Mens HEALTH

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..........?