Prospective analysis of scrotal pathology referrals - are referrals appropriate and accurate?

Testicular cancer is a relatively uncommon, treatable condition. A general practitioner would expect to see, on average, one case of testicular cancer in the whole of their career. Benign scrotal conditions are extremely common and the source of many primary care consultations. The main patient expectations of these attendances are accurate diagnosis and adequate re-assurance as often they are the source of much anxiety and perceived embarrassment. The aim of this study was to examine the content and referral practice of primary care referral of testicular pathology and the resultant findings of the specialist practitioner.

A total of 201 patients referred with scrotal pathology were prospectively analysed at the time of specialist practitioner assessment by means of data recording in a urological surgery unit and regional peripheral community clinics.

In the study group, 53 patients were referred under the 2-week rule. Of these, 9 (17%) were found to have testicular cancer. Five (36%) cancers were referred outside the 2-week rule referrals; 1 cancer was missed and 2 diagnoses delayed. In total, 44% of final clinical diagnoses differed between the referring primary care physician and the specialist practitioner. Of the 71 (35%) patients referred with a suspicion of cancer, 62 (87%) were subsequently found to be of clinically benign pathology. Overall, 80% of patients were referred more urgently than the opinion of the specialist practitioner.

Scrotal examination in the primary care setting appears to be of variable accuracy. Many patients referred with a high suspicion of cancer are found to have benign pathology. Two-week rule referrals have an acceptable positive predictive value for testicular cancer (17%). Disagreements exist in the referral priority of patients.