Short stories, Travel and Health Information
(This article by Associate Professor Sanjiva Wijesinha appeared in Medical Observer magazine – 31st January 2014)
Andrology, the study of male physiology and diseases specific to males, especially of the male reproductive organs, is well established as a clinical discipline in countries such as the US and Germany.
In Australia, however, although there is more awareness of male reproductive ailments and acceptance of these conditions as important topics for discussion, at the primary care level we still have the situation that diseases of the male reproductive organs are not being identified and treated as well as they should be.
This is almost certainly because:
Patients suffer from these problems but do not present to the GP because they have no obvious symptoms (e.g. early prostate cancer), or they have definite symptoms (e.g. testicular cancer, loss of libido, premature ejaculation or erectile difficulty) but are highly reluctant to disclose the fact. 1
GPs do not routinely ask for symptoms of male sexual disease when taking a history, because we feel that asking such intimate questions may offend, because we feel embarrassed to talk about these matters, or even because we ourselves are not confident about our knowledge of these subjects. 2
For a consultation to produce a beneficial result, it is important that the doctor is comfortable with both the patient and the problem, just as the patient should be comfortable in discussing the problem with his doctor. This is particularly important because male reproductive problems often co-exist with, and represent, a marker for other serious conditions.
The advent in the 1990s of sildenafil (Viagra), the first oral medication for erectile dysfunction, helped break the ice around male reproductive issues between men and their doctors.
Erectile dysfunction (ED), defined as “the inability to have or maintain an erection hard enough for satisfactory sexual intercourse”, has been shown to be strongly correlated with age: 3% of men aged 40—49, increasing to 64% of those aged 70—79, admit to having erections inadequate for intercourse. 3
It is imperative to understand that the basic defect in ED is cardiovascular. In the vast majority of men, the inability to achieve a hard erection is caused not by a deficiency of male hormones, but by faulty arterial flow to the corpora cavernosa of the penis.
ED is actually an early symptom of widespread cerebro-cardiovascular disease rather than a disease in itself, so it is vital that a man who has ED presents to, and is identified by, a doctor who can treat him. The correct treatment involves not only helping the man achieve better erections but also investigating and managing his cerebro-cardiovascular disease and preventing him suffering a heart attack or stroke.
Arterial narrowing shows up in small arteries like the penile arteries before narrowing of larger arteries like the coronary and cerebral arteries manifests itself with symptoms such as angina and TIAs.
If a man were to acknowledge his symptom of ED and seek help for it from his GP, he would have the serendipitous opportunity of his hitherto asymptomatic cardiovascular disease being diagnosed before it precipitates an acute cardiovascular event.
The other aspect of this condition is that we as GPs need to ask our male patients about erectile function as a risk factor for cardiovascular disease as routinely as inquiring about smoking history, angina or breathlessness.
Management of ED involves investigating for other cardiovascular risk factors such as hypertension, diabetes, elevated blood lipids and smoking, and introducing appropriate therapy.
Most men could be efficaciously treated (after appropriate examination and investigation) at primary care level with one of the PDE5 inhibitors like sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra).
There are contra-indications to the use of these drugs, in particular the concomitant use of long- and short-acting nitrates and nitrate-like medications. 4
It is important to educate and counsel patients before they use these medications so that they have a realistic idea of what to expect from their treatment.
Libido, known in layman’s language as sex drive, may be defined as a person’s overall desire for sexual activity. Levels of libido vary widely from person to person, and a man’s libido can change across relationships as well as in different social and environmental circumstances.
Low libido becomes a problem when it creates distress for the patient and/or difficulties across the relationship. 5 The mistaken belief that men desire sex anywhere and at any time may strongly influence a man’s feelings of shame and embarrassment if he experiences low sex drive.
Loss of libido is a not uncommon presenting symptom in general practice, although it is rare for a man to present complaining of increased libido.
Among the many factors that can affect a man’s libido are:
Careful questioning is required to elicit symptoms in these domains as loss of libido is usually an indicator of a more generalised problem. While some men may lose their libido as they grow older (as some females do with menopause), this is not always the case. A loss of sex drive in either partner may influence both the relationship and the libido of the other, resulting in conflict and even a situation where the partner seeks alternative relationships.
While low libido more commonly results from psychosocial factors, there are several rectifiable biological and iatrogenic causes that may be responsible, and it is important to look for these. Examples are:
Erectile dysfunction, while not necessarily a cause of low libido, may result in sexual avoidance behaviour which ultimately leads to loss of libido.
Increased sexual desire in contrast to low libido is not really a symptom that brings a man to consult his doctor. Pathological causes of heightened libido occur in bipolar illness in the hypomanic or manic phases and occasionally in psychoses.
Some psychoactive drugs (such as cocaine and alcohol in small doses) may also increase libido.
While loss of libido is a manifestation of depression, the treatment of depression may also adversely affect sex drive.
Failure to achieve orgasm (anorgasmia), as can result from the use of certain SSRIs, is a further manifestation of the complex interaction between depression, its treatment and sexual function.
GPs should feel empowered to discuss libido in the context of comprehensive history taking and counselling.
Moreover, when initiating new medication, it is important to be aware of the side effects these drugs may have on the patient’s sex drive and/or his relationship.
Premature ejaculation (PE) is defined by the International Society for Sexual Medicine (ISSM) as “a male sexual dysfunction characterised by ejaculation which always or nearly always occurs before or within approximately one minute of vaginal penetration; the inability to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences such as distress, bother, frustration and/or the avoidance of sexual intimacy”. 6
The condition is common, but the topic is so embarrassing that most men avoid broaching the problem with their doctor. 7 When raised (either by GP or patient), a frank and supportive approach by the primary care physician facilitates a discussion and therapeutic approach that can result in a more satisfying sex life for the patient and his partner.
Methods used to treat PE in the past have included cognitive and behavioural therapy, topical agents, and the empiric use of selective serotonin reuptake inhibitors (SSRIs), drugs that are usually indicated for the treatment of psychiatric disorders.
All these methods have their drawbacks: cognitive and behavioural therapy has not been associated with long-term improvements; topical agents such as local anaesthetic gels are, to put it bluntly, “messy”; and the on-demand use of SSRIs, which were intended to maintain constant blood levels to effectively treat conditions such as depression, can take several hours to reach therapeutic concentrations.
The introduction into Australia, in 2013, of dapoxetine (Priligy), a novel fast-acting SSRI with a short half-life, is likely to improve the success rate for PE treatment.
Plasma concentrations reach a maximum within an hour of oral administration and fall to less than 5% of this peak within 24 hours.
The drug has been available in several other countries for some years, and a recent pooled analysis of five studies that included over 6000 men worldwide confirmed the clinical benefits and acceptability of dapoxetine. 8
Testicular cancer is rare, being diagnosed in less than 700 Australians annually. Although it is the most common solid cancer in men aged 18—39, cure rates for testicular cancer are excellent, with about 95% of men surviving the diagnosis and going on to lead full and active lives.
Although there is no evidence from randomised controlled trials, and it is unlikely that such trials could ever be designed to prove that testicular self-examination reduces mortality, it stands to reason that early detection (before metastases have developed) reduces mortality and the need for toxic therapies like major abdominal surgery and chemotherapy. 9
Testicular cancer. Light micrograph of a section through a teratoma of the testis, a rare type of cancer.
A case can certainly be made for teaching testicular self-examination to young men, especially those who have risk factors (such as a family history, a history of undescended testis or congenital inguinal hernia), and encouraging young men with testicular lumps to present early for medical assessment. While most testicular swellings are the result of benign conditions such as cysts or hydroceles, an enlarged testicle can be the earliest sign of a testicular tumour, and needs to be properly examined and investigated.
Embarrassment inhibits many young men with testicular swellings from seeking a medical opinion. They only present when the symptoms of metastatic disease, such as severe bone pain, supervene. This has to change.
Men are often embarrassed to talk about their lower urinary tract symptoms (LUTS) such as nocturia, urge incontinence and reduction of the urinary stream that could indicate benign prostatic hypertrophy, and they are also embarrassed to undergo rectal examination, which is recommended for early detection of prostate cancer.
Each year in this country about 19,000 men are diagnosed with prostate cancer, and about 300 men die of the disease. Today there is uncertainty in the community about whether to be tested for prostate cancer, about the benefits of early treatment and about the best choice of therapy even when the need for treatment is accepted.
The European Randomized Study of Screening for Prostate Cancer, a very well designed randomised control study, clearly demonstrated (although there was a risk of overdiagnosis) the benefits of early detection in reducing mortality from prostate cancer, 10 so encouraging men to overcome their embarrassment and discuss the benefits of screening for prostate cancer with their family physicians is certainly a step in the right direction to reducing the mortality from this disease.
Up-to-date clinical guidelines on best practice management of men’s sexual and reproductive disorders are readily available online athttps://www.andrologyaustralia.org/health-professionals/clinical-summary-guidelines/
I am grateful to my colleagues Professor Leon Piterman, AM, and Dr Catherine Kirby for helpful advice and assistance during the preparation of this article.