The introduction of cancer and general diagnostic waiting time targets have lead us to look at how we can better deal with referrals to the urology departments in Lanarkshire and so minimise waiting times.
Patients with suspected urological malignancy should be referred through the SCI Gateway, Lanarkshire Cancer Referral Services These conditions include:
- Palpable renal mass
- Incidental renal tract mass on radiology
- Frank haematuria
- Symptomatic occult haematuria
- A scrotal lump which cannot be sparated from testes
- Suspected prostate cancer because of abnormal rectal examination or PSA outwith the age reference range
- Suspected penile tumour
All other referrals should be marked Routine. An explanation in the text of the referral such as chronic retention or severe colic will be treated urgently, even if marked routine. Referrals for conditions other than described above marked urgent may be down graded to routine.
The following referral guidelines are based on specific presentations likely in general practice. Not all patients will fit these broad categories, but we hope the suggestions will ease the initial decision in many cases.
| Presentation | Preparation and Initial Management |
|---|---|
| Asymptomatic non visible haematuria | If dipstick positive, send same sample for microscopy. Casts or abnormal forms indicate requirement for referral to renal physician. Investigate if 2+, or if consistently 1+ (as defined as 2 out of 3 samples) On flow cytometry of MSU, 1+ is defined as 40-100 rbc, 2+ is 100-250 rbc. Arrange MSSU. BP. biochemistry/haematology bloods. Book USS. Patient will be booked for direct access flexible cystoscopy. Manage positive results as indicated. |
| Symptomatic non visible haematuria In patients < 40 yrs | MSSU, BP Biochemistry/Haematology bloods, USS with post-mic residual. Patient will be booked for direct access flexible cystoscopy. Treat/refer positive results as indicated. |
| Testicular Lump | If lump distinctly separate and feels benign, then can be treated symptomatically. USS of scrotum if uncertain or there is a lot of anxiety. If patient fit and symptoms justify surgery refer to general urology clinic. In Wishaw and Monklands there is a separate scrotal lumps clinic for rapid assessment of all such lumps, but not non specific pain. |
| Testicular Pain | Examine for local causes including rectal. Check MSSU. Think of referred causes. If negative reassure. If suspicion or anxiety persists, arrange ultrasound. If normal reassure. Urological referral unlikely to be useful but if in doubt, Patient will be seen at the general urology clinic. |
| Positive uti in male | SIGN guidelines suggest men should be investigated if they have symptoms of upper tract infection, fail to respond to antibiotics or have two or more episodes in three months MSSU, BP, Biochemistry/Haematology bloods. Arrange an USS+KUB with post micturation residual. Patient will be booked for direct access flexible cystoscopy. |
| Recurrent cystitis in female / urinary tract infection in females Persisting pyuria | There are no clear guidelines for investigation. In young males, consider urethritis/ STI. In all, consider atypical infection. Check 3 EMUs. In over 40s, it may be worth excluding underlying abnormality. BP, biochemistry/haematology bloods. Book USS, with post-micturation residual. The patient will be booked for direct access flexible cystoscopy. |
| Persisting pyuria | Although there are no specific SIGN guidelines for referral, indications for referral could be as for males.MSSU, BP, Biochemistry/Haematology bloods. Book an USS, with post-mic residual. In those < 40 yrs, that may be enough but, if troublesome and in those > 40. The patient will be booked for direct access flexible cystoscopy. |
| Haematospermia | Chlamydia urine (white top container) in younger patient MSSU. PR/testicular exam to exclude obvious malignancy Check PSA in older age group. Dipstick urine for haematuria. Trial of quinolone for 2 weeks if investigations negative. Patient will be booked for routine general urology clinic only for difficult cases. |
| Suspected stone disease | MSSU, BP, Biochemistry/Haematology bloods, Arrange USS. If abnormal or history highly suggestive despite negative result. Patient will be booked for routine general urology clinic appointment. |
| Outflow obstruction in males > 50 yrs | MSSU, BP, Biochemistry/Haematology bloods. Fill in symptom score and fluid chart. For mild/ moderate symptoms give trial of alpha blocker. If fails to respond or symptoms severe patient will be booked for prostate clinic. |
| Stress incontinence | Examine for distended bladder/ pelvic mass. MSSU Address concomitant factors such as obesity, smoking. Refer for physiotherapy with pelvic floor exercises/ interferential bladder training. Refer to Continence Advisory Service, Lomond Road, Coatbridge, ML5 2JN. |
| Overactive bladder | Examine for distended bladder / pelvic mass. MSSU. Address concomitant factors such as obesity, smoking, fluid / caffeine intake. Fluid balance chart. Refer to physiotherapy for bladder exercises. Consider trial of anti-cholinergic. If fails conservative management, refer to Continence Advisory Service, Lomond Road, Coatbridge, ML5 2JN. |
| Erectile dysfunction | Check routine bloods including PSA and testosterone. Look at lifestyle and general issues such as obesity, smoking / alcohol intake, general fitness, medication and other diseases such as vascular, neurology, diabetes and psychology. Manage as appropriate. Next line of treatment if patient wishes this is with phosphodiesterase inhibitors such as Viagra/ Cialis/ Levetra. If this fails despite 8 doses, try another PDE5 inhibitor. If still fails or is contra-indicated and patient wishes to be considered for more interventive treatment, Patient will be booked for E.D clinic. If significant psychological component, consider referral to clinical psychologist. |
| Peyronies Disease | This may present with a penile lump and erectile deformity. There is no overlying skin problem. There may be an acute phase with pain and a changing deformity that may last up to a year. This phase can be treated symptomatically. It may be worth a trial of phosphodiesterase inhibitor for flaccidity. Once this has been settled, if the degree of penile deviation is such to make penetrative intercourse difficult enough to justify surgery with the side effects of penile shortening and impotence, refer routinely to general urology clinic. |
| Family planning | We do not offer a vasectomy reversal service. If a patient requests a vasectomy for family planning, they should be referred to local services , or to Sandyford Place in Glasgow for a local anaesthetic procedure. If a patient is deemed unsuitable by Sandyford place for a local anaesthetic procedure on medical grounds, and not just preference, they can be referred for a general anaesthetic vasectomy to the general urology clinic. |
| Paediatric conditions | The lower age limit for the urology service is thirteen years. We will see referrals above this age with mainly surgical conditions such as phimosis, and inguino-scrotal problems. The paediatricians will continue to see referrals upto fifteen with medical conditions such as uti, abdominal pain, enuresis. Surgical problems in children below thirteen years old can be marked paediatric surgery and sent to J McGowan, who is the secretary in Wishaw to the eye dept and the paediatric surgeons (Mr M. Flett and Mr Walker). Emergency cases in children upto thirteen should be directed to Yorkhill. |