When to refer to a pediatric urologist
A short pocket guide for pediatricians and family doctors: when a child needs to see a pediatric urologist as an emergency, when within the next few weeks, and when a routine referral is enough.
Emergency: same day
The child is sent straight to the emergency department or to a pediatric urologist. Waiting for imaging results must not delay treatment.
- Sudden-onset testicular or scrotal pain Torsion until proven otherwise. The first 6 hours are critical to save the testicle; ultrasound must not delay surgical assessment
- Paraphimosis The retracted, swollen foreskin does not return to its normal position
- Incarcerated inguinal hernia Painful, firm swelling that does not go back in, vomiting
- Acute urinary retention
- Suspected posterior urethral valves in a newborn boy Bilateral hydroureteronephrosis, thick-walled bladder, weak stream, history of oligohydramnios
- Ambiguous genitalia, bilateral nonpalpable testes, cryptorchidism with proximal hypospadias Together with an endocrinologist; risk of adrenal crisis
- Febrile UTI with obstruction, a solitary kidney or sepsis
- Abdominal pain and fever in a patient with an augmented bladder Until perforation is ruled out
Soon: within 1–2 weeks
The condition is not life-threatening, but a delay can harm the kidney or testicle.
- Postnatal UTD P2–P3, bilateral dilation, ureteral dilation
- Atypical or recurrent febrile UTI, a first febrile UTI under 12 months of age, abnormal ultrasound or DMSA after a UTI Situations in which VCUG is considered (EAU 2026); it is not done during the acute infection
- Reducible inguinal hernia, especially in infants Infants have a high risk of incarceration
- Gross hematuria without infection
- Constant dribbling of urine in girls who also void normally Ectopic ureter
- Weak stream, straining, voiding drop by drop
- Firm mass in the testicle
Routine referral
Refer at the age given so the best time for treatment is not missed.
- Undescended testicle If the testicle is not in the scrotum by 6 months (corrected age); in the acquired form, right away
- Hypospadias In the first months after birth; do not circumcise
- Hydrocele If it persists after 1–2 years of age. A change in size during the day suggests a communicating hydrocele and needs urological assessment; timing of surgery depends on persistence, an associated hernia and testicular pathology
- Symptomatic phimosis Painful voiding or a weak stream, white scarring, recurrent inflammation, no response to properly given treatment. Ballooning alone is not a reason for referral
- Vesicoureteral reflux, recurrent UTI
- Bedwetting If there is no response to first-line treatment or there are red flags
- Daytime wetting If there is no response to 3–6 months of urotherapy
- Varicocele in an adolescent Pain, a smaller testicle or asymmetry
- Penis that looks small To tell a buried penis apart from micropenis
- Symptomatic labial adhesions
What not to do
- Do not forcibly retract the foreskin: physiological phimosis is normal.
- Do not circumcise a child with hypospadias: the foreskin is used in the reconstruction.
- Do not lose time on ultrasound and hormone treatment for an undescended testicle.
- In acute testicular pain, do not delay surgical assessment while waiting for an ultrasound result.
- Do not use a urine bag for culture or diagnose a UTI from a positive bag sample: a bag sample only helps to exclude UTI when it is negative.
- Do not use nitrofurantoin for febrile UTI.
- In febrile UTI, do not delay antibiotics while waiting for culture or imaging results, and do not perform a VCUG during the acute infection.
What to attach to the referral
- All ultrasound reports, and images or a disc if possible
- Urinalysis and urine culture results (with how the sample was collected)
- For wetting, a 48-hour diary
- Previous reports, operative notes, current medications
Consultation
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These materials are intended for medical professionals. Decisions about an individual patient are made by the treating doctor.