3702 Men′s Health - Lecture notes 1 PDF

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3702 Men's HealthLearning outcomes for this topic : Understand gender health inequalities Describe the aetiology, epidemiology and management of Benign Prostatic Hyperplasia, Erectile Dysfunction and Male Pattern Baldness and critically discuss the role of drugs in relation to these disorders Evalua...

Description

3702 Men's Health Learning outcomes for this topic: •

Understand gender health inequalities

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Describe the aetiology, epidemiology and management of Benign Prostatic Hyperplasia, Erectile Dysfunction and Male Pattern Baldness and critically discuss the role of drugs in relation to these disorders

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Evaluate the safe and effective use of drugs taking into account awareness of common adverse drug reactions and drug interactions

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Analyse, assemble and evaluate published evidence and make recommendations for the management of a patient with a specific disease using this evidence to justify the choice

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Discuss how various treatment options could be explored with patients

Men and their health

There are significant differences in access to healthcare and health outcomes between men and women. In 2008, the Department of Health published The Gender and Access to Health Services Study which was carried out to understand the gender inequalities and to offer suggestions around removing these inequalities. You should be familiar with the key themes from this document, which are briefly discussed in this learning module.

Barriers to men accessing healthcare

Men use health services less than women. The reasons for this are complex, but s ome factors which create barriers for men accessing health services include a significant proportion of services being female friendly, with ready access to contraception clinics and female screening programmes such as cervical cancer and breast cancer screening. National policy often doesn't take into account the differences in requirements of men and women.

In addition to this, men's approach to health can also be a barrier to them accessing healthcare. It can be difficult to get men to think about potential health issues and how to avoid these. Men can also be reluctant to talk about health issues they are experiencing and often will bury their head in the sand, believing that if they ignore a problem it will resolve itself.

Lifestyle risk factors

Weight There are more overweight men than women. Obesity rates are about the same in both genders and, whilst there are more obese women than men, the trend is that men are increasingly experiencing health issues due to their weight. Men's approach to weight loss is different to that of women. With most weight loss programmes catering to women, this can make it even more difficult for men to lose excess weight.

Smoking and alcohol consumption Both smoking and alcohol consumption are more prevalent in men.

Diseases more prevalent in men

Cardiovascular Disease

Heart disease is the 2nd most common cause of death in middle aged men. Cardiovascular disease occurs 7-10 years earlier in men than women due to the cardioprotective effects of oestrogen in premenopausal women. The incidence of cardiovascular disease is about the same in men and women but men are less likely that women to identify an emergency. As a result, mortality due to a cardiac event is higher in men, with death mostly occurring before they reach hospital. Many of these deaths are preventable by modifying lifestyle and other risk factors, but men are less likely than women to have modifiable risk factors identified and managed.

Mental Health Far more women than men are diagnosed with mental health conditions. However, depression and anxiety is likely significantly underdiagnosed in men. There is a lack of knowledge as to the barriers men experience in relation to accessing mental health services. As a result of the low levels of access to mental health services, men are more likely to be 'sectioned' under the Mental Health Act. Suicide is also much more common in men than women, with three quarters of all reported suicide deaths in 2019 being men. These deaths are preventable if men are able to access the help they need.

1 - This video from the mental health charity Mind will give you an insight into how men experience mental health conditions and suicidal thoughts. Before you watch this, you should be aware that you may find some of the things discussed in this video upsettin g.

2 - This video, which is optional to watch, explores the impact of suicide on those left behind, possible ways of finding out if a man could be experiencing mental health issues and solutions to getting help to men who need it. Before you watch this, you should be aware that you may find some of the things discussed in this video upsetting.

Substance Dependency Substance misuse is more common in men than in women. Alcohol disorders are twice as likely in men, yet more women use alcohol dependency services than men. This may be due to women being considered more vulnerable if they have been drinking, whereas men can become more aggressive. Men who misuse alcohol are likely to reduce their life expectancy by over 20 years.

Sexual Health

Contraception is not always seen as the responsibility of men. Women often assume this responsibility due to the implications to them if contraception is not used. Whilst there is a lot of opportunity to provide health promotion advice to women when they access contraceptive services, there is a lack of opportunity to speak to men about their sexual health. There also tends to be less willingness by men to access advice and screening. In addition, men tend to use condoms for contraceptive purposes, rather than preventing STIs, making them more at risk of STIs during sexual encounters where alternative contraception is used or contraception is not needed.

Androgenic Alopecia This is hair loss which follows a particular pattern and is caused by dihydrotestosterone (DHT) hormone which changes to the growth cycle in hairs on the scalp. Women can experience this type of hair loss, although the hair loss follows a different pattern to men's. When men experience androgenic alopecia, it is commonly called male pattern baldness. It is very common, with approximately 80% of men developing it at some point. Hair loss usually starts later in life, but it can be experienced by young men in their late teens. Hair loss is gradual, progressive and follows a set pattern which can be classified using the Norward-Hamilton classification (see image for details). Despite not being detrimental to physical health, it can cause significant to distress to men as their appearance alters, particularly when hair thinning and receding of the hairline begins at a younger age.

3 - This shows you the different stages of androgenic alopecia. The condition progresses from I to VII.

Treatment Options

4 - Finasteride 1mg Inhibits DHT

5 - Hair transplant

6 - Topical Minoxidil Mechanism of action unclear

Health conditions specific to men

Prostate Problems

The prostate

The prostate is situated at the base of the bladder and surrounds the first part of the urethra. The main function of the prostate is to help in the production of semen. Most men develop a prostate problem at some stage in their life.

Common prostate diseases include: •

Prostatitis

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Benign prostatic hyperplasia

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Prostate cancer

All prostate problems have similar symptoms due to enlargement of the prostate which puts pressure on the urethra.

Symptoms of prostate disease

Prostatitis Acute This is a rare but severe infection of the prostate which is usually accompanied by a UTI. It may be managed in primary care with antibiotics, however hospitalisation may be required for IV antibiotics in more severe cases.

Chronic This presents as urogenital pain and may be associated with lower UTI symptoms and sexual dysfunction. Most cases (90%) are of unknown cause. These are usually managed in primary care with treatment focussing on symptomatic control. The remaining 10% of cases are caused by a bacterial infection and require referral to a urologist.

Benign Prostatic Hyperplasia (BPH)

BPH is very common in older men, affecting 50% of men 51-60 years and 90% of men over 85. It is not usually a serious threat to health, but it can have a significant impact socially and emotionally on patients. Quality of life can be severely impacted with some men finding it a challenge to leave the house, particularly if he will not have ready access to a toilet or if he is concerned that he would not be able to reach the toilet in time.

Diagnosis •

International Prostate Symptoms Score: This is a validating scoring system enabling an understanding of the patient's conditions and helps to determine the severity and impact of the symptoms.

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Digital rectal examination: An examination where the doctor inserts a finger into the rectum to feel for abnormalities of the prostate through the wall of the rectum.

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Urine test if infection is suspected

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Consider Prostate Cancer: A blood test checking for Prostate specific antigen (PSA), a marker for prostate cancer, may be carried out

BPH treatments Alpha adrenoceptor blockers Alpha receptors in the prostate cause the contraction of the smooth muscle with α 1A receptors thought to be the most dominant in the prostate. Alpha adrenoreceptor blockers reverse this contraction, relieving many of the urinary flow symptoms. Symptom relief is relatively quick, with benefits usually seen within a few days of starting treatment.

Drugs in this class used in the treatment of BPH

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Prazosin, terazosin, indoramin, doxazosin, tamsulosin and alfuzosin

Side-effects of alpha adrenoreceptor blockers include: postural hypotension (especially first dose), dizziness, fatigue, headache, drowsiness, sexual dysfunction 5 alpha-reductase inhibitors Testosterone is converted by 5α –reductase to DHT which is five times more potent than testosterone and stimulates prostatic enlargement. 5 α-reductase inhibitors block the conversion of testosterone to DHT and so downregulate this growth in the prostate. This results in improved symptoms and urinary flow, plus a decrease in acute urinary retention in patients. Symptom improvement is slower than with alpha adrenoreceptor blockers, taking several months to show maximum benefit.

Drugs in this class used in the treatment of BPH

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Finasteride and Dutasteride

Side-effects of 5 α -reductase inhibitors include: decreased libido, sexual dysfunction, breast enlargement, breast cancer, depression Effective contraception needed as there is a risk of malformation in a male foetus.

Prostate cancer

This is the most common cancer in men. It predominantly affects older men (75% of cases are in men aged 65-79 years) with men of black ethnicity at highest risk. The cancer develops slowly and is often diagnosed late when urethra is affected by enlarged prostate, presenting with similar symptoms to other prostate diseases.

Diagnosis •

PSA test: this test alone is not definitive as PSA levels can be raised due to other causes, but elevated levels give an indication that the diagnosis could be prostate cancer

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Digital rectal examination

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Biopsy

Testicular cancer Around 1400 men are diagnosed with testicular cancer each year, most of them being 25-35 years old.

Symptoms •

Painless swelling or lump on one of the testicles

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Change in shape or texture of testicles

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Other potential symptoms: increase in firmness, difference in appearance between testicles, dull ache or sharp pain in testicles or scrotum, feeling of heaviness in scrotum

Diagnosis •

Physical examination

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Scrotal ultrasound

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Blood test for testicular cancer markers alpha feto-protein (AFP) and human chorionic gonadotrophin (HCG)

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Biopsy

Penile cancer

This is a rare cancer of the skin on or within the penis which mostly affects men over 50 years old.

Symptoms •

A growth or sore that doesn ’t heal

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Bleeding from penis or under the foreskin

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Foul smelling discharge

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Thickening of skin or foreskin which can lead to difficulty drawing back the foreskin

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Change in colour of skin or foreskin

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Rash

Diagnosis •

Exclusion of STIs as many of the symptoms could be indicative of an STI

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Rapid referral to secondary care for biopsy

Erectile dysfunction (ED) Erectile dysfunction is the inability to get and maintain an erection sufficient for satisfactory sexual performance. It is a very common condition, particularly in older men but it can present at any age.

Causes Erectile dysfunction is often due to cardiovascular changes in older men and can be the first symptom of diabetes or cardiovascular disease. It occurs due to the narrowing of the blood vessels which restricts blood flow and prevents a full erection. Often psychological causes play a part, even when they aren't the primary cause.

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Organic causes -

Vascular problem (eg CVD, diabetes mellitus, smoking)

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Nerve problem (eg multiple sclerosis, Parkinson’s disease, chronic renal failure)

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Anatomical/structural problem

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Hormonal – low testosterone levels

Psychological causes -

Generalised (eg lack of arousal)

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Situational (eg new partner, performance-related issue s)

Drugs -

Prescribed (eg beta blockers, SSRIs, 5 alpha-reductase inhibitors)

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Recreational (eg alcohol, marijuana, anabolic steroids)

Diagnosis •

Detailed history to try and identify the cause including psychosexual history, medical and lifestyle history

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Physical examination

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HbA1c, lipid profile and total testosterone

ED treatment

Phosphodiesterase5 (PDE5) inhibitors Normally during sexual stimulation Nitric Oxide (NO) is released and activates guanylyl cyclase. This in turn increases cGMP which ultimately leads to vasodilation, increasing blood flow and enabling penile erection. The erection will subside naturally after climax or removal of sexual stimulation. cGMP is deactivated by PDE5. PDE5 inhibitors enhance the effect of NO by increasing the cGMP in the smooth muscle cells thus promoting an erection.

As NO is required for PDE5 inhibitors to work, they will only work if there is sexual stimulation.

PDE5 inhibitors are the most widely used and effective medicine for ED.

Drugs in this class used in the treatment of ED: •

Sildenafil, tadalafil, vardenafil and avanafil

Most are taken shortly before intercourse on a prn basis. There are differences in response times and how long treatment lasts. Those with a longer duration of action enable men to have sex multiple times from one dose of medication. Tadalafil is also available in a once a day dose, meaning the drug is constantly present in the blood plasma, enabling sex to be spontaneous without the need to wait for a prn dose to take effect. The 5mg strength of this daily tadalafil is also licensed to treat BPH, so is useful for those suffering with both conditions.

PDE5 inhibitors potentiate the hypotensive effects of nitrates and are contraindicated in patients taking these.

7 - This video, which is optional to watch, gives an interesting history about the discovery of sildenafil.

Premature ejaculation There is no standardised definition for premature ejaculation, so diagnosis is difficult. Diagnosis takes into account: •

intravaginal ejaculatory latency time (IELT) which is the time between penetration and ejaculation

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the patient’s perception of the problem

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any physical issues

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any psychological issues

The condition can cause significant stress to men and their partners, yet often men don't seek medical help for the condition.

Treatment •

SSRIs

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Dapoxetine is the only product licensed in UK when IELT...