Urology+Referrals

Urology referral guidelines

1. All patients should have a UA with culture if indicated, BUN, Creatinine (except for dermatological problems). 2. Cosmetic circumcisions (asymptomatic) and infertility workups are not covered benefits under any of the insurances we work with (this includes reversal of vasectomies). Advise the patients that they will need to see outside physicians on a cash basis. 3. Hematuria (>5/HPF for women, >5/HPF for men, NOT in the context of an infection or menses): In addition to the above labs (1), get urine cytology (once) and an imaging study (U/S, or CT for stones). 4. Dysuria: In addition to (1), get urine for GC/Chlamydia. 5. Polyuria: In addition to (1), get fasting glucose. 6. Polyuria and/or incontinence: the usual causes are: (a) Obstructive/overflow: characterized by slow flow, sensation of incomplete voiding, straining, low volume, usually in men. Try doxazosin or terazosin to maximal doses, or switch to tamsulosin if the patient develops orthostasis or hypotension on either of the first two. Check PSA, plus free PSA if PSA is between 4 and 10. Refer for symptoms not controlled, PSA>10, free PSA < 20%, or prostate nodule. (b) Stress: characterized by incontinence only with Valsalva. Usually in women, most often multiparous. (c) Overactive/urge incontinence: characterized by rapid flow, urge to urinate with little warning. Seen with both sexes. Try oxybutynin. Check PSA in men. (d) If in doubt whether incontinence/polyuria is obstructive or overactive in nature, check bladder U/S for PVR (if < 30 ml, it’s probably not obstructive). Note that the treatments for (a) and (c) are opposite, so if given for the wrong condition will make it worse. 7. Small kidney stones within the renal parenchyma are asymptomatic and do not obstruct. If a patient with back pain has stones within the renal parenchyma, the pain is not due to the stones, and other causes of back pain should be sought out and treated accordingly. 8. Kidney stones within the collecting system (ureter, calcyces, etc.): Make sure they have X-rays scanned into our system (transfer if done outside). CT for stones if long-standing or difficult to see on KUB. Request the patient repeat a KUB 1 or 2 days prior to urology visit to see if the stone has passed. Unless previously done, ask the patient to strain their urine with a strainer from the clinic or with a coffee filter and bring in any stone recovered. Most 3 mm stones pass spontaneously within a few days. 9. Impotence: Try the patient on two PDE2 inhibitors (Cialis, Levitra, or Viagra) to maximal tolerated doses. Advise the patient to take them at least an hour prior to planned intercourse, and that physical stimulation is required. Also advise them that Viagra needs to be taken away from food (take before dinner if planning evening activities). The alternatives are (e) Vacuum/rubber band devices, which patient can get with or without prescriptions (can be recommended by PCP) (f) Injections into the penile corpora cavernosa (g) Intra-urethral suppositories (h) Surgical implants. Also, patients should be made aware prior to being sent over that treatments for impotence are not covered by most of the insurances we deal with (including CCHP, MediCal, or Medicare). Most of the time we see men referred for ED, they are either not willing or able to go through treatments (b)-(d), so only send those who are. 10. Vasectomies. Dr. Kleinerman will no longer be performing vasectomies at CCHS clinics. All future referrals should be made as an outside urology referral to CCHP. CCHP has several contractors including Planned Parenthood When making the referral you can consent the patient to start the 30 day consent waiting period and have the consent scanned into ccLink and eventually sent to the consultant once the referral is approved and the referring site is determined.

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