AUTHOR'S REPLY.

The authors read with great interest the insightful discussion delivered by Dr. Benyo [1] in response to our article [2]. Individuals suffering from a psychiatric illness are known to carry an excess mortality and shorter life expectancy compared to the general population. This difference is largely attributable to physical disease [3].

Urology literature is bestrewn with insidious manifestations of physical disease in psychiatric patients, which can truly test the clinical acumen of the duty doctor. Such diagnostic challenges may be heightened by a number of factors including blunting of pain perception and/or pain expression among this patient cohort. A recent systematic review published by Engels et al concluded that the intensity of pain, when associated with an apparent medical cause, was decreased in patients with schizophrenia [4]. These hypalgesic changes may therefore delay the time to diagnosis, which could have irreversible sequelae in a true urological emergency such as testicular torsion.

Close adherence to the Oslerian tradition of taking a detailed patient history is thus paramount for the clinician when seeking to confirm the diagnosis. This is augmented by a thorough knowledge of drug profiles, remaining sensitive to the psychosexual needs of the patient and clear communication between urology and psychiatry colleagues.