Alan Wein: Hello again. I'm Alan Wein from the Desai Sethi Urology Institute at the University of Miami on behalf of UroToday, and today I have the great pleasure of discussing the topic of men's health with Bruce Kava, who's a clinical professor of urology at the institute and also in charge of the men's health program. So I just want to start this off, Bruce, by asking you maybe to summarize for those who aren't as familiar, what is men's health, and how is it different from women's health? Or is it? I mean, what makes men's health a topic?

Bruce Kava: Well, I think what I'll do is talk a little bit about gender-specific medicine because it's become in vogue at this point in time, gender-specific healthcare. It's not related just to the anatomical difference between men and women. There's a lot more to it. Women are much more likely to utilize healthcare services for usually chronic disorders such as anxiety, diabetes, back pain, high blood pressure. Men are not as likely to use these services as women do. Men tend to rationalize their medical symptoms. They have higher scores on self-rated health questionnaires. Masculine stereotypes often encourage control and self-reliance, and this results in disparities and delays in medical care. I mean, we know, Alan, you and I both have taken care of multiple people with testicular and penile cancers, and by the time they come to us, it's pretty far down the line.

And you often will say to them, "Well, what were you thinking? Why did you delay?" And they say, "Well, I was hoping that it would go away." And again, part of that is the masculine stereotypes of control, and they're in control of their lives. And if it goes away, that's great. I won't have to deal with it. But if it doesn't, then I'll have to deal with it. And they don't realize the magnitude of the problems that they can have as a result. This also results in a significant risk of sudden death. There's about a 20% chance of presenting with your first myocardial infarction to the ICU with sudden death for males, which is astounding. They may have had warning signs before, but sudden death, and that's it. They're gone. And we all know about this. We all know about friends, family members that suddenly out of nowhere, they just had a heart attack.

They were jogging, they were running, they were doing their exercises. But the problem is that exercise and physical fitness don't equate to health. And that's what we have to do as men. We have to look at these things and we have to look at cancer screenings a little bit differently, particularly for colorectal cancer screening where there are obvious benefits. Going to get your colonoscopy every 5 to 10 years, depending on your risk factors. Starting now at age 45. Men don't do this. And that's our biggest problem right now. And if you look at racial groups, African-American males are even poorer at going for their colorectal cancer screenings. So colorectal cancer, skin cancer, lung cancer, and prostate cancer, these are all potentially treatable disorders and curable disorders if caught early. But men don't do it.

This is the US life expectancy at birth. And you can see there's a tremendous disparity, five years difference between males and females. In 2021, the average life expectancy for women was about 78, 79 years old. Men was only 73. And this occurs across the world. I mean, it's not only the United States, it's in Europe. And if you look at every major country in the world, you'll find a disparity in life expectancy between men and women. So what I've done as a men's health advocate is we've drilled down into the causes of death for men. And I think as scientists, as medical people, we have to tackle this one at a time and see where we can do better. Heart disease, cancer, COVID-19 over the last several years, these are the major causes of death for males.

If you look at the fourth leading cause though, unintentional injuries, this includes drug overdoses, falls. It includes motor vehicle accidents. And I just had a meeting with our trauma team here, and the number one cause for male deaths in the trauma bay here is now motor vehicle accidents. They drive too quickly. They have risky behaviors, and this goes unchecked. So we've done a study here at the University of Miami where we looked at men's life expectancy in the state of Florida, and we found, again, exactly what we saw across the United States. The average life expectancy for males was 76, women was 81. If you look at the causes of death though, in the age group between 18 and 34 years old, 50% of the deaths were males. These were unintentional injuries. If we had gotten to them before, and we've looked at several interventions, we want to go into the school system and do this, but I've been told by our psychiatry team that this needs to be done early in life.

We have to change the way men feel about risky behaviors, about what it means to be male, because this hegemonic masculinity is a big problem for our younger males. And we have to try to change these attitudes early. I think I'm going to stop there, and we can have a little discussion about some of these issues because as a men's health advocate, as a urologist, I look primarily at the genitourinary tract. I'll look at the prostate or the bladder or the penis or the kidneys, and I think that it really stands out when you become somewhat of a men's health advocate, you look at the bigger picture. It's a multidisciplinary approach. It's not just looking at the prostate problem that the patient has or the erectile dysfunction problem the patient has, but that erectile dysfunction problem often is associated with coronary artery disease that at that point in time is silent.

Ian Thompson conducted a study around 2000. This was the Prostate Cancer Prevention Trial where they gave men a 5α-reductase inhibitor. They looked at the placebo group, and they checked what the men were like as far as their sexual function. And seven years later, if they had ED, within seven to nine years later, 11% had already had a major coronary event. That just tells you that ED is a marker for coronary artery disease. Not only that, but it's a marker for peripheral vascular disease, for stroke. These are things that we should be taking care of seriously. And as a urologist, I'm not prepared to put my patients on lipid-lowering agents or antihypertensive medications, but I have a whole panel of primary care doctors that I work with day in and day out here that when we see somebody with ED, we don't just look at the penile problem that they have, but we look at the bigger picture trying to prevent some major cardiac event if they have underlying coronary artery disease.

Alan Wein: You're the president of the American Society of Men's Health, right?

Bruce Kava: Yes.

Alan Wein: So basically, people look to you as to what someone who practices in men's health should really do. And I'm assuming that although you do a lot of other things that basically you must... I'll just give you a list of stuff and just say yes or no. So we'll start with the obvious BPH, lower urinary tract symptoms, right?

Bruce Kava: Yes.

Alan Wein: And then erectile dysfunction, sexually transmitted diseases?

Bruce Kava: Yes, we ask. That's part of a basic history. That should be part of our basic histories.

Alan Wein: Urinary tract infection?

Bruce Kava: Sure.

Alan Wein: Pelvic pain?

Bruce Kava: Yes.

Alan Wein: Andrology and hypogonadism?

Bruce Kava: We talk to them about their libido, we talk about their energy, if they have fatigue. Especially if they're presenting to us with erectile dysfunction, we'll be asking those questions. But for the average male coming in with prostate disorders, these are questions that are so easy to ask, and they could lead to another diagnosis or another problem that could be treated or another problem that could be prevented, in fact. So, yes, we ask about those things.

Alan Wein: So do you manage infertility?

Bruce Kava: I personally don't do a lot of work with infertility patients, but I work in an office where we have three fertility specialists here.

Alan Wein: So they're a part of the men's health team?

Bruce Kava: Yes. And actually we have a Sexual Medicine Society of North America-accredited fellowship here, which includes andrology, fertility and reconstructive urology as well as BPH. So these are the things that I think are so important for us as men's health experts to have involvement in.

Alan Wein: So you had mentioned earlier the major medical causes of death in men, what you should be concerned about. So how do you approach men with respect to... Does everyone get to talk about colorectal screening? Does everyone get to talk about routine, let's say, CT chest without contrast for lung screening or low-dose CT? I mean, do you go over all those things?

Bruce Kava: So it's hard to, in the time allotted for each patient, especially if they have a particular problem they're coming in for. If they're coming to you for a basic screening exam or basic men's health exam, that's a different story. But often the patients are coming in with a problem such as a prostate issue, whether the PSA is elevated or they have benign prostate issues going on and lower urinary tract symptoms. But it's so easy once you start asking questions. I don't necessarily have to counsel them, but I can take a little bit of a history. I usually ask them, "Hey, have you had your colonoscopy yet? You're 48 years old. The screening recommendation now starts at age 45." I don't have to do it. I'm not going to do a colonoscopy on you, but I have a whole gastroenterology and a colorectal surgery department here.

And that could benefit them, particularly if they're at risk for having one of these problems. Skin cancer screening, often we'll just ask them, especially if they're fair-haired, fair-skinned, or have red hair. We ask them, "Hey, have you gone for..." We have a wonderful dermatology department here at the University of Miami, and it's easy to get into these departments when a physician refers you, and that's the best part of this. I love it because I've collaborated with all types of different specialties here at the university, and the people are really good about accepting new patients and getting people in, especially for screening. So, yeah, do I really talk about every single thing? Well, I gloss over some of the things, especially if it's a 75-year-old gentleman who's coming in to me and he has some prostate condition, I will ask about their screening in general.

I'll ask him if he had smoked in the past. I'll do my basic urologic screening exam, but I'll also ask, "Any other issues going on? Any voiding disorders that you have, any problems? Have you had any STIs in the past, sexually transmitted infections?" Are you up to date on your vaccinations? That's an easy question to ask. It opens up Pandora's box, so you have to be careful, again, with a certain amount of time on each patient that you can spend. But if they say no, "What vaccinations do you think I need?" And so, again, there's a model that they use, ask, tell, ask.

And so I can tell them just a small amount of information. I can ask them if they've had it. I can tell them what I do know. I've attended many men's health meetings in the past, so I've learned a lot about a lot of these disorders. I can't practice primary care, but I know how to recognize the issues and I can bring them up and tell them that, "Listen, we have facilities and we have the people here that could help you with that and review a vaccination schedule with you."

Alan Wein: So as a urologist, would it be fair to say that it's difficult to practice in a vacuum, and really the best way to practice is if you're in a true multi-specialty group, whether academic or non-academic where you have access to all these other people that you can refer patients to?

Bruce Kava: You know I was in private practice before I joined the university. I joined the university 25 years ago, and when I was in private practice, you have a referral base, and you have a group of people that refer to you. You've gained their trust. And one hand washes the other. I can call up someone that refers me a bunch of prostate patients. I can say, "Hey, listen, I have this gentleman who came in and really hasn't seen his primary care doctor in five years, and my nurse checked his blood pressure and it was 180. He had been on blood pressure medication in the past, but he's not on it now." And they welcome that.

Alan Wein: So lastly, can you explain this chart so people can use it as a reference and go back and look at it as to what they could possibly do in the way of checking a man?

Bruce Kava: This is really exciting, Alan, because the previous men's health checklist, which was published by the American Urologic Association, was a very nice roadmap. That was the first step, but things have changed over the years, so they broke up the men's health problems into urinary tract problems and medical problems. But they didn't really provide a blueprint for how to implement this. Looking through this, you can see the cancer screenings and what ages you can recommend doing that. One point I want to make is testicular cancer screening through self-examination. One federal agency said that men shouldn't perform self-examination of their testes, and issued guidelines against self-examination.

We've changed that. We've done the research, and we have a white paper published on it. So we cover self-examination, cancers, communicable diseases. We have some basic diseases like hypertension, diabetes, obesity. As a urologist, I can look at my patient. If they're obese or I look at their measured BMI, or their waist circumference, these are all parameters I can use to say, "Hey, we should look into this a little bit further. I'll help you with the urinary problem and recommend Dr. Smith to take care of your other problem."

Alan Wein: Bruce, I wish everyone had the same degree of enthusiasm that you have about the practice of men's health. Thank you so much for conveying that level of enthusiasm and what you think a men's health practitioner should be.

Bruce Kava: Thank you so much. It was a great honor to be with you. Thank you, Dr. Wein.