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

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 2

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)

2. PROCEDURES EXPLORER FOR SCROTAL SWELLING

[hyperlink to Procedures Explorer]

3. QUALITY DASHBOARD FOR SCROTAL SWELLING

NHS Nottingham City CCG [hyperlink to Quality Dashboard]

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 Patients should be directed to appropriate information Do not aspirate hydrocoele with mechanical problems unless patient unfit for surgery Do not operate on hydrocoele/ varicocoele unless there are mechanical problems e.g. urination

Patient Information Secondary Care Intervention

Intervention

4.2 Quality Specification/ CQUIN Measure Description Data Specification (if required)

Rapid access to USS Aspiration

Access to scrotal/ testicular USS <2/52 Stop aspiration for asymptomatic hydrocoele

5. DIRECTORY 5.1 Patient Information Name Testicular Lumps (7) Testicular Lumps Testicular Awareness Publisher NHS Choices EMIS BUPA Link www.nhschoices.nhs.uk www.patient.co.uk www.bupa.co.uk

5.2 Clinician Information Name Referral for suspected cancer (4) Scrotal Swelling (5) Guideline on Paediatric Urology (3) Publisher NICE CG 27 NHS Clinical Knowledge Summaries European Society for Paediatric Urology Link www.nice.org.uk www.cks.nhs.uk www.uroweb.org

5.3 NHS Evidence Case Studies Name Publisher Link

6. BENEFITS AND RISKS

Consideration Patient outcome Patient safety Patient experience Equity of Access Resource impact

Benefit Ensure rapid access to USS Reduce chance of missing testicular malignancy Improve access to patient information Improve access to effective procedures Reduce unnecessary referral and intervention

Risk

Resource required to establish 2WW direct referral to USS

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 aspirationsclerotherapy 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, ONeil 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