Key distinguishing features of the most common diagnoses
|Recent Surgical Intervention||No||Possible||Yes||Possible||No|
|Urinary Tract Symptoms||No||Possible||Possible||Yes||No|
|Prostate Markedly Tender on PR||No||Yes||Possible||No||No|
Possible:FBC, ESR/CRP, PSA, urethral swab.
Small Print:INR, clotting screen, seminal fluid culture, transrectal ultrasound, prostate biopsy, urethroscopy.
- Urinalysis: Protein, nitrites, leucocytes and possible haematuria in any genito-urinary infection or prostatitis. Haematuria possible in malignancy and schistosomiasis.
- MSU: To confirm infection and identify pathogen.
- FBC and ESR/CRP: WCC may be elevated in infection; Hb may be reduced and ESR/CRP raised in malignancy; ESR/CRP also raised in infection.
- PSA: The pros and cons of this test might be discussed as a pointer to prostatic carcinoma.
- Urethral swab: If urethritis suspected (best taken at GUM clinic).
- INR, clotting screen: If patient on warfarin or a bleeding disorder suspected.
- Other investigations (usually hospital-based): These might include seminal fluid culture to investigate deep-seated infection; transrectal ultrasound and prostatic biopsy for detailed investigation of prostate; urethroscopy/cystoscopy if felt to be a structural urethral or bladder problem.
- A frank and open approach, using plain language, is important for the patient to feel comfortable and capable of describing an accurate history.
- Do not underestimate the patient’s level of anxiety – and ensure it’s properly addressed. Most men with this symptom are convinced they have serious pathology.
- The approach with this symptom has more to do with deciding on further action than establishing a precise diagnosis. This is because assessment in primary care rarely reveals any underlying pathology – management is more likely to be influenced by the patient’s age and the history than the clinical findings (see the following point).
- Men under the age of 40 with short-lived symptoms do not require referral, as the chance of significant pathology is miniscule. Older men – and those with persistent or recurrent haemospermia, or abnormalities on initial assessment – require referral for further assessment.
- A serious underlying cause is rare but should be considered in men over the age of 40 who have more than one episode.
- The chances of significant pathology are increased by the finding of microscopic haematuria – refer these cases.