Speaker abstracts

A01

Prevention of Prostate Cancer + Abstract # 1077

A. Aprikian

Department of Urology, MUHC – Montreal General Hospital, Montreal, QC, Canada

Abstract not available at the time of printing.

A02

How the aging male needs to understand female sexual function and vice-versa

I. Goldstein

The Journal of Sexual Medicine, Milton, MA, USA

The aging male needs to understand female sexual dysfunction for two basic and fundamental reasons. The first is that couples share their sexual dysfunctions. The second is that couples share their sexual solutions. The fact is that the current focus exclusively on one member (aging male) of the couple is illogical and irrational. If we do not address BOTH members of the couple, we cannot advance treatment for the aging male (and his partner). We review the evidence supporting the potentially strong association between female sexual dysfunction and sexual dysfunction in the male partner. Women with men who have erectile dysfunction may have their own sexual function adversely affected. In particular, a woman's sexual attitudes, her sexual beliefs, her sexual experiences, her sexual function (desire, arousal and orgasm) and her sexual quality of life may be impaired by her partner's erectile dysfunction. Accumulating scientific evidence indicates that there are adverse effects on the sexual function of women whose male partners have erectile dysfunction. In addition, data are developing that support the hypothesis that there is an independent improvement in the sexual quality of life of women whose partners have erectile dysfunction and receive successful erectile dysfunction treatment. This supports the theory that that there is a close relationship between women's sexual response and the quality of the erectile responses of their male partners. There are evidence-based findings suggesting that the woman whose male partner has erectile dysfunction often has concerns and distress about her own sexual function. It is important for clinicians to recognize that sexual dysfunction and its treatment is likely to have an effect on both members of the affected couple.

A03

The public, the press, the physician, the provinces and Health Canada: the politics and policies of testosterone deficiency syndromes

A. Morales

Centre for Applied Urological Research, Queens University, Kingston, ON, Canada

Testosterone deficiency syndromes (TDS) have been well recognized for decades by a variety of more or less accurate names. This has created confusion and skepticism of their clinical relevance among different groups involved in health care. For most of the rare syndromes (i.e. Kleinefelter, anorchia) little controversy exists regarding their treatment. For the truly common ones (i.e. TDS associated with aging) discrepant opinions are plentiful. The situation has been made worse by the vagaries of the clinical picture and the frequently challenged accuracy and relevance of assays for measuring serum testosterone (T). This large gap has allowed the media – both lay and professional – to offer sensationalistic versions of the truth (in articles and advertising) to a health-conscious but naive public and a medical profession confused by a barrage of studies, reviews and conferences of variable credibility. To this sad picture the bureaucracy of regulatory agencies has responded as expected: the creation of ad hoc committees that develop standards, guidelines and recommendations based on the same mixture of reliable and questionable information. In the United States, the National Institutes of Health have initiated studies aimed at clarifying some of the confusion regarding safety and efficacy of T treatment (TT). These are, population-wise, very large and chronologically long trials. Assuming that everything goes as planned, results will not be available for 10 to 15 years. The results, without question, will ignite further controversy. It is important, therefore, that a Canadian-tailored and nationally applicable set of practical recommendations with wide acceptance and appeal be developed as an interim bridge for the gap that currently exists. This will require extensive consultation and collaboration among groups with sufficient expertise in the field. The consultation must be free of suspicion, interference by financial interests, extensive and all embracing (the public, the physicians and the Health Canada). Costly? Probably. But vastly cheaper than the energy and effort being spent in opinions falling on deaf ears. We should avoid continuing discussing solitudes and focus on improving the well being of our ever increasing aging population.

A04

Steroids and muscle talk + Abstract # 1079

R.W. Hudson

Endocrinology and Metabolism Division, Department of Medicine, Queen's University, Kingston, ON, Canada

Abstract not available at the time of printing.

A05

Aging male: Ablatherm HIFU for PCA and potency preservation

C.J. D'Hont, P. Van Erps, J. Cortvriend, M. Sorber, W. Gelders

Department of Urology, ZNA Middelheim, Antwerpen, Belgium

Introduction: HIFU delivers focused ultrasound energy causing controlled rapid thermal necrosis of tissue within the target area without damaging the surrounding tissue. Nerve sparing Ablatherm-HIFU cures prostate cancer while preserving quality of life and potency.

Objectives and method: Clinical results on our first 450 biopsy proven T1-2(3a)N0M0 prostate cancer patients, treated with transrectal High Intensity Focused Ultrasound (HIFU). PSA, comorbidity and potency data are analysed per T stage and per risk group. Mean follow-up 38 months (3–74).

Results: 95% of patientts had PSA <1 ng/ml within 3 months after treatment; 85% of T1-2 patients had a stable nadir PSA <0.5 ng/ml (12 – >63 months after single HIFU treatment). Mean PSA (mPSA) stayed <0.5 ng/ml during the entire follow-up period for the low risk group, mPSA <1 ng/ml for the Intermediate risk group and mPSA <1.5 ng/ml for the High risk group (>80% PSA <1 ng/ml). In the T3a group more than 75% of patients kept a PSA <1 ng/ml. No major complications were seen: stricture/sloughing in 8% of patients; stress I-II/urge incontinence < 2%. Potency preservation was possible in >75% of patients after unilateral nerve-sparing treatment, >30% after full treatment and 8% in the T3 group. PDE-5 inhibitors are helpful but >60% of patients did not need the help of medication to restore normal potency (usually within 1 month).

Conclusion: Ablatherm-HIFU proves to be a safe, minimal invasive and possibly curative treatment option for patients with localized prostate cancer. Retreatment (also after EBRT-failure) remains a safe option and offers a second chance for cure. A majority of potent patients remain potent after (nerve sparing) Ablatherm-HIFU and can enjoy normal sex life with high patient and partner satisfaction. Continued monitoring of follow-up studies is mandatory.

A06

Aging and respiratory exercise: effects on fibre characteristics and expression of proinflamMatory cytokines in a typical rib cage respiratory muscle

J. Gea^1,2,3, C. Coronell², C. Casadevall², J. Sellarés^1,2, E. Barreiro^1,2,3

¹Muscle and Respiratory System Research Unit (URMAR), IMIM, Barcelona, Catalonia; ²Department of Respiratory Medicine, Hospital Del Mar, Barcelona, Catalonia; ³Experimental and Health Sciences Department (CEXS), UPF University, Barcelona, Catalonia, Spain

Background: Aging is associated with a progressive decline in muscle function that can be partially explained by changes in muscle phenotype. In this regard, leg muscles show changes in fibre type characteristics, as well as an increase in the expression of proinflammatory cytokines. This has been mainly attributed to muscle deconditioning, a factor that should not significantly affect respiratory muscles since ventilatory activity is maintained throughout life.

Aim: To assess fibre characteristics and the expression of different cytokines in a typical respiratory muscle.

Methods: Samples from the 6th external intercostal were obtained from 7 elderly and 8 young men (70 ± 6 and 26 ± 5 yrs, respectively) at baseline and following an inspiratory exhaustive exercise. Fibre type percentages and sizes were determined using immunohistochemical procedures (antibodies against different isoforms of myosin heavy chain), whereas cytokine expression was evaluated using both real-time PCR and ELISA.

Results: Aging resulted in airway obstruction, lung hyperinflation and reduced respiratory muscle strength on the one hand, and on the other, in decreased expression in TNF-alpha, IL-1 beta and IL-6, as well as in fibre size (more evident for type II), with no changes in fibre percentage counts. Intense exercise induced an increase in the expression of both TNF-alpha and IL-6.

Conclusions: Healthy aging only produces minor changes in fibre characteristics in the EI muscle. The increased activity of the respiratory muscles due to the impaired function of the senescent lung is likely to be involved in the downregulation of local proinflammatory cytokines. This, however, can be partly imbalanced by the deleterious effects of exhaustive exercise.

Acknowledgement: Funded by QLRT-2000-00417 (EU), and RTIC C03/11 & FIS PI052486 (Spain).

A07

A Comparison of vardenafil and sildenafil: diary-recorded outcomes in men with erectile dysfunction and cardiovascular risk factors

I. Goldstein¹, E. Rubio-Aurioles², H. Porst³, I. Eardley⁴, for the Vardenafil Sildenafil Comparator Study Group

¹The Journal of Sexual Medicine, Milton, MA, USA; ²Asociacion Mexicana Para La Salud Sexual AC, Tlalpan, Mexico; ³Private Urological Practice, Hamburg, Germany; ⁴Pyra Department of Urology, St James's University Hospital, Leeds, UK

Background and aims: To compare diary-recorded outcomes with vardenafil versus sildenafil, in men with erectile dysfunction (ED).

Methods: This was a prospective pooled analysis of two randomized, double-blind, crossover studies, one performed in the USA and one in Europe and Mexico. Both studies comprised two 4-week periods of treatment with either vardenafil 20 mg or sildenafil 100 mg, separated by a 1-week washout period. Study participants were men aged ≥18 years with ED for >6 months according to NIH criteria, and risk factors for cardiovascular disease (diabetes mellitus, hypertension and/or hyperlipidemia). All participants had to be in a stable, heterosexual relationship (>6 months). The primary endpoint of the study was treatment preference. Twelve diary questions were also answered during the study, including the Sexual Encounter Profile (SEP) questions 2 and 3.

Results: A total of 1,057 men were randomized to treatment. Of 12 diary questions, 9 indicated a better response to vardenafil treatment versus sildenafil (nominal significance, p < 0.05). These were: SEP2 (LS mean positive response: 83.9% with vardenafil, compared with 82.3% for sildenafil); SEP3 (74.4% versus 71.6%); ‘satisfied with hardness’ (55.7% versus 52.7%); ‘satisfied with sexual experience’ (64.9% versus 61.0%); ‘how hard was erection’ (LS mean score: 2.18 with vardenafil, compared with 2.13 for sildenafil); ‘maintain erection’ (3.11 versus 3.02); ‘erection stayed hard’ (3.33 versus 3.24); ‘satisfied with length’ (3.37 versus 3.27); and ‘satisfied with girth’ (3.36 versus 3.27). The remaining 3 questions showed a trend in favour of vardenafil (‘some erection’, ‘ejaculate’, and ‘satisfied with sensitivity’).

Conclusion: Diary-recorded outcomes demonstrated that vardenafil was superior to sildenafil (nominal significance) in 9/12 questions, including SEP2 and SEP3, satisfaction with sexual experience, erection hardness and maintenance of erection.

A08

A comparison of vardenafil and sildenafil: Treatment satisfaction among men with erectile dysfunction and cardiovascular risk factors, and their partners

I. Goldstein¹, E. Rubio-Aurioles², H. Porst³, I. Eardley⁴, for the Vardenafil Sildenafil Comparator Study Group

¹The Journal of Sexual Medicine, Milton, MA, USA; ²Asociacion Mexicana Para La Salud Sexual AC, Tlalpan, Mexico; ³Private Urological Practice, Hamburg, Germany; ⁴Pyra Department of Urology, St James's University Hospital, Leeds, UK

Background and aims: This prospective pooled analysis of two studies (one US and one European/Mexican) was performed to compare treatment satisfaction with vardenafil versus sildenafil, among men with erectile dysfunction (ED) and their partners.

Methods: Men aged ≥18 years with ED for >6 months (according to NIH criteria) and risk factors for cardiovascular disease (diabetes mellitus, hypertension and/or hyperlipidemia) were eligible to participate in the two randomized, double-blind crossover studies. All participants had to be in a stable, heterosexual relationship for >6 months. After screening, patients were randomized to receive vardenafil 20 mg or sildenafil 100 mg for 4 weeks, followed by 1 week of washout, then 4 weeks' therapy with the second drug. The Treatment Satisfaction Scale (TSS) was completed by patients and their partners at the end of each treatment period.

Results: A total of 1,057 men were randomized to treatment. After 4 weeks' treatment with each drug, vardenafil was shown by least squares (LS) mean scores to be superior (nominally significant) to sildenafil in 12/19 patient TSS questions (p < 0.05; no questions showed significantly greater improvement with sildenafil). A numerical advantage with vardenafil was observed in 6 questions, while a numerical trend in favour of sildenafil was observed in 1 question. Partners' TSS results showed equal LS mean scores for sexual desire, and a trend in favour of vardenafil in 14/18 questions. Vardenafil was superior to sildenafil (nominally significant) in the 3 questions relating to duration of erection, hardness of erection and sex when you felt like it.

Conclusion: The TSS demonstrated superior satisfaction (nominally significant) among men treated with vardenafil versus sildenafil in 12/19 questions, and numerically higher satisfaction with vardenafil in all but one question. Among partners, the LS mean score with vardenafil was numerically higher than that with sildenafil in 17/18 questions.

A09

Testosterone levels are lower in men with erectile dysfunction (ed) who have metabolic syndrome (ms) and insulin resistance (ir)

A.T. Guay, J. Jacobson

Department of Endocrinology, Center for Sexual Function, Lahey Clinic, Peabody, MA, USA

Background: Men with ED have been shown to have a predominance of cardiac risks. They also have a higher incidence of MS and IR, known markers of cardiac risks. Hypogonadsim has also been shown to be prevalent in men with ED, MS and IR.

Objective: To see if hypogonadism is more prevalent in men with ED who also have MS and IR than in men without these parameters, and also to see if the incidence of hypogonadism is similar in the two most common definitions of MS.

Methods: In a population of men with ED (n = 154), the incidence of hypogonadism (defined as a free T < 10 pg/ml) was compared in men with and without MS, by both NCEP-ATP III and WHO criteria. Similarly, the incidence of hypogonadism was compared in men with IR (defined as QUICKI < 0.356) to men without IR. Chi square analysis (with Fisher's Exact test, where appropriate) was used to determine statistically significant associations between variables.

Conclusions: Both the NCEP-ATP III and WHO methods of defining MS have a higher incidence of hypogonadism in men with ED (where p < 0.05). The incidence of hypogonadism in men with IR is quite higher than MS (p = 0.02). Men with ED should have testosterone levels checked, and if low a search for cardiac risk factors should be commenced. Low testosterone levels may be a marker of cardiac risk.

Table

Results	Hypogonadism	No hypogonadism
IR	92.3%	25.2%
No IR	7.7%	74.8%
NCEP-ATP III MS	51.3%	48.7%
No NCEP-ATP III MS	29.6%	70.4%
WHO MS	64.6%	35.4%
No WHO MS	34.7%	65.3%

A10

Urinary and sexual functions affect health-related quality of life

A. Komiya¹, M. Kino¹, T. Kato¹, H. Suzuki¹, Y. Naya¹, T. Imamoto¹, N. Kamiya¹, M. Takano¹, A. Komaru¹, M. Maruoka², T. Ichikawa¹

¹Department of Urology, Chiba University Hospital; ²Department of Urology, Chiba Cancer Center, Chiba-Shi, Chiba, Japan

Background and aims: We investigated how urinary and sexual functions affect health-related quality of life (QOL).

Methods: 90 patients who were negative for prostate biopsy were enrolled. The patients' age was 66 ± 7 (mean ± s.d.). Their prostate volume was 44.3 ± 21.9 ml. Serum total testosterone was 3.63 ± 1.18 ng/ml. Before prostate biopsy, patients were asked to fill-out questionnaires including I-PSS, SF-36, and UCLA-PCI to evaluate urinary symptoms, sexual function, and health-related QOL. Relationships among these were analysed.

Results: Between sexual function and SF-36 scores, significant positive relationships were observed in Physical functioning (r = 0.367, p = 0.0019), Role physical (r = 0.32, p = 0.0068), General health (r = 0.384, p = 0.0012), Vitality (r = 0.345, p = 0.0043), Social functioning (r = 0.302, r = 0.0112), Role emotional (r = 0.355, p = 0.0030), Mental health (r = 0.319, p = 0.0088), and Bodily pain (r = 0.332, p = 0.0054). Serum total testosterone was not related to SF-36 scores. Between sexual function and urinary symptoms, IPSS Q1 (sense of incomplete emptying, r = −0.212, p = 0.0232), Q3 (intermittency, r = −0.261, p = 0.0161), Q5 (weak urinary stream, r = −0.310, p = 0.0124), Q6 (straining to urinate, r = −0.260, p = 0.0191), Q7 (nocturia, r = −0.340, p = 0.0146) and sum of Q1–Q7 (r = −0.303, p = 0.198) had significant negative relationship to sexual function evaluated by UCLA-PCI. Between urinary symptoms (sum of IPSS Q1-7) and SF-36 scores, Physical functioning (r = −0.315, p = 0.0109), General health (r = −0.388, p = 0.0319), Social functioning (r = −0.312, p = 0.0147) had significant negative relationship to urinary symptoms. If each IPSS question was analysed, nocturia (Q7) revealed to have the most significant impact to health-related QOL; Physical functioning, Role physical, General health, Social functioning, Role emotional were deteriorated by nocturia.

Conclusions: Urinary symptoms, sexual function and health-related QOL revealed to have close relationships each other; those who show sexual dysfunction have worse urinary symptoms and deteriorated QOL. To treat urinary dysfunction, physicians need to keep sexual function to maintain better QOL.

A11

The microenvironment of the aged rat liver is conducive to clonal growth of normal and altered hepatocytes

S. Doratiotto, D. Pasciu, S. Montisci, M. Greco, S. Laconi, E. Laconi

Department of Science and Biomedical Technology, University of Cagliari, Cagliari, Italy

It has been proposed that aging increases the development of cancer via modifications in tissue microenvironment. However, the mechanisms underlying this effect are poorly understood. In this study we compared the microenvironments of young and aged rat liver in their ability to support the clonal growth of transplanted normal or nodular hepatocytes. Young (3 months) and aged (18 months old) male Fischer 344 rats were infused (via portal vein) with 2 × 106 normal hepatocytes or 2 × 105 nodular/preneoplastic hepatocytes, isolated from syngenic donors. Animals deficient in dipeptidyl-peptidase type IV (DPP-IV−) enzyme were used as recipients, allowing for the histochemical detection of injected, DPP-IV+ cells. Groups of animals transplanted with either normal or nodular hepatocytes were sacrificed 2 weeks, 3 months and 6 months thereafter. A significant expansion of donor-derived cells was observed in the liver of rats transplanted at old age: clusters comprising up to 20 DPP-IV+ hepatocytes/cross section were present after 3 months and were further enlarged after 6 months (up to 120 cells/cluster/cross section). One animal transplanted with preneoplastic hepatocytes developed a large nodule 2 cm in size. In striking contrast, no significant growth of either normal or nodular hepatocytes was seen in the liver of rats transplanted at 3 months of age. These results indicate that the microenvironment of the aged liver supports the clonal expansion of transplanted normal and preneoplastic hepatocytes. Such clonogenic potential is likely to contribute to the increased risk of cancer development associated with aging.

Acknowledgement: This work was supported in part by ROTRF grant 820172684 to E.L. and by the Italian Health Ministry.

A12

Vardenafil in Canadian males with erectile dysfunction: impact of education of the primary care physician and patient on patient outcomes

G. Brock¹, S. Carrier², P. Alarie³, P.J. Pommerville⁴, R.W. Casey⁵, S.B. Harris⁶, R.A. Ward⁷

¹St Joseph's Health Centre, London, ON; ²McGill University Health Centre-Royal Victoria Hospital, Montreal, QC; ³Hôpital StLuc, CHUM, Montreal, QC; ⁴Royal Jubilee Hospital, Victoria General Hospital, Victoria, BC; ⁵Halton Healthcare Services Corp-Oakville Site, The Credit Valley Hospital, Mississauga, ON, Canada; ⁶Thames Valley Practice Unit, Thames Valley, UK; ⁷Foothills Medical Centre, Alberta Children's Hospital, Calgary, AB, Canada

Background and aims: Patient education with phosphodiesterase-5 (PDE5) inhibitor therapy is thought to maximize the benefit of first-line treatment in patients with erectile dysfunction. Therefore, the need for specific education for the primary care physician (PCP) has been identified as a possible means to optimize patient education and improve success of treatment. This open-label, multi-centre, cluster-randomized clinical study compared the outcomes of patients using vardenafil after receiving only usual care education, receiving patient education material, or being treated by a physician who had received the PCP education or both types of education.

Methods: 1029 patients from 150 centres which were randomized to the four different education arms, started treatment with vardenafil 10 mg with possible titration at week 4, for 8 additional weeks. Efficacy assessments were conducted at each visit.

Results: A total of 956 patients were included in the intent to treat (ITT) population from across Canada, and included those with hypertension (41.2%), diabetes (20.8%) and the average baseline IIEF-EF score was 13. Shown in the table are the raw percentages of patients who reported an improvement in their erections (GAQ), Mean per subject successful intercourse rates (SEP3) at 4 week LOCF with baselines. Adverse events were infrequent and representative of the phosphodiesterase-5 inhibitor profile.

Conclusions: High success rates were observed across all treatment arms with vardenafil and likely a ceiling effect masked the potential impact of our educational program. Its value may be more evident among those populations with lower success rates such as post-prostatectomy or diabetic cohorts.

Table

	GAQ (%)	SEP3 (Mean)
	4 week	Baseline	4 week
No education	81.9	17.2	69.4
Physician education	80.2	18.2	70.1
Patient education	82.2	16.8	66.9
Physician + patient education	80.1	21.3	69.7

A13

Hormonal prevention of sarcopenia

J.E. Morley

Division of Geriatric Medicine, Saint Louis University Medical Center, St Louis, MO, USA

Sarcopenia is the excessive loss of muscle. Older persons who develop sarcopenia have an increased disability. Persons with obese sarcopenia or the ‘fat frail’ have been shown to have especially poor outcomes. The causes of sarcopenia are multifactorial. It is due in part to the decreased activity that occurs with aging. In some older persons peripheral vascular disease plays a major role in the development of sarcopenia. The decline in testosterone and IGF-1 have both been related to the loss of muscle. Mechanogrowth factor (MGF) plays a major role in the determination of the quality of muscle. It falls with aging and increases with resistance exercise. Cytokines cause loss of lean tissue. Myostatin inhibits muscle growth. At present, management of sarcopenia focuses on resistance exercise and possibly testosterone replacement. New managements will include selective androgen receptor molecules, anti-myostatin drugs, ghrelin agonists and a variety of nutritional approaches such as leucine and creatine.

A14

New approaches to androgen replacement in hypogonadal men

C. Wang, R.S. Swerdloff

Division of Endocrinology, Department of Medicine, Harbor-UCLA Medical Center, LA BioMed, Torrance, CA, USA

Older men have hypothalamic-pituitary-testis dysfunction characterized by low serum testosterone levels and disordered gonadotropin secretion. Androgen substitution in older hypogonadal men is indicated when there are clinical signs or symptoms of hypogonadism and when serum total, free or bioavailable testosterone levels are clearly in the range below the young adult men established in each individual laboratory. Once these criteria are met, the older man is administered testosterone either as oral, buccal, transdermal, intramuscular preparation or as subdermal implants. Though used by many older men, recent placebo controlled randomized clinical trials (RCT) demonstrated that DHEA administered orally at 50 mg/day does not have any significant effect on sexual function, body composition, bone mineral density, mood or quality of life. Transdermal dihydrotestosterone does not appear to have any advantage over administration of testosterone. Increasing endogenous production of testosterone have been studied in a small RCT using human chorionic gonadotropin injection which showed older men responded with increased in testosterone levels and small improvements in lean mass and muscle strength. Older men may have a lower acute response to clomiphene citrate (a partial estrogen receptor antagonist) stimulation, but small chronic treatment indicated that older men responded with increases in FSH, LH and free testosterone level suggesting that improvement in features of hypogonadism may be possible. In recent years, aromatase inhibitors have been used in short term studies in older men resulting in increases in serum LH and testosterone without adverse effects on bone metabolism. Long term RCT are lacking both for clomiphene and aromatase inhibitors. The future new approach to androgen replacement in older men depends on the development of selective androgen receptor modulators to effectively provide the beneficial effects and ameliorating any potential risks of androgens or stimulators of endogenous androgen production.

A15

A contemporary review of La Peyronie's disease

L. Levine

Department of Urology, Rush University Medical Center, Chicago, IL, USA

La Peyronie's disease (PD) remains a mystery as to its ideology, but the interest in this disorder has increased markedly over the past decade. This is in part due to progress in basic science research as well as the increase in patients presenting to the urologist with PD. This lecture will review several of the current misconceptions on La Peyronie's disease, including that it is not a rare disorder (up to 10% of men affected), it does not spontaneously resolve (less than 10%), it may occur in men of all ages (10% less than 40), it is frequently associated with ED (up to 90%) and that medical therapy such as intralesional injection should not be reserved until the disease stabilizes and should instead be initiated soon as possible.

As a brief review of non-surgical therapy we should be aware that there is no evidence from placebo-controlled trials that any of the well known oral agents used for La Peyronie's disease provide any therapeutic benefit over placebo. In spite of this, there is increased interest in Pentoxifylline, L-arginine, and the PDE5 inhibitors because of their purported anti-fibrotic qualities. Intralesional injection therapy does appear to be the most sensible approach to change La Peyronie's scar tissue. Verapamil and interferon are the most commonly used agents which have been shown in published reports to result in measured improvement in 40–60% of treated individuals. Neither of these agents should be considered a cure, but some improvement may be all that is necessary to improve function. The newest area for non-surgical treatment is the use of external stretching devices, such as vacuum and external penile extenders, to apply mechanical forces to the penis in an effort to stimulate remodelling.

On the surgical side, several algorithms have emerged over the past decade all of which agree that the two primary factors for deciding which surgical approach to take are pre-operative erectile capacity and degree of deformity. In those men who do not have good quality erections a penile prosthesis should be placed with a trial of manual modelling to straighten the penis. For those men who have satisfactory erections then some form of tunica plication or plaque incision and grafting is in order.

La Peyronie's disease remains a therapeutic dilemma for the practising urologist, surgical therapy should only be offered when the disease is stable and causing compromised sexual relations. Medical therapy is evolving but there is still no cure in sight, yet some of the available non-surgical approaches do appear to result in stabilization if not functional improvement.

A16

Endothelial dysfunction and erectile dysfunction

J. Lee

University of Calgary, AB, Canada

What's the connection?

Examine the relationship between endothelial dysfunction and erectile dysfunction.

Examine ED as a marker for cardiovascular disease.

Discuss the treatment of ED in the cardiovascular patient.

A17

Que Rest-T-IL de La Chirurgie de La Dysfunction Erectile en 2007

E. Wespes

Clinique Urologique, Hopital Erasme, Brussels, Belgium

Abstract not available at the time of printing.

A18

Is it safe to treat hypogonadism with testosterone? are there risks in not treating?

A.T. Guay

Department of Endocrinology, Center for Sexual Function, Lahey Clinic, Peabody, MA, USA

Abstract not available at the time of printing.

A19

Therapies age androgenic deficiency at patients hyperplasia prostatic

T.N. Nazarov, V.P. Alexandrov, D.G. Korenkov, V.N. Fesenko, G.N. Skrjabin

Department of Urology and Andrology, Medical Academy of Postgraduate Studies, St Petersburg, Russia

The objects of our research were 62 patients in the age of from 54 till 86 years which had a combination partial age androgenic deficiency and hyperplasia prostate the first stage. Parameters of levels of hormones of blood: the level LH is raised at all patients M ± m = 21.9 ± 1.0 mMe/l (1–9 mMe/l). The level prolactin at surveyed was on the top border of norm M ± m = 557.4 ± 8.0 mMe/l (62–630 mMe/l). The level FSH is raised M ± m = 18.7 ± 1.0 mMe/l (1–15 mMe/l). The level testosterone has been lowered M ± m = 1.8 ± 0.1 ng/ml (3–10 ng/ml). The level estrodiol was within the limits of norm M ± m = 49.9 ± 1.1 ng/ml (12–60 ng/ml). PSA was within the limits of norm M ± m = 2.8 ± 0.1 ng/ml, transrectal ultrasonic scanning prostate (TUSP) – M ± m = 45.4 ± 0.8 ml. Uroflowmetric has made M ± m = 11.5 ± 0.1 ml/sec. Data of results of questionnaire I-PSS were the following: M ± m = 10.4 ± 1.0 points. Results of an estimation of the questionnaire on quality of a life have made M ± m = 4.3 ± 0.1 points. For therapy age androgenic deficiency preparation androgel in the form of transdermal forms androgen is used, the doze of a preparation has made 10 mg day. After 6 month treatments are carried out control researches. Levels LH, prolactin, FSH, estrodiol have decreased at all patients. Their values were the following. Level LH –M ± m = 7.1 ± 0.2; prolactin –M ± m = 310.7 ± 11.3; FSH – M ± m = 8.7 ± 0.3; estrodiol –M ± m = 28.3 ± 1.0. And the level testosterone has raised in 4 times M ± m = 7.4 ± 0.1. Level PSA has decreased M ± m = 1.8 ± 0.1. Parameters TUSP have decreased up to M ± m = 37.1 ± 0.8 ml. Uroflowmetric has made M ± m = 14.9 ± 0.1 ml/sec. Data of results of questionnaire I-PSS during treatment have made M ± m = 3.3 ± 0.4 points. Results of an estimation of the questionnaire on quality of a life M ± m = 2.1 ± 0.1 points. Patients marked improvement of a dream, increase libido and sexual activity, improvement of memory and attention, functions of intestines, increase of physical endurance, and especially reduction dysuric the phenomena.

A20

Late onset hypogonadism in Turkish aging males

K. Onem¹, L. Gurkan², M. Tezer¹, T. Akman¹, H. Taskapu², A. Kadioglu²

¹Department of Urology; ²Department of Urology, Section of Andrology, Medical Faculty of Istanbul, Istanbul University, Istanbul, Turkey

Aim: To assess the prevalence of symptoms related to late onset hypogonadism of aging males in Turkish population and to define the relationship between these symptoms and lifestyle.

Method: A total of 7547 interviews were conducted between November 2005 and December 2005. A representative sample for Turkey's urban and rural areas was defined by using optimal allocation stratified sampling to determine the sample size and distribution. Participants of the research were males over 40 years of age. The survey consisted of AMS scale and additional questions about the socioeconomic status and life style habits of the participant.

Results: The 1225 successful contacts represented. The respondents were distributed over six regions of Turkey. Total of 54.9% of aging Turkish males have hormonal deficiency symptoms of differing severity. According to age breakdowns it is seen that severity of hormonal deficiency increases as males get older. 30% has mild, 20% has moderate and 5% has severe hormonal deficiency according to AMS scale. Those who answered yes to any of the questions within a single AMS category are analysed separately and it is seen that 81.6% of males have at least one psychological symptom, 76.9% have at least one somatic symptom and 74.7% have at least one sexual symptom. They have chronic diseases (diabetes: 8%, CV diseases: 15%, hypertension: 18%, other chronic diseases: 42%) and occurrence of these diseases increase as severity of hormonal deficiency increases. These AMS symptoms scores were similar to other European countries. Physical exhaustion/lacking vitality, sleep problems and decrease in ability/frequency to perform sexually are the symptoms that are perceived as most important by aging males.

Conclusion: Total of 54.9% of aging Turkish males have hormonal deficiency symptoms of different severity and correlate with age.

A21

Age-dependent features of bone tissue state in men

V. Povoroznyuk, Y. Kreslov

Department of Clinical Physiology and Pathology of Locomotor Apparatus, Institute of Gerontology AMS Ukraine, Ukrainian Scientific-Medical Centre for the Problems of Osteoporosis, Kiev, Ukraine

This research was aimed at studying the age-dependent peculiarities of bone mineral density and bone mineral content in men. A total of 210 men 20–89 years old (54.6 ± 1.2) were examined and divided into the following age-dependent groups: 20–29 years old, 30–39 years old, 40–49 years old, 50–59 years old, 60–69 years old, 70–79 years old, 80–89 years old.

The mineral density and mineral content of bone was determined using dual X-ray densitometry by means of ‘Prodigy' apparatus (GE Medical systems, Lunar, model 8743, 2005). Mineral density and mineral content of lumbar spine and hip in dependence on age are presented in Table I. The osteoporosis of lumbar spine was observed by X-ray densitometry in 4.3% of patients in group of 40–49 years, in 7.9%– group of 50–59 years, in 7.5%– group of 60–69 years, in 19.2%– group of 70–79 years, in 9.1%– group of 80–89 years; hip osteoporosis in 2.3%, 5.3%, 2.8%, 7.6% of patients respectively. Among patients of 80–89 years normal state of bone was observed in 77.3%.

Conclusions: Age in men has a substantial influence on hip BMD: the lowest indexes were observed in the group of 70–79 year-olds. The osteoporosis of lumbar spine was observed in 19.2%, hip osteoporosis in 7.6% of patients in this group.

Table

Parameters	20–29 years	30–39 years	40–49 years	50–59 years	60–69 years	70–79 years	80–89 years
n	20	24	44	38	36	27	21
Age	24.1 ± 0.6	34.7 ± 0.4	44.6 ± 0.5	55.2 ± 0.4	65.6 ± 0.5	75.1 ± 0.5	82.9 ± 0.6
Height, m	1.81 ± 0.002	1.76 ± 0.001	1.76 ± 0.001	1.74 ± 0.001	1.73 ± 0.001	1.70 ± 0.001	l.74 ± 0.001
Weight, kg	74.6 ± 2.9	80.1 ± 3.0	86.3 ± 2.6	85.7 ± 2.3	80.8 ± 2.8	78.0 ± 2.1	82.7 ± 1.0
BMI	22.9 ± 0.6	25.7 ± 0.8	27.7 ± 0.7	27.8 ± 0.6	28.4 ± 0.7	27.1 ± 1.0	27.0 ± 0.8
BMD spine	1.19 ± 0.04	1.16 ± 0.04	1.18 ± 0.03	1.15 ± 0.03	1.21 ± 0.05	1.17 ± 0.05	1.30 ± 0.06
BMC spine	74.7 ± 3.3	71.7 ± 3.1	76.7 ± 2.7	74.1 ± 2.7	80.9 ± 4.2	77.4 ± 4.1	83.2 ± 3.9
BMD hip	1.08 ± 0.05	1.01 ± 0.04	1.04 ± 0.02	0.99 ± 0.03	1.04 ± 0.03	0.95 ± 0.05	1.0 ± 0.05
BMC hip	39.8 ± 2.1	38.1 ± 1.4	40.0 ± 1.1	38.8 ± 1.2	41.3 ± 1.1	36.6 ± 1.5	38.7 ± 1.8

A22

Prevalence and risk factors of andropausal symptoms – a population based study

P. Quek¹, P.H.C. Lim², L.W. Khin³

¹Department of Urology, Changi General Hospital, ²Andrology and Urology Centre, Gleneagles Hospital, ³Clinical Trials and Epiemiological Research Unit, Ministry of Health, Singapore

We conducted a population based study of males aged 45 to 70 looking at the age and race specific prevalence, median age of onset and to determine if sociodemographic and ethnic factors, co-morbidities and lifestyle practices, stress, work related and major life events and the presence of a social support network were significant risk factors for these ‘andropausal’ symptoms. Briefly, 1500 men aged 45 to 70 were randomly sampled from the target population from the National Census. They were directly interviewed using a 19-page questionnaire detailing sociodemographic data, lifestyles, co-morbidities and social networks together with an internationally used andropause/PADAM scale and the International Index of Erectile Function (IIEF) questionnaire. Seventy-one per cent participated (1073 respondents), 6.5% had physiological symptoms, median age of onset was 55 years. Commonest symptoms include lack of energy, joint pains, sleep disorders and loss of appetite. Significant risk factors include age, race Malay or Indian, A and O level education, heart disease, alcohol consumption, lack of exercise and recent major life events. 18.3% had psychological symptoms. Median age of onset was 54 years. Risk factors include age more than 65, education A and O levels, heart disease, hypertension, lack of exercise, no regular social activity and work related stress events.

8.8% had sexual symptoms. The median age of onset was 62 years. Risk factors include advancing age, heart disease, diabetes mellitus, smoking, lack of regular exercise and social activity. These results show that prevalence of symptoms associated with PADAM and erectile function are similar to internationally published rates. While the debate on whether these symptoms are due to declining testosterone levels may continue, it is clear that many co-morbidities, sociodemographic factors and lifestyle practices are noted to significantly influence their presence.

A23

Testosterone blood level and erectile dysfunction: A prospective study in patients with chronic renal failure

D. Santoro, G. Bellinghieri, A. Mallamace, V. Savica

Division of Nephrology and Dialysis, University of Messina, Messina, Sicily, Italy

Recent studies showed that testosterone is involved in the pathogenesis of cardiovascular diseases. Moreover, blood testosterone concentrations, in observational studies, resulted consistently lower among men not only with cardiovascular disease but also in the uremic men. In order to correlate the blood level of testosterone with the degree of erectile disfunction (ED) and chronic renal failure (CRF) (stage I–V) we selected a group of patients with renal failure on conservative treatment, assisted in our ambulatory of nephrology. Ninety-three patients and ED, mean age 72+ years old (+8 SD) have been selected. All the patients had renal failure stage II and III, respectively with a creatinine clearance among 59–30 and 29–15 ml/m'. The sexual evaluation was done using a 15-item questionnaire: International Index of Erectile Function (IIEF).

Mean scores of patients with ED were significantly lower than mean scores for healthy controls for all 15 questions (all p values <0.01). The results showed a direct correlation between IIEF and GFR (R² 0.08); an inverse correlation between testosterone and cholesterol (R² 0.045); higher number of diabetic patients with lower level of testosterone, at level 3 of CRF; low levels of testosterone for smokers especially in stage II (GFR). These data confirm the direct correlation between ED and renal failure, and the role of diabetes and smokers in hypotestosteronemia, in patients with different degree of renal insufficiency. Further prospective studies are needed in order to correlate cardiovascular morbidity and mortality in patients with CRF and blood levels of testosterone.

A24

The effect of age on penile arterial flow

M. Al-Numi^1,2,3, L.I. De Young^2,3, G.L. Brock^1,2,3

¹Department of Surgery, The Unversity of Western Ontario, ²St Joseph's Health Care, Division of Urology, ³Lawson Health Research Institute, London, ON, Canada

Introduction: The most common cause of erectile dysfunction (ED) in men remains arterial insufficiency. The impact of advancing age on arterial cavernous flow across a wide age range still remains poorly described.

Objectives: In this report we measured cavernous arterial flow and associated co-morbid factors among a convenience sample of 589 men seen in our tertiary care ED clinic, ranging in age from 19 to greater than 70 years.

Methods: Adult men age 19 to >70 years assessed for ED underwent a high resolution duplex penile ultrasound. Cavernous arterial flow was measured following intracavernous injection of 5–10 μg of PGE-1 and self-stimulation to assure complete cavernous smooth muscle relaxation. Co-morbidity was determined through serum biochemistry and patient self-report. Erectile function was determined through use of validated questionnaires.

Results: A clear age-related diminution in arterial flow was measured with advancing age. 19–29 yrs = 29.4 cm/sec, 30–39 yrs = 27.2 cm/sec, 40–49 yrs = 27 cm/sec, 50–59 yrs = 23.8 cm/sec, 60–69 yrs = 22.4 cm/sec, >70 yrs = 18.9 cm/sec. Increasing rates of hypertension, diabetes and dyslipidemia were reported among the older men. The SHIM score before treatment was 19–29 yrs = 8.9, 30–39 yrs = 9.7, 40–49 yrs = 9.5, 0–59 yrs = 8.9, 60–69 yrs = 7.3 and >70 yrs = 5. The improvement of SHIM score with therapy was 5.1, 5.5, 2.2, 2, 1.8, and 3.7 respectively.

Conclusions: Senescence induced an age-related decrease in erectile function and arterial flow. Therapy was shown to be effective across all age strata, with the men over age 70 years having a fairly robust treatment response from severe erectile dysfunction at the start of therapy. Understanding the impact of arterial dysfunction in men can optimize therapeutic strategies in cases of ED.

A25

Haemoglobin level in men with heart failure is determined by serum levels of testosterone and insulin-like growth factor 1

E.A. Jankowska, B. Biel, J. Majda, J. Petruk-Kowalczyk, W. Banasiak, P. Ponikowski

Department of Cardiology, Military Hospital, Wroclaw, Poland

Background: In chronic diseases, anabolic deficiency unfavourably impairs haematopoiesis. We studied whether such a relationship may constitute a mechanism underlying anaemia in men with chronic heart failure (CHF).

Methods: We studied 232 men with systolic CHF (age: 63 ± 11 years, New York Heart Association [NYHA] functional class I/II/III/IV: 23/109/82/18, ischaemic aetiology: 82%, left ventricular ejection fraction [LVEF]: 32 ± 7%). Glomerular filtration rate (GFR) was estimated using the Cockroft-Gault formula. Serum levels of total testosterone (TT), dehydroepiandrosterone sulphate (DHEAS), insulin-like growth factor 1 (IGF1) were assessed using immunoassays.

Results: In men with CHF, mean haemoglobin (Hb) was 14.3 ± 1.4 g/dl (range: 10.5–17.6 g/dl), and anaemia (Hb < 12.5 g/dl) was found in 32 (14%) men with CHF. In univariable analyses, Hb was related to NYHA class (R = −0.25, p < 0.0001), LVEF (r = 0.21, p = 0.001), plasma N-terminal pro-brain natriuretic peptide (r = −0.19, p = 0.005), GFR (r = 0.23, p < 0.0001), serum TT (r = 0.26, p < 0.0001) and serum IGF1 (r = 0.18, p = 0.005), but not age, CHF aetiology and serum DHEAS. In a multivariable model, only reduced serum TT (r = 0.24, p = 0.0002), reduced serum IGF1 (r = 0.15, p = 0.02) and diminished GFR (r = 0.18, p = 0.004) remained independent determinants of lower Hb. The presence of 0, 1, 2, 3 established above risk factors (i.e. TT deficiency [TT < 3 ng/ml], IGF1 deficiency [IGF1 < 200 ng/ml], renal impairment [GFR < 60 ml/min/1.73 m²]) increased a risk of an occurrence of anaemia in men with CHF in a graded manner (0%, 6%, 18%, 39%, respectively –χ² = 22.29, p < 0.0001).

Conclusions: In men with systolic CHF, circulating TT and IGF1 are determinants of Hb level, independently of other clinical parameters, including disease severity and renal dysfunction. In this group of patients, anaemia constitutes a clinical element of anabolic depletion.

A26

Testosterone therapy and prostate cancer: how great are the risks?

A. Morgentaler

Division of Urology, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

The fear of causing prostate cancer (PCa) growth remains a great concern with regard to testosterone replacement therapy (TRT). This concern has been present since 1941 when Huggins not only showed that PCa regressed with severe reduction of testosterone (T), but also from his assertion that addition of T caused ‘enhanced growth’ of PCa. Although today there is no doubt that T reduction causes PCa regression, the concern that TRT might increase the risk of PCa remains without supporting evidence. Remarkably, Huggins' original assertion regarding enhanced growth was based on a single patient! The evidence over multiple small trials is that TRT is associated with a PCa detection rate of approximately 1%, a value similar to detection rates in screening studies. Longitudinal studies have failed to demonstrate that high T is a risk factor for PCa, or that men with higher T are at greater risk of subsequent diagnosis of PCa than men with lower T. Moreover, the natural history of PCa is that it becomes prevalent when men are older and have reduced T levels, and is exceedingly rare during the peak T years of young adulthood. The rationale for the lack of effect of higher T on PCa risk is provided by a recent study demonstrating that prostatic levels of T and DHT were unchanged after 6 months of TRT, suggesting a saturation effect in the target organ. Although we lack the certainty of a large-scale TRT trial, it is important to acknowledge that 65 years of T research has failed to provide any compelling evidence that TRT increases PCa risk in hypogonadal men.

A27

Diagnostic approaches to ed, hypogonadism and current management concerns in the aging male

E. Wespes

CHU Charleroi, Brussels, Belgium

The current availability of effective and safe oral drugs for ED, in conjunction with the tremendous media interest for the condition, has increased the number of men seeking help for ED. The introduction of new oral therapies has completely changes the diagnostic and therapeutic approach to erectile dysfunction. A detailed medical history that includes determining the presence of hypertension, diabetes mellitus, myocardial disease, lipidemia, hypercholesterolemia, renal insufficiency, hypogonadism, neurologic and psychiatric disorders, and indeed any chronic illness of patients must always be the first step in the evaluation of ED.

The use of validated questionnaires, such as the International Index for Erectile Function (IIEF), may be helpful to assess all sexual function domains (erectile function, orgasmic function, sexual desire, ejaculation, intercourse, and overall satisfaction) and also the impact of a specific treatment modality.

Although the majority of patients with ED can be managed within the sexual care setting, some circumstances may dictate the need for specific diagnostic testing. Male sexual function depends upon a complex interrelationship between psychological, neurological, vascular and hormonal factors. Testosterone is responsible for the initiation, development and maintenance of primary and secondary sexual characteristics as well as having a role in male sexual behaviour and potency. In adults, testosterone deficiency is associated with reduced libido and potency, infertility, lethargy and a number of behavioural modifications.

A significant percentage of men with erectile dysfunction presents with low testosterone. Patients who are non-responders to PDE5 inhibitors benefit in about 2/3 of the cases from testosterone supplementation, this being especially frequent in diabetic patients and patients presenting with metabolic syndrome. More logically, patients with ED should be evaluated for eventual testosterone deficiency and most probably initially supplemented with testosterone before considering PDE5 inhibitors. A significant percentage of these patients will benefit from testosterone alone and not need PDE5 inhibitors further, which more logically treats the cause rather than just a symptom.

A28

Results of randomized controlled trials of testosterone therapy in the aging male

J. Buvat

Centre ETPARP, Lille, France

Abstract not available at the time of printing.

A29

International Prostate Symptom Score (IPSS) in aging Nigerian males

A.O. Adedokun¹, A.O. Ogbera²

¹Department of Family Medicine, ²Department of Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria

Background and aim: Prostate enlargement is a common phenomenon in the aging males. About 50% of men at 60 years and 90% at 70 years will have enlargement of their prostate glands. Inadequate medical personnel and high illiteracy level hampers early detection also. A rapid screening tool is therefore required. This informs the study. The major aim of the study is to validate the International Prostate Symptom Score in our environment given the peculiarities.

Methods: 50 consequitive elderly Nigerians from 55 years had the standard self-administered IPSS questionnaire. Digital Rectal Examination (DRE) was also performed on each subject. Results were then subjected to statistical analysis.

Results: The mean age of the study was 64.4 ± 6 years, the mean IPS score was 18 ± 14. Prostatism was observed in 27 people while 14 people had urinary frequency and 9 men had no symptoms. 26 men had severe scores (20–35), while 1 man had moderate scores (8–19) and 23 men had mild scores. Increasing age was found to correlate positively with IPS Scores, and DRE findings (R = 0.6 and 0.6 respectively).

Conclusion: Using the IPSS questionnaire we were able to predict fairly accurately prostate enlargement in our subjects. It was therefore concluded that the IPSS is a valid tool in rapid screening of prostate enlargement even in the Nigerian males.

A30

The use of HRT in not-responsive patients to inhibitors of PDE 5

L. Alves Souza

Andrology Urology, Procriar Instituto de Andrologia e Urologia, Belo Horizonte, Minas Gerais, Brazil

Introduction: The inhibitor of phosphodiesterase 5 for treatment of erection dysfunction today is wide used. Some patients do not answer to this oral therapy due to low levels of total testosterone in blood.

Method: 15 patients with secondary hypogonadism who had made use of inhibitors of PDE 5, without obtaining penis erection had been followed. After blood dosage of total testosterone, prolactine, glucose and PSA, the use of 1 blister of 1000 mg of Testosterone Undecanoato (Nebido) and weekly use of inhibitors of PDE 5 was prescribed for a month.

Results: Thirteen patients reported an improvement in rigidity erection allowing sexual intercourse. The other two patients, did not obtain enough erection for penetration, but showed improvement of the libido.

Conclusion: The dosage of total testosterone must be part of diagnostic routine. Low total libido. testosterone can be the cause of not responsive oral treatment with inhibitors of PDE 5.

A31

Improvement of the symptoms of ADAM with use of spare therapy hormone (Nebido) – preliminary study

L. Alves Souza

Andrology Urology, Procriar Instituto de Andrologia e Urologia, Belo Horizonte, Minas Gerais, Brazil

Introduction: Patients with symptoms of deficiency of androgens (ADAM) present with low libido as one of the main symptoms. The use of 1000 mg of testosterone undecanoato (Nebido) quarterly has been shown efficient.

Objective: To evaluate the therapeutical effectiveness of the use of hormonal replacement therapy (HRT) of long duration in patients with secondary hypogonadism.

Method: 36 patients with androgenic deficiency had been followed. After laboratorial diagnostic and physical examination, the patients had been treated with 1000 mg of testosterone over 6 months.

Results: 76% of the patients had reported improvement of the symptoms related to ADAM. The other patients, 24%, had presented increase of the levels of blood testosterone without improvement in the symptoms related to ADAM.

Conclusions: The majority of the patients with secondary hypogonadism had benefited from the use of 1000 mg of undecanoato of testosterone.

A32

Adverse effects with use of 1000 mgof undecanoato of testosterone

L. Alves Souza

Andrology Urology, Procriar Instituto de Andrologia e Urologia, Belo Horizonte, Minas Gerais, Brazil

Introduction: The hormonal spare therapy for treatment of androgenic deficiency always was surrounded of concerns how much the possible collateral effect although the known benefits.

Objective: To evaluate the collateral effects in patients in use of hormonal spare therapy of long duration with undecanoato of testosterone.

Method: 36 patients in use of 1000 mg of undecanoato of testosterone with quarterly doses for 6 months. Laboratory examinations were done until and after therapy. Patients with levels of PSA > 2.5 ng/dl and modified rectal digital examination had been excluded from this study.

Results: The found collateral effects in this group had been: edema of inferior members in 6 patients; pain in the place of the application of the blister for 7 patients; chronic headache in 2 patients. No alteration was observed in the PSA levels above 4.0 ng/dl, and no significant alteration in blood cells.

Conclusion: The hormonal spare therapy with 1000 mg of undecanoato of testosterone presents low levels of collateral effects. In the followed group no increase of PSA level was identified. Further detailed study will be important to confirm these conclusions.

A33

Evaluation of patients with symptoms of deficiency of testosterone with normal levels

L. Alves Souza

Andrology Urology, Procriar Instituto de Andrologia e Urologia, Belo Horizonte, Minas Gerais, Brazil

Introduction: The therapy of hormonal replacement of testosterone is based on the low levels of total testosterone in the blood. However some patients presents signals and symptoms related to this syndrome of deficiency but laboratory examinations do not confirm this situation.

Objective: To evaluate patients with ADAM symptoms and normal levels of total testosterone.

Method: 32 patients with symptoms of ADAM had been followed. Ages of complainants varied between 34–62 years, and levels of total testosterone between 3500 to 9500 ng/dl. A questionnaire of score of symptoms was carried out.

Results: 28 patients of this group with hypogonadism complaints, mainly with low libido, had presented normal hormonal levels.

Conclusions: The deficiency diagnostic must associate clinical complaints with laboratory exams, when other factors can influence the symptoms.

A34

Gynecomastia of aging – male breast surgery

M. Bermant

American Board of Plastic Surgery, Ironbridge Medical Park, Chester, VA, USA

This 60-year-old had breasts consisting of excess fat over drooping pectoral muscles. Such breasts are a dynamic problem. The shape changes on movement and movies are a much better way of showing the problem and results after surgery. These results at only 10 days after surgery are too early to judge the true benefits of the 250 cc of fat removed. They do demonstrate the minimal bruising of the chest using the super-wet liposuction technique.

This series of photographs demonstrate the changing shape of the breast before surgery and contour markings I used to guide my liposuction surgery. For problems of male breast that are mainly fat, suction lipectomy alone is the surgical sculpting tool of choice. The remaining breast was of loose drooping pectoral chest muscles. Liposuction does not remove these muscles. To improve this chest further, the patient will have to use muscle exercising and building methods.

A35

Age related changes of DNA metabolism in pathogenesis of peptic ulcer

B.G. Borzenlo, E.V. Khomutov, L.M. Bakurova, O.P. Shatova

Department of Biochemistry, Donetsk State Medical University, Donetsk, Ukraine

The metabolism disturbance of DNA precursors plays a key role in pathogenesis of peptic ulcer and stomach cancer. The cooperative activities of thymidine metabolizing enzymes, anabolic thymidine kinase (TK) and catabolic thymidine phosphorylase are the factors that control tissue proliferation.

Objectives: The goal of this study was to determine the activity of thymidine metabolizing enzymes in blood serum and tissues of 23–60-year-old patients with peptic ulcer and stomach cancer, and compare the activity of the enzymes to that of control healthy males.

Method: The activities of enzymes were evaluated in 60 healthy males, 50 patients with peptic ulcer and 50 patients with stomach cancer by spectrophotometry and radiology analysis.

Results: The activities of TK and TP in blood serum appeared to correlate with their activities in tissues. While the activity of catabolic TP did not change with age, TK activity in blood serum significantly increased with age in healthy males. In 25–35-year-old ulcer patients the activity of TP remained similar to that of age-matched healthy males, however TK activity in blood serum of these patients increased from 1.95 = 0.05 mmol/min/mg (control group) up to 3.79 = 0.22 mmol/min/mg. In contrast, the activity of TK in blood serum of 40–60-year-old ulcer patients matched the activity of healthy individuals, while TP activity reduced from 4.7 + 0.5 mmol/min/mg (age-matched control) to 1.3 mmol/min/mg. Such cooperative changes in the activities of these enzymes may elevate the risk for development of peptic ulcer complication, as these changes resemble the trend of enzyme activities upon stomach cancer.

Conclusions: The observed correlation in TK and TP activities in ulcer and stomach cancer patients may serve as a prognostic indicator for development of ulcer complications before the appearance of clinical signs, especially for 46–60-year-old patients.

A36

The impact of age on erectile function management

P. Erdeljan, L. DeYoung, G. Brock

Division of Urology, University of Western Ontario, London, ON, Canada

Introduction: The impact of advancing age on increasing the rates of erectile dysfunction has been demonstrated unequivocally in several landmark epidemiological studies over the past two decades. However the changes in management of erectile dysfunction in different age groups remain poorly described, especially in men at the extremes of age groups. Whereas most product monographs describe initiating therapy with PDE5i among men older than 65 at the lowest dose, most clinicians report the necessity of the highest dose among this population.

Objectives: Our primary objective in this report was to determine response rates, management approach and overall success of erectile enhancement therapy among a large cohort of men with erectile difficulties presenting to a tertiary care clinic. Also, we tried to demonstrate that the men at two extremes of age should be treated distinctly.

Method: A convenience sample of 996 men older than 65 and younger than 40 years presenting for evaluation and management of ED were compared. Initial and post-treatment IIEF scores, method of therapy and overall satisfaction were recorded to determine if these two groups should be treated as distinct entities or not.

Results: 230 men of age under 40 (Group I) were compared to 776 men of age 65 and older (Group II). Cavernous arterial flow measurements showed a significant decrease with age. Group I (<40 years) average cavernous flow of 20 cm/sec versus Group II average cavernous flow of 28 cm/sec. Co-morbid conditions were more prevalent among the older men with hypertension, dyslipidemia and diabetes being the most common conditions. Using the SHIM as a validated instrument to assess erectile function, the older men had more severe ED (5.97 versus 10.2) with a more modest degree of improvement with therapy (9.2 versus 14.6).

Conclusions: This report demonstrated that sexual dysfunction in men less than 40 years of age, although seen less frequently than in older population, is still a significant health issue. Additionally, we showed the negative impact of sexual dysfunction on quality of life, in the same group of men, as well as the effectiveness of treatment. We conclude that the differences between the two populations should be considered carefully in order to allow the optimal medical management.

A37

Male breast cancer in south east England: incidence and outcome

I.S. Fentiman¹, A. Korir², K.M. Linklater², T. Massey², E. Davies²

¹Academic Oncology, Guy's Hospital, ²Thames Cancer Registry, Capital House, London, UK

Background and aims: Male breast cancer (MBC) is a rare disease accounting for <1% of all breast cancer cases in the UK. We have determined the incidence of MBC, distribution of stages at diagnosis and outcome in relation to treatment.

Methods: Data was obtained from Thames Cancer Registry on all males diagnosed with MBC between 1985 and 2003. Age-specific rates and age-standardized rates were obtained and outcome was determined in relation to stage and diagnosis and extent of treatment.

Results: 1132 cases of MBC were identified with a mean age at diagnosis of 69 years. There was a steady increase on age-specific incidence rates with age and the highest rate was above 75 years. The five year age-specific survival was 75% for those diagnosed between 1994 and 2000 compared with 77% for females diagnosed during the same period. Data will be presented on prognosis in relation to stage and extent of surgery.

Conclusions: There was a slight increase in MBC with time and the highest rates in those >75.

A38

Testosterone replacement with andriol testocaps in symptomatic late-onset hypogonadism – clinical and metabolic responses in a randomized, placebo-controlled study

T.B.P. Geurts¹, J.J. Legros², E.J. Meuleman³, P.M.G. Bouloux⁴, M.J.H. Kaspers⁵, J.M.H. Elbers⁶

¹International Medical Services, NV Organon, Oss, The Netherlands; ²Department of Endocrinology, University of Liege, CHR De La Citadelle, Liege, Belgium; ³Department of Urology, Free University Medical Center, Amsterdam, The Netherlands; ⁴Centre for Neuroendocrinology, Royal Free and University College School of Medicine, London, UK; ⁵Global Clinical Information – Biometrics, ⁶Global Clinical Development, NV Organon, Oss, The Netherlands

Objective: The objective of this multicentre, randomized, double-blind, placebo-controlled trial was to investigate the effects of oral testosterone undecanoate (TU) on clinical outcomes associated with LOH.

Method: In 14 study centres in 7 European countries, 322 eligible men ≥50 years with documented testosterone deficiency (calculated free testosterone <0.26 nmol/l) were randomized to treatment for 12 months with placebo, oral TU 80 mg/d, oral TU 160 mg/d or oral TU 240 mg/d in divided doses. The effects of treatment on LOH symptoms were measured using the Aging Males Symptoms (AMS) rating scale. Bone mineral density (BMD), lean body mass (LBM) and body fat mass (BFM) were measured using dual energy X-ray absorptiometry. Prostate safety was monitored using prostate specific antigen (PSA) and the International Prostate Symptom Score (IPSS).

Results: Oral TU treatment in men with LOH symptoms of moderate severity did not result in statistically significant changes on the total score of the AMS rating scale compared to placebo. The AMS sexual symptoms sub-domain improved statistically significantly with oral TU 160 mg/d at months 6, 9 and 12 compared to placebo (p < 0.05). After 12 months, treatment with oral TU statistically significantly increased BMD at the lumbar vertebrae and total hip (240 mg/d), increased LBM (80, 160 and 240 mg/d) and decreased BFM (160 mg/d). Oral TU had no effects on serum PSA level or IPSS. Oral TU was well tolerated and there were no between-group differences in (serious) adverse events or drop-out rates.

Conclusions: Treatment with oral TU improved objective symptoms of LOH, but was not different from placebo on subjective LOH symptoms (except for sexual function) as assessed with the AMS rating scale. There is a need for a validated rating scale for the measurement of clinical symptoms associated with LOH and the effects of androgen intervention.

A39

Vardenafil improves sexual function in men with erectile dysfunction and their female partners

I. Goldstein¹, W. Fisher², R. Rosen³, M. Mollen⁴, G. Brock⁵, G. Karlin⁶, P. Pommerville⁷, K. Bangerter⁸, Z. Herman-Gnjidic⁹, T. Taylor⁸, L. Derogatis¹⁰, for the Vardenafil Study Group

¹The Journal of Sexual Medicine, Milton, MA, USA; ²Department of Psychology, University of Western Ontario, London, ON, Canada; ³New England Research Institutes, Watertown, MA, ⁴Arizona Research Center, Phoenix, AZ, USA; ⁵Lawson Research Institute, St Joseph's Medical Center, London, ON, Canada; ⁶Lawrenceville Urology Practice, Lawrenceville, NJ, USA; ⁷CAN-MED Clinical Research Inc., Victoria, BC, Canada; ⁸Bayer HealthCare Pharmaceuticals, West Haven, CT, USA; ⁹Bayer HealthCare Pharmaceuticals, Toronto, ON, Canada; ¹⁰Johns Hopkins Center for Sexual Health and Medicine, Baltimore, MD, USA

Background and aims: To assess the influence of vardenafil on erection quality in men with erectile dysfunction (ED). Also, to determine whether treatment-induced changes in men's erectile function were associated with improvement in sexual function of their female partner.

Methods: 12-week, randomized, double-blind, multicentre, flexible-dose, parallel-group study involving men aged >18 years with ED for >6 months and their female partners. Men initially received placebo or vardenafil 10 mg, which could be titrated to 5 mg or 20 mg at weeks 4 and 8. Outcome measures included patients' responses to the erectile function domain of the International Index of Erectile Function (IIEF-EF) and erection quality scale (EQS), and partners' responses to the Female Index of Sexual Function (FSFI).

Results: 229 patients (mean age 59 years) were randomized to vardenafil (n = 116) or placebo (n = 113). Baseline IIEF-EF scores in the vardenafil and placebo groups were 13.2 and 13.4, indicating moderate ED. At last observation carried forward (LOCF), IIEF-EF scores were significantly higher in the vardenafil group compared with placebo (22.8 versus 12.7; p < 0.0001). This indicated a considerable increase in IIEF-EF scores in vardenafil patients (from moderate to mild ED) and no change in placebo patients. The EQS LS mean scores increased significantly from 15.3 at baseline to 36.1 at LOCF in the vardenafil group (p < 0.0001) but changed little in the placebo group (14.8 at baseline to 14.6 at LOCF). Among vardenafil-treated couples, treatment-related improvement in patients' IIEF-EF and EQS scores were significantly correlated with improvement in partners' FSFI total score (vardenafil r = 0.49 and 0.48 versus placebo r = 0.14 and 0.19) and all individual domain scores.

Conclusions: Men with ED showed significant improvement in erection quality (measured by the EQS) and IIEF-EF scores following treatment with vardenafil. Importantly, untreated women partners experienced improvement in sexual function associated with improving erectile function in men.

A40

Stable testosterone levels achieved with subcutaneous testosterone injections

M.B. Greenspan, M. Chang, K. Kwan

Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada

Objectives: Intramuscular (IM) testosterone (T) injections exhibit wide variations in levels. We investigated the sustainability of stable T levels using subcutaneous (SC) therapy.

Patients and methods: A one year pilot study of ten patients with hypogonadism was conducted. All had been stable on twice monthly IM injection for at least one year. Self injection with 100 mg of testosterone enanthate was done once weekly into the abdominal wall. T levels were measured before and 24 hours after injection weeks 1 through 4 and 96 hours post-injection weeks 6 and 8. The dose in two patients was reduced to 50 mg at week 4 because of ‘high’ levels. At week 12, PSA, CBC, and T levels were measured. All patients were followed with these levels for one year. A subgroup of 25 patients on SC injection has also been followed biochemically for 6 to 12 months.

Results: Prior to initiation of therapy in the pilot group, random T was 19.48 ± 3.48 nmol/l. During the first four weeks, there was a steady increase in T levels to 23.89 ± 9.15 (p = 0.1). After 8 and 12 weeks, the post and preinjection T levels remained stable and similar to those of week 1 (27.46 ± 12.91). Stable levels of T, PSA, and CBC were observed at twelve months. The subgroup showed a wider variation in levels but within acceptable limits.

Conclusions: Once weekly SC injection of 50–100 mg TE appears to achieve sustainable and stable levels of T in most patients. Decreased cost due to marked reduction in physician visits is an advantage. Long term physiologic and clinical effects of this method need ongoing and further evaluation.

A41

Age and gender influence bone mineral density (BMD) in dialysis patients

A.E. Grzegorzewska, M. Mlot-Michalska

Department of Nephrology, University of Medical Sciences, Poznan, Poland

Aim: To evaluate BMD in dialysis patients which were divided according to age (the older group over 65 years: n = 12; the younger group equal or lower than 65 years: n = 18) and according to gender (the female group: n = 18; the male group: n = 12). BMD was examined in femoral neck (N) and lumbar spine (L) by DEXA. Simultaneously PTH, calcium-phosphate balance parameters, blood pH, markers of inflammation, bioimpedance records of body composition, serum and anthropometric nutritional markers were evaluated.

Significant differences between the older and the younger groups concerned BMD in N (0.709 ± 0.111 g/cm² for the older group versus 0.884 ± 0.130 g/cm² for the younger one), T-score (−2.64, −4.06–0.17 for the older group versus −0.88, −3.25–2.37 for the younger group) and BMD expressed as % of peak BMD (68.0, 54.2–97.0% for the older group versus 89.5%, 61.4–135.0% for the younger group), indicating lower BMD in older patients, which also had lower serum albumin and higher serum ferritin. After adjustment of results for gender, differences between the age groups in BMD were maintained, additionally showing lower serum Ca, height and lean body mass as well as higher serum glucose in the older group.

Separation of patients according to gender did not reveal significant differences in BMD when results were not adjusted for age. After adjustment, the male group showed higher BMD in N (0.85 ± 0.16 g/cm²) and T-score (−1.90, −4.06–2.37) than the female group (N: 0.79 ± 0.14 g/cm², T-score: −1.30, −3.47–1.15).

Conclusion: Older age, which is more frequently associated with protein malnutrition, inflammation and glucose abnormalities, is the most important factor influencing loss of BMD in dialysis patients. A male gender is protective against bone loss in dialysis patients.

A42

Prevalence, and clinical and hormonal determinants of andropausal syndrome in men with chronic heart failure

E.A. Jankowska^1,2, M. Lopuszanska², A. Szklarska², B. Ponikowska³, A. Grzeslo¹, L. Borodulin-Nadzieja³, M. Medras⁴, W. Banasiak¹, P. Ponikowski¹

¹Department of Cardiology, Military Hospital, ²Institute of Anthropology, Polish Academy of Sciences, ³Department of Physiology, ⁴Department of Endocrinology, Wroclaw Medical University, Wroclaw, Poland

Background: Men with chronic heart failure (CHF) demonstrate severe deficiencies in circulating total testosterone (TT), dehydroepiandrosterone sulphate (DHEAS), insulin-like growth factor 1 (IGF1) which are related to increased mortality. We studied the prevalence of andropausal syndrome, and its hormone and clinical determinants in these patients.

Method: We examined 170 men with systolic CHF (age: 60 ± 10 years, New York Heart Association functional class I/II/III/IV: 24/86/54/6, left ventricular ejection fraction [LVEF]: 31 ± 9%, 72%– ischemic etiology) and 392 healthy men aged 35–80 living in the same area. Andropausal syndrome (AS) was diagnosed using the Polish version of Aging Male Symptoms' Rating Scale (≥27 points).

Results: AS was diagnosed in 29%, 49%, 57%, 79% of CHF men aged 35–44, 45–54, 55–64, 65–80 as compared to 4% (p < 0.001), 18% (p < 0.001), 39% (p = 0.03), 72% (p > 0.2) in age-matched healthy men. The more advanced NYHA class, the higher AS prevalence (NYHA I/II/III-IV: 29/51/85%, p < 0.0001). In a multivariable stepwise regression, AS intensity was independently determined by TT (p < 0.001), IGF1 (p = 0.03), DHEAS (p = 0.04), Beck Depression Inventory score (p < 0.01), age (p = 0.02), NYHA class (p = 0.03). CHF men with AS, as compared to those without AS, had more advanced disease (AS(+) versus AS(−), respectively, in all comparisons – NYHA class: 2.4 ± 0.6 versus 1.9 ± 0.6, p < 0.0001, plasma N-terminal-pro-brain natriuretic peptide: 3041 ± 5534 versus 1039 ± 1303 pg/ml, p < 0.01, peak oxygen consumption: 14.0 ± 4.5 versus 17.6 ± 4.9 ml/min/kg, p < 0.0001), and reduced total lean mass (55 ± 7 versus 59 ± 8 kg, p < 0.01), quadriceps strength (83 ± 27 versus 105 ± 27 Nm, p < 0.0001) and quality of life (50 ± 23 versus 28 ± 19 points, p < 0.0001).

Conclusions: Andropausal syndrome is common in men with CHF, and significantly impairs the patients' quality of life. Major independent determinants of its severity are: 1) advanced stage of CHF, 2) older age, 3) depressive symptoms and 4) multiple anabolic deficiency. Sexual and psychological counselling is advisable in this group of patients.

A43

Prevalence, clinical and hormonal determinants of bone status and bone loss over time in men with heart failure

E.A. Jankowska^1,2, A. Cwynar¹, J. Jakubaszko¹, B. Ponikowska³, J. Majda¹, K. Wegrzynowska¹, L. Borodulin-Nadzieja³, W. Banasiak¹, P. Ponikowski¹

¹Department of Cardiology, Military Hospital, ²Institute of Anthropology, Polish Academy of Sciences, Poland; ³Department of Physiology, Wroclaw Medical University, Wroclaw, Poland

Background: Bone status has not been comprehensively studied in chronic heart failure (CHF). In a cohort of men with CHF, we evaluated bone mineral status and bone loss over time, and established their clinical and hormonal determinants.

Methods: Bone mineral content (BMC) and bone mineral density (BMD) of arms, legs, trunk and total body were examined using dual energy X-ray absorptiometry in 187 men with CHF (age: 60 ± 11 years, left ventricular ejection fraction [LVEF]: 32 ± 7%, New York Heart Association [NYHA] functional class I/II/III/IV: 20/76/76/15, 76% ischaemic aetiology).

Results: In men with CHF, reduced BMD and BMC in all anatomical regions were detected mainly in NYHA class IV patients (NYHA I/II/III/IV: BMC-total [kg]– 3.17 ± 0.49/3.01 ± 0.34/2.94 ± 0.42/2.61 ± 0.49, respectively, p < 0.05 NYHA IV versus I–III). Reduced BMD and BMC were related to CHF severity (expressed as higher NYHA class, impaired LVEF, low peak oxygen consumption), reduced fat and lean tissue mass, and diminished serum levels of dehydroepiandrosterone sulphate and total testosterone (TT) (all p < 0.05), but not age, CHF aetiology, plasma N-terminal-pro-brain natriuretic peptide, serum insulin-like growth factor 1. Bone status was reassessed in 60 patients who survived >2 years. Significant bone loss over time (defined prospectively as a reduction in BMC-total ≥1%/year) occurred in 21 out of 60 (35%) men with CHF. Only baseline higher NYHA class (a reduction in BMC-total: NYHA I–II/III–IV – 0.2 ± 1.3/1.3 ± 1.6%/year, p = 0.003) and reduced TT (r = 0.60, p < 0.001) predicted greater bone loss.

Conclusions: In men with CHF, reduced bone mineral density and bone mass constitute another element of generalized body wasting, and are determined mainly by advanced stage of heart failure, and adrenal and gonadal androgen deficiency. Bone loss occurs in half of men with CHF, and is also related to testosterone depletion and disease severity.

A44

The dilemma of change, a global perspective down under

R.M. Massey

School of Population Health, University of Queensland, Brisbane, Australia

The most recent census data confirm that our elderly populations are growing at an unprecedented pace (Koenig 2004, p. 19). Population aging is a major focus of social and economic planners and policy makers in Australia, as it is throughout the more developed regions of the world (Australian Social Trends 1999). Demographic data is briefly discussed. This CSSAM/ISSAM congress event focuses upon the health care of the aging male. A brief overview of the perception of male health globally is presented by reference to the Australian Medical Association, the European Men's Health Forum, the Queensland Government's Department of Health, and the Pan American Health Organization (PAHO). In the PAHO (1986) report it states that ‘our response to the challenge of aging population therefore requires not simply an expansion of professional services but the adoption and implementation of the principles of primary health care advocated by the World Health Organization- namely the development of services to focus on the whole population, appropriate use of resources and technology, the involvement of all sectors and agencies in the development of service, and, most important of all, the participation of elderly people themselves'. Aspects of the statement are explored from the perspective of the 70-year-old presenter. The Fifth World Congress organized by ISSAM (Lunenfeld 2006) demonstrated that interdisciplinary collaboration is possible and can unite all forces in this relatively new discipline. He stated (in his 5th Congress welcome letter) ‘The health care of males in their aging years has tended to be piecemeal and somewhat uncoordinated’. The presenter looks at the role of sponsorship and the current practice of exclusion of disciplines other than medicine in the approach for corporate dollar consideration. A case for appreciation of other disciplines is presented.

A45

Estrogens in men

L.D. Komer^1,2, G. Tonnelly²

¹McMaster University, Hamilton, ON, ²Masters Men's Clinic, Burlington, ON, Canada

Estrogens in males are primarily the product of peripheral aromatization of testicular and adrenal androgens. In men, estrogens produce beneficial effects on skeletal growth. bone maturation and bone density. Estrogens exert positive effects on the brain in the areas of cognition, coordination of movement, pain and affect. Estrogen has positive effects on the cardiovascular system including lipid profiles, coagulation, platelets, inflammatory factors, and vascular wall effects (nitric oxide, endothelins). Adverse effects of elevated estrogens include suppression of testosterone production by increased negative feedback of the hypothalamic-pituitary-gonadal axis thus reducing pituitary output of LH. Excess estrogens increase plasma levels of SHBG which, due to preferential binding with testosterone, reduce testosterone activity. Eight per cent of men attending our clinic need treatment to lower estrogens. Reduction of estrogen results in increased levels of gonadotropins. We believe it a better clinical strategy to lower estrogens and upregulate the production of testosterone than to just supplement testosterone. Our clinic advocates plasma values of estradiol over 160 pmol/l be treated to reduce or eliminate estrogenic symptoms (sore breasts, gynecomastia, mood changes), to normalize testosterone production and to increase testosterone activity. Arimidex (anastrozole) 1 mg ¼ tablet three times weekly or Femara (letrozole) compounded capsule 0.5 mg once or twice weekly decreases serum estradiol levels appropriately but they remain within the normal male range. These aromatase inhibitors block the conversion of testosterone to estrogen and are highly specific substances mostly devoid of side effects and usually well tolerated. These estrogen reductions do not appear to have adverse effects on lipid profiles, inflammatory markers of cardiovascular risk or insulin resistance. We achieved the same clinical results with substantially lower doses than previous studies, increasing safety and tolerability while reducing the costs of these relatively expensive therapies to our patients.

A46

Depression and TRT

L.D. Komer^1,2, G. Tonnelly²

¹McMaster University, Hamilton, ON, ²Masters Men's Clinic, Burlington, ON, Canada

Hypogonadal men often exhibit depressive symptoms, which improve with testosterone replacement. Typical features of hypogonadism include diminished muscle mass and strength, decreased bone mineral density, decreased libido, anorexia, fatigue, dysphoria and irritability. Some of these symptoms overlap with those of depressive illness. At the Masters Men's Clinic, every patient is assessed for depressive illness by completing the 21 item Beck Depression Index (BDI). Although not one single patient has ever been referred for depressive illness reasons, our clinical procedures have identified that 35% of these patients meet the DSM-IV criteria for moderate to severe depression. When treated with testosterone, every patient in our clinic showed some response to treatment as the BDI scores decreased significantly from base line. The mean reduction in BDI scores was 68.4%. All patients who received testosterone achieved normalization of their testosterone levels. Testosterone appeared to benefit psychological aspects of depression such as depressed mood, guilt, and psychological anxiety items of the BDI to the same degree as the somatic aspects of depression such as sleep, appetite, and libido. Treatment-resistant depression is a persistent clinical problem. Testosterone levels may often be reduced in men with treatment-refractory depression and older men with dysthymia. Testosterone can effectively augment antidepressant treatment in hypogonadal men with refractory depression. Reasons for this clinical success could be attributed to the fact that: 1) testosterone stimulates 5-hydroxytryptamine receptors and serotonin transport in various central nervous system regions, 2) testosterone administration is associated with increased cerebral perfusion in specific brain regions that are important for memory and cognitive function, and 3) testosterone is linked to an increase in neuron somal size, neuritic growth, plasticity and synaptogenesis. One of the lesser known actions of testosterone is neuroprotection, an effect that results in salvage, recovery or regeneration of the nervous system, its cells, structure and function.

A47

Testosterone restoration therapy: options, pitfalls and solutions

L.D. Komer^1,2, G. Tonnelly²

¹McMaster University, Hamilton, ON, ²Masters Men's Clinic, Burlington, ON, Canada

There are many options for restoring testosterone levels into the optimum range. Each patient presents a unique biochemical and symptomatic clinical situation.

With a patient population approaching 1000 men, the Masters Men's Clinic has a varied and evolving experience in optimizing hormone levels. Patients are informed of their therapeutic options and encouraged to choose the therapy with which they feel most comfortable; this choice improves compliance and our continuation rates run over 90%. Patient doses are titrated to maximize improvement. We have learned methods to improve absorption and maintain consistent testosterone levels with testosterone undecanoate capsules (Andriol). The Masters Men's Clinic has found pitfalls and solutions with testosterone gel administration. We use injectible testosterone intramuscularly and latterly subcutaneously. Our clinic has experience with long lasting testosterone injections (Nebido). We work closely with a group of compounding pharmacists who formulate testosterone crème in strengths from ½ to 7.5% and we have found ways to optimize absorption. We usually start new patients on loading doses and then titrate them to a lower maintenance dose. Our testing has shown that 60% of the men we evaluate are low in DHEA. Some of these men choose to start their own DHEA supplementation. 8% of our men have or develop elevated estrogen levels that we lower with aromatase inhibitors. Elevated levels of prolactin are suppressed with cabergoline. Men who are interested in maintaining their fertility are treated with self-administered HCG injections with or without testosterone. Our experience is that TSH levels are optimal between 0.35 and 1.5 mIU/l whereas lab ranges of 0.35–5.0 are overly wide. We recently have found that danazol administration frees testosterone from SHBG and may be used as a specific treatment. Actual doses and specific recommendations will be discussed in our oral presentation.

A48

Correction age androgenic deficiency at patients nephrolitiasis

T.N. Nazarov, V.P. Alexandrov, V.V. Mihajlichenko, D.G. Korenkov, S.N. Kalinina, G.N. Skrjabin

Department of Urology and Andrology, Medical Academy of Postgraduate Studies, St Petersburg, Russia

The objects of our research were 48 patients having a combination age androgenic of deficiency and nephrolitiasis. Age of patients was from 58 to 86 years. The purpose of the present research is studying and correction age androgenic deficiency at patients with nephrolitiasis. Following results of research are received: testosterone – M ± m = 1.9 ± 0.1 ng/ml (norm of 3–10 ng/ml), LH – M ± m = 20.5 ± 0.6 mMe/l (1–9 mMe/l), FSH – M ± m = 17.1 ± 0.6 mMe/l (1–15 mMe/l), prolactin – M ± m = 549.1 ± 7.2 mMe/l (62–630 mMe/l), estrodiol – M ± m = 50.0 ± 0.7 ng/ml (12–60 ng/ml), Parameters of a PSA – M ± m = 2.7 ± 0.2 (norm up to 4.0 ng/ml). Volume prostate are received: M ± m = 35.7 ± 1.2 ml. With the purpose of correction androgenic deficiency preparation Androgel in the form of transdermal forms androgen which was put once a day on a leather. If at patients raised concentration LH (>9.0 mMe/l) and within the limits of normal parameters testosterone (<3.0 ng/ml) – the compensated stage the initial doze of a preparation has made 5 mg/day was marked. If at patients raised level LH (>9.0 mMe/l) and a low level testosterone (<3.0 ng/ml) – decompensated stage the dose of a preparation has made 10 mg/day came to light.

Parameters PSA in whey of blood were defined within the limits of norm-th and – M ± m = 2.4 ± 1.1. The volume prostatic has slightly decreased: M ± m = 29.7 ± 1.6 ml.

Through 6 months after the beginning of therapy control research of hormones of blood at all patients was carried out also. Decrease in levels LH, FSH, prolactin, estrodiol, and increase of the maintenance in blood testosterone is noted. Parameters testosterone have raised from 2.5 times (p < 0.05) up to 4 times (p < 0.05). The level LH hormone has decreased in 2–3 times (p < 0.05), FSH hormone has decreased from 1.6 times (p < 0.05) up to 2.2 times (p < 0.05). The level prolactin has decreased in 1.8 times (p < 0.05), estrodiol in 1.9 times (p < 0.05).

In our opinion, age decrease in a level androgenic in an organism can be the additional factor nephrolitiasis.

A49

Testosterone influences aspects of cognition in healthy aging men

R.H. Matousek¹, B.B. Sherwin¹, P. Chan²

¹Department of Psychology, McGill University, ²Department of Urology, Royal Victoria Hospital, Montreal, QC, Canada

This study investigated the possible relationship between testosterone levels and cognitive functioning in healthy aging men. Verbal learning and memory, visual-motor processing, spatial abilities, working memory and attention were evaluated in a group of healthy aging men (mean age = 68 years). Morning serum total testosterone, free testosterone, and bioavailable testosterone levels were obtained in all subjects. Multiple regression analyses were conducted to examine the hormonal predictors of performance on the various cognitive tests. Results of the regression analyses revealed that total testosterone levels predicted scores on a task of visual-motor processing, while both free testosterone and bioavailable testosterone levels predicted scores on measures of attention and delayed verbal memory. These results provide further evidence that testosterone levels are positively associated with performance on tests of attention, long-term memory and visual-motor processing in healthy aging men and suggest that performance on these cognitive tests may decline somewhat in older men with low free and bioavailable testosterone levels.

A50

Testosterone-associated changes in AKT and Foxo3A phosphorylation and atrogin 1 mRNA levels in mouse skeletal muscle

A. Mazza¹, M.J. Haas¹, M.T. Haren^2,3, A. Siddiqui⁴, V.M. Kumar^2,3, J. Armbrecht^2,3, R.T. Kevorkian^2,3, M.J. Kim⁵, W.A. Banks^2,3, J.E. Morley^2,3

¹Division of Endocrinology, ²Division of Geriatric Medicine, St Louis University School of Medicine; ³GRECC VA Medical Center St Louis; ⁴Department of Molecular Microbiology and Immunology, St Louis University, St Louis, MO, USA; ⁵Department of Family Medicine, College of Medicine, Pochon CHA University, Bundang CHA General Hospital, Seoul, Korea

Background and aims: Atrogin-1 may be increased, unchanged or decreased in aged skeletal muscle. Phosphorylation of Foxo transcription factors by activated AKT inhibits transcription of Atrogin-1. This reduces muscle atrophy in various animal models of muscle loss. The effect of castration and testosterone replacement on this pathway has not been examined. Castration induces muscle atrophy in mice after 10 weeks and is prevented by testosterone replacement. This study examined whether or not there is a correlation between AKT and Foxo expression and activity and Atrogin-1 transcription in castrated and testosterone-replaced animals.

Methods: Using gene chip microarrays (Affymetrix), the effect of T on gene changes in gastrocnemius muscle (mGas) was studied in 8 weeks old male CD-1 mice (n = 36; 12/group). Mice were randomly assigned to Castration + T [2.5 mg pellet s.c. (C + T)]; Castration + Placebo (C + P) or Sham + Placebo (S + P) for 14 days. Body weight and food intake were assessed. Levator Ani (L. Ani) and mGas were excised, weighed and RNA was isolated. Serum was assayed for T by RIA. Total and phosphorylated AKT1 and Foxo3a were measured by Western blot. Real-time RT-PCR was used to validate microarray results.

Results: There were no significant differences in food intake, body or mGas weight after 14-days. T levels (p < 0.001) and L. Ani weights (p < 0.05) were significantly lower in C + P compared to C + T and S + P. Microarray analyses in mGas revealed 122 differentially expressed genes. Atrogin-1 mRNA levels decreased 2-fold with castration and increased 2-fold by T, a finding validated by real-time RT-PCR. Phospho-AKT and Foxo3a levels significantly increased with castration, compared to both sham controls and testosterone replaced animals.

Conclusion: Changes in AKT and Foxo3A phosphorylation correlate with and may mediate the observed changes in atrogin-1 gene expression in mGas from castrated and testosterone-replaced mice.

A51

Cystectomy and its age-related complications

M. Nayeemuddin, S.D. Sharma

Department of Urology, Edith Cavell Hospital, Peterborough District Hospitals NHS Trust, Peterborough, UK

Purpose: Review of all cystectomies done over a period of one-year from September 2002 to September 2003.

Methods: Case notes and theatre registers were analysed.

Results: A total of 12 cystectomies were performed. 9 were radical, 2 were salvage and 1 was partial cystectomy. Mean age was 63.8 years (37–75), male to female ratio was 7:5 and mean hospital stay was 21.5 days (14–42). Out of 12 cystectomies, 10 were done for cancer of bladder, 1 for cancer of bowel and 1 for Crohn's disease. Among the two salvage cystectomies that were performed for recurrent cancer of the bladder, one died at day 20 secondary to pneumonia and septicaemia. Partial cystectomy was performed for colo-vesical fistula secondary to Crohn's disease at 37 yrs of age. Post-operative mortality at 30 days and 3 months was 8.3%. The main post-op complications were pneumonia (33%), wound infection (16%) and paralytic ileus (16%).

Conclusion: A high rate of pulmonary complications was particularly noticed in old patients who were operated on Friday. This was found to be due to inadequate chest physiotherapy over weekend. The need for chest physiotherapy over weekend was re-emphasized and appropriate arrangements were made.

A52

Diagnostics and treatment age androgenic deficiency

T.N. Nazarov

Department of Urology and Andrology, Medical Academy of Postgraduate Studies, St Petersburg, Russia

Twenty-eight patients in the age of from 52 till 78 years with attributes age androgenic deficiency are surveyed. All patients filled a questionnaire for revealing attributes androgenic deficiency. Research of hormones has shown, that at 16 patients the level plasma testosterone was defined on the bottom border of norm, that is so-called decompensated stage. At 12 was on the bottom border of norm – the compensated stage. Thus increase of level LH is noted at 14 person, at 9 on the top border of norm and at 5 below norm. FSH at the majority (74%) patients kept on the top border of norm. Prolactin at all surveyed it was defined above average indices of norm. The index free testosterone which was defined at 25 patients, was within the limits of 35–70%. For therapy preparation androgel in the form of transdermal forms androgen is used, the dose of a preparation has made 5 mg (at 16 patients) – 10 mg (at 12 patients) in day. Dynamic research sexual and hypophysis hormones in 3 and 6 months has shown, that at carrying out of replaceable therapy the level plasma testosterone has authentically increased (with 3.5 + 0.02 up to 9 + 0.1), contents LH of plasma in comparison with initial parameters (with 15.3 + 0.3 up to 7.8 + 0.1) has decreased. Level PSA did not vary, being within the limits of norm (not above 4.0 ng/ml). At all patients, according to a questionnaire, improvement of a dream, increase libido, sexual activity, improvement of memory and attention was marked. Adequate completion of age deficiency which criterion is normalization of level LH in plasma of blood, promotes reduction of intensity of development of processes of ageing at men, preventive maintenance of an atherosclerosis, a bony rarefication, adiposity, psycho emotional frustration, raises sexual activity, reduces risk of development hyperplasia and a cancer prostate.

A53

Therapy sexual dysfunctions at patients

T.N. Nazarov, V.V. Mihajlichenko

Department of Urology and Andrology, Medical Academy of Postgraduate Studies, St Petersburg, Russia

Surveys 36 patients with age androgenic deficiency. Age from 54 till 68 years. Maintenance LH, FSH, testosterone, prolactin, estrodiol, a PSA, a scale of a quantitative estimation man's copulation functions (MCF) and a scale ‘International Index Erection of Function’ (IIEF) was defined. Preparation nebido (testosterone undecanoate) – 2 injections of 4 ml intramuscularly every 12 weeks is appointed. For an estimation of efficiency of treatment patients are repeatedly surveyed in 6 months. Before treatment a level LH has been raised at 24 (66.7%) patients, and at 12 (33.3%) within the limits of norm, the level FSH accordingly 21 (58.3%) and 15 (41.7%), and a level prolactin and estrodiol at all patients is on the top border of norm. A level testosterone at all patients below norm. Level PSA the limits of norm. Average indice MCF has made 9 points, and on scale IIEF the total index has averaged 52.63 ± 1.8 points. After 6 months of a rate of therapy at patients authentic increase of average values of a level testosterone in blood from 4.1 up to 8.2 ng/ml is noted. Raised level FSH has decreased with 24.7 up to 8.4 mMe/l, and LH – has decreased to the top border of norm with 28.5 up to 8.2 mMe/l. With patients whose FSH and LH before treatment were within the limits of norm after control research remained practically without changes. Normalization of the maintenance of levels prolactin (with 567.4 up to 224.2 mMe/l) and estrodiol (with 56.7 up to 28.8 ng/ml) is fixed also. Level PSA within the limits of norm. The average indice of a condition copulation functions on scale MCF has increased up to 15 points, and on scale IIEF and 58.2 ± 1.8 points due to increased libido, frequency of sexual relations and improved erection.

A54

A man's sexual expression over time: the goals of sex therapy and medical management

D. Niedziela, I.W. Kuzmarov, A. Skamene, D. Eiley, A.L. Jacobson

West Island Sexual Dysfunction and Wellness Clinic, Pointe Claire, QC, Canada

In human sexual behaviour many complex factors are involved. Some are attributed principally to biological sources, others to social, cultural and interpersonal human relations. Physicians dealing with sexual dysfunction must consider the psychological and behavioral aspects of their patient's diagnosis and management, as well as organic causes and risk factors. Integrating sex therapy and sexual pharmaceuticals into the management will improve effectiveness, compliance and couple satisfaction. There are many factors that are involved in erectile dysfuntion in the aging male. Co-morbidities, physical and organic changes in the female partner with age, decline in testosterone levels, relationship issues, among others. This presentation provides information about four domains of sexo-corporal evaluation related to men's sexual expression: 1) physiological factors related to functional sexual excitement, 2) sexo-dynamic components such as archetypes, stereotypes, sexual pleasure, fantasies, sexual desire, codes of attraction and sexual assertiveness, 3) cognitive factors, and 4) relationship factors, as well as patient and partner resistance, which impact patient compliance and sex lives beyond organic illness and mere performance anxiety.

Erectile problems are found to affect men in both their intimate and nonintimate lives, including how they see themselves as sexual beings. Therefore, successful treatment requires a multidimensional understanding of all of the forces that created the problem, whether a solo physician or multidisciplinary team approach is used. By combining disciplines and therapeutic approaches to the given case, one is more likely to improve sexual desire, arousal, penile tumescence and sexual satisfaction, and return the patient to a normal organic and psychological state.

A55

Efficacy and tolerability of flexible-dose vardenafil taken 8 hours before intercourse: extended duration of vardenafil in ED (extended) trial

P. Pommerville¹, H. Porst², I. Sharlip³, D. Hatzichristou⁴, E. Rubio-Aurioles⁵, for the Vardenafil Study Group

¹Can-Med Clinical Research Inc., Victoria, BC, Canada; ²Practice of Urology and Andrology, Hamburg, Germany; ³Pan Pacific Urology, San Francisco, CA, USA; ⁴2nd Department of Urology and Center for Sexual and Reproductive Health, Aristotle University of Thessaloniki, Thessaloniki, Greece; ⁵Asociación Mexicana Para La Salud Sexual, Tlalpan,Mexico

Background and aims: To evaluate the efficacy of vardenafil in men with erectile dysfunction (ED) when taken 8 hours prior to intercourse.

Methods: Men with ED for >6 months and who failed 50% of intercourse attempts during a 4-week treatment-free period, were randomized to flexible-dose vardenafil or placebo for 10 weeks. Patients were instructed to take study drug 8 hours before attempting intercourse. Starting dose of vardenafil was 10 mg, with option to titrate to 5 mg or 20 mg at weeks 2 and 6. Efficacy measures included Sexual Encounter Profile (SEP) questions 2 (penetration) and 3 (maintenance of erection), Erectile Function (EF) domain score, and Global Assessment Question (GAQ). Data from weeks 2–10 for doses taken 8 2 hours before sexual intercourse were used for analysis.

Results: 383 patients were randomized to vardenafil (n = 194) or placebo (n = 189). Most had severe (36%) or moderate (31%) ED at baseline; mean EF domain score was 13.3. Over weeks 2–10, least squares (LS) mean per-patient success rates were significantly greater with vardenafil compared with placebo for penetration (81% versus 51%, p < 0.001) and maintenance of erection (69% versus 34%, p < 0.001). At week 10, LS mean EF domain score was significantly higher in vardenafil group versus placebo (22.8 versus 14.9, p < 0.001). Significantly more patients reported improved erections (GAQ) with vardenafil versus placebo (77% versus 27%, p < 0.001). Vardenafil was generally well tolerated; the most common (5%) treatment-emergent adverse events (% vardenafil/placebo) were headache (15/3), flushing (7/2), and nasal congestion (5/0).

Conclusion: Vardenafil, when taken at 82 hours before intercourse, demonstrated superior efficacy compared with placebo; penetration and maintenance of erection success rates were 81% and 69%, respectively, and EF domain score improved into the ‘mild’ range. These results demonstrate that patients can successfully use vardenafil when intercourse is attempted up to 8 hours after dosing.

A56

Influence of orchectomy on bone mineral density in male rats of reproductive age

V. Povoroznjuk¹, I. Gopkalova², Y. Kreslov¹

¹Department of Clinical Physiology and Pathology of Locomotor Apparatus Institute of Gerontology AMSU, Ukrainian Centre of Osteoporosis, Kiev, ²V. Danilevskiy Institute of Endocrine Problems Kharkov, Kharkov, Ukraine

Aim: To evaluate the influence of orchectomy on bone mineral density and bone mineral content in male rats of reproductive age.

Research object: There were inspected 16 male rats of reproductive age, ‘Wistar’ line, under vivarium conditions of the Institute of Gerontology. 10 rats (mass 0.18 ± 0.005 kg) made up a control group (CG); 8 animals of experimental group (mass 0.20 ± 0.006 kg) have undergone orchectomy (ORC).

Methods: Bone mineral density (BMD) and bone mineral content (BMC) were measured using dual energy X-ray densitometry (DEXA) and ‘Experimental animals’ software. Examination was made before orchectomy and over 30 days after operation. Increase was determined in percentage of bone mineral density and bone mineral content of the entire body. The index was calculated according to the formula: Δ BMD (%) = (Δ BMD/BMD ref.) × 100.

Results: Comparative dynamics indexes of bone mineral density and bone mineral content in male rats of control group and group after orchectomy are presented in Table I.

Conclusions: The orchectomy leads to a substantial decrease of bone mineral density and bone mineral content in male rats of reproductive age, allowing this method to be used for creation of an experimental model of osteoporosis.

Table I.  Dynamics of bone mineral density and bone mineral content in male rats of reproductive age after orchectomy.

Group	BMD ref.	Δ BMD	Δ BMD (%)	BMD ref.	Δ BMC	Δ BMC (%)
CG	0.105 ± 0.002	0.019 ± 0.009	19.33 ± 9.82	9.65 ± 0.26	2.44 ± 0.28	25.88 ± 3.48
ORC	0.113 ± 0.002	−0.003 ± 0.003	−2.87 ± 2.43	11.62 ± 0.31	−0.30 ± 0.31	−2.41 ± 2.65
F	5.84	3.89	4.01	7.12	32.52	26.7
p	0.015	0.047	0.041	0.009	<0.00001	<0.00001

M ± m; CG – animals of control group; ORC – animals with orchectomy; BMD ref. – initial indexes of bone mineral density of the entire body; BMC – initial indexes of bone mineral content of the entire body; F – Fisher index.

A57

The clinical value of 3 versus 8 month neioadjuvant hormonal therapy prior to radical prostatectomy

X.Y. Pu, X.H. Wang, H.P. Wang

Department of Urology, Guangdong Provicial People's Hospital, Guangzhou, Guangdong, China

Background and aims: Neoadjuvant hormonal therapy (NHT) before radical prostatectomy reduces the likelihood of positive margins in the literature. The aim of this study is to evaluate the clinical value of 3 versus 8 month NHT prior to radical prostatectomy.

Methods: 69 patients with clinically confined prostate cancer were randomized to receive 3 months of NHT, 8 months of NHT before radical prostatectomy or just prostatectomy. The treatment outcomes were compared in the three different therapies on prostate cancer.

Results: The serum PSA and prostate size were higher in the 3 month compared with the 8 month group before radical prostatectomy, respectively (p < 0.01). There was no significant difference between the 3-month or 8-month NHT and non-neoadjuvant groups with respect to mean operative time, mean blood loss, transfusion, seminal vesicle invasion and lymph nodes metastasis at the 61.2 months follow up (p > 0.05, respectively). The significant differences were determined between 3-month and 8-month NHT group or NHT and non-neoadjuvant group with respect to positive margin and capsular invasion (p < 0.01, respectively). The overall PSA recurrence rate was 16.1% at the period of follow-up. The significant difference was detected in the three groups regarding to biological recurrence p < 0.01.

Conclusion: 3 month and 8 month NHT decrease the positive margin, capsular invasion and biological recurrence on prostate cancer. The longer 8 month NHT may delay the PSA free survival and the long term results needed to explored.

A58

Concomitant placement of male sling with inflatable penile prosthesis by unique penoscrotal incision: surgical technique

L. Rolle¹, C. Ceruti¹, A. Tamagnone¹, I. Morra², F. Ragni², M. Timpano¹, P. Destefanis¹, C. Negro¹, D. Fontana¹

¹Divisione Universitaria di Urologia 2, Ospedale Molinette, Torino; ²Divisione Universitaria di Urologia, Ospedale San Luigi Gonzaga, Orbassano, Torino, Italy

Introduction: Erectile dysfunction and urinary incontinence are the two most frequent complications after radical prostatectomy. We describe the technique for the concomitant implantation of inflatable penile prosthesis with the synthetic male sling by a unique peno-scrotal incision.

Method: A 67 year-old patient underwent retropubic radical prostatectomy for organ-confined prostate cancer in January 2005. One year later, he complained of complete erectile dysfunction and a persistent mild stress urinary incontinence. The patient underwent treatment with placement of a synthetic bulbo-urethral sling (Invance^TM from American Medical Systems) with concomitant implantation of an inflatable penile prosthesis. A unique inverted V-shaped peno-scrotal incision was performed, starting with the male sling placement using 6 bone screws drilled into the descending pelvic rami bilaterally. Then, the implantation of the penile prosthesis was completed. Finally, the 4 × 7 silicone coated polymer mesh was stretched over the bulbo-spongiosus muscle. A sovrapubic drainage was positioned and removed 24 hours later.

Results: No perioperative complications occurred. The patient was discharged within 48 hours. Antibiotic prophylaxis and pain-killers were administered. Six months after the procedure the patient reported complete urinary continence (no use of pads) and is able to achieve complete sexual intercourse.

Conclusions: Our initial experience shows that the concomitant placement of the male sling with the inflatable penile prosthesis by unique incision is a feasible and easy technique.

A59

The modified Nesbit's operation for penile curvature: results in La Peyronie's disease

L. Rolle, C. Ceruti, A. Tamagnone, M. Timpano, C. Negro, D. Fontana

Divisione Universitaria di Urologia 2, Ospedale Molinette, Torino, Italy

Purpose: We restrospectively analysed the results of our proposed technical modification to Nesbit's operation, designed in order to increase the precision and to simplify the correction of penile curvature, in patients affected by La Peyronie's disease.

Methods: From September 2001 to October 2006, 48 patients were considered for a surgical treatment of penile curvature and underwent a modified corporoplasty procedure. Hospital records and follow-up data were retrospectively reviewed.

Results: Patients were affected by La Peyronie's disease with penile deformity with a mean angle of 48° (range 40–60), without hourglass deformity or hinge effects. Mean age was 62.6 (range 58–68). All these patients had spontaneous and full erections. Mean operative time was 62 + 15 min. No intra-operative complications were recorded. In all cases, the penile curvature was completely corrected. Neither residual curvature nor hypercorrection were recorded. Regarding erectile function, preoperative average IIEF-5 score was 17.83 + 4.17, whereas postoperative score was 19 + 4.63 (p = 0.036). Regarding overall satisfaction, 3 patients (6%) were unsatisfied due to penile shortening.

Conclusion: Our modified corporoplasty procedure results in an improvement of straightening outcome thanks to the possibility to perform the excision of tunica albuginea only after the surgeon has made and verified the exact correction, in real time. A slight but statistically significant improvement of erectile function was observed.

A60

Angiotensin receptor antagonism with valsartan decreases arterial stiffness in obese men with erectile dysfunction

U. Rushentsova¹, G. Alymov²

¹Department of Endocrinology and Hypertension, Moscow, Russia; ²Department of Hypertension, Nishny Novgorod, Russia

Background: Erectile dysfunction is related to endothelial function. Angiotensin II (AT II) plays a key role in the development of vascular disease. Arterial stiffness is an important, independent predictor of cardiovascular risk. We investigated the long-term effects of selective AT1 receptor blockade with valsartan on arterial stiffness in obese men with erectile dysfunction.

Study design and methods: We have examined 30 patients (aged 47 ± 1 years, BMI 38–46 kg/m²) with obesity in the double blind, placebo controlled study. We measured brachial blood pressure (BD, mmHg), brachial-ankle pulse wave velocity (baPWV, cm/s) and the augmentation index (Aix, %) by using tonometry, volume-plethysmography and Doppler ultrasonography before and after 20 weeks of treatment with valsartan (40 to 160 mg/day). Statistical significance was assessed by t-test or two-way ANOVA of the dose responses curves.

Results: After 20 weeks of treatment with valsartan, baPWV and Aix were reduced: mean delta systolic BP 12 ± 1.6 mmHg (p = 0.02 versus baseline), diastolic BP 5.1 ± 1.8 mmHg (p < 0.0001 versus baseline), mean BP 7.5 ± 2.7 mmHg (p = 0.003 versus baseline), baPWV 2.4 ± 0.03 cm/s (p = 0.02 versus baseline), Aix 23 ± 8% (p = 0.002 versus baseline).

Conclusion: Valsartan reduced the arterial stiffness significantly in obese men with erectile dysfunction. There is a possibility that AT1 receptor antagonism affects the improvement of erectile dysfunction via the decrease of pulse wave velocity, especially in patients with risk factors for arteriosclerosis.

A61

Comparison of prazosin with combination of prazosin and finasteride in success spontaneous voiding for 48 hours after removing of urethral catheter in men with acute urinary retention (aur) due to benign prostatic hyperplesia (BPH)

M. Salehi, F. Poorreza, H. Ghasemi, M. Fouladi Mehr

Department of Urology, Razi Hospital, Rasht, Gulian, Iran

Background and aims: Comparison of prazosin with combination of prazosin and finasteride in success spontaneous voiding for 48 hours after removing of urethral catheter in men with AUR due to BPH.

Methods: Men with first episode of AUR due to only BPH were included in this survey. After insertion of urethral in dwelling catheter and study of the urinary system by sonography and laboratory tests in a randomized controlled trial, patients who had an indwelling urethral catheter for 72 hours received a combination of prazosin and placebo (A) or a combination of prazosin and finasteride (B) in a random allocation. Thereafter the urethral catheter was extracted and success of TWOC for the next 48 hours was assessed.

Results: Group A had 40 patients and groupB had 40 patients. Mean weight of prostate and mean urinary residue after insertion of urethral catheter was 48 ± 11.4 and 592 ± 167.5 in group A and 50.23 ± 9.3 and 677.2 ± 165.5 in group B respectively. 57.5% of group A and 87.5% of group B had success of TWOC for 48 hours after extraction of catheter. In group A 42.5% failed for TWOC and in group B 12.5% failed for TWOC.

Conclusion: Patients of two groups hadn't any significant differences in numbers and mean prostatic weight (p = 0.523) and urinary residue after insertion of urethral catheter (p = 0.524). Success of early TWOC in group A (p = 0.01) prazosin efficacy is due to resolution of dynamic obstruction of prostatic in bladder outlet and finasteride added efficacy to prazosin, probably by early inhibition of vascular endothelial growth factor and angiogenesis and reduction of anatomical obstruction of prostatic suburethral vascular cushion.

A62

PROCURE Quebec prostate cancer biobank

V. Serre¹, S. Chiovitti¹, M. Bordeleau¹, A. Aprikian², F. Saad³, L. Lacombe⁴, M. Carmel⁵

¹PROCURE Quebec Prostate Cancer Biobank, Montreal; ²Department of Urology, McGill University Health Centre (MUHC), Montreal General Hospital; ³Department of Urology, Centre Hospitalier Université de Montréal (CHUM), Hôpital Notre-Dame, Montreal; ⁴Department of Urology, Centre Hospitalier Université de Québec (CHUQ), Hôpital Hotel-Dieu, Montreal; ⁵Department of Urology, Centre Hospitalier Université de Sherbrooke (CHUS), Hôpital Fleurimont, Montreal, QC, Canada

Prostate cancer is the most commonly diagnosed cancer in Canadian men. Detection methods are not conclusive, and available treatments continue to present enormous challenges. The need to accelerate large-scale research on prostate cancer and to make appropriate tools available to researchers is therefore urgent. The PROCURE Quebec Prostate Cancer Biobank is a Montreal-based non-profit organization. The Biobank will supply researchers and scientists with the critical resources needed to advance research. It will help to better understand the genetic and environmental factors that have an impact on the risk of developing prostate cancer. Currently, there is strong demand for access to a large database that combines samples and personal information for prostate cancer. To respond to this demand, PROCURE has begun to collect and store the highest quality biological materials (prostate tissue, blood and urine) and associated clinical and socio-demographic information from men who have developed prostate cancer. The Biobank, currently in its pilot phase, is following best practices in order to provide exceptional clinical, medical, demographic and analytic longitudinal information. The Biobank will allow researchers to take advantage of recent advances in the fields of genomics, proteomics and bioinformatics. The creation of a comprehensive database will provide scientists with a research tool that is reliable, long-lasting, useful and likely to considerably accelerate research programs leading to the prevention and to a cure for the disease. The Biobank will also help stimulate prostate cancer research in Quebec by linking Quebec's four principle universities, the Centre Hospitalier Université de Montréal (CHUM), the Centre Hospitalier Université de Québec (CHUQ), the Centre Hospitalier Université de Sherbrooke (CHUS) and the McGill University Health Centre (MUHC), with their affiliated teaching hospitals.

A63

Early onset mitochondrial dysfunction, health, aging, and disease

F.A. Shallenberger

The Nevada Center, Inc., Carson, NV, USA

Context: Mitochondrial efficiency appears to be the single most important aspect of health, aging, and degenerative disease. A decrease in mitochondrial efficiency is a consistent hallmark of aging and degenerative disease, and has traditionally been seen as a result of aging and degenerative disease. I assessed whether a decrease in mitochondrial efficiency occurs before the presence of aging or degenerative disease.

Method: The mitochondrial efficiency of fifty subjects was determined as they randomly presented to commercial and medical testing centres in three separate cities in the United States and in Singapore.

Results: Decreased maximal aerobic ATP production was observed in 46% of subjects. 100% of subjects who had decreased maximal aerobic ATP production also had a decrease in maximal ATP production from fat, whereas only 7% of the subjects with normal maximal aerobic ATP production had decreased maximal ATP production from fat.

Conclusion: A condition, designated as Early Onset Mitochondrial Dysfunction (EOMD) is described, which refers to a deterioration of mitochondrial efficiency that is commonly found in young, asymptomatic, and presumably healthy subjects. The condition is characterized by decreased maximal aerobic ATP production associated with decreased resting and maximal ATP production from fat. EOMD is different from mitochondrial decay. It is reversible, and occurs long before mitochondrial decay, aging, or degenerative disease. EOMD through the combined action of increased free radical production and decreased anti-oxidant buffering capacity may be the primary cause of mitochondrial decay. A new theory of aging called the Energy Deficit Theory Of Aging And Disease is presented. This theory states that aging and degenerative disease are the results of uncorrected EOMD, and that by correcting EOMD, it is possible to prevent degenerative disease and slow down the aging process.

A64

Nocturia in the elderly: age differences in functional bladder capacity as observed on cystometrogram

S.S. Steele, J.B. Gajewski

Department of Urology, Dalhousie University, Halifax, NS, USA

Introduction: The relationship between patient symptoms and cystometrogram (CMG) findings has been poorly explored. In this study, we attempted to discover the relationship between patient reported nocturia versus functional capacity and first sensation determined by CMG in men ≥ 60 and men < 60 years of age.

Methods: We have electronic charts on all patients who have undergone urodynamic testing from 1996–2006 at our institution contained in a urodynamics (UD) data base. Using the UD data base functional capacity and volume at first sensation was cross-referenced with the degree of nocturia reported by our male patients. The amount of nocturia was graded from 0 to 3. With 0, 1, 2 and 3 corresponding to 0 times/night, 1–2 times/night, 3–4 times/night and >4 times/night respectively. The patients were then divided into men 60 years of age and over and those less than 60 years of age. The mean and standard deviation for functional capacity (MCC) and first sensation (FS) were then determined for each level of nocturia in both groups of men. A one-way ANOVA (p < 0.05) was then applied to each level of nocturia to determine if the observed differences in their respective MCCs and FSs were statistically significant in men ≥ 60 and men < 60 years of age.

Results: There were 841 consecutive patients identified in the UD database who had the above parameters identified (495 ≥ 60, 386 < 60). First sensation did correlate with severity of nocturia in both older and younger patients (p < 0.0001 and p < 0.0247 respectively). However, functional bladder capacity only correlated with severity of nocturia in men greater than 60 years of age (p < 0.0001).

Conclusion: This study of 841 patients demonstrates that nocturia in the elderly is mainly caused by decreased functional capacity of the bladder and not nocturnal polyuria.

A65

malnutrition-inflammation complex syndrome (MICS) in aging male maintenance haemodialysis (MHD) patients

B. Stojimirovic¹, V. Vlatkovic²

¹Institute of Urology and Nephrology, Clinical Center of Serbia, Belgrade, Serbia; ²International Dialysis Center, Banja Luka, Bosnia and Herzgovina

Background: MICS influences morbidity and mortality in MHD patients. Malnutrition-Inflammation Score (MIS) is a quantitative adopted score, used for measuring inflammatory status in MHD patients, created as a surrogate for laboratory inflammatory markers. It could be used to predict outcome in MHD patients. Aging males with their specificity make up a significant part of the growing population of MHD patients, requesting permanent predictive health care evaluation, and improvement of treatment.

Aim: To characterize the MICS in the group of aging male MHD patients, and to compare results with data in control male group.

Methods and results: Data examined of the 46 selected MHD patients are given in Table I. Control group was selected randomly. General excluding criteria were difficult co-morbidities, such as diabetes, malignancies, cytostatic therapy, and inadequate treatment. MICS was established using a comprehensive MIS questionnaire (Kalantar-Zadeh et al.). Delivered dialysis dose was assessed using index spKt/V and URR.

Conclusion: Aging male MHD patients did not have significantly higher values of the MIS, suggesting that age in this group of patients possibly did not have influence on inflammatory syndrome.

Table I.  Patients data and results.

Items	Mean ± St D Median (range)		Significance
	Aging male	Control
Number	23	23	–
Age (yrs)	70.83 ± 5.05	58.04 ± 2.48	0.001470218
Body Mass Index	22.75 ± 3.42	23.59 ± 3.42	0.997516446
HD (months)	53 (22–185)	62 (21–258)	0.030642737
spKt/V	1.16 ± 0.2	1.3 ± 0.24	0.374302368
URR (%)	63.26 ± 8.29	65.22 ± 6.16	0.171273027
Charlston	5.22 ± 1.54	5.22 ± 1.2	0.261540852
MIS	5 (1–12)	4.5 (2–13)	0.640248789

HD (months) – duration of haemodialysis in months; spKt/V – dialysis adequacy single-pool Index Kt/V (Daugirdas); URR – Urea Reduction Ratio; Charlston – Charlston Co-morbidity Index.

A66

Clinical efficacy of yixinkangtai in patients with oligospermia and asthenospermia

X.Z. Sun, C.H. Deng, Y.P. Dai

Department of Urology, The First Affiliated Hospital of Zhongshan University, Guangdong, China

Aims: To observe the clinical efficacy and safety of yixinkangtai in patients with oligospermia and asthenospermia.

Methods: 120 patients with oligoasthenospermia were received at our clinic of andrology. They were randomly divided into treatment group and control group. The patients in the treatment group received yixinkangtai 6 caps daily, vitamin E 150 mg daily, zinc gluconate 3 tablets daily for 3 months, and the other patients in control group received vitamin E and zinc gluconate for 3 months. The sperm parameters of all patients were analysed by computer-assisted sperm analysis system before and after treatment.

Results: Patients in the two groups were significantly improved in sperm concentration, forward sperm motility, total sperm motility (p < 0.01). But the patients of the treatment group were significantly higher in all sperm parameters than those in the control group. No side effects were observed in either group.

Conclusion: Yixinkangtai can be an effective and safe option for treating oligoasthenospermia by means of significantly improving sperm concentration, forward sperm mortility, total sperm mortility.

A67

Clinical study of sertralin and vardenafil in the treatment of premature ejaculation complicated by erectile dysfunction

X.Z. Sun, C.H. Deng, Y.P. Dai

Department of Urology, The First Affiliated Hospital of Zhongshan University, Guangzhou, Guangdong, China

Aims: To evaluate the efficacy and safety of sertralin and vardenafil in the treatment of patients with concomitant erectile dysfunction (ED) and premature ejaculation (PE).

Methods: 60 patients with concomitant ED and PE were received at our clinic of andrology. They were randomly divided into vardenafil group and sertralin group. The vardenafil group received flexible doses of vardenafil from 10 mg to 20 mg for 2 months. The sertralin group received 50 mg daily for 2 months. The difference of IIEF-5 before and after the treatment were recorded and compared, then we evaluated the efficacy of ED treatment. Intravaginal ejaculatory latency time (IELT) was recorded to evaluate the efficacy of PE treatment.

Results: In vardenafil group, 24 patients had their ED improved and the efficacy rate was 80%. The effective rate of sertralin group was 27%. There was significant difference between the two groups (p < 0.05) In the vardenafil group, 20 patients had their PE improved and the effective rate was 67%. The effective rate of the sertralin group was 40%. There was significant difference between the two groups (p < 0.05) Both of the two groups, patients with improved ED had significantly higher effective rate of PE improvement than that with non-improvement of ED. Only mild side effects were recorded, and none withdrew from the treatment.

Conclusion: To patients with concomitant ED and PE, how to improve their erectile function is the key of treatment, the efficacy of vardenafil is better than sertralin.

A68

Free androgen index as a useful measure for the response to treatment in erectile dysfunction

A.A. Thwaini¹, D. Morgan², R. Ahmed³, G. Yahia³

¹Department of Urology, Barts and The London Hospitals, Chelmsford, UK; ²Department of Urology, Sheikh Khalifa Medical City, Abu Dhabi, ³Tawam Hospital, Al Ain, United Arab Emirates

Objectives: To describe a case series of erectile dysfunction (ED) patients with respect to certain sociodemographic and clinical characteristics, and to assess the relation of sex hormone levels in men, as measured by Free Androgen Index (FAI), with severity of sexual dysfunction and with their response to treatment.

Methods: We retrospectively reviewed the medical records of men who attended the Urology Clinic with the complaint of ED between March 2000 and October 2003. The FAI of patients was mathematically measured using certain formula and filled in the same form. The scoring system that reflects sexual performance was filled for all patients in their records. The Sexual Health Inventory for Men (SHIM) score was used as the main outcome measure in this study, and its variation was tested by certain variables using the Epi Info® software.

Results: A total of 150 men were studied. The majority of patients (93%) had FAI in the normal range levels, and had shown no relation to the SHIM score even after adjustment for other factors (p = 0.53 and 0.16 respectively). However, FAI was highly related to patients’ response to treatment (p = 0.00), with the higher the level the higher was the proportion of patients who responded well to treatment (p for trend = 0.00). Age of the patient was the only factor influencing the SHIM score they could attain, as shown by both ANOVA and linear regression analyses (p = 0.00).

Conclusion: The FAI level has no relation to the severity of erectile dysfunction. Its role however, is confined to the way patients are going to respond to medical treatment of ED. Further studies are therefore needed to assess the effectiveness of using this parameter as a reliable test of bioactive testosterone for men with sexual dysfunction.

A69

Real-life safety and efficacy of vardenafil (realise) – an international post-marketing surveillance study: Results from European patients ≥65 years

H. Van Ahlen¹, J. Zumbe², H. Landen³

¹Klinikum Osnabruck, Osnabruck, ²Klinikum Leverkusen, Leverkusen, ³Bayer HealthCare, Leverkusen, Germany

Background and aims: To determine the safety, efficacy and patient acceptance of vardenafil 5, 10 and 20 mg in real-life use in patients with erectile dysfunction (ED).

Methods: World-wide, prospective, non-interventional study with data collected in 11 European countries between March 2003 and April 2005. Subjects with ED for whom vardenafil was prescribed in routine practice were followed for 2 months. Efficacy was measured under daily life conditions. Data were acquired by interviews and, in 9 countries, additionally from patient diaries. Safety was determined by reporting of adverse events (AEs). Subjects taking at least one tablet and with follow-up data were valid for analysis. Data presented here are results of a subgroup analysis of patients ≥65 years.

Results: Data from 12,063 patients were analysed. Vardenafil 10 mg was the most frequently prescribed dose at the initial visit (69.2%) and last visit (54.3%); frequency of 20 mg prescriptions was 23.6% and 42.2%, respectively. Erections improved in 91% of patients and improvement occurred after the first tablet in 66.9%. In 89.3% of subjects overall efficacy was rated satisfying/very satisfying. Additional data were available from 41,430 intercourse attempts. In these subjects penetration was possible in 92.4% of all attempts; in 81.2% of attempts erections were maintained long enough to complete intercourse. Erections were considered satisfying/very satisfying in 84.7% of attempts. Overall incidence of AEs was 2.39%; incidence of drug-related AEs was 2.16%. The most frequently reported AEs were headache (1.00%) and flushing (0.46%), symptoms associated with the pharmacological action of phosphodiesterase type 5 inhibitors.

Conclusions: In this large pool of patients <65 years from across Europe, vardenafil was highly effective in over 90% of men, with high rates of SEP-2 and SEP-3 success. Vardenafil was generally safe and well tolerated. These data are consistent with those reported in other open-label trials of vardenafil.

A70

Study on effectiveness and safety of optimum program for prevention and treatment of renal insufficiency of diabetic nephropathy

L.F. Zhang, J.X. Zhao, R.H. Lv

Department of Nephropathy and Endocrinopathy, Dongzhimen Hospital Affiliated to Beijing University of Traditional Chinese Medicine, Beijing, China

Objective: To optimize the program for prevention and treatment of renal insufficiency of diabetic nephropathy (DN) and to evaluate the effectiveness and safety of the program of TCM treatment based on syndrome differentiation for protection of renal function.

Methods: With method of randomized, blind, controlled and multi-central clinical study, 221 cases of renal insufficiency of DN were divided into group A (TCM treatment based on syndrome differentiation group), group B (Losartan group) and group C (TCM treatment plus Losartan treatment group). The treatment course was 3 months.

Results: After treatment, the increasing amplitude of serum creatinine clearance rate (Ccr) in group A was higher than in group B (p < 0.05), and the decreasing amplitude of serum creatinine (SCr) in group A was higher than in group B (p <0.01) and C (p < 0.05); There was no significant difference in blood urea nitrogen (BUN) and 24-hour urinary protein among the 3 groups (p > 0.05). After treatment of 3 months, serum alanine aminotransferase (ALT), electrocardiogram (ECG) and B-ultrasonic examination results of the liver, gallbladder, spleen and pancreas did not have significant change (p > 0.05) with no significant difference among the 3 groups (p > 0.05).

Conclusion: The TCM treatment program in addition to diet regulation, decreasing blood sugar and expectant treatment is effective and safe in improving renal function, and the program is better than Losartan in increasing Ccr and decreasing SCr.

Acknowledgements: This work is supported by grants 2001BA701A13c from the China National Science and Technology Institutes of ‘Prevention and treatment Diabetic microvascular complications’.

A71

Increasing population of aging people as socio-economic problem for society

U. Pandey

Sri Rama Krishan PG College, Nandyal, AP, India

World-wide life expectancy at birth for men and women will have increased by about 20 years during the 50-year period between 1950 and 2000. As a result, the proportion of the elderly population is expected to increase significantly in the 21st century. Despite this increase in longevity for men and women, men still have significantly shorter life expectancy of approximately 5 years. To further reduce and prevent debilitating disease and disability in elderly men, a question is whether any type of interventions, such as hormone replacement therapy, may play a role in improving the quality of life as proven in post-menopausal women. Men experience age-related decline of capability physically and mentally. Various symptoms, such as nervousness, depression, impaired memory, inability to concentrate, easy fatigability, insomnia, hot flushes, periodic sweating, reduction of muscle mass and power, bone ache, and sexual dysfunction, are related to this change. The fact that a number of age-related changes resemble features of various hormonal deficiency has led to worldwide interest in the use of various hormonal preparations in an effort to prevent the aging process in elderly men. Even though there have been opinions against hormonal supplementation in the aging male, preliminary studies defining the risk/benefit ratio of androgen supplementation appear to be encouraging. To understand testosterone supplementation in the aging male, this review will discuss the following important topics: physiology of male hormonal balance, changes in reproductive organs in elderly men, endocrine evaluation of the male, pharmacological effects of testosterone on target organs, available preparations for testosterone, and testosterone supplementation.