Men's health

31 Pages·2016·3.74 MB·English

Independent learning program for GPs
Independent learning program for GPs
Unit 532 October 2016
Men’s health
www.racgp.org.au/check
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TThimise iss fao rv iisnudaivl idreuparle psaetnietanttiso nw oilln vlya royf. aP lpeaatsieen rte afet rs ttoe athdey sPtraotdeu scpt eIncfifoicrm inajteiocntio fnosr . d osing instructions.
Long acting Reandron® 10001*
*An average of 4–5 injections per year usually
maintains serum levels of testosterone within the physiological range.1
Diagnosis of testosterone deficiency should be made only in men with
consistent symptoms and signs and unequivocally low serum testosterone levels2
Reandron® 1000 (Minimum Product Information) Reandron 1000 (testosterone undecanoate) 1000 mg/4 mL, solution for injection. Indication: Testosterone replacement in primary
and secondary male hypogonadism. Dose: 1 ampoule/vial injected i.m every 10-14 weeks into gluteal muscle. The first injection interval may be reduced to a minimum of 6 weeks to
achieve steady-state testosterone levels more rapidly. Contraindications: Androgen-dependent prostate/breast carcinoma, hypercalcaemia accompanying malignant tumours,
hypersensitivity to testosterone undecanoate or the excipients, past or present liver tumours, use in women. Precautions: Regular prostate/breast and haemoglobin/haematocrit
monitoring. Patients with diabetes, bleeding or coagulation disorder, predisposed to oedema, hypertension, epilepsy or migraine, severe cardiac/hepatic/renal insufficiency. Potentiation
of pre-existing sleep apnoea. Effect on doping tests. Inject strictly i.m and very slowly to avoid pulmonary oily microembolism. Interactions: Hypoglycaemic agents, inducers of microsomal
enzymes (e.g. barbiturates), oxyphenabutazone, cyclosporin, oral anticoagulants, thyroid laboratory tests. Adverse Effects: Polycythaemia, weight increased, acne, PSA increased,
prostate examination abnormal, benign prostate hyperplasia, hot flush, various kinds of injection site reactions, suspected anaphylactic reactions. For other events refer to full PI.
Date of most recent amendment: 29 November 2013. References: 1. Reandron Product Information November 2013. 2. Bhasin S et al. Testosterone Therapy in Men with Androgen
Deficiency Syndromes: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, June 2010, 95(6):2536–2559.
PBS Information: Authority required. Refer to PBS Schedule for full information.
PLEASE REVIEW FULL PRODUCT INFORMATION BEFORE PRESCRIBING. Full Product Information is available
on request from Bayer Australia Ltd, or can be accessed from http://www.bayerresources.com.au/resources/
uploads/PI/file9425.pdf
Bayer Australia Ltd. ABN 22 000 138 714, 875 Pacific Highway, Pymble NSW 2073. ® Registered Trademark of the Bayer Group, Germany. L.AU.MKT.WH.07.2015.0585. July 2015.
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Independent learning program for GPs
Independent learning program for GPs
Men’s health
Unit 532 October 2016
About this activity 2
Acronyms 3
Case 1 Jeremy and Christina are trying for a child 4
Case 2 Ethan requests an HIV test 8
Case 3 Allan has just turned 40 13
Case 4 Steve has a rash 17
Case 5 Sebastian asks for a health check 21
Multiple choice questions 26
The five domains of general practice
C ommunication skills and the patient–doctor relationship
Applied professional knowledge and skills
Population health and the context of general practice
Professional and ethical role
Organisational and legal dimensions
ABOUT THIS ACTIVITY check Men’s health
ABOUT THIS ACTIVITY conducting research on the economic evaluations of innovative strategies
Australian general practitioners (GPs) are less likely to see male than to control HIV/STIs in Australia, Asia and Africa.
female patients, as they accounted for only 43.1% of all patient encounters Tim Senior (Case 3) BA (Hons), BMBCh, MRCGP, FRACGP, DTM&H,
in 2013–14.1 However, men in Australia are known to be less healthy DCH, is a general practitioner at an Aboriginal community controlled
than women, and have a life expectancy that is five years shorter than health service and the medical advisor in RACGP Aboriginal and Torres
their female counterparts.2 Australian men are also more likely to carry Strait Islander Health.
more burden of illness, compared with women.3 Ie-Wen Sim (Case 1) MBBS(Hons), BMedSci, FRACP, is an andrologist
In 2013, 86.9% of newly diagnosed human immunodeficiency virus (HIV) at Monash IVF and currently holds public appointments at Monash Health,
infections in Australia were in men.4 It is hoped that the introduction of Eastern Health and Western Health, as well as being a lecturer at the
pre-exposure prophylaxis (PrEP) may decrease this figure.5 According to University of Melbourne and adjunct senior lecturer at Monash University.
Bettering the Evaluation and Care of Health (BEACH) data, three out of Dr Sim graduated from the University of Melbourne with first class honours
every 100 patient encounters in general practice were for pregnancy and before undertaking a clinical fellowship in andrology and reproductive
family planning issues, and 1.2 for the male genital system.1 endocrinology and PhD studies in osteoporosis. He has authored numerous
While screening asymptomatic men for prostate cancer with prostate- publications and is a reviewer for reputed bone and andrology journals.
specific antigen (PSA) testing is currently not recommended, GPs need BK Tee (Case 2) MBChB, FRACGP, is the clinical director of the Centre
to recognise when PSA testing could be considered in those who are at Clinic, Victorian AIDS Council. He has a special interest in HIV medicine
high risk of developing the disease.6 The rates of sexually transmissible and healthcare of the lesbian, gay, bisexual and transgender (LGBT)
infections (STIs) are rising in Australia, where infectious syphilis has community. Dr Tee is an investigator in the VicPREP and PREPX studies.
increased from 6.1% in 2008 to 6.7% in 2012 among men.7 Simon Willcock (Case 5) MBBS (Hons 1), PhD, FRACGP, GAICD, is a
Aboriginal and Torres Strait Islander men’s health is among the worst of general practitioner and the clinical director of primary care at the
any subgroup in Australia, and this can be attributed to complex and Macquarie University Hospital. His education and research interests include
multifactorial reasons. the health of doctors, generational change in the medical workforce,
This edition of check considers the management and treatment of various men’s health and musculoskeletal medicine. Professor Willcock trained
conditions specific to men in general practice. as a rural procedural GP, and practiced in Inverell, NSW where his practice
included obstetrics and anaesthetics. For the past 20 years, he has worked
in academic and clinical practice in Sydney and has had a number of
LEARNING OUTCOMES
educational leadership roles. Professor Willcock is currently the chair of
At the end of this activity, participants will be able to: the Avant Mutual Group and a board member of the Sydney North Health
• outline the assessment of and investigations for male fertility Network, the NSW Doctors’ Health Advisory Service and a member of the
NSW Australian Medical Association’s Council of General Practice.
• summarise the investigations and treatment of patients exposed
to human immunodeficiency virus
• describe the diagnosis and management of syphilis PEER REVIEWERS
Vincent Cornelisse BSc (Hons), MBBS, FRACGP, is a general practitioner
• discuss the health assessment for Aboriginal and Torres Strait
and advanced registrar in sexual health at the Prahran Market Clinic in
Islander men
Melbourne. He is also a PhD candidate at the Melbourne Sexual Health
• list the current recommendations for prostate cancer screening.
Centre, Monash University.
Robert Menz MBBS, FRACGP, MClinEdu has been a general practitioner
AUTHORS
in the inner eastern Adelaide suburbs since 1980. He also has wide
Robert McLachlan (Case 1) MBBS (Hons), FRACAP, PhD, is director of experience in non-clinical aspects of medicine through organisations
Andrology Australia, a federal government initiative committed to research such as The Royal Australian College of General Practitioners (RACGP),
and community and professional education in male reproductive health. Australian Medical Association (AMA), Australian General Practice
He is a principal research fellow at Hudson Institute of Medical Research Accreditation Limited (AGPAL), Divisions of General Practice and National
and consultant endocrinologist at the Monash Medical Centre. Professor Primary Care Collaborative (NPCC). From 2001 to 2014, Dr Menz was
McLachlan is consultant andrologist to the Monash IVF Group, a past a senior medical adviser for the Commonwealth Department of Human
president of the Fertility Society of Australia, and a consultant to the Services (DHS). This role provides advice, education and stakeholder
World Health Organization on male fertility regulation. His clinical and engagement as part of the Health Professionals Branch and a professional
research interests are in the area of male reproductive health, especially link between the DHS and the medical profession. Dr Menz is the RACGP
in fertility and androgen physiology. Corlis Fellow for South Auatralia and the Northern Territory. He has been
Jason Ong (Case 4) PhD, MMed (Hons), FRACGP, MBBS, is a sexual an RACGP examiner since 1984 and was censor for SA/NT from 1997
health physician and general practitioner based at the Melbourne Sexual to 2003. He was an RACGP nominee to the AGPAL board from 2000 to
Health Centre. He is a National Health and Medical Research Council 2006, and is still a surveyor. Dr Menz was on SA/NT AMA branch council
(NHMRC) postdoctoral research fellow based at Monash University and and chaired the Council of General Practice in 1992–93. He remains on
the London School of Hygiene and Tropical Medicine, where he is the editorial committee. Dr Menz teaches undergraduate medical students
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check Men’s health CASE 1
at Flinders University, general practice registrars through NTGPE, and is REFERENCES
a medical educator for the RACGP. 1. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2013–14.
General practice series no. 36. Sydney: Sydney University Press, 2014. Available at
Kali Hayward MBBS, FRACGP, is a descendent of the Warnman people
http://ses.library.usyd.edu.au/handle/2123/11882 [Accessed 26 November 2015].
of Western Australia. She graduated from the University of Adelaide with
2. Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: AIHW, 2014.
an MBBS in 2005 and obtained her FRACGP in 2010. Dr Hayward currently Available at www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129548150
works as a general practitioner at Nunkuwarrin Yunti Inc, the largest [Accessed 26 November 2015].
Aboriginal community controlled health service in South Australia. Dr 3. Australian Institute of Health and Welfare. Australian burden of disease study: Fatal
burden of disease 2010. Australian burden of disease study series no. 1. Cat. no.
Hayward works as an Aboriginal medical educator/cultural mentor for GPEx
BOD 1. Canberra: AIHW, 2015. Available at www.aihw.gov.au/WorkArea/DownloadAsset.
in South Australia and is currently the president of the Australian Indigenous aspx?id=60129550178 [Accessed 26 November 2015].
Doctors Association. She mentors Aboriginal and Torres Strait Islander 4. Kirby Institute. HIV in Australia: Annual surveillance report 2014 supplement. Sydney:
medical students and general practice registrars. Dr Hayward has been Kirby Institute and University New South Wales, 2014. Available at https://kirby.unsw.
edu.au/sites/default/files/hiv/resources/HIVASRsuppl2014_online.pdf [Accessed 26
heavily involved with the Indigenous GP Registrar Network (IGPRN) and the November 2015].
RACGP’s Indigenous Fellowship Excellence Program (IFEP). She is a member 5. Burnet Institute. The PREPX study. Melbourne: Burnet Institute, 2016.
of RACGP Aboriginal and Torres Strait Islander Health Education Committee. 6. Cancer Council of Australia. Community Care and Population Health Principal Committee
Dr Hayward was the recipient of the GPET Aboriginal and Torres Strait of the Australian Health Ministers’ Advisory Council; NHMRC summary of the evidence.
Sydney: Cancer Council, 2014.
Islander Health award in 2011 and received the South Australian Premier’s
7. Department of Health. Don’t risk a STI – Always use a condom. Canberra: DoH, 2014.
National Aboriginal and Islander Day Observance Committee (NAIDOC)
Available at www.sti.health.gov.au/internet/sti/publishing.nsf/Content/syphilis [Accessed
award in 2015. 18 August 2016].
ACRONYMS
ACCHS Aboriginal community controlled health service MSM men who have sex with men
ART assisted reproductive technology MSU mid-stream urine
ARV antiretroviral medications NAAT nucleic acid amplification test
ASHM Australasian Society for HIV, Viral Hepatitis NHMRC National Health and Medical Research Council
and Sexual Health Medicine PBS Pharmaceutical Benefits Scheme
AUSDRISK Australian type 2 diabetes risk assessment tool PCR polymerase chain reaction
BEACH Bettering the Evaluation and Care of Health PEP post-exposure prophylaxis
BMD bone mineral density PHI prostate health index
BMI body mass index PHN Primary Health Network
BSL blood sugar level PIP Practice Incentives Program
CI confidence interval PrEP pre-exposure prophylaxis
CLIA chemiluminescence immunoassay PSA prostate-specific antigen
COPD chronic obstructive pulmonary disease RACGP The Royal Australian College of General Practitioners
CROI Conference on Retrovirus and O pportunistic Infections RPR rapid plasma reagin
DRE digital rectal examination SMS short message service
eGFR estimated glomerular filtration rate SNAP smoking, nutrition, alcohol, physical activity
FSH follicle stimulating hormone STI sexually transmissible infection
FTC emtricitabine STIGMA Sexually Transmissible Infections in
GP general practitioner Gay Men Action Group
HIV human immunodeficiency virus T2DM type 2 diabetes mellitus
IHI Indigenous Health Incentive TDF tenofovir disoproxil fumarate
LGBT lesbian, gay, bisexual, transgender TGA Therapeutic Goods Administration
LH luteinizing hormone TPPA Treponema pallidum passive particle agglutination
MBS Medicare Benefits Schedule VDRL venereal disease research laboratory
MRI magnetic resonance imaging WHO World Health Organization
3
CASE 1 check Men’s health
QUESTION 2
CASE 1
What further questions would you ask Jeremy?
JEREMY AND CHRISTINA ARE TRYING
FOR A CHILD
Christina, 29 years of age, comes to see you because
she and her partner Jeremy, also 29 years of age, have
been trying to conceive for eight months. Christina has
had regular menstrual cycles since stopping the
combined oral contraceptive pill nine months ago. She
has been actively monitoring her cycles and believes
Jeremy and she are having appropriately timed
intercourse. You establish that intercourse has been
occurring every second day over the fertile week.
QUESTION 1
How long after a couple had tried unsuccessfully to conceive would you
order investigations? What initial assessments would you perform? FURTHER INFORMATION
Your questions do not identify any risk factors for infertility, as Jeremy
answers ‘no’ to all except the question about his operation. He is
unsure of the nature of the operation he had when he was a young
child.
QUESTION 3
What are your thoughts so far? What examination needs to be performed
now?
FURTHER INFORMATION
Christina agrees to make an appointment for both of them the following
week.
Jeremy is a plumber. He does not smoke or drink, and attends the
gym regularly. He appears to be in excellent health. There is nothing
in his past medical history except a ‘groin operation’ when very young,
but he cannot provide any details.
Jeremy is fit and well, and has a normal body mass index (BMI).
A general examination is unremarkable.
FURTHER INFORMATION
Jeremy’s examination reveals:
• normal body/facial hair distribution and no gynaecomastia
• bilateral inguinal scars are noted
• testes: using an orchidometer, his testes are 10 mL in volume and
of normal texture. Testicular volumes of between 15 and 35 mL
would be considered normal in adulthood1
4
check Men’s health CASE 1
• epididymides: normal FURTHER INFORMATION
• vas deferens: normal Jeremy’s reproductive hormone levels are:
• varicoceles: none present • luteinizing hormone (LH): 12 IU/L (reference range: 1–8 IU/L)
• no penile abnormalities. • follicle stimulating hormone (FSH): 13 IU/L (reference range:
Jeremy’s testes are reduced in size. He has no symptoms of androgen 1–8 IU/L)
deficiency but you are aware that he is at increased risk and that • serum total testosterone levels: 10.5 nmol/L (reference range:
Jeremy may not recognise its features because of their chronicity. 9–29 nmol/L).
Jeremy returns to see you a week later for his semen analysis results
(Table 1).
QUESTION 5
Table 1. Jeremy’s semen analysis report
How do you interpret these hormone results?
Jeremy’s result Normal2
Volume of semen 3.2 mL ≥1.5 mL
Sperm concentration 1 million/mL ≥15 million per mL
Sperm motility 12% ≥40% motile within 60
minutes of ejaculation
Sperm morphology 2% normal ≥4% (ie percentage
(shape) normal)
pH 7.9 ≥7.2
White blood cells Nil <1 million cells per mL
Sperm antibodies Immunoglobulin G <50% motile sperm QUESTION 6
(IgG) – not detected showing antibody activity
What is your management plan?
Immunoglobulin A
(IgA) – not detected
Jeremy tells you that he asked his mother about the surgery he had
when he was younger, and she said that it was for undescended
testes (cryptorchidism).
You explain his sperm concentration is low and that his sperm showed
reduced motility and percentage of perfectly shaped sperm. These
changes are often associated with a marked decrease in fertility.
You explain to Jeremy that the semen analysis must be repeated in
a few weeks at a specialised laboratory (often affiliated with a fertility
program). FURTHER INFORMATION
Jeremy’s ultrasound scan came back normal.
QUESTION 4
What are the long-term health implications of undescended testes? QUESTION 7
Why should undescended testes be corrected?
Is there anything else you can offer Jeremy and Christina? What options
are available through an assisted reproductive technology (ART) clinic?
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CASE 1 check Men’s health
ANSWER 4
CASE 1 ANSWERS
Jeremy’s undescended testes were noted at six months of age and
surgically corrected.
Undescended testes are linked to:3,5
ANSWER 1 • testicular cancer
Most healthy couples conceive within 12 months; however, basic • androgen deficiency
investigations of both partners should be performed immediately when
• infertility (see ‘Resources for doctors and patients’).
risk factors are identified.3
Undescended testes are common in premature babies and are seen in
For women, history should include menstrual history, previous fertility
about 5% of full-term infants, but often descend spontaneously. If
and use of contraception. Initial assessment would be to perform a Pap
persisting at six months, surgery is recommended. Correction reduces
test and arrange to check her day 21 progesterone level, check rubella the risk of later cancer but may not enhance fertility prospects.6,7
and chickenpox immunity, and ensure she is taking a folate supplement.
Undescended testes must be distinguished from retractile testes and
You should explain to Christina that Jeremy will also need to be assessed
absent testes.
for risk factors. Male infertility is the second biggest factor after maternal
age in affecting the chances of conception.4
ANSWER 5
For men, risk factors for infertility include:3
Jeremy’s elevated serum FSH levels points to severely impaired
• a past history of chemotherapy
spermatogenesis. There are many congenital and acquired causes but
• undescended testes it is commonly seen in men with a past history of cryptorchidism even
• previous testicular trauma or infection. after corrective surgery.8,9
Semen analysis should be considered at presentation to avoid frustration The borderline testosterone and mildly elevated LH levels indicate reduced
of a late diagnosis of severe male infertility. testosterone secretory ability. Jeremy’s results suggest borderline but
as yet asymptomatic androgen deficiency, but this may become clinically
apparent in the future.
ANSWER 2
Specific questions to consider for Jeremy are:
ANSWER 6
• Has he previously fathered any children?
You explain to Jeremy and Christina that Jeremy has had a problem with
• Has he ever been diagnosed with swollen testes?
testicular development leading to undescended testes and now infertility.
• Has he ever had severe trauma to his testes? While his fertility is greatly reduced, couples such as Jeremy and Christina
• Has he used anabolic steroids or opioids? still have about a 30% chance of conceiving naturally over the next two
to three years.
• Has he had any sexually transmissible infections (STIs) or urinary
tract infections? You should refer them to a fertility specialist associated with an ART clinic
who can explain the different treatment options.
• What was the nature of his groin operation?
You should arrange for Jeremy to have a testicular ultrasound and explain
• Has he ever used anabolic steroids?
that while his risk of testicular cancer is low, it is much higher than the
• Does he have any problems with erections or ejaculation?
general population.10 Testicular ultrasound is able to detect testicular
• Does he have low libido or energy? lesions as small as 1–2 mm in diameter.
• Does he have mood problems? You should also educate Jeremy about regular testicular self-examinations
and ask him to present early if any lumps appear.
ANSWER 3
In the setting of infertility, an examination of Jeremy’s genitals and ANSWER 7
secondary sexual characteristics is mandatory (see ‘Resources for doctors It is important for general practitioners (GPs) to be available for counselling
and patients’). A reduction in the size of the testes suggests a and follow-up of patients going through fertility treatment, and in this
spermatogenic problem. Identification of inguinal scars would be consistent case, review Jeremy’s androgen status in the long term (see ‘Resources
with the history of a previous groin operation and suggest a past history for doctors and patients’).
of undescended testes.
Treatment to restore sperm output is not available, but if any motile sperm
You should also arrange for Jeremy to have semen tests, preferably at are found, couples can frequently achieve pregnancy using intracytoplasmic
a laboratory that provides onsite collection and uses World Health sperm injection.11
Organization (WHO) guidelines (Table 1).2 Jeremy should abstain from Finally, even in patients with overt symptomatic testosterone deficiency,
ejaculation two to five days prior to collection (see ‘Resources for doctors testosterone therapy should not be considered until fertility aspirations
and patients’). have been exhausted. Exogenous testosterone is contraindicated in men
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check Men’s health CASE 1
seeking fertility due to its potent contraceptive effect through the
suppression of gonadotrophin secretion.
RESOURCES FOR DOCTORS AND PATIENTS
• Andrology Australia, Fact sheet – Male infertility, www.andrologyaustralia.
org/wp-content/uploads/Factsheet_MaleInfertility.pdf
• Andrology Australia, Fact sheet – Undescended testes,
www.andrologyaustralia.org/wp-content/uploads/Factsheet_
UndescendedTestes.pdf
• Andrology Australia, Clinical summary guide – No 3: Adulthood.
Examination of male genitals and secondary sexual characteristics,
www.andrologyaustralia.org/wp-content/uploads/clinical-summary-
guide-03.pdf
• Andrology Australia, Clinical summary guide – No 5: Male infertility,
www.andrologyaustralia.org/wp-content/uploads/clinical-summary-
guide-05.pdf
REFERENCES
1. Prader A. Testicular size: Assessment and clinical importance. Triangle 1966;7(6):240−43.
2. World Health Organization. WHO laboratory manual for the examination and processing
of human semen. 5th edn. Geneva: WHO, 2010.
3. Sim I-W, McLachlan R. Clinical review – Male infertility: Pull-out and keep update.
Medical Observer. August 2015:15–20.
4. Quinn F. ‘We’re having trouble conceiving…’. Aust Fam Physician 2005;34(3):107–10.
5. Jungwirth A, Diemer T, Dohle A, et al. European Association of Urology guidelines on
male infertility. Arnhem, The Netherlands: EAU, 2015.
6. Chan E, Wayne C, Nasr A. Ideal timing of orchiopexy: A systematic review. Pediatr Surg
Int 2014;30(1):87–97.
7. Hanerhoff BL, Welliver C. Does early orchidopexy improve fertility? Transl Androl Urol
2014;3(4):370–76.
8. Kogan SJ. Fertility in cryptorchidism. An overview in 1987. Eur J Pediatr
1987;147(Suppl 2):S21.
9. van Brakel J, Kranse R, de Muinck Keizer-Schrama SM, et al. Fertility potential in a
cohort of 65 men with previously acquired undescended testes. J Pediatr Surg
2014;49(4):599–605.
10. Lip SZ, Murchison LE, Cullis PS, Govan L, Carachi R. A meta-analysis of the risk of boys
with isolated cryptorchidism developing testicular cancer in later life. Arch Dis Child
2013;98(1):20–26.
11. Johnson LN, Sasson IE, Sammel MD, Dokras A. Does intracytoplasmic sperm injection
improve the fertilization rate and decrease the total fertilization failure rate in couples
with well-defined unexplained infertility? A systematic review and meta-analysis. Fertil
Steril 2013;100(3):704–11.
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