American Urological Association

Ten Things Physicians and Patients Should Question

Released February 21, 2013 (1-5) and June 11, 2015 (6-10)

  1. 1

    A routine bone scan is unnecessary in men with low-risk prostate cancer.

    Low-risk patients (defined by using commonly accepted categories such as American Urological Association and National Comprehensive Cancer Network guidelines) are unlikely to have disease identified by bone scan. Accordingly, bone scans are generally unnecessary in patients with newly diagnosed prostate cancer who have a PSA <20.0 ng/mL and a Gleason score 6 or less unless the patient’s history or clinical examination suggests bony involvement. Progression to the bone is much more common in advanced local disease or in high-grade disease that is characterized by fast and aggressive growth into surrounding areas such as bones or lymph nodes.

  2. 2

    Don’t prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.

    While testosterone treatment is shown to increase sexual interest, there appears to be no significant influence on erectile function at least not in men with normal testosterone levels. The information available in studies to date is insufficient to fully evaluate testosterone’s efficacy in the treatment of men with erectile dysfunction who have normal testosterone levels.

  3. 3

    Don’t order creatinine or upper-tract imaging for patients with benign prostatic hyperplasia (BPH).

    When an initial evaluation shows only the presence of lower urinary tract symptoms (LUTS), if the symptoms are not significantly bothersome to the patient or if the patient doesn’t desire treatment, no further evaluation is recommended. Such patients are unlikely to experience significant health problems in the future due to their condition and can be seen again if necessary. [While the patient can often tell the provider if the symptoms are bothersome enough that he desires additional therapy, another possible option is to use a validated questionnaire to assess symptoms. For example, if the patient completes the International Prostate Symptom Scale (IPSS) and has a symptom score of 8 or greater, this is considered to be “clinically” bothersome.]

  4. 4

    Don’t treat an elevated PSA with antibiotics for patients not experiencing other symptoms.

    It had previously been suggested that a course of antibiotics might lead to a decrease in an initially raised PSA and reduce the need for prostate biopsy; however, there is a lack of clinical studies to show that antibiotics actually decrease PSA levels. It should also be noted that a decrease in PSA does not indicate an absence of prostate cancer. There is no information available on the implications of deferring a biopsy following a decrease in PSA.

  5. 5

    Don’t perform ultrasound on boys with cryptorchidism.

    Ultrasound has been found to have poor diagnostic performance in the localization of testes that cannot be felt through physical examination. Studies have shown that the probability of locating testes was small when using ultrasound, and there was still a significant chance that testes were present even after a negative ultrasound result. Additionally, ultrasound results are complicated by the presence of surrounding tissue and bowel gas present in the abdomen.

  6. 6

    Don’t prescribe antimicrobials to patients using indwelling or intermittent catheterization of the bladder unless there are signs and symptoms of urinary tract infection.

    Antibiotics in the absence of signs and symptoms (which may include fever; altered mental status or malaise with no other cause; flank or pelvic pain; flank or suprapubic tenderness; hematuria; dysuria, urinary urgency or frequency; and, in spinal cord injury patients, increased spasticity, autonomic dysreflexia or sense of unease) is not efficacious and risks inducing resistance to antimicrobials. This applies to both indwelling and intermittent catheterization of the bladder. The major exception is patients needing periprocedural antimicrobials. Additionally, initial placement of a suprapubic tube requires a skin puncture or incision and therefore antibiotics should be considered.

  7. 7

    Don’t obtain computed tomography scan of the pelvis for asymptomatic men with low-risk clinically localized prostate cancer.

    Computed tomography scan of the pelvis is very unlikely to provide actionable information in men with low-risk prostate cancer (one commonly accepted definition of low-risk prostate cancer is Gleason score less than 7, PSA less than 20.0 ng/mL, and tumor stage of T2 or less). Magnetic resonance imaging of the pelvis may be useful in some men considering active surveillance.

  8. 8

    Don’t remove synthetic vaginal mesh in asymptomatic patients.

    There is no clear benefit to mesh removal in the absence of symptoms, and mesh removal in this circumstance exposes the patient to potential complications such as bladder injury, rectal injury and fistula formation.

  9. 9

    Offer PSA screening for detecting prostate cancer only after engaging in shared decision making.

    Shared decision making (between health care provider and patient and, in some cases, family members) is an excellent strategy for making health care decisions when there is more than one medically reasonable option. Since both screening and not screening may be reasonable options, depending on the particular situation, shared decision making is recommended.

  10. 10

    Don’t diagnose microhematuria solely on the results of a urine dipstick (macroscopic urinalysis).

    Microhematuria is defined only on urine microscopy: three or more red blood cells per high-powered field on microscopy of a properly collected urinary specimen. Urine dipsticks positive for hemoglobin should be confirmed with urine microscopy, as false positive dipsticks are common. Performing radiographic and cystoscopic evaluation is unnecessary in the absence of microscopically confirmed microhematuria.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

Founded in 1902 and headquartered near Baltimore, Maryland, the American Urological Association is a leading advocate for the specialty of urology, and has more than 20,000 members throughout the world. The AUA is a premier urologic association, providing invaluable support to the urologic community as it fosters the highest standards of urologic care through education, research and formulation of health policy.

For information, visit www.auanet.org.

How This List Was Created

1–5: The American Urological Association (AUA) established a committee to review evidence from the association’s guidelines and identify potential topics for nomination to the AUA’s Choosing Wisely list. The committee reviewed a number of recommendations and through a consensus process identified the five tests or procedures that should be questioned. These recommendations were reviewed and approved by the AUA Board of Directors.

6–10: Following its previous successful participation in Choosing Wisely in 2013, the American Urological Association (AUA) established a new committee in 2014 to develop a second list of recommendations. The group sought input from the AUA membership in addition to drafting potential suggestions after studying evidence from the association’s evidence-based clinical practice guidelines and other clinical documents. The committee reviewed all recommendations and narrowed them to a list of fifteen possibilities. Again, the committee sought AUA member input by asking members to vote for their top five selections from the list of candidate recommendations. After the votes were tallied, the list of five recommendations was determined. These recommendations were reviewed and approved by the AUA Board of Directors in February 2015.

AUA’s disclosure and conflict of interest policy can be found at www.auanet.org.

Sources

  1. American Urological Association. Prostate-Specific Antigen Best Practice Statement. Revised 2009. [Internet]. Linthicum (MD): AUA; 2009 [cited 2012 Oct 16]. Available from: http://www.auanet.org/common/pdf/education/clinical-guidance/Prostate-Specific-Antigen.pdf.

    National Comprehensive Cancer Network. National Comprehensive Cancer Network clinical practice guidelines in oncology (NCCN Guidelines®): prostate cancer. Revised 2012 April. Fort Washington (PA): NCCN;2012.

  2. American Urological Association. Management of Erectile Dysfunction Clinical Practice Guideline. Updated 2006. [Internet]. Linthicum (MD):AUA;2005 [cited 2012 Oct 16]. Available from: www.auanet.org/content/clinical-practice-guidelines/clinical-guidelines.cfm?sub=ed.

  3. American Urological Association. Management of the Benign Prostatic Hyperplasia Clinical Practice Guideline. [Internet]. Linthicum (MD):AUA;2010[cited 2012 Oct 16]. Available from: www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=bph.

  4. Heldwein FL, Teloken PE, Hartmann AA, Rhoden EL, Teloken C. Antibiotics and observation have a similar impact on asymptomatic patients with a raised PSA. BJU Int [Internet]. 2011;107(10):1576-81.

    Stopiglia RM, Ferreira U, Silva Jr. MM, Matheus WE, Denardi F, Reis LO. Prostate specific antigen decrease and prostate cancer diagnosis: Antibiotic versus placebo prospective randomized clinical trial. J Urol [Internet]. 2010 3;183(3):940-5.

  5. Tasian G and Copp H: Diagnostic performance of ultrasound in Nonpalpable Cryptorchidism: A systematic review and meta-analysis. Pediatrics [Internet]. 2011 Jan: 127(1): 119–128.

  6. Diagnosis, prevention, and treatment of Catheter-Associated Urinary Tract Infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America [Internet]. Arlington (VA): Infectious Diseases Society of America; 2010 [cited 2014 Nov 4]. Available from: www.auanet.org/common/pdf/education/clinical-guidance/UTI-in-Adults.pdf.

  7. American Urological Association Prostate-Specific Antigen best practice statement, 2013 Revision [Internet]. Linthicum (MD): American Urological Association; 2013 [cited 2014 Nov 4].Available from: www.auanet.org/education/guidelines/prostate-specific-antigen.cfm.

  8. American Urological Association position statement on the use of vaginal mesh for the repair of Pelvic Organ Prolapse, 2011 [Internet]. Linthicum (MD): American Urological Association; 2011 [cited 2014 Nov 4]. Available from: www.auanet.org/about/vaginal-mesh-for-pelvic-organ-prolapse.cfm.

  9. Early detection of prostate cancer: American Urological Association guideline, 2013 [Internet]. Linthicum (MD): American Urological Association; 2013 [cited 2014 Nov 4]. Available from: www.auanet.org/education/guidelines/prostate-cancer-detection.cfm.

  10. Diagnosis, evaluation and follow-up of Asymptomatic Microhematuria (AMH) in adults: American Urological Association Guideline, 2012 [Internet]. Linthicum (MD): American Urological Association; 2012 [cited 2014 Nov 4]. Available from: www.auanet.org/education/guidelines/asymptomatic-microhematuria.cfm.