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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

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Presentation Transcript
slide1

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

PossibleTorsion

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

  • Referral option: LSUS
  • Management Options may include:
  • Excision epididymal }
  • cyst where
  • Hydrocelectomy } indicated
  • Varicocelectomy }

Developed by: Dr Raj Sinha and Mr Waleed Al-Singary

V1.0 18/7/11

slide2

Crawley/Horsham Primary Care Pathways

  • Management options could
  • Include:
  • Urodynamics /CMG
  • Uroflowmetry
  • Ultrasound of Bladder, Kidney and Prostate
  • Further medical management

Male Lower Urinary Tract Symptoms

  • Storage Symptoms
  • Frequency
  • Urgency
  • Nocturia
  • Urge Incontinence
  • Voiding Symptoms
  • Hesitancy
  • Poor, intermediate flow
  • Post-voiding dribbling

Mixed Symptoms

  • Investigations
  • Dipstick +ve for blood
  • Suspiciously raised PSA
  • Abnormal DRE
  • MSU +ve for infection

Refer to

Secondary

care Urologist

  • Severe Storage Symptoms
  • Recent nocturnal enuresis
  • Suspected neurogenic bladder
  • Previous acute retention
  • Previous TURP/pelvic surgery

NO

Age >50

Age < 50

IF normal DRE, PSA U&E then try Tamsulosin MR capsules for 4 weeks.

Referral option: LSUS

If no

better

Developed by: Dr Raj Sinha and Mr Waleed Al-Singary

V1.0 18/7/11

slide3

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
  • Urological Problems indentified
  • Low testosterone
  • Genital abnormalities
  • Peyronie’s disease
  • Premature ejaculation
  • 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)
  • Psychosexual
  • Suggested by
  • Psychological history
  • Sudden onset of ED
  • Normal early morning
  • erections
  • Normal erections with masturbation
  • ± Try Sildenafil orVardenafil for 4 weeks
  • Referral option: LSUS
  • Management Options
  • to include:
  • 3rd line medication
  • Suction pump
  • Caverjet Injection
  • Low testosterone
  • Sildenafil + Testosterone
      • Gel
      • Patches
      • Injections
      • Implant

Failure of treatment

Trial ED drugs as one-off treatment for 1 month max.

Developed by: Dr Raj Sinha and Mr Waleed Al-Singary

V1.0 18/7/11

slide4

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

Urine dipstick

MSU

All negative

No discharge

Refer to Secondary

Care Urologist

Positive

Ultra sound

Dipstick & MSU positive

Urethral discharge

Direct Access

ultrasound at

Crawley Hospital

Referral option: LSUS

for U/S and

management plan

Age < 35

Age > 35 and

change in

sexual lifestyle

Age > 35 and no

change in

sexual lifestyle

Refer GUM

  • 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

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