American Urological Association

Five Things Physicians and Patients Should Question

Released February 21, 2013

  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.

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 18,000 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.

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How This List Was Created

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.

AUA’s disclosure and conflict of interest policy can be found at


  1. American Urological Association. Prostate-Specific Antigen Best Practice Statement. Revised 2009. [Internet]. Linthicum (MD): AUA; 2009 [cited 2012 Oct 16]. Available from:

    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:

  3. American Urological Association. Management of the Benign Prostatic Hyperplasia Clinical Practice Guideline. [Internet]. Linthicum (MD):AUA;2010[cited 2012 Oct 16]. Available from:

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    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.