DEPARTMENT OF UROLOGY

BLACKBURN ROYAL ROYAL INFIRMARY

 MANAGEMENT GUIDELINES FOR GENERAL PRACTITIONERS

 The following sections are intended to help decision making by General Practitioners (GPs) about common urological clinical problems. They are derived from handouts printed by our department for local GPs. Guidelines are only ever intended to offer advice about management and are not a strict set of rules that must be followed. Each case may have other factors that will influence the process.

Haematuria
Prostatic Specific Antigen (PSA)
Paediatric Urology Referrals

Haematuria

This is divided into macroscopic (visible to the naked eye) and microscopic (found on testing).

Macroscopic

Painful:
 
 

 

 Culture urine and treat as urinary tract infection (UTI) if positive.
Refer urology for
- males (proven UTI or not).
- urine culture negative.
- bleeding recurs after treating UTI.
Painless:  Refer to urologist.

Microscopic

Predisposing Cause:

 

 For example UTI or hypertension.
- treat the above and retest urine.
- refer if haematuria persists. 
No Predisposing Cause:  Retest and refer if haematuria persists. 

Specialist referral depends on age
- under 40 -> nephrologist
- over 40 -> urologist

Prostatic Specific Antigen (PSA)

The following are derived from guidelines agreed at the North West Regional Urology Audit Meeting on 16 April 1998.
  1. In an asymptomatic patient PSA should not be performed unless requested and then only after appropriate counselling (see Patient Information Leaflets ). This should include information on false negative and false positive results, the need for further investigation (Tansrectal Ultrasound and Prostate Biopsy) and the possibility that this may not provide the diagnosis. The implications of a positive diagnosis should also be discussed in terms of potential treatment options and their relative efficacy and potential complications.
  2. In symptomatic patients with Lower Urinary Tract Symptoms (LUTS), a PSA test may be performed as part of the patient's clinical assessment which must include a digital rectal examination (DRE). However, also consider...
  3. In elderly patients with a life expectancy of less than 10 years and few clinical symptoms a PSA should only be carried out if there is good clinical evidence of prostate cancer. If the likely treatment in the event of a positive diagnosis is "Watchful Waiting" (i.e. the patient has early, localised disease), there is little point in performing a PSA test.
  4. Elevation of PSA above the "normal range" can be due to other causes apart from malignant disease. These include: Benign Prostatic Hyperplasia (BPH) with a large gland, prostatitis, prostatic infarction, prostatic manipulation, prostate biopsy and catheterisation.
  5. The normal range of PSA is age dependent :
    6. Age  PSA 
    40 - 49  2.5 
    50 - 59  3.5 
    60 - 69  4.5 
    70 - 79  6.5 
  6. In general, a result of:
    7. < 4 ng/ml  - makes carcinoma less likely but does not exclude it 
    4 - 10 ng/ml  - carcinoma in 17 - 26% of cases 
    10 - 59 ng/ml  - carcinoma in 66% of cases 
    > 60 ng/ml  - usually indicates metastatic cancer 
  7. In patients treated with finasteride, the PSA level is usually halved from the pre-treatment level within a period of 3 months. If this fails to occur, it should raise suspicion about the benign nature of the gland.
  8. PSA is not a substitute for a DRE. An abnormal feeling prostate should be grounds for referral in an appropriate patient (>10 years life expectancy) even if the PSA is within the age related normal range.

Paediatric Urology Referrals

Foreskin

The following are 'normal' and referral is not usually required The following usually require a circumcision and should be referred If the patient has a hypospadias, the foreskin should not be removed as it may be required for subsequent reconstruction by a specialist.

Testicle

The three common problems are as follows
Acute Scrotum URGENT referral
- usually requires surgical exploration 
Undescended testes  Observe until age 2 years
- refer if still undescended / impalpable. 
Hydrocele If asymptomatic and no suspicion of a hernia
- observe and refer only if still present after age 2 years 

Voiding Problems

The common problems are
Enuresis Ensure no UTI or daytime symptoms
Refer if age > 7 (usually to paediatrician) 
Urinary Tract Infection If proven, refer (usually to paediatrician) 
Dysfunctional Voiding Ensure no UTI
Consider vulvovaginitis, bowels, family situation
Refer only if persistent (>90% are behavioural) 

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