Marked testosterone deficiency-related symptoms may be associated to higher metabolic risk in men with low testosterone levels.

INTRODUCTION: Testosterone deficiency syndrome (TDS) is usually suspected on the basis of signs/symptoms. However, some men with low testosterone levels (low T) are asymptomatic or present mild, unnoticed symptoms. Would they have the same cardiovascular risk as symptomatic men? AIMS: This study aims to assess the relationship between presence/severity of low T-related symptoms and the likelihood of metabolic syndrome (MetS). METHODS: Data were taken from a multicenter, cross-sectional study conducted in Spain among men visiting men's healthcare offices aged ≥45 with low T (total T <8 nmol/L or <12 nmol/L and calculated free T <250 nmol/L). Only subjects whose MetS components and symptoms had been assessed were selected. Data available included anthropometrics, toxic habits, comorbidities, and total testosterone (TT) levels. MAIN OUTCOME MEASURES: MetS was defined using the harmonized definition. Erectile dysfunction was classified using the International Index of Erectile Function questionnaire. The Ageing Male Symptoms (AMS) scale assessed symptoms. Symptom severity was classified as "none/mild" and "moderate/severe." Bivariate and multivariate logistic regression analyses were performed to calculate the effect of moderate/severe symptoms on the odds ratio (OR) for MetS. RESULTS: Mean age (SD) was 61.2 (8.1) years. Erectile dysfunction (ED), AMS, and MetS prevalence were 97.4%, 94.9%, and 69.6%. Prevalence of MetS was higher in men with moderate/severe symptoms vs. men with no/mild ones (75.3% vs. 57.9%, P < 0.001). Age and prevalence of TT <8 nmol/L, moderate/severe ED, and obesity were significantly higher in men with moderate/severe symptoms. Multivariate analysis showed that besides obesity and moderate/severe ED, moderate/severe symptoms increased the likelihood of MetS. This effect disappeared in men with severe ED and in the nonobese. Three symptoms showed relationship with MetS after adjusting for all confounding factors. CONCLUSION: Severity of TDS symptoms may indicate higher cardiovascular risk in men with low T.

[Patient with TDS and lower urinary tract symptoms (LUTS)]. / Paciente con SDT y síntomas del tracto urinario inferior (STUI).

OBJECTIVE: [corrected] New investigations focus on the relationship between benign prostatic hyperplasia, lower urinary tract symptoms, erectile dysfunction and testosterone deficit; giving to this last one a common role in all of them. In this paper, we present a typical patient who complains of symptoms related to BPH, to treat him in terms of micturition quality, sexual function and hypogonadism . METHODS/RESULTS: 61 year-old male, with obesity, hypertension and hypercholesterolemia, who complains of long term mixed urinary symptoms, with an IPSS of 12 and IIEF-5 of 22. DRE: II/IVprostate, adenomatous. Blood parameters: PSA 1.9 ng/dl, total testosterone 238 ng/dl, triglycerides 213 mg/dl, glucose 89 mg/dl. Uroflowmetry :total volume 256 ml, maximum flow 12 ml/s, average 5.7 ml/s and post-void volume of 15 ml. Urinary ultra- sound: 5 mm detrusor and prostate volume of 39 cm3. Nowadays, LUTS are considered multietiologic, including testosterone as one of the causes. According to the classic criteria, this patient fits for treatment with combination therapy, as well as for daily PDE5i, recently approved for LUTS therapy. Administration of testosterone to treat LUTS is still controversial. It could restore the patient's levels of testosterone, improving the metabolic syndrome and creating an optimal environment for the 5PDEi. Nevertheless, according to some current scientific evidences, it could help improving LUTS. CONCLUSIONS: Given the necessity of larger studies, testosterone supplementation therapy seems to not worsen the evolution of BHP. It could even improve them if the testosterone deficit is documented.

[Testosterone and coronary artery disease]. / Testosterona y enfermedad coronaria.

UNLABELLED: Elderly patients present testosterone deficit syndrome (TDS) in a prevalent manner. TDS is defined as a clinical and biochemical syndrome with total fasting testosterone below normal levels in two consecutive measurements. A significant relationship with comorbidities such as diabetes mellitus, obesity or metabolic syndrome has been observed in these patients. These latter are recognized risk factors of coronary artery disease (CAD) and arteriosclerosis. It seems logical to think that CAD is more frequent in patients with TDS, and it is supported on multiple works demonstrating the correlation of theses two pathologies. We intend to illustrate the management of patients with TDS and CAD presenting a clinical case and the recommended diagnostic and therapeutic approach. A Sixty-four year old male with hypertension, non-insulin dependent diabetes mellitus and obesity consulted for erectile dysfunction and diminished sexual desire. Fasting total testosterone and glycosylate hemoglobin were determined. IIEF-5 was 12, Erection hardness Score was 2 and IIEF item 12 1 point over 5. His total testosterone was 150 ng/dl, which was confirmed in a second test; HDL cholesterol level was 30 mg/dl. Interrogated again, the patient referred oppressive chest pain appearing after running 50 meters for the last three months that never happened in rest or with minor efforts. APPROACH: It is a patient with high cardiovascular risk and atypical chest pain so recommendation was given to consult a cardiologist. Stress test was performed. It was a submaximal, evaluable test (reached 80% of his maximum theoretical heart rate) stopped due to angina. Clinically and electrically it was positive at medium charge. Coronary angiogram was indicated showing a severe (85%percnt;%) lesion at the medial third of anterior descendant artery. Balloon angioplasty was performed and a 3.0 x 24 mm drug-coated stent was placed. Cardiologic treatment was prescribed as well as combination therapy for his erectile dysfunction and diminished libido with testosterone and a PDE 5 inhibitor.

Paciente con SDT y síntomas del tracto urinario inferior (STUI) / Patient with TDS and lower urinary tract symptoms (LUTS)

OBJETIVO: Nuevas investigaciones hacen incapié en la interrelación existente entre la hiperplasia benigna de próstata, los síntomas del tracto urinario inferior, la disfunción eréctil y el déficit de testosterona; ejerciendo éste último un papel de coactivador en todas ellas. Planteamos en este artículo un paciente tipo, que consulta por clínica atribuible a HBP, para tratar al paciente globalmente en términos de calidad miccional, esfera sexual y DT. MÉTODO/RESULTADOS: Varón de 61 años, obeso, hipertenso e hipercolesterolémico, que consulta por cuadro miccional mixto de años de evolución con IPSS de 12 e IIEF-5 de 22. TR: II/IV, adenomatosa. En la analítica se observa: PSA 1,9 ng/dl, testosterona total 238 ng/dl, triglicéridos 213 mg/dl, glucosa 89 mg/dl. Flujometría: volumen de 256 ml, flujo máximo de 12 ml/s, medio de 5,7 ml/s y residuo postmiccional de 15ml. Ecografía de aparato urinario: detrusor de 5 mm y volumen prostático de 39 cc. Hoy en día se considera que el origen de los STUI en el hombre es multi-etiológico, habiendo quien incluye el déficit de testosterona como una causa de los mismos. Atendiendo a los criterios clásicos, parece un buen candidato para terapia combinada mediante un alfa-bloqueante y un inhibidor de la 5 alfa reductasa; si bien otra opción terapéutica sería el recientemente aprobado como tratamiento para STUI en el varón: tadalafilo 5 mg al día. La administración de testosterona en el varón afecto de STUI es un tema de debate controvertido. Trataría el déficit del paciente, con el beneficio que conlleva a nivel metabólico, e implicaría adicionalmente un ambiente óptimo para la administración de inhibidores de la 5-PDE.Además, a juzgar por algunas de las evidencias actuales, podría ayudar a la mejoría de los STUI del paciente (AU)

CONCLUSIONES: El tratamiento sustitutivo con testosterona, a falta de estudios más robustos, no parece interferir negativamente en la evolución de la HBP pudiendo incluso mejorar los síntomas miccionales en caso de constatarse déficit androgénico (AU)

OBJETIVE: New investigations focus on the relationship between benign prostatic hyperplasia, lower urinary tract symptoms, erectile dysfunction and testosterone deficit; giving to this last one a common role in all of them. In this paper, we present a typical patient who complains of symptoms related to BPH, to treat him in terms of micturition quality, sexual function and hypogonadism. METHODS/RESULTS: 61 year-old male, with obesity, hypertension and hypercholesterolemia, who complains of long term mixed urinary symptoms, with an IPSS of 12 and IIEF-5 of 22. DRE: II/IVprostate, adenomatous. Blood parameters: PSA 1.9 ng/dl, total testosterone 238 ng/dl, triglycerides 213 mg/dl, glucose 89 mg/dl. Uroflowmetry: total volume 256 ml, maximum flow 12 ml/s, average 5.7 ml/s and post-void volume of 15 ml. Urinary ultra- sound: 5 mm detrusor and prostate volume of 39 cm3. Nowadays, LUTS are considered multietiologic, including testosterone as one of the causes. According to the classic criteria, this patient fits for treatment with combination therapy, as well as for daily PDE5i, recently approved for LUTS therapy. Administration of testosterone to treat LUTS is still controversial. It could restore the patient’s levels of testosterone, improving the metabolic syndrome and creating an optimal environment for the 5PDEi. Nevertheless, according to some current scientific evidences, it could help improving LUTS. CONCLUSIONS: Given the necessity of larger studies, testosterone supplementation therapy seems to not worsen the evolution of BHP. It could even improve them if the testosterone deficit is documented (AU)

Paciente con SDT y enfermedad coronaria / Testosterone and coronary artery disease

Los pacientes de edad avanzada presentan, de manera prevalente, deficiencia sintomática de testosterona. El síndrome de déficit de testosterona (SDT) se define como un síndrome clínico y bioquímico con niveles de testosterona total en ayunas por debajo de niveles normales, en dos mediciones consecutivas. En estos pacientes se ha observado una relación significativa con comorbilidades como la diabetes mellitus, la obesidad o el síndrome metabólico. Estos últimos son reconocidos factores de riesgo de enfermedad coronaria y ateroesclerosis. Parece lógico pensar que la enfermedad coronaria es más frecuente en pacientes con SDT, y esto se sostiene con múltiples trabajos que demuestran la correlación entre estas dos patologías. Se propone ilustrar el manejo de pacientes con SDT y enfermedad coronaria mediante la presentación de un caso clínico y la actitud diagnóstico terapéutica recomendada. Varón de 64 años hipertenso y diabético no insulin-dependiente, obeso, que consulta por disfunción eréctil y disminución del deseo sexual. Se solicita una testosterona total en ayunas y hemoglobina glicosilada. Presenta un IIEF-5 de 12, un Erection Hardness Score de 2 y un ítem 12 del IIEF de 1 punto sobre 5. Presenta una testosterona total de 150 ng/dl que se confirma disminuida en una segunda medición, un colesterol HDL de 30 mg/dl. Reinterrogando al paciente refiere un dolor torácico opresivo que surge cuando corre 50 metros, desde hace 3 meses, y que no se produce nunca en reposo ni con esfuerzos menores. ACTITUD: Se trata de un paciente con alto riesgo cardiovascular y dolor torácico atípico por lo que se recomienda remitir a la consulta de cardiología (AU)

Se realiza una prueba de esfuerzo siendo una prueba submáxima valorable (alcanzó el 80% de su frecuencia cardiaca máxima teórica) suspendida por angina. Clínica y eléctricamente positiva a carga intermedia. Se indica un cateterismo coronario dando una lesión severa (85%) en el tercio medio de la arteria descendente anterior,s e realiza angioplastia de la lesión de la arteria descendente anterior con balón y stent farmacoactivo de 3.0x24 mm. Se indica tratamiento por parte de cardiología y tratamiento combinado para su disfunción eréctil y disminución de libido mediante testosterona y un inhibidor de la fosfodiesterasa 5 (AU)

Elderly patients present testosterone deficit syndrome (TDS) in a prevalent manner. TDS is defined as a clinical and biochemical syndrome with total fasting testosterone below normal levels in two consecutive measurements. A significant relationship with comorbidities such as diabetes mellitus, obesity or metabolic syndrome has been observed in these patients. These latter are recognized risk factors of coronary artery disease (CAD) and arteriosclerosis. It seems logical to think that CAD is more frequent in patients with TDS, and it is supported on multiple works demonstrating the correlation of theses two pathologies. We intend to illustrate the management of patients with TDS and CAD presenting a clinical case and the recommended diagnostic and therapeutic approach. A Sixty-four year old male with hypertension, non-insulin dependent diabetes mellitus and obesity consulted for erectile dysfunction and diminished sexual desire. Fasting total testosterone and glycosylate hemoglobin were determined.IIEF-5 was 12, Erection Hardness Score was 2 and IIEF item 12 1 point over 5. His total testosterone was 150 ng/dl, which was confirmed in a second test; HDL cholesterol level was 30 mg/dl. Interrogated again, the patient referred oppressive chest pain appearing after running 50 meters for the last three months that never happened in rest or with minor efforts (AU)

APPROACH: It is a patient with high cardiovascular risk and atypical chest pain so recommendation was given to consult a cardiologist. Stress test was performed. It was a submaximal, evaluable test (reached 80% of his maximum theoretical heart rate) stopped due to angina. Clinically and electrically it was positive at medium charge. Coronary angiogram was indicated showing a severe (85%) lesion at the medial third of anterior descendant artery. Balloon angioplasty was performed and a 3.0 x 24 mm drug-coated stent was placed. Cardiologic treatment was prescribed as well as combination therapy for his erectile dysfunction and diminished libido with testosterone and a PDE 5 inhibitor (AU)

Metabolic syndrome in men with low testosterone levels: relationship with cardiovascular risk factors and comorbidities and with erectile dysfunction.

INTRODUCTION: Testosterone deficiency and metabolic syndrome (MetS) are strongly associated. Patients consulting for sexual dysfunction may have testosterone deficiency, providing a valuable opportunity to assess MetS. The identification of variables predicting MetS is of great importance. AIMS: To identify cardiovascular comorbidities and risk factors, including erectile dysfunction (ED), associated with MetS in men aged≥45 with total testosterone (TT)<8 nmol/L (or <12 nmol/L when calculated free testosterone was <50 pmol/L) and to gain further insight into the relationship between both conditions. METHODS: Data were collected from a multicenter, cross-sectional, observational study conducted in Spain among men visiting men's health-care offices with a confirmed diagnosis of testosterone deficiency. Subjects with data for MetS assessment were included in this analysis. Other data available were anthropometrics, toxic habits, cardiovascular comorbidities, ED diagnosis, and TT values. MAIN OUTCOME MEASURES: The MetS harmonized definition was used. Waist circumference threshold was 94 cm. ED was diagnosed and classified using the International Index of Erectile Function-5 (IIEF-5) questionnaire. Bivariate and multivariate logistic regression analyses were performed to calculate odds ratios (ORs) for MetS. RESULTS: Mean age was 61.2±8.1 years. Prevalences of ED and MetS were 97.6% and 69%, respectively, both increasing with age. Bivariate analysis showed that moderate or severe ED, obesity, and peripheral vascular disease (PVD) were the variables associated with the greatest odds of MetS (OR=2.672 and 2.514, respectively), followed by alcohol intake (OR=1.911). Tobacco use, ag,e and testosterone deficiency severity had a minimal effect that disappeared on multivariate analysis. Elevated triglycerides and HDL-cholesterol were MetS risk factors associated with a lower TT level. CONCLUSION: The high prevalence of MetS among men with testosterone deficiency highlights the opportunity to assess cardiovascular health in patients consulting for sexual dysfunction. Moderate to severe ED, obesity, PVD, and alcohol intake significantly increase the likelihood of MetS.

Higher sex hormone-binding globulin and lower bioavailable testosterone are related to prostate cancer detection on prostate biopsy.

OBJECTIVE: Recent studies show an inverse relationship between testosterone levels and prostate cancer (PCa). The usefulness of hormonal patterns in PCa diagnosis is controversial. This study aimed to determine the relationship between hormonal patterns and PCa, and to find a cut-off point of hormone levels to assess PCa risk. MATERIAL AND METHODS: A prospective analysis was undertaken of 279 patients referred for first or second prostate biopsy in the Hospital Clínic Barcelona from November 2006 to May 2009. The indication for prostate biopsy was suspicion of PCa based on the results of digital rectal examination (DRE) and/or elevation of serum prostate-specific antigen (PSA). Screening was carried out with a 5+5-core transrectal ultrasound-guided prostate biopsy. Age, prostate volume, DRE (normal or abnormal), biopsy findings (normal or report of PCa), PSA, free-to-total PSA, PSA density, testosterone and sex hormone-binding globulin (SHBG) were also prospectively recorded. Free and bioavailable testosterone were calculated using Vermeulen's formula. RESULTS: In the multivariate analysis, abnormal DRE [odds ratio (OR = 5.46, p < 0.001], SHBG levels ≥ 66.25 nmol/l [OR = 3.27; 95% confidence interval (CI) 1.52 to 7.04, p < 0.002] and bioavailable testosterone levels ≤ 104 ng/dl (OR = 4.92, 95% CI 1.78 to 13.59, p = 0.002) were related to the diagnosis of prostate adenocarcinoma. Age, free testosterone, PSA, testosterone, PSA/testosterone, PSA/free testosterone and PSA/bioavailable testosterone were not related to PCa diagnosis. CONCLUSIONS: Low bioavailable testosterone levels and high SHBG levels were related to a 4.9- and 3.2-fold risk of detection of PCa on prostate biopsy owing to PSA elevation or abnormal DRE. This fact may be useful in the clinical scenario in counselling patients at risk for PCa.

Linguistic and psychometric validation of the Erection Hardness Score to Spanish.

INTRODUCTION: The Erection Hardness Score (EHS) is a one-item questionnaire that assesses rigidity on a 4-point scale. AIM: To perform a validation of a Spanish version of the EHS by comparison with the International Index of Erectile Function (IIEF) questionnaire. METHODS: Validation of the EHS included: (i) professional translation of the scale; (ii) scientific evaluation of the translation from four independent urologists; (iii) assessment on five individuals to test correct comprehension and idiomatic adequacy (iv) validation of the EHS by a cross-sectional, multicenter comparison with the IIEF. MAIN OUTCOME METHODS: Patients were required to respond to a Spanish version of the EHS and IIEF. Statistic correlation was carried out between the EHS score and IIEF-erectile function domain (EF) score. RESULTS: A total of 125 patients were recruited. Overall prevalence of erectile dysfunction (ED) by the EHS questionnaire was of 80.2% patients (n=97). Mean EHS was 2.74±0.97. Mean IIEF-EF score was 17.4±9.5. The EHS showed good reliability. The rate of missing responses to the EHS questionnaire was 0%. A one-factor analysis of variance was performed between the EHS and EF subdomain of IIEF (P=0.000). Pearson's correlation coefficient between EHS and EF subdomain of IIEF was 0.834, P<0.01. CONCLUSIONS: The EHS is a reliable tool to test ED and its Spanish version was satisfactorily understood by patients and correlated with IIEF-EF.

Disfunción eréctil de origen vascular / Vascular erectile dysfunction

La etiología vascular de la disfunción eréctil está presente en el 60% de los pacientes con DE. La enfermedad de pequeños vasos, como en la diabetes, y la arteriosclerosis de arterias de mayor tamaño, como en la hipertensión, causa insuficiencia arterial y disfunción eréctil.El tabaco altera la hemodinámica arterial del pene, causando disfunción eréctil en un alto porcentaje de fumadores de edad avanzada: la fibrosis y estenosis de las arterias pélvicas acelera la arteriosclerosis existente. La disfunción venoclusiva puede deberse a la disminución de la distensibilidad de cuerpos cavernosos o anormalidades inherentes en la albugínea.El factor de crecimiento vascular endotelial puede desempeñar un papel en la modulación de la vascularización de la arquitectura normal del pene.Distintos acontecimientos, todos ellos importantes, pueden causar disfunción eréctil. Además, ninguna causa puede participar de forma independiente. Una cascada de situaciones (incluidos los factores psicológicos, así como los orgánicos) pueden llevar a la disfunción eréctil. Una comprensión continuada de las causas orgánicas de la disfunción eréctil permitirá al médico descubrir tratamientos para su corrección, así como proporcionar seguridad al paciente(AU)

Vascular etiology is present in up to 60% of the patients with erectile dysfunction (ED). Both small vessel disease, such as that in diabetes mellitus, and arteriosclerosis of bigger size arteries, as in hypertension, cause arterial insufficiency and erectile dysfunction.Tobacco smoking alters the arterial hemodynamics in the penis, causing erectile dysfunction in a high percentage of advanced age smokers: pelvic arteries fibrosis and stenosis accelerates the existing arteriosclerosis. Venous occlusive dysfunction may be due to the decrease of corpora cavernosa compliance or tunica albuginea inherent anomalies.Vascular endothelial growth factor may play a role in the modulation of vascularization of the normal penile architecture. Various events, all of them important, may cause erectile dysfunction. Moreover, no cause can participate independently. A cascade of situations (including psychological factors as well as organic) may lead to erectile dysfunction. A continuous understanding of organic causes of erectile dysfunction will allow physicians to discover treatments for their correction, as well as to give confidence to the patient(AU)