The measurement of psychological distress in men being investigated for the presence of prostate cancer.

High levels (>50%) of anxiety are reported in patients undergoing screening for prostate cancer, which may affect health-related quality of life. We aimed to determine the level and prevalence of anxiety and depression and to identify those aspects of the diagnostic pathway that induce the most stress in men being investigated for prostate cancer. A total of 159 prostate-specific antigen-unscreened men undergoing a transrectal ultrasound-guided biopsy of the prostate (TRUS-B) completed two questionnaires, prior to their biopsy and before receiving results, containing the Hospital Anxiety and Depression Scale (HADS) and a 10-point Visual Analogue Scale (VAS). Median scores and prevalence of anxiety (4-5, 4-7%) and depression (1-2, 1.4%) respectively were low for both questionnaires. Waiting for biopsy results received the highest median VAS score (6) and was the most stressful event in 65% of men. There is a low incidence of clinically significant anxiety and depression in men being investigated for prostate cancer but questionnaires such as HADS identify patients with psychological distress who may benefit from early counselling. Uncertainty about the future while awaiting biopsy results after TRUS-B seems to be the most stressful event in patients' lives and minimizing this wait should help optimize patient care.

Testicular granulocytic sarcoma, a source of diagnostic confusion.

We report a case of granulocytic sarcoma of the testis without hematologic manifestations. The patient was disease free 7 years after the initial presentation. The initial pathology interpretation favored a diagnosis of high-grade non-Hodgkin's lymphoma but additional histologic staining confirmed the diagnosis of granulocytic sarcoma. Only 2 cases of testicular granulocytic sarcoma without an associated hematologic disorder have been described. To our knowledge, this is the third reported case. The diagnosis of this rare tumor is difficult and should be in the differential diagnosis when non-Hodgkin's lymphoma is considered.

A novel testosterone gel formulation normalizes androgen levels in hypogonadal men, with improvements in body composition and sexual function.

OBJECTIVE: To compare the safety and efficacy of two doses of a new testosterone gel formulation (Testim Auxilium Pharmaceuticals, Inc., Norristown, PA, USA) to a permeation-enhanced testosterone patch (Andropatch), GlaxoSmithKline, UK) for treating men with confirmed low serum testosterone levels, and associated signs and symptoms of hypogonadism. PATIENTS AND METHODS: In all, 208 men were randomized and treated at 29 centres in Denmark, Germany, Netherlands, Sweden and the UK. The men were treated for 90 days, and the pharmacokinetics and treatment effectiveness of Testim at two doses (50 and 100 mg/day, delivering a daily dose of 5 and 10 mg testosterone, respectively) and Andropatch (2 x 2.5 mg patches, each delivering 2.5 mg testosterone and containing 12.2 mg of testosterone) were compared. Pharmacokinetic profiles were obtained, body composition measured, and mood and sexual function data recorded. RESULTS: Testim produced dose-dependent improvements in all pharmacokinetic variables compared with Andropatch. The mean increases from baseline to 90 days in testosterone were 12.41, 6.54 and 3.82 nmol/L for Testim 100 and 50 mg/day and the Andropatch, respectively. Both doses of Testim significantly improved positive and negative mood over baseline; Andropatch did not. All three treatments increased lean body mass, and the higher dose of Testim produced a significant decrease in percentage body fat. At all sample times both doses of Testim significantly improved sexual performance, sexual motivation, sexual desire and spontaneous erections. Andropatch provided insignificant improvements from baseline at all sample times for sexual desire, an inconsistent improvement in sexual motivation, but no effect on spontaneous erections. These results are similar to those previously reported for testosterone replacement therapy in hypogonadal men, suggesting that normalization of serum testosterone restores sexual function. However, the present data suggest that higher serum testosterone levels may further improve sexual function. Gel treatment was well tolerated, while patch treatment produced higher rates of application-site reactions and study discontinuation. CONCLUSION: The favourable pharmacokinetic profile and treatment outcome, combined with the enhanced tolerability of Testim, suggest that this new gel formulation is a safe and effective treatment in men with low serum testosterone levels and associated signs and symptoms of hypogonadism.

Sildenafil influences lower urinary tract symptoms.

OBJECTIVE: To assess the possible relationship between erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) in men, and whether treatment of their ED with sildenafil influences their LUTS. PATIENTS AND METHODS: In all, 112 men with ED attending the andrology outpatient clinic were offered oral sildenafil and reviewed 1 and 3 months after treatment. They completed the International Index of Erectile Function and the International Prostate Symptom Score (IPSS) questionnaires at baseline and each review. Scores were designated to indicate the visit number and differences between the visits calculated. RESULTS: A third of the men had an initial IPSS of > 7; there was no relationship between baseline urinary and sexual function scores. After treatment with sildenafil, the urinary scores at 3 months correlated strongly with the sexual function scores. There was a significant inverse relationship between the baseline IPSS and sexual function scores after treatment. The overall trend in the IPSS was towards improvement after treatment with sildenafil. CONCLUSIONS: In men with ED there is no relationship between sexual function scores and urinary symptom scores before treating ED. Treatment with sildenafil appears to improve urinary symptom scores. A lower IPSS at baseline appears to predict a better response to ED therapy with sildenafil.

A study comparing various noninvasive methods of detecting bladder cancer in urine.

OBJECTIVES: To compare the nuclear matrix protein (NMP)-22 assay, bladder tumour specific antigen (BTAstat) test, telomerase activity (using the telomeric repeat amplification protocol assay, TRAP) and a haemoglobin dipstick test for their ability to replace voided urine cytology (VUC) for detecting bladder cancer. PATIENTS AND METHODS: The study included 120 urological patients prospectively recruited and assessed before surgery. A single freshly voided urine sample (approximate 100 mL) was collected from each patient and aliquoted for each test. All assays were conducted according to the manufactures' guidelines; 79 patients were tested for telomerase activity. The results were then compared with VUC and the diagnosis confirmed by cystoscopy and histology. RESULTS: Fifty-two patients had histologically confirmed transitional cell carcinoma. The overall sensitivity for BTAstat, NMP22, telomerase, VUC and dipstick testing was 63%, 81%, 84%, 48% and 50%, respectively. Combining the results for telomerase and NMP22 gave a sensitivity of 100%. For G1 tumours the respective sensitivities were 23%, 62%, 56%, 23% and 15%, for G2 tumours, 68%, 86%, 92%, 50% and 41% and for G3 tumours 88%, 88%, 100%, 71% and 82%. For pTa tumours the respective detection rates were 48%, 70%, 84%, 39% and 30%, for pT1 tumours 80%, 90%, 90%, 50% and 50%, for pT2/pTis tumours, 100/100%, 100/100%, 100/100%, 88/100% and 88/83%. The overall specificity for the respective tests was 82%, 87%, 93%, 87% and 54%; combining the results of NMP22 and telomerase activity increased the specificity to 96%. CONCLUSIONS: There was significantly better detection than VUC when using the NMP22 and TRAP assay, especially for well-differentiated (P < 0.001 and 0.0027, respectively) and superficial tumours (P < 0.001 and 0.034, respectively). Combining the results of NMP22 and telomerase activity yielded values comparable with cystoscopy.

Ultrasonography and abdominal radiography versus intravenous urography in investigation of urinary tract infection in men: prospective incident cohort study.

OBJECTIVES: To compare ultrasonography and abdominal radiography with intravenous urography in the investigation of urinary tract infection in men. DESIGN: Prospective study in two hospital departments. Radiological procedures and urological assessments performed on different days by different clinicians SETTING: District general hospital. PARTICIPANTS: Consecutive series of men (n=114) referred to the department of urology for investigation of proved urinary tract infection. INTERVENTIONS: Ultrasonography and intravenous urography of renal tract and assessment of urinary flow rate. Clinical assessment, cystoscopy, urodynamic studies, and transrectal ultrasonography with biopsy. MAIN OUTCOME MEASURES: Sensitivity and specificity of ultrasonography and abdominal radiography compared with intravenous urography. RESULTS: Important abnormalities were seen in 53 of 100 fully evaluated patients, the most common being a poorly emptying bladder (34). The combination of plain radiographs of kidneys, ureter, and bladder and ultrasonography detected more abnormalities than intravenous urography alone. No important abnormality was missed by this combination (sensitivity 100% and specificity 93%). CONCLUSIONS: Ultrasonography with abdominal radiography is as accurate as intravenous urography in detecting important urological abnormalities in men presenting with urinary tract infection. This combination is safer than intravenous urography and should be the initial investigation for such patients. Additional determination of urinary flow rate is useful for the assessment of an incompletely emptying bladder.

Prevalence of undiagnosed prostate cancer in men with erectile dysfunction.

OBJECTIVE: To explore the prevalence of prostate cancer in men presenting with erectile dysfunction (ED). PATIENTS AND METHODS: In a prospective study, 127 men with ED of at least 6 months duration underwent screening for prostate cancer using prostate specific antigen (PSA) and a digital rectal examination (DRE). Men with a high PSA level (> 4 ng/mL) had sextant biopsies taken under sedoanalgesia. The serum testosterone level was measured in all the men. RESULTS: Twenty-six men were aged < 50 years and all had a normal PSA level; of 101 men aged > 50 years, 20 had an abnormal PSA. The detection rate for prostate cancer using PSA and DRE was 5%, which was not significantly higher than in the general population. All the detected cancers were clinically significant (> T2a, Gleason grade > 4). Two of the five men diagnosed with prostate cancer were Afro-Caribbean. Of the 127 men, 31% had a low serum testosterone level, but there was no association between testosterone and PSA levels. CONCLUSIONS: Prostate cancer is no more common in men with ED than in the normal male population. Therefore, routine screening for prostate cancer in men with ED is not indicated.

Acute periprostatic haematoma following a transrectal ultrasound-guided needle biopsy of the prostate.

Transrectal ultrasound (TRUS)-guided needle biopsy is routinely performed to diagnose and stage prostate carcinoma in an outpatient setting. Although serious adverse effects are rare, minor complications are common. We report the occurrence of an acute periprostatic haematoma as an unusual complication of TRUS-guided needle-biopsy of the prostate, resulting in the patient requiring prompt resuscitation and hospital admission.

Prevalence of undiagnosed diabetes mellitus in male erectile dysfunction.

OBJECTIVE: To determine the prevalence of previously undiagnosed diabetes mellitus (DM) in men presenting with erectile dysfunction (ED), using fasting blood glucose (FBG) compared with urinary dipstick testing for glycosuria. PATIENTS AND METHODS: A prospective prevalence study was carried out in an andrology outpatient clinic of a urology department in a district general hospital serving a mixed urban and rural population. In all, 129 consecutive men presenting with ED underwent FBG and urinary dipstick testing to detect undiagnosed DM in those presenting with ED. RESULTS: The prevalence of known DM was 17% and the that of undiagnosed DM 4.7% of the 107 remaining men; an abnormal fasting glucose level was found in a further 12%. The sensitivity of urine dipstick test for diagnosing DM was 20%. CONCLUSIONS: The prevalence of undiagnosed DM is higher in men with ED than in the general population. ED is a marker symptom for DM and DM should be actively sought in men presenting with ED. Urinary dipstick testing for glycosuria, if used as a screening test, will miss the diagnosis in 80% of these men. FBG testing should be undertaken to reliably diagnose DM in men presenting with ED.

The early detection and diagnosis of bladder cancer: a critical review of the options.

Bladder cancer has a high worldwide incidence matched by a tendency to recur, necessitating close and regular follow-up. Current methods of investigation of bladder cancer involve cystoscopy, ultrasound scanning and contrast urography, with additional information provided by cytology. These methods, although having a high detection rate, are expensive, time-consuming, invasive and uncomfortable. There is, therefore, a need for an inexpensive, noninvasive, quick and simple investigation with a high sensitivity and specificity for the detection of bladder cancer. There are an increasing number of molecular assays available for the detection of bladder cancer. From bladder tumour antigens to nuclear matrix proteins to adhesion molecules, cytoskeletal proteins and growth factors, urology has looked at them all to support the early detection and diagnosis of bladder cancer. This review critically discusses both the commercial as well as the research-based diagnostic assays available (their mode of action, overall accuracy - both by stage and grade, and their uses and limitations from both a clinical as well as a practical point of view). Aiming to give an insight into the options currently available for noninvasive bladder cancer diagnosis, it also provides prospective comment on what new methods/technologies may be useful in the medium term.

Increased patient satisfaction from transrectal ultrasonography and biopsy under sedation.

OBJECTIVE: To determine the acceptability and patient satisfaction of transrectal biopsy undertaken with the patient under sedation. Patients and methods A retrospective questionnaire was sent to 100 patients who had undergone transrectal biopsy between January and August 1998. Levels of patient acceptability and satisfaction were assessed using visual analogue scales (VAS, with a maximum score of 10 being the least satisfactory or acceptable) and direct questions about the side-effects of the procedure. A subsequent prospective study was undertaken on 130 patients undergoing transrectal biopsy with sedation between January 1999 and January 2000. RESULTS: The mean score for patient discomfort with sedation was 1.5, compared with 3.5 with no sedation. The overall satisfaction score improved from 3.1 to 0.9 with sedation. Complication rates were comparable, although slightly higher overall in the prospective group. Conclusion Sedation can significantly reduce patient discomfort and make the transrectal biopsy a more satisfactory experience for the patient. This is particularly important in the proportion of men who need to be considered for repeat biopsies.

Lower urinary tract symptoms suggestive of benign prostatic obstruction: what are the current practice patterns?

OBJECTIVE: The current clinical practice patterns for the management of LUTS suggestive of BPO in the US and in various European countries will be reviewed. METHODS: Information was obtained from published scientific articles and IMS/GERS market analysis data. RESULTS: Community-based surveys demonstrate that the prevalence of moderate to severe LUTS in elderly men is high and increases with age. The role of the GP in the initial management of LUTS is growing. In France, Italy and the UK, most patients with LUTS initially visit a GP. More and more patients in the US also first seek medical advice from a primary care physician or an internal medicine specialist. In Germany, both GPs and office-based urologists are involved in the initial management of LUTS. In Poland and Spain, office-based urologists initiate primary therapy for LUTS, although a trend towards involvement of GPs is also seen, especially in Poland. The shift in the initial management of LUTS from secondary to primary care accompanies a decreased incidence of surgery and a growing demand for medical therapy. Currently, there are considerable differences between the medical management of LUTS suggestive of BPO across Europe in real life practice. For example phytotherapy is particularly popular in countries such as Germany, France and Spain, whereas finasteride is more commonly used in Italy, Poland and the UK. alpha(1)-Adrenoceptor antagonists are used in most of these countries as the primary treatment modality. The data furthermore suggest that the current management of patients is often more opinion- than evidence-based, which may at least partly be due to the fact that data on long-term effectiveness of treatment options in real life clinical practice are largely lacking. CONCLUSIONS: [corrected] Due to the ageing and longevity of the population, the costs associated with the management of LUTS suggestive of BPO will rise in the future, whereas healthcare budgets will be relatively restricted. In order to improve cost-effective management of LUTS, more and better studies are needed in real life practice in primary care. These studies should not only be based on classical efficacy and safety data, but also on effectiveness of treatment in the long-term and the associated costs.

The use of lasers in benign prostatic enlargement.

This article reviews the laser techniques available for the treatment of lower urinary tract symptoms. Early data on short-term mortality, morbidity, complication rates, and outcome are available, but information on cost-effectiveness, long-term outcome, and patient preference are as yet unavailable. In the 8 years since laser methods became popular it has become clear that substantial and variably durable flow and symptomatic responses are achieved that do not quite match transurethral resection of the prostate (TURP). Less immediate physiologic stress is balanced by a delay before full response. Same-day surgery may be possible, but an extended period of catheterization may be necessary. Laser methods remain an option for treatment and are particularly applicable to the less fit man. Whether men will choose a less effective but less invasive treatment option for symptom relief is not yet obvious. Limited early data suggest the holmium laser technique most closely approaches the gold standard.

Management of symptomatic BPH in the UK: who is treated and how?

OBJECTIVE: To review the contemporary management of symptomatic benign prostatic hyperplasia (BPH) in the United Kingdom (UK). METHODS: Information was obtained from published scientific articles, IMS market analysis data and surveys among primary care practitioners and urologists. RESULTS: A survey in Stirling (Scotland) identified the number of men aged 40-79 years with symptomatic BPH defined as a prostate size >20 g with urinary symptoms (total symptom score >/=11) and/or a maximum urinary flow rate <15 ml/s. It appeared that 25% of men had symptomatic BPH. Approximately 2.5 million men fall in this category in the UK currently and the number is expected to grow by almost 50% by the year 2025. Although not every man with symptomatic BPH is bothered by his LUTS and will therefore seek medical advice, many men with mainly filling symptoms and greater symptom severity do visit their physician, especially now more medical treatment options are available. Due to the low number of urologists in the UK, general practitioners (GPs) have traditionally been more involved in the diagnosis and management of symptomatic BPH than in other countries. The contribution of GPs and nurses in managing this condition will probably increase even more when the National Health Services (NHS) reform with GPs and nurses co-operating in primary care groups (PCGs) which are responsible for the total healthcare budget is fully implemented. Although urologists will have to define their role in this new system, this trend will probably help them to cope with the increasing numbers of elderly males seeking medical advice for LUT problems in the next millennium and to reduce already existing out-patient and surgical waiting lists. First results suggest that two thirds of patients attending shared care prostate clinics have uncomplicated LUTS related to BPH and can initially be managed at primary care level. The number of consultations and prescriptions for medical therapy for symptomatic BPH has increased considerably during the 1990s whereas the number of surgical procedures performed on an annual basis has remained stable at around 40,000 cases/year accounting for 70 million Euro/year. Of the two medical treatment approaches approved for the treatment of symptomatic BPH in the UK, the sales for alpha(1)-adrenoceptor antagonists have increased steadily during the latter part of the 1990s whereas that for finasteride has remained flat. In 1998, alpha(1)-adrenoceptor antagonists had 64% market share and finasteride 36% from a total market of 53 million Euro. CONCLUSIONS: In the UK, challenges for the future management of symptomatic BPH will be the increased number of patients, further enhancement of efficient co-operation between PCGs and urologists and evaluation of most appropriate management of this condition from a disease progression and cost-effectiveness point of view. Copyrightz1999S. KargerAG,Basel