Case scenarios in androgen deficiency

Deciding whether to choose androgen replacement for a particular patient is one of the many tasks facing the urologist. Factors including androgen levels, medical history, symptom profile, current medications, and prostate cancer risk all need to be considered when making this decision. However, the role each of these factors plays in arguing for or against androgen replacement remains controversial and more research is needed in many of these areas before the outstanding issues can be resolved. This article presents three cases involving patients who may require androgen supplementation. The cases describe (1) partial androgen deficiency syndrome, (2) testosterone deficiency in an anorchic man after bilateral orchiectomy for seminoma, and (3) a patient with sildenafil-refractory erectile dysfunction following treatment of localized prostate cancer with radiation therapy and androgen ablation. These cases illustrate some of the dilemmas and controversies surrounding androgen replacement that face the practicing urologist.     

Prostatic involution: effect on androgen receptors and intracellular androgen transport.

In the regressing rat prostate gland the concentration of cytoplasmic receptor declines from a maximal level of 174 ± 24 fmoles/mg protein 1 day after orchiectomy and is virtually undetectable after 7 days. The results of tissue mixing experiments in which equal amounts of prostate from rats orchiectomized 1 day and 7 days previously are incubated and homogenized together indicate that at the latter time the prostate contains factors, presumed to be proteolytic enzymes, which can eradicate the binding of radioactive dihydrotestosterone to cytoplasmic receptor. In the apparent absence of cytoplasmic receptor, the capacity of the cell to transfer androgens into the nucleus is kept intact at a level 30–60% of the experimentally determined maximum, and the competence to form intranuclear receptor is preserved. However, the nuclear receptor observed 7 days after orchiectomy is smaller than the one observed 1 day after orchiectomy.     

Adrenocortical function of the domestic fowl: effects of orchiectomy and androgen replacement

The effect of orchiectomy and androgen replacement on cockerel adrenocortical function was investigated. Orchiectomized cockerels (2 weeks old) were implanted with Silastic tubing containing various amounts of one of the following steroids: cholesterol, testosterone (T), androstenedione (A4), and 5 alpha-dihydrotestosterone (DHT). Birds were administered additional implants, containing doses of steroids equivalent to those of the initial implants, at 4 and 8 weeks of treatment (i.e., 6 and 10 weeks of age). Sham-operated cockerels administered empty implants served as intact controls for comparison of data. Animals were killed after 10 weeks of treatment (12 weeks old). Trunk plasma corticosterone (B) and plasma T, and B production by collagenase-isolated adrenocortical cells incubated briefly (2 hr) with or without steroidogenic agents were measured by radioimmunoassay. Orchiectomy with implantation of the inert sterol, cholesterol (hereafter referred to as orchiectomy), did not alter plasma B concentrations and did not affect basal cellular B production or cellular B production induced by a maximal steroidogenic concentration of ACTH or that maximally supported by 25-hydroxycholesterol. However, orchiectomy did lower maximal 8-bromo-cyclic AMP-induced B production by 30%. Low-implant doses of A4 (1-cm implant) and T (0.3-cm implant), that maintained comb growth, lowered plasma B concentrations by 24-42%, whereas a high-implant dose of T (3-cm implant) and all implant doses of DHT had no effect on plasma B concentrations. Thus, androgen replacement had different effects on plasma B depending on the type of androgen and the implant dose. In contrast, androgen replacement consistently suppressed basal and maximal ACTH-induced cellular B production regardless of the type of androgen. Furthermore, the degree of suppression was dose-dependent. These results suggest that the differential effect of androgen replacement on plasma B concentrations was due to differences in the clearance of circulating B and/or differences in blood volume. In addition, the present study suggests that in the absence of the testes, androgens are suppressants of adrenocortical cell function in the domestic fowl.     

Glyceraldehyde-3-phosphate dehydrogenase expression during apoptosis and proliferation of rat ventral prostate.

Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) is a multifunctional enzyme known to play a critical role in neuronal apoptosis. We undertook the current studies to determine whether GAPDH also plays a role in prostate epithelial cell apoptosis in response to androgen deprivation. To do so, we analyzed GAPDH staining by immunohistochemistry during castration-induced involution and androgen-induced regeneration of rat ventral prostate. We found that GAPDH was undetectable in secretory epithelial cells at baseline and that staining did not increase in the epithelium during the period of peak apoptosis from 1 to 3 days after castration. However, GAPDH levels did increase within nuclei of some basal epithelial cells 5 days after castration and within the cytoplasm of all secretory epithelial cells 7 days after castration. GAPDH was also abundant within the cytoplasm of secretory epithelial cells during the period of maximal cell proliferation from 2 to 3 days after androgen replacement and was clearly apparent within nuclei of some epithelial cells 4 days after androgen replacement. Our studies suggest that GAPDH plays multiple roles during prostate epithelial cell apoptosis and proliferation.     

Influence of hormonal replacement on the ventral lobe of the prostate of rats (Rattus norvegicus albinus) submitted to chronic ethanol treatment

The harmful influence of the chronic alcohol ingestion on the male reproductive system leads to important alterations including hypogonadism and feminization, besides the morphological and functional disorganization of the different sexual glands. So, the aim of this study was to analyse the structural changes on the ventral lobe of the prostate of rats with hormonal replacement associated to chronic alcohol ingestion. A total of 30 rats (Rattus norvegicus albinus) was divided into three groups: control-received water; alcoholic-received ethanol diluted to 20% and hormone-treated alcoholic-received ethanol diluted to 20% associated with the administering of testosterone (5mg/kg of weight) during the last 30 days of treatment. After 150 days of treatment, the animals were sacrificed, the prostate removed and submitted to transmission and scanning electron microscopies, histochemical analysis for acid phosphatase, testosterone level and stereologic analysis. In the alcoholic group the results demonstrated reduction of the total cellular volume and disorganization of the organelles involved in the secretory process. It was characterized a partial recovery of the cellular volume after treatment with testosterone. It was concluded that the ethanol impaired the cellular morphology and the hormonal replacement by itself did not bring about efficient remodeling of the organelles responsible for the secretory process.     

Hormone-independent polyamine metabolism of squamous cell carcinoma of the prostate

The levels of polyamines and their synthesizing enzymes in squamous cell carcinoma of prostate implanted in intact as well as castrated male rats were determined after certain hormonal manipulations. The tumour was found to grow with an identical rate in non-castrated and castrated rats. Polyamine content and activities of polyamine synthesizing enzymes in the tumour were found to be much lower compared to their values in ventral prostate. Moreover, the levels of these parameters were comparable in tumours whether implanted in non-castrated or gonadectomized animals. The sequential analyses of putrescine and spermidine and activities of L-ornithine decarboxylase and S-adenosyl-L-methionine decarboxylase of tumours at different time intervals showed a significant reduction in their levels at 30 days compared to 10 days post implantation in non-castrated as well as castrated rats. Daily intramuscular administration of tumour-bearing intact or castrated animals with testosterone (50 micrograms/g), beta-estradiol (2 micrograms/g) or cyproterone (12.5 micrograms/g) for 10 days did not influence polyamine metabolism in tumour tissue. However, either beta-estradiol and cyproterone treatments or castration were found to decrease polyamine synthesis in ventral prostate. At the same time, the testosterone replacement therapy did not allow polyamine levels or activities of polyamine synthesizing enzymes to decline in the ventral prostate of castrated rats. Our results demonstrated that contrary to ventral prostate, the polyamine metabolism in squamous cell carcinoma of prostate is independent of hormonal control. The loss of hormonal sensitivity of polyamine metabolism in the prostatic tumour could be the result of qualitative changes that occurred during transformation.     

Effect of extirpation of the sensorimotor cortex on the formation of conditioned reflexes to a complex signal in the ontogeny of the cat

In kittens of the age from 39 days to 4 months the influence was studied of the sensorimotor cortex (SMC) ablation on formation and preservation of previously elaborated reflex to a simultaneous complex stimulus (light + sound) with extinction of reaction to nonreinforced components of the complex signal. It is shown that SMC ablation in the age up to 2.5 months does not affect the formation or preservation of the conditioned reflex. The SMC ablation in preliminarily trained kittens in the age of 3.5 months and older leads to disinhibition of components differentiation with preservation of the positive conditioned reflex to the complex signal. In untrained kittens of the same age the SMC ablation leads to disability of animals to inhibit the motor reaction to differentiation signal. The question is discussed of SMC significance in the ontogenesis at formation of adequate forms of behaviour requiring heterosensory interaction.     

The reactions of cats to species-specific acoustic signals during electrical stimulation of the hypothalamus before and after the removal of the sensorimotor area of the cortex

In conditions of chronic experiment cats reactions were studied to species-specific acoustic signals (SAS) presented separately and against the background of the electric stimulation of the hypothalamus before and after partial bilateral ablation of the sensorimotor area of the cortex (SMC). It was shown that separately presented SAS caused in animals motor reactions, mainly orienting and negative. Ablation of SMC (field 4,6) caused an increase of positive reactions to sound, including also orienting reactions. A selective character of the reaction to SAS of agonistic type was revealed in animals with "true" aggression to combined (acoustic and subthreshold electric) stimulation. In animals with "false" aggression the combined stimulation caused only nonspecific elements of motor reactions and agonistic vocalizations. SMC ablation caused an increase of aggressive reactions to combined stimulation, revealed in the form of tendency for all animals. In this case in animals with "true" aggression after operation the probability increased of the appearance of motor reactions of aggressive type in comparison with agonistic vocalizations.     

Ultrastructural study of the ventral lobe of the prostate of mice with streptozotocin induced diabetes (C57BL/6J)

Morphological and functional changes caused by diabetes in the accessory sex organs and especially the prostate have been reported by several investigators. The aim of the present study was to examine the possible deleterious effects of experimentally induced diabetes on the secretory epithelium of the ventral prostate of mice. Sixteen adult male C57BL/6J mice were divided into two groups. The diabetic group received a streptozotocin injection of 75 mg/kg, while the control group received only 0.1 ml citrate buffer, i.p. After 30 days, the diabetic state was ascertained, the animals were sacrificed and the ventral lobe of the prostate was collected for histological and ultrastructural examination. The results showed reduction in glandular epithelium cell height, increased numbers of cytoplasmic vacuoles and thickening of the extracellular matrix. In conclusion, experimental diabetes has harmful effects on the secretory epithelial cells of the ventral lobe of the prostate of mice.     

Structural,ultrastructural and immunohistochemical evidence of testosterone effects and its ablation on the bulbourethal gland of the Artibeus planirostris bat (Chiroptera,Mammalia)

This study evaluated the effects of testosterone in the bulbourethral glands (BG) of the bat, Artibeus planirostris, by performing castration and posterior hormonal supplementation of the animals. The results showed a decrease in testosterone levels in animals 15 days after castration, which induced a small reduction in epithelium height, percentage of AR+ cells, and an increase in the amount of basal cells. This reduction became more severe in groups castrated for longer periods (19 and 22 days), where there was also an increase in apoptotic cells. Moreover, the hormonal supplementation increased testosterone levels (after 3 and 7 days of supplementation), causing a glandular reactivation that increased the epithelium height and AR expression. In conclusion, BG took longer to respond to ablation of testosterone than other reproductive glands, since it showed evident aspects of regression only in animals 22 days after castrated.     

Preliminary studies on the cultivation and characterization of mini-pig prostate epithelial cells

Mini-pig prostate epithelial cells exhibited the unique metabolic characteristics associated with the specialized function of production and secretion of high levels of citric acid. Epithelial cell suspensions from mini-pig prostate were successfully grown in primary and secondary cultures. The cultured epithelial cells exhibited rapid proliferation reaching confluency in approximately 6 days. Growth and proliferation of fibroblasts were markedly restricted by the dominance of epithelial cell growth. Confluent cultures could be maintained for approximately 6 weeks. The epithelial cells retained their polymorphic appearance in primary and secondary cultures and exhibited the characteristic formalin-resistant acid phosphatase reaction. Testosterone stimulated mitochondrial aspartate aminotransferase (mAAT) activity and citrate production by confluent epithelial cell cultures. These initial results indicate that cultured epithelial cells derived from mini-pig prostate might be an excellent model related to human for studies of prostate biology and hormonal regulation.     

Modulation of smooth muscle cell function: morphological evidence for a contractile to synthetic transition in the rat ventral prostate after castration

In this study, we evaluated the involvement of rat ventral prostate smooth muscle cells (SMC) in secretory activity and whether this function is modulated after castration. Cell morphology was examined at both light and electron microscopy levels and the organelles involved in secretory function were labeled by the zinc-iodide-osmium (ZIO) method at the ultrastructural level and their volume density was determined by stereology. Castration resulted in marked changes of the SMC, which adopted a spinous aspect and abandoned the layered arrangement observed in the prostates of non-castrated rats. The volume density of ZIO reactive organelles increased progressively after castration, reaching significantly higher levels 21 days after castration. Since previous studies have demonstrated that SMC express SMC markers (even 21 days after castration) and are able to respond to adrenergic stimulation, we concluded that differentiated SMC are able to shift from a predominantly contractile to a more synthetic phenotype without changing their differentiation status.     

Ultrastructural and proliferative features of the ventral lobe of the prostate in non-obese diabetic mice (NOD) following androgen and estrogen replacement associated to insulin therapy

Diabetes causes harmful effects on prostatic function. Thus, the aims of this study were to characterize morphological and proliferative features of the prostate of diabetic mice after long-term glycemic control and testosterone and estrogen replacement. A total of 48 mice (Nod and BALBc) were used. After 20 days in a diabetic state, the mice were divided into six groups: the control group received a 5 mL/kg dose of peanut oil; the diabetic group received the same treatment as the control group; the diabetic-insulin group received 4 IU doses of insulin; the diabetic-testosterone group received a 5 mg/kg dose of testosterone cypionate; the diabetic-estrogen group received a 25 μg/kg dose of 17β-estradiol; the diabetic-insulin-testosterone-estrogen group received insulin, testosterone and estrogen at the same concentration as the other groups. After 20 days, the ventral lobe was processed for morphological and immunological analyses. The results showed structural disorganization, which was more intense in the diabetic group than in the other groups. The diabetic state showed a proliferation and apoptosis rate that was two times higher than that found in the control group. To conclude, diabetes disturbed the prostatic secretory activity and the association of insulin, testosterone and estrogen was crucial for glandular structural restoration, characterizing the complex activity of the prostate. The imbalance verified between the proliferation process and apoptosis in diabetic mice showed diabetes to be a triggering factor for prostatic pathogenesis.     

Thyroidal involvement in the expression of avian muscular dystrophy

We showed previously that propylthiouracil (PTU), a thyroid inhibitor, could alleviate several major signs of hereditary muscular dystrophy in chickens. The goals of the present investigation were to: (1) determine whether a nearly athyroid condition (achieved within two days after hatching by surgical thyroidectomy plus PTU) during an 11-day period beneficially affects the dystrophic condition when followed by triiodothyronine (T3) replacement to 33 days of age; (2) determine the beneficial effects on the expression of avian dystrophy when the thyroidectomized-PTU-treated chickens received a wide range of moderate to low T3 replacement doses beginning by two days after thyroidectomy; and (3) examine the thyroid hormone receptor system in dystrophic muscle for a possible abnormality. Thyroid deprivation increased muscle function (righting ability) and reduced plasma creatine kinase activity in dystrophic chickens. The major thyroid-related abnormality in dystrophic pectoralis muscles was an increased maximum binding capacity of solubilized nuclear T3 receptors.     

Hormonal therapy for stage D cancer of the prostate.

Adenocarcinoma of the prostate is the most common malignant neoplasm occurring in men. About half of patients present with metastatic disease. The mainstay of the treatment of stage D cancer of the prostate is hormonal therapy. Bilateral simple orchiectomy remains the gold standard with which other therapies must be compared. Luteinizing hormone-releasing hormone analogues and antiandrogens are now most commonly used but are costly. Initiating hormonal therapy immediately on diagnosing metastatic disease appears to have some advantage over delaying therapy until a patient is symptomatic. Total androgen blockade also appears to be beneficial in terms of survival but at high cost.     

Hormonal therapy for prostate cancer

Updates on hormonal therapy in the treatment of prostate cancer are presented. The most common therapy is to reduce testosterone to castrate levels. A dosage of 1 mg diethylstilbestrol daily prolonged survival in patients with advanced prostate cancer. The leuteinizing hormone-releasing hormone agonists have essentially replaced surgical orchiectomy in the vast majority of clinical settings; however, a major problem with the leuteinizing hormone- releasing hormone agonists has been the surge and flare of testosterone levels. If hormonal therapy is initiated early, the risk of major complications is significantly decreased. Combined androgen blockade is better than monotherapy, although there is only a small clinical benefit. When androgen deprivation is used for a short time and the normal androgen milieu is re-established, the side effects and toxicity of androgen deprivation are decreased. The major complications of androgen deprivation include hot flushes, reduction of bone mineral density, osteoporosis, and anemia. Intermittent androgen blockade might have the same benefits of total androgen suppression with fewer side effects, increased duration of androgen dependence, and less cost. The 10 steps to take when advising patients about initiation of androgen deprivation therapy are reviewed.     

Differential proliferative response of the ventral prostate and seminal vesicle to testosterone replacement

We have investigated epithelial cell proliferation and the rate of glandular recovery of the ventral prostate (VP) and seminal vesicle (SV) promoted by testosterone replacement (TR) in castration-induced regressed glands. Adult male Wistar rats were castrated and, after 21 days, they were treated with testosterone propionate (4 mg/kg/day). Intact (CT) and castrated rats without TR (CS) were also analysed. VP and SV were processed for histochemistry, morphometric-stereological analysis and immunocytochemistry to determine the PCNA index (PI). After 10 days of TR, the VP weight reached approximately 72% of the CT values, while the SV weight exceeded approximately 17% of the CT values. By the third day of TR, VP and SV presented a mean PI of 34% and 94% for distal region and 14% and 22% for proximal region, respectively. SV also had more luminal cells PCNA-positive than VP, mainly in the distal region. The PI values fell on days 5, 7 and 10, but were still higher than CT. These findings indicate that epithelial cells from involuted SV are more responsive to TR than those from VP when stimulated to proliferate and replace the luminal cell population, suggesting a different mechanism regulating cell proliferation in response to androgenic stimuli.     

Notch1-expressing cells are indispensable for prostatic branching morphogenesis during development and re-growth following castration and androgen replacement

Notch expression is frequently associated with progenitor cells, and its function is crucial for development. Our recent work showing that Notch1 is selectively expressed in basal epithelial cells of the prostate and higher Notch1 expression during development suggests that Notch1-expressing cells may define progenitor cells in the prostate. To test this hypothesis, we have generated a transgenic mouse line in which the Notch1-expressing cells can be ablated in a controlled manner. Specific targeting was achieved by expressing the bacterial nitroreductase, an enzyme that catalyzes its substrate into a cytotoxin capable of inducing apoptosis, under the Notch1 promoter. Cell death in transgenic prostate was confirmed by histological analyses including terminal dUTP nick-end labeling and caspase 3 immunocytochemical staining. We evaluated the consequences of ablation of Notch1-expressing cells in two systems, organ culture of early postnatal prostates and re-growth of prostate in castrated mice triggered by hormone replacement. Our data show that elimination of Notch1-expressing cells inhibited the branching morphogenesis, growth, and differentiation of early postnatal prostate in culture and impaired prostate re-growth triggered by hormone replacement in castrated mice. Furthermore, we found that Notch1 expression following castration and hormone replacement was concomitant with known basal cell markers p63 and cytokeratin 14 and was high in the proliferative human prostate epithelial cells. Taken together, these data suggest that Notch1-expressing cells define the progenitor cells in the prostatic epithelial cell lineage, which are indispensable for prostatic development and re-growth.     

Inhibition of 5-alpha-reductase activity induces stromal remodeling and smooth muscle de-differentiation in adult gerbil ventral prostate

Prostatic differentiation during embryogenesis and its further homeostatic state maintenance during adult life depend on androgens. Dihydrotestosterone, which is synthesized from testosterone by 5 alpha-reductase (5 alpha-r), is the active molecule triggering androgen action within the prostate. In the present work, we examined the effects of 5 alpha-reductase inhibition by finasteride in the ventral prostate (VP) of the adult gerbil, employing histochemical and electron microscopy techniques to demonstrate the morphological and organizational changes of the organ. After 10 days of finasteride treatment at a dose of 100 mg/kg/day, the prostatic complex (VP and dorsolateral prostate) absolute weight was reduced to about 18%. The epithelial cells became short and cuboidal, with less secretory blebs and reduced acid phosphatase activity. The luminal sectional area diminished, suggestive of decreased secretory activity. The stromal/epithelial ratio increased, the stroma becoming thicker but less cellular. There was a striking accumulation of collagen fibrils, which was accompanied by an increase in deposits of amorphous granular material adjacent to the basal lamina and in the clefts between smooth muscle cells (SMC). Additionally, the periacinar smooth muscle became loosely packed. Some SMC were atrophic and showed a denser array of the cytoskeleton, whereas other SMC had a highly irregular outline with numerous spine-like projections. The present data indicate that 5 alpha-r inhibition causes epithelial and stromal changes by affecting intra-prostatic hormone levels. These alterations are probably the result of an imbalance of the homeostatic interaction between the epithelium and the underlying stroma.