Red Flags in Primary Care: When to Refer for Suspected Urological Cancer
For GPs and referring practitioners. Quick reference for the urological cancers most likely to present in general practice — prostate, kidney and bladder — and what warrants urological assessment.
PSA and prostate referral
Refer if any of the following apply.
⚠ First — check for finasteride or dutasteride
5-alpha reductase inhibitors halve PSA. If your patient takes finasteride or dutasteride, double the PSA value before applying any threshold below.
A reported PSA of 2.8 in a man on finasteride is effectively 5.6 — that meets referral criteria, not reassurance. This is the most commonly missed step in prostate referral.
Suspicious examination
A DRE showing a hard, irregular or otherwise suspicious prostate — refer regardless of PSA level.
Under 70, standard risk
Two PSA tests, 1–3 months apart, showing either:
PSA above 3.0 ng/mL with a free-to-total ratio under 25%, or
repeat PSA above 5.5 ng/mL
Under 70, higher risk
First-degree relative with prostate cancer, or known BRCA1/BRCA2 mutation, plus:
Two PSA tests 1–3 months apart above 2.0 ng/mL with a free-to-total ratio under 25%
70 and over
Two PSA tests 1–3 months apart above 5.5 ng/mL with a free-to-total ratio under 25%
Send the PSA history with dates, not just the latest value. A PSA of 4.2 that rose from 1.8 over two years reads differently to one stable at 4.2 for five.
Include: PSA history with dates, free-to-total ratio, DRE findings, whether the patient is on finasteride or dutasteride, other current medications, family history, urinary symptoms.
Haematuria
Visible haematuria — refer. A single episode is enough. Painless macroscopic haematuria is a classic bladder cancer presentation; absence of pain is not reassuring.
Do not let anticoagulation delay assessment — patients on anticoagulants still harbour malignancy.
Haematuria recurring after UTI treatment also warrants referral; a UTI can coexist with an underlying lesion.
Microscopic haematuria: persistent on two or more occasions without a benign cause — particularly over 40, smokers, or occupational exposure to aromatic amines.
Include: MSU, renal function, any imaging, medications including anticoagulants, smoking and occupational history.
Incidental renal mass
Any enhancing renal mass on CT — refer. Enhancement indicates vascularity and raises the probability of renal cell carcinoma.
Cystic lesions: Bosniak I–II generally low risk; IIF, III and IV warrant specialist input. If the report doesn't classify the lesion, request clarification or refer.
Solid masses: small masses under 4 cm may suit active surveillance rather than surgery — but that decision benefits from specialist assessment.
Include: imaging report and images, renal function, comorbidities, smoking history.
Testicular mass
Any solid, painless testicular mass — refer promptly for ultrasound and urological assessment. Predominantly affects younger men, highly treatable when caught early.
Acute scrotal pain where torsion cannot be excluded is an emergency, not a routine referral.
Unexplained hydronephrosis or ureteric obstruction
New unilateral hydronephrosis without an obvious cause — investigate. Ureteric obstruction from an undetected upper tract TCC can be clinically silent until advanced.
With associated infection, this is urgent.
Refer urgently
Macroscopic haematuria with clots, or causing retention
PSA significantly above threshold, or clearly rising on serial testing
Renal mass with systemic symptoms (weight loss, constitutional features)
Ureteric obstruction with infection — emergency
Solid testicular mass in a young man
New unexplained hydronephrosis
When in doubt, call the rooms. A brief triage conversation is always welcome.
What makes a referral fast to action
A referral saying "haematuria — please review" is workable but slow.
"65-year-old, two episodes macroscopic haematuria, non-smoker, USS bladder normal, no UTI, PSA 2.1" allows same-day triage.
Include: the specific concern, PSA trend with dates, imaging reports (and images where possible), relevant pathology, current medications, and any urgency flags stated clearly.
About this practice
My practice focuses on urological cancer surgery and complex urological conditions, with particular focus on robotic prostate, kidney and bladder cancer surgery. I'm happy to discuss cases before referral where the picture is unclear.
For urgent referrals — confirmed or strongly suspected cancer, symptomatic obstruction — contact the rooms directly and we'll prioritise accordingly.
Referral details, clinic locations and contact information are on the For Physicians page. Further information is available on the Prostate Cancer, Kidney Cancer and Bladder Cancer pages.
Clinical note: intended for healthcare professionals and reflects general referral principles. Individual clinical decisions should be based on the full clinical picture and local guidelines.
Last reviewed: July 2026
Dr Deanne Soares is a Melbourne-based urologist with a subspecialist focus in robotic prostate, kidney and bladder cancer surgery.
