“Reduce the Stigma and See Your Doctor,”
Says the Urologist
Written By: Girish K. Mour, M.B.B.S., Nahid Punjani, M.D., M.P.H., and Daniel M. Frendl, M.D., Ph.D
As Urologists, we remain the gatekeeper for men’s health.
Not only are men are known to engage in higher-risk behavior but are also less likely to see to their primary care provider and avoid seeking care or treatment for an active health issue. Men often will also not see a health care provider unless their partner/significant other encourages them or accompanies them to their visit. Compounded with this is a societal stigma and embarrassment around many issues specific to men’s health. The reality is, there is growing evidence about the relationship between certain men’s health-specific issues and their overall health, examples include erectile dysfunction at a young age may be a harbinger of systemic cardiovascular disease, and men who have fertility issues are known to have higher risks of cancer, autoimmune disease and even earlier mortality.
Urologic issues remain those that are most likely to get men through their providers door and therefore represent a ripe opportunity to further improve engagement and care of our male patients.
Here we will review some of the key take aways for men regarding common urologic issues:
Testosterone Deficiency
Also commonly known as hypogonadism, testosterone deficiency is the medical diagnosis of a man with low testosterone measured by a lab test as well as signs and symptoms of low testosterone. Based on guidelines from the American Urologic Association, this is a testosterone value of <300ng/dL measured in the morning, with physical, cognitive or sexual signs and symptoms including reduced energy, fatigue, reduced lean muscle mass, altered mood, poor memory, irritability, diminished sex drive and erectile dysfunction. Men who experience these symptoms should reach out to their doctor about having their hormones evaluated and if appropriate may benefit from therapy. Having normal testosterone levels between 400-700ng/dL is thought to be protective for cardiovascular, diabetic and bone health, but also comes with side effects which should be discussed with a health care provider, but an important one for younger men to remember is that it may reduce sperm counts.
Sexual Dysfunction
Erectile dysfunction is a common in men of all ages. Many do not realize how common it is in younger men with rates of 20% for men 18-24 years, 25% for those 45-54 years, and 30% for those 55-64 years. Rates are just under 50% for men 65-74 years, and over 50% for men older than 75 years. Erections have both a physiologic and psychologic problem, the former which tends to present was men having difficulties obtaining their erection, and the latter with men having challenges maintaining their erections. Since there are numerous causes of erectile dysfunction, men who experience it should speak to their provider, as it may be an underlying symptom of another condition. Treatment options for erectile difficulty are variable including lifestyle changes (heart-healthy diet, good sleep hygiene and regular exercise), oral pills, penile injections and even surgery. We encourage men to seek out care from their doctors to discuss further.
Prostate Cancer
There has been a lot of controversy about whether men should be getting routine prostate cancer screening and what screening should involve. Prostate cancer remains the most common solid organ malignancy in men, but is thankfully not the leading cancer killer. Many men diagnosed with lower-risk prostate cancer may only need monitoring and may not require treatment. The goal of prostate cancer screening is to identify the smaller group of men with more aggressive disease at an early stage to ensure a high chance of cure. The best reflection of current consensus recommendations among urologists and cancer doctors is summarized in the recommendations of the National Comprehensive Cancer Network:
Who should get prostate cancer screening?
- All Men 45 to 75 years of age should consider regular screening
- Black men, men with a first or second degree relative with prostate cancer, ovarian cancer, breast cancer, or pancreatic cancer should consider screening starting at age 40.
What does prostate cancer screening involve?
- A blood test for prostate specific antigen (PSA) is the first step in screening. A rectal exam is most useful if the PSA test is elevated and isn’t necessary for every patient upfront. A rectal exam alone is inadequate for screening.
- If your PSA is very low (under 1ng/mL) you may only need it rechecked every 2 to 4 years.
- If your PSA is under 3 ng/mL, and you have no risk factors you may only need screening PSA tests at 2-year intervals.
- Any elevated PSA test should be re-checked together with a urine test to rule out infection as that can be temporarily increase the PSA number.
- For men with an elevated PSA over 3ng/mL, we highly recommend having a multiparametric magnetic resonance imaging (mpMRI) of the prostate.
- If the PSA is elevated on retest you should see a urologist to discuss the next steps
How do you diagnose prostate cancer?
- A prostate biopsy is the gold-standard test for diagnosing prostate cancer. It is performed with transrectal ultrasound probe guidance and is most accurate if also combined with targeting software to sample areas that looked suspicious on an MRI if the MRI reported suspicious regions for cancer.
- When high risk disease for metastatic spread is identified on biopsy, a prostate specific membrane antigen (PSMA) PET scan can be valuable to evaluate for possible disease outside of the prostate. This is now a better test than the bone-scan for evaluating spread.
- Prostate biopsy can be performed transrectally with appropriate careful antibiotic preparation or can be performed transperineally to minimize the risk of infection by avoiding passing any needles through the rectal wall. Both techniques have a similar rate of cancer detection but transperineal biopsy may have a slight advantage in reducing the risk of infection.
What are the treatment options?
Prostate cancer treatment recommendations are highly individualized and rely on extensive shared decision-making between patients and their doctors. Nearly half of men diagnosed with prostate cancer have low or favorable intermediate risk prostate cancer, much of which may initially be observed. A large randomized controlled trial from the United Kingdom recently showed that through 15-years of follow up there was no increase in the risk of prostate-cancer related death for men with low and favorable intermediate risk prostate cancer if they initially started with surveillance over immediate treatment with surgery or radiation. An emerging alternative to active surveillance for men diagnosed with lower volume intermediate risk prostate cancer is focal therapy, or partial destruction of the prostate. Focal therapy uses minimally invasive techniques to treat smaller volume of cancer and offers a lower risk of sexual and urinary side effects than traditional treatments. For men with organ-confined high risk prostate cancer, robotic radical prostatectomy or radiation therapy offer the best opportunity for cure. Advanced therapies for patients who have metastatic disease detected continue to evolve at a rapid pace and have helped extend longevity for men compared to decades past where there were limited options for these patients.
Voiding Dysfunction
Most men experience a slow in their urinary stream from a growth of the prostate or benign prostatic hyperplasia (BPH) as they age. Decisions to treat BPH are dependent on the degree of patient reported bother. There are two major classes of medication that over the last two decades have dramatically improved patient’s urinary quality of life and helped to avoid the need for surgical intervention to improve urination. These include medications to relax the muscle at the bladder neck, such as tamsulosin, and medications that work on the hormones that promote prostate growth, such as finasteride. Additionally, a low dose of the erectile dysfunction medicine tadalafil, taken daily, also has been shown to improve urinary bother in addition to erections. BPH treatment should start with a trial of medical management directed by a primary care physician or urologist. If patients do not experience adequate symptom relief with medication, there are now ten surgical techniques, mostly minimally invasive through a camera, that urologists can offer for treatment. The decision for which surgical technique is used is dependent on prostate size, anatomical shape, side effect profile and recovery time. Urologic consultation can be very helpful for men who are experiencing bother from their urinary symptoms. Earlier access to urologic intervention can prevent a decrease in bladder function that can occur over time for men with chronic obstruction. Early assessment is highly preferable to delaying until developing severe symptoms or acute urinary retention.
While these are common and popular urologic issues, they represent a fraction of diseases and conditions that impact men’s health. We want to educate providers about men’s health care issues and welcome everyone to join us at our upcoming Mayo Clinic Men’s Health Course this December 2024.
See link: https://ce.mayo.edu/internal-medicine/content/2024-men%E2%80%99s-health-update-engagement-prevention-and-performance#group-tabs-node-course-default1
