Refer urgently patients (considering possible prostate cancer):

• with a hard, irregular prostate typical of a prostate carcinoma. Prostate-specific antigen (PSA) should be measured and the result should accompany the referral. (An urgent referral is not needed if the prostate is simply enlarged and the PSA is in the age-specific reference range*.)
• with a normal prostate, but rising/raised age-specific PSA, with or without lower urinary tract symptoms. (In patients compromised by other comorbidities, a discussion with the patient or carers and/or a specialist may be more appropriate.)
• with symptoms and high PSA levels

Refer urgently patients (considering bladder and renal cancers):

• of any age with painless macroscopic haematuria
• aged 40 years and older who present with recurrent or persistent urinary tract infection associated with haematuria
• aged 50 years and older who are found to have unexplained microscopic haematuria
• with an abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract

Refer urgently patients with a swelling or mass in the body of the testis

Refer urgently patients with symptoms or signs of penile cancer. These include progressive ulceration or a mass in the glans or prepuce particularly, but can involve the skin of the penile shaft. (Lumps within the corpora cavernosa can indicate Peyronie's disease, which does not require urgent referral.)

PSA testing of asymptomatic men or screening for prostate cancer is not a national screening policy. It is recommended that a PSA test, except in men clinically suspicious of prostate cancer should only be performed after provision of written information and full counselling.

* the age-specific cut-off PSA measurements recommended by the Prostate Cancer Risk Management Programme are as follows:

• aged 50-59 >= 3.0 ng/ml;
• aged 60-69 >= 4.0 ng/ml;
• aged 70 and over > 5.0 ng/ml.
• (Note that there are no age-specific reference ranges for men over 80 years. Nearly all men of this age have at least a focus of cancer in the prostate. Prostate cancer only needs to be diagnosed in this age group if it is likely to need palliative treatment.)

Notes:

• Refer non-urgently patients under 50 years of age with microscopic haematuria. Patients with proteinuria or raised serum creatinine should be referred to a renal physician. If there is no proteinuria and serum creatinine is normal, a non-urgent referral to a urologist should be made
• 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

Reference:

1. NICE (June 2005). Referral Guidelines for Suspected Cancer