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Urological Health
Retired England goalkeeper, Ray Clemence, on his prostate cancer journey P8 SOURCE: PROSTATE CANCER UK
Intuitive proudly supports Urology Awareness Month. We commend the vital work of urological organisations and clinicians who champion quality of life for their patients.
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Benign Prostate Enlargement and improvements in treatment, according to Consultant Urological Surgeon, Miss Kate Warren P4-5
How penile prostheses are transforming erectile dysfunction, according to Consultant Urological Surgeon, Mr Asif Muneer P6-7
The Movember Foundation’s CEO, Owen Sharp, discusses the unspoken symptom of Prostate Cancer, urinary incontinence, and how men can find help P8
IMAGE: GETTYIMAGES
The 'wait and see' approach can be detrimental
Professor Chris Chapple Consultant Urological Surgeon and Secretary General, European Association of Urology
As men get older it is sad that he who is master of his destiny often becomes a servant to his bladder. When it comes to seeking advice, it is often men who prefer to put things off. But this ‘wait and see’ approach can often be detrimental to their quality of life. After all, men, but also women, are predisposed to urinary tract problems – especially as they get older.
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s of the age of 50, more men suffer from increased urinary frequency which may disturb sleep and generally interfere with quality of life. It is therefore perhaps no surprise that with an ageing population, an increase in diseases affecting function of the bladder Follow us
and male erectile function, such as diabetes and obesity, occur. Men tend to make light of the situation and while this can be all well and good for raising the spirits, there is very much an attitude of ‘it won’t happen to me’. And certainly, although it is common, avoiding difficulty, increased urinary frequency, erectile dysfunction or more sinister findings, such as finding blood in your urine, are topics that men might find hard to open up about. It is important for them to speak up and realise that some conditions such as prostate cancer can develop silently. A lot of information on urological issues can be found on the internet. Some of this information comes MediaplanetUK
from trusted authorities, like hospitals, but quite a lot of it comes from unreliable and biased sources. It is important to look for a dependable source of patient information on the internet like EAU Patient Information (www.patients. uroweb.org), enabling patients and their family to educate themselves more easily. To that end, as healthcare professionals, we are perhaps guilty of using jargon that can mystify our patients slightly. There is so much information out there that urological health can seem very confusing to someone unaware of typical symptoms or treatments. It is a urologist’s job to advise and guide patients and facilitate a patient’s @MediaplanetUK
struggles to find recent and up-todate material. If men and their families are wellinformed, they can better face the reality of these problems. I believe this could empower them to take more ownership of their medical care and facilitate their decisions. Women tend to have more open and frank conversations about urological health. This means that, often, a male patient will only present when accompanied by their partner – in many cases one fed up of being woken in the night by frequent bathroom visits! The urologist is to me exactly like the gynaecologists’ role for women, dealing with all aspects of urinary abnormalities for both men and women. @MediaplanetUK
Men need to accept that there is a strong likelihood that they – or someone they know – will suffer a urological condition at some stage of their lives. Having knowledgeable resources or the ability to ask a healthcare professional, are important tools that more men should access. However, only by talking more openly about these conditions and spreading this information can we really equip the people who might need it the most. 7\SHG IURP 3URI &KDSSOH·V dictation by Jen Tidman, 5HVHDUFK 6HFUHWDU\
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Biomarkers are the future for prostate cancer diagnosis
Professor Mark Emberton Professor of Interventional Oncology, Division of Surgery and Interventional Science, University College London (UCL)
Studies show that novel biomarkers are making prostate cancer diagnosis more accurate and effective — which means fewer men will undergo unnecessary biopsies in future.
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rostate cancer isn’t easy to diagnose. Historically, diagnosis has largely been driven by a prostate examination, a PSA test (which measures the levels of Prostate Specific Antigen in the blood), and a likely further investigation via an invasive biopsy. However, this practice has become old fashioned, and we are in need of a more accurate, less invasive solution that detects only the tumours that need detecting, and doesn’t detect those that are not clinically significant. The term ‘biomarker’ - a measurable indicator of the presence, activity or likely course of a disease - is one that’s becoming increasingly familiar in oncology. PSA is a biomarker that acts as a proxy for the likely course of disease. MRI scanning is a biomarker that allows us to visualise
how the disease has manifested itself. And genetic biomarkers are moving increasingly to the fore as binary indicators of clinically significant disease. Biomarkers play unique roles in the detection of disease Ninety per cent of urologists will now offer patients with elevated PSA an MRI scan, which has been a brilliant development towards improved diagnosis. According to Mark Emberton, Professor of Interventional Oncology at University College London (UCL), “MRI scanning can double the detection of clinically significant disease and lower the detection of insignificant disease,’’ but there remain instances where use of MRI is not possible, or where the results are indeterminate. That’s when a reliable ‘companion’ biomarker is useful. Equally, according to Professor Emberton, we are in need of something better than PSA to determine who is eligible for further tests – these are what we call ‘triage’ biomarkers.
Not all tumours need detection We are in an age of constant research and developments, and many say that it’s an exciting time for medicine, but with 10,000 men still dying from prostate cancer each year, there is still lots to be done.
With 10,000 men dying from prostate cancer each year, there is still lots to be done Clearly, early detection is important, but so is the right kind of detection, stresses Professor Emberton, because over-diagnosis can be harmful to patients. “This type of cancer is so prevalent that testing needs to be more sophisticated than just finding tumours,” and that could be where we rely on novel biomarkers to improve accuracy and reduce scope for misinterpretation. Paving the way for a national screening programme “The next challenge is one of implementation so that all men, globally, have access to high quality
screening,” Professor Emberton says. “Most of the screening scandals that occur are because of poor quality [screening] in what is a very complex intervention. It’s a very complex pathway and if you don’t get everything right, you’ll miss out on those few patients whose lives you could have prolonged.” Soon, a country-wide prostate screening programme could be possible in the same way that breast cancer screening is available to women over 50, and it’s an area being led by the NHS and UK medicine. The MRC and CRUK have funded a study called ‘Re-imagine’, which will test possible new screening techniques including the biomarkers earlier alluded to. Dubbed a ‘hugely important’ study by Professor Emberton, results won’t be available for a couple of years, but it could pave the way to revolutionising our ability to screen for, and therefore more effectively treat prostate cancer. Tony Greenway
Aspire Pharma has partnered with MDNA Life Sciences to market and distribute the Mitomic® Prostate Test (MPT™) in the UK. MPT™ is a liquid biopsy test for the early detection of clinically significant prostate cancer in advance of biopsy and is independent of PSA and age. 1010463462 v 1.0 September 2018
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Benign Prostatic Enlargement (BPE) The doctor’s perspective... *BPE is often referred to as Benign Prostatic Hyperplasia (BPH)
Miss Kate Warren Consultant Urological Surgeon, Bristol Urological Institute, Southmead Hospital
Improvements in the treatment of benign prostate enlargement mean that side effects and recovery time can now be greatly reduced.
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IMAGE: OLYMPUS EUROPA SE & CO.KG
enign prostate enlargement (BPE) is something that will affect a significant number of men during their lifetime. It is increasingly common as men get older. The prostate gland’s position is below the bladder and it surrounds the urethra. Its function is to produce secretions, which make up the ejaculate but as it enlarges it can obstruct the flow of urine. The resulting symptoms may be a slowing of the urinary stream, stopping and starting of the stream, difficulty emptying the bladder and as a result more frequent visits to the toilet, both during the day and night. Men present to their GP with symptoms if these are affecting their quality of life or they are worried about the possibility of prostate cancer. GPs will refer to secondary care on a fast track pathway if there are symptoms suggestive of prostate cancer. GPs will also consider if the symptoms are typical of bladder outflow obstruction because of BPE by taking a history and performing a clinical examination. Initially, patients presenting with symptoms of BPE, would be advised on lifestyle alterations by their GP and potentially offered medication
to improve the urinary flow. The choice to go on medication should involve information about potential side effects of medication versus how bothered the patient is by their symptoms. If medication and lifestyle modification is not enough to sufficiently improve the symptoms, GPs will refer to secondary care for further investigations and consideration of surgical treatment.
Surgery involves removing part of the prostate gland After a secondary care assessment, if the lower urinary tract symptoms are due to BPE and the patient wishes to consider surgery, a transurethral resection of the prostate (TURP) is one option. This involves removing part of the prostate gland, using a device called a resectoscope, which is passed through the urethra (waterpipe). A heated loop is used to remove the central part of the prostate gland, creating a channel through the prostate to reduce the obstruction. As with any operation, there are potential side effects and anyone considering surgery should be fully informed of the alternatives to this surgery and of the potential complications. Patient information leaflets can be found on the British Association of Urological Surgeons website about the risks of urological surgical procedures.
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and her patient’s story... Anthony Pagano enjoying a holiday abroad after his treatment for BPE at Bristol Urological Institute.
The traditional monopolar TURP has been replaced in many NHS trusts by a bipolar or PLASMA device to remove prostate tissue. The electrical current passes between two electrodes rather than through the patient and uses a combination of cutting and vaporization of the prostatic tissue. The benefits of this is a reduction in bleeding during and after the procedure and the ability to use an irrigation fluid during the surgery that has a similar concentration to the body’s own fluids. This reduces the chance of a complication called TUR syndrome, which is when the dilute irrigation fluid (used with older TURP techniques) can be absorbed into the body causing complications. Miss Kate Warren, a Consultant Urological Surgeon from Bristol, where the treatment is performed as standard, explains why such techniques are needed. “As men get older and live longer, lower urinary tract symptoms due to BPE become very common. Approximately 50% of men in the sixth decade of their life and 80% in their eighth decade are affected by symptoms due to BPE. There are a number of surgical treatment options available for BPE and each patient should have their surgical options discussed with them. Some patients may opt to pursue non-surgical options but if their symptoms are increasingly bothersome, they may consider surgery in the future.”
Improved urinary flow reduces the risk of UTIs The intended benefit of surgery is a better urinary flow and ability to empty the bladder more completely. Poor bladder emptying can result in recurrent urinary tract infections, bladder stone formation and sometimes altered kidney function. In these situations, a patient would be recommended a surgical option or, if not fit enough, a long-term urinary catheter. The potential long-term side effects of surgical treatment of the prostate include incontinence, alteration in ejaculation and reduced ability to get erections. The different surgical techniques have different risks of each of these and need to be discussed fully with the surgeon. The newer technologies for prostate surgery aim to be more minimally invasive and patients are able to recover more quickly. “We have been able to treat 80% of our TURP patients as day cases, which is a considerable advantage compared to previously, when patients stayed in hospital for a couple of days,” says Miss Warren. Gina Clarke
Anthony Pagano BPE Patient
I started to suffer with increased symptoms of BPE when I was in my mid-70s. First, my urine slowed to a trickle, then I found myself getting up two or three times in the night.
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went to visit my GP who suggested medication with Finasteride tablets, but despite an improvement for the first few months, it soon lost effect. These tablets also, blocked the production of testosterone, which caused a very significant loss of sexual functions. My GP then offered muscle relaxants, but this gave me nausea that I found quite scary. I was referred to the Bristol Urological Institute and offered the TURP procedure. I met my consultant, Miss Warren, on the morning of the operation and, despite the risks, explained I was eager to go ahead as my BPE was getting worse – to the point that it was affecting my sleep and my way of life. Although I knew it was a relatively new procedure, it was well-tested, so I wasn’t worried. My anaesthetist decided on a spinal anaesthetic, which meant I was awake for the two-hour operation. I was anxious, but my nerves were calmed every step of the way. I could not move my lower limbs for several hours after the surgery. I was kept under observation until medical staff were satisfied
I understood that there were risks involved, like with any operation, but I felt informed about my decisions I was OK, and then my wife came to collect me to take me home. Although slightly unsteady on my feet I was able to walk to the car. That was 18-months ago and, despite the odd urge to get up in the night, my symptoms are better. I’m so pleased that I went through with it. I understood that there were risks involved, like with any operation, but I felt informed about my decisions and was treated with dignity and respect. It really was excellent care. Gina Clarke
Read more at healthawareness.co.uk
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A 360° look at erectile dysfunction The doctor’s perspective... Mr Asif Muneer Consultant Urological Surgeon and Andrologist, University College London Hospital
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n estimated 7,000 men in the UK are currently eligible for a penile prosthesis (also referred to as a penile implant) for erectile dysfunction which has not responded to pharmacological treatments, yet fewer than 10% go on to have the surgery, despite the high success rates. Case study For Christopher, an aggressive form of prostate-cancer in his mid-50s, left him with the embarrassing side effect of erectile dysfunction after his prostate was surgically removed. Not only was it highly embarrassing for the father of four, but it was something that deeply affected his previously loving relationship with his wife.
SOURCE: 1: AMS PENILE PROSTHESIS PRODUCT LINE INSTRUCTIONS FOR USE. AMERICAN MEDICAL SYSTEMS. 2012 2: AMS PENILE PROSTHESIS PRODUCT LINE INSTRUCTIONS FOR USE. AMERICAN MEDICAL SYSTEMS. 2012
Common side effect of prostate cancer “The majority of men I treat will
have had a similar experience to Christopher; it is an incredibly common side-effect as the nerves and blood vessels run close to the prostate gland in a complex network,” explains Mr Asif Muneer, Consultant Urological Surgeon and Andrologist from the Department of Urology and NIHR Biomedical Research Centre, University College London Hospital. Returning full sexual function Erectile dysfunction may improve following a clinical assessment and first line treatments, such as a lifestyle changes, oral tablets or injections given by patients into their penis. But, if required, a penile prosthesis returns full erectile function in almost 100% of patients six weeks after surgery. “It’s a relatively uncomplicated operation in high volume centres such as ours,” says Mr Muneer. “Patients
are often surprised that such a lot of ‘equipment and components’ can be placed through a small incision in the scrotum. I often hear, “I didn’t realise it was so easy.” Most of our patients are discharged the next day and report over 90% satisfaction rates once the device is used.” Of course, there is a degree of ‘teaching’ the patient to use the mechanism, but, after two weeks, by which time the pain and swelling subsides, a patient can practise inflating and deflating the implant. Six weeks later they will be able to have full, penetrative intercourse.
A penile prosthesis returns full erectile function in almost 100% of patients six weeks after surgery
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and his patient’s journey... John Goodridge Sexually Active Pensioner
A REFERENCES 1: GANDAGLIA G, BRIGANTI A, JACKSON G, ET AL. A SYSTEMATIC REVIEW OF THE ASSOCIATION BETWEEN ERECTILE DYSFUNCTION AND CARDIOVASCULAR DISEASE. EUR UROL. 2014 MAY;65(5):968-78. 2: JACKSON G, ROSEN RC, ET AL. THE SECOND PRINCETON CONSENSUS ON SEXUAL DYSFUNCTION AND CARDIAC RISK: NEW GUIDELINES FOR SEXUAL MEDICINE. J SEX MED. 2006 JAN;3(1):28–36.
Erectile dysfunction can have a serious impact on mental health It is important not to underestimate the psychological impact that erectile dysfunction can have on a man, as recognised by the World Health Organization, which states that sexual health is fundamental to the physical and emotional wellbeing of humans. Alongside the psychological aspect, is the issue of age and the worry that older men need to ‘put up with it’. “Within my work, there is no discrimination regarding age. I have treated men from their early 20s to a man in his 90s. It really makes no difference to us, as long as they fulfil the criteria and we can make a difference to their lives,” says Mr Muneer.
With an ageing population and the treatment of more aggressive cancers, particularly those from childhood, Mr Muneer has seen an increase in younger men affected by erectile dysfunction following cancer treatment, such as Gary. Gary’s cancer left him with erectile dysfunction “Gary was a young man in his late 30s who had been treated for a particularly aggressive, rare pelvic tumour. Unfortunately, he developed erectile dysfunction as a side-effect of the treatment. But following his operation it has transformed his relationship with his wife. They’re both incredibly happy.” These cases will only add to the testimony as to what the device can do, and with a low complication
rate following the operation (the mechanical device often lasts over a decade before a replacement may be needed), Mr Muneer is certain that there will be a growing demand for penile implants in the future. He says, “I think a lot of people simply don’t know that this treatment exists. For anyone currently suffering with erectile dysfunction and who has exhausted pharmacological treatment options, I would simply say, ‘ask for additional help’, because these solutions are out there and with such a great satisfaction rate, I see this becoming a much more wellknown and popular operation over the next few years.” Gina Clarke
t 77 years old, I count myself very lucky to be here. I’ve survived cancer four times in total, but when I had my prostate removed in 2010, following a diagnosis of prostate cancer, I suffered a common side effect – erectile dysfunction. While prostate problems are incredibly common, the side effects are not so well known. I developed urinary incontinence after the operation, but that soon passed. However, I found the side effect of erectile dysfunction harder to ignore. As a red-blooded male I was determined to find a way to return my libido and, despite my initial embarrassment, I was determined to keep going back to my doctor until we found a treatment that worked. Over the next three years, I found myself searching for the right treatment. I became depressed and confused mainly because, although these conditions are well known, they are rarely talked about. Men like to joke but it is women who are far more practical at getting themselves help. While it wasn’t something I felt I could talk about openly, privately, I was doing a lot of research. I rejected the idea of injections for
a few years just because it seemed like the idea of an injection in such a sensitive area was a big deal for me mentally. So, after tablets, pumps and – finally – injections failed me, I booked an appointment with my GP in 2013 to hear more about penile implants, delighted that they were available on the NHS. This led me to the excellent care of the urology department who explained more about the minor operation and that, after two days in hospital and six weeks rest, I would have a fully functioning sex life. The past five years have been nothing short of wonderful. I was given a lesson on how to work the implant, which is very simple, and it has been a breakthrough both for myself and my partner, who has supported me through those difficult years. My life now is as active as ever. The implant is incredibly small and very easy to use. I would recommend the treatment to anyone. Gina Clarke Read more at healthawareness.co.uk
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Incontinence; an unspoken side effect of prostate cancer treatment
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“Men don’t talk, and we need to talk,” says ex-England footballer on prostate cancer
Owen Sharp CEO, Movember Foundation
For many men, incontinence is the most difficult aspect of their prostate cancer journey. The urinary leakage that follows surgery or radiation therapy often comes as an unexpected surprise. TrueNTH UK’s continence management programme, funded by the Movember Foundation, has set out to prepare men diagnosed with prostate cancer to effectively manage incontinence.
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ixty-eight-year-old Robert Leiper likes to be out and about. The retired engineer and project manager enjoys spending his time at beer festivals with his mates or exploring the outdoors with his wife. But unlike his friends, who refer to him as Bob, leaving the house requires some precision planning. “Whenever I go out I have to think about how long I’ll be away from home and make sure I have enough pads to last. At the beginning I would also take a spare pair of trousers in case I had a major leak.” Since having his prostate removed in March 2009, following a prostate cancer diagnosis, Bob has had to grapple with ongoing incontinence.
Prostate cancer can strike at the heart of what it is to be a man
Ray Clemence Retired England Football Goalkeeper, Prostate Cancer UK Ambassador
IMAGE: PROSTATE CANCER UK
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etired England football goalkeeper, Ray Clemence, was first diagnosed with prostate cancer in 2005. Both Ray and his son Stephen (a first team coach at Aston Villa), remember when he was first diagnosed with cancer and what happened next.
Owen Sharp
Read more at healthawareness.co.uk
Q. Ray, how has the discussion around men’s health changed since you were Stephen’s age?
Stephen, how did you cope with your father’s prostate cancer diagnosis?
Ray: In my era, nobody spoke about it. Men don’t talk and we need to talk. It’s amazing when people realise that you’ve got it or you had it. They will come and talk to you then because they need to speak to somebody who has actually been there and knows about it.
Stephen: It’s obviously a difficult period when you know your dad is going for checks and when you get that phone call to say there’s something not quite right, you just want to know that he’s ok and if there’s anything you can do for him. As a family we try and be as positive as we can, and be there not just for my dad, but for my mum as well, because it’s difficult for her too.
Stephen: I think the charity Prostate Cancer UK is really helping to raise awareness, there’s a lot of high-profile celebrities doing a lot of great work and I think it is a subject now that is more talked about. I think the younger players in their 20s are still enjoying life – and rightly so – but I think there is an awareness once you get over 40, especially 50, that you have to get these things checked out.
Q. What was it like seeing your dad go through treatment?
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The West Sussex local is stoic about his personal experience, however he explains that, as a trained engineer who relies on facts and logic, he doesn’t like surprises and would have benefited from knowing all about the side effects of incontinence prior to surgery. An inability to control bladder function generally occurs post-surgery or post-radiation therapy due to irritation of the urethra or bladder, or damage to the urinary sphincter (muscles that contract to prevent urine from flowing out of the bladder). The impact can be devastating to many men. Prostate cancer can strike at the heart of what it is to be a man – sexual function, fertility, continence, relationships, and mental health can all be affected. While looking for better treatments – and ultimately cures – for the disease, the quality of life experienced by each man is also critically important. Education is key to help men manage the radical change they will experience in their lifestyle due to incontinence following prostate cancer treatment. At the Movember Foundation, we offer tools, resources, and education to improve the quality of life for men throughout their cancer journey – addressing their needs before, during and after treatment.
Stephen Clemence First Team Coach, Aston Villa Football Club
Stephen: It’s never nice to see your dad in intensive care just after an operation, but he’s coped with it very well. He’s had three lots of chemotherapy, radiotherapy, quite a large operation at the start and dealt with a tumour on his brain. It’s not nice. What we do as a family while he is having treatment is try and make sure that we can be there to support him through that, although it’s not always easy.
Q. Does it make you more aware of your own risk? Stephen: Yes. I am aware of the risk but I’m lucky to have medical people around me where I can get checked on a regular basis. After Dad’s diagnosis it is something that I tell my friends about. All the members of the family are aware of it as well. Ray: Conversations like this are very important as it does pass down the chain. My father had it, although he didn’t die of it, but he did have it. That doesn’t mean it’s something to worry about, but it is something you’ve got to be aware of. If anything is wrong then it can be sorted out before it’s gone too far.
What do you both think of Prostate Cancer UK funding research towards better ways to diagnose prostate cancer, that could hopefully form part of a national screening programme? Stephen: At the moment there is a lot of great work being done, this being one of them, but the biggest thing is actually to make sure people do get checked out. We need to let people know that the earlier you get checked the more chance you have, and I think that’s the most important thing for me. Ray: Absolutely. In 10 to 15 years, with the right investment, then they can really get on top of this. Gina Clarke * Ralph Ellis, the hugely-respected football writer who wrote the original article, recently passed away at 62 from prostate cancer less than two years after his initial diagnosis. A passionate advocate for Prostate Cancer UK’s work, in June he raised more than £15,000 for the charity by cycling to Amsterdam with friends and family.
Read more at prostatecanceruk.org
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IMAGE: GETTYIMAGES
Reducing the side effects of radiotherapy for prostate cancer patients SPONSORED Dr Philip Camilleri MRCP M.D. FRCR, Consultant Clinical Oncologist
There have been many advancements in treating prostate cancer over the years, including one specifically designed to decrease bowel toxicity.
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hen faced with a diagnosis such as prostate cancer, there can be a number of choices of treatment. One of the options is radiotherapy, a very effective treatment that avoids the need for surgery. If you choose this treatment, you’re likely to be under the care of a consultant, such as Dr Philip Camilleri. Dr Camilleri meets with a team of other experts weekly, to decide on a care plan most suitable for the patient. Often, the plan involves hormone therapy (HT) and radiotherapy. The HT and radiotherapy timetable can take between four and seven weeks to complete and the resulting side effects can include needing to urinate more frequently and more urgently, with similar effects on the bowel. There is also a risk of erectile dysfunction.
It’s one of those, ‘Why didn’t I think of that?’ solutions Working to combat these potential side effects is an innovative gel, which, coupled with advancements in radiotherapy machines, lowers bowel toxicity. It could also facilitate a more powerful form of radiation (stereotactic radiotherapy) that could dramatically reduce the number of treatments given to just five .
Making space around the prostate In terms of the male anatomy, the front wall of the rectum touches the back of the prostate. Although the two make contact, they are not stuck together. The makers of the gel realised that, with a very carefully placed needle, the two can be pushed apart and a ‘spacer’ gel can be inserted. This harmless gel goes in under anaesthetic and takes around 20 minutes to place. Patients have occasionally reported only a mild feeling of ‘fullness’, which soon goes away. It lasts three months in its current form before becoming absorbed by the body naturally over a further three months. “It complements the radiotherapy treatment very well,” says Dr Camilleri.
Additional treatment The hydrogel is well-known in the US and has been in widespread use in the UK from January. This simple solution is something that the consultant has seen reduce bowel related side effects in his own clinic. Clinical studies have shown that the rate of bowel side effects is reduced by up to 50%. In addition, erectile dysfunction rates were also reduced. Dr Camilleri says, “It’s one of those, ‘why didn’t I think of that?’ solutions. By inserting a gel to push apart the prostate and the rectum, the bowel is spared, and the treatment is better tolerated. I can also envisage the gel being useful to provide greater protection to the bowel with more complicated, higher dose radiation which is given over a shorter period of time. This is called stereotactic radiotherapy.” GenesisCare have specialists who use this gel to help provide the best possible treatment for their patients undergoing radiotherapy treatment for prostate cancer. Gina Clarke
Mr Simon Brewster MD FRCS Consultant Urology Surgeon
As treatments for prostate cancer advance, Consultant Urologist, Mr Simon Brewster explains how a new ultrasound-guided treatment lays the groundwork for radiotherapy.
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ithin the last five years, the field of urological conditions and prostate cancer has rapidly progressed, so much so that some medical innovations might be on their second or third refinement by the time the NHS adopts them, or the patient hears about them. But the discovery of a small amount of free space between the wall of the bowel and the prostate really does change the way some of our most common procedures, such as radiotherapy, are carried out. Mr Simon Brewster, a Consultant Urologist in Oxford, is one of the surgeons helping to make the process easier in a new wave of personalised medicine. He adds a small step to the timeline of typical hormone treatment and radiotherapy, a brief day case procedure that involves the insertion of a hydrogel, approved by NICE, using ultrasound. “If they are candidates for prostate radiotherapy and they have a rectum – which some may not as it could have been removed for other reasons – then the vast majority will be suitable for the insertion of the gel, which combats the risk of rectal toxicity from the radiotherapy by moving the rectum away from the prostate and forming a barrier with the hydrogel.” Patients often come to him to have this new gel inserted in a treatment that takes just minutes and has few reported side effects.
He says, “I’ve been inserting the gel using ultrasound since January. Once a patient has been diagnosed and had the option of radiotherapy offered to them, then they tend to be referred back to me. It’s important that patients lie still while the procedure is being carried out. For that reason, most patients have a brief general anaesthetic. I have also performed the procedure under local anaesthetic without any issues, however most patients prefer not to be awake.”
The gel is part of the toolbox for fighting prostate cancer A few weeks before they are due to start radiotherapy, they come to Mr Brewster to have the procedure, preceded by a short consultation, in which he ensures that they are completely suitable. As Mr Brewster sees it, the gel is part of the toolbox for fighting prostate cancer. A brief day surgery means no overnight stays, and despite warning his patients that they may feel a slight bit of discomfort afterwards, none have reported any. Those undergoing the procedure simply have to wait a few hours to pass urine, and can be discharged ready to start their radiotherapy treatment with the knowledge that their next consultant has more delineated lines to work with. Gina Clarke Read more at genesiscare.com/prostate
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How many people suffer from bladder incontinence?
Catriona Williams Director, talkhealth
In a recent survey from talkhealth it has been found that 65% of men and women need to urinate more than once every two hours, and 18% have pain during urination. The numbers behind bladder incontinence Over 1,400 people took part in the talkhealth survey on pelvic floor muscles and bladder incontinence; 90% were female and 10% male. The findings of the survey were as follows: • 65% needed to urinate more than once every two hours • 33% had a strong signal to urinate that couldn’t be ignored, leading to involuntary loss of urine • 26% experienced difficulty urinating despite the urge to go
Support for bladder incontinence Of those that were living with bladder incontinence, over half of respondants stated that they have not sought medical advice on their condition. When questioned as to why they had not yet sought advice, 39% felt their symptoms were not serious enough to seek medical support and a further 37% citied embarrassment as the main reason behind not seeking advice. Despite this, many have turned to alternative sources of information to help manage their conditions. Alternative areas that respondents used for information includes: • 67% opting to seek advice through the internet
With bladder incontinence having such a huge impact on an individual’s lifestyle and wellbeing, we suggest that contacting your GP or urologist should be your first port of call if you exhibit any signs of bladder incontinence as early as possible in order to receive the best possible support and treatment options. In addition to this, there are plenty of charities that are able to provide professional advice and support, including the likes of Bladder and Bowel UK and The Urology Foundation. Additionaly, talkhealth provides a wealth of information around bladder incontinence, which can work alongside medical advice and support. Catriona Williams
• 18% had pain during urination • 16% had experienced general bladder pain
• 32% using health advice websites • 28% reaching out to family and friends for support
These numbers make it clear that bladder incontinence is a widespread issue across the UK, and finding support and information around the condition is of upmost importance for those living with the condition.
• 16% seeking out advice via forums • 9% have used books to help find further support
Read more at healthawareness.co.uk
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The psychological trauma of urology disease Louise de Winter Chief Executive, The Urology Foundation
A major study has shown that cancer patients are three times more likely to commit suicide than the general public but that urological cancer patients are ďŹ ve times more likely.
T
his stat is reective of the fact that there is something particularly insidious about urology disease; its effects are hardly ever limited to the physical and almost always force their way into the psychological. It’s about time we recognised and addressed the psychological trauma that urology disease causes. Let me explain with a few examples from recent data that was
collected by The Urology Foundation ahead of Urology Awareness Month. Understanding incontinence in children Nearly 50% of parents are not conďŹ dent that they could correctly identify incontinence in their child. That’s not a good stat. Even worse, around 1 in 10 parents say that their child over the age of 5 has had to miss an event or come home because they had wet themselves. Of the children who wet themselves, 7% are afraid to leave home, 1 in 10 are embarrassed or have been bullied and a further 1 in 10 have had to decline social invitations. Those stats do not tell the tale of happy children. That nearly 1 in 10
children who wet themselves are afraid to leave the home is reective of the damage that incontinence causes, it speaks to a shame that so often plagues urological conditions. It’s not a trend that’s limited to children
Urological cancer patients are ďŹ ve times more likely to commit suicide than the general public Adults (and their sex lives) For Urology Awareness Month 2018, we wanted to explore the impact that urology disease has on sex lives. Our polls showed us that 1 in 2 British
adults have been stopped from having sex at some stage in their life because of a urological condition and that 1 in 10 have avoided pursuing relationships for the same reason. A quarter of British adults miss out on sex ‘sometimes’ or ‘often’ because of a urology condition. This could be anything from incontinence to UTIs, cancer to erectile dysfunction. Not being able to have sex because of urology disease is a distressing experience. This kind of statistic is an insight that allows you a glimpse at how urology disease will pervade every facet of your life. As you consider this pervasiveness, you might begin to understand why suicide rates are so high amongst urology patients.
Nobody likes to talk about their bladder, but when things are wrong, talking to someone with knowledge and understanding is exactly what you need. Here at Bladder Health UK, we have been offering patients help and advice for the past 20 years. Over that time, we have helped thousands of people manage their condition.
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The bottom line While none of these statistics are good, we shouldn’t lose hope. Urology Awareness Month was set up by The Urology Foundation to galvanise patients, doctors, nurses, researchers, and supporters around the idea that we can lead the ďŹ ght against urology disease. One in two Brits will have a urology condition and 1 in 4 of us knows someone with a urology cancer. It’s hard to escape urology disease, so why don’t you stand with us and join the ďŹ ght? Tim Burton Read more at theurologyfoundation.org
@bladdersupport @BladderHealthUK
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Urinary Tract Infection (UTI) Mr Ian Pearce Consultant Urological Surgeon, Manchester Royal Infirmary
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What is a urinary tract infection (UTI)? A UTI is a bacterial infection of the urinary tract, most commonly the bladder, but occasionally the kidneys (also known as pyelonephritis).
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How common are UTIs? UTIs are common. Over 50 % of women are likely to suffer at least one UTI during their life. Men may also suffer but less commonly.
3
What causes a UTI? The most common cause of UTIs is dehydration. Other risk factors are increasing age, being sexually active, diabetes and passing urine infrequently.
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How will I know if I have a UTI? Most UTIs present with symptoms of urinary frequency, urgency and painful urination. In severe cases, patients may pass blood or develop a temperature, loin pain or shivering attacks, (known as rigors).
How incontinence and mental health are interlinked Jane Brocksom Urology and Continence Nurse Specialist and Vice President, British Association of Urological Nurses
Incontinence: it can feel like a life sentence for once bubbly and outgoing women. And the changes both mentally and physically are not to be underestimated. For one in three women, urinary incontinence is something they will have to endure throughout their lives. Whether it was the outcome of pregnancy or the onset of menopause, there is certainly more acceptance these days that it can happen. However, little is mentioned about the psychological effects suffering can have.
Incontinence can cause anxiety and embarrassment
How can UTIs be treated? UTIs are treated with pain relief and antibiotics for between three and five days and in more severe cases 7 to 14 days. It is best to increase fluid intake. Read more at baus.org.uk/patients/conditions/14/urinary_infection_adult
The anxiety that women feel while suffering from urinary incontinence is a personal interest for Urology and Continence Nurse Specialist, Jane Brocksom, soon to be the President of The British Association of Urological Nurses. “Mental health and incontinence go hand-in-hand,” she says. “I have ladies who can only plan a trip into town if they know where all the toilets will be. It is even stopping previously outgoing ladies from
leaving the house because they are scared they might leak and embarrass themselves. It really is debilitating.” And, with scandals in the media such as the Mesh campaign, there often seems like little choice for women but to suffer in silence. However, that’s not the case says Brocksom. “Often, I find that the act of speaking up and talking to your GP or a specialist nurse is half the battle. I find that, for a lot of ladies, being able to have a good chat and examine why you might be suffering often goes a long way to resolving some of the problems.”
Feel yourself again with lifestyle re-training With women often juggling young families and older parents, there can be little opportunity to think of their own health. But often a frank and honest chat with a professional can help women to re-evaluate their drinking and toilet habits. “I can’t remember learning to drink or go to the toilet” says Brocksom. “Sometimes we just need a bit of re-education. We might drink five cups of tea a day and think we’re hydrated, but we’re not getting the good stuff that we need. Equally, our
lives are more sedantry, so if we’re sat on an office chair for most of the day, our pelvic floor muscles just aren’t getting any training. And it’s this lifestyle evaluation that a health professional can offer.” Today’s women have little training on the pelvic floor, or the need to rest after childbirth, so with the onset of the menopause causing the pelvic floor to weaken, it can often come as a shock that the body is not as robust as it once was. Brocksom says, “It’s being able to evaluate and say, ‘I can’t do at 60 what I could do at 18, but how can I improve and continue to live my life?’. If I can help a woman to feel able to leave the house or pick the grandkids up, that’s a huge step forward.” Certainly for Brocksom, making sure that women have access to specialist continence nurses is a big concern of hers. She says, “Women just need to know that there is someone there who cares about them, mentally that can make all the difference.” Gina Clarke Read more at healthawareness.co.uk
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Campaign calls for public to ‘look before you flush’
Professor Julia Verne Public Health England
Blood in urine is key symptom of bladder and kidney cancers - both in the top ten most common cancers in England - but new research finds that only 16% of those most at risk check the colour of their urine every time they go to the toilet. Being clear on bladder and kidney cancer Every year, around 19,1001* new cases of bladder and kidney cancer are diagnosed in England and around 8,000 people die from these diseases.2 However, we know these cancers are more treatable if they are found early. Of those diagnosed with kidney cancer at the earliest stage (stage 1) 84% will live for at least five years.1 At a late stage (stage 4), however, this drops to just 10%2†. Similarly, 77% of those diagnosed with bladder cancer at the earliest stage (stage 1) will live for at least five years,1,2† but when diagnosed at a late stage (stage 4), this drops to 9%.1,2† With these figures in mind, in July, we at Public Health England relaunched our national ‘Be Clear on Cancer’ campaign across England to raise awareness of one of the key symptoms of these diseases, blood in
urine. Blood in urine is a symptom in almost two thirds (64%)3 of bladder cancer patients and around a fifth (18%)4 of kidney cancer patients.
Look before you flush The campaign message is clear – we want everyone to ‘look before they flush’ and visit their GP (family doctor) without delay if they notice blood in their urine, even if it’s just once. For the campaign this year, we conducted new research, which found that around half (47%) of adults aged 50 and over in England - those most at risk - would not seek medical advice if they saw blood in their urine just once, with 45% saying they would wait and see if it happened again, potentially putting off a vital diagnosis.5 We also found that only a small number (16%) of these adults check the colour of their urine every time they go to the toilet – with women being less likely to check every time (12% vs. 20% of men).5
they would not go to the GP straight away, one in five (20%) said they would be worried about wasting the GP’s time and nearly a quarter (23%) would only book an appointment sooner if they had other symptoms.5 It’s important for people of all ages, but in particular the over 50s, to get into the habit of looking before they flush so that they spot any signs of blood in their urine. If there is blood, they should go to their GP – they shouldn’t wait for other symptoms or to see if it comes back. This will help diagnose more people at the early stages, when cancer is more treatable, improving their chances of living longer. For further information about the signs and symptoms of bladder and kidney cancer, search ‘Be Clear on Cancer’.
Don’t delay in telling a doctor The campaign is aimed at people over the age of 50 because this age group is most at risk of bladder and kidney cancers.1 When we asked the over 50s why
Read more at healthawareness.co.uk
* BASED ON AVERAGE ANNUAL DATA FOR 2012 – 2016 DIAGNOSES † SURVIVAL IS RELATIVE PERIOD SURVIVAL FOR 2009–2013 DIAGNOSES
1: INCIDENCE DATA SUPPLIED BY PUBLIC HEALTH ENGLAND BASED ON THE NATIONAL CANCER REGISTRATION & ANALYSIS SERVICE DATASET, 2018 2: DEATHS DATA SUPPLIED BY PUBLIC HEALTH ENGLAND BASED ON THE ONS MORTALITY DATA, 2012–2016 3: PRICE SJ, SHEPHARD EA, STAPLEY SA, ET AL. (2014) NON-VISIBLE VERSUS VISIBLE HAEMATURIA AND BLADDER CANCER RISK: A STUDY OF ELECTRONIC RECORDS IN PRIMARY CARE. THE BRITISH JOURNAL OF GENERAL PRACTICE. 64, PP584–589. 4: SHEPHARD, E.A., NEAL, R.D., ROSE, P., WALTER, F.M AND HAMILTON, W.T. (2013) CLINICAL FEATURES OF KIDNEY CANCER IN PRIMARY CARE: A CASE-CONTROL STUDY USING PRIMARY CARE RECORDS. THE BRITISH JOURNAL OF GENERAL PRACTICE. 63 (609), PP250-255. 5: ALL FIGURES, UNLESS OTHERWISE STATED, ARE FROM YOUGOV PLC. TOTAL SAMPLE SIZE WAS 2484 ADULTS AGED 50+ IN ENGLAND. FIELDWORK WAS UNDERTAKEN BETWEEN 7TH - 13TH JUNE 2018. THE SURVEY WAS CARRIED OUT ONLINE. THE FIGURES HAVE BEEN WEIGHTED AND ARE REPRESENTATIVE OF ALL ENGLAND ADULTS (AGED 50+).
Urology Awareness Month Where Can I Find Out More? Some may have heard of prostate cancer and the signs and symptoms. However, fewer may know about kidney, bladder, penile and testicular cancers. To gain more information about urological cancers visit the websites of the charities listed below. Charities:
UCAN
Kidney Cancer UK
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We are the UK’s leading kidney cancer charity working for the patient, here to listen, inform and support kcuk.org.uk
Prostate Scotland
The Urology Foundation
Fight Bladder Cancer
Informing, supporting and advancing on prostate disease in Scotland prostatescotland.org.uk
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Kidney Cancer Support Network
Action Bladder Cancer
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Raising awareness, supporting patients, improving early diagnosis and supporting research actionbladdercanceruk.org
Sponsored by Intuitive, who proudly support Urology Awareness Month. We commend the vital work of urological organisations and clinicians who champion quality of life for their patients