1 Clinical Summary Guide Step-by-Step: Male Genital Examination Examination of male genitals and secondary sexual characteristics.

Testicular volume

Testicular volume is assessed using an orchidometer; a sequential series of beads ranging from 1 mL to 35 mL (see Image 1). Testicular volume is measured using the following steps: 1. Conduct the examination in a warm environment, with the patient lying on his back 2. Gently isolate the testis and distinguish it from the epididymis. Then stretch the scrotal skin, without compressing the testis 3. Use your orchidometer to make a manual side-by-side comparison between the testis and beads (see image 2) 4. Identify the bead most similar in size to the testis, while making allowance not to include the scrotal skin.

Normal testicular volume ranges

Childhood Puberty Adulthood Image 1 – Orchidometer < 3 mL 4-14 mL 15-35 mL Why use an orchidometer? Clinical notes Testicular volume is important in the diagnosis of androgen • Asymmetry between testes is common (e.g. 15 mL versus deficiency, infertility and Klinefelter syndrome. 20 mL) and not medically significant • Asymmetry is sometimes more marked following unilateral testicular damage • Testes are roughly proportional to body size • Reduced testicular volume suggests impaired spermatogenesis • Small testes (<4 mL) from mid puberty are a consistent feature of Klinefelter syndrome

Examination of secondary sexual characteristics Gynecomastia • Gynecomastia is the excessive and persistent development of benign glandular tissue evenly distributed in a sub-areolar position of one or both breasts (see image 3) Image 2 – Example of 30 mL and 4 mL adult testis • Can cause soreness and considerable embarrassment • Common during puberty, usually resolves in later adolescence • Causes include marijuana, androgen abuse, abnormal liver function • Distinguish glandular tissue from sub-areolar fat in obese subjects • Rare secondary causes include hypothalamic/pituitary and adrenal/testis tumours (oestrogen excess) • Rapidly developing gynecomastia may indicate testicular tumour • In contrast to gynecomastia, breast cancer can be located anywhere within the breast tissue and feels firm or hard Onset of puberty • Average onset is 12-13 years Virilisation Image 3 – Gynecomastia • Facial and body hair development • Muscle development (Photo courtesy of Mr G Southwick, Melbourne Institute of Plastic Surgery) • Penile growth Examination of testis and scrotal contents

Gently palpate the testis If a testis cannot be felt, gently Examine the testis surface for between your thumb and palpate the inguinal canal to see if irregularities. It should be smooth, with first two fingers. testis can be ‘milked’ down. a firm, soft rubbery consistency. Testis Note: Atrophic testes are Note: Testis retraction can be caused Note: A tumour may be indicated by deep often more tender to palpa- by cold room temperature, anxiety or surface irregularity, or differences in tion than normal testes. and cremasteric reflex. consistency between testes.

Locate the epididymis, which lies along the • Tenderness, enlargement or hardening can occur as a result of obstruction posterior wall of the testis. () or infection. This can be associated with obstructive infertility. Epididymis It should be soft, slightly • Cysts in the epididymis are quite common. These are something mistaken for irregular and non-tender to a testicular tumour. touch.

Locate the , a firm rubbery tube Nodules/thickening around the vas deferens ends approximately 2-3 mm in may be apparent after vasectomy. diameter. Vas deferens The vas deferens should be distinguished from the Absence of the vas deferens is a congenital condition blood vessels and nerves of associated with low volume and azoospermia. the spermatic cord.

Indicators include: • Palpable swelling of the spermatic Penis Perform examination veins above testis with the man standing. • Swelling is usually easy to feel Spermatic Varicocele A Valsalva manoeuvre or vein and can be compressed without coughing helps delineate discomfort Testes smaller varicoceles. • Nearly always on left side • Associated with infertility (Photo courtesy of Prof. D de Kretser)

Examination of penile abnormalities

Hypospadias Peyronie’s disease Micropenis Phimosis Urethral stricture

Abnormal position of Fibrous tissue, causing The foreskin cannot Abnormal urethral meatus on the underside pain and curvature of May indicate androgen be pulled back behind narrowing, which alters of the penile shaft. May the erect penis. deficiency prior to the glans penis. Can be urination. Can be caused be associated with a Check for tenderness puberty. normal in boys up to 5-6 by scar tissue, disease or notched penile head. or thickening. years. injury.

Hypospadias Peyronie’s Disease Position of urethral opening Glans penis

Glanular Corpus Subcoronal cavernosum

Fibrous plaque Penile

Scrotal

Urethra Perineal

(Photo courtesy of Dr M Lowy, Sydney Centre for Men’s Health)

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 2 Clinical Summary Guide Male Child and Adolescent Genital Examination Examination of male genitals and secondary sexual characteristics in children and adolescence.

When should I perform an examination? When is it best to perform an examination?

A physical examination including male children and adolescents 1. Part of a standard health check-up with new or existing is vital for the detection of conditions such as testicular cancer, patients Klinefelter syndrome, penile and hormonal abnormalities. 2. On presentation of relevant disorders or symptoms, including:

How do I approach an examination with young Risk Factor Associated disorder patients? Undescended testes as an infant Testicular cancer Good communication can assist the process of physical examinations with children and adolescents. Delayed puberty Androgen deficiency • Communicate with both the patient and his parents, using Gynecomastia Androgen deficiency, simple language and visual aids if available Klinefelter syndrome, • Explain why you need to perform the examination and ask for Testicular cancer permission to proceed Past history of testicular cancer Testicular cancer • Allow the patient to ask questions and express any discomfort before/during the examination Acute testicular - groin pain Testicular cancer • When it seems appropriate, humour can be used (particularly with children) to reduce anxiety, foster rapport and improve Testicular pain or lumps Testicular torsion cooperation before or during the examination • If you refer the patient to another specialist, take the time to explain why, and what may be involved Adolescent history and examination

Childhood history and examination Presentation with acute testicular pain • This is a medical emergency Presentation with acute testicular pain • Later follow up review (e.g. epididymo–orchitis) • Testicular torsion • Refer immediately for evaluation for possible surgery History • Undescended testes History • Pubertal development • Undescended testes (increased risk of testicular cancer, • Testicular trauma, lump, cancer and associated with inguinal hernia) • Gynecomastia • Inguinal-scrotal surgery or hypospadias • Prior inguinal-scrotal surgery or hypospadias Testicular examination Testicular examination • Undescended testes • Testicular volume • Testicular volume: Normal childhood (pre-pubertal) range of testicular volume is ≤ 3 mL --Normal pubertal range is 4-14 mL --< 4 mL by 14 years indicates delayed or incomplete puberty Penile examination --Small testes (< 4 mL) may suggest Klinefelter syndrome • Hypospadias --Adult testis size is established after completion of puberty • Micropenis • Scrotal and testicular contents --Abnormalities in texture or hard lumps (tumour or cyst)

Penile examination • Hypospadias • Micropenis • Infections (STI) or inflammation • Foreskin: balanitis, phimosis

Examination of secondary sexual characteristics • Gynecomastia: excessive and/or persistent breast development • Delayed puberty (average onset is 12-13 years). Indicators: --Short stature compared to family, with reduced growth velocity --Absent, slow or delayed genital and body hair development compared to peers --Anxiety, depression, school refusal, or behaviour change in school years 8-10 (age 14-16 years) Puberty: delayed onset or poor progression Testicular mass Presentation Presentation • Short stature compared to family • Painless lump • Absent, slow or delayed genital development • Self report, incidental • Anxiety, depression, school refusal, behaviour change • Past history undescended testes (cancer risk) (±) Other features • Consider possibility of epididymal cyst • Headache/visual change (CNS lesions) Primary investigations • Inability to smell (Kallmann’s syndrome) • Testicular ultrasound • Behavioural or learning difficulty (47,XXY) Treatment and specialist referral • Unusual features (rare syndromes) • Refer to uro-oncologist Primary investigations • Offer pre-treatment sperm cryostorage • Growth chart in context of mid parental expectation Refer to Clinical Summary Guide 6: Testicular Cancer (velocity, absolute height) • Penile size (standard growth chart) Penile abnormality • Testicular volume (> 4 mL: puberty imminent) Presentation • Bone age • Hypospadias Specific investigations • Micropenis • LH/FSH (may be undetectable in early puberty, but if raised can • Phimosis be useful) Treatment and specialist referral • Total testosterone level (rises with onset of puberty) • Refer to urologist for investigation and treatment plan • Karyotype (if suspicion of 47,XXY) • Refer to paediatric endocrinologist for investigation of General investigations micropenis • U&E, FBE & ESR, coeliac screen, TFT Gynecomastia Treatment and specialist referral Presentation in adolescence • If all normal for prepubertal age, observe for 6 months • Excessive and/or persistent breast development • Refer to paediatric endocrinologist if patient is >14.5 years • More prominent in obesity without pubertal onset and/or a specific abnormality • Often normal, resolves over months Clinical notes: Precocious puberty (very rare) is indicated by premature/early onset of pubic hair and testes > 4 mL before 10 Rare secondary causes: years. Refer to paediatric endocrinologist. • Hypothalamic pituitary lesions • Adrenal/testis lesions (oestrogen excess) Klinefelter Syndrome (47,XXY) Treatment and specialist referral Presentation • If persistent or acute onset, refer to paediatric endocrinologist • Small testes < 4 mL characteristic from mid puberty • Presentation varies with age, and is often subtle • Behavioural and learning difficulties • Gynecomastia (adolescence) • Poor pubertal progression (adolescence) Investigations • Total testosterone level (androgen deficiency) • LH/FSH level (both elevated) • Karyotype Treatment and specialist referral • Refer to paediatric endocrinologist • Refer for educational and allied health assistance if needed Refer to Clinical Summary Guide 10: Klinefelter Syndrome

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 3 Clinical Summary Guide Male Adulthood Genital Examination Examination of male genitals and secondary sexual characteristics in adults.

When should I perform an examination? Adulthood history and examination

1. As part of a standard health check-up with new or existing Presentation with acute testicular pain patients • This is a medical emergency 2. 45-49 year old health assessment (MBS) (Note, Aboriginal and Torres Strait Islander men are eligible at younger ages) • Testicular torsion 3. Prior to initiation of drug treatment (e.g. testosterone, PDE5 • Refer immediately for evaluation for surgery inhibitors) or investigation of conditions such as infertility or • Later follow up review (e.g. epididymo–orchitis) disease History 4. On presentation of relevant risk factors and symptoms (below) • Fertility in current and past relationships • Testicular trauma, cancer, STI Risk Factor Associated disorder • Inguinal-scrotal surgery (undescended testes, childhood hernia) Undescended testes as an infant Testicular cancer • Symptoms of androgen deficiency • Systemic treatment for malignancy, immunosuppression, Past history of delayed puberty Androgen deficiency organ transplant (for possible testicular damage) Gynecomastia Androgen deficiency, • Gynecomastia Klinefelter syndrome, • Occupational or toxin exposure Testicular cancer Testicular examination Infertility Androgen deficiency, Testicular cancer Testicular volume Erectile dysfunction (ED) Co-morbidities • Normal range of adult testicular volume: 15-35 mL • Small testes <4 mL suggests Klinefelter syndrome Past history of testicular cancer Testicular cancer Scrotal and testicular contents Gynecomastia Androgen deficiency, • Abnormalities in the texture or hard lumps: suggests tumour or Klinefelter syndrome, cyst Testicular cancer • Enlargement, hardening or cysts of the epididymides Pituitary disorders Androgen deficiency, • Varicocele Male infertility • Nodules or absence of vas deferens Osteoporosis and Androgen deficiency atraumatic fractures Penile examination

Haemochromatosis Androgen deficiency, • Hypospadias Male infertility • Peyronie’s disease • Micropenis Symptoms Associated disorder • Urethral stricture • Evidence of infection (STI) or inflammation Testicular pain or lumps Tumour or cyst • Foreskin: balanitis, phimosis

Reduced libido, hot flushes, fatigue, Androgen deficiency Secondary sexual characteristics of gynecomastia, ED, mood changes, androgen deficiency reduced beard or body hair, poor or reduced muscle development • Reduced facial, body and pubic hair • Gynecomastia • Reduced or poor muscle development How do I best approach an examination with my patient? Prostate and other examinations • In suspected prostate disease, digital may • Posters or pamphlets in your clinic can raise awareness about be considered, or an initial referral to urologist men’s health examinations and convey that patients can • If prostate enlargement, tenderness or nodularity is found, refer discuss reproductive health concerns with you to urologist • Explain why you need to perform the examination and ask for • General medical review of erectile dysfunction. permission to proceed Focus on cardiovascular risk (BP, pulses) & diabetes (including • Allow the patient to ask questions and express any discomfort neuropathy) before/during the examination • Ask specific questions during history-taking, to assist those patients reluctant to raise sensitive problems Androgen deficiency (AD) Penile abnormality Presentation Presentation • Symptoms of AD in men of any age • Hypospadias • Following testis surgery, torsion, trauma, cancer treatment • Peyronie’s disease • Incidental findings of small testes • Micropenis • In association with infertility • Urethral stricture Primary investigations • Phimosis • Total testosterone level (two morning fasting samples) and LH/ Treatment and specialist referral FSH level • Refer to urologist for investigation and treatment plan

Investigations if low total testosterone with Testicular mass normal or low LH/ FSH • Serum prolactin (prolactinoma) Presentation • MRI pituitary (various lesions) • Painless lump • Olfactory testing (Kallmann’s syndrome) • Self report, incidental • Iron studies (haemochromatosis) • Past history undescended testes (cancer risk) • Also commonly seen with co-morbidities (obesity, depression, • Confirm lump is in testis rather than epididymal cyst chronic illness): focus on underlying condition Primary investigations Other investigations • Testicular ultrasound • SHBG/calculated free total testosterone (selected cases, e.g. • Treatment and specialist referral obesity, liver disease) • Refer to uro-oncologist • Bone density study (osteoporosis) • Offer pre-treatment sperm cryostorage • (if fertility is an issue) Refer to Clinical Summary Guide 6: Testicular Cancer • Karyotype (if suspicion of 47,XXY) Gynecomastia Treatment and specialist referral • Testosterone Replacement Therapy (TRT) Presentation in adulthood (common) *Contraindicated in prostate and breast cancer • Excessive and/or persistent breast development *Withhold treatment until investigation complete • Androgen deficiency • In general, TRT is not justified in older men with borderline • Chronic liver disease low testosterone levels and without underlying pituitary or • Hyperprolactinaemia testicular disease • Adrenal or testicular tumours • Low-normal total testosterone is common in obesity or other illness and may not reflect AD. Address underlying • Drugs (e.g. spironolactone), marijuana, sex steroids disorders first. • Distinguish from ‘pseudogynecomastia’ of obesity • Consult a specialist to plan long term management: Primary investigations --Refer to endocrinologist • Total testosterone level, estradiol, FSH/LH --Refer to fertility specialist as needed • LFTs, iron studies (haemochromatosis) Refer to Clinical Summary Guide 4: Androgen Deficiency • Serum prolactin (pituitary tumour) • Karyotype (if suspicion of 47,XXY) Klinefelter syndrome (47,XXY) • βhCG, αFP, ultrasound (testicular cancer) Presentation Treatment and specialist referral • Small testes <4 mL characteristic from mid puberty. Infertility (azoospermia) or androgen deficiency • Refer to endocrinologist • Other features vary, and are often subtle. These include • Refer to plastic surgeon (after evaluation) if desired taller than average height, reduced facial and body hair, Male infertility gynecomastia, behavioural and learning difficulties (variable), osteoporosis and feminine fat distribution Presentation Primary Investigations • Failure to conceive after 12 months of regular (at least twice weekly) unprotected intercourse • Total testosterone level (androgen deficiency) • Consider early evaluation if patient is concerned and/or • LH/FSH level (both elevated) advancing female age an issue • Karytope confirmation (±)Other features: Other investigations • Testis atrophy (androgen deficiency) • Bone density study (osteoporosis) • Past history undescended testis (cancer risk) • Semen analysis (usually azoospermic) • Psychosexual issues (primary/secondary) • TFT (hypothyroidism) • Past history STI (obstructive azoospermia) • Fasting blood glucose (diabetes) Primary investigations Treatment and specialist referral • Semen analysis: twice at 6-week intervals. Analysis at • Develop a plan in consultation with an endocrinologist specialised reproductive laboratory if abnormalities • Refer to endocrinologist, as TRT is almost always needed • FSH: increased level in spermatogenic failure • Refer to fertility specialist as appropriate, for sperm recovery • Testicular ultrasound (abnormal physical examination, past from testis (occasionally) or donor sperm history of undescended testes) Refer to Clinical Summary Guide 10: Klinefelter Syndrome • Total testosterone and LH (small testes <12 mL or features of androgen level) Treatment and specialist referral • Healthy lifestyle, cease smoking • Advice on natural fertility timing • Identification of treatable factors (often unexplained and no specific treatment) • Refer to an endocrinologist as necessary • Refer to a fertility specialist (ART widely applicable) Refer to Clinical Summary Guide 5: Male Infertility

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 4 Clinical Summary Guide

Androgen Deficiency Diagnosis and management

Androgen deficiency (AD) * Pituitary disease, thalassaemia, haemochromatosis.

• Androgen deficiency is common, affecting 1 in 200 men under ** AD is an uncommon cause of ED. However, all men presenting 60 years with ED should be assessed for AD • The clinical presentation may be subtle and its diagnosis Examination and assessment of clinical features of AD overlooked unless actively considered Pre-pubertal onset – Infancy The GP’s role • Micropenis • GPs are typically the first point of contact for men with • Small testes symptoms of AD • The GP’s role in the management of AD includes clinical Peri-pubertal onset – Adolescence assessment, laboratory investigations, treatment, referral • Late/incomplete sexual and somatic maturation and follow-up • Small testes • Note that it in 2015 the PBS criteria for testosterone • Failure of enlargement of penis and skin of scrotum becoming prescribing changed; the patient must be referred for a thickened/pigmented consultation with an endocrinologist, urologist or member of • Failure of growth of the larynx the Australasian Chapter of Sexual Health Medicine to be eligible for PBS-subsidised testosterone prescriptions • Poor facial, body and pubic hair • Gynecomastia Androgen deficiency and the ageing male • Poor muscle development

• Ageing may be associated with a 1% decline per year in serum Post-pubertal onset – Adult total testosterone starting in the late 30s • Regression of some features of virilisation • However, men who remain in good health as they age may not • Mood changes (low mood, irritability) experience a decline in testosterone • Poor concentration • The decline may be more marked in obese men • Low energy (lethargy) • Some estimates suggest that AD affects up to 1 in 10 men over • Hot flushes and sweats 60 years • Decreased libido • Acute and chronic illnesses result in decreased serum • Reduced beard or body hair growth testosterone and may present with AD-like symptoms • Low semen volume • The role of testosterone replacement therapy (TRT) in older men with modest declines in serum testosterone remains • Gynecomastia controversial • Reduced muscle strength • The most consistent effects of TRT are on: • Fracture (osteoporosis) --body composition and bone • Erectile dysfunction (uncommon) --selected aspects of mood and cognition Refer to Clinical Summary Guide 6: Testicular Cancer --libido Laboratory assessment of AD • Most studies of men with age-related AD have not shown any significant improvement in sexual function (erectile function) • Normal range serum total testosterone 8-27 nmol/L (but may with TRT vary according to the assay used) • The use of TRT for ageing men who do not meet the established • Two morning fasting samples of serum total testosterone*, criteria (PBS guide) is not recommended taken on different mornings • Older men treated outside of guidelines should be informed Guidelines for the diagnosis of AD (PBS criteria): that long-term risks/benefits are not yet documented 1. AD in a patient with an established pituitary or testicular disorder Diagnosis 2. For men aged 40+: --Testosterone < 6 nmol/L** Medical history OR • Undescended testes --Testosterone between 6 and 15 nmol/L and LH greater than • Surgery of the testes 1.5 times the upper limit of the eugonadol reference range for • Pubertal development young men** • Previous fertility * If a second total testosterone sample is indicated, a LH level • Genito-urinary infection should also be ordered. • Co-existent medical illness* ** These criteria apply to men without underlying pituitary or • Change in general well-being or sexual function** testicular pathology, to be eligible for PBS subsidy. • Degree of virilisation • Prescription or recreational drug use Other investigations Management • SHBG/calculated free testosterone (selected cases - obesity, liver disease) Assessment of treatment indications • Semen analysis (if fertility is an issue) PBS-approved indications for the prescription of testosterone • Karyotype (if suspicion of Klinefelter syndrome, 47,XXY) are: Investigations if low total testosterone with normal or • Micropenis, pubertal induction, or constitutional delay of growth low LH/FSH: or puberty, in males <18 years • Serum prolactin (prolactinoma) • AD in males with established pituitary or testicular disorders • Iron studies (haemochromatosis) • AD (confirmed by at least 2 morning fasting samples, both < 6 nmol/L) in males aged 40+ who do not have established • MRI (various lesions) pituitary or testicular disorders other than ageing • Olfactory testing (Kallmann’s syndrome) Testosterone replacement therapy (TRT) Causes of hypogonadism (AD) Clinical note: Dosing ranges are provided below as dosage should be titrated according to clinical response and serum Testicular (primary) testosterone levels

• Chromosomal: Klinefelter syndrome (most common cause) T formulation Usual (starting) Dosage range • Undescended testes dosage • Surgery: bilateral orchidectomy Injections (IM) • Trauma Sustanon®, 250 mg every 2 weeks 10 to 21-day • Infection: mumps orchitis Primoteston® intervals Reandron® 1000 mg every 12 weeks Longer term: 8 to • Radiotherapy/chemotherapy/drugs (spironolactone, following loading dose at 16-week intervals ketoconazole) 6 weeks (i.e. 0, 6, 18, 30 • Systemic disease: haemochromatosis, thalassaemia, myotonic weeks) dystrophy Transdermal patch Hypothalamo-pituitary (secondary) Androderm® 2.5 mg and 5.0 mg preps: 2.5 to 5 mg daily • Idiopathic hypogonadotrophic hypogonadism: Kallmann’s 5 mg applied nightly syndrome Transdermal gel • Pituitary microadenoma (<1 cm) or macroadenoma (>1 cm) Testogel® 1%: 50 mg in 5 g sachet 2.5 to 10 g gel (25 - functional or non-functional: in men typically or pump pack dispenser; mg to 100 mg T) macroprolactinoma applied daily daily • Other causes of hypothalamic pituitary damage: surgery, Transdermal cream radiotherapy, trauma, infiltrative disease such as AndroForte®5 5% (50 mg/mL): 2 mL (100 Review levels in 1 haemochromatosis mg) applied to the torso month, up to 4 mL once daily daily Klinefelter syndrome Oral undecanoate • Is the most common genetic male reproductive disorder Andriol 40 mg capsule: 160 to 240 80 to 240 mg daily (1 in 550 men) Testocaps® mg in 2 to 3 doses daily • Is the most common cause of hypogonadism * Sustanon® is not available on the Australian Pharmaceutical • Reproductive features: small testes <4 mL, infertility, failure Benefits Scheme (PBS) to progress through puberty, gynecomastia, eunuchoidal proportions, diminished or absent body hair, decreased skeletal Follow-up muscle mass Monitoring TRT is essential • Other: learning difficulties & behavioural problems, particularly • Testosterone levels: results should be interpreted in context of in adolescence the treatment modality being used Refer to Clinical Summary Guide 10: Klinefelter Syndrome • Prostate: PSA, as per standard guidelines • Cardiovascular risk factors: blood pressure, diabetes, lipids, as Clinical notes and contraindications per guidelines • Osteopaenia/osteoporosis (fractures): bone density-DEXA • Absolute contraindications to TRT are known or suspected • Polycythaemia: haemoglobin and haematocrit, pre-treatment, hormone-dependent malignancies (prostate or breast) or at 3 and 6 months, and annually thereafter haematocrit >55% • Sleep apnoea: clinical assessment for presence of sleep apnoea • Relative contraindications include haematocrit >52%, (polysomography) untreated sleep apnoea, severe obstructive symptoms of BPH and advanced congestive heart failure Specialist Referral • Fertility: Exogenous testosterone results in suppression of • It is a requirement for PBS-subsidised testosterone that the spermatogenesis in eugonadal men. For men with secondary patient is referred for a specialist consultation (endocrinologist, causes of AD, and in whom fertility is desired, gonadotropin urologist or member of the Australasian Chapter of Sexual therapy should be instituted Health Medicine) and the name of the specialist must be • Low-normal serum testosterone common in obesity or other included in the authority application illness may not reflect AD. Address underlying disorders first • Refer to an endocrinologist to plan long-term management • Withhold treatment until all investigations are complete of AD • Certain adverse effects must be prospectively sought, • Refer to a fertility specialist as needed especially in older men, including polycythaemia and sleep • Refer to a paediatric endocrinologist if >14.5 years old with apnoea, however the testosterone preparations discussed do delayed puberty not cause abnormal liver function

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 5 Clinical Summary Guide

Male Infertility Diagnosis and management

The GP’s role Physical Examination

• Do not wait before beginning assessments General Acute/chronic illness, nutritional status • GPs can begin with simple, inexpensive and minimally invasive examination investigations Genital Refer to Clinical Summary Guide 1: • Infertility needs to be assessed and managed as a couple, and examination Step-by-Step Male Genital Examination may require several different specialists Degree of Androgen Deficiency / Klinefelter Syndrome • See Healthy Male’s Male Fertility Assessment tool to virilisation accompany this guide on our website. Prostate If history suggests /STI Diagnosis examination

Brief assessment and pre-pregnancy advice Investigations Age What age is the couple? Semen analysis is the primary investigation for male Fertility history How long have they been trying to conceive, and have they ever conceived previously (together/ infertility. separately)? Do they have any idea why they Key points have not been able to conceive? • Men should abstain from sexual activity for 2–5 days before Contraception When it was ceased, and the likely speed of its sample collection reversibility • Two semen analyses should be performed at 6 week intervals. Fertile times Whether the couple engage in regular In men whose initial test is poor, the second test should ideally intercourse during fertile times be performed in a specialised laboratory

Female risk Aged 35+, irregular menstrual cycles, obesity, • Semen analysis provides guidance to fertility; it is not factors painful menses, or concomitant medical a direct test of fertility. Fertility remains possible even in conditions those with severe deficits

Female health Screening for rubella and chicken pox immunity, Normal ranges for semen analysis (modified WHO, 2010) Cervical Screening Test (25 years or older) Volume ≥1.5 mL Lifestyle: Diet, exercise, alcohol, smoking cessation and female folate supplementation pH ≥7.2 Lifestyle: male Diet, exercise, alcohol, smoking cessation Sperm ≥15 million spermatozoa/mL concentration

Reproductive history Motility ≥40% motile within 60 minutes of ejaculation

Assess the male for: Why? Vitality 58% or more live, i.e. excluding dye

Prior paternity Previous fertility White blood cells <1 million/mL

Psychosexual issues (erectile, Interference with conception Sperm antibodies 50% motile sperm with binding ejaculatory) Serum total testosterone Pubertal development Poor progression suggests underlying reproductive issue • Testosterone is often normal 8-27nmol/L*, even in men with significant spermatogenic defects A history of undescended testes Risk factor for infertility and • Some men with severe testicular problems display a fall in testis cancer testosterone levels and rise in serum LH, these men should Past genital infection (STI), Risk for testis damage or undergo evaluation for AD mumps infection or trauma obstructive azoospermia • The finding of low serum testosterone and low LH suggests Symptoms of androgen Indicative of hypogonadism a hypothalamic-pituitary problem e.g. prolactinoma (serum deficiency (AD) prolactin levels required) * Testosterone reference range may vary between laboratories Previous inguinal, genital or Testicular vascular impairments, pelvic surgery damage to vasa, ejaculatory Serum FSH levels ducts, ejaculation mechanisms • Elevated levels are seen when spermatogenesis is poor (primary testicular failure) Medications, drug use Transient or permanent damage to spermatogenesis • In normal men, the upper reference value is approximately 8IU/L General health (diet, exercise, Epigenetic damage to sperm smoking). affecting offspring health • In an azoospermic man: --14 IU/L strongly suggests spermatogenic failure --5 IU/L suggests obstructive azoospermia but a testis biopsy may be required to confirm that diagnosis Management

Treatment options Protecting and preserving fertility Mumps vaccination, sperm cryopreservation (prior to chemotherapy, vasectomy or androgen replacement), safe sex practices, and early surgical correction of undescended testes.

Options for improving natural fertility Exist for a minority of infertile men, including those with pituitary hormonal deficiency or hyperprolactinemia, genitourinary infection, erectile and psychosexual problems, and through the withdrawal of drugs. Evidence for varicocele removal to improve fertility is limited but may have a place in selected cases: seek specialist input.

Assisted reproductive technology (ART) ART options range in cost and invasiveness • Artificial insemination with men’s sperm at midcycle • Conventional IVF • Intracytoplasmic sperm injection (ICSI) for severe male factor problems. Sperm can be readily obtained by testicular needle aspiration in the setting of obstructive azoospermia. Some azoospermic men with spermatogenic failure may have sperm recovered for ICSI from a testicular biopsy. Donor insemination: For men with complete failure of sperm production.

Specialist referral and long-term management Warning: Never institute testosterone replacement therapy in a newly recognised androgen deficient man who is seeking fertility. The fertility issue must be addressed first as testosterone therapy has a potent contraceptive action via suppression of pituitary gonadotrophins and sperm output.

When should I refer a patient to a specialist? GPs can refer couples immediately or after a few months during which baseline tests are performed.

Referral to specialists will depend on the associated problem • Endocrinologist (endocrine associated problems) • Urologist (undescended testes, surgery) • Fertility specialist/ART clinic that offers full assessment, including examination of the male partner Long-term management • Includes assessment for late-onset androgen deficiency, testis cancer Fertility Clinics A list of Australian ART Clinics, accredited by the Reproductive Technology Accreditation Committee are available via the Fertility Society of Australia website fertilitysociety.com.au

Supporting the couple • Acknowledge both partners’ experience of infertility, and encourage couple communication • Provide empathy and normalise feelings of grief and loss • Refer on to a psychologist or counsellor if the couple require further support

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 6 Clinical Summary Guide

Testicular Cancer Diagnosis and management

• Testicular cancer is the second most common cancer in men Diagnosis and management aged 20-39 years. It accounts for about 20% of cancers in men aged 20-39 years and between 1% and 2% of cancers Medical history in men of all ages • Scrotal lump • The majority of tumours are derived from germ cells (seminoma • Genital trauma and non-seminoma germ cell testicular cancer) • Pain • More than 70% of patients are diagnosed with stage I disease (pT1) • History of subfertility or undescended testis • Testicular tumours show excellent cure rates of >95%, mainly • Sexual activity/history of urine or sexually transmitted infection due to their extreme chemo- and radio-sensitivity Physical examination • A multidisciplinary approach offers acceptable survival rates • Perform a clinical examination of the testes and general for metastatic disease examination to rule out enlarged nodes or abdominal masses The GP’s role Clinical notes: On clinical examination it can be difficult to GPs are typically the first point of contact for men who have distinguish between testicular and epididymal cysts. Lumps in noticed a testicular lump, swelling or pain. The GP’s primary role is the epididymis are rarely cancer. Lumps in the testis are nearly assessment, referral and follow-up. always cancer. • All suspected cases must be thoroughly investigated and Refer to Clinical Summary Guide 1: Step-by-Step Male referred to a urologist Genital Examination

• Treatment frequently requires multidisciplinary therapy that Ultrasound may include the GP • Organise ultrasound of the scrotum to confirm testicular mass • Most patients will survive, hence the importance of long-term (urgent, organise within 1-2 days) regular follow-up --Always perform in young men with retroperitoneal mass Note on screening: there is little evidence to support routine screening. However, GPs may screen men at higher risk, including Investigation and specialist referral those with a history of previous testicular cancer, undescended • Advice on next steps for investigation and treatment testes, infertility or a family history of testicular cancer. • Referral to urologist (seen within 2 weeks) Benign cysts • CT scan of chest, abdomen and pelvis Epididymal cysts, spermatocele, hydatid of Morgagni and • Serum tumour markers (AFP, hCG, LDH) before orchidectomy: hydrocele are all non-cancerous lumps that can be found in the may be ordered by GP prior to urologist consultation scrotum. Diagnosis can be confirmed via an ultrasound. • Semen analysis and hormone profile (testosterone, FSH, LH) • Discuss sperm banking with all men prior to treatment Common fluid-filled cysts which feel slightly separate from the testis and are often detected • Fine needle aspiration: scrotal biopsy or aspiration of testis Epididymal when pea-sized. Should be left alone when tumour is not appropriate or advised cysts small, but can be surgically removed if they Clinical notes: The urologist will form a diagnosis based on become symptomatic. inguinal exploration, orchidectomy and en bloc removal of testis, tunica albuginea, and spermatic cord. Organ-sparing surgery Fluid-filled cysts containing sperm and can be attempted in specific cases (solitary testis or bilateral sperm-like cells. These cysts are similar to Spermatocele epididymal cysts except they are typically tumours) in specialist referral centres. connected to the testis. Follow-up Small common cysts located at the top of the Patient follow-up (in consultation with treating specialist) for: Hydatid of testis. They are moveable and can cause pain Morgagni if they twist. These cysts should be left alone • Recurrence unless causing pain. • Monitoring the contralateral testis by physical examination

A hydrocele is a swelling in the scrotum • Management of complications, including fertility caused by a buildup of fluid around the testes. Hydroceles are usually painless but gradually increase in size and can become very large. Hydrocele Hydroceles in younger men may be a warning of an underlying testis cancer, albeit rarely. In older men, hydroceles are almost always a benign condition, but a will exclude testicular pathology. Classification and risk factors Patient support

There are three categories of testicular epithelial cancer (Box 1). Diagnosis and treatment can be extremely traumatic for the Germ cell tumours account for 90-95% of cases of testicular patient and family. Regular GP consultations can offer patients cancer according to the World Health Organisation (WHO) a familiar and constant person with whom to discuss concerns classification system. Risk factors (Box 2) are well established. (e.g. about treatment, cancer recurrence, and the effects of testis removal on sexual relationships and fertility). Referral to a 1. The recommended pathological classification psychologist may be required. (modified WHO, 2004) Patient follow-up 1. Germ cell tumours • Regular follow-up is vital, and patients with testicular cancer a. Seminoma should be watched closely for several years. The aim is to detect b. Non-seminoma (NSGCT) relapse as early as possible, to avoid unnecessary treatment and to detect asynchronous tumour in the contralateral testis • Embryonal carcinoma (incidence 5%) • Yolk sac tumour • Plan follow-ups in conjunction with the specialist. Follow-up • Choriocarcinoma schedules are tailored to initial staging and treatment, and can • Teratoma involve regular physical examination, tumour markers and scans to detect recurrence. The timing and type of follow-ups need to 2. Sex cord stromal tumours be determined for each patient in conjunction with the treating 3. Non-specific stromal tumours specialist(s)

2. Prognostic risk factors Semen storage Pathological (pT1-pT4) • Men with testicular cancer often have low or even absent • Histopathological type sperm production even before treatment begins. Chemotherapy • For seminoma or radiotherapy can lower fertility further. All men should be --Tumour size (>4 cm) offered pre-treatment semen analysis and storage as semen --Invasion of the rete testis can be stored long-term for future use in fertility treatments. Men who have poor sperm counts may need to visit the • For non-seminoma sperm-banking unit on 2 or 3 occasions or, in severe cases, --Vascular/lymphatic invasion or peri-tumoural invasion an Andrology referral may be required. Surgical removal of --Percentage embryonal carcinoma >50% one testis does not affect the sperm-producing ability of the remaining testis --Proliferation rate (MIB-1) >70% • Provide prompt fertility advice to all men considering Clinical (for metastatic disease) chemotherapy or radiotherapy, to avoid delaying treatment. It • Primary location is highly recommended that men produce semen samples for • Elevation of tumour marker levels (AFP, hCG, LDH) sperm storage prior to treatment. • Presence of non-pulmonary visceral metastasis* • Sperm storage for teenagers can be a difficult issue requiring * Only clinical predictive factor for metastatic disease in seminoma. careful and delicate handling. Coping with the diagnosis of cancer at a young age and the subsequent body image Staging of testicular tumours problems following surgery can be extremely difficult. The TNM (Tumour, Node, Metastasis) system (UICC, 2009) is Fatherhood is therefore not likely to be a priority concern. recommended for classification and staging purposes. Producing a semen sample by can also be The IGCCCG staging system is recommended for metastatic stressful for young men in these circumstances. disease. • Refer the patient to a fertility specialist or a local infertility clinic. These clinics usually offer long-term sperm storage Refer to Clinical Summary Guide 6.1: Testicular Cancer Supplement facilities.

Treatment of testicular cancer

• The first stage of treatment is usually an orchidectomy: removal of the diseased via an incision in the groin, performed under general anaesthetic. Men can be offered a testicular prosthesis implant during or following orchidectomy • Further treatment depends on the pathological diagnosis (seminoma vs non-seminoma and the stage of disease) and may include surveillance, chemotherapy or radiotherapy --Men with early stage seminoma have treatment options of surveillance, chemotherapy or radiotherapy. The treatment is based on patient and tumour factors --Men with early stage non-seminoma have treatment options of surveillance, chemotherapy or further surgery. The treatment is again based on patient and tumour factors Schematic diagram of the testis

--Men with early stage disease who relapse and men with Diagram courtesy Of Dr C Borg, Monash Institute Of Medical Research advanced disease are generally referred for chemotherapy. If chemotherapy leaves residual masses, these may contain cancer and usually will need surgical removal • If a man has a bilateral orchidectomy (rare) he will require ongoing testosterone replacement therapy. Refer to Clinical Summary Guide 6.1: Testicular Cancer Supplement

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 6.1 Clinical Summary Guide

Testicular Cancer Supplement Classification and treatment

TNM staging pT - Primary Tumour* classification for testicular cancer pTX Primary tumour cannot be assessed (UICC, 2017 8th Edition) pT0 No evidence of primary tumour (e.g. histologic scar in testis) pTis Intratubular germ cell neoplasia or ITGCN (sometimes loosely referred to as carcinoma in situ) pT1 Tumour limited to testis and epididymis without vascular/lymphatic invasion: tumour may invade tunica albuginea but not tunica vaginalis pT2 Tumour limited to testis and epididymis with vascular/lymphatic invasion, or tumour extending through tunica albuginea with involvement of tunica vaginalis pT3 Tumour invades spermatic cord with or without vascular/lymphatic invasion pT4 Tumour invades scrotum with or without vascular/lymphatic invasion

Regional Lymph Nodes Clinical

NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis with a lymph node mass 2 cm or less in greatest dimension, or multiple lymph nodes, none more than 2 cm in greatest dimension N2 Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension or multiple lymph nodes, any one mass more than 2 cm but not more than 5 cm in greatest dimension N3 Metastasis with a lymph node mass more than 5 cm in greatest dimension

Regional Lymph Nodes Pathological

pNX Regional lymph nodes cannot be assessed pN0 No regional lymph node metastasis pN1 Metastasis with a lymph node mass 2 cm or less in greatest dimension and 5 or fewer positive nodes, none more than 2 cm in greatest dimension pN2 Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or more than 5 nodes positive, none more than 5 cm; or evidence of extranodal extension of tumour pN3 Metastasis with a lymph node mass more than 5 cm in greatest dimension

Distant Metastasis

MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis M1a Non-regional lymph node(s) or lung M1b Other sites

Serum Markers†

Sx Serum markers not available or cannot be assessed S0 Serum marker study levels within normal limits S1 LDH < 1.5 x ULN; hCG < 5000 mIU/mL; AFP < 1000 ng/mL S2 LDH 1.5-10 x ULN; hCG 5000-50,000 mIU/mL; AFP 1000-10,000 ng/mL S3 LDH > 10 x ULN; hCG > 50,000 mIU/mL; AFP > 10,000 ng/mL

† LDH, lactate dehydrogenase; hCG, human chorionic gonadotrophin; AFP, alpha fetoprotein; ULN, upper limit of normal * Except for pTis and pT4, where radical orchidectomy is not always necessary for classification purposes, the extent of the primary tumour is classified after radical orchidectomy; see pT. In other circumstances, TX is used if no radical orchidectomy has been performed. Treatment options for localised testicular cancer

Following orchidectomy for stage I (localised) disease, metastases can occur in 15-20% of seminoma and 20-30% of NSGCT patients. Adjuvant treatments can decrease this risk, but come at the cost of adverse effects. Surveillance is another management option often used as many patients will not have a recurrence. A risk-adapted approach is now used to determine subsequent management.

pT1 Seminoma

• Surveillance is recommended (if facilities are available and the patient willing and able to comply) • Carboplatin-based chemotherapy can be recommended (decreases recurrence rates from 15-20% to 1-3%) • Adjuvant treatment not recommended for patients at very low risk (<4 cm size, absence of rete testis invasion) • Radiotherapy is not recommended as adjuvant treatment, although it is a treatment option

pT1 Non-Seminomatous Germ Cell Tumour (NSGCT)

Low risk High risk (No Lymphovascular invasion, Embryonal component <50%, (Lymphovascular invasion, pT2-pT4) Proliferative index <70%) • Adjuvant chemotherapy with one or two courses of BEP is • If the patient is able and willing to comply with a surveillance recommended. policy, long-term (at least 5 years) close follow-up should be • If the patient is not willing to undergo chemotherapy or recommended. if chemotherapy is not feasible, nerve-sparing RPLND or • In patients not willing (or unsuitable) to undergo surveillance, surveillance with treatment at relapse (in about 50% of adjuvant chemotherapy or nerve-sparing retroperitoneal patients) are options. lymph node dissection (RPLND) are options.

Treatment of Metastatic disease (pt2-t4)

The treatment of metastatic germ cell tumours depends on: NSGCT • The histology of the primary tumour and • Low volume NSGCT with elevated markers (good or intermediate prognosis), three of four cycles of BEP; if no • Prognostic groups as defined by the IGCCCG marker elevation, repeat staging at 6 weeks surveillance to (International Germ Cell Cancer Collaborative Group) make final decision on treatment. Seminoma • Metastatic NSGCT with a good prognosis, primary treatment three courses of BEP. • Radiotherapy (30Gy), or chemotherapy (BEP) can be used with the same schedule as for the corresponding prognostic groups • Metastatic NSGCT with intermediate or poor prognosis, four for NSGCT. courses of BEP and inclusion in clinical trial recommended. • Any pT, N3 seminoma is treated as “good prognosis” metastatic • Surgical resection of residual masses after chemotherapy in tumour with three cycles of BEP or four cycles of EP. NSGCT is indicated in case of visible residual mass and when tumour marker levels are normal or normalising. • PET scan plays a role in evaluation of post-chemotherapy masses larger than 3 cm

IGCCCG Prognostic- based staging system for metastatic germ cell cancer

Prognosis Seminoma Non-Seminoma

If all criteria are met: •• Any primary site Good •• Testis/retroperitoneal primary •• No non-pulmonary metastases (If ALL criteria are met) •• No non-pulmonary metastases e.g. liver, brain •• Normal AFP/normal LDH, low hCG •• Lower levels of tumour markers

If all criteria are met: If all criteria are met:

Intermediate •• Any primary site •• Testis/retroperitoneal primary

(If ALL criteria are met) •• No non-pulmonary metastases •• No non-pulmonary metastases e.g. liver, brain

•• Normal AFP/normal LDH, medium hCG •• Medium levels of tumour markers

If any criteria are met:

Poor •• No seminoma carries poor prognosis Non-pulmonary metastases e.g. liver, brain (If ANY criteria are met) •• Higher level of tumour markers

•• Mediastinal primary for NSGCT

Additional Investigations Other Examinations Serum Tumour Markers Assessment of abdominal and mediastinal nodes and viscera (CT scan) and supraclavicular nodes (physical examination) Post-orchidectomy half-life kinetics of serum tumour markers • Other examinations such as brain or spinal CT, bone scan • The persistence of elevated serum tumour markers 3 weeks or liver ultrasound should be performed if metastases are after orchidectomy may indicate the presence of metastases, suspected while its normalisation does not necessarily mean an absence of tumour • Patients diagnosed with testicular seminoma who have a positive abdominal CT scan are recommended to have a chest • Tumour markers should be assessed until they are normal, as CT scan long as they follow their half-life kinetics and no metastases are revealed on scans • A chest CT scan should be routinely performed in patients diagnosed with NSGCT because in 10% of cases small subpleural nodes are present that are not visible radiologically

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 7 Clinical Summary Guide

Prostate Disease BPH and Prostatitis - Diagnosis and management

1. Benign Prostatic Hyperplasia (BPH) Other PSA Tests • PSA velocity or doubling time: if the PSA level doubles in 12 • BPH is the non-cancerous enlargement of the prostate gland months it may indicate or prostatitis. An • Whilst not normally life threatening, BPH can impact elevated PSA and a stable velocity suggests BPH considerably on quality of life • Free-to-total PSA ratio: high ratio (>25%) suggests BPH; low The GP’s role ratio (<10%) suggests prostate cancer • GPs are typically the first point of contact for men with BPH • Prostate Health Index (PHI): not covered by the MBS, PHI thought to be more specific for diagnosing prostate cancer • The GP’s role in the management of BPH includes clinical than PSA level alone; good quality evidence lacking & not assessment, treatment, referral and follow-up recommended in Australian prostate cancer testing guidelines • Creatinine levels Diagnosis • Post-void residual urine (ultrasound) Medical History Optional investigations (usually by the urologist) • Lower urinary tract symptoms (LUTS) • Uroflowmetry (specialist only) Urinary symptoms of BPH • Pressure-flow study • Hesitancy • Endoscopy • Weak and poorly directed stream • Urinary tract imaging • Straining • Voiding chart • Post-urination dribble or irregular stream Management • Urinary retention • Overflow or paradoxical incontinence Treatment • Urgency Observation and review: for mild or low impact symptoms • Frequency • Optimise through reassurance, education, periodic monitoring • Nocturia and lifestyle modifications Note: Some men with BPH may not present with many or any symptoms of the disease. Medical therapy: for moderate to severe symptoms

Symptom Score α-blockers • Evaluation of symptoms contributes to treatment allocation • Suited to patients with moderate/severe LUTS and response monitoring • All α1-blockers (Alfuzosin, Tamsulosin, Terazosin, Prazosin) have • The International Prostate Symptom Score (IPSS) a similar clinical efficacy (side-effect pro les favour Tamsulosin) questionnaire is recommended 5α-reductase-inhibitors Physical examination • Suited to patients with moderate/severe LUTS and enlarged (>30–40 mL) • Digital rectal examination (DRE): can estimate prostate size and identify other prostate pathologies • Including Dutasteride and Finasteride • Basic neurological examination • Finasteride and Dutasteride both reduce prostate volume by 20-30% and seem to have similar clinical ef cacy • Perianal sensation and sphincter tone • Bladder palpation Combination therapy • Calibre of the urethral meatus • Combination of α-blocker (tamsulosin) with 5 α-reductase- inhibitor (dutasteride), available in Australia as Duodart® Investigations • Shown to be more beneficial and durable than monotherapy • Urine analysis: midstream urine: microscopy, culture and sensitivity (MC&S) Beta 3-adrenoceptor agonists & antimiscurinics: • Prostate specific antigen (PSA) levels: while PSA levels are • Used for overactive bladder or storage symptoms mostly used as a marker of prostate cancer, PSA levels can Day procedure (Urolift® system): be elevated as a result of non cancerous prostate disease • Involves placement of several retractors into the prostatic lobes (BPH and prostatitis) - benefits & risks of PSA testing should to increase the urethral opening be discussed • Not suitable for all men (urologist assessment) PSA levels for different age groups of Western men • Short-term side-effects pro le better than surgery but longer Age range Serum PSA Serum PSA (ng/mL) term outcomes unknown years (ng/mL) median upper limit of normal 40-49 0.65 2.0 50-59 0.85 3.0 60-69 1.39 4.0 70-79 1.64 5.5 Surgical therapy: for severe or high impact symptoms Diagnosis • Transurethral resection of the prostate (TURP) for prostates 30–80 mL Medical History • Transurethral incision of the prostate (TUIP) for prostates <30 • Urinary symptoms mL and without middle lobe • Pain • Open or TURP for those >80 mL Symptoms of prostatitis • Laser ablation or resection of BPH available in specific surgical • Dysuria – painful urination centres. • Urgent need to urinate • Laser surgery regarded as equivalent efficacy to TURP • Frequent urination • Other options also available • Painful ejaculation Specialist referral • Lower back pain • Indicators for referral to a urologist • Perineal pain • The patient’s symptoms become more serious: their symptom • Chills and/or fever score moves into the ‘severely symptomatic’ category • Muscular pain • The patient’s symptoms significantly interfere with their quality • General lack of energy of life – score of 5 ‘unhappy’ or 6 ‘terrible’ on the IPSS • After an episode of urinary retention, urinary infection, Investigations haematuria • Digital rectal examination (DRE): prostate tenderness or • No response to medical treatment swelling • A risk of prostate cancer exists • Prostate specific antigen (PSA) levels: elevated PSA levels • Post void residual urine on ultrasound assessment >100 mL • PSA velocity: if the PSA level doubles in 12 months it may indicate prostate cancer or prostatitis Follow-up • Urine analysis: • It is appropriate for the GP to monitor and follow-up a patient • First pass urine: Chlamydia urine PCR test with respect to all the treatment modalities. However, if the • Midstream urine: MC&S patient is not responding to medical treatment, refer to the urologist. • Urine PCR for STIs should be done if Chlamydia or other STI a likely cause • Clinical notes: Men who have had TURP remain at risk for prostate cancer and need routine prostate cancer checks, as per guidelines. Management

Recommended follow-up timeline after BPH treatment Treatment Treatment First year after Annually • There are several therapeutic options available. Evidence for modality treatment thereafter benefits of these treatment options is limited; however, they 6 weeks 12 weeks 6 months Observation & review X X may be trialled with the patient 5α-reductase inhibitors X • With respect to management by the specialist, use of the α-blockers X following forms of treatment will vary according to the Surgery or minimal individual, their condition and the stage of their treatment invasive treatment • Most patients at some stage in their treatment however will have antibiotic therapy 2. Prostatitis Bacterial prostatitis (acute and chronic) can be treated using antibiotics. Once diagnosed, rapid treatment is essential to avoid • Prostatitis is an inflammation of the prostate gland further complications. • It can be a result of bacterial or non-bacterial infection Chronic nonbacterial prostatitis (chronic prostate pain • Acute bacterial prostatitis, the least common form, can be life syndrome); causal treatment is difficult and cure is often not an threatening if the infection is left untreated option. Treatment focus is on symptom management, to improve • Whilst not normally life threatening, prostatitis can impact quality of life. considerably on a man’s quality of life Medication options The GP’s role • α-blockers • GPs are typically the first point of contact for men with --Suited to patients with moderate/severe LUTS prostatitis --All α1-blockers (Alfuzosin, Tamsulosin, Terazosin, Prazosin, • The GP’s role in the management of prostatitis includes clinical Silodosin) have similar clinical efficacy and side-effects assessment, treatment, referral and follow-up • Antibiotics (not all antibiotics penetrate the prostate gland) --Recommend: Norfloxacin, Ciprofloxacin, Trimethoprim, Sulphamethoxazole/Trimethoprim, Erythromycin, Gentamicin --Young men with confirmed Chlamydia prostatitis: Doxycycline (Vibramyocin®) • Muscle relaxants: Diazepam, Baclofen • Analgesics • Non-steroidal anti-inflammatory drugs • 5α-reductase-inhibitors: Finasteride Surgical options* • Transurethral incision of the bladder neck • Transurethral resection of the prostate *Surgery has a very limited role and requires an additional, specific indication e.g. prostate obstruction, prostate calcification

Other options • Lifestyle changes: avoid activity that involves vibration or trauma to the perineum e.g. bike riding, tractor driving, long- distance driving, cut out caffeine, spicy foods, alcohol, avoid constipation • Pelvic floor relaxation techniques • Prostate • Supportive therapy: biofeedback, relaxation exercises, acupuncture, massage therapy, chiropractic therapy and meditation • Heat therapy

Specialist referral Indicators for referral to a urologist: • When the GP is not confident in managing the condition • If the GP is concerned there are other potential diagnoses, particularly prostate or bladder cancer • Those who do not respond to initial first-line therapy such as antibiotics and/or α-blockers. For these patients, more invasive investigations, such as cystoscopy and transrectal prostate ultrasound scan, are commonly done Follow-up • The need for specialist follow-up depends on the patient’s progress • Most specialists will refer back to the GP to monitor the progress of the patient • The specialist will seek re-referral if the patient’s progress is not satisfactory • A GP can re-refer if they do not feel comfortable in managing a relapse

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 8 Clinical Summary Guide

Ejaculatory Disorders

1. Premature Ejaculation (PE) Physical examination • General examination • The most common ejaculatory disorder • Genito-urinary: penile and testicular • Ejaculation that occurs sooner than desired --rectal examination (if PE occurs with painful ejaculation) • Primary (lifelong) PE • Neurological assessment of genital area and lower limb --patient has never had control of ejaculation Refer to Clinical Summary Guide 1: Step-by-Step Male Genital --disorder of lower set point for ejaculatory control Examination --unlikely to diagnose an underlying disease • Secondary (acquired) PE Management --patient was previously able to control ejaculation --most commonly associated with erectile dysfunction (ED) Treatment • Definition (ISSM, 2014): Treatment decision-making should consider: --an intravaginal ejaculatory latency time (IELT) of less than about 1 minute (lifelong) or about 3 minutes (acquired), and • Aetiology --an inability to delay ejaculation on nearly all occasions, and • Patient needs and preferences --negative personal consequences such as distress. • The impact of the disorder on the patient and his partner • Primary (lifelong) PE tends to present in men in their 20s and • Whether fertility is an issue 30s; secondary (acquired) PE tends to present in older age Management of PE is guided by the underlying cause groups Primary PE: Clinical notes: PE is a self reported diagnosis, and can be based on sexual history alone • 1st line: SSRI, reducing penile sensation, e.g. using topical penile anaesthetic sprays (only use with a condom) The GP’s role • 2nd line: Behavioural techniques, counselling • GPs are typically the first point of contact for men with a • Most men require ongoing treatment to maintain disorder of ejaculation normal function • The GP’s role in management of PE includes diagnosis, Secondary PE treatment and referral • Secondary to ED: Manage the primary cause or • Offer brief counselling and education as part of routine management • 1st line: Behavioural techniques, counselling • 2nd line: SSRI, reducing penile sensation, PDE5 inhibitors How do I approach the topic? • Many men return to normal function following treatment • “Many men experience sexual difficulties. If you have any difficulties, I am happy to discuss them.” Treatment options: Erectile dysfunction (ED) treatment Diagnosis • If PE is associated with ED, treat the primary cause (e.g. PDE5 inhibitors) Medical history Sexual history Behavioural techniques • ‘Stop-start’ and ‘squeeze’ techniques, extended , • Establish presenting complaint (i.e. linked with ED) pre-intercourse masturbation, cognitive distractions, alternate • Intravaginal ejaculatory latency time sexual positions, interval sex and increased frequency of sex • Onset and duration of PE • Techniques are difficult to maintain long-term • Previous sexual function Psychosexual counselling • History of sexual relationships • Address the issue that has created the anxiety or • Perceived degree of ejaculatory control psychogenic cause • Degree of patient/partner distress • Address methods to improve ejaculatory control. Therapy • Determine if fertility is an issue options include meditation/relaxation, hypnotherapy Medical and neuro-biofeedback • General medical history • Medications (prescription and non prescription) • Trauma (urogenital, neurological, surgical) • Prostatitis or hyperthyroidism (uncommonly associated) Psychological • Depression • Anxiety • Stressors • Taboos or beliefs about sex (religious, cultural) Oral pharmacotherapy Delayed ejaculation / no A common side-effect of some selective serotonin reuptake Delayed ejaculation inhibitors (SSRI) and tricyclic antidepressants is delayed • Delayed ejaculation occurs when an ‘abnormal’ or ‘excessive’ ejaculation. SSRIs are commonly prescribed for PE; except amount of stimulation is required to achieve orgasm with for Priligy®, all other SSRIs are used off-label for treating PE. ejaculation Common dosing regimens are: • Often occurs with concomitant illness • Dapoxetine hydrochloride (Priligy®): a short-acting on-demand SSRI,the only SSRI approved for treatment of PE in Australia; 30 • Associated with ageing mg taken 1-3 hours before intercourse • Can be associated with idiosyncratic masturbatory style • Fluoxetine hydrochloride: 20 mg/day (psychosexual) • Paroxetine hydrochloride: 20 mg/day. Some patients find 10mg Investigation effective; 40 mg is rarely required. Pre-intercourse dosing • Testosterone levels regime is generally not effective Treatment: • Sertraline hydrochloride: 50 mg/day or 100 mg/day is usually effective. 200 mg/day is rarely required. Pre-intercourse dosing • Aetiological treatment: Management of underlying condition regime is generally not effective or concomitant illness e.g. androgen deficiency • Clomipramine hydrochloride*: 25-50 mg/day or 25 mg 4-24 hrs • Medication modification: consider alternative agent pre-intercourse * Suggest 25 mg on a Friday night for a weekend of benefit (long acting) or ‘drug holiday’ from causal agent PDE-5 Inhibitors: e.g. Sildenafil (Viagra®: 50-100 mg), 30-60 • Psychosexual counselling minutes pre-intercourse if PE is related to ED. Anorgasmia ‘Start low and titrate slow’. Trial for 3-6 months and then slowly • Anorgasmia is the inability to reach orgasm titrate down to cessation. If PE reoccurs, trial drug again. If one • Some men experience nocturnal or spontaneous ejaculation drug is not effective, trial another. • Aetiology is usually psychological Reducing penile sensation Investigation • Topical applications: Local anesthetic gels/creams can diminish • Testosterone levels sensitivity and delay ejaculation. Excess use can be associated with a loss of pleasure, orgasm and erection. Apply 30 minutes Treatment: prior to intercourse to prevent trans-vaginal absorption. Use a • Psychosexual counselling condom if intercourse occurs sooner. • Medication modification: consider alternative agent or ‘drug • Lignocaine spray: 10% (‘Stud’ 100 Desensitising spray for holiday’ from causal agent men; this should be used with a condom to prevent numbing of • Pharmacotherapy: Pheniramine maleate, decongestant partner’s genitalia) medication such as Sudafed® or antihistamines such as • Condoms: Using condoms can diminish sensitivity and delay Periactin® may help but have a low success rate. ejaculation, especially condoms containing anaesthetic Clinical notes: combination treatment can be used. Orgasm with no ejaculation Retrograde “dry” ejaculation Specialist referral • Retrograde ejaculation occurs when semen passes backwards For general assessment refer to a specialist (GP, endocrinologist through the bladder neck into the bladder. Little or no semen is or urologist) who has an interest in sexual medicine. discharged from the penis during ejaculation Refer to a urologist: If suspicion of lower urinary tract disease • Causes include prostate surgery, diabetes Refer to an endocrinologist: If a hormonal problem is diagnosed • Patients experience a normal or decreased orgasmic sensation Refer to counsellor, psychologist, psychiatrist or sexual therapist: • The first urination after sex looks cloudy as semen mixes For issues of a psychosexual nature into urine Refer to fertility specialist: If fertility is an issue Investigation 2. Other Ejaculatory Disorders • Post-ejaculatory urinalysis - presence of sperm and fructose

• Spectrum of disorders including delayed ejaculation, Treatment: anorgasmia, retrograde ejaculation, anejaculation and • Counselling: to normalise the condition painful ejaculation • Pharmacotherapy: possible restoration of antegrade • Can result from a disrupted mechanism of ejaculation ejaculation and natural conception; note that pharmacotherapy (emission, ejaculation and orgasm) may not be successful • Disorders of ejaculation are uncommon, but are important to --Imipramine hydrochloride (10 mg, 25 mg tablets) 25-75 mg manage when fertility is an issue three times daily • Etiology of ejaculatory dysfunction are numerous and --Pheniramine maleate (50 mg tablet) 50 mg every second day multifactorial, and include psychogenic, congenital, anatomic --Decongestant medication such as Sudafed®; antihistamines causes, neurogenic causes, infectious, endocrinological and such as Periactin® secondary to medications (antihypertensive, psychiatric • Medication modification: consider alternative agent or ‘drug (SSRIs), α-blocker) holiday’ from causal agent • Behavioural techniques: The patient may also be encouraged to ejaculate when his bladder is full, to increase bladder neck closure • Vibrostimulation, electroejaculation, or sperm recovery from post-ejaculatory urine: Can be used when other treatments are not effective, to retrieve sperm for assisted reproductive techniques (ART) Anejaculation • Anejaculation is the complete absence of ejaculation, due to a failure of semen emission from the prostate and seminal ducts into the urethra • Anejaculation is usually associated with normal orgasmic sensation Investigation • Testosterone levels • Post-ejaculatory urinalysis - absence of sperm and fructose • Ultrasound of and post ejaculatory ducts (usually via the ) Treatment: • Counselling: to normalise the condition • Medication modification: consider alternative agent or ‘drug holiday’ from causal agent • Vibrostimulation or electroejaculation: Used when other treatments are not effective, to retrieve sperm for ART • Pharmacotherapy: Pheniramine maleate, decongestant medication such as Sudafed® or antihistamines such as Periactin® may help but have a low success rate. Painful ejaculation • Painful ejaculation is an acquired condition where painful sensations are felt in the perineum or urethra and urethral meatus • Multiple causes e.g. ejaculatory duct obstruction, post- prostatitis, urethritis, autonomic nerve dysfunction Investigation • Urine analysis (first pass urine- chlamydia & gonorrhoea urine PCR test; midstream urine MC&S) • Cultures of semen (MC&S) • Cystoscopy Treatment: • Aetiological treatment (e.g. infections-prostatitis, urethritis): Implement disease specific treatment • Behavioural techniques: If no physiological process identified. Use of relaxation techniques (i.e. ejaculation in conditions when muscles can be relaxed), use of fantasy for distraction • Psychosexual counselling

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 9 Clinical Summary Guide

Erectile Dysfunction Diagnosis and management

• Is a persistent or recurrent inability to attain and/or maintain Management a penile erection sufficient for satisfactory sexual activity and intercourse Treatment decision-making • Is a common condition affecting 1 in 5 men over the age of 40 • Cause: organic, psychosocial or combined years • Patient and partner preferences • Is associated with chronic disease including cardiovascular • Benefits, risks and costs of treatment options disease and diabetes. Furthermore, ED may be an early warning sign of these chronic diseases Treatment summary • Is a treatable condition that can impact strongly on the well- 1st line being of men and their partners • Alter modifiable risk factors and causes • The sexual health of older patients is often overlooked. • Facilitate sexual health • Understanding female partners’ sexual needs as part of management should be considered 2nd line The GP’s role • GPs are typically the first point of contact for men with erectile • Oral agents (PDE5 inhibitors) dysfunction • Counselling and education • The GP’s role in the management of erectile dysfunction • Vacuum devices/rings includes clinical assessment, treatment including counselling, referral and follow-up 3rd line › Consider specialist referral How do I approach the topic? • Intracavernous vasoactive drug injection • “Many men (of your age/with your condition) experience sexual difficulties. If you have any difficulties, I am happy to discuss them” 4th line › Specialist referral • “It is common for men with diabetes/heart disease/high blood • Surgical treatment (penile implants) pressure to have erectile problems. Also, erectile problems can indicate you are at higher risk for future health problems such For full details of treatment, refer over page as heart disease. So it’s an important issue for us to discuss if it is a problem for you.” Specialist referral Diagnosis Indicators for specialist referral History • Level of GP training/experience • Patient request Medical Sexual Psychosocial Refer to endocrinologist Define the nature of Lifestyle Depression • Complex endocrine disorders the sexual dysfunction General health ED onset Anxiety Refer to urologist Spontaneous Relationship • Pelvic or perineal trauma Chronic disease morning erections difficulties • Penile deformities Genital disease Penetration possible Sexual abuse • Patients for penile implants Maintenance of Medications Refer to ED specialist (either endocrinologist or urologist) erection Complex problems including vascular, neurological and treatment failures Physical examination • Genito-urinary: penis, testes Refer to counsellor, psychologist, psychiatrist or sexual • Cardiovascular: BP, HR, waist circumference, cardiac therapist • examination, carotid bruits, foot pulses • Relationship problems • Neurological: focused neurological examination • Complex psychiatric or psychological disorder Refer to Clinical Summary Guide 1 : Step-by-Step Male Genital Follow-up Examination Follow-up is essential to ensure the best patient outcomes.

Investigations Assess: • Diabetes mellitus • Effectiveness of treatment, patient/partner satisfaction • Hyperlipidemia • Any adverse effects of treatment • Hypogonadism • Overall physical and mental health • Cardiovascular disease • Partner’s sexual function (e.g. libido), couple’s adaptation to • Others as indicated changes to sex life Treatment of erectile dysfunction (ED) 3rd Line Treatment › consider referral or specialist training Intracavernous vasoactive drug injection 1st Line Treatment • Alprostadil (Caverject Impulse®): 10 and 20 mcg is the first Alter modifiable risk factors and causes choice for its high rate of effectiveness and low risk of priapism • Modify medication regime: Change current medications linked and cavernosal fibrosis. If erection is not adequate with to ED (e.g. antidepressants, antihypertensives) when possible alprostadil alone, it may be combined with other vasoactive drugs (bimix/trimix) to increase efficacy or reduce side-effects • Manage androgen deficiency: When diagnosed and a cause is established, androgen replacement therapy • Commence with minimum effective dose and titrate upwards if necessary • Address psychosocial issues: Includes relationship difficulties, anxiety, lifestyle changes or stress • Initial trial dose should be administered under supervision of an experienced GP or specialist Facilitating sexual health • Erection usually appears after 5 to 15 minutes and lasts • Lifestyle changes: Smoking cessation, reduced alcohol, according to dose injected. Aim for hard erection not to last improved diet and exercise, weight loss, stress reduction, illicit longer than 60 minutes drug cessation, compliance with diabetes and cardiovascular • Recommended maximum usage is 3 times a week, with at least medications 24 hours between uses • Discuss sexual misinformation: Includes importance of • Contraindicated in men with history of hypersensitivity to drug sufficient arousal and lubrication, and realistic expectations, or risk of priapism such as normal age-related changes • Patient comfort and education are essential. Inform patient of 2nd Line Treatment side-effects (priapism, pain, fibrosis and bruising, particularly if on Aspirin or Warfarin). Provide a plan for urgent treatment of Oral agents: PDE5 inhibitors priapism if necessary • Adapt dose as necessary, according to the response and side- effects 4th Line Treatment › Refer to urologist (surgical treatments) • Treatment is not considered a failure until full dose is trialled • Penile prosthesis: A highly successful option for patients who 7-8 times prefer a permanent solution or have not had success with pharmacologic therapy. Surgery is irreversible and eliminates • Ensure patient knows that is required for the normal function of the corpus cavernosa. Cost may be a drug to work limiting factor for some patients • Common side-effects: headaches, flushing, dyspepsia, nasal • Vascular surgery: Microvascular arterial bypass and venous congestion, backache and myalgia ligation surgery can increase arterial inflow and decrease • Contraindicated in patients who take long and short-acting venous outflow but restoration of normal function is uncommon nitrates, nitrate-containing medications, or recreational nitrates (amyl nitrate) Possible emerging treatments • Exercise caution when considering PDE5 inhibitors for patients • Low dose shock wave therapy, topical nitrates and new oral with: active coronary ischaemia, congestive heart failure and agents are being evaluated and may play a role in treatment of borderline low blood pressure, borderline low cardiac volume ED in the future. status, a complicated multi-drug antihypertensive program, and drug therapy that can prolong the half-life of PDE5 inhibitors On demand dosing: Sildenafil (Viagra® & generics): 25, 50 and 100 mg; recommended starting dose 50 mg (usually need 100 mg) Tadalafil (Cialis®): 10 and 20 mg; recommended starting dose 20 mg Vardenafil (Levitra®): 5, 10 and 20 mg; recommended starting dose 10 mg (usually need 20 mg)

Daily dosing: Tadalafil (Cialis®): 5 mg at the same time every day. The dose may be decreased to 2.5 mg but not exceed 5 mg daily

Counselling and education • Offer brief counselling and education to address psychological issues linked with ED, such as relationship difficulties, sexual performance concerns, anxiety and depression • Consider concurrent patient/couple counselling with a psychologist, to address more complex issues, and/or to provide support during other treatment trials Vacuum devices and rings • Suitable for men who are not interested in, or have contraindications for pharmacologic therapies • Not suitable for men with severe ED • Typically suitable for patients in long-term relationships • Adverse effects include penile discomfort, numbness and delayed ejaculation

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 10 Clinical Summary Guide

Klinefelter Syndrome Diagnosis and management

Klinefelter syndrome

• A genetic condition affecting 1 in 550 men • Due to the presence of an extra X chromosome (47,XXY) • Chromosomal mosaicism (both 47,XXY and 46,XY cells) occurs in 10% --Usually have milder signs and symptoms, depending upon the level of mosaicism • The most common cause of androgen deficiency • Characterised by: 30 mL normal 4 mL Klinefelter syndrome --Impaired testosterone production (androgen deficiency) Figure 2 – Example of 30 ml and 4 ml adult testis --Impaired spermatogenesis (azoospermia) • Up to 70% of cases remain undiagnosed Diagnosis • Classical features may be present (Figure 1), however, there is a wide spectrum of signs and symptoms Medical history • Small testes < 4 mL is the only consistent feature • Pubertal development (poor progression) • Men will benefit from life-long testosterone treatment • Sexual function (low libido) Clinical notes: penile development may be normal or at the lower • Degree of virilisation end of the normal range. • Psychosocial (learning, schooling, behaviour) The GP’s role • Infertility • The clinical presentation may be subtle and its diagnosis Examination overlooked unless actively considered Infancy: • Most males are diagnosed prenatally, during puberty or in association with infertility, or androgen deficiency • No hormonal features prior to puberty • The GP’s role includes clinical assessment, laboratory • Undescended testes investigation, treatment, referral and follow-up • Rarely ambiguous genitalia Clinical notes: the low detection rate (~30%) of Klinefelter • Occasional finding of small firm testes in childhood syndrome would be improved if testicular examination became Adolescence: a regular part of a male physical examination. • Small testes (< 4mL) characteristic from mid puberty • Poor pubertal progression and facial, body and pubic hair Taller than average height relative to age Reduced Facial Hair • Gynecomastia Reduced TallerBody Hair than average height Breast Development (Gynecomastia) • Feminine fat distribution Reduced Facial Hair Feminine Fat Distribution • Taller than average height OsteoperosisReduced Body Hair Small TestesBreast ( Testicular Development Atrophy) (Gynecomastia) • Poor muscle development Varicose Veins Feminine Fat Distribution Adult: Osteoperosis • Small testes (< 4mL) Small Testes ( Testicular Atrophy) • Reduced facial, body and pubic hair Varicose Veins • Gynecomastia • Feminine fat distribution (& weight gain) • Taller than average height • Poor muscle development Refer to Clinical Summary Guides 1-3

Testicular Volume Assessment of testicular volume is essential Figure 1 – Clinical features of Klinefelter syndrome • Testicular volume is assessed using an orchidometer Features present may be few, some or all. • Normal testicular volume range: --childhood 3 mL or smaller --puberty 4–14 mL --adulthood 15–35 mL • Small testes < 4 mL is the only consistent feature of Klinefelter syndrome (Figure 2) Clinical notes: the testes may start to develop in early puberty, but soon regress to < 4mL by mid puberty. Usual T formulation (starting) Dosage range Investigations dosage • Two morning fasting samples of serum total testosterone, taken on different mornings Injections (IM) • Total serum testosterone, low or low normal from mid puberty (normal range 8–27 nmol/L) Serum LH, elevated from mid Sustanon®, 250 mg every 2 10 to 21-day puberty (normal range 1-8 IU/L) Primoteston® weeks intervals • Serum FSH, elevated from mid puberty (normal range 1-8 IU/L) 1000 mg every 12 • Karyotype (47,XXY) weeks following Longer term: 8 to --10% mosaic 46,XY/47,XXY Reandron® loading dose at 6 16-week intervals weeks (i.e., 0, 6, 18, Other investigations: 30 weeks) • Bone density study, DEXA (osteoporosis) • Semen analysis if fertility is an issue (usually azoospermic) Transdermal patch • TFT (hypothyroidism) 2.5 mg and 5.0 mg • Fasting blood glucose (diabetes) Androderm® preps:

5 mg applied 2.5 to 5 mg daily Management nightly

Testosterone replacement therapy (TRT) Transdermal gel • TRT is life-long and may be started from mid puberty although 1%: 50 mg in 5 g many boys initially virilise normally 2.5 to 10 g gel (25 sachet or pump Testogel® mg to 100 mg T) • Gynecomastia is an indication to start TRT pack dispenser; daily • Teenage boys usually start on a low dose and build to full adult applied daily dose as puberty progresses • Even if measured T levels are normal, there is evidence that Transdermal cream bone density is reduced in the presence of chronically raised LH 5% (50 mg/mL): levels, suggesting that TRT is indicated Review levels in 1 2 mL (100 mg) AndroForte®5 month, up to 4 mL applied to the daily Clinical notes: In adults, consult with a fertility specialist torso once daily (if appropriate) to develop a plan for fertility prior to TRT, as TRT will suppress spermatogenesis. Oral undecanoate * Sustanon® is not available on the Australian Pharmaceutical Benefits Scheme (PBS) 40 mg capsule: Andriol Testocaps® 160 to 240 mg in 2 80 to 240 mg daily Other treatments to 3 doses daily • Gynecomastia may be transient, lasting one to three years • Adequate testosterone replacement often results in complete • Cardiovascular: venous ulcers, venous thromboembolic disease resolution over 12 months • Auto-immune: systemic lupus erythematosis (SLE), coeliac • Surgical removal, mastectomy (do not refer for early surgery disease as it may resolve naturally or following TRT) Some features of Klinefelter syndrome are specific to the Follow-up syndrome (e.g. behavioural and cognitive) and some features relate to the androgen deficiency (e.g. osteoporosis). Monitoring TRT is essential Prostate: Specialist referral • Men with Klinefelter syndrome are less likely to die from Children and adolescents prostate cancer, and restoring testosterone levels to the • Refer to a paediatric endocrinologist normal range is likely only to return their risks to those of their eugonadal peers • Refer for educational and allied health assistance if needed • Subject to the same advice about testing for prostate cancer Adults as their peers (PSA) • Develop a plan in consultation with an endocrinologist for: Clinical notes: Exclusion of significant prostate pathology --Hormone deficiency is essential for those aged >40 years at the commencement --Infertility of therapy. --Osteoporosis Raising clinical awareness • Refer to a fertility specialist, as appropriate, for sperm recovery Aside from cognitive and behavioural features, it is important to from testis (occasionally) or donor sperm note that despite the following recognised disease associations with Klinefelter syndrome the absolute risk is low. • Tumours: leukaemia, mediastinal germ cell tumours, lymphoma, teratoma, breast cancer • Endocrine: hypothyroidism, diabetes mellitus (Type 1 and 2, rare) Infertility

Infertility is a major implication of Klinefelter syndrome • Most men are azoospermic • Sperm are rarely found in the ejaculate but in 30-50% of cases sperm can be found in testicular biopsy tissue • Treatment options --Intracytoplasmic Sperm Injection (ICSI) - the risk of 47,XXY offspring is low --Donor insemination • Counselling may be necessary Refer to Clinical Summary Guide 5: Male Infertility

Learning and behaviour difficulties

The general intellectual ability of boys with Klinefelter syndrome is within the normal range. However, boys with Klinefelter syndrome may have: • Difficulties with speech and reading • Delayed motor development • Reduced attention span • Behavioural problems (particularly in adolescence) • Educational and allied health assistance may be required

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 11 Clinical Summary Guide

Engaging Men In primary care settings

• There is a myth that men don’t visit their doctor. In fact, most What influences GPs interaction with men?3 men 40+ years have visited a doctor in the last 12 months. But compared to women, men visit the doctor less often, have • The amount (or lack) of time a GP has for a consultation shorter consultations and tend to see their GP later in the • The nature of the relationship with the patient, e.g. a new/ course of their illness established patient; appreciation of the individual’s background • A range of barriers appear to exist for men seeking help, • Religious, cultural and communication barriers of the GP particularly if the topic is of a sensitive nature • The perceived patient reluctance or embarrassment to discuss • Discussing sensitive issues such as mental health, sexual sensitive issues dysfunction or reproductive health is a shared responsibility • GP embarrassment or attitude to discussing sexual or mental between patient and doctor health • It is important for GPs to maximise opportunities to engage • The GP’s level of knowledge in sensitive areas such as sexual or men effectively mental health The GP’s role • Stereotyping men with respect to their health concerns and • The GP is often the first point of contact for men when they needs, e.g. older men are less likely to have sexual issues; men decide to seek help for their health concerns don’t have depression • The GP is ideally placed to effectively engage men in • The gender and age of the GP, i) a male GP may be preferred discussions about their health and ii) the younger the GP and the greater the age difference can influence the discussion of sexual issues • GPs can play a leading role in identifying, assessing and managing major physical and mental health concerns faced 3 Andrews CN et al., Aust Fam Physician 2007; 36:867-9 by men • GPs are the primary source of help for sexual difficulties in men Strategies for GPs to engage men in discussion and women of all ages, particularly for older couples about their health4

• Stating facts clearly during consultations What influences men’s interaction with GPs1,2 • Using terminology that is easily understood • Men are often influenced by their partners and friends when • Providing written information for patients to read after thinking about seeking help consultations • Metaphors comparing men’s bodies to cars have been used • Listening to and responding to patient needs to facilitate an in health promotion to enhance men’s understanding of empathetic style of communication based on respect and trust preventable risk factors, although it may not appeal to all men • Aiming to deal with a man’s health issues quickly and • Displaying and disseminating health information in the comprehensively local community may improve men’s health awareness and • Referring patients onto specialists when required, particularly if encourage men to visit their GP regularly the problem remains unresolved • Creating more ‘male friendly’ environments by i) using men’s • Keeping abreast of the latest developments and conveying health displays ii) acknowledging the challenges men face in these during consultations making and waiting for appointments iii) providing a broad range of services and iv) providing evening appointments. • Applying and explaining the role of ‘new’ knowledge to patients However, the effectiveness of ‘male friendly’ environments when making diagnoses should be tested at a local clinic level • Alleviating the perceived seriousness of health concerns by • The perception of mental health conditions such as depression using humour thoughtfully to facilitate the building of rapport and anxiety as weaknesses as opposed to physical illnesses • Being proactive and sensitive in managing patients’ sexual and can act as a barrier to seeking help. It’s important that GPs mental health concerns via: reinforce the message that depression and anxiety are illnesses • Routine sexual and mental health history taking, within medical that can be managed in most cases like any other illness histories • The gender of the GP does not matter, except when dealing • Asking about sexual and mental health when risk factors are with issues related to sexual or reproductive health where a evident male may be preferred by some men, particularly for older men 4 Smith JA et al., Med J Aust 2008; 189:618-21 • In older men and/or couples, barriers to sexual health help seeking include the GP’s personal attitudes towards sexuality, the perceived relationship with the GP and a preference for the GP to be the same age

1 Harris MF et al., Med J Aust 2006; 185:440-4 2 Gott M et al., Fam Pract 2003; 20:690-5 How do I approach sensitive issues? Using humour thoughtfully • GPs need to be comfortable to talk to their patients about More than just sharing a joke – it is about facilitating a ‘laid back’ sensitive issues. A lead-in sentence to engage men should be a and ‘friendly’ environment in which men feel comfortable to speak common and comfortable question. openly about their health concerns. • “Are there any other issues you want to talk about… your • “A good laugh a day never hurt anyone, you know.” relationship, family/work stress, feeling down?” • “A sense of humour wouldn’t go astray you know, because quite • “Many men experience periods of feeling down, but find it often it can sort of alleviate the seriousness.” difficult to talk to anyone about it. I can help you, if you are having problems.” Showing empathy • “Many men [of your age/with your condition] experience The ability to communicate easily, at the same level as the sexual difficulties. If you have any difficulties, I am happy patient, and listen and understand from the patient’s perspective. to discuss them.” • “You want to find someone who you can approach and talk to – • “It is common for men with [diabetes/high blood pressure/heart and talk in terms that you can understand what is going on.” disease] to experience erectile problems. I can help you, if you • “With doctors, like with anybody, if you don’t get on the same are having problems.” wave length, if you don’t feel comfortable with them, then you • “How are things going with your sex life?” find someone else.”

What qualities do men value when communicating with Resolving health issues promptly GPs?4 Men value GPs who resolve health issues promptly. Adopting a frank approach • “I just want someone who can do their job, someone who I feel confident in, someone who doesn’t mess me around. If he Being concise, direct and matter-of-fact when communicating doesn’t know, he sends you to a specialist straight away.” with men in primary care settings. • “I don’t want someone who shrugs me off, because I only go • “I prefer him [GP] because... he doesn’t beat around the bush. He when I am really bad.” tells you what is what.” 4 Smith JA et al., Med J Aust 2008; 189:618-21 • “I like straightforwardness... my doctor’s very straightforward.” Demonstrating professional competence The perceived confidence and knowledge conveyed by the GP and dexterity with physical tasks. • “She ah, impresses me, as knowing what she’s talking about.” • “As long as they can do the job properly… As long as they’re competent I couldn’t care less.” Debunking myths about men’s engagement in health services Myth Reality Implications for health service provision

Men ‘behave badly’ Men do seek help... often after a period Appreciating some men actively monitor their health prior to seeking and don’t seek help of self-monitoring to see if the problem help resolves Taking time to understand men’s previous illness experiences Recognising men may seek help to maintain regular activities, e.g. for sporting activity rather than improving health Understanding that perceived illness severity may influence the decision to seek help

Men don’t talk about Men do talk about their health… if provided Adopting a frank approach their health with the right environment in which to do Demonstrating professional competence so, particularly when using health services Using humour thoughtfully Showing empathy Resolving health issues promptly Ensuring sufficient time for discussion by offering a long consultation

Men don’t care about Men do care about their health… if Listening to the way men speak about their health and understanding their health we take time to understand how they what is important to them (improving their health may be important conceptualise health and health care to family/relationships)

Traditional concepts Traditional masculine traits intersect Recognising traditional masculine traits (independence) can be used to of masculinity explain with other physiological, sociological and promote self care why men don’t seek cultural aspects of men’s lives when they Appreciating age, sexual orientation, cultural background and help are deciding to seek help occupation shape the way masculine traits are perpetuated by men in daily life Appreciating the importance of cultural background so information is not missed Acknowledging older men may see the GP as the ‘expert’ and allow them to make decisions on their behalf, whereas young men may be more informed (e.g. via the internet) of alternative option

‘Real men don’t cry’ Men do use mental health services if they Recognising men are at risk of depression and anxiety and therefore don’t are tailored to men’s needs, e.g. Mensline Informing men that depression is an illness, not a weakness and effective use mental health Australia 1300 789 978 treatments are available services Acknowledging men are more likely to describe the physical symptoms of depression (feeling tired, losing weight), rather than saying they feel low

Older men are not Men aged over 70 years are still having sex Being proactive in managing sexual health in older patients sexually active or (37% of this age group). The most common Not dismissing questions about sexual health sexually capable reason for not having sex is the lack of a partner Discussing sexual problems when other chronic conditions (e.g. diabetes) may exist

Health services meet It cannot be assumed that current health Reassessing your clinic’s services, e.g. clinic times the needs of men services and providers are able to engage Developing strategies to promote services specifically for men men effectively to support their health care needs Understanding the qualities men value when visiting their GP

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007 12 Clinical Summary Guide Engaging Aboriginal and Torres Straight Islander men In primary care settings

Aboriginal and Torres Strait Islander men have higher death rates, Where remote clinics are available it is important to: and are more likely to die at much younger ages from circulatory • Get male IHP/IHW to help organise outreach services in the disease than the general population, and often have poor access community as needed, or in appropriate spaces such as men’s to effective health services. areas • Have male-orientated clinics to help men feel comfortable. If What are the barriers for Aboriginal and Torres Strait the environment feels ‘foreign’ then men may be less likely to Islander men to access health services? engage with doctors or be upfront in providing information • Where appropriate, plan and involve family members in the Some significant issues affect the way Aboriginal and Torres consultations so that the family understands the medical Strait Islander men engage with the health system and access treatment and can provide support if needed health services. In particular, when seeking health care for multiple issues the pathway from one service to another can be • Provide flexible delivery, such as telemedicine, home visits or difficult due to any or all of the following factors: after hours services • Engage the local community by holding a clinic meet-and- Societal Illness related stigma greet or open day so that men can meet the current/new staff. Gender differences in health If feasible, arrange a tour of the clinic and its functions, led by the IHP/IHW Cultural Traditional gender-related lores, masculinity and gender roles • Develop men’s health promotion resources (such as posters/ brochures) that include artwork or imagery of local men; if Logistical Lack of transport specific to men’s business, posters can be placed in public/ Appointment times conflict with other family council male restrooms and community priorities (e.g. ceremonies) • Respect Aboriginal and Torres Strait Islander men and their Health system Limited access to specialist service and/or cultural values. For example, it is important for men (and treatment women) to be able to enter and leave a clinic without passing Complicated referral process through a shared reception, particularly when they present for Too few (male) health professionals (leading more sensitive health concerns. to patients seeing many different doctors) To ensure health services are engaging men appropriately by Medical terminology/jargon identifying and valuing culture, it is important to: Financial Difficulties in meeting health service costs • Undertake an informal community consultation process to better understand the health care service needs of the local Individual Knowledge/perception of the nature of the men, if not already documented by local men/service illness • Learn local protocols from local health workers on how to Previous illness experience access/ engage men or men’s groups Low prioritisation of preventative healthcare • Set up a male-specific clinic in a dedicated men’s space Lack of understanding and embarrassment Self-esteem and confidence • Where possible, have more male health staff (doctors, nurses and Indigenous Health Workers (IHWs)) and men’s counselling Strategies for health services to engage men programs to help support men, and go out into the community from remote communities to encourage access to health services • Encourage doctors to stay for the long haul to help men feel Cultural diversity means that what may work in one setting may comfortable and develop trust not work in another. The need for a male-specific place may not • Minimise waiting times where possible and encourage men to be as strong in urban settings as there may be greater integration bring a male IHW, a family member or friend to an appointment and interaction with non-Indigenous people compared to a to help translate remote area. Seeking feedback from the community is important. • Advise the patient in advance of additional costs when being Where English is often the second language and men may not be referred onto other health services/clinics familiar with a clinic environment it is important to: • Integrate Follow-up Care Plans as part of ongoing care to • Identify, acknowledge and consult with “cultural bosses” and ensure the patient has followed treatment and understands community male elders when they need to come back for results/re-testing • Gain local knowledge from men’s groups through consultation • Promote Aboriginal and Torres Strait Islander men and women and documentation of their needs and issues who work in the health service to build empowerment and encourage community members to return to the health service. • Plan services with input from local men: for men who are employed and cannot regularly attend the clinic during normal (daytime) operating hours, consider having an after-hours clinic or mobile/outreach service to visit men in their workplaces and/or at men’s places • Check patient register for the proportion of adult and young males attending • Involve male Indigenous Health Practitioners (IHPs)/IHWs and traditional healers in outreach services in communities, such as 715 Health Checks with the footy team, providing confidentiality is not compromised. Strategies for GPs and other healthcare professionals Strategies to talk about sexual health issues with to engage Aboriginal and Torres Strait Islander men Aboriginal and Torres Strait Islander men

Most health professionals intuitively communicate well with Aboriginal and Torres Strait Islander men can find it hard to open patients but when speaking with men from different cultural up and discuss personal and sensitive health issues, particularly if backgrounds, additional strategies may be helpful. For many they see someone other than their usual doctor. If a man is seen men, attending a health service can be a negative experience, for regularly and feels comfortable with the doctor he is more likely example when blood/urine collection is needed. Trying to make to initiate discussion. the visit a pleasant experience with positive interaction will help For sexual health matters, it is particularly important for health ensure that men return and feel sufficiently comfortable to open professionals to be aware of cultural protocols around service up about health concerns, particularly those more sensitive and providers engaging with Aboriginal and Torres Strait Islander men: personal issues. Men will often talk to their family and friends when they have had a positive health experience: word-of-mouth • Provide a safe, private, and comfortable environment that is one of the best ways to encourage Aboriginal and Torres Strait supports open and free dialogue Islander men to attend health services. • Confidentiality is a major concern of Aboriginal and Torres • Work on developing trust in the relationship: lifestyle behaviour Strait Islander men, particularly when family and community change may only come after a long, trusting relationship has members are working for the health service they may present developed between the patient and doctor to. Hence, seek approval from the client facilitated by other allied health service providers including traditional healers and • Involve a male IHW that may help to identify issues before IHPs/IHWs the appointment • Men may not open up in the first consultation–it may take time • Check when the man had his last annual health assessment to build trust–but balance is also needed to take advantage of and take the opportunity while he is at the clinic to repeat it if opportunistic discussions it has been longer than 12-months • For the older man, more care should be taken in approaching • Reinforce confidentiality and ensure all health discussions are sensitive issues. However, often when the conversation has private and not in open spaces such as reception areas started, men are interested in their sexual health • Provide simple, clear and accurate explanations of common • Ask about erectile function for men with cardiovascular risk medical terms and procedures to help reduce a patient’s fears factors. Use simple analogy and resources (such as brochures, and anxieties about his health care: this may include locally flip-charts, DVDs, visual aids) to help explain the links between developed material using imagery that men can relate to. erectile dysfunction and chronic disease • Incorporate questioning into annual health checks such as: Supporting cultural respect with regard to “Have you got any sexual difficulties?” or “About half of men men’s health with diabetes will have difficulty getting an erection–is that a problem for you?” Adopting a holistic approach to Aboriginal and Torres Strait Islander health is important. This includes not just the physical • Sometimes men have erectile problems when taking prescribed well-being of an individual but also the social, emotional and medication for other health issues: it is important to explain cultural well-being of the whole community. to men why this may happen and think about other treatment options if erectile problems are a concern Working in the Aboriginal and Torres Strait Islander health sector • Raise the awareness about lifestyles that may impact on can be challenging for doctors/healthcare professionals who have erectile dysfunction like smoking and heavy drinking been educated in a Western approach to health service provision. • Think about making the consulting room more inclusive for It is important that non-Indigenous health professionals talking about sensitive issues, for example a model or pictures delivering services to Aboriginal and Torres Strait Islander people of the male pelvis might help initiate discussion undergo cultural competency training. • Consider the sensitivity of physical examinations, such as DRE, This provides the basic tools to avoid cultural pitfalls while for men with a past history of being sexually abused. providing valuable insight into Aboriginal and Torres Strait For the purposes of this guide, IHPs/IHWs provide clinical and Islander perceptions. Cultural respect is shown and real progress primary health care for individuals, families, and community can be made. groups. To support cultural competency training, health professionals can Healthy Male would like to thank the Aboriginal and Torres Strait also: Islander Male Health Reference Group for guidance and input into • Practice in a service that allows longer consultation times the development of this guide. (e.g. half hour consultations) to build relationships and provide useful knowledge • Stay in the community for the long-haul to develop a cumulative knowledge of people and backgrounds • Take opportunities when in remote settings to visit the community and learn some of the local language • Seek advice and learn from the experience of other health professionals and local IHWs Issues of cultural respect are particularly important for older Aboriginal men so a considered approach to some subjects (such as sexual health) is needed.

Date reviewed: March 2018 © Healthy Male (Andrology Australia) 2007