Testosterone Replacement Therapy for Male Hypogonadism.

Testosterone deficiency, or male hypogonadism, is a clinical syndrome that can be defined as persistently low serum testosterone levels in the setting of symptoms consistent with testosterone deficiency. Studies suggest that testosterone replacement therapy may improve sexual function, depressive symptoms, bone density, and lean body mass. Evidence is conflicting regarding its effect on cardiovascular events and mortality. Although prior studies suggested that testosterone replacement therapy increased the risk of cardiovascular disease, a large, randomized trial showed that it does not increase the risk of myocardial infarction or stroke, even in patients at high risk. After a detailed discussion of the potential benefits and risks through shared decision-making, testosterone replacement therapy should be considered for men with testosterone deficiency to correct selected symptoms and induce and maintain secondary sex characteristics. Treatment method should take into consideration patient preference, pharmacokinetics, potential for medication interactions, formulation-specific adverse effects, treatment burden, and cost. Clinicians should monitor men receiving testosterone replacement therapy for symptom improvement, potential adverse effects, and adherence. Serum testosterone, hematocrit, and prostate-specific antigen levels should be measured at baseline and at least annually in men 40 years or older receiving testosterone replacement therapy. (Am Fam Physician. 2024;109(6):543-549.

AGA Clinical Practice Guideline on the Pharmacological Management of Irritable Bowel Syndrome With Constipation.

BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction associated with significant disease burden. This American Gastroenterological Association guideline is intended to support practitioners in decisions about the use of medications for the pharmacological management of IBS-C and is an update of a prior technical review and guideline. METHODS: The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The technical review panel prioritized clinical questions and outcomes according to their importance for clinicians and patients and conducted an evidence review of the following agents: tenapanor, plecanatide, linaclotide, tegaserod, lubiprostone, polyethylene glycol laxatives, tricyclic antidepressants, selective serotonin reuptake inhibitors, and antispasmodics. The Guideline Panel reviewed the evidence and used the Evidence-to-Decision Framework to develop recommendations. CONCLUSIONS: The panel agreed on 9 recommendations for the management of patients with IBS-C. The panel made a strong recommendation for linaclotide (high certainty) and conditional recommendations for tenapanor, plecanatide, tegaserod, and lubiprostone (moderate certainty), polyethylene glycol laxatives, tricyclic antidepressants, and antispasmodics (low certainty). The panel made a conditional recommendation against the use of selective serotonin reuptake inhibitors (low certainty).

AGA Clinical Practice Guideline on the Pharmacological Management of Irritable Bowel Syndrome With Diarrhea.

BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder associated with significant disease burden. This American Gastroenterological Association Guideline is intended to support practitioners in decisions about the use of medications for the pharmacological management of IBS with predominant diarrhea (IBS-D) and is an update of a prior technical review and guideline. METHODS: The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The technical review panel prioritized clinical questions and outcomes according to their importance for clinicians and patients and conducted an evidence review of the following agents: eluxadoline, rifaximin, alosetron, loperamide, tricyclic antidepressants, selective serotonin reuptake inhibitors, and antispasmodics. The guideline panel reviewed the evidence and used the Evidence-to-Decision Framework to develop recommendations. CONCLUSIONS: The panel agreed on 8 recommendations for the management of patients with IBS-D. The panel made conditional recommendations for eluxadoline, rifaximin, alosetron, (moderate certainty), loperamide (very low certainty), tricyclic antidepressants, and anstispasmodics (low certainty). The panel made a conditional recommendation against the use of selective serotonin reuptake inhibitors (low certainty).

The Adult Well-Male Examination.

The adult well-male examination should provide evidence-based guidance toward the promotion of optimal health and well-being. The medical history should focus on tobacco and alcohol use, risk of human immunodeficiency virus and other sexually transmitted infections, and diet and exercise habits. The physical examination should include blood pressure screening, and height and weight measurements to calculate body mass index. Lipid screening is performed in men 40 to 75 years of age; there is insufficient evidence for screening younger men. One-time screening ultrasonography for detection of abdominal aortic aneurysm is recommended in men 65 to 75 years of age who have ever smoked. Screening for prostate cancer using prostate-specific antigen testing in men 55 to 69 years of age should be individualized using shared decision making. Screening for colorectal cancer should begin at 50 years of age for average-risk men and continue until at least 75 years of age. Screening options include fecal immunochemical testing, colonoscopy, or computed tomography colonography. Lung cancer screening using low-dose computed tomography is recommended in men 55 to 80 years of age who have at least a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. Immunizations should be updated according to guidelines from the Advisory Committee on Immunization Practices.

Urinary Retention in Adults: Evaluation and Initial Management.

Urinary retention is the acute or chronic inability to voluntarily pass an adequate amount of urine. The condition predominantly affects men. The most common causes are obstructive in nature, with benign prostatic hyperplasia accounting for 53% of cases. Infectious, inflammatory, iatrogenic, and neurologic causes can also affect urinary retention. Initial evaluation should involve a detailed history that includes information about current prescription medications and use of over-the-counter medications and herbal supplements. A focused physical examination with neurologic evaluation should be performed, and diagnostic testing should include measurement of postvoid residual (PVR) volume of urine. There is no consensus regarding a PVR-based definition for acute urinary retention; the American Urological Association recommends that chronic urinary retention be defined as PVR volume greater than 300 mL measured on two separate occasions and persisting for at least six months. Initial management of urinary retention involves assessment of urethral patency with prompt and complete bladder decompression by catheterization. Suprapubic catheters improve patient comfort and decrease bacteriuria and the need for recatheterization in the short term; silver alloy-coated and antibiotic-impregnated catheters offer clinically insignificant or no benefit. Further management is decided by determining the cause and chronicity of the urinary retention and can include initiation of alpha blockers with voiding trials. Patients with urinary retention related to an underlying neurologic cause should be monitored in conjunction with neurology and urology subspecialists.

Erectile Dysfunction.

Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. It is common, affecting at least 12 million U.S. men. The five-question International Index of Erectile Function allows rapid clinical assessment of ED. The condition can be caused by vascular, neurologic, psychological, and hormonal factors. Common conditions related to ED include diabetes mellitus, hypertension, hyperlipidemia, obesity, testosterone deficiency, and prostate cancer treatment. Performance anxiety and relationship issues are common psychological causes. Medications and substance use can cause or exacerbate ED; antidepressants and tobacco use are the most common. ED is associated with an increased risk of cardiovascular disease, particularly in men with metabolic syndrome. Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions. Oral phosphodiesterase-5 inhibitors are the firstline treatments for ED. Second-line treatments include alprostadil and vacuum devices. Surgically implanted penile prostheses are an option when other treatments have been ineffective. Counseling is recommended for men with psychogenic ED.

Institution-Specific Factors Associated With Family Medicine Residency Match Rates.

UNLABELLED: Phenomenon: Existing research provides little specific evidence regarding the association between public and private medical school curricular settings and the proportion of medical students matching into family medicine careers. Institutional differences have been inadequately investigated, as students who match into family medicine are often consolidated into the umbrella of primary care along with those matching in internal medicine and pediatrics. However, understanding medical school contexts in relation to career choice is critical toward designing targeted strategies to address the projected shortage of family physicians. This study examines factors associated with family medicine residency match rates and the extent to which such factors differ across medical school settings. APPROACH: We combined data from a survey of 123 departments of family medicine with graduate placement rates reported to the American Academy of Family Physicians over a 2-year period. Chi-square/Fisher's Exact texts, t tests, and linear regression analyses were used to identify factors significantly associated with average match rate percentages. FINDINGS: The resulting data set included 85% of the U.S. medical schools with Departments of Family Medicine that reported 2011 and 2012 residency match rates in family medicine. Match rates in family medicine were higher among graduates of public than private medical schools-11% versus 7%, respectively, t(92) = 4.00, p < .001. Using a linear regression model and controlling for institutional type, the results indicated 2% higher match rates among schools with smaller annual clerkship enrollments (p  = .03), 3% higher match rates among schools with clerkships lasting more than 3 to 4 weeks (p  = .003), 3% higher match rates at schools with at least 1 family medicine faculty member in a senior leadership role (p  = .04), and 8% lower match rates at private medical schools offering community medicine electives (p < .001, R(2) = .48), F(6, 64) = 9.95, p < .001. Three additional factors were less strongly related and varied by institutional type-informal mentoring, ambulatory primary care learning experiences, and institutional research focus. Insights: Educational opportunities associated with higher match rates in family medicine differ across private and public medical schools. Future research is needed to identify the qualitative aspects of educational programming that contribute to differences in match rates across institutional contexts. Results of this study should prove useful in mitigating physician shortages, particularly in primary care fields such as family medicine.

The spectrum of constipation-predominant irritable bowel syndrome and chronic idiopathic constipation: US survey assessing symptoms, care seeking, and disease burden.

INTRODUCTION: The irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) are associated with substantial symptom and disease burden. Although typically classified as distinct diseases, symptoms frequently overlap. AIM: The objective of this study was to characterize symptom and disease burden in IBS-C and CIC sufferers and examine a subset of CIC sufferers with abdominal symptoms. METHODS: In a US population-based survey, respondents meeting the Rome III criteria for IBS-C or CIC rated symptom frequency and bothersomeness, missed work and disrupted productivity, and degree of obtaining and satisfaction with physician care. CIC respondents were analyzed in two subgroups: those with abdominal symptoms ≥once weekly (CIC-A) and those without (CIC-NA). RESULTS: Of the 10,030 respondents, 328 met the criteria for IBS-C and 552 for CIC (363 CIC-A; 189 CIC-NA). All symptoms were significantly more frequent in IBS-C vs. CIC respondents (P<0.0001). Constipation was extremely/very bothersome in 72% of IBS-C respondents, 62% of CIC-A, and 40% of CIC-NA (P<0.01 all pairs). All 11 other measured symptoms were significantly more bothersome in IBS-C and CIC-A vs. CIC-NA respondents. In IBS-C vs. CIC-A, abdominal discomfort, bloating, straining, and pellet-like stools were also significantly more bothersome, with other remaining symptoms similar. Gastrointestinal symptoms disrupted productivity a mean of 4.9 days per month in IBS-C respondents, 3.2 in CIC-A, and 1.2 in CIC-NA (P<0.001 all pairs); missed days were similar in IBS-C and CIC-A respondents. CONCLUSION: CIC respondents with abdominal symptoms experience greater disease burden compared with CIC respondents without frequent abdominal symptoms and have a disease burden profile that is similar to IBS-C respondents.

Peyronie's Disease: AUA Guideline.

PURPOSE: The purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of Peyronie's disease. MATERIALS AND METHODS: A systematic review of the literature using the PubMed®, EMBASE® and Cochrane databases (search dates 1/1/1965 to 1/26/15) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of PD. The review yielded an evidence base of 303 articles after application of inclusion/exclusion criteria. RESULTS: The systematic review was used to create guideline statements regarding treatment of PD. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty). Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional consensus statements related to the diagnosis of PD are provided as Clinical Principles and Expert Opinions due to insufficient published evidence. CONCLUSIONS: There is a continually expanding literature on PD; the Panel notes that this document constitutes a clinical strategy and is not intended to be interpreted rigidly. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment. As the science relevant to PD evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Imprecise Clinical Assessments and Inaccurate Grades: Family Medicine Clerkship Director Perspectives.

BACKGROUND AND OBJECTIVES: As application to residency programs becomes increasingly competitive, educational leaders face growing student concern about imprecise clinical assessments and clerkship grades. METHODS: As part of a large annual survey of family medicine clerkship directors (FMCDs), 10 questions were disseminated in May 2023 about perceived levels of imprecise assessments by faculty. We aimed to determine to what extent respondents felt their institution's evaluation system propagated inaccurate grading. RESULTS: A total of 52% of 169 FMCDs responded to the survey. Of these, 7% of respondents were completely confident that their preceptors would give two students of identical competence the same clinical evaluation rating. FMCDs estimated that an average of 38% of their preceptors inaccurately rate student performance. Most clerkships use an Honors/High Pass/Pass/Fail grading system. We found that 51% of FMCDs prefer to use a different grading paradigm than they currently use. We asked FMCDs to estimate the percentage of students that expressed concern over inaccurate preceptor ratings. Grading systems with more tiers were associated with a higher percentage of concerned students. CONCLUSIONS: Clerkship grades are widely used by residency program directors to classify and differentiate student applicants. We identified a significant concern from FMCDs that clinical evaluation ratings can vary greatly. Given the high stakes and perceived inaccuracy of clerkship grading, we recommend continued investigation into the appropriate weighing and usage of clinical evaluations. Continued exploration is recommended to develop grading paradigms centered on criterion-based assessment.

Current Procedural Practices of Family Medicine Teaching Physicians.

BACKGROUND AND OBJECTIVES: Proficiency in procedural care achieved during residency is a major driver of family physician scope of practice. To date, no inventory exists of the advanced procedures and clinical skills performed by teaching family physicians. This study comprises the first such survey and assesses the attitude of respondents toward the importance of family physicians performing procedures. METHODS: We sent a clinical skills inventory to a convenience sample of teaching family physicians employed at 18 medical school-affiliated, community, and military residency programs across the United States. RESULTS: The overall response rate was 46% (N=337). Respondents performed a median of 12 advanced procedures and clinical skills (IQR: 8-18). Endorsed procedures ranged from skin biopsy (n=316, 93.8%) and joint injection (n=279, 82.8%) to colonoscopy (n=21, 6.2%) and cesarean delivery (n=23, 6.8%), and reported skills ranged from medication-assisted treatment (n=181, 53.7%) to highly active antiretrovial therapy (n=35, 10.4%). Gender and career stage were associated with statistically significant differences in endorsement of specific procedures. For example, fracture management was more likely to be performed by late- versus early-career faculty (54.1% vs 24.2%, P<.001) and by male versus female respondents (54.9% vs 24.2%, P<.001). Most respondents (84.3%) agreed that future family physicians should learn procedures and advanced clinical skills. CONCLUSIONS: Family medicine teaching faculty perform a wide array of procedures and advanced skills. Apparent differences by career stage and gender identity in the performance of some of the procedural and skill areas may portend a shift in the procedural training of future family physicians.

Storylines of family medicine VII: family medicine across the lifespan.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VII: family medicine across the lifespan', authors address the following themes: 'Family medicine maternity care', 'Seeing children as patients brings joy to work', 'Family medicine and the care of adolescents', 'Reproductive healthcare across the lifespan', 'Men's health', 'Care of older adults', and 'Being with dying'. May readers appreciate the range of family medicine in these essays.

The adult well male examination.

The adult well male examination should incorporate evidence-based guidance toward the promotion of optimal health and well-being, including screening tests shown to improve health outcomes. Nearly one-third of men report not having a primary care physician. The medical history should include substance use; risk factors for sexually transmitted infections; diet and exercise habits; and symptoms of depression. Physical examination should include blood pressure and body mass index screening. Men with sustained blood pressures greater than 135/80 mm Hg should be screened for diabetes mellitus. Lipid screening is warranted in all men 35 years and older, and in men 20 to 34 years of age who have cardiovascular risk factors. Ultrasound screening for abdominal aortic aneurysm should occur between 65 and 75 years of age in men who have ever smoked. There is insufficient evidence to recommend screening men for osteoporosis or skin cancer. The U.S. Preventive Services Task Force has provisionally recommended against prostate-specific antigen-based screening for prostate cancer because the harms of testing and overtreatment outweigh potential benefits. Screening for colorectal cancer should begin at 50 years of age in men of average risk and continue until at least 75 years of age. Screening should be performed by high-sensitivity fecal occult blood testing every year, flexible sigmoidoscopy every five years combined with [corrected] fecal occult blood testing every three years. [corrected]. The U.S. Preventive Services Task Force recommends against screening for testicular cancer and chronic obstructive pulmonary disease. Immunizations should be recommended according to guidelines from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

A Narrative Review of Irritable Bowel Syndrome with Diarrhea: A Primer for Primary Care Providers.

Irritable bowel syndrome with diarrhea (IBS-D) is a chronic disorder of gut-brain interaction, characterized by recurrent abdominal pain in association with more frequent, loose stools. The pathophysiology of irritable bowel syndrome (IBS) includes disordered gut motility, alterations in gut microbiota, neural-hormonal system abnormalities, immune reactivity, and visceral hypersensitivity. Timely diagnosis of IBS-D can be achieved easily using clinical criteria. Formal IBS diagnosis is important for optimizing treatment and patient outcomes and facilitating patient access to appropriate educational resources. Yet, given the symptom overlap with other gastrointestinal conditions, diagnosis of IBS-D often is perceived to be challenging. Treatment of IBS includes both nonpharmacologic and pharmacologic options. Rifaximin, alosetron, and eluxadoline are effective treatments indicated for IBS-D, but have limited availability internationally. Dietary approaches may also be indicated for certain patients with IBS-D. Psychological interventions may be effective in treating abdominal pain alone and global symptoms in IBS. We describe use of these diverse therapies and provide an overview to facilitate the primary care provider's approach to distinguishing IBS-D from other conditions with symptom overlap.

Addressing policy barriers to paternal involvement during pregnancy.

Efforts to reduce infant mortality in the United States have failed to incorporate paternal involvement. Research suggests that paternal involvement, which has been recognized as contributing to child development and health for many decades, is likely to affect infant mortality through the mother's well-being, primarily her access to resources and support. In spite of that, systemic barriers facing the father and the influence on his involvement in the pregnancy have received little attention. The Commission on Paternal Involvement in Pregnancy Outcomes (CPIPO) has identified the most important social barriers to paternal involvement during pregnancy and outlined a set of key policy priorities aimed at fostering paternal involvement. This article summarizes the key recommendations, including equitable paternity leave, elimination of marriage as a tax and public assistance penalty, integration of fatherhood initiatives in MCH programs, support of low-income fathers through employment training, father inclusion in family planning services, and expansion of birth data collection to include father information.

Men's Health: Prostate Cancer Screening.

Prostate cancer is the second most common nondermatologic cancer in males in the United States. The median age at diagnosis is 66 years and median age at death is 80 years, with most patients diagnosed between ages 55 and 74 years. Black men are at greatest risk of developing and dying of prostate cancer. The U.S. Preventive Services Task Force (USPSTF) and American Urological Association (AUA) guidelines recommend shared decision-making in consideration of screening for men ages 55 to 69 years. Currently, digital rectal examination alone is not recommended for prostate cancer screening. The serum prostate-specific antigen (PSA) test remains the most common screening tool. Novel formulas and algorithms, including the Prostate Health Index (phi) and the 4Kscore, which use total PSA, free PSA, and other information to estimate risk, have shown greater predictive values for detection than the PSA test. Risk assessment with magnetic resonance imaging (MRI) study with or without MRI/transrectal ultrasonography (TRUS) targeted biopsy requires fewer biopsy specimens than traditional TRUS-guided biopsy, and is associated with higher detection rates. Studies of specific lifestyle modifications to minimize prostate cancer risk have shown inconclusive results; however, high carbohydrate and animal fat intakes may increase the risk.

Men's Health: Scrotal and Testicular Conditions.

Scrotal and testicular conditions include benign masses, infections, testicular torsion, and testicular cancer. Common palpable benign scrotal masses include spermatocele, varicocele, and hydrocele. Most patients with these masses require no treatment. Some varicoceles are associated with impaired fertility, probably due to an increase in scrotal temperature that leads to testicular hyperthermia, oxidative stress, and reduced spermatogenesis. Patients with documented infertility or scrotal pain should be referred to a urology subspecialist for consideration of surgical management. Epididymitis and epididymo-orchitis are caused by infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or enteric bacteria. Antibiotics and supportive measures (eg, scrotal elevation, bed rest) are recommended for management of acute epididymitis. Testicular torsion is a urologic emergency that requires rapid surgical exploration and orchidopexy to reduce the risk of testicular loss due to ischemia. Salvage rates exceed 90% when surgical exploration is performed within 6 hours of symptom onset. Testicular cancer commonly manifests as a painless, incidentally discovered mass in a single testis. Ultrasonography is recommended to confirm the diagnosis. The recommended primary intervention for a suspected malignant testicular tumor is radical inguinal orchiectomy.