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Urology Referral Recommendations

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Urology Referral Recommendations CPAC Urology UROLOGY REFERRAL RECOMMENDATIONS These referral recommendations are provided for core Urology Services in the public health system. The public sector excludes social or cultural circumcision, vasectomy reversal, male fertility and access to primary erectile dysfunction. Erectile dysfunction secondary to surgical intervention is included. In cases of urological emergency requiring urgent treatment or admission, the on call Urological Registrar may be contacted via the Hospital switchboard. Diagnosis Evaluation Management Options Referral Guidelines In the context of these referral Evaluation is indicated from a primary Treatment options at a primary level Urology will prioritise urgency of recommendations, Urology Specialist care perspective. Standard history and may be minimal for surgical diagnoses; assessment based on: examination is required for all Services have been grouped under the however, options are indicated where following headings: situations. Key points in relation to appropriate. 1. High suspicion or confirmed individual diagnoses are highlighted cancer • High suspicion or confirmed and investigations indicated. cancer 2. Impaired function with a risk of permanent impairment if left • Impaired function with a risk of untreated permanent impairment if left untreated Telephone/fax/e-mail communication with the urological referral nurse / registrar will enhance access to the service. The following symptoms require investigation and urgent referral as these patients are at high risk of urological cancer: • Visible haematuria in adults. • Microscopic haematuria in adults over 50 years. • Swellings in the body of the testis. • Solid renal masses found on imaging. • Elevated age-specific prostate specific antigen (PSA) in men with a 10 year life expectancy. • A high PSA (>20ng/ml) in men with a clinically malignant prostate or bone pain. • Any suspected penile cancer. Updated December 2014 Page 1 of 7 CPAC Urology Surveillance for High Risk Subjects Recognition of Symptoms and Signs Diagnostic Investigation Referral Guidelines Prostate Cancer • Targeted screening is justified in Patients may present with lower urinary • DRE Digital Rectal Examination Patients with acute urinary retention, familial and hereditary prostate tract symptoms (LUTS) or symptoms of • PSA Prostate Specific Antigen clot haematuria, severe pain indicative cancer families. metastatic disease. Urgent referral preferably 2 tests, at least 4 of bony metastatic disease or • Hereditary prostate cancer is said should be made based on the criteria weeks apart), neurological symptoms compatible with to exist in a family where: below: • MSU spinal cord compression - require • 3 generations are affected or 3 • With a hard, irregular prostate • Rectal examination findings immediate referral. first degree relatives affected or typical of a prostate carcinoma. • a GP ordered Transrectal any 3 relatives are affected before Prostate-specific antigen (PSA) ultrasonography (TRUS) is NOT All other patients should be seen by age 55 years. should be measured and the result required the specialist within 1-3 months of • A single first degree relative under should accompany the referral. identifying any abnormal result. age of 55 is sufficient to trigger • With a normal prostate, but Refer Urgent-Semi-urgent investigation of prostate cancer. rising/raised age-specific PSA, with • Recommendation of annual or without lower urinary tract DRE/PSA from age of 40 onwards symptoms. in counselled individuals • With symptoms and high PSA levels. Note: In patients compromised by other comorbidities, a discussion with the patient or carers and/or a specialist may be more appropriate. Penile Cancer Individuals with a high risk of developing Physical examination and history. It is Patients may present with: Suspected cases of penile cancer are penile cancer should be monitored important to record: • Colour changes, bumps or urgent and should be discussed with accordingly. Risk factors associated • Diameter of the penile lesion or thickening of the skin of the glans the registrar or referrals nurse refer with penile cancer include: suspicious areas or prepuce particularly, but can Urgent • Location(s) on the penis involve the skin of the penile • Smoking • Number of lesions shaft • Phimosis and chronic irritation • Morphology of the lesion, whether • Persistent discharge or bleeding processes related to poor hygiene papillary, nodular, ulcerous or flat • Abdominal CT • Human Papilloma Virus (HPV) • Relationship with other structures types 16 and 18 (e.g. submucosa, corpora With symptoms or signs of penile • Lack of or late circumcision spongiosa and/or cavernosa, cancer. These include progressive urethra) ulceration or a mass in the glans or • Colour and boundaries of lesion. prepuce particularly, but can involve Updated December 2014 Page 2 of 7 CPAC Urology Clinical assessment needs to the skin of the penile shaft. discriminate between Peyronie's plaque (benign and affects up to 15% of men) Note: Lumps within the corpora Refer semi-urgent / routine referral and penile cancer (rapidly malignant) cavernosa can indicate Peyronie’s depending on symptoms – Semi- arising from the skin (cancer) disease. urgent-Routine Surveillance for High Risk Subjects Recognition of Symptoms and Signs Diagnostic Investigation Referral Guidelines Bladder Cancer Haematuria is a symptom of cancer • Of any age with painless • Physical examination Refer Urgent requiring investigation and referral, macroscopic haematuria • Diagnostic investigations and particularly in individuals with risk • Aged 40 years and older who staging routinely include urinary factors. Risk factors include: present with recurrent or persistent tract ultrasound and intravenous • Frank haematuria urinary tract infection associated urography or CT urography. • Over 40 years of age with haematuria • upper tract imaging (either • Smoking • With an abdominal mass identified ultrasound or CT-IVP if high risk) • Family history clinically or on imaging that is prior or in the pipeline for referral • Those with a poor fluid intake thought to arise from the urinary • Renography, MRI and PET are • Bilharzia / Schistosomiasis tract used selectively. infection • Aged 50 years and older who are • Cystoscopy+/- retrograde • Previous treatment for cancer; in found to have unexplained pyleoureterography particular radiotherapy to the microscopic haematuria (semi- • Transurethral resection pelvis and some forms of urgent referral) chemotherapy. • Haematuria clinics exist in some centres streamlining review Updated December 2014 Page 3 of 7 CPAC Urology Surveillance for High Risk Subjects Recognition of Symptoms and Signs Diagnostic Investigation Referral Guidelines Testicular Cancer Only a small proportion of men with Symptoms: If ultrasound and clinical examination Suspected cases of testicular cancer scrotal swellings have cancer; a • testicular masses suggest the presence of cancer, are urgent and should be discussed GP may see only one case of testicular • other unexplained testicular blood should be taken before surgery with the registrar or referrals nurse cancer every 20 years and is symptoms to assess levels of tumour refer Urgent not likely, therefore, to be able to • sensation of scrotal heaviness markers including: distinguish between tumours and • alpha-fetoprotein (AFP), non-malignant causes of symptoms. Testicular cancer can be reliably • lactate dehydrogenase (LDH) confirmed or excluded by a and GPs should refer men with combination of clinical examination and • beta-human chorionic testicular masses or other unexplained ultrasound imaging with staff who are gonadotrophin (βhCG). testicular symptoms for specialist skilled in interpreting ultrasound images assessment of the scrotum. GPs who have rapid access to these services should do so to determine benign/malignant nature and make appropriate referral. Scrotal Abnormality • Right, left, bilateral Dependent of symptoms and specific Semi-urgent- Routine • Cord or Vas pathology • Varicocoele / Hydrocele • Epididymal cyst • Physical examination • Ultrasound mandatory Undescended testis An undescended testis is one that Conservative management is In a clinically obvious associated cannot be manipulated into the bottom reasonable in patients over 40 years hernia, they should be managed as of the scrotum. hernia Referral Recommendation. All testes should be situated within the scrotum by the age of 3 months. Updated December 2014 Page 4 of 7 CPAC Urology Surveillance for High Risk Subjects Recognition of Symptoms and Signs Diagnostic Investigation Referral Guidelines Kidney Cancer Risk factors include: Patients with kidney cancer may • Physical examination will identify Refer Urgent • Smoking present with: a palpable mass in side or • Obesity • Haematuria abdomen • Hypertension • Pain in the side that doesn’t go • Hypertension • Long term dialysis away • Von Hippel–Lindau (VHL) • A lump or mass in the side or the • Check urine for blood Syndrome abdomen • ESR and U&E, Creatinine • Gender (males more likely) • Weight loss • CT or ultrasound • Fever Female incontinence • Obstetric history • Duration of symptoms Conservative management by a Routine if conservative measures fail. • • Previous gynaecological/urological Predominantly stress incontinence trained physiotherapist or continence surgery • Predominantly urge incontinence specialist. • • PV findings Urge/stress incontinence • MSU • • Neurological signs Does the patient require pads, • Bladder drills. number per day?
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