REMEDY : BNSSG referral pathways

Scrotal Swellings & Testicular Lumps & Pain

Checked: 20-04-2018 by katy.kearley Next Review: 22-02-2019

Principles of Management - Testicular Lumps

If Testicular cancer is suspected, then refer in accordance with the NICE cancer guidelines:

Testicular cancer

1.6.7 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for testicular cancer in men if they have a non‑painful enlargement or change in shape or texture of the testis. [new 2015]

1.6.8 Consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms. [new 2015]

CKS has comprehensive guidelines and includes advice on assessment and management of suspected testicular cancer, testicular torsion, varicocele, hydrocele and epididymo-orchitis.
Please note, referral to consider surgery for Epididymal Cysts and Hydroceles (once malignancy has been excluded) needs an Individual Funding Request to be submitted.  See link to INNF policies below; 

Hydroceles in males

Epididymal cysts

Principles of Management - Testicular Pain

Acute testicular pain may be due to infection or torsion and should be treated or referred as appropriate (see above).

Chronic pain can have a variety of causes.  Exclude cancer by USS as 5% of testicular cancers present with pain.

Consider infection and treat with oral antibiotics if suspected.  Refer to the BNSSG Antimicrobial Prescribing Guidelines.

If there is still no improvement then manage pain with oral analgesia.  Amitriptyline may also be worth a try.  If symptoms persists then a referral to pain management may be considered.  The sexual health clinic also runs a clinic for pelvic pain in men.

Referral to Urology is usually unnecessary as surgery is very rarely indicated.  Epididectomy or devervation are possible but only in a very selected group of patients.

Microlithiasis

There are guidelines from the European Society of Urogenital Radiology which have been discussed with local radiologists and urologists.  The below approach has been suggested:

If testicular USS shows microlithiasis and there are not additional risk factors then reassure and do not rescan as there is not evidence to show it is beneficial in picking up early cancers.  Patients should still be advised to undertake monthly self examination.

If microlithiasis is found in men under 55 and is associated with any risk factors then advice is to scan annually (until age of 55).  Risk factors include a personal or family history of germ cell tumor, maldescent, orchidopexy and testicular atrophy.  Men in this group should also undertake monthly self-examination.

In men over the age of 55 the risk of testicular cancer is consider low and therefore USS screening is not advised, however self-examination should still be encouraged.

Red Flags - Microlithiasis

If microlithiasis is associated with a testicular mass then refer 2WW.