1. Men Presenting with Health Problems
Dr Nick Pendleton

3. 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.

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

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

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

8. Stanley, 17

9. Stanley, 17

10. 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.

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

12. 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

13. Raj, 39

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

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

16. 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

17. 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.

18. PSA and Rectal Examination
test counselling 

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

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

21. 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.

22. 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)

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

24. 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

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

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

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

29. 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.

30. 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.

31. 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

32. 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

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

34. Pubertal gynaecomastia
Danny 14
Pubertal gynaecomastia
Patient Information Leaflet:

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

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

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

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

39. 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

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

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

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

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

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

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

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

47. Jake, 15

48. Jake, 15

49. Jake, 15

50. Pitted Keratolysis

51. 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

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

53. 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