men presenting with health problems dr nick pendleton
TRANSCRIPT
Men Presenting withHealth 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
• 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
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• 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/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
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/GYNAECOMASTIA_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
• 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
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