Community Urology Plenary Education Meeting December 2011

1. Community Urology • Plenary Education Meeting • December 2011 • Christof Kastner Consultant Urologist Addenbrooke’s 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 Male LUTS One-Stop PSA Follow-up Specialist Clinics Follow-up Clinics Continence Community Urology

3. Screening forProstate Cancer 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

4. Screening forProstate Cancer Male patients presenting with Haematuria, LUTS and UTIs • Assessment • (prioritise the order according to presentation) • EXCLUDE INIDCATORS FOR CANCER: • ABNORMAL PSA ORRECTAL EXAMINATION • HAEMATURIA • History of presentation including IPSS / QoLVoiding 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 -

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 letter 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

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

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 Practices to confirm receipt of referral to 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 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 GP/PN/midwife notes FEMALE URINARY INCONTINENCE Information sources Establish predominant symptom (stress, urge or mixed) History and exam (abdo, neurol, pelvic) including dipstix urine. Bladder diary for 3 days. Red flags Refer direct to secondary care Fast track 2 week referral to appropriate specialty Suspected CA Haematuria Palpable mass Advice for all patients: Lifestyle advice, bladder diary assessment, pelvic floor exercises & bladder training. Patient Info: Female Bladder Health Persistence Symptoms Improved Review 6 weeks Discharge Choice of provider on proforma Consider using concurrent medication on advice of community continence service COMMUNITY CONTINENCE SERVICE (ORACCREDITED ALTERNATIVE PROVIDER) refer using proforma: Word, EMIS PCS, SystmOne, Vision Assessment, advice, supervised pelvic floor exercises 3/12 and/or 6/52 bladder training 1stline 2 months oxybutinin (immediate release) but be aware of risk of side effects in >65s 2nd line M/R or T/D oxybutinin If no success then try alternatives Consider vaginal oestrogen if atrophy and OAB Cambridgeshire formulary NICE Ongoing symptoms Stress Mixed Urge Review Symptoms improved? NO YES Treat predominant symptom Discharge NO Review 4-8 weeks Symptoms improved? Blue: GP Green: Community Continence Service Orange: Secondary Care YES Specialist Continence Service 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. Pathway 2+ TWOC postGA retention (other secondary care) Pathway 2 PAINFUL RETENTION Trials without catheter Underlying cause treated (constipation/UTI) Review medication Prescribe α-blocker for at least 2 days prior to TWOC TWOC TWOC request from secondary care Urology Confirm date & time for bladder scan with CCS Catheter removed by D/N or GP Voiding volumes x3 Same day Bladder scan Comfortable voiding? Post void residual <300ml? Follow plan given in discharge/clinic letter Yes No PASS FAIL Offer ISC as alternative to catheter PASS without previous symptoms Treatment naive All FAIL (unless Elderly / frail etc, GP to weigh up) PASS (unless see left) GP review LUTS assessment Urology Outpatients (Refer using LUTS proforma) Orange = Urology Blue = GP Green = Continence service Back to initial page

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

17. LUTS Lepor H (ed). Prostatic Diseases WB Saunders 2000: 127–142 Abrams P. BMJ 1994; 308: 929-930

18. International Prostate Symptom Score (IPSS)* * The IPSS also includes a ‘question 8’ which asks about the patients overall quality of life

19. Current treatments Recommended? • 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] √ √ √ √ √ √ √ 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 Alpha blockers • Act by relaxing smooth muscle within the prostate and the bladder neck

22. Alpha-blockers + - • No effect on prostate volume • Do not reduce the overall long-term risk of AUR or surgery • Rapid symptom relief • Generally well tolerated (side effects including dizziness, erectile dysfunction, aesthenia and postural hypotension) European Association of Urologists BPH Guideline. 2004

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

24. 5ARIs + - • 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 McConnell JD et al. NEJM 1998; 338: 557–563 Roehrborn CG et al. Urology 2002; 60: 434–441

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

26. Assessment • (prioritise the order according to presentation) • EXCLUDE INIDCATORS FOR CANCER: • ABNORMAL PSA ORRECTAL EXAMINATION • HAEMATURIA • History of presentation including IPSS / QoLVoiding 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. Bothersome = patient feels impact of symptoms justifies the side-effects of treatment Improvement = improved IPSS/QoL + patient happy Pathway 3A BOTHERSOME LUTS Predominantly VOIDING ( also known as obstructive symptoms ) Lifestyle advice Patient Info: Male LUTS Improvement Discharge Re-assess at 6/52 Persistence 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] ). PSA < 1.4 and prostate < golf ball PSA >1.4 or prostate > golf ball α-blocker α-blockers & 5-ARI Re-assess at 8/52 with IPSS 6/12 Pathway 3B STORAGE LUTS FREQUENCY - URGENCY - NOCTURIA keep on α-bl / 5ARI Consider discharge Part-response, residual Storage symptoms Improvement Persistence Urology Outpatients Ensure all info provided (Refer using LUTS proforma) Orange = Urology Blue = GP Green = Continence service Back to initial page Please forward any feedback on this pathway to add-tr.UrologyPartnersCambs@nhs.net

28. Lower Urinary Tract Symptoms (LUTS) • 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

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. Yourcomments, please