South Birmingham VTS 24/3/16 Men’s Health South Birmingham VTS 24/3/16

Why Men’s Health?

Why men’s health? Gender specific health problems Hard to reach group Men on average die 5-7 years younger than women ‘Higher’ risk with some problems: eg. IHD and death by suicide. Urology hospital jobs not commonly part of VTS. Patient and doctor gender bias?

Carousel Case 1

CASE 1   Doctor: Mr. Smith is a 52 yr. old man who last saw the practice nurse for a hypertension review 2 months ago. He is relatively fit and well and doesn’t often come to see his GP. He last saw his GP, 2 years ago for a short period off work with ‘stress related problems’ following a divorce. He smokes 10 per day. Medication: Atenolol 50mg daily Bendroflumethazide 2.5mg daily Last blood tests were 2 years ago: Chol: 5.8, HDL 0.7 U+E’s normal Last examination 2 months ago was: BP: 140/84 mmHg, BMI 34 You have no idea why he may be coming to see you today.

Patient:   You are Mr. Smith aged 52yr. You work as a busy publican. You smoke 10 a day and drink ‘quite a lot’ – in excess of 50 units a week. Your rarely see your GP but do come twice a years to have your BP checked with the nurse. You saw her 2 months ago and were told ‘all is ok’. You take two tablets most days for your BP but cannot remember the name of them exactly if asked. Two years ago you went through a rather messy divorce with your then wife and had 6 weeks off work with ‘stress’. That is all behind you now and things are going ok again. More recently you have met another lady (Claire). She is in her late 40’s and you have hit it off. You have been seeing each other for 3-4 months and have now just taken things ‘to the next stage’. Before you divorced things in your relationship had been wrong for some time so sex had not been happening for at least 1-2 years prior to the eventual break up. Sex before that was often all over in 2-3 minutes. Your morning erections had become less frequent too.

Now you have a new girlfriend and you have ‘under performed’ Now you have a new girlfriend and you have ‘under performed’. The first time you ‘got together’ you struggled to get an erection. You felt a bit guilty about having sex with ‘another woman’, even though you have been divorced for 2-3 years. You had to apologise to Claire when nothing happened. She was sweet about things and told you ‘not to worry, maybe next time’. You tried two weeks later and were able to get an erection this time but weren’t able to maintain it for long, because you ejaculated after about 90 seconds. Again you felt bad and apologized to Claire. She was very understanding again. You are worried about what to do now and so have come to see your GP.   As a ‘blokey bloke’ you are a bit embarrassed about the whole thing. You’ve heard about Viagra and just want a script and to get out of the door. BE EVASIVE if the Dr ‘pries’ into your sex life. Only if he is patient and makes you feel comfortable will you open up about exactly what happened during your first two ‘disastrous’ sexual encounters with Claire. Examination findings: normal genitalia, no fibrosis of shaft, normal sized testes. BP 140/90 mmHg.

Case 1 – key points What is the diagnosis? What are the key parts of the history that help? Is examination of the patient necessary? What further information might you want? What are the management options? When would you like to review this man?

Case 1 : Diagnosis Psychological: performance anxiety / depression? Erectile dysfunction? Premature ejaculation? Cardio vascular disease? ‘Brewer’s Droop’? Iatrogenic?

Is examination necessary? YES – look for causes ED : Cardiovascular disease Phimosis Tight frenulum Shaft fibrosis Hypogonadism Prostate ?

Further information Repeat bloods : last ones were 2 yrs ago: Lipids Glucose / HbA1c 8-11am Testosterone levels

Management Psychological: time, reassurance, antidepressants, counseling, sex therapy. Premature ejaculation: practice, breathing techniques, L.A. in condoms, ?paroxetine CVD: diet, lifestyle, BP, diabetes, cholesterol meds Brewers Droop: timing and and amount of alcohol Iatrogenic: change atenolol and BFZ Hypogonadism : testosterone supplement

Management of ED PDE5 inhibitor : sildenafil, vardenafil, tadalafil Vacuum erection devices Intracavernous injection therapy Intraurethral alprostadil : MUSE Topical alprostadil + skin penetration enhancer Surgery: Penile prosthesis, Peyronie’s disease op.

CASE 2 Doctor: Steven Jones is a 17 yr. old lad who you last saw with acne 3 years ago. He almost never comes to see his GP. He has no significant past medical history of note. You have no idea why he is coming today.

Patient: You are Steven Jones a 17yr lad who rarely sees his doctor. The last time you went to see your GP it was with acne as a young teenager. You smoke 10 a day. You have a girlfriend (Stacey) who you have been sexually active with for the last 3 months. One day during while ‘messing around’ in her bedroom, you felt a slight discomfort in your testicle. You didn’t say anything to her, but later that evening to your horror you found a lump in your scrotum. You are worried it might be cancer. You did nothing for a week and the discomfort has gone. Then you got scared when the lump remained, and decided to see you GP. You are convinced you at least need scan, and will push the GP for this today. If asked to describe the lump you will be a bit vague, it was ‘kind of on the left side’. You are unsure if it was attached to or separate to the testicle. It’s now painless, not hot nor red. You have no urinary symptoms, or penile discharge. You always use condoms during sex, but have never been screen for STDs before if asked. You’ve not noticed the lump before this, but then you didn’t really check yourself either. If the GP asks to examine say ‘ok’, but you are a bit embarrassed, and ask them exactly what the examination will entail, and get the GP to explain it to you. Examination findings: Both testes are smooth and non-tender, there is a soft irregular mass adjacent to the left test, a bit like a bag of worms; which also is non-tender. There is nil else abnormal in the scrotum.

Case 2 What’s the diagnosis? What’s the differential diagnoses? What needs to be done next? What is the management?

Testicular examination Examine standing first Examine lying down Inspect, palpate, transilluminate, cough Check patient is able to do it for himself.

Diagnosing testicular lumps Where is it? What does it feel like? Attached or separate to the testicle? Can you get above it? Does it transilluminate? Hot, red or tender?

Testicular lumps Normal findings : testes, epididymis, vas deferens Abnormal findings: Scrotal cyst Testicular cancer Varicocoele Hydrocoele Cyst of the epididymis or cord Hernias Infections

Testicular cancer Germ cell tumours: 95% Seminoma 40 - 45 % Non-seminoma: 40 - 45% Leydig Cell tumours: 1-3% Sertoli Cell Tumours: 1-3% Lymphoma : 4% Teratoma: 1%

Testicular cancer risk factors Cryptorchidism Family History or Previous ca. testis Caucasian: African Caribbean ratio 5:1 Age : 15-45yr ( Peak 35-40yr) Infertility (x3) Smoking HIV / AIDS Height : 6’1’’ or taller

Testicular Cancer Investigation Ultrasound scan CT scan Bloods: AFP, HCG, LDH Biopsy

Testicular Cancer Staging Tumour size, Nodes, Metastases Stage 1 : in the scrotum Stage 2: LN spread in abdomen and pelvis Stage 3: LN upper chest Stage 4: tumour in other organs eg. lungs

Treatment Chemotherapy Radiotherapy Orchidectomy Lymph node dissection If bilateral surgery required: Sperm banking Testosterone replacement

Take home message: get them checking!