Influence of age and endocrine factors on the volume of benign prostatic hyperplasia

The Etiology and Pathogenesis of Benign Prostatic Hyperplasia: The Roles of Sex Hormones and Anatomy

Benign prostatic hyperplasia (BPH) mainly causes lower urinary tract symptoms in ageing men, but its exact etiology and pathogenesis have not been established. The objective of this review was to design an update on the advances of human BPH research. We undertook a literature search for identifying studies of the roles of sex hormones (androgens and estrogens) in the onset and development of human BPH using the Pubmed database. In literature, many studies have indicated that ageing and obesity are the factors for preceding the onset of BPH. No evidence for the role of testosterone (T) or dihydrotestosterone (DHT) is found in BPH initiation. Since BPH exclusively occurs in the transitional zone (TZ) surrounding the urethra, it is postulated that years of exposure to uncharacterized urinary toxins could disrupt the homeostasis of the stroma and/or epithelium of this prostatic zone that are typically occurring in ageing men. After cellular damage and subsequent inflammation generated, the intraprostatic DHT produced mainly from T by 5α-reductase promotes BPH development. Further, estrogens could take part in the nodular proliferation of stromal cells in some BPH patients. The confounding of BPH may attenuate the development of prostate tumor in the TZ. In conclusion, evidence in literature suggests that androgens are not etiological factors for BPH, and intraprostatic DHT along with chronic inflammation are mainly responsible for nodular proliferation of stromal and/or epithelial cells in prostatic TZ. The urinary factors for the etiology of BPH and BPH as a prediction of PCa progression still need further investigation.

Metabolic syndrome-related factors as possible targets for lower urinary tract symptoms in Korean males

INTRODUCTION

A positive association between benign prostate hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and metabolic syndrome (MetS) was reported in several studies, but studies from Asia often showed conflicting results.

MATERIALS AND METHODS

Medical records were obtained from a health promotion center database between 2021 and 2022. Men without a history of treatment for LUTS were evaluated using the International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), transrectal ultrasonography.

RESULTS

Of 1345 individuals, 603 (44.8%) had MetS. Older age, higher IPSS values, higher prevalence rates of BPH and overactive bladder, higher triiodothyronine, and lower testosterone and sex-hormone binding globulin were observed in individuals with MetS than in individuals without MetS. The severity of LUTS significantly increased in the individuals with MetS (p = .002). In individuals with MetS, age, HbA1c, and cerebrovascular disease (CVD) were associated with IPSS. For OABSS, age, HbA1c, thyroid-stimulating hormone (TSH), coronary artery occlusive disease, and CVD were identified as predictors.

CONCLUSIONS

We confirmed the positive correlation between MetS and BPH/LUTS in Korean. Factors including TSH and atherosclerosis affected LUTS in individuals with MetS. These findings suggested a potential role of thyroid hormones and atherosclerosis in the etiology and treatment of BPH/LUTS in patients with MetS.

Impact of COVID-19 on male urogenital health: Success of vaccines

Throughout 2021, the scientific and medical communities were concentrated on dealing with the acute morbidity and mortality induced by the COVID-19 pandemic due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We reviewed the present data for adverse effects of COVID-19 on the different parts of the male urogenital system during the dynamic situation of the COVID-19 pandemic. With the approval of COVID-19 vaccinations, there is a ray of hope at the end of this dark tunnel and a chance to look ahead for the management of long-term consequences in males with urogenital illness. A multidisciplinary investigation of these cases could provide information for establishing and optimizing treatment protocols.

Impact of COVID-19 pandemic on lower urinary tract symptoms in patients with benign prostatic hyperplasia and predictors of urine retention in such patients

OBJECTIVES

We assess the effect of coronavirus disease 2019 (COVID-19) on lower urinary tract symptoms (LUTS) of patients with benign prostatic hyperplasia (BPH). Moreover, we delineate risk factors for urine retention in such patients.

METHODS

All COVID-19 infected males were expeditiously evaluated. All enrolled patients were assessed using the International Prostate Symptom Score (IPSS), uroflowmetry, and pelvi-abdominal ultrasonography for prostate volume and postvoiding residual urine (PVR) estimation.

RESULTS

Fifty patients, who were diagnosed with BPH, were enrolled. The mean age (±SD) was 62.64 ± 7.69. In the pre- and post-COVID-19 group, the mean (±SD) IPSS was 13.42 ± 4.32 and 26.62 ± 5.77, respectively (P < .001), while PVR was 90.40 ± 32.75 and 185.42 ± 73.42, respectively (P < .001), and maximum flow rate was 14.40 ± 2.75 and 10.74 ± 3.43, respectively (P < .004). After infection with COVID-19, 13 (26%) patients were managed by urethral catheter fixation owing to urine retention. On bivariate analysis, age, diabetes, large prostate on digital rectal examination, alpha-blocker monotherapy, microscopic hematuria, positive urine culture, and pre-COVID-19 IPSS were significantly correlated with urine retention (P < .001, P = .01, P < .001, P = .06, P < .001, P = .04, and P < .001, respectively). On multivariate analysis, age, pre-COVID-19 IPSS, and positive urine culture were the independent predictors of urine retention (P = .05, P < .001, and P = .01, respectively).

CONCLUSION

LUTS in BPH patients were significantly affected by COVID-19. COVID-19 increases IPSS leading to a change in the treatment modality of BPH. On multivariate analysis, age, pre-COVID-19 IPSS, and positive urine culture were the independent predictors of urine retention post COVID-19 infection.

Ten Rules for Conducting Retrospective Pharmacoepidemiological Analyses: Example COVID-19 Study

Since the beginning of the COVID-19 pandemic, pharmaceutical treatment hypotheses have abounded, each requiring careful evaluation. A randomized controlled trial generally provides the most credible evaluation of a treatment, but the efficiency and effectiveness of the trial depend on the existing evidence supporting the treatment. The researcher must therefore compile a body of evidence justifying the use of time and resources to further investigate a treatment hypothesis in a trial. An observational study can provide this evidence, but the lack of randomized exposure and the researcher's inability to control treatment administration and data collection introduce significant challenges. A proper analysis of observational health care data thus requires contributions from experts in a diverse set of topics ranging from epidemiology and causal analysis to relevant medical specialties and data sources. Here we summarize these contributions as 10 rules that serve as an end-to-end introduction to retrospective pharmacoepidemiological analyses of observational health care data using a running example of a hypothetical COVID-19 study. A detailed supplement presents a practical how-to guide for following each rule. When carefully designed and properly executed, a retrospective pharmacoepidemiological analysis framed around these rules will inform the decisions of whether and how to investigate a treatment hypothesis in a randomized controlled trial. This work has important implications for any future pandemic by prescribing what we can and should do while the world waits for global vaccine distribution.

Variation of prostatic morphology in Chinese benign prostatic hyperplasia patients of different age decades

OBJECTIVE

Our study aimed to investigate the age-related growth in prostatic morphological parameters in Chinese benign prostatic hyperplasia (BPH) patients, and to find out the regularity of how these parameters change with aging.

METHODS

Medical records of 1038 BPH patients were obtained from a retrospective database of first-visit men with BPH. Change regularity of prostatic anatomical factors with aging was analyzed.

RESULTS

Patients were classified into four groups according to different age decades. All prostatic anatomical factors assessed in this research increased with age growth (p < .0001). However, these anatomical factors sustained stably when older than 70 years. By analyzing the detailed correlation between age and prostatic morphological parameters, transitional zone index (TZI) (Pearson r = 0.358, r² = 0.128, p < .0001) and transitional zone width (TZW) (Pearson r = 0.344, r ²= 0.118, p < .0001) showed the best correlation coefficient with age. After adjusted the influence of cardiovascular disease (CVD) and diabetes mellitus (DM), the result remained still similarly.

CONCLUSION

Prostatic morphological parameters increase progressively with age growth when patients were younger than 70 years, indicating reasonable interventions to be provided to BPH patients before 70 years. In addition, TZI and TZW are two practical, easy-to-measure prostatic parameters that are significantly associated with the growth of age compared to others.

The Effect of the Presence of Lower Urinary System Symptoms on the Prognosis of COVID-19: Preliminary Results of a Prospective Study

Purpose

To investigate the effectiveness of benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS), which occur as a natural result of aging and androgen exposure, in predicting disease prognosis in male patients diagnosed with COVID-19.

Methods

The study was planned prospectively. The study included 63 male patients over 40 years of age diagnosed with COVID-19. The patients were diagnosed with COVID-19 based on the results of reverse transcription polymerase chain reaction tests of oropharyngeal and nasopharyngeal swabs obtained as per the World Health Organization guidelines. The presence of LUTS was assessed by the International Prostate Symptom Score (I-PSS), a subjective assessment, and the I-PSS was filled for the patients included in the study. The patients were divided into three groups based on their scores in the I-PSS survey: group 1: mild (0–7), group 2: moderate (8–19), and group 3: severe (20–35). The data of all three groups were statistically analyzed.

Results

In the assessment performed between the groups, it was identified that for patients in group 3, the length of hospital stay was longer, intensive care requirement was more frequent, and their mortality rates were numerically higher. In the evaluation made regarding the time to intensive care admittance, this was identified to be the shortest in group 3.

Conclusion

As a result of our study, we think that in patients with COVID-19, BPH-related LUTS can guide clinicians in predicting prognosis.

Clinical Implication of Enlarged Prostate in Patients with the Ileal Pouch-anal Anastomosis for Inflammatory Bowel Disease

Background

Enlarged prostate is often noticed in patients with ileal pouch-anal anastomosis (IPAA) in our clinical practice. The aims were to identify the factors associated with enlarged prostate and to investigate its clinical implications.

Methods

IPAA patients with available prostate imaging after IPAA were included. Prostate length and width were measured in the axial plane and height in coronal plane. Prostate volume was calculated with the formula (length × width × height) × π/6. A volume greater than 40 cm³ was used to define enlarged prostate.

Results

Prostate enlargement was found in 58 (24.8%) out of 234 patients. Factors associated with prostate enlargement included advanced age at imaging examination (55.6 ± 11.5 vs. 41.3 ± 13.6 years, P < 0.0001), age at pouch surgery (46.0 ± 11.8 vs. 32.5 ± 12.9 years, P<0.0001), and the presence of an S-pouch (6.9% vs. 1.1%, P = 0.03). Postoperative use of biologics was less common in patients with enlarged prostate (5.2% vs. 17%, P = 0.03). However, pouch duration was comparable (10.0 ± 5.9 vs. 8.8 ± 6.8 years, P = 0.2) and pouch failure rate was similar. A trend towards an increased risk for acute pouchitis in patients with enlarged prostate was noticed (19% vs. 9.1%, P = 0.06). The association of S-pouch (odds ratio: 7.2, 95% confidence interval: 1.1 - 46.4) and enlarged prostate remained significant after adjusting for age, acute pouchitis, and redo pouch on multivariate analysis.

Conclusions

Prostate enlargement appears to be uncommon after IPAA and it was associated with S-pouch configuration and advanced age. Enlarged prostate in the setting of IPAA does not seem to have adverse impact on pouch outcomes, although there is a trend in correlation between enlarged prostate and acute pouchitis.

The association between triglyceride high density lipoprotein cholesterol ratio and benign prostate hyperplasia in non-diabetic patients:a cross-sectional study

OBJECTIVES

To assess the association between triglyceride (TG)/high density lipoprotein (HDL) ratio and benign prostate hyperplasia/lower urinary tract symptoms (BPH/LUTS).

METHODS

Four hundred patients who were admitted to the Urology Clinic between January and December 2014 with complaints of BPH/LUTS were enrolled in this cross-sectional study. Patients were divided into two groups according to their International Prostate Symptom Score and prostate volume (PV). They were compared in terms of age, body mass index (BMI), PV, PSA, post micturional residual volume, uroflowmetry Q max value, fasting blood sugar, TG and high density lipoprotein-cholesterol (HDL-C) level and TG/HDL ratio.

RESULTS

Although univariate analyses reveal that age, BMI, waist circumference (WC), FBS, TG, HDL-C level, and TG/HDL ratio were correlated with PV, only age [1.125 OR (1.088-1.164), p = .00001], BMI [1.119 OR (1.040-1.204), p = .003], TG [(1.043 OR (1.016-1.071), p = .002], HDL-C [(0.923 OR (0.860-0.990), p = .025], and TG/HDL ratio [(1.224 OR (1.130-1.315), p = .014] were statistically significant in multivariate analysis. The calculated area under the curve (AUC) for PV of 30 ml, 40 ml, and 50 ml was 0.668 (0.608-0.727), 0.617 (0.561-0.673), and 0.592 (0.530-0.654), respectively.

CONCLUSIONS

Our results indicate that the TG/HDL ratio correlates with enhancement in PV. Further studies are warranted to better evaluate this relationship.

Comparative analysis of resected prostate weight in diabetic and non-diabetic benign prostatic hyperplasia Patients

Background:

Benign prostatic hyperplasia (BPH) is the most common benign tumor in men. The etiology of BPH is still unresolved and multiple systems are likely to be involved. The effects of diabetes on urinary system are a risk factor for BPH. We then assessed the effects of diabetes on the parameters related to BPH, especially weight and volume.

Methods:

This study was conducted on patients with BPH who underwent surgery during 2010-2013. The patients’ demographic and clinical data including age, height, weight, history of diabetes, abdominal sonography, prostate-specific antigen(PSA), fasting blood sugar (FBS), triglyceride, and cholesterol, resected sample weight, and pathological diagnosis were extracted.

Results:

The mean age of all 225 patients (35 (15.6%) diabetic patients and 190 (84.4%) non-diabetic patients) who entered the study was 71.5±8.7 years. The patients were divided in to 3 body mass index (BMI) groups: 48 (21.3%) were normal, 151 (67.1%) were overweight and 26 (11.6%) were obese. The mean weight of resected prostate was higher in diabetic patients (22.9±6.9 vs 21.7±14.3, P=0.02). The resected prostate weight had a significant relationship with BMI (P=0.001), prostate–specific antigen (PSA) level (P=0.001), and prostate volume sonography (P=0.001). No significant relationship was detected between resected prostate weight with age, FBS and triglyceride however, it is significant with cholesterol.

Conclusion:

We concluded that diabetes has a role in the development and progression of BPH with effect on prostate weight and volume. As well, BMI is a risk factor in BPH progression.

Cross-sectional analysis between prostate volumes and serum sex hormones in Japanese men attending a urological clinic

AIM

To evaluate epidemiologically the association between measured prostate volume and sex hormones.

METHODS

Between December 2012 and September 2014, 226 patients attending the urological clinic were assessed for the relationship between prostate volume (PV) and, serum sex hormones, physical size, personal habits, etc. Prostate volume was measured by using transabdominal ultrasonography. Statistically, the Pearson correlation coefficients test was used.

RESULTS

Total cases, the cases of PV ≤ 25 ml, and the cases of PV > 25 ml were evaluated respectively. Total cases and the cases of PV > 25 ml showed a positive significant correlation with testosterone (T), but the cases of PV ≤ 25 ml showed no such correlation. The cases of PV > 25 ml had a positive significant correlation with estradiol (E2), but total cases and cases of PV ≤ 25 ml did not. Dehydroepiandrosterone sulfate (DHEAS) showed no correlation with any case of PV, however it decreased significantly with age and had a correlation with alopecia. The E2/T ratio had no correlation with any case of PV, but on the other hand, the T/DHEAS and E2/DHEAS ratios had significant positive correlation with PV > 25 ml.

CONCLUSIONS

Serum T and E2 had significant positive correlation with measured PV especially in larger prostates. This result seems to correspond with the conventional theory that T and E2 have an etiological effect on benign prostatic hyperplasia. DHEAS did not show direct correlation with PV, however it appeared to suppress the role of T and E2 on benign prostatic hyperplasia growth. DHEAS might be a key to understanding the etiology of benign prostatic hyperplasia with aging.

Prostatic Artery Embolization (PAE) for Symptomatic Benign Prostatic Hyperplasia (BPH): Part 1, Pathological Background and Clinical Implications

Pathological features of benign prostatic hyperplasia (BPH) dictate various responses to prostatic artery embolization (PAE). Typically, BPH originates in the transition zone and periurethral region, where should be considered the primary target area in PAE procedures. Given that histological heterogeneity of components in hyperplasia nodules, epithelial or stromal, identifying the more responsive nodules to PAE will have clinical implications. Since some lower urinary tract symptoms (LUTS) in patients with BPH are usually related to bladder outlet obstruction-induced changes in bladder function rather than to outflow obstruction directly, proper selection of candidate patients prior to PAE is of great clinical importance. BPH is a typical chronic progressive condition, suggesting PAE could aim not only to relieve LUTS but also to delay or prevent the clinical progression. Awareness of the pathological background of BPH is essential for interventional radiologists to improve clinical outcomes and develop new treatment strategies in clinical practice of PAE.

Do baseline estrogen and testosterone affect lower urinary tract symptoms (LUTS) prior to or after pharmacologic treatment with tadalafil?

Little is known about how total testosterone and estradiol-17β influence lower urinary tract symptoms (LUTS) in men with benign prostatic hypertrophy (BPH). We analyzed data from a subset of men aged ≥18 years randomized to tadalafil 5 mg once-daily or placebo who had ≥6 month history of LUTS and an International Prostate Symptom Score (IPSS)≥13 enrolled in one of three randomized, placebo-controlled tadalafil clinical trials (N = 958). Three specific aims were addressed, as follows: (i) To characterize enrolled men by treatment randomization and testosterone level; (ii) to assess cross-sectional associations of estradiol-17β, testosterone, and LUTS prior to treatment with tadalafil; and, (iii) to assess longitudinal associations between baseline estradiol-17β and testosterone and improvements or worsening of LUTS during a 12-week period of tadalafil or placebo administration. LUTS were assessed by total IPSS, IPSS voiding sub-score (IPSS-V) and IPSS storage sub-score (IPSS-S) for cross-sectional analyses, and change in total IPSS (ΔIPSS), ΔIPSS-V, and ΔIPSS-S between baseline and 12-week visit for longitudinal analyses. Correlation analyses and linear regression examined associations. Baseline testosterone was not significantly associated with IPSS. In contrast, estradiol-17β was inversely correlated with IPSS (r = -0.08; p < 0.05) and IPSS-S (r = -0.14; p < 0.05). Tadalafil treatment resulted in greater IPSS improvements in men with lower baseline estradiol-17β versus those with higher baseline estradiol-17β. Lower baseline estradiol-17β was significantly associated with modestly improved ΔIPSS-V (p = 0.04) and Δtotal IPSS (p = 0.05) but not with ΔIPSS-S, following treatment which may substantiate the role of bladder dysfunction because of nerve and smooth muscle changes in the bladder in addition to benign prostatic enlargement in LUTS. Circulating baseline testosterone did not predict ΔIPSS. Men with lower baseline estradiol-17β levels showed greater responsiveness to tadalafil 5 mg treatment than those with higher baseline estradiol-17β levels when responsiveness was measured using total IPSS and IPSS-V.

Challenging the Inevitability of Prostate Enlargement: Low Levels of Benign Prostatic Hyperplasia Among Tsimane Forager-Horticulturalists

BACKGROUND

Often considered an inevitable part of male aging, benign prostatic hyperplasia (BPH) is the most common non-life threatening disease to affect men in Western populations. We examine age-related change in prostate size and BPH risk and related serum biomarkers among the Tsimane Amerindians of the Bolivian Amazon who live a traditional lifestyle of hunting and small-scale horticulture. The Tsimane are a critical case study for understanding the etiology of BPH as they have low levels of obesity and metabolic syndrome, as well as lower levels of testosterone than age matched U.S. males, factors associated with BPH in previous research.

METHODS

Ultrasounds were conducted on 348 men aged 28-89 years (median age 56 years). Testosterone, prostate specific antigen, sex hormone binding globulin, and glycosylated hemoglobin were examined in relationship to prostate size and BPH.

RESULTS

Tsimane have less than half of the BPH prevalence experienced by U.S. men, and prostate volumes 62.6% smaller. While Tsimane have low levels of testosterone and subclinical levels of metabolic syndrome compared to U.S. men, Tsimane with high testosterone were more likely to experience BPH, as were those with higher glycosylated hemoglobin, suggesting targets for clinical interventions to reduce BPH.

CONCLUSIONS

These results have clinical significance for the growing number of men taking testosterone supplementation; even at low levels the additional testosterone exposure could be placing these men at higher risk of BPH. Overall, these data suggest that BPH may not have been an inevitable part of male aging throughout human evolutionary history.

Influence of E. coli-induced prostatic inflammation on expression of androgen-responsive genes and transforming growth factor beta 1 cascade genes in rats

BACKGROUND

Prostatic inflammation is reportedly associated with the development of prostatic hyperplasia. We investigated the effects of prostatic inflammation on expression levels of androgen-responsive genes and growth factors in the rat prostate.

METHODS

Prostatic inflammation was induced by Escherichia coli (strain 1677) injection (0.2 ml of 1 × 10(8) CFU/ml) into the prostatic urethra of male Sprague-Dawley rats, and ventral lobes of the prostate were harvested on day 84. Rats were given 10 mg/kg celecoxib during the last month in the COX-2 inhibitor treated group. Histopathology and multiplex enzyme-linked immunosorbent assay (ELISA) for inflammation-related proteins were performed. Glandular epithelial cells and stromal regions were separately isolated using laser-capture microdissection (LCM). Real-time RT-PCR was performed to examine mRNA levels of androgen-responsive genes in the epithelium and tumor growth factor-β1 (TGF-β1) cascade genes in the stroma.

RESULTS

Hematoxylin and eosin staining showed that mild inflammation was distributed diffusely throughout the prostate. Polymorphonuclear cells infiltrated the slightly edematous stroma, but no morphological changes were observed in the epithelium. Immunohistochemically, expression of androgen receptor and TGF-β1 in addition to IL-6 and cyclooxigenase-2 (COX-2) were enhanced in the E. coli inoculated rats. All of these factors were suppressed in the celecoxib-treated rats. Upregulation of IL-1α, IL-1β, IL-6, and RANTES in the E. coli-inoculated rats was normalized by celecoxib treatment. Significant upregulation of androgen receptor and androgen-responsive genes such as Eaf2, ELL2, FKBP5, calreticulin, and ornithine decarboxylase was observed in the LCM-dissected epithelium. Also TGF-β1 and its downstream cascade genes such as Hic-5, collagen 1, and fibronectin were upregulated significantly in the LCM-dissected stroma. The COX-2 inhibitor treatment suppressed upregulation of these genes.

CONCLUSIONS

Prostatic inflammation changed the expression of androgen-responsive genes in the epithelium and TGF-β1 cascade genes in the stroma. Activation of TGF-β1 cascade genes in the inflamed stroma, as well as altered androgen-responsive gene expression in the epithelium, might be involved in the development of BPH. Prostate 75:381-389, 2015. © 2014 Wiley Periodicals, Inc.

Male issues of the ileal pouch

: Restorative proctocolectomy with ileal pouch-anal anastomosis is the standard surgical treatment modality for patients with ulcerative colitis who require colectomy. There are special issues related to male gender. We performed systemic literature review on the topic, incorporating the experience in our specialized Center for Ileal Pouch Disorders, and provide recommendations for the identification and management for the gender-specific issues in male patients with ileal pouches. Chronic pouchitis, particularly ischemic pouchitis, anastomotic leak, and presacral sinus are more common in male patients than their female counterparts. Sexual dysfunction can occur after pouch surgery, particularly in those with pouch failure. Diagnosis and management of benign and malignant prostate diseases can be challenging due to the altered pelvic anatomy from the surgery. Digital rectal examination for prostate cancer screening is not reliable. Transpouch biopsy of prostate may lead to pouch fistula or abscess. Pelvic radiation therapy may have an adverse impact on the pouch function. In conclusion, sexual dysfunction and enlarged prostate can occur in patients with the ileal pouch. The measurement of serum prostate-specific antigen is a preferred method for the screening of prostate cancer. If biopsy of the prostate is needed, the perineal route is recommended. The risk for pouch dysfunction and the benefit for oncologic survival of pelvic radiation for prostate cancer should be carefully balanced.

Predictors of Gleason score upgrading in patients with prostate biopsy Gleason score ≤6

INTRODUCTION

The discrepancy between prostate biopsy and prostatectomy Gleason scores is common. We investigate the predictive value of prostate biopsy features for predicting Gleason score (GS) upgrading in patients with biopsy Gleason scores ≤6 who underwent radical retropubic prostatectomy (RRP). Our aim was to determine predictors of GS upgrading and to offer guidance to clinicians in determining the therapeutic option.

METHODS

We performed a retrospective study of patients who underwent RRP for clinically localized prostate cancer at 2 major centres between January 2007 and March 2013. All patients with either abnormal digital examination or elevated prostate-specific antigen at screening underwent transrectal ultrasound-guided prostate biopsy. Variables were evaluated among the patients with and without GS upgrading. Our study limitations include its retrospective design, the fact that all subjects were Turkish and the fact that we had a small sample size.

RESULTS

In total, 321 men had GS ≤6 on prostate biopsy. Of these, 190 (59.2%) had GS≤6 concordance and 131 (40.8%) had GS upgrading from ≤6 on biopsy to 7 or higher at the time of the prostatectomy. Independent predictors of pathological upgrading were prostate volume <40 cc (p < 0.001), maximum percent of cancer in any core (p = 0.011), and >1 core positive for cancer (p < 0.001).

CONCLUSIONS

When obtaining an extended-core biopsy scheme, patients with small prostates (≤40 cc), greater than 1 core positive for cancer, and an increased burden of cancer are associated with increased risk of GS upgrading. Patients with GS ≤6 on biopsy with these pathological parameters should be carefully counselled on treatment decisions.

Prostate volume and biopsy tumor length are significant predictors for classical and redefined insignificant cancer on prostatectomy specimens in Japanese men with favorable pathologic features on biopsy

Background

Gleason pattern 3 less often has molecular abnormalities and often behaves indolent. It is controversial whether low grade small foci of prostate cancer (PCa) on biopsy could avoid immediate treatment or not, because substantial cases harbor unfavorable pathologic results on prostatectomy specimens. This study was designed to identify clinical predictors for classical and redefined insignificant cancer on prostatectomy specimens in Japanese men with favorable pathologic features on biopsy.

Methods

Retrospective review of 1040 PCa Japanese patients underwent radical prostatectomy between 2006 and 2013. Of those, 170 patients (16.3%) met the inclusion criteria of clinical stage ≤ cT2a, Gleason score (GS) ≤ 6, up to two positive biopsies, and no more than 50% of cancer involvement in any core. The associations between preoperative data and unfavorable pathologic results of prostatectomy specimens, and oncological outcome were analyzed. The definition of insignificant cancer consisted of pathologic stage ≤ pT2, GS ≤ 6, and an index tumor volume < 0.5 mL (classical) or 1.3 mL (redefined).

Results

Pathologic stage ≥ pT3, upgraded GS, index tumor volume ≥ 0.5 mL, and ≥ 1.3 mL were detected in 25 (14.7%), 77 (45.3%), 83 (48.8%), and 53 patients (31.2%), respectively. Less than half of cases had classical (41.2%) and redefined (47.6%) insignificant cancer. The 5-year recurrence-free survival was 86.8%, and the insignificant cancers essentially did not relapse regardless of the surgical margin status. MRI-estimated prostate volume, tumor length on biopsy, prostate-specific antigen density (PSAD), and findings of magnetic resonance imaging were associated with the presence of classical and redefined insignificant cancer. Large prostate volume and short tumor length on biopsy remained as independent predictors in multivariate analysis.

Conclusions

Favorable features of biopsy often are followed by adverse pathologic findings on prostatectomy specimens despite fulfilling the established criteria. The finding that prostate volume is important does not simply mirror many other studies showing PSAD is important, and the clinical criteria for risk assessment before definitive therapy or active surveillance should incorporate these significant factors other than clinical T-staging or PSAD to minimize under-estimation of cancer in Japanese patients with low-risk PCa.

Benign prostatic hyperplasia: a new metabolic disease?

BACKGROUND

Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) are conditions extremely prevalent in the aging male. Although androgens are involved in prostate growth during developmental age, their role in the pathogenesis of BPH/LUTS is debated. Recent data indicate that low testosterone and high estradiol favor disease progression. In addition, the role of other determinants, such as metabolic syndrome or prostate inflammation, is emerging.

AIM

We reviewed the evidence regarding the pathogenesis of BPH/LUTS with particular attention to metabolic influence.

MATERIALS AND METHODS

A review of published evidence was performed using Medline.

RESULTS

Available evidence shows that a three-hit hypothesis can be drawn. An overt, or even a subclinical, bacterial or viral infection could induce prostatic inflammation (first hit) that could be autosustained or exacerbated by the presence of an altered metabolism and in particular by hypercholesterolemia (second hit). Hypogonadism and/or hyperestrogenism could act as a third hit, favoring the maintenance of this inflammatory state. The combined action of all three hits, or even two of them, may result in overexpression of Toll-like receptors (TLRs), transformation of prostatic cells into antigen-presenting cells and activation of resident human prostate-associated lymphoid tissue ending in overproduction of growth factors which, in turn, will induce prostate remodeling and further prostate enlargement. The mechanical obstruction, along with the direct action of the unfavorable metabolic and hormonal milieu on the bladder neck, helps in generating LUTS.

CONCLUSION

Inflammation, dyslipidemia and altered sex-steroid milieu mutually concur in determining BPH/LUTS.

Benign prostatic hyperplasia: a new metabolic disease of the aging male and its correlation with sexual dysfunctions

Metabolic syndrome (MetS) is a well-recognized cluster of cardiovascular (CV) risk factors including obesity, hypertension, dyslipidemia, and hyperglycaemia, closely associated with an increased risk of forthcoming cardiovascular disease and type 2 diabetes mellitus. Emerging evidence indicates that benign prostate hyperplasia (BPH) and its related lower urinary tract symptoms (LUTS) represent other clinical conditions frequently observed in subjects with MetS. Several modifiable factors involved in MetS determinism, such as inadequate diet, lack of physical exercise, and smoking and drinking behaviours are emerging as main contributors to the development of BPH. The pathogenetic mechanisms underlying the connection between MetS and BPH have not been completely clarified. MetS and its components, hypogonadism, and prostate inflammation probably play an important role in inducing BPH/LUTS. Although historically considered as a "normal" consequence of the aging process, BPH/LUTS should now be faced proactively, as a preventable disorder of the elderly. Type of diet and level of physical activity are now considered important factors affecting prostate health in the aging male. However, whether physical exercise, weight loss, and modifications of dietary habit can really alter the natural history of BPH/LUTS remains to be determined. Further research is advisable to better clarify these points.

Opposite effects of tamoxifen on metabolic syndrome-induced bladder and prostate alterations: a role for GPR30/GPER?

BACKGROUND

BPH and LUTS have been associated to obesity, hypogonadism, and metabolic syndrome (MetS). MetS-induced prostate and bladder alterations, including inflammation and tissue remodeling, have been related to a low-testosterone and high-estrogen milieu. In addition to ERs, GPR30/GPER is able to mediate several estrogenic non-genomic actions.

METHODS

Supplementing a subgroup of MetS rabbits with tamoxifen, we analyzed the in vivo effects on MetS-induced prostate and bladder alterations. The effects of selective ER/GPER ligands and GPER silencing on prostate inflammation were also studied in vitro using hBPH cells.

RESULTS

ERα, ERβ, and PR expression was upregulated in MetS bladder, where tamoxifen decreased ERα and PR expression, further stimulating ERβ. In addition, tamoxifen-dosing decreased MetS-induced overexpression of inflammatory and tissue remodeling genes. In prostate, sex steroid receptors, pro-inflammatory and pro-fibrotic genes were upregulated in MetS. However, tamoxifen did not affect them and even increased COX-2. In hBPH cells, 17β-estradiol increased IL-8 secretion, an effect blunted by co-treatment with GPER antagonist G15 but not by ER antagonist ICI 182,780, which further increased it. GPER agonist G1 dose-dependently (IC50  = 1.6 nM) induced IL-8 secretion. In vitro analysis demonstrated that GPER silencing reverted these stimulatory effects.

CONCLUSIONS

GPER can be considered the main mediator of estrogen action in prostate, whereas in bladder the mechanism appears to rely on ERα, as indicated by in vivo experiments with tamoxifen dosing. Limiting the effects of the MetS-induced estrogen action via GPER could offer new perspectives in the management of BPH/LUTS, whereas tamoxifen dosing showed potential benefits in bladder.

Linking pre-diabetes with benign prostate hyperplasia. IGFBP-3: a conductor of benign prostate hyperplasia development orchestra?

Benign prostatic hyperplasia (BPH) represents a pattern of non-malignant growth of prostatic fibromuscular stroma. Metabolic disturbances such us pre-diabetes and metabolic syndrome may have a role in BPH pathophysiology. A potential explanation for the above relationship involves the insulin-like growth factor (IGF) axis as well as IGF binding proteins, (IGFBPs) of which the most abundant form is IGFBP-3. Therefore, the aim of the present study was to investigate the association between intra-prostatic levels of IGF-1, IGF-2 as well as to evaluate the role of locally expressed IGFBP-3 in BPH development in pre-diabetes. A total of 49 patients admitted to the Urology department of a tertiary urban Greek hospital, for transurethral prostate resection, or prostatectomy and with pre-diabetes [impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) or both] were finally included. The majority of the sample consisted of subjects with IGT (51.0%), followed by IFG and IGT (32.7%) and isolated IFG (16.3%). For all participants a clinical examination was performed and blood samples were collected. In addition, total prostate (TP) volume or transitional zone (TZ) volume were estimated by transrectal ultrasonography. The results of the multivariate analysis regarding TP volume showed that higher PSA (p<0.001), larger waist circumference (p=0.007) and higher IGFBP-3 expression levels (p<0.001) independently predicted higher TP volume. The results regarding the volume of the TZ showed that higher PSA (p<0.001), larger waist circumference (p<0.001) and higher IGFBP-3 expression levels (p=0.024) were independently associated with higher TZ volume. Our findings show that intra-prostatic levels of IGFBP-3, PSA and waist circumference, but not overall obesity, are positively associated with prostate volume. IGFBP-3 seems to be a multifunctional protein, which can potentiate or inhibit IGF activity.

Relationship between serum sex hormones levels and degree of benign prostate hyperplasia in Chinese aging men

Benign prostatic hyperplasia (BPH) is one of the most common medical conditions in middle aged and older men. This study investigated the relationship between serum levels of sex hormones and measures of BPH in the aging male population of China. Prostate symptoms were assessed as part of a free health screening program for men ≥ 40 years of age. The examination included digital rectal examination, determination of serum prostate-specific antigen levels, International Prostate Symptom Score (IPSS) and transrectal ultrasonography. Serum levels of total testosterone (TT), sex hormone binding globulin (SHBG), free testosterone (FT), luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL) and estradiol (E(2)) were evaluated. The men also completed a health and demographics questionnaire and received a detailed physical examination. The final study population consisted of 949 men with a mean age of 58.9 years. Pearson correlation analysis indicated that there were significant correlations between age and levels of all sex hormones except TT, and between age and prostate volume (PV; r=0.243; P<0.01) or IPSS (r=0.263; P<0.01). Additional significant correlations were found between IPSS and serum levels of LH (r=0.112; P<0.01) and FSH (r=0.074; P<0.05), but there were no significant correlations between sex hormone levels and PV. Multivariate linear regression analysis showed significant correlations between age and body mass index (BMI) with PV (P<0.0001). In addition, there was a significant correlation between age and PV with IPSS (P<0.0001). Serum sex hormone levels did not correlate with PV or IPSS. The effects of endocrine changes on measures of BPH in aging men require further investigation in longitudinal and multicenter studies that include patients with all severities of BPH.

Relationship of sex hormones and nocturia in lower urinary tract symptoms induced by benign prostatic hyperplasia

OBJECTIVE

The study sought to clarify the relationship between sex hormone levels and lower urinary tract symptoms (LUTS) in patients with benign prostate hyperplasia.

METHODS

Between 2007 and 2010, serum total testosterone (TT), free testosterone, and estradiol were prospectively measured in patients who were transferred to our university hospital. The 924 subjects were divided into two groups. Group I (n = 646) were treated with an alpha blocker only and group II (n = 278) were treated with an alpha blocker + a 5-alpha reductase inhibitor over 3 months before their visit. Clinical conditions were assessed by digital rectal examination, prostate-specific antigen, International Prostate Symptom Score (IPSS), transrectal ultrasonography and maximum urinary flow rate and postvoid residual urine.

RESULTS

The mean age was 69.65 ± 6.56 years. The total IPSS and subscore (storage symptom) was significantly associated with age (p < 0.001/p < 0.05) and the TT level (p < 0.05/p < 0.05). TT level was significantly decreased in patients with ≥ 4 episodes of nocturia. The TT level was significantly related to the presence of severe LUTS (p < 0.05).

CONCLUSIONS

Endogenous testosterone may have a beneficial effect on lower urinary tract function and that a high frequency of nocturia may induce testosterone deficiency.

Significant association between serum dihydrotestosterone level and prostate volume among Taiwanese men aged 40-79 years

INTRODUCTION

We evaluated the association between serum sex hormone levels and prostate volume in Taiwanese men.

METHODS

A cross-sectional study was conducted in 505 men (aged 40-79 years, mean age 58 years). Serum total testosterone (TT), free testosterone (FT), dihydrotestosterone (DHT) and estradiol (E2) levels were measured. Total prostate volume (TPV) and transition zone volume (TZV) were measured by transrectal ultrasonography. Body mass index (BMI), DHT/TT and E2/TT were calculated. Correlations were determined using univariate and multivariate regression analyses.

RESULTS

Apart from DHT, an age-dependent change of sex hormone levels were observed. On univariate analyses, age, BMI, serum DHT level and DHT/TT ratio, as well as serum E2 level and E2/TT ratio, but not serum TT and FT levels showed a significant association with prostate volume. On multivariate analysis, however, only serum DHT level and DHT/TT ratio remained significant. Logistic regression analysis showed that the odds ratios (95% confidence interval) of the second, third, and fourth quartiles of serum DHT levels for benign prostatic hyperplasia (defined as TPV ≥ 20 ml) risk were 2.06 (1.21-3.51), 2.66(1.56-4.53) and 7.15(4.0-12.6), respectively (p < 0.001).

CONCLUSIONS

Higher serum DHT level and DHT/TT ratio were associated with larger prostate volume and higher prevalence of BPH in Taiwanese men.

Androgens and estrogens in benign prostatic hyperplasia: past, present and future

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) are common clinical problems in urology. While the precise molecular etiology remains unclear, sex steroids have been implicated in the development and maintenance of BPH. Sufficient data exists linking androgens and androgen receptor pathways to BPH and use of androgen reducing compounds, such as 5α-reductase inhibitors which block the conversion of testosterone into dihydrotestosterone, are a component of the standard of care for men with LUTS attributed to an enlarged prostate. However, BPH is a multifactorial disease and not all men respond well to currently available treatments, suggesting factors other than androgens are involved. Testosterone, the primary circulating androgen in men, can also be metabolized via CYP19/aromatase into the potent estrogen, estradiol-17β. The prostate is an estrogen target tissue and estrogens directly and indirectly affect growth and differentiation of prostate. The precise role of endogenous and exogenous estrogens in directly affecting prostate growth and differentiation in the context of BPH is an understudied area. Estrogens and selective estrogen receptor modulators (SERMs) have been shown to promote or inhibit prostate proliferation signifying potential roles in BPH. Recent research has demonstrated that estrogen receptor signaling pathways may be important in the development and maintenance of BPH and LUTS; however, new models are needed to genetically dissect estrogen regulated molecular mechanisms involved in BPH. More work is needed to identify estrogens and associated signaling pathways in BPH in order to target BPH with dietary and therapeutic SERMs.

Molecular mechanisms of bladder outlet obstruction in transgenic male mice overexpressing aromatase (Cyp19a1)

We investigated the etiology and molecular mechanisms of bladder outlet obstruction (BOO). Transgenic (Tg) male mice overexpressing aromatase (Cyp19a1) under the ubiquitin C promoter in the estrogen-susceptible C57Bl/6J genetic background (AROM+/6J) developed inguinal hernia by 2 months and severe BOO by 9 to 10 months, with 100% penetrance. These mice gradually developed uremia, renal failure, renal retention, and finally died. The BOO bladders were threefold larger than in age-matched wild-type (WT) males and were filled with urine on necropsy. Hypotrophic smooth muscle cells formed the thin detrusor urinae muscle, and collagen III accumulation contributed to the reduced compliance of the bladder. p-AKT and ERα expression were up-regulated and Pten expression was down-regulated in the BOO bladder urothelium. Expression of only ERα in the intradetrusor fibroblasts suggests a specific role of this estrogen receptor form in urothelial proliferation. Inactivation of Pten, which in turn activated the p-AKT pathway, was strictly related to the activation of the ERα pathway in the BOO bladders. Human relevance for these findings was provided by increased expression of p-AKT, PCNA, and ERα and decreased expression of PTEN in severe human BOO samples, compared with subnormal to mild samples. These findings clarify the involvement of estrogen excess and/or imbalance of the androgen/estrogen ratio in the molecular pathogenetic mechanisms of BOO and provide a novel lead into potential treatment strategies for BOO.

Urinary estrogen metabolites and prostate cancer risk: a pilot study

BACKGROUND

The high incidence of and few identified risk factors for prostate cancer underscore the need to further evaluate markers of prostate carcinogenesis. The aim of this pilot study was to evaluate urinary estrogen metabolites as a biomarker of prostate cancer risk.

METHODS

Using a liquid chromatography-tandem mass spectrometry method, urinary concentrations of 15 estrogen metabolites were determined in 77 prostate cancer cases, 77 healthy controls, and 37 subjects who had no evidence of prostate cancer after a prostate biopsy.

RESULTS

We observed an inverse association between the urinary 16-ketoestradiol (16-KE2) and 17-epiestriol (17-epiE3)--metabolites with high estrogenic activity--and prostate cancer risk. Men in the lowest quartile of 16-KE2, had a 4.6-fold risk of prostate cancer (OR=4.62, 95% CI=1.34-15.99), compared with those in the highest quartile.

CONCLUSIONS

We observed modest differences in estrogen metabolite concentrations between prostate cancer patients and subjects without cancer. Larger studies with both androgen and estrogen measurements are needed to confirm these results to clarify further whether estrogen metabolites are independent biomarkers for prostate cancer risk and whether androgen/estrogen imbalance influences prostate cancer risk.

Role of insulin and testosterone in prostatic growth: who is doing what?

Previous studies have demonstrated increased incidence of benign prostatic hyperplasia in insulin-resistant individuals. In addition to androgens, prostatic growth is sensitive to the peptide growth factors including insulin. Experimental studies employing intervention of selective β-cell toxin streptozotocin and castration suggest that depletion of either insulin or testosterone results in the severe prostatic atrophy (>80%). Exogenous testosterone and diet-induced experimental hyperinsulinemia induces prostatic enlargement in rats. Further, hyperinsulinemia sensitizes prostate towards the growth promoting effect of testosterone, and testosterone augments prostatic growth even in the hypoinsulinemic rats. However, in castrated rats diet-induced hyperinsulinemia fails to promote prostatic growth. Based on these evidences it is hypothesized that in the presence of testosterone insulin plays an important role in the prostatic growth. The epidemiological reports witnessing increased incidences of prostatic enlargement in men with metabolic syndrome, which are known to have increased level of insulin, provides a validating clue to the hypothesis. Further, the hypothesis suggests that targeting insulin signaling pathway could be a new objective for the treatment of prostatic enlargement.

Effect of a hypercholesterolemic diet on serum lipid profile, plasma sex steroid levels, and prostate structure in rats

OBJECTIVES

The purpose of this study was to examine the impact of a hypercholesterolemic diet (HD) on serum lipid profile, plasma sex steroid levels, and ventral prostate structure in rats.

METHODS

Beginning at 120 days of age, male Wistar rats were fed for 5 months with either standard rat chow (15 animals) or standard chow enriched with 4% cholesterol and 1% cholic acid (15 animals). The body and ventral prostate weights (VPWs), plasma sex steroid levels, and lipid profiles were determined, and prostate morphology in fixed tissue sections were studied.

RESULTS

The body weight of rats fed with HD did not differ from that of controls. However, both absolute and relative VPWs of HD animals were significantly lower than those of controls. HD resulted in significant elevation in total serum cholesterol and LDL levels, whereas HDL and triglyceride levels were comparable. Plasma total testosterone and estriol levels did not differ between groups, but their free fraction, along with sex hormone-binding globulin levels, were significantly affected. HD also affected the microscopic structure of the ventral prostate. Epithelial cells of the distal area formed papillary projections within the acinar lumen and had more cytoplasm than controls. In most cases, vesicular formations within the cytoplasmic area were also noted.

CONCLUSIONS

Hypercholesterolemia causes marked changes in the ventral prostate, serum lipid profile, and plasma sex steroid profile in rats and possibly alters prostate morphology by affecting the sex steroid axis, thus contributing to prostatic disease pathogenesis.

Clinical characteristics of bladder urothelial tumors in male patients--the influences of benign prostatic hyperplasia/benign prostatic enlargement

OBJECTIVES

To investigate the clinical characteristics of bladder urothelial tumors in male patients.

PATIENTS AND METHODS

The clinical characteristics of 356 patients with newly diagnosed bladder urothelial tumors from July 2005 to January 2010 were analyzed. Characteristics of different age groups were compared. Furthermore, tumor characteristics were analyzed to define the relationship, if any, with benign prostatic hyperplasia/benign prostatic enlargement.

RESULTS

For bladder urothelial tumors, the percentage of carcinoma increased significantly with increasing age (P < 0.001), and differences were found among 3 age groups in the distribution of high grade carcinoma (P = 0.012). Especially in non-muscle-invasive carcinoma, the percentage of high grade carcinoma increased significantly with increasing age (P = 0.006), with significant differences between the ≤50 years group and the 51-69 years group and ≥70 years group (P = 0.031, P = 0.002). Interestingly, compared with non-benign prostatic hyperplasia/benign prostatic enlargement patients, benign prostatic hyperplasia/benign prostatic enlargement patients were more frequently diagnosed with poorly differentiated tumors, and logistic regression confirmed associations between benign prostatic hyperplasia/benign prostatic enlargement and unfavorable carcinoma, controlling for age (P = 0.009).

CONCLUSIONS

Age is an unfavorable influence on the clinical characteristics of bladder urothelial tumors in men, and it was observed that the percentage of unfavorable tumors increased with age. Interestingly, noticeable changes of tumor differentiation appeared at the age of 50 years, and it was indicated that the natural history of carcinoma appeared to differ according to benign prostatic hyperplasia/benign prostatic enlargement statuses. There was a tendency for the men, who were diagnosed with benign prostatic hyperplasia/benign prostatic enlargement, to present with unfavorable carcinoma.

Expression of proteinase-activated receptor-2 (PAR2) is androgen-dependent in stromal cell line (hPCPs) from benign prostatic hyperplasia

BACKGROUND

Growth properties of the prostate are regulated by a variety of hormones and growth factors. Benign prostatic hyperplasia (BPH) is characterized by abnormal epithelial and stromal proliferation. Varying androgen hormone levels in elderly men are correlated with abnormal proliferations of the prostate. Proteinase-activated receptor-2 (PAR2), a subtype of G-protein-coupled receptors, is known to induce multiple biological processes. It could also play a key role in the proliferation and metastasis of prostate cancer, but its effect on BPH pathogenesis is to a great extent unknown.

METHODS

Localization of PAR2 was determined both in pathologically altered and in normal prostate tissues by using immunohistochemical techniques. PAR2 activity was assessed by measuring changes in intracellular calcium [Ca(2+)](i) following stimulation of cultured stromal cells with a PAR2 agonist (trypsin) and a synthetic PAR2-activating peptide (AP). DHT-dependence of PAR2 expression in prostate cancer and prostatic stromal cell lines was examined with semi-quantitative and quantitative PCR. Cultured stromal cells (hPCPs) were stimulated with PAR2 AP and cell proliferation was determined through [(3)H]-thymidine incorporation.

RESULTS

In comparison to normal prostate, PAR2 expression was increased in BPH stroma. DHT induced a higher expression of PAR2 when sub-physiological DHT-levels were used. Higher levels of DHT produced reduced PAR2 expression. A mitogenic effect was induced by applying PAR2 AP to hPCPs-cells.

CONCLUSIONS

In conclusion, we found that PAR2 expression is hormone-dependent in prostatic stromal cells with a negative correlation and we consider it to be an important factor in mitogenesis in BPH.

Androgens regulate adenylate cyclase activity and intracellular calcium in stromal cells derived from human prostate

BACKGROUND

Increased smooth muscle tone is a significant component of benign prostatic hyperplasia, the onset of which correlates with age and declining serum testosterone levels. This study investigates the effects of androgens on key regulators of smooth muscle tone: intracellular calcium ([Ca(2+)](i)) and cyclic adenosine monophosphate (cAMP) in human cultured prostatic stromal cells (HCPSC).

METHODS

HCPSC were cultured in the absence or presence of dihydrotestosterone (DHT; 3, 30, and 300 nM) or testosterone (0.3-300 nM) alone or in the presence of flutamide (10 microM). Changes in [Ca(2+)](i) were determined in FURA-2AM (10 microM) loaded cells. Changes in cAMP were determined by Alpha Screen(R) assay.

RESULTS

Up to 32% of cultured cells exhibited spontaneous elevations of [Ca(2+)](i). The frequency of these elevations was reduced by nifedipine (10 microM), ryanodine (1 microM), and the adenylate cyclase inhibitor MDL 12,330A (20 microM). Compared to steroid-free cells, a 3-day incubation of cells with testosterone (only 3 nM) elevated basal, but not peak [Ca(2+)](i). In the presence of flutamide, all concentrations of testosterone tested elevated basal, but not peak [Ca(2+)](i). DHT (30 and 300, but not 3 nM) lowered peak and basal [Ca(2+)](i). Increased testosterone concentration dependently decreased resting cell cAMP (pIC(50): 7.64 +/- 0.29 nM).

CONCLUSIONS

These findings demonstrate that some HCPSC have the ability to spontaneously and transiently elevate [Ca(2+)](i). The magnitude of these [Ca(2+)](i) peaks, along with resting levels of calcium and cAMP, appear to be regulated by androgens.

Estrogens and bladder outlet obstruction

Increasing evidence indicates a direct interrelationship between benign prostatic hyperplasia and chronic non-bacterial prostatic inflammation in the development of human voiding dysfunction in aging male, which gradually transforms to bladder outlet obstruction (BOO). Increased prevalence of BOO along with the aging process further suggests that estrogen or more precisely decreased androgen to estrogen ratio in serum is involved in the pathogenesis of BOO. In this review, we will analyze the hormonal causes, clinical relevance, and biologically relevant estrogen-modulated animal models potential for BOO study. In light of the data presented in this review, it becomes apparent that direct inhibition of estrogen action may provide important pharmaceutical treatment of the BOO.

Androgen regulated genes in human prostate xenografts in mice: relation to BPH and prostate cancer

Benign prostatic hyperplasia (BPH) and prostate carcinoma (CaP) are linked to aging and the presence of androgens, suggesting that androgen regulated genes play a major role in these common diseases. Androgen regulation of prostate growth and development depends on the presence of intact epithelial-stromal interactions. Further, the prostatic stroma is implicated in BPH. This suggests that epithelial cell lines are inadequate to identify androgen regulated genes that could contribute to BPH and CaP and which could serve as potential clinical biomarkers. In this study, we used a human prostate xenograft model to define a profile of genes regulated in vivo by androgens, with an emphasis on identifying candidate biomarkers. Benign transition zone (TZ) human prostate tissue from radical prostatectomies was grafted to the sub-renal capsule site of intact or castrated male immunodeficient mice, followed by the removal or addition of androgens, respectively. Microarray analysis of RNA from these tissues was used to identify genes that were; 1) highly expressed in prostate, 2) had significant expression changes in response to androgens, and, 3) encode extracellular proteins. A total of 95 genes meeting these criteria were selected for analysis and validation of expression in patient prostate tissues using quantitative real-time PCR. Expression levels of these genes were measured in pooled RNAs from human prostate tissues with varying severity of BPH pathologic changes and CaP of varying Gleason score. A number of androgen regulated genes were identified. Additionally, a subset of these genes were over-expressed in RNA from clinical BPH tissues, and the levels of many were found to correlate with disease status. Our results demonstrate the feasibility, and some of the problems, of using a mouse xenograft model to characterize the androgen regulated expression profiles of intact human prostate tissues.

The impact of diabetes type 2 in the pathogenesis of benign prostatic hyperplasia: a review

Introduction. Clinical observation of larger prostate glands in men with diabetes mellitus type 2 led some investigators to hypothesize that an association between these two conditions exists. In fact, both diseases are very common in men as they age and seem to be sharing similar epidemiologic features. Several studies examining the above hypothesis were yielded. Aim. The purpose of this paper is to summarize the existing literature focusing on the coexistence of BPH and diabetes mellitus type 2 and to elucidate whether or not an association among these conditions exists. Methods. We identified studies published from 1990 onwards by searching the MEDLINE database of the National Library of Medicine. Initial search terms were benign prostatic hyperplasia, epidemiology, and risk factor, combined with diet hyperinsulinemia, and diabetes mellitus type 2. Results. Diabetes mellitus type 2 and hyperinsulinemia are quite common conditions and often coexist with BPH. There are several studies (observational, epidemiological, and experimental) examining the association between them in literature. Conclusion. Evidence suggests that an association between BPH and diabetes through a common pathogenic mechanism is possible. The specific pathway interfering in the development of both conditions is still poorly investigated; thus, the exact relationship of BPH to diabetes remains unclear.

Prostate growth and prevalence of prostate diseases in early onset spinal cord injuries

BACKGROUND

Controversial data on modifications of prostate size, function and disease of spinal cord injury (SCI) patients has been previously reported.

OBJECTIVE

An analytical observational cohort study on male SCI patients was planned in order to evaluate prostate gland growth, including benign prostatic hyperplasia in relation to the age of the patient at SCI onset. Additional evaluations considered hormonal and biochemical parameters and prostate cancer.

DESIGN, SETTING AND PARTICIPANTS

113 SCI patients (mean age 61.3) and 109 age-matched able bodied subjects (mean age 65.4) were enrolled and stratified according to the patient age at SCI onset (< or = 30, 31-49, and > or = 50 years).

INTERVENTION

A complete medical history was then collected from all SCI patients and able bodied subjects.

MEASUREMENTS

Total prostate antigen (PSA) and testosterone (T) serum levels and urine culture were collected. Digital rectal examination and transrectal ultrasonography were performed.

RESULTS AND LIMITATIONS

Patients with SCI showed PSA value and prostate size significantly lower than those observed in able bodied subjects, and an inverse relationship was observed in SCI patients between these two parameters and patient age at the time of lesion onset. T serum levels were lower in SCI patients when compared to able bodied subjects. No SCI patient presented prostate cancer, while 9.7% of control subjects were affected by prostate cancer.

CONCLUSIONS

Prostate volume and PSA levels are lower in SCI patients and are inversely related to the patient age at lesion onset. Whether this effect is mediated directly or indirectly by a impaired nerve supply to the prostate remains to be determined. Despite the present observation of reduced prostate disease, as during the last twenty years life expectancy in SCI patients has improved significantly, the need to screen these patients for the occurrence of prostate disease should not be disregarded.

A possible relationship between testosterone and lower urinary tract symptoms in men

PURPOSE

In this study we searched for possible associations between serum testosterone levels and the severity of lower urinary tract symptoms in men.

MATERIALS AND METHODS

In 278 patients with a mean age of 62 years blood levels of total testosterone, albumin, sex hormone-binding globulin, fasting glucose, fasting insulin and high sensitivity C-reactive protein were measured. Free testosterone, bioavailable testosterone and homeostasis model assessment of insulin resistance were calculated. Prostate volume was measured by transrectal ultrasonography and the severity of lower urinary tract symptoms was assessed using the International Prostate Symptom Score.

RESULTS

Calculated free testosterone and bioavailable testosterone were negatively related to International Prostate Symptom Score total scores and subscores (voiding symptoms) after adjusting for age, prostate volume, high sensitivity C-reactive protein and homeostasis model assessment of insulin resistance (p <0.05). In addition, calculated free testosterone and bioavailable testosterone were significantly related to the presence of severe lower urinary tract symptoms (International Prostate Symptom Score 20 or greater) using unadjusted and adjusted models (p <0.05), although the odds ratio of bioavailable testosterone was lower than that of calculated free testosterone on multivariate analysis. High sensitivity C-reactive protein was negatively correlated with serum total testosterone (r = -0.128, p = 0.038) and bioavailable testosterone (r = -0.126, p = 0.041), and homeostasis model assessment of insulin resistance was negatively correlated with serum total testosterone (r = -0.236, p <0.001), calculated free testosterone (r = -0.179, p = 0.003) and bioavailable testosterone (r = -0.162, r = 0.007). However, no significant correlation was found between high sensitivity C-reactive protein or homeostasis model assessment of insulin resistance, and International Prostate Symptom Score total scores, voiding symptoms scores and storage symptoms scores.

CONCLUSIONS

Our findings support the favorable role of endogenous testosterone in lower urinary tract function and suggest that testosterone deficiency may be a pathophysiological mechanism connecting lower urinary tract symptoms and the metabolic syndrome in men.

Immunohistochemical Analysis of Low-Affinity Nerve Growth Factor Receptor in the Human Urinary Bladder

INTRODUCTION

Interest in the regulation of nerve growth factor (NGF) production in the urinary tract derives from its probable involvement in obstructive, inflammatory and developmental disorders. Our aim was to investigate the presence of low-affinity nerve growth factor receptor (LNGFR) in the vesical urothelium of patients with bladder outlet obstruction.

SUBJECTS AND METHODS

The study included 20 patients with urodynamically confirmed outflow obstruction and 10 control patients without outflow obstruction. Cold cup biopsies of the posterior wall of the urinary bladder were obtained from all patients. Intensity and distribution of LNGFR in the human urinary bladder were examined immunohistochemically.

RESULTS

We detected LNGFR immunostaining in all specimens, and it was observed at the (luminal) epithelial surface and in nerve fibers. In the obstruction group, LNGFR immunoreactivity scores were higher than in the control group, but there was no statistically significant difference (p > 0.05).

CONCLUSIONS

The presence of LNGFR was demonstrated in the urothelium of the human urinary bladder, and these findings show that cells in hypertrophied and normal bladder can synthesize NGF. This observation may have a potential role for therapeutic implications. However, further studies are needed for an explanation of the pathophysiology and the role in treatment.