Holden et al. BMC Public Health 2010, 10:96 http://www.biomedcentral.com/1471-2458/10/96 study to demonstrate the strong association with all reproductive health disorders examined in the one sam- ple population. This observation highlights the effect of reproductive health problems on quality of life, as potentially manifest by psychosocial factors. The findings from this study are not unique to Aus- tralian men as evidenced by studies from a range of other populations and clinical cohorts in different set- tings, where various aspects of our findings have been reported [7,44-47]. As for any observational study, the associations identified cannot confer causality or affirm its direction (if any), and the role of unmeasured con- founding may be influencing these effects. Nevertheless the consistency of association between lifestyle and bio- medical factors over a wide range of male reproductive health disorders suggests a definite underlying pattern for which only more complex longitudinal and interven- tional studies can fully define. This study therefore high- lights the importance of longitudinal and/or interventional studies to determine the causality of potential risk factors and identify possible preventative measures to retard or reverse disease progression. Similarly, the present observational study suggests that maintaining general health with beneficial lifestyle beha- viours that are more often associated with other co- morbid disease, such as physical activity, may confer benefits for reproductive health of middle-aged and older men, a concept that warrants further direct study. Physical activity appears to confer benefits in sexual function among older men, with physically active older people reporting higher rates of sexual activity and sex- ual satisfaction than their less active counterparts [48]. Similarly, studies suggest that physically active older adults report lower rates of depressive illness [49,50]. If the direction of causality in the associations identified in this study were verified, such as via interventional or longitudinal studies, the interaction of physical activity, reproductive health and depression could be further investigated as such associations may provide the basis of education campaigns that benefit many aspects of health and well-being in the middle-aged and older population. Conclusions The study highlights that reproductive health should not be considered in isolation from general health in mid- dle-aged and older men. If opportunities to identify reproductive health disorders are being missed [4-6], the risk of more life-threatening conditions may also be left undetected. Identification of modifiable risk factors that contribute to chronic disease but also to a possible decline in reproductive health with age will be essential for the development of appropriate preventative strate- gies and will better inform health policy development Page 7 of 9 and service provision for the progressively ageing popu- lation. Education for both the community and the pro- fessions is imperative to ensure that middle-aged and older men know when to seek treatment for reproduc- tive health problems and receive appropriate manage- ment when accessing health services. Finally, the strong association with cardiovascular disease and depression (depressive symptomatology and medication use) for a range of reproductive health disorders highlights the importance of including male reproductive health as both a sentinel marker and an outcome in other chronic disease studies. Acknowledgements The financial support of the Andrology Australia program by the Australian Government Department of Health and Ageing is acknowledged by the authors. The authors also wish to acknowledge the assistance of the Hunter Valley Research Foundation, NSW in survey administration, data collection and statistical data analysis. Statistical analysis and advice from Mr Paul Agius (Australian Research Centre in Sex, Health and Society, La Trobe University, Vic) and A/Prof Damien Jolley (Monash Institute of Health Services Research, Vic) is also gratefully acknowledged together with the constructive criticism of this manuscript by Dr Megan Cock. The authors thank Dr Veronica Collins (Andrology Australia) for help with editing the manuscript. The Centre for Clinical Effectiveness, Monash Institute of Health Services Research is also acknowledged for their assistance in the identification of population-based studies and validated tools for the survey instrument. Finally, the authors wish to thank the men who participated in the MATeS study. Role of the Sponsor The Australian Government Department of Health and Ageing had no role in the design and conduct of the study, in the collection, analysis, interpretation of the data, or in the preparation, review or approval of the manuscript. Author details 1Andrology Australia, Monash Institute of Medical Research, Monash University, Melbourne, Victoria, Australia. 2Prince Henry’s Institute, Melbourne, Victoria, Australia. 3Australian Research Centre in Sex, Health and Society, La Trobe University, Victoria, Australia. 4Centre for Education & Research on Ageing and School of Public Health, University of Sydney, Sydney, NSW, Australia. 5Department of Medicine, University of Adelaide, Adelaide, SA, Australia. 6Formerly: Department of Human Services, Victoria, Australia. 7Monash Institute of Medical Research, Monash University, Melbourne, Victoria, Australia. 8Department of Andrology, Concord Hospital, ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia. Authors’ contributions All authors contributed to study design; survey development, checking and analysing data; and took part in interpretation of findings and drafting and preparation of the manuscript. CAH had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. JPE performed logistic regression analysis. All authors have read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 3 December 2009 Accepted: 24 February 2010 Published: 24 February 2010 References 1. Meigs JB, Mohr B, Barry MJ, Collins MM, McKinlay JB: Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men. J Clin Epidemiol 2001, 54:935-944. 2. Haidinger G, Temml C, Schatzl G, Brossner C, Roehlich M, Schmidbauer CP, Madersbacher S: Risk factors for lower urinary tract symptoms in elderly