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COMMISSIONING GUIDE FOR SCROTAL SWELLING

[BAUS/ BAPS/ BAPU Logo]

Introduction

1. High Value Care Pathway

2. Procedures Explorer

3. Quality Dashboard

4. Levers for Implementation

4.1 Audit and Peer Review Measures

4.2 Quality Specification/ CQUIN

5. Directory

5.1 Patient Information

5.2 Clinician Information

5.3 NHS Evidence Case Studies

6. Benefits and Risks

7. Further Information

7.1 Research Recommendations

7.2 Other Recommendations

7.3 Evidence Base

7.4 Guideline Development Group

(Need to consult BAPS/ BAPU)

Sponsoring Organisation: BAUS/ BAPS/ BAPU

Date of publication: Month Year

Date of Review: Month Year

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INTRODUCTION

The differential diagnosis of scrotal swelling includes testicular torsion, malignancy, epididymal

cyst, hydrocoele and varicocoele.

Testicular torsion is a surgical emergency.

Malignancy cannot be excluded by clinical examination.

There should be direct access to USS on a 2WW pathway for patients with scrotal swelling.

There were over 7,000 procedures for hydrocoele in England in 2011/12. 70% (4,900) in adults and

30% in children (2,100).

There is over 3 fold variation in procedure rates for hydrocoele per 100,000 population by CCG

across England.

Hydrocoele may be safely observed.

Hydrocoelectomy should only be considered for mechanical problems e.g. urination.

Aspiration of hydrocoele should is ineffective and should only be considered in patient with

mechanical problems who are unfit for surgery.

National Variation Plot by CCG for hydrocoelectomy 2011/12

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1. HIGH VALUE CARE PATHWAY FOR SCROTAL SWELLING

Primary care

Refer:

• testicular torsion as an emergency (1,2)

• children <16 years to a paediatric surgical service (3)

• adults direct to USS on a 2WW pathway (4,5)

Hydrocoele/ Varicocoele/ Epididymal Cyst (5)

• reassure patient

• refer to urology if there are mechanical problems e.g. urination

Patients should be directed to appropriate supporting information e.g. NHS Choices

Secondary Care

Testicular torsion: (to be completed)

Paediatric hydrocoele (3,5):

• surgical treatment is not indicated <24 months because of the tendency for

spontaneous resolution, unless there is suspicion of a concomitant inguinal hernia or

underlying testicular pathology

• persistence beyond 24 months of age may be an indication for surgical correction

• sclerosing agents should not be used because of the risk of chemical peritonitis

• aspiration is ineffective

Malignancy: (to be completed)

Hydrocoele with mechanical problems (5):

• consider hydrocelectomy

• aspiration and sclerotherapy - associated with fewer complications but a lower success

rate and patient satisfaction - should only be considered if the patient is unfit for

surgery (6).

Varicocoele with mechanical problems: (to be completed)

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2. PROCEDURES EXPLORER FOR SCROTAL SWELLING

[hyperlink to Procedures Explorer]

3. QUALITY DASHBOARD FOR SCROTAL SWELLING

NHS Nottingham City CCG

[hyperlink to Quality Dashboard]

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4. LEVERS FOR IMPLEMENTATION

4.1 Audit and Peer Review Measures

Standard Description Data

Specification

(if required)

Primary

Care

Referral Do not refer patients with USS proven

asymptomatic hydrocoele/ varicocoele/

epididymal cyst

Patient

Information

Patients should be directed to appropriate

information

Secondary

Care

Intervention Do not aspirate hydrocoele with mechanical

problems unless patient unfit for surgery

Intervention Do not operate on hydrocoele/ varicocoele

unless there are mechanical problems e.g.

urination

4.2 Quality Specification/ CQUIN

Measure Description Data

Specification

(if required)

Rapid access to USS Access to scrotal/ testicular USS <2/52

Aspiration Stop aspiration for asymptomatic hydrocoele

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5. DIRECTORY

5.1 Patient Information

Name Publisher Link

Testicular Lumps (7) NHS Choices www.nhschoices.nhs.uk

Testicular Lumps EMIS www.patient.co.uk

Testicular Awareness BUPA www.bupa.co.uk

5.2 Clinician Information

Name Publisher Link

Referral for suspected

cancer (4)

NICE CG 27 www.nice.org.uk

Scrotal Swelling (5) NHS Clinical Knowledge

Summaries

www.cks.nhs.uk

Guideline on Paediatric

Urology (3)

European Society for

Paediatric Urology

www.uroweb.org

5.3 NHS Evidence Case Studies

Name Publisher Link

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6. BENEFITS AND RISKS

Consideration Benefit Risk

Patient outcome Ensure rapid access to USS

Patient safety Reduce chance of missing

testicular malignancy

Patient experience Improve access to patient

information

Equity of Access Improve access to effective

procedures

Resource impact Reduce unnecessary referral

and intervention

Resource required to establish 2WW

direct referral to USS

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7. FURTHER INFORMATION

7.1 Research Recommendations

Models of care: patient experience, patient safety, cost effectiveness

• referral to Urology – 2WW vs.

• direct referral to USS – 2WW vs.

• referral to one stop Urology and USS clinic – 2WW (8)

7.2 Other recommendations

Improved patient Information: to include information about

• hydrocoele/ varicocoele/ epididymal cyst

• risks and benefits of aspiration/ hydrocelectomy

7.3 Evidence Base

1. Ringdahl E, Teague L. Testicular torsion. American Family Physician. 2006 Nov

15;74(10):1739-43

2. Yin S, Trainor JL. Diagnosis and Management of Testicular Torsion, Torsion of the

Appendix Testis, and Epididymitis. Clinical Pediatric Emergency Medicine 2009

Mar;10(1):38-44

3. Tegul S, Riedmiller H, Gerharz E et al. Guidelines on Paediatric Urology. European

Association of Paediatric Urology. (2009) www.uroweb.org

4. NICE. CG27 Referral for suspected cancer (2005). www.nice.org.uk

5. Scrotal Swelling. Clinical Knowledge Summaries (2010). www.cks.nhs.uk

6. Khaniya S, Agrawal CS, Koirala R, Regmi R, Adhikary S. Comparison of aspiration-

sclerotherapy with hydrocelectomy in the management of hydrocele: a prospective

randomized study. International Journal of Surgery 2009 Aug;7(4):392-5

7. Choices N. Testicular Lumps And Swellings - Treatment - NHS Choices.

8. Moore JA, O’Neil C, Fawcett D. A one-stop clinic for men with testicular anxiety. Annals

of the Royal College of Surgeons of England. 2009 Jan ;91(1):23-24

7.4 Guideline Development Group

A commissioning guidance development group was established to review and advise on the

content of the commissioning guide. This group met [frequency], with additional interaction taking

place via email.

Name Job Title Affiliation