AKT – Men’s health

Peter Wainwright, aged 68, presents for review after routine screening showed a PSA level of 6.2 ng/mL. He is asymptomatic and has no urinary symptoms. He has no personal or family history of prostate cancer. DRE reveals a mildly enlarged, smooth prostate without nodules.

Relevant Past history: Hypertension, hyperlipidaemia

Medications: Ramipril, atorvastatin

What is the most appropriate next step?

Daniel Conroy, aged 54, presents complaining of a three-month history of reduced libido, tiredness and occasional erectile dysfunction. He is otherwise well. His weight has been stable and he denies any mood symptoms or sleep disturbance.

Past History: Nil of note

Medications: Nil

Examination: BMI 26, testicular examination normal

Investigations: Morning total testosterone 6.1 nmol/L (ref 10–30), LH elevated

What is the most likely diagnosis?

Tom Delaney, aged 45, presents for a general check-up. He has no symptoms and no significant medical history. He is concerned because his brother was diagnosed with testicular cancer at age 38.

Social history: Non-smoker, drinks 10 standard drinks per week

Examination: Normal testes with no palpable masses or asymmetry

What is the most appropriate advice to give Tom?

Jeremy O’Neill, aged 36, presents with his partner seeking pre-conception advice. They have been trying to conceive for 12 months. He has no significant past history. His partner has a normal menstrual cycle. Semen analysis shows low sperm count and low motility.

Social history: Previously played competitive rugby, had testicular trauma at age 20

What is the most appropriate next step in Jeremy’s assessment?

George O’Malley, aged 76, presents with his daughter due to increasing confusion and urinary incontinence over the past month. He has a background of benign prostatic hyperplasia. His daughter notes he has had two recent falls.

Medications: Tamsulosin, sertraline

Examination: GCS 15, no focal neurology, wide-based gait. MMSE 23/30

CT brain: Ventriculomegaly out of keeping with sulcal atrophy

What is the most likely diagnosis?

Michael Travers, aged 59, presents with new onset left breast swelling and tenderness. He noticed it about three weeks ago. There is no nipple discharge or skin changes. He is otherwise well.

Medications: Spironolactone for hypertension

Examination: Unilateral tender enlargement of the left breast with no mass or lymphadenopathy

What is the most likely cause of his presentation?

Andrew Mahoney, aged 51, presents with difficulty initiating urination and a weak stream. He also wakes twice at night to urinate. There is no haematuria, dysuria or weight loss.

Examination: Abdomen soft, bladder not palpable. DRE reveals an enlarged, smooth prostate

What is the most appropriate next step in management?

Stephen Ngata, aged 47, presents with concerns about erectile dysfunction for the past 6 months. He is in a stable relationship. He denies morning erections and reports low libido. He has a history of type 2 diabetes.

Medications: Metformin, gliclazide, amlodipine

Examination: BMI 33, BP 142/90, testicular exam normal

What is the most appropriate initial investigation?

Liam Fraser, aged 19, presents with acute left testicular pain that began suddenly two hours ago. He has vomited once. There is no history of trauma.

Examination: Left hemiscrotum is tender, elevated and the cremasteric reflex is absent

What is the most appropriate next step?

Nigel Lawton, aged 62, presents with a 2-month history of perineal discomfort and urinary frequency. He reports occasional dysuria but no haematuria. Symptoms are worse after long periods of sitting. He denies fever or rigors.

Examination: Prostate non-tender but mildly enlarged on DRE

MSU: No growth

What is the most likely diagnosis?

Callum Brooks, aged 23, presents after noticing a painless lump in his right testicle while showering. He has no history of trauma, infection, or systemic symptoms. There is no family history of cancer.

Examination: Firm, non-tender 2cm mass in right testicle, no transillumination, no inguinal lymphadenopathy

What is the most appropriate next step in management?

Brian Chan, aged 66, presents with worsening nocturia, reduced stream and sensation of incomplete bladder emptying. He has a known history of BPH. His symptoms have worsened despite 6 months of tamsulosin therapy.

Examination: DRE – moderately enlarged smooth prostate

PSA: 1.9 ng/mL (normal), Renal function: Normal

What is the most appropriate next step?

Zane Wilcox, aged 48, presents with fatigue, reduced libido and recent weight gain. He also reports poor concentration. He works night shifts and drinks 6–8 beers on weekends.

Examination: BMI 31, Testes small and soft

Testosterone: 7.4 nmol/L (low), LH and FSH both low

What is the most likely cause of his symptoms?

Matthew Leach, aged 40, presents with new erectile dysfunction and difficulty achieving orgasm. He also complains of reduced enjoyment in activities and poor sleep.

Review of systems: Normal

No significant medical history, no medications

What is the most likely underlying cause?

James O’Grady, aged 58, presents for results of a DEXA scan which was ordered after a low trauma wrist fracture. T-score at the femoral neck is -2.6. He has no history of corticosteroid use, smoking or alcohol excess.

Past medical history: Type 2 diabetes

What is the most appropriate management?

Chris Doukas, aged 39, presents with concerns about premature ejaculation. He says he ejaculates within 1 minute of penetration and this has been a long-standing issue. He is otherwise healthy.

Psychosexual history: No issues with libido, erectile function, or relationship satisfaction. No history of trauma or abuse.

What is the most appropriate first-line management?

Henry Lee, aged 75, presents with unintentional weight loss, fatigue, and bone pain. He has also noticed increased thirst and passing more urine than usual.

Examination: Mild pallor, no lymphadenopathy

Investigations: Normocytic anaemia, elevated total protein, raised calcium

What is the most likely diagnosis?

Oliver Francis, aged 61, presents with ongoing hot flushes and decreased libido. He is on androgen deprivation therapy for metastatic prostate cancer diagnosed 9 months ago. He is finding the symptoms increasingly bothersome.

What is the most appropriate management option to address his symptoms?

Luke Martin, aged 44, presents with concerns about increasing breast size and tenderness. He started taking cimetidine 6 months ago for reflux. No alcohol use or illicit drugs. No family history of breast cancer.

Examination: Bilateral breast enlargement, tender, no nipple discharge or masses

What is the most appropriate next step?

Gavin McIntyre, aged 68, presents for review of his testosterone therapy. He was diagnosed with late-onset hypogonadism 2 years ago. His current testosterone level is within range. He mentions he has recently developed polycythaemia on recent bloods (Hb 187 g/L).

What is the most appropriate next step?

Patrick Samuels, aged 57, presents with a 6-month history of progressive fatigue and decreased libido. He was previously well. On examination, he is pale and has reduced pubic hair and testicular volume.

Investigations: Hb 112 g/L, Na 132 mmol/L, K 5.1 mmol/L, morning cortisol 120 nmol/L, LH and FSH both low

What is the most appropriate next investigation?

Lachlan Reid, aged 42, presents with persistent urinary frequency and burning with ejaculation. He has had similar episodes before which improved with antibiotics. MSU is sterile and STI screen is negative.

Prostate exam: Slightly tender, no nodules

What is the most likely diagnosis?

Dominic Huynh, aged 52, presents requesting testosterone supplementation. He feels tired and has gained weight over the past year. He has no morning erections but no ED. He has read online about low T.

Initial morning testosterone: 9.1 nmol/L (low)

What is the most appropriate next step?

Harley Fisher, aged 61, presents with difficulty voiding and a sensation of incomplete bladder emptying. He has been treated for BPH for two years. Bladder scan post-void residual is 220 mL.

What is the most appropriate next step?

Noah Wallace, aged 33, presents with difficulty conceiving after 18 months of trying. His partner has been assessed and no issues identified. Semen analysis shows azoospermia. Testes are small bilaterally.

What is the most appropriate investigation to perform next?

Graham Everett, aged 63, presents with new-onset lower back pain and unintentional weight loss over the past 3 months. He has a history of treated prostate cancer 6 years ago.

Examination: Tenderness over lumbar spine, normal neurology

What is the most appropriate next investigation?

Dylan Singh, aged 29, presents with scrotal discomfort and a dragging sensation. He has noticed this especially after standing for long periods. No issues with urination or ejaculation.

Examination: Soft mass above left testicle, increases with Valsalva, reducible

What is the most likely diagnosis?

Martin Giles, aged 77, presents with recent onset of urge incontinence. He often has a sudden, strong urge to urinate and doesn’t make it in time. No dysuria or haematuria.

Examination: NAD. MSU is negative.

What is the most appropriate initial management?

Andrew Weston, aged 65, presents for cardiovascular risk assessment. He has no symptoms and is on no medications. BP 138/82, non-smoker, total cholesterol 6.1 mmol/L, HDL 1.0 mmol/L. He asks about erectile dysfunction and cardiovascular risk.

What is the most appropriate next step?

Jason O’Connor, aged 50, presents with generalised fatigue. He has recently migrated from the UK. On review, he has a history of haemochromatosis in his brother.

Investigations: Ferritin 820 µg/L, transferrin saturation 65%

What is the most appropriate next step?

Damien Parker, aged 58, presents for routine check-up. He is asymptomatic but notes that his father died from prostate cancer at age 62. Damien has no urinary symptoms.

DRE: Normal. PSA: 3.8 ng/mL (age-adjusted upper limit 3.5)

What is the most appropriate next step?

Felix Ramos, aged 40, presents with concerns about male pattern hair loss. He has noticed progressive thinning over the crown for 2 years. There is no associated itching or scaling. He is otherwise well.

Family history: Father had similar hair loss in his 30s

What is the most appropriate management option?

Thomas Yin, aged 64, presents with fatigue and mild erectile dysfunction. He has a history of type 2 diabetes, hypertension, and obesity. Morning testosterone is 7.0 nmol/L.

What is the most appropriate next investigation?

Geoffrey Miles, aged 76, presents with persistent perineal discomfort, increased urinary frequency and discomfort during ejaculation. He has been treated multiple times for presumed UTI but cultures are consistently negative.

Examination: Prostate is mildly tender

What is the most appropriate next step?

Aaron Blake, aged 30, presents with a painless lump in his right testicle discovered a few days ago. He denies trauma, dysuria or fever. On examination, the lump is firm, non-tender, and does not transilluminate. There is no lymphadenopathy.

What is the most appropriate immediate investigation?

Jared Smith, aged 55, presents for a general health check. He mentions occasional difficulty maintaining an erection. He has a 10-year history of type 2 diabetes. He takes metformin and gliclazide. He has no chest pain or other symptoms.

What is the most appropriate initial management?

William Kerr, aged 63, presents with worsening lower urinary tract symptoms despite 6 months on tamsulosin. DRE shows moderately enlarged smooth prostate. PSA is 2.5 ng/mL. Post-void residual volume is 180 mL.

What is the most appropriate next step in management?

Nathan Zhou, aged 24, presents with pain and swelling of the right testicle for the past 2 days. He has also had dysuria. No nausea or vomiting. He is sexually active and does not use condoms consistently.

Examination: Tender right testicle, epididymal swelling, positive Prehn’s sign

What is the most appropriate next step?

Samuel Black, aged 49, presents with lethargy and new-onset erectile dysfunction. He has a past history of depression and is taking sertraline. He denies low mood or other depressive symptoms.

What is the most likely cause of his symptoms?

Ethan Varga, aged 61, presents with lower back pain and urinary hesitancy. He has a known history of prostate cancer treated with radiotherapy 4 years ago. PSA today is 12.8 ng/mL.

What is the most appropriate next investigation?

Leonard Fraser, aged 67, presents with nocturia, weak stream, and incomplete emptying. He has a normal PSA and has not previously tried any medications.

Examination: DRE shows a moderately enlarged, smooth prostate. No bladder distension.

What is the most appropriate first-line treatment?

Julian Marks, aged 52, presents with fatigue and weight gain. He is concerned about low testosterone after reading about andropause online. He has no erectile issues or mood symptoms.

Morning testosterone: 13.5 nmol/L (normal range 10–30)

What is the most appropriate next step?

Kevin Zhao, aged 45, presents with recurrent urinary tract infections and a history of poor urinary flow since adolescence. He has had several episodes of post-void dribbling and sensation of incomplete emptying.

What is the most likely diagnosis?

Mark Russo, aged 36, presents with painful ejaculation and deep perineal discomfort lasting for hours after sex. No urinary symptoms or fever. Symptoms have been present for over 3 months.

MSU: No growth, STI screen negative

What is the most likely diagnosis?

Robert Lang, aged 72, presents with unintentional weight loss, back pain, and a history of prostate cancer treated 5 years ago. DRE is unremarkable. PSA is 18.5 ng/mL.

What is the most appropriate next step?

Ben Craddock, aged 28, presents after noticing painless swelling above his left testicle. It fluctuates in size and becomes more prominent when standing. There is no pain or redness.

Examination: Non-tender, cystic mass above testicle, transilluminates, no erythema

What is the most likely diagnosis?

Lucas Grant, aged 69, presents with a history of prostate cancer treated with prostatectomy 2 years ago. His latest PSA is 0.3 ng/mL, up from <0.01 previously.

He is currently asymptomatic.

What is the most appropriate next step?

Jordan Webb, aged 43, presents with ongoing issues with infertility. Semen analysis shows oligospermia. Examination reveals a grade 3 varicocele on the left.

What is the most appropriate next step?

Trevor Munro, aged 60, presents with recurrent episodes of urethral discharge and dysuria. STI testing has been negative. Symptoms resolve temporarily with antibiotics.

Examination: NAD. MSU negative.

What is the most likely diagnosis?

Daniel Borg, aged 72, presents with bothersome urinary urgency and frequency. He has been on tamsulosin for 8 months with partial improvement. No evidence of obstruction or retention on bladder scan.

What is the most appropriate next step?