Epididymo-orchitis is an inflammation of the testis and epididymis, generally of infectious origin. In young men epididymo-orchitis is most often associated with sexually transmitted infections. In those aged over 35 the causative pathogens are more likely to be non-sexually transmitted coliform organisms associated with urinary tract infections. Other causes include viral infections such as mumps in immunocompromised, non-immunised or prepubescent males, local trauma, and medication such as amiodarone. 

Prostate cancer is the most common cancer in men in the UK. In men with possible symptoms of prostate cancer, an assessment of LUTS, relevant risk factors and past medical history is essential. NICE recommends performing a DRE; this will give an impression of prostate size. If the prostate feels malignant on DRE this should trigger a fast-track referral to secondary care, via a suspected cancer pathway referral even if the PSA is normal. A PSA test should also be offered to men with LUTS or an abnormal DRE.

Most men with testicular cancer present with a lump that they have identified in their scrotum. Although the scrotal swelling is usually painless, pain is the first symptom in around 20% of patients, typically a dull or dragging ache in the testicle or a heaviness in the scrotum. NICE recommends that all men who have a non-painful enlargement or change in shape or texture of their testis should be referred urgently to urology using the two-week wait pathway. In men who have unexplained or persistent testicular symptoms, an urgent direct access testicular ultrasound scan should be requested. 

Varicoceles are usually asymptomatic but some patients may present with a scrotal swelling or pain. The patient should be examined in both the standing and supine positions, with and without a Valsalva manoeuvre. Patients may also present with primary or secondary infertility, with a varicocele detected on clinical examination or by imaging. Men presenting with infertility should be assessed with a reproductive history, semen analysis and hormone profile, including testosterone, LH and FSH.

Men born after 1960 in the UK now have a 1 in 6 estimated lifetime risk of being diagnosed with prostate cancer. NICE recommends that men over 50 years old who request a PSA test should be fully counselled about the test beforehand. The test should also be offered to men with LUTS or an abnormal DRE. If the prostate feels malignant on DRE this should trigger a fast track referral to secondary care, via a suspected cancer pathway referral, even if the PSA is normal. Men with PSA values above the age-specific reference range should also be referred to urology urgently, via a suspected cancer pathway referral.

Lower urinary tract symptoms (LUTS) in men can be defined by clinical symptoms arising from the bladder, bladder neck, urethral sphincter, urethra or prostate. Benign prostatic hyperplasia (BPH) is the most common cause of LUTS. By 80 years of age almost 90% of men have developed BPH at varying symptomatic levels. If the patient’s symptoms and examination findings are suspicious of cancer then an urgent two week wait referral should be made to urology. Other reasons for referral include: complicated LUTS with recurrent or persistent UTI, retention, renal impairment, stress incontinence or bothersome LUTS not resolved by conservative or drug management.

Acute prostatitis is an acute bacterial infection of the prostate gland, often associated with other urinary tract infections. Patients with acute prostatitis present feeling generally unwell with fever, rigors, pelvic pain and lower urinary tract symptoms. Acute prostatitis can also present with, or lead to, acute urinary retention. Patients who are systemically unwell should be referred urgently to secondary care for intravenous antibiotics and further investigation, as should those failing to respond appropriately or deteriorating on review after 48 hours. Chronic bacterial prostatitis is characterised by symptoms that last for more than three months. 

Nocturia can be a symptom of an underlying disease process or behavioural. The history should not just focus on lower urinary tract symptoms but should also include past medical history, current medications and fluid intake. It is important to ask specifically about the onset and progression of symptoms, and to what extent the patient is troubled by the nocturia. An abdominal examination should always be performed and should exclude urinary retention. A digital rectal examination of the prostate should also be offered.

Prostate cancer is the most common cancer in men in the UK. Men have a 1 in 8 lifetime risk of being diagnosed with the disease. Factors associated with an increased risk of prostate cancer include: age > 50 years, black ethnicity, a first-degree relative with prostate cancer, and obesity. Patients may present with erectile dysfunction or lower urinary tract symptoms such as frequency, hesitancy, nocturia, or haematuria.

Urinary retention is the most common urological emergency and more than 95% of cases occur in men. Acute urinary retention (AUR) is defined as the sudden inability to pass any urine voluntarily associated with a painful, palpable or percussable bladder. In chronic urinary retention (CUR) there is a non‐painful bladder, which remains palpable or percussable after the man has passed urine, with a post-void residual volume > 300 ml. In acute on chronic urinary retention no urine can be voluntarily passed but the condition is relatively painless and the residual volume on catheterisation is > 1.5 litres.

Although the incidence of testicular cancer has increased over the past few decades, testicular tumours are still rare and many GPs will only see one or two new diagnoses in their career. When examining scrotal swellings, the key question is whether the lump is intra- or extra-testicular, as palpable intra-testicular lesions are highly likely (around 90%) to be malignant, whereas those lying outside the testis are usually benign.

Androgens play a crucial role in bone, muscle and fat metabolism, erythropoiesis and cognitive health. In men aged 40-79 years the incidence of biochemical deficiency and symptomatic hypogonadism is 2.1-5.7%. Decreased libido or reduced frequency and quality of erections, fatigue, irritability, infertility or a diminished feeling of wellbeing may be presenting complaints. However, a significant proportion of men with androgen deficiency will be identified when they present for unrelated concerns.

Up to 90% of men aged 50 to 80 may suffer from troublesome lower urinary tract symptoms (LUTS). A thorough urological history is essential to inform management. It is important to determine whether men have storage or voiding LUTS or both. Based on history, examination and investigation findings an individualised management plan should be formulated.

The prostate specific antigen (PSA) test clearly provides the opportunity for clinically relevant prostate cancer to be detected at a stage when treatment options are greater and outcomes may be improved. In addition, a raised PSA may often indicate benign prostatic enlargement, and this may provide an opportunity for treatment of this condition before complications develop. However, in some patients the PSA test may lead to investigations which can identify clinically insignificant cancers which would not have become evident in a man’s lifetime.

Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis. Clinical assessment includes a thorough history and examination. A digital rectal examination should be performed after a midstream urine sample has been collected for urine dipstick, microscopy and culture. The prostate should be checked for nodules.

Advanced prostate cancer remains an incurable and lethal disease. Innovation continues to provide new hope for patients with advanced disease, with improved survival while maintaining quality of life. As patients live longer with increasing treatment options, education of all healthcare professionals involved in their care is crucial in ensuring holistic care for this complex disease.

A suspicion of a diagnosis of prostate cancer is usually based on either induration or nodularity of the prostate on digital rectal examination or, more commonly, a rise in serum prostate specific antigen (PSA) level. The usual cut-off point for PSA is taken as 4 ng/ml, but in men below 65 a value of more than 2.5 ng/ml should raise suspicion. The Gleason grading of any cancer identified is an important part of the decision-making process concerning the need for active treatment, as opposed to surveillance alone. Gleason pattern 6 cancers are regarded as low risk, Gleason 7 intermediate risk and 8-10 high risk. [With external links to the current evidence base]

Testicular cancer accounts for 1% of all malignancies in males. However, it is the most frequently occurring solid tumour in men between the ages of 15 and 34 years. Testicular tumours have excellent cure rates, even in those with metastases, as they are extremely sensitive to chemotherapy and radiotherapy. Early diagnosis is, however, very important as treatment is more successful and less intensive, and long-term health consequences can be minimised. [With external links to current evidence and summaries]

Epididymitis and orchitis normally co-exist with isolated epididymitis being more common than an isolated orchitis. Sexually transmitted infection is the most common cause in younger men and urinary tract pathogens are the more common culprits in older men. The most common pathogens in the under 35s are N. gonorrhoeae and C. trachomatis and E. coli is the most common cause of acute epididymitis in the over 35s. Acute testicular torsion is the most important differential diagnosis of acute testicular pain especially in younger men. If there is any suspicion of testicular torsion, the patient should be referred to secondary care immediately as surgery is required within four to six hours.

Prostate cancer is the most common cancer in men in the UK. It accounts for nearly a quarter of all male cancer diagnoses and is the second most common cause of male cancer death. Most patients present with localised disease, but there are still many who present with metastatic disease. Medical castration using LHRH analogues has become the gold standard in managing both locally advanced prostate cancer, in combination with radiotherapy, and metastatic disease. Eventually most men with advanced prostate cancer become resistant to androgen deprivation therapy. This is called castrate refractory prostate cancer, and is associated with a poor prognosis. There is now hope for patients who progress after chemotherapy with the emergence of several new agents that have been shown to benefit patients. [With external links to the current evidence base]

GPs are playing an increasing role in managing both prostate cancer and benign prostatic hyperplasia (BPH). More than 70% of men over 70 years are affected by BPH, and prostate cancer is the most common cancer in men in the UK. GPs play an important part in the initial management of men presenting with lower urinary tract symptoms and in addressing concerns regarding prostate cancer and the significance of the patient’s symptoms. While there is no proven causal link between prostate cancer and BPH, associations have been found. BPH may increase the chance of an incidental prostate cancer being diagnosed through PSA testing and other investigations.  [With external links to current evidence and summaries]

Varicocoele is present in 15% of men. Patients suspected of having underlying malignant pathology or with significant discomfort from a large varicocoele should be referred for specialist review. The data regarding the relationship between the condition and infertility is inconclusive. NICE does not recommend surgical treatment of varicocoele for infertility. Patients or couples with infertility should be referred to a urologist with a specialist interest in fertility and an expert in assisted reproduction techniques, ideally to be seen in a joint clinic.

Benign prostatic hyperplasia (BPH) is one of the most common diseases to affect older men.Histological (microscopic) BPH, which is characterised by both stromal and glandular hyperplasia, is present in more than 60% of men beyond their sixties. More than 40% of men in this age group have lower urinary tract symptoms (LUTS) and about half this group have impaired quality of life. The prevalence increases with age, and the overall number of patients affected is rising worldwide as populations age. At current intervention rates, about one-fifth of patients with symptomatic disease who present to a doctor will eventually be treated surgically, although this may be falling. The remainder will often be managed initially by watchful waiting. However, the majority of these individuals suffer gradual progression of symptoms and the bother associated with them, and increasingly require treatment either with medication or surgery. [With external links to the evidence base]

Acute urinary retention (AUR) is a common urological emergency. AUR is more than ten times more common in men than women. AUR in men tends to occur in the elderly and the risk of AUR is higher in men > 70 years. Those in this age group have a 10% risk of developing AUR over a five-year period. The incidence of AUR is low in the general male population of 45 years or older.  However, in almost 50% of AUR patients with benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS), AUR was their first symptom. GPs can play a major role in identifying patients who need assessment for BPH/LUTS and starting early treatment with pharmacotherapy. Health education should address the importance of compliance with medication and patients should be followed up to reduce the risk of AUR and surgical intervention. Urological intervention may only be required in cases where specialised assessment or treatment is needed and in patients where catheter insertion has failed during an episode of AUR.

GPs are increasingly becoming involved in the care of patients with prostate cancer. Prostate cancer is currently diagnosed in more than 34,000 men every year. It claims more than 10,000 lives per annum in the UK, and many more than that internationally. Men dying from advanced disease often suffer intractable bone pain and debilitating lower urinary tract symptoms which have a considerable impact on their quality of life. In the absence of a breakthrough [ time of writing 2010] in the treatment of metastatic disease, earlier diagnosis and more effective eradication of clinically significant disease currently seem to afford the best opportunity of stemming the tide.  [With external links to current evidence and summaries]

Urology practice includes large numbers of ageing men presenting with urinary symptoms, haematuria, urogenital cancer and sexual dysfunction. As with women, hormonal changes in men may be associated with significant health-related problems. Often symptoms are misleading in older patients and may be related to different pathology. [ With external links to the evidence base]

Prostate cancer is the most common cancer in men. More than 35,000 new cases are diagnosed annually and almost 10,000 men die each year in the UK from this disease.  Now an increasing majority of patients present with an isolated increase in prostate specific antigen (PSA). In the USA, where PSA testing is widely adopted, the death rate from prostate cancer is falling four times faster than in the UK. [With external links to the evidence base]

Finding an unusual lump in the scrotum or testicle can be very distressing for patients. Although less than 5% of testicular lumps are cancerous a systematic approach needs to be undertaken in all cases to rule out malignancy. Testicular lumps require careful clinical assessment and may need further investigations such as ultrasound. [With external links to the evidence]

Erectile dysfunction (ED) is a common condition defined by the inability to achieve and sustain an erection adequate for sexual intercourse. Population studies estimate a prevalence of between 32% and 52% for all grades of ED.^1,2 ED is more common as age increases, and one study found the prevalence of complete ED to triple, from 5% to 15%, between the ages of 40 and 70.² there is increasing evidence to support a vascular aetiology. ED and cardiovascular disease (CVD) share common risk factors. So modifying risk factors for CVD may lead to an improvement in erectile function. Early identification of ED may also provide a window of opportunity in which clinicians can take preventative measures against the development of CVD. There is increasing evidence to support a vascular aetiology. ED and cardiovascular disease (CVD) share common risk factors. So modifying risk factors for CVD may lead to an improvement in erectile function. Early identification of ED may also provide a window of opportunity in which clinicians can take preventative measures against the development of CVD. [ With external links to the evidence base]

Men are at an increased risk of premature mortality across all major disease areas. There are three possible explanations:• Men are biologically more vulnerable than women; • Men's lifestyles (such as higher rates of smoking and alcohol intake) create more life-limiting disease • Men are more reluctant or unable to seek early medical attention. It appears that the health of men, in particular the ways in which men may be uniquely at risk, is still failing to receive adequate attention. [With external links to the evidence base]

Benign prostatic hyperplasia (BPH) is the most common condition to affect older men. Almost half of all men older than 65 years have lower urinary tract symptoms (LUTS), consisting of poor flow and frequency of micturition, which may have a severely negative impact on quality of life. As BPH is generally a disorder of older men, it is frequently associated with comorbid conditions such as erectile dysfunction, hypertension and prostate cancer. These need to be identified and taken into account at the time of diagnosis, as their presence may impact on treatment strategies.The main risk factors for BPH are age, family history and possibly obesity.[With external links to the evidence base]

Scrotal pain has a variety of causes, which can lead to considerable morbidity and mortality if left undiagnosed. It is important to establish the aetiology to ensure appropriate investigation and management. Causes of acute scrotal pain have been identified by various retrospective reviews in children: in a review of 238 cases, 16 per cent were caused by testicular torsion, 46 per cent by torsion of the testicular appendage and 35 per cent by epididymitis. Given the proportion of patients who have testicular torsion, early assessment of scrotal pain is critical. [With links to the evidence base]

Around one in four couples will see their gp about infertility problems. Large epidemiological studies show that failure or difficulty in conceiving a child is a surprisingly common, worldwide problem with between one in six and one in seven couples classed as sub-fertile. Sperm dysfunction is the most common cause of infertility and affects one in fifteen men. Studies using semen assessment as the criteria for sub-fertility show that up to one in five 18-year-olds are classed as sub-fertile. Recent reports suggest that the incidence of male infertility is increasing. [With links to the evidence base]

A single prostate specific antigen (PSA) measurement is of limited use in differentiating between prostate cancer and BPH, unless it is significantly elevated. When the most frequently used PSA cut-off point of 4.0 ng/ml is employed, a significant number of patients with BPH are identified as false positives for prostate cancer. Men with a PSA of between 4.0 and 10.0 ng/ml have around a 20 per cent chance of having prostate cancer; in those with a PSA of >10.0 ng/ml, the chance of a positive biopsy is 62 per cent. However, the recent Prostate Cancer Prevention Trial (PCPT) demonstrated that 17 per cent of men who were identified with prostate cancer in fact had a PSA value below 4.0 ng/ml, and some patients had a value below 2.5 ng/ml. Annual measurement of PSA may improve accurate diagnosis, but is also controversial. [With external links to the evidence base]