Men's health Flashcards
Causes of haematospermia
Infection (prostatitis, urethritis, epididymo-orchitis - including TB and schisto)
Iatrogenic (post biopsty, vasectomy, orchidectomy, RTx)
Malignancy (prostate, bladder, testicular, urethral)
Trauma (coital, perineal)
Prolonged abstinence
Obstruction (ductal, cysts, calculi)
Systemic disorders (HTN, liver disease, lymphoma, leukaemia, amyloid, coagulopathies)
Idiopathic
Red flags for haematospermia
Patient >40y
Recurrent or persistent haematospermia
Prostate cancer risk factors (family history, African heritage)
Constitutional symptoms (weight loss, anorexia, bone pain)
How long after a prostate biopsy will it take for haematospermia to resolve?
approx 20 ejaculations
How to investigate haematospermia in presence of haematuria
As per haematuria work up
- urine cytology
- CT IV pyelogram
- Cystoscopy
Examination required in work up for haematospermia
BP ?severe hypertension
Temp
Genital examination (penis, urethral meatus, testes, epididymis and spermatic cord) for masses, tenderness or superficial lesions
DRE ?prostatitis or prostate Ca
Investigations for patients with haematospermia
ALL patients:
- urine MCS
- urine cytology
- CBE and coagulation studies
As indicated:
- Chlamydia/gonorrhoea NAAT
- PSA if abnormal DRE, >40y or high risk
- urine and semen acid-fast bacilli OR parasites if suspect TB or schistosomiasis
When to refer patients with haematospermia to urology
Men >40y
Persistent or recurrent haematospermia
Suspicious DRE findings
Abnormal PSA results
Suspicion of prostate, bladder, testicular or urethral malignancy on history, examination or investigations
Concurrent haematuria
Haematospermia continues despite treatment for suspected cause
Prevalence of erectile dysfunction
20% of men >40yo
only 30% of these will discuss the issue with their GP
Risk factors for erectile dyfunction
Advanced age
Atherosclerosis risk factors (smoking, HTN, CVD, Lipids, DM)
Neuro conditions (MS, PD, AD, CVA, Spinal cord disorders, peripheral nerve disorders e.g. diabetic neuropathy)
Pelvic surgery (e.g. prostatectomy), radiation or trauma
Endocrinology (hypogonadism, hyperprolactinaemia, hyperthyroidism)
Obesity and metabolic syndrome
Sleep apnoea
Penile abnormalities
Psychological and psychiatric conditions (GAD, MDD, psychosis, partner-related stress/guilt, low self esteem, prior sexual abuse)
medications (antihypertensives, psychotropic medications, anticonvulsants, anti-Parkinson’s, anti-antrogens, steroids, chronic opioids)
Substance abuse (alcohol, illicit drugs)
Important info to ascertain on history of erectile dysfunction
Onset Spontaneous morning erections Is penetration possible Maintenance of erection after penetration Penile deformity Penile pain Ejaculation Orgasm
Validated questionnaire to assess baseline male sexual function/erectile function
Sexual Health Inventory of Men
Examination of man presenting with erectile dysfunction
Examination of penis and testes ?Signs of hypoandrogenism CVD: - BP/HR - BMI and wasit circumference - Cardiac examination - carotid bruits, foot pulses Focused neuro examiantion
Investigations in erectile dyfunction
FBG/HbA1c
Morning testosterone
Lipids
If indicated: prolactin, thyroid function, EUC, LFT
First line treatment of erectile dysfunction
CONSERVATIVE
Review medications
Manage androgen deficiency if indicated
Address psychosocial issues (relationship issues, anxiety, stress)
Lifestyle changes: smoking cessation, alcohol reduction, improved diet and exercise, weight loss, stress reduction, illicit drug cessation, compliance with chronic disease management
Discuss importance of sufficient arousal and lubrication
Discuss realistic expectations including normal age-related changes
Common side effects of PDE5 inhibitors
Headaches Flushing Dyspepsia Nasal congestion Backache Myalgia
Contraindications to use of PDE5 inhibitors
Patients on nitrate medications or recreational nitrates
Precautions to take when prescribing PDE5 inhibitors
Patients with active coronary ischaemia
CCF with borderline low BP
Borderline low cardiac volume status
Complicated multi-drug antihypertensive therapy
Drug therapy that can prolong half-life of PDE5 inhibitors
Which PDE5 inhibitors should be taken on an empty stomach
Sildenafil and vardenafil (absorption is reduced by fatty meals)
3rd and 4th line options for management of erectile dysfunction
IF PDE5 inhibitors contraindicated or unsuccessful: Vacuum devices Penile injections External shockwave lithotripsy Penile prosthesis
(all require urology referral)
Primary v Secondary premature ejaculation definitions
Primary (lifelong): <1min intravaginal ejaculatory latency time
Secondary (acquired after period of normal ejaculation): <3 minutes intravaginal ejaculatory latency time
Secondary usually due to ED
Management of premature ejaculation
Primary: SSRIs (side effect of delayed ejaculation), reduced penile sensation e.g. with topical anaesthetic
Behavioural techniques and counselling
Secondary: if secondary to ED, manage primary cause first
Behavioural techniques/counselling before medical options of primary
Investigation in delayed ejaculation
testosterone levels
Investigation in anorgasmia
testosterone levels
Investigations in retrograd (dry) ejaculation
Post-ejaculatory urinalyisis looking for presence of semen and fructose
Causes of painful ejaculation
Prostatitis
Urethritis
Autonomic nerve dysfunction
Ejaculatory duct obstruction (e.g. calculi or cyst - both are rare)
Investigations for painful ejaculation
Urine STI screen
Mid-stream urine MCS
Semen MCS
Cystoscopy
