Men's Health 500/13

Question 1

1. ATSI and Sexual health Hx

Answer 1

Many Aboriginal and Torres Strait Islander youth, especially those from rural and remote settings, may be very uncomfortable seeing a GP, especially one they don’t know. It is culturally appropriate for Aboriginal and Torres Strait Islander patients to see a GP of the same gender and this should be arranged when possible. Some patients will have taboos in speaking to the opposite sex as there is a notion of ‘men’s business’ and ‘women’s business’ that should be respected. These patients may refuse to be examined by someone who is not the same gender.

Taking time to establish rapport by asking about family and personal interest might help reduce anxiety and shyness, and can constitute part of a HEADSS assessment.

Try to avoid looking directly at the young person, but rather keep your eyes lowered – they are likely to do the same. If you have access to Aboriginal and Torres Strait Islander Health Workers, make use of their services as their expertise can be invaluable. Cultural awareness training is available from many sources and can be of great value in helping to bridge the gap that one may experience.

Question 2

1. Urethiritis with penile discharge

Answer 2

A thick, purulent discharge is likely to be due to gonorrhoea caused by Neisseria gonorrhoeae, although on occasion it may also be caused by organisms such as C. trachomatis and Mycoplasma genitalium.

In general, non-gonococcal urethritis (NGU) tends to be less dramatic in its presentation; it has a clear, mucoid discharge and less dysuria, although presentations may vary widely and it is unwise to make a definitive diagnosis solely on clinical presentation. Tests should include a swab of the discharge for microscopy and culture, and a swab for C. trachomatis polymerase chain reaction (PCR) testing. PCR testing for N. gonorrhoeae can also be performed on the swab for chlamydia, but is not necessary if the culture specimen will be received promptly at your local laboratory. The sensitivity of a male meatal swab for gonorrhoea is excellent.

As patient has one sexually transmissible infection (STI) it is recommended to look for others. For a young heterosexual man this should include a blood test for syphilis and hepatitis B, as well as HIV. Given homemade tattoos in case, a test for hepatitis C is also worthwhile, even though this is not considered an STI.

Question 3

1. Symptomatic STI Rx

Answer 3

Where possible STIs should be treated straight away.

The general rule for those with STIs is to offer treatment on the spot to reduce the risk of transmission to others.

The recommended treatment for a urethral discharge is

• ceftriaxone 500 mg via intramuscular injection,
• plus 1 g of oral azithromycin.

This regimen will treat both gonorrhoea and chlamydia with a very high cure rate.

There is no need for a test-of-cure, given the high efficacy of treatment, although a test-of-reinfection is recommended at 3 months as people who contract chlamydia are at high risk of reinfection. Approximately 15–20% of those diagnosed and treated for chlamydia will have it again when retested some months later.

In addition, from case; patient has syphilis as all of his blood tests for this infection are reactive. He has adequate immunity to hepatitis B through vaccination, and he has acquired hepatitis C at some stage. He has no evidence of HIV infection.

Confirmed cases of gonorrhoea and chlamydia (laboratory definitive evidence) should be notified to the Commonwealth’s National Notifiable Diseases Surveillance System (NNDSS).

Hepatitis C (unspecified) that is confirmed by laboratory definitive evidence, that does not meet the criteria for newly acquired infection and has been present more than 24 months should also be notified to NNDSS.

For more information, refer to the Australian Government Department of Health website at www.health.gov.au/casedefinitions#c

Partner notification (**contact tracing)** should be carried out either
by yourself (if he gives you the names of his sexual contacts) or
by patient, who can contact his sexual partners and advise them to have testing and treatment.

Australian guidelines recommend that sexual partners for the previous 6 months should be followed up for chlamydia and those for the previous 2 months for gonorrhoea.

Follow-up of syphilis will depend on the stage of infection, i.e. primary, secondary or early latent.

Question 4

1. STI contact tracing

Answer 4

Question 5

1. Syphillus Inx and interpretation

Answer 5

Serum Inx (active)

• Syphillis EIA (reactive)
• RPR (ratio. *& : $%)
• TPPA (reactive)

Examination may be helpful, looking for

• a chancre,
• rash,
• mucosal lesions,
• patchy alopecia or
• lymphadenopathy.

If he cannot recall any of these (and this is a not-uncommon occurrence), and nothing is present on examination, then he should be treated for ‘syphilis of unknown duration’ – an intramuscular injection of 1.8 g benzathine penicillin is given weekly for 3 weeks.

Follow-up serology (using the rapid plasma reagin [RPR], which will fall with effective treatment) should then be performed at 1, 6 and 12 months.

Question 6

1. Hep C Inx

Answer 6

If hepatitis C antibodies are reactive, indicating exposure at some stage in his life.

• Approximately 25% of those who contract hepatitis C will clear it spontaneously, though they will remain antibody-positive.
• A hepatitis C PCR test should be ordered; if negative, it indicates patient has cleared the infection.
  
  • If positive, he has ongoing hepatitis C infection and should be followed up for this chronic viral infection, which is curable in most cases with modern antiviral treatments

Question 7

2. Acute Testicular Pain- young man

Answer 7

2.

Examination of a prepubescent or adolescent male with lower abdominal and/or testicular pain is mandatory.

Embarrassment may lead young males to omit or deny symptoms of testicular pain, so examination of the external genitalia should be carried out in a sensitive manner.

The diagnosis to be excluded is torsion of the testicle, as rapid surgical treatment is necessary to save the testicle from necrosis.

Torsion of the testicle is the most common cause of testicular loss in young males.

Some 26% of cases of acute scrotal pain are due to torsion.

Other possibilities include epididymo-orchitis and torsion of a testicular appendix.

The most common age group affected is 12–16 years, although it can occur at any age.

Torsion is more likely with

• pain of less than 24 hours’ duration,
• nausea or vomiting,
• a high position of the testicle,
• transverse lie of the affected testis
• and an abnormal cremasteric reflex

Examination

Testicular Appendix torsion

• When the appendix testis undergoes torsion, a hard, tender nodule 2 to 3 mm in diameter may be palpable on the upper pole of the testicle. A blue discoloration may be visible in this area and is referred to as the “blue dot sign.” Scrotal edema develops rapidly, however, and often obscures the physical examination findings. Finally, the epididymis remains posterior when only the appendix testis undergoes torsion. The affected testis is comparable in size to the unaffected testis.

Testicular torsion

• In contrast, in patients with testicular torsion, the epididymis may be located medially, laterally, or anteriorly, depending on the degree of torsion. The epididymis may be located posteriorly with 360 degrees of torsion. The spermatic cord shortens as it twists, so the testis may appear higher in the affected scrotum. This is a very specific finding and, when present, is strong evidence of testicular torsion. Because of venous congestion, the affected testis also may appear larger than the unaffected testis.

The most sensitive physical finding in testicular torsion is the absence of the cremasteric reflex. This reflex is elicited by stroking or pinching the medial thigh, causing contraction of the cremaster muscle, which elevates the testis. The cremasteric reflex is considered positive if the testicle moves at least 0.5 cm. In a study of 225 healthy boys, investigators noted that this reflex was present in all of the boys older than 30 months but in less than one half of those younger than 30 months

From case

The examination findings are typical of testicular torsion, but epididymo-orchitis and torsion of a testicular appendix are also possible, though less likely. With epididymo-orchitis, there may be erythema of the scrotum and testicular and epididymal tenderness, but the cremasteric reflex is generally not affected.

It is important to note that treatment should not be delayed by ordering investigations. Investigations such as Doppler ultrasound of the scrotal contents can improve diagnostic accuracy significantly, especially when the probability of testicular torsion is considered low. In epididymo- orchitis the vascular flow to the epididymis and adjacent testicle is increased, whereas with torsion the blood flow is compromised and much reduced. Radionuclide scans are very accurate but time- consuming and not always available.

Question 8

2. Testicular torsion Mx

Answer 8

Suspected torsion of the testicle is a surgical emergency and rapid referral is vital to save the testicle.

If treated surgically within 6 hours, there is a high chance (approximately 90%) of preserving the testicle. At 12 hours the rate decreases to 50%, at 24 hours it drops to 10% and after 24 hours the rate of preservation approaches 0%.

Analgesia should be given parenterally if patient is in significant pain.

Manual detorsion can be performed if there will be a significant delay in attending surgery. The procedure for manual detorsion of the testis is similar to the ‘opening of a book’ when the physician is standing at the patient’s feet. Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves twisting outward and laterally.

Unfortunately, lateral rotation has been described in up to one-third of testicular torsions and in such cases further lateral rotation will worsen the condition. In the literature, the success rate of manual detorsion has varied widely: success rates ranged from 26.5% to morethan 80%. Generally speaking, surgical referral is far preferable.

Question 9

2. Phimosis Mx

Answer 9

Case

You find that he has a tight phimosis and that the foreskin cannot be retracted over the glans penis.

You let him get dressed again and explain the situation – he has a constriction of the foreskin that has probably been present for a long time, but has only become a real problem since becoming sexually active (though some men find it is a problem with masturbation, too).

It may be helpful to provide some basic information about the foreskin and encourage Sam to gently retract the skin and wash regularly when bathing or showering.

The treatment initially involves daily application of a potent corticosteroid cream such as betamethasone dipropionate (0.05%) for 2–4 weeks to the scarred area in order to thin the scar tissue and allow stretching of the constricted foreskin. This conservative treatment is often effective.

If not, then preputioplasty (in which
a limited dorsal slit with transverse closure is made along the constricting band of skin) can be performed by a surgeon. It has
the advantage of limiting pain and a short healing period relative to circumcision and avoids cosmetic effects.

It is rare to require formal circumcision if more conservative measures are tried.

Question 10

3. Tiredness

Answer 10

A large number of medical conditions can lead to feelings of tiredness. In general practice, tiredness is the second most common complaint after cough with 5–7% of patients presenting with
this symptom.

Physical conditions such as

• infections,
• endocrine problems,
• nutritional deficiencies,
• sleep apnoea,
• coeliac disease and
• diabetes

can all present with fatigue.

People with mental health issues such as

• stress,
• bereavement,
• depression,
• anxiety and
• chronic fatigue syndrome may also present with tiredness.

A 2009 Australian survey reported a 45.5% lifetime prevalence of any mental health issue in the general population.

Question 11

3. Tireness- Hx

Answer 11

Hx

• systematic enquiry of the main organ systems,
• sleep duration and quality,
• infections,
• pain, and
• review of mood and physiological shift symptoms (appetite, weight, motivation, concentration, memory, guilt, hopelessness)
• as well as drug and alcohol use.

A general examination of the patient including

• assessment of weight,
• blood pressure and
• temperature should be undertaken, as well as
• performing a urinalysis.

For those with prolonged fatigue and infrequent consultations with general practitioners,

• baseline blood tests including a full blood count,
• erythrocyte sedimentation rate,
• liver function,
• renal function,
• thyroid function and
• blood sugar levels

would be helpful first-line investigations.

If depression is suspected,

• use of a validated psychological assessment tool such as the Hamilton Depression Rating Scale or the Kessler Psychological Distress Scale (K10) may help determine the level of depression and anxiety at baseline and can provide a means by which to assess treatment response.

Question 12

3. Depression

Answer 12

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) describes a major depressive episode as

• consisting of either depressed mood or diminished interest, with changes in appetite, weight, energy, concentration, motivation or guilt for a period of at least two weeks.

Differential diagnosis includes alcohol-induced mood disorder or a mood disorder due to a general medical condition

Men are less frequently diagnosed with depression, compared with women.

Possible socio-cultural reasons for this may include the masculine gender role, which is less emotion-focused and more likely to interpret seeking help as incompetent or dependent.

Consequently, depression is less likely to be recognised by men, who are then less likely to seek help.

Men also may present with substance use issues and anger when depressed rather than complaints of depressed mood.

Question 13

3. Depression vs Sadness

Answer 13

Although there may be a continuum of severity and pervasiveness from sadness to clinical depression, depression can be considered to be an exaggerated or disproportionate response to adverse
life events.

Many who are exposed to stressful life events do not develop a depressive syndrome. The physical changes (lethargy, amotivation) and cognitive changes (guilt, hopelessness) are more likely described by those suffering with depression rather than sadness.

Question 14

3. Depression and Suicide Risk

Answer 14

Current guidelines recommend questioning people with depression directly about suicide risk.

This can be achieved through sensitive use of open-ended questions to gently explore the risk of harm, including suicide ideation and intent. Where the risk of harm is deemed to be significant, consider referral to specialist services.

Current risk factors for suicide in men include

• middle aged,
• male,
• abusing alcohol and having depression.

Along with risk factors, protective factors also need to be identified (see Table 2).

Question 15

3. Depression Mx

Answer 15

A supportive and empathic relationship between doctor and patient
is important in formulating a management plan tailored to the needs of the individual. Factors that could be considered might include the treatment setting, patients’ preferences, concomitant psychiatric and physical disorders, concurrent drugs, patients’ experiences with previous treatments, the severity of depressive symptoms or subtypes of depression, risk of suicide and the availability of treatment options.

Most patients with depression can be managed in the general practice setting, and this may involve using the GP Mental Health Care Items through the Medicare Benefits Schedule (MBS), which include preparation of written mental health care plans for individual patients. Specialist referral is indicated for severe depressive states or those at immediate risk of harm. In a rural area, access to specialist mental health services may be limited and the benefits of referral to specialist treatments in metropolitan settings need to be weighed against the disruption of lifestyle and relationships that may result from a change of setting.

Provision of education regarding depression and treatment options, as well as written information including after hours contact details in case of clinical deterioration or emergencies need to be discussed with the patient and family.

Question 16

3. Depression Mx

Answer 16

Psychological and/or pharmacological interventions could be offered to Michael.

Psychological interventions could be offered given the presence of psychosocial issues such as grief and work-related stress.

In mild to moderate depression, psychological treatments are as effective as antidepressant medication.

Cognitive behavioural therapy (CBT) and interpersonal therapy have the strongest evidence for efficacy in mild to moderate depression.

The Access to Allied Psychological Services Program (ATAPS) is part of the Better Outcomes in Mental Health Care Initiative, which is funded by the Department of Health and managed locally by Medicare Locals.

ATAPS allows GPs to refer patients to mental health professionals for a maximum of 12 sessions per calendar year, with the possibility of an additional six sessions, at minimal cost to the patient.

Lastly, advising Michael to engage in regular exercise and improve his lifestyle by socialising and engaging with support systems in the community is also important.

Antidepressants are indicated in moderate to severe major depression. While it is generally accepted that antidepressants have similar efficacies, individual patient responses may vary.

Selective serotonin reuptake inhibitors (SSRIs) are often considered to be appropriate first-line treatment choices given their favourable risk– benefit ratio, particularly in overdose.

Full antidepressant response may not be seen for 6–8 weeks; however improvement is often seen within several weeks.

Patient preference is an important consideration in determining treatment options. Patients who do not respond to an adequate trial of antidepressants should be referred to a psychiatrist.

Although in the case weight loss is consistent with a depressive disorder, given his age, other causes of weight loss, such as carcinoma, should be considered and excluded through history taking and investigations as considered appropriate.

Question 17

4. Erectile dysfunction

Answer 17

Community-based epidemiological studies suggest ED is a common disorder in men, affecting up to 52% of men aged 40–70 years and is associated with reduced quality of life.

Data from Australian, US and UK studies are similar, and estimate the prevalence of complete ED as approximately 5% among 40-year-olds, 10% among men in their 60s, 15% among men in their 70s and 30–40% among men in their 80s.

It is projected that by 2025, 322 million men worldwide will have ED.

Prevalence studies show that, when controlling for other factors,

• increasing age,
• obesity,
• diabetes,
• hypertension,
• hyperlipidaemia and
• vascular disease are contributive factors.

Question 18

4. Erectile dysfunction and social impact

Answer 18

It is increasingly recognised that a diagnosis of ED can have a profound impact on the patient’s and partner’s quality of life.

ED can lead to withdrawal from intimacy, avoidance of all physical contact with a partner and an increase in emotional stress, which itself can perpetuate any psychogenic component to the ED.

The condition can affect a man’s self-esteem and self-image, and lead to anxiety and hence depression.

Treatment of ED has been shown to lead to resolution of depression and restoration of self-esteem, and thus improvement in quality of life.

Question 19

4. Erectile dysfunction- causes

Answer 19

It is now recognised that vascular disease of the penile arteries is the most common cause of ED in older age group, accounting for up to 80% of cases.

Apart from age, the main risk factors are those for vascular disease (smoking, diabetes mellitus, hypertension, abnormal lipid profile, obesity and lack of exercise).

Essentially, any condition that damages endothelial function can result in ED.

ED may be an early manifestation of generalised endothelial dysfunction and a predictor and a precursor of other forms of cardiovascular disease.

More than half of men with ED who have no cardiac symptoms have an abnormal stress test, and 40% have been found to have significant coronary artery disease when studied.

Endocrine disorders, such as hypogonadism, have a significant role in ED physiology.

• Testosterone regulates cavernosal nerve structure and function, nitric oxide synthase (NOS) expression and activity, PDE-5 and corporal smooth muscle cell growth and differentiation.
• Men with benign prostatic hyperplasia (BPH) have a high prevalence of ED. The explanation for this association remains unclear, and the quality of life of men with BPH is reduced by its effects on sexual function.

Although in most men, ED has an underlying vascular cause, usually related to endothelial dysfunction, there is always a contributing, sometimes substantial, psychogenic component related to performance anxiety.

Treatment of this psychological component alone may be sufficient to restore normal erections. Lastly, use of certain medications, including commonly prescribed antihypertensives, may contribute to ED.

Given the above considerations, the following are possible contributors to the case: his age, diabetes, hypertension, dyslipidaemia, obesity, smoking and use of telmisartin.

Question 20

4. Erectile dysfunction and diabetes

Answer 20

ED is reported to occur in 35–70% of men with DM.

More than 50% of men develop ED within 10 years of being diagnosed with DM.

ED occurs at an earlier age in men with DM, compared with men without DM and the age-adjusted probability of complete ED is nearly 3 times higher.

The prevalence of ED increases with age, from 9% in men with DM aged 20–29 years to 95% in men >70 years, and increases with duration, poor glycaemic control, and complications of DM such as vascular and microvascular disease and neuropathies.

One study reported that as many as 11% of men seeking treatment for ED have undiagnosed DM.

Question 21

4. Erectile dysfunction Hx and exam

Answer 21

Evaluation should include a full history (medical, sexual and psychosocial), physical examination and consideration of appropriate investigations.

A full history and thorough clinical examination of the patient is needed to:

• confirm that the patient is suffering from ED and/or another sexual dysfunction, such as hypoactive desire or premature ejaculation
• assess the severity of the condition
• determine whether ED is psychogenic or organic in origin
• identify risk factors or comorbid disease
• assess the fitness of the patient for resuming sexual activity.

There are a range of suitable initial questions to ask the patient with ED, for example:

• What is the problem with your erections?
• How frequently do you have the problem?
• When did you last have successful sexual intercourse?
• How strong is your desire for sex, now and in the past?
• What has been the effect of your sexual difficulties on your relationship with your partner?
• What is your partner’s attitude to the problem?
• What are you and your partner hoping to gain from any treatments that may be available?
• Several validated questionnaires have been developed to score the erectile problem objectively. Questionnaires may be completed in the waiting room, before a consultation or between consultations. The short five-question form of the International Index of Erectile Function (IIEF), or the IIEF-5 or Sexual Health Inventory for Men (SHIM), are useful for both diagnosis and assessment of response to treatment.
• The association between anxiety and ED should be established. Psychogenic ED can be caused by a number of problems, principally performance anxiety, but also guilt, depression, relationship problems, or fear and personal anxiety. Careful enquiry should be made about current medications, such as beta-blockers, thiazide diuretics and anti-depressants, as well as the use of recreational drugs.

Physical examination of a man with ED will be directed, to a certain extent, by his history, and should include assessment of the external genitalia, the endocrine and vascular systems, and the prostate gland in most patients.

• The penis should be carefully palpated to exclude the presence of fibrous Peyronie’s plaques and to check for phimosis.
• Prostatic induration or a palpable nodule should raise the suspicion of prostate cancer.

Question 22

4. Erectile dysfunction Inx

Answer 22

The degree to which men should undergo clinical investigation depends on the patient’s history and examination findings.

General investigations include

• serum concentrations of total testosterone (before 11am),
• fasting glucose and
• fasting lipids and,
• in men over 50 years of age, prostate-specific antigen (PSA).

Further investigations may be required based on the results of these initial investigations including

• serum concentrations of free testosterone,
• sex hormone binding globulin (SHBG),
• luteinizing hormone and
• prolactin.
• Case*
• John’s raised fasting glucose and HBA1c indicate poor glycaemic control of his diabetes with an increased risk of diabetic microvascular complications. Similarly, John’s raised lipids and central obesity suggest metabolic syndrome and an increased risk of coronary artery and cerebrovascular disease. John’s total testosterone is within the normal range and is consistent with his eugonadal appearance.*

Question 23

4. Erectile dysfunction- Rx

Answer 23

Three highly potent, selective PDE-5 inhibitors

• sildenafil,
• tadalafil and
• vardenafil

are currently available for the treatment of ED in Australia.

The overall efficacy of the different PDE-5 inhibitors appears similar and is related to the extent and severity of ED, with significantly reduced efficacy demonstrated in patients with severe vasculogenic ED, diabetic ED and post-radical prostatectomy ED.

Despite the demonstration of efficacy and tolerability in
a broad range of ED aetiologies and severities in multiple large multicentre clinical trials, 30–35% of patients will fail to respond.20 PDE-5 inhibitors are contraindicated in those with a recent myocardial infarct, concurrent users of nitrate therapy and those at high risk of cardiovascular disease.

The reasons for initial or delayed PDE-5 inhibitor failure are
diverse and manifold, and include

• severe ED at first presentation,
• worsening of endothelial dysfunction and progression of penile atherosclerosis,
• post-radical prostatectomy ED,
• unrecognised hypogonadism,
• inadequate patient education and incorrect drug usage,
• the possible development of tachyphylaxis or drug tolerance,
• and the presence or development of comorbid psychosocial factors.

It may be useful to explain the indications for PDE-5 inhibitors, how they work and their correct use, as this may lead to improved efficacy.

Question 24

4. Erectile dysfunction -2nd line Rx

Answer 24

Second- and third-line treatment options include

• intra-corporeal injection therapy (ICI),
• vacuum constriction devices (VCDs) and
• intrapenile penile prostheses (IPP).

ICI: Treatment with patient-administered ICI using vasodilator drugs such as alprostadil, which relaxes the arterial and trabecular smooth muscle, is an effective treatment for ED. ICI can be used in most men with ED, but is especially useful in men who fail to respond to oral pharmacological agents. Alprostadil resulted in an erection of sufficient rigidity for sexual intercourse in 72.6% of men with ED. Self-injection technique should be taught by either the physician or the practice nurse. Relative contraindications to ICI include anticoagulant therapy, previous poor compliance and a history of priapism.

VCD: This involves application of a vacuum to the penis in a vacuum cylinder causing tumescence and rigidity, which is sustained using a constricting ring at the base of the penis. Vacuum constriction devices require enthusiasm on the part of the patient and a sympathetic partner. They are more popular in middle and older age group couples, and are an uncommon treatment choice in single younger men. Approximately 60–70% of men find using the device straightforward.

IPP: Surgical treatment of ED with an IPP is usually reserved for patients in whom more conservative therapy has failed, or for whom conservative therapy is contraindicated. Most of these patients will have significant arterial or venous disease, penile corpus cavernosum fibrosis or Peyronie’s disease or will, by choice, prefer the prospect of a ‘one-off’ solution. While the outcome of surgical intervention may be more reliable in certain selected patients, the incidence of morbidity and complications is significantly greater than with medical treatment. Multi-component inflatable penile implants are associated with high patient satisfaction rates, and device failure and prosthetic infection are uncommon. Infection is the most problematic complication following surgery and often requires removal of the prosthesis and either immediate replacement or staged re-implantation at a later stage.

Question 25

5. Opportunistic health care Young Men

Answer 25

In addition to asking questions of presernting complaint- this presentation provides an opportunity to assess his general wellbeing and lifestyle risk factors, aiming to reduce future risk.

Young adult men aged 15–24 years present less often to their GPs, compared with women in the same age group (men in this age group comprise 3.1% of GP encounters, compared with 5.4% for women).

Young men are more likely to report unhealthy behaviours, compared with women.

In the 20–29 year age group, 19.7% of men report daily smoking, compared with 16.3% of women; 3.4% of men report daily drinking, compared with 0.9% of women.

Similarly, 30.5% of men report using illicit drugs compared to 24.3% of women. In 2011, 95.2% of cases of newly diagnosed HIV/AIDS cases in Australia were in men.

For young men, age-specific preventative activities should be considered.

Questions could be asked using the SNAP framework to explore weight and nutrition (N), alcohol use (A) and physical activity (P) on a two-yearly basis.

Smoking (S) should be broached opportunistically and ideally at every visit.

Blood pressure should be checked every two years, or more often for those at high cardiovascular risk. Review of sexual health, including chlamydia risk should be assessed opportunistically every 12 months. Chlamydia is the most commonly diagnosed and curable STI in Australia and regular screening in sexually active people aged 15–29 years is recommended to minimise risk of complications.

Question 26

5. Dysuria and urethral discharge- young man

Answer 26

In addition to obtaining a sexual history for the presenting complaint (e.g. duration of symptoms, amount and nature of discharge), you should conduct a risk assessment of sexual behaviour
in a non-judgmental manner.

When determining sexual behaviour risks, elicit information on the number and gender of recent sexual partners, the nature of sexual activity, sexual contact with sex workers and use of condoms for insertive intercourse.

In the event of the diagnosis of a sexually transmissible infection, notification of sexual partners should be discussed.

Depending on Robert’s responses, a number of tests could be considered.

• For example, a full check for STIs including HIV infection would be appropriate.
• Gonococcal infection has been shown to be a co-factor in the acquisition of HIV infection although the impact of the current pattern of STIs of men who have sex with men in Australia on the acquisition of HIV is not clear.

A complete physical examination to check for the presence of other STIs, such as syphilis, and ordering of a urethral Gram stain, gonococcal culture and PCR testing for C. trachomatis, pre- and post-test counselling for HIV antibody test would be reasonable.

Hepatitis A, B and C screening and/or vaccination may also be relevant.

Patient’s informed consent is required for all tests.

Question 27

5. Gonococcal urethritis Rx

Answer 27

Treatment of gonococcal urethritis should be based on the results of urethral (if discharge is evident) or endocervical swab Gram stain; bacterial culture for N. gonorrhoeae and other possible bacterial pathogens and, if relevant, susceptibility testing, and/or nucleic acid test (NAT) on first stream urine or genital swab for C. trachomatis, N. gonorrhoeae and M. genitalium.8

Reports of gonococcal strains resistant to penicillin, tetracyclines and fluoroquinolones are common in most Australian communities (including urban centres).

Case

Given that in Robert’s case chlamydia infection was ruled out, an intramuscular infection of ceftriaxone 500 mg in 2 mL of 1% intramuscular lignocaine, as a single dose, is appropriate. Dissolving ceftriaxone in lignocaine reduces the pain associated with injecting ceftriaxone intramuscularly.

A confirmed case of gonorrhoea (laboratory definitive evidence) should be notified to the Commonwealth’s NNDSS.

Sexual contacts from the last 6 months should be contacted and treated presumptively and any follow up undertaken in line with current guideline recommendations (e.g. in cases of chlamydia, repeat testing for reinfection after 3–12 months may be appropriate).

Robert should be retested in 6 weeks for HIV infection, as HIV antibodies can take some time to appear after HIV exposure.

Hepatitis A, B and C serology and/or immunisation for hepatitis A or B could also be considered.

Question 28

5. Risk taking behaviour in young men

Answer 28

The presence of high-risk alcohol consumption may be an indication of general high risk taking, which is more common in younger men. This includes

• sexual risk taking,
• the use of recreational drugs and
• risk of accidental injury.

Question 29

5. Safe sexual practices

Answer 29

Patients may need to be counselled to help reduce the high-risk behaviours that may have resulted in STIs.

This encounter provides an important opportunity to reinforce education about safe sexual practices and discuss any possible anxiety or other risk behaviours to help prevent patients from acquiring HIV or other infection(s).

This discussion should include the increased risk of harm associated with alcohol and recreational drug use in the context of men who have sex with men and strategies for reducing this risk. This may require referral to a counsellor skilled in this area.

The lifetime risk of alcohol-related injury increases more rapidly for men. Nearly one-third of self-inflicted injuries and suicides are linked to alcohol consumption in men.

The discussion should inform patient that safe drinking levels constitute two standard drinks per day for men, and recommend annual screening for STIs in line with current recommendations for gay men and men who have sex with men (MSM). The provision of written materials would be appropriate.