No abstract

Testicular pain can be a particularly challenging problem to manage in primary care, with potential pitfalls for the unwary. The most important acute diagnosis to consider is testicular torsion, as ischaemia, infarction and subsequent loss of function can occur within a few hours of onset. This article considers a range of different conditions that may present with testicular pain, sometimes with other accompanying symptoms. An accurate history is important in assessing testicular pain, and GPs should be aware of the perceived embarrassing nature of testicular symptoms. Examination skills are essential when considering the different causes of testicular pain. This article describes how to assess patients presenting with testicular pain in primary care, the different conditions causing testicular pain and when to refer to secondary care.

Introduction: The aim of this study was to create a model based upon significant prognostic factors to guide patient selection for shockwave lithotripsy. Patients and methods: We identified 150 patients attending for shockwave lithotripsy for ureteric stones between October 2010–February 2016. Data was collected retrospectively from electronic case notes and radiological images. All patients were treated with an on-site Storz Modulith SLX-F2 lithotripter. A model was created using computer software ‘R’. Results: One hundred and thirty-three patients were treated and 66% of those were deemed radiologically stone-free with shockwave lithotripsy. Four factors were found to be independently statistically significant with regards to stone-free status; age ( p=0.003), Hounsfield units ( p=0.002), prior nephrostomy insertion ( p=0.022) or prior stent insertion ( p=0.002). Our resulting model is:[Formula: see text] Discussion and conclusions: Our shockwave lithotripsy success would likely increase with improved patient selection. Age appears to be a novel significant factor in stone passage. This is an interesting observation worthy of further study given ageing populations in the developed world. The model will require further validation in order to confirm our findings, however the results have proven very encouraging. Level of evidence: 2c

Renal cell carcinoma encompasses a range of histological subtypes. The treatment of metastatic disease in this context remains challenging. Papillary renal cell carcinoma is the second most common subtype and forms a significant subsection of non-clear cell renal cell carcinoma. Tyrosine kinase inhibitors form a significant part of the treatment of this largely incurable disease; however, outcomes tend to be poor. The aim of this article is to scrutinise whether these treatments are evidence-based in their use for metastatic papillary renal cell carcinoma and if good outcomes are reported. A literature review was made using PubMed of major prospective and retrospective studies. The European Association of Urology and European Society of Medical Oncology have both published guidance suggesting sunitinib should be offered first line in the treatment of metastatic papillary renal cell carcinoma. This, however, is based upon weak evidence produced by the ASPEN trial, although this did not discriminate between non-clear cell subtypes and results in further studies were modest. The National Institute for Care and Health Excellence has recently published new guidelines for the use of cabozantinib, which has shown evidence of improved progression-free survival and overall response rates compared with sunitinib. Unfortunately, many of the relevant studies did not specifically assess these treatments in patients solely with papillary renal cell carcinoma and had modest overall success. There is weak evidence that tyrosine kinase inhibitors give significant benefit in those patients with metastatic papillary renal cell carcinoma. Level of evidence: 2a