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UROLOGY REFERRAL RECOMMENDATIONS

Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines

These referral recommendations are provided for core Urology Services in the public health system. They exclude social or cultural circumcision, vasectomy
reversal, and access to impotence treatment. In cases of urological emergency requiring urgent treatment or admission – Category 1 & 2, the duty Urological
Registrar may be contacted via the Hospital switchboard.
In the context of these referral Evaluation is indicated from a primary Treatment options at a primary level Circumstances for referral are
recommendations, Urology Specialist care perspective. Standard history and may be minimal for surgical diagnoses; indicated below with reference to the
Services have been grouped under the examination is required for all however, options are indicated where appropriate specialty/specialties.
following headings: situations. Key points in relation to appropriate.
individual diagnoses are highlighted Telephone/fax/e-mail communication
• Female incontinence and investigations indicated. will enhance access to the service.
• Hematuria
• Lower urinary tract symptoms
(male)
• Male genitalia
• Male infertility
• Paediatrics – congenital
abnormality
• Paediatrics – male genitalia
• PSA screening
• Stones
• Suspected cancer of the prostate

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines

Female incontinence
KEY POINTS:
• Predominantly stress
incontinence.
• Predominantly urge incontinence.
• Urge/stress incontinence.
• Does the patient require pads,
number per day?
Conservative management by a Refer for OPD assessment – Category
trained physiotherapist or continence 3 if conservative measures fail.
specialist.
Surgery for stress incontinence can be
– Review by continence advisor Urology or Uro-Gynaecology
– Bladder drills.
– Pelvic floor exercises

• History of UTIs. – Treat UTI’s

• Duration of symptoms. – Anticholinergics if low residuals on

bladder scan
• Obstetric history.
• Previous gynaecological/urological
surgery.

PV findings, Neurological signs.

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines

Hematuria
Macroscopic (gross). KEY POINTS: Continuous gross hematuria – refer as
• ?Complete (urine uniformly blood- Category 2, OPD assessment,
stained). otherwise – Category 3.
• ?Initial stream, ?end stream?
clots. An open access Hematuria Clinic will
Confirm Hematuria on MSU if not sure.
• ?Pain/dysuria. be opened in the future for immediate
Even if urine clear after event, always
assessment of patients with hematuria,
• Onset, duration, episodes. investigate. All patients over 45 years
eg Hollywood Public Hospitals.
even with UTI must be fully evaluated.

Females:
• Other gynaecological symptoms.
• PV findings.

Males:
• Other urological symptoms.
• DRE.

Treat infection, treat symptoms. IVU

INVESTIGATIONS: probably best investigation.
Refer for ? Cystoscopy
• MSU (RBCs, WCCs, culture).
• PSA.
Consider: KUB
US } in consultation
IVU } with specialist
Urology service

(See Imaging Referral

Recommendations.)
Microscopic (defined as >25RBCs in 3 INVESTIGATIONS: Routine referral – Category 3.
urine specimens).
• MSU x 3

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines

Lower Urinary Tract Symptoms (Male)
Known as B.O.O (Bladder Outflow
Obstruction)
Most ‘troublesome’ symptoms need
assessment, eg nocturia, urgency,
incontinence, hematuria or pain
KEY POINTS:
• Previous lower urinary tract
surgery.
• Has the patient required
catheterisation?
• Is he catheterised?
• Documented previous UTIs?
Continence advisors can provide
triage, MSU, flow rate and bladder
residuals
Trial of alpha adrenergic blockers after
flow rate and bladder scan residual.
Refer to OPD assessment – Category
3 after trial of alpha adrenergic
blockers.
Bothersome symptoms refer category
3

PHYSICAL EXAMINATION:
• Palpable/percussible bladder?
• DRE – asymmetry, hardness,
nodules, induration.

INVESTIGATIONS:

MSU – WCC, RBC culture.

PSA.

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Diagnosis / Symptomatology
Male genitalia
Testicular Abnormality.
Scrotal Abnormality.
Penis Deformity.
Last updated February 2006
Evaluation Management Options Referral Guidelines
KEY POINTS:
Hard mass, painless, ultrasound and
• Right, left, bilateral. urgent referral Intra-Testicular mass refer urgently
– Category 2.
• Body of testis.
• Right, left, bilateral ?. Refer for OPD assessment – Category
Any mass outside the testis, eg 3, if problem is bothersome.
• Cord or vas including varicocoele Epididymal. Cyst is never malignant.
?. U/sound and reassurance
• Epididymal cyst.
• Foreskin. Phimosis – Use steroid creams Refer for OPD assessment – Category
3.
• Glans.
Peyronie’s – Rare, Use Vitamin E
• Shaft.
• Functional.
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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines

Male infertility
KEY POINTS: Refer for OPD assessment – Category
3.
– Has the patient had unprotected
intercourse for 12 months or
more?
– Has the patient previously
biologically fathered children?
– Has the current partner had
previous pregnancies?
– Has his partner undergone any
investigations?
• Does the patient have a past
history of: Semen Analysis must be done with at
least 5 days abstinence and sent to a
– Mumps orchitis. laboratory geared for fresh semen
analysis
– Inguinal hernia repair.
– Testicular torsion.
Blood Tests are fasting testosterone,
– Orchidopexy. FSH and LH
– Varicocoele repair.
– Any significant illness in the last six
months.
– Smoking marihuana
Physical examination
?Male habitus testes

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines

Paediatrics – Congenital Abnormality
Paediatric Urology – (See Paediatric Surgery Referral Recommendations)

Inguinal and/or Scrotal Swellings. Non-acute hernia and hydrocoeles can Child under 3 months with Hernia or
be difficult to differentiate in children. It uncertain diagnosis:
is important to recognise a hernia in a Refer urgently – Category 2 to
child under the age of 3 months. Paediatric Surgery/Urology Service.

Varicocoeles are difficult to

differentiate. If suspected, refer as per
Hernia over the age of 3 months:
hernia Recommendation.
Refer semi-urgently to Paediatric
Surgical Service or local General
Surgical Service – Category 3.

Difficult Hernia:
Any hernia that is reduced with
difficulty, is at significant risk of
strangulation and should be referred
urgently – Category 2 – irrespective of
age.

Hydrocoele:
If a hydrocoele is confidently
diagnosed, it can be treated
expectantly. If it persists past the age
of 2 or causes symptoms, or grows
rapidly, it should be referred routinely –
Category 3.

Acute Scrotal Pathology. Epidydimo-orchitis is very rare in Scrotal Pain with or without swelling:
children and should not be diagnosed
Always consider torsion or Refer immediately – Category 1.

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clinically. strangulation and refer urgently

The following conditions are included:
– Torsion of testis.
– Torsion of appendix of testis.
– Strangulated hernia.
– Incarcerated hernia.
– Idiopathic scrotal oedema.
– Uncertain mumps orchitis.
Undescended testis. Risk of infertility if orchidopexy is Refer from the age of 6 months to
delayed, increases with age. It is now Paediatric Surgery or Urology Service.
recommended that orchidopexy should Routine referral – Category 3.
be performed by the age of 1 year.

An undescended testis is one that In a clinically obvious associated

After age 40 may be best left alone
cannot be manipulated into the bottom hernia, they should be managed as
of the scrotum. All testes should be hernia Referral Recommendation.
situated within the scrotum by the age
of 3 months.
Retractile testis. Retractile testes are not normally Refer routinely at the age of 2 to the
situated within the scrotum, but can be Paediatric Surgery or Urology Service
manipulated into the scrotum. The – Category 3.
current recommendation is that they be
fixed in the scrotum surgically if they
remain retractile after the age of 2.

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Diagnosis / Symptomatology
Paediatrics – Male Genitalia
Phimosis/Paraphimosis.
Social/Religious Circumcisions.
Hypospadias.
Urethral Meatal Stenosis.
Balanitis.
Other Genital Anomalies.
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Evaluation
No problem if good urinary stream. A
large percentage of foreskins are fused
to the glans and will separate
spontaneously over a number of
months or years. There is no
necessity to retract or be able to retract
the foreskin (at least before 5 years of
age).
Ballooning with micturition frequently
occurs and is acceptable providing
there is a good urinary stream.
Do not circumcise.
Evaluate adequacy of urinary stream.
Often abnormalities, undescended
testis?
Usually neonatally circumcised boys.
Evaluate urinary stream.
Accumulation of smegma under the
foreskin is common and normal, but
can be mistaken for pus. Referral
and/or intervention is not required. It
will continue to extrude spontaneously
until all the prepucial adhesions have
disappeared. Foreskin retraction and
cleaning is not necessary.
Management Options
Teach hygiene, cleansing, washing,
gentle retraction, Reassure
May need renal tract ultrasound
Urethral dilations from continence
advisors
Frank infection requires treatment with
oral antibiotics (eg cotrimoxazole) and
surgery if it is recurrent.
Referral Guidelines
Phimosis:
Indications for referral:
• Inability to retract after the age of
5.
• Recurrent balanitis.
• Pinhole prepucial orifice with very
poor urinary stream.
• Refer routinely – Category 3.
Paraphimosis:
Refer immediately – Category 1.
Not provided in public health system.
Refer at diagnosis routinely – Category
3, to Paediatric Surgery or Urology
Service.
Refer immediately if poor urinary
stream – Category 1.
Refer routinely – Category 3.
Recurrent balanitis – refer routinely, as
above – Category 3.
Refer routinely Category 3 to
Paediatric Surgical Service or
appropriate local Paediatric Medical
Service.
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Urinary Tract
Antenatally Diagnosed
Hydronephrosis.
Urinary Tract Infection.
Many urological abnormalities will
present as an urinary tract infection.
These include:
• Vesicoureteric reflex.
• Pelvi-ureteric junction obstruction.
• Vesicoureteric junction
obstruction.
• Primary Mega-ureter.
• Neurogenic bladder.
• Duplex system +/- ureterocoele.
• Posterior urethral valves.
Neuropathic Bladder.
Last updated February 2006
Applies to hydronephrosis at any
gestation. Post natal examination for
abdominal mass. Ultrasound after 5
days of age.
LMC has responsibility to ensure GP is
informed.
Evaluation of urinary tract infections:
The diagnosis of UTI requires great
care and skill.
Clear evidence of UTI is essential.
(Note: Guidelines of UTI in Children is
attached.)
Urine results must be provided with the
referral.
INVESTIGATION:
With reference to local
recommendation.
Check for spinal abnormality, ie mass
or spina bifida occulta. Exclude
constipation.
Regular urine check-ups.
Seek specialist review
Start antibiotics pending culture report.
Five day course. Consider long term
surveillance and prophylactic
antibiotics until investigations are
completed.
Treat constipation, toileting hygiene.
• Treat constipation.
• Long term antibiotics.
Referral to Paediatric or Urology
Service if dilation is present – Category
2.
Note: Majority of urinary abnormalities
present as either UTI or as
hydronephrosis following antenatal
ultrasound.
Refer for assessment patients with
abnormal imaging results or if requiring
investigations, noting local
Recommendations. Routine Category
3.
Refer recurrent urinary tract infections.
Routine Category 3.
Refer to Paediatric or Urology Service
if diagnosis suspected.
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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines

Stones
KEY POINTS: Poorly controlled renal/ureteric colic
refer for OPD assessment – Category
• Past history of stones and stone Fever, pain, rigors – Immediate 2. This is usually via an A&E
surgery. admission department. Otherwise – Category 3
• Pain score : obstructed kidney, refer Category 2.
Indicid suppositories, 100mg bd –
– Severe, poorly controlled. useful for proven renal colic if stone
passes Many Stone cases are offered early
– Moderate controlled. intervention, stents or lasertripsy,
– Minimal well controlled.
– Asymptomatic. Specialised units have access to
lasers.
• Analgesia requirement.
• Acute renal coli – right/left –
duration of symptoms.
• Known urinary tract calculus.
– size of stone.
– location.
– how diagnosed.
Metabolic Disease ? Gout.
INVESTIGATIONS: (Xrays are the
only way to diagnose)
• MSU (microscopy).
Consider: KUB } in conjunction with
USS } urology service
IVU } CT Spinal scan best modality for
(See Primary Referred Imaging investigation
Referral Recommendations.)

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines

Suspected Cancer of the Prostate
Including elevated PSA.
Usually in older men. Men below 70
usually have PSA screening.
Over 70 – 75, symptoms that are
worrying should be evaluated.
Screening of asymptomatic men over
75 is not recommended.
KEY POINTS:
• Family history of Ca prostate.
• Weight loss.
• Bony pain.
• Hematuria.
• Previous bladder/prostate surgery.
PHYSICAL EXAMINATION:
• Palpable/percussible bladder?
• DRE – asymmetry, hardness,
nodules, induration.
Often the worried will want
assessment. PSA Screening in over
75 yrs should be discouraged.
Symptomatic patients should have
urological review – Category 3
Refer Category 2 – Patients with
advanced disease, pain, etc
Prostate biopsies with transrectal
U/Sound are only performed where
uroligically evaluated.

INVESTIGATIONS:
• PSA, Percentage Ratio
• FBC, + ESR.
• U + E.
• Creatinine.
• Alkaline Phosphatase.

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