Crawley/Horsham Primary Care Pathways

1. 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

2. 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

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 • 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

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 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