1. CCG Educational meeting Ipswich Urology Dept Mr Rob Brierly And Mr George Yardy 11 th September 2014

2. 2week Wait referrals Haematuria and PSA 11 th September 2014 Mr Robert Brierly Consultant Urologist Associate Medical Director Medical Education Ipswich Hospital NHS Trust

3. Urology Update 2WW referrals Haematuria and 2ww referral Asymptomatic microscopic haematuria (AMH) PSA and prostate screening PSA and 2ww referral Review of Urology 2ww criteria

4. Haematuria 2 Week Rule Patients with Frank (visible) Haematuria 25% Cancer Microscopic (Invisible) haematuria (>50years) 1-8.3% Cancer

5. Blood in Pee Campaign Blood in Pee Campaign ran from 15 th October 2013 to 20 th November 2013 Regional Pilots – 28% increase in 2WW referrals Ipswich Hospital – 27% increase in 2WW referrals over 6 week period Pilot 48% increase in bladder and renal cancer diagnoses (Tyneside) To be repeated Autumn 2014

6. Asymptomatic Microhaematuria (AMH) A few RBCs can be found in the urine of most normal people So what is significant? When to refer How to follow-up

7. Significant Microhaematuria RBCs / HPF (High powered field) 500,000 RBCs/12H = 3 RBCs / HPF No standard »Time of centrifuge »Speed of centrifuge »Volume of resuspension »Volume examined »Definition of HPF AUA consensus 2009

8. Automated urine analyser Flow cytometry Cells per microlitre 3RBCs / HPF = 16.5 cells IQ200 Analyser

9. Automated urine analyser Flow cytometry Cells per microlitre 3RBCs / HPF = 16.5 cells IQ200 Analyser Ipswich lowest report category <20 RBCs / microlitre

10. Dipstick Haematuria Test for haemoglobin Oxidation of organic peroxide Peroxidase activity of Hb Intact RBCs Punctate Free Hb Uniform stain

11. Dipstick Haematuria Trace can be considered as negative ≥1+ is Positive

12. Can you ignore +ve Dipstick and -ve Microscopy? 20% patients significant urinary tract pathology 5% malignancies Lynch T BJU 1994

13. Repeat Testing 1000 asymptomatic Israeli airforce personnel Regular testing15 years 38.7% Positive for Microhaematuria Froom BMJ 1984

14. How common is microhaematuria AuthorNumber of patientsDefinition% Microhaematuria Wright (1959)60002RBCs<2% Alwal (1973)26433RBCs3.9%Male 5.7%Female 7RBCs1.0%Male 2.0%Female 11RBCs0.6%Male 1.4%Female Ritchie (1986)10,050Dipstick2.5% Carel (1987)21,000Dipstick2.6%Male 8.1%Female Hiatt (1994)20,571Dipstick4.3% Iseki (1996)107,192Dipstick2.8%Male 11.0%Female

15. 2ww referral haematuria Painless macroscopic haematuria any age Persistent/ recurrent UTI assoc with haematuria (>40years) Persistent Asymptomatic microscopic haematuria (>50years) Defined as : 2 out of 3 1+ dipsticks or MSU +ve microscopy done at weekly intervals over a period of 1 month

16. What about the <50year old? BAUS and renal association guideline Think about renal disease and monitor

17. Haematuria learning points Refer all Frank haematuria as 2ww. Microhaematuria is not uncommon with repeat testing. +ve dipstick cannot be ignored because of –ve microscopy. 2ww referral AMH over 50years: 2 out of 3 1+ dipsticks or significant RBCs on microscopy/ MSU done at weekly intervals over a period of 1 month For <50ys think renal (can always refer as non 2ww)

18. Prostate Cancer and PSA PSA Testing and Screening for Prostate cancer. 2ww referral

19. A 50 y old fit and healthy male solicitor visits you. He is totally asymptomatic, but has heard about the PSA test and is worried about having prostate cancer. He requests the test, for ‘peace of mind’. There is no Family history. Please advise the patient PSA

20. What would you do? A) Refuse the test on the basis that he has no symptoms. B) Perform rectal examination which is entirely normal and refuse test on this basis C) Following rectal exam discuss the pros and cons of opportunistic screening and agree to arrange PSA if patient still keen.

21. Does screening reduce prostate cancer mortality? European Randomized Study of Screening for Prostate Cancer (ERSPC) 29 percent relative reduction in prostate cancer deaths among those screened when compared to those that were not at 11 years (Schroder 2012). The Prostate, Lung, Colon, and Ovary (PLCO) Trial National Cancer Institute No difference in prostate cancer deaths at 7-10 years of follow- up when comparing those screened to those that were not. (Andriole 2009).

22. Screening ERSPC trial 2009 To prevent 1 Prostate cancer death over 10years: 1410 men would need to be screened 48 men treated

23. PSA 63 year old fit and well man has longstanding mild lower urinary tract symptoms (LUTS). DRE moderately enlarged (25cc) smooth benign feeling prostate. Annual PSA for last 3years have been normal around 3.0. Now PSA 6.1 What will you do?

24. Age-related PSA Age (years)Reference range (ng/ml) 40-490-2.5 50-590-3.5 60-690-4.5 70+0-6.5

25. PSA is an unreliable marker Prostate specific but not cancer specific Transient rise: –Infection –Ejaculation –Instrumentation –Urinary retention –Non-infective inflammation related to BPH –Bicycles

26. Fluctuations in annual PSA measurements occur frequently. Isolated elevation in PSA should be confirmed several weeks later. Eastham, JAMA 2003 “The PSA level should be verified after a few weeks by the same assay under standard conditions” EAU Guideline 2014

27. PSA 63 year old fit and well man has longstanding mild lower urinary tract symptoms (LUTS). DRE moderately enlarged (25cc) smooth benign feeling prostate. Annual PSA for last 3years have been normal around 3.0. Now PSA 6.1 Urine dip is NAD. You repeat PSA after 3 weeks 6.0 Refer as 2 ww

28. PSA The Diagnostic Triad in Prostate Cancer

29. All Options Active surveillance

30. Initial GP Appointment PSA Further Consultation and Referral InitialOPA<2w Rpt PSA Biopsy MDT and OPA Stage MRI and BS OPA Referral to tertiary centre OPA tertiary centre TreatRTRPAS 62 Days! Current Pathway

31. 2ww referral for suspicion of Ca Prostate Any irregular feeling prostate on rectal exam (Please check PSA to accompany the referral). A raised age-specific PSA with or without lower urinary tract symptoms. For an isolated raised PSA please arrange repeat test after a few weeks before referral. If there is clinical or bacteriological evidence of urinary tract infection, PSA repeated after treatment might be appropriate. A high PSA (>20) with symptoms

32. Learning points Discuss pros and cons of PSA testing and gain consent before arranging test. Indications for testing include: –Patient request –Symptoms –Irregular examination PSA measurements can fluctuate and an isolated rise after excluding infection should have a repeat test after a few weeks before referral.

33. Adult Female Urinary Incontinence IESCCG pathway George Yardy Consultant Urologist The Ipswich Hospital NHS Trust Trinity Park 11 th September 2014

40. local incontinence pathway - treatment Lifestyle advice for all patients wt loss if BMI>30 caffeine reduction avoid excessive or small quantities of fluid 6-8 glasses water / day smoking cessation 3 day bladder diary Then categorise incontinence -Stress UI -Overactive Bladder (OAB) with or without urge UI -Mixed UI – treat predominant Sx

42. Midurethral slings

43. Urethral Bulking Agents

44. local incontinence pathway – OAB treatment Lifestyle advice for all patients Bladder retraining / pelvic floor muscle exercises -Patient.co.uk advice page Drug treatment More invasive treatments available in secondary care

45. Drug treatment – NICE CG171, Sept 2013 First line: oxybutynin immediate release – not for frail older women tolterodine immediate release darifenacin once daily If first treatment not effective / well-tolerated, offer another drug with the lowest acquisition cost Offer a transdermal OAB drug to women unable to tolerate oral medication For guidance on mirabegron for treating symptoms of OAB, refer to Mirabegron for treating symptoms of overactive bladder NICE technology appraisal guidance 290

46. Mirabegron for OAB, NICE TA290, June 2013 1.1Mirabegron is recommended as an option for treating the symptoms of overactive bladder only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side-effects

47. Drug treatment - IESCCG

49. More invasive treatments available in secondary care Sacral neuromodulation Percutaneous posterior tibial nerve stimulation Bladder botox injections “Clam” cystoplasty Ileal conduit urinary diversion

50. Sacral neuromodulation

52. PTNS: percutaneous posterior tibial nerve stimulation

53. Botox

55. Administration of Botulinum toxin Flexible cystoscope Instillagel Bladder filled to 100ml 1050mm 27G needle Into submucosa or detrusor, not beyond 100-300 units BTX-A 20-30 sites injected with ~1ml each Spare trigone ? -  pain, VUR Harper, BJUi 2003

56. Clam, conduit

58. local incontinence pathway – treatment Lifestyle advice Bladder retraining / pelvic floor muscle exercises Drug treatment More invasive treatments available in secondary care

59. Thank you