AUA issues recommendations on PSA, PCa imaging, mesh

Antimicrobial prescription, imaging for localized prostate cancer, and shared decision making for PSA screening are among the topics of the AUA’s latest Choosing Wisely recommendations.

Related: Do you follow the AUA’s Choosing Wisely guidelines?

The effort is part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, which is designed to encourage clinicians and patients to scale back medical tests and procedures that may be unnecessary and even potentially harmful.

While most of the recommendations are straightforward, one practicing urologist called for more precise wording on the recommendation regarding shared decision making for prostate cancer screening.

The AUA’s second, most recent list includes the following recommendations:

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

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

• Don’t remove synthetic vaginal mesh in asymptomatic patients.

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

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

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“Our work with programs such as this is part of our continued commitment to offer our members and the rest of the healthcare community the best information to help them provide quality care to patients. The AUA recognizes the importance of making patients partners in their care and advocates engaging patients in conversations about and educating them of their care and treatment options. This shared approach benefits everyone,” said J. Stuart Wolf, Jr., MD, in a press release from the AUA.

Dr. Wolf is the AUA’s Science & Quality chair and also led the organization’s Choosing Wisely work group.

Urology Times Clinical Practice Board member Henry Rosevear, MD, said that while these recommendations won’t surprise the practicing urologist, he would have liked the wording of the PSA recommendation to be “more precise.”

“I agree that when PSA testing is used as a screening tool to risk-stratify carefully pre-selected patients, the AUA's statement is perfectly appropriate and necessary,” Dr. Rosevear told Urology Times. “On the other hand, when a clinician is presented with potential signs or symptoms of locally invasive or metastatic prostate cancer, engaging in a full discussion on the risks and benefits of PSA testing is not necessary for the simple reason that you are not screening those patients, you are diagnosing them.

“Had the powers that be asked this small-town plumber's opinion, I would have proposed that urologists ‘offer PSA testing for the detection of asymptomatic prostate cancer only after engaging in shared decision making.’ ”

The AUA first issued Choosing Wisely recommendations as part of the program in 2013. Those recommendations included:

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

• Do not prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.

• Do not order creatinine or upper tract imaging in men with BPH.

• Do not treat an elevated PSA with antibiotics for patients not experiencing other symptoms.

• Do not perform ultrasound on boys with cryptorchidism.

Other organizations that have participated in Choosing Wisely include the American Society of Radiation Oncology, the American Society of Clinical Oncology, and the American Association of Family Physicians, among several others.

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