Download Common Urological Guidelines

Primary care management of common adult Urological
problems
This is a local pathway and local guidance; there may be more detailed but national
guidance available on at http://cks.nice.org.uk/ and clinical decision aids as well at
http://www.mapofmedicine.com/ for those who want or need to delve further.
Drug advice is as advised by the Sheffield Formulary except where this is not covered.

Balanitis

Hydrocele

Phimosis and Paraphimosis

Priapism

Infertility

Varicocele

Ejaculatory_disorders

Epididymal_Cysts

Prostatitis

Erectile Dysfunction

Male_lower_urinary_tract_symptoms

loin_Pain

Renal_Calculi

Haematospermia

Peyronies_Disease

Sterile_Pyuria
Balanitis
Balanitis refers to inflammation of the glans penis. The majority of cases in adults are due to
a fungal infection or represent early balanitis xerotica obliterans (BXO). Rarely, a red patch
on the Glans can represent carcinoma of the penis (CIS). In the absence of an associated
phimosis (scarring of the foreskin making retraction of the foreskin impossible), most cases
can be managed in Primary Care with simple hygiene and cleaning, topical weak steroid and
anti-fungal agents (e.g. Daktacort®) or antibiotics (CKS offers advice of flucloxacillin (or a
macrolide), or metronidazole if Gardnerella is suspected)
http://cks.nice.org.uk/balanitis#!topicsummary
In the presence of phimosis, routine referral to Urology is indicated, as long as the patient is
prepared to undergo circumcision.
If Balanitis is recurrent in absence of phimosis consider whether there is CIS; swabs may be
appropriate, as may reviewing concordance.
Consider urgent referral [2ww] to Urology if there are any suspicious features such as
i.
Associated palpable mass underlying non-retractile foreskin
ii. Failure of red patch to clear despite trial of topical therapy (? Erythroplasia of
Queyrat – CIS of penile glans)
Hydrocele
A Hydrocele is a collection of fluid around the testis which is transilluminable. The majority
have no obvious underlying cause, however rarely there is a secondary cause such as
testicular cancer. Most Hydroceles can be managed in Primary Care without onward
referral. If the testicle cannot be palpated or there is doubt, an urgent ultrasound scan is
indicated. If there is concern about the testicle on an Ultrasound Scan then 2WW referral is
indicated.
Referral for an opinion on a Hydrocele is not necessary unless there are concerns that the
underlying testicle contains tumour.
Asymptomatic Hydroceles require no treatment. Aspiration of a Hydrocele is no longer
recommended, except in exceptional circumstances, because of a high recurrence rate and
the risk of introducing infection.
Where a hydrocele is causing significant symptoms, the general condition of the patient
should be taken into account before referring for a surgical opinion.
Phimosis and Paraphimosis
Phimosis refers to scarring of the foreskin, resulting in a non-retractile foreskin. The majority
of cases are caused by Balanitis Xerotica Obliterans [BXO], otherwise known as Lichen
Sclerosis et atrophicus. It is to be remembered that the foreskin may be non-retractile in
boys, without any evidence of scarring. This is a physiological phenomenon and does not
require any intervention.
Conservative treatment [and possible avoidance of Circumcision] could be tried in Primary
Care where there is inflammation or early scar formation prior to referral. This involves
applying a steroid cream for 4 weeks with gentle stretching of the foreskin. If there is no
improvement consider referral. If there is mature scar tissue and fissuring, refer to Urology.
Phimosis is sometimes associated infection and poor hygiene, a swab may be indicated, but
often gives a mixed growth and candida.
If the foreskin is fissured and scarred then Circumcision is almost always indicated.
Paraphimosis refers to a condition is where the foreskin fails to return to its natural position
after retraction. This forms a tight constriction ring around the Glans causing pain and
swelling. When seen early, reduction of the Paraphimosis can be attempted in Primary care
by squeezing the Glans to reduce the oedema and then pulling the foreskin forward. Most
cases however require urgent urological referral for reduction and subsequent circumcision.
Priapism
This is a medical emergency where the erect penis does not return to its flaccid state. Most
cases are iatrogenic and associated with interventions used for the treatment of erectile
dysfunction. Rarely, priapism may be a presenting feature of a haematological malignancy
or complicate conditions such as sickle cell anaemia. Potential complications include
ischaemia and impaired erectile ability.
The patient should be referred immediately to a Urologist. (It is noted that the 111 pathway
suggests A&E but when there is a clear diagnosis this will only add in an extra stage and
referral straight to Urology will be faster for the patient>)
Infertility
Infertility is a couple issue and both partners should be fully assessed.
Where there is strong suspicion of male factor infertility, take a full clinical and drug history
with examination of secondary sexual characteristics, genitalia (mainly for testicular
location, size and presence of a varicocele) and rectal examination. Arrange a sperm counts
to be analysed within 2 hours of production and which follows 2 days of abstinence from
sexual intercourse. (A second count could be indicated if the first is ambiguous).
Arrange blood samples to measure FSH, LH, Testosterone and SHBG, TSH and Prolactin.
Azoospermia refers to the complete absence of sperm in the ejaculate. The main
differentiation is between obstructive causes and non-obstructive causes. Where the FSH
levels are normal, obstructive azoospermia is a possibility and urological referral is
indicated. Azoospermia with very high FSH indicates Primary Testicular Failure and is best
dealt with by Reproductive Medicine.
Hormonal abnormalities. Refer to Endocrinology if raised prolactin or evidence of
hypogonadism or hypopituitarism
If results indicate a low sperm count, poor morphology and /or motility, consider the
following advice to the patient:
Stop smoking.
Lose weight if obese.
Consider stopping any contributory drugs [anabolic steroids, cimetidine,
spironolactone, phenytoin, sulfasalazine], and check if “recreational drugs” or herbal
remedies may be implicated.
Though frequently shared it is important to note that general advice such as avoidance of
hot tubs and wearing boxer shorts rather than briefs does not have much evidence of
benefit.
Repeat sperm count after 3-6 months to assess response to treatment. In the absence of a
defined endocrine abnormality, there is no evidence that androgen supplementation has
any benefit.
Fertility referral form:
http://www.sheffieldccgportal.co.uk/pressv2/index.php/referral-forms/item/fertilityservice-referralform?highlight=WyJmZXJ0aWxpdHkiLCJzZXJ2aWNlIiwiaW4iLCJmZXJ0aWxpdHkgc2VydmljZSI
sImZlcnRpbGl0eSBzZXJ2aWNlIGluIiwic2VydmljZSBpbiJd
Varicocele
Varicoceles are almost exclusively on the left side and are present in 10% of the male
population. If on the right side consider a Retroperitoneal tumour and request an
ultrasound scan of the retroperitoneum. A Varicocele developing suddenly in an older man
may indicate an underlying Renal Tumour. If in doubt carry out a renal ultrasound scan.
Urological referral is rarely indicated. Only refer for troublesome symptoms such as aching.
In cases of male subfertility there is little evidence that treatment of the varicocele in an
adult man will improve fertility. Sperm count may rise but there is no increase in pregnancy
rates.
Treatment options: Transvenous embolization, surgical ligation through groin.
Ejaculatory Disorders
Ejaculatory disorders are common in primary care and rarely indicate underlying organic
disease. Most patients do not need urological referral. It is important to take a full medical
and social history as several recreational drugs, antidepressant agents and antipsychotic
agents can cause ejaculatory dysfunction. Similarly a thorough physical examination,
including examination of the external genitalia and a rectal examination is mandatory.
Benign prostatic enlargement can be associated with a reduction or alteration in semen
volume/ character. In the absence of significant symptoms or abnormality on rectal
examination, no referral is required and simple reassurance may be all that is necessary.
Ejaculatory disorders can be sub-classified as below.
Premature Ejaculation. Although there is no true definition of this condition, the complaint
is usually life-long and refers to emission taking place prior to vaginal penetration. Lesser
degrees may respond to topical local anaesthetic application, but referral to the
Psychosexual Clinic is indicated if first line advice from a Primary Care Clinician fails.
Secondary premature ejaculation can rarely be indicative of an underlying acquired
neurological condition.
Dapoxetine ( Priligy®) has a marketing authorisation for the treatment of premature
ejaculation and is classified as an amber drug in the Sheffield Traffic Light Drug list and
should be prescribed only when all the criteria specified in the SPC are met. A maximum
supply of 6 tabs per month is advised by the Sheffield APG.
For further information:
http://www.uroweb.org/gls/pdf/14_Male%20Sexual%20Dysfunction_LR.pdf
Delayed ejaculation. This is usually situational – again psychosexual counselling may be
required. Where it is non-situational (i.e. masturbation or intercourse), it can be associated
with underlying organic disease such as diabetes or an endocrine disorder.
Anejaculation/ Retrograde Ejaculation. These are different conditions but manifest by
absence of an emission despite orgasm. Retrograde may be as a result of TURP or bladder
neck surgery. If fertility is an issue refer to Reproductive Medicine.
Haematospermia/ haemoejaculate. See specific advice
Lumpy Semen or discoloured semen. This is rarely of any significance. If there are risk
factors for an associated STI, appropriate swabs/ specimens should be taken.
Epididymal Cyst
Epididymal cysts should normally be managed in Primary Care. Any early discomfort usually
settles spontaneously within 3-6 months. If there is any doubt about the diagnosis [cyst is
normally separate from the testicle and soft] an Ultrasound Scan can be requested. It is
important to note that simple epididymal cysts are usually asymptomatic, thus where there
are severe symptoms such as pain, an alternative diagnosis such as epididymitis should be
considered. There is no indication for antibiotics unless one suspects epididymitis.
Aspiration is not recommended and conservative management is suggested in most cases.
Referral should only be considered in a fit man where there are overriding symptoms and no
concerns about future fertility.
Prostatitis
Prostatits is the commonest recurrent urological condition affecting men. The current
classification scheme for prostatitis allows rational selection of management strategy. The
presentation of ‘prostatitis’ in a man under 40 years of age should raise the suspicion of a
sexually transmitted infection and GUM referral is probably indicated.
Type1 Acute Prostatitis
This is associated with suprapubic/ perineal pain, strangury and severe systemic upset. It is
commonest following prostate biopsy, but is otherwise very rare
Refer for emergency admission for parenteral antibiotic therapy with acute prostatitis; (i.e.
with severe systemic upset; or in retention or severe voiding issues or at high risk of sepsis
(Diabetic, elderly and frail, on immunosuppressants)
Type 2 chronic bacterial prostatitis
This usually presents with recurrent urinary tract infection. It would normally be appropriate
to ensure that there is no sinister cause for this by routine urology referral as well as
offering treatment in primary care. Treatment is indicated with 1 -2 months of ciprofloxacin
(Sheffield Formulary choice) supplemented with NSAIDs if no contra-indication. (Sheffield
Formulary choice is ibuprofen up to 1200mg per day. See chapter 10 for further information
on prescribing of NSAIDs). Relapse is common and generally can be managed in the
Type3a [abacterial prostatitis]
community.
Symptomatic rx only, consider alpha blockers (Sheffield Formulary choice is tamsulosin
400mcg MR capsule) and NSAID (see above for Sheffield Formulary recommendation).
Chronic pelvic pain
May need pain management referral.
Erectile Dysfunction
Most patients can be managed in Primary Care by looking at lifestyle, drugs, relationship
issues, psychological issues, smoking and alcohol. Exclude physical causes such as genital
abnormalities [Peyronie`s Disease], neurogenic such as MS, Parkinson`s Disease, Stroke and
hormonal issues, lack of libido [if indicated]. Exercise and losing weight, reducing alcohol
and smoking cessation have been shown to improve Erectile Dysfunction. Discuss
medication that causes Erectile Dysfunction such as anti-hypertensives.
Always examine with a focus on CVS, waist circumference, heart rate, blood pressure as a
minimum. Examination of genitalia including DRE.
Investigation: Calculate 10 year CVS risk. Take bloods including FBC, U and E, LFT`S Hba1c ,
Lipids and serum testosterone and SHBG. If testosterone is low or borderline repeat with
prolactin. Testosterone best measured between 9 and 11 am.
If no contraindication, initiate oral treatment with a PDE-5 inhibitor. In broad terms,
approximately 75% of men will respond a PDE-5 inhibitor. sildenafil is the Sheffield
Formulary choice. A man should receive 8 doses before being classified as a non-responder.
If treatment has not been satisfactorily effective, consider switching to an alternative PDE-5
inhibitor.
Do not prescribe to any men taking nitrates or nicorandil. Do not prescribe to men with
hypotension [systolic below 90], recent stroke, unstable angina or MI in last 6 months.
These drugs are also contra-indicated in severe hepatic impairment. Prescribe with caution
in Left Ventricular outflow obstruction and Peyronie`s Disease, Sickle-cell Disease, Myeloma
and Leukaemia.
Prescribing of drugs for erectile dysfunction on the NHS is in accordance with the defined
DH criteria and the prescriptions endorsed ‘SLS’.
Patients with low testosterone, refer to testosterone pathway.
http://www.sheffieldccgportal.co.uk/pressv2/index.php/clinicalpathways/item/endocrinology-low-testosterone-clinicalpathway?highlight=WyJ0ZXN0b3N0ZXJvbmUiLCJjbGluaWNhbCIsInBhdGh3YXkiLCJ0ZXN0b3N
0ZXJvbmUgY2xpbmljYWwiLCJ0ZXN0b3N0ZXJvbmUgY2xpbmljYWwgcGF0aHdheSIsImNsaW5
pY2FsIHBhdGh3YXkiXQ==
Refer to Porterbrook:

Patients with psychosexual problems

young men who have always had difficulty in obtaining or maintain erection
Refer to urology:

men with a history of trauma to genitals pelvis or spine.

Men who do not respond to at least 2 oral agents.

(Nurse led clinic) oral treatment is contra-indicated, ineffective or not tolerated.
Refer to Cardiology

men who have severe CVS disease where sexual activity considered unsafe.
Options include
Injection of penis with Prostoglandins E1
MUSE [medication urethral system for erection]
Venous leak surgery
Angioplasty for large vessel disease.
Refer to the shared care protocol for Male Erectile Disorder for further information
Male lower urinary tract symptoms
Lower urinary tract symptoms associated with benign prostatic enlargement are common in
men over the age of 50. It is important to remember that the symptoms of frequency,
urgency, poor urinary flow and nocturia are not diagnostic of benign prostatic obstruction,
but may indicate underlying prostate cancer, prostatitis or even carcinoma in situ of the
bladder. Nocturnal urinary frequency should be differentiated from nocturnal polyuria, the
latter being commonly associated with systemic illness such as diabetes and incipient heart
failure.
A focussed history and clinical examination is essential in assessing
1. the severity of symptoms
2. presence or absence of significant underlying illness
3. requirement for referral
In most cases, male LUTS can be managed appropriately in primary care, with referral
required for complications (e.g. acute retention of urine, renal impairment) or suspected
other pathology.
A Frequency volume chart is essential in ruling out unsuspected underlying conditions such
as nocturnal polyuria and standardised symptom scores help in longitudinal follow-up of the
patient. The presence of significant dysuria or any haematuria in the absence of proven UTI
should raise the suspicion of underlying significant disease and precipitate urgent referral.
Digital rectal examination forms the cornerstone of clinical examination, with the detection
of any irregularity of surface or texture of the prostate forming grounds for referral.
Examination of the abdomen for the presence of a palpable bladder is important as is
examination of the external genitalia for penile or meatal abnormalities.
Urinalysis for blood or infection is indicated in men with LUTS, particularly in the presence of
severe storage symptoms.
Although a PSA test is optional, it is good practice to discuss the pros and cons of PSA testing
with such men, particularly those with an estimated life-expectancy of 10 or more years.
The PCRMP of NHS England has written patient information sheets for men considering a
PSA test ( see http://www.cancerscreening.nhs.uk/prostate/prostate-patient-infosheet.pdf).
Assessment of renal function is recommended as renal dysfunction may co-exist with
chronic retention of urine (interactive obstructive uropathy) or may result in polyuria. If
there is a deterioration in renal function or clinical possibility of retention than an
Ultrasound is advised, though if both are present consider urgent referral.
Following clinical evaluation, in the absence of any complicating factors, first-line treatment
rests between an alpha-blocker (Sheffield Formulary choice is tamsulosin 400mcg MR
capsule) or life-style advice and self-management. Most men with mild/ moderate
symptoms, when given reassurance that symptoms are not likely to progress and that
cancer has been excluded, will opt for self-management. An alpha-blocker is effective in
around 70-80% of men with moderate/ severe symptoms. In the presence of a very
enlarged benign prostate gland, addition of a 5alpha-reductase inhibitor may help (Sheffield
Formulary choice is a combination of finasteride and tamsulosin).
Urgent referral to a urologist is indicated if
1. Chronic retention of urine with renal impairment
2. Suspected locally advanced prostate cancer (PSA greater than 20 ng/mL or abnormal
DRE)
3. Elevated Age-specific PSA level in man with life-expectancy of 10 or more years
Suspected bladder cancer (severe storage LUTS with dipstick haematuria or frank
haematuria).
Referral should be considered if
1. Symptoms fail to respond to conservative treatment
2. Adverse events associated with medical treatment
3. Progression of symptoms.
http://pathways.nice.org.uk/pathways/lower-urinary-tract-symptoms-in-men
Loin Pain
Can occur as a result of renal calculi amongst other causes. Commonly in Primary Care not a
Urological problem. Need to consider Calculi, Pelvi-ureteric junction obstruction [PUJ],
Pyelonephritis and in older patients Abdominal Aortic Aneurysm. Peak incidence of stone is
35 to 45. It is less common as a first presentation in the elderly. Back pain is very common in
all age groups.
Risk of renal stones over a lifetime in men is 12% and 4 % for women. Consider renal calculi
as a cause if of recent onset, male, and young, severe, colicky with nausea and vomiting.
Patient normally writhing around. There is normally haematuria [non-visible or visible].
Pyelonephritis, patient often ill with loin pain, rigors and pyrexial. There may be symptoms
of a UTI. Urinalysis will probably contain nitrites and leucocytes [possibly blood].
Blood clots can cause Loin pain following renal biopsy or bleeding from renal tumour for
example.
PUJ obstruction. Pain normally follows drinking a lot of fluids.
Renal Tumours. The pain is normally of gradual onset .There may be painless haematuria
and a mass.
Renal infarct especially in older patients with Atrial Fibrillation.
Non renal causes include Dissecting Aortic Aneurysm, muscular pain, injury to lower ribs
causing neural irritation, radiculitis, pulmonary causes. Non exhaustive list.
Investigations. Urinalysis and microscopy, gross haematuria present in 85% of renal colic.
Conversely 15% will not have visible or non-visible haematuria. Pyuria can be present with
renal calculi. Blood tests would include U&E, Bone profile and uric acid.
Imaging. Consider an uss and a plain abdominal Xray. [consider women of child bearing age
re Xray].Consider a CT scan.
Advice
In the event of severe loin pain, urgent referral to the surgical assessment unit for initial
evaluation and imaging is indicated. Where a urological condition is demonstrated on
imaging, transfer/ referral to the urology unit is indicated.
Renal Calculi
Advice: Asymptomatic stones or those found incidentally do not normally require referral.
Advice re diet if stone-maker: drink 2-3 litres a day [4-6 pints]. Reduce tea coffee and
alcohol. Avoid large portions of meat fish and eggs cheese and milk. Reduce salt in diet. Do
not take vitamin D supplements, avoid vitamin C supplements . The above advice can reduce
stone formation by 50%.
Prior to referral some basic metabolic tests are useful:
Urea and Electolytes, Bone Metabolism tests, Urate.
If possible stone analysis for recurrent stone formers.
Imaging: Most sensitive is CT if available, otherwise consider USS and Plain Abdo Xray [not
women under 50 if risk of pregnancy].
Refer symptomatic stones to the (urology) stone clinic for either Surgery for larger stones or
Lithotripsy is offered as Out Patient. If stones are large Ureteric Stent may be inserted.
These cause significant symptoms such as loin pain, haematuria, frequency and dysuria.
NSAIDs may be helpful. Antibiotics have no benefit.
Haematospermia/ Haemoejaculate
Blood in the ejaculate rarely indicates any underlying organic disease. In younger men,
consider testicular/ epididymal disorder and in older men (>50), consider prostate cancer.
Thorough examination, including a digital rectal examination, is indicated.
If the prostate feels normal on examination, there is no haematuria, the PSA is normal and
scrotal examination is normal, the man can be reassured. Persistent haemoejaculate will
probably warrant referral to urology.
The underlying cause may be benign prostatic hyperplasia, low grade seminal tract infection
or an AV malformation. Conservative management is indicated.
Peyronie`s Disease
Peyronie’s disease refers to an inflammatory condition affecting the corpus cavernosus of
the penis. The initial features are usually of pain, lump formation and later of erectile
deformity (bending towards the side of the lump). Still later, erectile dysfunction may
follow. The condition is normally self-limiting with spontaneous resolution in 60-70% of
cases within 12 to 18 months, although the majority of men will be left with some penile
deformity and erectile dysfunction. There is an association with Hypertension, Diabetes,
Ischaemic Heart Disease, Arteriosclerosis as well as certain drugs such as beta- blockers,
antidepressants and antihistamines. It occurs in 3% of men, mostly middle-aged but not
exclusively.
There is some evidence that oral Potaba® (potassium aminobenzoate) taken for 3 months
may speed up resolution of the discomfort. Less specifically, NSAIDs may also reduce pain in
early stages (Sheffield Formulary choice is ibuprofen up to 1200mg per day. See chapter 10
for further information on prescribing of NSAIDs). No treatment has been shown to affect
the final result. Men should be reassured (a rectal examination is indicated as a rare
presentation of prostate cancer is with painful penile metastases) and surgery is certainly
not first line treatment. Resolution of pain is an early sign of the disease settling.
Surgery is not considered until disease has been stable for 6-12 months. Nesbit`s procedure
is associated with penile shortening.
Refer if the penile bend prevents penetrative intercourse once the condition has been
stable for 6 months. Consider treatment for Erectile Dysfunction in primary care if the main
problem is distal flaccidity.
Advice: This condition can normally be managed in Primary Care. Always perform a rectal
examination.
Sterile Pyuria
This is usually due to incompletely treated UTI. However it can be due to renal calculi or
more importantly urothelial cancer. Rarely it can be due to TB of the Renal Tract. TB is a
consideration in the immune-compromised or immigration from country where TB is
prevalent. If this is considered likely, then 3 early morning urine samples to Microbiology is
indicated.
In younger people consider Chlamydia. Consider Urethritis and in women swab any Vaginal
discharge.
Always examine the patient (NB local causes).
Consider ix such as USS and Abdominal X-ray [not women at risk of pregnancy].
Refer: for persistent sterile pyuria which has been investigated as above (2ww)
Written 7.2014 by Dr Michael Boyle with input from Mr Derek Rosario and Sheffield Clinical
Reference Group
Review summer 2015
Sheffield Formulary is available here:
http://www.intranet.sheffieldccg.nhs.uk/medicines-prescribing/sheffield-formulary.htm