AKT questions

1. A 19-year-old man attends complaining of a rash on his penis for the last 3 months. (See Figure 1) What is the SINGLE most appropriate intervention for this patient? Select ONE option only.

A. Cryotherapy
B. Prescribe oral aciclovir
C. Prescribe topical podophyllotoxin (Warticon)
D. Reassure
E. Refer to genitourinary medicine clinic

Answer: D

This picture shows the typical appearance of pearly penile papules. They are common, occurring in up to 20% of men and present as flesh-coloured, smooth, rounded papules predominantly around the coronal margin of the glans. They are often arranged in parallel rows or concentric rings. They are not sexually -transmitted.Pearly penile papules may be mistaken for warts by both patients and clinicians.No treatment is necessary, although if cosmesis is a problem for the patient, then cryotherapy may be tried.Aciclovir is the treatment of choice for genital herpes which typically presents acutely with very painful ulcers.Cryotherapy and topical podophyllotoxin are both treatment options for genital warts. Podophyllotoxin cannot be used in pregnant or breastfeeding women.

2. Which ONE of the following is NOT associated with an increased risk of developing penile intraepithelial neoplasia? Select ONE option only. [Show Discussion]

A. Atopic dermatitis
B. Chronic infection with human papilloma virus (HPV)
C. Lichen sclerosus
D. Smoking
E. Uncircumcised males

Answer: A

Penile intraepithelial neoplasia (PIN) is associated with:

• Chronic infection with human papilloma virus (HPV)

• Chronic skin disease, especially lichen sclerosus and lichen planus

• Smoking

• ImmunosuppressionIf untreated,

PIN is associated with the development of invasive squamous cell carcinoma.www.dermnet.nz

3. In which ONE of the following situations can phosphodiesterase type-5 inhibitors such as sildenafil (Viagra) be prescribed on an National Health Service (NHS) prescription rather than on a private prescription? Select ONE option only.

A. In men aged 60 years or over
B. In men with chronic kidney disease stage 3 (CKD 3)
C. In men with hypogonadism
D. In men with hypothyroidism
E. In men with Parkinson’s disease

Answer: E

Phosphodiesterase type-5 inhibitors are not prescribable under the NHS, except to treat erectile dysfunction in men who:

• Have diabetes, multiple sclerosis, Parkinson’s disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, or spinal cord injury

• Are receiving dialysis for renal failure

• Have had radical pelvic surgery, prostatectomy (including transurethral resection of the prostate), or kidney transplant

• Were receiving Caverject®, Erecnos®, MUSE®, Viagra® or Viridal® for erectile dysfunction, at the expense of the NHS, on 14 September 1998

• Are suffering severe distress as a result of impotence (prescribed in specialist centres only)www.bnf.org.uk

4. A 23-year-old man attends complaining of difficulty getting an erection since starting a new relationship 4 months ago. He has already tried sildenafil (Viagra) which he had bought on the internet, but this has not helped. On examination, he has bilateral gynaecomastia, small testes and scanty axillary and pubic hair. His recent blood tests reveal the following:Testosterone 6 nmol/l (11–36 nmol/l)Luteinising hormone (LH) 27 IU/l (0.5–9 IU/l)Follicle stimulating hormone (FSH) 19 IU/l (1–8 IU/l)Which is the single MOST appropriate initial intervention for this patient? Select ONE option only. [Show Discussion]

A. Refer to clinical geneticist
B. Refer to endocrinologist
C. Refer to neurologist
D. Refer to psychosexual counsellor
E. Refer to urological surgeon

Answer: A

This scenario describes the typical phenotypical appearance of a patient with Klinefelter’s syndrome (47 XXY). It is the most common cause of male hypogonadism and infertility, affecting approximately 1 in 600 to 1 in 800 live births.It is characterizsed by hypergonadotrophic hypogonadism (raised gonadotrophins and low testosterone) and usually remains undiagnosed until adulthood.Referral to an endocrinologist would be required for advice regarding hormonal treatment;, however, the most appropriate initial referral would be to a clinical geneticist for genetic counselling and testing to confirm the diagnosis. They would be able to advise him regarding longer-term implications, including fertility issues (azoospermia) and risk of male breast cancer.

5. A 56-year-old man attends the surgery complaining of inability to maintain an erection during intercourse for the last 3 months. He describes normal early morning erections. On examination, his blood pressure is 150/84 mmHg and his body mass index (BMI) is 32. Physical examination is otherwise unremarkable.What is the SINGLE most likely underlying diagnosis in this patient? Select ONE option only.

A. Depression
B. Hypertension
C. Parkinson’s disease
D. Spinal cord injury
E. Type 2 diabetes

Answer: A

A good quality early morning erection makes an organic cause of erectile dysfunction unlikely

6. Which ONE of the following drugs does NOT cause erectile dysfunction? Select ONE option only.

A. Bendroflumethiazide
B. Chlorpromazine
C. Nifedipine
D. Sildenafil
E. spironolactone

Answer: D

Sildenafil is the generic name for Viagra, a phosphodiesterase-5 inhibitor which is used to treat erectile dysfunction. All of the other drugs listed can cause erectile dysfunction.Other commonly used classes of drugs which may cause erectile dysfunction include:• Anti-cholinergics• Anti-depressants• Anti-histamines• Anti-hypertensives• Anti-psychotics• Tranquilisers

7. A 58-year-old man attends complaining of inability to get an adequate erection for the last 5 months. He asks whether you would be able to prescribe him Viagra (sildenafil).Which ONE of the following would be a CONTRAINDICATION to the use of a phosphodiesterase type-5 inhibitor such as Viagra in this patient? Select ONE option only. [Show Discussion]

A. Current blood pressure of 178/96 mmHg
B. Current diagnosis of angina pectoris
C. Currently taking bisoprolol
D. Currently taking isosorbide mononitrate
E. Currently taking warfarin

Answer: D

Phosphodiesterase type-5 inhibitors are contra-indicated in patients receiving nitrates, in patients in whom vasodilation or sexual activity are inadvisable, or in patients with a previous history of non-arteritic anterior ischaemic optic neuropathy.In the absence of information, manufacturers contra-indicate these drugs in hypotension (avoid if systolic blood pressure below 90 mmHg), recent stroke, unstable angina, and myocardial infarction.www.bnf.org.uk