INTRODUCTION AND OVERVIEW

When discussing men’s health, it is important to appreciate that there are two aspects to the subject:

Despite the significant advances in healthcare of this century and the previous, men still have poorer health outcomes than women—an example is the current average male life expectancy of 78 years, compared to 83 for females.¹ GPs regularly see male patients ignoring warning symptoms, denying health problems and dying prematurely from heart disease and cancer. Statistics show that, compared with females, males in the 25–64 year age group have four times the risk of dying from heart disease, twice the risk of dying from cancer and three times the risk of dying from alcoholic liver disease.

Males in developed countries have higher rates of the following conditions, which goes a large way to explaining their lower life expectancy:

As to whether these differences are simply due to the presence of a Y chromosome (nature) or the result of broader issues such as lifestyle, attitudes, social expectations and upbringing (nurture) is a matter of speculation—but the typical male in most cultures is brought up to:

REGULAR SERVICE PREVENTS BREAKDOWNS

As GPs we face not only the problem of getting men in the community to come and see us when they have symptoms, but also the difficulty of getting male patients to present for a regular check-up.

Men confront a number of challenges and barriers in being more proactive about their health. First, self-awareness and self-care are often not cultivated by men as much as women, and are not part of the traditional male culture. Images of male resilience and strength are more commonly inflexible and independent. Men also tend to be very career focused, in such a way that taking time off for ‘non-essential’ or ‘non-urgent’ things like GP consultations does not rate highly on the priority list unless the health matter cannot be ignored. Even then, denial is more common among men. Or men can avoid going to the doctor because they find talking about personal issues or vulnerability a lot more difficult than women do, particularly when those issues are of an emotional nature, regarding relationships, for example, or depression or anxiety. Self-medicating for such problems is an important part of the reason that substance abuse is more common among men. Many men may have a preference for consulting a GP of a particular gender. For example, some men may prefer to discuss emotional issues with women, or relationship or sexual issues with an experienced male practitioner. Often when a man presents with psychological and emotional concerns, he may want to approach the problem in a different way than a woman would—for example, a woman (and female practitioner) may wish to discuss the emotions and issues at greater length, whereas the man may want to discuss more direct and pragmatic solutions to dealing with the ‘problem’, whatever that may be. Being flexible in consulting style, or knowing how to open up discussion about emotional issues in a non-confronting way, may be an important skill for the healthcare practitioner to have in dealing with health matters for men. Furthermore, women tend to more often take the children and other family members to the doctor for appointments and so will more commonly establish a stronger link with healthcare practitioners and clinics, or are reminded about personal health issues while there. Women’s greater role than men in nurturing and caring is partly due to nature (biological and hormonal) and partly due to nurture (culture and upbringing). Therefore, confronting the barriers to men being more active participants in their own healthcare requires not only a healthcare practitioner who is sensitive to the consulting issues and psychology of men, but also a change of societal images of manhood.²

Ideally, health checks should be performed regularly through childhood, adolescence and adulthood (see Ch 17, The general check-up)—once men become familiar with the concept of being proactive rather than reactive, the GP can schedule a long consultation and perform the same comprehensive check-up, directed to conditions relevant to the age of the man, for older and younger patients.

In fact, if we as GPs can inculcate in the community—particularly the males in our community—the idea of presenting for an annual check-up in a similar manner to taking their cars for a regular service, then it stands to reason that the incidence of ‘breakdowns’ will be far less than it is now!

Because most people remember their own birthdays, a useful method is to encourage patients to come for their check-up during the month of their birthday. As a minimum, in addition to a basic clinical examination (with or without a prostate check), they should have their weight, girth and blood pressure measured, plus blood tests for glucose, lipids and liver function. Based on the results, further examinations and investigations may be indicated. More likely is the situation where the results of the tests provide an opportunity for health education and counselling about appropriate lifestyle interventions—for example, practical steps that could be taken if their cholesterol or blood pressure is outside the expected range.

FIGURE 48.1 The corpus cavernosa of the penis, showing how increasing blood flow increases turgor

ERECTILE DYSFUNCTION

Erectile dysfunction is discussed in detail in Ch 49, Erectile dysfunction.

With the advent of medications for erectile dysfunction and media attention focusing on prostate cancer, GPs are now seeing more men presenting for advice about these conditions, which in the past were either suffered in silence or accepted as the price one paid for growing old. Impotence, now known as erectile dysfunction (ED), is defined as the persistent inability to attain and/or maintain an erection adequate to permit satisfactory sexual intercourse.

It is important to be aware that ED is common, and in most men is not caused by a deficiency of male hormones or a lack of masculinity. Despite its common incidence, only about a third of men affected have consulted a doctor about it. Erection is essentially a vascular phenomenon, brought about by increasing blood flow to the penis, so anything that inhibits the augmentation of blood flowing into the corpora cavernosa can stop the erection.

The strong association of ED with a diseased cardiovascular system is easy to understand if one appreciates that the inadequacy of blood flow in the penile arteries is simply a manifestation of what is happening in other similar-sized blood vessels. This explains why ED is more common in patients with conditions such as hypertension, high cholesterol, diabetes and ischaemic heart disease. Although ED is a common cause of emotional stress and relationship issues, one should also remember that stress and relationship issues are also common causes or exacerbating factors for ED. A significant finding by Thompson and colleagues was that men diagnosed with ED at the start of their study who were followed over 9 years had a higher incidence of heart attacks and strokes than a control population.³

ED can present to GPs in one of two ways:

In the case of the former, it is important to confirm that the symptoms are actually caused by ED rather than low libido, premature ejaculation or relationship difficulties, and to ensure that the dysfunction is not caused by undue anxiety to perform. Using the IIEF-5 questionnaire⁴ (described in Ch 49) can be useful in helping to ascertain whether the patient’s problem really is ED.

With patients who suffer from the chronic diseases that damage blood vessels, it may be difficult to tactfully broach the topic of ED during a routine consultation. One technique is to provide a brief preliminary explanation about how diabetes (or high cholesterol or high blood pressure) damages the small blood vessels and affects the circulation to the eyes, kidneys, penis, heart and limbs—and then say, ‘Many men with diabetes experience problems with getting an erection—have you ever had this problem yourself?’. This allows the patient to identify with the ‘majority’ rather than labouring under the misconception that he has a unique and embarrassing ailment.

The management of ED is discussed at length in Ch 49. The important message here is that ED is common, can be effectively and easily treated in the majority of men, and may be the first symptom indicating more generalised serious disease.

TESTICULAR CANCER

Responsible for 10% of all cancer deaths in the 15–35 year age group, testicular cancer is the most common cancer affecting young men. Ninety per cent of these tumours originate from germ cells, and are divided into seminomas (40%), non-seminoma germ cell tumours (NSGCT, 35%) and mixed tumours (seminoma plus NSGCT, 15%). The remaining 10% of testicular tumours are non-germ cell tumours.

Over the past 30 years, the annual incidence has risen. Mortality rates, however, have declined dramatically (5-year relative survival today is about 95%) as a consequence of earlier diagnosis and new treatment techniques, such as platinum-based chemotherapy.

Identified risk factors include:

A testicular cancer typically presents as a painless, hard, enlarged testis. Pain, if at all, occurs due to a bleed into the lesion—and this may delay diagnosis by mimicking epididymo-orchitis.

If a man is suspected to have a cancer in his testis, it is mandatory to perform an ultrasound scan, which can usually differentiate a solid (cancer) from a cystic (benign) swelling. Such a patient should undergo thorough clinical examination as well as CT scans for features of metastatic cancer in the retroperitoneal nodes and lungs. The basic management of the primary tumour is orchidectomy through an inguinal incision.

Seminomas are exquisitely radio-sensitive, so early-stage disease is currently treated with postoperative radiotherapy to the draining nodes—although some centres use a single dose of carboplatin chemotherapy followed by active surveillance. Opinions differ as to the best method of dealing with NSGCT. Some centres advocate radical removal of the para-aortic lymph nodes at the time of orchidectomy; others adopt a surveillance approach, monitoring the patient with regular measurement of tumour markers and CT scans.

Our task as GPs is to get the simple message out into the community that any man who detects a lump in the testis should have it examined by his doctor—who will, after examination, arrange an ultrasound scan (with or without other investigations) to distinguish a testicular cancer from the more common benign causes of testicular lumps.

PROSTATE DISEASE

General practitioners now see more older men presenting with urinary symptoms. This is most likely due to the increasing lifespan of our patients. Previously termed prostatism, lower urinary tract symptoms (LUTS) include obstructive symptoms (straining to pass urine, difficulty in initiating micturition and poor urinary stream) and irritative symptoms (frequency, urgency and nocturia). The last can often be due to other factors that cause over-activity of the bladder (OAB)—and in this situation, bladder ultrasound and urine cytology are important investigations that help exclude bladder calculi and early bladder cancer. If a post-micturition scan shows that that the bladder empties well, treatment with anticholinergic drugs can be considered.

The term benign prostatic hypertrophy (BPH) is used to denote the pathological condition, while bladder outlet obstruction (BOO) describes the clinical syndrome, which may also be caused by other conditions such as bladder neck hypertrophy or urethral stricture. BPH was originally and impractically defined histopathologically as ‘a prostate larger than 20 g plus either elevated symptom score or reduced peak flow’, although no single definition has gained universal acceptance.⁵

Fifty per cent of men aged over 60 years suffer from BPH.⁶ We now know that BPH is not necessarily progressive; symptoms stay the same or regress spontaneously in at least half these men. Moreover, the impact of the symptoms is variable, and although there is a small risk of acute retention, in many cases all the GP need provide is reassurance, together with periodic monitoring of symptoms.

SUMMARY

It is only recently that we as doctors have come to realise that men suffer a considerable degree of morbidity as well as mortality from andrological causes. Awareness of the unique health needs of men and cognisance of the latest information about the management of these conditions, as well as community education to encourage men to consult their doctors for preventive healthcare as well as when they develop symptoms, will go a long way towards improving male health in the twenty-first century.

Take-home messages: