GP: Men's Health

Question 1

International Prostate Symptom Score (SYMPTOMS OF BPH)

Answer 1

Poor stream
Intermittency
Straining
Superimposed infection (not actually in IPSS)
Errrrgh - hesitancy 
Dribbling

Frequency
Urgency
Can’t hold it
Kept awake

+ QOL RATING

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

Question 2

Causes of Lower Urinary Tract Symptoms

Answer 2

UTI
constipation
anxiety
diabetes
recent radiotherapy or surgery
medications, most commonly:
diuretics
anticholinergics, including antihistamines, tricyclic antidepressants, and phenothiazines

Question 3

Ix of BPH

Answer 3

MSU – urinalysis and culture
Prostate-specific antigen (PSA), following joint decision making with the patient.
Creatinine
Ultrasound is not required routinely. However, arrange renal ultrasound if:
- the bladder is palpably enlarged
- abdominal mass
- reduced eGFR suspected to be due to chronic urinary retention:
-aged younger than 70 years and eGFR lower than 45 mL/min
-aged 70 years or older and eGFR lower than 30 mL/min

Question 4

Rx of BPH

Answer 4

Non pharmacological

• ‘Watch and wait’
• Reducing caffeine, alcohol, and fluids in the evenings.

Pharmacological
α-blockers (eg. tamsulosin)
• 5α-reductase inhibitors (eg. dutasteride)
• PDE5 inhibitor (eg. tadalafil)
- Anticholinergics (only if primarily irritative and no urinary retention)

Interventions
- Catheterisation as needed 
• TURP +/- laser
• TUIP (Transurethral incision of the prostate)
• Prostatic lift surgery

Question 5

Causes of gynaecomastia

Answer 5

• Physiological
• Pseudogynaecomastia (fat/muscle rather than true breast tissue)
• Chronic liver disease
• Chronic kidney disease
• Drug causes: PPI, spironolactone, anabolic steroids etc.
• Breast cancer
• Neoplastic endocrine causes

Question 6

Side effects of anabolic steroid use

Answer 6

Reversible: appetite, anxiety, aggression, acne, libido change, scrotal pain and impotence, oedema
Irreversible: hirsutism, striae, testicular atrophy etc.

Question 7

PSA testing

Answer 7

For men at average risk of prostate cancer who have been informedof the benefits and harms of testing and who decide to undergo
regular testing for prostate cancer, offer PSA testing every 2 yearsfrom age 50 to age 69, and offer further investigation if total PSA is
greater than 3.0 ng/mL.

Question 8

Causes of erectile dysfunction

Answer 8

Vascular: Cardiovascular disease, hypertension, diabetes mellitus, hyperlipidemia, smoking, major surgery (radical prostatectomy) or radiotherapy (pelvis or retroperitoneum)

Neurologic: Spinal cord and brain injuries, Parkinson disease, Alzheimer disease, multiple sclerosis, stroke, major surgery (radical prostatectomy) or radiotherapy of the prostate

Local penile (cavernous) factors Peyronie’s disease, cavernous fibrosis, penile fracture

Hormonal: Hypogonadism, hyperprolactinemia, hyper- and hypothyroidism, hyper- and hypocortisolism

Drug induced:Antihypertensives, antidepressants, antipsychotics, antiandrogens, recreational drugs, alcohol

Psychogenic:Performance-related anxiety, traumatic past experiences, relationship problems, anxiety, depression, stress

Question 9

Rx of erectile dysfunction

Answer 9

• Treat CVD
• Medication review
• PDE-5 inhibitors (contraindicated if using nitrates, caution hypotension with alpha blockers)
• Second line: penile self injecting drugs, vacuum devices

Question 10

Rational prescribing framework

Answer 10

Rational Prescribing Framework
Together with the patient:
1) Define the patient’s problem
2) Specify the therapeutic goal(s)
3) Consider non-drug and lifestyle measures
4) Choose a drug treatment and verify its suitability
5) Decide how treatment will be reviewed and monitored against the therapeuitc goal(s)
Provide information, instructions and warnings that the patients and carers will need