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                                 Abnormal PSA Test
                Lower Urinary Tract Symptoms in Men / Enlarged Prostate
                                      Renal Colic

December 2008 ver.2
Approved by Barwon Health Urology Unit

       EVALUATION                            INVESTIGATIONS                             REFERRAL GUIDELINES
   •   Painful or painless               •   Confirm +ve dipstix with formal MSU
   •   Initial terminal or total                                                        Please ensure investigations completed
   •   Associated features           Minimum investigations prior to referral
                L.U.T.S.               • MSU inc RBC morphology                    UROLOGY REFERRAL
                Fever or rash.         • U+E’s/Cr/eGFR                               • If haematuria (macro or micro) confirmed
                Trauma                 • Urine cytology (if smoker or >50yrs)        • For cystoscopy
                Flank pain             • Coags (if on anticuagg. Rx.)                • Possibly further imaging – IVU or CT
                Irritative voiding     • US urinary tract, KUB
                symptoms                                                           NEPHROLOGY REFERRAL
   •   Examination:                                                                  • If HT, nephrotic, increasing Cr, proteinuria
                BP                                                                     with painless haematuria
                Abdo/loin mass                                                       • organise – random urine protein/Cr ratio

December 2008 ver.2
Approved by Barwon Health Urology Unit
                                                   L.U.T.S. IN MEN

       EVALUATION                           INVESTIGATIONS                           REFERRAL GUIDELINES

   •   Assess severity of symptoms: Minimum investigations prior to referral   GP MANAGEMENT
              Nocturia                • MSU                                      • If mild/moderate symptoms – medical
              Weak steam              • U+E’s/Cr                                    therapy
              Urgency                 • US urinary tract – Inc. post void        • Options:
              Straining                  residual                                   1. Prazosin (Pressin) – initially 0.5mg bd
              Terminal dribbling      • PSA                                             inc. to 2.0mg bd over 3-4 weeks
              Hesitancy                                                             2. Tamsulosin (Flomaxtra) 400mcg/d no
              Intermittency                                                             dose titration, less s/e’s but cost ~ $60
              Bladder emptying                                                          month (not on PBS but is DVA)
              How bothered is the                                                   3. Proscar 5mg/d – esp. fpr larger prostaes
              patient                                                                   and if prazosin fails, 6/12 for maximal
   •   Phx – retention, stricture.                                                      effect but cost ~ $100 month (not on
   •   Examination                                                                      PBS but is DVA)
              Bladder palpable?
              Phimosis                                                         UROLOGY REFERRAL
              DRE – size,                                                          • If severe symptoms
              consistency features                                                 • If failed medical therapy
              of ca (hard/nodular)                                                 • Abnormal – DRE, PSA, US, MSU. Inc
                                                                                     Cr. Haematuria or bladder stones

December 2008 ver.2
Approved by Barwon Health Urology Unit
                                                           RENAL COLIC

    EVALUATION                 INVESTIGATIONS                                       REFERRAL GUIDELINES
•   Consider Ddx.             Minimum investigations             GP MANAGEMENT
       AAA                    • FBE                                 • Analgesia
       Testicular pathology   • U+E’s/Cr                                     - Morphine initially
       Pyelonephritis         • Ca++                                         - Indomethacin 100mg bd pr or 25mg tds orally
       appendicitis           • Urate                                        - panadeine forte / tramadol for breakthrough
       Renal infarct          • MSU                                 • Advise pt - strain urine (send stone for analysis) and moderate fluid intake
•   Phx. stones               • KUB                                 • Consider need for early / emd / urgent review – see below
                              • CT (non-Contrast) will
                                  confirm stone size and         URGENT / EMD / EARLY REVIEW
                                  position (CT) and likelihood   For possible removal, stenting, or drainage if:
                                  of passing:                        • Infection
                                         <4mm – 90% pass             • Unrelieved pain or recurrent pain
                                         4-6mm – 50% pass            • Persisting n. and v.
                                         >6mm - 10% pass             • Increasing Cr.
                              ** Imaging – in order to dx and        • Single kidney
                              treat both KUB & CT reqd. **           • Stone unlikely to pass on basis of size

                                                                 OUTPATIENT REVIEW
                                                                     • Within 2-4 weeks of initial dx. If no indication for early review (very
                                                                       unlikely that renal damage will occur in this time)
                                                                  Pt must have had redo imaging within 24hrs of outpatient review and bring
                                                                     • KUB (only) - If stone easily seen on original KUB
                                                                     • CT – if stone not seen on original KUB but was seen on CT

December 2008 ver.2
Approved by Barwon Health Urology Unit
                                             ABNORMAL P.S.A. TEST

           EVALUATION                             INVESTIGATIONS                               REFERRAL GUIDELINES
     •   Ensure patient understands the      •   Repeat PSA test in 4-6 weeks            GP MANAGEMENT
         risks and benefits of screening              o Instruct patient to avoid bike     • If second test in normal range and free total
     •   Routine yearly (screening) PSA                   riding, intercourse and             ratio is >25% - GP review for repeat test in
         testing if 10yr life expectancy                  ejaculation for 48hrs before        6 months
         and:                                             second test                      • Then continue yearly PSA screening for
             o 50 – 70 yrs                   •   If the initial PSA 2 -10ug/L repeat          increase – refer later if abnormal. PSA or if
             o 40 – 70yrs and +ve family         PSA test including free total ratio.         PSA velocity is >.75ug/L/yr
     •   Consider/Exclude other causes
         raised PSA                                                                      OUTPATIENT REVIEW
             o UTI, prostatitis                                                            • All abnormal PSA tests (confirmed on
             o BPH                                                                           second test) in a patient with a 10yr life
             o Recent instrumentation                                                        expectancy need specialist review
     •   DRE – any nodule/hard/size                                                              o For consideration of biopsy
     •   >70yrs. – do PSA test only if in                                                  • Abnormal DRE (hard, nodule) in a patient
         excellent health for his age. (up                                                   with a 10yr life expectancy need specialist
         to 75yrs) or if symptoms of                                                         review (regardless of PSA level)
         LUTS or metastatic Ca                                                                   o For consideration of biopsy
                                                                                           • Increased PSA velocity (>.75ug/L) in pt
                                                                                             with at least x2 PSA’s a year apart


December 2008 ver.2
Approved by Barwon Health Urology Unit

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