Tag: testicular

Urology, Suspicion of Cancer Referral

Scott McLaughlin
Urological cancers
Prostate cancer

Prostate cancer is the most common cancer in males in Scotland, with approximately 2,800 new cases diagnosed every year. Risk increases with age and approximately 99% of cases are diagnosed in men aged over 50 years. Men are 2.5 times more likely to be diagnosed with prostate cancer, if their father or brother has had it. In the UK, the lifetime risk of prostate cancer in Black men (1 in 4) is double that of the lifetime risk of all men combined (1 in 8).

Men presenting with unexplained possible symptoms and signs suggestive of prostate cancer such as changes to urinary patterns, erectile dysfunction, haematuria, lower back pain, bone pain or weight loss should have a digital rectal examination and a prostate specific antigen (PSA) test with counselling. A PSA test should not be performed within 1 month of a proven urinary tract infection (UTI). It should be noted that the majority of men with prostate cancer have no symptoms at all.

Bladder and kidney cancer

Visible haematuria is the most common presenting symptom for both bladder and kidney cancer. Other presenting features include loin pain, renal masses, non-visible haematuria, anaemia, weight loss and pyrexia. Both cancers are uncommon, with around 800 new bladder and 860 new kidney cancers each year.

Testicular and penile cancer

Although scrotal swellings are a common presentation in general practice, testicular cancer is relatively rare, with around 200 new cases per annum, of which approximately 70% are between 15 and 45 years. Solid swellings affecting the body of the testis have a high probability (>50%) of being due to cancer. Cancer of the penis is rare, with around 60 new cases each year in Scotland, but its incidence is rising.

All patients presenting with symptoms or signs suggestive of urological cancer should be referred to a team specialising in the management of urological cancer, depending on local arrangements.

Urgent suspicion of cancer referral

Prostate cancer

Evidence from digital rectal examination of a hard, irregular prostate

Elevated or rising age-specific PSA. Rough guide to normal PSA levels:

  • men less than 60 years – less than 3ng/ml
  • men aged 60 – 69 years – less than 4ng/ml
  • men aged 70 years and over – less than 5ng/ml

Bladder and kidney cancer

  • Patients with painless visible haematuria
  • Patients with non-visible haematuria and symptoms suggestive of UTI but with sterile mid-stream urine (MSU)
  • Abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract

Testicular and penile cancer

  • Swelling in the body of the testis
  • Suspicious scrotal mass found on imaging
  • Men considered to have epididymo-orchitis or orchitis which is not responding to treatment
  • Any non-healing lesion on the penis or painful phimosis

Non urgent referral

  • Elevated age-specific PSA where urgent referral will not affect outcome due to age or comorbidity
  • Asymptomatic persistent non-visible haematuria without obvious cause
  • Patients over 40 who present with recurrent UTI associated with any haematuria

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 85 – Management of transitional cell carcinoma of the bladder
Clinical Lead: Mr Rehan Khan, Consultant Urology Surgeon, NHS Lanarkshire
Review Date April 2017

Urology General Referral

Scott McLaughlin

The introduction of cancer and general diagnostic waiting time targets have lead us to look at how we can better deal with referrals to the urology departments in Lanarkshire and so minimise waiting times.

Patients with suspected urological malignancy should be referred through the SCI Gateway, Lanarkshire Cancer Referral Services These conditions include:

  • Palpable renal mass
  • Incidental renal tract mass on radiology
  • Frank haematuria
  • Symptomatic occult haematuria
  • A scrotal lump which cannot be sparated from testes
  • Suspected prostate cancer because of abnormal rectal examination or PSA outwith the age reference range
  • Suspected penile tumour

All other referrals should be marked Routine. An explanation in the text of the referral such as chronic retention or severe colic will be treated urgently, even if marked routine. Referrals for conditions other than described above marked urgent may be down graded to routine.

The following referral guidelines are based on specific presentations likely in general practice. Not all patients will fit these broad categories, but we hope the suggestions will ease the initial decision in many cases.

PresentationPreparation and Initial Management
Asymptomatic non visible haematuriaIf dipstick positive, send same sample for microscopy. Casts or abnormal forms indicate requirement for referral to renal physician. Investigate if 2+, or if consistently 1+ (as defined as 2 out of 3 samples) On flow cytometry of MSU, 1+ is defined as 40-100 rbc, 2+ is 100-250 rbc. Arrange MSSU. BP. biochemistry/haematology bloods. Book USS. Patient will be booked for direct access flexible cystoscopy. Manage positive results as indicated.
Symptomatic non visible haematuria In patients < 40 yrsMSSU, BP Biochemistry/Haematology bloods, USS with post-mic residual. Patient will be booked for direct access flexible cystoscopy. Treat/refer positive results as indicated.
Testicular Lump If lump distinctly separate and feels benign, then can be treated symptomatically. USS of scrotum if uncertain or there is a lot of anxiety. If patient fit and symptoms justify surgery refer to general urology clinic. In Wishaw and Monklands there is a separate scrotal lumps clinic for rapid assessment of all such lumps, but not non specific pain.
Testicular Pain Examine for local causes including rectal. Check MSSU. Think of referred causes. If negative reassure. If suspicion or anxiety persists, arrange ultrasound. If normal reassure. Urological referral unlikely to be useful but if in doubt, Patient will be seen at the general urology clinic.
Positive uti in male SIGN guidelines suggest men should be investigated if they have symptoms of upper tract infection, fail to respond to antibiotics or have two or more episodes in three months MSSU, BP, Biochemistry/Haematology bloods. Arrange an USS+KUB with post micturation residual. Patient will be booked for direct access flexible cystoscopy.
Recurrent cystitis in female / urinary tract infection in females Persisting pyuria There are no clear guidelines for investigation. In young males, consider urethritis/ STI. In all, consider atypical infection. Check 3 EMUs. In over 40s, it may be worth excluding underlying abnormality. BP, biochemistry/haematology bloods. Book USS, with post-micturation residual. The patient will be booked for direct access flexible cystoscopy.
Persisting pyuria Although there are no specific SIGN guidelines for referral, indications for referral could be as for males.MSSU, BP, Biochemistry/Haematology bloods. Book an USS, with post-mic residual. In those < 40 yrs, that may be enough but, if troublesome and in those > 40. The patient will be booked for direct access flexible cystoscopy.
Haematospermia Chlamydia urine (white top container) in younger patient MSSU. PR/testicular exam to exclude obvious malignancy Check PSA in older age group. Dipstick urine for haematuria. Trial of quinolone for 2 weeks if investigations negative. Patient will be booked for routine general urology clinic only for difficult cases.
Suspected stone disease MSSU, BP, Biochemistry/Haematology bloods, Arrange USS. If abnormal or history highly suggestive despite negative result. Patient will be booked for routine general urology clinic appointment.
Outflow obstruction in males > 50 yrs MSSU, BP, Biochemistry/Haematology bloods. Fill in symptom score and fluid chart. For mild/ moderate symptoms give trial of alpha blocker. If fails to respond or symptoms severe patient will be booked for prostate clinic.
Stress incontinence Examine for distended bladder/ pelvic mass. MSSU Address concomitant factors such as obesity, smoking. Refer for physiotherapy with pelvic floor exercises/ interferential bladder training. Refer to Continence Advisory Service, Lomond Road, Coatbridge, ML5 2JN.
Overactive bladderExamine for distended bladder / pelvic mass. MSSU. Address concomitant factors such as obesity, smoking, fluid / caffeine intake. Fluid balance chart. Refer to physiotherapy for bladder exercises. Consider trial of anti-cholinergic. If fails conservative management, refer to Continence Advisory Service, Lomond Road, Coatbridge, ML5 2JN.
Erectile dysfunctionCheck routine bloods including PSA and testosterone. Look at lifestyle and general issues such as obesity, smoking / alcohol intake, general fitness, medication and other diseases such as vascular, neurology, diabetes and psychology. Manage as appropriate. Next line of treatment if patient wishes this is with phosphodiesterase inhibitors such as Viagra/ Cialis/ Levetra. If this fails despite 8 doses, try another PDE5 inhibitor. If still fails or is contra-indicated and patient wishes to be considered for more interventive treatment, Patient will be booked for E.D clinic. If significant psychological component, consider referral to clinical psychologist.
Peyronies DiseaseThis may present with a penile lump and erectile deformity. There is no overlying skin problem.

There may be an acute phase with pain and a changing deformity that may last up to a year. This phase can be treated symptomatically. It may be worth a trial of phosphodiesterase inhibitor for flaccidity.

Once this has been settled, if the degree of penile deviation is such to make penetrative intercourse difficult enough to justify surgery with the side effects of penile shortening and impotence, refer routinely to general urology clinic.
Family planningWe do not offer a vasectomy reversal service. If a patient requests a vasectomy for family planning, they should be referred to local services , or to Sandyford Place in Glasgow for a local anaesthetic procedure. If a patient is deemed unsuitable by Sandyford place for a local anaesthetic procedure on medical grounds, and not just preference, they can be referred for a general anaesthetic vasectomy to the general urology clinic.
Paediatric conditions The lower age limit for the urology service is thirteen years. We will see referrals above this age with mainly surgical conditions such as phimosis, and inguino-scrotal problems. The paediatricians will continue to see referrals upto fifteen with medical conditions such as uti, abdominal pain, enuresis. Surgical problems in children below thirteen years old can be marked paediatric surgery and sent to J McGowan, who is the secretary in Wishaw to the eye dept and the paediatric surgeons (Mr M. Flett and Mr Walker). Emergency cases in children upto thirteen should be directed to Yorkhill.

Urology Cancer Template

Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

  • Asymptomatic
  • Symptomatic but completely ambulatory
  • Symptomatic, <50% in bed during the day
  • Symptomatic, >50% in bed, but not bedbound
  • Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Prefered Hospital:

  • Hairmyres Hospital
  • Monklands Hospital
  • Wishaw General Hospital
  • First Available appointment

Clinical Examinations and Findings

Examinations and Findings

Frank haematuria in an adult (unexplained):

  • Yes (If Yes, please provide brief details)
  • No

Symptomatic, non-visible haematuria in a patient over 40 years old:

  • Yes (If Yes, please provide brief details)
  • No

Palpable renal mass with/without pain, with/without haematuria:

  • Yes (If Yes, please provide brief details)
  • No

Solid renal mass found on imaging:

  • Yes (If Yes, please provide brief details)
  • No

PSA outwith age related reference range:

  • Yes (If Yes, please provide brief details)
  • No

Clinically malignant prostate on PR exam and/or bone pain suspicious of metatastic prostate cancer:

  • Yes (If Yes, please provide brief details)
  • No

Swelling in body of testis or other suspicion of testis cancer:

  • Yes (If Yes, please provide brief details)
  • No

Suspected penile cancer:

  • Yes (If Yes, please provide brief details)
  • No

Investigations

Please indicate if any of these tests have been checked.

MSSU:

  • Yes
  • No

U&E and FBC:

  • Yes
  • No

PSA – after patient has been counselled:

  • Yes
  • No

Urology cancer guideline