLCO (US)

no difference in death rate

Screening forProstate Cancer

Assessment(prioritise the order according to presentation)

EXCLUDE INIDCATORS FOR CANCER:ABNORMAL PSA OR RECTAL EXAMINATION

HAEMATURIA

History of presentation including IPSS / QoL Voiding diary

Medical history identify other medical conditions which can cause symptomsMedication including herbal and over-the-counter medicines Physical examination in specific abdomen, external genitalia and digital rectal examination

Blood Creatinine (definitely if there is clinical indication of obstructive renal failure)

PSA - Give information, advice and time before offering - Consider age / life expectancy / UTI - PSA patient information leaflet Urine Dipstick +/- MSU

Christof Kastner - Consultant Urologist -

Screening forProstate Cancer

Male patients presenting with

Haematuria, LUTS and UTIs

PSA FU

Follow-up groups

•Secondary Care

•Primary Care under LES

•Normal biopsy BUT risk above normal population

•Low risk Dx, controlled 3 years after radical treatment

(up to seven years usually)

•Low to intermediate risk Dx, controlled palliative treatment

•Primary Care for Screening and Re-assurance

•Normal biopsy BUT risk as normal population

Discharge to Primary Care PSA Follow-up

Dear Dr xxxx

We recently reviewed your patient in clinic and agreed for future PSA follow up to take place in primary care, as described in the LES agreement. Details are as follows:

Yours sincerely

Mr x xxxx (Consultant)

Encl.: PSA Follow up information for GPs (GP copy only)Also available on: camurology.org.uk/general_practitioners/info_sheets_gp.php

Copy: (patient name & address)

Please acknowledge receipt of this letter, confirming the continuation of care at your practice to: add-tr.PSACambridge@nhs.net For advice on patients on the 'LES PSA FU’ scheme please email: add-tr.PSACambridge@nhs.net

Discharge letter

Diagnosis Grade Stage PSA / presentation

CA prostate Gleason 3+4 T2a 9.3

Treatment / Biopsy Year Benign Biopsy / PSA nadir

RALP 2007 0.01

Issues PSA / discharge

ED 0.01

Recommendation

FU interval Re-referral criteria

6-monthly (super-sens. PSA)PSA >0.02 or if symptomatic

Patient identified by consultant as appropriate for PSA follow-up in community (see criteria)

Community follow-up offered

Follow up stays in secondary careStructured discharge letter to GPGP and Patient information sheet

Patient held record

Patient entered onto RegisterRecall set up

PSALUTS (IPSS)

Weight (looking for loss)Bone pain

Confirmation to secure email

3/12 return to Urology department

Patient entered onto database

Results entered on databaseAudit

6/12

No concerns – recall

Abnormal

Meets criteria set out in structured discharge letter

New referral to discharging specialitymarked PSA f/u, seen as urgent

Advice via secure email address

– Primary Care PSA FU• Stable prostate cancer after treatment (~3y)• Selected PSA monitoring after normal diagnostics

– Detailed information about diagnosis, treatment and follow-up advice given on discharge

– Consider effects of finasteride and dutasteride and UTIs

– PSA FU advice via email • add-tr.psacambridge@nhs.net – Addenbrookes patients

– Practices to confirm receipt of referralto collect and return data on visits (next quarters data due by 15th Jan 12)

– Audit shows dangerous lack of control / insight• Specialist assurance impossible• Consideration of halting and modification of community follow-up

Key MessagesPSA Follow-Up

Continence

Causes include - UTI, weak pelvic floor muscles, prolapse, atrophy, detrusor muscle dysfunction, obstruction, incompetent sphincter, urethral diverticulum, fistula, congenital lesion, cognitive impairment

Causes include - UTI, weak pelvic floor muscles, prolapse, atrophy, detrusor muscle dysfunction, obstruction, incompetent sphincter, urethral diverticulum, fistula, congenital lesion, cognitive impairment

Fast track 2 week referral to

appropriate specialty

Fast track 2 week referral to

appropriate specialty

Suspected CAHaematuriaPalpable mass

Red flags Refer direct to secondary care

Red flags Refer direct to secondary care

Specialist Continence ServiceSpecialist Continence Service

DischargeDischarge

GP/PN/midwife notes FEMALE URINARY INCONTINENCE

NO

NO

YES

Information sources

Review Symptoms improved?

Review Symptoms improved?

1st line 2 months oxybutinin (immediate release) but be aware of risk of side effects in >65s 2nd line M/R or T/D oxybutininIf no success then try alternatives

Consider vaginal oestrogen if atrophy and OAB Cambridgeshire formulary NICE

1st line 2 months oxybutinin (immediate release) but be aware of risk of side effects in >65s 2nd line M/R or T/D oxybutininIf no success then try alternatives

Consider vaginal oestrogen if atrophy and OAB Cambridgeshire formulary NICE

Ongoing symptoms

Consider using concurrent medication on advice of community continence service

Blue: GP

Green: Community Continence Service

Orange: Secondary Care

COMMUNITY CONTINENCE SERVICE (OR ACCREDITED ALTERNATIVE PROVIDER)

refer using proforma:Word, EMIS PCS, SystmOne, Vision

Assessment, advice, supervised pelvic floor exercises 3/12 and/or 6/52 bladder training

COMMUNITY CONTINENCE SERVICE (OR ACCREDITED ALTERNATIVE PROVIDER)

refer using proforma:Word, EMIS PCS, SystmOne, Vision

Assessment, advice, supervised pelvic floor exercises 3/12 and/or 6/52 bladder training

Establish predominant symptom (stress, urge or mixed)History and exam (abdo, neurol, pelvic) including dipstix urine.

Bladder diary for 3 days.

Establish predominant symptom (stress, urge or mixed)History and exam (abdo, neurol, pelvic) including dipstix urine.

Bladder diary for 3 days.

YES

Advice for all patients: Lifestyle advice, bladder diary assessment, pelvic floor exercises &

bladder training. Patient Info: Female Bladder Health

Advice for all patients: Lifestyle advice, bladder diary assessment, pelvic floor exercises &

bladder training. Patient Info: Female Bladder Health

Review 6 weeksReview 6 weeksPersistence

Choice of provider on proformaDischargeDischargeSymptoms Improved

StressStress MixedMixed UrgeUrge

Treat predominant

symptom

Treat predominant

symptom

Review 4-8 weeksSymptoms improved?

Review 4-8 weeksSymptoms improved?

Consider stopping drugs after 3-6 months

Consider stopping drugs after 3-6 months

Please forward any feedback on this pathway to add-tr.UrologyPartnersCambs@nhs.net

• Key Messages

– Treatment flowchart available on various websites (GPConnect, CamUrology, CATCH)

– [All referrals initially to Community Continence]

– Use ‘Life style’, ‘bladder training’ and ‘PFE’ before drugs

– Collaboration between GP, Cont service and Spec– Secondary Care referral only after failed community

treatment

Continence

Underlying cause treated(constipation/UTI)

Review medication

Yes NoPASS FAIL

Offer ISC as alternative to catheter

PASS

without previous symptoms

Treatment naive

GP review LUTS assessment

All FAIL (unless Elderly / frail etc, GP to weigh up)PASS (unless see left)

TWOC

postGA retention(other secondary care)

TWOC request from secondary

care Urology

Urology Outpatients

(Refer using LUTS proforma)

Bladder scanBladder scan

Comfortable voiding?Post void residual <300ml?

Catheter removed by D/N or GPVoiding volumes x3

Catheter removed by D/N or GPVoiding volumes x3

Confirm date & time for bladder scan with CCS

Same day

Orange = UrologyBlue = GPGreen = Continence service

Pathway 2+TWOC

Pathway 2PAINFUL RETENTION

Prescribe α-blockerfor at least 2 days prior to TWOC

Follow plan given in discharge/clinic

letter

Back to initial page

Trials without catheter

• Key Messages

– All Male TWOCs require a PVR scan• Detection of otherwise unknown chronic retention• Reduction of emergency admissions for UTI and renal failure

– Book via District nurse– District nurse to liaise with Continence service– Availability within a week– PVR to be done within 24h

Trials without catheter

Lower Urinary Tract Symptoms (LUTS)

Normal

Anatomy of BPHBPH

Hypertrophied detrusor muscle

Obstructed urinary flow

Prostate

Bladder

Urethra

Adapted from Kirby RS et al. Benign Prostatic Hyperplasia.Health Press 1999

LUTSSymptom type Symptom

Voiding Weak urinary stream

Prolonged voiding

Abdominal straining

Hesitancy

Intermittency

Incomplete bladder emptying

Storage Frequency

Nocturia

Urgency / Urge incontinence

Associated symptoms

Dysuria

Haematuria

HaematospermiaLepor H (ed). Prostatic Diseases WB Saunders 2000: 127–142

Abrams P. BMJ 1994; 308: 929-930

International Prostate Symptom Score (IPSS)*

Not at allLess than one time in five

Less than half the time

About half the time

More than half the time

Almost always

Your Score

Incomplete emptyingIn the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?

0 1 2 3 4 5

Frequency 0 1 2 3 4 5

Intermittency 0 1 2 3 4 5

Urgency 0 1 2 3 4 5

Weak Stream 0 1 2 3 4 5

Straining 0 1 2 3 4 5

Nocturia 0 1 2 3 4 5

TOTAL SCORE (MAX 35)

* The IPSS also includes a ‘question 8’ which asks about the patients overall quality of life

Current treatments

Behavioural / Lifestyle

Pelvic Floor Exercises / Bladder training

Alpha-blockers

5-alpha-reductase inhibitors (5ARIs)

Anticholinergics [not covered in this presentation]

Combination therapy

Surgery HoLEP / TURP[not covered in this presentation]

Recommended?

European Association of Urologists BPH Guideline. 2004

√

√

√

√

√

√

√

Lifestyle and Exercises

• Drinking– Avoid all caffeinated drinks– Avoid other drinks (fizzy, blackcurrant, alcohol)– Focus drinking to little impact times of the day

• Pelvic Floor Exercises

• Bladder Training(NICE: ‘both supervised’)

Alpha blockers

Alpha blockers

Act by relaxing smooth muscle within the prostate and the bladder neck

Alpha-blockers

European Association of Urologists BPH Guideline. 2004

• Rapid symptom relief

• Generally well tolerated (side effects including dizziness, erectile dysfunction, aesthenia and postural hypotension)

• No effect on prostate volume

• Do not reduce the overall long-term risk of AUR or surgery

5α-Reductase Inhibitors (5ARIs)

5ARIs

Act by ‘shrinking’ the prostate by means of androgen deprivation

5ARIs

McConnell JD et al. NEJM 1998; 338: 557–563Roehrborn CG et al. Urology 2002; 60: 434–441

• Improvement in BPH symptoms• Reduction in prostate volume• Reduction in risk of AUR and

surgery• Generally well tolerated

(side effects including impotence, ejaculation disorders, gynaecomastia )

• Maximal symptom improvement may take a few months to achieve

Men presenting to GPswith

LUTS (+/- pelvic pain) Painful retentionPalpable bladder Nocturnal enuresis / Nocturnal incontinence UTI

Assessment

EXCLUDE INDICATORS FOR CANCER:ABNORMAL PSA OR RECTAL EXAMINATION

HAEMATURIA

Elevated age-related PSA

Abnormal DRE

Haematuria

Previous de-obstructing surgery

>1 UTI (MSU proven)

Indicators for chronic retention: -Renal impairment suspected due to lower urinary tract dysfunction -Palpable bladder -Nocturnal enuresis -Nocturnal incontinence

Urology OutpatientsPlease ensure all info provided

Painful retention

Pathway 2Painful retention

Bothersome LUTS

Treat predominant symptom

Pathway 3ABothersome LUTS

Predominantly Voiding

2-week-ruleGuidelines

Routine / Urgent

Pathway 1Chronic retention

Pathway 2+TWOC

Pathway 3BBothersome LUTS

Predominantly Storage &

nocturnal polyuria

Please forward any feedback on this pathway to add-tr.UrologyPartnersCambs@nhs.net

Orange = UrologyBlue = GPGreen = Continence service

HIGH RISK LOW RISKSuitable for GP management

on an individual basis

Assessment(prioritise the order according to presentation)

EXCLUDE INIDCATORS FOR CANCER:ABNORMAL PSA OR RECTAL EXAMINATION

HAEMATURIA

History of presentation including IPSS / QoL Voiding diary

Medical history identify other medical conditions which can cause symptomsMedication including herbal and over-the-counter medicines Physical examination in specific abdomen, external genitalia and digital rectal examination

Blood Creatinine (definitely if there is clinical indication of obstructive renal failure) PSA - Give information, advice and time before offering - Consider age / life expectancy / UTI - PSA patient information leaflet Urine Dipstick +/- MSU

Please forward any feedback on this pathway to add-tr.UrologyPartnersCambs@nhs.net

PSA < 1.4 and prostate < golf ball

PSA >1.4 or prostate > golf ball

Persistence

6/12

α-blocker α-blockers & 5-ARI

Improvement

Re-assess at 6/52

Pathway 3ABOTHERSOME LUTS

Predominantly VOIDING( also known as obstructive symptoms )

Lifestyle advicePatient Info: Male LUTS

DischargeImprovement

Persistence

Re-assessat 8/52

with IPSS

Consider discharge

Bothersome= patient feels impact of symptoms justifies the side-effects of treatment

Improvement = improved IPSS/QoL + patient happy

Part-response, residual Storage symptoms

keep on α-bl / 5ARIPathway 3B

STORAGE LUTSFREQUENCY -

URGENCY - NOCTURIA

Urology Outpatients

Ensure all info provided(Refer using LUTS

proforma)

Back to initial pagePlease forward any feedback on this pathway to add-tr.UrologyPartnersCambs@nhs.net

Orange = UrologyBlue = GPGreen = Continence service

Please use the PCT formulary to choose an appropriate α-blocker, 5-ARI or combinations. Consider 5ARI take effect only after ~3-4 months and that PSA measurements after 6 months of 5-ARI will be 50% less than the initial value. (available 5ARI: finasteride, dutasteride, also available as fixed dose combination with tamsulosin [Combodart] ).

• Key Messages

– NICE supports medical treatment in the community with less need of diagnostic tests

– Treatment flowchart available on various websites (GPConnect, CamUrology, CATCH)

– Use proforma to optimise the handover of gathered clinical information

– Drop in referral numbers by 25%– Better content of referral letters / use of proforma– Use of pathway in peer review of referrals– Few rejections required

Lower Urinary Tract Symptoms (LUTS)

• Key Messages

– Collaboration results inmeasurable benefits to patients, GPs, Urology departments, commissioners and the health economy as a whole

– Some organisations lack/lacked commitment, integrity and reliability– Individuals involved made it work

– Continued education and collaboration of clinicians crucial and making it worthwhile

– Promissing signs that PCT / CCS will make definite commitment– West Essex (Uttlesford) may join in some form– Other C&B providers consider joining (Cambridge Urology Partnership @

Nuffield)

– Other potential projects:• Haematuria assessment in the community• ED

Community Urology Partnership

Your comments, please