What do family physicians need to know about men's sexual health?

S S Wijesinha 衛智星

HK Pract 2003;25:486-490

Summary

This article reviews the latest developments in male reproductive health and identifies their relevance to today's family physicians. Erectile Dysfunction, a condition eminently treatable by the family physician, is closely associated with cardiovascular risk factors. New treatments are available for benign as well as malignant prostate disease. Screening selected asymptomatic patients can detect prostate cancer at a pre-metastatic, curable stage - thus reducing mortality. Intracytoplasmic sperm injection (ICSI) offers hope for infertile couples. Testicular cancer today has an excellent prognosis if detected early.

摘要

本文回顧了男性生殖健康的最新發展及其與家庭醫生關係。性功能障礙和心臟血管疾病的危險因子有密切關係， 因此家庭醫生可以給予適當的治療。前列腺疾病，無論是良性或是惡性，都有用新的治療方法。 選擇性地進行普查可以儘早發現可治愈的早期非轉移性前列腺癌，以減低死亡率。 胞質內的精子注射為不育夫婦帶來新的希望。睪丸癌如果及時發現則預後極好。

Introduction

During the 20th century, while medical students were taught in great detail about gynaecology and women's health, the subject of male sexual and reproductive health was hardly ever discussed.

We now know that conditions such as prostate and testicular cancer, benign prostatic hyperplasia (BPH), erectile dysfunction (ED), male infertility and male hormone disorders can cause significant morbidity, and mortality, in our patients. In the past, however, perhaps because men seldom consulted their doctors for sexual problems (unless these were very severe), andrological ailments were considered to be of less importance.

With the advent of the new drug sildenafil citrate, Viagra, patients have begun consulting their doctors for the male disorder, male impotency. They now expect not only to know the latest andrological information but also to feel confident and comfortable in talking about these conditions more openly.

So what can we as family physicians do?

Erectile dysfunction

Since the recent availability of oral treatment for impotence, there is now less reluctance, especially in countries like America and Australia, for patients to discuss this subject with their doctors.

Unfortunately, both the community and even the medical profession still lack accurate information about this subject. How does one define ED? How does one diagnose it accurately? How prevalent is it in our community? Can we extrapolate the findings from research done overseas^1-3 to patients in Hong Kong?

In the past we were taught that in most men with impotence, the cause was "psychological" or emotional. Today, in contrast, we know that the majority of patients with ED have associated physical problems. Diabetes is a major risk factor - 64% of men with diabetes experience some form of ED, while men with diabetes are 2.5 times more likely to have ED compared to non-diabetics.²

Another significant risk factor is cardiovascular disease - 52% of men with hypertension reported some form of ED and 26% reported complete ED and up to 57% of men with peripheral vascular disease experience this same problem.² A meta-analysis of studies examining smoking and ED found 40% of men with ED were current smokers.⁴

With the availability of new effective oral medications and vacuum devices, the majority of patients with ED can be managed effectively by their family physicians. If we know what questions to ask our patients and what to look for, this area of medicine will provide an increasing workload for us in the future.

One of the most important messages we should convey to the community is that men with ED need to seek medical advice not only for the sexual problem itself but also because of its close association with other medical conditions like diabetes and cardiovascular risk factors. Rarely, ED may be the presenting symptom of a serious underlying disease e.g. a pituitary tumour. Further epidemiological studies are needed to find out whether, for example, improving cardiovascular risk factor profile in older men would concurrently reduce the prevalence of sexual dysfunction. Studies can also be conducted to see whether the prevalence and presentations of ED vary in different cultures.

Prostate disease

As a population gets older, the prevalence of both benign and malignant prostate diseases will naturally increase.

In the past any man with prostatic symptoms⁵ and an enlarged prostate gland would be a good candidate for prostatectomy - but we now know that LUTS (Lower Urinary Tract Symptoms) are not necessarily due to BOO (Bladder Outlet Obstruction). The mere presence of an enlarged prostate is no justification for its removal - the criterion today is the degree of bother that the man's symptoms are causing him.⁶

More careful assessment of a man's symptoms and more precise investigation of his prostate gland with ultrasonography and voiding studies may be necessary before deciding to actively treat the condition. We now have safe and effective drugs like 5-alpha-reductase inhibitors and alpha-blockers to treat BPH. Although transurethral resection of the enlarged prostate (TURP) remains the treatment of choice when the gland is obstructing the bladder outlet, medical treatment is today one practical option when previously it was only amenable to surgery.

The incidence of prostate cancer - a malignancy that has the potential to progress through an unpleasant and protracted course until death - continues to increase, but the mortality due to this condition has remained stable.

The past decade has seen a dramatic change in the way prostate cancer presents. The introduction in the late eighties of blood testing for Prostate Specific Antigen (PSA) as an adjunct to Digital Rectal Examination (DRE) to screen patients for prostate cancer resulted in a greater detection rate of clinically localised disease. Evidence from around the world has shown that the number of men having metastases at the time of diagnosis has fallen dramatically.⁷ More men now undergo radical rather than just palliative therapy - with an increased expectation of cure.

Until research studies currently underway are completed, we do not yet have enough evidence to provide absolute guidelines for screening. However, a practical policy is to advocate annual testing (both blood test for PSA as well as DRE) for men over fifty years old who are in good health with a life expectancy of at least ten years. In men with a strong family history of prostate cancer, screening from about 45 years of age is recommended.

Today, therapy for prostate cancer must be tailored to the individual⁸ and this is where we, with our intimate knowledge of our patients as their family doctor become valuable members of the management team.

Newer and more efficacious techniques of surgery and radiotherapy have significantly improved outcomes and decreased side-effects. With more men having prostate cancer living in the community, the onus of monitoring progress, managing side-effects and providing long-term support will naturally fall on family physicians.

Whether we should routinely screen our patients for prostate cancer is still controversial. Until more definitive studies are available, the current consensus is that doctors should only proceed with DRE + PSA testing (after explaining the limitations of the test to the patient) if they are convinced that the patient has a reasonable life expectancy and that making the diagnosis of cancer will benefit the patient. In practical terms this equates to testing patients who have a life expectancy of at least ten years.

Male infertility

Another field that has seen some dramatic advances is that of male infertility.

In Australia, approximately one in 20 couples has infertility problem - and in about half of the couples who seek help, the cause lies with the male.⁹

Many family doctors may not be aware¹⁰ of the efficacy of a new procedure - Intracytoplasmic Sperm Injection (ICSI), a technique that allows previously infertile couples to use their own gametes for conception.

Even if the male partner has little or no sperm in his semen (as may happen in congenital, infective or obstructive lesions of the vas) ICSI allows a single viable sperm, obtained from the epididymis or from a small focus of spermatogenesis in the testis, to be injected directly into an ovum. ICSI technique can also be utilised where a man's semen has sperm antibodies (which prevent sperms binding to the zona pellucida of the ovum) - a condition that occurs in about 6% of men presenting with infertility.

Sperm retrieval can be performed under local anaesthesia - either by percutaneous fine needle aspiration from the epididymis or the testis. Couples who were especially reluctant to accept sperms from outside donors (Artificial Insemination by Donor or AID) can now take advantage of in-vitro fertilisation (IVF) using ICSI. Today most centres report pregnancy rates of 30 to 35% for ICSI.

Testicular cancer

Over the last 25 years, our concept of testicular cancer has changed. From being a disease that would be fatal in most of those affected, it is today one with a truly excellent prognosis - the five year survival rate being 95%. A well known example to quote is Lance Armstrong¹¹ who won the gruelling Tour de France cycle marathon four times, after undergoing surgery, radiotherapy and chemotherapy for his testicular cancer!

Testicular cancer is the commonest form of cancer in men aged between 15-44, usually presenting in the first instance to the family doctor.

In almost all patients where testicular cancer is detected early and treated in specialist units, the condition is now curable. Early detection of recurrences, using tumour markers such as Beta HCG and Alpha-foetoprotein as well as whole body CT scanning, together with the use of platinum-based chemotherapy, have greatly improved prognosis. Because many such cancers are now curable, patients should be counselled about sperm storage before undergoing their treatment with radiotherapy and chemotherapy. This allows them to consider the possibility of using their cryopreserved sperm for artificial insemination at a later date.

We should also be aware of the significant links between infertility and cancer of the testis and other associated factors e.g. undescended testes and infantile hernia which can lead to, respectively, fourfold and twofold increases in cancer of the testis. Interestingly, it was noted that the increased risk of testicular cancer disappeared if orchidopexy was performed before 10 years of age.¹²

Conclusion

As family physicians of the 21st century we now need to know the latest in male reproductive health. We need to understand not only the physiological issues but also the emotional aspects of male problems, and we must continue to keep abreast of recent developments in order to have the skills and knowledge required to effectively manage these problems.

In simple terms, we have to know what the most up-to-date information is - and then understand what questions to ask, what we can do as family physicians as well as when to refer our male patients, and to where.

Key messages

1. Men with erectile dysfunction should seek medical advice because this condition is closely associated with cardiovascular disease - and it is also readily treatable by the family physician.
2. TURP remains the gold standard treatment for bladder outlet obstruction caused by benign prostatic hypertrophy - however several options for effective medical therapy are now available.
3. Although the efficacy of routine screening for prostate cancer is not yet proven beyond all doubt, prostate cancer can be diagnosed at a curable stage by regularly testing asymptomatic healthy men in the appropriate age group with Digital Rectal Examination and Prostate Specific Antigen.
4. Modern therapies such as intracytoplasmic sperm injection and sperm storage provide greater hope for infertile men.
5. Testicular cancer if diagnosed early and treated appropriately has an excellent prognosis.