Search Results (817)

Metastatic involvement of the male genitourinary tract by lung cancer is exceedingly rare. We report a 56-year-old man with metastatic lung adenocarcinoma (initial stage T3N2M1b) under pembrolizumab, who presented with severe pelvic pain. Pelvic magnetic resonance imaging and computed tomography demonstrated a large mass with an imaging epicentre favouring the left seminal vesicle, involving the prostate and fistulising to the distal rectum, without pelvic ascites or peritoneal disease. A total PSA of 0.81 ng/mL and a previous negative prostate biopsy made a primary prostatic malignancy less likely. Biopsy of the rectal component revealed a poorly differentiated carcinoma with an immunophenotype (CK7+, TTF-1+, p40−, CDX2−, NKX3.1−, PAX8−) consistent with metastatic adenocarcinoma of pulmonary origin. The patient underwent palliative pelvic radiotherapy, with improvement of pelvic pain; he subsequently developed pneumaturia and faecaluria and died eight months later from disease progression. Seminal vesicle metastasis from lung carcinoma has been reported previously; to our knowledge, however, this is the first report presenting with rectal fistulisation. This case highlights a diagnostically challenging presentation and the need to consider metastatic disease when evaluating atypical seminal vesicle masses in oncological patients. Full article

Background/Objectives: Uterine fibroids are one of the most prevalent forms of benign tumors in women and may substantially impair quality of life due to heavy menstrual bleeding, pelvic pain, and pressure-related symptoms. Transvaginal radiofrequency ablation (TV-RFA) has emerged as a promising minimally invasive, uterus-sparing treatment approach. However, there exists a paucity of data regarding the early vascular response evaluated through quantitative Doppler parameters. This study aimed to assess the short-term clinical outcomes and ultrasound effectiveness of TV-RFA in treating symptomatic uterine fibroids, with particular emphasis on early vascular and morphological response. Methods: This retrospective study included 38 women who presented with symptomatic uterine fibroids and underwent TV-RFA between July 2024 and December 2025. Inclusion criteria were as follows: (1) presence of up to three intramural fibroids (FIGO types 3–6) and (2) maximum diameter of fibroids: ≤6 cm. Patients were assessed at baseline and at 1- and 3-month follow-up visits. Ultrasound evaluation included the measurement of fibroid dimensions and volume as well as quantitative Doppler parameters (Pixels Power, Ratio, and CM² Power Index). Clinical outcomes were assessed based on the intensity and duration of menstrual bleeding. Statistical analysis was performed using nonparametric tests with significance set at p < 0.05. Results: Significant reductions in fibroid dimensions and volume were observed at both follow-up time points, with the greatest effect at 3 months (p < 0.001). Doppler analysis demonstrated a marked decrease in vascularization parameters, particularly CM² Power Index and Pixels Power (p < 0.001), suggesting an early vascular response to treatment. Clinically, the proportion of patients experiencing heavy menstrual bleeding considerably reduced, accompanied by a significant shortening of bleeding duration (p < 0.001). No major complications requiring surgical intervention were reported. Conclusions: TV-RFA was associated with significant short-term reductions in fibroid vascularization, fibroid volume, and bleeding-related symptoms in this cohort of women with symptomatic uterine fibroids. Quantitative Doppler parameters may serve as valuable early markers of treatment response; however, further studies with larger cohorts and a longer follow-up duration are warranted. Full article

Background: The surgical management of chronic pelvic pain (CPP), particularly in endometriosis, often focuses on lesion excision or nerve decompression. However, persistent pain frequently occurs despite “anatomical perfection,” suggesting central nervous system involvement. Neuropelveology faces a “surgical paradox” when dealing with central sensitization (CS), where peripheral interventions fail to address a systemic nociplastic state. Methods: This systematic review followed PRISMA guidelines and was registered in PROSPERO (CRD420261335008). A search across PubMed, Embase, and Cochrane (2010–2026) identified 71 relevant studies involving over 12,000 participants. Results: CS prevalence in the endometriosis population ranges from 11.3% to 58.2%, rising to 74.8% in specialized tertiary referral centers. The Central Sensitization Inventory (CSI) is a robust predictor of surgical failure; every one-point increase in preoperative CSI raises the risk of persistent pain (OR 1.02, p = 0.02). Objective markers, such as the collapse of Conditioned Pain Modulation (CPM), confirm that “high-sensitizers” (CSI ≥ 40) suffer from a systemic “software” failure of pain inhibition. Conclusions: We propose a paradigm shift in neuropelveology. In patients with high CSI scores (≥40), functional neuromodulation—specifically the LION procedure—should be prioritized over traditional nerve decompression to address the nociplastic nature of the pain. Full article

Background: Pelvic floor dysfunction (PFD) is frequent in neurological disorders, but it is often approached as a secondary urological or gynecological problem rather than a functional rehabilitation target. Neurological disease can disturb cortical, pontine, spinal, sacral, autonomic, somatic, and sensory pathways that regulate bladder storage, voiding, bowel evacuation, sexual function, and pelvic pain modulation. Methods: This narrative review synthesized biomedical evidence identified through PubMed searches from database inception to 2 May 2026. Search concepts included neurogenic lower urinary tract dysfunction, urinary and bowel dysfunction, sexual dysfunction, pelvic pain, pelvic floor rehabilitation, biofeedback, electrical stimulation, neuromodulation, telerehabilitation, robotics, and major neurological disorders. The review was oriented according to the Scale for the Assessment of Narrative Review Articles (SANRA) and was not designed as a systematic review or meta-analysis. Results: Evidence from multiple sclerosis, stroke, Parkinson’s disease, Alzheimer’s disease and related dementias, spinal cord injury, and fibromyalgia or nociplastic pain syndromes supports a phenotype-based framework in which pelvic floor muscle training, bladder and bowel training, biofeedback, neuromuscular electrical stimulation, posterior tibial nerve stimulation, sacral neuromodulation, telerehabilitation, robotics, and multidisciplinary care are considered complementary rather than interchangeable strategies. Conclusions: PFD in neurological disorders may be more appropriately conceptualized as a multidimensional neurorehabilitation target. Effective care depends on disease-informed phenotyping, individualized rehabilitation goals, attention to cognition and adherence, and standardized outcome measurement. Future studies should test phenotype-specific pathways that integrate bladder, bowel, sexual, pain, participation, safety, and caregiver outcomes. Full article

Background: The prevalence of sacral insufficiency fractures resulting from minor trauma has been on the rise in parallel with the globally aging population. For similar injuries typical to the elderly population, such as hip fractures, surgery and early mobilization have been shown to improve postoperative mortality and morbidity rates. As such, there has been a recent increase in the literature in studies advocating for early surgical fixation for sacral insufficiency fractures. However, traditional fluoroscopic techniques are technically demanding and bear an inherent complication risk even in experienced hands. Robotic-assisted surgery has emerged as a promising technological advancement in spinal and pelvic surgery. We share our experience with this surgical technique. Methods: We conducted a retrospective analysis of five consecutive patients with sacral insufficiency fractures who failed non-operative management. Using the Mazor X robotic system, patients underwent CT-planned, guided placement of fenestrated sacroiliac screws followed by cement augmentation. Primary outcomes included surgical time, radiation exposure, complications, and mobilization, with a minimum three-month follow-up. Results: The cohort consisted of five females with a mean age of 78 years. The mean operative time was 36 min (15–47), and the median fluoroscopy count was 13 shots (6–19). All patients reported significant pain relief and achieved successful mobilization on postoperative day 1. No operative or postoperative complications were recorded. Conclusions: This pilot study suggests that robotic-assisted percutaneous sacroiliac fixation with cement augmentation is a safe, efficient, and minimally invasive approach for the treatment of sacral insufficiency fractures. The precision of the robotic system facilitates stable fixation, providing immediate pain relief and early mobilization with a favorable complication profile. Further studies should be performed to verify these findings. Full article

Background/Objectives: Ultrasound-guided fascial hydrorelease (FHR) occasionally elicits a brief localized contraction (“local twitch”) at the moment the needle tip contacts a fascial layer; the anatomical basis of this reaction has not yet been systematically characterized. To examine local twitch occurrence relative to stacking fascia (yes/no) at the needle tip (primary outcome), as well as the anatomical distribution and per-video capture rate (secondary outcomes). Methods: We retrospectively analyzed 11,205 ultrasound videos from a single pain clinic (October 2015–March 2026). Twitches were identified by prospective clinical observation and computational screening (frame-difference-based Profile Match classifier; 417 candidates over 30 review rounds). The stacking fascia status was independently determined by two FHR-experienced clinicians, with discordant cases jointly adjudicated. Results: Inter-rater agreement was 86/90 (95.6%; 95% CI 89.0–98.8%); one case was reassessed, deemed to not be a twitch, and excluded. In the final cohort (n = 89), local twitches occurred at stacking fascia in 89/89 (100%; 95% CI 95.9–100%). Events were concentrated in gluteal/pelvic (51%) and lumbar paraspinal (29%) regions, with a per-video capture rate of 0.98% (110/11,205; 95% CI 0.81–1.18%). Conclusions: Local twitches during ultrasound-guided FHR essentially always coincide with the needle tip lying within stacking fascia, identifying this as the structural locus within this cohort. This figure represents inclusion-criterion-bound selectivity within the twitch-positive subset, not the positive predictive value of stacking fascia for twitch occurrence. Full article

Background/Objective: Anorectal disorders are a common yet underdiagnosed component of pelvic floor dysfunction, particularly among postpartum women. These conditions, including hemorrhoids, anal fissures, and fecal incontinence, are associated with physical discomfort and may negatively affect psychological well-being. Self-esteem has been identified as a potential mediator linking somatic symptoms to mental health outcomes, including depression. We aimed to assess the relationship between anorectal symptoms, self-esteem and the severity of depressive symptoms in a Polish population of postpartum women. Methods: A cross-sectional questionnaire-based study was conducted between June and December 2025, including 120 women aged >18 years, at least 3 months postpartum. Data were collected using online and paper questionnaires. The assessment tools included the Pelvic Floor Distress Inventory—Short Form 20 (PFDI-20), Rosenberg Self-Esteem Scale (RSES), and Beck Depression Inventory (BDI). Statistical analyses included the multiple regression model, logistic regression and Spearman’s rank correlation. Results: The most frequently reported anorectal symptoms included pain (45.83%), bleeding (42.5%), and pruritus (41.7%). The mean PFDI-20 score was 41.15 (SD 31.13). High self-esteem was observed in 55% of participants, whereas depressive symptoms were present in varying degrees of severity, ranging from no depressive symptoms (55.83%), mild (30%) to severe (0.83%). Significant positive correlations were found between pelvic floor dysfunction severity (particularly CRADI-8 and UDI-6 subscales) and depressive symptoms (BDI), while their correlation with self-esteem (RSES) was negative. The strongest positive correlation was observed between the overall PFDI-20 score and depression (r = 0.389). Multiple regression analyses identified anorectal symptoms, parity, hypothyroidism, and pre-pregnancy depression or anxiety as significant predictors of self-esteem. Anorectal symptoms and hormonal contraceptive use were significant predictors of depressive symptom severity. Among women who delivered vaginally, perineal tear was independently associated with greater depressive symptom severity (OR = 1.07, 95% CI: 1.01–1.14, p = 0.019). Conclusions: Postpartum anorectal and pelvic floor dysfunction symptoms are significantly associated with poorer psychological outcomes, including higher depressive symptoms and lower self-esteem. These findings highlight the importance of a multidisciplinary approach with routine psychological screening in postpartum care. Full article

Endometriosis is increasingly recognized as a chronic systemic disorder extending beyond the classical estrogen-dependent paradigm, integrating metabolic, immune, fibrotic, and nociceptive pathways that sustain lesion persistence and refractory pelvic pain. We propose a mechanistic, translational hypothesis in which tirzepatide, a dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist, may modulate four interconnected pathological axes of refractory endometriosis—Warburg-type metabolic reprogramming with lactate accumulation, peritoneal immune dysfunction, NF-κB/NLRP3/TGF-β1-driven inflammatory–fibrotic remodeling, and persistent nociceptive sensitization—through three convergent molecular nodes: AMPK-associated signaling, GLP-1 receptor activity in peritoneal macrophages and spinal microglia, and the NF-κB/NLRP3/TGF-β1 axis. Particular emphasis is placed on the concept of “peritoneal incretin deficiency”, characterized by reduced peritoneal GLP-1 concentrations and increased expression of incretin-degrading proteases. This concept currently rests on a single, non-replicated case–control study, and the broader mechanistic chain is supported largely by indirect evidence extrapolated from adjacent inflammatory, metabolic, and neuroimmune disease models rather than by endometriosis-specific data. Direct experimental or clinical validation in endometriosis-specific models is currently absent. Accordingly, this article represents a hypothesis-generating framework rather than evidence of established efficacy, or a clinical treatment recommendation, intended to guide future mechanistic and prospective clinical investigation of incretin-based modulation as a potential adjunctive strategy in refractory endometriosis. Full article

Endometriosis is a long-term gynecological condition marked by the growth of endometrial-like tissue outside the uterus, which undergoes proliferation, bleeding, and regeneration. This disease is associated with disrupted steroid hormone signaling, notably progesterone (P4) resistance and estradiol (E2) dominance. P4 resistance has been associated with impaired activation of the progesterone receptor (PR) and reduced transcription of P4 target genes, while elevated E2 levels induce estrogen receptor (ER)-mediated signaling, enhancing estrogen-dependent lesion growth. This hormonal imbalance contributes to a pro-inflammatory microenvironment, chronic pelvic pain, infertility, and enhanced neuroangiogenesis. Emerging evidence indicates that the coordinated regulation of neurotrophins and sex hormones promotes nerve fibers and blood vessel growth and invasion within endometriotic lesions. P4 and E2 have been shown to modulate the expression of key neurotrophins, including nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF). This review presents current evidence on the interplay between neurotrophins and ovarian steroids in endometriosis, with a specific focus on their contribution to neuroangiogenesis and pain pathophysiology. The review includes articles in English containing the Medical Subject Headings (MeSH) terms: “endometriosis”, “neurotrophins”, “nerve growth factor”, “brain-derived neurotrophic factor”, “neuroangiogenesis”, “progesterone”, and “estradiol”, found in the PubMed database published between 2000 and 24 May 2026. This review included a range of original research articles, systematic reviews, meta-analyses, prospective observational studies, case–control studies, and review papers, for a total of 122 articles. Full article

Background: Pain is a prominent and disabling manifestation of inflammatory bowel disease (IBD), including abdominal, pelvic, musculoskeletal, axial, and neuropathic pain phenotypes. Patients referred to pain clinics represent a selected subgroup with clinically meaningful, persistent, refractory, or diagnostically complex pain. Objective: To characterize pain phenotypes, treatment patterns, interventional pain-care exposure, and utilization burden among patients with IBD evaluated in tertiary pain-clinic settings and to explore differences between Crohn’s disease and ulcerative colitis patients. Methods: We performed a retrospective electronic medical-record cohort study of patients with documented IBD who were evaluated in pain-clinic settings between 24 October 2010 and 14 May 2026. Repeated clinical entries were aggregated into unique visit dates and patient-level variables. IBD diagnosis, pain phenotypes, treatment documentation, interventional procedures, and pain-clinic utilization were summarized descriptively using counts, percentages, means, medians, interquartile ranges, and ranges as appropriate. Crohn’s disease and ulcerative colitis subgroups were compared using univariable odds ratios with 95% confidence intervals and two-sided p-values. Because repeated clinical entries could belong to the same patient, the primary analytic unit was the patient rather than the individual note. Results: The source dataset included 19,615 clinical entries representing 7053 unique pain-clinic visits among 596 unique patients with IBD. The cohort included 314 patients with Crohn’s disease (52.7%), 247 with ulcerative colitis (41.4%), and 35 with IBD-unclassified (5.9%). The mean number of pain-clinic visits per patient was 11.8, with a median of four visits (interquartile range, 1–11). The dominant patient-level pain phenotypes were limb or peripheral joint pain (395/596, 66.3%), back or axial spine pain (358/596, 60.1%), and abdominal or pelvic pain (246/596, 41.3%). Overall, 437 patients (73.3%) had documentation of at least one interventional pain procedure. Compared with ulcerative colitis, Crohn’s disease was associated with higher documentation of abdominal or pelvic pain (148/314, 47.1% vs. 82/247, 33.2%; odds ratio, 1.79; 95% confidence interval, 1.27–2.53; p = 0.001) and fibromyalgia-like or widespread pain (83/314, 26.4% vs. 39/247, 15.8%; odds ratio, 1.92; 95% confidence interval, 1.25–2.93; p = 0.0027). In contrast, radiofrequency procedures (59/314, 18.8% vs. 78/247, 31.6%; odds ratio, 0.50; 95% confidence interval, 0.34–0.74; p = 0.0005) and facet or medial branch procedures (79/314, 25.2% vs. 87/247, 35.2%; odds ratio, 0.62; 95% confidence interval, 0.43–0.89; p = 0.012) were less frequently documented in Crohn’s disease than in ulcerative colitis. Conclusions: Among patients with IBD referred to tertiary pain-clinic evaluation, pain was heterogeneous and predominantly musculoskeletal, axial, neuropathic, and procedurally targetable rather than exclusively visceral. These findings support structured, mechanism-based pain assessment integrated with gastroenterology, rheumatology, and pain-medicine care. Full article

Objective: The aim of this study was to evaluate the safety and efficacy of robot-assisted laparoscopic ureteroureterostomy (RALUU) and laparoscopic ureteroureterostomy (LUU) for duplicated kidney malformations in infants. Methods: This retrospective comparative cohort included infants with duplicated kidney malformations who underwent RALUU or LUU between May 2021 and April 2025. Perioperative variables assessed included operative duration, blood loss, oral feeding time, FLACC pain score, hospital stay, and complications. Follow-up outcomes included changes in anteroposterior pelvic diameter (APD), ureteral diameter (UD), and renal function (RF) of the affected upper moiety, assessed using renal ultrasonography and radionuclide imaging, with preoperative measurements serving as the baseline reference. The minimum follow-up duration was 12 months. Surgical success was determined based on fulfillment of all three criteria: resolution or alleviation of clinical symptoms, a reduction in APD and UD, and preserved or improved upper-moiety renal function compared with baseline. Results: The final cohort consisted of 52 infants (RALUU, n = 28; LUU, n = 24). Demographic and clinical profiles were comparable between groups. RALUU was associated with a shorter operative duration than LUU (139.6 ± 16.6 vs. 151.8 ± 21.6 min, p = 0.029). Estimated blood loss, time to oral feeding, FLACC pain score, and hospital stay were comparable. Postoperative complications were observed in 2 RALUU patients and 3 LUU patients. One patient in the LUU group developed urine leakage, which was managed conservatively. Postoperative urinary tract infection occurred in 2 patients in each group. No patient required secondary surgery. At a mean follow-up of 26.8 ± 10.4 and 28.1 ± 11.7 months in the RALUU and LUU groups, both groups showed significant reductions in APD and UD, with preserved RF and a modest postoperative increase. Conclusions: Both RALUU and LUU were safe and effective for duplicated kidney malformations in infants. RALUU was associated with a shorter operative time, while postoperative recovery, complication rates, and follow-up outcomes were comparable. Full article

Background/Objectives: Given the growing need for prenatal care, Nordic Walking (NW) is a promising intervention for maintaining maternal physical activity and quality of life (QoL). We aimed to investigate the influence of NW on gait kinematics, pelvic girdle pain, low back pain (LBP), and QoL during pregnancy. Methods: This is a single-blind randomized controlled trial. A total of 44 pregnant women aged 20 to 40 years with 13–28 weeks of gestation and mild to moderate musculoskeletal pain were included. Participants were randomly assigned to either the study (NW) group or the control group. The study group received the NW program for 12 weeks, three sessions per week, each lasting 45 min. The control group received standard prenatal care plus 30 min of moderate walking three days a week. The GAITRite system was used to measure gait kinematics, and the Visual Analog Scale (VAS) for pain and the SF-36 for QoL were administered at baseline, the fourth week, and the twelfth week. Results: NW significantly improved gait kinematics and reduced musculoskeletal pain (p < 0.001) with improvements in pain and gait speed exceeding the previous reported MCID thresholds. QoL improved across all SF-36 domains in the NW group (p < 0.001) compared with the control group, with large effect sizes observed for the primary outcomes. Conversely, the control group experienced declines in several QoL domains, including energy/fatigue and emotional well-being, despite moderate walking exercise and standard prenatal care over 12 weeks. Conclusions: NW may represent an effective prenatal exercise regimen associated with improved gait, reduced pain, and better overall QoL compared with moderate exercise, consistent with standard prenatal care. Full article

Background: Metastases to the uterine cervix from extragenital malignancies represent uncommon clinical events, with breast invasive lobular carcinoma (ILC) documented as the predominant primary source in reported literature. Objectives/Aim: To characterize the clinicopathologic features of ILCs metastatic to the uterine cervix. Methods: We performed a PubMed search using several keywords. Results: A total of 29 studies were included in the final analysis. The mean age at presentation of cervical metastasis was 56.8 ± 2.0 years. The mean interval between the initial diagnosis of ILC and the detection of cervical metastasis was 55.6 ± 8.2 months. Clinical presentations included vaginal bleeding, pelvic pain, and unhealthy enlarged, indurated uterine cervix on local examination. The diagnosis was established via tissue biopsy and immunohistochemical stains (positive reactivity for CK7, ER, PR, E-Cadherin, GATA3, GCDP-15 and mammaglobin). There are no consensus treatment protocols, and therapy should be tailored individually based on the extent of disease. Combined surgical and systemic therapy was the most commonly used modality. Conclusions: Metastasis of breast ILCs to the uterine cervix poses a significant diagnostic challenge. A high index of clinical suspicion and detailed clinical history are essential for accurate diagnosis. Full article

Introduction: Obstructed HemiVagina and Ipsilateral Renal Anomaly (OHVIRA) syndrome, also known as Herlyn–Werner–Wunderlich syndrome, is a rare congenital Müllerian duct anomaly, characterized by uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis. Symptoms typically appear shortly after menarche and include dysmenorrhea and pelvic pain. The psychological burden associated with fertility and reproductive outcomes in women with OHVIRA syndrome remains poorly investigated. Materials and methods: A 30-year-old primigravida with left renal agenesis and a history of vaginal abscess, dysmenorrhea, and chronic pelvic pain received a delayed OHVIRA syndrome diagnosis. The patient had previously been informed that spontaneous conception and an uncomplicated pregnancy were highly unlikely because of her congenital gynecological condition, resulting in significant fertility-related anxiety and psychological distress. Under careful supervision and counseling, she conceived successfully, and the pregnancy progressed without complications; an elective cesarean section was performed at term. A literature search using the PubMed and Embase databases was conducted between November 2025 to April 2026 to identify studies reporting reproductive outcomes and psychological aspects in patients diagnosed with OHVIRA syndrome and other Müllerian anomalies. Results: Evidence-based counseling contributed to improvement of quality of life and reduction of pregnancy-related anxiety of the reported patient with OHVIRA syndrome. A limited number of studies discuss the mental burden and fertility-related anxiety of patients with OHVIRA syndrome and other Müllerian anomalies. Conclusions: Spontaneous conception and uncomplicated pregnancy are possible for women with OHVIRA syndrome. The psychological burden associated with congenital gynecological conditions remains under-recognized and requires further investigation. Comprehensive counseling and interdisciplinary care are essential to improve reproductive education, mental health support, and pregnancy outcomes in patients with congenital gynecological anomalies. Full article

[¹⁸F]-PSMA PET/CT is a high-impact modality for the staging and restaging of prostate cancer, but its wide anatomic coverage and tracer biology generate frequent incidental findings on both PET and the accompanying low-dose CT (LDCT). This narrative review is restricted in scope to fluorine-18 PSMA tracers because tracer-specific biodistribution and pitfall profiles shape what is perceived as incidentaloma: how confidently lesions can be categorized, and how often borderline findings trigger downstream testing, particularly for skeletal foci with [¹⁸F]-PSMA-1007. Specifically, [¹⁸F]-PSMA-1007 shows substantially higher rates of focal unspecific bone uptake than [⁶⁸Ga]-PSMA-11—reported in multicenter studies as affecting up to 40–50% of patients—which directly inflates the pool of potential incidentalomas and creates a tracer-specific false-positive problem with no parallel in gallium-68 practice. Additionally, [¹⁸F]-DCFPyL has different urinary clearance kinetics that affect bladder and ureteral uptake patterns, altering what qualifies as physiologic versus incidental in the pelvis. These differences mean that the threshold for Category B versus C classification—and the appropriate cascade-resistant language—must be tuned to the specific tracer in use. A framework built on [⁶⁸Ga]-PSMA-11 data would systematically underestimate bone pitfall frequency in [¹⁸F]-PSMA-1007 practice and could therefore paradoxically increase rather than reduce cascades if applied uncritically across tracers. These biodistribution differences have direct and concrete consequences for reporting behaviour and downstream management. In [¹⁸F]-PSMA-1007 practice, a focal bone uptake without a CT correlate in a mechanically plausible location—such as an anterior rib or vertebral endplate—should trigger Category B language in the report conclusion: the finding is documented in the body with explicit safety netting (“most consistent with unspecific uptake; no routine workup unless interval growth, new pain, or aggressive CT morphology”), and no referral to bone scintigraphy or MRI is generated. Without tracer-specific awareness, the same finding would typically prompt a reflex bone scan or whole-body MRI referral, delaying definitive prostate cancer management by weeks and adding imaging costs without diagnostic gain. By contrast, in [⁶⁸Ga]-PSMA-11 practice, an equivalent focal bone uptake without a CT correlate carries a higher prior probability of true metastatic disease given the lower background rate of unspecific uptake and should more often be reported at Category B with a lower threshold for escalation or more cautious language. For [¹⁸F]-DCFPyL, the higher urinary activity in the pelvis means that ureteral segments can mimic lymph node disease; recognizing this as a physiologic variant (Category C) rather than an equivocal nodal finding (Category B) avoids unnecessary pelvic MRI referrals that would otherwise be triggered by an uncontextualized report. In practical terms, the tracer-specific calibration of the overlay therefore changes not only the category assigned but also the specific safety-netting language and the escalation trigger, which directly modifies the downstream management pathway for each affected finding type. The scanned population—predominantly older men with a high prevalence of degenerative, inflammatory, and vascular abnormalities—creates substantial background noise that can drive low-value diagnostic cascades if incidental findings are communicated without actionability context. We integrate society-endorsed frameworks (EANM/SNMMI procedure guideline 2.0; E-PSMA; PSMA-RADS; and PROMISE/miTNM with miPSMA score) and propose a cascade-aware overlay for incidental findings that can be appended to existing PSMA reporting standards rather than replacing them. The A/B/C actionability overlay is a structured expert-consensus framework informed by existing evidence-based guidelines for specific finding types and by tracer-specific cohort data; it has not yet been prospectively validated as a standalone tool, and its current level of evidence is therefore analogous to a structured expert recommendation rather than an evidence-based clinical guideline. We operationalize a three-tier actionability scheme across PET- and CT-dominant findings, provide cascade-resistant language for conclusions, and clarify why SUVmax-only “probability scales” for lymph nodes are not recommended in routine reports. Three practical tables summarize PET incidental findings, lymph node reporting frameworks, and LDCT incidental findings, and two structured report templates are provided (concise and extended), with the extended version explicitly labelling actionability tiers and escalation triggers. Finally, we outline concrete AI use cases for standardization and triage while emphasizing governance to avoid the amplification of false positives and paradoxical growth of cascades. Full article