Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

Ready Reckoner

Key distinguishing features of the most common diagnoses

UnknownProstatitisPost-opGU infectionTrauma
Recent Surgical InterventionNoPossibleYesPossibleNo
Recent TraumaPossibleNoNoNoYes
Urinary Tract SymptomsNoPossiblePossibleYesNo
Prostate Markedly Tender on PRNoYesPossibleNoNo

Possible Investigations

Likely:Urinalysis, MSU.

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.

Top Tips

  • 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.

Red Flags

  • 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.
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