1. 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

2. 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

3. 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

4. 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