A large share of an APP's day is triage — deciding what is an emergency, what needs a same-day or urgent visit, and what can be handled by advice or a routine appointment. Use this as a starting framework, and always apply clinical judgment and your…
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A large share of
an APP's day is triage — deciding what is an emergency, what needs
a same-day or urgent visit, and what can be handled by advice or a
routine appointment. Use this as a starting framework, and always
apply clinical judgment and your practice's protocols. When in doubt,
bring them in or ask someone — that is always the safe answer.
19.1 Immediate action — office or ED now
Acute severe
scrotal pain (possible torsion), especially in a younger male — do
not schedule this for tomorrow.
A rigid,
painful erection lasting > 4 hours (ischemic priapism) — come to
the office immediately if it is open; go to the ER if it is closed.
Fever or
rigors with flank pain, or with a known obstructing stone (possible
urosepsis).
Inability to
urinate with a painful, distended bladder (acute retention) that
cannot be managed in clinic.
Heavy gross
hematuria with clots and inability to urinate (clot retention).
Perineal or
genital pain with swelling, dusky skin, crepitus, or systemic
toxicity (possible Fournier's).
FEVER OR
RIGORS AFTER A PROSTATE BIOPSY — this is sepsis until proven
otherwise.
Fever,
rigors, or systemic illness after BCG instillation.
New
neurologic deficits with urinary retention, saddle anesthesia, or
back pain (cauda equina / cord compression).
A suprapubic
tube that has fallen out — come to the office immediately if it is
open; go to the ER if it is closed (the tract closes within hours).
A catheter
that is blocked or not draining and cannot be cleared at home — come
to the office immediately if it is open; go to the ER if it is closed.
19.2 Urgent / same- or next-day visit
New gross
hematuria without clot retention — needs a prompt work-up but not
the ER.
Suspected
UTI or pyelonephritis with fever, but the patient is stable and
tolerating oral intake.
New
non-emergent scrotal swelling or moderate pain once torsion is
confidently excluded.
A post-op
patient with escalating pain, low-grade fever, or wound concerns.
An
indwelling stent with worsening pain, or a stent past its removal
date.
Acute
urinary retention that was relieved with a catheter, needing
follow-up and a plan.
19.3 Routine / advice
Stable
chronic LUTS, mild OAB, or a follow-up on medications already
started.
Asymptomatic
bacteriuria — do NOT treat outside of pregnancy or a pending
procedure. Counsel that cloudy or smelly urine without symptoms is
not an infection.
Expected
post-procedure symptoms: mild hematuria after a biopsy or with a
stent; hematospermia after a prostate biopsy (can last months);
retrograde ejaculation on tamsulosin; irritative voiding after BCG
or TURBT.
Chronic
stable scrotal findings (a small hydrocele, a long-standing
varicocele) without red flags.
A mildly
elevated PSA in an asymptomatic man — repeat it and exclude
infection before escalating.
19.4 How to take a good triage call
Establish
acuity first: “Are you having fever, chills, or shaking?” “Are
you able to urinate?” “How severe is the pain, 0–10?” These
three questions sort most calls.
Get the
relevant history: recent procedures, catheters or stents,
anticoagulants, and immunosuppression.
Decide the
disposition and STATE IT CLEARLY: ER now, clinic today, clinic this
week, or advice.
Give
explicit return precautions: the exact symptoms that mean “call
back or go to the ER.”
Document the
symptoms reported, your advice, the disposition, and the return
precautions.
Documentation habit
For every triage encounter,
record the reported symptoms, the disposition you advised, the
specific return precautions you gave, and the follow-up plan.
Good documentation is your best protection and the patient's best
safety net.
If you are unsure, escalate. Nobody at New Jersey Urology
has ever been criticized for asking — and this is a group that
genuinely wants to help you.
Clinical Pathway
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A large share of an APP's day is triage — deciding what is an emergency, what needs a same-day or urgent visit, and what can be handled with advice or a routine appointment. Use this as a starting framework, and always apply clinical judgment and your practice's protocols. When in doubt, bring them in or ask someone — that is always the safe answer.
Twelve presentations that require immediate action. Priapism, a dislodged suprapubic tube, and a blocked catheter come to the office immediately when it is open; use the ER if it is closed. The remaining presentations go to the ED now.
Select a box to open its teaching details.
Ask, in this order
"Are you having fever, chills, or shaking?"
"Are you able to urinate?"
"How severe is the pain, 0–10?"
Why
These three questions sort most calls. If any of the immediate patterns below is present, stop triaging and give the specified office-or-ED disposition.
Then get
Recent procedures
Catheters or stents
Anticoagulants
Immunosuppression
Ch 19.4
Time-critical
Disposition
ED now.
Pitfalls
Do not schedule this for tomorrow.
Ch 19.1
Time-critical
Disposition
Come to the office immediately if it is open for a rigid, painful erection lasting > 4 hours. If the office is closed, go to the ER.
Ch 19.1
Time-critical
Disposition
ED now.
The pattern
Fever or rigors with flank pain
Fever or rigors with a known obstructing stone
Ch 19.1
Time-critical
Disposition
ED now if the retention cannot be managed in clinic.
Note
Acute retention that was relieved with a catheter is an urgent visit, not an ED visit — see the urgent track.
Ch 19.1
Time-critical
Disposition
ED now.
The distinction
Gross hematuria without clot retention is an urgent work-up, not an ER visit. It is the clots plus the inability to urinate that sends them.
Ch 19.1
Time-critical
Disposition
ED now.
The findings
Swelling
Dusky skin
Crepitus
Systemic toxicity
Ch 19.1
Time-critical
Disposition
ED now.
Why
FEVER OR RIGORS AFTER A PROSTATE BIOPSY — this is sepsis until proven otherwise.
Ch 19.1
Time-critical
Disposition
ED now for fever, rigors, or systemic illness.
Pitfalls
Irritative voiding alone after BCG is expected and is routine advice — it is the systemic picture that is emergent.
Ch 19.1
Time-critical
Disposition
ED now.
The penile fracture triad
An audible pop
Detumescence
Eggplant deformity
Ch 19.1
Time-critical
Disposition
ED now.
The pattern
New neurologic deficits with urinary retention, saddle anesthesia, or back pain
Ch 19.1
Time-critical
Disposition
Come to the office immediately if it is open. If the office is closed, go to the ER.
Why the clock matters
The tract closes within hours — this is not a next-day problem.
Ch 19.1
Time-critical
Disposition
Come to the office immediately if it is open. If the office is closed, go to the ER.
Ch 19.1
Needs to be seen promptly, but not in the emergency department.
Select a box to open its teaching details.
Before you land here
Re-check the three acuity questions — fever/chills, able to urinate, pain 0–10
Confirm none of the ED-now patterns applies
Say it plainly
"Clinic today" or "clinic this week" — do not leave the disposition implied
Ch 19.2
Disposition
Urgent same- or next-day visit for a prompt work-up
Pitfalls
If there are clots and the patient cannot urinate, this becomes clot retention — ED now.
Ch 19.2
Conditions for the urgent tier
The patient is stable
The patient is tolerating oral intake
Pitfalls
Fever or rigors with flank pain, or with a known obstructing stone, is possible urosepsis — that is an ED disposition, not this one.
Ch 19.2
Condition
Torsion must be confidently excluded first
Pitfalls
Acute severe scrotal pain, especially in a younger male, is an ED disposition. If you are not confident torsion is excluded, it is not this tier.
Ch 19.2
Triggers
Escalating pain
Low-grade fever
Wound concerns
Ch 19.2
Triggers
Worsening pain with an indwelling stent
A stent past its removal date
Pitfalls
Fever changes the tier. Fever plus flank pain, or fever in a patient with a stone or any indwelling drainage, is an emergent call — reassess against the send-to-ED criteria in 19.1 rather than booking a routine visit.
Ch 19.2
Disposition
Urgent follow-up visit to make a plan — the catheter is not the plan
Ch 19.2
Safe to handle with reassurance, education, or a routine appointment — with the exact phrasing to use.
Select a box to open its teaching details.
Before advising
No fever, chills, or rigors
Able to urinate
Pain is not severe
No recent-procedure red flag
Still do
State the disposition clearly
Give explicit return precautions
Document
Ch 19.3
Fits here
Stable chronic LUTS
Mild OAB
Follow-up on medications already started
Ch 19.3
The rule
Do NOT treat asymptomatic bacteriuria outside of pregnancy or a pending procedure
What to say
Counsel that cloudy or smelly urine without symptoms is not an infection.
Ch 19.3
Expected
Mild hematuria after a biopsy or with a stent
Hematospermia after a prostate biopsy — can last months
Retrograde ejaculation on tamsulosin
Irritative voiding after BCG or TURBT
Pitfalls
Expected symptoms plus fever or rigors is no longer routine — post-biopsy fever is sepsis until proven otherwise, and systemic illness after BCG is emergent.
Ch 19.3
Fits here
A small hydrocele
A long-standing varicocele
Without red flags
Ch 19.3
What to do
Repeat the PSA
Exclude infection
Then escalate if it persists
Ch 19.3
The five steps that turn a phone call into a defensible clinical encounter.
Select a box to open its teaching details.
Ask
"Are you having fever, chills, or shaking?"
"Are you able to urinate?"
"How severe is the pain, 0–10?"
Ch 19.4
Ask about
Recent procedures
Catheters or stents
Anticoagulants
Immunosuppression
Ch 19.4
The four dispositions
ER now
Clinic today
Clinic this week
Advice
Pitfalls
An implied disposition is not a disposition — say which of the four it is, in those words.
Ch 19.4
Time-critical
What to give
The exact symptoms that mean call back or go to the ER — not "call if you get worse"
Ch 19.4
Record for every triage encounter
The symptoms reported
The disposition you advised
The specific return precautions you gave
The follow-up plan
Ch 19.4 — documentation habit
Local policy
Our position
If you are unsure, escalate
Nobody at New Jersey Urology has ever been criticized for asking — this is a group that genuinely wants to help you
The default
When in doubt, bring them in or ask someone — that is always the safe answer.