Men Presenting with Health Problems Dr Nick Pendleton

About this presentation: The scenarios in this slide presention are based wholly or partly on real patients who have presented to GP surgeries. They have been anonymised for use as a teaching tool for GPs in Training. For realism the patients have been given fictional names, ages and professions.

It’s my left knee, I can hardly walk! Mr Barlow, 49 It’s my left knee, I can hardly walk!

Mo, 28 “I’ve noticed a lump on one of my testicles…

Painless lump, dull ache, heaviness Testicular Cancer Painless lump, dull ache, heaviness Ages 15- 44 1% of all male cancers FH and undescended testes Seminomas 40%, Teratomas 60% Respond well to Chemotherapy 95% cured if identified early

Stanley, 17

Stanley, 17

ACNE GRADING Grade 1 (mild) – acne is mostly confined to whiteheads and blackheads with just a few papules and pustules. Grade 2 (moderate) – there are multiple papules and pustules which are mostly confined to the face. Grade 3 (moderately severe) – there is a large number of papules and pustules as well as the occasional inflamed nodule. The back and the chest are also affected by acne. Grade 4 (severe) – there is a large number of large painful pustules and nodules.

I’ve had blood in my semen! Peter, 25 I’ve had blood in my semen!

Haematospermia UTI Prostate Cancer if > 40 (NICE CKS) Testicular Cancer BPH Prostatitis Trauma or instrumentation STI Bleeding disorder 3 or more episodes if no identifiable cause needs investigation. If age < 40 sinister cause very unlikely if less than 3 episodes

Raj, 39

Roger, 32 “I keep needing to go to the loo every 15 minutes and in the night as well!”

Mr Parker, 62 “I keep needing to go to the loo every 15 minutes and in the night as well!”

PSA is a type of enzyme secreted by the prostate gland It liquefies semen and allows the sperm to swim freely It becomes elevated in prostate cancer

PSA PSA test counselling PSA has a high rate of false positive results with only 30 percent of patients who have high PSA level are prostate cancer positive after biopsy. Other causes of raised PSA? PSA is mildly raised in 30-50% of men with BPH. Higher levels increase likelihood of Ca PSA is normal in 20% of cases of prostatic cancer.

PSA and Rectal Examination http://www.ncbi.nlm.nih.gov/pubmed/1377290PSA test counselling 

Mr Parker, 62 “I keep needing to go to the loo every 15 minutes and in the night as well!” PSA 5.6 (age 60 to 69 normal <4)

Brian, 31 “Sometimes I can’t get an erection and it’s starting to bother my wife”

Possible causes of erectile dysfunction Vasculogenic — such as cardiovascular disease, hypertension, hyperlipidaemia, diabetes mellitus, smoking. Neurogenic — such as multiple sclerosis, Parkinson’s disease, tumours, stroke. Anatomical — such as Peyronie’s disease, hypospadias. Hormonal — such as hypogonadism, hyperthyroidism, hypothyroidism, Cushing’s disease. Drugs — such as diuretics, antihypertensives, antidepressants, cytotoxics, alcohol. Psychosocial — relationship problems, mental health problems.

Sildenafil Citrate (Viagra) Acts by inhibiting cGMP-specific phosphodiesterase type 5 (PDE5) PDE5: an enzyme promoting degradation of cGMP, which regulates blood flow in the penis Tadalafil (Cialis) Levitra (Vardenafil)

Sildenafil Citrate (Viagra) Sildenafil is now available as an NHS prescription

SLS (Selected List Scheme) DM, MS, PD, Polio, Prostate Ca. severe pelvis injury, genetic neurological disease, spina bifida, spinal cord injury On dialysis for renal failure Radical pelvic surgery or prostatectomy, renal transplant Were getting them free or similar before 1998 Severe distress – only by a specialist

Daniel Hoffman 49 I’ve come for my results. My mouth was sore – she took a sample

Swab result – Candida isolated What is the significance of the result? What is the differential diagnosis? Any other questions to ask? Further tests?

Sohail, 25 “I can get an erection, but sex is over in about 2 minutes!”

Premature Ejaculation (PE) Many men are unsure about how long ‘normal’ sex should last before ejaculation. A study looking at 500 couples from five different countries found the average time between penetration and ejaculation was around five-and-a-half minutes.

Premature Ejaculation (PE) However, it is up to the individual and his partner to decide whether or not they are happy with the time it takes for him to ejaculate. Regularly ejaculating before or within one minute of penetration would usually be regarded as a medical problem that requires treatment.

PE self help Masturbating an hour or two before having sex Using a thick condom to help decrease sensation Taking a deep breath to briefly shut down the ejaculatory reflex (an automatic reflex of the body during which ejaculation occurs) Having sex with your partner on top (to allow them to pull away when you are close to ejaculating) Taking breaks during sex and thinking about something boring

Medication: SSRIs – paroxetine, fluoxetine, sertraline PE – therapy options Couples therapy Squeeze technique Medication: SSRIs – paroxetine, fluoxetine, sertraline Dapoxetine (PRILIGY) – new. Short acting SSRI. 1h before sex

Attends with mum: ‘He’s got a lump under his nipple’ Danny 14 Attends with mum: ‘He’s got a lump under his nipple’

Pubertal gynaecomastia Danny 14 Pubertal gynaecomastia Patient Information Leaflet: https://www.bsped.org.uk/patients/docs/GYNAECOMASTIA_TR_VERSION.pdf

‘I think I’ve got blood in my urine!’ Patrick, 31 ‘I think I’ve got blood in my urine!’

Renal/ureteric stones Urethritis BPH, prostate Ca HAEMATURIA Common: UTI Bladder tumour Renal/ureteric stones Urethritis BPH, prostate Ca

Jogging/hard exercise Renal cancer Chronic interstitial cystitis HAEMATURIA Occasional: Jogging/hard exercise Renal cancer Chronic interstitial cystitis Anticoagulant therapy Nephritis/glomerulonephritis

HAEMATURIA Rare: Renal TB Polycystic Kidney Disease Blood dyscrasias eg thrombocytopenia, haemphilia, sickle cell Infective Endocarditis Schistosomiasis (common abroad Trauma Symptom Sorter – Hopcroft & Forte

HAEMATURIA MANAGEMENT Painless microscopic (male or female) - refer urgently Macroscopic and no infection - refer urgently All adults > 40 years old with persistent UTI and haematuria – refer urgently <50 and with proteinuria & raised creatinine – renal referral

‘I think I’ve got blood in my urine!’ Patrick, 31 ‘I think I’ve got blood in my urine!’

Mr Odeyo, 46 Clip No. 1 ‘A Request for Slimming Pills’

CSA Marked in 3 areas: Data Gathering, Technical and Clinical Assessment skills Clinical Management skills Interpersonal skills

Tom 19, University Student I’ve got some spots on my penis can you have a look?

Tom 19, University Student Does it look OK to you…Size wise? Average 14-16cm (5.5-6.3 inches) when erect Average girth for an erect penis is 12-13cm (4.7-5.1 inches) A penis would only be considered unusually small if it was less than 3 inches (7.6cm) long when erect

Penis Anxiety Distorted views about normality and importance of penis size, affecting self-confidence and causing fear about sexual relationships Counselling/psychological therapies

Jake, 15 Attended with Mum – Can you do anything about his feet – the smell is disgusting – its not normal

Jake, 15

Jake, 15

Jake, 15

Pitted Keratolysis

I’ve come to arrange a vasectomy Tim 37, Teacher I’ve come to arrange a vasectomy more than 99% effective. 1 pregnancy per 2000 vasectomised men/lifetime

Reversal 55% success within 10 years 25% greater than 10 years Rarely available on NHS

Mens Health Gout, testicular lumps Acne, haematospermia Male pattern baldness Urinary frequency – young/older ED, oral thrush, PE Pubertal gynaecomastia Haematuria, fordyce spots, penis size/anxiety. DVD consultation about weight Pitted keratolysis, Vasectomy