S3: men's health

Question 1

Describe phimosis

Answer 1

Prepuce cannot be fully retracted in adult (physiological phimosis – normal non-retractability up to adolescence)
Sequelae: poor hygiene, pain on intercourse, balanitis (inflamed glans), posthitis (inflamed foreskin/prepuce), balanitis xerotica obliterans, paraphimosis, urinary retention, penile cancer

Question 2

Describe paraphimosis

Answer 2

Painful constriction of the glans penis by the retracted prepuce proximal to the corona
Commonest causes: phimosis, catheterisation, penile cancer

Question 3

Compare phimosis and paraphimosis treatments

Answer 3

Phimosis – may be associated with other pathologies, beware man with phimosis & balanitis
-circumcision is best treatment
Paraphimosis – needs reduction (achieved manually)

Question 4

Describe penile cancer (SCC)

Answer 4

Risk factors: phimosis, HPV 16 & 18
Untreated, most dead in less than 2 years, almost all less than 5 years
Important not to miss – GP may only see one in their lifetime

Question 5

List indications for circumcision

Answer 5

Paediatric: religious, recurrent balanitis/UTIs
Adult: recurrent balanitis, phimosis, recurrent paraphimosis, balanitis xerotica obliterans, penile cancer

Question 6

List causes of acute scrotal pain

Answer 6

Testicular torsion 
Epididymitis/orchitis/epididymo-orchitis (UTI, STI, mumps)
Torsion of hydatid of Morgagni 
Trauma 
Ureteric calculi (rarely)

Question 7

Describe history and examination for testicular torsion

Answer 7

History – usually younger patient, sudden onset, unilateral pain, may be nauseated/vomit, often no LUTS
Examination – testis is very tender, lying high in scrotum with horizontal lie
If you suspect testicular torsion, the patient needs emergency scrotal exploration

Question 8

Describe history for epididymo-orchitis

Answer 8

Age: 20-40/50: STI, 40/50+: UTI
Gradual onset
Usually unilateral
Often recent history of UTI, unprotected intercourse, catheter/urethral instrumentation, check for mumps history

Question 9

Describe examination findings for epididymo-orchitis

Answer 9

May be pyrexial, can be septic
Scrotum erythematous
Testis/epididymis enlarged, tender
Rarely – necrotic area of scrotal skin (Fournier’s gangrene) -> high mortality rate

Question 10

Describe investigations and treatment for epididymo-orchitis

Answer 10

Investigation: bloods, urine, radiology
Treatment:
1) Epididymo-orchitis – antibiotics
2) Abscess – surgical drainage and antibiotics
3) Fournier’s gangrene – emergency debridement & antibiotics

Question 11

Describe different presentations for scrotal lumps

Answer 11

Painless, non-tender scrotal lump – testis tumour, epididymal cyst, hydrocele, reducible inguino-scrotal hernia
Painless/aching at end of day, non-tender – varicocele
Painful & tender – epididymitis, epididymo-orchitis, strangulated inguino-scrotal hernia (emergency)

Question 12

Describe the history and examination of a testicular tumour

Answer 12

History – usually painless, history of undescended testis (germ cell tumours in men <45), older men (lymphoma)
Examination – body of testis is abnormal, can ‘get above’
Refer to urology -> arrange urgent ultrasound of scrotum & check testis tumour markers

Question 13

Describe hydrocele

Answer 13

Slow/sudden onset
Uni/bilateral scrotal swelling -> imbalance of fluid production and resorption between tunica albuginea and tunica vaginalis
On examination: testis not palpable, can usually ‘get above’, transilluminates

Question 14

Describe an epididymal cyst

Answer 14

Usually painless

On examination: separate from testis, can ‘get above’ mass, transilluminates

Question 15

Describe varicocele

Answer 15

Dull ache, at end of the day (more common on left compared to right)
May be associated with reduced fertility
On examination: ‘bag of worms’ above testis, NOT tender

Question 16

List causes of urinary retention

Answer 16

Prostatic enlargement – BPH & cancer 
Phimosis/urethral stricture/meatal stenosis 
Constipation 
UTI
Drugs 
Over-distension 
Following surgery
Neurological

Question 17

Describe the different types of urinary retention and the treatment for each

Answer 17

Acute (painful) – pain is relieved by drainage, residual volume <1000ml, no kidney insult, trial without catheter after addressing exacerbating factor
Chronic (painless/less painful) – may just notice abdominal swelling, residual volume >300ml, may have kidney insult, learn to self catheterise
Acute on chronic (painful) – residual volume >1000ml, usually have kidney insult, long-term catheter or surgical intervention

Question 18

Compare voiding and storage symptoms

Answer 18

Voiding – hesitancy, poor flow, post micturition dribbling

Storage – frequency, urgency, nocturia

Question 19

List causes of storage LUTS

Answer 19

Irritative
Overactive bladder
Low compliance of bladder
Polyuria

Question 20

List causes of voiding LUTS

Answer 20

Bladder outflow obstruction – physical, dynamic & neurological
Reduced contractility

Question 21

Describe primary care assessment of male LUTS

Answer 21

International prostate symptom score
Examination – DRE, is the bladder palpable? Neurological if suggestive history
Investigations – dipstick, consider PSA

Question 22

Outline primary care management of BPH

Answer 22

Lifestyle – reduce caffeine intake, avoid fizzy drinks, no need to drink more than 2.5L
Alpha blockers (tamsulosin) – act by relaxing smooth muscle within the prostate and the bladder neck 
5alpha-reducatase inhibitors (finasteride/dutasteride) – act by shrinking the prostate by means of androgen deprivation, slower symptom relief than alpha blocker

Question 23

Outline secondary care management of BPH

Answer 23

Flow rate
Surgical intervention if: failed lifestyle & medical management, urinary retention needing intervention
Standard: transurethral resection of prostate (TURP)

Question 24

List physical causes of erectile dysfunction

Answer 24

Atherosclerosis 
Smoking cigarettes 
Damage to key blood vessels due to cycling 
Diabetes 
Regular heavy drinking – can damage the nerves leading to the penis & reduce testosterone levels 
Spinal cord injury 
Prescribed medication 
Prostate gland surgery

Question 25

List psychological causes of ED

Answer 25

Stress and anxiety 
Depression
Relationship conflicts 
Sexual boredom 
Unresolved sexual orientation

Question 26

Outline treatments for erectile dysfunction

Answer 26

Oral drugs (cialis, Viagra) – common side-effects are headaches and facial flushing 
Injection therapy 
MUSE
Vacuum pumps 
Penile implants 
Therapy