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Next Lesson - Palliative Care
Abstract
- There are said to be three ages of men, those developing through childhood, adulthood, and reaching older age.
- Each stage comes with its own set of challenges.
- Men are often portrayed as the strong silent type who don’t feel emotions and can solve their problems on their own, this could not be further from the truth.
Core
Risk Factors that Contribute to Male Morbidity and Mortality in Men
Shockingly in an advanced country such as the UK, one in five men do not make it past the age of 65. Approximately 20% of men die before they retire[1]. Inequality is evident across the region with a 10-year life expectancy difference for those born in deprived areas of Glasgow versus those born in Kensington. This is vastly dependent on socioeconomic circumstance and can dramatically change over a matter of miles.
Men are 67% more likely to die from cancers that affect both men and women, and 37% more likely to die from cancer overall (with sex specific cancers as exceptions)[1]. Interestingly more men died of breast cancer than testicular cancer in 2018. The potential embarrassment in getting checked out by a doctor for “a woman’s disease” is often a huge barrier and leads to men presenting later with more advanced disease for breast cancer.
Conversely campaigns such as “It’s in the bag” and “Movember” that encourage men to check for testicular lumps lead to patients catching testicular cancer at earlier stages in their presentations and so, lowering the death rate[2].
Prostate cancer affects thousands of men every year and is a common cause of cancer-related death in older men. This said, most patients die with prostate cancer rather than from it[3]. Use of the prostate specific antigen (PSA) blood test in younger, asymptomatic men without appropriate counselling can cause unnecessary anxiety and over-investigation.
Factors that increase a patient's risk of cardiovascular disease include an increased body mass index (BMI), which is a measure of the relationship of a patient’s weight and height to determine if that weight is healthy. Men are more likely to be overweight than women in every single age group, yet will often describe their diet as normal[4]. What normal means to the patient needs to be articulated fully, especially regarding salt, sugar, cholesterol and alcohol intake. The size of a patient’s waistband is known to directly correlate with the overall cardiovascular risk and the risk of diabetes[5].
Risk factors used to assess a patient’s cardiovascular risk include:
- Older age
- Male sex
- South Asian ethnicity
- A postcode associated with a low socio-economic area
- Positive smoking status. The risk is correlated to the patient's pack year history
- A BMI classified as overweight or greater
- An elevated current systolic blood pressure value
- The patient is on existing blood pressure treatment
- A first degree relative under 60 who suffers with angina or has had a heart attack
- A raised total and HDL cholesterol
- If they suffer from diabetes
- If they suffer from rheumatoid arthritis
- If they suffer from any chronic kidney disease
- If they suffer from atrial fibrillation
The more of these that are present, the higher the risk of the patient suffering a major cardiovascular event such as a myocardial infarction or stroke within the next 10 years[6].
There are risk tools such as the Q risk score that can be used to calculate and quantify the patient's overall cardiovascular risk. Such tools are consistently updated with new risk factors such as taking long-term atypical antipsychotics, corticosteroids, and those patients suffering with migraines as new research and associations come out. This is easily explained to a patient in terms of a room full of 100 people that all have the same risk factors, in 10 years’ time, if nothing is done then that number of people will have had either a heart attack or a stroke. For example, with a Q risk of 15%, in 10 years, 15 out of the 100 imaginary people will have suffered a cardiovascular event. Discussions about risk modification are vital in these patients to reduce the number of events, as a number of the risk factors, such as BMI, cholesterol, and smoking status are modifiable.
Suicide is one of the leading causes of death in men under the age of 50[7], with the peak age group between 45 and 49 at 25.5 deaths per 100,000 males[7]. The main reason why is that men may feel that they do not receive enough support - they may feel they cannot talk and reveal what is troubling them, stopping 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 also may be worried that it will affect relationships with their family or their colleagues or that they may lose their jobs from the stigma associated with poor mental health. This can mean that some men become used to living like this and think that it is normal, or think that if these feelings are pushed into a corner then they will go away despite this being clearly not the case. They 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.
Men are more likely to exhibit risk-taking behaviour in response to stress[8], and this can be in the form of misusing alcohol or unprotected sex. When relationships break down, men are often told to get over it, are more likely to lose custody of children in a divorce, and turn to depression and suicide after this. They often do not have the same support networks that women do in these situations to get through.
Men are known to look down on psychological talking therapies more than women, this can be seen as they make up only 36% of referrals to cognitive-based therapy sessions[9]. 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 increases suicide risk by almost 2-3 times[10]. Men are still seen to be the ones who should be the provider for the family and so depression commonly follows when this expectation is not achieved. In a survey 34% of men admitted that they would be ashamed to take time off work for depression and anxiety[11], whereas they would not be ashamed if they suffered a physical injury requiring the same absence. Working full-time or multiple jobs often prohibits men from seeing their GP during weekdays without requiring time off.
When men hit the middle age around their 40’s they often start to assess their priorities in life and question as to 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 a reason to why there is a peak in depression and suicide around these ages.
Men are far less likely to see their GP than women[12] due to a misconception of being perceived as weak for requiring help. Generally, men appreciate being listened to in these consultations as this is often what they are missing. Normalising the consultation 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 inability to either maintain or achieve an erection required for sexual intercourse.
Upon hearing this, the doctor must remain calm and professional to help to encourage the trusting relationship between the doctor and the patient.
There are a number of different things that need to be asked about when investigating erectile dysfunction, including exactly what is happening, and whether the patient feels that there are any contributing factors. This may be described as being related to their partner 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, and this needs to be examined thoroughly. Sources of stress, anxiety, guilt, or anger can interrupt the mental state required for intercourse, encouraging a vicious cycle to form of being unable to perform, and becoming stressed because of this. 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 play a part in barriers to this.
Physical causes should also be excluded. Physical causes of ED are commonly related to vascular disease affecting blood flow to the penis, although neurological and hormonal factors may also contribute, meaning high pressure within the corpus cavernosum cannot be maintained, leading to the inability to maintain an erection.
ED has a very high prevalence in male diabetic patients with an incidence rate of 25% in the 30-34 age brackets, and up to 75% in the 60-64 age bracket as a result of microvascular complications that limit the blood supply to the penis[13].
Smoking is a major risk factor for erectile dysfunction[14], and even cycling can cause direct trauma due to repeated impacts to the area directly superficial to these blood vessels.
Other physical causes are related to neurological damage to the parasympathetic system nerves involved in stimulating the erection, this can include spinal cord injury or regular heavy drinking. Excessive alcohol consumption can damage these nerves, and can work to reduce testosterone levels and increase oestrogen levels.
Certain medications such as antihypertensives and antidepressants can lead to ED. Some surgeries such as radical prostatectomies and inguinal hernia repairs can also contribute.
First line treatment for erectile dysfunction is related to addressing the root cause. After that, oral medications such as sildenafil, more commonly known as Viagra can be considered. This works through relaxing the smooth muscle of the vasculature and increasing blood flow to the penis. It is possible to access sildenafil without a prescription in the UK, meaning patients may have tried the over-the-counter tablets before presenting to a doctor. It is also possible for patients to turn to vacuum pumps and penile implants before a formal consultation with a general practitioner.
Therapy is often used to treat patients’ psychological causes, or help them come to terms with and work past their erectile dysfunction if it is not resolvable.
[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
[7] https://www.england.nhs.uk/blog/tackling-the-root-causes-of-suicide/
[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/
Edited by: Dr. Maddie Swannack
Reviewed by: Dr. Thomas Burnell
In this article
There are said to be three ages of men, those developing through childhood, adulthood, and reaching older age.
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