Assessing the feasibility of a one-stop approach to diagnosis for urological patients.

INTRODUCTION: Conventional publicly funded out-patient services in many specialties are characterised by delays, fragmented diagnostic processes, and overloaded clinics. This is bad for patients as it is clinically dangerous; bad for managers who spend hours managing the failure; bad for doctors who respond by overloading clinics; and bad for purchasers who have to fund the multiple out-patient visits needed. Sound clinical and financial reasons exist for introducing more efficient diagnostic processes. PATIENTS AND METHODS: A total of 330 consecutive patients referred to the urology department of Guy's and St Thomas' NHS Foundation Trust were invited to attend one of nine one-stop clinics staffed by consultant urologists with specialist registrars, nurses, and clerical staff. Pre-clinic blood and urine tests were ordered based on the referral letter. Clinics had facilities to perform cystoscopy, ultrasound, and urinary flow studies. Correspondence was generated in real time, and a copy given to the patient. RESULTS: Overall, 257 patients attended the clinics. Twenty-three patients cancelled appointments and 50 patients did not attend. Pre-clinic tests were requested in 133 patients and were completed by 86% of the patients who attended. Of patients, 42% were diagnosed and discharged; 28% were listed for surgery, extracorporeal shock wave lithotripsy (ESWL), or referred to another specialty. About 30% of patients needed further out-patient review; in approximately two-thirds to complete a diagnosis and one-third to review the results of therapy initiated. An estimated 350 appointments and 550 patient visits to hospital were saved. CONCLUSIONS: A one-stop method of consultation is efficient across a range of urological presenting complaints, and dramatically reduces the need for follow-up consultations. It has potential to: (i) reduce delays to being seen in out-patients; (ii) lead to more cost-effective care; and (iii) increase safety and patient satisfaction. It should become the standard of care in urology, and is probably applicable in many other disciplines.

Redefining urological history taking - anal intercourse as the cause of unexplained symptoms in heterosexuals.

INTRODUCTION: Symptoms suggestive of genito-urinary infection are frequent reasons for visits to general practitioners and account for approximately 15% of referrals to out-patient urology. The symptoms may be non-specific, and patients can undergo multiple investigations in an attempt to identify a cause. PATIENTS AND METHODS: We have seen several such patients, all of whom had engaged in unprotected heterosexual anal intercourse prior to the onset of their symptoms. Presenting complaints included urethral discomfort, acute epididymitis resistant to standard antibiotics, and sudden onset of overactive bladder symptoms. RESULTS: These patients illustrate the importance of careful history taking. Whilst some questions may be difficult to ask, they may reveal precipitating factors that the patient will be reluctant to volunteer. The repetitive nature of the behaviour may explain the chronicity of symptoms experienced by the patients, and avoidance of this activity may be the only management needed to improve them. For those with infective symptoms, the clinician's choice of antibiotic can be altered to provide anaerobic cover. CONCLUSIONS: A history of anal intercourse should be sought in patients with unexplained genito-urinary symptoms.