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

1
Crawley/Horsham Primary Care Pathways
Non Acute Scrotal Swelling
Differential Diagnosis Hydrocoele Varicocele Ep
ididymal 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

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

2
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

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 lt 50
Age gt50
IF normal DRE, PSA UE then try Tamsulosin MR
capsules for 4 weeks.
Referral option LSUS
If no better
3
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

• 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
• Peyronies disease
• Premature ejaculation

• 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.
4
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
Positive
Refer to Secondary Care Urologist
Ultra sound
Dipstick MSU positive Urethral discharge
Age lt 35
Age gt 35 and change in sexual lifestyle
Age gt 35 and no change in sexual lifestyle
Direct Access ultrasound at Crawley Hospital
Referral option LSUS for U/S and management
plan
Refer GUM

• Management may include
• Neuropathic medication
• Spermatic cord de-nervation
• Epididymectomy
• Orchidectomy

Need Flexicystoscopy