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Crawley/Horsham Primary Care Pathways
Non Acute Scrotal Swelling
Differential Diagnosis:
Hydrocoele
Varicocele
Epididymal Cyst
Thickened Epididymis
Spermatocele (Post Vasectomy)
Sebaceous Cyst
Consider:
History of trauma
Urethral Discharge – Epididymitis
Maldescent or atrophied testis
Frequent self-examination
Possible Torsion
Possible Testicular
lesions (consider
differential diagnosis)
Definite clinically
suspicious
testicular lesion
2 Week Rule
Urgent referral
to duty
hospital urologist
GP confident clinical presentation
epididymal cyst reassure patients
Refer to secondary
care urologist
If patients symptomatic or GP
unsure of diagnosis, request
Scrotal ultrasound scan
Ultrasound
Direct access ultra
sound at Crawley
Referral option: LSUS
for ultrasound
and management plan
Developed by: Dr Raj Sinha and Mr Waleed Al-Singary
V1.0 18/7/11
Referral option: LSUS
Management Options may include:
• Excision epididymal }
cyst
where
• Hydrocelectomy
} indicated
• Varicocelectomy
}
Crawley/Horsham Primary Care Pathways
Male Lower Urinary Tract Symptoms
Storage Symptoms
•Frequency
•Urgency
•Nocturia
•Urge Incontinence
Voiding Symptoms
•Hesitancy
•Poor, intermediate flow
•Post-voiding dribbling
Refer to
Secondary
care
Urologist
Mixed Symptoms
Investigations
• Dipstick +ve for blood
• Suspiciously raised PSA
• Abnormal DRE
• MSU +ve for infection
•Severe Storage Symptoms
•Recent nocturnal enuresis
•Suspected neurogenic bladder
•Previous acute retention
•Previous TURP/pelvic surgery
NO
Age >50
IF normal DRE, PSA
U&E then try
Tamsulosin MR
capsules for 4 weeks.
Developed by: Dr Raj Sinha and Mr Waleed Al-Singary
V1.0 18/7/11
Age < 50
If no
better
Referral option: LSUS
Management options could
Include:
•Urodynamics /CMG
•Uroflowmetry
•Ultrasound of Bladder,
Kidney and Prostate
•Further medical management
Crawley/Horsham Primary Care Pathways
Erectile Dysfunction
History
• Medical
• Sexual
• Psychological
• Drugs
Examination
• Secondary sexual characteristics
• Genital Examination
(Deformities, foreskin problems, shaft nodules)
• Blood Pressure
Blood Tests
• Glucose
• Lipids profile
• Testosterone
Psychosexual
Suggested by
• Psychological history
• Sudden onset of ED
• Normal early morning
erections
• Normal erections with
masturbation
± Try Sildenafil
orVardenafil for 4
weeks
Trial ED drugs as oneoff treatment for 1
month max.
Cardiovascular Risk factors
• Treat risk factors
• If no contraindications, Trial ED
drugs. Try 2 different drugs for
at least 2 months (Beware of
NHS guidelines Regarding
prescription ED drugs)
Urological Problems
indentified
• Low testosterone
• Genital abnormalities
• Peyronie’s disease
• Premature ejaculation
Referral option: LSUS
Failure of
treatment
Developed by: Dr Raj Sinha and Mr Waleed Al-Singary
V1.0 18/7/11
Management Options
to include:
• 3rd line medication
• Suction pump
• Caverjet Injection
• Low testosterone
Sildenafil + Testosterone
-Gel
-Patches
-Injections
-Implant
Crawley/Horsham Primary Care Pathways
Chronic Scrotal Pain
Intermittent or constant scrotal pain for 3 or more months
-Significantly interferes with daily activity
- Prompts request for medical advice
Consider :
Idiopathic
Infective or post infective
Post vasectomy
Chronic Prostatitis
Neuromuscular disorder
Psychosomatic
Refer to Secondary
Care Urologist
Urine dipstick
MSU
Positive
All negative
No discharge
Ultra sound
Dipstick & MSU positive
Urethral discharge
Age < 35
Age > 35 and
change in
sexual lifestyle
Age > 35 and no
change in
sexual lifestyle
Refer GUM
Direct Access
ultrasound at
Crawley Hospital
Referral option:
LSUS
for U/S and
management plan
Management may include:
• Neuropathic medication
• Spermatic cord de-nervation
• Epididymectomy
• Orchidectomy
Need Flexicystoscopy
Developed by: Dr Raj Sinha and Mr Waleed Al-Singary
V1.0 18/7/11