Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Men’s health is often described in terms of male-specific, sexual and reproductive health problems, however, there are broader health issues and behaviours, including men’s engagement with health services, that impact overall men’s health.1 Risk-taking behaviours are seen more frequently in men, with men twice as likely as women to die in motor vehicle accidents2,3 and as a result of injuries from violence.2 Occupational injury and death is a major cause of male morbidity, and more than nine out of 10 people killed at work are men.4 Men are more likely to be homeless or involved in the justice system compared with women. Men also have higher rates of substance abuse and suicide,2 and unhealthy behaviours, including smoking tobacco and exceeding recommended drinking guidelines.5

Men have a life expectancy of 80.7 years, which is lower than women (84.9 years), however, this has improved over the last decade.5 In 2019, the leading cause of death for men was coronary heart disease followed by lung cancer and dementia including Alzheimer's disease.6 Men are less likely to have the necessary supports and social connections in place when they experience physical and mental health problems.3 Men visit their general practitioner (GP) less often than women and usually have shorter consultations resulting in missed opportunities for screening.2 They also may present when an illness is advanced, leading to increased morbidity and mortality.5

Socio-cultural barriers are more prevalent for Aboriginal and Torres Strait Islander men who have the highest morbidity and mortality rates and lowest rate of health service utilisation in Australia.7 This is in part due to the strict protocols in Aboriginal and Torres Strait Islander culture, known as Men's and Women's business, that determine what can and should be discussed or undertaken by men and women, which includes healthcare.8,9

Men who live in rural and remote Australia are more likely to have health risks and suffer chronic conditions than those who live in cities.10 Access to healthcare may be more difficult, and these men statistically are more likely to be involved in risky health behaviours, as well as live with social and economic disadvantage resulting in poorer health outcomes.10

Other barriers may include a view of healthcare which avoids preventive health measures, and the distorted notion of masculinity in Australian male culture that can deter men from admitting vulnerability and seeking help.7 Men may also be more comfortable seeing a male GP,2 which may be difficult in clinics with a majority female workforce.

GPs are well positioned to provide health checks for men and screen for relevant conditions. Cancer of the prostate is the second most diagnosed cancer and the second most common cause of cancer death in Australian men.11 Although screening for prostate cancer in asymptomatic men is not recommended, some men have individual concerns and see the benefits of prostate cancer screening as part of their regular check-up.12,13 It is important for GPs to engage men in shared decision-making when ordering prostate-specific antigen (PSA) testing.

GPs play a pivotal role in improving health literacy amongst men and need to embrace opportunities to engage early with boys and young men to develop meaningful relationships through to adulthood. GPs may negotiate and reduce barriers for men accessing healthcare. Dedicated men’s health services including those that are culturally safe for Aboriginal and Torres Strait Islander men may help enhance timely and effective access to care.14

References
  1. Britt H, Valenti L, Bayram C. General practice encounters with men. Aust Fam Physician 2016;45(4).
  2. Australian Medical Association. Position Statement: Men’s Health. Barton, ACT: AMA, 2018 [Accessed 16 September 2021].
  3. National Road Safety Partnership Program. NRSPP Q&A: Road trauma and young drivers – Does gender make a difference? Clayton, Vic: Monash University, NRSPP, 2018 [Accessed 1 December 2021].
  4. Australian Institute of Health and Welfare. The health of Australia's males: Work. Canberra, ACT: AIHW, 2019 [Accessed 1 December 2021].
  5. Australian Institute of Health and Welfare. Life expectancy and death. Canberra, ACT: AIHW, 2021 [Accessed 16 September 2021].
  6. Australian Institute of Health and Welfare. Deaths in Australia. Canberra, ACT: AIHW, 2021 [Accessed 16 September 2021].
  7. Canuto K, Wittert G, Harfield S, Brown A. "I feel more comfortable speaking to a male": Aboriginal and Torres Strait Islander men's disclosure on utilizing primary health care services. Int J Equity Health 2018;17(185). doi:
  8. NSW Health. Communicating positively: A guide to appropriate Aboriginal terminology. Sydney, NSW: NSW Health, 2019 [Accessed 1 December 2021].
  9. Gurney R. Men's Business. Albury, NSW: RVTS, 2019 [Accessed 1 December 2021].
  10. Healthdirect. Rural men face greater risk of health problems, including suicide. Canberra, ACT: Healthdirect, 2019 [Accessed 1 December 2021].
  11. Australian Government Cancer Australia. Prostate Cancer in Australia Statistics. Canberra, ACT: Cancer Australia, 2021 [Accessed 16 September 2021].
  12. Prostate Cancer Foundation of Australia and Cancer Council Australia. PSA testing and early management of test-detected prostate cancer: Clinical practice guidelines. Sydney, NSW: Prostate Cancer Foundation of Australia and Cancer Council Australia, 2016 [Accessed 16 September 2021].
  13. The Royal Australian College of General Practitioners. Guidelines for preventative activities in general practice. 9th edn. East Melbourne, Vic: RACGP, 2018 [Accessed 16 September 2021].
  14. Vincent AD, Drioli-Phillips PG, Le J, et al. Health behaviours of Australian men and the likelihood of attending a dedicated men's health service. BMC Public Health 2018;18(1):1078:2–10.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate a professional, inclusive and culturally sensitive approach when discussing health concerns with male patients of all ages
1.1.1, 1.1.3, 1.1.4, AH1.3.1, AH1.4.1, 1.2.1, 1.2.2, 1.4.4, 1.4.5
  • use a range of communication techniques suited to the individual male patient’s level of health literacy
1.1.1, 1.2.1
  • sensitively ask about a man’s sexual health and history, including sexual dysfunction 
1.1.1, 1.1.2, 1.2.1, 1.3.1 
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • diagnose and manage common health conditions that affect male patients 
2.1.1, 2.1.2, 2.1.3, 2.1.4, 2.1.5, 2.1.6, 2.1.7, 2.1.8, 2.1.9, 2.1.10, AH2.1.2, RH2.1.1, 2.3.1, 2.3.4 
  • interpret investigation results within the context of the man’s life stage and situation
2.1.7, 2.1.8  
  • identify and manage red flag presentations in men’s and boy’s health 
2.1.3, 2.1.8, AH2.1.2  
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • use planned and opportunistic health promotion and disease prevention for early identification of male health issues
3.1.1, 3.2.2, 3.2.3, 3.2.4 
  • promote and engage in men’s and boy’s health activities in the community
3.2.2, 3.2.4, AH3.2.1 AH3.2.2, RH3.2.1 
  • recognise the barriers, enablers and motivators that influence male patients when engaging with their healthcare services 
3.2.1, 3.2.2, 3.2.4, AH3.2.1, RH3.2.1
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • reflect on personal attitudes and values about masculinity, the role of men in society, and how this may influence interactions with patients, their families and carers
4.2.1, 4.2.2, 4.2.4 
  • identify and acquire the necessary skills and knowledge to address the specific healthcare needs of men in their local community 
RH4.2.2, RH4.2.3, AH4.3.1, AH4.4.1 
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • use practice management recall systems to encourage regular check-ups and follow-up appointments for male patients 
5.2.3, 5.2.4, AH5.2.1 
  • describe specific Medicare items that can be used to promote the health of men
5.2.3, 5.2.4, AH5.1.3 

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Men may be reluctant to present to a GP often, so be flexible and opportunistic to provide preventive health checks when they do present so that important screening is done. This is especially important in rural areas where there may be additional barriers to men presenting.
  2. Be comfortable talking to and engaging men about their mental health and sexual concerns, such as erectile dysfunction, loss of libido and urinary symptoms, when appropriate. Normalise common male problems and don’t be embarrassed to use appropriate terminology such as erection, ejaculation etc, to make men feel at ease to talk freely about their concerns.
  3. Consider the challenges and barriers that men, including Aboriginal and Torres Strait Islander men, face in accessing healthcare and work to overcome these during and after a consultation.
  4. Keep up to date with information about men’s health and provide easy-to-read handouts to men about their conditions during a consultation. This will allow them to consider this information in their own space and time.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Men's health

John is 68 years old and presents for a check-up. He has not seen a GP for several years and says that there is nothing wrong with him. He has come to see you at the insistence of his wife after a recent admission to hospital for a urinary tract infection.

John tells you that he has trouble with his ‘water works’ and difficulty maintaining an erection. He puts this down to his age. He has a family history of heart disease. His father had a heart attack at the age of 50 and was diagnosed with prostate cancer at the age of 75. John feels embarrassed talking to you about his symptoms as he feels that this makes him less of a man.

Questions for you to consider Clinical exam assessment area Domains

What communication skills could you use to help reduce John’s feeling of embarrassment?

You identify several health concerns. How could you engage John to discuss and prioritise these?

How could you encourage him to return for a follow-up consultation with you?

What if he was an Aboriginal or Torres Strait Islander? 

  1. Communication and consultation skills
1,2,5

What other history do you need to explore during this consultation? What if John was 50 years old?

What examination would you like to do?

  1. Clinical information gathering and interpretation
2   

What diagnoses are you considering?

What diagnoses would you consider if John was 28 years old and febrile with testicular pain?

  1. Making a diagnosis, decision making and reasoning
2

What are your priorities when managing John? How would your management change if he wanted to discuss his concerns about his erection?

What resources or guidelines could you use to determine recommended prevention strategies?

  1. Clinical management and therapeutic reasoning
2   

What advice would you give John about prostate cancer screening? How would your advice differ if he had a family history of prostate cancer?

If John was an Aboriginal or Torres Strait Islander, what specific challenges or barriers might he have in seeking healthcare?

What other opportunistic screening would you recommend for John?

  1. Preventive and population health 
1,2,3

How would you deal with any personal beliefs or attitudes if John was engaging in behaviour that you found unacceptable?

What if John was 20 years old and requested a testosterone injection for muscle building?

  1. Professionalism
4   

What systems do you have in place to make sure that John returns for the results of any investigations you order?

What monitoring do you need to consider for a man requiring ongoing testosterone supplementation for medical need?

  1. General practice systems and regulatory requirement
5   

If John presented to your local rural emergency department with urinary retention, how would you explain to him the need to insert a urinary catheter and how it would be done? Do you need to upskill in this procedure?

  1. Procedural skills
2   

How would you manage John while waiting for results of investigations?

How would you approach and manage a consultation with a man who thinks that his recent low testosterone levels are the cause of his tiredness?

  1. Managing uncertainty
2   

What if John presented to you with a fever and in urinary retention?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

From your current knowledge, what is your approach to a consultation with a man presenting with scrotal or testicular discomfort and a lump? 

  • What differential diagnoses did you consider? What clinical history and examinations will help you formulate a provisional diagnosis? Did your investigations confirm your provisional diagnosis?
  • Check guidelines or an evidence-based resource and compare the information with what you currently know.

Explore your understanding of common foreskin problems that may occur in men at all stages of life.

  • What are the common foreskin conditions that infant males, boys, adolescents and men might present with? How would you manage such conditions?
  • What is the role of circumcision in a patient with foreskin problems?

Identify the last five male patients over the age of 45 years you have seen and review the notes to identify if you undertook any opportunistic health promotion and prevention.

  • What health promotion or screening did you do? How did you manage this in the consultation? Did you ask them to come back?
  • If you didn’t undertake any screening or promotion, why was this? What were the barriers? How could these be overcome? Could you do even just a small amount opportunistically next time?
With a supervisor

Observe your supervisor inserting an anti-testosterone implant.

  • Describe to them the steps involved during the process.
  • What is the mechanism of action? Discuss the indications/contraindications for its use.
  • What monitoring (blood test or radiology) would you do to screen for any sequelae?

With your supervisor, discuss your approach to men with symptoms of androgen deficiency.

  • How would your approach differ in managing younger and older men presenting with symptoms of low testosterone?
  • What ethical and regulatory requirements do you need to consider when prescribing testosterone replacement therapy?

Men are more likely to engage in risk-taking behaviour. Discuss with your supervisor how you might raise this with men of all ages.

  • What are the possible common risk-taking behaviours at different ages for men? What role can you as a GP play in minimising the harm from these behaviours? How can you discuss this with patients?
In a small group

Role-play a consultation with a man requesting a blood test to check for prostate cancer. Do the role play again changing the scenario: a 75-year-old man with a family history requesting a PSA test, and then a 50-year-old man with symptoms.

  • What resources can you use to discuss the specificity and sensitivity of the PSA test?
  • What are the risks and benefits of ordering a PSA test in a man with no symptoms or family history of prostate cancer?
  • Would your approach to ordering a PSA test differ for a 40-year-old man with no symptoms?

Discuss your approach to assessing and managing a patient with concerns about ejaculation.

  • What are the common ejaculatory problems? What questions do you need to ask and how to do you ask them? How comfortable are you asking such questions?
  • What strategies can you use to manage conditions that men may find difficult or feel embarrassed about discussing with their GP?
  • How would you engage with Aboriginal and Torres Strait Islander male patients to discuss sensitive sexual health issues? What impact does communication have on the success of these types of consultation?
With a friend or family member

Ask a male friend or family member if you can practise explaining a health check. Explain to them what a health check is, why it is important and what will be covered. Ask them what barriers they see in attending for health checks.

  • Ask for feedback on how well you explained health checks. Did they have any questions? Are they more likely to have a health check after your discussion? (Note: do not offer any medical advice.)
  • What can you or your practice do to encourage men to have regular health checks?

Ask a friend of any age if you can practise describing the changes that occur during adolescence and puberty in a male, both physical and psychological.

  • Ask for feedback on how you went. Did you approach this sensitively? What questions did they ask you?
  • How comfortable were you discussing the changes that occur during puberty?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Have a structured approach to a man presenting for a health check and provide general preventive care, especially related to mental and physical health.
  • Address specific men’s health concerns in a sensitive manner:
    • prostate:
      • prostatitis
      • benign prostatic hypertrophy
      • urinary difficulties
      • prostatic cancer, including prostate specific antigen (PSA) screening
    • testicular problems:
      • testicular pain
      • undescended testicle
      • hydrocele and varicocele
      • testicular torsion and torsion of a testicular appendage
      • epididymo-orchitis
      • testicular cancer
    • penile problems:
      • phimosis
      • paraphimosis
      • balanitis
      • urethritis
      • hypospadias
      • Peyronie’s disease
      • priapism
      • penile cancer
    • sexual issues:
      • erectile dysfunction
      • ejaculation problems
      • loss of or reduced libido
    • breast problems:
      • normal breast changes in adolescence
      • gynaecomastia
      • breast lumps and cancer.
  • Understand and work to address the challenges and barriers men face in accessing healthcare.
  • Carry out relevant procedures (eg testosterone implant, catheter insertion).
  • Provide appropriate management of common men’s health presentations and encourage appropriate follow-up. 

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
The principles of the pathogenesis, presentation, assessment and management of BPH in a primary care setting. The clinical approach to men who present with non-specific androgen deficiency-like symptoms. A review of changes in prostate cancer diagnosis and management. Assessment and current treatment modalities for erectile dysfunction.
Online resources
Various chapters relevant to men’s health issues at various stages of life. Various chapters relevant to Aboriginal and Torres Strait Islander men’s health issues at various stages of life. A patient information sheet on the risks and potential benefits of prostate cancer screening. Recommendations on how GPs can support men in making an informed decision for or against PSA testing. Information on optimal care pathways, clinical guidelines and patient information related to prostate and testicular cancers. Information on approaches to assessing and managing common men’s health presentations. This website has information about the social and psychological wellbeing of men and boys.
Learning activities
  • The Royal Australian College of General Practitioners. gplearning:
    • check, unit 583, June 2021: Urology
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/mens-health 27/09/2022