Semen Cytology for Diagnosing Prostate Cancer

Widespread PSA screening has led to an inordinate number of prostate biopsies being performed. The biopsy is an invasive procedure, fraught with potential complications. Preliminary studies suggest that semen cytology may provide an accurate and definitely less invasive diagnostic tool which might avoid subjecting the patient to biopsy. Ideally the cytologist could not only identify the tumor cells but, with the use of special staining techniques, also be able to ascertain the grade of the underlying tumor.

I would like to stimulate a more thorough study of this possibility in order to validate the use of semen cytology as an alternative to prostate biopsy.

EPILOGUE (for MANAGEMENT OF COMMON UROLOGICAL PROBLEMS)

EPILOGUE (for MANAGEMENT OF COMMON UROLOGICAL PROBLEMS)

I feel very privileged to have practiced medicine for so many years. Gratifying, satisfying, rewarding are words which describe my experience. Referrals from other physicians presented me with an opportunity of sharing my medical philosophy with these physicians. I have found over the years that injecting a bit of humor into my letters was much appreciated by the physicians and perhaps even more so by their office staff. Indeed, very often I received referrals directly from the staff, who confessed to me later that their primary motivation for the referral (with tongue in cheek?) was to get my referral letter!

I realize that not everyone will agree with my management of certain medical problems. But I want to make a plea that physicians remain open to the individual needs of their patients as they guide them in their medical dilemmas--and help them evaluate the numerous diagnostic and therapeutic options available for most medical problems. We must try to achieve the optimal approach for that individual person.

TERMINALLY ILL PATIENT (FAMILY DEMANDS)

TERMINALLY ILL PATIENT (FAMILY DEMANDS):

Dear Sumner:

I am faced with a very difficult situation. It involves a 79 year old man who was diagnosed with bladder cancer about 4 years ago. He has since had a stroke, which has left him with left sided weakness as well as aphasia. He has had many episodes of hematuria, necessitating readmission to the hospital for multiple blood transfusions and local cauterization to try to control the bleeding. Earlier in his care, he had expressed the desire that, should the situation arise when he would be considered “incurable”, he did not wish to have his life prolonged by artificial measures. (He had expressed these wishes in a living will.) Because of the aphasia, he is currently unable to communicate with either me or his family, He continues to have bleeding, and since his family has been unable to handle the problems at home , I have had to admit him to the hospital many times in the past few months for both catheter irrigations as well as for blood transfusions. While I personally think that it is futile to continue to give him blood transfusions since the underlying tumor remains his son demands that we continue with active treatment. Would you be willing to see this patient (and his son)?

Dear Percy:

I certainly share your, and the family’s distress. This is, indeed, a very difficult situation. My first effort was directed to his son. I listened as he explained that even though his father had previously signed a living will requesting that no undue measures be taken to prolong his life, there was no way of knowing if, indeed, his father had since changed his mind. (Of course, given his father’s current aphasic state, this presumption is only conjectural). I discussed the very practical considerations involving the utilization of limited resources, e.g. blood, nursing time, time taken up by the surgical and nursing staff and the expense of the supplies as well as the repeated catheter irrigations and bladder cauterizations causing trauma to his father. His son counter-argued that he has paid into the insurance company for many years, and his father is entitled to this care. Quite frankly, Percy, I believe that the son has strong feelings of guilt that he, the son, is not fulfilling his filial duties if he permits the cessation of active therapy on his father. After a lengthy with the son, I suggested that his father’s case be presented to the Ethics Committee of our local hospital, which is made up of medical staff as well as clergy and lawyers. When all members of the committee agreed that cessation of active therapy would be the wisest course here, the son accepted this suggestion with apparent relief, since it seemed to take the burden of this decision off of him personally.

TERMINALLY ILL PATIENT

TERMINALLY ILL PATIENT:

Dear Sumner:

I would like you to see Harry, a 68 year old patient of mine who was diagnosed with renal cancer about 5 years ago. He underwent a radical nephrectomy shortly after the lesion was discovered. He has had no recent weight loss and currently has no symptoms suggestive of recurrent tumor. However, a routine chest X-ray done a few days ago revealed obvious metastatic lesions. Blood chemistries are consistent with spread of the tumor into the liver. These came as quite a shock to both him and his family, since they had been reassured by his previous urologist that the tumor had been completely removed. Needless to say, some active steps should be taken to handle this very distressing situation. Although Harry, himself, is currently in no dire distress, given the radiological and serological findings, we are likely dealing with a non-curable process that will likely manifest itself clinically in the very near future. I and the family will be most grateful for your input.

Dear Bill:

I had a very frank discussion with Harry and his family about the various aspects of kidney tumors. It was interesting to note Harry’s attitude shift from one of anger and total dismay to one of relative calm as he gradually came to grips with his own disease process. (Of course, it would have been a better situation if Harry as well as his family would have already anticipated the possible happenstance of metastatic/terminal disease before this state actually occurred, but unfortunately, this was not the case here.) Harry asked some very thoughtful and practical questions about possible scenarios involving metastatic disease. We spoke quite openly about the potential conflicts involving the issues of quality versus quantity of life and the fact that medical technology today has awesome capabilities of prolonging life. Harry expressed his preferences regarding the future management of his care, stating quite emphatically that he wanted neither to have his life prolonged by artificial means, nor to suffer with severe pains. I think it was also very helpful for Harry to have his family in on the discussion as he came to grips with his current condition.( This can really help avoid future feelings of guilt if family members feel that insufficient steps are being taken to prolong the patient’s life.) Harry and his family agreed that as his physical condition deteriorated, Hospice care would be initiated.

PROSTATIC CANCER TREATMENT (WITHOUT BIOPSY)

PROSTATIC CANCER TREATMENT (WITHOUT BIOPSY):

Dear Sumner:

Mr. Y., an 86 year old man, came to my office last week complaining of progressive slowing of his urinary stream along with rather severe lower back pains. The back pains lessened with the use of Tylenol, local heat and bed rest. He is a bit “fragile,” having had a heart attack about 3 years previously and is generally quite weak. He is currently on prophylactic low dose aspirin. On rectal examination I found his prostate to be hard and bumpy. I obtained a PSA level, which the lab reported as 32 (normal level for that lab is <4). style=""> Where should we go from here? Do we need a tissue diagnosis prior to starting hormonal therapy?

Dear Bob:

I certainly agree with you about the high probability of your patient having prostate cancer. The question arises as to the best way of handling the current situation. I had a long discussion with both Mr. Y and his family about the “statistics” of prostatic cancer with increasing age: i.e. after the age of 70, there is approximately a 70% chance of there being a focus of cancer in the prostate, over the age of 80, an 80% incidence, and after 90, almost all men will have a focus of cancer in the prostate. The message is: if you live long enough, you will die with, but not from, prostate cancer. (Of course, in this case, he could, indeed, die from metastatic disease.).

Re the question you brought up about the necessity of obtaining a tissue diagnosis prior to initiating treatment, under the best of circumstances, prostatic biopsies run the risk, albeit very low, of possible complications such as bleeding or infection, not to mention the discomfort. And taking into account your patient’s age, his past medical history, the fact that he is on prophylactic aspirin, and the clinical picture of probable prostatic cancer (PSA of 32 with an underlying firm and irregular prostate), I would opt for starting him on anti-androgen therapy without having a tissue diagnosis.

HEMATURIA

HEMATURIA:

Dear Sumner:

How do you handle a 62 year old man with red urine? Harry, who I has been my patient for 22 years, told me during his yearly routine checkup that for the past 6 months or so he has noted a reddish discoloration of his urine. Since this was intermittent, lasting only for one or two urinations and he had no associated discomfort, he figured that there was nothing seriously wrong and saw no need to call me earlier. I didn’t want to alarm him, but, quite frankly, I am, indeed, worried about a possible serious problem. (I seem to remember from my medical school days that with gross blood in the urine a tumor somewhere within the urinary tract must be ruled out. Am I correct in this assumption? I suggested he call your office for an appointment for the very near future.

Dear Ben:

First of all, thanks for encouraging Harry to see me so promptly. Statistically speaking, hematuria is more likely to be secondary to a benign process such as from an inflammatory/infectious process or a stone, although I always worry about the possibility of a tumor within the urinary tract. Of course, it is possible that the reddish discoloration of his urine was secondary to dye or some breakdown products in medication or foods rather than from blood. When I checked Harry’s urine today, I did not find any red blood cells in either the urethral washings or mid-stream urine samples. However, that does not mean he didn’t have them before, and with the history as presented, I feel that Harry’s urinary tract should be visualized via some radiological study and urine examined for abnormal cells (cytology). (I have a general rule that every patient with hematuria be it gross or microscopic only, gets a minimum of a renal/bladder ultrasound and urine for cytology; with gross hematuria, I will add cystoscopy to the workup).

If there is anything suspicious noted on the renal ultrasound, or if the urine is subsequently found to contain red blood cells, or if the urine cytology shows any abnormal cells, then I will follow with an intravenous pyelogram (IVP). A CT scan or MRI study as well as cystoscopy may also be done. I will let you know my findings and further thoughts.

Dear Ben:

The renal/abdominal ultrasound study showed no gross abnormalities and the urine cytology, no abnormal cells. However, I subsequently found red blood cells in both the 1^st and 2^nd glass urines, suggesting their source to be proximal to the bladder neck, i.e. from the bladder, ureters or kidneys. I did obtain a CT scan which, happily, revealed no obvious tumors or enlarged lymph nodes. On cystoscopy, however, I found a sessile lesion which had the gross appearance of a low grade tumor and, indeed, on histological examination that diagnosis was confirmed. (By the way, Ben, a negative cytology does not rule out the presence of a tumor, only that, if a tumor is present, it is likely low grade and probably not invading the deeper layers of the bladder wall). I will be looking in Harry’s bladder at three month intervals for one year and then at increasing intervals thereafter. Should there be multiple recurrences, and then consideration would be given to the use of intravesical therapy, such as chemotherapeutic or immune boosting agent. Hopefully, the use of such will not be necessary. Generally in cases of superficial tumors of the bladder, the overall prognosis is quite good.

BED WETTING (ENURESIS)

BED WETTING (ENURESIS):

Dear Sumner:

I need your advice on how to handle Beverly, a four year old girl, who wets her bed nightly. I realize that this situation of itself is not unusual, but her parents are very distraught, and are not willing to accept the fact that she will likely “outgrow it.” Her mother has told me--numerous times--how bright and well-adjusted she is and how she gets along so well with her pre-school classmates. However, as soon as Beverly walks through the door of my office, she becomes very emotional and immediately starts crying and clinging to her mother. Her urine is free of infection and no gross abnormalities are noted on physical exam. When I suggested a trial of medication, her parents refused this approach. When I suggested some “counseling” they became very angry. However, they did agree, and in fact, were most pleased, when I suggested that they have you see her. Are you willing? I hope so since they’ve already made an appointment.

Dear Phil:

I appreciated very much your introductory note on Beverly, particularly with the warning of her seeming emotional lability. As my office manager always tells me: “Forewarned is forearmed!” For that reason, when Beverly first walked into my office (clinging to her mother), I informed her that I’m a cookie doctor, not a “shot” doctor. (I always have a supply of chocolate chip cookies in my office). I chose to examine her in my office (consultation room), rather than in a separate examining room. Sitting on her mother’s lap during the exam seemed to add to her feeling of security. Before embarking on my examination of Beverly, she and I examined her doll. No abnormalities were found on either Beverly or her doll.

My approach with Beverly was an attempt to involve her in solving the problem. Assuming that Beverly really wanted to stop wetting the bed, I asked her to make a calendar and, if she woke up dry, to affix a star of her favorite color to that day (for daytime wetting one can modify the calendar accordingly). If she wet, she will record possible causes—with the help of her parents. (Phil, I want you to know that some of the things the kids write down are quite original: e.g. “the dog peed on my leg “or “my pajamas fell into the toilet.”) In addition, I asked her to postpone voiding as long as possible, noting the maximum volume of urine she could produce at any one time. Obviously one of her parents will have to help her collect and measure the urine. (Whether this actually increases her bladder capacity is not as important as making her aware of the sensation of bladder fullness, and then recognize that the time has come to deposit the urine in a proper receptacle.) I further suggested that she stop and start the stream during voiding to try to reinforce her awareness that she can control her voiding pattern. I am well aware that these steps may not result in totally dry beds, but if we can get any dry nights, this will be a positive start.

I then asked the family to make an appointment for 3-4 weeks hence in order for me to go over the record with the child. (Her parents’ eyebrows rose at the thought of paying for another office visit, but quickly relaxed when they are told there will be no charge for that subsequent visit.) Phil, it is very gratifying when a child appears with a big smile, so pleased that there are some stars on the calendar to show me (besides which, she also gets a chocolate chip cookie along with my encouraging words). The main point is that she must answer to a person other than a parent.

As a reward for sending me this “challenge,” I’d like to share with you a couple of experiences I had with some other families involving bed wetters. As you know it is critical to observe the interchange between the child and family members. For example, I had one 5 year old boy who sat quietly in the room sucking his thumb as his mother pointed an accusing finger at him, telling me how “this little brat can never stay dry and always embarrasses us with his constant wetting.” This is certainly not a very healthy family constellation! Another example involved a 6 year old youngster who came to office with his mother. Unlike with the other case, this mother looked lovingly at her son, smiling at his every word and action. “Dear Johnny,” said she, “tries so hard to stay dry and whenever he does, we give him a reward. Why last week alone he got a new tricycle, a special puzzle and a Mickey Mouse watch.” When I talked to Johnny separately, I asked him how he felt about being dry. He acknowledged that, while it did make him happy to wake up dry. he didn’t want to wake up dry every day, at least not right away. His reason: “Doc, I got it made! Do you see the way I got my Mom twisted around my little finger?”

However, not all parents will accept my approach. I had one mother who wore a very satisfied look on her face when she brought her son back for a follow-up visit. “Doctor” she said, “you may have all your fancy calendars and chocolate chip cookies, but I discovered a quicker way to stop my son from wetting. I got him an electric blanket and told him that if he wet the bed, he’d electrocute himself. (I personally do not recommend this approach for the treatment of enuresis!)

Medications or alarm systems remain other options.