5.5 Urological Cancers, Prostate Disease & Scrotal Emergencies
Key Takeaways
Suspected testicular torsion needs immediate surgical exploration without waiting for ultrasound; testicular salvage is best within 6 hours of onset.
NICE NG12 refers men with a non-painful enlargement or change in shape or texture of a testis on the suspected cancer pathway.
Testicular cancer is removed by radical inguinal orchidectomy; a trans-scrotal biopsy is avoided because it disturbs lymphatic drainage.
People aged 45 or over with unexplained visible haematuria without UTI need a suspected cancer pathway referral for bladder or kidney cancer (NICE NG12).
Multiparametric MRI is the first-line investigation for suspected clinically localised prostate cancer before biopsy (NICE NG131).
Urological Cancers, Prostate Disease & Scrotal Emergencies
The Acute Scrotum
| Condition | Typical Patient | Key Features | Management |
|---|---|---|---|
| Testicular torsion | Adolescents (peak 12–18) and neonates | Sudden severe pain, nausea and vomiting; high-riding testis with a horizontal lie; absent cremasteric reflex; elevation does not relieve pain | Immediate scrotal exploration (do not delay for imaging); detorsion and bilateral orchidopexy; best salvage within 6 hours |
| Torsion of a testicular appendage | Pre-pubertal boys | Gradual pain at the upper pole, "blue dot" sign | Analgesia, rest; explore if torsion cannot be excluded |
| Epididymo-orchitis | Sexually active men; older men with urinary infection | Gradual pain and swelling, fever, dysuria, urethral discharge; pain may ease on elevation | Under 35 or likely STI: test for gonorrhoea and chlamydia, ceftriaxone 1 g IM plus doxycycline 100 mg twice daily for 10–14 days (BASHH); likely enteric organisms: a quinolone such as ofloxacin for 14 days |
| Mumps orchitis | Unvaccinated adolescents and men | Parotitis a few days before; can cause subfertility | Supportive; notify mumps |
Caution
Torsion Is a Clinical Diagnosis: Any acute testicular pain in a child or young man is torsion until proven otherwise. Ultrasound can be falsely reassuring and delays surgery; the testis is often lost after about 6 hours of ischaemia.
Scrotal Lumps
- Hydrocele: soft, fluctuant, transilluminates, the testis is difficult to feel; you can get above it. In adults, ultrasound to exclude an underlying tumour.
- Varicocele: "bag of worms", usually left-sided, more obvious standing; associated with subfertility. A new varicocele that does not empty on lying down, or a right-sided one, may indicate a renal tumour obstructing venous drainage.
- Epididymal cyst: smooth, separate from and above the testis, transilluminates.
- Inguinoscrotal hernia: you cannot get above the swelling; there may be a cough impulse.
- Testicular tumour: a hard, painless lump within the testis that does not transilluminate.
Testicular Cancer
The commonest solid cancer in men aged about 15–45. Risk factors: undescended testis (cryptorchidism), previous testicular cancer, family history, infertility.
- Types: germ cell tumours (over 95%): seminoma and non-seminomatous germ cell tumours (teratoma, embryonal carcinoma, yolk sac tumour, choriocarcinoma).
- Tumour markers: AFP (raised in non-seminomatous tumours; a raised AFP excludes pure seminoma), beta-hCG (raised in many non-seminomatous tumours and some seminomas) and LDH (tumour burden).
- Referral (NICE NG12): suspected cancer pathway for non-painful enlargement or change in shape or texture of the testis; consider direct-access ultrasound for unexplained or persistent testicular symptoms.
- Treatment: radical inguinal orchidectomy (a scrotal incision or biopsy is avoided because it opens a new lymphatic route), staging CT, then surveillance, chemotherapy or radiotherapy. Offer sperm banking before treatment. Cure rates exceed 95% overall.
Benign Prostatic Hyperplasia (BPH) & Urinary Retention
Lower urinary tract symptoms (LUTS) are voiding (hesitancy, weak stream, straining, terminal dribbling, incomplete emptying) or storage (frequency, urgency, nocturia).
Assessment: International Prostate Symptom Score, examination including digital rectal examination, urinalysis, frequency-volume chart, renal function if retention is suspected, and PSA after counselling (if LUTS suggest bladder outlet obstruction from an enlarged prostate, or the prostate feels abnormal).
Drug treatment (NICE CG97):
- Alpha-blocker (tamsulosin) for moderate or severe voiding symptoms (warn about postural hypotension and retrograde ejaculation).
- 5-alpha reductase inhibitor (finasteride) if the prostate is estimated at more than 30 g or PSA is above 1.4 ng/mL with a high risk of progression; it takes months to work and halves the PSA.
- Combination of both for bothersome symptoms with an enlarged prostate.
- Antimuscarinic for storage (overactive bladder) symptoms.
- Surgery (transurethral resection of the prostate and newer techniques) for refractory symptoms or complications.
Acute urinary retention: painful, palpable bladder; catheterise (record the residual volume), look for precipitants (constipation, anticholinergics, opioids, infection), and start an alpha-blocker before a trial without catheter. Painless chronic retention with high pressure can cause obstructive AKI and post-obstructive diuresis after catheterisation.
Prostate Cancer
The most common cancer in UK men; risks are age, Black ethnicity, family history and BRCA2 variants.
- Referral (NICE NG12): suspected cancer pathway if the prostate feels malignant on DRE or the PSA is above the age-specific reference range. Consider PSA and DRE in men with LUTS, erectile dysfunction or visible haematuria.
- PSA is raised by benign enlargement, prostatitis, UTI, retention, catheterisation and recent ejaculation or vigorous exercise; there is no national screening programme, so men without symptoms who ask for a test receive balanced counselling.
- Investigation: multiparametric MRI first (NICE NG131), then targeted (usually transperineal) biopsy; grade by Gleason/ISUP; stage with imaging.
- Treatment: active surveillance for low-risk disease; radical prostatectomy or radiotherapy (with hormone therapy) for higher-risk localised disease; androgen deprivation therapy for advanced disease (cover the testosterone flare of GnRH agonists with an anti-androgen when there are bone metastases, which can otherwise cause cord compression).
Bladder & Kidney Cancer
Haematuria Referral (NICE NG12)
- Suspected cancer pathway for bladder or kidney cancer: age 45 or over with unexplained visible haematuria without UTI, or visible haematuria that persists or recurs after successful UTI treatment.
- Bladder cancer: also age 60 or over with unexplained non-visible haematuria plus dysuria or a raised white cell count.
Bladder Cancer
Usually urothelial (transitional cell) carcinoma presenting with painless visible haematuria. Risk factors: smoking, aromatic amines (dye, rubber and leather industries), pelvic radiotherapy, cyclophosphamide; schistosomiasis causes squamous cell carcinoma. Investigate with flexible cystoscopy and CT urography; treat with transurethral resection, intravesical BCG or chemotherapy, or cystectomy for muscle-invasive disease.
Renal Cell Carcinoma
Classic triad of haematuria, loin pain and a flank mass (now often found incidentally). Paraneoplastic features: polycythaemia (erythropoietin), hypercalcaemia, hypertension. It may cause a left varicocele and "cannonball" lung metastases, and is associated with von Hippel-Lindau disease. Treatment is partial or radical nephrectomy, with immunotherapy and targeted therapy for metastatic disease.
Foreskin Problems & Penile Cancer
- Phimosis: a non-retractile foreskin is normal (physiological) in young boys and usually resolves; pathological phimosis (scarring, often from lichen sclerosus) causes ballooning, infection or difficulty passing urine and is treated with topical steroids or circumcision.
- Paraphimosis: a retracted foreskin that cannot be returned, causing painful glans swelling (often after catheterisation or examination). It is an emergency: reduce it with analgesia and manual compression; a dorsal slit may be needed if this fails. Always replace the foreskin after catheterising.
- Penile cancer: usually squamous cell carcinoma, linked to HPV, phimosis, smoking and lichen sclerosus; a persistent penile lump, ulcer or change in the foreskin or glans needs a suspected cancer pathway referral (NICE NG12).
A 14-year-old boy wakes with sudden severe left testicular pain and vomiting that started 2 hours ago. The left testis is high-riding with a horizontal lie and the cremasteric reflex is absent. What is the most appropriate next step?
Analgesia and review in the urology clinic the next day
Ceftriaxone and doxycycline for epididymo-orchitis
Urgent scrotal Doppler ultrasound before deciding on surgery
Immediate referral for surgical exploration of the scrotum
A 29-year-old man has a painless, hard lump within his right testis. Ultrasound shows a solid intratesticular mass. Serum AFP is markedly raised. Which statement is correct?
The tumour is most likely a pure seminoma
He should have a radical inguinal orchidectomy after being offered sperm banking
A trans-scrotal biopsy should confirm the diagnosis before surgery
He should be observed with repeat ultrasound in 6 weeks
A 52-year-old man who smokes has one episode of painless visible haematuria. Urine culture is negative and he has no urinary symptoms. According to NICE NG12, what is the most appropriate action?
Arrange a PSA test and refer only if it is raised
Repeat the urine dipstick in 3 months and refer if positive
Suspected cancer pathway referral (bladder and kidney)
Treat empirically for a urinary tract infection
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