Practicing urologists should be aware that there is a high prevalence of SDT among men who come for routine check-ups and urinary disorders. Diagnosis and treatment of men with age-related androgen deficiency should be based on currently accepted international expert recommendations.
There is now a great interest in the study of age-related androgen deficiency in men from various medical specialties.
Testosterone Deficiency Syndrome (TDS) is an age-related syndrome in males that presents with clinical symptoms and biochemical signs of decreased testosterone levels (below reference values for young healthy adult males). It is known that after the age of 30, men experience a gradual (by about 1–3% per year) decrease in the levels of total and free testosterone in the blood, which increases the likelihood of clinical signs of androgen deficiency. The timing of development and the severity of symptoms depend on the individual characteristics of testosterone secretion and metabolism , as well as on the structure of androgen receptors.
The prevalence of SDT in 40–70 year old men is 30–70%. In connection with the trend towards an increase in the number of older people in developed countries, the issues of prevention, timely diagnosis and correction of SDT are becoming increasingly relevant. Given the variety of androgen-dependent mechanisms of regulation of various organs and systems, the development of approaches to the diagnosis and treatment of patients suffering from androgen deficiency is carried out on an interdisciplinary basis.
Patients with testosterone deficiency syndrome at the urologist
Older men often turn to a urologist in connection with urination disorders caused by age-related changes in the bladder and infravesical obstruction against the background of benign prostatic hyperplasia and cancer, sclerosis of the bladder neck, urethral stricture, etc. Moreover, regardless of the severity symptoms and patient concerns, the high incidence of pathological changes in the prostate, as well as the risks of progression of neoplasms and the development of obstructive uropathy, served as the basis for recommending annual preventive examinations by a urologist to all men over the age of 50.
Detection of androgen receptors in the lower urinary tract and prostate gland, description of testosterone-dependent mechanisms of regulation of the detrusor function and the ability of androgen receptors to act as proliferation suppressor genes in normal and oncogenes in malignantly transformed prostate cells, on the one hand, open up prospects for preventive use hormone replacement therapy with testosterone (HRT) in a large number of men, and on the other hand, require a balanced approach in determining indications and contraindications. In this regard, patients before and during HRT are required to be examined and interpreted by a specialist urologist.
The low specificity of symptoms of SDT, the appearance of signs of copulative disorders embarrassing men, the presence of free and bound forms of testosterone in the blood, the natural variability of its indicators during the day, the error of laboratory diagnostics are far from a complete list of issues leading to low attendance of patients, difficulties diagnostics and standardization of therapeutic approaches to this problem. Despite the fact that a number of scientific communities have formulated clinical guidelines for the diagnosis, treatment and monitoring of patients with TSD, the degree of evidence for many of the provisions contained in them remains low and requires further research.
Diagnosis of Testosterone Deficiency Syndrome
Diagnosis of SDT consists of assessing the clinical symptoms of hypogonadism and confirming androgen deficiency by biochemical methods.
Depending on the individual characteristics of the structure of androgen receptors, secretion and metabolism of testosterone, men gradually develop clinical signs of its deficiency: a decrease in libido, muscle mass and strength, bone mineral density, vigor, as well as erectile dysfunction, obesity, and depressed mood.
Decreased libido is most closely associated with the development of hypogonadism and is perhaps its most common primary symptom, after which, with a subsequent decrease in testosterone levels, loss of energy, obesity, depressed mood, sleep disturbance, loss of ability to concentrate, hot flashes and erectile dysfunction.
You can more accurately judge the presence of hypogonadism by identifying a combination of characteristic symptoms, for example, erectile dysfunction, decreased libido and the frequency of morning rigid erections or decreased libido, a feeling of fullness of vitality and the appearance of a depressive mood. In men with urination disorders, the most typical complaints for STD were complaints of a decrease in the frequency and ability of sexual relations, a decrease in the number of morning erections and increased sweating.
Treatment of testosterone deficiency syndrome
Erectile dysfunction and/or decreased libido are the main indications for HRT in men with MTD in urological practice. The high prevalence of hypogonadism among men seeking help for ED, and the failure of many of these patients to respond to medical treatment for ED with TSD, led to the inclusion of blood testosterone levels in the recommendation for their screening. In most cases, the normalization of libido strength and the appearance of morning erections occur after 3-6 months, after which sexual activity usually increases and the quality of sexual life improves.
At the same time, it is known that, regardless of the presence of STD, copulative disorders can be the result of the development of other pathological conditions (diabetes mellitus, hyperprolactinemia, metabolic syndrome, bladder outlet obstruction, peripheral neuropathy) or medication. In this regard, the lack of effect from the behavior of HRT suggests a re-analysis of the causes of the development of sexual dysfunction.
In addition, in the presence of a clinical picture of hypogonadism and borderline blood testosterone levels, a trial of HRT for 3 months is possible, based on the results of which it can be concluded that hypogonadism plays a role in the development of symptoms and recommend continuation or termination of testosterone deficiency replenishment.
The synergistic treatment effects of testosterone and phosphodiesterase type 5 inhibitor drugs in hypogonadal or low normal testosterone men presenting with erectile dysfunction should also be considered and recommended for patients in whom monotherapy has failed.
HRT has a positive effect on bone metabolism, musculature, erythropoiesis, cognitive function, memory, spatial orientation and general well-being in men with age-related androgen deficiency. It has been experimentally established that testosterone has a vasodilating effect and enhances blood flow; clinical studies have proven its ability to normalize performance in patients with metabolic syndrome.
Regardless of the method of drug administration, the appearance of exogenous testosterone inevitably leads to a decrease in the activity of the hypothalamic-pituitary-gonadal axis and inhibition of spermatogenesis due to the negative feedback mechanism. This should be taken into account when choosing a treatment for hypogonadism in men interested in preserving fertility. Patients, who are planned to receive testosterone preparations, should be informed about the benefits and risks of therapy, and during treatment they should be under regular supervision and undergo follow-up examinations.
To exclude prostate cancer, in which HRT is absolutely contraindicated, men should perform digital rectal examination and analysis of the level of prostate specific antigen. It is known that testosterone therapy can stimulate growth and aggravate symptoms in men with locally advanced and metastatic prostate carcinomas. Until data on the long-term results of the use of HRT in men over 45 years of age with SDT have been accumulated,
Due to the fact that urination disorders can develop with hypogonadism due to testosterone-dependent regulatory mechanisms, HRT may help reduce dysuria. To date, the long-term results of the use of HRT in men with urination disorders are unknown, as well as data on the efficacy and safety of the combined use of androgen replacement therapy and drugs from the alpha-blockers and 5-alpha-reductase inhibitor groups have not been obtained. In this regard, when determining the tactics of managing patients with moderate urination disorders, it is advisable to be guided by modern recommendations and conduct dynamic monitoring during treatment.
The presence of symptoms of androgen deficiency in a man who has received successful radical treatment for prostate cancer can be considered an indication for HRT. The lack of information on the long-term results of the use of androgens in this category of patients implies careful consideration of the benefits and risks of their use. The condition for the safety of treatment is the absence of clinical and laboratory signs of prostate cancer during dynamic monitoring of patients, as well as regular and thorough monitoring of their condition.
The benefits and risks of HRT, as well as the need for dynamic monitoring, should be discussed with patients prior to treatment, taking into account the severity of symptoms, laboratory diagnostic data, and other examination methods. Prolonged-release formulations of testosterone, which have the ability to maintain blood testosterone levels within the limits of physiological values, are becoming more and more widespread.
According to www.lvrach.ru
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