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Introduction: The concept of subclinical or compensated male hypogonadism (SHG), characterized by increased gonadotropins and normal testosterone levels is emerging. However, its real clinical significance is still conflicting. The aim of the present study was to summarize and discuss the available evidence related to the possible definition of SHG and the possible advantages of testosterone replacement therapy (TRT)., Evidence Acquisition: A comprehensive systematic Medline, Embase and Cochrane search was performed. Publications from January 1, 1969 up to February 29, 2020 were included. The search was restricted to English-language articles and studies of human participants., Evidence Synthesis: Two main clinical forms of SHG can be described. The first identifies young patients who have a positive medical history for testis damage occurring before puberty onset. The second form can occur as a consequence of an age-dependent decline of T. Whereas the former can be the consequence of several congenital or acquired diseases, also possible causes of primary hypogonadism, the real significance of the latter is still debatable. Available evidence indicates that age-related SHG is quite a common phenomenon, occurring in 9.4% of aging men from the general population. Cross-sectional and longitudinal data have documented that it is associated with poor health and can be a sign of forthcoming increased cardiovascular mortality and morbidity., Conclusions: Although available evidence suggests that in aging populations SHG can be considered a particular condition associated with an increased CV risk, it is still unknown if treatment with T can improve any outcomes in these subjects. Hence, further interventional studies are advisable to better understand the characteristics of SHG and the possible advantages of an early TRT.

Androgen deprivation therapy (ADT) is the gold standard treatment in patients with locally advanced or metastatic prostate cancer (PC). Emerging evidence has documented a tight association between ADT and body composition, along with metabolic profile impairment. These alterations might underpin the observed ADT-related increase in cardiovascular (CV) and thromboembolic (venous thromboembolism, VTE) mortality and morbidity. However, the specific mechanisms underlying these associations have not yet been completely elucidated. In the present review we summarize and discussed the available evidence linking ADT to increased cardio-metabolic risk, using both preclinical and clinical data. When possible, meta-analytic studies were preferred. Preclinical evidence, using a rabbit model of gonadotrophin-releasing hormone analogue-induced hypogonadism, indicates that the induced condition is associated with a dramatic increase in visceral adiposity and with an impairment of acetylcholine induced vascular relaxation, along with an increased propensity towards fatty liver. This suggests a direct role of ADT in inducing a worsened metabolic profile. In contrast, available clinical data are not sufficient to clarify a direct pathogeniclink between reduced testosterone (T) and altered metabolism. In fact, although T deprivation is associated with an altered metabolism, it is possible that the association between ADT and CV or VTE risk could simply be the result of a selection bias, related to the poor health status of patients with advanced PC. Despite the aforementioned considerations, all patients who are candidatesfor ADT should be screened for CV risk factors at baseline and monitored during the therapy. Life-style modifications and physical exercise are strongly encouraged., Competing Interests: The authors have nothing to disclose., (Copyright © 2021 Korean Society for Sexual Medicine and Andrology.)

Introduction: Since 2010 some evidence supporting the possible increased cardiovascular (CV) risk related to testosterone treatment (TTh) has created much debate in the scientific community. Based on these results, the US Food and Drug Administration agency has questioned TTh for aging men recognizing its value only for classical hypogonadism due to genetic or organic causes. To better clarify this topic, we scrutinized and summarized, also by using meta-analytic methods, the data generated during the last 7 years, as derived from the analysis of randomized controlled trials (RCTs) on TTh and CV risk. Areas covered: Analysis included 31 RCTs published between 2010 and 2018. Retrieved trials included 2675 and 2308 patients in TTh and placebo groups, respectively. The analysis documented that TTh was not associated with an increased CV mortality or morbidity either when overall or major adverse CV events were considered. Expert commentary: Despite present evidence it is important to recognize that the duration of the available trials is short (lower that 3 years) limiting final conclusions on this topic. In particular, the available information on possible long-term effects of TTh on CV risk is limited. Long-term safety studies are advisable to better clarify these points.

Late onset hypogonadism (LOH) is the most commonly used term to indicate the age-dependent reduction of testosterone. Sexual dysfunction represents the most important determinant for medical consultation and the most specific symptoms associated with LOH. In particular, data from the European Male Ageing Study (EMAS), a population-based survey on more than 3400 subjects, recognized that a triad of sexual symptoms (low libido and reduced spontaneous and sex-related erections) is the only syndromic association with decreased testosterone levels. Accordingly, a meta-analysis of the available randomized controlled trials documented that testosterone therapy (TTh) is able to improve all aspects of sexual function when compared to placebo. Despite this evidence, however, the relative clinical significance and the potential benefit of TTh in LOH are still the subject of strong criticisms in the scientific community. The debate is further complicated by the recent position statement of the US Food and Drug Administration (FDA) emphasizing a possible increased cardiovascular risk of TTh. However, this position was not endorsed by the European Medicines Association (EMA), which reached an opposite position after a specific review of the available data. In this review, all the conflicting data supporting the different positions of the FDA and EMA will be discussed. In particular, data derived from either population-based studies or interventional trials will be analyzed in detail. Although some evidence suggests an increase in TTh-related cardiovascular risk, the data derived from controlled trials do not support this position especially when the incidence of major adverse cardiovascular events are considered. Symptomatic men with documented reduced testosterone levels can be safely treated with TTh.

Objective: To investigate if 30-Minutes-TUMT was useful and safe in the treatment of chronic urinary retention due to BOO in patients with ASA II-III-IV., Material and Methods: 19 patients with chronic urinary retention (mean age 73.5 years) were scheduled for TUMT treatment because of absolute or relative contraindications to surgery. According to ASA classification there were 8 patients ASA II, 9 ASA III and 2 ASA IV. Routinely parameters were studied before and after treatment. Pain and patient's discomfort before, during and after TUMT treatment were registered using the VAS score (visual analogue scale: 0 = no pain and 10 = maximal pain). Urgency, irritation, and "how they feel" were registered at 2 days, 1, 2 and 4 weeks after TUMT using VAS technique., Results: Mean follow-up was 31,6 months (range 24-47), among the 9 responders patients (47.4%) who void normally without need of catheterisation, one patient died 12 months after the treatment for reasons not connected to the TUMT. Six patients (21.6%) failed the treatment and underwent TURP one or two years later (5 were ASA II and one ASA III). Among the 4 of 19 (21.0%) who had intermittent catheterisation after the treatment two died 1 and 2 years later, one has detrusor instability and one continued intermittent catheterisation. VAS during treatment was: 0 minute = 0.0; 5' = 3.1; 15' = 2.9; 25' = 2.8; 2 h after the treatment = 0.3. At 3 years follow up IPSS, QoL and Qmax were still acceptable. No major complication occurred., Conclusions: 47.4% of the patients responded positively to the new 30 minutes TUMT removing the urethral catheter, without needing surgical procedure avoiding the operation risk. 68.4% also improved their QoL. Local anaesthesia and oral/intravenous analgesia were sufficient during treatment. TUMT seems to have no anesthesiological risk. It is an option in patients with high risk of operation.

Objectives: Bladder-scan before uroflowmetry is useful to reduce non-evaluable Q(max)-data. A significant problem is to receive an adequate voided volume in uroflow-measurements. Aims of this study were 1--to confirm if pre-voiding bladder scan can reduce the number of inadequate flow measurements, 2--to establish threshold values for prevoiding bladderscan volumes before and after different treatments options 3--to study if it is possible to predict the post-residual voided volume., Material and Methods: 121 patients performed 2 uroflowmetry before and after different treatments. Bladder volume was measured by transabdominal ultrasound when the patient had the sensation to void and after uroflowmetry to calculate residual urine. Same investigations were repeated after different treatments., Results: 21% of the patients had insufficient voided volume < 125 ml in 1st recording and 22% in 2nd; while 28% of the patient had a volume voided < 150 ml in 1st recording and 33% in 2nd. There was a strong correlation between the pre-voiding measured volume and the voided volume (r = 0.801, p < 0.0001), linear regression analysis yielded 1st flow rate recording is Void-Vol = 32.703 + (0.637 * Pre-Vol) and 2nd flow rate recording is Void-Vol = 16.264 + (0.704 * Pre-Vol) (r = 0.855; p < 0.0001)., Conclusions: Bladder scanning before uroflowmetry reduces the number of non-evaluable Q(max) data. If a voided volumes of > 125 ml (> 150 ml) is required a mandatory pre-voiding bladder scan volume should be > 200 ml (> 250 ml), so non elegible Q(max) recordings will decrease from 21% to 5.8% (28% to 4.1%) in BPH patients who will undergo treatment and from 22% to 7.4% (33% to 5.8%) in BPH-treated patients. There is a difference between patients before and after treatment. It is not possible to predict the post residual voided volume by the bladder scan using the virtual calculation.

Aims: To evaluate the long-term outcome of transurethral resection of the prostate (TURP) and transurethral microwave thermotherapy (TUMT) in men with symptomatic benign prostatic hyperplasia (BPH), when allocation to the treatment-group was based on urodynamic diagnosis of bladder outlet obstruction (BOO)., Methods: A total of 231 elderly men with symptomatic BPH were treated either by TURP or by low-energy TUMT. A pressure-flow study was performed to detect the obstruction and to help in the selection of the two treatments. The patients were examined at baseline then checked again after 2 and 8 years., Results: At 2 years of follow-up there was a significant improvement for both IPSS and QoL (P < 0.0001) in both groups of treatment. This was accompanied by a significant improvement (P < 0.0001) in the maximum flow rate from 10.0 (5.8) to 16.4 (7.6) in the TURP group and from 12.1 (5.2) to 14.9 (5.7) in the TUMT group. These findings persisted at 8 years, they were, however, more pronounced after TURP. The overall retreatment rate reached a value of 11% in the TURP group and 27% in the TUMT group, respectively. At the follow-up, 95% of the patients who underwent TURP and 70% of the patients treated by TUMT claimed to be satisfied with that choice., Conclusions: With durable symptomatic improvement and lowest retreatment rate, TURP still presents a standard treatment option for patients with severe BOO. Low-energy TUMT has sufficiently relieved patients' symptoms and can be offered to less obstructed patients as an alternative.

Purpose: To evaluate the durability of the effect of transurethral microwave thermotherapy (TUMT) for lower urinary-tract symptoms (LUTS) suggestive of bladder outlet obstruction (BOO)., Patients and Methods: A total of 841 patients with LUTS received TUMT using the Prostatron device at Sahlgrenska University Hospital, Sweden. Two treatment programs were used: low-energy Program 2.0 and high-energy Program 3.5. A questionnaire, including International Prostate Symptom Score (IPSS), quality of life (QoL) score, and questions about general health status, was sent to all the patients. The mean followup after TUMT was 8.8 years for Program 2.0 and 2.5 years for Program 3.5., Results: At the end of follow-up, 67% of the patients treated with Program 2.0 were satisfied with the TUMT. During the follow-up period, 37% of patients experienced worsened symptoms, 18% various complications (e.g., hematuria), and 25% transient urinary-tract infection, and 16% went into retention. Secondary treatment (repeat TUMT, transurethral resection, medical therapy) was needed in 32% of patients. The mean IPSS was 13.5, and QoL score decreased to 2.1. With Program 3.5, 82% of the patients were satisfied, with another 17% having increased symptoms, 17% various complication, 25% urinary tract infection, and 26% retention. Only 7% of patients needed secondary treatment. The IPSS and QoL score went down to 11.4 and 1.6, respectively., Conclusion: These long-term data show that TUMT produces durable improvement and, with its safety and low retreatment rate, presents an attractive alternative for patients with LUTS suggestive of BOO.

Objective: Mondor reported the first superficial venous thrombosis on the chest wall in 1939. This condition is usually a benign and self-limited process, requiring only symptomatic treatment. Mondor's disease of the penis is an uncommon condition, which usually involves the superficial dorsal veins, it was first described by Braun-Falco in 1955. Isolated superficial dorsal vein-thrombosis was reported in 1958 by Helm et al. Since then around fifty cases have been reported. Patients experience a cord or string-like induration along the penile superficial dorsal vein, which is often painful and accompanied by localized inflammatory changes. This condition is benign and self-limited in most patients with complete resolution after 6 to 8 weeks of conservative management although sometimes surgery is indicated when it is associated with chronic or severe local pain., Material and Methods: We report on a 23-year sold man with Mondor's disease of the penis following a normal sexual intercourse, who recently underwent microsurgical left varicocelectomy., Results: Treatment consisted in NSAID Aulin (100 mg orally twice a day for 3 weeks) Ciproxin (500 mg orally twice a day for 10 days), Reparil 1 x 3 orally for 25 days and Lansox 30 mg orally 1 per day for 21 days. The patient was advised to abstain from sexual intercourse or masturbation until the thrombosis had completely resolved. In the follow-up visit there was the complete resolution of the disease with no evidence of superficial dorsal vein thrombosis or palpable penile plaque 30 days later. The patient was also able to have sexual intercourse without problems., Conclusion: Although penile Mondors' disease is rare, proper clinical diagnosis and consequent reassurance can help the patient to dissipate the anxiety and the following erectile dysfunction. Ultrasound and Doppler Ultrasonography examination was not useful for diagnosis but helped the clinician to show the patient that the disease is a benign condition.

Objectives: To detect obstruction in patients with LUTS suggestive of BPH comparing the prostatic intravesical protrusion detected by abdominal ultrasounds with uroflowmetry testing results with urodynamic study to make evidence of obstruction., Material and Methods: A series of 25 patients (mean age 67.9 years) at the first visit for BPH problems, underwent to routine examination including: abdominal ultrasound examination, TRUS, uroflowmetry IPSS and QoL questionnaires and urodynamic evaluation. We evaluated the degree in mm of prostatic intravesical protrusion by ultrasounds with a bladder volume between 150-220 cc. The degree of protrusion was classified as mild (<5 mm), moderate (5-10 mm) and severe (>10 mm), Qmax was divided in obstructed (<10 ml/s), equivocal (10-15 ml/s) and unobstructed (>15 ml/s). Confirmation or not of obstruction was validated by urodynamic study., Results: mean prostate volume was 41.4cc; IPSS 22.4; Quality of Life 4.0; post voided residual urine 97.8 cc; DAMPF 62.6; Schäfer 3.4; Qmax 9.9 ml/s. Almost all the patients with severe protrusion had obstructed flow confirmed by P/F study. Patients with severe protrusion and unobstructedflow have obstruction compensated by high pressure voiding., Conclusions: These results, despite of the numbers of patients, suggest that the degree of prostatic protrusion measured by abdominal ultrasounds is a data that, if correlated to obstructed Qmax, can be used in the evaluation of BPH patients and their grade of obstruction.

Objectives: To assess the precision of five different calculation methods in real-time bladder volume measurement., Material and Methods: Bladders from 10 medical staff volunteers were examined. Two examinations of each subject were performed by one examiner using the same ultrasound scannet Five different calculation algorithms were used on the frozen ultrasound pictures: the prolate ellipsoid method based on the formula: volume = length x width x heigth x 0.52 on two dimensions; the double area method based on the formula: volume = ex [C1 + C2 x ln(A1) + C3 x ln(A2)] on two dimensions; The double ellipsoid method on two dimensions; the method of one dimension of the shape of the bladder outlined manually with the maximal longitudinal diameter; the method of one dimension of the shape of the bladder outlined by smooth ellipsoid with the maximal longitudinal diameter After registration of the voided volume the subjects were scanned again in order to assure complete emptying., Results: Voided volumes ranged from 120 ml to 465 ml. The precision of each method was equal. Errors were not more than 25% of the voided volume. No significant improvement in accuracy for any of the methods was found., Conclusions: Ultrasound bladder volume calculation is an easy method for estimation of bladder volume. Errors can be reasonably accepted. Large variation, irrespective of methods, from the true bladder volume, indicates that the clinical evaluation of ultrasound bladder measurement must be interpreted with great care in some patients.

Sildenafil is the most prescribed oral agent for patients with erectile dysfunction (ED). Vardenafil is a new phosphodiesterase type 5 (Pde-5) inhibitor that was approved by the US Food and Drug Administration last year to treat patients with ED of various causes. Both of these Pde-5 inhibitors have vasodilating properties and effects on blood pressure (BP), and like nitrates, they work through the nitric oxide cyclic guanosine monophosphate pathway. The aim of this study was to investigate the influence of these Pde-5 inhibitors on BP and heart rate (HR) in normotensive men with ED by a crossover comparison. Thirty-five patients with ED were enrolled to evaluate and compare the effect of sildenafil (50 mg) and vardenafil (10 mg) on BP and HR. At the screening (baseline [B]) visit, sitting systolic blood pressure (B-SBP), diastolic blood pressure (B-DBP), and HR were measured. We performed a multiple administration for both drugs and, therefore, multiple measurements of BP and HR changes, 3 doses a week, on alternate days, late in the afternoon, and on an empty stomach. B-SBP, B-DBP, and HR were recorded before each 50-mg sildenafil dosing and after 30, 60, 120, and 240 minutes. Data were averaged over the 4 time points and compared with the baseline values obtained before each dosing. After a 3-week wash-out period, patients were crossed over to vardenafil (10 mg) with the same study design. After administration of both drugs, we observed a statistically significant decrease of BP and an increase of HR. On average, sildenafil caused a decrease of SBP ranging from 5.1 +/- 3.9 mm Hg during the first dosing to 4.7 +/- 4.2 mm Hg during the third dosing, DBP ranged from 4.4 +/- 4.9 to 4 +/- 4.1 mm Hg, and HR increased 1.8 +/- 2.0 bpm (first dose) and 1.2 +/- 0.9 bpm (third dose). With vardenafil, we recorded a greater variation for SBP and DBP. SBP decreased from 8.02 +/- 8.0 mm Hg during the first dosing to 5.4 +/- 5.5 mm Hg during the third dosing, whereas DBP decreased from 6.6 +/- 7.2 to 5.0 +/- 5.3 mm Hg, respectively. Recorded HR showed an increase of 3.1 +/- 3.2 bpm (first dose) and 2.4 +/- 2.3 bpm (third dose). After the first vardenafil administration, we recorded fainting episodes in 3 patients because of a decrease in BP greater than 20 mm Hg. Two of the patients were in therapy with doxazosin for benign prostatic hyperplasia (BPH). Cardiovascular response was not significantly different after the first dose between the 2 treatments. Vardenafil demonstrated clinically significant differences (fainting) with respect to sildenafil only during the first doses. We suggest that before starting therapies with Pde-5 inhibitors, particularly with the newer ones, that baseline cardiovascular parameters are measured and monitored, especially during the first dose, because of the presence of a "first dose effect." Moreover, it is necessary to pay particular attention to those patients in treatment with other drugs that could have a synergistic hypotensive effect as a result of vasodilation potentiation.

Primary Objective: to investigate if 30-MINUTES-TUMT can be performed under topical anesthesia and analgesics., Secondary Objectives: to evaluate retrospectively analgesics and to study parameters connected with pain., Materials and Methods: Eighty-nine patients underwent TUMT. Patients were divided into four groups with different medications. Paracetamol and tolterodin-L-tartrate were administered in all groups. The first group was also given hydromorphone hydrochloride and atropine sulphate, the second group dextropropoxyphene, the third group morphine and diclofenac, and the fourth group morphine and dextropropoxyphene. Pain during TUMT was registered using the VAS scale., Results: Pain during TUMT was (VAS in mm), respectively, total-first-second-third-fourth group: at 5 min -30, 31, 12, 28, 35; at 15 min -30, 23, 16, 25, 34; at 25 min -30, 28, 18, 25, 35. All patients accepted the treatment. No significant difference between the different drug schedules was noticed., Conclusions: It is possible to treat patients with 30-MINUTES-TUMT with local anesthesia and analgesics. The pain can be accepted by all patients.

Objective: Flow rate measurements in clinical studies require an amount of voided urine greater than 125 to 150 mL. Often patients do not void sufficient amounts of urine, and having them produce repeated flows is often difficult. Transabdominal sonographic scanning of the bladder is a simple method for estimating bladder volume. We determined by sonography the prevoiding bladder volume needed to void a sufficient amount of urine., Methods: Sixty-seven patients with a mean age +/- SD of 67.5 +/- 8.0 years underwent free flow rate measurement. Bladder volume was measured by transabdominal sonography when the patient had the sensation to void and after uroflowmetry to calculate residual urine., Results: The voided volume was 220 +/- 127 mL; the postvoiding residual urine volume was 92 +/- 88 mL; and the bladder scan volume was 309 +/- 158 mL. Among all patients, 23.9% had insufficient voided volumes of less than 125 mL in the flow rate measurements, and 31.3% had voided volumes of less than 150 mL. There was a strong correlation between the prevoiding measured volume and the voided volume (r = 0.836; P < .0001). Linear regression analysis of the flow rate recording yielded the following formula: voided volume = 11,766 + (0.673 x prevoiding volume)., Conclusions: Bladder scanning before uroflowmetry is a useful test for reducing the amount of nonevaluable flow rate data. If a voided volume of greater than 125 mL (>150 mL) is required, the mandatory prevoiding bladder scan volume should be greater than 200 mL (>250 mL), which would decrease the number of noneligible flow rate recordings from 23.9% to 4.5% (31.3% to 4.5%).

Objectives: To estimate the relationship between age and the values of different diagnostic tests in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic enlargement (BPE) and to compare prostate growth curves between the normal population sample, healthy men and men with LUTS., Material and Methods: A series of 354 men (mean age 70.2 years; range 45-91 years) with LUTS due to BPE were stratified into seven age groups and reviewed retrospectively. All patients underwent a standard evaluation, involving determination of the International Prostate Symptom Score (IPSS), digital rectal examination, uroflowmetry, determination of the prostate-specific antigen (PSA) level and transrectal ultrasonography. Descriptive statistics were used to describe all the variables and Spearman's correlation test was used to evaluate the relationships between them., Results: The mean prostate volume was 40.1 (+/-23.9) cm(3) and mean PSA concentration 3.9 (+/-4.2) ng/ml. Both values increased progressively from 27.5 ml and 1.5 ng/ml, respectively in the <54 years age group to 48.2 ml and 5.4 ng/ml, respectively in the <80 years age group. However, in the 75-79 years age group there was a decrease in both prostate volume and symptom score; PSA concentration remained unchanged and maximal flow rate increased slightly. A statistically significant but weak correlation was found between prostate volume and age (r = 0.25, p < 0.0001) and between PSA and age (r = 0.28, p < 0.0001). Prostate volume correlated positively with serum PSA (r = 0.54, p < 0.0001). The correlations between maximum flow rate and age, prostate volume, PSA and IPSS were r = -0.21, p < 0.0001; r = -0.18, p < 0.0006; r = -0.29, p < 0.0001; and r = 0.14, p < 0.0098, respectively., Conclusions: These data confirm that prostate volume and serum PSA concentration are significantly correlated and increase with advanced age. The correlations between uroflowmetry (Qmax) and age, prostate volume, serum PSA and IPSS were also significant. However, there was no relationship between symptoms and objective measures of BPE. The increase in different parameters of the severity of benign prostatic hyperplasia with advanced age is not continuous. The prostate volume alone is not useful in the estimation of disease severity.