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Next Lesson - Palliative Care
Contents
Abstract
- Men go through three life stages: childhood, adulthood and older age.
- Each stage comes with its own set of challenges.
- Men are often portrayed as the strong, silent type who do not feel emotions and can solve their problems alone. This is not true.
Core
Risk Factors that Contribute to Morbidity and Mortality in Men
In England and Wales, about one in five male deaths (19%) is in a man under the age of 65. The figure for female deaths is 12%[1]. Health inequality is also clear. Life expectancy (the average number of years a person is expected to live) at birth for men in England in 2022 to 2024 was 73.2 years in the most deprived areas. In the least deprived areas it was 83.6 years. This is a gap of about 10 years[15]. Deprivation reflects socioeconomic circumstance (a person’s social and financial position).
Men are more likely than women to die from cancer. A 2013 report found that men in the UK were over 35% more likely to die from cancer overall. When breast cancer and sex-specific cancers (such as prostate, testicular and ovarian cancer) were left out, men were 67% more likely to die from cancers that affect both men and women[16, 17]. Cancer is also the biggest single cause of death in men, at 31% of male deaths registered in 2015[1]. Interestingly more men died of breast cancer than testicular cancer in 2018. Breast cancer is often seen as “a woman’s disease”, and many men do not know that it can affect them. Low awareness, stigma (unfair shame and negative attitudes) and embarrassment can delay a man in seeking medical advice. Men with breast cancer tend to present at a later stage, when the disease is more advanced[38, 39].
Campaigns such as “It’s in the bag” and “Movember” encourage men to check their testicles for lumps[2]. Early diagnosis matters. In England in 2022, 90% of testicular cancers with a known stage were found at an early stage (stage I or II), and about 96.5% of men diagnosed in the UK are expected to survive for ten years or more[18]. Men should see a GP about any lump or swelling in a testicle[19].
Prostate cancer is diagnosed in about 58,000 men in the UK each year and causes about 12,300 deaths a year. It is the second most common cause of cancer death in men, and about three-quarters of these deaths are in men aged 75 and over[3]. Many men with early prostate cancer (cancer that has not spread beyond the prostate) live for years and die of something else. The ProtecT trial followed 1,643 men in the UK who had early prostate cancer found by prostate specific antigen (PSA) blood testing. After about 15 years, 2.7% had died of prostate cancer, while 21.7% had died of any cause[20]. Use of the PSA blood test in younger, asymptomatic (symptom-free) men without appropriate counselling can cause unnecessary anxiety and over-investigation.
Factors that increase a patient's risk of cardiovascular disease (disease of the heart and blood vessels) include a high body mass index (BMI). BMI is a person’s weight in kilograms divided by their height in metres squared[4]. Men are more likely to be overweight than women. In England in 2024, 70% of men were overweight or living with obesity, compared with 62% of women[22]. When taking a diet history, ask what “normal” means to the patient. Explore salt, sugar, cholesterol and alcohol intake in detail. A larger waist measurement is a sign of central (abdominal) obesity, which adds to the health risk of being overweight[22]. Waist size is also linked to cardiovascular risk and the risk of diabetes[5].
Risk factors used by the QRISK3 tool (described below) to assess a patient’s cardiovascular risk include:
- Older age
- Male sex
- South Asian ethnicity
- A postcode associated with a low socio-economic area
- Smoking status: non-smoker, former smoker, or light (1 to 9 a day), moderate (10 to 19 a day) or heavy (20 or more a day) smoker. The more a patient smokes, the higher the risk
- A higher BMI (QRISK3 uses the BMI value itself, not only whether it is classed as overweight)
- An elevated current systolic blood pressure value
- The patient is on existing blood pressure treatment
- A first degree relative (parent, brother, sister or child) who developed angina (chest pain caused by reduced blood flow to the heart) or had a heart attack before the age of 60
- A raised ratio of total cholesterol to HDL cholesterol
- If they suffer from diabetes (type 1 or type 2)
- If they suffer from rheumatoid arthritis (an autoimmune disease that inflames the joints)
- If they suffer from chronic kidney disease stage 3, 4 or 5
- If they suffer from atrial fibrillation (an irregular and often fast heart rhythm)
The more of these that are present, the higher the risk of the patient suffering a major cardiovascular event such as a heart attack (myocardial infarction) or stroke within the next 10 years[6].
There are risk tools that can be used to calculate and quantify the patient's overall cardiovascular risk. NICE recommends the QRISK3 tool (the “Q risk score”). It estimates the risk of cardiovascular disease over the next 10 years in people aged 25 to 84 who do not already have cardiovascular disease[23]. NICE advises against using a risk tool for people who are already at high risk of cardiovascular disease. This includes people with type 1 diabetes, chronic kidney disease or familial hypercholesterolaemia (an inherited condition that causes very high cholesterol)[23]. QRISK3 includes risk factors that the earlier version (QRISK2) did not. Examples are long-term atypical antipsychotics (medicines used for serious mental illness), corticosteroids (steroid medicines), migraine (severe, recurring headaches), severe mental illness and erectile dysfunction[24]. QRISK3 gives the risk as a percentage, which is easy to explain to a patient. Picture a room of 100 people who all have the same risk factors as the patient. If nothing is done, some of them will have had a heart attack or a stroke within 10 years. For example, a QRISK3 score of 15% means that, in 10 years, 15 out of the 100 imaginary people will have suffered a cardiovascular event (a heart attack or stroke). Discuss how to reduce the risk with any patient whose risk is raised, because several risk factors can be changed (they are modifiable). Examples are BMI, cholesterol and smoking status.
Suicide is one of the leading causes of death in men under the age of 50[7]. NHS England has described suicide as the leading cause of death for men under 50[7]. In 2018, ONS figures put the peak age group between 45 and 49, at 27.1 deaths per 100,000 males in the UK[40]. In the latest Office for National Statistics (ONS) figures, men aged 50 to 54 had the highest suicide rate: 28.0 deaths per 100,000 men in England and Wales in 2025[25]. One reason for the high male suicide rate may be that men feel that they do not receive enough support. They may feel they cannot talk and reveal what is troubling them. Traditional expectations that men should be strong and in control can make it harder for them to ask for help[9]. This can stop them from accessing the care and help that they need.
Patients may describe that they are living two different lives, presenting a sociable and cheerful front to their friends and family and struggling behind closed doors. They may be scared that people won’t understand what they are going through or won’t take it seriously. They may also worry about their relationships with family or colleagues. They may fear losing their jobs because of the stigma (unfair shame and negative attitudes) linked to poor mental health. Some men become used to living like this and think that it is normal. Others think that the feelings will go away if they push them aside. This is not the case. These men suffer in silence.
Doctors need to reach out and build trusting relationships in their consultations so that patients can open up. There is a fine balance between not giving the patient enough opportunity to talk, and overstepping into a patient’s comfort zone.
Stress can change how people behave in risky situations[8]. Men are more likely than women to respond to stress with risk-taking behaviour, such as misusing alcohol and drugs[11]. Relationship breakdown, such as divorce, is more likely to lead men than women to suicide[11]. Men also have measurably lower access to the social support of friends, relatives and community[11].
Men are less likely than women to use psychological talking therapies. In the first three quarters of 2015, men made up only 36% of the people accessing these therapies in the NHS[11]. The service was then called Increasing Access to Psychological Therapies (IAPT) and is now called NHS Talking Therapies. If patients have had negative experiences of opening up around friends and family or even their doctor, then they will be far more likely to dismiss the idea that talking about feelings can be helpful.
Unemployment is linked to a higher risk of suicide. A New Zealand study found a two- to threefold higher risk in unemployed adults. About half of this link may be due to mental illness that was already present[10]. Men are often expected to be the breadwinner (the main earner) for the family, and this can make it harder for them to ask for help[9]. In a Men’s Health Forum survey, 34% of men said they would be embarrassed or ashamed to take time off work for a mental health concern such as depression or anxiety. Only 13% said the same for a physical injury[11]. Men who work full-time or in more than one job may find it hard to see their GP on weekdays without taking time off.
When men reach middle age, around their 40s, they often start to assess their priorities in life. They may question whether they have achieved their goals or got to where they wanted to be by this stage in life. Not managing to achieve these goals may be one reason why mental health problems and unhappiness are more common in mid-life than at younger or older ages[11].
Men are less likely to see their GP than women. In UK general practice data from 2010, the crude consultation rate (the overall rate, before adjusting for other factors) was 32% lower in men[12]. The gap was largely removed when men and women with similar underlying conditions (judged by the medicines they were prescribed) were compared. Generally, men appreciate being listened to in these consultations as this is often what they are missing. Normalising the consultation (making clear to the patient that seeking help is normal and common) and making a positive plan to follow up with the patient always helps to put them at ease.
Sometimes described colloquially as “problems in the bedroom”, erectile dysfunction (ED) is the persistent inability to get and keep an erection sufficient for satisfactory sexual performance[26]. It is a symptom, not a disease. Most cases have both physical and psychological causes.
When a patient raises erectile dysfunction, the doctor must remain calm and professional to help to encourage the trusting relationship between the doctor and the patient.
The doctor should ask exactly what is happening. The doctor should also ask whether the patient feels that there are any contributing factors. The patient may link the problem to their partner, for example if they have lost sexual interest or the relationship is breaking down.
Patients can have pain that puts them off during intercourse, such as the pain caused by phimosis (a foreskin that is too tight to pull back), and the foreskin and penis need to be examined thoroughly. Sources of stress, anxiety, guilt, or anger can interrupt the mental state required for intercourse. This can start a vicious cycle. The patient is unable to perform, becomes stressed because of this, and is then even less able to perform. Establishing how the patient perceives the problem and what they think may be causing the issues can go a long way in terms of identifying what is causing it.
Psychological causes of erectile dysfunction include stress, anxiety, and depression. Relationship conflicts, sexual boredom, and even uncertainty or distress about sexual identity can also contribute to erectile dysfunction.
Physical causes should also be excluded, because ED can be the first sign of another condition. In a man with no other symptoms, it may be a marker of coronary artery disease (narrowing of the arteries that supply the heart muscle) or of endocrine (hormone) disease[27]. ED is also one of the risk factors in the QRISK3 score[24]. The assessment therefore includes blood pressure, waist circumference and BMI. It also includes blood tests: either HbA1c (a measure of average blood glucose over the past weeks) or a fasting glucose; a lipid profile (cholesterol and other blood fats); and a fasting testosterone level taken between 9 and 11 am. The doctor should also calculate the 10-year cardiovascular risk and judge the cardiac risk of sexual activity[27].
Physical causes of ED are commonly related to vascular disease affecting blood flow to the penis, although neurological and hormonal factors may also contribute. In all of these cases, high pressure within the corpus cavernosum (the spongy erectile tissue of the penis that fills with blood) cannot be maintained, leading to the inability to maintain an erection.
ED is very common in men with diabetes. It is estimated to affect 35% to 75% of them[13]. Men with diabetes are thought to develop ED 10 to 15 years earlier than other men[13]. Diabetes can damage the small blood vessels (microvascular complications), which limits the blood supply to the penis. It can also damage the nerves that control the erection[13, 28].
Smoking is a major risk factor for erectile dysfunction[14]. Regular cycling may also contribute in some men. UK guidance advises a trial break from cycling if a man cycles for more than 3 hours a week[29]. If he cannot stop, he should use a properly fitted bicycle seat.
Other physical causes involve neurological damage to the nerves that bring about an erection, including the parasympathetic system nerves that stimulate it. Causes include spinal cord injury, multiple sclerosis (a disease that damages the nerves of the brain and spinal cord), Parkinson’s disease (a brain disease that mainly affects movement), stroke, and nerve damage from diabetes[28]. Excessive alcohol consumption can damage these nerves, and can work to reduce testosterone levels and increase oestrogen levels.
Certain medicines can cause or worsen ED[28]. These include some antihypertensives (drugs that lower blood pressure), such as beta-blockers (drugs that slow the heart rate and lower blood pressure). They also include diuretics (drugs that increase urine output) such as thiazides and spironolactone. Antidepressants can be a cause too, including SSRIs (selective serotonin reuptake inhibitors) and tricyclic antidepressants (an older group of antidepressants). Other examples are antipsychotics (medicines for serious mental illness, such as schizophrenia), anti-androgens (medicines that block the effects of male hormones) and finasteride (a hormone-modifying medicine used for an enlarged prostate). A patient should not stop a medicine on their own. For most men, treating the underlying condition is more likely to help than changing the medicine[29]. Some surgeries such as radical prostatectomies (operations to remove the prostate gland) and inguinal hernia repairs (operations for a hernia in the groin) can also contribute.
The first step in managing erectile dysfunction is to address the root cause. This includes lifestyle advice: weight loss and regular exercise if needed, stopping smoking, and cutting down alcohol. It also means treating conditions such as diabetes, high blood pressure and abnormal cholesterol, and thinking about whether a medicine is the cause[29]. Drug treatment does not need to wait until this is done. NICE Clinical Knowledge Summaries (CKS), the UK guidance for GPs, advise considering oral medications called phosphodiesterase type 5 (PDE-5) inhibitors, whatever the suspected cause, in men who are not at high cardiac risk from sexual activity[29]. High cardiac risk includes unstable angina (chest pain that is new, getting worse or occurring at rest), a heart attack in the last 2 weeks, and uncontrolled high blood pressure[27]. The options are sildenafil (more commonly known as Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Spedra)[29]. This works through relaxing the smooth muscle of the vasculature and increasing blood flow to the penis. Sildenafil 50 mg tablets (Viagra Connect) can be bought from a pharmacy without a prescription[29, 34]. In 2023 the Medicines and Healthcare products Regulatory Agency (MHRA), the UK medicines regulator, reclassified tadalafil 10 mg (Cialis Together) so that pharmacies could sell it without a prescription too[35]. Other PDE-5 inhibitors, and other doses, are available on prescription. Patients may therefore have tried tablets before they see a doctor. Some may have bought them online. Many websites sell fake medicines, and the ingredients can vary from one pack to another[34].
PDE-5 inhibitors are not safe for every man. They must not be prescribed to a man with unstable angina, or with angina that occurs during sexual intercourse[36]. They are also unsuitable after a recent heart attack (within the last 90 days for tadalafil) or stroke, in men with a history of non-arteritic anterior ischaemic optic neuropathy (NAION, sudden vision loss caused by damage to the optic nerve), or if the systolic blood pressure is below 90 mmHg[36, 37]. They must never be taken with nitrates (medicines that widen blood vessels, used to treat angina, such as isosorbide mononitrate), with nicorandil (another angina medicine), or with amyl nitrate (known as “poppers”). This combination is absolutely contraindicated, which means it must not be used, because of the risk of severe, life-threatening hypotension (very low blood pressure)[36]. A man at high cardiac risk should be referred for specialist cardiology assessment and advised to avoid sexual activity until the cardiology assessment has been done[29].
Some patients may try a vacuum pump before they see a doctor. This is a device that draws blood into the penis to cause an erection. Pumps work for most men, but they are not always available on the NHS[34]. Penile implants (devices placed in the penis by surgery) are a specialist treatment that needs assessment and surgery. Penile injections and other specialist options are also offered after referral to a urology specialist (a doctor who treats problems of the urinary tract and male genital organs). A GP offers this referral if tablets are ineffective, not tolerated or not suitable[29].
Therapy is often used to treat patients’ psychological causes, or help them come to terms with and work past their erectile dysfunction if it cannot be resolved. If psychological factors are contributing, psychosexual counselling (talking therapy for sexual problems) combined with a PDE-5 inhibitor may be more effective than either one alone[29].
[1] https://www.menshealthforum.org.uk/key-data-mortality
[2] https://itsinthebag.org.uk
[4] https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity
[6] https://qrisk.org/three/ (this page is no longer available; the QRISK3 demonstration calculator is at https://qrisk.org/)
[7] https://www.england.nhs.uk/blog/tackling-the-root-causes-of-suicide/ (this page is no longer available; archived copy of 25 January 2022)
[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4732013/
[9] https://www.mentalhealth.org.uk/a-to-z/m/men-and-mental-health
[10] https://jech.bmj.com/content/57/8/594
[11] https://www.menshealthforum.org.uk/key-data-mental-health
[12] https://bmjopen.bmj.com/content/3/8/e003320
[13] https://www.diabetes.co.uk/diabetes-erectile-dysfunction.html
[14] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4485976/
[16] https://www.menshealthforum.org.uk/men-and-cancer-saving-lives-expert-report
[19] https://www.nhs.uk/conditions/testicular-cancer/symptoms/
[20] https://pubmed.ncbi.nlm.nih.gov/36912538/
[21] https://www.nhs.uk/tests-and-treatments/psa-test/
[23] https://www.nice.org.uk/guidance/ng238/chapter/Recommendations
[24] https://pmc.ncbi.nlm.nih.gov/articles/PMC5441081/
[26] https://cks.nice.org.uk/topics/erectile-dysfunction/
[27] https://cks.nice.org.uk/topics/erectile-dysfunction/diagnosis/assessment/
[28] https://cks.nice.org.uk/topics/erectile-dysfunction/background-information/causes/
[29] https://cks.nice.org.uk/topics/erectile-dysfunction/management/management/
[30] https://pubmed.ncbi.nlm.nih.gov/25336765/
[31] https://pubmed.ncbi.nlm.nih.gov/7017755/
[32] https://pubmed.ncbi.nlm.nih.gov/23334479/
[33] https://pubmed.ncbi.nlm.nih.gov/31852527/
[34] https://www.nhs.uk/conditions/erection-problems-erectile-dysfunction/
[35] https://www.gov.uk/government/news/mhra-reclassifies-cialis-together-tablets-to-a-pharmacy-medicine
[37] https://bnf.nice.org.uk/drugs/sildenafil/
[38] https://pubmed.ncbi.nlm.nih.gov/41776707/
[39] https://pubmed.ncbi.nlm.nih.gov/32167660/
[41] https://web.archive.org/web/20201112010604/https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer/mortality (archived copy of 12 November 2020; the live page now gives later figures)
[42] https://web.archive.org/web/20201206021950/https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/testicular-cancer/mortality (archived copy of 6 December 2020; the live page now gives later figures)
Edited by: Dr. Maddie Swannack
Reviewed by: Dr. Thomas Burnell and Dr. Marcus Judge
Quiz
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