Domain – Men’s health – (case)

John is 68 years old and presents for a check-up. He has not seen a GP for several years and says that there is nothing wrong with him. He has come to see you at the insistence of his wife after a recent admission to hospital for a urinary tract infection.

John tells you that he has trouble with his ‘water works’ and difficulty maintaining an erection. He puts this down to his age. He has a family history of heart disease. His father had a heart attack at the age of 50 and was diagnosed with prostate cancer at the age of 75. John feels embarrassed talking to you about his symptoms as he feels that this makes him less of a man.

1. Communication and Consultation Skills

What communication skills could you use to help reduce John’s feeling of embarrassment?

• Empathy and Normalization Example: “Many of my patients your age have similar concerns, and it’s something we can manage effectively. You are not alone in this.”
• Open-ended Question Example: “What has been the most challenging part of dealing with these symptoms for you?”
• Private and Comfortable Environment Example: Ensure the room has comfortable seating and a calm atmosphere, perhaps with neutral colors and minimal distractions.
• Active Listening Example: “I hear you, John. You’re feeling like these symptoms are affecting your quality of life. Let’s explore the best ways to address them.”

You identify several health concerns. How could you engage John to discuss and prioritize these?

Health Concerns

• Urinary Symptoms: These could be indicative of benign prostatic hyperplasia (BPH), prostatitis, or even prostate cancer, especially given his family history.
• Erectile Dysfunction: This can be a sign of underlying cardiovascular issues, hormonal imbalances, or psychological factors.
• Family History of Heart Disease: With a father who had a heart attack at age 50, John is at an increased risk for cardiovascular diseases.
• Family History of Prostate Cancer: His father’s diagnosis at age 75 raises the possibility that John might be at increased risk for prostate cancer.
• Recent Urinary Tract Infection (UTI): This may indicate an underlying issue such as BPH or chronic urinary retention.

Building Rapport and Trust

• Introduce Yourself and Your Role: “Hi John, I’m Dr. [Your Name], and I’m here to help you with any health concerns you might have.”
• Express Empathy: “I understand that it can be difficult to talk about these issues, but many men experience similar problems, and it’s important to address them.”

Normalize the Discussion

• Reassure Him: “John, these symptoms are quite common, and many men your age go through similar experiences. Talking about them is the first step to finding a solution.”
• Use Non-Judgmental Language: “There is no reason to feel embarrassed. These are medical issues that we can manage together.”

Use Open-ended Questions

• Explore Symptoms: “Can you tell me more about the trouble you’re having with your water works? When did you first notice these symptoms?”
• Discuss Erectile Dysfunction: “How long have you been experiencing difficulty maintaining an erection? Have you noticed any patterns or triggers?”

Prioritize Health Concerns

• Create a Shared Agenda: “Let’s make a list of the things you want to discuss today. It sounds like your urinary symptoms and erectile dysfunction are significant concerns. Is there anything else you’d like to add?”
• Family History: “Given your family history of heart disease and prostate cancer, it’s important to look at your overall health. We can do some tests to check for any potential issues.”

Provide Education and Next Steps

• Inform About Risks and Tests: “Because of your family history, we should consider checking your prostate and heart health. This might include a PSA test for your prostate and some heart health screenings.”
• Plan of Action: “How about we start with a physical exam and some blood tests? This will give us a clearer picture of what’s going on and help us decide on the next steps.”

Offer Support

• Encourage Questions: “Do you have any questions or concerns about what we’ve discussed so far?”
• Reiterate Availability: “I’m here to help, and we can address these concerns one step at a time. You’re not alone in this.”

How could you encourage him to return for a follow-up consultation with you?

• Follow-up Plan: Outline a clear follow-up plan and explain the importance of regular check-ups for monitoring and managing his health.
• Reassurance: Reassure John that you are there to support him and that follow-up visits will help ensure his well-being.
• Reminders: Use your practice’s reminder system to send John a reminder for his next appointment.

What if he was an Aboriginal or Torres Strait Islander?

• Understanding “Men’s Business”
  • Cultural Practices: “Men’s business” can involve ceremonies, rituals, and knowledge that are exclusively shared among men. These practices are deeply rooted in their cultural heritage.
  • Health Matters: In a healthcare context, “men’s business” may refer to sensitive health issues, including those related to sexual health, reproductive health, and other topics considered private among men.
• Handling “Men’s Business” in a Healthcare Setting
  • To respectfully handle “men’s business” and ensure that John feels comfortable and understood, consider the following approach:
• Building Cultural Competence
  • Cultural Awareness: Educate yourself about the specific customs and traditions of Aboriginal and Torres Strait Islander peoples. Understanding their worldview can help you provide more culturally appropriate care.
  • Seek Guidance: If unsure, seek guidance from Aboriginal or Torres Strait Islander health workers or cultural liaison officers who can provide insight into culturally appropriate practices.
• Creating a Culturally Safe Environment
  • Respect Privacy: Ensure that the consultation space is private and that John feels safe to discuss his health concerns.
  • Use Appropriate Language: Be mindful of using respectful and culturally appropriate language. Avoid medical jargon and use plain language that is easily understood.
• Engaging Respectfully
  • Acknowledge Cultural Practices: “John, I understand that there are certain aspects of health and well-being that are considered men’s business in your culture. I want to ensure we respect that during our conversation today.”
  • Ask for Preferences: “Is there anything specific you would like me to know about how we can discuss your health concerns in a way that respects your cultural practices?”
• Facilitating Discussion
  • Involve Male Health Workers: If available, offer the presence of an Aboriginal or Torres Strait Islander male health worker to support the consultation. “Would you feel more comfortable if we had [name of male health worker] join us?”
  • Open-ended Questions: “Can you tell me more about how we can address your health concerns while respecting your cultural practices?”
• Providing Support and Education
  • Educational Materials: Provide health information that is culturally appropriate and available in the patient’s language if needed.
  • Respect Decision-Making: Respect John’s decisions and preferences regarding his care, acknowledging the influence of his cultural beliefs.
• Example Conversation
  • Acknowledge and Respect: “John, I appreciate that discussing some of these issues might be sensitive. I want to respect your cultural practices and ensure you feel comfortable. How can we make this conversation easier for you?”
  • Empathy and Support: “Many men in your community face similar health concerns, and it’s important we address them together. Let’s work in a way that respects your traditions and helps you get the care you need.”

2. Clinical Information Gathering and Interpretation

What other history do you need to explore during this consultation?

• Detailed Urological History: Inquire about the duration and severity of urinary symptoms, nocturia, urgency, and incontinence.
• Sexual Health: Ask about erectile dysfunction, libido, and any related concerns.
• Cardiovascular Health: Given his family history, explore symptoms of cardiovascular disease such as chest pain, shortness of breath, and palpitations.
• Lifestyle Factors: Smoking, alcohol use, physical activity, and diet.
• Medication and Allergies: Current medications, over-the-counter drugs, and any allergies.
• Mental Health: Assess for symptoms of anxiety or depression, which could be contributing to his symptoms.

If John was 50 years old:

• Focus on Preventive Health: Emphasize screening for cardiovascular risk factors and prostate health.
• Work and Social History: Inquire about stress, occupation, and social support systems.

What examination would you like to do?

• General Examination: Assess general appearance, vital signs, and cardiovascular system.
• Abdominal Examination: Check for bladder distension, tenderness, and any masses.
• Digital Rectal Examination (DRE): Evaluate prostate size, consistency, and any nodules.
• Genital Examination: Inspect for any abnormalities, tenderness, or signs of infection.

3. Making a Diagnosis, Decision Making, and Reasoning

What diagnoses are you considering?

Potential Diagnoses

• Benign Prostatic Hyperplasia (BPH):
  • Reasoning: John’s age and urinary symptoms (trouble with “water works”) are classic signs of BPH, which is common in older men.
  • Evaluation: Digital rectal examination (DRE), urine flow studies, and measurement of post-void residual volume.
• Prostate Cancer:
  • Reasoning: Family history (father diagnosed with prostate cancer) increases his risk. Symptoms can overlap with BPH.
  • Evaluation: Prostate-specific antigen (PSA) test, DRE, and potentially a prostate biopsy if PSA levels are elevated.
• Chronic Prostatitis:
  • Reasoning: Could explain recurrent UTIs and urinary symptoms.
  • Evaluation: Urine culture, prostate fluid culture, and consideration of chronic bacterial or non-bacterial prostatitis.
• Urinary Tract Infection (UTI):
  • Reasoning: Recent hospitalization for UTI indicates susceptibility or possible underlying conditions like BPH or prostatitis.
  • Evaluation: Urinalysis, urine culture, and sensitivity tests.
• Erectile Dysfunction (ED):
  • Reasoning: Age-related changes, psychological factors, or underlying cardiovascular issues.
  • Evaluation: Detailed sexual history, hormonal profile (testosterone levels), and assessment of cardiovascular health.
• Cardiovascular Disease:
  • Reasoning: Family history of heart disease (father had a heart attack at age 50) and erectile dysfunction can be an early sign of cardiovascular problems.
  • Evaluation: Lipid profile, blood pressure monitoring, ECG, and possibly a stress test or echocardiogram.
• Diabetes Mellitus:
  • Reasoning: Can cause both urinary symptoms and erectile dysfunction.
  • Evaluation: Fasting blood glucose, HbA1c levels, and potentially an oral glucose tolerance test.
• Hormonal Imbalances:
  • Reasoning: Low testosterone or other hormonal issues can cause erectile dysfunction.
  • Evaluation: Serum testosterone levels, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels.

What diagnoses would you consider if John was 28 years old and febrile with testicular pain?

Differential Diagnoses

• Epididymitis:
  • Reasoning: Common in sexually active men. Typically presents with gradual onset of testicular pain, swelling, and often fever.
  • Evaluation: Urinalysis, urine culture, sexually transmitted infection (STI) testing (e.g., for Chlamydia trachomatis and Neisseria gonorrhoeae), and ultrasound of the scrotum.
• Orchitis:
  • Reasoning: Inflammation of the testicle often secondary to infections, can be bacterial or viral (e.g., mumps orchitis).
  • Evaluation: Similar to epididymitis with additional testing for mumps virus if clinically suspected.
• Testicular Torsion:
  • Reasoning: Urological emergency requiring prompt diagnosis and treatment. Typically presents with sudden, severe testicular pain and swelling, often without fever initially but can become febrile if delayed.
  • Evaluation: Physical examination (high-riding testis, absent cremasteric reflex), Doppler ultrasound to assess blood flow.
• Torsion of the Testicular Appendage:
  • Reasoning: Presents with acute scrotal pain, often less severe than testicular torsion, and a palpable “blue dot” sign.
  • Evaluation: Physical examination and ultrasound to rule out testicular torsion.
• Inguinal Hernia:
  • Reasoning: Herniation can cause referred pain to the testicle and may present with fever if incarcerated or strangulated.
  • Evaluation: Physical examination, ultrasound, and possibly CT scan if complicated.
• Sexually Transmitted Infections (STIs):
  • Reasoning: Younger sexually active males are at higher risk. Symptoms can overlap with epididymitis.
  • Evaluation: STI screening (urine tests, urethral swabs), including testing for Chlamydia trachomatis and Neisseria gonorrhoeae.
• Prostatitis:
  • Reasoning: Can cause referred pain to the testicles and present with fever, dysuria, and perineal pain.
  • Evaluation: Digital rectal examination, urine culture, and possibly prostate fluid culture.
• Trauma:
  • Reasoning: Recent history of testicular trauma can lead to pain, swelling, and secondary infection.
  • Evaluation: History of trauma, physical examination, and ultrasound to assess for hematoma or other complications.

4. Clinical Management and Therapeutic Reasoning

What are your priorities when managing John? How would your management change if he wanted to discuss his concerns about his erection?

• Symptom Relief: Address his urinary symptoms and erectile dysfunction.
• Screening and Prevention: Given his family history, prioritize cardiovascular and prostate health screening.
• Education and Reassurance: Provide education on his conditions and reassure him about the treatment options.

If John wanted to discuss his concerns about his erection:

• Address ED Directly: Discuss the potential causes and treatment options, including medications, lifestyle changes, and possible referral to a specialist.
• Screen for Underlying Causes: Evaluate cardiovascular health, diabetes, and hormonal levels.

What resources or guidelines could you use to determine recommended prevention strategies?

• RACGP Guidelines: Use the RACGP (Royal Australian College of General Practitioners) guidelines for preventive health strategies.
• Australian Prostate Cancer Guidelines: Refer to these for screening and management of prostate health.
• Australian Heart Foundation: For cardiovascular health management.

5. Preventive and Population Health

What advice would you give John about prostate cancer screening? How would your advice differ if he had a family history of prostate cancer?

Discuss Symptoms and Family History:

• Trouble with ‘Water Works’: His urinary symptoms and difficulty maintaining an erection could be related to prostate issues, which warrant further investigation.
• Family History: Although John’s father was diagnosed with prostate cancer at age 75, this puts John at increased risk, particularly since he is already experiencing urinary symptoms.

Recommendation for PSA and DRE:

Australia Cancer Council Guidelines on PSA Screening

• The Cancer Council Australia provides specific guidelines regarding PSA testing for prostate cancer screening. Here’s a summary of the key points from their recommendations:

General Recommendations

• Age-Based Screening:
  • Men Aged 50-69:
    • Recommendation: Men in this age group should have a detailed discussion with their GP about the potential benefits and risks of PSA testing for prostate cancer. The decision to undergo PSA testing should be made based on informed consent.
  • Men Over 70:
    • Recommendation: Routine PSA testing is not recommended for men over 70 due to the higher likelihood of harms outweighing the benefits. However, individual circumstances may warrant testing in some cases.
  • Men Under 50:
    • Recommendation: Routine PSA testing is generally not recommended for men under 50 unless they are at higher risk (e.g., those with a strong family history of prostate cancer).
• High-Risk Groups:
  • Family History:
    • Men Aged 40-45 with a Family History: Men with a first-degree relative (father, brother) who had prostate cancer, especially if diagnosed at a young age, are at higher risk. These men should discuss the potential benefits and risks of PSA testing with their GP and consider starting screening earlier, around age 45.
    • Men with Multiple Family Members Affected: Those with multiple first-degree relatives affected by prostate cancer might benefit from starting screening at age 40.
• Role of DRE in Prostate Cancer Screening
  • Supplementary to PSA Testing:
    • Combination Use: While PSA testing is the primary method for prostate cancer screening, DRE can be used as a supplementary tool. It involves a physical examination where the doctor feels the prostate through the rectum to detect abnormalities such as lumps, hard areas, or asymmetry.
    • When to Perform: DRE may be performed if the PSA level is elevated or if there are symptoms suggestive of prostate cancer, such as difficulty urinating, blood in the urine, or pelvic pain.
  • Guidelines and Recommendations:
    • Routine Screening: The Cancer Council Australia does not recommend routine DRE for all men as part of the initial screening process for prostate cancer. The primary focus is on informed decision-making regarding PSA testing.
    • Clinical Judgment: The decision to perform a DRE should be based on the clinician’s judgment and the patient’s specific circumstances, including PSA levels, age, family history, and overall health.
  • Benefits of DRE:
    • Detection of Abnormalities: DRE can detect abnormalities in the prostate that might not be indicated by PSA levels alone, potentially identifying cancers that do not elevate PSA.
    • Assessment of Prostate Size: It provides information about the size and texture of the prostate, which can help in the diagnosis of benign conditions like benign prostatic hyperplasia (BPH).
  • Limitations of DRE:
    • Sensitivity: DRE has limited sensitivity and may miss cancers, especially those located in areas of the prostate that are not easily reachable.
    • Patient Discomfort: Some patients may find the procedure uncomfortable or invasive, which can affect compliance.
• PSA Testing Protocol
  • Initial Test:
    • Discussion: Before conducting the test, men should be fully informed about the potential outcomes of PSA testing, including false positives, overdiagnosis, and the possibility of unnecessary treatments.
    • Testing: If a decision is made to proceed, a PSA blood test is performed.
  • Follow-Up Testing:
    • Frequency: If PSA testing is initiated, it is typically recommended every two years for men aged 50-69, or as advised by their GP based on individual risk factors and PSA levels.
    • Elevated PSA Levels: If PSA levels are elevated, further diagnostic procedures such as repeat PSA tests, digital rectal examination (DRE), imaging, or prostate biopsy may be recommended to confirm the presence of cancer.
• Benefits and Risks
  • Benefits:
    • Early detection of prostate cancer can potentially lead to more effective treatment and better outcomes.
    • PSA testing may identify cancer at an earlier, more treatable stage.
  • Risks:
    • Overdiagnosis: Some prostate cancers detected by PSA testing may never cause symptoms or become life-threatening, leading to unnecessary treatment and associated side effects.
    • False Positives/Negatives: Elevated PSA levels can result from conditions other than cancer, such as benign prostatic hyperplasia (BPH) or prostatitis, leading to unnecessary anxiety and invasive procedures. Conversely, some cancers may not elevate PSA levels.
    • Treatment Side Effects: Treatments for prostate cancer, such as surgery or radiation, can have significant side effects, including incontinence and erectile dysfunction.

With Family History:

• For men with a family history of prostate cancer, such as John:
• Start Screening Earlier:
  • Age 45-69: Men with a first-degree relative diagnosed with prostate cancer are generally recommended to start screening at age 45.
  • More Frequent Screening: Depending on initial PSA results, more frequent monitoring may be recommended.
• Increased Vigilance:
  • Higher Risk: Emphasize the importance of regular screenings due to the increased risk of developing prostate cancer.
  • Personalized Plan: Discuss a personalized screening plan based on his specific risk factors and any symptoms he is experiencing.

If John was an Aboriginal or Torres Strait Islander, what specific challenges or barriers might he have in seeking healthcare?

• Access to Care: Barriers such as distance, cultural differences, and trust in healthcare providers.
• Cultural Competence: Ensure culturally competent care and possibly involve Aboriginal health workers.
• Socioeconomic Factors: Address potential financial and social barriers.

What other opportunistic screening would you recommend for John?

1. Cardiovascular Risk Assessment

• Blood Pressure: Regular monitoring, at least every 2 years, or more frequently if elevated.
• Cholesterol Levels: Lipid profile every 5 years, or more frequently if elevated or if there are other risk factors.
• Blood Glucose Levels: Fasting blood glucose or HbA1c every 3 years for those at risk of diabetes.

2. Diabetes Screening

• HbA1c or Fasting Glucose: Every 3 years for individuals aged 40 and over, particularly if they are overweight or have other risk factors.

3. Colorectal Cancer Screening

• FOBT (Fecal Occult Blood Test): Every 2 years for individuals aged 50 to 74. This is part of the National Bowel Cancer Screening Program.
• Colonoscopy: Recommended if FOBT results are positive or if there is a significant family history of colorectal cancer.

4. Prostate Cancer Screening

• PSA Testing and DRE:
  • Discussion-Based: PSA testing is not routinely recommended for all men without symptoms. Men aged 50-69 should have a detailed discussion with their GP about the benefits and risks of PSA testing.
  • High-Risk Individuals: Men with a family history of prostate cancer should discuss PSA testing starting at age 45.

5. Bone Health Assessment

• DEXA Scan: Bone mineral density testing for osteoporosis is recommended for men aged 70 and over, or earlier if there are risk factors such as previous fractures or long-term steroid use.

6. Vision and Hearing Screening

• Eye Exam: Regular eye examinations are recommended for adults over 65 to screen for glaucoma, cataracts, and age-related macular degeneration.
• Hearing Test: Regular hearing checks are advisable, especially if there are symptoms of hearing loss.

7. Renal Function Assessment

• Kidney Function Tests: eGFR and serum creatinine should be monitored regularly, particularly if there are risk factors such as hypertension or diabetes.

8. Liver Function Tests

• Liver Enzymes: Periodic testing of liver function, particularly if there are risk factors like excessive alcohol use or medications affecting the liver.

9. Vaccinations

• Influenza Vaccine: Annual vaccination.
• Pneumococcal Vaccine:
  • Pneumococcal Conjugate Vaccine (PCV13): Once after age 65.
  • Pneumococcal Polysaccharide Vaccine (PPSV23): Once after age 65, at least one year after PCV13.
• Shingles Vaccine: Recombinant zoster vaccine (Shingrix) recommended for adults aged 70 and over.
• Tetanus, Diphtheria, and Pertussis (Tdap) Booster: Every 10 years.

10. Mental Health Screening

• Depression and Anxiety Screening: Routine screening using tools like the PHQ-9 for depression and the GAD-7 for anxiety, especially if there are symptoms or risk factors.

11. Lifestyle and Social Factors

• Smoking Cessation Counseling: If John smokes, provide support and resources to quit.
• Alcohol Use Assessment: Screen for excessive alcohol use and provide appropriate interventions.

6. Professionalism

How would you deal with any personal beliefs or attitudes if John was engaging in behavior that you found unacceptable?

• Non-judgmental Approach: Maintain a non-judgmental and professional attitude regardless of John’s behaviors.
• Patient-Centered Care: Focus on providing the best care based on medical evidence and the patient’s needs.

What if John was 20 years old and requested a testosterone injection for muscle building?

• Ethical Considerations: Explain the risks and long-term consequences of non-medical use of testosterone.
• Evidence-Based Practice: Advise against the use and suggest safer alternatives for muscle building, such as proper diet and exercise.

7. General Practice Systems and Regulatory Requirements

What systems do you have in place to make sure that John returns for the results of any investigations you order?

• Reminder Systems: Use electronic health record (EHR) reminders, phone calls, or letters to ensure John returns for results.
• Follow-up Appointments: Schedule follow-up appointments before John leaves the clinic.

What monitoring do you need to consider for a man requiring ongoing testosterone supplementation for medical need?

1. Regular Blood Tests

• Testosterone Levels:
  • Frequency: Every 3-6 months initially, then annually once stable.
  • Purpose: To ensure testosterone levels are within the therapeutic range and adjust dosing as necessary.
• Hematocrit and Hemoglobin:
  • Frequency: Every 3-6 months initially, then annually.
  • Purpose: To monitor for polycythemia (elevated red blood cell count), which can increase the risk of thrombosis. Hematocrit levels should ideally remain below 54%.
• Prostate-Specific Antigen (PSA):
  • Frequency: Every 3-6 months for the first year, then annually.
  • Purpose: To monitor for any potential prostate abnormalities, including prostate cancer, as testosterone therapy can stimulate prostate tissue.
• Liver Function Tests:
  • Frequency: Annually or as clinically indicated.
  • Purpose: To monitor liver function, especially if oral testosterone formulations are used, as they can affect liver enzymes.
• Lipid Profile:
  • Frequency: Annually.
  • Purpose: To monitor changes in cholesterol levels, as testosterone supplementation can affect lipid metabolism.
• Bone Density:
  • Frequency: Every 1-2 years.
  • Purpose: To monitor for osteoporosis, especially in men with risk factors or those who have been hypogonadal for a long time.

2. Regular Clinical Assessments

• Side Effects and Complications:
  • Frequency: Every 3-6 months initially, then annually or as needed.
  • Common Side Effects: Acne, breast tenderness or enlargement (gynecomastia), sleep apnea, and fluid retention.
  • Complications: Monitor for signs of cardiovascular events (e.g., heart attack, stroke), polycythemia, and worsening of benign prostatic hyperplasia (BPH) symptoms.

8. Procedural Skills

If John presented to your local rural emergency department with urinary retention, how would you explain to him the need to insert a urinary catheter and how it would be done? Do you need to upskill in this procedure?

• Explanation: Describe the need to relieve urinary retention and the procedure steps in simple terms.
• Reassurance: Reassure about the safety and comfort measures taken during the procedure.
• Upskilling: If needed, seek additional training or refresher courses on catheterization.

9. Managing Uncertainty

How would you manage John while waiting for the results of investigations?

• Symptomatic Treatment: Provide treatment to alleviate symptoms while awaiting definitive results.
• Clear Communication: Keep John informed about the process and expected timelines for results.

How would you approach and manage a consultation with a man who thinks that his recent low testosterone levels are the cause of his tiredness?

• Comprehensive Evaluation: Assess for other causes of tiredness and low energy, such as thyroid dysfunction, anemia, or depression.
• Patient Education: Discuss the multifactorial nature of tiredness and the potential role of lifestyle changes.

10. Identifying and Managing the Significantly Ill Patient

What if John presented to you with a fever and in urinary retention?

• Immediate Management: Assess and manage the acute situation, including possible sepsis.
• Hospital Admission: Consider admitting John to the hospital for further investigation and treatment, including IV antibiotics and catheterization.