Elderly men

Causes of aging

The hormonal changes, mainly the change in testosterone level may be responsible for most of the differences of aging or so to call the symptoms of being elderly. The level of male sexual hormone starts declining after the third decade. The testosterone level of a 75 year old man is only 65% of a young man’s level!
The decline of hormone level appears in the decline of total testosterone level and in the decline of free (not bound to any protein) or so to call biologically available testosterone level. The decline of total testosterone level is 0.4%, while free testosterone declines 1.2% a year. The level of hormone binding protein (SHBG) increases that speeds up the lack of testosterone. On the level of neural regulation the potency of LH (luteinizing hormone) that stimulates the production of male sexual hormones is decreased. The level of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) declines in the adrenal gland that indicates that the second possibility of testosterone production is shaken. The number of testosterone producing cells (Leydig cells) is not changing in the testicles with age but their activity is significantly decreasing. The hormonal differences don’t depend on the Body Mass Index (BMI).
Overall the state of testosterone deficiency is developed.


Symptoms of aging

General symptoms

The emotional stability of the man is loosening, and behavioral changes occurring as a consequence of the declining testosterone level. Men may be more nervous and aggressive at such times, their impatience is growing. The occur of hot flashes, agitation, locked-up stress, dizziness, headache and low concentration ability are general symptoms too. Sleep disorders may occur and memory decays. Sleep disorder fortifies the symptoms, fatigability increases and physical capacity decreases. Men suffer more from work-relating conflicts so more patience is required in their family life from their family members. The incidence of depression is significantly increases. Total body muscle mass decreases and so does muscle length and strength too. Men are having troubles with hair growth, especially with the longitudinal growth. Reaction to touch stimuli decrease, sensory system generally decays that leads to increasing sexual problems.
During testosterone deficiency the risk of cardiovascular diseases increases since the protective effect of the male sexual hormone is missing. There are changes in blood formation, too.

Sexual symptoms

The attitude that old people don’t require sexual intercourse seems to be general even today; the examination of sexual functions or questions about it at least does not include the age group above 65 years. However the elderly age group requires sexual life too. According to surveys 28% of men 66-71 years of age have 1 intercourse per week, while 83% of men and 64% of women 80-102 years of age require – though without intercourse- sexual affection and touch.
Late in life several factors influence sexual life. Libido decreases due to hormonal changes and erectile dysfunctions are more frequent. Ejaculation problems occur too. Sexual symptoms may be increased by the more common diseases, systematic diseases and the medicines taken because of these diseases. The age-related physical and psycho-social changes may team up with these too.
Old-age sexual activity is influenced by mood, self-confidence, human relations and general satisfaction with life. Late in life legitimate sexual life is typical and its frequency is related with the couple’s previous sexual relationship. Late in life the cessation of sexual activity is most frequently caused by the lack of partner. In addition intimacy is less accepted socially. It is generally accepted that reaching the age of retirement means you have to retire from sexual life too.
The decreasing libido is an often consequence of aging, though it may occur in earlier age too, with hormonal changes or psychological causes in the background, but chronic prostatitis has similar symptoms too.
Erectile dysfunctions are the most common sexual change. One of its causes is the previously mentioned hormonal change. The details of complex erection process are well known by nowadays. Vision, touch and smell generate stimuli equally that gets through the cerebral and spinal pathways and parasympathetic branches to the penis. Here the stimuli cause release of nitric oxide from endothelial cells that diffuse easily to smooth muscle cells of arteries in corpus cavernosum and spongiosum where they have a vasodilating effect through a biochemical reaction. When these muscle cells relax the vessel wall relaxes, the vessel itself dilates and the flow of blood is increased. By the special construction of the vessels of corpus cavernosum and spongiosum bigger venous sinuses are filled with blood constricting the veins and preventing blood from leaving to develop erection. So an appropriate sexual stimulus, the physiological function of the neural pathways and the participating structures and the elasticity of vessel wall is required to achieve erection. If one of these is not functioning properly, the penis will not be fully erect. These systems often sustain an injury during the process of aging therefore it is understandable that erectile dysfunctions are more common in older men.

Erectile dysfunction is defined as a persistent (at least for 3 months) or recurrent inability to obtain or maintain until completion of the sexual activity, an adequate erection. It may be of constitutional or psychological origin though the simultaneous appearance of both causes together is naturally the most common. Vascular diseases are the most common of constitutional changes but nerve damages, hormonal changes, anatomical differences, certain systematic diseases and their medication may occur too. The main risk factor is diabetes where erectile dysfunctions are four times more likely since it induces vascular and nerve damage and high blood pressure since it induces vascular damage too. High cholesterol level and high triglyceride level, cardiac diseases, prostate diseases and their certain treatment methods are among the most important risk factors too. Don’t forget: Smoking induces vascular damage too! This is the symptom that often leads aging man or a patient suffering from male menopause to physician and this is how certain systematic diseases or e.g. cardiac problems are diagnosed.
The ejaculation problem is common too, where the decrease of semen volume is typical, but painful ejaculation may occur too which is mainly caused by low urinary tract symptom that is described later in a different chapter.

The diagnostic methods have developed remarkably in the last years; both the strength and the angle of erection can be measured painlessly and objectively with instruments. Diagnostic imaging techniques have developed significantly too. With their help the origin of the disorder may be diagnosed painlessly providing an opportunity to casual treatment to achieve the best result. If there is no cure for the diagnosed cause but it can be maintained, like e.g. diabetes the erection ability may be improved though functional restoration is not possible, the occasional erection may be achieved at least.
Aging –in contrast with previous assumptions- is not necessarily accompanied with fundamental changes of sexual possibilities and habits. Regular sexual life helps to maintain juvenile appearance and plays its role in maintaining optimal body weight.


Prostate diseases

The prostate starts growing in puberty and reaches its weight of 15-20 g. After that it remains unchanged for a decade then the histological changes typical in benign prostatic hyperplasia (BPH) are getting more and more obvious.
The most common prostate disease is the chronic prostatitis. Usually a bacterial infection is in its background; microorganisms can get to the prostate in several ways: from the so called chills through a bacterial focus to a sexually transmitted infection. Other pathogenic microorganisms are also known (the so called obligate intracellular parasites, for instance: Chlamydia trachomatis, Mycoplasma hominis and genitalium, or Ureaplasma urealyticum) that they may infect the prostate and there is a chronic prostatitis of non-bacterial origin, too.
The process of Benign Prostatic Hyperplasia (BPH) has two phases: the pathological phase which is asymptomatic with histological changes only, and the clinical phase when the symptoms occur. The BPH is very common among urological diseases of men; its incidence is 50-90% in men 50-85 of age, according to literature. This process is clearly age-related and begins in the periurethral glandular tissue of the prostate gland. The development of the symptoms is a clear consequence of the disability to empty the bladder. The simplified mechanism of the process has two components: a static and a dynamic. The static component means a decreased urine flow and a weakened urine stream besides the prostatic enlargement, while the dynamic components are the symptoms of irritation, the frequency of urination and motivation symptoms. There is a strong correlation between the quantity of male sexual hormone (testosterone) and BPH. The level of testosterone declines, while the level of estrogen increases during aging. The dynamic components are caused by increased tone of smooth muscles in the capsule of the prostate gland and the neck of the bladder. Besides the contractility of the bladder wall is decreased and the muscle tone is increased. Adrenergic receptors play an important role here.
The malignant tumor of the prostate or prostate cancer develops in men above 50 of age. Its incidence is increasing with aging. The level of PSA (prostate specific antigen) in blood may indicate prostate cancer but the results of physical examination are of decisive importance too. The change diagnosed in time may be treated radically and may be cured. That is the explanation for the necessity of regular urological checkup in men above 50 of age. The progression of the cancer may metastasize to lymph nodes first, then to bones and other distant organs (lung, liver).


Symptoms of prostate diseases

The complaints are typical in all of the above mentioned prostate diseases. Dysuria, the difficulty starting urination, especially at dawn or in the morning, the weak stream, decreased intensity of urine, urge to urination, frequent urination, nocturia (increased urination at night), anuria or incidental hematuria may be found in connection with many clinical appearance, so it is practical to summarize them as Lower Urinary Tract Symptoms (LUTS). Any obstruction (Bladder Outlet Obstruction BOO) in the low urinary tract may cause LUTS: the prostate gland enlargement (Benign Prostatic Enlargement BPE), the prostate cancer (PCA), the bladder neck stenosis, or rigidity, the urethral stenosis and even the functional disorders of bladder musculature. The differentiation between these causes in the background of LUTS may be performed only by time-consuming urodynamic investigations.
The lower urinary tract syndrome caused by the prostate gland enlargement may be led back to three causes basically: 1. the compression of the prostatic urethra by the enlarged prostate gland (static component), 2. the increased adrenergic activity detected in the prostate gland and the bladder neck (dynamic component) and 3. the changes of bladder musculature (decreased contractility of bladder muscles, increased irritability).
The International Prostate Symptom Score (IPSS) is currently the best method to characterize the symptoms and measure the effectiveness of the treatment. Kidney function tests and urinalysis have utmost importance among the laboratory parameters, the check of prostate specific antigen (PSA) is inevitable, while the digital rectal exam and transrectal ultrasonography give information on the actual size of the prostate gland. Uroflowmetry measures the volume of urine released from the body while the volume of residual urine is determined by ultrasound.


Osteoporosis

The incidence of osteoporosis in men is 23% in Hungary, 314.000 men are affected. While in the 60-79 year age group twice as much women have osteoporosis than men, this ratio is equalized between men and women in the 80 year age group. The mortality following a fractured bone is 50% higher in men than in women. 6% of men above 50 of age suffer from osteoporosis. These clearly indicate the age relation of osteoporosis in men.
The reduction of bone mineral density is a prolonged process in men. Bone mass is higher in man than in women, though bone mineral density is the same. Cortical bone loss is increased and bone production is decreased by age. Besides the lack of testosterone the change of estrogen hormone level plays an even more important role in its mode of action.
The diagnosis is made upon radiological findings – osteodensitometry and biochemical results. The screening of the disease or as called the “silent epidemic” is required in the affected age group.


The treatment of elderly men

The treatment of aging and male menopause is a complex job; a simultaneous co-work of several specialists is required. The male menopause may be a temporary pathological condition with proper treatment, that can be cured and the patient may regain his full strength again.
The primary task is to have a supply of testosterone. The only contra-indication of it is prostate cancer (PCA) and Benign Prostatic Hyperplasia (BPH). If the chance of PCA is excluded by investigations, the treatment (under strict supervision) may be applied without any age limits. Its indication is the proven decline of testosterone. If total testosterone level of the blood serum is below 10 nmol/L, the treatment is reasonable. The aim of the treatment is not to reach normal androgen level, maintaining of a “subnormal” level (slightly below normal) should be sufficient to reduce or improve the symptoms.
Vitamin combinations and aphrodisiacs may be applied if libido is decreased, erectile dysfunction should be treated by a casual therapy if possible. The monitoring of hormone levels and their supplication is essential within the bounds of possibility. There are 3 oral medications available in Hungary that can provide an appropriate erection in 80% of the cases, thanks to their revolutionary development in the past years. The function may be restored as much that the medication should be applied only for a period of time in many cases. These medications interfere with the above mentioned biochemical processes. Patients taking nitrate containing medicines or men with uncontrolled hypotension or suffering from severe cardiac, renal and hepatic diseases shouldn’t apply these!
Besides medications there is a possibility of a (painless!) injection treatment. An intracavernous injection of a small amount of medicine with a very small fine needle is applied to achieve a reflex erection. The patient will learn the method during the dosage determination and will apply it as a self-injection therapy.
If the erectile dysfunction is caused by the insufficiency of venous system in the penis a surgical intervention may be performed to improve erection ability.
If the above mentioned methods have no result or they are not applicable a penile prosthesis implantation may be the final solution. You can choose from permanently erect prosthesis and malleable ones or the most advanced technique that is inflatable and deflatable by a small pump located under the skin in the scrotum.
The complaints of lower urinary tract syndrome significantly influence the quality of life. The treatment of chronic bacterial prostatitis requires a prolonged (even for 4-6 weeks!) treatment with targeted antibiotics or their combination if necessary. This may be supplemented with anti-inflammatory or – depending on the severity of symptoms- other medicinal treatments and herbal remedies.
BPH treatment involves the application of alpha-blockers, 5α-reductase inhibitors and herbal remedies. They may be applied in combination with each other. In the early stage of BPH and the symptoms the use of natural medicines is preferred to treat the symptoms. One of the most common phytoterapeutic agents is the extract of African saw palmetto (Serenoa repens) that has a proven 5α-reductase inhibitoring and anti-estrogen effect. The extract of the fruit of saw palmetto and African plum tree (Sabal serrulata, Pygeum africanum), the extract of stinging nettle (Urtica radix), the extract of pumpkin seed (Cucurbita semen), the pollen extract of rye grass (Secale cereale), pollen of rye, a corm extract (Hypoxidaceae) are well known, widely accepted herbal remedies that can be applied as a supplementation to surgical or medicinal treatment.

When symptoms don’t subside, the stream is weakening, the volume of residual urine is increasing, urinary retention occurs, and the renal function is impaired, then surgery is indicated. An open prostate surgery (bigger than 50-60 g) or a transurethral (in case of a smaller prostate), a so called endoscopic surgery is performed depending on the size of the prostate. The other group of interventions consists of the minimally invasive procedures, where tissue breakdown is achieved by prostatic tissue necrosis with the utilization of different energy sources. (laser, radio wave, needle electrodes (TUNA), microwave (TUMT) , ultrasound wave (HIFU))
The treatment of prostate cancer depends on the determined stage at diagnosis. Early stage prostate cancer may be treated by surgery or radiotherapy, while in case of an advanced prostate cancer application of hormone therapy and depending on the cancer extension cytostatics and bone protecting medication and the use of supplemental therapy is required.

Make an appointment with:
Ferenc Szabó MD
Ferenc Szabó MD
Zsolt Kopa MD, PHD
Zsolt Kopa MD, PHD