![Page 1: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/1.jpg)
Men Presenting withHealth Problems
Dr Nick Pendleton
![Page 2: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/2.jpg)
![Page 3: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/3.jpg)
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.
![Page 4: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/4.jpg)
Mr Barlow, 49
• It’s my left knee, I can hardly walk!
![Page 6: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/6.jpg)
Mo, 28
“I’ve noticed a lump on one of my testicles…
![Page 7: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/7.jpg)
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
![Page 9: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/9.jpg)
Stanley, 17
![Page 10: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/10.jpg)
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.
![Page 11: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/11.jpg)
Peter, 25
• I’ve had blood in my semen!
![Page 12: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/12.jpg)
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
![Page 13: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/13.jpg)
Raj, 39
![Page 14: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/14.jpg)
Roger, 32
“I keep needing to go to the loo
every 15 minutes and in the night as well!”
![Page 15: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/15.jpg)
Mr Parker, 62
“I keep needing to go to the loo every 15 minutes and in the night as well!”
![Page 16: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/16.jpg)
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
![Page 17: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/17.jpg)
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.
![Page 18: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/18.jpg)
PSA and Rectal Examination
• http://www.ncbi.nlm.nih.gov/pubmed/1377290PSA test counselling
![Page 19: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/19.jpg)
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)
![Page 20: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/20.jpg)
Brian, 31
“Sometimes I can’t get an
erection and it’s starting to bother my wife”
![Page 21: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/21.jpg)
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.
![Page 22: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/22.jpg)
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)
![Page 23: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/23.jpg)
Sildenafil Citrate (Viagra)
• Sildenafil is now available as an NHS prescription
![Page 24: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/24.jpg)
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
![Page 25: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/25.jpg)
Daniel Hoffman 49
I’ve come for my results. My mouth was sore – she took a sample
![Page 26: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/26.jpg)
![Page 27: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/27.jpg)
Swab result – Candida isolated
• What is the significance of the result?
• What is the differential diagnosis?
• Any other questions to ask?• Further tests?
![Page 28: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/28.jpg)
Sohail, 25
“I can get an erection, but sex is over in about 2 minutes!”
![Page 29: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/29.jpg)
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.
![Page 30: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/30.jpg)
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.
![Page 31: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/31.jpg)
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
![Page 32: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/32.jpg)
PE – therapy options
• Couples therapy• Squeeze technique• Medication: SSRIs – paroxetine,
fluoxetine, sertraline• Dapoxetine (PRILIGY) – new.
Short acting SSRI. 1h before sex
![Page 33: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/33.jpg)
Danny 14
Attends with mum:
‘He’s got a lump under his nipple’
![Page 34: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/34.jpg)
Danny 14
Pubertal gynaecomastia
Patient Information Leaflet:https://www.bsped.org.uk/patients/docs/GYNAECOMASTIA_TR_VERSION.pdf
![Page 35: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/35.jpg)
Patrick, 31
‘I think I’ve got blood in my urine!’
![Page 36: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/36.jpg)
HAEMATURIA
Common:• UTI• Bladder tumour• Renal/ureteric stones• Urethritis• BPH, prostate Ca
![Page 37: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/37.jpg)
HAEMATURIA
Occasional:• Jogging/hard exercise• Renal cancer• Chronic interstitial cystitis• Anticoagulant therapy• Nephritis/glomerulonephritis
![Page 38: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/38.jpg)
HAEMATURIA
Rare:• Renal TB• Polycystic Kidney Disease• Blood dyscrasias eg thrombocytopenia,
haemphilia, sickle cell• Infective Endocarditis• Schistosomiasis (common abroad• Trauma
Symptom Sorter – Hopcroft & Forte
![Page 39: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/39.jpg)
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
![Page 40: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/40.jpg)
Patrick, 31
‘I think I’ve got blood in my urine!’
![Page 41: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/41.jpg)
Mr Odeyo, 46
Clip No. 1
‘A Request for Slimming Pills’
![Page 42: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/42.jpg)
CSA
Marked in 3 areas:
1. Data Gathering, Technical and Clinical Assessment skills
2. Clinical Management skills
3. Interpersonal skills
![Page 43: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/43.jpg)
Tom 19, University Student
• I’ve got some spots on my penis can you have a look?
![Page 44: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/44.jpg)
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
•
![Page 45: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/45.jpg)
Penis Anxiety
• Distorted views about normality and importance of penis size, affecting self-confidence and causing fear about sexual relationships
• Counselling/psychological therapies
![Page 46: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/46.jpg)
Jake, 15
• Attended with Mum – Can you do anything about his feet – the smell is disgusting – its not normal
![Page 51: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/51.jpg)
Tim 37, Teacher
• I’ve come to arrange a vasectomy
• more than 99% effective. 1 pregnancy per 2000 vasectomised men/lifetime
![Page 52: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/52.jpg)
Reversal
• 55% success within 10 years
• 25% greater than 10 years
• Rarely available on NHS
![Page 53: Men Presenting with Health Problems Dr Nick Pendleton](https://reader030.vdocument.in/reader030/viewer/2022032701/56649c895503460f949418c6/html5/thumbnails/53.jpg)
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