Urology - Referral Guidelines

The Division of Urology at Children’s National Medical Center is the area’s largest and most experienced groupof physicians trained especially to treat children with illnesses of the genitourinary tract. Children’s Nationalpediatric urologists have more than 100 years of combined experience in the diagnosis and treatment of allgenitourinary disorders in infants, children, and adolescents. This includes genital reconstruction (undescendedtestes, hernias, hydroceles, hypospadias, ambiguous genitalia), evaluation and surgical repair of congenitaland acquired urinary tract abnormalities (hydronephrosis, posterior urethral valves, vesicoureteral reflux,neuropathic bladders), evaluation and medical management of daytime and nighttime wetting, urinary tractinfections, and vesicoureteral reflux. Phone consultations from physicians are encouraged. The physicianreferral line is 202-476-2670.

Parents may arrange outpatient consultations by phoning 202-476-5042 (option #2). However, evaluation ofchildren who may need imaging studies for urinary tract infections or hydronephrosis is best arranged throughthe hospital office (202-476-5042 option #3). To reduce the number of trips for the family, radiographic andsonographic evaluation will be arranged for the date of consultation. If studies have been done previously, theseshould be sent with the patient at the time of the initial visit.

The Division of Urology compiled the following guidelines to assist referring physicians in the evaluation andmanagement of pediatric patients presenting with common urological problems. You can also download a pdf of these guidelines

For additional reference, viewPediatrics, Vol. 110, No 1, July 2002.


Phimosis/NonRetractable Foreskin:

Referral When:

  • Tight foreskin, inability to reduce the foreskin in boys olderthan 12 years of age that does not improve treatment withat least 6 weeks with steroid cream application.(Betamethasone cream 0.05% applied to foreskin openingtwice a day for 6 weeks.)
  • Tight phimosis causing ballooning of foreskin with voidingwhich persists after treatment with steroid cream as above. 
  • Documentation of recurrent (more than 2 episodes)infection of the glans (balanitis), foreskin (posthitis), orboth (balanoposthitis). 
  • Documentation of urinary tract infection in males, especiallyif associated with abnormal renal US and/or VCUG; a congenitalurinary tract anomaly (hydronephrosis, vesicoureteralreflux, posterior urethral valve, prune belly syndrome,myelomeningocele). 
  • History of paraphimosis (inability to replace foreskin overglans penis after it has been retracted). 
  • Trauma to the penis, especially the foreskin. 
  • We do not recommend routine referrals for elective,non-medically indicated circumcisions in boys older thanone month of age

Data Needed:

  • Clinic notes 
  • Pertinent laboratory data

Urinary Tract Infection

Referral When:

  • Any child with documented febrile UTI
  • Any male with a documented UTI
  • A female with 2 or more occurrences of afebrile symptomatic UTI.
  • Document urine clearance after appropriate therapeutic treatment for a febrileUTI then place the child on suppressive antibiotics. Prior to the evaluation,children should be on suppressive antibiotics. (Prophylaxis dose = 1/4 dailydose).
  • Any child with symptomatic UTI and congenital spinal dysraphism(myelomeningocele, sacral agenesis) should be referred to the Spina BifidaClinic with a request to see a Children’s urologist.

Data Needed:

  • Clinic notes 
  • Urine culture documentation (include all)
  • For patients who have undergone US and/or VCUG have patient bring films or CD toappointment.
  • Patients who have not had studies should call 202-476- 5042 (option #3) to setup appropriate imaging studies and consultation at Children’s.

Voiding Dysfunction, Daytime Wetting, and/or Nocturnal Enuresis:

Referral When:

  • Refer to WASH Clinic (Wetting and Soil Help) :
  • Children older than 7 years with isolated bed wetting.
  • Children older than 7 years with day and night wetting.
  • If less than 6 years old.
  • Refer to a pediatric urologist when:
  • Any child with a febrile urinary tract infection with abnormal renal US and/orVCUG
  • Any child with a congenital anatomic genitourinary anomaly (posterior urethralvalve, vesicoureteral reflux, hydronephrosis, ureteropelvic junctionobstruction, bladder or urethral abnormalities, or genital malformation)

Data Needed:

  • KUB, Urine culture results
  • KUB and pre/post renal bladder sonogram, urine culture results
  • No studies before referral, Urine culture results
  • Clinic notes
  • Urine culture documentation, if available (include all)
  • If radiologic studies have been done, send reports with referral. The patientshould bring films or CD to the appointment

Undescended testes, Hydroceles, hernias:

Referral When:

  • Hydroceles that persist beyond 18 months of age (hydroceles in infants usuallyresolve spontaneously)
  • Reducible hernias.
  • Testicles should be in the scrotum by 6 months of age. Referral should be madeif that is not the case or if neither testicle can be felt as a newborn.

Data Needed:

  • No imaging studies should be done prior to referral. Sonography rarely adds totesticular management.

Hypospadias:

Referral When:

  • Refer between 3-4 months of age.

Data Needed:

  • No imaging studies prior to referral

Prenatal hydronephrosis:

Referral When:

  • Unilateral with normal contralateral kidney – refer 3 to 4 weeks of age.
  • Bilateral or solitary kidney – contact pediatric urologist as soon as possible.

Data Needed:

  • Bring prenatal and postnatal imaging (films or CD) (postnatal sonogram at 2-3weeks of age)
  • Bring prenatal and postnatal sonogram films or CD, lab work

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