Urology for the outpatient primary care physician

Part 1

Part 1: The four pillars that keep your ass covered

Colleague. You've just left university and landed in the trenches. Those trenches are called the local outpatient clinic.

You have met reality: you get 12 minutes per patient, there are no ultrasound appointments for the next month, your department head spouts nonsense from the last century, and the insurer would choke itself over every penny.

On one side are the Clinical Guidelines, which have become almost law since 2025. Fail to follow them and the prosecutor will come knocking. On the other are common sense and real life, often telling you the opposite.

So this guide is more than a retelling of clinical guidelines. It is a PTU survival manual: how to play this game with an understanding of the rules, helping your patient while keeping yourself out of prison.

Before we get into specific conditions, remember three basic principles.

1. Know your guidelines, but don't be their slave

Clinical guidelines are not the Bible. They are your main legal armor. They are often awkwardly written, detached from real life and overloaded. But sometimes they are your shield.

What to do:

Open the Ministry of Health website (cr.minzdrav.gov.ru).

Download to your phone the 5-6 main urological clinical guidelines you will encounter every day:

Your job is to know the minimum mandatory investigations specified there. You don't have to memorize every dose. Trust me: skim the diagnostic section and you'll already know more than 90% of your colleagues. But you must know that suspected stone disease calls for a kidney ultrasound in the assessment plan. This is your shield against the prosecutor's question: On what grounds did you NOT order an ultrasound?

2. Use common sense and recognise red flags

Clinical guidelines are a map. But you need to use your own head to navigate the terrain. Common sense always comes first.

Example No. 1: The guideline says: "Haematuria is an indication for referral to a urologist for cystoscopy." Common sense says: "FIRST ASK THE WOMAN WHETHER SHE IS HAVING HER PERIOD!"

Example 2: The guideline for acute cystitis says: ‘A single 3 g dose of fosfomycin is a drug of choice.’ Your department head says: ‘Don't waste antibiotics; prescribe Canephron!’ Common sense—and, as it happens, the guidelines themselves—says to prescribe an appropriate antibiotic that works. Herbal treatment for an acute bacterial infection is misguided and a direct route to pyelonephritis.

Your other job is not to miss a DISASTER.

3. Speak the patient's language

4. Document everything!

This is your main pillar, your key skill for surviving the system. Your outpatient record is not just paperwork. It is your formal record of what happened. If it was not documented, it did not happen.

• The system will not give you an ultrasound slot? Write in the record: "Routine renal ultrasound is recommended (as no appointments are available at the outpatient clinic within the next month). The option of obtaining the examination on a self-pay basis has been explained to the patient."
• Is the patient refusing admission? Write: "The patient categorically refused the offered emergency admission to ... Hospital and was warned of possible risks (disease progression and life-threatening complications, including death). The refusal was documented in the presence of nurse [full name]." And get a signature!
• The department head says one thing, but you suddenly disagree? Write: "Consulted by the head of the internal medicine department [full name], who recommended herbal treatment. In view of the severity of clinical symptoms and to prevent complications, the decision was made to follow management in accordance with the Russian Ministry of Health clinical guideline [guideline number and date]."

That's it. Your ass is covered. You did everything you could and documented it.

Part 2

Part 2: Haematuria. When should you panic?

Colleague, few things frighten a patient or an inexperienced doctor more than seeing red urine. A primal fear. A signal that something inside has gone wrong.

Your job as an internist is not to treat haematuria. Your job is to not to miss cancer and promptly direct the patient to the right service.

The PTU Urology algorithm for a primary care physician:

Step 1: Rule out nonsense.

Before sounding the alarm, rule out the obvious in 30 seconds:

• In women: "Are you having your period now? When was your last one?" (The most common explanation for apparent blood in the urine.)
• For everyone: Did you eat beetroot or rhubarb yesterday? Are you taking any medicines, such as rifampicin?
• In athletes: Did you run a marathon yesterday? Lift weights at the gym until you nearly crapped yourself? (Exercise-induced haematuria).

Step 2: Assess the scale of the problem.

• Visible haematuria (red, pink or meat-wash-coloured urine) — a RED FLAG. There is no time to ponder. Refer straight to a urologist.
• Microscopic haematuria (red blood cells detected only on testing). This is serious too, but gives you a little more room to act.

Step 3: Assemble the essential minimum set.

Yes, you have 12 minutes and no appointment slots. But this is what you MUST order and document in the medical record:

• Urinalysis — the starting point. Look not only at red blood cells, but also at white blood cells, protein and bacteria. This helps distinguish bleeding associated with cancer from bleeding associated with inflammation.
• Ultrasound of the kidneys and bladder. You are looking for tumours, stones and hydronephrosis. Yes, there are no appointment slots. So you write in the record: Kidney and bladder ultrasound recommended on a routine/urgent basis. If the patient pays for the test, great. If not, you have done your job and made the recommendation. Do not blame yourself if they could not get it done; that is their responsibility.
• Urology consultation — the final destination of your investigation. ALWAYS.

Part 3

Part 3: Dysuria. When are antibiotics needed?

"Doctor, it hurts to pee." You will hear this complaint in your office more often than "HELLO". And this is where the most common trap for a primary care physician lies.

Trap No. 1: Calling everything cystitis. A woman complains of pain and burning when urinating. Your reflex? "Acute cystitis." Treatment? Reach for fosfomycin or Furadonin. Is that right? Yes, in 80% of cases. But you must remember the other 20%.

Primary care algorithm for dysuria in women:

Step 1: Confirm infection.

Your main tool is urinalysis. Are there white blood cells? Bacteria? Nitrites? Good, this is our case. What do the clinical guidelines say? A young, non-pregnant woman with typical uncomplicated cystitis can be treated even without urinalysis. What does common sense say? DO THE TEST. It takes time, but it protects you from major mistakes and gives you a solid basis for prescribing an antibiotic.

Step 2: Prescribe the RIGHT antibiotic.

Forget herbs and ‘urinary antiseptics’ for an acute bacterial infection. That is misguided practice and malpractice.

The clinical guideline "Cystitis in women" clearly states:

Step 3: If it did not help or symptoms returned — DIG DEEPER.

This is where real medicine begins. If cystitis recurs—2 times in six months or 3 times in a year—it is no longer a case for you to manage alone. Your job is not to keep giving her antibiotics indefinitely. Your job is to find the reason for recurrence.

An internist's algorithm for dysuria in men:

This is more complicated.

Why? Because a long urethra is a good barrier. If an infection has made it through, there must be a reason:

So your management here is different. You do NOT treat this on your own. Your job is to assess quickly and refer to a urologist.

Part 4

Part 4: Lower back pain — spinal degeneration or renal colic?

"Doctor, my back has seized up." On hearing this, 9 out of 10 primary care physicians reflexively diagnose spinal osteochondrosis, prescribe diclofenac and send the patient home.

And in 8 out of 10 cases they will be right. But in the other two, they will miss renal colic. And if that colic is complicated by infection, they will miss obstructive pyelonephritis.

Your main task is to tell one from the other in 5 minutes.

PTU's quick-and-dirty differential diagnosis:

A primary care physician's algorithm for suspected renal colic:

Step 1: Relieve the pain, but do it properly!

According to the Renal Colic guidelines, first aid is NOT an antispasmodic, despite the usual habit! First-line treatment is NSAIDs—nonsteroidal anti-inflammatory drugs!

• Ketorolac (Ketorol) 30 mg intramuscularly.
• Diclofenac 75 mg IM.
• Or even an indomethacin/diclofenac suppository up the ass.

Step 2: Put together the usual basic work-up.

• Urinalysis: look for red blood cells. Their absence does NOT rule out colic, but their presence strongly supports it.
• Kidney ultrasound: look for hydronephrosis (dilation of the renal pelvis). The stone may not be visible on ultrasound, but dilation of the collecting system is the main sign of obstruction.
• Plain urinary tract radiograph: a cheap but relatively uninformative method. You will see only radiopaque stones.
• Urology consultation / Hospital admission.

Part 5

Part 5: Men's health and ageing — more than the prostate

A man aged 50+ comes to your appointment. He complains of blood pressure, tiredness and a bit of back pain. A classic. Your standard route: ECG, cholesterol, blood pressure tablets. All correct.

But you need to look deeper. Behind this facade of age-related changes, two time bombs often hide: BPH and erectile dysfunction. Your job is to find and defuse them.

1. BPH (enlarged prostate): an older man, his urine stream and common sense

We already discussed this with 4th-year students and revisited it in the 6th year, but for you as a practising doctor, let us repeat the essentials.

Your task is to assess not the size, but the FUNCTION. The patient's symptoms fall into two groups:

• Obstructive symptoms: Weak stream, straining, intermittent urination, a feeling of incomplete emptying. That is the mechanics.
• Irritative symptoms: Frequent and sudden urges, nighttime trips to the toilet. This is the bladder's response to obstruction.

The PTU Urology algorithm for a primary care physician:

LISTEN AND COUNT:

Give the patient the IPSS questionnaire (International Prostate Symptom Score). It takes 5 minutes — while you enter the data into the medical information system — and provides an objective score rather than just "Well, my urination isn't great."

LOOK AND MEASURE:

• Ultrasound of the prostate (transabdominal) and bladder: assess prostate volume and, most importantly, post-void residual urine volume (PVR). A PVR > 50-100 ml is already concerning.
• Blood PSA test. MANDATORY for all men over 45–50 with any urinary complaints! This is your main tumor marker.

REFER WISELY:

• Refer to a urologist refer if: IPSS > 8 (moderate or severe symptoms), there is residual urine, PSA is elevated, or the patient is concerned.
• What can you do yourself? If symptoms are mild (IPSS < 8), there is no residual urine and PSA is normal, you can give basic advice (avoid drinking before bed, spicy food and alcohol) and monitor. In some cases, clinical guidelines even allow an internist to start an alpha-blocker (such as tamsulosin), but it is better to leave this to the urologist.

2. Erectile dysfunction (ED): the heart's canary in the coal mine

This is the most important part. When a man aged 50+ complains that he cannot get an erection, it is more than just an awkward problem.

Why? It is simple. The arteries supplying the penis are two to three times narrower than the coronary and carotid arteries. An atherosclerotic plaque will block them much earlier. They are the canary in the coal mine: while the canary sings — the penis gets erect — there is still oxygen in the mine, meaning the vessels of the heart and brain. As soon as the canary dies, it is time to act.

The PTU Urology algorithm for a primary care physician:

ASK PROACTIVELY:

Men won't bring it up themselves, especially if their primary care doctor is a woman. They're embarrassed. Ask a simple, direct question: How is your sexual function, your erections? Have you noticed any changes? Normalize the problem.

LOOK FOR THE CAUSE:

If you see ED, look for cardiovascular risks!

• Measure blood pressure.
• Order a lipid profile (cholesterol and its fractions).
• Check blood glucose or glycated haemoglobin.

TREAT IT. DO NOT BE AFRAID!

A primary care physician CAN and SHOULD prescribe first-line ED treatment — PDE5 inhibitors (sildenafil, tadalafil). Above all — RULE OUT CONTRAINDICATIONS! The main one is taking nitrates! ("Do you take nitroglycerin under the tongue?"). Taking them together can cause a fatal fall in blood pressure.

REFER TO THE RIGHT SPECIALIST:

• Refer to a urologist — if your first-line treatment has not worked.
• To a cardiologist — if you find high risks (hypertension, dyslipidaemia, diabetes). This man may already need carotid ultrasound and coronary angiography, not just Viagra.

Part 6

Part 6: The primary care physician as the lead doctor for men's health

Let us finish by talking about the main issue. All the demographic statistics tell the same story: men in Russia live short, poor-quality lives. They die from heart attacks and strokes 10-15 years earlier than women. They put off seeing a doctor until an ambulance arrives with flashing lights. To them, going to an outpatient clinic is a sign of weakness.

And who is the one doctor this man will actually see? Not a urologist. Not a cardiologist. A primary care physician. For sick leave with a respiratory infection. For blood pressure. For a swimming-pool medical certificate.

At that moment, you are not merely dealing with a patient who has a runny nose. You have a unique chance to save his life. Not today, but perhaps in 10 years.

To him, you're not just a primary care physician. You're the chief manager of his health. The only person who can look at him as a whole and make him think.

A PTU-style check-up for a man aged 45+ — what you can do in your 12 minutes:

Forget complicated algorithms. Remember a simple acronym: P.U.K. (Prostate. Confidence. Cardiovascular risks).

Now you know these three indicators are directly linked to his erections. And that's a great argument for getting him to take his tablets. Not just to avoid a stroke, but to get hard like he did when he was young. That works on men better than any lecture on the dangers of cholesterol.