Androgen deprivation therapy (ADT) in men with prostate cancer is associated with a small but significant increase in fracture risk, a UK study has shown. Using the Hospital Episodes Statistics database for 2004-2008, the authors identified 8,902 men with prostate cancer who had been admitted to hospital with a fracture. Of these, 3,372 (37.8%) had been treated with ADT and 5,530 (62.2%) had not. There were 228,852 admissions in the background population.

Testosterone therapy in men 65 and over with low testosterone levels produced moderate improvements in sexual function and some improvement in mood but had no effect on vitality or walking. All men enrolled were randomised to either testosterone gel or a placebo gel for one year.

The addition of docetaxel at the time of hormone therapy initiation for advanced prostate cancer improved overall survival by 10 months, in a large  randomised controlled trial. The STAMPEDE study commenced in 2005, and has recruited men with metastatic, high-risk localised or node-positive prostate cancer who were newly diagnosed or had high-risk recurrence following previous local therapy. STAMPEDE utilises a multi-arm approach to test whether addition of other agents at the time of hormone therapy initiation improves overall survival.

Although initial treatment of urinary tract infection (UTI) with ibuprofen reduced the use of antibiotics, women had a greater symptom burden and a higher risk of pyelonephritis than those treated with antibiotics from the outset, a primary care study from Germany has found.

The newer prostate-specific alpha blockers produce a small but significant increase in the risk of falls in older men with lower urinary tract symptoms (LUTS), a study from Canada has shown. The alpha blocker cohort consisted of 147,084 men aged 66 years and over, starting a selective alpha blocker (84% tamsulosin). An equal cohort of matched men, not taking alpha blockers was created on a 1:1 basis. The primary outcome measures were falls and fractures 90 days after initiation of therapy. Secondary outcomes were major osteoporotic fractures, hip fractures, hypotension and head trauma.

Regular physical activity reduces the risk of prostate cancer in older men, a single-centre study from Italy has shown.

Mirabegron in combination with solifenacin significantly reduced overactive bladder (OAB) symptoms, in a small preliminary study from Japan. This was an open label study with no placebo arm, over a relatively short time period of 16 weeks of treatment. So the results must therefore be interpreted with caution. Clearly, combination therapy represents a promising development in the medical treatment of the symptoms of overactive bladder. Formal, double blind, randomised controlled trials are shortly due to report and it will be interesting to see if these findings are replicated in a more rigorous trial setting. More importantly, the results will need to be analysed to see if improvements in symptoms are clinically significant to patients in order to justify the addition of a further long-term therapy, and a significant increase in the cost of medical treatment.

Black men are less likely to choose investigation for symptoms that may herald prostate cancer, at all levels of risk, a UK study has found. A total of 555 men (286 black, 269 white), aged ≥ 40, were approached while awaiting a GP appointment and recruited to the study from four GP surgeries in Bristol. This study emphasises ethnic differences in attitudes towards prostate cancer diagnosis, and a different approach to risk. It is important therefore to be aware of these differences when discussing investigations with Afro-Caribbean men. Better targeting of PSA testing in higher risk black men is vital if we are to lessen the disparate burden this disease has on the Afro-Caribbean population.

Ultrasound may be a viable alternative to CT scanning as an initial investigation for suspected nephrolithiasis, the findings from a study in the United States suggest. A total of 2,759 patients aged 18-76, presenting to an emergency department with suspected renal colic were randomly assigned to either initial diagnostic ultrasound carried out by an emergency physician (908), ultrasound by a radiologist (893), or abdominal CT scan (985).

Vasectomy may be associated with a small increase in absolute risk of prostate cancer, the findings from a large cohort study in the United States suggest. A cohort of 49,405 men taking part in the Health Professionals Follow-Up Study, run by Harvard University, was followed up from 1986 to 2010. During this period 12,321 men (25%) had vasectomies. [With external links to the current evidence base]

Combining an antimuscarinic with a beta-3 adrenoceptor agonist could improve the symptoms of overactive bladder (OAB), while allowing a lower dose of antimuscarinic and thus reducing side effects, results of an early study suggest. A total of 1,306 patients, at 141 centres across 20 European countries, were randomised in this study. Two-thirds of the patients were women, and all had had symptoms of OAB for 3 months or longer.  [With external links to the current evidence base]

Radical prostatectomy significantly reduced the risk of death compared with watchful waiting in men under 65 with early prostate cancer, in a large study from Sweden. However, in older men although surgery was associated with a reduced risk of metastases there was no effect on mortality. [With external links to the current evidence base]

Patients with BPH being treated with combination therapy for LUTS are more likely to be able to stop the alpha blocker treatment than the 5-alpha reductase inhibitor (5-ARI), a study from Taiwan suggests.[With external links to the current evidence base]

Younger men with good function before surgery are likely to maintain their level of sexual function and continence following prostatectomy, research published in European Urology has shown. Two studies followed more than 1,700 consecutive radical prostatectomy patients of a single ‘high-volume’ surgeon. Patients were followed up at 3, 6, 12, 24, 96 and 120 months using a series of validated questionnaires. [With external links to the current evidence base]

Drinking beer, wine or coffee can reduce the risk of kidney stone formation, according to a study from the USA. On the other hand, regular consumption of sugar-sweetened soft drinks increased the risk. The study combined patients from the Health Professionals Follow-Up Study and the two Nurses Health studies (I and II) to amass a total of 194,095 participants. They were followed up by biennial questionnaire for a median of more than eight years, and assessed for their fluid intake and development of renal calculi.

Treatment for four years with a 5-alpha reductase inhibitor (5-ARI) for lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement was not associated with the development of prostate cancer, a case control study has found.

The link between overactive bladder (OAB) and irritable bowel syndrome (IBS) suggests that it is worth GPs asking about bowel symptoms when assessing patients with symptoms suggestive of OAB, a study from Japan concludes. The researchers investigated the prevalence of OAB and IBS using a large-scale internet-based survey. Questionnaires were sent to 10,000 patients, 5,000 men and 5,000 women, with 1,000 of each gender represented from each decade from 20-29 through to 60 and over. [With external links to the current evidence base]

Erectile dysfunction is a risk marker for cardiovascular disease, a large prospective population-based study from Australia has found.

Robot-assisted radical prostatectomy (RARP) produced better continence and potency rates at three months compared with laparoscopic radical prostatectomy (LRP), in a prospective randomised study from Italy.

Although short-to medium-term functional outcomes favoured radiotherapy over surgery in terms of sexual and urinary function in localised prostate cancer, by 15 years follow-up there were no differences in functional outcomes between the two treatment groups, in the PCOS. [With external links to current evidence and summaries]

Compared with continuous treatment intermittent androgen deprivation therapy (ADT) can improve patients’ quality of life and does not adversely affect survival, a study in the NEJM concludes. [With external links to current evidence and summaries]

Radical prostatectomy for low-risk localised prostate cancer has no significant effect on all-cause or prostate cancer specific mortality compared with observation, a randomised controlled trial has shown.

The latest data from the European Randomized Study on Screening for Prostate Cancer (ERSPC) has confirmed its earlier findings that PSA screening significantly reduces deaths from prostate cancer but does not affect all-cause mortality.

Waist circumference, a simple measure of central obesity, appears to be predictive of the severity of lower urinary tract symptoms (LUTS) in men, a study from the United States has found.

Immediately after a first prostate biopsy only one in ten men had concerns about undergoing a repeat biopsy, this proportion had increased to one in five at seven days, according to a study in the BMJ.

A clinical diagnosis of benign prostatic hyperplasia (BPH) appeared to be associated with an increased risk of prostate cancer, in a large cohort study. However, the authors caution that this does not mean that the association is causal. This study, while impressive in size and duration, can be criticised on a number of counts...

A long-term prospective study from Scotland has concluded that transurethral resection of the prostate (TURP) does not damage erectile function. However, there is an important proviso in this study...

Finasteride and dutasteride appear to have similar efficacy in benign prostatic hyperplasia (BPH) over 12 months, a head-to-head study has shown.

PSA testing has not increased in general practice in the UK despite raised public awareness and highly publicised research findings. Older men and men living in more affluent areas were most likely to be tested, a practice-based study has found.

Giving 5-alpha reductase inhibitors (5-ARIs) to men with low-risk prostate cancer undergoing active surveillance was associated with a lower rate of pathologic progression in a small retrospective cohort study.

Silodosin, a new alpha-blocker, shows promise in the treatment of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). A total of 955 men, aged >50 years, with LUTS caused by BPH were randomised (2:2:1) to receive either silodosin 8 mg, tamsulosin 400 µg or placebo for a 12-week period following a 4-week placebo run in. Importantly, the study was powered to show superiority of silodosin to placebo, but only non-inferiority to tamsulosin. Response was measured in terms of change from baseline in International Prostate Symptom Score (IPSS), storage and voiding subscores, quality of life due to urinary symptoms and maximum urinary flow rate (Qmax). Silodosin is super-selective for the α1A receptor (50 to 100 times more selective) which should in theory mean that it is better tolerated in terms of cardiovascular side effects, and even more efficacious in terms of improving LUTS. 'Although the study demonstrated silodosin's superiority to placebo and non-inferiority to tamsulosin an adequately powered study is needed to determine whether silodosin can be shown to be clinically significantly superior to tamsulosin. Further research is required to see if non-responders to tamsulosin respond to silodosin and whether the long-term effectiveness of silodosin is better than that of tamsulosin. There is a fair way to go before silodosin has an established role in the management of LUTS caused by BPH.'

The empirical use of antibiotics for asymptomatic patients with raised PSA levels confers no benefit and should be discouraged, the authors of a study in the BJUI conclude. The trial aimed to compare the outcomes for patients who presented with borderline PSA who either had a repeat PSA after 45 days, or who received levofloxacin 500 mg daily for 30 days followed by a repeat PSA after the same interval.  ' The practice of prescribing antibiotics to patients in this situation has been used to a degree by UK urologists. This study is by no means definitive, but makes it clear that the evidence for this practice is far from conclusive. For GPs the message must be that this is not a technique we should implement ourselves before referring for a urological opinion. There is clear value in repeating the PSA of a patient with a borderline result, but prescribing of antibiotics is not as yet an established management practice.'

A study from the University of Nottingham suggests that patients with an index finger longer than their ring finger have approximately two-thirds the risk of prostate cancer of those with equal finger lengths or longer ring fingers. The hypothesis is that the ratio of 2nd and 4th digit (index and ring fingers, 2D and 4D) length is fixed in utero and is altered by exposure to sex hormones at that time. The 2D:4D ratio is negatively correlated with testosterone exposure and positively related to oestrogen concentrations. This ratio may therefore act as a proxy indicator for prenatal testosterone levels. 'The study suggests that patients with an index finger longer than their ring finger have approximately two-thirds the risk of prostate cancer of those with equal finger lengths or longer ring fingers. Clearly, before you start studying your right hand, or that of your partner/father/friends etc, it should be remembered that this study has many limitations. It is a relatively small case-control study, relying on subjective self-collected data.'However, the findings are consistent with those of a paper in the British Journal of Urology,1 where those with a lower digit ratio (i.e. index finger shorter than ring finger) had higher mean PSA levels, higher risk of prostate biopsy and subsequent diagnosis of prostate cancer.

Statin usage may defer the development of lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE) by up to seven years. The Olmsted County study, a huge cohort study that has been running in Minnesota for many years, has produced several important urological papers. The Olmsted County database was used to carry out a retrospective study of almost 2,500 men, aged 40-79 years, from 1990 to 2007. 'This study has significant flaws, most notably that it is a retrospective cohort study rather than a randomised controlled trial. Furthermore, the Olmsted County population is a largely affluent Caucasian community, and therefore it is unclear as to whether these results would apply across other ethnic and socio-economic groups. However, the results are interesting at a time of ever increasing statin prescription. There is a potential for vast public health benefit if the findings of this study were reproduced across our at-risk population.'

For patients with non-visible haematuria, the probability of missing malignant disease with a guideline-based clinic protocol is less than 1% up to the age of 90. However, for visible haematuria the risk increases with age, and is greater than 4% by 70. This paper in the BJU follows up patients referred to the Plymouth haematuria clinic between 1998 and 2003. A total of 4,020 patients took part in the original study. All patients had a plain x-ray, renal tract ultrasound and flexible cystoscopy as part of their original investigation. Intravenous urography was also performed after abnormal first-line investigation or in patients with persistent haematuria at presentation where no abnormality had been detected. 'We must never assume that the haematuria clinic protocol for investigation is infallible, and for patients with visible haematuria it is important to repeat investigation if further episodes occur (or at least seek specialist advice). However, the study does not support the unselected use of additional upper tract imaging in all haematuria patients, but instead suggests that this should be targeted towards those over 50 with visible haematuria.'

Antimicrobial sensitivity results from a previous infection are a useful guide to empirical treatment of re-infection, a study from Ireland has shown. The researchers aimed to analyse sensitivity patterns to identify predictive values of previous E. coli isolates for the treatment of re-infections in clinical practice. 'Resistance to nitrofurantoin was low in this sample, and even when detected was found to decay relatively quickly. This study would suggest that nitrofurantoin is now, therefore, a better choice of empirical antibiotic for UTI unless previous MSU results have suggested trimethoprim susceptibility (within the previous year). This is consistent with the latest guidelines from the Health Protection Agency (HPA), recommending the use of nitrofurantoin as first-line empirical antibiotic in UTI.'

Absence of symptoms and negative dipstick results do not rule out infection in patients with suspected UTI, a primary care study has found. The researchers aimed to identify which clinical features and dipstick variables independently predict laboratory diagnosis of UTI, and to validate clinical decision rules based on these independent predictors. A total of 434 women with suspected UTI were recruited to the study from practices in the south of England. They were asked to rate the presence of symptoms and their severity. A midstream urine specimen was examined for cloudiness to the naked eye, and offensive odour, before urine dipstick testing was carried out. 'GPs need to be aware that in a patient with suspected UTI, absence of classic symptoms or negative dipstick results do not reliably rule out the presence of infection. Thus, alternative strategies are required for these patients, whether arranging clinical review if symptoms persist or the use of delayed prescriptions.'

The risk of prostate cancer increases with the number of family members with the disease, particularly brothers, and with younger age at diagnosis, a nationwide study has shown. The national Swedish family cancer database was used to estimate age-specific familial risks of being diagnosed with prostate cancer according to the number and type of affected first-degree relatives and according to paternal and fraternal age at diagnosis. The registry includes records of >11.8 million individuals and their cancers over nearly 50 years. The authors also calculated the risk of dying from prostate cancer according to family history. This is the largest family study published with more than 26,000 prostate cancer cases, of which 5,600 were familial. 'The take home message... is that the risk of prostate cancer increases with the number of affected first-degree family members, particularly brothers, and with younger age at diagnosis. Therefore, patients who fall into higher-risk groups can be identified.'

More men are receiving conservative management for low-grade prostate cancer, a British study has found. The authors used a longitudinal observational database, the British Association of Urological Surgeons Cancer Registry, to investigate patterns of care for low-risk, localised prostate cancer from 2000 to 2006. The database contains data from approximately 150 institutions and 400 urologists throughout the UK. 'This trend towards increasing conservative management of low-risk disease is in marked contrast to practice in the United States. If the findings of the study represent an accurate picture of patterns of care across the UK, it would indicate a significant shift in clinical practice.'

Anxiety and distress levels do not change significantly during active surveillance for low-risk prostate cancer, the findings of a small Dutch study suggest.These results are useful to clinicians involved in helping patients in this complex decision making process. The impact of perceived physician involvement in decision making is important and emphasises the need for greater patient involvement. As well as informative literature and interactive technology, prostate cancer specialist nurses can also play a key role. These nurses have been shown to have a hugely beneficial role in helping patients arrive at a management decision.

Having a full discussion with patients, before commencing treatment, about the pros and cons of medications for overactive bladder (OAB) syndrome and the role of lifestyle measures could improve adherence to therapy. This was the conclusion of a survey conducted in the United States used families participating in a large nationwide market research panel of 600,000 households. [With external links to the current evidence base]

Although expulsion rate was not improved by tamsulosin, patients may benefit from an analgesic effect and hence a reduced requirement for analgesics until stone expulsion.

This study is directly applicable to patients seen in primary care. It would suggest a safe strategy of initiating an alpha-blocker in patients with mixed storage and voiding symptoms, reviewing at 4-6 weeks, and adding an anticholinergic for those patients whose storage symptoms remain bothersome. It is always possible to trial removing the anticholinergic after a few months of bladder retraining, particularly to see if a placebo effect had a significant role, with therapy reintroduced if storage symptoms relapse. [With external links to the current evidence base]