1. Community Urology Plenary Education Meeting December 2011 Christof Kastner Consultant Urologist Addenbrookes Hospital Mark Brookes GP Nuffield Road Surgery, Cambridge Co-chairs Urology Community Partnership, Cambs Aaron Horner Coordinator

2. Urology 2010: Designed around the Patient Outpatient Innovation Community Urology One-Stop Specialist Clinics Follow-up Clinics PSA Follow-up Continence Male LUTS

3. 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 for Prostate Cancer

4. 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 symptoms Medication 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 for Prostate Cancer Male patients presenting with Haematuria, LUTS and UTIs

5. 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

6. 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.netadd-tr.PSACambridge@nhs.net For advice on patients on the 'LES PSA FU scheme please email: add-tr.PSACambridge@nhs.netadd-tr.PSACambridge@nhs.net Discharge letter DiagnosisGradeStagePSA / presentation CA prostate Gleason 3+4T2a9.3 Treatment / BiopsyYear Benign Biopsy / PSA nadir RALP20070.01 IssuesPSA / discharge ED0.01 Recommendatio n FU intervalRe-referral criteria 6-monthly (super-sens. PSA) PSA >0.02 or if symptomatic

8. Patient identified by consultant as appropriate for PSA follow-up in community (see criteria) Community follow-up offered Follow up stays in secondary care Structured discharge letter to GP GP and Patient information sheet Patient held record Patient entered onto Register Recall set up PSA LUTS (IPSS) Weight (looking for loss) Bone pain Confirmation to secure email 3/12 return to Urology department Patient entered onto database Results entered on database Audit 6/12 No concerns – recall Abnormal Meets criteria set out in structured discharge letter New referral to discharging speciality marked PSA f/u, seen as urgent Advice via secure email address

9. –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 –Practicesto confirm receipt of referral to collect and return data on visits (next quarters data due by 15 th Jan 12) –Audit shows dangerous lack of control / insight Specialist assurance impossible Consideration of halting and modification of community follow-up Key Messages PSA Follow-Up

10. Continence

11. 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 CA Haematuria Palpable mass Red flags Refer direct to secondary care Red flags Refer direct to secondary care Specialist Continence Service Discharge GP/PN/midwife notes FEMALE URINARY INCONTINENCE NO YES Information sources Review Symptoms improved? Review Symptoms improved? 1 st line 2 months oxybutinin (immediate release) but be aware of risk of side effects in >65s 2 nd line M/R or T/D oxybutinin If no success then try alternatives alternatives Consider vaginal oestrogen if atrophy and OAB Cambridgeshire formulary NICE 1 st line 2 months oxybutinin (immediate release) but be aware of risk of side effects in >65s 2 nd line M/R or T/D oxybutinin If no success then try alternatives 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: WordWord, EMIS PCS, SystmOne, VisionEMIS PCSSystmOneVision Assessment, advice, supervised pelvic floor exercises 3/12 and/or 6/52 bladder training COMMUNITY CONTINENCE SERVICE (OR ACCREDITED ALTERNATIVE PROVIDER) refer using proforma: WordWord, EMIS PCS, SystmOne, VisionEMIS PCSSystmOneVision 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 Bladder diary for 3 days. Establish predominant symptom (stress, urge or mixed) History and exam (abdo, neurol, pelvic) including dipstix urine. Bladder diary 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 weeks Persistence Choice of provider on proforma Discharge Symptoms Improved Stress Mixed Urge Treat predominant symptom Review 4-8 weeks Symptoms improved? Review 4-8 weeks Symptoms improved? Consider stopping drugs after 3-6 months Please forward any feedback on this pathway to add-tr.UrologyPartnersCambs@nhs.net

12. 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

13. Underlying cause treated (constipation/UTI) Review medication YesNo PASSFAIL 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 scan Comfortable voiding? Post void residual <300ml? Catheter removed by D/N or GP Voiding volumes x3 Catheter removed by D/N or GP Voiding volumes x3 Confirm date & time for bladder scan with CCS Same day Orange = Urology Blue = GP Green = Continence service Pathway 2+ TWOC Pathway 2 PAINFUL RETENTION Prescribe α-blocker for at least 2 days prior to TWOC Follow plan given in discharge/clinic letter Back to initial page Trials without catheter

14. 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

15. Lower Urinary Tract Symptoms (LUTS)

16. Normal Anatomy of BPH BPH Hypertrophied detrusor muscle Obstructed urinary flow Prostate Bladder Urethra Adapted from Kirby RS et al. Benign Prostatic Hyperplasia.Health Press 1999

17. LUTS Symptom typeSymptom VoidingWeak urinary stream Prolonged voiding Abdominal straining Hesitancy Intermittency Incomplete bladder emptying StorageFrequency Nocturia Urgency / Urge incontinence Associated symptoms Dysuria Haematuria Haematospermia Lepor H (ed). Prostatic Diseases WB Saunders 2000: 127–142 Abrams P. BMJ 1994; 308: 929-930

18. International Prostate Symptom Score (IPSS)* Not at all Less than one time in five Less than half the time About half the time More than half the time Almost always Your Score Incomplete emptying In the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? 012345 Frequency012345 Intermittency012345 Urgency012345 Weak Stream012345 Straining012345 Nocturia012345 TOTAL SCORE (MAX 35) * The IPSS also includes a question 8 which asks about the patients overall quality of life

19. 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

20. 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)

21. Alpha blockers Act by relaxing smooth muscle within the prostate and the bladder neck

22. 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

23. 5α-Reductase Inhibitors (5ARIs) 5ARIs Act by shrinking the prostate by means of androgen deprivation

24. 5ARIs McConnell JD et al. NEJM 1998; 338: 557–563 Roehrborn 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

25. Men presenting to GPs with LUTS (+/- pelvic pain) Painful retention Palpable 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 Outpatients Please ensure all info provided Painful retention Pathway 2 Painful retention Bothersome LUTS Treat predominant symptom Pathway 3A Bothersome LUTS Predominantly Voiding 2-week-rule Guidelines Routine / Urgent Pathway 1 Chronic retention Pathway 2+ TWOC Pathway 3B Bothersome LUTS Predominantly Storage & nocturnal polyuria Please forward any feedback on this pathway to add-tr.UrologyPartnersCambs@nhs.net Orange = Urology Blue = GP Green = Continence service HIGH RISKLOW RISK Suitable for GP management on an individual basis

26. 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 symptoms Medication 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

27. PSA < 1.4 and prostate < golf ball PSA >1.4 or prostate > golf ball Persistence 6/12 α-blockerα-blockers & 5-ARI Improvement Re-assess at 6/52 Pathway 3A BOTHERSOME LUTS Predominantly VOIDING ( also known as obstructive symptoms ) Lifestyle advice Patient Info: Male LUTS Discharge Improvement Persistence Re- assess at 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 / 5ARI Pathway 3B STORAGE LUTS FREQUENCY - URGENCY - NOCTURIA Urology Outpatients Ensure all info provided (Refer using LUTS proforma) Back to initial page Please forward any feedback on this pathway to add-tr.UrologyPartnersCambs@nhs.net Orange = Urology Blue = GP Green = 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] ).

28. 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)

29. 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

30. Your comments, please