Non Acute Scrotal Swelling 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 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

Male Lower Urinary Tract Symptoms 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 >50 Age < 50 IF normal DRE, PSA U&E then try Tamsulosin MR capsules for 4 weeks. Referral option: LSUS If no better Management options could Include: Urodynamics /CMG Uroflowmetry Ultrasound of Bladder, Kidney and Prostate Further medical management Developed by: Dr Raj Sinha and Mr Waleed Al-Singary V1.0 18/7/11

Erectile Dysfunction Crawley/Horsham Primary Care Pathways 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 Peyronie’s 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. Developed by: Dr Raj Sinha and Mr Waleed Al-Singary V1.0 18/7/11

Chronic Scrotal Pain Crawley/Horsham Primary Care Pathways 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 Age < 35 Age > 35 and change in sexual lifestyle Age > 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 Developed by: Dr Raj Sinha and Mr Waleed Al-Singary V1.0 18/7/11