12. LATE EFFECTS SURVIVORSHIP AND MENS HEALTH
The Panel have extensively reviewed the literature to provide guidance on: (i) late effects of urological diseases (both occurring during childhood and adulthood) on male sexual and reproductive health; (ii) late and long-term effects of cancers on male sexual and reproductive health; and, (iii) future directions to support personalised medicine strategies for promotion and raising the awareness of male sexual and reproductive health overall.
A systematic literature search for original English-language publications and review articles published up to December 2019 and a further search up to December 2020 were performed using both PubMed and Google, yielding only a limited number of papers addressing the role of healthcare professionals in supporting male patients who have suffered from cancers in terms of sexual and reproductive health, or the concept of Men’s Health programmes.
Despite considerable public health initiatives over the past few decades, the Panel have observed that there is still a significant gap between male and female life expectancy [2045]. The main contributors to male mortality in Europe are non-communicable diseases (namely CVDs), cancer, diabetes, respiratory disease and injuries [1766], as highlighted in a WHO report, disproving the prevailing misconception that the higher rate of premature mortality among males is a natural phenomenon [2045,2046]. The COVID-19 pandemic further demonstrates how the development of strategies dedicated to male health is of fundamental importance [2047].
The WHO report also addresses male sexual and reproductive health, which is considered under-reported, linking in particular male infertility, as a proxy for overall health, to serious diseases in males [1989,1990,2048-2051]. These data suggest that healthcare policies should redirect their focus to preventive strategies and pay attention to follow-up of males with sexual and reproductive complaints [1992,2052]. Considering that infertile men seem to be at greater risk of death simply because of their inability to become fathers, is unacceptable [1993]. The Panel aims to develop a concept of a more streamlined and holistic approach to men’s health.
For these Guidelines, the Panel aimed to challenge clinicians to look beyond the pathology of disorders and consider the potential associations with other health disorders. Males with varicoceles have a higher incidence of heart disease and higher risk of diabetes and hyperlipidaemia following diagnosis [2052]. A diagnosis of infertility may have a profound psychological impact on men (and their partners), potentially resulting in anxiety, enduring sadness, anger, and a sense of personal inadequacy and “unmet masculinity” [2053]. A combination of factors, personality, sociocultural background, and specific treatments/professional support, will determine how males cope with this diagnosis [2042].
The most common cancer among European males (excluding non-melanoma skin cancer) is PCa [2054]. Due to new therapeutic approaches, survival rates have improved significantly [2055] and as males live longer, health-related QoL and related sexual well-being will become increasingly important [303]. Regardless of the type of treatment used [1779], sexual dysfunction and distress are common post-treatment complications [304,2056-2058].
Furthermore, little is known about the relevance of fertility and fertility-preservation strategies in cancer survivors [2059-2063]. In PCa, it has been documented that the psychological consequences persist, even after complete remission or cure and restoration of EF [2064]. In addition, special attention must be given to gay and bisexual men with PCa – these men present specific sexual concerns steaming from heteronormative standards that have a negative impact in healthcare quality [2065]. Urologists dealing with sexual and reproductive health are primed to act as a vanguard for cancer survivorship programmes.
The relationship between ED and heart disease has been firmly established for well over two decades [2066-2072]. Cadiovascular disease is the leading cause of both male mortality and premature mortality [2073-2076]. Studies indicate that all major risk factors for CVD, including hypertension, smoking and elevated cholesterol are more prevalent in men than women [2077-2083]. Erectile dysfunction is an established early sign of atherosclerotic disease and predicts CV events as an independent factor [2068]. It provides urologists with the unique opportunity for CVD screening and health modification to optimise CVD risk factors, while treating men’s primary complaint (e.g. ED). Currently, both the EAU and American Urological Association Guidelines recommend screening for CVD risk factors in males with ED and LOH [2084-2086] (see Sections 3.5.5 and 5.2).
There is clearly a need to prospectively collect data addressing all aspects of male health, including CVD screening protocols, and to assess the impact of primary and secondary preventive strategies. The Panel aims to promote and develop a long-term strategy to raise men’s health at a global level.