Minutes of an International Weekly Meeting on “Men’s Health, the New Superspecialty”

Dr Raman Tanwar, MBBS, MS, FMAS, MCh (Urology), National Expert in Andrology, Urology, and Men’s Health 

September 9, 2023 (Saturday, 9.30-10.45 am)

• The X chromosome has 3,000 genes, while the Y chromosome has 50 genes. It is said that the Y chromosome is dwindling. There will only be women with male characters. This could happen in 1,000 years from now. 
• Humans could face extinction as sperm counts decline. The average sperm count of men in 1973 was 101 million sperms per mL of semen. This has declined to 49 million sperms per mL of semen in 2018.
• There is a gap between men and women. In India, men are dying 2 to 3 years earlier than women. This is the same globally.
• When we talk about gender equality, we should also talk of gender equity. Women empowerment has been pushed to the forefront. But men also need to be supported. Only then, we will have an equitable society. In Russia, there is a 10- to 12-year gap in longevity between men and women.
• Men have enjoyed privileged health status in ancient times, which was a patriarchal society. Health of men was correlated with strength of the nation. Woman was regarded as an inferior immature version of man.
• Male needs are different in terms of health. Men have a higher threshold. They usually do not go the hospital till the problem becomes more severe. They are more self-reliant and fear sharing as it is linked to livelihood. Substance abuse leads men to a downward spiral.
• They battle loneliness, work stress, family responsibility. They rarely tell and the reason for this is who can they talk to.
• Women interact with health care at several points in their lives. But there are no other checkpoints for men aside from childhood visits and if they develop any disease later on in life. 
• There are too many misconceptions and judgementalism even by misguided professionals. Sexual health and hygiene has to start from an early age and misconceptions and taboos broken.
• The triggers to interaction with health care for men are unable to work or sexual problems.
• In a survey of more than 500 men, they were asked who is a doctor for men; 92% did not know whom to meet, while most knew that doctors for women are gynecologists. Eighty-four percent felt that men’s health means sexual health, 76% needed someone to treat them and 21% had already been to a quack.
• When men do not know whom to visit, then they do not get the right treatment and the result is incomplete cure.
• There is a direct implication of men’s health on the family. Poor health leads to financial problems, which affect the resources as they are diverted in health care. This affects children and their education. There are other problems such as substance abuse, domestic abuse; smoking affects other family members (passive smoking).
• Men face occupational hazards. Early deaths or disabilities would leave many families unsupported.
• Men’s health is not just andrology or sexology. It also caters to specific disease of organs present in men such as prostate, testes and other common diseases such as stroke, heart disease, metabolic syndrome.
• Men’s health is a subspecialty of medicine related to the study and management of diseases, behaviors and social conditions specific and more common in men. The definition is still evolving. 
• There is a need to create a strategy for men’s health. Every visit is important as men do not visit health care very often. It is a golden opportunity and the risk factors should not be missed. It goes beyond health. It is a nation-building exercise so that men remain healthy. Men will not go to different doctors. So, the strategy should be to provide a one-stop shop (holistic therapy), which provides a comfortable experience.
• Men’s health is a continuum through comorbidities. Lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) are a part of the bigger picture. ED is bothersome, but endothelial dysfunction is hidden and can be fatal. ED can be used to detect endothelial dysfunction. 
• Sexual dysfunction is a part of metabolic syndrome. Patients will come very early if they have ED. But they will come very late for problems like diabetes mellitus (DM), hypertension (HT), insulin resistance (IR), dyslipidemia.
• A men’s health expert can evaluate men for sexual health issues. Treat every problem of men holistically and provide basic management of ED (Lifestyle, medication, refer/learn, regular follow-up and spread awareness) and establish a men’s health clinic.
• Assess sexual history, do a focused examination (general, androgenization, local, multisystemic), laboratory tests (random blood sugar, testosterone, lipid profile), do an oral sildenafil test/audio-visual sexual stimulation (AVSS) response.
• Do a cardiovascular examination. Simple questions like “are you able to climb two flights of stairs?” can help assess the cardiovascular health.
• Re-emphasize lifestyle changes. Make men aware of exercise, weight reduction, quality of diet, smoking cessation, alcohol control, stress reduction. Start with motivation. Prescribing phosphodiesterase-5 inhibitor (PDE5i) on first visit will help. Don’t wait for discovering the etiology. Prepare for cerebrovascular accidents.
• Understand the cause of ED. Start with PDE5i/L-arginine/nerve tonics. They can be combined or given as SOS therapy. If they do not work well, then intracavernosal injections can be given. If these do not work, then implants (malleable/inflatable). Lifestyle changes (exercise/low-fat diet) and manage the primary disease.
• The medical management of ED entails consideration of correct patient (age/requirement/marital status/comorbidites/suitability/past usage/degree of ED/economic status/associated sexual dysfunction), which drug (nutraceuticals/sildenafil/tadalafil/vardenafil/udenafil/selective estrogen receptor modulators [SERMs]/testosterone/combination/others), what dose (chronic low/on demand/highest/higher than permitted) and what formulation (pill/strip/mouth dissolving).
• Concomitant use of PDE5i with nitrates is absolutely contraindicated as they potentiate the hypotensive effects of nitrates.
• Concomitant medications that potentially require lower doses of PDE5i include ketoconazole, itraco­nazole, erythromycin, clarithromycin, human immunodeficiency virus (HIV) protease inhibitors (ritonavir, indinavir), grapefruit juice, cimetidine and antacids.
• Concomitant medications potentially require higher doses of PDE5i include rifampin, phenobarbital, phenytoin and carbamazepine.
• Nitrates should be avoided for 24 hours and 48 hours after an individual has taken sildenafil or tadalafil.
• PDE5i have an additive nitric oxide pathway. With nitrates, they may produce life-threatening
• Support the patient with fluid resuscitation and alpha-adrenergic agonists.
• For recurrent angina after sildenafil use, other non-nitrate antianginal agents, such as beta-blockers should be available.
• Sildenafil (100 mg) has also been shown to potentiate the hypotensive effect of amlodipine (5/10 mg) and doxazosin (4 mg).
• Vardenafil (10/20 mg) when concomitantly administered with alpha-blockers (terazosin, tamsulosin) and with nifedipine to healthy volunteers resulted in some subjects experiencing hypotension.
• Any alpha-adrenergic antagonist other than 0.4 mg once-daily tamsulosin is contraindicated as tadalafil (20 mg) significantly enhanced the blood pressure (BP)-lowering effect of doxazosin.
• Lower starting doses are recommended for older men (25 mg for sildenafil and 5 mg for vardenafil. No adjustments for elderly men taking tadalafil.
• If the patient needs more than just the basic evaluation and management, it is best to refer e.g., post-traumatic, post surgery, psychiatric illness, major uncontrolled comorbidity, altered orientation, spinal cord injury, hormonal disturbances (hypogonadism).
• Every men’s health specialist has to have a circle of colleagues whom they can refer the patient to for different problems.
• Men should be able to get holistic health when they come to a men’s health specialist. 
• Men’s health is also important for older men.
• Issues related to sexuality and sexual health should be discussed without anxiety or discomfort.
• There is a need to adopt strategies, which create environments that are more supportive of sexuality.
• Health centers should be equipped to handle men’s health. They should at least offer screening, if not treatment. The objective is to cover up the gaps in health care.
• It is easy to start with new checkpoints such as premarital check-up (20-35 years age), executive check-up (30-50 years age) and geriatric (>50 years) recheck-up.
• There should be posters in clinics to encourage men to speak up about their problems. Make the clinics more men’s health-friendly places.
• Enlist the services offered such as mental health consult, wellness check-ups, sexual health consult, premarital counseling, lifestyle disease management and executive check-up.
• Educational intervention with involvement of partner helps to improve men’s intention to screen and increased screening uptake.
• Men usually do not come forward because men in general have poorer health knowledge than women. They avoid showing weakness to women. They regard screen in as a waste of time. Also, screening facilities are usually cumbersome. 
• To increase screening, develop mobile health apps or websites on health screening to reach out to men. More male-sensitive interventions need to be developed, which address male-specific behaviors, Framing of messages is important. Involving partners can help to increase screening. Do screening in a fun way with mainly male workforce.
• Screening should be made a part of policy, which forces men to go for screening. 
• To change practice to men’s health, understand what is men’s health and how is it different. Equip yourself properly with guidelines, resources and peer support. Reform your facility by providing screening opportunities and outpatient sensitization. Associate with men’s health for a social cause.
• Strategies to initiate a continuum through ages include establishing points of intervention (entry check-ups and at parenthood), making health an important performance indicator and making health accessible and friendly. It is easy to start small. Offer basic diagnostics (uroflowmetry, ECG). Evening clinic (part time practice) is the easiest way.
• It is important to upgrade to maintain gender ratio (F:M 1:1 and not 10:1). There should be a central National program for men’s health similar to mother and child health programs.
• Men’s health is yet to make a comeback. There are only a few centers offering this specialized service and very few trained experts. There is ample avenue for training. 
• We need to change the way we look at men’s health. We have to look at them as a weaker sex and understand that they are not going to come to the clinic again and again (precious visit). See the problem differently, i.e., the problem is only a presentation. Holistic treatment is needed. Provide men friendly facilities. 
• Men’s health is an opportunity waiting to be taken up. It can be a huge financial success.
• Giving a little time to men’s health practice is one way to contribute to this. This entails organizing screening camps, celebrate special days (e.g., November is Prostate Health Awareness month), corporate programs, allocate a budget to men’s health, holding camps, include men’s health in national and state level programs and introduce checkpoints for interaction with health. 
• Awareness is key. 
• Future directions include encouraging research and talking more about men’s health.

Participants: Dr Akhtar Hussain, South Africa; Dr Ashraf Nizami, Pakistan; Dr Wonchat Subhachaturas, Thailand

Invitees: Dr Monica Vasudev, USA; Dr Mulazim Hussain Bukhari, Pakistan; Dr Colin Goldberg; Dr Asima Rashid; Dr Hamid Manzoor; Dr Zameer Naqvi; Dr Joher Hassan; Dr Milind Joshi; Dr DR Rai; Dr Deepak Jumani; Dr Arun Jamkar; Dr A Muruganathan; Dr Mahadev Harani; Dr Sanchita Sharma, Editor-IJCP Group

Moderator: Mr Saurabh Aggarwal