Scrotal Conditions

Who to refer:

• Refer to Emergency On-Call Urology Team for Suspected testicular torsion
• Refer to Urology as USOC (see below) if US report is suspicious of cancer
• Refer for Ultrasound. Ultrasound is indicated for:
  • Intra-testicular lump, or diffusely swollen testis
  • Scrotal lump, if uncertain whether it is intra or extra testicular
  • New hydrocele, if the underlying testis cannot be palpated as normal or clinically suspected hydrocele if patient appropriate for referral to Urology
  • Clinically suspected varicocele where referral to Urology is anticipated
  • Clinically suspected epididymal cyst where referral to Urology is anticipated
  • Persistent testicular pain that has not resolved with treatment for epididymitis and referral to Urology is anticipated (but see notes below re Epididymo-orchitis not resolving after two weeks of antibiotics)
• Ultrasound is not routinely indicated for
  • Extra-testicular lump with normal testes on examination (these are likely to be benign)
  • Subcutaneous lumps
• Refer to Urology for
  • Testicular pain not responding to antibiotics
  • Varicocele palpable on standing and painful OR Hydrocele palpable on standing and concerns about fertility status (check semen analysis and include with referral) OR Hydrocele with signs of testicular atrophy (size discrepancy, small soft testicle)
  • Hydrocele if symptomatic and patient wishes to consider surgery
  • Epididymal cyst if symptomatic and patient wishes to consider surgery
• Refer to Sexual Health for Suspected Epididymo-orchitis where gonorrhoea is suspectedinely indicated for
  • Extra-testicular lump with normal testes on examination, e.g. epididymal cyst
  • Subcutaneous lumps

Who not to refer:

• Epididymo-orchitis (with no suspected gonorrhoea) which settles with antibiotics
• Varicocele where surgery not wanted and no concerns about fertility or testicular atrophy
• Hydrocele where surgery not wanted
• Epidydmal cyst where surgery not wanted

How to refer for scrotal conditions (other than USC) that require a referral

For Ultrasound:

• SCI GATEWAY > ELCH or LB or Leith CTC or RIE or SJH or WGH > Clinical Radiology > LI Radiology Ultrasound. In the referral select Ultrasound Testes (selecting appropriate priority)

For Urology:

• SCI GATEWAY > WGH > LI Scrotal Swelling (selecting appropriate priority)

Testicular Cancer

Clinical features for Testicular Cancer include:

• A swelling or lump in the testis or scrotum
• A dull ache in the abdomen or groin
• SOLID SWELLINGS AFFECTING THE BODY OF THE TESTIS HAVE A MORE THAN 50% CHANCE OF BEING CANCER

Refer as USC (Ultrasound and then to Urology as per the pathway below)

• A non-painful enlargement or change in shape or texture of the body of the testis
• An epididymo-orchitis not improving after two weeks of antibiotics
• Consider a testicular USS for men with unexplained or persistent symptoms despite a normal examination

How to refer – USC Referrals

For patients where Testicular Cancer is suspected:

• Refer to Radiology for Ultrasound:

SCI GATEWAY > ELCH or LB or Leith CTC or RIE or SJH or WGH > Clinical Radiology > LI Radiology Ultrasound. In the referral select Ultrasound Testes and check priority USOC

• Onward Referral to Urology

SCI GATEWAY > WGH > LI Scrotal Swelling (selecting USOC as priority)

Where the US is reported as suspicious for testicular cancer the report will be emailed by radiology to the Clinical Inbox of the referring GP practice and will require the GP to inform the patient and to send a USOC SCI Gateway referral. It will also be emailed to the Testicular cancer clinic. The GP email will contain the following information along with the US report:

Dear GP,

URGENT EMAIL, GP ACTION REQUIRED

Please see the report below. I would be grateful if you could inform the patient of the result, warn the patient to expect an urgent appointment and send a formal USOC referral to Urology via SCI Gateway:

SCI GATEWAY > WGH > LI Scrotal Swelling (selecting USOC as priority)

This email is being sent to the Practice Clinical Inbox and will also be emailed to the Urology Testicular Cancer Clinic (email address). A SCI GW referral is still needed.