Dear Colleagues,
It is a great honour and privilege to welcome you to the second Japanese-ASEAN Men's Health & Aging Conference and the 7th Annual Meeting of the Japanese Society for the Study of the Aging Male, to be held in Yamanaka Resort-Spa, Japan from 16 to 18 November 2007. This is the first joint meeting of the Japan-ASEAN Men's Health & Aging Conference and the 7th Annual Meeting of the Japanese Society for the Study of the Aging Male.
Medical progress and economic growth has led to expanded life expectancy during this half century, and the aged population will increase in developed and developing countries alike. Generally, aging in males is accompanied by increasing morbidity and disability. There is an urgent need to conduct research into aging and reduce the burden of coping with socioeconomic problems. This congress will aim to discuss the promotion of healthy aging and prevention of morbidity and disability of the aged male, especially in the whole Asian region.
I hope you will enjoy the exciting programme at the meeting, which consists of plenary lectures, symposia, luncheon seminars, satellite symposia and free communication sessions submitted from not only ASEAN countries and Japan, but also all over the world.
As Organizing Chairman, I should like to express my great appreciation to those who have devoted themselves to preparing for this meeting. Without a doubt this meeting will provide an excellent venue for many scientists to exchange knowledge and experiences in the field of men's health and the aging male.
I want to especially thank our many sponsors, whose generous donations have made the various events of this meeting possible. I also would like to extend my heartfelt thank to Professor Akihiko Okuyama, Chairman of the Japanese Urological Association and Professor Dato’ Dr Tan Hui Meng, Secretary General of APSSM and APSSAM, for outstanding advice.
Finally, Yamanaka hot-spring resort and nearby Kanazawa Area have many places of historic interest and scenic beauty, as well as delicious sea foods. It is my sincere hope that all of you will fully enjoy your stay in our beautiful area in its best season.
Professor Mikio Namiki
Organizing Chairman
Keynote Lecture
K-1
Communication in sexual medicine and men's health
S. Meryn
International Society for Men's Health and Gender (ISMH) and Medical University Vienna, Austria
The prevalence of reproductive health disorders and associated health concerns is high in middle-aged and older men. Several studies show that reproductive and sexual health problems are often not explicitly discussed with health professionals. General practitioners and urologists are even often reluctant to initiate discussions with older patients about sexual health. But more and more evidence indicates that reproductive including sexual health is a “portal” to men's health.
Why talk about sexual health and men's health at all in the physician's office? Because of the patient's need, unidentified and widespread diseases and secondary sequelae, which are anxiety, depression or as important difficulties with the sexual partner. The method of choice for patients with erectile dysfunction, sexual health and men's health problems in general is the patient-centred type of communication. It facilitates communication between the patient and the helper, improves the process of obtaining and passing information and improves therapy and enhances satisfaction on both sides. The physician confronted with men with disorders of reproductive and sexual health is in a unique position to address general health questions of the patient and to improve the general health and well-being of his male patients. This presentation will focus on theoretical as well as on all practical aspects of successful patient-physician communication in sexual and men's health. Various cases of patients to seek help as well as to talk about sexual and men's health and ED will be discussed.
K-2
Potential solution for the improvement of men's health in Asia
H.M. Tan
University of Malaya Medical Centre, Kuala Lumpur, Malaysia; Subang Jaya Medical Centre, Selangor, Malaysia
Men's health problems encompass medical, psychosocial, demographic, economic and public health issues. The rapid changes in the world resulting in societal syndrome have exacerbated the general health of men even further. The vicious cycle of poor men's health resulting in decreased productivity, decreasing economic wealth and depleting health budget will lead to a spiralling decline in economic development, especially in countries with emerging economies.
There is urgent need to tackle men's health issues in the context of a rapidly changing and competitive world. Men will continue to be autonomous, bear heavy responsibility, take charge of organizations and often have to decide on key family matters. Masculinity traits of Asian men need to be studied, modified or altered to prevent or mitigate many of the detrimental effects on men's health. Further research in this area is urgently needed.
Conducting good and effective men's health research is generally a complex and difficult task. The main difficulties are in defining, developing, documenting and reproducing complex interventions to improve certain aspects of men's health. There is certainly a need to consider the process of development and evaluation of such complex interventions as having several distinct phases, so as to obtain useful and implementable components of the research findings.
In Asia, numerous studies covering a variety of areas are still needed to fill the potential research gaps and knowledge to promote and improve men's health. High qualitative and quantitative research to bring about a change in the practice of health professional and patient behaviour can result in significant improvement in the health of the male community. Such research works with high societal impact factors are needed to translate discoveries or development of medical science for the benefits of the public at large.
The multidisciplinary men's health research team of the Malaysian Society of Andrology and The Study of the Aging Male have contributed a number of key studies in the development men's health in Malaysia and Asia. These include:
The 2003 Petaling Jaya men's health study
The 2006 Subang men's health research
Qualitative study on men's perception on health and illness and factors influencing their health and illness behaviour and the roles of women in men's health
The Asian men's attitudes to life events and sexuality study
Annotated bibliography of men's health in Asia
Translation and validation of aging male studies into the Malay language
The effects of testosterone therapy using depot testosterone undercanoate in aging males with low testosterone
The Subang men's longitudinal study
Study to reduce obesity related risk factors using active lifestyle interventional programme
K-3
Men's health (development in Japan)
S. Horie
Department of Urology, Teikyo University, Tokyo, Japan
Men's health is emerging as an important issue in an increasing number of countries around the world. However, progress towards international contact and collaboration between men's health advocates with an interest that extends beyond traditional clinical concerns such as erectile dysfunction or prostate cancer has so far been extremely slow. In many ways this is not surprising. The idea that men have specific health needs, experiences, and concerns related to their gender as well as their biological sex is relatively new, certainly much newer than the concept of ‘women's health’. Even in those countries where greater attention has been paid to men's health issues, initiatives have generally remained small scale. In Japan, issues of men's health have been gradually put on the agenda of the regional health initiatives. However, we need more intra-national, international men's health initiatives focusing on the specific issues of men such as testosterone deficiency and hormonal replacement, which corresponds to the Women's Health Initiative (WHI). WHI is a long-term national health study that has focused on strategies for preventing heart disease, breast and colorectal cancer and osteoporotic fractures in postmenopausal women. This 15-year project is one of the most definitive, far-reaching clinical trials of post-menopausal women's health ever undertaken in the USA. The results of those clinical trials have evidently strong influence on the health policy making world wide. To promote the public awareness of the importance of men's health, we need an organization that attracts a broad range of professionals, policy makers, and practitioners working in a variety of settings dedicated to men's health and well-being. ASEAN-Japan Men's Health and Aging conference is a great opportunity to increase awareness of men's health among the medical community, to facilitate networking, and to address current men's health issues.
Japan-ASEAN Symposium 1 (Health/Social Insurance and Education)
S-1-1
Helping men to make healthcare decisions
C.J. Ng
University of Malaya, Kuala Lumpur, Malaysia
Men are faced with numerous healthcare decisions throughout their lives. These decisions include: promotion of general health (physical, psychological and social); screening to detect early diseases (such as prostate cancer, cardiovascular risk factors); diagnosis and treatment of acute and chronic diseases (such as erectile dysfunction, lower urinary tract symptoms, testosterone deficiency syndrome, prostate cancer, testicular cancer); as well as rehabilitation, placement and end-of-life decisions. In the past decade there has been an increasing emphasis in patient participation in decision making in the clinical consultation. There is a shift from the traditional paternalistic decision-making model to one in which decisions are shared between the healthcare professionals and the patients. Studies in Japan have reported patients' preference for participation in decision-making and the physicians who involved patients in decision-making had greater patient satisfaction.
A ‘good’ decision is one which results in an outcome which is important to men. Ideally, the decision should be an informed choice and is based on men's values. For examples, in men with testosterone deficiency syndrome who are considering androgen replacement therapy, they should be aware of the uncertainties in evidence, benefits and harms of the treatment. At the same time, they should be clear as to how important these risks and benefits are to them personally (‘values’). An informed decision which is consistent with men's values is more likely to be followed through, leading to improve health outcomes. There are other factors which influence men's decision making, including socio-demography, past experience with the healthcare system, relationships with healthcare providers, influence of family and friends, support services and resources, male identity and social stigma.
In order to help men to make appropriate and timely healthcare decisions, it is essential to address these factors on an individual level. Traditionally, counselling by healthcare professionals has been used to facilitate decision making when patients are faced with a healthcare choice. However, there is a wide variation in how counselling is being conducted; this has resulted in inconsistent decision quality and outcome, depending on the competence of the healthcare providers and organizations (such as consultation time, support services). Therefore, decision support tools such as patient decision aids and couching have been developed and used as an adjunct to clinical consultation.
Patient decision aids are evidence-based tools which present risks and benefits in a balanced and understandable format; they also clarify patients' values helping them to work systematically towards informed and value-based decisions. Patient decision aids can either be self-administered or assisted by healthcare professionals (physicians or nurses); they can come in the form of a web-based interactive programme, pamphlet, video or audio-assisted tool. They are different from patient educational materials because, in addition to providing essential health information, they focus on helping the users to understand the evidence and clarify their values.
This paper will attempt to draw a theoretical framework and discuss how this framework can be used in helping men to make healthcare choices in the context of their healthcare needs and from a gender perspective.
S-1-2
Japan's shrinking population: Challenge and opportunity
M. Yasuda
Department of Urology, Teikyo University, School of Medicine, Tokyo, Japan
Japan has been facing an ‘aging population’ and is entering the era of ‘shrinking population’. Japan's population is aging at a rapid pace which is unprecedented in the world. The older population, those 65 and over was 18.5% of the total population in 2002.
It is expected to reach 25.9% by 2025 and 36.4% by 2050. The projections of the total population vary but most experts believe that Japan's population will peak some time in 2007, and then begin a long, steady slide that will last several decades at least. It will fall to somewhere between 92 million and 108 million by midcentury, with a medium case prediction of about 100 million in 2050.
A shrinking population has an adverse impact on the Japanese economy. First, an aging population will not able to provide enough young people to enter the labour force to maintain its adaptability and productivity. Second, a decline in the population causes contraction of the domestic market. It will lead to curtailing investment. Finally, Japan's declining population will affect the rest of the world. Japan is among the key players in the world economy, including the United States and European nations. The global economy would suffer a great deal if the Japanese economy shrank. Japan's shrinking economy would also mean smaller official development assistance. This is bound to negatively affect developing countries.
How Japan can cope with its aging society is a test case for most of the world. A key is to give chances to the elderly to contribute to the society as long as possible, benefiting from their wisdom and filling the emerging shortage in the work pool. In 2015, the baby boomers will enter the senior stage in their lives. They will have more diversity in lifestyle preferences in their later life than do the present elderly. More flexible and various options will be needed in order to meet their demands. The government must start planning the longitudinal programmes for the elderly now.
Innovative approaches should be taken to benefit from the great fountain of wisdom and experience available from our elders. The critical question is whether the Japanese government has the foresight and flexibility to lead such initiatives.
S-1-3
The attitude of thai urologists on men's health
K. Ratana-Olarn, S. Permpongkosol
Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Introduction and objective. Gynaecologists have been specialized physicians for the medical care of women for quite a long time. Men's health concerns have been relatively neglected and actually there are no specific groups of physicians who take responsibility for men's health. Generally, men visit a physician less often than women. However, the first symptom that frequently persuades men to request a medical check up is a urologic problem and at that time many other diseases are revealed. Urologists are being encouraged to take a role in men's health similar to gynaecologists' role in women's health. However, most surgically orientated urologists are still reluctant to be the men's health physicians.
In Thailand, the Ministry of Public Health has developed policies on men's health since 1998, but activities are still limited. Men's health clinics are mainly run by gynaecologists. Recently, the Thai Urological Association (TUA) has prepared several activities to encourage members to play more roles in men's health. To assess Thai urologists' attitudes on men's health is one of the activities.
Methods. Questionnaires concerning men's health issues were sent to the members of the Thai Urological Association (TUA).
Results. Thirty-eight of 175 members (21%) responded to the questionnaires. There were still very few men's health clinics which were mainly available in medical schools. Thirty-three respondents (92.1%) admitted that the men's health clinic was beneficial but only 19 (50%) agreed that they should have a men's health clinic in their hospitals. Twenty-six (68.4%) thought that urologists should be the primary physicians to run the clinic. Twenty-eight (73.7%) were interested to attend the academic activities on men's health organized by TUA.
Conclusions. Thai urologists realize men's health as well. However, uro-surgical workload and time constraints are the main obstacles that prevent them from sharing this specific healthcare issue.
Japan-ASEAN Luncheon Seminar 1
L-1-1
Prostate brachytherapy in the United States: New trends and results
J.L. Lederer1, M.A. Tsou11, M. Morita2, T. Fukagai2, Y. Ogawa3, M. Shimada3
1The Queen's Medical Center, Hawaii, USA; 2Department of Urology, Showa University School of Medicine, Japan; 3Showa University Northern Yokohama Hospital, Japan
Prostate cancer is the most commonly diagnosed male cancer in the United States. It is estimated that over 235,000 cases were diagnosed in the United States 2006. A wide range of options exist, including newer modalities such as robotic-assisted laparoscopic surgery and proton beam irradiation. We will discuss evolving approaches and long-term results in the use of brachytherapy in the treatment of prostate cancer. In order to decrease the side-effects of permanent seed implant of the prostate, more complex treatment planning has evolved. These efforts are aimed primarily at decreasing potential urinary and rectal toxicity, while maintaining excellent tumour control rates. Newer dosimetry parameters will be reviewed. The role of external beam radiotherapy when given in combination with permanent seed implants has been unclear. Some centres in the USA apply a supplemental external beam to all cases, while most use a risk-adapted plan based on PSA, Gleason, score, clinical stage, and other parameters. Newer imaging modalities may be predictive of the extent of disease within the prostate and of the presence of nodal metastases. A more accurate understanding of the extent of disease may help define the role of external beam and androgen deprivation therapy in combination with brachytherapy. We will discuss the role of MRI and nuclear medicine techniques in assessing extent of disease.
We have followed a cohort of Japanese-ancestry patients who have undergone permanent seed implant of the prostate in Honolulu since 1998. All patients were stratified by initial PSA level, Gleason score, and clinical stage. Brachytherapy as monotherapy was utilized in patients with low risk disease. Patients with intermediate or high-risk disease receive five weeks of external beam therapy followed by permanent seed implant as a ‘boost’. Androgen deprivation was utilized for both intermediate and high-risk disease, and for downsizing of the prostate. The long-term results for these patients treated at The Queen's Medical Center will be presented. Prostate brachytherapy has proven to be an effective and safe modality for the treatment of prostate cancer.
L-1-2
Permanent prostate brachytherapy in Japan
T. Fukagai, M. Morita, M. Nagata, N. Sudo, K. Suzuki, Y. Ogawa
Department of Urology, Showa University School of Medicine, Japan
After overcoming legal hurdles, permanent prostate brachytherapy for localized prostate cancer was initiated in Japan in 2003. Largely because of concerns over radiation safety, permanent brachytherapy utilizing iodine-125 seeds had been prohibited by law in Japan. After the technique was introduced, the number of cases has increased rapidly. To date, it has been estimated that 6000 implants have been performed.
But legal obstacles still exist, especially for the approval of treatment devices in Japan. Implantation of free seeds utilizing the Mick applicator is the only approved procedure for permanent brachytherapy. Therefore the facilities that initiated permanent prostate brachytherapy in the early days tended to convert from the preplan methodology commonly employed in the United States to the intraoperative technique more suitable for Mick applicator technique. After utilizing interactive techniques, we were able to demonstrate improved dosimetry parameters in our facility. Updated planning software utilizing newer nomograms will be available in our facility in the near future. This should result in shorter operative times and better dose distribution in the management of high risk of prostate cancer.
Japan-ASEAN Symposium 2 (LOH: Definition and Treatment)
S-2-1
LOH: Molecular biological bases studies on LOH
Z.C. Xin
Andrology Centre, Peking University First Hospital, Peking University, Beijing 100009, China
The terms late-onset hypogonadism (LOH) or a partial androgen deficiency of the aging male (PADAM) describe a clinical entity which has been defined as a syndrome associated with advanced age in which significant alterations in the quality of life and adversely affect the function of multiple organ systems. Recent studies showed that this syndrome is characterized by a deficiency in serum testosterone levels and testosterone substitution may be an effective way to manage this condition.
To understand the molecular biological mechanism of LOH, the testis regression in aging males, we investigated the differentiations of gene expression in aging male testis (normal young male 3 cases and aged male 3 cases) by Clon-Tech cDNA microarray methods which showed that serum testosterone levels significantly decreased in aging males with testis tissue hypotrophy. In the results of cDNA microarray, we found that the gene expression profile in aged male testis was changed significantly as compared with that in normal young controls and testis regression in aging males may relate multi-gene differentiations, especially the differentiations of respiratory chain related gene. Among them, the 117 (1.46%) gene differentiations in aged male increased at least more than 1.0 fold, the 83 genes were down regulated and the 34 genes up regulated. The down expressed genes related to metabolism were 16 (19.3%), gene or protein expression 18 (21.7%), cell signalling or cell communication 16 (19.3%), cell division 19 (22.9%), cell structure or motility 6 (7.2%) and unknown function 4 genes (4.8%). The up expressed genes related to cell division were 11 (32.4%), gene or protein expression 10 (29.4%) and metabolism 3 (8.8%).
It is interesting to find that respiratory chain related gene cox7a2 was up regulated and at p450 down regulated significantly which as further confirmed by RT-PCR analysis with sequence analysis in the products of the RT-PCR by T-A cloning and in the results of investigation the regulatory function of Cox7a2 on steroidogenesis and the mechanism involved in TM3 mouse Leydig cells, Cox7a2 is well located mitochondria, which could inhibit LH-induced StAR protein expression, and consequent testosterone production, at least in part, by increasing ROS activity in TM3 mouse Leydig cells, which may be an important candidate gene in the study of the mechanism of testis regression in aging males.
LOH decreased testosterone level could be through several different molecular biological mechanisms, such as a primary impairment of the testes, the pituitary gland and the neurohypothalamic component, and age-associated changes in peripheral steroid metabolism, however, the molecular biological bases study is still to be further exploded.
S-2-2
Approach to managing andropause and somatopause
P.H.C. Lim
Department of Urology, Changi General Hospital, Singapore; Edith Cowan University, Australia; Andrology, Urology and Continence Centre, Gleneagles Hospital, Singapore
Aging results from many ‘pauses’ in physiologic function including somatopause, andropause, and other endocrine dysfunctions. The correction or balancing of hormone levels in the case of somatopause restores energy, sleep, functionality and mobility, muscle mass and reduced fat and good quality skin and looks when done in concert with other ‘anti-aging strategies’ like exercise, vitamin supplementation, detoxification from excess rare elements and minerals, judicious intake of fish oils and adequate use of antioxidants and a good psychological approach to positive aging and life itself. Correcting thyroid deficiencies, e.g. the ubiquitous occult T-3 deficiency and inadequate serum DHEA, due to adrenopause goes a long way to reducing the ‘biological age’ to ten years younger than the ‘chronological age’ – the end point of any anti-aging programme. Measuring slowing of brain activity and other parameters in the ‘Brain Electrical Activity Mapping Test’ in aging provides the clinician with a baseline to improve brain function. There are other ‘pauses’ that time does not permit me to elaborate in this lecture. Suffice it to say that for an ‘anti-aging’ clinic work-up, the doctor will cover all the tests for the biological markers of aging (including chromosomal and genetic) and determine all hormone levels as well as levels of vitamins, minerals, essential fatty acids, free radical activity, etc., that will be the platform for treatment which includes modification of lifestyle and psychological aspects. There must be no hormone-sensitive cancer resident in the patient before hormonal therapy is initiated and a complete check is mandatory beforehand.
We begin by focusing on andropause. Andropause (male menopause) does not have a definite hormonal cut-off although the endocrine profiles in males do show a pattern of declining sex and trophic hormones. The contributing etiologic factors have also yet to be well studied. The symptoms of andropause are broadly categorized as physical, psychological and sexual symptoms. Common symptoms will include bone and joint aches, increased susceptibilty to fractures, fatigue, vasomotor symptoms; memory and concentration lapses and mood changes; erectile and libido dysfunction. Fears of unwanted effects on the prostate may be unwarranted as men with Ca-prostate have extremely low levels of testosterone and there is no evidence that testosterone replacement therapy would increase BPH or Ca-prostate in aging men and men treated with testosterone. In the case of somatopause, this results in adult growth hormone deficiency syndrome (AGHDS). After Rudman's publication in 1990, growth hormone was dubbed the ‘fountain of youth’. Growth hormone appeared able to change some of the clinical signs and symptoms of aging and AGHDS, i.e. weight gain, increased fat mass, decreased lean body mass, reduced muscle mass and strength, increased waist to hip ratio, increased total cholesterol, increased triglyceride, increased LDL cholesterol, decreased HDL cholesterol, increased cardiovascular mortality, increased vascular wall thickness, reduced left ventricular mass, decreased fractional shortening of cardiac myocytes, decreased cardiac output, decline in exercise capacity, reduced bone size, density and bone mineral content, thin dry skin, hair loss, impaired sweating, reduced vitality and energy, fatigue, memory impairment, reduction of many cognitive functions especially speed of information processing, low self esteem, emotional lability, impaired self control, social isolation, depression, anxiety and impaired sleep cycle and insomnia. And in respect of safety concerns, over the last 47 years, no case of carcinoma caused by HGH therapy has ever been reported. Is therefore the proper and judicious use of HGH in patients who have AGHDS warranted?
This lecture will show the indications, contraindications and demonstrate the work-up needed to treat andropausal/somatopausal patients with the entire gamut of dermatologic, oral, injectable and other agents available today as the basis for setting up an age management centre and provide practical pearls of such a service and leave the audience to decide whether ‘anti-aging’ is indeed a myth or reality as at November 2007.
S-2-3
Late-onset hypogonadism – significance, symptom scales, screening and treatment
H.M. Tan
University of Malaya Medical Centre, Kuala Lumpur, Malaysia and Subang Jaya Medical Centre, Selangor, Malaysia
Since time immemorial, self-confidence and self-esteem have been eroded by signs and symptoms of decreased libido, erectile dysfunction, loss of physical strength, changes in body composition and depression. The constellation of symptoms of hormonal deficiency is similar to those related to the aging process. Many clinical features of aging in men are similar to clinical changes seen in younger hypogonadal men.
Testosterone deficiency syndrome (TDS) or symptomatic late-onset hypogonadism (SLOH) were first reported in the literature about 60 years ago. However, extensive clinical researches have only been carried out in the last 15 years or so. Numerous studies of late continue to validate the extent and significance of TDS or SLOH in the general male population. These include the 2003 Petaling Jaya Men's Health Study and the 2006 Subang Men's Health Research.
Overall at least one fifth of men above 40 years old suffer from TDS or SLOH. Besides sexual dysfunction, TDS affects other important bodily systems and functions including haematoporesis, bone mineralization, CNS (behaviour and mood), carbohydrate and lipid metabolism, calcium haemostasis and prostate growth. Common disabilities associated with adult TDS include frailty (contributed by anaemia, musculoskeletal changes, and osteoporosis), CVS diseases (related to lipid and carbohydrate abnormalities), CNS changes (behaviour and mood) and sexual dysfunction (ED, libido and ejaculatory problem).
Adult TDS or SLOH can therefore significantly affect men's overall health and well being, and severely compromise the quality of life of aging men. Many well validated symptoms scales are now being used to assist in detecting aging men with bothersomeness or disabilities which significantly affect their daily lives. These symptoms scales, e.g. St Louis ADAM Scale (ADAM), Heinemann's Aging Male Symptoms Scale (AMS), The International Index of Erectile Function (IIEF) and The International Prostate Symptoms Scale (IPSS) have been increasingly used to detect men's significant aging problems and co-morbidities. Potentially, the AMS which is a well designed and validated instrument with domains covering psychological, physical and sexual symptoms can be used as a single clinical instrument to screen for common problems in the aging male population. Lately, the AMS is also increasingly being used to measure changes in pre- and post-testosterone replacement therapy (TRT).
With the coming of age of the largest segment of male population, the baby boomers, the demand for testosterone replacement therapy is rapidly increasing. TRT is currently well accepted in the treatment of symptomatic aging men with confirmed abnormal low testosterone level. Numerous international guidelines are currently available to add confidence and support to well informed and competent physicians who are treating men with LOH.
S-2-4
Guideline for LOH in Japan: A biological marker for loh diagnosis is serum free testosterone
T. Iwamoto & Working Group of the Committee for LOH Guideline
Centre for Infertility and IVF, International University of Health and Welfare Hospital, Japan
Late-onset hypogonadism (LOH) is relatively common. Symptoms start when low testosterone level results in disturbance of the androgen target organs or functions. However, we still do not know well how we diagnose LOH in patients and treat them. Therefore, we have to find the best laboratory parameters to determine hypogonadism. Determination of bioavailable testosterone (BAT), the calculated BAT and the calculated free T, calculated using the total T value, the SHBG value and the albumin value have been accepted to obtain the bioactive T value. In Japan, however, since the measurement of SHBG has not been covered by insurance, they cannot be recommended generally. In recent findings, since a good correlation is observed between the calculated BAT and BAT and between the calculated free T and free T, determination of this free T has come to be examined from the viewpoints of economical efficiency and ease. However, derived testosterone measures, such as free, bioavailable and calculated free testosterone and free androgen index, which are increasingly reported, are not validated as diagnostic tests and have little practical diagnostic value. Since the rationale for the standard values of total T and free T proposed at the present time is unclear, clinical practice is confused and it has been necessary to re-establish the standard values of total T and free T in adult Japanese males. We planned to determine total T and free T normal values. 1,172 adult healthy males aged 20 to 77 years, were invited to set the standard values. All the blood samples for hormone measurements were collected in the morning. Total T and free T were determined by RIA method using DPC-testosterone kit and DPC-free testosterone kit (Mitsubishi Kagaku Iatron, Inc.), respectively. The total T value showed a tendency towards a decrease with aging but showed almost no change in and after the fifties, and kept constant. The standard value determined from the mean±2SD was 2.01 to 7.50 ng/mL. On the other hand, free T showed strong correlation with age and decreased with aging. The correlation was y = −0.161x + 20.7 (r = −0.521), and the reduction rate was −1.61 pg/mL (−9.2%) in 10 years. The standard free T value determined from the mean±2SD was 8.5 to 27.9 pg/mL for the twenties, 7.6 to 23.1 pg/mL for the thirties, 7.7 to 21.6 pg/mL for the forties, 6.9 to 18.4 pg/mL for the fifties, 5.4 to 16.7 pg/mL for the sixties and 4.5 to 13.8 pg/mL for the seventies. Finally, we decided to adopt that free T is less than 8.5 pg/ml for diagnosis of LOH and the candidate of androgen replacement therapy (ART). Furthermore, if patients have typical symptoms of LOH and free T level from 8.5 pg/ml to 11.8 pg/ml, trial of ART might be considered. (Free T 11.8 pg/ml is 70% of YAM (Young Adult Mean) level.) The study to determine whether free T is a good biomarker and ART can improve typical symptom of LOH is mandatory.
Japan-ASEAN Symposium 3 (ED in Elderly Men)
S-3-1
Pathophysiology of ED: Basic and clinical aspects
P.G. Adaikan
Department of Obstetrics and Gynecology, National University of Singapore, Singapore
Some degree of sexual dysfunction is seen in half of all men over 40 years. There are a number of causes for erectile dysfunction (ED) which include physical/medical problems affecting the blood supply and neurological function in addition to psychological aspects such as stress, fatigue, anxiety, partner conflicts and unresolved family issues. All these may have compounding effects on satisfactory sexual performance. Sexual dysfunctions could also be due to the side effect of prescription medications such as treatments for high blood pressure or depression. Both alcohol and cigarette smoking have deleterious effects on sexual performance by complex mechanisms. Obesity and high cholesterol levels affect the blood circulation, endothelial function as well as the hormonal status of testosterone. Similarly, being physically inactive, which results in poor cardiovascular reserve, may also increase the risk for developing ED. The aim of successful management of ED is restoration of quality of life and sexual health in aging couples. Another compounding factor in this age group is late-onset hypogonadism (LOH), which is seen together with other physical changes such as increase in abdominal fat, loss of libido, lean body mass, bone density and cognitive function. Androgen supplements may be useful in these ED patients (also improve the PDEI efficacy). Since hyperoestrogenemia caused loss of libido and ED in men, its delicate balance with testosterone may be considered important in patients, particularly with LOH for successful management outcome. Studies have also established the causative roles of high lipid (cholesterol and triglyceride), hypertension, diabetes mellitus and chronic alcoholism in ED in addition to endothelial dysfunction and aging. Therefore, the importance of lifestyle modifications in overcoming sexual problems cannot be underestimated.
These measures will be important adjuvants to currently available PDE inhibitors. In some patients with mild to moderate ED, L-arginine analogs, cAMP activators, melanocortin-stimulating hormone analogs, endothelin antagonists and others may become useful. Once commonly used penile prostheses have a limited role now in the management of ED, being reserved for patients with severe organic ED in whom all other therapeutic measures have failed. Together with the drug-management for ED and FSD (sexual arousal, desire and pain disorders), the co-existent conditions in males such as ejaculatory problems, desire, arousal and orgasmic dysfunctions and interpersonal conflicts have to be recognised and managed for a holistic couple care and success rate.
S-3-2
The role of testosterone replacement therapy in managing erectile dysfunction in aging males
T.Y. Ahn
Department of Urology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
The recently burgeoning population of older people increases the interest of the medical community in improving the quality of their lives. Urology healthcare for older men encompasses prostate disease (benign prostatic hyperplasia or prostate cancer), the penis (erectile dysfunction, ED), and the testis (testosterone deficiency syndrome, TDS). The decline in androgen production associated with increasing age results in symptom complexes called TDS. The prevalence of ED also increases with aging. ED is one of the clinical features associated with low level of testosterone in aging males. Although the relationship between testosterone and ED is still controversial, many animal studies have shown that the nitric oxide erectile pathway is testosterone-dependent. In addition, clinical studies have shown that surgical or medical castration results in the loss of libido and erectile function. In general, it is believed that testosterone affects sexual desire and arousal, spontaneous erections (nocturnal, morning), orgasm, ejaculation and psychic erections.
Phosphodiesterase-5 (PDE-5) inhibitor has also been reported to be beneficial for older men with ED. In addition, patients who failed a single treatment with PDE-5 inhibitor could expect improvement in erectile function after the combination of testosterone replacement therapy (TRT). Several clinical studies have demonstrated the benefits of a combination of testosterone and PDE-5 inhibitor. For example, many studies have shown that hypogonadism is one of the main co-morbidities related to PDE-5 inhibitor non-response in addition to diabetes mellitus, hypertension, and benign prostatic hyperplasia. Therefore, serum testosterone should be included in the basic evaluation of older men with ED in order to confirm or exclude the hypogonadism. Indications of TRT in older men with ED include primary hypogonadism, low sexual desire and decreased nocturnal penile tumescence with borderline testosterone, non-response to PDE-5 inhibitor with borderline testosterone, ED associated with testosterone deficiency syndrome, and ED associated with metabolic syndrome.
In conclusion, testosterone evaluation is necessary in older males with ED, and TRT may be beneficial for treating ED in men with low to low-normal testosterone levels who have failed prior treatment with PDE-5 inhibitors.
S-3-3
The roles of testosterone therapy for the sexual function of the hypogonadal men
H.S. Chiang
College of Medicine, Fu Jen Catholic University, Taipei, Taiwan
Introduction and objectives. A randomized, double-blind, placebo-controlled trial was conducted to (1) evaluate efficacy and safety of transdermal testosterone gel (AndroGel) for hypogonadal men in Taiwan, and (2) observe improvements in sexual function through International Index of Erectile Function (IIEF) scores.
Methods. Eligible hypogonadal men were randomized to receive 50 mg/day transdermal testosterone gel (TTG) or placebo for 3 months. Primary end point was change from baseline in total testosterone (TT) and free testosterone (FT). Secondary end points were change from baseline in serum hormone levels (such as dihydrotestosterone (DHT), estradiol (E2), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and sex-hormone-binding globulin (SHBG)) and changes in IIEF scores. Safety evaluations included adverse events (AEs) and skin irritation assessment.
Results. Compared with baseline, the TTG group (n = 20) had statistically significant increases in mean TT levels at month 1 (P = 0.024) and month 2 (P = 0.025), but no significant changes at month 3. TT levels in the placebo group (n = 18) showed no statistically significant change at any visit. Changes in FT levels paralleled changes in TT levels in both groups. TTG group IIEF scores were significantly increased at month 3 (P = 0.01), compared with a decline in placebo scores. No drug-related AEs occurred in the TTG group; the placebo group had 2 AEs (mild skin rash).
Conclusion. TTG effectively restores serum TT and FT levels to a normal physiological range for hypogonadal men in Taiwan and improves sexual function.
S-3-4
Sex management in elderly men
P. Sugkraroek
Bumrungrad International Hospital, Bangkok, Thailand
The inevitable sexual changes of the aging male begin somewhere between the ages of 45 and 55, varying from man to man in terms of when the changes become apparent and how rapidly they progress. Following are the most common changes:
Sexual drive and urgency decrease
Spontaneous erections cease to occur
Direct stimulation becomes necessary
Continual stimulation is often necessary
Erections take longer to achieve
The pre-ejaculate diminishes
Erections are not as firm as they once were
The angle of erection changes
Erections become unstable
Firmness might wax and wane
A longer period of stimulation is needed to ejaculate
There is a closing window of opportunity to ejaculate
Ejaculations can become elusive
The volume and velocity of the ejaculate decreases
Diminished experience of orgasm
A longer time is needed to recover after ejaculation
S-3-5
ED guideline in Japan
H. Sasaki
Showa University Fujigaoka Hospital, Urology, Japan
It is considered that the Japanese ED population is approximately eleven million. This is the first formal guideline in Japan for urologists who do not specialize in ED treatment and for general physicians.
Japanese ED diagnostic procedure does not differ from foreign countries. However, there is a great difference between Japanese ED treatment and other countries.
The risk factors are smoking, lifestyle related diseases such as high blood pressure/diabetes/hyperlipemia, obesity, depression and ischaemic heart disease.
Basic evaluation. We investigate inquiry and physical examination, blood sampling including lipid profile and sexual hormone and sexual function scales and questionnaires (IIEF, IIEF5).
Optional and/or specialized diagnostic testing. Psychosocial evaluation, NPT (Nocturnal penile tumescence) evaluation, intracavernosal injection test/colour Doppler ultrasonography, cavernosometry and cavernosography, angiography/CT-angiography.
Therapy. Counselling, oral agents, PDE-5-Is: it is well known that PDE-5-Is is the first therapeutic option, but 100 mg Sildenafil has not been authorized now, and 20 mg Valdenafil were authorized on 20 July this year. And on 30 July Tadalafil was authorized at long last. Apomorphine SL: unauthorized. Intracavernosal injction (ICI) therapy: unauthorized. Intraurethral therapy: unauthorized. Vacuum constriction devices: only one kind of VCD available. Surgical therapy: deep dorsal vein re-vascularization/venous ligation, penile prostasis. Unfortunately, patients treated for ED is extremely few compared to overseas.
Novartis Satellite Symposium
NSS
Prevention of bone lesions in prostate cancer: The role of bisphosphonates
C. Schulman
University Clinics of Brussels, Belgium
Bone metastasis in prostate cancer. Prostate cancer is the second leading cause of cancer death in men. About 75% of prostate cancer patients will ultimately develop bone metastases and virtually all men who die of prostate cancer have evidence of metastatic bone disease. Bone metastases are known to cause significant skeletal complications which increase morbidity, decrease quality of life, and cause significant bone pain. Until recently, commonly available bisphosphonates which effectively treat metastatic bone disease in breast cancer and multiple myeloma were found to be ineffective in prostate cancer. The lack of efficacy in this setting may be related to their comparatively low potency.
The first bisphosphonate effective in prostate cancer. The new third generation bisphosphonate zoledronic acid (ZOMETA®) has dramatically improved treatment options for metastatic bone disease in prostate cancer. The most potent drug in its class known, zoledronic acid is the first bisphosphonate proven effective in bone lesions from prostate cancer. It was shown to significantly reduce the proportion of patients with bone complications, delay the first skeletal related event, lower the annual incidence and the risk of developing skeletal complications, and reduce bone pain.
Preventing chemotherapy-induced bone loss in prostate cancer.Asymptomatic prostate cancer patients with rising prostate specific antigen (PSA) levels after radiation and/or surgical prostatectomy commonly receive androgen deprivation therapy (ADT) which results in castrate levels of androgens. Such patients may live for many years and accelerated bone loss due to ADT substantially increases their risk of osteoporotic fractures and other skeletal complications. Zoledronic acid was shown to effectively preserve and increase bone mineral density in these patients.
Conclusion. It is clear that zoledronic acid is a major improvement in the treatment options for prostate cancer both in the early and advanced stage. The use of bisphosphonates has been a standard of care in treating metastatic breast carcinoma for over a decade. In comparison to breast cancer patients, prostate cancer patients have a higher incidence of bone metastases and a longer 5-year survival. Zoledronic acid has demonstrated even higher efficacy in bone metastases from prostate cancer than previous agents have had in breast cancer. It offers effective bisphosphonate therapy to prostate cancer patients with a relatively simple 15-minute infusion which can be administered in most urological offices.
Annual Meeting of the Seventh Japanese Society for the Study of Aging Male (JSSAM)JSSAM Keynote Lecture
J-K-1
Medical care for men's health, considered from the international viewpoint
Y. Kumamoto
President of the Japanese Medical Society for Men's Health
What is a man?
Until what age can men maintain their maleness?
Until recently, clinical andrology was very backward in scientific development compared to clinical gynecology. That is the reason why the complicated male physiology is not well understood compared with female physiology. In particular, determination of the testosterone level in each patient was not routinely easy in general medical clinics, and was done only in research projects at special laboratories. Thus data about the patient's andrological situation related to clinical symptoms were not available for the consulting doctor.
However, as measurement of the testosterone level has recently become easier, this has enabled doctors to make judgements based upon endocrinological data. Such a clinical situation has actually promoted the development of the medical field of men's health.
Clinical andrology is necessary for aging males, whose population is recently rapidly increasing throughout the world, and who have many QOL problems, both physically and psychologically. Thus, as a result of this situation in the medical field, ISSAM, APSSAM and also our medical society for men's health were recently established to deal with the complaints of these patients.
Our study of clinical andrology for the aging male should catch up with the study of the female side, closing the medical gap as quickly as possible. Important research problems of androgen deficiency syndrome in clinical andrology for the aging male include: 1) the male climactic, 2) male metabolic syndrome, 3) sexual dysfunction and so on.
For such clinical and endocrinological problems, especially in the aged male, we should seriously consider ethnic differences, taking into account the racial and cultural backgrounds. I especially believe that there are many ethnic differences between Asians and Caucasians. For that clinical approach, we have to collect our national research data and compare the differences.
The final aim of our clinical studies on medical problems of the aging male is to elucidate what a man is, which is still remarkably obscure, and how to medically support the maintenance of maleness.
Finally, we would like to devote ourselves to bringing the male life span closer to that of the female as it is now several years shorter.
These are our research dreams.
JSSAM Oral Session
O-1
Age related changes in α1-adrenergic responsiveness of rat genital system
M. Yono1, J. Latifpour2, A. Imanishi1, M. Yoshida1, S. Ueda1
1Department of Urology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; 2Section of Urology, Yale University School of Medicine, New Haven, Connecticut, USA
Purpose. Despite the extensive use of α1-adrenoceptor antagonists in aging men with benign prostatic hyperplasia (BPH), little is known about the mechanism involved in the age dependent differences in the incidence of ejaculatory dysfunction (EjD) with tamsulosin. α1-Adrenoceptors are widely distributed in all the organs participating in the emission phase of ejaculation, such as seminal vesicle and vas deferens, suggesting that α1-adrenoceptors may play an important role in the emission phase. Therefore, we investigated age related changes in the functional, biochemical and molecular properties of α1-adrenoceptor in the rat seminal vesicle and vas deferens.
Materials and methods. The characteristics of α1-adrenoceptor in the seminal vesicle and epididymal and prostatic portion of vas deferens of 3 and 22-month-old rats were determined using an isolated muscle bath, radioligand receptor binding and real-time reverse transcriptase-polymerase chain reaction techniques.
Results. Old rats had significantly higher body weight and lower testosterone than young rats. Although there was no significant age dependent difference in the properties of α1-adrenoceptor in the prostatic portion of vas deferens, the maximum contractile responses to phenylephrine, total α1-adrenoceptor density and mRNA expression of all 3 α1-adrenoceptor subtypes were significantly lower in the seminal vesicle and epididymal portion of vas deferens of 22-month versus 3-month-old rats.
Conclusions. Our data indicate the presence of region and age dependent differences in the functional, biochemical and molecular properties of α1-adrenoceptors in the rat seminal vesicle and vas deferens. These findings suggest the possibility of differences in the response to α1-adrenoceptor antagonists with aging. Because α1-adrenoceptor antagonists may be associated with a higher incidence of EjD in young versus old patients, quality of life and sexuality should be considered in sexually active young men to improve patient acceptability and compliance when α1-adrenoceptor antagonists are used to treat lower urinary tract symptoms secondary to BPH.
O-2
Metabolic syndrome in men with klinefelter syndrome
T. Ishikawa, K. Yamaguchi, Y. Kondo, Y. Sakamoto, T. Haraguchi, A. Takenaka, M. Fujisawa
Division of Urology, Department of Organs Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
Klinefelter syndrome (KFS) is the most common sex-chromosome disorder; it affects approximately one in every 660 men. This syndrome is characterized by the presence of one or more extra X chromosomes, and the karyotype 47, XXY is the most prevalent type. The prototypic man with KFS has traditionally been described as tall, with narrow shoulders, broad hips, sparse body hair, gynecomastia, small testicles, androgen deficiency, azoospermia and decreased verbal intelligence. Male hypogonadism is an independent risk factor for the development of metabolic syndrome. Accordingly, the aim of this study was to investigate the metabolic syndrome and sex hormones in patients with KFS (no testosterone treatment), nonobstructive azoospermia (NOA) and age-matched obstructive azoospermia (OA). We examined 60 patients with KFS, 60 patients with NOA, and 50 patients with OA. Height, weight, waist circumference, and blood pressure were examined. Fasting blood samples were analysed for sex hormones (follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone (T), free testosterone (free T), prolactin (PRL), estradiol (E2)), total cholesterol (T-chol), high-density lipoproteins (HDL) and low-density lipoprotein (LDL) cholesterol, triglyceride (TG) and plasma glucose. Testosterone, PRL, free T and HDL cholesterol were significantly lower, whereas height, waist circumference, FSH, LH, and LDL cholesterol levels were significantly higher in KFS patients than in NOA and OA groups. Hypogonadism in KFS may cause an unfavourable change in body composition, primarily through increased truncal fat and decreased muscle mass and metabolic syndrome. Patients with KFS should be treated with lifelong testosterone supplementation that begins at puberty, to secure proper masculine development of sexual characteristics, muscle bulk and bone structure, and to prevent the long-term deleterious consequences of hypogonadism.
O-3
The relationship between testosterone levels and aging males' symptoms score (By Two Questionnaires)
T. Suetomi1, K. Matsuki1, H. Toma1, A. Joraku2, T. Oikawa2, N. Sekido2, S. Hinotsu2, N. Miyanaga2, K. Kawai2, T. Shimazui2, H. Akaza2
1Department of Urology, Ushiku Aiwa General Hospital, Japan; 2Department of Urology, Institute of Clinical Medicine, University of Tsukuba, Japan
Introduction and objectives. Late-onset hypogonadism (LOH) is a clinical and biochemical syndrome associated with a deficiency in serum testosterone levels. Several studies suggested that there was no significant relationship between total testosterone (TT) levels and LOH symptoms. It was reported that not TT but free testosterone (FT) declined with age in the Japanese male population. We investigated the relationship between TT and FT levels and aging males' symptoms score (using Heinemann's Aging Male Symptoms (AMS) scale and Kumamoto's questionnaire).
Methods. A total of 166 patients (mean age: 59 years) who were admitted to our clinics were included in the study. Patients with a history of urological malignancies and those who had undergone hormone replacement therapy were excluded from the study. Of these men, 17.8% reported LOH symptoms, 28.1% erectile dysfunction, 27.4% lower urinary tract symptoms, 12.3% urolithiasis, and 14.4% others. Two aging male symptoms questionnaires were completed by all patients. TT and FT were measured for all patients.
Results. There was a significant correlation between Heinemann's and Kumamoto's questionnaires (p < 0.01, r = 0.85). The scores of both questionnaires were significantly higher in patients who visited our LOH clinic. No significant correlation was found between TT level and age, whereas FT level declined with age (p < 0.01, r = −0.46). Although a weak correlation was found between TT level and score of both questionnaires (p < 0.05, r = −0.20), no significant correlation was found between FT level and score of both questionnaires.
Conclusions. This study confirmed that Kumamoto's questionnaire performs similarly to the AMS scale. We did not find a significant relationship between the score of both questionnaires and FT level. Our results suggest that LOH symptoms are not induced by testosterone deficiency alone.
O-4
The change of hormone profiles by chronic treatment with PDE-5 inhibitor for late-onset hypogonadism patients
M. Yasuda, K. Furuya, T. Yoshii, Y. Kamiyama, H. Ide, S. Horie
Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
Objective. Although clinical practice guidelines have been published for Androgen replacement therapy (ART) for late-onset hypogonadism, there were some patients who are refractory to ART or for whom it cannot be available due to the suspicion of prostate cancer, untreated occlusive sleep apnoea, erythrocytosis, and severe lower urinary tract symptoms associated with benign prostatic hypertrophy. The evidence has been accumulated to suggest that chronic administration of PDE-5 inhibitors can improve endothelial function and benefit not only those with erectile dysfunction but also those with a myriad other conditions. We hypothesized that chronic administration of PDE-5 inhibitors could stimulate HPT axis and ameliorate the symptomatology of LOH by changing hormone profiles.
Materials and methods. 20 LOH patients were recruited in this study (mean age: 53, range: 42–73). The inclusion criteria were: 1) hormone refractory patients, 2) those who did not want ART, 3) those with a willing and able partner, 4) those with IIEF-5 score <11 (severe ∼moderate ED).
The patients were asked to regularly take sildenafil citrate 50 mg at least once a week for 6 months. However, they were told that it was enough to be with their partner after taking a pill, despite sexual intercourse.
The evaluation included hormone profiles (LH, FSH, serum testosterone, salivary testosterone), IIEF-5 score, and AMS score.
The study was approved by Teikyo University review board and all patients signed written informed consent.
Results. After 6 month administration of sildenafil citrate, serum free testosterone (p = 0.009) and salivary testosterone (p < 0.001) significantly increased compared to baseline, which led to the significant improvement of both IIEF-5 and total AMS scores. Although we did not achieve statistical significance, LH and FSH were likely to increase after chronic administration.
Conclusion. PDE-5 inhibitor could be beneficial to some LOH patients due to stimulating HPG axis.
O-5
Examination of holistic care for prostate cancer patients receiving hormonal therapy
M. Kozu1, Y. Yamashita1, C. Kaneko1, A. Imazeki1, K. Kawamura2, N. Kamiya2, Y. Awa2, T. Imamoto2, H. Suzuki2, T. Ichikawa2
1Department of Nursing, Chiba University Hospital, Japan; 2Department of Urology Graduate School of Medicine, Chiba University, Japan
Objectives. A prostate cancer patient receiving hormonal therapy faces the fact that he has progressive cancer, and his body image will change. As hormonal therapy could affect both their mind and body, holistic care should be considered.
Methods. Some references contributing to the purpose of this study were collected from the Japanese medical database ‘ICHUSHI’ using the keywords ‘cancer’ and ‘hormonal therapy’. The changes arising from hormonal therapy were described, and holistic care for prostate cancer patients was examined.
Results. Seven references about hormonal therapy for prostate cancer were collected; three general remarks, two studies on hot flushes, and two studies on Quality of Life (QoL). The changes arising from hormonal therapy were described as a drop in sexual desire, erectile dysfunction, hot flushes, fatigue, a drop in vitality, a loss of muscular strength, a drop in bone density, anaemia, a drop in lipid metabolism, breast swelling and pain, liver damage, and depression. Two references about hormonal therapy for breast cancer were collected; both of them were on QoL. The changes arising from taking anti-oestrogen were described as hot flushes, fatigue, body weight gain, stiffness in the shoulders, chills, anxiety, and depression. One reference reported the correlation of the symptoms of menopause with anxiety and depression.
Conclusion. The results suggested that the changes arising from hormonal therapy could weaken their masculinity and ability to control their feelings, which could lead to anxiety and depression. In conclusion, two following points seem to be important to perform holistic care for patients: 1) attending to and understanding their changes in mind and body. This would help recover their self-confidence and ultimately help stabilize their emotions, 2) building a good relationship between medical staffs and patients. This would give them the ability to control their feelings and positive views.
O-6
Analysis of changes in QOL of patients with late-onset hypogonadism patients receiving androgen replacement therapy
H. Taniguchi, G. Kawa, H. Kinoshita, T. Matsuda
Department of Urology and Andrology, Kansai Medical University, Japan
Materials and methods. We obtained the answer sheets from 112 men aged 37 to 75 years (mean 56.2) who underwent androgen replacement therapy (ART) in Kansai Medical University Hospital between September 2002 and June 2007. ART was continued for 6 months and was then stopped. We evaluated changes in score on the SF-36 between pre-treatment and 3, 6, and 9 months after initiation of treatment.
Results. Although prior to ART all subcategory scores on the SF36 were lower than those for age-matched healthy Japanese men, each was significantly improved after beginning ART, especially for the role-emotional (RE) subscale. No significant difference was noted between 3 months after initiation of treatment and 6 or 9 months (3 months after stopping ART) in any subcategory score.
Conclusions. The ART for LOH patients was effective not only for symptoms but also QOL. Effects of ART presented comparatively early periods of treatments and were maintained after stopping the treatment for at least 3 months.
O-7
The clinical efficacy of testosterone ointment (glowmin) to lower abdominal skin for late-onset hypogonadism patients: comparison with trans-scrotal skin application
T. Amano1, T. Imao1, K. Takemae1, T. Iwamoto2,3, K. Yamakawa3, K. Baba3, M. Nakanome3, H. Sugimori4, T. Tanaka4, K. Yoshida4, T. Katabami5, M. Tanaka6
1Department of Urology, Nagano Red Cross Hospital, Nagano, Japan; 2Reproductive Centre, International University of Health and Welfare, Nasu, Tochigi, Japan; 3Department of Urology, St Marianna University, Kawasaki, Japan; 4Department of Preventive Medicine, St Marianna University, Kawasaki, Japan; 5Department of Metabolism and Endocrinology, St Marianna University, Kawasaki, Japan; 6Department of Pharmacology, St Marianna University, Kawasaki, Japan
Introduction. We have reported the profile of serum testosterone levels after application of testosterone ointment (Glowmin, GL) on scrotal skin and its clinical efficacy in late-onset hypogonadism (LOH) patients. However, the area of scrotal skin is rather limited. In this study we administered GL to lower abdominal skin for LOH patients once a day, and its clinical efficacy was investigated. Furthermore, the obtained results were compared with previous data of scrotal skin administration.
Methods. Thirty-three LOH patients were treated by administration of 6 mg of GL once a day on lower abdominal skin. Serum free testosterone (FT) levels were measured before and 12 weeks after GL treatments. Aging male symptoms (AMS) rating scale were also compared before and after GL application.
Results. Of 33, 27 patients (81.8%) completed 12 weeks of GL treatments. Serum FT levels were significantly elevated 12 weeks after GL treatments (6.4±1.3 pg/ml before treatment versus 8.2±2.4 pg/ml after 12 week GL therapy, p = 0.0016). All 3 domains of AMS score were also improved significantly 12 weeks of GL applications (p ≤ 0.0001). No serious adverse reactions were observed. In comparison with the previous data of scrotal skin administration, only the psychological domain of AMS was significantly improved at trans-lower abdominal GL application. The other domains of AMS were not significantly different between these two GL administration routes. Six patients (18.2%) could not continue GL application, because of a change of therapy to testosterone injection in 2, referred to department of psychology in 1, prior to treating another disease in 1, and unknown in 2.
Conclusions. Trans-abdominal dermal application of GL is considered an acceptable and safe treatment for LOH patients.
O-8
Predictive factors related to the effects of art on LOH and the borderline group
I. Mizuno, A. Watanabe, T. Akashi, H. Fuse
Department of Urology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
Objective. Androgen replacement therapy (ART) is performed for late-onset hypogonadism (LOH) and the borderline group, but it is difficult to predict the effects of treatment. In this study, the predictive factors regarding the effects of ART are investigated.
Patients and methods. The patients were classified into three groups according to the blood level of free testosterone (FT) – a low value group (LOH) (<8.5 pg/ml), a borderline group (≥8.5 pg/ml, <11.8 pg/ml), and a normal group (≥11.8 pg/ml). Intramuscular administration of testosterone enanthate (125 or 250 mg) every 2 to 3 weeks was performed for the two groups except a control. The effects of treatment were determined by the patients' reports and the same doctor's judgement, and the patients were categorized into the ART-effective and ART-ineffective group.
Results. The ART-effective group consisted of 9 cases, and the ART-ineffective group included 8 cases. In these two groups, the ages were 52.1±10.4 and 59.6±4.9 years (NS), the values of FT were 6.1±2.2 and 8.0±1.4 pg/ml (p < 0.05), the values of total testosterone were 3.01±1.37 and 3.52±0.99 ng/ml (NS), respectively. Concerning the Aging Male Symptoms (AMS) scores, the psychological factor was evaluated as 11.0±3.0 and 10.4±4.1 (NS), the somatovegetative was evaluated as 18.0±6.1 and 16.5±4.8 (NS), the sexual was evaluated as 13.7±4.5 and 12.4±4.1 (NS), and the totals of the AMS scores were 42.7±11.6 and 39.2±10.0 (NS) in the ART-effective and ART-ineffective group, respectively.
Conclusions. In the ART-effective group, the values of FT were significantly lower than in the ART-ineffective group, so the value of FT may be a useful predictive factor for the effects of ART.
JSSAM Workshop 1 (Bone Health)
WS-1-1
Bone health and gender differences
S. Ogawa
Department of Geriatric Medicine, Graduate School of Medicine, University of Tokyo, Japan
Osteoporosis is associated not only with decreased bone density and altered quality as a consequence of imbalance between bone resorption and bone formation, but also with increased morbidity, mortality and costs. Although osteoporosis affects both sexes, male osteoporosis, which is prone to be underestimated so far, represents specific clinical importance and public health problem. Androgen is thought to be essential for skeletal development and maintenance of bone mass, whereas the pathophysiological roles of androgen receptor (AR), as well as those of estrogen receptor (ER), in bone metabolism have not been well established. The aging process involves an increase in the incidence of osteoporotic fracture, with a ratio of about 2 to 3 to 1 in the elderly female to male for hip and vertebral fractures. Morbidity and mortality after osteoporotic fractures appear to be more serious compared with non-fracture group in male. In addition to these sex differences in pathophysiology of osteoporosis and in age-specific incidence of osteoporotic fractures, there are also some similarities in both sexes. The higher incidence of fracture in female than in male might be derived from quantitative differences in common risk factors rather than from its' qualitative differences like sex-specific risk factors. And an incidence of fracture seems to be similar in both sexes when adjusted for age, BMD, and prevalent fracture, suggesting that baseline BMD, its loss and prior vertebral fracture predict the risk of future fracture in the elderly. In this workshop, clinical characteristic of male osteoporosis, its risk factors, pharmacological and nonpharmacological interventions, in relation to the recent findings about female osteoporosis, will be introduced.
WS-1-2
Prostate cancer and bone health: Third generation bisphosphonate improves osteoporosis caused by hormonal therapy in prostate cancer patients
A. Mizokami, E. Koh, M. Namiki
Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Sciences, Japan
Osteoporosis with menopausal syndrome by an oestrogenic decline becomes a problem after menopause in women. In addition, bone mineral density decreases in the mechanism that is similar to menopausal syndrome when we carry out hormonal therapy in breast cancer. As for the main side effect of hormonal therapy for prostate cancer, there are thermoregulation disorders such as hot flushes/rush of blood to the head/diaphoresis and mental disorder such as irritation/a depression tendency, anaemia, a decline of bone mineral density, which are equivalent to female menopausal syndrome. These side effects result from an androgenic sudden decline similar to female menopausal syndrome. A decline in bone mineral density increases the risk of a fracture. On this account bone lesion often decreases QOL of the patient. Therefore, it is extremely important to prevent a decline of bone mineral density because the prognosis is good when we carry out hormonal therapy for the comparatively early prostate cancer patient.
Bisphosphonates, the pyrroline acid derivatives that are calcification inhibitors, inhibit osteoclast differentiation and proliferation. We can prevent osteoporosis by using bisphosphonates. There are some reports that a decline of bone mineral density can be prevented by using a bisphosphonate together in breast cancer and prostate cancer from the hormonal therapy initiation. However, these reports were reports about preventive administration of bisphosphonates and it is not clear whether there was a therapeutic effect of bisphosphonate for the osteoporosis that occurred after hormonal therapy.
We gave risedronate which was a bisphosphonate pharmaceutical for the prostate cancer patient who had already had hormonal therapy, and investigated therapy effect for osteoporosis.
The age of risedronate administrated group (n = 23) was 74.2±6.9 years old, and the period of hormonal therapy was 19.2±14.0 months; the age of risedronate non-administration group (n = 24) was 73.3±8.0 years old and the period of hormonal therapy was 16.8±10.0 months. Six months after risedronate administration initiation the increased rate of bone mineral density (BMD) was 1.98±5.34%, and the increased rate of bone resorption marker DPD in the urine was −20.15±16.47%. The increased rate of BMD of risedronate non-administration was −0.69±2.45%, and the increased rate of DPD in the urine was −4.26±19.31%. Risedronate administration significantly improved BMD and inhibited bone absorption. This result suggests the potentiality for bisphosphonate to improve bone metabolism of the prostate cancer patient who has already undergone hormonal therapy.
JSSAM Education Seminar 1
J-E-1
Clinical efficacy of finasteride on androgenetic alopecia and polymorphism of the androgen receptor gene
A. Satoh
Tokyo Memorial Clinic Hirayama, Japan
Since finasteride had been approved for treatment of androgenetic alopecia in 2005, not enough clinical studies were conducted to prove the efficacy in Japan. However, we have been treating AGA with finasteride since 1999 and have accumulated extensive clinical experiences in our clinic, Tokyo Memorial Clinic Hirayama. In the present two studies, effectiveness of finasteride and the association between the drug efficacy and androgen receptor (AR) polymorphism were examined in patients with androgenetic alopecia (AGA) who visited Tokyo Memorial Clinic Hirayama.
In the short-term study, 1 mg/day of finasteride was administered to 1087 patients with AGA who initially visited our clinic between 25 July and 30 November in 2006. In the long term study, 20 patients who received 1 mg/day of finasteride and remained on the treatment for over 5 years were evaluated for the drug efficacy. Improvement from the baldness was evaluated by the photographic score, giving 1 for the hair is greatly decreased, 2 for moderately decreased, 3 for mildly decreased, 4 for no change, 5 for mildly increased, 6 for moderately increased and 7 for greatly increased. In the short term study, the correlation between AR gene polymorphism and the clinical efficacy of finasteride was examined. For AR gene polymorphism, the number of polyglutamine triplet (CAG) repeat in AR gene was determined by DNA sequencing and fragment analysis.
In the short-term study, among 708 patients who completed 6-month finasteride treatment 91.8% (650/708) improved with score 4–7. During the period, 14 patients had adverse experiences, all of which were mild. In the long-term study, among 20 patients who remained on the finasteride treatment for 5 years 100% of patients achieved the improvement of score 4–7.
When the correlation between the improvement score with finasteride and the number of CAG repeat was examined in 247 AGA patients according to the scattered plot, patients with the baldness improved more had shorter CAG repeat, demonstrating reversed correlation between CAG repeat length in AR gene and the drug efficacy.
We concluded that finasteride has excellent clinical efficacy to treat AGA in men and it is more potent in patients with shorter CAG repeat in AR gene. Analysis of CAG repeat related polymorphism in AR gene is useful for predicting effectiveness of drug for AGA treatment.
Although finasteride is known to be competitive inhibitor of type 2 5α-reductase and inhibits the conversion of testosterone to DHT, the definite mechanism of action on hair growth has not been explained.
We will discuss the issues related to androgen on AGA and the correlation between the clinical effectiveness of finasteride and AGA.
JSSAM Workshop 2 (The Status Quo and the Issue of the Practice of LOH in Japan)
WS-2-1
The prevalence of men with late-onset hypogonadism (LOH) syndrome in Japanese males
N. Itoh, K. Kobayashi, R. Kato, T. Tsukamato
Department of Urology, Sapporo Medical University School of Medicine, Japan
Objective. Late-onset hypogonadism (LOH) syndrome is defined as a clinical and biochemical syndrome associated with advanced age and characterized by typical symptoms of deficiency in serum testosterone levels by the International Society for the Study of the Aging Male (ISSAM). To clarify the prevalence of men with LOH syndrome in Japanese males it might be relevant to consider the necessity of androgen replacement therapy to maintain quality of life in aged males in the near future. The aim of this study was to define the prevalence of LOH syndrome in Japanese males through assessment of serum testosterone levels and aging males' symptoms.
Subjects and methods. This was a cross-sectional and observational study. A total of 200 males aged from 20 to 77 years who visited hospitals for health check-ups were recruited after giving informed consent. Symptoms were evaluated using the Heinemann Aging Male Symptoms rating scale (AMS). Serum total and free testosterone were measured using commercially available radioimmunoassay kits. Calculated bioavailable testosterone was estimated by total testosterone, albumin and sex hormone-binding globulin (SHBG). This study was approved by the institutional review board of our hospital.
Results. We diagnosed men as having LOH syndrome when aging males' symptom score was moderate to severe (37 or more in AMS score) and serum free testosterone level was less than 8.5 pg/ml (the lower limit of 20s in healthy Japanese males). The prevalence of men with moderate to severe aging males' symptoms increased with age: 0%, 19.4%, 17.6%, 30.4%, 46.5% and 60% of those twenties, thirties, forties, fifties, sixties and seventies, respectively. The prevalence of LOH syndrome also increased with age: 5.9%, 13%, 25.6% and 26.6% of those forties, fifties, sixties and seventies, respectively. The total AMS score was significantly correlated with serum free testosterone levels (r = −0.236, p < 0.01) and calculated bioavailable testosterone levels (r = −0.172, p < 0.05). No correlation was shown between total testosterone levels and the total AMS score.
Conclusions. This preliminary study showed that a number of Japanese males over 40 years had aging male symptoms and low androgen levels (LOH syndrome). Serum free testosterone level is suspected to be the most appropriate value to predict aging male symptoms in the general population. These findings would provide a strong argument for an interventional study of androgen replacement therapy in aged males.
WS-2-2
QOL of patients with LOH: Effects of art
T. Matsuda, H. Taniguchi, G. Kawa
Department of Urology and Andrology, Kansai Medical University, Japan
Objective. Late-onset hypogonadism (LOH) causes deterioration of quality of life (QoL) of patients. We evaluated QoL in patients with LOH receiving androgen replacement therapy (ART) using a comprehensive health-related QoL scale, SF-36.
Materials and methods. Four hundreds and fifty-four patients aged 33 to 77 years (mean 54.1) visited the LOH clinic of Kansai Medical University Hospital and symptoms and hormonal status were studied. Two hundred of them were temporarily diagnosed as LOH because the free testosterone levels were low or low-normal and the symptoms were compatible with those of typical LOH patients, and received ART with testosterone enanthate 250 mg every 3 weeks. The efficacy of ART was evaluated at 3 months on 155 patients. ART was continued for 6 months when it was effective, and then was stopped. The effects of ART were evaluated using the Aging Male Symptom scale (AMS), the Self-rating Depression scale (SDS) and SF-36 at pre-treatment and 3, 6, and 9 months after the initiation of ART.
Results. ART was effective in 52.9% of the 155 patients. The mean value of the total scores of AMS and SDS significantly decreased after the initiation of ART when compared to the pre-treatment value, indicating effectiveness of ART in reducing the symptoms of the patients. Scores of SF-36 were studied in 112 men. Although prior to ART all subcategory scores on the SF36 were lower than those for age-matched healthy Japanese men, each score was significantly improved after beginning ART. The improvement of the role-emotional subscale was the largest. There was no significant difference between the scores at 3 months and those at 6 or 9 months after initiation of ART in any subcategory score.
Conclusions. QoL of LOH patients heavily deteriorated when assessed using SF-36. ART for LOH patients was effective not only to reduce the symptoms but also to improve QoL of the patients. Effects of ART appeared after a short period and were maintained after discontinuation of ART.
WS-2-3
The issue of the practice for LOH in Japan
A. Tsujimura
Department of Urology, Osaka University Graduate School of Medicine, Japan
Late-onset hypogonadism (LOH) has received widespread attention in the popular and medical media in the last few years. LOH is defined as a biochemical syndrome associated with advancing age and is characterized by a deficiency in serum androgen with or without decreased genomic sensitivity to androgen. There are still several issues of diagnosis and treatment for LOH in Japan.
The first issue is the measurement method of serum testosterone. To make a diagnosis for LOH, the cut-off value of serum testosterone is necessary. In plasma, testosterone is bound non-specifically to albumin and specifically to sex hormone binding globulin (SHBG); a small percentage is available as unbound or free testosterone (FT). It is well known that FT decreases significantly with aging, but total testosterone (TT) does not decrease with aging. Although the recommended assay of FT is equilibrium dialysis, it is difficult to perform and largely inaccessible to most clinicians. The measurement of bioavailable testosterone (BT), which reflects the physiological activity of testosterone, is also too complicated and difficult. The measurement of SHBG, which is necessary to obtain calculated BT (cBT) according the formula is also not covered by National Health Insurance (NHI). Thus, we decided to use FT based on analogue ligand (aFT), which is clinically used and covered by NHI, for the practice of LOH in Japan. In this year, the cut-off value based on serum aFT has been reported; patients whose concentration of serum FT is less than 8.5 ng/ml are indicated for androgen replacement therapy (ART), patients whose concentration of serum FT is less than 11.8 ng/ml are relatively indicated for it. According to these criteria, we have to collect evidence for the practice of LOH. The second issue is the treatment, particularly ART. It is well accepted that the first-choice treatment for LOH is usually ART. Many researchers have reported that ART can improve sexual function and libido as well as maintain bone and muscle mass. Oral and transdermal testosterone preparations as well as injections have been used clinically for LOH worldwide and their efficacies have been reported. However, testosterone is generally administered by injection in Japan because oral and transdermal high-quality testosterone preparations that can maintain a physiologic testosterone level have not been available in Japan. The last issue is the treatment for patients without hypogonadism with LOH related symptom. We have reported that LOH related symptoms as evaluated by several questionnaires were not related to serum testosterone concentration in a study of 90 patients with LOH related symptoms. Furthermore, about half the patients who had LOH symptoms and visited special clinics for LOH did not involve hypogonadism. Thus, it remains unclear whether all LOH related symptoms can be explained by a decrease in serum testosterone concentration alone. In addition, a higher prevalence of major depressive disorder was reported in Japanese patients with LOH. Therefore, how treat eugonadal patients with LOH related symptoms by other tools than testosterone preparation is a serious problem.
In this symposium, I will make these issues clear and discuss details.
Japan-ASEAN and JSSAM Conjugated Symposium (Metabolic Syndrome)
J-A & JSSAM-S-1
Cardiovascular risk in aging men
E.M. Khoo
Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia
Cardiovascular disease (CVD), which includes coronary heart disease (CHD) and stroke, is the leading cause of death worldwide. It is predicted that about half of the world's cardiovascular (CV) burden will occur in the Asia Pacific region. Stroke, in addition, is also the leading cause of adult disability globally and accounts for 3% of the world's disability burden in 1990. By 2020, it is estimated that stroke mortality will double, mainly as a result of increasing numbers of older people and inadequate control of risk factors in less developed countries.
Men have twice the coronary disease mortality compared to women. They also have higher age-specific stroke incidence rates than women except in 35–44 years old and those in over 85 years. As the population are aging rapidly especially in the developing countries, and CV morbidity and mortality increase with age, we are facing an exponential healthcare burden contributed by the disease and its risk factors in the aging men.
Cardiovascular risk can be expressed as the percentage chance of an individual experiencing a CV event over a pre-defined period of time, usually the next 10 years. It is known that CV risks include hypertension, diabetes mellitus, dyslipidaemia, male gender, increasing age, smoking, positive family history, obesity and previous CV events. Other relative risk factors include excessive alcohol ingestion and physical inactivity. The role of testosterone as CV risk factor is still debatable.
Hypertension is prevalent in the Asia-Pacific region, ranging from 11% to 32%. Similarly, Type 2 diabetes and obesity are also rising exponentially in this region.
In Malaysia, a randomized population-based study of urban men aged >40 years showed the prevalence of coronary heart disease was 10.7%, hypertension 29.3%, Diabetes 13.3%, LDL-cholesterol (>2.6 mmol/l) 78.9%, smoking 16.6%, obesity 51.1%. The 10-year CHD risk is 41.3% in the <10% risk, 47.2% in 10%−20% risk, and 5.9% in the >20% risk. This risk increases significantly with increasing age.
Meta-analyses of randomized controlled trials confirm blood pressure lowering would lead to 30%–40% reduction in stroke risk. The Asia Pacific Cohort Studies Collaboration has also shown that a 10 mmHg lower than usual systolic blood pressure was associated with 54% lower stroke risk and 46% lower CHD risk. Lowering blood cholesterol has been associated with a 25% to 30% reduction in the risk of CVD mortality and illness among high-risk people. Treatment of diabetes mellitus reduces and delays development of complications.
As CVD is prevalent in aging men, it is clear that it is important to reduce their CV risk through effective primary and secondary prevention such as lifestyle and behavioural changes (stopping smoking, a healthy diet that is low in saturated fat, reducing salt, promoting exercise) as well as optimizing their control of hypertension, diabetes and dyslipidaemia.
J-A & JSSAM-S-2
A Review of metabolic syndrome with special reference to male hypogonadism
P.K. Yap
Subang Jaya Medical Centre, Selangor, Malaysia
Despite recent controversy over the diagnostic criteria and relevance of metabolic syndrome (MetS) it still remains a useful tool to assess risk of cardiovascular disease. The IDF consensus for the diagnosis of metabolic syndrome has not been fully validated in clinical practice so the NCEP ATP III criteria using the Asian waist cut-off points will be used for this presentation. The data presented will show that the prevalence of metabolic syndrome in this region is rising in tandem with the epidemic of obesity.
There is a strong link between MetS and male hypogonadism, primarily because a low testosterone level is associated with visceral obesity and insulin resistance, the key features of MetS. This relationship will be explored using local and regional data.
Although visceral obesity is commonly seen as a consequence of male hypogonadism, it is important to note that obesity itself can also lead to low testosterone levels by activation of the ‘hypogonadal-obesity-adipocytokine cycle’. Visceral obesity leads to increased activity of the enzyme aromatase, present in adipose tissue, which converts testosterone to oestrogen. This sets up a vicious cycle, with the resulting low testosterone level increasing lipoprotein lipase enzyme activity and as well as triglyceride uptake, leading to further visceral obesity and insulin resistance. Visceral obesity is also associated with increased leptin secretion and increased pro-inflammatory adipocytokine secretion and both these can potentially reduce testosterone secretion via the hypothalamic-pituitary axis and probably by a direct effect on the testes as well.
This raises the question of which came first: hypogonadism or visceral obesity? One way to resolve this would be to review the effects of testosterone replacement therapy on subjects with visceral obesity and conditions associated with insulin resistance, for example type 2 diabetes as well as metabolic syndrome. Currently, no large, long-term studies have been carried out, but a few small selected studies will be reviewed.
Finally, the implications of the link between hypogonadism and metabolic syndrome will be discussed with reference to screening and management.
J-A & JSSAM-S-3
Metabolic syndrome and diabetes mellitus
J. Soh1, Y. Naya2, A. Ochiai1, Y. Naito1, K. Yoneda1, Y. Mizutani1, A. Kawauchi1, M. Fukui3, T. Yoshikawa4, T. Miki1
1Department of Urology, Graduate School of Medical Science Kyoto Prefectural University of Medicine, Japan; 2Department of Urology, Matsushita Memorial Hospital, Japan; 3Department of Endocrinology and Metabolism, Graduate School of Medical Science Kyoto Prefectural University of Medicine, Japan; 4Department of Inflammation and Immunology, Graduate School of Medical Science Kyoto Prefectural University of Medicine, Japan
Introduction and objective. It is reported that total serum testosterone levels and free testosterone levels are lower in diabetic patients than in non-diabetic patients, and results of the Massachusetts Male Aging Study suggest that there is some relation between the acquisition of insulin resistance and the onset of type 2 diabetes. We investigated the relationship between testosterone levels in patients with type 2 diabetes and various risk factors.
Methods. The subjects were 253 patients with type 2 diabetes whose total serum testosterone levels and free testosterone levels were measured. Their average age was 62±9.9 years. The items examined were age, age at onset, duration of disease, BMI, HbA1c, systolic blood pressure, diastolic blood pressure, total cholesterol, neutral fat, severity of retinopathy, severity of nephropathy and method of treating diabetes (whether or not insulin is used), and we investigated the relationship of these items to total serum testosterone levels and free testosterone levels.
Results. Total serum testosterone levels were 4.4±1.6 (ng/ml) and free testosterone levels were 10.8±4.2 (pg/ml) in the 253 patients with type 2 diabetes. BMI was inversely related to total testosterone (r = −0.206, p = 0.0015). Age (r = −0.420, p < 0.0001), age at onset (r = −0.289, p < 0.0001) and duration of disease (r = −0.165, p = 0.0114) showed inverse relation to free testosterone levels, and total cholesterol was positively related to free testosterone (r = 0.145, p = 0.0238). HbA1c, systolic blood pressure, diastolic blood pressure, neutral fat, severity of retinopathy and severity of nephropathy did not relate to total and free testosterone levels. With regard to the method of treating diabetes, free testosterone was significantly lower in diabetic patients who use insulin than in those who don't (8.2±4.9 versus 11.3±4.0).
Conclusions. No decrease in total serum testosterone levels or free testosterone levels was observed in patients with type 2 diabetes, but decreased free testosterone levels in patients with type 2 diabetes may be related to treatment modalities of diabetes (whether or not insulin is used).
J-A & JSSAM-S-4
Approach to managing metabolic syndrome in Japan
T. Yanase
Department of Medicine and Bioregulatory Science, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
Obesity is a world-wide problem and Japan is no exception. It is reported that 20%–25% of Japanese men meet the criteria for metabolic syndrome (MetS), which is considered a risk factor for cardiovascular disease beyond just cholesterol levels. Under these criteria, visceral fat obesity is defined as the most likely pathogenesis and can be taken as present when the waist circumference diameter (WCD) exceeds 85 cm. However, there is still some controversy about the proper criteria for MetS. The International Diabetes Federation (IFDF) has proposed a cut-off value of 90 cm for the diagnosis of MetS in Asian men. However, in our study of 1685 asymptomatic male subjects undergoing medical checkups, WCD positively correlated with carotid intima plus media thickness (IMT), an indicator of early atherosclerosis. The increase in IMT was also positively associated with the increase in the number of the risk components of MetS. We performed ROC analysis to estimate an ideal cut-off value for WCD that would enable us to determine multiple risk components (more than 2) with maximum sensitivity and specificity. We found the point was 87 cm in male subjects by either Japanese or IDF criteria. Also, the Japanese criteria appeared more suitable for Japanese men than the IDF for the early detection of atherosclerosis using IMT.
The initial, and standard, therapy for MetS is a combination of proper diet and exercise aimed at reducing visceral fat obesity. In some cases, drug therapies for risk such as diabetes mellitus, hyperlipidemia and hypertension may also be applicable. Interestingly, in patients with MetS complicated with hypertension, use of an angiotensin receptor blocker may be beneficial. This is because such a blocker works as a partial agonist or selective modulator of PPARγ thus leading to the improvement of insulin resistance in patients with MetS without an increased incidence of weight gain, which is often observed when antidiabetic drugs such as thiazolidinediones (TZD), a potent full agonist of PPARγ, are administered.
Our data showed that the visceral fat to subcutaneous fat ratio increases with age in men. Also, we found that free testosterone concentrations in men are inversely correlated with the body fat percentage suggesting that endogenous testosterone in men is protective against the increase of fat mass with aging. This finding was supported by our recent animal study showing that male androgen receptor knockout mice develop late-onset obesity, mainly by decreased energy expenditure and decreased lipolysis. Thus, there exists a critical need for the realization of safe and effective oral therapies that would offer greater separation between the desired anabolic and undesired androgenic effects. In line with this theory, the development of a kind of selective androgen receptor modulator (SARM), which could lead to the improvement of metabolic syndrome by decreasing fat mass in elderly men but without the concomitant deleterious effects on the prostate, is highly anticipated.
Daiichi Satellite Symposium
DSS
Male LUTS update
O. Nishizawa
Department of Urology, Shinshu University School of Medicine, Japan
Lower urinary tract symptoms (LUTS) are not specific to prostatic obstruction in men and are just as common in women. LUTS are equally bothersome to men and women. LUTS describe patients' urinary complaints without implying a cause. LUTS were defined by the standardization subcommittee of the International Continence Society (ICS) in February 2002 as the subjective indicators of a disease or change in conditions as perceived by the patients, carer or partners and may lead him/her to seek help from healthcare professionals. They are usually qualitative. In general, LUTS cannot be used to make a definitive diagnosis. LUTS can also indicate pathologies other than lower urinary tract dysfunction, such as urinary infection. LUTS are categorized as storage, voiding, and post micturition symptoms. Prevalence of LUTS was generally higher in men and aged population. Only a small proportion of symptomatic individuals visited physicians.
LUTS greatly affect the quality of life of male patients. Among LUTS, overactive bladder (OAB) symptoms are troublesome. The primary goals of therapy for male LUTS patients are to eliminate LUTS and improve urinary flow rate. Targeting both the prostate and bladder is reasonable in order to reduce storage symptoms of male LUTS patients. In USA and Europe, combination therapy of α1-blocker and 5α-reductase inhibitor is common for effective treatment for male LUTS patients with demonstrable prostatic enlargements. In Japan, 5α-reductase inhibitors have not been approved for administering to treat male LUTS patients. Therefore, anticholinergics, which seem to have a theoretical risk of increased voiding dysfunction are often administered to treat OAB symptoms of male LUTS patients with a caution about urinary retention related to anticholinergics.
Combination therapy demonstrated advantages compared to α1-blocker monotherapy. Urinary retention rarely occurred in patients of combination therapy. Combination therapy did not impair voiding function. Combination therapy with α1 blocker and anticholinergics may be effective in about 70% of male LUTS patients refractory to α1-blocker monotherapy. If α1-blocker monotherapy does not adequately improve the symptoms of male LUTS patients, combination treatment with α1-blocker and anticholinergics is recommended as an effective therapy for OAB symptoms of male LUTS patients.
Japan-ASEAN Plenary Lecture
Lecture1
Overactive bladder in aging males
M. Takeda, M. Yoshiyama, H. Zakohji, Y. Mikami, I. Araki
Department of Urology, University of Yamanashi, Faculty of Medicine, Japan
The International Continence Society (ICS) recently reported a modified terminology for lower urinary tract function and established the symptom-based term ‘overactive bladder’ (OAB). As life expectancy rises in industrialized countries, the importance of OAB will further increase. OAB is a common disease with a socioeconomic impact comparable to diabetes mellitus. The socioeconomic consequences of the overactive bladder syndrome were recently estimated in a large US study and a total cost of 12.6 billion US dollars was calculated.
Two recently published multinational prevalence studies from Europe and Asia show different prevalence values (Europe: 15.6% (men), 17.4% (women); Asia: 53.1% (women)), which may be due to methodological differences. According to an epidemiologic survey on lower urinary tract symptoms in Japan, the prevalence of OAB was 12.4%, which consisted of 6.4% with urge incontinence (≥ once per week) and 6.0% without it, if overactive bladder (OAB) was defined as a clinical condition having urinary frequency (≥8 micturitions per day) and urinary urgency (≥ once per week). The most problematic symptom was nocturia (38.2%), daytime frequency (19.3%), stress incontinence (14.5%), urgency (10.4%), urge incontinence (9.8%), and reduced urinary flow (6.6%). All 3 studies report an increase of OAB prevalence corresponding with age. The cumulative incidence of OAB is rising faster in aging males than in aging females. Two thirds of the European, one fourth of the Asian, and more than half of individuals affected by OAB complained about impaired quality of life, but only 60% of the European and 21% of the Asian sufferers have talked to a doctor or sought treatment. One out of four patients visiting their healthcare professional for OAB symptoms is currently under medication. To avoid high treatment costs and side effects, pharmacotherapy (e.g., antimuscarinics) should only be given after detailed diagnostic evaluation.
The etiology of OAB comprises neurogenic and non-neurogenic detrusor overactivity as well as detrusor hypersensitivity. Neurogenic detrusor overactivity may be caused by insufficient cortical inhibition, degenerative neuropathies, and spinal cord lesions, whereas bladder aging and bladder outlet obstruction (BOO) are possible causes for non-neurogenic detrusor overactivity. Nearly all men will develop histological benign prostatic hyperplasia (BPH) by the age of 80, but the degree of prostatic enlargement resulting from the hyperplasia and the degree of BOO is highly variable.
Hence, the pathophysiology of aging male OAB is not solely detrusor change by BOO due to BPH. Lower urinary tract dysfunctions in the elderly are generally multifactorial in origin and are classifiable to a large extent by age and pathology related changes. Age related changes involve a decrease of voided volume and urinary flow and an increase in overactive bladder symptoms and post void residues. Consequently, decreased maximum bladder capacity, terminal detrusor overactivity and detrusor overactivity with impaired contractile function are typically found in the elderly. Patients with terminal detrusor overactivity are well treated by bladder training and timed voiding, sometimes combined with anticholinergic drugs, whereas patients with phasic detrusor overactivity are often good candidates for non-invasive electrical neuromodulation.
Lecture2
The role of oestrogen in benign prostate hyperplasia and prostate cancer
D.M. Soebadi
Department of Urology, Soetomo Hospital – Airlangga University School of Medicine, Surabaya, Indonesia
Benign prostate hyperplasia (BPH) is a disease of the aging male. In BPH, the imbalance of cell proliferation and programmed cell death (apoptosis) leads to continuous stromal growth. The standard medical therapies for symptomatic benign prostate hyperplasia (BPH) are 5α-reductase inhibitors or α1-adrenoceptor antagonists.
Ongoing efforts are focused on understanding and manipulating the apoptotic pathways for a more effective medical treatment of BPH. BPH is caused by an increase in prostate epithelial and stromal cells, especially the latter. Induction of apoptosis in the stromal cell compartment of the prostate could be an effective treatment for BPH.
We performed studies to show the role of anti-oestrogen (tamoxifen) in prostate disease especially in BPH, and clinically in combination with 5α-reductase inhibitor (dutaseride). In BPH patients without urine retention, TGF-β1 was significantly increased in all patients given tamoxifen, dutaseride, and combination of two agents compared with placebo; but PSA was not significantly decreased in all treated patients.
In another study, tamoxifen, dutaseride and a combination of the two agents were given in 4 groups compared to placebo. The IPSS, Q-max, and prostate volume were evaluated. Dutaseride gives the most volume reduction compare to tamoxifen or combination of dutaseride and tamoxifen.
A study of correlation between oestrogen level and prostate volume was conducted in young male subjects and old male subjects with and without BPH. There is a significant correlation between oestrogen level and prostate volume in old male with clinical BPH, but no correlations were found in young or old male subjects without clinical BPH.
The effect of oestrogen treatment in hormonal refractory prostate cancer patients was re-evaluated.
These studies urge investigations for the possibility of using oestrogen or in combination with other agent(s) in treating prostate disease.
Lecture3
Testosterone replacement in urologic diseases
Jose Albert C. Reyes III
Section of Urology, Department Surgery, St. Luke's Medical Center, Philippines
The concept of testosterone replacement therapy for late-onset hypogonadism (LOH) or testosterone deficiency syndrome (TDS) in aging males has come to the forefront. New options together with the increasing general information and awareness of the symptoms of late-onset hypogonadism enhance the demand of patients and the willingness of doctors to use androgen therapy.
The concerns about testosterone in aging men with late-onset hypogonadism mainly address the risk of prostatic disease, i.e. either benign prostatic hyperplasia (BPH) or prostate cancer (PCa). Both conditions are highly dependent on androgen action.
Benign prostatic hyperplasia (BPH) and prostate cancer (PCa) represent the most common benign and malignant diseases in aged men. Concerns about prostate safety and possible risks of androgen therapy are of high interest. Therefore, the decision for long term testosterone therapy entails the responsibility for the patient's monitoring by the physician.
After the fourth decade of life, prostate increases steadily with age in healthy and hypogonadal men independently of their hormonal status. Prostate volume is strongly related to PSA levels and this relationship also depends on age. In contrast to this phenomenon of prostate volume, androgen serum levels steadily decrease after age 40 as shown in the Massachusetts Male Aging Study (MMAS). The age related growth of the prostate in healthy aging males cannot be explained by a mere increase in total androgens but is rather caused by a shift of hormonal ratios. BPH is clearly associated with aging and its prevalence is increasing from 8% in the fourth decade of life to more than 70% in the seventh decade. Prostate enlargement associated with bladder outlet obstruction (BOO) is considered to be a contradiction for testosterone therapy.
The more serious and life threatening concerns of testosterone therapy in aging males are potential risk of initiating de novo prostate cancer and stimulating pre-existing malignancy. The urologist is well aware of the fact that androgen withdrawal in metastatic prostate cancer can cause significant hypogonadal symptoms in the patient, which are sometimes difficult to manage. Testosterone therapy in hypogonadal aging males means supplementation of androgens from a decreased baseline level to the normal range. Occult/latent prostate cancer was affected by testosterone therapy rather than de novo prostate cancer. Low serum testosterone was found in some way a significant indicator of increased malignant tumour potential. Prostate tumour produces inhibin and thereby decreases testosterone production via negative feedback on the central hypothalamic pituitary axis.
A rise of PSA within the normal range after initiation of therapy is a frequent phenomenon not indicating prostate cancer activity. Only excessive increases arouse suspicion of an existing occult/latent prostate cancer and should be investigated by prostate biopsy.
Practical recommendations for testosterone therapy concerning prostate safety; recommendations for monitoring prostate related adverse experiences during testosterone replacement in older men, and indications for urological consultation in men receiving testosterone replacement are presented in this lecture. It is hoped that these recommendations will help us better understand and be able to institute testosterone replacement in urologic diseases.
Lecture4
Satisfaction with quality of life among men with erectile dysfunction (ED): Comparison between Japanese and Malaysian men – findings from Asian males
W.Y. Low1, C.J. Ng1, H.M. Tan1,2, M. Sugita3, N. Ishii3, K. Marumo4, W. Fisher5, M. Sand6
1University of Malaya, Malaysia; 2Subang Jaya Medical Centre, Malaysia; 3Toho University, Japan; 4Tokyo Dental College, Ichikawa General Hospital, Japan; 5University of Western Ontario, London, Ontario, Canada; 6Bayer HealthCare, Wuppertal, Germany
Introduction and objectives. Among Asian men with ED, are there any differences in their quality of life? This paper formed part of the Asian Men's Attitudes to Life Events and Sexuality (MALES) study, comparing Malaysian and Japanese men in their perception of the various domains of quality of life.
Method. Among 10,934 men, aged 20–75 years, there were 3000 Malaysian and 1877 Japanese men. They were recruited via random digit dialling, street interception and face-to-face interviews. A modified version of a questionnaire previously designed for a similar multinational study was utilized for the survey, and used to assess self-reports of satisfaction with various domains of quality of life. A 5-point Likert scale was used to measure satisfaction (1 = not at all satisfied to 5 = perfectly satisfied). Those answering 1 or 2 were considered as dissatisfied, for the purpose of this analysis.
Results. Japanese men (mean = 44 years) were significantly older than Malaysian Men (mean = 37 years) (p < 0.0001). Prevalence of self-reported ED in Japanese versus Malaysian men was 14% versus 2.8% respectively. Among Japanese men with ED, they were most dissatisfied with their sex life (40.3%), followed by their work life (22.6%), health (22.2%), partner relationship (15.3%), family life (11.8%) and overall contentment (11.2%). Comparatively, Malaysian men were most dissatisfied with their health (7%), sex life (5.3%), work life (5%) and family life (2.4%). All Malaysian men were satisfied with their overall contentment in life.
Conclusions. Japanese men showed more dissatisfaction in all the domains of their quality of life compared to Malaysian men. ED does have an impact on quality of life of both Japanese and Malaysian men.
Japan-ASEAN Luncheon Seminar 2
L-2
Erectile function and erectile dysfunction in the aging male
N.C. Park
Pusan National University School of Medicine, South Korea
The strong relationship between erectile function (ED) and aging has been demonstrated in many epidemiologic and observational studies. The relative risk for ED associated with older age, regardless of health status or previous ED, is increasing; 2% to 26% among men 50 to 60 years of age and 18–93% among older than 70 years of age.
A progressive decline of erectile function in health aging men is regarded as a physiological situation of the natural aging process, accompanying lengthened latency to erection, less firm erection, fewer spontaneous erection and decreased number of morning erection. Additionally, tumescence, frequency and duration of nocturnal erection are decreased in aging men without self recognition. The decline in erectile function in the elderly is accompanied by diminished sexual functions including decreased sexual thought and desire, decreased penile tactile sensitivity, early ejaculation, loss of forceful ejaculation, decreased ejaculatory volume, poor orgasmic pleasure and frequency, longer refractory period and poor response to therapeutic trial.
Mechanistic studies in human and animal models have performed to investigate the relationship between erectile function and aging process. Which factors are playing a role on early onset and progression of ED only in aged males, but not in others? From anatomic to functional aspects, from risk factors to co-morbid conditions, from central to peripheral factors as well as from gross to molecular levels, there are many contributing factors to induce sexual dysfunction as concurrent problems in aging male. Among contributing factors, specific co-morbid medical illness such as cardiovascular disease, components of metabolic syndrome-risk factors including diabetes mellitus, visceral obesity, hypertension and dyslipidemia, lower urinary tract symptoms and depression, as well as lifestyle factors like high fat diet, smoking, alcohol consumption and exercise frequency are important as risk factors of ED. These risk factors are related with various organic etiologies of ED in aging men, for example, neurogenic, vascular, endocrinologic and mixed. Underlying molecular mechanisms are not clarified yet, even though the pathophysiology of ED is almostly elucidated.
Sexual behavior in the elderly is also different from that of younger group. In aspect of coital frequency, the sexually inactive elderly men occasionally find that he loses much sexual competence after protracted period of inactivity. More strong penile stimulation may be required to induce erection. Additionally, pharmacodynamically more potent, early acting agent is suggested as more ideal oral agent for aged ED patients in the preferred choice of PDE-5 inhibitor, like vardenafil.
Furthermore, decreased sexual function in aging men is associated with decrements in quality of life. ED is already a conquered disease with recent advances in diagnosis and treatment of ED. Many ED cases can be prevented, which should be focused on public education to maintain erectile function and to avoid the risk factors as well as to preserve the vascular endothelial health. From now on, development of new drug directed to a novel therapeutic target is required in age-related ED related to broad ranges of etiologies and co-morbidities.
Japan-ASEAN Symposium 4 (Sexual Medicine)
S-4-1
Erectile dysfunction (ED), late onset hypogonadism (LOH) and the metabolic syndrome (MetS) in the elderly
S. Meryn
International Society for Men's Health and Gender (ISMH) and Medical University Vienna, Austria
The aim of this presentation is to provide a comprehensive overview of the current status of ED, LOH and the MetS. The world wide rapidly increasing incidence and prevalence of the MetS currently represents one of the most challenging world health issues. The MetS is characterized by central obesity, insulin resistance and type 2 diabetes, increased levels of triglycerides, and hypertension. Obesity seems to play a key role in the MetS, with visceral fat distribution as a special risk factor for cardiovascular disease (CVD). Notably, ED is highly prevalent in men with both CVD and MetS. Furthermore MetS is strongly associated with hypogonadism and testosterone treatment may be indicated to treat ED in these patients. Nevertheless the evidence that testosterone therapy is indicated in obese men to reduce complications is still limited and controlled studies are still lacking. However, testosterone therapy seems to improve insulin resistance and may slow down the development of type 2 diabetes. Therefore testosterone should be measured routinely in all patients with CVD, increased vascular risk and MetS. Lifestyle changes are essential as a form of prevention and management. The best advice to give to patients with MetS is to reduce their weight and increase their physical activity.
S-4-2
Sexual life in the elderly in Japan
K. Marumo, K. Hata, M. Matsumoto
Department of Urology, Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan
Aging and sexual activity. There are a number of factors involved in the etiology of erectile dysfunction (ED) in elderly men. The effects of age and concomitant chronic illness on male sexual function has been investigated administrating a questionnaire from the International Index of Erectile Function (IIEF) to 2,311 men of ages 23 to 79 along with a survey of health status.
There was significant correlation between age and sexual function, demonstrating the prevalence of men with moderate and severe ED were 2.6% and 0% for ages 30 to 39 years, and up to 27.9% and 36.4% for ages 70 to 79 years, respectively. Hypertension, heart disease, diabetes, and hyperlipidemia are significantly associated with lower scores for erectile function.
Sexual life in Japan, Asian, and western countries. The global study was conducted among men and women aged 40 to 80 years, involving 27,500 men and women in 29 countries representing all world regions. In the present study, data from 9 countries of East Asian (China, Japan, Korea), European (Germany, Sweden, UK, France), and North American (Canada, USA) groups are compared.
The importance of sex in respondents' overall lives was higher in European, North American countries and Korea with 70–87% of subjects, and lowest in China and Japan, with 53% of subjects reporting that sex was very or extremely important. The percentage of respondents who reported having less than one episode of sexual intercourse per month was highest in Japan (41%) and low in European, North American countries and Korea (3–18%). The proportion of subjects reporting emotionally or physically satisfying relationships with their partners was lowest in Japan.
Reason which may affect sexual life in Japan. We assumed that one of the reasons would be associated with residential environment in Japan, hence we investigated relationship of such factors with sexual activity in Japanese male. A total of 228 men (aged 20–75 years), who were enrolled in MALES study in Japan as subjects having erectile dysfunction were selected and investigated with regard to their quality of sexual life, co-inhabitants, number of rooms, privacy of bedroom and other living situation. Out of 145 men, who had co-habitant other than their partners, 87 men (60%) felt anxious about having sexual activity due to their co-habitants, and 108 men (74.5%) were unable to express sexual pleasure freely during sexual intercourse. Frequency of intercourse was higher in men who shared a bedroom with their partner alone, than men who shared a bedroom with their children or co-habitants, however, type of residence, number of rooms, presence of co-habitants, or separation of bedrooms from other members of family's were not correlated to frequency of intercourse.
Conclusions. Obtained results suggested that stress in residential environment might not be a major cause of less frequent sexual activities in Japanese male and that other reasons should be investigated (e.g. stress in the work place especially in zero-growth economy, or inherent racial characteristics) in future.
S-4-3
Sexual attitudes of thai men
A. Kongkanand
Bumrungrad International Hospital, Thailand
There are several attributes in the survey since there are up to 3 kinds of oral medicine including long and short acting on the treatment.
The questionnaire in the survey will include how do they approach the problem and the physician should know how to ask the question or approach the patients, for example some patients would talk to friends or his family rather than his wife.
The patients prefer to use different type of drugs than cream, oral medicine seems to be their favourite.
The patients seem to know how to take care of themselves regarding exercise or oral medicine but they do not know where the pill is available from. Many of them seem to get information from friends; names seem to matter most since we use the men's health rather than impotence or erectile dysfunction.
Frequency of sexual intercourse shows as expected; numbers will decline as years age.
The erectile dysfunction for Thai in this age group is at 42%.
S-4-4
Therapies for female sexual dysfunction
P.L.H. Chye
Andrology, Urology and Continence Centre, Gleneagles Hospital, Singapore; Department of Urology, Changi General Hospital, Singapore; Edith Cowan University, Australia
Introduction. Recently, female sexual dysfunction (FSD) has been brought to prominence, being 43% prevalent in the USA. Between age 18–59 years there were 33.4% with lack of interest, 24% with anorgasmia, 21.2% with non-pleasurable sex, 15% with lubrication problems, and 14% with painful sex.
Evaluation. In the evaluation of patients with FSD, the clinician should take a directed history, and ask leading questions. He must be non-judgemental and sympathetic and try to elicit the history of sexual desire problems, sexual arousal problems, orgasmic problems or sexual painful disorders which stem from a background of medical disorder/disorders or from past surgery or psychogenic factors from the women or from both partners. The physical evaluation follows after a detailed questionnaire analysis, subjective evaluation of arousal and vaginal sensations during VSS and finally vaginal photoplethysmography/colour Doppler analysis of blood flow at VSS. Blood is then drawn if indicated for hormonal and other evaluations.
Treatment. Psychosexual therapy is indicated for psychogenic causes, e.g. performance anxiety and aberrant partner-partner interactions. Aids to help with the various categories of FSD to increase sexual satisfaction by increasing arousal, stimulation, increasing vaginal secretions and fostering orgasm have appeared which are now available for clinical application, e.g.:
Eros-CTD clitoral stimulation device: This device is an FDA approved medical prescription device.
Topical products: Topical application of alprostadil to the coropral bodies of the clitoris via transdermal absorption causes local stimulation of the clitoris with increased blood flow much like the Eros-CTD. Versions available are Topical alprostadil (Femprox TD) and topical alprostadil (Topiglans), Zestra and other arginine or NO-donor-based creams are abundantly available.
Other products: Oral products include: phentolamine (Vasomax) and other adrenergic blockers; newer, more highly selective dopamine agonists (including a formulation for nasal application); arginine; and L-arginase inhibitors. Another for intracavernous injection include: a melanocyte stimulating hormone (MSH) derivative, melanotan II; agents which act as nitric oxide donors; and vasoactive intestinal polypeptide and phentolamine. Most over-the-counter products contain arginine, a precursor to nitric oxide. PDE-5 inhibitors have a small but definite place and this author's experience 10 mg Levitra appears promising. Viagra has been tested for women with 28% success only, with headaches an undesirable and significant complication when used in women. Newer trials with other PDE-5 inhibitors are ongoing. Apomorphine stimulates the paraventricular nucleus of the sex centre in the brain. Finally, the most promising is PT-141 currently being evaluated as an intranasal insufflation agent for both women (and men). It increases sex drive and sexual responses during intercourse.
Testosterone for FSD: This is a new and exciting area and the entire basis for its use for women (both menopausal and non-menopausal) will be covered, especially the testosterone patches. Who are suitable, what formulations are available, safety concerns and the results of current trials will be revealed.
S-4-5
Surgical treatment of ED in elderly men
J.H. Liu
Department of Urology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
Erectile dysfunction (ED) seriously affects the quality of life of patients and their partners, especially for elderly men because the incidence increases dramatically with age. According to the MMAS the probability increased from 39% in men 40 years old to 67% in men 70 years old. Cardiovascular disease, diabetes, smoking, radical prostatectomy and neurological disorders have been indentified as high risk factors. Within 5 years of onset of diabetes mellitus, 60% of patients experience some erectile dysfunction, and ED occurs in 25% of men treated for hypertension. And the prevalence of the above diseases increases significantly with aging. The marked decrease in serum levels of testosterone is another risk factor for the elderly.
The assessment of elderly men with ED should include a thorough medical and sexual history, a systemic and focused physical examination and selected laboratory tests (Rigiscan included), which is necessary to identify the etiology and co-morbidities and to discuss the treatment options with the patient and his partner.
Oral therapy (phosphodiesterase type 5 (PDE-5) inhibitors) is considered by WHO to be the first-line therapy. And whenever ED is secondary to the other treatable disorders these should be treated simultaneously. When non-surgical options have been unsuccessful, surgical therapy may be considered, for instance patients with diabetes not responding to pharmacologic treatment or those who have had radical prostatectomy. According to the AUA, surgeries performed with the intent to limit the venous outflow of the penis are not recommended, and arterial reconstructive surgery cannot be performed in patients older than 55 years old. The implant of penile prosthesis would be the only choice for older patients in whom surgery is needed.
The insertion of a penile prosthesis is a big step for patients; they and their partners should consider the relative irreversibility of the procedure and the ‘unnaturalness’ of the erection. Two types of prosthesis exist: semi-rigid and inflatable (two- or three-piece), most patients prefer the three-piece inflatable devices due to the more ‘natural’ erection. Significant surgical risks include haematoma formation, infection, erosion and device malfunction, in which infection is the most dreaded complication, and in case of that, explantation of the prosthesis is often required. Pre-operative preparation of the implant recipient is directed primarily at reducing the risk of infection; prosthetic surgery should not be performed in the presence of systemic, cutaneous or urinary tract infection. Antibiotics are usually started prophylactically one hour prior to the procedure and continued for 48 hours postoperatively. Better control of diabetes mellitus may reduce risk of infection, but current data do not support this fact. In addition, patients in the presence of cardiovascular disease at high risk (unstable angina; uncontrolled hypertension; CHF; MI or a cardiovascular accident within the previous 2 weeks and so on), should not receive surgery until their condition has stabilized.
Penile prosthesis is the least chosen and most invasive treatment option, but has the highest satisfaction rate of all available ED options and provides a reliable result.
Poster Session
P-1
LOH in haemodialysis patients
H. Terada, M. Harada, S. Ozono
Department of Urology, Hamamatsu University School of Medicine, Japan
Purpose. A questionnaire survey was conducted to evaluate the symptoms of LOH in patients on maintenance haemodialysis.
Patients and methods. Group A consisted of 80 male patients (with diabetes mellitus (DM): 32, without DM: 48) undergoing haemodialysis at three medical institutions (age 37–90 years; mean 64.3±10.2 years). Group B included 36 men not on haemodialysis who presented to the department of urology with symptoms suggestive of LOH (age 35–72 years; mean 63.3±7.9 years). LOH was rated using the Japanese versions of the screening questionnaire for Androgen Decline in the Aging Male (ADAM) by Morley et al., and the Aging Male Symptoms rating scale (AMS) by Heinemann et al. Prior to the study, informed consent was obtained from all patients, and appropriate measures were taken to ensure their privacy.
Results and discussion. In Group A, 76.8% of patients had LOH as assessed by the ADAM scale. However, this set of questions puts emphasis on sexual function, requiring the results in elderly patients to be carefully interpreted in both Groups A and B. The patients on haemodialysis had a low mean AMS score of 32.4±9.6 (with DM: 34.4±9.0, without DM: 29.1±9.9). Group A patients were slightly more likely to be diagnosed with LOH based on ADAM rating scale (with DM: 5.9±3.6: 87.1%, without DM: 5.0±2.8: 78.2%) than Group B (4.2±3.0: 76.8%), whereas AMS scores, a measure of LOH symptoms, did not differ significantly between the two groups. Endocrinological examination of haemodialysis patients showed a normal range of Testosterone and free testosterone levels in a subset of patients with DM and without DM. On the other hand, no correlation was found either between age and Hct. or Hb. (hematocrit and homoglobin), or between age and erythropoietin dose. In conclusion, these data demonstrated that haemodialysis patients are not necessary to do androgen replacement therapy.
P-2
Is partial androgen deficiency in the aging male (PADAM) present in haemodialysis patients?
T. Naganuma, Y. Takemoto, C. Nishihara, M. Kato, N. Ninomiya, T. Deguchi, K. Kuratsukuri, R. Yoshimura, T. Nakatani
Department of Urology, Osaka City University Medical School, Osaka, Japan
Background. Partial androgen deficiency in the aging male (PADAM) is a syndrome caused by a decrease in androgen due to aging. It is well known that testosterone levels are lower in male haemodialysis (HD) patients than in age-matched control men. However, PADAM in HD patients has yet to be elucidated. In this study, we examined the prevalence and severity of PADAM in HD patients.
Methods. A cross-sectional study was conducted to investigate the prevalence of PADAM in HD patients (n = 62). Total testosterone (TT) levels were measured in 62 consecutive HD patients. PADAM was diagnosed when the patient had more than 27 points on Heinemann's Aging Male Symptoms (AMS) rating scale as well as hypogonadism with a serum TT level of less than 317.3 ng/dl. We compared various clinical parameters between those with and without PADAM in HD patients. Moreover, we compared AMS scores between age-matched PADAM patients with normal renal function (n = 18) and HD patients who were diagnosed as PADAM.
Results. A total of 20 patients (32.3%) had hypogonadism with serum TT levels of less than 317.3 ng/dl. In 51 patients (82.3%), the AMS scores were greater than 27 points. As a result, 18 patients (29%) were diagnosed as PADAM. Serum TT levels inversely correlated with age r = −0.278, P = 0.0286 and HD duration r = −0.284, P = 0.0276.
Total and somatovegetative AMS scores were significantly elevated in PADAM patients with normal renal function (PADAM patients) than HD patients who was diagnosed as PADAM (HD-PADAM patients) 53.1±9.5 versus 41.7±11.1, 22.8±4.0 versus 16.9±4.4 points: P = 0.0186, P = 0.0040, respectively.
Conclusion. These results suggested that PADAM might be prevalent in male HD patients. However, the severity of HD-PADAM patients was significantly lower than that of PADAM patients.
P-3
Influence of antidepressants for LOH treatment on endocrine profiles in patients visiting an LOH clinic
T. Matsusihta1, R. Nakazawa2, K. Yamakawa2, M. Nakanome2, T. Katabami3, Y. Mizushima4, E. Koh5, M. Namiki5, T. Iwamoto6
1Urology Department of Ohunatyuou Hospital, Japan; 2Urology Department of St Marianna University School of Medicine, Japan; 3Metabolism and Endocrinology Department of St Marianna University School of Medicine, Japan; 4Institute of Medical Science St Marianna University School of Medicine, Japan; 5Urology Department of Kanazawa University, Japan; 6Centre for Infertility and IVF, International University of Health and Welfare Hospital, Japan
Introduction and objectives. Many patients who visit the late-onset hypogonadism (LOH) clinics for a number of mild non-specific symptoms including depressive symptoms have already been medicated with antidepressants and other drugs. Some such drugs can change endocrine profiles. The aim of this study is to investigate influence of endocrine profiles in patients with/without medication.
Methods. 71 men who visited the LOH clinic of St Marianna University School of Medicine and Kanazawa University Hospital were evaluated. The average age of the patients was 52.3 years old (range 23 to 73). Thirty patients (non-med-group) had not taken any drugs. Forty-one patients (med-group) had been medicated with antidepressants and other drugs. We measured total testosterone (T), free testosterone (FT), bioavailable testosterone (Bio-T), DHEA, DHT, total cortisol (F), and bioavailable cortisol (Bio-F) in their serums, as well as T(Sa-T)and F(Sa-F) in saliva. Serum and saliva samples were collected during morning. And the Hospital Anxiety and Depression scale (HAD) and IIEF-5 were used for evaluation of LOH symptoms and relationship with endocrine profiles.
Results. Negative correlations were recognized between aging and levels of FT, Bio-T and DHEA in serum and Sa- T in the non-med-group. In the med-group, no correlation was recognized between aging and all hormone levels other than DHEA. In both groups positive correlations were recognized between Sa-T and FT and Bio-T, and between Sa- F and F and Bio-F. The mean score of depression domain in HAD was significantly higher in the med-group than that in the non-med-group. This score showed positive correlation to FT, Bio-T, Bio-F, and Sa-F levels in the non-med-group.
Conclusions. Psychotropic medication has an impact on FT and Bio-T levels. The LOH diagnosis based on FT and Bio-T levels should be made under no influences of the medication. T and F levels in saliva are as useful as FT and Bio-T levels in serum.
P-4
Relationship between SLOH and other co-morbidities in Malaysian men
W.S. Tan1, H.M. Tan2, W.Y. Low3, C.J. Ng4, E.M. Khoo4
1School of Medicine, Cardiff University, UK; 2Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia; 3Health Research Development Unit, University of Malaya, Kuala Lumpur, Malaysia; 4Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia
Introduction. Today, aging men with symptoms of late-onset of hypogonadism (SLOH) are increasingly seeking treatment. Evidently SLOH has been associated with a number of adverse effects and co-morbidities.
Objective. This paper examines the prevalence of SLOH (total testosterone < 11 mmol/l) and its co-morbidities in men above 40 years of age.
Methodology. 1046 men (63% response rate) aged > 40 years were randomly selected from Subang Jaya, an urban area in Malaysia, based on the 2004 electoral roll. One-to-one interviews were conducted by trained physicians with each participant to obtain the following information: socio-demographic data, self-reported medical problems (hypertension, diabetes mellitus, heart disease, abnormal cholesterol, erection difficulties, prostate problem), lifestyle (smoking, alcohol consumption), IIEF-5, IPSS, blood pressure, body mass index and waist circumference. Morning fasting blood samples for glucose, full lipid profile and total testosterone were taken.
Results. The mean age of men was 55.8 years (±8.4). 19.1% (n = 198/1037) of these men suffered from SLOH. Our results showed that there was a significant association between SLOH and obesity (BMI = 25, AP criteria) (p < 0.001), waist circumference (=90 cm) (p < 0.001), self-reported diabetes (p = 0.001), triglycerides (=1.7 mmol/l) (p < 0.001), HDL (=1.0 mmol/l) (p < 0.001), total cholesterol/HDL ratio (>4.5) (p < 0.001) and glucose level (=6.1 mmol/l) (p < 0.001). Logistic regression analysis showed that obesity (OR = 2.47; 95% CI: 1.5–4.2), waist circumference (OR = 1.76; 95% CI: 1.1–2.9) HDL (OR = 1.66; 95% CI: 1.1–2.6) and glucose level (OR = 2.00; 95% CI: 1.2–3.2) were significantly associated with SLOH.
Conclusion. The study shows that most of the variables associated with SLOH are related to metabolic risk factors. Men with SLOH were found to have 2.47 folds more likely to be obese, 1.76 folds abnormal waist circumference, 1.66 folds abnormal HDL and 2 folds abnormal glucose level. Hence, men with SLOH should be screened for metabolic risk factors and vice versa.
P-5
Free testosterone level is associated with insulin resistance in Japanese men with metabolic syndrome
H. Ueshiba, G. Yoshino
Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
Low testosterone levels in men have been found to predict insulin resistance. Studies in healthy men have shown an inverse relationship between total testosterone levels and insulin concentrations. Insulin resistance is an essential component of metabolic syndrome, which is recently noticed. We examined the relation between free testosterone and insulin resistance in 43 Japanese men (age: 59.8±9.9 yrs, BMI: 27.0±3.3, waist: 90.6±5.2 cm; Mean±SD) with metabolic syndrome. Fasting plasma glucose (FPG), fasting serum insulin (F-IRI), HbA1c, total cholesterol, triglyceride, HDL-C and free testosterone were measured. We used homeostasis model assessment (HOMA-R) as an index of insulin resistance and investigated the relation between free testosterone and each parameter. Free testosterone levels correlated negatively with HOMA-R index (r = −0.391, p < 0.01) and waist (r = −0.266, p < 0.05).
In conclusion, it is suggested that free testosterone level is associated with insulin resistance in Japanese men with metabolic syndrome.
P-6
Long-acting intramuscular testosterone undecanoate for the treatment of hypogonadal men who have failed to respond to oral testosterone treatment
S. Permpongkosol, K. Ratana-Olarn
Division of Urology, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Objective. The objective of this study was to investigate the effects of long-acting testosterone undecanoate (1000 mg, TU) in hypogonadal men, who have failed to respond to previous therapy with oral testosterone treatment.
Patients and methods. In this study 22 patients with documented testosterone deficiency and previous failure of oral testosterone treatment (mean use time 38.7±21 months) were investigated. The mean age and body mass index of patients were 61.5±7.2 years and 25.9±3.5 kg/m2, respectively. The patients received TU 1000 mg on day 1, day 42 and thereafter every 12 weeks. During the follow-up the patients were physically examined and serum levels of total and free testosterone were measured. In addition TU therapy effects were assessed by using the Aging Males' Symptoms rating scale (AMS) questionnaire, International Prostate Symptom Score (IPSS) questionnaire and the international index of erectile function (IIEF-5).
Results. During the 30-week follow-up, the mean total and free testosterone serum levels increased from 260.3±80, and 6.5±12 ng/dl to 563±323, and 7.4±0.9 ng/dl, respectively. In 90.9% of the patients testosterone serum levels reached the normal range (300 ng/dl). However, stable testosterone levels within the physiological range were not observed after the first three injections. PSA and haematocrit levels increased in 68.1% and 59% of patients, respectively. The mean changes were 0.5±0.9 ug/l and 1.4±3%, respectively. The analysis of the questionnaires showed a treatment satisfaction of 73.3%, although the AMS scores and the IIEF-5 did not show significant improvement after three TU injections.
Conclusion. In our study we have observed promising effects of the treatment with TU in hypogonadal men who have failed to respond to oral testosterone treatment. Further studies with longer follow-up periods are warranted to optimize the administration schedule and to explore the long term effects of TU in these patients.
P-7
Sex hormone study in aging Thai males
C. Somboontanakit, K. Tantiwongse, A. Kongkanand
Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Introduction and objectives. To evaluate the correlations between aging male symptoms (AMS) scales and sex hormone level in aging Thai males.
Methods. ED patients, age 40 to 70 years old, who walked in to the male infertility clinic of King Chulalongkorn Memorial Hospital completed the AMS questionnaires. The serum testosterone, SHBG, and albumin were examined between 8 a.m. and 11 a.m. Free testosterone level was calculated by free and bioavailable testosterone calculator from www.issam.ch. Pearson's Product Moment Correlation was used the test the correlation between AMS scale and hormones.
Results. 42 ED patients were enrolled in this study. Mean age was 60±9.05 years old (42–82). Mean AMS scales was 41.45±14.04. Mean total testosterone was 4.58±1.26 nmol/L. Mean free testosterone was 9.03±2.32 ng/dl. Mean bioavailable T was 218.6±62.6 ng/dl. AMS scale had no correlation with the total testosterone, free testosterone, and bioavailable testosterone.
Conclusions. This is the pilot study in aging Thai males. It suggests that testosterone level doesn't affect aging male symptoms.
P-8
Effect of COX7A2 on LH induced testosterone production and expression of star protein, P450 and 3β-HSD enzymes in TM3 mouse leydig cells
Z.C. Xin, L. Chen, T. Sun, L. Tian, Y.M. Yuan, G. Liu, Y.L. Guo
Andrology Centre, Peking University, First Hospital, Peking University, Beijing 100009, China
Objective. The cloning of Cox7a2 one respiratory chain related gene showed highly expressed in aging male testis tissue in previous study and the effect of Cox7a2 on steroidogenesis and the involved mechanism was investigated.
Methods. In the present study, TM3 cells are over-expressed Cox7a2 by transient transfection of recombinant Cox7a2 cDNA plasmid. LH-induced testosterone production is observed by ELISA, and the expression of StAR, P450scc and 3β-HSD was investigated by Western blotting in TM3 cells over-expressing Cox7a2 fusion protein.
Results. Cox72 inhibited the LH-induced testosterone in TM3 mouse Leydig cells. In the results of Western blotting, the expression of StAR protein decreased in TM3 cells over-expressed Cox7a2, but the expression of P450scc and 3β-HSD did not alter noticeably.
Conclusion. Data presented here reveal an unknown role of Cox7a2 in the regulation of the expression of StAR protein, and in its consequent mediating androgen biosynthesis. In TM3 cells, the negative regulatory effect of Cox7a2 on steroidogenesis is, at least, a result of the decreased expression of StAR protein.
P-9
Can sexual health be a successful and sustaining portal to men's health?
S.H. Teoh, T.K. Gan, C.S.K. Yeo
Singapore Men's Health Clinic, Singapore
Introduction and objectives. It is said that sexual health is a portal to men's health. The Singapore Men's Health Clinic (SMHC) is a private men-only primary healthcare facility addressing general health problems and health issues specific to men. This presentation examines whether sexual health can be a successful and sustaining avenue to men's health in the community through an analysis of the first 482 new patients seen.
Methods. This is a retrospective study of the case records of all new patients who attended the clinic from 17 November 2003, when the clinic started, through 17 November 2004.
Results. 482 new patients were seen. Erectile dysfunction (ED), premature ejaculation (PE) and sexually transmitted diseases (STD) accounted for 61.6% of the patients seen. Other health problems made up the remaining cases seen and these also included prostate problems and complaints regarding the penis. 39.8% of patients with ED made three or more visits to the clinic, as did 36.2% of men with PE, 24.1% of men with STD, and 13% of patients with other complaints. Overall, only 26.6% of patients made 3 or more visits to the clinic. Among patients with ED, 49.7% had associated medical conditions.
Conclusions. Sexual health issues predominantly bring men to the clinic. Ideally, opportunistic screening and exploration of factors surrounding sexual health problems would enable the health provider over time to provide continuous and comprehensive care to these men. Our experience shows that the majority of patients seek resolution of their primary complaints only and the longitudinal relationship that is expected with the patient is sustained in less than a third of them. Opportunity for health promotion is highest among ED patients. Thus while sexual health is a portal to men's health it has limited sustainability and success in promoting men's health. Broader initiatives impacting policy, education and societal attitudes are required.
P-10
Traditional medicine in erectile dysfunction (ED) – an elusive unmet need of ED sufferers – findings from Asian males
H.M. Tan1,2, W.Y. Low1, C.J. Ng1, L.P. Wong1, W. Fisher3, M. Sand4
1University of Malaya, Kuala Lumpur, Malaysia; 2Subang Jaya Medical Centre, Selangor, Malaysia; 3University of Western Ontario, London, Ontario, Canada; 4Bayer HealthCare, Wuppertal, Germany
Introduction. Traditional medicine has a long history in Asia. The attributes of traditional medicine in the treatment of ED have often not been proven or tested. Despite the advent of highly effective oral medication, the misconception and long ingrained belief of traditional medicine remains prevalent among ED sufferers.
Objectives. To explore Asian men's attitudes towards the role of traditional medicine in the treatment of ED and their attitudes towards PDE-5 inhibitors.
Methods. 1,286 men with ED from China, Japan, Korea, Taiwan and Malaysia were interviewed in a cross-sectional study to understand the nature of their sexual problems, their attitudes towards ED, health-seeking behaviour and needs. The questionnaire was modified from a similar study conducted across Europe, US and South America (MALES study). The participants were asked to indicate their agreement with a series of statements about TM using a 5-point Likert scale (from ‘strongly agree’ to ‘strongly disagree’).
Results. Majority of ED respondents had a favourable attitude towards traditional medicine. More men felt that traditional medicine was better than Western medicine (WM) because it: improves men's overall well being (agree 39.4% versus disagree 22.9%); improves blood circulation (39.5% versus 22.1%); cures ED and not just treats it (39.0% versus 24.6%); and is less expensive (33.4% versus 29.0%). The traditional medical practitioners were felt to be more reassuring and positive (35.0% versus 23.6%). 53.9% of ED sufferers felt that traditional medicine practitioners are helpful.
In this study, men avoided PDE-5 inhibitors because they: were worried that the medication may be dangerous for them (20.1%); wanted to try more natural methods (10.3%); were currently using something else that worked (11%), felt that their ED problem was not important enough to justify taking drugs (11.6%). The ED sufferers preferred the ED medications to contain only natural ingredients (94%); to be safe and without bad reactions (96%); can be obtained without doctor's prescription (87%), and to cure ED permanently (95%).
Conclusions. Misconception and unrealistic expectations in traditional medicine are widely prevalent among Asian men. Physicians need to explain and help ED sufferers with accurate knowledge and information on ED therapies, and they should also emulate the more empathic and reassuring qualities of traditional medicine practitioners.
P-11
Administering change from sildenafil to vardenafil in ED patients
K. Kuratsukuri, T. Naganuma, C. Nishihara, Y. Nitta, T. Tanaka, T. Nakatani
Department of Urology, Osaka City University, Graduate School of Medicine, Japan
Administration to the patients with ED was changed sildenafil to vardenafil for their need. This study was evaluated the effect and the adverse event in conversion of these medications.
Thirty-five patients of ED that consulted ED outpatient department in the Osaka City University Hospital were evaluated.
IIEF-5, the satisfaction rating was used for evaluation, and the reason and the adverse event of change of prescription were investigated by the questionnaire form. The average age was 57 years old (33–78). All patients changed from the sildenafil 50 mg to the vardenafil 10 mg except one case.
In the comparison of both medicines by IIEF-5, 46% of patients has equal effect of both medicines. Increasing of the IIEF-5 number was admitted in 34% of patients using vardenafil after using sildenafil. Moreover, it was an almost similar result for both satisfaction ratings. The adverse event thought to originate in both medicines was not admitted.
The improvement was admitted by the vardenafil use in the case of 34% though the case to whom the effect between both medicines was equal was most in the comparison of the effects concerning the erection function of sildenafil by IIEF-5 and vardenafil. The expectation for conversion new medicine occurs a placebo effect. But vardenafil may have the effect in the case that had an insufficient effect by sildenafil.
P-12
Association between ED and LUTS in Japanese motorcyclists
Y. Naya1, J. Soh2, A. Ochiai3, N. Kanemitsu4, A. Kawauchi2, T. Miki2
1Department of Urology, Matsushita Memorial Hospital, Japan; 2Department of Urology, Kyoto Prefectural University of Medicine, Japan; 3Department of Urology, Ymashina-Aiseikai Hospital, Japan; 4Department of Urology, Rakuwakai-Marutamachi Hospital, Japan
Objective. Previously, we reported the association of motorcycling and erectile dysfunction (ED) Also, lower urinary tract symptoms (LUTS) were reported to be associated with ED. The aim of this study is to evaluate the association of ED with LUTS in motorcyclists.
Methods. We investigated the prevalence and the status of ED using a 5-item version of the International Index of Erectile Function (IIEF-5) in 150 motorcyclists who belonged to motorcyclist clubs in the Kansai district of Japan. ED was diagnosed when the IIEF-5 score was less than 22. The International Prostate Symptom Score (IPSS) was also applied, and the relationship between IIEF-5 and IPSS was evaluated.
Results. Of the 150 motorcyclists, 106 (71%) had ED, and 31 (21%) had moderate or severe symptoms of LUTS (IPSS ≥ 8). Of the 119 motorcyclists who had mild symptoms of LUTS (IPSS < 8), the prevalence of ED was 65% (77/119). Of the 26 motorcyclists who had moderate symptoms of LUTS (IPSS 8–19), 92% (24/26) had ED. All of the 5 motorcyclists who had severe symptoms of LUTS had ED. The IIEF-5 was significantly associated with the severity of IPSS (p = 0.002) and age (p < 0.0001). The IIEF-5 was also significantly associated with the scores of both voiding (p < 0.0001) and storage symptoms (p = 0.001). On stepwise logistic regression analysis, age and storage symptoms are independent risk factors for ED in motorcyclists.
Conclusions. LUTS seemed to be associated with ED in motorcyclists.
P-13
Evaluation of 1,109 men at a men's health clinic in Thailand
S. Permpongkosol, K. Ruenrojrung, K. Ratana-Olarn
Division of Urology, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Objective. To evaluate a men's health clinic in Thailand between 2004 and 2006.
Materials and methods. Of a consecutive series of 1,109 men who visited at a men's health clinic of Ramathibodi Hospital between 2004 and 2006, we reviewed the medical records retrospectively with emphasis on patient demographics, major presentations, laboratory tests and therapies. In addition, we analysed the results for the patients who responded to all questions on the Aging Male Symptoms scale (AMS), International Prostate Symptom Score (IPSS) and International Index of Erectile Function-5 (IIEF-5), and correlations between these scores and serum testosterone level.
Results. The majority of patients (37.1%) presented with hyperlipidemia. The percentages of the patients presented with erectile dysfunction, lower urinary symptom, and hypogonadism were 32.6%, 28.9% and 21.5%, respectively. A wide variety of conditions were diagnosed, including hypertension, diabetic, osteopenia, and osteoporosis. Eight per cent of visitors were healthy. All of the 231 patients who received androgen replacement therapy had never been diagnosed with prostatic carcinoma at the time of follow-up period. Interestingly, there were no significant correlations between AMS score and serum testosterone.
Conclusion. Further study and a multidisciplinary approach are needed to explore the formative evaluation of the men's health clinic in Thailand.
P-14
Clinical study of urologic surgeries in patients aged 80 years and older: A 30-year retrospective study
T. Takao, A. Tsujimura, K. Yamamoto, S.I. Fukuhara, J. Nakayama, T. Ueda, H. Kiuchi, T. Hirai, K. Komori, K. Fujita, Y. Matsuoka, Y. Miyagawa, S. Takada, N. Nonomura, A. Okuyama
Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
Purpose. Life expectancy of the Japanese population is relatively long, and the elderly population is increasing in Japan. Therefore, patients suffering from urologic disorders are increasing in number, and the number of surgeries for these patients must be increased not to save lives but to increase quality of life. In order to investigate changes in the management of cases over time, we conducted retrospective analysis of urologic surgeries performed in patients aged 80 years and older in a single institution over the last 30 years.
Methods. Between 1975 and 2004, 402 patients aged 80 years and older underwent 412 operations in our department. We reviewed the clinical records and analysed changes in clinical data over time. We then evaluated pre-operative and post-operative complications in selected patients for whom clinical records were complete.
Results. The number of operations performed in patients aged 80 years and older increased every 5 years. Of the 412 operations, endourologic surgery accounted for 298 (72.3%) and open surgery accounted for 96 (23.3%). Over time, the number of endourologic and laparoscopic surgeries increased. Although 225 of 255 patients (88.3%) had at least 1 pre-operative complication, only 51 patients had post-operative complications. The number of pre-operative complications, such as cardiovascular disorder, central nervous system disorder, and diabetes mellitus increased over the most recent 10 years. However, there is no difference in post-operative complications over time.
Conclusions. Although elderly patients had various preoperative complications, the postoperative morbidity rate is acceptable. Our data indicated that urologic surgery is safe in patients aged 80 years and older.
P-15
What matters most to men in Japan and Malaysia? findings from the Asian men's attitudes towards life events and sexuality (Asian Males) study
C.J. Ng1, H.M. Tan1,2, W.Y. Low1, M. Sugita3, N. Ishii3, K. Marumo4, W. Fisher5, M. Sand6
1University of Malaya, Kuala Lumpur, Malaysia; 2Subang Jaya Medical Centre, Selangor, Malaysia; 3Toho University, Japan; 4Tokyo Dental College, Ichikawa General Hospital, Japan; 5University of Western Ontario, London, Ontario, Canada; 6Bayer HealthCare, Wuppertal, Germany
Introduction and objectives. Male identity has been considered as an important influencing factor in men's health. How men perceive male identity varies in different countries. (Or perception of male identity varies between countries.) This paper aims to determine what men in Japan and Malaysia considered as important indicators of male identity.
Methods. This paper reported part of the findings from the Asian MALES study, a cross-sectional survey of 10,934 men from five countries. Men aged 20–75 were recruited via random digit dialling and street interception in 2004. Telephone and face-to-face interviews were conducted by trained interviewers using a standardized questionnaire. We asked the participants what they considered as the most important feature of male identity.
Results. There were similarities and differences in the socio-demographic data between men in Japan (n = 1877) and Malaysia (n = 3000). Men in Japan (Japanese men) were (significantly) older (44 years) than Malaysian men (37 years); they were also more likely to live in the city (84.4% versus 27.5%) and to drink alcohol (71.1% versus 16.3%). Men in both countries were mostly employed (Japan 80.3% versus Malaysia 83.5%), married (71.1% versus 64.0%) and were smokers (52.7% versus 47.2%).
Important indicators of male identity prioritized by men in Japan were: ‘being seen as a man of honour’ (25.9%); ‘having a good job’ (16.7%); ‘being in control of life’ (15.3%); ‘being a family man’ (13.1%) and ‘able to cope with problems’ (10.1%). For men in Malaysia, ‘having a good job’ (24.8%); ‘being a family man’ (20.1%); ‘having lots of money’ (16.2%); ‘being seen as a man of honour’ (13.3%) and ‘being in control of life’ (8.9%) were felt to be important.
Conclusions. Both Japanese and Malaysian men associated male identity with their career, family and honour. Malaysian men placed more emphasis on financial status whereas Japanese men desired more control in life.
P-16
Privacy in the bedroom and frequency of sexual intercourse: Asian males study – Japan
K. Marumo1, K. Hata1, M. Sugita2, N. Ishii3
1Department of Urology, Ichikawa General Hospital, Japan; 2Department of Urology, Toho University, Tokyo, Japan; 3Department of Environmental and Occupational Health Toho University, Tokyo, Japan
Objectives. Some investigators pointed out that sexual activity of Japanese men with their partners is less frequent than those of other Asian or Caucasian men. We assumed that one of the reason would be associated with the residential environment in Japan especially in urban areas, hence, in this survey, we investigated the relationship of such factors with sexual activity in Japanese males.
Methods. A total of 228 men (aged 20–75 years), who were enrolled in MALES study Japan as subjects with having erectile dysfunction were selected and investigated with regard to their quality of sexual life, co-habitants, number of rooms, privacy of bedroom and other living situations.
Results. Out of 145 men who had co-habitants other than their partners, 87 men (60%) felt anxious about having sexual activity due to their co-habitants, and 108 men (74.5%) were unable to express sexual pleasure freely during sexual intercourse. Frequency of intercourse was higher in men who shared a bedroom with their partner alone, than men who shared a bedroom with their children or co-habitants (parents, relatives or acquaintances), however, type of residence (individual or apartment house), number of rooms, presence of co-habitants, or separation of bedrooms from other family members (a thin sliding door, a hallway, empty room between the two rooms, different floor and different section of a building) were not correlated to frequency of intercourse.
Conclusions. The present result suggested that stress in the residential environment might not be a major cause of less frequent sexual activities in Japanese male and that other reasons should be investigated (e.g. stress in the workplace, especially in zero-growth economy, or inherent racial characteristics) in future.
P-17
Sexual life in normal married couples in Japan: an investigation by questionnaire
K. Nagao, H. Kobayashi, K. Nakajima, H. Hara, K. Miura, N. Ishii
Department of Urology, School of Medicine, Toho University, Tokyo, Japan
After sildenafil, an inhibitor of type-5 phosphodiesterase (PDE-5), was put on the Japanese market in March 1999, vardenafil also emerged in June 2004, the diagnosis and therapy of erectile dysfunction (ED) has been changed dramatically in Japan. However, there have been few studies meanwhile concerning the actual sexual life in married couples, and it has been almost impossible to understand and access the target(s) and the communication concerning sex life between the couples in establishing medical treatment for a patient with ED. Therefore, here we conducted a questionnaire survey into the frequency, periodicity and foreseeability of sexual intercourse and other relevant matters in the 300 married couples who in advance revealed they had one or more sexual intercourses per 3 months. The results obtained clearly show that very few couples have carnal intercourse more than once during an opportunity of having sexual intercourse, and the majority of them occur in the night. Furthermore, the results indicate that more than 80% of the couples could not predict the sexual intercourse more than 30 minutes earlier. It is concluded that the drug as a treatment for ED should be fast in onset of action and needs to make it possible to have sexual intercourse without feeling uncomfortable or taking the very few opportunity.
P-18
Pedicle scrotal flap: The one-stage repair in penile paraffinoma
W. Naiyaraksaree
Queen Savang Vadhana Memorial Hospital, Chol Buri, Thailand
Introduction and objectives. Oil injection into the penile skin, for penile enlargement, is currently common among Thai males. Inflammatory granuloma, phimosis, chronic unhealed ulcers, penile deformities and inability to achieve sexual activities are following complications. We report the one-stage surgical treatment, pedicle scrotal flap, that achieved optimal aesthetic and functional results.
Methods. Between 2003 and 2006, 51 patients who had oil injection into the penile skin were retrospectively evaluated. Thirty-seven underwent complete excision of the affected skin and subcutaneous tissue. The pedicled scrotal flap was prepared, directly turned up and wrapped around the denuded penile shaft. The scrotal incision was then closed.
Results. Mean age of the patients was 34.5 years (18–65 years) and duration of oil injection was 2.9 years (1 month–18 years). Mean operative time of the one-stage surgical treatment, pedicle scrotal flap was 109.8±16.4 minutes (75–145 minutes). Ten patients (27.0%) had minor skin necrosis and delayed healing. Three cases (8.1%) had late penile shortening from scar contracture at the penopubic junction. Two patients (5.4%) had decreased glans sensation.
Conclusions. The scrotal skin is elastic and has sensation similar to penile skin. The pedicle scrotal flap is the only treatment that is able to achieve both aesthetic and functional results.
P-19
China's experience of penile prosthesis implantation for severe erectile dysfunction
Z.C. Xin, W.D. Song, Z.C. Zhang, L. Tian
Andrology Centre of Peking University First Hospital, Peking University, Beijing, China
Purpose. To evaluate the effects of different kinds of penile prosthesis implantation for Chinese patients with severe erectile dysfunction (SED).
Subjects and methods. A total of 98 cases of Chinese patients with SED were treated by different kinds of penile prosthesis implantation during October 2001 to January 2007 were followed up using a questionnaire form. Mean age of patients was 33.4±10.6 years old and duration of SED was 5.5±4.5 years. Among the vasculargenic SED were 63 cases (64.3%), neurogenic ED 20 cases (20.4%), DM 10 cases (11.2%), Peyronine's disease 4 cases (4.1%). Three-piece penile prosthesis AMS700 CXM for 69 cases (70.4%) and Manto alpha I for 3 cases (3.1%) and AMS 650 malleable prosthesis 26 cases (26.6%). Among them, 3 cases were one-stage implantations of AMS700CXM with visual internal urethrotomy. Patients and partner's satisfaction with penile prosthesis implantation were followed up with questionnaire forms.
Results. Among patients, 2 cases (2.0%) had mechanical malfunction, 1 case of mechanical malfunction with tube rupture in DM patients with severe cacernosum fibrosis was reimplanted AMS650 malleable, and 1 case of malfunction with fluid leakage, however, the patient was satisfied with oral medication with PDE-5i such as sildenafil, tadanafil and vardenafil. Patients' and partners' satisfaction with penile prosthesis implantation were 92.4% and 89.8%.
Conclusion. Different kinds of penile prosthesis implantation were ideal methods for treatment of SED in Chinese patients, and one-stage implantation AMS700CXM with visual internal urethrotomy seems a safe and effective method for treatment of SED with urethra stricture.
P-20
Two cases of non-ischaemic priapism
T. Shichijo, H. Sasaki, K. Oshinomi, T. Aso, M. Ota
Department of Urology, Showa University Fujigaoka Hospital, Tokyo, Japan
Many cases of non-ischaemic priapism occur after perineal blunt trauma. Arterial embolization has been performed as the first line therapy. However, watchful waiting was proposed recently. We report two interesting cases.
Two cases (22 years old and 68 years old) are characterized antecedent trauma, penis was neither fully rigid nor painful, cavernous blood gases was not hypoxia or acidosis and unregulated cavernous arterial inflow on colour Doppler ultrasonography. In accordance with AUA guidelines, watchful waiting was performed with close analysis of cavernous blood gas and colour Doppler US or CT-angiography.
The first case (22 years old) was succeeded observation therapy. However, the second case (68 years old) was failed observation therapy. Ten month later, arteriography and embolization were performed, and treated with non-absorbable materials.
For these two cases, their erectile function is recovered.
P-21
Penile siliconoma
M.D. Amiruddin1,3, M. Ghaznawie2,3
1Department of Dermato-Venereology, Medical Faculty of Hasanuddin University, Indonesia; 2Department of Pathology, Medical Faculty of Hasanuddin University, Indonesia; 3Dr Wahidin Sudirohusodo General Hospital, Makassar, Indonesia
Background. Siliconoma (silicon granuloma) is a granulomatous foreign body reaction towards silicon. Liquid silicon injection is commonly used for cosmetic purposes, such as anti-aging, scars, repairing atrophic skin, and enlarging certain organs. Augmentation of the body contour by localized injection of hard and soft agent is often done. In Indonesia, the injection is sometimes carried out illegally by paramedics. Complications of the injection often occur. Siliconoma has become a big concern in our clinic because of the increasing number of cases.
Case report. We are reporting 4 cases of siliconoma who attended our clinic recently. The ages of the patients ranged between 25 to 65 years old. Most of the patients developed lumps around 2 weeks after the injection. On examination all patients showed similar lesions, i.e. multiple painful hard nodules, skin coloured, on the skin surface of the penis. The biopsy shows granulomatous foreign body reaction in the dermis, consisting of epithelioid and numerous foreign body giant cells. The reaction surrounds round spaces, presumably liquid silicon. Multinucleated giant cells are also present inside these spaces. Extirpation followed by reconstructive plastic surgery was carried out. The lesions disappeared and there was no recurrence after 6 months in all cases.
Conclusions. Foreign body granulomatous reaction occurs after the injection of liquid silicon. The lesions can be treated by extirpation followed by reconstructive surgery with great success.
P-22
A case of rathke's cleft cyst with emission less
Y. Kobori, K. Sugimoto, Y. Maeda, E. Koh, M. Namiki
Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
We encountered a 33-year-old male who had complaint of the emission less and general fatigue. He did not have an erectile dysfunction and a sexual desire. The level of hormone was as follows; LH = 1.1 mlU/mL, FSH 2.7 mlU/mL, testosterone 16 ng/dL and prolactin (PRL) 33.9 ng/mL. The value of gonadotropine was relatively low, and that of PRL is a little bit higher than normal limits. Endocrine examination of the hypothalamo-pituitary-gonad (HPG) axis showed a lack of response to LH and FSH, and normal response to CRF, GRH, LH-RH and TRH stimulation tests. MRI of the brain revealed the presence of a Rathke's cleft cyst. The diagnosis is a hypogonadotropic hypogonadism due to Rathke's cleft cyst. The tumor was resected by transsphenoidal surgery was performed. After surgery, the response to LH was recovered and the weak response to FSH was continued. Moreover, the value of the testosterone increased along with normalization of HPG axis. In the present case, after removal of the pituitary compression due to the mass, the emission less abolished. Thus, testosterone shortage causing the low value of LH and FSH may be responsible for the development of these disorders. However, it is remains unknown which hormonal circumstance plays more major role in the development of sexual functions. This is a very rare case of emission less causing compression of normal pituitary due to Rathke's cleft cyst.
P-23
Pre-treatment serum testosterone level as a predictive factor of pathological stage in localized prostate cancer patients treated with radical prostatectomy
T. Imamoto, H. Suzuki, M. Takano, K. Kawamura, N. Kamiya, Y. Naya, T. Ichikawa
Department of Urology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
Objective. Pre-treatment serum level of testosterone (T) is a potential prognostic factor for prostate cancer. The present study was conducted to evaluate the clinical significance of pre-treatment serum T level in patients with clinically localized prostate cancer.
Materials and methods. The subjects were 82 clinically localized prostate cancer patients treated with radical prostatectomy, whose pre-treatment T levels were recorded. We investigated clinical and pathological factors such as pre-treatment serum T level, age, pre-treatment PSA or pathological Gleason score concerning the association with pathological stage and biochemical recurrence.
Results. The mean pre-treatment T level was significantly lower in patients with non-organ-confined prostate cancer (pT3-T4, N1; 3.44±1.19 ng/ml) than in patients with organ-confined cancer (pT2; 4.33±1.42 ng/ml) (p = 0.0078). Multivariate analysis demonstrated that pathological Gleason score, pre-treatment serum T level and pre-treatment PSA were significant predictors of extraprostatic disease. When the patients were divided into high and low T level groups according to the median value, pre-treatment T levels were not significantly associated with PSA recurrence rates (p = 0.7973).
Conclusions. A lower pre-treatment T level appears to be predictive of extraprostatic disease in patients with localized prostate cancer.
P-24
The effects of SOY isoflavone and curcumin on the serum PSA level of biopsy-negative men
H. Ide, T. Nakagawa, M. Yasuda, Y. Kamiyama, S. Muto, S. Horie
Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
Introduction and objectives. Chronic inflammation in the prostate can be a cause of high serum PSA level, which may also contribute to prostate carcinogenesis. We analysed the effects of isoflavone and curcumin on the serum PSA level in the biopsy-negative men and the biological effects of prostate cancer cells.
Methods. Under the approval of local IRB, 89 participants were recruited from men who were not found either cancer or PIN by biopsy. We compared change in PSA concentration between isoflavone and curcumin and placebo groups at the time of enrolment and 6 months later. Using LNCaP cells, we tested the expression of PSA and the activation of DNA damage response proteins including ATM (ataxia-telangiectasia-mutated kinase), H2AX (histone H2AX variant) and Chk2 (checkpoint kinase2).
Results. PSA level at 6 months was significantly decreased in the treatment group. Isoflavone and curcumin suppressed the expression of PSA and induced the phosphorilation of ATM, H2AX and Chk2 in LNCaP cells.
Conclusions. Our results may indicate that isoflavone and curcumin can modulate serum PSA level and presumably suppress the prostate carcinogenesis through the activation of DNA damage response.
P-25
Peripheral effect of fluoxetine on human seminal vesicle in vitro study
P. Birowo1,2, S. Ückert1, G. Kedia1, C. Keil3, M. Meyer4, H.J. Mägert3, S. Machtens5, W.F. Thon6, F. Scheller7, U. Jonas1, A. Taher2, D. Rahardjo2
1Department of Urology, Hannover Medical School, Hannover, Germany; 2Department of Urology, University of Indonesia School of Medicine/Cipto Mangunkusumo Hospital, Jakarta, Indonesia; 3Department of Biotechnology, Anhalt University of Applied Sciences, Köthen/Anhalt, Germany; 4IPF Pharmaceuticals GmbH, Hannover, Germany; 5Department of Urology, Marien-Krankenhaus GmbH, Bergisch Gladbach, Germany; 6Department of Urology, Klinikum Region Hannover-Krankenhaus Siloah, Hannover, Germany; 7Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
Introduction and objectives. Premature ejaculation (PE) is treated ‘off label’ with selective serotonin reuptake inhibitors (SSRIs) assuming that SSRIs act centrally rather than peripherally. The objective of this present study was to evaluate the expression of serotonin (5-HT) receptors in the human seminal vesicle (HSV), the effect of fluoxetine as selective serotonin reuptake inhibitor on the relaxation of norepinephrine (NE) contracted isolated HSV strips and the effect of fluoxetine on cAMP-cGMP production in isolated HSV.
Methods. Expression of the RNA was analysed by reverse transcriptase polymerase chain reaction under standard conditions. Using organ bath technique, the inhibition effect of fluoxetine at 1 μM each, followed by cumulative NE application from 0.1 to 10 μM was studied. Inhibition of contraction was expressed as a percentage of the maximum contraction plateau induced by NE. Statistical analysis was performed using one-way ANOVA. Following freezing, homogenization and extraction of cyclic nucleotides, cAMP and cGMP were measured by means of radioimmunoassay. Forskolin and sodium nitroprusside were used as reference compounds.
Results. The positive signals for 5-HT1A, 5-HT1B, 5-HT2C, 5-HT4, and 5HT7 receptors mRNAs were detected in the samples prepared from HSV samples but not 5HT2A and 5HT2B receptors. The contraction induced by NE was effectively inhibited through preincubation with fluoxetine 76.1% (n = 6). This inhibitory effect was statistically significant compared to control (p < 0.05). The inhibitory effects of fluoxetine was correlated by a 1.3 to 2.6 fold increased in cAMP or cGMP production.
Conclusions. Our results show that SSRI inhibit in vitro the NE-induced contraction of HSV muscle strips. This demonstrated for the first time that SSRI may act on the seminal vesicle as the peripheral target organ.
P-26
Silodosin improved premature ejaculation – a case report
K. Kobayashi, R. Kato, K. Hashimoto, S. Yamashita, N. Masumori, N. Itoh, T. Tsukamoto
Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
Objective. To report a case of premature ejaculation improved by silodosin.
Case report. A 34-year-old man suffered from premature ejaculation. He achieved orgasm within approximately 1 minute during sexual intercourse. Although he took paroxetine 10 mg/day for 2 weeks, intravaginal ejaculatory latency time was not changed. As the next step, we suggested that he take silodosin, which has been known to cause ejaculatory dysfunction as an adverse event. We prescribed the drug for him after obtaining informed consent. After he took silodosin, the time period to achieving orgasm was prolonged till 2 minutes. He got much better sexual intercourse by taking silodosin, although he had a complete lack of ejaculation. Because the anejaculation induced by silodosin does not have any impact on orgasm he is satisfied with and has continued this treatment.
Discussion. Silodosin is a highly selective α1A-adrenoceptor antagonist. Ejaculatory dysfunction has been reported as an adverse event of α1A-blockers such as silodosin. We previously reported that silodosin caused a loss of seminal emission by blocking α1A-receptors in reproductive organs. In our patient, the quality of orgasm was not worsened although he had anejaculation due to silodosin intake. We might be able to apply α1A-blockers such as silodosin to treatment for premature ejaculation although this needs further study.
P-27
Bone dynamics in men with prostate cancer
M. Nagata, T. Fukagai, N. Sudo, K. Suzuki, M. Morita, Y. Ogawa
Department of Urology, Showa University School of Medicine, Tokyo, Japan
Androgen deprivation therapy (ADT) decreases bone mineral density (BMD) and increases the risk of fracture in men with prostate cancer. Smith has stated that prostate cancer patients show a degradation of BMD prior to ADT. We, therefore, studied the bone dynamics in Japanese prostate cancer patients prior to ADT.
BMD of the total hip, femoral neck, lumbar spine and forearm were measured by dual-energy x-ray absorptiometry (DEXA) before treatment in 53 prostate cancer patients without bone metastasis and in 16 patients with bone metastasis. Bone metabolism measurements of serum NTX and serum BAP were also carried out before treatment in 62 prostate cancer patients without bone metastasis and 22 patients with bone metastasis.
Measurements in the total hip of nine of the 53 patients without bone metastasis indicated osteoporosis. Measurements of the femoral neck in eleven of the 53 patients indicated osteoporosis. Results show that Japanese prostate cancer patients without bone metastasis do not suffer from bone density degradation prior to ADT; only the Z score of the forearm showed a minus value. Serum NTX and BAP were significantly elevated in prostate cancer patients with bone metastasis compared with those without bone metastasis.
No screening guidelines currently exist; however, patients at risk of decreased BMD should be screened and treated to prevent consequent fractures. Serum NTX and BAP monitoring of prostate cancer patients might facilitate the timely diagnosis of bone metastasis.