Guidelines

Sexual and Reproductive Health

11. LATE EFFECTS, SURVIVORSHIP AND MEN’S HEALTH

The EAU Guidelines Panel of Sexual and Reproductive Health 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 health care 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 has observed that there is still a significant gender gap between male and female in life expectancy [2044]. The main contributors to male mortality in Europe are non-communicable diseases (namely CVDs, cancer, diabetes and respiratory disease) and injuries [1679], as highlighted in a recent WHO report disproving the prevailing misconception that the higher rate of premature mortality among men is a natural phenomenon [2044,2045]. The recent pandemic situation linked with SARS-CoV-2 infection associated diseased (COVID-19) further demonstrates how the development of strategies dedicated to male health is of fundamental importance [61].

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 men [1934,1939,1940,2046-2048]. These data suggest that health care policies should redirect their focus to preventive strategies and in particular pay attention to follow-up of men with sexual and reproductive complaints [1942,2049]. [2049]. Considering that infertile men seem to be at greater risk of death, simply because of their inability to become fathers, is unacceptable [1943]. 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 alone and consider the potential associations with other health disorders. Men with varicoceles have a higher incidence of heart disease and higher risk of diabetes and hyperlipidaemia following diagnosis [2049]. 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” [2038]. A combination of factors, personality, sociocultural background, and specific treatments/professional support, will determine how men cope with this diagnosis [2041].

The most common cancer among European men (excluding non-melanoma skin cancer) is PCa [399]. Due to new therapeutic approaches, survival rates have improved significantly [2050] and as men live longer, health-related quality of life and related sexual well-being will become increasingly important [389]. Regardless of the type of treatment used [1692], sexual dysfunction and distress are common post-treatment complications [390,2051-2053].

Furthermore, little is known about the relevance of fertility and fertility-preservation strategies in cancer survivors [1931,2054-2057]. In PCa, it has been documented that the psychological consequences persist, even after complete remission or cure and erectile function is restored [2058]. In addition, special attention must be given to gay and bisexual men with PCa; these men present specific sexual concerns steaming from heteronormativity standards that have a negative impact in health care quality [2059]. Therefore urologists dealing with sexual and reproductive health are primed to act as a vanguard for cancer survivorship programmes.

Finally, the relationship between ED and heart disease has been firmly established for well over two decades [315,316,318,2060-2063]. Cadiovascular disease is the leading cause of both male mortality and premature mortality [2064-2067]. Studies indicate that all major risk factors for CVD, including hypertension, smoking and elevated cholesterol are more prevalent in men than women [2068-2074]. Given that ED is an established early sign of atherosclerotic disease and predicts cardiovascular events as an independent factor [318], it provides urologists with the unique opportunity for CVD screening and health modification and optimise CVD risk factors, while treating men’s primary complaint (e.g., ED). Currently, both the EAU and AUA guidelines recommend screening for CVD risk factors in men with ED and late onset hypogonadism [2075-2077] (see Sections 3.7.3 and 5.2).

There is clearly a need to prospectively collect data addressing all aspects of male health, including CVD screening protocols and assess the impact of primary and secondary preventive strategies. The EAU Sexual and Reproductive Health Guidelines Panel aims to promote and develop a long-term strategy to raise men’s health at a global level.