Balanitis: Causes and Management

Balanitis is a common condition that presents in general practice. It can have various causes, but the most likely cause in many cases is an irritant reaction from excessive washing and use of soaps. Other common causes include Candida, psoriasis, and other skin conditions. If there is any discharge, swabbing should be done. If ulceration is present, herpes simplex virus (HSV) should be considered. In older men with persistent symptoms, Premalignant conditions and possible biopsy may be considered.

The management of balanitis involves advice, reassurance, and a topical steroid as the initial treatment. Testing for glycosuria should be considered to rule out Candida. If the symptoms persist, further investigation may be necessary to determine the underlying cause. It is important to identify the cause of balanitis to ensure appropriate management and prevent recurrence. By understanding the causes and management of balanitis, healthcare professionals can provide effective care to patients with this condition.

After a prostatectomy, the PSA level should be undetectable, meaning it should be less than 0.2ng/ml. If the PSA level is 2 after 3 months (even though it falls within the normal range for untreated patients), it is still considered significantly high and requires immediate referral to oncology for further examination.

PSA Testing for Prostate Cancer

Prostate specific antigen (PSA) is an enzyme produced by the prostate gland, and it is used as a tumour marker for prostate cancer. However, there is still much debate about its usefulness as a screening tool. The NHS Prostate Cancer Risk Management Programme (PCRMP) has published guidelines on how to handle requests for PSA testing in asymptomatic men. The National Screening Committee has decided not to introduce a prostate cancer screening programme yet, but rather allow men to make an informed choice.

The PCRMP has recommended age-adjusted upper limits for PSA, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. However, PSA levels may also be raised by other conditions such as benign prostatic hyperplasia, prostatitis, urinary tract infection, ejaculation, vigorous exercise, urinary retention, and instrumentation of the urinary tract.

PSA testing has poor specificity and sensitivity, and various methods are used to try and add greater meaning to a PSA level, including age-adjusted upper limits and monitoring change in PSA level with time. It is important to note that digital rectal examination may or may not cause a rise in PSA levels, which is a matter of debate.

Chronic Prostatitis: A Complex Diagnosis

The diagnosis and underlying cause of chronic prostatitis can be challenging to determine. While some experts debate whether it is a chronic pain syndrome, only 10% of cases are caused by infection, and antibiotics are often ineffective in treating the condition. As a result, the term chronic pelvic pain syndrome has been adopted to better reflect the complex nature of this condition. Despite ongoing research, the diagnosis and management of chronic prostatitis remain a challenge for healthcare professionals.

Prostate Cancer in England and Wales

Approximately 10,000 men die of prostate cancer each year in England and Wales, making it the second leading cause of cancer deaths in men after lung cancer. The lifetime risk of a prostate cancer diagnosis in the UK is 1 in 14 men. However, one of the difficulties with investigating and diagnosing prostate cancer in older men is that as we age, most men have detectable prostate cancer. But, three-quarters of them will grow older and die of something else, and the prostate cancer itself will not impact their life expectancy.

The five-year survival rate from prostate cancer in the UK is 81%, which is relatively high compared to other types of cancer. However, early detection and treatment are crucial for improving survival rates. Therefore, it is important for men to be aware of the symptoms of prostate cancer and to undergo regular screenings, especially if they are at higher risk due to factors such as age, family history, or ethnicity. By detecting prostate cancer early, men can receive timely treatment and improve their chances of survival.

Factors to Consider in Prostate Cancer

Ethnicity is a significant factor to consider when discussing prostate cancer. The incidence of prostate cancer varies geographically, with the highest rates found in men of black ethnic group and the lowest rates in Chinese men. Age is another important factor, as prostate cancer is rare in men under 50 years old, with the majority of diagnoses made in patients over 65. Family history is also a risk factor, particularly in younger men. Prostate cancer can cluster within families, and having a first-degree relative under 70 with prostate cancer can double a patient’s relative risk of developing the disease. Finally, diet is another factor to consider, as a diet rich in red meat and dairy products has been linked to an increased risk of prostate cancer. By taking these factors into account, healthcare professionals can better assess a patient’s risk of developing prostate cancer and provide appropriate screening and treatment.

Treatment options for metastatic prostate cancer

In the treatment of metastatic prostate cancer, any luteinising hormone releasing hormone (LHRH) analogue can be used, such as goserelin or leuprorelin. However, there is a small risk of tumour flare in patients with metastatic disease, so it is recommended to initiate LHRH analogue therapy with a short-term anti-androgen like bicalutamide or cyproterone acetate. This risk is minimal, but it is considered good practice to take precautions.

Once treatment has been established, three-monthly preparations of LHRH analogues are convenient for both patients and healthcare professionals. Anti-androgen mono-therapy for metastatic prostate cancer is not recommended. It is important to discuss all treatment options with a healthcare provider to determine the best course of action for each individual case.

Managing Urge Incontinence

Urge incontinence is a condition where urine leakage occurs involuntarily, often preceded by a sudden urge to urinate. According to NICE guidance on Urinary incontinence (CG171), women with urge incontinence or mixed incontinence should be offered bladder training as a first-line treatment for at least six weeks. This involves learning techniques to control the urge to urinate and gradually increasing the time between visits to the toilet. If bladder training is not effective, immediate release oxybutynin may be offered as an alternative treatment.

If a patient experiences an increase in serum creatinine after starting an ACE-inhibitor like ramipril, it may indicate renal artery stenosis. Other signs of this condition include refractory hypertension and recurrent pulmonary edema with normal left ventricular function. A normal urine dip makes options 1, 2, and 3 unlikely, and there are no symptoms of cancer, infection, or diabetes. While polycystic kidney disease is a possibility, it is inherited in an autosomal dominant manner and typically presents with hypertension, kidney stones, haematuria, or an abdominal mass. However, given the patient’s history and lack of family history of renal disease, renal artery stenosis is the more likely diagnosis.

Chronic kidney disease (CKD) is a condition where the kidneys are not functioning properly. To estimate renal function, serum creatinine levels are often used, but this may not be accurate due to differences in muscle. Therefore, formulas such as the Modification of Diet in Renal Disease (MDRD) equation are used to estimate the glomerular filtration rate (eGFR). The MDRD equation takes into account serum creatinine, age, gender, and ethnicity. However, factors such as pregnancy, muscle mass, and recent red meat consumption may affect the accuracy of the result.

CKD can be classified based on the eGFR. Stage 1 CKD is when the eGFR is greater than 90 ml/min, but there are signs of kidney damage on other tests. If all kidney tests are normal, there is no CKD. Stage 2 CKD is when the eGFR is between 60-90 ml/min with some sign of kidney damage. Stage 3a and 3b CKD are when the eGFR is between 45-59 ml/min and 30-44 ml/min, respectively, indicating a moderate reduction in kidney function. Stage 4 CKD is when the eGFR is between 15-29 ml/min, indicating a severe reduction in kidney function. Stage 5 CKD is when the eGFR is less than 15 ml/min, indicating established kidney failure, and dialysis or a kidney transplant may be necessary. It is important to note that normal U&Es and no proteinuria are required for a diagnosis of CKD.

Research suggests that catheterised patients with a UTI experience better outcomes when treated with a 7-day course of antibiotics instead of a 3-day course. In cases where a patient has mild symptoms, it may be appropriate to wait for a culture before administering treatment. However, if a patient is experiencing significant discomfort, delaying treatment is not recommended. A history of only one previous UTI is not sufficient reason to refer a patient to urology. At present, there is no recommendation for the use of topical antibiotics in catheterised patients with UTIs.

Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. Lower UTIs are more common and can be managed with antibiotics. For non-pregnant women, local antibiotic guidelines should be followed, and a urine culture should be sent if they are aged over 65 years or have visible or non-visible haematuria. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. Pregnant women with symptoms should have a urine culture sent, and first-line treatment is nitrofurantoin, while amoxicillin or cefalexin can be used as second-line treatment. Asymptomatic bacteriuria in pregnant women should also be treated with antibiotics. Men with UTIs should be offered antibiotics for seven days, and a urine culture should be sent before starting treatment. Catheterised patients should not be treated for asymptomatic bacteria, but if they are symptomatic, a seven-day course of antibiotics should be given, and the catheter should be removed or changed if it has been in place for more than seven days. For patients with signs of acute pyelonephritis, hospital admission should be considered, and local antibiotic guidelines should be followed. The BNF recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days for non-pregnant women.

The NICE clinical knowledge summary (CKS) guidelines recommend phosphodiesterase (PDE-5) inhibitors, such as sildenafil and tadalafil, as the first-line treatment for erectile dysfunction (ED) unless there are contraindications. However, those who cannot or will not take PDE-5 inhibitors may benefit from vacuum erection devices, which are recommended as the first-line treatment for well-informed older men with infrequent sexual intercourse and comorbidity requiring non-invasive, drug-free management of ED. Lifestyle changes and risk factor modification should also be considered, but this patient already has good control of his risk factors and regularly exercises. Intracavernous injections may be a second-line option for men with pelvic trauma or spinal cord injury. Vasculogenic causes, such as cardiovascular disease, are the most common organic cause of ED, and lifestyle changes and drug treatment can be effective in managing this condition.

Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.

To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.