Urology Clinic

Brief summary of appropriate URGENT referrals

(see more thorough explanations in text below):

• Patients with symptoms that are both acute and severe should be referred to Emergency Department. This list is for all other patients.
• Scrotal swelling
  • Obtain a scrotal sonogram
    • If solid structure in scrotum (e.g., possible tumor), obtain serum alpha fetoprotein, serum beta-HCG, and serum LDH
    • If fluid-filled structure in scrotum (e.g., hydrocele or spermatocele), then referral is routine priority
• Kidney mass
  • Obtain abdominal CT with & without contrast, or abdominal MRI without contrast if renal insufficiency present
    • If solid renal mass (e.g., possible tumor), obtain CBC and chemistry
    • If fluid-filled structure (e.g., cyst), then referral is routine priority
• Bladder mass or Gross hematuria
  • For gross hematuria, exclude UTI first. Obtain a CT urogram, or abdominal-pelvic MRI without contrast if renal insufficiency present
• Penile mass
  • No imaging necessary if < 2 cm. If > 2 cm, and/or palpable inguinal nodes, obtain abdominal-pelvic CT with & without contrast, or abdominal-pelvic MRI without contrast if renal insufficiency present
• Hydronephrosis
  • Obtain serum chemistry
    • If eGFR < 60, then refer urgently
    • If eGFR > 60, then referral is routine priority

Brief summary of appropriate ROUTINE referrals

(see more thorough explanations in text below):

 

• Urinary tract stones
  • After imaging, at least KUB and NOT solely US, has revealed any bladder or ureteral stones, or a renal stone that causes signs or symptoms or exceeds 5 mm in size
• Microscopic Hematuria
  • After confirming 2 or more RBC per hpf on microscopic urinalysis, and after excluding UTI
• Obstructive urinary symptoms in men
  • For man > 50 years-of-age (likely BPH), after checking post-void residual urine volume (see next entry) and trialing both fluid restriction (especially in the evening hours for symptoms of nocturia) and an alpha-blocker for at least 2 weeks
  • For man < 50 years-of-age (possible urethral stricture or other), after checking post-void residual urine volume (see next entry)
• Complete urinary retention or post-void residual urine volume > 300 ml plus symptoms and/or high risk features (hydronephrosis or eGFR < 60)
  • After failing voiding trial while on alpha blocker
• Overactive bladder, urinary frequency and/or painful urination (dysuria)
  • After obtaining microscopic urinalysis and ruling out UTI, and (in a woman) trialing fluid restriction and an anti-muscarinic for at least 2 weeks, or (in a man) treating any concurrent obstructive symptoms as above. For predominant dysuria, trial phenazopyridine 100 – 200 mg po tid.
• Urinary incontinence in a man (women are referred to Women’s Health)
  • After obtaining post-void residual urine volume (to rule out overflow incontinence) and microscopic urinalysis (to rule out UTI)
• Elevated PSA
  • After confirming with repeat value at least 4 weeks later, and after treating any urine or prostate infection
• Hematospermia
  • If persistent, and after obtaining microscopic urinalysis and ruling out UTI
• Testicular or scrotal pain
  • After trialing NSAIDs and scrotal support, and obtaining a scrotal sonogram if these measures fail
• Perineal or pelvic pain in a man (women are referred to Women’s Health)
  • After trialing NSAIDs or a 3-week course of antibiotics.
• Erectile dysfunction
  • After trialing PDE5 inhibitor
• Hypogonadism (low testosterone)
  • After confirming with morning serum testosterone level and obtaining serum LH and FSH.
• Recurrent Urinary Tract infections
  • After confirming infection on at least 2 urine cultures
• Peyronies disease (curvature of penis)
  • After confirming that it is painful or precludes intercourse
• Polycystic kidney disease associated with flank or abdominal pain, urinary stones, or upper tract infections
  • After checking serum chemistry; if eGFR < 90 refer to Nephrology
• Neurologic conditions causing urinary issues (e.g. multiple sclerosis, Parkinson’s disease, etc)
  • After obtaining microscopic urinalysis and ruling out UTI
• Penile abnormalities such as phimosis (tight foreskin), recurrent balanoposthitis, buried penis, urethral meatal narrowing, etc.
  • (For phimosis), after trialing 0.1% triamcinolone cream application to the foreskin BID for 3 months
• Sterile Pyuria (2-5 leukocytes per high powered field on microscopic urinalysis)
  • After obtaining negative urine culture for tuberculosis, Haemophilus, Ureaplasma, Trichomonas, N. gonorrhea, and Chlamydia
• Urethritis/Urethral Discharge
  • After testing and/or empiric treatment for gonorrhea and chlamydia

Please do NOT refer the following patients:

• Proteinuria (Refer to Renal Clinic)
• Skin rashes in genital area
• Pediatric patients (age < 18)
• Acute, non-recurrent UTI’s
• Vasectomy (see vasectomy referral information)
• Infertility
• Cystocele or Rectocele in women (Refer to Women’s Health)
• PCKD with renal failure (Refer to Nephrology)
• Urinary incontinence in women (Refer to Women’s Health)

Documentation required for scheduling an appointment:

• Completed referral form, problem list, and medication list
• Lab results requested above, plus other pertinent results
• Radiographic images and reports requested above, plus other pertinent results

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Detailed Recommendations

Urinary Tract Stones – Medical prevention

In all patients with nephrolithiasis we recommend primary preventative measures to help reduce the risk of future stone formation. These include drinking 2 to 3 liters of fluid daily, eating a low salt diet, and eating smaller portions of meat. Certain patients should be referred to the Urology clinic for additional evaluation and management, including high-risk and/or recurrent stone formers. These are the patients most likely to benefit from metabolic testing and therapy. High-risk stone formers include those with a family history of stone disease, malabsorptive intestinal disease or resection, recurrent urinary tract infections, obesity or medical conditions predisposing to stones (e.g., prior bariatric surgery, renal tubular acidosis, primary hyperparathyroidism, gout, diabetes mellitus type 2). Patients with a solitary kidney are considered “high-risk” because of the serious implications of stone passage/obstruction in a solitary kidney. Recurrent stone formers include patients with repeated stone episodes as well as those with multiple stones at initial presentation.

A) Ureteral stones
Any patient with a ureteral stone should be referred to the Urology clinic, since a ureteral stone that does not pass spontaneously carries an appreciable risk of ureteral damage if left in situ too long. Please make sure that the patient is staying well hydrated by drinking at least 2 liters of water/fluids per day and pain is controlled with ibuprofen or narcotic pain medication. Prescribe tamsulosin 0.4 mg daily at bedtime to help with stone passage. Many ureteral stones will pass on their own with these interventions.
The patient needs to be instructed to present to the emergency department immediately for any fevers or chills prior to stone passage since this may be caused by obstructive pyelonephritis and requires emergent treatment.
Please obtain imaging before referral, either a KUB (preferably plus a renal US) or a CT scan.

B) Kidney Stone
Not all renal stones require active management. Renal stones < 5 mm in size, even multiple ones, that are not obstructing or causing symptoms may not require active management.

Refer a patient with kidney stones to the Urology clinic for stones > 5 mm in size, or if any of the following are also present: obstruction, flank pain, persistent urinary tract infection, immune-suppression, prior symptomatic stones, family history of stones in a first degree relative, or a systemic disease predisposing to urinary stone formation such as prior bariatric surgery, renal tubular acidosis, primary hyperparathyroidism, gout, or diabetes mellitus type 2. Stones without these factors do not require further evaluation.
The patient needs to be instructed to present to the emergency department immediately for any fevers or chills prior to stone passage since this may be caused by obstructive pyelonephritis and requires emergent treatment.

Please obtain imaging before referral, either a KUB (preferably plus a renal US) or a CT scan.

Overactive bladder, urinary frequency (including nocturia) and/or painful urination (dysuria)

After obtaining microscopic urinalysis and (in a woman) trialing fluid restriction and an anti-muscarinic (oxybutynin 5 mg po TID) for at least 2 weeks, or (in a man) treating any concurrent obstructive symptoms (see next entry). Note that expected anti-muscarinic side effects include dry mouth and constipation. It is expected that patients will experience these side effects when they are on an effective dose of anticholinergic medication to help their bladder symptoms.

If the urinalysis suggests possible UTI, then culture the urine and for a UTI even if the colony count is low. The urinary frequency may not allow bacterial colony counts to rise to levels that are normally considered positive for infection.

Assess bladder emptying by checking a post-void residual urine volume with a bladder scan or straight catheterization. Normal post-void residual volume should be less than 100 mL, but referral to Urology is not necessary until the volume is > 300 ml.

Isolated nocturia as the primary complaint may also be due to lower extremity edema, fluid intake at night, or taking a large volume of pills with fluid or diuretics at night. Trial lower extremity elevation in the afternoon (if there is lower extremity edema), decreased fluid intake prior to bed, and taking any prescribed diuretics in the morning.

For predominant dysuria, trial phenazopyridine 100 – 200 mg po tid.

If symptoms persist after the applicable measures above, then refer to the Urology Clinic.

Obstructive urinary symptoms in men
For man > 50 years-of-age (likely BPH), check post-void residual urine volume (see next entry) and trial both fluid restriction (especially in the evening hours for symptoms of nocturia) and tamslosin 0.4 mg po qHs alpha-blocker for at least 2 weeks. This alpha blocker relaxes the muscle in the prostatic stroma, which allows more effective voiding. Additional conservative measures include eliminating spicy foods from diet and avoidance of caffeine or alcohol.

If symptoms persist after these measures, then refer to the Urology Clinic.

For man < 50 years-of-age, this might be a urethral stricture or other narrowing. Urethral stricture is a narrowing of the urethra that is caused by scar tissue. It may be caused from trauma or infection. It can block the flow of urine and may need an operative intervention to fix this. Do NOT insert any catheter unless the patient is unable to void. Check a post-void residual urine volume (see next entry) and then refer to the Urology Clinic since additional evaluation may be required.

Acute or Chronic Urinary Retention
Patients who present with a recently placed urinary catheter for urinary retention should undergo a voiding trial following initiation of an alpha-blocker (ie. tamsulosin 0.4 mg po qhs). Following 5 to 7 days on the alpha blocker, the patient’s catheter may be removed with a “fill-pull-void” trial. Fill the bladder with up to 300mL of sterile water or until the patient reports discomfort. Remove the catheter, keeping the fluid in the bladder. Instruct the patient to urinate into a urinal, and then calculate the residual urinary volume. If the patient voids more than 50 ml or the residual volume is < 300 ml then there is no need for catheter re-insertion. If the patient is unable to void, re-insert a Foley catheter and refer to the Urology clinic. If the patient reported that the catheter placement was difficult or traumatic, then no attempt a voiding trial should be made until speaking with a Urologist. The alpha-blocker may be continued until the patient is seen by Urology.

In cases of elevated post-void residual urine volume (“chronic urinary retention”) detected during evaluation of urinary complaints (see above), referral to the Urology Clinic is necessary only if the residual volume is > 300 ml and there are either urinary symptoms and /or high risk features (hydronephrosis or eGFR < 60) AND the volume does not decrease to < 300 ml with trial of tamsulosin.

Urinary incontinence in a man (women are referred to Women’s Health) 
It is important to make sure the patient is not retaining urine and having overflow incontinence. Check a post-void residual urine volume with a bladder scanner or with straight catheterization (see above for management of urinary retention). Also obtain a microscopic urinalysis to exclude an active infection.

Elevated PSA
A flawless and standardized interpretation of elevated PSA values has yet to be determined. Although it has been well demonstrated that patients with elevated serum PSA levels are more likely to be harboring aggressive prostate cancer, elevated PSA levels can also be seen in less biologically aggressive prostate cancers as well as benign prostatic hypertrophy, infection, urogenital tract instrumentation (ie catheter placement) and anything that can cause inflammation within the prostate gland. As such, any elevated PSA value should be repeated in 4 weeks and confirmed. If persistently elevated, a referral to Urology should be placed after excluding a symptomatic UTI with a urinalysis. Initiation of antibiotics without a diagnosis of acute prostatitis but merely for an elevated PSA is ill advised. “PSA elevation” is defined as PSA > 2.5ng/mL in men ages less than 60 and a PSA > 3.5ng/mL in men greater than 60 years of age.

PSA screening
The American Urological Association recommends the following for PSA screening. No screening should be performed before age 40. Men ages 40-54 should be screened only if they are at high risk (e.g. African American or family history of prostate cancer). Men ages 55-69 are the cohort of men with the greatest benefit of screening. Practitioners are urged to discuss PSA screening in this age group and reach a shared decision. Men over 70 years or with less than 15-year life expectancy, should NOT be screened with a PSA test. For patients in whom PSA screening may be considered, the shared decision making process can be carried out in the primary care setting, or after referral to the Urology Clinic. Decision Aids can be helpful in this endeavor.

• English Decision Aid http://www.urologyhealth.org/Documents/Product%20Store/Prostate-Cancer-Screening-Decision-Tool-english.pdf
• Spanish Decision Aid http://www.urologyhealth.org/Documents/Product%20Store/Prostate-Cancer-Screening-Decision-Tool-spanish.pdf

Hematospermia
Hematospermia is typically benign and self-limited. It may be caused by inflammation or infection, so we recommend evaluation for urinary tract and sexually transmitted infections. We also recommend a blood pressure check as uncontrolled hypertension may result in hematospermia. Trauma to or pressure on the perineum including constipation and bicycle riding have also been known to cause hematospermia. Our typical evaluation of hematospermia includes history and physical examination including blood pressure, genital examination, and digital rectal examination. Laboratory testing includes a urinalysis +/- urine culture, and testing for sexually transmitted diseases. In almost all cases hematospermia resolves spontaneously and no treatment is required. If the hematospermia persists and is very bothersome to the patient, then refer to the Urology Clinic.

Microscopic or Gross Hematuria (or bladder mass detected on imaging)
Microscopic hematuria is defined only on urine microscopy: three or more red blood cells per high-powered field on microscopy of a properly collected urinary specimen. Urine dipsticks positive for hemoglobin should be confirmed with urine microscopy, as false positive dipsticks are common. Performing radiographic and cystoscopic evaluation is unnecessary in the absence of microscopically confirmed microhematuria. If the urinalysis suggests possible UTI, culture the urine and treat even a low colony count of bacteria, and then reassess for hematuria with another microscopic urinalysis. Refer to the Urology clinic only for well-documented microscopic hematuria.

For gross hematuria, exclude UTI first and then refer to Urology Clinic urgently if there is no infection. Obtain a CT urogram, or abdominal-pelvic MRI without contrast if renal insufficiency present.

For bladder mass detected on imaging, obtain microscopic urinalysis and refer to Urology Clinic urgently.

Follow-up of negative microscopic hematuria workup
American Urological Association Guidelines recommend that a negative microscopic hematuria work-up should be followed with annual urinalysis for at least two years, If the urinalysis is negative at each follow-up, the patient may be released from care, with instructions to return if new symptoms develop or subsequent urine studies show the presence of microscopic hematuria. For patients whose urine is recurrently positive for microscopic hematuria, re-refer with the Urology Clinic three to five years after the initial negative workup.

Erectile dysfunction
Unless contraindicated (e.g., using nitrates) trial a phosphodiesterase 5 inhibitor like sildenafil (which is now generic). We typically prescribe 50 mg tablets and instruct the patient to break them in half for a starting 25 mg dose. This should be taken 30 minutes to 4 hours prior to intercourse on an empty stomach. The patient also needs to be in the mood for intercourse and have some stimulation for erection to occur. If a partial erection occurs with sildenafil at a lower dose, the dose may be increased to a maximum of 100 mg po daily.

If the PDE5i trial fails or if the patient cannot take a PDE5i, refer to the Urology clinic to discuss additional treatment options like intercavernosal injection therapy and the vacuum erection device.

Hypogonadism (low testosterone, low T)
Men who complain of low libido or decreasing energy or fatigue should undergo hypogonadal work up. A serum testosterone level should be checked in the morning and repeat again if low (ie < 300). If low on repeat testing, obtain a serum FSH and LH and refer to the Urology clinic.

Painful Ejaculation
Painful ejaculation may occur due to infection/inflammation or during closure of the bladder neck during ejaculation. We recommend physical examination of the external genitals and prostate. Laboratory testing includes urinalysis +/- urine culture and sexually transmitted infection testing as indicated.
NSAIDs may help reduce the pain. In the setting of negative infectious work up, trial tamsulosin 0.4 mg po qHs to help relax the bladder neck during ejaculation. Men may note retrograde ejaculation with this medication.

If symptoms persist after these measures, then refer to the Urology Clinic.

Peyronie’s Disease (curvature of the penis)
Peyronies disease is penile curvature caused by plaque calcifications. If this curvature is painful or precludes intercourse, trial pentoxifylline 400mg po BID x 1 week, then titrate up to 400mg po TID dosing if there is no GI upset. This medication has been shown to decrease calcified penile plaques in Peyronies disease and is the only treatment needed for some men.
If the curvature is painful or precludes intercourse, and persists after several months of pentoxifylline therapy, then refer to the Urology Clinic. Please also ask him to bring a photograph of his erect penis to clinic. This is required prior to any surgical planning and will save him a return clinic visit.

Penile abnormalities such as phimosis (tight foreskin), recurrent balanoposthitis, buried penis, urethral meatal narrowing, etc.
Phimosis is a condition that often can be treated medically. Apply 0.1% triamcinolone cream liberally to the foreskin (apply with a Q-tip) BID gently retracting the foreskin after application of the cream. This usually loosens the skin enabling skin retraction without pain. If this treatment regimen is ineffective after 3 months, or if the patient would like to proceed with a circumcision, then refer to the Urology Clinic.

Recurrent Urinary Tract infections
Many suspected UTIs are not actually infections, so obtain urine culture should be performed by a clean catch or straight catheter collection. At least 2 positive cultures should be documented before referral to the Urology Clinic.

Note that use of a spermacidal agent on condoms or as a form of birth control frequently contributes to UTIs. We recommend eliminating spermacide from birth control, if possible, to help reduce UTIs. In women who only have UTIs after sexual intercourse, we sometimes prescribe prophylactic antibiotics with one tablet of nitrofurantoin 50 mg or a SS TMP-SMX tablet, to be taken after intercourse. Consider trialing this before referral to the Urology Clinic.

For post-menopausal women with recurrent UTIs, we recommend vaginal estrogen cream to help alter vaginal pH to pre-menopausal states. This can significantly limit recurrent UTIs in this patient population. Consider trialing this before referral to the Urology Clinic.

Scrotal swelling (tumor, hydrocele, spermatocele, etc,)
Obtain a scrotal sonogram. If there is a solid structure in scrotum, then this might be a tumor.
Obtain serum alpha fetoprotein, serum beta-HCG, and serum LDH, and refer urgently to the Urology Clinic. If there is a fluid-filled structure in scrotum, then this is a hydrocele or spermatocele. Both are benign and surgical intervention is indicated only if they become large, painful, or very bothersome to the patient as there is a risk of recurrence and a small risk of chronic scrotal pain after operation. If the swelling is very bothersome to the patient, then refer to the Urology Clinic.

Sterile Pyuria
Sterile pyuria is defined as 2-5 leukocytes per high powered field on urinalysis with microscopy. This must be diagnosed on UA with microscopy and not on urine dip stick. Sterile pyuria may be associated with vaginal leukocyte contamination of the urine specimen, infection with non-commonly tested organisms for UTI, interstitial nephritis, nephrolithiasis, and transitional cell carcinoma. As initial workup in the setting of no renal colic or history of nephrolithiasis, we recommend urine culture for the organisms listed below: tuberculosis, Haemophilus, Ureaplasma, Trichomonas, N. gonorrhea, and Chlamydia. If these tests are negative, then refer to the Urology Clinic.

If the patient has HIV, HIV associated nephropathy may demonstrate sterile pyruia, is also typically associated with proteinuria, and may be associated with nephrotic syndrome and renal insufficiency. A nephrology consult is recommended if this diagnosis seems likely based on evaluation of proteinuria and renal function.

Urethritis/Urethral Discharge
Causes of urethritis and urethral discharge in males include chlamydia, N. gonorrhea, herpes, trichomoniasis, and ureaplasma. After testing and/or empiric treatment for GC/Chlamydia, we recommend testing and empiric treatment for these other organisms that may also cause urethritis. If there is still urethral discharge after appropriate treatment for these organisms, or if these tests are negative, then refer to the Urology Clinic.

Testicular or scrotal pain
First trial NSAIDs and scrotal support (athletic supporter/jock strap). If these measures fail, then obtain a scrotal sonogram and refer to the Urology Clinic.
Perineal or pelvic pain in a man (women are referred to Women’s Health)
First trial NSAIDs or a 3-week course of antibiotics (Bactrim DS). If these measures fail, then refer to the Urology Clinic.

Perineal or pelvic pain in man (women are referred to Women’s Health)
First trial NSAIDs or a 3-week course of antibiotics (Bactrim DS). If these measures fail, then refer to the Urology Clinic.

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