A 13-year-old uncircumcised male patient has been treated for phimosis and returns to the nurse practitioner for follow-up. A referral should be made to the urologist if the adolescent

Rationale: A. Inability to retract a previously retractable prepuce (paraphimosis or recurrent phimosis) after treatment may indicate an underlying structural problem and warrants referral to a urologist. B. Difficulty maintaining hygiene is common in uncircumcised adolescents and can often be managed with education on proper cleaning techniques. C. Desire for circumcision alone is not an urgent indication for urology referral; it can be elective. D. Nocturnal erections are a normal physiological process in adolescent males and do not necessitate referral.