Practice Nurse

Men's Health

Men's health is a particularly important area of clinical practice in primary care, with erectile dysfunction being one of the most common presenting problems. Roughly 40% of males over the age of 40 experience erectile dysfunction with emerging therapies revolutionising the treatment of the disorder. Similarly, hypogonadism and low testosterone in males have emerged as important and treatable clinical conditions along side the more traditional prostate problems that befall aging males.
This resource focuses upon some common problems related to men's health which one might see in practice. The resource is composed of 10 assessment questions covering aspects of investigation, diagnosis and treatment of erectile dysfunction and hypogonadism.

On completion of this resource, the user should:

Have an improved understanding and ability to implement the diagnostic strategy for erectile dysfunction and male hypogonadism.

Have improved familiarity with the approach to the treatment of erectile dysfunction.

Have an improved understanding of the basic investigation and treatment of prostate disorders.

Investigation, treatment and monitoring of late-onset male hypogonadism

NHS Guidelines on the management of erectile dysfunction

Men's health is a particularly important area of clinical practice in primary care, with erectile dysfunction being one of the most common presenting problems. Roughly 40% of males over the age of 40 experience erectile dysfunction with emerging therapies revolutionising the treatment of the disorder. Similarly, hypogonadism and low testosterone in males have emerged as important and treatable clinical conditions along side the more traditional prostate problems that befall aging males.
This resource focuses upon some common problems related to men?s health which one might see in practice. The resource is composed of 10 assessment questions covering aspects of investigation, diagnosis and treatment of erectile dysfunction and hypogonadism.

Be able to understand and implement the diagnostic strategy for erectile dysfunction and male hypogonadism.

Be familiar with the approach to treatment of erectile dysfunction.

Be familiar with the investigation and treatment of other male disorders relating to the prostate.

A 55 year old male presents to the clinic with a 6 month history of erectile dysfunction and reduced libido. He has a 5 year history of type 2 diabetes and weight gain. He takes amlodipine and metformin. His weight is 98kg, his BMI is 35.4 kg/m

 and his waist circumference 106cm. He attended clinic two weeks ago and had some tests which reveal: (normal ranges shown in brackets)

What is the likely cause for his current presentation?

This obese man with type 2 diabetes presents with erectile dysfunction and a poor sex drive. He has been appropriately investigated and his results show a low testosterone but normal LH and FSH indicating that the pituitary is not compensating adequately by increasing LH and FSH secretion in an attempt to drive up the testosterone. This problem could be caused by a pituitary tumour but is more likely to be a consequence of weight and diabetes. A low testosterone is common in diabetes occurring in roughly 30% of diabetic men. Erectile dysfunction can be a common consequence of this.


Erectile dysfunction has similar risk factors to cardiovascular disease, these include:

 to suggest that lifestyle changes can significantly help patients whose erectile dysfunction is related to their obesity or diabetes. Exercise and weight loss have both been shown to improve erectile function.

Question 1

A 58 year old man attends clinic as he has noticed tiredness, lack of energy, reduced sex drive and erectile dysfunction over many months. He has a problem with obesity and hypertension and you note from his records that his testosterone is low at 6.1 nmol/l (9-30) and this has been attributed to a weight related hypogonadotrophic hypogonadism.

, his waist circumference is 103cm with a blood pressure of 136/88 mmHg. You see from his notes that he has a fasting plasma glucose concentration of 6.2 mmol/l (3.5-5.5).

Which is the most appropriate approach to treating this man?

This man has a low testosterone concentration associated with features of the metabolic syndrome including obesity with central obesity (high waist circumference), high blood pressure and impaired fasting glucose (above 6.1 mmol/l). He has symptoms indicative of the low testosterone which include erectile dysfunction, tiredness and lack of energy. The low testosterone has been attributed to a weight related hypogonadism. The symptoms plus decreased sex drive are unlikely to improve with PDE-5 inhibitors such as Viagra and Cialis and so testosterone would be the most appropriate initial treatment.Testosterone replacement could be given as a daily gel formulation (Tostran, Testogel) or as a depot IM injection (Sustanon, Nebido).

Men with a serum testosterone less than 12nmol/l may benefit from a trial of up to 6 months of testosterone therapy and studies suggest improvements in many of the parameters of the metabolic syndrome associated with testosterone therapy (1). If there is an unsatisfactory response to this then combination therapy (with PDE5 inhibitor) should be considered.

Review: Testosterone and the metabolic syndrome

 Muralheedharan V. Therapeutic advances in Endocrinology and Metabolism 2010;1(5):207-223.


British Society for Sexual Medicine guidelines

Merck Manual for healthcare professionals - erectile dysfunction

Question 2

A 25 year old man has come to clinic as he has noticed problems with erectile dysfunction and poor sex drive. He is otherwise very fit, is a body builder and lifts heavy weights 3-4 times each week. He is very muscular with a weight of 102kg, a BMI of 34.4 kg/m

 and a waist circumference of 88cm. His GP has checked the following blood tests.

What is the most likely cause of his symptoms?

This young man is a body builder and has a low testosterone with low LH and FSH indicating pituitary dysfunction. This is most likely to be due to anabolic steroid abuse. The anabolic steroids are typically a potent testosterone type drug which suppresses the normal pituitary function. Use over a longer term can cause a permanent suppression of LH and FSH secretion and therefore results in this type of hypogonadism. The patient should be asked about the use of anabolic steroids.
Over zealous female athletes often report amenorrhea and changes to libido but hypogonadism in male athletes is rarely attributable to exercise. Primary testicular failure would typically produce high LH and FSH levels.

Encyclopedia of Sports Medicine and Science

Question 3

A 54 year old male with a 6 year history of type 2 diabetes attends clinic as he has had problems with poor erections and inability to have sex with his wife. His erectile function has deteriorated over the last 1 year or so. His libido is unaffected and he also informs you that he shaves regularly. He takes metformin 500mg tds. His blood tests show:

Which of the following is the most appropriate approach to treating this man?

This man with diabetes has typical erectile dysfunction and normal testosterone concentration. Erectile dysfunction is very common in patients with diabetes and may be a consequence of a number of factors including impaired vascular function as well as nerve involvement. The most appropriate initial approach to this man would be a trial of Viagra or a similar PDE-5 inhibitor.
Oral phosphodiesterase inhibitors (PDE-5 inhibitors) are a group of drugs including sildenafil, vardenafil and tadalafil. They work by increasing nitric oxide (a potent vasodilator) release, which is essential for a normal erection. All PDE-5 inhibitors are taken approximately 1 hour before sexual intercourse. Side effects include flushing, visual abnormalities and headache. They can also cause coronary veins to dilate so should not be taken with nitrates, all nitrates are contraindicated for 24 hours after taking a PDE-5 inhibitor.

Question 4

A 65 year old male attends clinic complaining of difficulty with passing urine and some dribbling after micturition. This he feels has developed and deteriorated over the last 2 years. He has otherwise been well with no past medical history of note. He does not take any medication. He does not smoke and drinks about 12 units of alcohol weekly. He is married with 5 grown up children. He does not admit to any issues with erectile dysfunction. His weight is 92kg with a BMI of 31.2 kg/m

. Which of the following blood tests would you request?

This man has symptoms of prostatism with hesitancy and dribbling. From the investigations provided, the most relevant investigation is measurement of PSA

Dribbling of urine before and after micturition

Question 5

A 56 year old man comes back to clinic as he was prescribed Viagra for erectile dysfunction but has found that this has not had the desired effect. He has tried the Viagra on a number of occasions and in maximal doses but he has not achieved an adequate erection. He now enquires as to what else he might try?

Approximately 20% of patients fail to achieve adequate erections with PDE-5 inhibitors. There are other approaches to treat the erectile dysfunction. Intracavernosal (Caverject) or intraurethral alprostidil (Muse) may be used as alternatives in such patients. A pump or prosthesis is a potential treatment option but less invasive measures should be tried first.
Alprotsadil is a prostaglandin which works as a vasodilator. The injection takes roughly 5 to 10 minutes to take affect and should last between 30 to 60 minutes. Potential side effects include:

Priapism (an erection lasting more than 4 hours)

Question 6

A 31 year old man attends clinic as he has noticed tiredness, poor erectile function and reduced libido over the last few months. He has been a body builder for a number of years and has felt well. He denies taking any medication, does not smoke and occasionally takes alcohol. He has a muscular physique with a weight of 90kg and a BMI of 31.5 kg/m

 with a waist circumference of 80cm. The results of investigations show:

Which of the following is the likely cause for his presentation and results?

This patient who is a body builder and presents with symptoms of testosterone deficiency has a low testosterone, LH and FSH but his prolactin is particularly elevated at 31000 mu/l indicating that the likely diagnosis is a prolactinoma. Anabolic steroids would not cause an elevation of the prolactin. A prolactinoma is due to a tumour of the pituitary lactotrophs. It is a typically benign tumour that responds to dopamine agonist therapy such as Cabergoline, Bromocriptine or Quinagolide. Surgery is usually unnecessary as the tumour responds so well to dopamine agonist treatment.

Question 7

A 16 year old male comes to clinic with his father who is concerned about his lack of development. He has not noticed any pubertal development and is concerned that he has not started to shave or grow any body hair. He is tall for his age but has had some problems at school being in the remedial class. The GP has examined him and states that he has delayed pubertal development. His results show:

This young man who is tall and has problems with his educational achievement presented with delayed puberty which is due to a primary gonadal dysfunction - the testes appear not to be functioning appropriately as the testosterone is low yet the pituitary gland is over secreting LH/FSH in an attempt to stimulate the testes. This is primary gonadal failure and is most likely due to Klinefelter

Question 8

A 55 year old male is receiving testosterone treatment for testicular failure. He was started on testosterone gel 50mg daily three months ago and his testosterone concentration is 15.8 nmol/l (9-30). He is quite happy with the gel preparation which suits his lifestyle and he feels better with replacement treatment. He attends clinic as he has been told that besides his testosterone, other monitoring tests need to be performed. Which of the following blood tests would you check in this man?

Patients who are started on testosterone should have full blood count checked as testosterone is associated with increasing the red cell mass, potentially causing a polycythaemia. It is also recommended that PSA be checked before initiation of treatment, every 3 months in the first year and then semiannually as a rise in PSA above 2ng/ml from baseline may be associated with an unmasking of prostate cancer. If PSA is elevated at the outset this should be investigated and patients should undergo a digital prostate examination. Testosterone therapy can also cause acne, gynecomastia, headache and mood changes - less common with topical application.

Question 9

A 55 year old man attends clinic as he has had problems with erectile dysfunction for the past year. This problem has been affecting his sense of well being and has been causing issues in his relationship with his wife. He is keen to have a prescription for Viagra as he believes this will help. Which of the following drugs that he is taking would be a contra-indication to him receiving Viagra?

Viagra as well as other PDE-5 inhibitors should not be prescribed with nitrates as this might precipitate a severe hypotensive reaction. This is due to the vasodilating affect on the coronary blood vessels of both groups of drugs. Other drugs that should not be prescribed with PDE-5 inhibitors include all nitrates such as nicorandil.

Men's Health

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