Chapter 110: Male health: an overview

In recent years, increasing attention has been focused on men’s health, mainly because it became evident that the average male’s lifestyle was slowly killing him. As doctors we are beginning to understand that a great proportion of male ill-health is related to behavioural and social factors.

An important statistic is the constant discrepancy in average life expectancy (ALE) between the sexes. At present in Australia, the ALE is 80.3 years for males born between 2012 and 2014 compared with 84.4 years for females.²

Since the beginning of the 20th century and even further back this discrepancy has continued. In 1900 the ALE for males was 55.2 years and 58.8 for females.² This increased to a difference of 6 years for most of the past century. However, the significant increase in ALE for both sexes has been encouraging.

Men have a significantly greater incidence of medical conditions and problems, such as cardiovascular disease, obesity, alcoholism, HIV and hypertension, as well as having higher rates of accidental death and suicide. The following comparative statistics for Australian society highlight this difference.

• Up to 14 years, boys are at least twice as likely as girls to die from accidental injury (e.g. motor vehicle accidents [MVAs] and drowning).

• In the 15–24 years age group, males are three times more likely to die in MVAs and three times more likely to commit suicide. The overall death rate is 3.65 times higher than for females.

• In the 25–65 age group, males are four times more likely to die from coronary artery disease, three times more likely to die in MVAs, three times more likely to commit suicide, four times more likely to die in other accidents, and twice as likely to die from cancer. The overall death rate is two times that of females.

• The figures are worse in the lower socioeconomic groups. Low-income males are nearly three times more likely to state that their overall health is poor compared to men with higher incomes.

• About 2 in 3 adult males and 1 in 4 older boys are overweight or obese.

• Roughly 1 in 4 men have a disability and almost 1 in 3 have a chronic health problem.

• Only 1 in 4 men ≥65 years get sufficient physical activity.

• An estimated 1 in 2 men (54%) have experienced sexual difficulty in the past 12 months.

• At least 4 out of 5 heroin overdose deaths occur in males.

• Aboriginal males’ life expectancy is 17 years less than that of non-Aboriginal males. In the 35–45 age group, the death rate is 11 times that of non-Aboriginals.

• Workplace deaths—93% occur in males (who constitute 56% of the workforce).

• Some 46% of Australian marriages end in divorce. The majority of these are initiated by women.

• Among those convicted for acts of violence, 90% are males; 80% of the victims are males.

• In Australian schools, 90% of children with documented behavioural problems are males.

(Most of this list has been reproduced with the permission of Andrew Pattison.)

These statistics are very revealing and reflect attitudes to lifestyle. Men smoke more, drink more and indulge in greater risk-taking behaviour in general. Only 5% of men have adequate fruit and vegetable intake.³

Young males in particular are more likely than young females to take risks in areas such as conflict or violence, sexual behaviour, drinking, gambling and accident prevention.⁴ The main causes of death by age group for Australian males are summarised in TABLE 110.1.⁵

Ageing men find disorders of the prostate almost inevitable, as they become aware of lower urinary tract symptoms (LUTS). The usual cause of benign prostatic hyperplasia is now being managed better with α-blocking agents, such as tamsulosin and 5-alpha reductase inhibitors (such as Dutasteride), which delay the almost inevitable resection of the prostate—a procedure that provokes considerable anxiety in men. Cancer of the prostate is the second commonest cause of death from cancer in men and the third overall including both sexes, yet its management remains controversial and at times confusing, especially the screening issues (see CHAPTER 114).

Androgen deficiency, which affects about 1 in 200 men under 60 years of age and possibly 1 in 10 older men, is likely to be an underdiagnosed condition. About 1 in 3 cases are associated with Klinefelter syndrome, which is more common than realised, with 50% remaining undiagnosed. Androgen deficiency should be considered when the following signs and symptoms present:

• infancy—micropenis, small testes

• puberty—delayed, small testes, failure of growth of larynx or penis, failure of skin of scrotum to thicken and/or pigment, poor muscle development, poor facial, body and pubic hair, marked and persisting gynaecomastia

• adult—regression virilisation, mood changes, poor concentration, lethargy, hot flushes, sweats, decreased libido, decreased semen volume, gynaecomastia, osteoporotic fracture, erectile dysfunction (ED)

Androgen deficiency is an uncommon cause of ED, but men presenting with ED should be assessed for androgen deficiency (ED will be discussed in CHAPTER 116). This should be done initially through history and examination rather than a blood test, including examining the size and firmness of the testes. An orchidometer (a series of beads of various sizes to match clinical testicular size) can assist with this and can be obtained through Andrology Australia.⁸

Diagnosis is by at least two testosterone levels taken on different mornings (luteinising hormone added to the second collection if the first testosterone is low).⁶ Other tests may include semen analysis (if fertility is an issue), bone density, karyotype (Klinefelter syndrome—see CHAPTER 18), FSH and iron studies (haemochromatosis).

Abnormal testosterone (for healthy males) results:⁶

• 21–35 years <10.4 nmol/L

• 70–89 years <6.4 nmol/L

Treatment under consultant guidance is with testosterone replacement with injections, gel, implants, patches or tablets.^6,7 There is no evidence that testosterone gel is a panacea.⁹

While more common in women, osteoporosis still has a high prevalence in men and remains a major health concern for older men. Almost a third of Australian men >60 years of age will suffer an osteoporotic fracture.¹⁰ Yet the identification of osteoporosis in men remains particularly poor, and this may be because it is considered a predominantly female condition. BMD testing rates for women are four times those of men.¹²

Prevention can be achieved through reducing risk factors where possible. Risk factors include poor dietary calcium, lack of weight-bearing exercise, vitamin D deficiency, hypogonadism, smoking, excess alcohol and medications (corticosteroids used for >3 months, anti-epileptics, e.g. phenytoin). Other risk factors for osteoporosis and fractures include a family history of osteoporosis, malabsorption, hyperthyroidism, hypothyroidism, hyperparathyroidism, being underweight and being at risk of falls. Men with risk factors should be screened using BMD testing. Other indications for screening include height loss, kyphosis or back pain suggesting possible vertebral fractures, low-impact fractures and possibly even high-impact fractures.¹³

Investigations can include bone densitometry, FBE, LFTs, testosterone and vitamin D. When identified, osteoporotic men should be encouraged to have adequate dietary calcium, be educated on fall-prevention strategies and encouraged to do weight-bearing exercise. Medication management options include oral bisphosphonates (first-line treatment) and calcium, vitamin D or testosterone if deficient.

This is a ‘true’ enlargement of the male breasts, not to be confused with false enlargement of obese men. Gynaecomastia occurs in up to 50% of adolescent boys. Virtually no breast tissue is palpable in normal men.

If present in adult men, look for evidence of testosterone deficiency. Other causes include drugs (e.g. anabolic steroids, oestrogen, digoxin, calcium antagonists, marijuana, spironolactone, amiodarone, tricyclic antidepressants, cimetidine), liver failure, testicular feminisation syndrome and oestrogen-secreting tumours, such as adrenal carcinoma and Leydig cell tumour.

Males bear the burden of X-linked recessive gene disorders, which always manifest as there is no normal gene on the additional X chromosome (as there is in the female) to counteract the action of the abnormal gene.

Occasionally a gene can be carried on an autosome but manifests only in one sex. An example is male-pattern baldness, manifesting as an autosomal dominant disorder in males but as a recessive disorder in females.

Examples of X-linked disorders significantly affecting males include:

• haemophilia A and B

• glucose-6-phosphate dehydrogenase deficiency

• Duchenne muscular dystrophy

• retinitis pigmentosa

• Hunter syndrome

• ocular albinism