5: MEN’S HEALTH

Published on 27/05/2015 by admin

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Last modified 22/04/2025

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CHAPTER 5 MEN’S HEALTH

Erectile dysfunction
Premature ejaculation
Peyronie’s disease
Sexually transmitted infections
Scrotal swellings
Testicular pain
Testicular cancer
Abdominal aortic aneurysm screening

ERECTILE DYSFUNCTION

Estimated to affect approximately 1 in 10 men, erectile dysfunction is increasingly seen in general practice. It is defined as the inability to get or maintain an erection sufficient for the completion of sexual activity.

Diagnosis

History.

Most men have a combination of physical and psychological causes. Ask about:

• general health and current well-being
• pre-existing illness such as diabetes, prostatism, atherosclerosis
• lifestyle – smoking, alcohol, drugs, stress
• relationship problems
• depression, performance anxiety.

Examination.

This is not usually necessary unless specific concerns have been raised, e.g. pain on erection suggesting Peyronie’s disease (see p. 75)

Investigation.

It is worth sending baseline bloods: TFTs, fasting glucose, testosterone, C&Es, LFTs and γ-GT if alcoholism is suspected.

Management

• Lifestyle advice: advise the patient to try to avoid stress and anxiety, to reduce smoking and alcohol and to discuss any problems of sexual dissatisfaction with his partner.
• All treatments can be used for both psychogenic and organic causes.
• Phosphodiesterase type-5 inhibitors are usually effective irrespective of the cause, e.g. sildenafil, at a starting dose of 50 mg (25 mg in the elderly) approximately 1 hour before sexual activity. It should not be used in those receiving nitrates.

Tip

Most patients will need private prescriptions.

An NHS prescription can be issued to patients whose erectile dysfunction is felt to be caused by:

• diabetes
• pelvic surgery/trauma
• prostate cancer
• neurological disease
• severe emotional distress.

Remember to endorse these prescriptions ‘SLS’.

• Refer for psychosexual counselling, if appropriate.
• Consider referral to a urologist, e.g. for vasoactive injections, penile prostheses or vacuum devices.

PREMATURE EJACULATION

This is very common, particularly in young men having their first sexual relationships.

Assessment

History.

Ask whether the problem has been lifelong or of recent onset. Most men establish a pattern of ejaculating too soon for their liking, but recent anxiety, change of partner or of sexual position/practice may be the cause.

Ask if the man has discussed the problem with his partner. Many men are too embarrassed to do this but successful treatment is more likely if the partner is involved.

Examination.

This is not usually necessary, unless there is a complaint of penile/testicular pain or swelling.

Management

The general principle of treatment is to encourage the man to learn how it feels when he is about to ejaculate and to stop the stimulation before reaching that point, resuming when the feeling has declined. It can usually be treated satisfactorily by the stop/start or the squeeze technique: when the man feels close to ejaculation he should stop and relax for 30 seconds, or the woman should squeeze his glans for 30 seconds. Stimulation can then continue and the process may be repeated. The man will eventually improve his control.

Prescription of one of the SSRI antidepressants may help some men. Not only does the antidepressant effect help if there is associated performance anxiety, but the SSRIs, like most antidepressants, have the side-effect of delaying or preventing ejaculation in some men.

Referral for psychosexual counselling is often appropriate.

PEYRONIE’S DISEASE

Peyronie’s disease is rarely seen in general practice despite being present in over 80 000 adult men in the UK. All ages can be affected but it is most common around 50 years of age.

Assessment

History.

Ask about:

• a fibrous plaque in the shaft of the penis
• pain on erection
• angulation of the penis on erection.

Because the problem is often painful it can lead to erectile dysfunction/impotence. Micturition is unaffected.

Examination.

A fibrous, flat plaque is palpable beneath the skin of the shaft of the penis. It is usually 1–3 cm in diameter and on either the lateral or the ventral surface. The overlying skin is normal.

Tip

Some men are concerned that they may have cancer of the penis when they present with Peyronie’s disease.

Management

There are surgical and non-surgical techniques for Peyronie’s disease, including surgical excision, extracorporeal shock wave therapy, injections, tamoxifen, verapamil and vitamin E.

Referral to a urologist, preferably with a special interest in penile disorders, is advised.

Management of any associated erectile dysfunction should be guided by specialist advice, especially if erection is painful.

SEXUALLY TRANSMITTED INFECTIONS

Chlamydia is the commonest sexually transmitted infection (STI) in men and is often asymptomatic. Other STIs include gonorrhoea, syphilis, HIV/AIDS, genital warts, herpes simplex and thrush.

Men present to their GPs in two ways:

• with symptoms or suspicions of infection
• having been advised to be treated as the partner of an infected person.

Refer to a GUM clinic. Patients can self-refer to any clinic.

Assessment

History.

The symptoms of chlamydia in men can include:

• pain on micturition
• urethral pain
• urethral discharge
• testicular pain
• joint pains (Reiter’s syndrome).

Examination.

Examination is usually normal, even in symptomatic men. Look for signs of other sexually transmitted infections:

• genital warts
• herpetic ulcers
• urethral discharge
• inguinal lymphadenopathy
• candidal balanitis.

Treatment

Treatment depends on the infection identified. Empirical treatment is advised in contacts of diagnosed infection without the need for confirmatory testing. For infection or contact with:

• chlamydia, give doxycycline 100 mg twice daily for 1 week, or azithromycin as a 1 g single dose.
• thrush, prescribe clotrimazole cream to be applied to the glans twice a day for 1 week.
• other diagnosed STIs, refer the patient to a GUM clinic for testing, treatment and contact tracing.

Contact tracing

This is an essential part of the population control of STIs. Most GP practices lack the resources for adequate contact tracing, which often involves patients who are not registered with the practice. If a patient is diagnosed by the practice with an STI, it is important to encourage the patient to inform their sexual partner(s) to seek treatment, either from their own GP or from a GUM clinic.

SCROTAL SWELLINGS

The most common causes of a swelling in the scrotum are an epididymal cyst, an inguinoscrotal hernia or a hydrocele.

A sebaceous cyst of the scrotal skin may be described as a scrotal swelling.

Testicular tumours are rare (see p. 80).

Diagnosis

History.

Ask about pain in the scrotum. The following are painless:

• inguinoscrotal hernia
• hydrocele
• epididymal cyst.

Otherwise, see testicular pain, p. 78.

A history of trauma suggests either a secondary hydrocele or haematocele.

Examination

• Examine the patient standing.
• If palpation above the swelling is impossible, it is an inguinoscrotal hernia.
• If palpation above the swelling is possible and the swelling is above the testicle, it is either an epididymal cyst or a varicocele: an epididymal cyst will transilluminate; a varicocele feels like a bag of worms.
• A hydrocele is usually large and tense and transilluminates easily. The testicle cannot be palpated as it is within the hydrocele.
• A sebaceous cyst is superficial and confined to the scrotal skin.
• Testicular tumours cause enlargement of a testicle.

Investigations.

If there is any doubt about the diagnosis, particularly with regard to excluding a possible tumour of the testis, request a scrotal ultrasound scan.

Management

• Sebaceous cyst: reassure.
• Hydrocele: small hydroceles require no further action as long as a normal testis is palpable. Larger hydroceles may be aspirated (see below) or referred to a urologist.
• All other scrotal swellings: refer.

Aspiration of a hydrocele.

Only attempt if the GP has the confidence to perform the procedure correctly. Otherwise, refer.

• Avoid the testicle by locating it with transillumination.
• Clean the skin with an alcohol wipe.
• Insert a green needle on a 20-ml syringe and draw off as much fluid as possible.
• Always palpate the testicle afterwards to exclude a tumour of the testis as a cause of the hydrocele.
• Repeat the procedure as necessary. Frequent recurrences need surgical treatment.

TESTICULAR PAIN

The most common presentation of testicular pain in general practice is mild and transient, and a cause is often not found.

Diagnosis

History

Severe pain in the testicle suggests torsion or acute epididymo-orchitis. Nausea and vomiting often occur in torsion. Torsion is extremely rare over the age of 25.

• A recent history of cystitis, prostatitis or prostatectomy suggests epididymo-orchitis, as does a history of STI or urethral discharge.
• Mumps may be complicated by orchitis.

Examination

• In torsion the genitalia are often too tender to examine.
• In epididymo-orchitis there may be red skin over the infection, and the most tender part is often felt to be above the testicle.
• In both torsion and epididymo-orchitis there may be scrotal swelling due to oedema or inflammation.
• Examination of the painful testicle is often normal, in which case mild epididymitis is probably the cause.
• Other possible causes of pain in the testicle include:

– ureteric calculi
– inguinoscrotal hernia
– groin strain
– malignancy
– psychological.

Management

Admit all cases of severe pain as possible torsion.

In less severe cases, where the examination is normal, it is wise to wait and see what happens with time. Most cases resolve spontaneously without any treatment. Those that do not settle may be helped by prescribing an anti-inflammatory, such as ibuprofen 400 mg tds.

If there are signs suggesting epididymo-orchitis, such as erythema and fever, take an MSU (and urethral swab for gonococcus and chlamydia, if appropriate) and treat with a broad-spectrum antibiotic such as ciprofloxacin 500 mg bd for 5 days. Consider referral to the GUM clinic.

TESTICULAR CANCER

Testicular cancer is rare. The highest incidence is in the 20–40-year age group.

Assessment

History.

The commonest symptom of testicular cancer is a swelling or lump in one testicle. It is usually painless but can cause an ache. Very rarely testicular cancer presents with symptoms of metastatic spread, such as breathlessness due to pulmonary secondaries.

Examination.

Examination of the normal testicles usually reveals similarly sized, smooth, ovoid testes with the soft epididymi along the posterior surface.

The most common abnormality is an epididymal cyst, which feels like a firm swelling distinctly separate from the testicle and within the epididymis. These are usually between a few millimetres and 1 cm in size.

Swellings within the body of a testicle should be considered suspicious of testicular cancer.

Don’t forget the hydrocele. This is a swelling that feels distinctly fluid-filled and envelops the testicle. They usually transilluminate well with a good pen torch in a dark room.

Management

• If examination is suspicious, an urgent referral to a urologist is advised.
• If the diagnosis is uncertain, refer for an ultrasound scan on an urgent basis.

Screening

No national screening programme exists for testicular cancer. Men should be encouraged to examine their testes monthly, after a warm bath, to learn what feels normal for them and to report any changes.

ABDOMINAL AORTIC ANEURYSM SCREENING

There is no NHS screening programme for aortic aneurysms at present. Screening is, however, available privately.

When to screen

Current evidence suggests that men should have a single ultrasound examination to measure the diameter of their abdominal aorta at 65 years of age. Men over 65 should be screened once, up to the age of 80.

Follow-up

Aneurysm diameter:

• >6 cm diameter: refer for surgery
• 4.5–5.9 cm: re-scan 3 monthly
• 3–4.4 cm: re-scan annually
• <3 cm: no further screening is necessary.

Men screened in this way have a 63% reduction in mortality from abdominal aortic aneurysm at 5 years.

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