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Five-minute Practitioner: January 2008

Only got five minutes? Then just read these key points on: erectile dysfunction, benign prostatic hyperplasia, improving men's health and emerging psychosis

Only got five minutes? Then just read these key points on: erectile dysfunction, benign prostatic hyperplasia, improving men's health and emerging psychosis

Erectile dysfunction

Erectile dysfunction may be a clinical manifestation of endothelial dysfunction, affecting penile circulation. This may be part of a generalised vascular disorder that leads to MI, angina and stroke. As the penile arteries are smaller in diameter than the coronary or carotid arteries, the clinical manifestation, ED, may appear before symptoms of CVD or cerebrovascular disease.

ED may predate a cardiovascular event and serve as a warning for the development of CVD. Similarly, there is a significantly raised risk of ED in patients with established CVD. Diabetes and raised fasting blood glucose have also been associated with ED.

History taking should not only focus on CVD risk factors, but also aim to elicit other causes of ED, psychological, psychosocial or physical.


Almost half of all men older than 65 years have lower urinary tract symptoms, consisting of poor flow and frequency of micturition.

In BPH, the central portion of the prostate, the transition zone, slowly enlarges over time, resulting in progressive bladder outflow obstruction. In response, the detrusor muscle of the bladder wall undergoes hypertrophy and becomes trabeculated. This secondary change results in the symptoms of bladder overactivity, including nocturia, urgency and urge incontinence.

Men with larger prostates (>30ml), higher PSA levels and more severe symptoms are at increased risk of complications, including acute urinary retention (AUR). GP assessment includes taking a history and evaluating symptoms, digital rectal examination, urinalysis and PSA.

When complications of BPH occur, such as AUR, bladder stone formation, recurrent UTIs or haematuria, patients should be referred to a urologist.

Improving men's health

GP consultations by girls and boys are similar until the teenage years, when attendance increases in young women but decreases in young men. This difference remains up to the age of 55 years and then levels out.

Morbidity and mortality are both greater in men than women for: heart disease, mental health, sexual health, cancers and accidents.

Men are more likely to develop CHD at any age. One in four men aged 75 years and over have CHD, compared with one in five women. One in four men aged 45 will have a stroke if they live to 85, compared with one in five women.

Men's health in primary care may be improved by a more systematic, protocol-driven approach towards the organisation of services specifically for men, including the development of well man clinics. These should focus on conditions that target men exclusively or preferentially and integrate some or all of the following: the provision of detailed, accurate and current health information; health screening, systematically searching for diseases where early detection is important; treatment monitoring and adjustment for chronic conditions; surveillance and monitoring of borderline abnormalities.

Emerging psychosis

The lifetime risk of experiencing a psychotic episode is around 3 in 100, with 80% of cases starting between 16 and 30 and 5% in patients under 16.

GPs are often the first healthcare professional contacted for help and provide a vital conduit to specialist early intervention services.

Guidance on emerging psychosis has been published by the RCGP and RCPsych. It gives helpful information about early symptoms. These include poor sleep, panic, mood changes, social withdrawal, problems at work or school and breakdown of relationships.

If uncertain, GPs are advised not to dismiss problems but to maintain a watching brief.

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