Common Urology presentations Dave Heath sees in his day-to-day clinical practice as a Nurse Practitioner. Written by Dave Heath. The original FULL article is here: Day in the life of a Urology Nurse Practitioner!

Prostate Issues

I see new referrals for elevated PSA (prostate blood test).

These can also have bladder symptoms i.e. difficulty with passing urine.

The first appointment

Consists of me taking a history including co-morbidities, medications, and allergies, presenting complaint/ symptoms (if any as an elevated PSA in isolation can be symptom-free), family history, smoking status, home environment and employment.

The next part consists of an examination

I always take time to discuss indication for examinations as I feel strongly if the patient is of the same understanding as to why the examination forms a large part they are more relaxed and confident in my management moving forward.

The examination consists of a lower urinary tract exam in that I access for a palpable bladder, I access for flank tenderness, I exam external genitalia and perform a digital rectal exam. For a patient with a high PSA and or other symptoms suggestive of advanced disease risk I will perform a neuro exam plus general thoracic and cervical skeletal exam (? Bone disease and symptoms suggestive of bone pain).


Investigations for elevated PSA referrals consist of imaging with CT, Ultrasound, Bone scans (depending on presentation) and MRI which requires a consultant to request as does a Pet scan. Pathology and urine tests are something that I routinely request, pathology consists of repeating the PSA, renal function and occasionally LFTs (again determined on a case by case basis). These investigations are then reviewed and assist in guiding both management but also a response to any treatments that may have commenced.

Some of the treatments used include medications for bladder symptoms, these medications are most commonly ALPHA blockers which help relax the bladder neck and can at times improve obstructive symptoms.

Prostate Biopsy

For a man with a persistently elevated PSA (each man is accessed independently despite PSA ref range) i.e. a PSA that is not appropriate for that man and his prostate (it’s a size thing) is commonly a biopsy of his prostate.

A prostate biopsy is a procedure that comes under my scope of practice as a NP they then end up on one of my lists for the biopsy. Post biopsy they are then followed up in the NP outpatient’s clinic that I run with regards to results and discussion around next step (depending on results).

Erectile Dysfunction (ED)

I See men with erectile dysfunction (ED).

These consults again involve a thorough history taking and also a physical examination. Pathology investigations including a cardiovascular screen as declining erections can be an early sign of cardiovascular disease.

Imaging mostly consists of ultrasound for men with reported Peyronie’s disease (I have been trained in corporal ultrasound and we are able to offer this in the private rooms).

TNB addition: ‘Peyronie’s disease is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis. Specifically, scar tissue forms causing pain, abnormal curvature, erectile dysfunction, indentation, loss of girth and shortening.’

The management for erectile dysfunction (ED) in the first instance is mostly pharmacological i.e. drugs, but in saying that surgery also plays a role for some men with ED and some forms of Peyronie’s this is obviously not something that I perform but I am involved in both the pre-op and post-op care/ management and follow up.

Bladder Cancer

Bladder cancer is another urological condition that comes under my scope.

Flexible cystoscopy

My involvement with bladder cancer patients consists of surveillance flexible cystoscopy, this procedure is done as a day case and involves the use of a scope that provides an image of the lower urinary tract. The purpose of cystoscopy surveillance is to inspect and examine for bladder cancers. Pre-op investigations include pathology (predominately UEC) urine analysis for infection and malignant cells, imaging in the form of either a CT or Ultrasound depending on presentation.

Another part of my role in bladder cancer follow up is for patients that have undergone a cystectomy with either a neobladder or conduit. The long term follow up and monitoring of these patients form an increasing part of my role.

Renal Cancer

Finally, renal cancer patients come under my care in regards to long term follow up and monitoring.

These patients have routine imaging and pathology investigations for 5 years and are a patient that I see in my outpatient clinic. The imaging consists of CT and Ultrasound (depending on the individual case) and pathology is routine full blood exam and renal function.

What is the most important piece of advice you can give men about prostate health?

For me, the most valuable piece of advice/ information around prostate health is to be aware of your own family history in regards to prostate issues (not just cancer) and to have a good understanding of your own PSA result. It’s important to be aware that PSA is a variable test that differs greatly between men and that not all men and their PSAs are the same.

Like all body systems, there are times when a specialist needs to be consulted and the prostate is no different. If a man has an increasing PSA and or symptoms he should be referred for a specialist opinion to evaluate that individual’s symptoms and risk. It’s important to ensure that men are informed off all the things that increase a PSA and that’s it’s not a cancer test specifically it’s more of a size/ inflammation test and each case needs to be evaluated on its own merits by a suitably qualified clinician.  

How can our readers within the healthcare community best contribute to men’s health and wellbeing?

In my opinion, the best way to contribute to men’s health is to ensure that we all create the opportunity for conversations. This is not always an easy thing but with enough time and an environment that allows for conversations to take place, it can be amazing the topics that come up.