Men's health - Special interest

Most men with testicular cancer present with a lump that they have identified in their scrotum. Although the scrotal swelling is usually painless, pain is the first symptom in around 20% of patients, typically a dull or dragging ache in the testicle or a heaviness in the scrotum. NICE recommends that all men who have a non-painful enlargement or change in shape or texture of their testis should be referred urgently to urology using the two-week wait pathway. In men who have unexplained or persistent testicular symptoms, an urgent direct access testicular ultrasound scan should be requested. 

Men born after 1960 in the UK now have a 1 in 6 estimated lifetime risk of being diagnosed with prostate cancer. NICE recommends that men over 50 years old who request a PSA test should be fully counselled about the test beforehand. The test should also be offered to men with LUTS or an abnormal DRE. If the prostate feels malignant on DRE this should trigger a fast track referral to secondary care, via a suspected cancer pathway referral, even if the PSA is normal. Men with PSA values above the age-specific reference range should also be referred to urology urgently, via a suspected cancer pathway referral.

Nocturia can be a symptom of an underlying disease process or behavioural. The history should not just focus on lower urinary tract symptoms but should also include past medical history, current medications and fluid intake. It is important to ask specifically about the onset and progression of symptoms, and to what extent the patient is troubled by the nocturia. An abdominal examination should always be performed and should exclude urinary retention. A digital rectal examination of the prostate should also be offered.

Urinary retention is the most common urological emergency and more than 95% of cases occur in men. Acute urinary retention (AUR) is defined as the sudden inability to pass any urine voluntarily associated with a painful, palpable or percussable bladder. In chronic urinary retention (CUR) there is a non-painful bladder, which remains palpable or percussable after the man has passed urine, with a post-void residual volume > 300 ml. In acute on chronic urinary retention no urine can be voluntarily passed but the condition is relatively painless and the residual volume on catheterisation is > 1.5 litres.

Androgens play a crucial role in bone, muscle and fat metabolism, erythropoiesis and cognitive health. In men aged 40-79 years the incidence of biochemical deficiency and symptomatic hypogonadism is 2.1-5.7%. Decreased libido or reduced frequency and quality of erections, fatigue, irritability, infertility or a diminished feeling of wellbeing may be presenting complaints. However, a significant proportion of men with androgen deficiency will be identified when they present for unrelated concerns.

The prostate specific antigen (PSA) test clearly provides the opportunity for clinically relevant prostate cancer to be detected at a stage when treatment options are greater and outcomes may be improved. In addition, a raised PSA may often indicate benign prostatic enlargement, and this may provide an opportunity for treatment of this condition before complications develop. However, in some patients the PSA test may lead to investigations which can identify clinically insignificant cancers which would not have become evident in a man’s lifetime.