Men's health: How urology and primary care can work together

When asked to write about the relationship between urology and primary care, we realized that the topic limited men’s health to simply a working relationship between these two disparate specialties. In our experience, men’s health is far more than the working relationship between urology and primary care centered around male-specific medical concerns, and includes several different and significant subspecialties. These encompass and are not limited to internal medicine, family medicine, pulmonology, cardiology, oncology, endocrinology, psychology, psychiatry, and geriatrics (figure).

SLIDESHOWS: Take a tour of 4 men's health centers

Men are referred into a dedicated men’s health center (MHC) or a clinical program for a multifaceted evaluation that includes a complete medical and urologic assessment. The focus is on a “cardiometabolic” assessment, given that the most significant causes of poor health in men are adverse cardiovascular health habits and obesity leading to metabolic syndrome and ultimately, diabetes mellitus or coronary artery disease.

The subsequent referrals generated from this comprehensive evaluation can be directed toward other individualized medical subspecialties or lifestyle and holistic health tutors complementing the primary care clinician’s goals of health surveillance and disease prevention. These subspecialties can then individualize referrals to the MHC for a comprehensive urologic/medical assessment when indicated. All of these evaluations and interventions are viewed as extensions of and collaborations with the patient’s own primary care clinician. These evaluations are frequently triggered by one of three conditions commonly encountered by andrology/urology:

• erectile dysfunction

• testosterone deficiency

• infertility.

These conditions are often complemented by two urologic conditions managed most commonly by primary care and can serve as a focus of an MHC:

• BPH/lower urinary tract symptoms

• PSA screening for prostate cancer.

These conditions are exclusive to men, or rather the narrow lens of urologic male conditions. Together with those conditions that are not necessarily exclusive to men but are common in both the male and female population, they form the field of men’s health.

Next: Men's gender-based medical and psychological concerns/needs

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Men have unique and specific gender-based medical and psychological concerns and needs. These include depression, post-traumatic stress disorder, stress management, and veteran’s health needs; cardiovascular risk stratification; pulmonology, including obstructive sleep apnea and insomnia or sleep medicine; cancer screening, including prostate, bladder, lung, and colorectal; exercise capacity and physiology; substance abuse; and metabolic issues of obesity, including the spectrum of metabolic syndrome, glucose intolerance, and dyslipidemia, hypertension, and proper diet.

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Medical conditions not isolated to men often present as male urologic conditions. It is the presentation of the man through the preventive lens of male medical and urologic health that becomes the foundation of an MHC. Such a center of excellence must include the expertise of both the medical-focused men’s health clinician and the astute urologist, who both recognize the broad nature and comorbidities associated with male urologic conditions.

The formation of an MHC program is not an attempt to replace or take on the role of a primary care clinician. Clearly, most urologists do not have the knowledge or skill set to efficiently evaluate men in the role of a primary care clinician. Yet urologists often have the unique opportunity to initially meet and monitor men as they enter the medical infrastructure, and many men do not yet have primary care clinicians. For example, when these men present for male-specific urologic concerns, the urologist can connect the patient to a knowledgeable primary care clinician and seek a cardiovascular risk evaluation as part of that individual’s presentation of erectile dysfunction.

This does not exclude the urologist from taking an active role in the medical comorbidities uncovered in these evaluations, but often these are best served by evaluation via the medical clinician and/or psychologist in a paired visit, when coding allows this to occur for appropriate reimbursement. This is an opportunity to take advantage of the presentation of men who desire to “fix their urologic problem” but also address the underlying causes. This also aids the male patient who is hesitant to visit the physician due to time or psychological constraints.

The men’s health evaluation

The basis of any men’s health evaluation begins with the notation of the patient’s vital signs: height, weight, pulse, blood pressure, body mass index, and abdominal waist circumference (table). This measurement of visceral adiposity and understanding of its predictive significance for cardiometabolic disease by the urologist, the men’s health general medical clinician, and patient serves as the first significant marker of the male patient’s cardiovascular risk. It also allows the opportunity to identify men with previously undiagnosed hypertension or monitor men previously diagnosed with hypertension. It allows for a quick classification of degree of obesity in order to structure the appropriate nutritional guidance and exercise program that may follow.

Next: More on workup

A waist circumference greater than 40 inches (measured at the umbilicus) allows a simple determination of the presence or absence of metabolic syndrome. Further measurements of a man’s lipid profile, specifically targeting the total cholesterol/HDL cholesterol ratio and triglyceride levels, together with a measurement of a fasting serum glucose or a non-fasting glycosylated hemoglobin, allows the determination of the degree of metabolic syndrome or the diagnosis of type 2 diabetes mellitus. This construct is well understood to have a bidirectional relationship with testosterone deficiency.

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To complement this evaluation, a clinician may order a high-sensitive or cardio-sensitive C-reactive protein to assess for underlying cardiometabolic risk. Other biomarkers of cardiometabolic risk can be individualized according to each patient, but may include any of the following: apolipoprotein B (a surrogate measurement of small-particle LDL cholesterol), urine microalbumin to serum creatinine ratio, and 25-hydroxy vitamin D level. It should be noted that none of these markers has been shown to be highly effective at discrimination of cardiovascular risk greater than traditional cardiovascular risk factors such as the presence of tobacco abuse, family history of premature heart attack, and obesity.

In addition, none of the above factors has been shown to exceed the risk predictive capacity of traditional risk equations such as the Framingham risk profile or the new risk calculator developed via the collaboration of the American College of Cardiology and American Heart Association in 2013, yet each has an evolving role in the determination of cardiometabolic risk. When cardiovascular risk is equivocal or intermediate, the only risk marker with a significant sensitivity and specificity is a coronary artery CT calcium score (J Am Coll Cardiol 2014; 63:2889-934).

When assessing cardiometabolic risk in the male patient, it is also vital to assess the presence of other health co-factors, including diet; exercise capacity and habits; sleep (quantities and disorders) and levels of stress; depression and anxiety; and alcohol, tobacco, and illicit substance abuse (AUA 2014 annual meeting course by Carrion/Swierzewski). Validated questionnaires can be used to gather the symptomatic data to assist in assessing each of these cofactors to determine risk.

Conclusion

We live in a time of great stress upon the medical system and health care providers. The adaptation of the patient-centered medical home model and electronic medical records, as well as increasing scrutiny of testing and outcomes, all add to our burden of clinical management of male patients. Compared to their female counterparts, men tend to present to health care providers later with symptoms and when disease is far more advanced.

A men’s health program and concentration can allow those symptoms men see as vital to a healthy life (eg, sexual function) and propel them into a softer landing for a greater preventive focus and risk factor analysis. This effort requires an astute urologist who acknowledges and seeks evaluation of appropriate medical comorbidities coupled with a productive partnership with primary care clinicians or focused within the context of a men’s health program or center established to address these needs.

A portion of the Affordable Care Act involves the implementation and use of preventive services in the care of patients. Benchmarks will be set to track and validate outcomes and the performance of health care providers, whether urologists or primary care clinicians. Men’s health serves as a gender-based opportunity to tailor these improved outcomes to the health-consuming habits of men and improve preventive care. This is best done in synch with the medical clinician, whether that individual is the patient’s primary care clinician or a trained men’s health clinician.

We live in an age of women’s health, family health, and pediatric health. It is vital that we understand the factors and determinants of improving men’s health and lessening the gender gap as it pertains to both disease morbidity and mortality.

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