Men die younger and when sick they seek help later. While it is now accepted that many of the causes of premature death in men are potentially remediable by appropriate education, counseling, diagnosis, and therapy, few, if any, inroads have been made in terms of actually closing the mortality gap between the sexes. Why, given the facts, is men's health still so neglected?
Taking a comprehensive approach, Men's Health, Edition 2 fills a gap in the available literature on specifically male health issues. Completely revised and updated, the second edition covers disease management, maintenance, and prevention. The editors address the full range of men's healthcare problems, from sexual to surgical, medical to psychiatric, and including illness prevention and health maintenance.
Like its predecessor, this new edition is intended not only for primary care practitioners, who wrestle everyday with the consequences of ill health among men, but also for specialists such as cardiologists, urologists, and others, who deal with the diseases that afflict men. A well-illustrated clinical guide, the textbook is an exhaustive reference on male health from childhood to old age.
Men die several years earlier than women. They have more health-risk behaviors and see physicians less often than women. Yet there are few medical books about men's health, whereas those about women's health abound. I was able to find only one other book for physicians, published by Oxford University Press in 1998, specifically about men's health (Tom O'Dowd and David Jewell, editors. Men's Health). So the publication of a comprehensive textbook on this subject might be, as Acheson suggests in the foreword, "a major literary event." Whether or not it is that, this book is a landmark. It begins to define a field.
Are there so few medical books about men's health because men, unlike women, have too few health problems they can call their own? The contents of this book reflect what the editors believe is the domain of men's health. Disorders of the male sex organs (specifically, the prostate, penis, and testes) provide the strongest justification for a separate field. Prostate cancer is the second most frequent cancer among men, and just about everything about it -- tests to screen for it, the natural history of the disease, and the effects of treatment -- remains controversial. Prostatic hyperplasia is common among older men, and there are many options for its management. Prostatitis is also frequent and troublesome, and the causes and management of most cases are uncertain. As for erectile dysfunction, one could argue that the introduction of highly effective drugs for treating it launched the men's health movement. The editors give these disorders, which occur only in men, center stage.
The inclusion of other diseases in a book on men's health is justified by their high frequency among men relative to women. For instance, the male-to-female ratio for inguinal hernia requiring surgery is 12:1 (for good anatomical reasons), and for the incidence of duodenal ulcer the ratio is 4:1. The chapter on suicide points out that although women attempt suicide at least three or four times as frequently as men, four times as many men as women die by suicide each year. The frequency of disease does matter, because a higher prior probability of disease affects the choice and interpretation of diagnostic tests. But the argument that these diseases are special in men would be more convincing if they had a different presentation, natural history, or treatment in men. For the most part, however, they do not.
Many other conditions seem to be included in this book simply for completeness, because they occur as commonly in men as they do in women. Among them are conditions related to cigarette smoking, cardiovascular diseases, and sports injuries. A chapter on osteoporosis reminds readers that diseases usually associated with women often occur in men, too. These diseases are described as they might be in a textbook on primary care, thus indirectly weakening the case for men's health as a separate field.
The social and emotional problems of men, such as risk taking and suicide, are well presented. An attempt to define the male menopause, however, is largely unconvincing. The author of this chapter acknowledges that "there is no finite event, symptom or measurement by which the male menopause can be identified." As is usual in medicine, the physical aspects of disease are given more attention than the emotional aspects. The discussion of sexuality is mainly about erection, orgasm, and infertility, and there is little information about libido and the effects that fatigue, anxiety, and marital strife can have on sexuality.
For those of us who love books, this one is exceptionally well prepared. The fonts are large and crisp, and the layout open and inviting. Colorful illustrations convey key information effectively; for example, there are figures showing nine causes of enlargement of the scrotum, the various presentations of groin hernias, and several types of penile prosthetic implants.
The editors and authors of this book come from both sides of the Atlantic and from several specialties, yet the coverage is remarkably uniform and balanced. Basic anatomy and physiology have a comfortable place beside clinical and epidemiologic information. However, the partition of information among the chapters is idiosyncratic. "Diet, Fat and Cancer of the Prostate" has its own chapter, whereas all the other information about prostate diseases is crammed into another single chapter, where there is not enough space to describe each disease effectively. Scrotal masses are included in the chapter entitled "Lumps, Lesions and Skin Cancer." Many abbreviations seem unnecessary (for example, RMH for Royal Marsden Hospital) or have no commonly understood meaning (for example, MSM for men who have sex with other men).
Although the book includes references, it falls short of the best up-to-the-minute, evidence-based medicine. Evidence from randomized trials, where it exists, is not highlighted, and the performance of diagnostic tests is not described quantitatively, in terms of sensitivity and specificity (or likelihood ratios). Systematic reviews are rarely mentioned. Major references dealing with the natural history and symptoms of prostatic hyperplasia, such as the excellent monograph prepared by the Agency for Health Care Policy and Research (Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline. No. 8. AHCPR publication no. 94-0582. Washington, D.C., 1994), are omitted, as are authoritative guidelines.
This book makes the case for a special body of knowledge about men's health. Does it mark the advent of a separate field, such that we will be "Setting up a Well Man Clinic in Primary Care," as the title of the last chapter suggests? I hope that the effect is not to split patients up in yet another way, as they now are split up according to organ, age, and technique (such as medical treatment or surgery). Rather, I hope that this book, and others to follow, will help all of us, especially generalists, take better care of men than we have in the past.
Robert H. Fletcher, M.D.
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