Category: Urology

2WW – Suspected Cancer

Some patients present to ED with symptoms or investigations suspicious an undiagnosed cancer, but don’t require emergency admission. To reduce the barriers to care the trust has implemented a referral route for ED.

Emergency Department MDT referral request – HERE

Once completed the PPC team will review the request and feed them into either “Fast-Track Clinics” if further workup required or MDT’s if fits those pathways.

This should allow our patients quick access to appropriate clinics, without the inherent delays and wasted clinical time of asking the patient to attend their GP. BMA/NHSe

Necrotising Fasciitis

Necrotising fasciitis (NF) is a rare but serious bacterial infection that affects the soft tissue and fascia (Fournier gangrene, is NF affecting the perineum). In many cases NF progresses rapidly and early recognition and treatment is vital to halt progress. The mainstay of treatment is IV antibiotics and aggressive surgical debridement. Any delay increased the amount of tissue loss as well as the mortality. Read more

Acute Cystitis and Pyelonephritis Pathway

A joint Medical-Urology pathway has been agreed for Pyelonephritis

Study Running  – Send Urine Sample prior to Antibiotics

(if this does not interfere with treatment of Red-Flag Sepsis)

 

Imaging in ED is only required if ED suspects:

  • Ureteric Obstruction – Renal colic symptoms/Hx of stone
  • Acute Surgical Abdomen
  • Emphysematous pyelonephritis – Rare necrotising infection of the renal tract, presenting with flank pain and fever, 90% in uncontrolled diabetes mellitus (but immunocompromise and stones also increase chances)
  • Renal Abscess – Presents with flank pain and fever, risk factors include; diabetes mellitus, Renal stones, obstruction

Read more

Urinary Catheterisation in ED

Pre-catheterisation

  • Confirm appropriate indication
    • Relief of acute or chronic urinary retention
    • Need for accurate measurements of urinary output in critically ill patients
    • Patient requires prolonged immobilisation (e.g potentially unstable traumatic injury)
    • To improve comfort for end of life care
  • Bladder scan & document result
  • Appropriate consent from patient

Read more

Sexual Health Referrals

Appropriate Conditions for GUM
  • Genital ulcers
  • Urethral discharge
  • Pelvic Inflammatory Disease (PID)
  • Testicular pain
  • Genital warts
  • Vaginal discharge
  • Emergency/ongoing Contraception
  • HIV risk concerns
  • Possible syphilis
  • PEP follow up
  • Pre-menopausal irregular vaginal bleeding
  • Known HIV patient please contact 01484 347077
PID Referral Criteria

History/Exam. – NICE CKS (Here) 

  • History:
    • Pelvic or lower abdominal pain (usually bilateral but can be unilateral).
    • Deep dyspareunia particularly of recent onset.
    • Abnormal vaginal bleeding (intermenstrual, postcoital, or ‘breakthrough’) which may be secondary to associated cervicitis and endometritis.
    • Abnormal vaginal or cervical discharge as a result of associated cervicitis, endometritis, or bacterial vaginosis. This is often very slight and may be transient, especially with chlamydial infection.
    • Right upper quadrant pain due to peri-hepatitis (Fitz–Hugh–Curtis syndrome).
    • Secondary dysmenorrhoea.
    • Ask about the possibility of pregnancy.
  • Exam: 
    • Lower abdominal tenderness (usually bilateral).
    • Adnexal tenderness (with or without a palpable mass), cervical motion tenderness, or uterine tenderness (on bimanual vaginal examination).
    • Abnormal cervical or vaginal mucopurulent discharge (on speculum examination).
    • A fever of greater than 38°C, although the temperature is often normal.

GUM Exclusions – Ref to Gynae

  • Pregnancy
  • Sepsis
  • Abscess

No GUM Exclusions – Complete following

  • Patient to preform 2 High Vaginal Swabs- Send For:
    • Chlamydia +Gonorrhoea 
    • TV
  • If Clinical Signs of PID – Treat with following (if allergies D/W Micro)
    • Ceftriaxone 1g i.m. – ONCE ONLY
    • Doxycycline 100mg twice a day & Metronidazole 400mg twice a day for 14 days
  • Refer to GUM (with/Without Signs)
Testicular Pain Criteria

GUM Exclusions – Ref to Urology

  • Torsion
  • Sepsis
  • Abscess

No GUM Exclusions – Complete following

  • 2 Urine Samples:
    • First Pass (white top) – Chlamydia +Gonorrhoea 
    • MSU (red top)
  • Treat with following (if allergies D/W Micro)
    • Doxycycline 100mg twice a day for 14 days
  • Refer to GUM 
Contacts

Kirklees

Calderdale

  • E-Mail referral (patient details and brief description): Sexualhealthservices.chft@nhs.net
  • Patient Self Referral: 01422 261370
  • Address: Broad St, Halifax, HX1 1UB

Urology Referral Pathways

Referral

The first point of contact for urology advice and referral is the general surgical SHO. This is the on-call surgical SHO carrying the on-call bleep. Some of the on call general surgical SHO have a urology background.

If a time critical emergency such as torsion is presenting, then the first point of contact should be the urology registrar.

In the case of Urological/Surgical emergency

  1. Refer directly to Middle Grade on-call
  2. If Middle Grade unavailable/uncontactable – Contact speciality consultant on-call
  3. If NO senior available – inform ED senior
    • Admit directly (admission rights) to SAU/Ward 4 HRI
    • Attempt to contact surgical SHO (to inform)

(agreed with both surgical and urological leads)

 

Under 3’s go to Leeds

Urologist are happy to operate on patients over the age of 3 years old. Under the age of 3 if this on a urological emergency such as a torsion then this patient should be referred to Leeds paediatric urology services.

Streaming

Any patent with a post op complication for up to 7 days form urological procedure – should be streamed directly to the urology team via the surgical SHO. If the patient is unwell and needs resuscitation and immediate management for example sepsis, then ED team needs to be involved in resuscitation measures and the urological registrar needs to be involved as well

Pyelonephritis

Currently ALL Pyelonephritis should be admitted under the urology team. There is a conversation between urology and medical teams happening currently to see if that requires further rationalisation. However currently the position is all pyelonephritis patients who need admitting are done so under the urology team.

  • Uncomplicated pyelonephritis – does not require CT scanning or ultrasound scanning from the emergency department.
  • Suspicion of an obstructive uropathy –  CT KUB needs to be arranged from the ED

Investigations including:

  • FBC
  • U&E, CRP
  • Blood Cultures
  • Urine cultures

Appropriate Antibiotics should be prescribed using the current antibiotic guidelines.

Renal Colic

CTKUB are now available 24/7.

Patient presenting >50 years old  with a renal colic story, should have a ultrasound scan done at the bedside to ensure that there is no aortic aneurysm before being sent for a CT KUB.

Uncomplicated renal colic needs a non contrast CT scan. This should be organised by the ED

Uncomplicated renal colic patients can wait CT KUB for  results on SDEC. (The case must be to be discussed with the surgical SHO on-call and accepted by them before transfer of the patient. SDEC closes at 6 pm)

Haematuria

All frank hematuria needs investigation

  • Admit + 3-way catheter – those at risk of clot retention and shock 
    • Hb <100
    • Post void bladder scan>250 ml 
  • All those discharged: will need a OPD cystoscopy arranged as well as a USS (the request for flexible cystoscopy on EPR is Urol Cystoscopy  post Wd Dis)
Catheters

New catheters and catheter complications – follow current guidelines. Community nurses follow up for TWOC or other catheter care (HOUDINI team in Kirklees)