Age and training intensity differently affect male runners' endocrine and sexual parameters.

Physical activity is widely recognized to improve health and its inclusion in daily life at all ages is highly recommended. Gonadal hormones are known to be affected by physical activity. The exercise-induced effects on male runners of different ages were investigated by dividing 31 runners by age (Young, Y, 30-55 years; Old, O, 56-70 years) and amount of training (Light, L, <50 km/week; Heavy, H, 50 or more km/week). To test the somatic, sexual, and psychological health aspects, the Aging Male's Symptoms Scale (AMS) and the International Index of Erectile Function-6 (IIEF-6) questionnaires were administered and blood samples were drawn for adrenocorticotropic hormone, testosterone (Total-TT), free testosterone (Free-T), cortisol (C), dihydrotestosterone (DHT), estradiol, and sex hormone-binding globulin determinations. Clinical evaluations and questionnaire results showed the presence in all groups of some subclinical symptoms and "Light" dysfunctions. TT in the old-heavy (OH) group was significantly lower than in the OL group (2.38 ± 0.18 ng/mL vs. 3.36 ± 0.44 ng/ml, P = 0.05). The TT/DHT ratio was significantly higher in YH than in OH (3.64 ± 0.16 vs. 2.92 ± 0.23, P < 0.05). TT was positively correlated with AMS sexual subscale and negatively correlated with IIEF-6. Physical activity can significantly affect andrological health and testosterone levels in runners at all ages. Thus, due to the important testosterone-mediated vital functions in men, the evaluation of these parameters would be indicated in old as well as in young subjects.

Clinical importance of the micro-focal prostate cancer on a single sample of a trans-rectal 8-core biopsy.

OBJECTIVE: We tried to verify retrospectively, the clinical importance of a single microfocal prostate cancer at biopsy (as microscopic aspect of a group of 12 neoplastic glands 40x) in patients subsequently treated with radical prostatectomy (RP). MATERIALS AND METHODS: from January 2008 to November 2010 we carried out 760 eight-core prostate biopsies for increased PSA in patients with a prostatic volume of d < or =40 cc. A total of 252 patients (33.15%) had a prostate cancer and out of them 17 (6.7%) had a microscopic prostate cancer--16 a single microscopic focus and a case 2 microscopic foci in two different specimens. PSA ranged 5 to 7.4 ng/ml (mean 6.2 ng/ml), age ranged 61 to 75 (mean 68.29), Gleason score was G6 in all cases; in 4 cases a microscopic focus of PIN3 was associated. RESULTS: All patients had a RP and the pathologic stage was T2a in 4, T2b in 1, T2c in 9 (3 of these had microscopic PIN3 at biopsy) and T3a in 3 (including the one with 2 microscopic foci of prostate cancer on 2 different bioptic samples). Gleason was G6 in 12 cases and G7 in 5. DISCUSSION: The single microscopic focus of prostate cancer has always raised diagnostic problems, in fact some authors report these patients have 30 to 90% of probability to have a significant prostatic cancer (volume > 0.5 mi) whereas other authors found an insignificant prostatic cancer in 30% of the patients with a single microscopic focus of prostate cancer. It is really very difficult to predict the extent of the tumor in these cases because the different parameters employed are not reliable. Our series, although very small, support the hypothesis that significant cancers are more frequently associated with a single microscopic focus of prostate cancer at biopsy (in fact 17 out of 17 patients had a significant cancer) and consequently we feel that it is more oncologically correct to choose an aggressive therapy in these cases (RP, radiotherapy or androgen deprivation according to the individual case) rather then a "wait and see" which could be less cautious.

Hormone replacement therapy in morphine-induced hypogonadic male chronic pain patients.

BACKGROUND: In male patients suffering from chronic pain, opioid administration induces severe hypogonadism, leading to impaired physical and psychological conditions such as fatigue, anaemia and depression. Hormone replacement therapy is rarely considered for these hypogonadic patients, notwithstanding the various pharmacological solutions available. METHODS: To treat hypogonadism and to evaluate the consequent endocrine, physical and psychological changes in male chronic pain patients treated with morphine (epidural route), we tested the administration of testosterone via a gel formulation for one year. Hormonal (total testosterone, estradiol, free testosterone, DHT, cortisol), pain (VAS and other pain questionnaires), andrological (Ageing Males' Symptoms Scale-AMS) and psychological (POMS, CES-D and SF-36) parameters were evaluated at baseline (T0) and after 3, 6 and 12 months (T3, T6, T12 respectively). RESULTS: The daily administration of testosterone increased total and free testosterone and DHT at T3, and the levels remained high until T12. Pain rating indexes (QUID) progressively improved from T3 to T12 while the other pain parameters (VAS, Area%) remained unchanged. The AMS sexual dimension and SF-36 Mental Index displayed a significant improvement over time. CONCLUSIONS: In conclusion, our results suggest that a constant, long-term supply of testosterone can induce a general improvement of the male chronic pain patient's quality of life, an important clinical aspect of pain management.

The use of the hyperbaric oxygenation therapy in urology.

The basic principle of the hyperbaric oxygenation therapy (HOT) is to increase the dissolved oxygen in the blood when it is administered at high pressure. Then O2 will be distributed to the tissues through the pressure gradient, in this way obtaining an hyper-oxygenation of the tissue that has anti-inflammatory and pain-killing effects and induces augmentation of bacterial permeability to the antibiotics, neo-angiogenesis, enhancement of lymphocytes and macrophages function, augmentation of the testosterone secretion (in male), and healing of wound. These positive effects can be used in urology in several conditions: Scroto-perineal fascitis; Radiation-induced cystitis (and proctitis); Interstitial cystitis (urgency-frequency syndrome); Chronic pelvic pain. Our experience and the specific literature on this subject, suggest that HOT, sometimes associated with other medical and surgical therapies, can be a useful tool for treating such urologic diseases; in some cases this use is codified (Fournier's gangrene and Radiation-induced cystitis) in others (urgency-frequency syndrome and chronic pelvic pain) it represents a promising technique and needs further research.

Can Hyperbaric Oxygen Therapy (HOT) have a place in the treatment of some urological diseases.

HOT (Hyperbaric Oxygen Therapy) is used in urological diseases: Scrotal/perineal fasciitis and Radiation-induced cystitis (and proctopathy); in urgency and frequency syndrome and with chronic pelvic pain the use of HOT is still experimental. The basic principle of HOT is to increase oxygen dissolved in the blood when it is administered at high pressure. O2 is then distributed to the tissues through the pressure gradient; tissue hyper-oxygenation has anti-inflammatory and pain-killing effects, it increases bacterial permeability to antibiotics, strengthens neo-angiogenesis, reinforces lymphocytes and macrophages function, augments testosterone secretion (in males), and finally enhances wound healing process. We treated with HOT (integrating other treatments) 17 cases of necrotizing fasciitis, 13 radiation-induced cystitis and 4 cases of urgency and frequency syndrome. We always had good results, with a good cleansing of the dissected areas in Fournier's gangrene; in the cases of radiation-induced cystitis we had an improvement in the symptoms and hematuria, and finally in cases of urgency and frequency syndrome we had a transient reduction of symptomatology and pain. Our experiences and the specific literature on this subject suggest that HOT, sometimes associated with other medical and surgical therapies, can be an effective tool to treat urological diseases; in some cases its efficacy was well demonstrated (Fournier's gangrene and Radiation-induced cystitis), in others (urgency-frequency syndrome and chronic pelvic pain) it is a promising technique which definitely needs further research.

Endocrine consequences of opioid therapy.

Gonadal hormones are known to be affected by morphine and other opioids. In this paper, we summarize data collected in recent years which clearly indicate that the opioid-induced effects on steroid hormones depend on the opioid used and in some cases on the sex of the subject. Indeed morphine is able to reduce hormones like testosterone and cortisol in both male and female subjects in just a few hours, probably acting directly on peripheral glands. These depressant effects of morphine on hormones are also present in the treatment of surgical pain and are quickly reversible once opioid administration is suspended. Similar actions were also found to occur in experimental animals and in vitro in glial cells, further confirming the morphine-induced reduction of testosterone cell content. Testosterone and its metabolites are well known substances involved in the development and maintenance of the brain and all body structures. Thus when treating pain with opioids, their effects on hypothalamo-pituitary-gonadal and hypothalamo-pituitary-adrenal-related hormones must be considered and, where possible, hormone replacement therapy should be started.

From methylene blue (methylthionine chloride) to Al-Ghorab procedure: the therapy of priapism (our experience).

OBJECTIVE: The better knowledge concerning the anatomo-physiology of erection has brought important changes to the management of priapism. We experimented with a staged therapeutic protocol forthis condition. MATERIALS AND METHODS: 17 patients, aged from 27 to 71 (mean age 43) were treated for ischemic priapism; the pathogenesis was idiopathic in 9 cases, in 4 cases secondary to intracavernous injection (IcI) of PGE1, in 2 cases to papaverine Icd, in 1 case to haemolympho-pathy and in another patient to treatement with heparin. Cavernous PO2, PCO2 and pH were checked. All patients underwent removal of 100 cc of blood, irrigation with NaHCO3 solution of the cavernous corpora and Methylen blue (MB) IcI 10 mg every 5 minutes 10 times, repeated twice. RESULTS: From 3 to 6 hours from the beginning of therapy, detumescence was achieved in 10 cases. In 5 cases the priapism persisted and we administered adrenaline 20 pg every 5-10 minutes: 2 cases had detumescence respectively in 5 and 7 hours whereas in the patient with leukaemia the erection persisted and we desisted from further therapy; in 2 other cases the erection persisted and we did a distal cavernosum-glans shunt and the detumescence a was achieved in 30 and 58 hours respectively. In the last 2 cases, before adrenaline we administered an IcI of ethylephrine 5 mg every 5 minutes for 4-5 times but finally we had to perform a shunt. In all cases, during the treatment, and during the following 6-8 hours, we administered 200 mg of MB intravenous. CONCLUSIONS: The introduction of oral drugs has changed the epidemiology of priapism. A better knowledge of the molecular mechanisms that govern the cavernous contraction and myorelaxation has allowed us to use adrenergic drugs and also the MB. This staged therapeutic protocol goes from a less invasive therapy (irrigation with NaHCO3, MB, ethylephrine, adrenaline) to a surgical procedure which must not be delayed and this progression could allow a reduction in the collateral effects.

Perineural invasion in prostatic carcinoma treated with radical prostatectomy: the role of TR systematic biopsy.

Perineural invasion (PNI) is a morphological entity which has been known for many years, though its significance in prostatic neoplasms has only been studied recently. Therefore, we tried to assess, with the help our experience, its presence and its significance. Ninety-four patients, aged between 49 and 74 (average 65.8)--with a PSA between 2.69 and 52 ng/ml (average 11.44)--underwent RP for prostatic carcinoma; 58 patients had stage T2 and 36 had T3. 48 patients had Gleason 7 or higher, and 46 had G 6 or lower. Fifty patients (53,1%) were PNI+ and 44 (46,9%) PNI-. Between the two groups there was no significant difference as to age (1" group: average age 67 years; 2nd group: 68) and PSA (1st group: average 9.73 ng/ml, 2nd group: average 8,17) (Z 0,639). The distribution according to the stage showed that 24 patients (48%) PNI+ were T2 and 26 (52%) PNI+ T3, 34 (77.2%) PNI- T2 and 10 (22%) PNI- T3 and therefore 72,23% of the T3's were PNI+ and 41.3% of the T2's were PNI+; 34 patients (70.8%) with G>7 were PNI+ and 14 (29.16%) PNI-, 16 patients (34,78%) with G<6 were PNI+ and 30 (65.2%) PNI-. Among the PNI+ 50 patients, 36 had undergone biopsy in our hospital, and therefore we re-examined the operation tissue and found out that 16 (44%) were biopsy PNI+ while for 22 (55.5%) it was not possible to assess the PNI on the biopsy tissue. PNI is an important morphological element in the staging of prostatic cancer and is connected with the disease negative prognostic factors: in fact, it can be traced with a high frequency in stage diseases and higher Gleasons. It does not seem to be connected with PSA, above all for values between 4 and 20 ng/ml. We think that a very important element to be stressed is the fact that this condition is not always detected with biopsy (about 45%) and this does not allow, in such cases, an adequate therapy plan. Also our experience seems to confirm that, therefore, in spite of the above said limits, it is advisable to search PNI both with biopsy--in order to have a further prognostic element and therefore arrange the most suitable therapy plan--and on the surgery piece, in order to better determine the biological nature of the disease and to be able to suggest adequate integrative therapies.

The association of TR systematic echobiopsy of the prostate with power Doppler (PDU) in borderline PSA patients.

OBJECTIVE: TR systematic biopsy of the prostate is currently a method to diagnose prostate cancer, though with limited reliability. Many ancillary procedures have been put forward to improve its effectiveness, and PDU appears a very promising one Wehave attempted to verify whether PDU and eighth core TR biopsy together can ihcrease reliability especially in those patients with PSA values between 4 and 10 ng/ml. MATERIAL AND METHODS: Two groups of patients suffering from altered PSA and/or a palpable prostatic nodule underwent eighth core TR biopsy of the prostate. The first group was composed by 56 patients aged 55-82 (av.69.39) with PSA values ranging between 0.87 and 94.91 ng/ml (11.45 +/- 10.14) of which 29 had a palpable nodule. The second group was constituted by 96 patients aged 49-84 (av.69.84) with PSA values ranging between 1.14 and 59.7 ng/ml (12.8 +/- 11.66) of which 55 had a palpable nodule. The first group underwent eighth core TR biopsy, the second group TR biopsy and PDU. RESULTS: Twenty-five patients of the first group (44.64%) showed prostate cancer and 48 of the second (50%) were prostate cancer positive. We then divided them according to their PSA: 33 belonging to the first group (biopsy without PDU) had PSA values ranging between 4 and 9.6 ng/ml (7.59 +/- 1.61) and 13 (39.39%) were positive to Ca; 56 patients belonging to the second group (biopsy with PDU) had PSA values ranging between 4.09 and 9.66 ng/ml (7.02 +/- 1.56) and 26 (46.42%) were positive to Ca. We also ran tests with other groups of patients according to their PSA values although the above findings remained the most significant. CONCLUSIONS: Compared to other similarly interesting but more complex procedures, PD is easy to learn and easy to perform. Literature already shows how it can effectively be associated with systematic TR biopsy. On the basis of the above data we can conclude that PDU realistically improves reliability of eighth core TR biopsy--though not replace it--especially for those patients with PSA values between 4 and 10 ng/ml.

A more effective TR systematic biopsy of the prostate associated with power doppler ultrasonography (PDU): technical and morphological aspects.

OBJECTIVES: It is by now ascertained how PDU improves the effectiveness of systematic biopsy of the prostate. We have attempted to find better technical and imaging methods to optimise results. MATERIAL AND METHODS: We associated echo-biopsy with PDU on 131 patients. 64 patients (48.85%) showed prostate Ca. Their age was between 53 and 84 (av. 71.7) with PSA ranging from 1.14 and 59.7 (r. 9.,55 +/- 11.99 ng/ml). We then tried to locate in each sector areas of altered vascularization. RESULTS: In 34 cases (53.12%) we found hypo/hyper/iso reflecting areas surrounded by numerous vessels and crossed by one or more vascular branches (usually 2-3). In 8 cases (12.5%) we found hypo/hyper vascular echogenic virtually avascular, i.e. only a small perforating or surrounding branch. In 13 cases (20%) we found an aspecific and often widespread hyper-vascularization not associated to echographically atypical areas, bilateral in 4 cases. In 9 cases (14%) we did not find evident vascular alterations during PDU. Through the correlation of power Doppler ultrasonography images with histology we noticed that the area of altered vascularization was positive to Ca in 38 patients (59.37%) whereas the same was not true in 5 patients (7.8%), and finally in 21 patients (32.8%) the echo-doppler results (12 hypervascular and 9 "normal") was too aspecific to allow any kind of histomorphologic correlation. DISCUSSION: There are no pathognomonic patterns detectable through PDU for prostate Ca; although in the light of the above data it is safe to assume the existence of PDU detectable vascular alterations that in a good number of cases are not always neoplastic but prostatic disease which often coincide (about 60%) with cancer. The association of systematic biopsy and PDU helps highlight these areas thereby considerably improving diagnoses.

Power Doppler ultrasonography (PDU) as an additional tool to increase reliability of systematic biopsy of the prostate: a brief evaluation.

PDU is currently being tested as an aid to diagnosing prostate cancer. Our attempt has been to verify its usefulness to improve effectiveness of eight core TR biopsy. Two groups of patients were examined for increased PSA with or without a palpable prostatic nodule. The first group was composed by 52 patients between 55 and 83 years of age (mean 69.57) with PSA values between 0.87 and 94.91 ng/ml (8.085 +/- 14.056) of which 29 (55.75%) showed a palpable nodule. All patients underwent prostatic eight core TR echobiopsy. The second group was composed by 56 patients between 49 and 84 years of age (mean 69,19) with PSA values between 1.14 and 59.7 ng/ml (8.74 +/- 12.977) of which 33 (58.97%) showed a palpable nodule. This group of patients underwent a PDU just before TR biopsy in order to assess prostatic blood supply and locate possible alterations. Prostatic volume in both groups was never higher than 50 cc. Of the first group 25 patients (48.08%) were prostate cancer positive. Of the second group 31 patients (55.36%) were positive to a biopsyfor prostate cancer. In addition 22 out of the 31 showed a palpable nodule and vascular irregularity. PDU is being tested in order to reduce the number of biopsies and tissue samplings. The above results (tests carried out by the same operator with two homogeneous groups of patients) show how PDU was useful in diagnosing a higher number of prostate cancers. We could therefore safely conclude that the use of PDU in association with TR biopsy greatly increases diagnostic sensitivity and specificity.

[The meaning and usefulness of spiral CT for radiolucent ureteric stones diagnosis: our experience]. / The meaning and usefulness of spiral TC for radiolucent ureteric stones diagnostic: our experience.

The aim of this work was to report some case histories on the usefulness of spiral TC, used for several years both to diagnose renal colic and urinary lithiasis and to study radio lucent stones that are often difficult to be detected with traditional radiology. 13 patients, aged between 31 and 76 (average age: 54.2), were therefore examined. Eight of them had a ureteral colic when examined, while five patients had shown symptoms some days before being hospitalised in our ward. In all cases, ultrasonography showed a significant hydronephrosis, while direct radiography of the urinary tract could not detect any images that could be associated with radio-opaque lithiasis. All patients therefore underwent an abdominal spiral TC with no contrast medium within 24 hours after hospitalisation. The confrontation between the results obtained by ultrasonography and those obtained by spiral TC, showed the usefulness of the former method to detect stones located in the proximal ureter or in its intramural tract, while the latter could detect the lithiasis of the proximal ureter in 3 cases (23%), of the mid ureter in 2 cases (15.3%), and of the distal ureter in 8 cases (61%). The stones had, approximately, a 5 mm diameter in 5 cases. In 6 cases the diameter was between 6 and 10 mm, and more than 1 cm in 2 cases. Both methods proved to be equally accurate in the assessment of the hydronephrosis degree and of the thickness of the renal parenchyma. The therapy was medical in 2 cases and open surgery in 3 cases, while 8 patients were treated with ureterolitholapaxy with a ballistic searcher. The usefulness of TC in the study of urolithiasis nowadays is supported by a large literature which clearly supplies with documentary evidence the high sensitivity and specificity of such a method in diagnosing the presence of urolithiasis in general and above all of ureteric stones. Such a method not only makes an accurate evaluation of the stones location possible, but it can also assess the calculi dimensions and the indirect signs of the functionality of the kidney affected, without having to use the contrast medium. This method needs very limited execution times and allows a diagnostic of possible collateral pathologies. The main disadvantage of spiral TC, if compared to conventional radiology, is that the patient is exposed to a larger quantity of ionizing radiations, although such an inconvenience will be overcome by the new and more technologically advanced machines. According to our experience, though based on a limited number of cases, spiral TC allowed us to get a quick diagnosis of radio-lucent lithiasis, to see the seat and dimensions of the calculi and finally to chose the most effective treatment. We can therefore think of a diagnostic protocol, for ureteral colics with hydronephrosis or complicated by hyperpyrexia or sepsis, with spiral TC in order to have a quick diagnosis and start the most effective therapy in case an ultrasonographic research should not result diriment.

[Acceptability and safety of transrectal prostatic 8-core biopsy]. / Accettabilità e sicurezza della biopsia prostatica TR per ottavi.

The safety of sextant prostate biopsy has already been documented since the end of the 90's. As a higher efficacy of biopsy has been proved when increasing the number of samples taken, we have tried to assess the safety and tolerability of prostatic 8-core biopsy. From January to December 2001, 204 patients, aged between 50 and 88 (average 70) with a PSA between 0.74 and 196 ng/ml (10 +/- 9.25), underwent in 8-core prostate biopsy. After biopsy, the patients were given an oral antibacterial for 3 days. After taking the samples, patients were interviewed about the tolerability of the biopsy, and especially about the following: I. A feeling of irritation (77 patients, 37.7%); 2. A slight pain (72 patients, 35.29%); 3. A moderate pain (32 patients, 15.68%); 4. Intense pain (23 patients 11.27%). After 20 days all patients came back and were interviewed again about possible complications (biopsy was Ca positive in 86 cases, 42.15%). 153 patients (75%) reported a slight hematuria for an average period of 5 days; 88 patients (43.13%) showed slight anal-rectal hematic discharges, mainly after defecation efforts. It was never necessary to hospitalize any patients because of complications. 71 patients (34.8%) reported a perineal pain which disappeared after 24-48 hours. 175 patients reported having had an ejaculation after biopsy and 158 (90.2%) of them showed hematospermia. 4 patients (2%) had a short period temperature and only 2 (0.98%) were hospitalized for hyperpyrexia with symptoms of genitourinary sepsis. It has been proved that TR prostate biopsy is almost exclusively followed by minor complications, major ones being an exception. A biopsy with more than six samples (8-10-12) shows a higher number of minor complications (hematospermia and hematuria). The fact that a higher number of samples proves this method to be significantly more suitable, pays off all the problems. Also, such a casistics makes us think that prostatic 8-core biopsy is generally well tolerated (73% of patients reported either irritation or slight pain) and fairly safe, as complications are mainly minor ones. We must therefore underline the suitability, good tolerability and safety of the TR prostatic 8-core biopsy.