The ageing male

More about health problems men face as they age.

THIS article continues the series on hormone-related problems in the adult and ageing male. In the previous articles, I wrote about the declining levels of HGH (human growth hormone/somatotropin) and testosterone, causing overall ageing (somatopause) and male menopause (andropause).

Together, the low levels of these hormones are the main causes of ageing of the brain (dementia, poorer cognitive functions), heart (artherosclerosis, weakened heart), bones (osteopenia or osteoporosis), sexual system (loss of libido and function), skin (thinning, dryness, sagging, and loss of elasticity), and possibly all other organs and tissues, since the hormones influence the functioning of almost all cells.

If you want to avoid being among those who suffer in old age, then you must understand what ageing does to your body, so that you can take the necessary precautions and actions. Foremost among these are leading a healthy lifestyle, having a healthy nutrient-dense diet (with nutritional supplements as required), maintaining a healthy weight, doing sufficient exercise, optimising your hormones, managing stress, avoiding injuries, and avoiding serious infections.

Benign prostate hyperplasia/hypertrophy (BPH)

This is perhaps the most common problem that afflicts ageing men, as about 75% of men will have the condition if they live up to 80 years. The hyperplasia (increase in the number of cells) that leads to the prostate enlargement actually begins in the 30s. The probability that you have BPH (after age 30) is roughly equivalent to your age.

Fortunately, only 40% to 50% of those with BPH have symptoms. Since this is not a premalignant condition, the lack of symptoms means no treatment is necessary even if the condition is detected at a routine examination. However, in such a situation, it would be wise to take steps to prevent the progression and emergence of symptoms later.

The symptoms are categorised as storage or voiding symptoms and are due to the obstruction of the urethra by the enlarged prostate. Storage symptoms include urinary frequency, urgency (urgent need to urinate), urgency incontinence (leakage due to urgency), and urinating at night (nocturia).

Voiding symptoms include poor urinary stream or dribbling, hesitancy (having to wait for the stream to begin), intermittency (the poor stream starts and stops intermittently), and straining to urinate. Sometimes voiding may be painful. BPH may also give ejaculatory problems during sex.

Severe obstruction may lead to frequent urinary infections, urinary retention (failure to void completely) and bladder or kidney stones. Acute urinary retention (inability to void) requires emergency treatment. Over time, untreated cases may lead to damage to the ureters and kidneys, which may result in serious complications such as kidney disease and even kidney failure.

The International Prostate Symptom Score (IPSS) helps the patient and doctor assess the severity of the condition, progress of disease, and effectiveness of treatment. This helps the doctor decide whether you need treatment, and if you do, what kind of treatment. People with the same degree of symptoms may be affected differently and may require different management of their problem.

If you have any of the symptoms, it is best to consult your doctor early, so that the appropriate advice may be given. You may not need any treatment at all, but only given advice (eg. to avoid alcohol and caffeinated drinks, and to empty your bladder and avoid drinking just before bedtime).

Some doctors may advice herbal or nutritional supplements, which may include saw palmetto and pumpkin seed extracts. While these are popular in Europe (and also here in Malaysia), the effectiveness is disputed, and the remedy is not as popular in the US.

If your symptoms are more serious, then your doctor will conduct a proper evaluation/examination, which may include a rectal examination, blood tests, and ultrasound.

Since prostate cancer is also a concern for ageing men (and the symptoms may overlap), your doctor will always be watchful for that condition too. The blood PSA (prostate-specific antigen) is often checked as a screening tool, but PSA alone is not useful. For PSA levels above 2, the PSA/free PSA ratio has been found to be more predictive.

The most likely cause of BPH is the inappropriate high level of free (active) testosterone around the prostate glands due to malfunctioning valves of the internal spermatic vein. The varicocele (enlarged malfunctioning veins) and retrograde (reverse) flow causes the testosterone directly coming from the testes to surge to many times (up to 130 times) over that in the systemic circulation. Oestrogens have also been implicated as contributory factors.

It has been known for sometime that androgens (testosterone, and especially its metabolite DHT) promote BPH, but the failure to recognise the correct mechanism described above have made it impossible for the most appropriate treatment to be offered, until now.

Understanding this mechanism also gives comfort that you need not worry about BPH if you are on androgen therapy, and if you do not have the internal spermatic vein varicocele and retrograde flow.

If androgens cause BPH, why do they occur in ageing men (who have low androgens)? It does not seem right to treat the condition by anti-androgens at the expense of their overall health. The proper treatment should first be to treat the varicocele and retrograde flow, which cause a high local concentration of testosterone, despite the low systemic levels. However, since the discovery of the above mechanism as the most probable cause was recent (2008), it will take some time before enough studies are done to show if the specific treatment to reverse the abnormality (a minimally-invasive interventional radiological procedure called the Gat-Goren Technique) works as expected. Results so far are good.

Since androgens are blamed for BPH, medical treatment to reduce prostate size has been based on anti-androgens. The drugs (5-reductase inhibitors) prevent conversion of testosterone to DHT (dihydrotestosterone, which is synthesised in the prostate by conversion of testosterone, is 10 times stronger than its precursor, and is the main promoter of prostate hyperplasia).

Unfortunately, most men with BPH already have low circulating androgens (most are already post-andropause), and anti-androgen treatments make their overall condition worse. The only advantages are the improvement of BPH, and less balding (since DHT is also the main culprit for male-pattern baldness). However, they may end up with less libido, erectile dysfunction, central obesity, gynaecomastia (enlarged breasts), and other problems related to depleted androgens (see previous articles).

Another group of drugs (alpha blockers) used are those that relax the muscles at the prostate and bladder necks, thus relieving the urinary blockage. Their side effects include postural hypotension, ejaculation problems, nasal congestion, and body weakness.

Other drugs (including Viagra) have been used with some beneficial results. Some doctors may prescribe mineral supplements (eg zinc), and drugs which prevent the conversion of testosterone to oestrogen.

Surgery may be advised if there is risk of recurrent infections and serious long-term damage to the ureters and kidneys. There are several options the urologist may opt, from minimally invasive techniques to the gold-standard TURP (trans-urethral resection of prostate).

Prostate cancer

After age 50, the probability of having prostate cancer cells is approximately your age minus 20. That means at 70, it is 50%, and if you live to 120, it will be 100%. Of course, that is only a statistical guideline, and you can reduce it by having a healthy lifestyle, good diet, plenty of exercise, and practising qigong. But it does give reason for us to worry, and the incidence will definitely rise as life-expectancy increases.

One interesting fact is that clinically diagnosed prostate cancer is 120 times higher in the US compared to China!

Since most prostate cancers progress slowly (only one-third are aggressive and metastasise), diagnosis is often late. After diagnosis, the patient is more likely to die of other causes than the prostate cancer.

The symptoms are quite similar to BPH, but with the possibility of bloody urine (hematuria). Painful micturition (dysuria) and pain may also be a feature.

Many are diagnosed on presentation of these symptoms, or through routine PSA screening. Once confirmed by biopsy, treatment depends on the aggressiveness of the cancer as well as the age and general wellbeing of the patient. Since it affects older men, and is often slow growing, the pros and cons of the side-effects of treatment versus the expected benefits have to be weighed, especially if the cancer is localised.

Treatment may include surgery, chemotherapy, radiotherapy, high-intensity focused ultrasound, cryosurgery, and other modalities.

Since androgens stimulate prostate cells, hormonal therapy is one option. Again there is controversy because the patients are all elderly post-andropausal men with little androgens to start with!

The first “proof” that androgens are implicated was the regression of prostate cancer after castration, and relapse after testosterone treatment. However, paradoxically, other studies showed that men with resistant prostate cancers have better quality of life and survival rates if they have higher testosterone levels. Since then, it has been realised that the progression with testosterone only happens in castrated patients.

Then there are the possible roles of oestrogens and progesterone. There are many different opinions on this subject, which you should discuss with your doctor if you are unfortunate enough to have prostate cancer. It is a pity if you are deprived of the androgens (through castration or anti-androgens) when these are what you need to have a healthy life.

With all the confusion, I hope you will also consider qigong as a safe complementary method to fight the cancer.