Testosterone replacement therapy and voiding dysfunction

The Impact of Testosterone Therapy on Benign Prostatic Hyperplasia in Hypogonadal Males

OBJECTIVE

To determine the impact of testosterone therapy (TT) on the incidence of benign prostatic hyperplasia (BPH) in a large cohort of hypogonadal males and to evaluate the relationship between TT in hypogonadal males and prostatic interventions.

METHODS

We used the 2011-2020 International Business Machines Corporation MarketScan database to identify hypogonadal males above 18 years old and determine if they received TT. International Classification of Diseases, 9th and 10th Revisions, Current Procedural Terminology, Healthcare Common Procedure Coding System Procedure Codes, and National Drug Code (NDC) codes were used for diagnoses, interventions, and medications. We ran Cox proportional hazard models to determine the effect of TT on receiving a diagnosis of BPH and interventions. Models were adjusted for age, region, population density, and comorbidities, with TT within the last 6 months considered a time-varying covariate.

RESULTS

In our total cohort of 882,570 hypogonadal males, 157,185 (17.8%) were diagnosed with BPH. For the first 2.5 years after hypogonadism diagnosis, there was no significant difference in the diagnosis of prostatic hyperplasia between patients on TT and those who were not (HR:1, 95%CI:0.98-1.01, P = .66). However, from 2.5 years onward, males who were on TT had a 32% higher risk of receiving a diagnosis of BPH (HR:1.32, 95%CI:1.28-1.36, P <.001). Hypogonadal males with BPH who received TT showed no significant difference in interventions compared to those who did not receive testosterone (HR:0.95, 95%CI:0.89-1, P = .08).

CONCLUSION

In the long term, TT increased the risk of receiving a diagnosis of BPH in hypogonadal males. TT in hypogonadal males with BPH did not change the need for interventions.

Correlation between Higher Aging Males' Symptoms Scores and a Higher Risk of Lower Urinary Tract Symptoms

BACKGROUND

Late-onset hypogonadism (LOH) is a condition caused by the decline of testosterone levels with aging and is associated with various symptoms, including lower urinary tract symptoms (LUTSs). Although some reports have shown that testosterone replacement treatment for LOH improves LUTSs, no large study has revealed a correlation between LUTSs and LOH. This study investigated the correlation between the severity of LOH and LUTSs in Japanese males >40 years of age using a web-based questionnaire with the Aging Males' Symptoms (AMS) scale.

METHODS

We asked 2000 Japanese males to answer both the AMS and IPSS/QOL questionnaires using a web-based survey. Among these 2000 individuals, 500 individuals were assigned to each age group.

RESULTS

The IPSS total score was positively correlated with the severity of AMS (shown as median [mean ± SD]): no/little group, 2 (3.67 ± 5.36); mild group, 6 (7.98 ± 6.91); moderate group, 11 (12.49 ± 8.63); and severe group, 16 (14.83 ± 9.24) (p < 0.0001).

CONCLUSIONS

Individuals with higher AMS values, representing cases with severe LOH symptoms, had a higher risk of experiencing nocturia and LUTSs than those with lower AMS values.

Exploring the Enigma of 5-ARIs Resistance in Benign Prostatic Hyperplasia: Paving the Path for Personalized Medicine

PURPOSE OF REVIEW

Despite the widespread utilization of 5-alpha reductase inhibitors (5-ARIs) for managing benign prostatic hyperplasia (BPH), certain BPH patients exhibit unresponsiveness to 5-ARIs therapy. This paper provides a comprehensive overview of the current perspectives on the mechanisms of 5-ARIs resistance in BPH patients and integrates potential biomarkers and underlying therapeutic options for 5-ARIs resistance. These findings may facilitate the development of novel or optimize more effective treatment options, and promote personalized medicine for BPH.

RECENT FINDINGS

The pathways contributing to resistance against 5-ARIs in certain BPH patients encompass epigenetic modifications, shifts in hormone levels, autophagic processes, and variations in androgen receptor structures, and these pathways may ultimately be attributed to inflammation. Promisingly, novel biomarkers, including intravesical prostatic protrusion, inflammatory factors, and single nucleotide polymorphisms, may offer predictive insights into the responsiveness to 5-ARIs therapy, empowering physicians to fine-tune treatment strategies. Additionally, on the horizon, GV1001 and mTOR inhibitors have emerged as potential alternative therapeutic modalities for addressing BPH in the future. After extensive investigation into BPH's pathological processes and molecular landscape, it is now recognized that diverse pathophysiological mechanisms may contribute to different BPH subtypes among individuals. This insight necessitates the adoption of personalized treatment strategies, moving beyond the prevailing one-size-fits-all paradigm centered around 5-ARIs. The imperative for early identification of individuals prone to treatment resistance will drive physicians to proactively stratify risk and adapt treatment tactics in future practice. This personalized medicine approach marks a progression from the current standard treatment model, emerging as the future trajectory in BPH management.

Elevated endogenous testosterone levels are not associated with significant clinical morbidity

OBJECTIVES

To investigate the association between elevated endogenous testosterone levels and deleterious effects associated with testosterone therapy. Elevated serum testosterone levels in men receiving testosterone therapy have been associated with side effects, though precise thresholds above which these occur are unknown. Data on the association between naturally elevated endogenous testosterone levels and their physiologic effects is sparse.

METHODS

We examined National Health and Nutrition Examination Survey data between 2011-2016, analyzing men aged 18 and older not on testosterone or androgen ablation therapy, excluding men who had testosterone <300ng/dL, to compare men with elevated testosterone (>800ng/dL) to men with normal testosterone (300-800ng/dL). We used multivariable logistic and linear regressions for comparison.

RESULTS

After excluding men with testosterone levels <300ng/dl, 3,673 men met inclusion criterion. Only 146 (4%) of men had a testosterone >800ng/dL. When compared to men with normal testosterone, men with high testosterone had similar rates of sleep disorders, urinary symptoms, and depression. Men with elevated testosterone had higher hematocrit regression coefficient (βi 1.30, 95% confidence interval [CI] 0.69-1.90 P<0.01), AST (βi 8.48, 95% CI 0.31-16.66, P=0.04) and ALT (βi 12.23, 95% CI 0.70-23.77, P=0.04) compared to men with normal testosterone.

CONCLUSIONS

No association was found between higher endogenous testosterone levels and adverse events associated with testosterone therapy. Men with higher testosterone had increased hematocrit, but this was not clinically significant. This challenges what is considered a safe target for testosterone therapy and prompts future prospective studies to delineate the safety of elevated endogenous and exogenous modulated levels of testosterone.

The Translational Role of Animal Models for Estrogen-Related Functional Bladder Outlet Obstruction and Prostatic Inflammation

The prevalence of LUTS and prostatic diseases increases with age both in humans and companion animals, suggesting that a common underlying cause of these conditions may be age-associated alterations in the balance of sex hormones. The symptoms are present with different and variable micturition dysfunctions and can be assigned to different clinical conditions including bladder outlet obstruction (BOO). LUTS may also be linked to chronic non-bacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS), but the relationship between these conditions is unknown. This review summarizes the preclinical data that supports a role for excessive estrogen action in the development of obstructive voiding and nonbacterial prostatic inflammation. Preclinical studies that are emphasized in this review have unequivocally indicated that estrogens can induce functional and structural changes resembling those seen in human diseases. Recognizing excessive estrogen action as a possible hormonal basis for the effects observed at multiple sites in the LUT may inspire the development of innovative treatment options for human and animal patients with LUTS associated with functional BOO and CP/CPPS.

Hypogonadism in Adult Males with Prader-Willi Syndrome-Clinical Recommendations Based on a Dutch Cohort Study, Review of the Literature and an International Expert Panel Discussion

Prader-Willi syndrome (PWS) is a complex genetic syndrome characterized by hyperphagia, intellectual disability, hypotonia and hypothalamic dysfunction. Adults with PWS often have hormone deficiencies, hypogonadism being the most common. Untreated male hypogonadism can aggravate PWS-related health issues including muscle weakness, obesity, osteoporosis, and fatigue. Therefore, timely diagnosis and treatment of male hypogonadism is important. In this article, we share our experience with hypogonadism and its treatment in adult males with PWS and present a review of the literature. In order to report the prevalence and type of hypogonadism, treatment regimen and behavioral issues, we retrospectively collected data on medical interviews, physical examinations, biochemical measurements and testosterone replacement therapy (TRT) in 57 Dutch men with PWS. Fifty-six (98%) of the patients had either primary, central or combined hypogonadism. Untreated hypogonadism was associated with higher body mass index and lower hemoglobin concentrations. TRT was complicated by behavioral challenges in one third of the patients. Undertreatment was common and normal serum testosterone levels were achieved in only 30% of the patients. Based on the Dutch cohort data, review of the literature and an international expert panel discussion, we provide a practical algorithm for TRT in adult males with PWS in order to prevent undertreatment and related adverse health outcomes.

Melatonin alleviated oxidative stress induced by energy restriction on sheep Leydig cells through Sirt1/Sod2 pathway

Energy balance is essential for normal reproduction of ram. However, the effect of energy restriction (ER) on reactive oxygen species (ROS) of sheep Leydig cells (LCs) and the rescuee methods are still unclear. To investigate the in vitro effect of melatonin on cellular ROS in fER-treated sheep LCs and explore the underlying mechanism, Hu sheep LCs were restricted energy using no serum culture medium and resaved with 10 ng/ml melatonin, respectively. The results showed that ER significantly increased MDA level, while decreased CAT, GHS-px expression and ΔΨm (p < 0.05). Meanwhile, ER decreased testosterone concentration and cell proliferation rate (p < 0.05). And the expression of testosterone synthesis-related enzymes was also down-regulated by ER (p < 0.05). Furthermore, we revealed that melatonin reversed the defective phenotypes in ER-treated LCs via Sirt1/Sod2 pathway. The interference of Sirt1 abolished the melatonin-mediated improvement of cellular ROS and testosterone secretion. Taken together, our study firstly indicated that melatonin could alleviate the excessive ROS accumulation and promote testosterone biosynthesis in ER-treated sheep LCs via the activation of Sirt1/Sod2 pathway.

Prevalence of andropause among Iranian men and its relationship with quality of life

INTRODUCTION

Andropause is a complicated process in men's life which can negatively affect their quality of life in both physical and psychological dimensions.

OBJECTIVES

The aim of this study was to determine the prevalence of andropause among Iranian men age 40-85 years and its relationship with quality of life.

MATERIALS AND METHODS

This was a cross-sectional study among 393 men attending ten urban healthcare centers in Ilam province in southwestern Iran. Study participants were recruited using proportional random sampling. The Male andropause symptoms self-assessment questionnaire (MASSQ) and SF-12 were used for data collection. Data were analyzed using SPSS version 22 (Chicago, IL).

RESULTS

The mean (SD) of participants scores in MASSQ was 57.46 (17.56). Only 61 (15.5%) men were classified at "don't need testosterone" category based on MASSQ. There were significant associations between the eight aspects of HRQoL and the andropause severity (p < .001). Older age, lower education, having depression, coronary heart disease, and incontinence were associated with increased odds of andropause (p < .05).

CONCLUSION

This study confirmed findings of previous studies regarding andropause and its relationship with men's quality of life. Future studies in this topic are needed to discover all the factors that may influence men andropause.

The association between metabolic syndrome and benign prostatic hyperplasia: a systematic review and meta-analysis

OBJECTIVE

We performed this meta-analysis to assess the association between metabolic syndrome (MetS) and benign prostatic hyperplasia (BPH).

METHOD

We conducted extensive searches on the PubMed, Science and Cochrane Library to identify all articles. Outcomes including annual prostate growth rate, prostate volume (PV), International Prostate Symptom Score (IPSS), IPSS sub-scores (voiding and storage), prostate- specific antigen (PSA), maximum urine flow rate (Qmax), post-void residual urine volume (PVR) and quality of life (QoL) were assessed.

RESULTS

21 studies with 15,317 patients were included. Patients with MetS had higher annual prostate growth rate [weighted mean difference (WMD) = 0.79; p < .001], larger PV (WMD = 2.62; p < .001), lower Qmax (WMD = -0.48; p = .001) and more PVR (WMD = 8.28; p < .001). However, no significant differences were found between two groups in IPSS (WMD = 0.20; p = .37), IPSS-voiding (WMD = -0.05; p = .78), IPSS-storage (WMD = -0.22; p = .26), PSA (WMD = 0.04; p = .43), and QoL (WMD = -0.01; p = .70).

CONCLUSIONS

The study suggested that MetS may be one of the risk factors for the clinical progress of BPH. However, further study is warranted to support these results.

Manganese exposure caused reproductive toxicity of male mice involving activation of GnRH secretion in the hypothalamus by prostaglandin E2 receptors EP1 and EP2

Exposure to manganese (Mn) can cause male reproductive damage and lead to abnormal secretion of sex hormones. Gonadotropin-releasing hormone (GnRH) plays an important role in the neuromodulation of vertebrate reproduction. Astrocytes can indirectly regulate the secretion of GnRH by binding paracrine prostaglandin E₂ (PGE₂) specifically to the EP1 and EP2 receptors on GnRH neurons. Prior studies assessed the abnormal secretion of GnRH caused by Mn exposure, but the specific mechanism has not been reported in detail. This study investigated the effects of Mn exposure on the reproductive system of male mice to clarify the role of PGE₂ in the abnormal secretion of GnRH in the hypothalamus caused by exposure to Mn. Our data demonstrate that antagonizing the EP1 and EP2 receptors of PGE₂ can restore abnormal levels of GnRH caused by Mn exposure. Mn exposure causes reduced sperm count and sperm shape deformities. These findings suggest that EP1 and EP2, the receptors of PGE₂, may be the key to abnormal GnRH secretion caused by Mn exposure. Antagonizing the PGE₂ receptors may reduce reproductive damage caused by Mn exposure.

MiR-1197-3p regulates testosterone secretion in goat Leydig cells via targeting PPARGC1A

As a fundamental regulator of mitochondrial function, peroxisome proliferator-activated receptor gamma coactivator 1 alpha (PPARGC1A) acts as a powerful coactivator of many transcriptional factors that relate to steroidogenesis, while the regulatory mechanism remains unclear. In the present study, testosterone secretion of goat Leydig cells (LCs) mediated by miR-1197-3p via PPARGC1A was investigated. We found PPARGC1A protein was diversely localized in testis, and the expression of PPARGC1A in testis of 9-month-old goat was significantly higher than that in 3-month-old goat. In addition, suppression of PPARGC1A significantly decreased the testosterone secretion in goat LCs, as well as reduced the expressions of key steroidogenesis related genes [steroidogenic acute regulatory protein (StAR), cytochrome P450 family 11 subfamily A member 1 (CYP11A1), and 3 beta-hydroxysteroid dehydrogenase (3BHSD)], and overexpression of PPARGC1A showed the opposite effects. Moreover, we observed suppression of miR-1197-3p increased the synthesis of testosterone and promoted the expressions of PPARGC1A, StAR, CYP11A1, and 3BHSD by directly targeting PPARGC1A in the LCs. Furthermore, overexpression of PPARGC1A could alleviate miR-1197-3p induced aberrant steroidogenesis related gene expressions and testosterone synthesis. Taken together, miR-1197-3p could act as an essential regulator of LC testosterone secretion in goat testis by targeting PPARGC1A. These results provide a novel view of the regulatory mechanisms involved in male sexual maturation and help us to understand the molecular role of PPARGC1A in testosterone synthesis.

Hypogonadal men with moderate-to-severe lower urinary tract symptoms have a more severe cardiometabolic risk profile and benefit more from testosterone therapy than men with mild lower urinary tract symptoms

Purpose

To analyze data from an observational, prospective, cumulative registry study in 805 hypogonadal men stratified by mild or moderate-to-severe lower urinary tract symptoms (LUTS) according to International Prostate Symptom Score.

Materials and Methods

A total of 412 men underwent testosterone therapy (TTh) with injectable testosterone undecanoate, 393 men served as untreated controls. Measures of urinary function, anthropometric and metabolic parameters were performed at least twice per year.

Results

Data from 615 men with mild LUTS (253 treated, 362 untreated) and 190 with moderate-to-severe LUTS (159 treated, 31 untreated) were available. During a follow-up period of 8 years a significant improvement of LUTS was noted for all TTh-patients whereas the control-groups showed deterioration or fluctuation around initial values. Despite advancing age, TTh fully prevented worsening of symptoms. In parallel, a considerable improvement of anthropometric parameters, lipids and glycemic control, blood pressure, C-reactive protein, and quality of life was found. Moderate-to-severe LUTS was associated with worse cardiometabolic risk profile at baseline as well as worse cardiovascular outcomes during follow-up in comparison to mild LUTS. Effect size of TTh was more pronounced in men with moderate-to-severe than with mild LUTS.

Conclusions

Correcting hypogonadism by TTh is highly effective and safe for improving LUTS in hypogonadal men. TTh may also improve cardiometabolic risk and major adverse cardiovascular events.

Impact of Testosterone Deficiency and Testosterone Therapy on Lower Urinary Tract Symptoms in Men with Metabolic Syndrome

Lower urinary tract function is modulated by neural, vascular and urethral and bladder structural elements. The pathophysiological mechanisms of lower urinary tract symptoms (LUTS) encompass prostate enlargement, alterations in urethra histological structure bladder fibrosis and alterations in pelvic neuronal and vascular networks, The complex pathophysiological relationship between testosterone (T) deficiency (TD) and the constellations LUTS, and metabolic dysfunction manifested in the metabolic syndrome (Met S) remains poorly understood. TD has emerged as one the potential targets by which Met S may contribute to the onset and development as well as worsening of LUTS. Because it has been recognized that treatment of men with Met S with T therapy ameliorates Met S components, it is postulated that T therapy may represent a therapeutic target in improving LUTS. Furthermore, the effect of TD on the prostate remains unclear, and often debatable. It is believed that T exclusively promotes prostate growth, however recent evidence has strongly contradicted this belief. The true relationship between benign prostatic hyperplasia, TD, and LUTS remains elusive and further research will be required to clarify the role of T in both benign prostatic hypertrophy (BPH) and LUTS as a whole. Although there is conflicting evidence about the benefits of T therapy in men with BPH and LUTS, the current body of literature supports the safety of using this therapy in men with enlarged prostate. As the population afflicted with obesity epidemic continues to age, the number of men suffering from Met S and LUTS together is expected to increase.

Amelioration of sexual behavior and motor activity deficits in a castrated rodent model with a selective androgen receptor modulator SARM-2f

Sarcopenia and cachexia present characteristic features of a decrease in skeletal muscle mass and strength, anorexia, and lack of motivation. Treatments for these diseases have not yet been established, although selective androgen receptor modulators (SARMs) are considered as therapeutic targets. We previously reported that a novel SARM compound, SARM-2f, exhibits anabolic effect on muscles, with less stimulatory effect on prostate weight compared with testosterone, in rat Hershberger assays and cancer cachexia models. In this study, we studied the mechanism of action for SARM-2f selectivity and also assessed whether the muscle increase by this compound might lead to improvement of muscle function and physical activity. First, we examined the tissue distribution of SARM-2f. Tissue concentration was 1.2-, 1.6-, and 1.9-fold as high as the plasma concentration in the levator ani muscle, brain, and prostate, respectively. This result showed that the tissue-selective pharmacological effect did not depend on SARM-2f concentration in the tissues. The ability of SARM-2f to influence androgen receptor (AR)-mediated transcriptional activation was examined by reporter assays using human normal prostate epithelial cells (PrEC) and skeletal muscle cells (SKMC). SARM-2f exerted higher activity against AR in SKMC than in PrEC. Mammalian two hybrid assays showed different co-factor recruitment patterns between SARM-2f and dihydrotestosterone. Next, we studied the effect of SARM-2f on motivation and physical functions such as sexual behavior and motor activities in castrated rat or mouse models. SARM-2f restored the sexual behavior that was lost by castration in male rats. SARM-2f also increased voluntary running distance and locomotor activities. These results suggest that tissue-specific AR regulation by SARM-2f, but not tissue distribution, might account for its tissue specific androgenic effect, and that the muscle mass increase by SARM-2f leads to improvement of physical function. Together, these findings suggest that SARM-2f might represent an effective treatment for sarcopenia and cachexia.