Visiting Professor, The Prostate Centre, London, writes the ‘Message for the clinic’
A questionnaire was mailed to 120 GPs in the North-West Thames region to determine whether they were prepared to take on basic urological investigations/procedures. In all, 85 questionnaires were returned (response rate 70.8 per cent). Ten were inadequately completed, thus 75 (62.5 per cent) were available for analysis. Only one respondent had a specialist interest in urology.
The survey showed that less than half of the GPs were ‘happy to manage’ common urology problems such as erectile dysfunction (ED) (49 per cent), female voiding difficulties (45 per cent) and benign prostatic hyperplasia (BPH) (43 per cent). Only a tiny minority felt able to manage patients with haematuria (2 per cent), female incontinence (16 per cent) and family planning (28 per cent). Hence, a large majority of GPs are referring these patients to hospital-based urologists for management. A large proportion of GPs refer patients with haematuria (51 per cent), family planning (48 per cent) and female incontinence (39 per cent) immediately without any investigations, while this was less evident for patients with BPH (16 per cent), female voiding difficulties (14 per cent) and ED (8 per cent).
Overall, very few GPs carry out urological procedures or interpret urological investigations, apart from digital rectal examination (DRE), which was performed regularly by 62 per cent of GPs. Importantly, almost one-fifth (19 per cent) of GPs never perform DRE for urological conditions, which may be of potential clinical importance. Few expressed any intention in learning how to interpret urological investigations [urodynamics (16 per cent), flow rate and residual (40 per cent)] or perform basic urological operative procedures [flexible cystoscopy (16 per cent), minor scrotal surgeries (16 per cent), neonatal circumcision (28 per cent), vasectomy (28 per cent)].
If the present study is representative of primary care nationwide, it is likely that the relocation of basic urology services from secondary care is premature. Training, mentoring, assessment and support of community-based practitioners are crucial. In the meantime, hospital and primary care services need to work more closely together until a proper infrastructure is in place for primary care practitioners to take on more of this responsibility.
Mahmalji W, Mukerji G, Abel P, Raza A. A community urology service: fact or fiction? BJU Int 2010;106(10):1428–30.
Message for the clinic
This paper reviews the political changes since 2002 that were designed to shift the balance of power and subsequently move more urological care into the community. The results of the questionnaire suggested that only a minority of GPs are confident or willing to investigate and treat common urological symptoms, especially haematuria. This is not surprising, given the current workload of GPs and the focus on the Quality and Outcomes Framework, which does not presently include lower urinary tract symptoms, although this has been proposed and is under review. In addition to this, the number of female GPs increases year by year, and often their workload can be heavily weighted towards the female patients, resulting in a lack of exposure to male urological problems. Community
clinics delivering shared care run by specialist nurses have been shown to be effective in the past, but only work well when there are clear protocols and an educational element supported by the local urologist. Where there is a supportive urological department and a
local GP with a special interest, there will undoubtedly be commissioning opportunities in the future.
This study reviewed the evidence in support of the effectiveness of phosphodiesterase 5 (PDE 5) inhibitors in lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). Relevant studies were identified by performing a literature search using MEDLINE and the Cochrane Library. The criteria used during the search included randomised, placebo-controlled trials of treatment for LUTS secondary to BPH using the International Prostate Symptom Score (IPSS) as an outcome measure. Four trials that included a total of 1928 patients met the inclusion criteria. All four studies showed a statistically significant difference in the IPSS, quality of life and erectile function in favour of PDE 5 inhibitors. Meta-analysis of the results was not possible because of heterogeneity across the studies.
PDE 5 inhibitors used in the clinical setting can therefore significantly improve LUTS secondary to BPH, erectile function and quality of life. Maximum urinary flow improvement was not statistically significant. Future research should focus on pathophysiological principles and cost analysis.
Laydner HK, Oliveira P, Oliveira CRA, et al. Phosphodiesterase 5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review. BJU Int 2010. DOI: 10.1111/j.1464-410X.2010.09698.x
Message for the clinic
This paper initially reviews the biological plausibility that PDE 5 inhibitors may be a clinically effective treatment for LUTS and draws the conclusion that there are indeed several mechanisms by which they may work. The results were encouraging, with a mean improvement in the IPSS from 14.3 to 11.5 (p<0.05), demonstrating a reduction in urinary symptoms, and an improvement in the International Index of Erectile Function from 11.95 to 18.32 (p<0.05). The improvement in the IPSS is equivalent to the effect of treatment with alpha-blockers. For the man with LUTS and erectile dysfunction, clearly, the use of PDE 5 inhibitors may produce benefit to both symptoms, but cost will remain an issue. The mechanism of action in LUTS remains obscure, especially as there was no evidence of an increase in the flow rate. Future research is called for, especially focusing on the use of daily treatment with long-acting PDE 5 inhibitors.
This study investigated the correlation between penile hypersensitivity and premature ejaculation (PE), as defined by the criteria identified by the International Society of Sexual Medicine (ISSM). Penile hypersensitivity as a cause of PE is based on historical clinical neurophysiological data and clinical efficacy of the topical desensitising agent PSD502 in the treatment of PE. PSD502 is a eutectic-like mixture of two local anaesthetics, lidocaine and prilocaine, whose primary action is to reduce neuronal conduction in sensory afferents.
Historical neurophysiological data were reviewed, together with data from the recent PSD502 clinical trials, including the first published double-blind clinical trial data evaluating a topical desensitising agent in a population of men with PE, as per the new ISSM definition. The clinical profile of PSD502, based on its local anaesthetic properties, is used as a surrogate index of the role of sensory afferents in the ejaculatory reflex.
The published data do not support unequivocally penile hypersensitivity as the cause of PE. Interpretation of the data is hampered by the variability of the populations described as having PE across studies. Data from the PSD502 clinical trials clearly show that PSD502 increases ejaculatory latency, and improves control and sexual satisfaction when applied topically to men with PE five minutes before intercourse, enabling subjects to delay ejaculation up to six times longer than those who used a placebo.
The clinical profile of PSD502 lends credibility to the penile hypersensitivity hypothesis for PE. The predominant action of local anaesthetics is to reduce neuronal firing in sensory afferents; the clinical profile of PSD502, which shows improvement of ejaculatory function in the absence of a generalised reduction in penile sensitivity, can most readily be explained based on an underlying hypersensitivity in patients with PE.
Wyllie MG, Hellstrom WJG. The link between penile hypersensitivity and premature ejaculation. BJU Int 2010. DOI: 10.1111/j.1464-410X.2010.09456.x
Message for the clinic
The use of local anaesthetics to help men with PE is widespread. The patients often complain of numbing and decreased pleasurable sensations. This paper reviews the use of topical desensitising agents and the circumstantial evidence that penile hypersensitivity may be an underlying cause of PE. It is interesting that PSD502 increases the ejaculatory latency time in the absence of penile numbing. This raises the concept that these men have underlying hypersensitivity and the topical agent restores the normal degree of sensitivity. However, at the moment we have no clear definition of what normal is.