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Mens HEALTH. Alex and Chris Sept 2011. Objectives. To examine men’s attitude to their health To further develop understanding of how men approach and use healthcare To understand that opportunistic consultation techniques are useful to explore male health issues

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  1. Mens HEALTH Alex and Chris Sept 2011

  2. Objectives • To examine men’s attitude to their health • To further develop understanding of how men approach and use healthcare • To understand that opportunistic consultation techniques are useful to explore male health issues • To revise medical conditions that may effect men • To revise basic treatment of these conditions • To cement understanding by case histories

  3. Today's Content • Male attitudes to health + access to healthcare • Alcohol, smoking, drugs & mental illness in men • Prostate problems and management • Testicular lumps + bumps and management • Erectile dysfunction and management • Other urological conditions applicable to GP

  4. Male attitudes to health/healthcare • In the developed world men suffer more severe medical complaints, consistently have higher death rates and die 3-7 years before women on average • Health beliefs and behaviours contribute significantly to this difference • Stereotypical masculine behaviours are reinforced from birth, and the resources men use to enact gender and masculinity are largely unhealthy • In one study men scored more highly in 13/16 sex independent behavioural risk factors for disease or death, including smoking, excess alcohol, drink driving, not wearing seatbelts and attending health screenings • Men represent 65% of those patients who have not seen their GP in 2-5 yrs, & 70% of those who havent seen a GP for 5+yrs. This is regardless of social status, income or ethnicity • Men are consistently less likely to perceive they are at risk from health problems, and engage in more risky behaviours • Male health knowledge is considerably less than women's

  5. Alcohol, smoking and drugs • Men consistently have higher, and heavier smoking rates than women • They are less likely to seek help to quit smoking, and relapse more often • More men (2/5) consume higher than recommended limits of alcohol than women (although this has changed in the UK in recent year & women are catching up) • Men are more likely to become ‘problem drinkers’ with alcohol impacting upon others areas of their life, and they are less likely to have insight into this effect than women • Excess alcohol consumption has a high correlation to domestic violence • Men are more likely to experiment with illegal drugs, and are more likely to become ‘problem drug users’ • Of note men are less likely to undertake physical activity than women once over the age of 25, and are less likely to eat a healthy diet!

  6. Mental illness • Men are much less likely to report mental illness to their GP • They are less likely to engage in treatment, or accept a diagnosis • Men are more likely to try and ‘self-medicate’, often with alcohol or drugs • At any one time ~30-35% of men will feel ‘low’, the most common concerns being stress at work, money, job security • 2.7 million men in the UK suffer from anxiety, depression or stress • The effect of this is that 75% of all suicides are committed by men • The male prison population has a particularly high level of mental illness, often severely undertreated • Men are more likely to develop schizophrenia at a younger age, and suffer from more severe forms

  7. Benign Prostatic Hypertrophy • Benign enlargement of prostate. So common that can be considered ‘normal’ • Hormone dependant gland, therefore BPH does not occur in castrated males • Unusual before 45 years, but 90% have histological evidence by 80 years • Effects quality of life in ~35% of those over 50 years of age • Symptoms include: Urinary frequency, nocturia, urgency, hesitancy, poor stream, incomplete bladder emptying, need to ‘push hard’ to pass urine • Examination should include: PR to assess prostate shape & size, possible cardio + resp exams to ensure fitness for surgery. • To not forget to exam suprapubic region for chronic retention suggestive of neuropathic bladder, & also for bony tenderness (back) • Useful tool is the International Prostate Symptom Score (IPSS) to assess impact on quality of life

  8. Investigation/Treatment of BPH • First line Ix includes: Urine dip and MSU. Bloods (FBC, U+Es, LFTs) • Beware: Isolated raised Alk phos can suggest prostate malignancy • Prostate specific antigen (PSA) • Potentially Abdo USS, urography, urodynamic studies Medical • Alpha blockers: Reduce bladder neck muscle tone. Tamsulosin most selective. Others are prazosin, alfuzosin and indoramin. Avoid in postural hypotension & micturition syncope. Less selective may be of use in eg, hypertension • 5-alpha reductase inhibitors: Block synthesis of dihydrotestosterone from testosterone. Finasteride is an example. May affect sexual performance Surgical TURP, open prostatectomy, others

  9. PSA Testing • PSA produced exclusively by prostate epithelial cells • PSA can be raised in retention, prostatitis, BPH, carcinoma, after catheter • No indication for routine screening based on trials to date • The patient must be counselled BEFORE the PSA test is done • At the time of the test the patient must not have: active UTI, ejaculated in last 48 hours, prostate biopsy in last 6/52, had PR exam in last 1/52 • PSA is non-specific: 1/5 with negative PSA will have cancer, 2/3 with positive PSA will have no cancer cells on biopsy • No evidence that early detection of prostate cancer leads to longer survival • PSA cannot distinguish between aggressive and slow growing cancers. PSA cannot monitor the progress of a cancer

  10. Prostate Cancer • 2nd most common male cancer, with ~200 cases/yr for every 1000 men • Risk factors: Much more common with advancing age, family history, black males • When developing at an early age is usually aggressive, but often follows a non-aggressive course with elderly men dying of other medical problems • Local disease: Often presents with urinary symptoms/recurrent UTI • Locally invasive: Haematuria, perineal/suprapubic pain, impotence, urinary or rectal symptoms • Metastatic: Bone pain, symptoms of cord compression or ureteric obstruction, lymph node enlargement, systemic symptoms • PR exam: Gland asymmetry, isolated nodule, ‘craggy’ feel, induration, lack of mobility-adhesion to surrounding tissue • Abdo exam: Palpable bladder due to outflow obstruction

  11. Investigation/Treatment • Intially: Urine dip, MSU and bloods (FBC, U+Es, LFTs) • PSA: Often raised, and these men need to be offered prostate biopsy, which is done with transrectal USS • Potentially: CT, MRI and bone scan to stage the disease • Staging is via the TNM system and gleason scoring for histology • NICE: Urgent referral for men with PSA <20, with clinically malignant prostate or bone pain • Depending upon the stage and grade (+ patient factors) treatment options include watchful waiting, radiotherapy, chemotherapy, hormonal therapy, surgery • Complications can include urinary tract obstruction, sexual dysfunction, metastatic spread, SEs of treatments • Prognosis is variable. Local disease often 5 years +, locally invasive up to 5 years, distant spread 1-3 years

  12. Testicular lumps and bumps • Hydrocele: Abnormal collection of fluid within the remnants of the processus vaginalis. Congenital communicating hydroceles are common in adults, but may be secondary to other problems. Scrotal enlargment with non-tender cystic swelling, that lies anterior and often below the testis. Transilluminates. In adults needs secondary cause ruling out. • Epididymal Cysts: Smooth extratesticular cyst, sphericl shape around epididymal area. USS may assist diagnosis. Do not require treatment unless causing symptoms or becoming very large. • Spermatocele: Similar cystic structure to an epididymal cyst, but filled with milky fluid containing spermatozoa. Found around the epididymis. Usually no treatment needed. • Varciocele: abnormal dilatation of the testicular veins in the pampiniform venous plexus, caused by venous reflux. Can cause reduced fertility. Feels like a ‘bag of worms’. Surgical/no treatment

  13. Testicular cancer • Most common malignancy in men aged 20-35. ~1500 cases/yr, but still rare • Risk factors: testicular maldescent, family history, infertility, low birth weight, others • 45% are seminomas, 50% are teratomas, 5% others • Presentation: 85% painless lump, 15% painful lump, 30% ‘dragging sensation’. May present with gynaecomastia or signs of metastatic spread • Ix: 2/52 referral if malignancy suspected. USS usually confirms diagnosis, histology follows an orchidectomy, CT for staging. • BhCG is good tumour marker for both types, alphafetoprotein for teratomas • Treatment is via orchidectomy and radiotherapy/chemotherapy depending upon tumour • 5% will develop tumour in other testis, so surveillance neccessary • Most have 5 year survival of 70-95%, except choriocarcinoma that has a dismal prognosis

  14. Erectile Dysfunction • Inability to attain and maintain an erection sufficient for satisfactory sexual performance. ~24 new cases/yr per 1000 men • Studies showed ~52% men aged 40-70 were affected as some time • Can cause severe stress and problems with relationships • Risk factors are the same as for cardiovascular disease • Common causes include vascular causes, neurological causes, psychogenic, drug related. There are others however • Common causative drugs are: antihypertensives, b-blockers, diuretics, anticonvulsants, antidepressants, hormonal agents • Factors pointing to psychogenic causes include: Morning erections, erection whilst self stimulating, sudden onset, major life events, relationship difficulties • Organic causes: risk factors, drugs, gradual onset, normal ejaculation, surgery/trauma/radiotherapy to pelvic region

  15. Investigation/treatment • Examine cardio system, genitourinary system, BP, consider PR in those aged 50+ • Investigate depending upon Hx/exam findings. UK guidelines suggest BM, Bloods (U+Es, FBC, LFTs), urine dip and MSU. More specialist tests may be needed • Referral indicated if: endocrine abnormality, underlying organic disease as appropriate (eg neurologist), pelvic/perineal trauma, penile deformity/disorders Management • Lifestyle measures + treat any underlying causes • Sex therapy and counselling • Drugs: Phosphodiesterase inhibitors (sildenafil, tadalafil) are first line (relax smooth muscle). Do not use with nitrates • Second line is alprostadil, but there are others • Consider vacuum devices/penile prothesis • Note there are stringent requirements for NHS prescribing

  16. Other Urology • Testicular torsion can present in young adults. Acutely painful, and needs emergency referral • Ensure hernias are considered when examining lower abdomen/scrotum • Sexually transmitted diseases are also an important cause of male genitourinary problems • Don't forget that skin cancers can present on male genitalia • UTIs are uncommon in men under 50. Seek a cause, especially if recurrent • Prostatitis and orchitis are diagnoses that can sometimes mimic more serious disease (and can be serious in their own right!) • Acute urinary retention requires emergency referral • Men should be reminded about routine self testicular examining, and given written info if possible on how to do this

  17. Summary • Men do not look after their health as well as women, they are reluctant to seek health advice and need to be screened at every opportunity • Alcohol/drug problems and smoking are common amongst men, the good GP needs to actively seek out these problems and offer treatment • Mental health problems are prevalent in men, and often present late. Effective questioning can help start a dialogue and plan with these patients • BPH is very common and seriously effects men's quality of life. There are effective treatments both medical and surgical. Beware of the younger man with symptoms, & explore these appropriately. IPSS is a useful GP tool • Prostate cancer is mainly older men, there is no good evidence for screening for it • Men need to be appropriately counselled before a PSA test • Testicular cancer is mainly younger men, but most testicular lumps are not cancer • Erectile dysfunction is common, causes a great deal of stress & embarrassment to men who suffer from it, is usually treatable, but often overlooked.

  18. Questions Any Questions..........?

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