In an asymptomatic male with a borderline level of PSA, repeat the PSA test after 1 to 3 months. If the PSA level is rising, refer the patient urgently.

A digital rectal examination and a PSA test (after counselling) are recommended for patients with any of the following unexplained symptoms:

• inflammatory or obstructive lower urinary tract symptoms
• erectile dysfunction
• haematuria
• lower back pain
• bone pain
• weight loss, especially in the elderly

Exclude urinary infection before PSA testing. Postpone the PSA test for at least 1 month after treatment of a proven urinary infection.

In male or female patients with symptoms suggestive of a urinary infection and macroscopic haematuria, diagnose and treat the infection before considering referral. If infection is not confirmed, refer them urgently.

Consider an urgent ultrasound in men with a scrotal mass that does not transilluminate and/or when the body of the testis cannot be distinguished.

Referral Criteria

Prostate cancer

• Prostate feels malignant on digital rectal examination (please complete PSA before referral).
• Features of malignancy include asymmetry, irregularity, nodules and differences in texture, e.g. firm or hard.
• PSA levels are above the age-specific reference range.
• PSA level before referral 1st test ng/ml 2nd test after 6 weeks ng/ml

Age specific PSA abnormal range (from Macmillan referral guidance):

• 40–49 years more than 2.5 ng/L
• 50 – 59 years more than 3.5 ng/L
• 60 – 69 years more than 4.5 ng/L
• 70 years and older more than 6.5 ng/L

Consider alternative contributing factors that may influence an individual's PSA ranges.

The PSA test should be postponed for at least 1 month after treatment of a UTI.

In patients with a borderline raised PSA, repeat the PSA after 1 month and refer as a fast track if the second PSA has risen.

In patients compromised by co-morbidities or with a below 10 year life-expectancy, a discussion with the patient or carers and/or urologist may be more appropriate.

Risks of cancer less than 10% when PSA is within normal range, 20% when PSA 4-10 ng/ml, 30% if more than 10ng/ml and 50% if more than 20ng/ml.

Bladder and Renal cancer

Aged 45 and over and have:

• Unexplained visible haematuria without urinary tract infection or
• Unexplained' haematuria refers to patients who do not currently have conditions that can cause haematuria, e.g. urinary stone disease and UTI.

Visible haematuria that persists or recurs after successful treatment of urinary tract infection

Aged 60 and over and have:

• Unexplained non-visible haematuria with dysuria.
• Unexplained' haematuria refers to patients who do not currently have conditions that can cause haematuria, e.g. urinary stone disease and UTI. Dysuria is defined as burning or discomfort in the urethra on voiding.

Menstruating females may have non-visible haematuria for 3 days prior to and 5 days post menstruation. Non-visible haematuria may also be present for 3 days post intercourse. Please exclude these prior to referral

Aged 60 and over and have:

Unexplained non-visible haematuria with a raised white cell count on a blood test.

If possible

• Please provide: FBC (less than 8 weeks old). Unexplained' haematuria refers to patients who do not currently have conditions that can cause haematuria, e.g. urinary stone disease and UTI. A raised WCC is defined as more than 11 x 109/L

A soft tissue mass identified on imaging thought to arise from the urinary tract.

If possible

• Please provide: FBC, U&E (including creatinine and eGFR) (less than 8 weeks old). This includes solid renal masses, complex renal cysts (i.e. cysts containing septa, calcification or soft tissue elements) and soft tissue bladder masses. This does not include distended bladders of urinary retention.

Testicular cancer

• Non-painful enlargement or change in shape or texture of the testis. If swelling is clearly separate from Testis on examination, it is unlikely to be a testicular tumour. Consider ultrasound before referral.
• Always perform transillumination to exclude benign epididymal cyst(s). Consider a direct access ultrasound scan for a scrotal mass

Penile cancer

• Penile mass or ulcerated lesion, where a sexually transmitted infection has been excluded as a cause (consider)
  • This includes progressive ulceration or a mass particularly in the glans penis or prepuce, but can involve the skin of the penile shaft. Lumps within the corpora cavernosa not involving the penile skin are usually not cancer but indicate benign Peyronie's disease, which does not require urgent or fast track referral.

A persistent penile lesion after treatment for a sexually transmitted infection has been completed.

Unexplained or persistent symptoms affecting the foreskin or glans (consider). This does not include simple phimosis, fungal infections and balanoposthitis

Referral Instructions

The GP should: use e-Referral Service to book an appointment or send the referral.

Please ensure you include:

• The patient's NHS number
• Tell the patient that this is an urgent referral and they will be seen within 14 days

e-Referral selection:

• Specialty: 2WW
• Clinic type: 2WW Urology
• Service: 2WW Urology - NDHCT - NDDH - RBZ

For any patients that you are unable to process through NHS e-Referral please contact the drss.helpdesk@nhs.net

Referral Forms

Suspected Urological cancer referral form - No merge fields

Suspected Urological cancer referral form - Emis 

Suspected Urological cancer referral form - Systmone

Evidence

NICE referral guidelines for suspected cancer

GP Information

Suspected Cancer Guidelines A-Z

NICE referral guidelines for suspected cancer

bmj - New NICE guidance on referral for cancer

bmj - Assessing and referring adult cancers infographic

New Leaflet available for patients who are referred to exclude a diagnosis of cancer

Patient Information

Macmillan

New Leaflet available for patients who are referred to exclude a diagnosis of cancer

Pathway Group

This guideline has been signed off by NHS Devon.

Publication date: November 2016