Urologists say that while the AUA's recommendations are good guidelines, it's important to take the individual patient's characteristics into consideration.
"Those are good general rules. That’s the way I practice. It’s a good idea for the AUA to promote those guidelines, although the honest truth is, if any doctor doesn’t know these guidelines, there’s an issue with his practice. They’re really basic stuff for anyone practicing urology. I have had to look up guidelines, but usually for more obscure things.
I’ve been in practice 27 years and things have changed. I don’t practice the same way I did back then. You’ve got to keep up with the literature and go to conferences. On the other hand, following some of the guidelines will be dependent on other symptoms the patient has. If there are other symptoms, those have to be taken into account and can change what I do. But you have to go with what the literature says and your own experience.”
Irving Thorne, MD
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"I don't follow those guidelines blindly. I think some of them are almost an effort to be too politically correct. I think we should approach every patient as an individual-not just take a global view.
I do agree with some of the guidelines-like not prescribing testosterone for men with ED but normal testosterone levels and not performing ultrasound on boys with cryptorchidism-but I do have issues with some of the others.
I get bone scans for men with low-risk cancer. I think they’re necessary because ‘low risk’ is a relative term that doesn’t exclude significant exceptions. On individual patients, some low risks do turn up with metastases in the bones; therefore, I don’t agree with not doing them. It’s unusual, but you don’t know which ones metastasize before you do the studies.
I will do a creatinine or imaging on some patients with BPH because silent prostatism, in which men have little or no symptoms but may be in renal failure, is a syndrome which exists, so I believe it’s our obligation to assess upper tract function in people with BPH. I don’t do it on everyone, but you need to know a person’s renal function is OK and you can’t just get that from their history and physical.
Treating an elevated PSA with antibiotics is basically treating for prostatitis, which is the other cause of elevated PSA besides cancer of the prostate, because even in men without symptoms, in my 37 years’ experience, I have found that about half of the men will respond to antibiotic treatment and that takes care of the problem.”
H. Alan Bigley, Jr., MD
Colonial Heights, VA
"I do follow the guidelines. I think the American Board of Internal Medicine Foundation probably asked most specialties to develop these to make better use of resources and make it evidence based. I think the AUA should have published the guidelines, given the number of patients I see on a regular basis who are treated with antibiotics for months for an elevated PSA, only to undergo a later biopsy. All it’s done is increase the risk of drug-resistant infections.
I think it’s important to educate people in the specialty with guidelines, and I think these are things we should be thinking about in these situations. When I was doing pediatrics, I saw that this was not just good for urology but it was good for primary care physicians as well, who were ordering ultrasounds for undescended testicles. We did the numbers and the money that was wasted would never have affected patient care; all that was needed was a physical exam, which is much more cost efficient.
Reducing bone scans is the same. They are all efforts to eliminate resource expenditure that doesn’t improve actual care. All of us are interested in that. But patients are different; discretion should always be up to the physician. The doctor-patient relationship shouldn’t be downgraded because of some guidelines.”
Ian Thompson, III, MD
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