While some of these differences can be attributed to men’s hormones and anatomy, others are linked to their well-documented reluctance to see a doctor for medical treatment. (For example, a study published in March 2016 in the journal BMC Family Practice found that women were more likely than men to say they’d visit their doctor in response to health concerns.) That tendency to brush off symptoms until they’re impossible to ignore can, unfortunately, lead to worse outcomes, including conditions that range from depression to sexual dysfunction. “Men tend to have a more complicated course with Crohn’s compared to women,” says Taha Qazi, MD, a gastroenterologist at Cleveland Clinic in Ohio who specializes in treating people with inflammatory bowel disease (IBD). Here’s what men need to know about Crohn’s disease, including how to ease their symptoms, reduce the risk of other complications, and get the treatment they need.
Men With Crohn’s Disease May be More Likely to Have Some Sexual Dysfunction
While there’s not a lot of research on the sexual function of men with IBD, including Crohn’s, current studies suggest men with active disease are more likely to have sexual dysfunction, erectile dysfunction, and lower sexual desire, says George Salem, MD, a gastroenterologist and advanced IBD fellow at Johns Hopkins Medicine in Baltimore. “In general, patients with IBD are at a higher risk of sexual dysfunction, especially if they’re younger than 50,” says Dr. Qazi. Both doctors point to a July 2019 study published in the journal Inflammatory Bowel Disease of men who were newly diagnosed with IBD, which found that 94 percent reported erectile dysfunction. One reason ED was so prevalent among this population, says Dr. Salem, who wasn’t affiliated with the research, was because the doctors weren’t aware of — and, therefore, weren’t treating — the condition. In other words, men aren’t necessarily seeking help from their doctors. Crohn’s can cause sexual dysfunction for many reasons, explains Salem. Chronic inflammation in the body can cause hormonal changes, which can decrease sex drive, and perianal disease, which causes discomfort and sometimes incontinence. Both can lower men’s confidence. Some research also shows that while ileal pouch–anal anastomosis (IPAA) surgery (also known as J-pouch surgery) can reduce complications, it may either improve or worsen sexual function. The surgery requires several procedures, and many men report improved sexual function after the inflamed colon is removed in the first stage of surgery, possibly because surgery removes the source of chronic inflammation and improves overall health, says Salem. Most cases of sexual dysfunction occur after the final surgery (dissection of the pelvis, where the ileal pouch is connected to the anus) and are linked to nerve damage and poor pouch function, says Salem. Prolonged hospitalization and surgery side effects can also lead to mood changes, decreased body image, and concerns about fertility and sexual pleasure. Research published in October 2003 in the International Journal of Colorectal Disease found that 20 percent of men had some sexual dysfunction. While nerve damage is usually permanent, doctors can take steps to improve pouch function, says Salem. Ultimately, the risk of postoperative problems seems to be unknown: A survey published in October 2005 in the journal Colorectal Disease found that men actually had better erectile function, sexual desire, and overall satisfaction with sex after undergoing the surgery, so talk to your doctor about what’s best for you. “Early diagnosis of Crohn’s disease, ideally before developing surgical complications, is key to achieve better outcomes in general,” says Salem. Medications help improve disease complication and progression, and generally avoiding corticosteroids while keeping inflammation under control helps maintain hormonal balance. “Having a multidisciplinary team who has the time to inquire about sexual dysfunction and provide adequate consultative assistance is essential for diagnosis and management,” he says.
Certain Crohn’s Medications May Cause (Temporary) Infertility
Sulfasalazine is an older Crohn’s drug that’s prescribed less these days due to numerous side effects, including interfering with sperm formation, according to a study published in June 2017 in the journal Andrology. The Crohn’s medication methotrexate also lowers sperm quality by directly impacting sperm-producing cells, according to a study published in September 2015 in the journal Gastroenterology and Hepatology. “Contraception is strongly advised for men who are actively using methotrexate,” says Salem. Fortunately, sperm gets back to normal within a couple of months of stopping these medications, although he points out that men who are considering having a child should continue using contraception for at least 3 months after they take their last dose. It’s important to note that some research has shown that infertility rates among people with Crohn’s are about the same as for the general public, but a study published in September 2013 in the journal Alimentary Pharmacology and Therapeutics suggests that infertility rates may be higher among some men with Crohn’s, due not to the condition itself but to men voluntarily choosing not to try to have children out of fertility issue fears.
Osteoporosis is Much More Common Among Men With Crohn’s
Osteoporosis is four times as common in older women than men, according to a May 2017 study in the Journal of Clinical Medicine Research, due to women’s decreasing estrogen levels with age. But that disparity disappears among people with Crohn’s disease, which increases the risk of osteoporosis in men and women of all ages. According to the Crohn’s and Colitis Foundation, an estimated 30 to 60 percent of people with Crohn’s disease have lower-than-average bone mineral density, which can result in osteoporosis. Crohn’s disease boosts levels of cytokines, i.e., small proteins in the body that increase inflammation and interfere with healthy bone formation. “A chronic inflammatory state leads to significant amounts of bone loss,” says Qazi. “More importantly, the ability to absorb and keep vitamin D is significantly decreased in IBD, and some medications, like corticosteroids, are linked to significant risk of osteoporosis,” says Qazi. You should have a bone scan when you’re diagnosed, he adds, and doctors may want to regularly order follow-up scans, especially if you’ve been on long-term immunotherapy. To reduce your risk of osteoporosis, Qazi says it’s critical to manage your Crohn’s disease. Because corticosteroids can increase the risk of osteoporosis and other conditions, they’re considered a bridge drug to other treatments; most people are usually put on a course of four to six weeks, max. Your doctor will likely recommend vitamin D supplements also and may refer you to a bone specialist. Exercise, especially weight lifting, also helps increase bone mass and density.
Crohn’s May Increase Prostate Cancer Risk
A study of more than 10,000 men, which was published in May 2019 in the journal European Urology, found that those with Crohn’s disease were four to five times more likely to be diagnosed with prostate cancer, although experts point out that the study only looked at people who visited one specific medical center. An increased risk of prostate cancer could be due to body-wide inflammation caused by immune system abnormalities in people with IBD, says Salem, who wasn’t affiliated with the study. Many men with Crohn’s disease have inflammation in the rectum, which sits next to the prostate. This localized inflammation may increase levels of prostate-specific antigen (PSA), a protein produced by cancerous and noncancerous tissue in the prostate; elevated PSA levels can indicate prostate cancer. Patients in this study may have had more advanced stages of prostate cancer, he says, because doctors initially linked their elevated PSA levels to IBD, delaying diagnosis. Ultimately, managing the disease is critical to reducing your risk of many Crohn’s complications. “Controlling inflammation in the colon is not only important to control symptoms and disease progression, but also protective from cancer transformation, especially in areas chronically affected with this inflammation,” says Salem. “Ideally, male patients should continue to follow the universal screening recommendations for prostate cancer with their respective primary care providers,” he says.
Untreated Depression is More Common Among Men with Crohn’s
Crohn’s disease may increase a man’s risk of depression. A meta-analysis of 13 studies, published in March 2016 in the journal Inflammatory Bowel Diseases, found that people who have IBD, including Crohn’s disease, are significantly more likely to experience anxiety and depression, especially during flare-ups. “IBD patients are at higher risk of depression, anxiety, and PTSD,” says Qazi. “These mood disorders are also linked to a worsening course of disease.” It’s not surprising that a chronic illness — especially one that can interfere with people’s daily lifestyles — contributes to depression, says Salem. Drugs used to treat Crohn’s disease, including steroids, have also been linked to mental health conditions, including acute psychosis, mania, hypomania, and depression. What’s more, men are far less likely to seek treatment for depression than women, possibly because men have a harder time expressing their emotions and may hide symptoms by overworking or engaging in risky behaviors, according to the American Psychological Association. “Multiple studies clearly show that masculine norms and attitudes often directly lead men to refuse help, particularly for mental health issues,” says Salem. “This could be due to the stigma that is perceived by men with this diagnosis.” It’s important to be treated for depression, Qazi says, because it can also improve Crohn’s symptoms and quality of life. Symptoms of depression in men may include fatigue, sleep disturbances, loss of interest in work or other activities, irritability, and anger. Talk to your doctor about the range of treatments available, which may include everything from medications and talk therapy to mindfulness meditation, hypnosis, and yoga.
Testosterone Therapy Could Help Improve Crohn’s Symptoms
Research published in May 2016 in the journal Endocrine Abstracts suggests that men with IBD are more likely to have relatively low testosterone levels, possibly due to chronic inflammation, says Salem. Plus, he says, corticosteroids have been shown to decrease levels. There’s some evidence, including research published in June 2015 in the journal Hormone Molecular Biology and Clinical Investigation, showing that testosterone replacement therapy improves Crohn’s symptoms, although Salem says it’s not standard treatment. “At this juncture, testosterone replacement therapy, when indicated, should be addressed by an endocrinologist … and shouldn’t be perceived as a form of therapy in patients with Crohn’s disease,” he says. Talk to your doctor if you have symptoms of hypogonadism (low testosterone), including decreased sex drive and fatigue. You may be referred to an endocrinologist for testing and diagnosis. On the whole, men with Crohn’s tend to have a harder time managing their condition than women, partly because they’re hesitant to acknowledge their symptoms and seek treatment, so they’re diagnosed at a later stage, says Salem. “Many people with IBD are not open with providers about problems like sexual dysfunction, hypogonadism, depression, and anxiety,” says Qazi. “Providers are not normalizing these kinds of questions in practice. Some questions are not easy for men to ask, for a variety of reasons.” Fortunately, there are treatments available. You just need to speak up.
