MEN'S HEALTH

The physical health of men in the UK is poorer than that of women; for example, heart disease occurring before 65 years of age is more than twice as common in men than it is women. Men are also at significantly greater risk of both getting and dying from nearly all of the common cancers that occur in both sexes. And while women are more likely to be diagnosed with a mental disorder, men are more likely to become alcohol dependent, misuse drugs, go missing from home, have a personality disorder or commit suicide.

A factor in this gender inequality is men’s much lower usage of primary healthcare services. Men often perceive general practices as inaccessible, and many practices could do more to encourage men to engage in their healthcare. Offering outreach health checks, eg in workplaces or sports and youth clubs, can help draw men into a practice; sessions are generally well attended and effective for risk assessment and basic health education.

BENIGN PROSTATIC HYPERPLASIA (BPH)

Common in older men, usually presents at age 60–70 years. The prostate is a gland the size of a walnut. It lies under the bladder, surrounding the urethra, and makes seminal fluid. The prostate tends to enlarge with age. Pressure on the urethra from an enlarging gland can cause partial or complete obstruction of urine flow. Presentation is often with outflow obstruction or retention issues, for which management is medical treatment or a surgical procedure. If symptoms are mild to moderate, management is watchful waiting, with treatment indicated if condition worsens. The International Prostate Symptoms Score is used to assess effect of BPH on quality of life.

Interpretation of IPSS score

Classification	Mild symptoms	Moderate symptoms	Severe symptoms
Score	0-7	8-19	20-35

BLADDER AND RENAL CANCER

Bladder cancer is the fourth most common cancer in men, but less common in women. Men are also more frequently diagnosed with kidney cancer than women.

Refer urgently patients:

• of any age with painless macroscopic haematuria
• aged ≥40 years who present with recurrent or persistent urinary tract infection associated with haematuria
• aged ≥50 years who have unexplained microscopic haematuria
• with an abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract.

BREAST CANCER

ERECTILE DYSFUNCTION (ED)

Inability to attain and maintain an erection sufficient for satisfactory sexual intercourse. ED may be psychogenic or organic. If the latter, it is often an indicator of atherosclerosis. ED is common in men with diabetes, cardiovascular disease and hypertension; medication for these conditions may be the cause in many cases.

Incontinence

Urinary incontinence is not exclusively a female problem, although some causes differ because of men’s different anatomy and because men do not experience pregnancy and childbirth. Potential causes in men include BPH and treatment for prostate cancer.

PENILE CANCER

Refer urgently patients with symptoms or signs of penile cancer

These include progressive ulceration or a mass in the glans or prepuce particularly, but can involve the skin of the penile shaft. (Lumps within the corpora cavernosa can indicate Peyronie’s disease, which does not require urgent referral.)

PROSTATE CANCER

The second most common cause of cancer death in UK men, prostate cancer usually presents at age 65–85 years; rare before this age. Locally advanced or metastatic disease causes weight loss, bone pain, lethargy and ureteric obstruction. Risk is higher:

• if family history in a first-degree family member
• in West African men and black men from the Caribbean.

Tumour grows slowly and often remains asymptomatic, but reliable prediction of which tumours will be aggressive is not possible. Treatment can affect sexual and urinary function so, after diagnosis, management options include ‘watchful waiting’.

Screening and the PSA test

Historically, prostate cancer presented when locally advanced or metastatic disease caused weight loss, bone pain, lethargy and ureteric obstruction. Now, screening by measurement of PSA (prostate-specific antigen) is increasingly identifying the disease in younger, asymptomatic men. PSA is an enzyme produced by the prostate that can be measured in the blood, and the PSA test is the most effective single test for early detection of prostate cancer. However, PSA levels can be affected by factors other than the presence/absence of cancer (e.g. age, obesity, benign prostatic hyperplasia [BPH], recent digital rectal examination [DRE]) and the test has a high rate of false positive and false negative results. This lack of discrimination and the unpredictable behaviour of a prostate tumour (see above) are two of the reasons why screening for prostate cancer by PSA test is not routine in the UK, and why men should be counselled before taking the test.

Symptoms/investigation

A digital rectal examination (DRE) and a PSA test (after counselling) are recommended for men with any of the following unexplained symptoms:

• inflammatory or obstructive lower urinary tract symptoms
• erectile dysfunction
• haematuria
• lower back pain
• bone pain
• weight loss, especially in the elderly.

(exclude UTI before PSA testing; postpone test for at least 1 month after treatment of a proven UTI). In an asymptomatic male with a borderline PSA level, repeat the PSA test after 1 to 3 months. If the PSA level is rising, refer the patient urgently.

TESTICULAR CANCER

Diagnosed in around 2100 men every year in the UK. More common in younger and middle-aged men. Undescended testicles not corrected in childhood are a risk factor. Rates are rising but treatment is effective and nearly all men are cured. Men should be encouraged to check their testicles monthly for lumps or swelling. Refer urgently patients with a swelling or mass in the body of the testis (see NICE CG27 www.nice.org.uk/cg27)