Associations between longitudinal changes in serum estrogen, testosterone, and bioavailable testosterone and changes in benign urologic outcomes

Serum Testosterone and Dihydrotestosterone and Incidence and Progression of Lower Urinary Tract Symptoms: Results From the REDUCE Study

PURPOSE

Though the pathogenesis of benign prostatic hyperplasia is unclear, it was previously believed that increasing androgen levels contributed, though not all data support this idea. We tested if elevated serum testosterone or dihydrotestosterone were risk factors for lower urinary tract symptoms incidence in asymptomatic men and for lower urinary tract symptoms progression in symptomatic men.

MATERIALS AND METHODS

A post hoc analysis of REDUCE was performed in 3009 asymptomatic men and in 2145 symptomatic men. REDUCE was a randomized trial of dutasteride for prostate cancer prevention in men with an elevated prostate-specific antigen and negative prestudy biopsy. We estimated multivariable adjusted hazard ratios and 95% confidence intervals using Cox models to test the association between quintiles of serum testosterone and dihydrotestosterone at baseline and lower urinary tract symptoms incidence and progression and tested for interaction by treatment arm (dutasteride vs placebo).

RESULTS

In asymptomatic men, there was no evidence serum testosterone or dihydrotestosterone were related to lower urinary tract symptoms incidence (P = .9, P = .4). In symptomatic men, there was no evidence serum testosterone or dihydrotestosterone were related to lower urinary tract symptoms progression (P = .9, P = .7). Results were similar in both placebo and dutasteride arms (all P interaction ≥ .3).

CONCLUSIONS

In REDUCE, higher serum testosterone and higher serum dihydrotestosterone were not associated with either lower urinary tract symptoms incidence in asymptomatic men or lower urinary tract symptoms progression in symptomatic men. These data do not support the hypothesis that serum androgens in middle-aged men are associated with lower urinary tract symptoms.

Dietary reversal reverts diet-induced alterations in obstructed bladders of Wistar rats

OBJECTIVES

The aim of this study was to investigate the effects of diet reversal to standard chow on diet-induced changes in structure and function of normal and obstructed bladders in male Wistar rats.

METHODS

Eighty animals were equally divided into sham-surgery and bladder outlet obstruction (BOO) dietary groups and fed standard chow (control), high-carbohydrate, high-fat, and high-protein diets. BOO groups had surgically induced BOO, whereas sham surgery was performed on sham groups at the end of week 8. Animals were continued on the treatment diets for 4 wk after surgery, then the diets were all changed to standard chow for the remainder of the study period. Bladder weight, detrusor contractility, Rho-associated protein kinase (Rho-kinase), and myosin light chain kinase were determined. Polymerase chain reaction was used to assay for transforming growth factor-β, connecting tissue growth factor, hypoxia-inducible factor-1α, and platelet-derived growth factor subunit A levels in the bladder. C-reactive protein, insulin-like growth factor-1, nerve growth factor, and C-X-C motif chemokine ligand 12 concentrations were determined by enzyme-linked immunosorbent assay. The collagen content of the bladder was estimated by liquid chromatography/mass spectrometry.

RESULTS

Reversal of diet to standard chow resulted in reversal of diet-induced changes in all variables measured in obstructed bladders. High-fat-diet-induced alterations in normal bladders were also reversed.

CONCLUSION

The results suggested that in obstructed bladders of animals, reversal of the diet could reverse all diet-associated changes that increase inflammation and fibrosis in obstructed bladders. This is especially important in changes related to high consumption of fatty diets and associated lower urinary tract symptoms.

Testosterone therapy may reduce prostate cancer risk due to testosterone deficiency at a young age via stabilizing serum testosterone levels

Objectives: To investigate whether testosterone replacement therapy (TRT) reduces prostate cancer (PCa) risk via stabilizing serum testosterone (T) levels beyond simply elevating serum T levels and whether TRT reduces PCa risk due to low serum T levels at a young age.Methods: We analyzed data of 776 hypogonadal men from a urology center in Bremerhaven, Germany through 2004-2016 to investigate whether the TRT group has more stable T levels and whether TRT can reduce the risk of PCa due to low serum T levels at an early age. We derived an index, Maximum Decline of T Relative to Baseline (MDRB), to describe the magnitude of T declines and variations over time.Results: We found the TRT group has more stable serum T levels (e.g. smaller drop-offs) during the follow-up period as compared to the non-TRT group, and the mean of MDRB is significantly higher in the untreated group (1.553 nmol/L VS 0.013 nmol/L; p-value < .001). TRT significantly reduces the risk of PCa associated with T deficiency at a young age (p-value = .00087).Conclusions: TRT may reduce PCa risk via maintaining serum T levels within individual's normal range; T surveillance may be needed for males who have low serum T levels at a young age to monitor abnormal variations of T levels and ensure timely treatment when necessary to reduce PCa risk.

Late-onset hypogonadism: Prostate safety

BACKGROUND

There have always been concerns regarding testosterone replacement therapy and prostate safety because of the central role of testosterone in prostate tissue. Even though there is a body of evidence supporting that the benefits of testosterone replacement therapy outbalance the risks of prostate disease, this matter is still debatable and represents a common concern among testosterone prescribers.

OBJECTIVES

The aim of this article was to review the influence of testosterone on prostate pathophysiology and discuss the potential impact of testosterone replacement therapy on the most common prostate pathologies, including benign prostatic hyperplasia and prostate cancer.

MATERIALS AND METHODS

We have performed an extensive PubMed review of the literature examining the effects of testosterone replacement therapy on the prostate and its most common affections, especially in terms of safety.

RESULTS

Testosterone replacement therapy has been shown to improve components of metabolic syndrome and decrease prostate inflammation, which is related to the worsening of lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia. Studies evaluating the link between testosterone replacement therapy and benign prostatic hyperplasia/LUTS have mostly demonstrated no change in symptom scores and even some benefits. There are a significant number of studies demonstrating the safety of testosterone replacement therapy in individuals with late-onset hypogonadism and a history of prostate cancer. The most recently published guidelines have already acknowledged this fact and do not recommend against T treatment in this population, particularly in non-high-risk disease.

CONCLUSION

Testosterone replacement therapy could be considered for most men with late-onset hypogonadism regardless of their history of prostate disease. However, a discussion about the risks and benefits of testosterone replacement therapy is always advised, especially in men with prostate cancer. Appropriate monitoring is mandatory.

Compliance With American Urological Association Guidelines for Nonmuscle Invasive Bladder Cancer Remains Poor: Assessing Factors Associated With Noncompliance and Survival in a Rural State

OBJECTIVE

To identify factors associated with nonmuscle invasive bladder cancer (NMIBC) American Urological Association (AUA) guideline compliance in a rural state, to evaluate compliance rates over time, and to assess the impact of patient and provider rurality on delivery of NMIBC care.

METHODS

We identified 847 Iowans in Surveillance, Epidemiology, and End Results-Medicare from 1992 to 2009 with high-grade NMIBC who survived 2 years and were not treated with cystectomy or radiation during this period. Compliance with AUA guidelines was assessed over time and compared to patient demographic, tumor, and treatment institution variables. Impact of rurality was analyzed using Surveillance, Epidemiology, and End Results ZIP code data travel distance of patient to nearest urologist practice location.

RESULTS

Overall compliance with AUA guidelines was low (<1%), and did not markedly improve over the study period. In the multivariable model, only care at an academic medical center (OR 11.68, 95% CI 7.07-19.29) and tumor stage (Tis; OR 3.24, 95% CI 1.86-5.63) increased the odds of compliance. Patients living closer (<10 miles) to their urologists underwent more cystoscopies than patients living further (>30 miles) but distance did not affect compliance with other measures. Compliance was not associated with cancer-specific survival.

CONCLUSION

Compliance with post-Transurethral Resection of Bladder Tumor (TURBT) NMIBC treatment guidelines has improved but remains suboptimal in our rural state, and is highly associated with treatment at an academic cancer center for reasons that could not be fully explained with these data.

[How to prevent LUTS due to BPH development and progression]

OBJECTIVE

Our objective was to define potential risk factors for lower urinary tract symptoms (LUTS) related with benign prostatic hyperplasia (BPH).

METHOD

A non-systematic review of the scientific literature was conducted from the PubMed database to extract the most relevant scientific publications between 2000 and July 2018 and cross them with the recommendations of the AFU and the EA by combining the keywords HBP with diet, diet, physical activity, spa treatments, tobacco, alcohol, cardiovascular risk factors, testosterone or inflammation. A synthesis has been proposed in order to identify the important elements to proscribe or modify in order to limit the development and progression of LUTS/BPH.

RESULTS

LUTS due to BPH are clearly associated with erectile dysfunction, cardiovascular diseases and metabolic syndrome. Some reversible risk factors have been identified such as low physical activity, overweight and hypercaloric nutrition. Interventions such as increased physical activity, weight-loss, and a diet including vegetables, tomatoes, carrots, vitamin E, lycopene, selenium, carotene, correction of the metabolic syndrome, stress reduction, and a suitable urinary behavior may impact progression of the disease.

CONCLUSION

Education of the patients on reversible risk factors for LUTS due to BPH is crucial and should be included in everyday practice. Physical activity and weight-loss are the most important factors to take into account.

LEVEL OF EVIDENCE

5 consensus d'experts.

A possible relationship between serum sex hormones and benign prostatic hyperplasia/lower urinary tract symptoms in men who underwent transurethral prostate resection

In this study, we examined the relationship between sex hormone levels and lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH) who underwent transurethral surgery. The study was conducted in 158 patients who came to our hospital for surgery. Clinical conditions were assessed by body mass index (BMI), digital rectal examination, International Prostate Symptom Score (IPSS) and transrectal ultrasound (TRUS). The levels of sex hormones (including total testosterone (TT), estradiol (E₂), progesterone (P), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and prolactin (PRL)) and prostate-specific antigen (PSA) were reviewed. Correlations were determined through statistical analysis. The mean age was 72.06 ± 8.68 years. The total IPSS was significantly associated with the TT level (r = −0.21, P= 0.01). Other sex hormone levels were not correlated with total IPSS. However, some ratios such as E₂/TT (r = 0.23, P= 0.00) and FSH/LH (r = −0.17, P = 0.04) were associated with total IPSS. Further analysis showed that the nocturia was associated with age (r = 0.16, P= 0.04), BMI (r = 0.21, P = 0.01), and TT (r = −0.19, P= 0.02). Moreover, we divided the patients into two subgroups based on IPSS severity (<20 or ≥20). The mean TT level was in the normal range, but it was significantly related to the presence of severe LUTS. In summary, our study has shown that the severity of LUTS is associated with TT, E₂/TT and FSH/LH in men who underwent prostate surgery. Increasing nocturia was observed in lower testosterone patients. Additional larger studies are needed to elucidate the potential mechanisms.

Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme

Background

Electronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.

Objective

To evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.

Design

Epidemiological cohort, health informatics, health economics and ethnographic approaches were used.

Setting

230 NHS hospitals and 226 general practices in England and Wales.

Participants

Up to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.

Main outcome measures

Quality of care, fatal and non-fatal cardiovascular disease (CVD) events.

Data platform and methods

We created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.

Results

CALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.

Conclusions

Emerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.

Future work

The vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.

Study registration

CALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).

Testosterone replacement therapy and voiding dysfunction

Testosterone replacement therapy (TRT) represents an increasing popular treatment option for men with late-onset hypogonadism (LOH). Because of unsubstantiated beliefs of testosterone’s effect on the prostate, the FDA has recently placed a warning on testosterone products, stating that TRT may worsen benign prostatic hyperplasia (BPH). Within this review article we have demonstrated the current understanding of the physiology of testosterone and its relationship with prostatic and lower urinary tract physiology. The current evidence suggests that not only does TRT not worsen lower urinary tract symptoms (LUTS), but that hypogonadism itself is an important risk factor for LUTS/BPH.

Testosterone Replacement Therapy: The Emperor's New Clothes

The mean age of the world population has steadily increased in the last decades, as a result of increased life expectancy and reduced birth rate. Global aging has led to a greater worldwide cost for healthcare: hormonal alterations contribute to the pathogenesis of several conditions and might cause a significant reduction in the perceived sense of well-being. Menopause is archetypal of hormonal alterations occurring during aging: in males, sex hormones do not decrease abruptly, yet testosterone levels decrease steadily and continuously during aging, ultimately resulting in late-onset hypogonadism. Treatment of this condition might mitigate most symptoms; however, testosterone replacement therapy (TRT) should be prescribed only in selected patients and it should not be considered as an antiaging treatment. In recent years, different authors have questioned health risks associated with testosterone treatment; while position statements from many scientific societies seem to be reassuring, the Food and Drug Administration has issued a warning in regard to the possible side effects of this therapy. We aim to review recent controversies and discoveries in regard to TRT.

Increased susceptibility of estrogen-induced bladder outlet obstruction in a novel mouse model

Disorders of the prostate and lower urinary tract are common in elderly men. We investigated the role of metallothionein-1 (MT1) in prostate carcinogenesis by generating a prostate-specific, MT1-expressing mouse. Unexpectedly, genomic analyses revealed that a 12.1-kb genomic region harboring several conserved noncoding elements was unintentionally deleted, upstream of the transgene integration site in the mouse, which we named it 12.1ΔMT1. Male 12.1ΔMT1 mice chronically treated with testosterone (T) plus 17β-estradiol (E2) to induce prostate cancer exhibited no evidence of precancerous or cancerous lesions. Instead, most of them exhibited a bladder outlet obstruction (BOO) phenotype not observed in treated wild-type (WT) mice. Thus, we hypothesized that 12.1ΔMT1 is a novel model for studying the hormonal requirement for BOO induction. Adult male 12.1ΔMT1 and WT mice were treated with T, E2, bisphenol A (BPA), T+E2, or T+BPA for up to 6 months. Histologic and immunohistochemical analysis of the prostate, bladder, and urethra were performed. No significant prostate pathologies were observed in WT or 12.1ΔMT1 mice treated with any of the hormone regimens. As expected, prostatic regression occurred in all E2-treated animals (WT and 12.1ΔMT1). Of great interest, despite a small prostate, 100% of E2-treated 12.1ΔMT1 mice, but only 40% of E2-treated WT mice, developed severe BOO (P<0.01). In contrast, T+E2 treatment was less effective than E2 treatment in inducing severe BOO in 12.1ΔMT1 mice (68%, P<0.05) and was completely ineffective in WT animals. Similarly, T, BPA, and T+BPA treatments did not induce BOO in either WT or 12.1ΔMT1 mice. The BOO pathology includes a thinner detrusor wall, narrowing of bladder neck and urethral lumen, and basal cell hyperplasia in the bladder body and urethra. These findings indicate that 12.1ΔMT1 mice exhibit enhanced susceptibility to E2-induced BOO that is independent of prostate enlargement but that is attenuated by the conjoint treatment with T.

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.

Data resource profile: cardiovascular disease research using linked bespoke studies and electronic health records (CALIBER)

The goal of cardiovascular disease (CVD) research using linked bespoke studies and electronic health records (CALIBER) is to provide evidence to inform health care and public health policy for CVDs across different stages of translation, from discovery, through evaluation in trials to implementation, where linkages to electronic health records provide new scientific opportunities. The initial approach of the CALIBER programme is characterized as follows: (i) Linkages of multiple electronic heath record sources: examples include linkages between the longitudinal primary care data from the Clinical Practice Research Datalink, the national registry of acute coronary syndromes (Myocardial Ischaemia National Audit Project), hospitalization and procedure data from Hospital Episode Statistics and cause-specific mortality and social deprivation data from the Office of National Statistics. Current cohort analyses involve a million people in initially healthy populations and disease registries with ∼10⁵ patients. (ii) Linkages of bespoke investigator-led cohort studies (e.g. UK Biobank) to registry data (e.g. Myocardial Ischaemia National Audit Project), providing new means of ascertaining, validating and phenotyping disease. (iii) A common data model in which routine electronic health record data are made research ready, and sharable, by defining and curating with meta-data >300 variables (categorical, continuous, event) on risk factors, CVDs and non-cardiovascular comorbidities. (iv) Transparency: all CALIBER studies have an analytic protocol registered in the public domain, and data are available (safe haven model) for use subject to approvals. For more information, e-mail s.denaxas@ucl.ac.uk

The "Aging Males' Symptoms" Scale (AMS): predictive value for lowered circulating androgens

BACKGROUND

Symptoms of the "male climacteric" are often at least in part referred to an age-dependent decline of serum androgen levels. Therefore, we evaluated the relationship of climacteric symptoms as assessed by the "Aging Males' Symptoms" (AMS) Questionnaire with circulating androgen levels.

METHODS

146 ambulatory men (age, 27-85 years) were surveyed with the AMS Questionnaire and sampled for serum values of total testosterone (tT) and sexual hormone binding globulin (SHBG). Free testosterone (fT) was calculated from tT and SHBG. A total AMS score ≥37 was considered pathological; the lower limits for tT and fT were set to 8 nmol/l and 180 pmol/l, respectively.

RESULTS

A significant deficit in tT and fT was shown in 25 (17.1%) and 34 (24.5%) men, respectively; the AMS Questionnaire showed pathological results for 66 (45.2%) men. In predicting a tT deficit, the AMS Questionnaire rendered a sensitivity of 76% and a specificity of 61.6%, only. However, multiple regression analysis revealed a significant correlation of lowered tT with a pathological somatovegetative and psychological AMS subscore (p = 0.042 and p = 0.01) and a correlation of lowered fT with a pathological sexual subscore (p = 0.039).

CONCLUSION

In predicting hypogonadism the AMS Questionnaire in total did not render a sufficient diagnostic efficiency.

Office evaluation of male patients with lower urinary tract symptoms

Lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) are one of the most common urologic disorders in men. Accurate history-taking and focused physical examination allows us to diagnose the majority of cases. A better understanding of risk factors helps us tailor our treatment and predict outcomes more accurately. Population studies are crucial in our understanding of LUTS/BPH natural history. Temporary prostatic urethral stents that are used for the management of urinary retention may also be used for evaluation of patients with detrusor hypo-contractility. The use of ultrasound to measure intravesical prostatic protrusion (IPP) and the Doppler study for prostate capsular artery resistive index are promising. Near-infrared spectroscopy (NIRS) examines the tissue oxygenation that may be affected by bladder outlet obstruction. The mathematical algorithm needs some fine-tuning, and its reproducibility is debatable. Serum and urinary biomarkers may help us to diagnose the disorder, and more effectively monitor patients' response to therapy. Among all, IPP is clinically more applicable at this time.

Lower urinary tract symptoms and diet quality: findings from the 2000-2001 National Health and Nutrition Examination Survey

OBJECTIVE

To evaluate the association between dietary quality and the prevalence of lower urinary tract symptoms (LUTS).

METHODS

We used urinary symptom and dietary data obtained from the 2000-2001 National Health and Nutrition Examination Survey (NHANES) for the study. Dietary quality was assessed using the 10-component United States Department of Agriculture (USDA) Healthy Eating Index (HEI). We used bivariate methods to examine rates of LUTS among men with poor versus good diets. Multivariable logistic regression was used to calculate odds ratios after applying sample weights and controlling for age, race/ethnicity, smoking status, diabetes, alcohol intake, and exercise.

RESULTS

Our study cohort consisted of 1385 men aged ≥40 years, of whom 279 (21.1%) reported LUTS. We found higher rates of LUTS among men with poor dietary intake of dairy (22.4% vs 16.4%, P = .013) and among men with poor intake of protein (24.6% vs 17.9%, P = .012) as well as among those with overall poor diet (25.8 vs 17.8%, P = .018) with little dietary variety (26.1 vs 17.6%, P = .001). On multivariate analysis, an unhealthy diet (odds ratios [OR] = 1.7; 95% confidence interval [CI] = 1.05-2.90) was associated with more LUTS, whereas alcohol intake was protective from LUTS (OR = 0.67; 95% CI = 0.48-0.93).

CONCLUSION

In an analysis of NHANES data, we found that poor diet quality was independently associated with patient-reported LUTS.

Practice patterns of recently fellowship-trained reconstructive urologists

OBJECTIVE

To analyze the practice patterns of recently fellowship-trained reconstructive urologists to help guide fellowship program curriculum development and to evaluate the impact that formal reconstructive urology training has on academic urology programs.

METHODS

We evaluated the case logs of 7 recently fellowship-trained reconstructive urologists affiliated with US academic institutions from August 2009 to August 2011 (median years in practice = 2, range 1-6 years). We categorized cases into endoscopic, oncological, female, general (nononcological), and reconstructive. Our primary outcome was the volume of reconstructive procedures as a percentage of all procedures. Our secondary outcome was the correlation between years in practice and reconstructive volume and case complexity.

RESULTS

A total of 3561 cases were analyzed, representing 12 surgeon-years. Endoscopic surgery was most common (42.7%), followed by reconstructive (36.1%), general urologic (10.5%), and oncological (3.7%). The most common type of reconstructive procedure performed was anterior urethroplasty (mean 42.8 per year) followed by bladder reconstruction (mean 17.7 per year). The percentage of yearly cases considered reconstructive was positively associated with total years in practice (r = .688, P = .013) as was the complexity of artificial urinary sphincter cases (r = .857, P = .0004), but not urethral reconstructive complexity (r = .40, P = .197).

CONCLUSION

The demand for services delivered by fellowship-trained reconstructive urologists is high, as evidence by the large percentage of reconstructive procedures in this cohort even early in practice. With additional years in practice comes further specialization.

Total testosterone may not decline with ageing in Korean men aged 40 years or older

OBJECTIVE

It is generally believed that gonadal function in men declines with ageing. However, observations on ageing-related decrease in total testosterone (TT) are not consistent. The aim of this study is to examine the ageing-related changes of testosterone and to investigate the influence of the ageing-related factors on TT.

DESIGN

Changes of TT with ageing were observed in longitudinal design in a single health promotion centre.

SUBJECTS

A total of 220 Korean men aged ≥40 years were included between 2002 and 2011. TT assay was repeated for all subjects, with an interval of ≥3 years.

MEASUREMENTS

Information of medical history and lifestyle habits was collected. Anthropometry and blood pressure were measured. TT, glucose, creatinine, highly sensitive C-reactive protein, liver enzymes and lipid profiles were tested.

RESULTS

Mean TT level did not decline significantly with ageing during median 4·3 years follow-up (18·1 vs 17·8 nm, P = 0·439). Longitudinal change of TT was approximately + 0·8% per year. TT was negatively correlated with body mass index (BMI), waist circumference and glucose. With mixed effects model, diabetes (P = 0·038) and BMI (P = 0·007) affected TT level, but age and follow-up interval did not.

CONCLUSIONS

TT did not change significantly in 220 Korean men for a median 4·3 years follow-up. TT was not influenced by the age and follow-up interval. BMI and diabetes mellitus affected TT decline.

Estrogens in men: clinical implications for sexual function and the treatment of testosterone deficiency

INTRODUCTION

The role of estrogens in male sexual function and the pathogenesis of testosterone deficiency remain controversial and poorly understood.

AIMS

To review the distribution of estrogens in normal and testosterone deficient men, their potential role in sexual function, and the clinical implications of elevated estrogens during testosterone therapy.

METHODS

A comprehensive, broad-based literature review was conducted on the role of estrogens in male sexual function and testosterone deficiency.

RESULTS

Estrogens elicit a variety of physiological responses in men and may contribute to modulation of sexual function. In the absence of testosterone deficiency, elevations in estrogens do not appear to be harmful and estrogens may help maintain some, but not all, sexual function in castrated men. While the therapeutic use of estrogens at pharmacologic doses has been used to suppress serum testosterone, naturally occurring elevations of estrogens do not appear to be a cause of low testosterone. During testosterone replacement, estrogens may rise and occasionally reach elevated levels. There is a lack of evidence that treatment of elevated estrogen levels during testosterone replacement has benefit in terms of male sexuality.

CONCLUSION

Further research on the importance of estrogens in male sexual function is needed. Current evidence does not support a role of naturally occurring estrogen elevations in testosterone deficiency or the treatment of elevated estrogens during testosterone therapy.

Testosterone protects from metabolic syndrome-associated prostate inflammation: an experimental study in rabbit

Metabolic syndrome (MetS) and benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS) are often associated. One of their common denominators is hypogonadism. However, testosterone supplementation is limited by concerns for potential prostatic side effects. The objective was to determine whether MetS-associated prostate alterations are prevented by testosterone supplementation. We used a previously described animal model of MetS, obtained by feeding male rabbits a high-fat diet (HFD) for 12 weeks. Subsets of HFD rabbits were treated with testosterone or with the farnesoid X receptor agonist INT-747. Rabbits fed a standard diet were used as controls. HFD-animals develop hypogonadism and all the MetS features: hyperglycemia, glucose intolerance, dyslipidemia, hypertension, and visceral obesity. In addition, HFD-animals show a prostate inflammation. Immunohistochemical analysis demonstrated that HFD-induced prostate fibrosis, hypoxia, and inflammation. The mRNA expression of several proinflammatory (IL8, IL6, IL1β, and TNFα), T lymphocyte (CD4, CD8, Tbet, Gata3, and ROR γt), macrophage (TLR2, TLR4, and STAMP2), neutrophil (lactoferrin), inflammation (COX2 and RAGE), and fibrosis/myofibroblast activation (TGFβ, SM22α, αSMA, RhoA, and ROCK1/ROCK2) markers was significantly increased in HFD prostate. Testosterone, as well as INT-747, treatment prevented some MetS features, although only testosterone normalized all the HFD-induced prostate alterations. Interestingly, the ratio between testosterone and estradiol plasma level retains a significant, negative, association with all the fibrosis and the majority of inflammatory markers analyzed. These data highlight that testosterone protects rabbit prostate from MetS-induced prostatic hypoxia, fibrosis, and inflammation, which can play a role toward the development/progression of BPH/LUTS.

[Benign prostatic hyperplasia and urolithiasis]

The Academy Spring Forums held as part of the Southwest German Congress in Tübingen and the Congress of North Rhine-Westphalia in Aachen offer urologists in private practice and likewise hospital urologists a compact overview of new developments. This article summarizes the newest work on e.g. interventional therapy, uroliths, and extracorporeal shock wave lithotripsy for benign prostatic hyperplasia and urolithiasis.