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.
Mr Barlow, 49
• It’s my left knee, I can hardly
walk!
Mo, 28
“I’ve noticed a lump on
one of my testicles…
Testicular Cancer
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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.
Peter, 25
• I’ve had blood in my semen!
Haematospermia
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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
• 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/13772
90PSA 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-anda-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
PE – therapy options
• Couples therapy
• Squeeze technique
• Medication: SSRIs – paroxetine,
fluoxetine, sertraline
• Dapoxetine (PRILIGY) – new.
Short acting SSRI. 1h before sex
Danny 14
Attends with mum:
‘He’s got a lump under his
nipple’
Danny 14
Pubertal gynaecomastia
Patient Information Leaflet:
https://www.bsped.org.uk/patients/docs/G
YNAECOMASTIA_TR_VERSION.pdf
Patrick, 31
‘I think I’ve got blood in my
urine!’
HAEMATURIA
Common:
• UTI
• Bladder tumour
• Renal/ureteric stones
• Urethritis
• BPH, prostate Ca
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
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:
1.
Data Gathering, Technical and Clinical
Assessment skills
2.
Clinical Management skills
3.
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
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Distorted views about normality and
importance of penis size, affecting
self-confidence and causing fear
about sexual relationships
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Counselling/psychological therapies
Jake, 15
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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
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
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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