Is there a link between BPH and prostate cancer?

BPH is one of the most common diseases of older men, with more than 70% of men over 70 years affected, and prostate cancer is the most common cancer in men in the UK. Prostate cancer generally presents in one of three ways: asymptomatic patients who are screened (usually by a PSA test); men with LUTS who are investigated and undergo prostate biopsy; or patients with symptoms of metastasis such as bone pain. Men can be reassured that the main cause of LUTS is BPH. Only a small proportion of men have LUTS that are directly attributable to prostate cancer. Digital rectal examination (DRE) gives an evaluation of prostate size, which is relevant in particular to BPH management, and along with PSA testing it is one of the only ways of differentiating clinically between BPH and prostate cancer. If a nodular abnormality is present there is around a 50% chance of a diagnosis of prostate cancer being made on biopsy. Raised levels of serum PSA may be suggestive of prostate cancer, but diagnosis requires histological confirmation in almost every case. A normal PSA, PSA density and DRE can give reasonable confidence with regards to excluding clinically significant prostate cancer. BPH is not a known risk factor for prostate cancer, although the two frequently coexist. Age is the strongest predictor of prostate cancer risk, along with family history. BPH is not considered to be a precursor of prostate cancer. It is likely that although BPH may not make prostate cancer more likely to occur, it may increase the chance of diagnosing an incidental cancer.     

The role of molecular forms of prostate-specific antigen (PSA or hK3) and of human glandular kallikrein 2 (hK2) in the diagnosis and monitoring of prostate cancer and in extra-prostatic disease.

Prostate-specific antigen (PSA or hK3) is a glandular kallikrein with abundant expression in the prostate that is widely used to detect and monitor prostate cancer (PCa), although the serum level is frequently elevated also in benign and inflammatory prostatic diseases. PSA testing is useful for early detection of localized PCa and for the detection of disease recurrence after treatment. However, PSA has failed to accurately estimate cancer volume and preoperative staging. There is no PSA level in serum that definitively distinguishes men with benign conditions from those with prostate cancer, although PCa is rare in men with PSA levels in serum < 2.0 ng/ml. This prompted searches for enhancing parameters to combine with PSA testing, such as PSA density, PSA velocity, and age-specific reference ranges. Due to the protease structure, PSA occurs in different molecular forms in serum and their concentrations vary according to the type of prostatic disease. Human glandular kallikrein 2 (hK2) is very similar to PSA, but expressed at higher levels in prostate adenocarcinoma than in normal prostate epithelium. Blood testing for hK2 combined with different PSA forms improves discrimination of men with benign prostatic disease from those with prostate cancer. Many data have also been reported on the extra-prostatic expression of both PSA and hK2, and it is now believed that they may both have functions in tissues outside the prostate.     

The kallikrein family of proteins as urinary biomarkers for the detection of prostate cancer

BackgroundSeveral urinary biomarkers have been assessed as showing a discriminatory ability to differentially diagnose prostate cancer, albeit with manipulation of the prostate. Here we examine the clinical utility of multiple members of the kallikrein family of proteins in non-manipulative urinary biomarker testing.MethodsForty urine samples were collected from patients admitted for urological examination. Twenty, with a confirmed benign diagnosis and 20 with prostate cancer. The levels of 14 kallikrein proteins were measured in patient's urine and normalized for creatinine.ResultsTen of the 14 kallikreins tested had detectable levels in urine. However, none showed statistical significance in discriminating patients. Serum PSA was superior to urine PSA and other urinary kallikreins in separating patients with and without prostate cancer.ConclusionsWe were unable to distinguish men with and without prostate cancer using multiple kallikreins as urinary biomarkers. These results highlight the difficulties in diagnosing prostate cancer via urine testing for soluble biomarkers.     

Prevalence of lower urinary tract symptoms and prostate enlargement in the primary care setting

PURPOSE: Men with lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia often do not discuss their symptoms with their primary care physicians (PCPs). The primary objectives of this study were to estimate the prevalence of LUTS, prostate enlargement, and prostate-specific antigen (PSA) > or = 1.5 ng/ml in men visiting their PCP and to assess patients' intent to discuss LUTS with their PCP. METHODS: Men over age 50 presenting for a routine office visit at one of six PCP offices during the 8-week data collection period were invited to participate in this cross-sectional study. Men with prostate cancer, bladder cancer, indwelling urethral catheter or previous pelvic irradiation were excluded. Four hundred and forty-four men were enrolled and completed a self-administered questionnaire [including the International Prostate Symptom Score (IPSS)], provided a blood sample for PSA, and underwent a digital rectal examination (DRE), with the prostate classified as enlarged or non-enlarged by their PCP. RESULTS: Forty-two per cent of men had IPSS > 7; 48% had an enlarged prostate based on DRE and 43% had PSA > or = 1.5 ng/ml. Twenty-nine per cent (n = 129) of men had IPSS > 7 and enlarged prostate or PSA > or = 1.5 ng/ml. Of these men, 33% (n = 42) intended to discuss their symptoms with their PCP. CONCLUSIONS: Although a significant percentage of men in this older population had enlarged prostate and LUTS, only one-third of them intended to discuss their symptoms with their physician. PCPs may need to increase efforts to detect LUTS and enlarged prostate in older men.     

Benign prostatic hyperplasia and urinary symptoms: Evaluation and treatment

Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting middle-aged men. This condition can be microscopic, macroscopic, symptomatic, or asymptomatic. Up to 15% to 25% of men aged 50–65 years have lower urinary tract symptoms (LUTS) consisting of nocturia, urgency, frequency, a sensation of not completely emptying the bladder, stop-start urination, straining to urinate, a need to urinate soon after voiding, and weak urinary stream. These symptoms usually are associated with benign enlargement of the prostate gland that is of sufficient severity to interfere with a man’s quality of life. Although LUTS is often associated with BPH, LUTS can also be due to various unrelated syndromes such as heart failure, urinary tract infections, and diabetes. Most men will have benign hyperplasia of the prostate gland and this benign growth compresses the urethra resulting in LUTS. This article will discuss the evaluation, pharmacological management, minimally invasive treatment, and surgical therapy of this common condition affecting millions of American men.     

前列腺癌尿液肿瘤标志物的研究进展

前列腺癌是男性生殖系统最常见的恶性肿瘤之一,也是导致男性癌症死亡的第五大原因,早期诊治可改善患者预后。目前,前列腺癌的诊断主要依赖于直肠指诊或血清前列腺特异性抗原(prostate specific antigen,PSA)检测后前列腺穿刺活检确诊。但血清PSA检测特异性较低,不能有效区分惰性前列腺癌与具有临床意义的前列腺癌,导致不必要的活检及过度治疗,因此迫切需要更具特异性的肿瘤标志物。前列腺癌细胞可将肿瘤标志物释放至前列腺液中,而后进入尿液,因此通过尿液即可检测前列腺癌肿瘤标志物。近年来,已开发了多种基于尿液及其外泌体的肿瘤标志物,如PSA、PCA3、MALAT1及微RNA等,本文将阐述尿液肿瘤标志物在前列腺癌诊断中的研究进展。     

Improving lower urinary tract symptoms in BPH

Benign prostatic hyperplasia (BPH) is one of the most common diseases to affect older men. Histological disease is present in more than 60% of men beyond their sixties, and more than 40% of men in this age group have lower urinary tract symptoms (LUTS). The prevalence increases with age. About one-fifth of patients with symptomatic disease who present to a doctor will eventually be treated surgically. The remainder will often be managed initially by active surveillance. The majority of these men suffer gradual progression of symptoms and increasingly require treatment. BPH is characterised by a spectrum of obstructive and irritative symptoms, known collectively as LUTS. Poor urinary flow and the sensation of incomplete bladder emptying are the two symptoms that correlate most closely with the eventual need for prostate surgery. Untreated, a significant number of men with BPH will eventually develop acute urinary retention. In addition tosymptom assessment, digital rectal examination can provide an estimate of prostate volume and exclude a palpable nodule suggestive of prostate cancer. PSA testing provides additional information about the risk of prostate cancer being present. Medical management of BPH is suitable for most patients with moderate symptoms. The two main evidence-based approaches are treatment with alpha1-blockers and 5alpha-reductase inhibitors (5-ARLs). Severely symptomatic patients may also respond to these drugs. Mild symptoms should usually be managed by active surveillance. Combination therapy with an alpha1-blocker and a 5-ARI is more effective than monotherapy in terms of symptom relief and prevention of progression.     

Factors influencing southern Taiwanese men's acceptance of prostate‐specific antigen screening

Prostate‐specific antigen (PSA) testing is a common screening among adult men for early awareness of prostate cancer. Although prostate cancer is the seventh most common cause of death from cancer in males in Taiwan in 2008, this testing is still unpopular in Taiwanese society. The purpose of this study was to explore the prevalence of acceptance of PSA testing and related factors in Taiwanese males. A cross‐sectional study was conducted. The sample population was recruited from two counties in southern Taiwan. Three hundred and thirty male participants completed the structured questionnaire. The following outcomes were studied: patient profiles, knowledge of PSA screening, acceptance of PSA testing, the reasons for acceptance of PSA testing and history of benign prostate hypertrophy (BPH). The results indicated that 29·4% of the respondents reported having had a PSA test. The logistic regression model showed age, having heard of PSA testing, BPH history and annual income to be the statistically significant factors. The odds of accepting PSA testing increased 9·56‐fold in men with a history of BPH compared with men without a BPH history. Acceptance of PSA testing increased 7·98‐fold in patients who had heard of PSA testing compared with those participants who had not heard of PSA testing. The odds of accepting PSA testing increased 4·43‐fold in patients aged 56–65 years, 8·14‐fold in those aged 66–75 years and 11·20‐fold in those older than 76 years when compared with men younger than 55 years. This study shows that male acceptance of PSA testing is still not popular in Taiwan. The results can help health care providers to take the responsibility for seeking appropriate strategies to improve the rate of acceptance of PSA testing.     

The diagnostic value of abdominal ultrasound,urine cytology and prostate‐specific antigen testing in the lower urinary tract symptoms clinic

Introduction: Lower urinary tract symptoms (LUTS) affect 18–26% of men aged 40–79 years, many of whom present with a fear of having cancer. Current guidelines for the assessment of LUTS focus mainly upon benign prostatic hypertrophy. It has been our practice to perform an abdominal ultrasound scan (USS), a prostate‐specific antigen (PSA) blood test and urine cytology during the assessment of males presenting with LUTS to investigate the alternative potentially life‐threatening causes for LUTS. We report on the added value of these tests during the assessment of men with LUTS. Results: A total of 263/3976 (6.6%) patients investigated for LUTS were found to have incidental urological malignancies, urinary tract calculi or abdominal aortic aneurysms (AAA). Abdominal USSs resulted in the incidental diagnosis of four renal carcinomas (0.1%), 45 AAAs (incidence = 1.1%) and 44 urinary tract calculi (1.1%). Urine cytology testing and bladder USSs helped diagnose 17 new bladder cancers (0.4%), five of which did not present with haematuria. Patients found to have an elevated age‐specific PSA had a 23.6% chance of being diagnosed with prostate cancer (3.8%). Conclusion: The addition of abdominal ultrasound scanning, urine cytology and PSA testing as part of an LUTS assessment protocol can help to diagnose significant, potentially life‐threatening conditions in up to 6.6% of patients. While the pick up rate of each individual condition is not higher in the LUTS patient than in the general population, the combined pick up rate may justify these additional investigations.     

Minority issues in prostate disease

This article has discussed the increased incidence and disproportionately increased mortality of prostate cancer among African American men.Although the exact reasons are unknown, genetics may play a role, in addition to health care practices. Morbidity from other disease states, such as diabetes, obesity, or hypertension, may influence the overall survival of patients with prostate cancer. Current research tools will continue to explore biologic differences between the races; however, socioeconomic status and access to health care must not be overlooked. Several studies have demonstrated that similar disease stages and equal access to health care will result in similar outcomes.It is recognized that screening for prostate cancer will remain a controversial topic. Several influential professional societies recommend against screening and other professional societies endorse screening. Large-scale trials are currently underway hoping to answer this critical question.Since the advent of current screening tools, however, it seems that the overall mortality for prostate cancer has decreased and this cannot be ignored. Certainly, screening programs and clinical trials have traditionally had difficulty in recruiting minority participants, although more recent trials seem to be finding success. A primary care physician who is viewed as competent by their patients can certainly have a positive impact on their African American patients' willingness to participate in studies and screening programs. Most importantly, on the individual level, primary care physicians can provide a great service to their minority patients by offering educational materials on prostate cancer and by offering screening to qualified patients. The current American Urologic Association and National Cancer Institute guidelines recommend offering screening to all men age 50 and above. African American men or men with a first-degree relative with prostate cancer should be offered screening beginning at age 40.Proper screening consists of both a digital rectal examination to assess for asymmetry or nodules of the prostate and a serum PSA. Current recommendations are that individuals with a serum PSA greater than 4 ng/mL ora prostate nodule or asymmetric prostate should be referred to an urologist,where a biopsy can be performed easily in the office setting.The PSA cutoff of 4 has recently been questioned. A study by Thompson et al [31] evaluated 2950 men with a PSA of 4 or less with prostate biopsy.They found that the risk of prostate cancer in men with a PSA between 3.1 and 4 was 26.9% and that 25% of these men with prostate cancer had high-grade disease. All men found to have cancer had T1 disease. The clinical relevance of this surprisingly high rate of prostate cancer in men with a normal PSA is yet to be determined and is pending in studies on the ultimate effect of screening on mortality from prostate cancer. This information is not intended to confuse the issue, but intended to provide the most up-to-date information and allow for the best clinical decision making by the primary care physician. What can currently be recommended is if a patient is concerned about his possibility of having prostate cancer despite a normal PSA, a referral to an urologist to at least further discuss the issue may be in order. This may be especially true if the patient is African American or has a family history of prostate cancer at an early age.     

Prostate-specific antigen and prostate cancer

Serum prostate-specific antigen (PSA) measurement is used to investigate patients with lower urinary tract symptoms and to screen for prostatic malignancy in symptom-free males over 50 years of age. Approximately 60% of patients with early (prostate-confined) occult malignancy show increased serum PSA levels, as do some 20% of patients with prostatic symptoms from benign prostatic disease. When PSA is only slightly raised, serial PSA measurements, correction for prostatic volume and especially measurement of free (unbound) PSA (which is reduced in prostatic malignancy) may assist the differentiation of prostatic cancer from benign hypertrophy. Serial measurements are also of value for monitoring treatment of prostate cancer and for post-treatment surveillance.     

Prostate-specific antigen screening: friend or foe?

Prostate cancer is the most frequently diagnosed cancer among men in the United States. The prostate-specific antigen (PSA) blood test is the most commonly utilized test to detect early prostate malignancy. Elevated PSA levels suggest to providers the possibility that their patients are at a higher statistical risk of harboring asymptomatic, organ-confined prostate cancer. Although PSA testing has become a primary screening method for prostate cancer in the United States, this test has come under scrutiny. PSA screening lacks a high level of specificity due to frequent false-positive results. Additionally, major health organizations differ in their screening recommendations for use of the PSA test. However, the medical community, and more importantly, patients, must understand the benefits and possible detriments of this screening test. Providers should approach each man individually when recommending a PSA test, noting that many risk factors must be considered in a screening protocol for prostate cancer.     

PS1-07: PSA Test Use in Primary Care

Background/Aims Some professional organizations advocate for PSA testing to screen for prostate cancer while others recommend against it. Regardless of position, each advocates for consideration of individual risk factors and for patients to consult with their physician when deciding. We describe men's use of PSA testing around the time of a periodic health examination (PHE), whether test use varies by patient risk factor status, and the extent to which PSA testing occurs following patient-physician discussion of PSA testing, prostate cancer, or both. Methods Physician and patient subjects were enrolled in an observational study of patient-physician decision making in primary care. Physicians were salaried, general internal and family medicine physicians. Patients were insured, aged 50-80 years, without a history of prostate cancer, and due for colorectal cancer screening at the time of an audio-recorded office visit between 2007-2009. Office visit recordings were joined with data from pre-visit patient surveys and automated laboratory data for the 6 prior and 8 subsequent weeks. Content of patient-physician discussions was coded with a structured coding worksheet (mean Cohen's Kappa = 0.77). Generalized estimating equations were used to evaluate associations among patient-physician screening-related talk, patient risk factors, and PSA use. Results Among N=161 study-eligible men, just over half (53%) presented with at least one risk factor: 11.2% family history; 29.2% aged 65+; and 21.2% black. Eighty-one percent used PSA testing around the time of their PHE (8.3% prior and 72.7% subsequent to visit). Test use did not differ significantly by risk factor status: family history, 94.4% vs. no family history, 79.4%, (p=0.13); aged 65+, 85.1% vs. aged <65, 79.8% (p=0.39); and blacks, 76.5% vs. whites, 82.7%(p=0.49). Prostate cancer, PSA testing, or both was mentioned during 82% of visits: 34.8% mentioned prostate cancer and 79.5% PSA testing. Among men tested subsequent to visit, these percents were 92.9%, 35.0% and 89.3%, respectively. Discussion PSA testing is common among men who schedule a PHE, regardless of risk factor status. Furthermore, 7% of men who receive PSA testing subsequent to their PHE, do so in absence of any mention of prostate cancer or PSA screening during the visit.     

Predictors of prostate cancer screening intention among older men in Jordan

Intention to prostate cancer screening (PCS) is one of the major factors affecting the long‐term success of population‐based PCS programmes. The aim of this study is to explore strong factors linked to intention to PCS among older Jordanian adults using the Health Belief Model (HBM). Data were obtained from Jordanian older adults, aged 40 years and over, who visited a comprehensive health care centre within a ministry of health. A pilot test was conducted to investigate the internal consistency of the Champion Health Belief Model Scale for PCS and the clarity of survey questions. Sample characteristics and rates of participation in PCS were examined using means and frequencies. Important factors associated with intention to PCS were examined using bivariate correlation and standard multiple linear regression analysis. About 13% of the respondents were adherent to PCS over the prior decade. Four out of the seven HBM‐driven factors (perceived susceptibility, benefits and barriers to prostate‐specific antigen (PSA) test, and health motivation) were statistically significant. Those with greater levels of susceptibility, benefits of PSA test and health motivation and lower levels of barriers to PSA testing were having more intention to participate in PCS. Family history, presence of urinary symptoms, age and knowledge about prostate cancer significantly predicted the intention to PCS. Intervention programmes, which lower perceived barriers to PSA testing and increase susceptibility, benefits of PSA testing and health motivation, should be developed and implemented.     

Diagnosis and management of benign prostatic hyperplasia

Benign prostatic hyperplasia is a common condition affecting older men. Typical presenting symptoms include urinary hesitancy, weak stream, nocturia, incontinence, and recurrent urinary tract infections. Acute urinary retention, which requires urgent bladder catheterization, is relatively uncommon. Irreversible renal damage is rare. The initial evaluation should assess the frequency and severity of symptoms and the impact of symptoms on the patient's quality of life. The American Urological Association Symptom Index is a validated instrument for the objective assessment of symptom severity. The initial evaluation should also include a digital rectal examination and urinalysis. Men with hematuria should be evaluated for bladder cancer. A palpable nodule or induration of the prostate requires referral for assessment to rule out prostate cancer. For men with mild symptoms, watchful waiting with annual reassessment is appropriate. Over the past decade, numerous medical and surgical interventions have been shown to be effective in relieving symptoms of benign prostatic hyperplasia. Alpha blockers improve symptoms relatively quickly. Although 5-alpha reductase inhibitors have a slower onset of action, they may decrease prostate size and alter the disease course. Limited evidence shows that the herbal agents saw palmetto extract, rye grass pollen extract, and pygeum relieve symptoms. Transurethral resection of the prostate often provides permanent relief. Newer laser-based surgical techniques have comparable effectiveness to transurethral resection up to two years after surgery with lower perioperative morbidity. Various outpatient surgical techniques are associated with reduced morbidity, but symptom relief may be less durable.     

Prostate-specific antigen in screening of prostate cancer

Prostate-specific antigen (PSA) is a wellcharacterized human prostate-specific glycoprotein. PSA has been shown to be the most effective immunohistologic marker for prostate cancer, as well as the most useful serologic test in staging and monitoring prostate cancer and in early detection of recurrent disease. The greatest clinical value of PSA is as an aid for early detection of prostate cancer. Recent studies have indicated that PSA-based screening of the older population for organ-confined early-stage prostate cancer is an acceptable, practical, and reliable modality. The accuracy of PSA screening is within the same range as the mammogram. The cost-effectiveness of PSA is comparable to other cancer screening tests. Although the increase in the patient's survival due to PSA-based detection of early prostate cancer remains to be documented, it is generally agreed that the PSA test along with digital rectal examination (DRE) should be included in the annual physical examination for men 50 years of age or older. Highrisk men are urged to commence at age 40. Asymptomatic men who have both a negative DRE and normal PSA blood test need only to continue an annual DRE and PSA check-up. Men who have a negative DRE and elevated PSA, and all those who have a suspicious DRE regardless of PSA results, should undergo further diagnostic workup, such as transrectal ultrasonography with biopsy of visible lesions. The cure rate is high with timely treatment, when prostate cancer is detected while still confined to the prostate. © 1994 Wiley-Liss, Inc.     

Initial experience of a community‐based prostate cancer risk assessment clinic for men of black and minority ethnicity background

We designed and implemented a community‐based prostate cancer risk assessment clinic targeting men from black and minority ethnicity (BME) background. This service had the dual aims of optimizing detection of prostate cancer within a local BME population, with a secondary goal of encouraging longer‐term engagement with primary care for follow‐up prostate‐specific antigen (PSA) testing in order to facilitate early diagnosis of future disease. “Drop‐in” clinics were set up in strategic locations and, staffed by experienced urology nurses. Risk assessment was offered in the form of a PSA test, and digital rectal examination (DRE). We targeted men of BME background aged between 45 and 75 but all attending individuals were given access to counselling and assessment as appropriate. In total, 312 men attended clinics for risk assessment. We diagnosed nine prostate cancers with histological confirmation, with a further two individuals considered to have prostate cancer based on clinical/biochemical parameters. These findings were consistent with similar previously published reports. Nurse‐led, community‐based targeted risk assessment is feasible, leads to the detection of significant numbers of prostate cancers and is well received by patients.     

Prostate cancer and prostate-specific antigen (PSA) screening in Austria

The possible effect of prostate-specific antigen (PSA) testing on prostate cancer mortality has remained controversial, despite the test's widespread application. We examined age-specific mortality trends for prostate cancer in Austria before and after the introduction of (opportunistic) PSA testing, to ask whether PSA screening reduces prostate cancer mortality in a uniform cohort of men with equal access to health care. Prostate cancer mortality data covering all 9 federal states of Austria were analysed from 1970 to 2002. PSA testing became widely available in Austria not before 1989. Tyrol, one of the nine federal states of Austria, independently launched a mass prostate cancer prevention project in 1993. We applied join-point regression models to identify changes in the slope of age-specific mortality trends in selected age groups (50-59, 60-69, 70-79, and 80-89 years) and calculated the annual percent change (APC) in mortality between 1970 and 2002 for Tyrol and the rest of Austria separately. After 12 years of follow-up, we were not able to observe a significant reduction in prostate cancer mortality since the introduction of the PSA test in the age groups of 50-59, 60-69, and 80-89 years. A significant decrease was found in the age group of 70-79 (Austria without Tyrol 1989 through 2002: APC, -2.36; 95% CI, -3.38 to -1.34; Tyrol 1991 through 2002: APC, -6.42; 95% CI, -8.92 to -3.86). In this age group the join points 1989 and 1991 cannot be related to PSA testing. PSA screening does not appear to reduce prostate cancer mortality in a uniform cohort of men with equal access to health care. However, given the long lead-time for prostate cancer, even longer follow-up may still be needed to detect any important trends.     

Antimuscarinics for treatment of storage lower urinary tract symptoms in men: a systematic review

Despite potential benefits, primary care clinicians may avoid using antimuscarinics in men with overactive bladder (OAB) symptoms because of safety concerns. To review the efficacy and safety of antimuscarinics, alone or in combination with an α-blocker, for the treatment of men with OAB symptoms, we conducted a systematic review of articles published before 22 July 2010, using PubMed. Data from 12-week, randomised, double-blind, placebo-controlled trials of tolterodine extended release (ER), oxybutynin and solifenacin show that combined antimuscarinic+α-blocker treatment is generally more effective than monotherapy or placebo in men with OAB symptoms. The efficacy and safety of tolterodine ER+α-blocker treatment was not affected by prostate size or prostate-specific antigen (PSA) level. In men meeting entry criteria for OAB and benign prostatic obstruction trials, tolterodine ER alone was effective selectively in men with prostate size or PSA level below study medians. Incidence of acute urinary retention (AUR) in men receiving antimuscarinics with or without an α-blocker was ≤3% in all of these trials; changes in postvoid residual volume and maximum flow rate did not appear clinically meaningful. Post hoc analyses from double-blind, placebo-controlled trials and prospective studies of fesoterodine, oxybutynin, propiverine, solifenacin and tolterodine also suggest that antimuscarinics are generally safe and efficacious in men. A retrospective database study found that risk of AUR in men was the highest in the first month of treatment and decreased considerably thereafter. Antimuscarinics, alone or with an α-blocker, appear to be efficacious and safe in many men with predominant OAB symptoms or persistent OAB symptoms despite α-blocker or 5-α-reductase inhibitor treatment. However, antimuscarinics are not approved for the treatment of benign prostatic hyperplasia. Monitoring men for AUR is recommended, especially those at increased risk, and particularly within 30 days after starting antimuscarinic treatment.     

PSA-screening for prostate cancer--yes or no?

Prostate cancer is a mayor health care problem, especially in the industrialised countries of the Western world. At this time it is the second most common cancer reason for death (CH: 1500 men/year) which will even get more importance in the future by demographic developments. While there is no doubt that in individuals early detection of organ confined disease with localised treatment the prostate cancer can be eradicated and individual men be cured there are uncertainties whether mass screening a population will contribute to reducing prostate cancer related mortality. Its value has not been proved definitively by prospective randomised controlled studies. Most of Medical Societies recommend a "well informed" decision by family physicians, where the men between 50-70 years know about the benefits and harms including: risk of cancer, diagnostic procedures, therapeutic consequences and possible side effects. After agreement of early detection a biopsy has to be done directly above a PSA level of 4.0 ng/ml or a suspicious digital rectal examination. A PSA "grey zone" 4-10 ng/ml can not further be postulated. The ratio of free/total PSA gives no support to prolong biopsy in this moment, because an elevated benign prostate with a higher production of free PSA can mask the tumor in the peripheral zone. Results of the ERSPC and the PLCO trials are expected to give information about the benefits and harms of mass screening in 2006/8.