Urology Referrals QP Day 5/11/13

Why Urology

Audit Results

Top Referral Reasons

PSA 26% referrals Top Tips Follow up and discharge 52% of referrals – could we manage those patients in primary care? Top Tips PSA Velocity – normal rise 0.7 every year. If less than this, < 10% cancer risk. Urologists advise more watchful waiting in the community.

LUTS 6% referrals 1/3 were either followed up or discharged. Top Tips Normal voiding is 5-6 times a day 300-500mls Flow measurements not useful in the community OAB – fluid advice, bladder training, lifestyle, pelvic floor training. Anticholinergics – 1% bladder retention. Urologists feel we’re not prescribing combination therapy or giving it time to work. Alpha blocker 6mo then add in 5ARI – give 3-6 mo again. Minimal chance of retention, if decreased flow – stop meds.

LUTS Guidelines

Haematuria 16% referrals Top Tips Urologists feel too many people sent 2ww, could have been sent to one stop haematuria clinic instead. 2/3 urine samples +ve If under 40 – send to nephrology. 15% of referrals were discharged at first clinic review. National Guideline's – CKS, NICE, BAUS

Testicular problems 8% referrals ? Cancer, epididymal cysts, hydroceles, varicocele, testicular lumps, skin conditions 1/3 referrals discharged at initial review. 10% had imaging Top Tips Arrange Imaging in the community, even for suspected 2ww – urgent USS prior. * Balanitis/ Phimosis – 17 referrals all had surgery.

Erectile Dysfunction 2% referrals 12 referred only 3 had specialist treatment Top Tips Only refer if needing specialised treatment. Urologists feel this is an area we could really reduce referrals in. Prescribe! ‘Viagra’ -sildenafil now £8 a month approx.

Stones 5% referrals 1/3 patients discharged at first review. No clear pathway or guidance ?? What imaging to do in primary care – X-Ray(60% visible), USS, Spiral CT. What investigations do I perform? UE, FBC, Urine dip (nitrites suggest uti) When to refer….. Top Tips 90% pass spontaneously If small < 5mm – do nothing Alpha antagonists or calcium channel blockers can increase expulsion

Key Messages If we look at all the referrals that were discharged from the first appointment we could have potentially saved 112 referrals - 22% of referral activity. Clear guidance on specific topics – haematuria, LUTS, raised PSA, stones. Better access to imaging in the community. ????