Man of 46 Who Saw Blood in His Semen Once — Free SCA Practice Case

Character Overview: You are Hector Pelling, a 46 year old dental technician who makes crowns and dentures in a small laboratory. You live with your wife Ishbel, who works for the council, and your son Torin, who is 14. You are a careful, slightly anxious man who prefers facts. Last weekend you saw brown streaks in your semen for the first time. It has not happened since, but you could not leave it alone and read several websites late at night. One said blood in the semen can mean prostate cancer in men over 40. Your father's brother, your uncle Everard, was treated for prostate cancer in his late sixties, so the word stuck. You have told Ishbel only that you are "getting something checked". You are embarrassed to be talking about this, you speak quietly at first, and you relax if the doctor is matter of fact. You want to be told what has caused it and whether you need tests.

Opening Sentence: "Morning, doctor. This is a bit embarrassing. Last weekend I noticed some brown streaks in my semen. It hasn't happened again, but I looked it up and it said it can be cancer, so I thought I'd better come."

History if Asked (Data Gathering Phase)

• ●What he saw: "Brown streaks, like rusty threads, running through the semen. It wasn't bright red. There were no clots."
• ●When and how often: "Once, on Saturday morning last weekend, so about nine days ago. It was when Ishbel and I had sex. I have not seen it before or since. We have had sex twice since and it was normal."
• ●How much: "A small amount, maybe a few streaks. The whole sample was mostly its normal colour."
• ●Gap beforehand: "About ten days. Ishbel had been away for work, so longer than usual."
• ●Partner's period: "Ishbel's period finished a week before, so I don't think it was from her. She had no bleeding at the time."
• ●Pain: "No pain when I ejaculated or afterwards. No pain in the testicles, the groin, between my legs, the lower tummy or my back."
• ●Urine: "Normal. I haven't seen blood in my urine, it isn't cloudy and it doesn't sting. I pass water normally, with a good stream, and I get up once a night at most."
• ●Discharge or infection: "No discharge from the penis, no sores, no rash. No fever."
• ●Injury and procedures: "No injury. I cycle on Sunday mornings, usually about 40 miles, and I did a ride the day after, but I have been riding for years with no trouble. I have never had a catheter, a camera test, a prostate biopsy or any operation on my waterworks."
• ●Bleeding tendency: "I don't bruise easily. No nosebleeds or bleeding gums. My blood has never been described as thin and nobody in the family has a bleeding problem."
• ●Weight and general health: "My weight is the same. I feel completely well. No night sweats, no bone pain, no tiredness beyond a normal week."
• ●Lumps: "I haven't noticed a lump or swelling in my testicles. I checked after I read the websites and it felt normal, but I'm not an expert."

Ideas, Concerns, Expectations

Gating note: Hector does not raise any of the following himself beyond the opening line. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

• ●Ideas: "The websites said it could be an infection or a prostate problem, and some said it can be cancer, especially over forty. I think that is what I have got. Old blood that has been sitting there makes me think something has been bleeding for a while."
• ●Concerns: "That it's prostate cancer, like my uncle Everard. He was in his late sixties when he was treated and he's alive now, but he doesn't talk about it. I'm also frightened of being told nothing is wrong and then finding out later that something was. Torin is only 14."
• ●Expectations: "I'd like to know what it is. I assumed I would need a scan or a blood test for the prostate. My uncle said I should ask for a PSA. I don't mind being examined, though I'm not looking forward to it."

If Asked: Medical History and Medications

Gating note: Hector answers each of these plainly when the doctor asks about it.

• ●Past illness: "Just hay fever. No blood pressure problems that I know of. A health check three years ago was fine."
• ●Medicines: "Cetirizine for hay fever in the pollen months, nothing else. No aspirin, no blood thinners, no prostate tablets, no supplements. I take ibuprofen once or twice a year for a bad back after a long ride, nothing recently."
• ●Allergies: "None to medicines."
• ●Prostate tests so far: "I've never had a PSA test or had the finger examination."
• ●Sexual health: "I've been faithful to Ishbel for 18 years. I've never had a sexual infection and I have no other partners. I am not worried about that side of things."
• ●Travel: "Only Europe, camping in France every year. Nothing further afield. I've never had tuberculosis or been in contact with it."

Family History

• ●Prostate and other cancers: "Uncle Everard, my dad's brother, had prostate cancer in his late sixties. My dad died at 78 of a heart attack. No one else I know of with prostate, bowel or testicular cancer. My mother is well."
• ●Blood disorders: "Nothing that I know of."

Social History and Lifestyle

• ●Home and work: "I work long days at the bench, mostly sitting, with a lot of fine detail. The laboratory is small and my boss relies on me, but I can take an hour out in the week."
• ●Habits: "Never smoked. Around ten units a week, mostly at weekends. No drugs."
• ●Availability to be seen: "I could come into the surgery on Thursday or Friday, or after five on any day. I would rather not tell the lab why I need the time off."
• ●Home: "Ishbel knows I'm seeing you but not why. I'd tell her once I knew something."

If Asked: Associated Symptoms

Gating note: Hector answers these only when asked. Every one is negative unless stated.

• ●If asked about weight loss, night sweats, fever or loss of appetite: "No, none of those."
• ●If asked about bone pain, back pain or new tiredness: "No, I feel fine."
• ●If asked about testicular lumps, swelling or heaviness: "Nothing that I've noticed."
• ●If asked about a poor stream, dribbling, straining or incomplete emptying: "No, my waterworks are normal."
• ●If asked about blood in the urine or in the stool: "No, never."
• ●If asked about a change in bowel habit or rectal bleeding: "No."
• ●If he is asked to examine himself, measure his own temperature or blood pressure on screen: "I'm not sure I'd get it right. Wouldn't you rather check me properly in person?" He says he has a home thermometer and it read normal this morning, but that he has no blood pressure machine.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that haematospermia is usually harmless and self limiting but needs checking at his age:
  • ●Reaction: Relieved, then pressing. "So it's probably nothing? Then why does my age matter?" If told that cancer is a more common cause in men over 40 than in younger men, though still uncommon, and that checks are needed to rule out causes: "That makes sense. I'd rather know than guess." He becomes upset if told "it's nothing" without any checks: "My uncle had prostate cancer. How can you be sure?"
• ●If the doctor arranges an examination in person, a urine test and a blood pressure check:
  • ●Reaction: Agreeable but nervous. "Yes, of course. Will you be doing the finger examination? I've never had one." If a chaperone is offered and the examination is explained: "Thank you. That helps. I could come on Thursday after lunch, or Friday morning." He can bring a urine sample if told how to collect a midstream sample.
• ●If the doctor raises a PSA blood test:
  • ●Reaction: Keen but unsure. "My uncle told me to ask for that. Does it give a clear answer?" If told that a raised result can have non cancer causes, and a normal result does not rule out cancer entirely: "I hadn't realised it could be so unclear. What would happen if it was raised?" After a balanced explanation, he says he would like the test. If told to avoid sex and a long cycle ride for two days beforehand: "Right, no Saturday ride then. I'll book it for a Monday."
• ●If the doctor says that a specialist referral would be advised at his age even if the tests are normal:
  • ●Reaction: Alarmed. "Specialist? Doesn't that mean you think it's cancer?" If told it is a standard step for men over 40 when no cause is found, to be thorough, and not a diagnosis: "So it's like a second pair of eyes. How long would I wait?" He accepts it if told it would be a routine appointment unless something worrying is found.
• ●If the doctor says an urgent two week referral is needed without any findings:
  • ●Reaction: Frightened. "Urgent? Has something shown up?" If told this is only if the examination or tests are abnormal: "Oh. Good. Let's wait for those."
• ●If the doctor gives safety netting or advice about sex and the family:
  • ●Reaction: Wants specifics. "Is it safe to carry on having sex? And should I tell Ishbel now?" If told sex is safe and that he may tell her when he is ready, he agrees. If the safety net is vague ("come back if worse"): "Worse how? What would make me ring you the same day?" He repeats back clearly when given specifics such as fresh blood returning, blood in his urine, pain or fever, a lump, or unexplained weight loss.