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Ask the doctor

Renowned Urologist, Mike Bolus (1976F) writes about Male Health this Movember.

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Class of 1976

Why male health?

November this year marks the 20th anniversary of the Movember Movement, initiated by a group of Australian men in 2003 to raise awareness of men’s health issues pertaining mostly to testicular and prostate cancer, as well as mental health. 

I have been asked to write an article to summarise the main issues that men face from a urological point of view and to give some insight into early disease detection so that timeous treatment can be instituted to prevent poor long term outcomes. 

I would like to stray from the beaten track and refer to male health as opposed to men’s health as often urological problems can originate early in life, before the onset of manhood.   

What urological conditions most commonly affect infant males or developing boys?

The two conditions that infant males, or boys, might be faced with are the questions around the need for circumcision at birth which has advantages and disadvantages, as well as the risk of testicular torsion, especially in puberty.   

  • Circumcision:

Circumcisions are often performed shortly after birth for religious reasons, but the official medical standpoint is that there is no good reason to perform a circumcision routinely in the neonatal period.  The advantages include the reduction in risk of sexually transmitted diseases, specifically HIV and the reduction of penile cancer in the long term.  However, significant disadvantages include bleeding, infection and scarring and the inevitable discomfort the young lad has to go through. 

The overall consensus is that it should not be carried out routinely.  However, should problems develop in early years, with recurrent infections of the foreskin or narrowing that does not allow retraction to maintain good hygiene, then a circumcision may well be indicated.  This will need to be discussed with your GP, for referral to a urologist as deemed necessary. 

  • Testis torsion:

Testis torsion mostly occurs in the pubertal period when testosterone levels are kicking in and anatomy in the nether regions starts changing dramatically!  This is when a boy is most at risk of torsion, where the testis twists within the sack around the testicle causing a cut off of the blood supply to the testicle itself. 

This usually causes severe pain and swelling, with occasional vomiting, and if it is not surgically reversed within six hours the testis could become nonviable and need to be removed. 

The message is that any boy or young man in his twenties who develops sudden onset of testicular pain will need immediate medical attention to be evaluated for this condition. 

Parents need to inform their sons of this possibility so that that they are immediately notified if any symptoms of pain or discomfort in the testes is experienced.

Often boys are too embarrassed to inform their parents as they feel is it something they have done wrong, but this attitude needs to be discouraged as it can result in the loss of a testicle. 

What must males aged 15 to 40 look out for?

Testicular cancer is a condition which traditionally effects males between the ages of 15 to 40.  Ironically it is a cancer that men tend to outgrow as they get older, but it can still present in the latter years. 

The most important aspect of early detection is to do regular self-examination of the testes from the pubertal years.  Unfortunately playing pocket billiards is not sufficient to detect any testicular lumps or bumps.  Self-examination of both testes should be carried out every 3 months, preferably after a hot shower or bath, when the scrotal skin is thin and the contours of the testis can be felt with ease. 

If any new lumps or bumps are noted within or around the testes, it should be followed up, initially by the GP and if necessary by a Urologist. 

Is testicular cancer painful?

Pain is seldom a feature of testicular cancer in the early stages, although it can be present.  Further investigations would include blood tests and ultrasound, before deciding on further management. 

What are your odds if you get testicular cancer?

Testicular cancers are one of the success stories of modern medicine, with a 95% cure rate being achieved these days. This is done through initial removal of the testicle and subsequent chemotherapy if necessary, depending on the exact features of the testicular cancer. 

Are males aged over 50 more vulnerable to Prostate Cancer?

Prostate cancer remains a controversial and challenging condition in 2023.  Epidemiological studies have shown that prostate cancer is more prevalent than we think, with up to 40% of fifty year olds having histological evidence of this disease, even though they may have no symptoms or signs of prostate cancer. 

The percentage increases with age, with  80% of eighty year olds having histological disease. The majority of these older patients will die with their prostate cancer rather than because of it. 

Further studies have shown that in 50 year old gentlemen who get diagnosed with early prostate cancer, 20% will not succumb to the disease, but 80% will if not treated with curative intent.  That ratio changes to 50/50 at the age of 70.   Our dilemma is that we are still not able to accurately predict which prostate cancers will progress and therefore need to be treated, and which will remain stable for up to 40 years. 

Research to try to determine how an individual’s prostate cancer will behave in the long term is ongoing. I am sure that the person who discovers this will get the Nobel Prize for Medicine! Until we are able to determine this accurately, the diagnosis and treatment of prostate cancer will remain controversial and many men will undergo treatment unnecessarily with possible complications.   

Having said that there are certain features of prostate cancer that do imply a more aggressive nature and do warrant further treatment after diagnosis.  Therefore we still advise regular prostate checks to assess for the possibility of cancer or obstructive elements that could also be detrimental to health.  This especially applies to certain high risk groups.

Who would form part of the high risk groups?

  • Men with a strong family history of prostate cancer (father, uncles, brothers or grandfathers)
  • Men with a history of breast cancer in the family. 
  • Men of black ethnicity as they have more than double the chance of developing prostate cancer.

What other urinary symptoms must males of any ages be aware of?

Any men developing bothersome urinary symptoms, no matter what their age, should also be screened. Blood seen in the urine must always be investigated further as it could cancer anywhere in the urinary tract. 

What advice can be given to high risk groups?

  • Screening

Our advice for high risk groups is to start screening at age 40 and at 45 for the rest.  Screening is usually done by competent GP’s with a PSA blood test (Prostate Specific Antigen, which is a protein produced by prostate cells) and a prostate examination.   Elevation of the PSA count is often the first sign of prostate cancer. However, it is not only prostate cancer that causes PSA elevation with infection, inflammation and infarction of the prostate also being possible causes. 

The PSA tends to increase with age and we adjust the upper limits of normal accordingly. 

  • Prostate examinations

Unfortunately the PSA alone is not sufficient as it is only 80% accurate in excluding prostate cancer. Therefore we strongly advise a prostate examination to also be carried out to determine whether there are any suspicious clinical signs of prostate cancer that may not show up in the PSA.  This is especially relevant if the prostate cancer is of a more aggressive high grade variety, which occasionally does not produce PSA and therefore may only be detected by a clinical examination. 

How often should checks be done?

These checks should be done yearly, although every second year would be acceptable for a PSA of less than 0.5mcg/L where the prostate is clinically normal. 

Should the PSA start climbing significantly, or any abnormality be detected on prostate examination, the trend nowadays is to do a prostate MRI to determine areas of suspicion in the prostate. 

If there is a sufficiently high index of suspicion then prostate biopsies will be carried out as this is the only way of diagnosing prostate cancer. 

How do you know the severity of a cancer diagnosis?

Prostate cancers are graded from 6/10 (implying slow growing and potentially indolent cancer) to 10/10 (a more aggressive cancer that may spread early). 

Staging tests with MRI of the body can be done to determine whether there has been any spread of the cancer.  If it is still localised to the prostate only, there are various approaches which could be followed. 

What are the treatment options?

Deciding which treatment is very much a team effort with the Urologist, the patient and his family and Oncologist being involved in the process. 

  • Options include active surveillance where it is felt that the cancer might not be aggressive and can be monitored on a regular basis with follow up PSA’s, MRI’s and possible repeat prostate biopsies, to ensure that the cancer is not becoming more aggressive.
  • Forms of treatment for curative purposes would be removal of the prostate, mostly done with robotic assisted laparoscopic surgery, which has certainly improved the outcomes of surgical intervention.  With more accurate dissection, the complication rate in terms of erectile dysfunction, urinary incontinence, blood loss and stricture formation is certainly reduced compared to an open prostatectomy. 
  • Other forms of curative treatment are radiation options, including external beam radiation or the implantation of radioactive seeds into the prostate (Brachytherapy). 

Again, the decision as to which of these modalities is adopted is very much a team approach. In general, we would only advise curative therapy in patients with a life expectancy of more than 15 years due to the slow growing nature of most prostate cancers.

Should there unfortunately be spread beyond the prostate, there are no curative therapy options, but with hormone treatment where testosterone levels are reduced, the cancer could be kept under control for a number of years.   

What are some other male health issues that may arise?

I have not discussed erectile dysfunction as this can be multifactorial, but is often related to lifestyle factors.  Increasing the risks are obesity, diabetes mellitus, hypertension, smoking and raised cholesterol.

A healthy lifestyle will help to prevent a number of these factors.  Patients experiencing ED should also consult with a cardiologist as it may be a sign of narrowing of the arteries, which may also affect the heart. There are treatment options for ED that could be discussed with your GP. 

How can male health be improved?

In summary, male health can certainly be improved by following these simple guidelines. 

  • Any disease, if caught early, generally has a better outcome. 
  • It is also very important for overall health to maintain a regular exercise routine and follow a healthy diet.  In this regard there are no specific diets or supplements which have been shown to help prevent prostate cancer, but a diet high in animal fats is thought to be contributory.
  • Try to maintain a balanced lifestyle, taking regular breaks with loved ones and enjoying your favourite activities to help avoid burnout.   

Unfortunately, Life has no rules, but it is a journey, not a race! Enjoy every day! 

 

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