UROLOGY REFERRAL RECOMMENDATIONS - WA Health

1 REFREC025 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 RECOMMENDATIONS , UROLOGY Specialist Services have been grouped under the following headings: Female incontinence Hematuria Lower urinary tract symptoms (male) Male genitalia Male infertility Paediatrics congenital abnormality Paediatrics male genitalia PSA screening Stones Suspected cancer of the prostate Evaluation is indicated from a primary care perspective.

2 Standard history and examination is required for all situations. Key points in relation to individual diagnoses are highlighted and investigations indicated. Treatment options at a primary level may be minimal for surgical diagnoses; however, options are indicated where appropriate. Circumstances for REFERRAL are indicated below with reference to the appropriate specialty/specialties. Telephone/fax/e-mail communication will enhance access to the service. Last updated February 2006 Page 1 of 12 REFREC025 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? History of UTIs. Duration of symptoms.

3 Obstetric history. Previous gynaecological/urological surgery. PV findings, Neurological signs. Conservative management by a trained physiotherapist or continence specialist. Review by continence advisor Bladder drills. Pelvic floor exercises Treat UTI s Anticholinergics if low residuals on bladder scan Refer for OPD assessment Category 3 if conservative measures fail. Surgery for stress incontinence can be UROLOGY or Uro-Gynaecology Last updated February 2006 Page 2 of 12 REFREC025 Diagnosis / Symptomatology Evaluation Management Options REFERRAL guidelines Hematuria Macroscopic (gross). KEY POINTS: ?Complete (urine uniformly blood-stained). ?Initial stream, ?end stream? clots. ?Pain/dysuria. Onset, duration, episodes. Females: Other gynaecological symptoms. PV findings.

4 Males: Other urological symptoms. DRE. INVESTIGATIONS: MSU (RBCs, WCCs, culture). PSA. Consider: KUB US } in consultation IVU } with specialist UROLOGY service (See Imaging REFERRAL RECOMMENDATIONS .) Confirm Hematuria on MSU if not sure. Even if urine clear after event, always investigate. All patients over 45 years even with UTI must be fully evaluated. Treat infection, treat symptoms. IVU probably best investigation. Refer for ? Cystoscopy Continuous gross hematuria refer as Category 2, OPD assessment, otherwise Category 3. An open access Hematuria Clinic will be opened in the future for immediate assessment of patients with hematuria, eg Hollywood Public Hospitals. Microscopic (defined as >25 RBCs in 3 urine specimens).

5 INVESTIGATIONS: MSU x 3 Routine REFERRAL Category 3. Last updated February 2006 Page 3 of 12 REFREC025 Diagnosis / Symptomatology Evaluation Management Options REFERRAL guidelines Lower Urinary Tract Symptoms (Male) Known as (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? PHYSICAL EXAMINATION: Palpable/percussible bladder? DRE asymmetry, hardness, nodules, induration. 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.

6 Bothersome symptoms refer category 3 INVESTIGATIONS: MSU WCC, RBC culture. PSA. Last updated February 2006 Page 4 of 12 REFREC025 Diagnosis / Symptomatology Evaluation Management Options REFERRAL guidelines Male genitalia Testicular Abnormality. KEY POINTS: Right, left, bilateral. Body of testis. Hard mass, painless, ultrasound and urgent REFERRAL Intra-Testicular mass refer urgently Category 2. Scrotal Abnormality. Right, left, bilateral ?. Cord or vas including varicocoele ?. Epididymal cyst. Any mass outside the testis, eg Epididymal. Cyst is never malignant. U/sound and reassurance Refer for OPD assessment Category 3, if problem is bothersome. Penis Deformity. Foreskin. Glans. Shaft. Functional. Phimosis Use steroid creams Peyronie s Rare, Use Vitamin E Refer for OPD assessment Category 3.

7 Last updated February 2006 Page 5 of 12 REFREC025 Diagnosis / Symptomatology Evaluation Management Options REFERRAL guidelines Male infertility KEY POINTS: 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: Mumps orchitis. Inguinal hernia repair. Testicular torsion. Orchidopexy. Varicocoele repair. Any significant illness in the last six months. Smoking marihuana Physical examination ?Male habitus testes Semen Analysis must be done with at least 5 days abstinence and sent to a laboratory geared for fresh semen analysis Blood Tests are fasting testosterone, FSH and LH Refer for OPD assessment Category 3.

8 Last updated February 2006 Page 6 of 12 REFREC025 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 be difficult to differentiate in children. It is important to recognise a hernia in a child under the age of 3 months. Varicocoeles are difficult to differentiate. If suspected, refer as per hernia Recommendation. Child under 3 months with Hernia or uncertain diagnosis: Refer urgently Category 2 to paediatric Surgery/ UROLOGY Service. Hernia over the age of 3 months: 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.

9 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 children and should not be diagnosed Always consider torsion or Scrotal Pain with or without swelling: Refer immediately Category 1. Last updated February 2006 Page 7 of 12 REFREC025 clinically. The following conditions are included: Torsion of testis. Torsion of appendix of testis. Strangulated hernia. Incarcerated hernia. Idiopathic scrotal oedema. Uncertain mumps orchitis. strangulation and refer urgently Undescended testis. Risk of infertility if orchidopexy is delayed, increases with age. It is now recommended that orchidopexy should be performed by the age of 1 year.

10 An undescended testis is one that cannot be manipulated into the bottom of the scrotum. All testes should be situated within the scrotum by the age of 3 months. After age 40 may be best left alone Refer from the age of 6 months to paediatric Surgery or UROLOGY Service. Routine REFERRAL Category 3. In a clinically obvious associated hernia, they should be managed as hernia REFERRAL Recommendation. Retractile testis. Retractile testes are not normally situated within the scrotum, but can be manipulated into the scrotum. The current recommendation is that they be fixed in the scrotum surgically if they remain retractile after the age of 2. Refer routinely at the age of 2 to the paediatric Surgery or UROLOGY Service Category 3. Last updated February 2006 Page 8 of 12 REFREC025 Diagnosis / Symptomatology Evaluation Management Options REFERRAL guidelines Paediatrics Male Genitalia Phimosis/Paraphimosis.