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© 2007 Informa UK Ltd

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Foreword

This a long road knows no turning (Sophokles: Ajax) to meet one of the greatest challenges of the 21st
century, which will profoundly affect many aspects
In the “sleepwalkers” (1964) Arthur Koestler of our life, social institutions and perhaps even eth-
remarks that “I mistrust the word progress and much ical values. The Population division of the United
prefer the word evolution simply because progress, Nations Secretariat estimates that last year (2006)
by definition, can never go wrong, whereas evolu- some 11% of the global population (688 million
tion constantly does and so does the evolution of persons) were aged 60 years or more and 13% of
the ideas. Indeed, it is fascinating to observe these persons were aged 80 years and over. The sex
throughout history the evolution of quite a few “rul- ratio of those aged 60 and over was 82 men for 100
ing” ideas , moving from gradual acceptance, to women and among those aged 80 years and more it
popularization, vulgarization, overextension, col- was 55 men for 100 women. Life expectancy at the
lapse and disappearance. At the height of their age of 60 was 17 years for men and 21 years for
importance, some of them are so generally accepted, women. The Population division projects that by
that they become the spirit of the time (the famous the year 2050 , 22% of the world population (or
“Zeitgeist” in German) with all of its societal conse- almost 2 billion people) will be aged 60 years and
quences, masterfully characterized by Virginia over and that 20% of these 2 billion persons will be
Woolf (1929) saying that “what is amusing now had aged 80 years or more. The United Nations also
to be taken in desperate earnest once”. Other ideas point out that, by the year 2050 – for the first time
may show a markedly different evolution; as Jean in our history – the population of persons older than
Monnet (1978) emphasized in his Mémoires, “When 60 years will be larger than the population of chil-
an idea corresponds to the necessity of an epoch , it dren (0 to 14 years of age). Humankind is growing
ceases to belong to those who invented it and it rapidly and it is ageing very rapidly… Fortunately,
becomes stronger than those who are in charge of scientific knowledge is growing even more rapidly .
it”. In fact, such an idea may become stronger than In 1830, Alfred Tennyson still could say with some
political power by developing into the common justification that “Science moves, but slowly slowly,
property of humankind ; it may deeply influence the creeping on from point to point ”. However, by the
spiritual content of an entire era and may resist the mid-fiftees of the 20th century it was recognized,
historical forces of destruction for a long time. In a that science progresses in proportion to the mass of
few, rare , cases a new idea becomes exceptionally knowledge that is left to it by preceding generations,
strong, when – in addition – it is generated as a that is under the most ordinary circumstances in
response to powerful historical challenges by some geometrical proportion (F.Engels, 1963). The same
new realities. The ageing of populations presents year Derek John de Solla Price has put this progress
such a challenge. It is a fundamentally new and in a proper perspective: “Using any reasonable defi-
unique problem in our history, with no previous nition of a scientist, we can say that between 80 and
analogies. Hence, people and their governments 90 per cent of all scientists that have ever lived are
have not had yet enough time (and/or courage?) to alive now. Now depending on what one measures
consider the necessary - and in part fundamental – and how, the crude size of science in manpower or
socioeconomical and political adjustments needed in publications tends to double within a period of
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Foreword

10 to 15 years”. This was 44 years ago and nowadays contemporary knowledge, particularly, when it
it is often said that today the amount of new infor- contains so many carefully selected articles, as the
mation tends to double every 6 to 7 years…. And present textbook. In fact, when the perimeter
when the amount of new information increases so between the known and unknown rapidly increases,
rapidly, the perimeter between the known and it inevitably results in increasing specialisation and
unknown also increases and opens new avenues in the establishment of new disciplines. The estab-
for fruitful investigation. If I am allowed to quote lishment of a new discipline for the Study of the
another forword written more than 400 years ago, in Ageing Male slightly more than a decade ago, was
the Preface to De La Sagesse, Pierre Charron considered then by some medical scientists as a
remarks that “La vraye science et le vray étude de courageous innovation with a somewhat uncertain
l´homme c´est l´homme” (The true science and study future. Few, if any of them would doubt today that
of mankind is this discipline has come to stay and for a long time,
man). This will particularly be true in the world of since more and more evidence is forthcoming to
tomorrow, where the octagenarian populations will indicate that many aspects of ageing are gender spe-
grow most rapidly of all groups and lot of new infor- cific, like the localisation of certain receptors in dif-
mation will be required on their pathophysiology ferent tissues or the functions of the blood-brain
and optimal medical care.It is said, that Leonardo barrier. Therefore, an in-depth study of the various
da Vinci was the last scientist in history, who still aspects of gender specificity is likely to lead to
could grasp the entire body of knowledge of his improved diagnostic and therapeutic methods for
epoch. I doubt very much that there exists any med- ageing populations. Therefore, as Shakespeare says
ical scientist today, who could claim to grasp all “What is past is prologue”. Last, but not least, I feel
medical knowledge, or eventhat of any major disci- that the scientific community ought to be grateful
pline, the Study of the Ageing Male being no to theeditors and contributors of this Textbook.
exception. It is sufficient to look at a few of the Their effort should remind us that the acquisition,
almost 60 excellent articles of the present textbook critical evaluation, systematisation and dissemina-
to be convinced. Science is organized knowledge, said tion of positive knowledge are the only human
Herbert Spencer; therefore, a textbook will always activities which are truly cumulative and progres-
represent an important contribution to the body of sive (George Sarton, 1930, paraphrased).

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Preface & Acknowledgments

Text to come
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Contents

Introduction 1
History of research on the aging male – selected aspects 1
Micheal Oettel, Sergio Musitelli & Dirk Schultheiss

Section I: Biology of aging 11

1. The biology of gender differences in animal models of aging 13
HJ Armbrecht
2. The biologic basis for longevity differences between men & women 23
Rafi T Kevorkian & Oscar A Cepeda
3. The biology of the aging brain 31
Xi Chen & Shirley Shidu Yan
4. The blood-brain barrier: age & gender differences 39
William A Banks

Section II: Diagnostics & Primary Assessment 47

5. Aging men – The challenge ahead 49
Bruno Lunenfeld
6. Screening of the aging male 63
Louis JG Gooren, Alvaro Morales & Bruno Lunenfeld
7. Laboratory tests in the endocrine evaluation of aging males 97
Michael John Wheeler

Section III: The Genitourinary System 111

8. Genitourinary System: an introduction 113
Claude C. Schulman
9. Benign prostatic hyperplasia 115
Simon RJ Bott & Roger S Kirby
10. Prostate cancer 131
Michaël Peyromaure, Vincent Ravery & Laurent Boccon-Gibod
11. Erectile dysfunction in the aging male 147
Andrea Gallina, Alberto Briganti, Andrea Salonia, Federico Dehò,
Giuseppe Zanni, Pierre I Karahiewiz & Francesco Montorsi
12. Infertility in the aging male 161
Wolfgang Weidner, Thorsten Diemer & Martin Bergmann
13. Urinary incontinence 167
Adrian Wagg
14. Testicular cancer 183
Axel Heidenreich
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Contents

Section IV: Sexual Dysfunction 205

15. Treatment of erectile dysfunction in the elderly 207
Kok Bin Lim & Gerald B Brock
16. Assessment of the aging man with sexual dysfunction 229
Sidney Glina

Section V: Endocrine System 239

17. Endocrinology of the aging male: an overview 241
John E Morley
18. Androgen deficiency and its management in elderly men 245
Louis JG Gooren & Bruno Lunenfeld
19. Growth hormone and aging in men 265
Marc R Blackman
20. The Thyroid 273
Mary H Samuels & Jerome M Hershman

Section VI: Aging and Body Composition 281

21. Aging testosterone, and body composition 283
Alex Vermeulen
22. Growth hormone & body composition in the aging male 289
Fred Sattler
23. Androgens & lean body mass in the aging male 307
Melinda Sheffield-Moore, Shanon Casperson & Randall J Urban
24. Visceral obesity, androgens and the risks of cardiovascular disease 313
Louis JG Gooren

Section VII: Nutrition, Digestion and Metabolism 327

25. Nutrition in older men 329
David R Thomas
26. Obesity in middle-aged men 345
Richard YT Chen & Gary A Wittert
27. Diabetes in the elderly male: nutritional aspects 355
John E Morley
28. Lipids through the ages 363
Margaret-Mary G Wilson
29. Insulin resistance syndrome in older people 373
Angela Marie Abbatecola & Giuseppe Paolisso
30. Free radicals and vitamins 391
Seema Joshi
31. Resistance exercise 405
Charles P Lambert
32. Constipation & diarrhoea 421
Syed H Tariq
33. Macrovascular complications in the elderly diabetic 431
Nikiforos Ballian, Mahmoud Malas, and Dariush Elahi
34. Upper gastrointestinal complaints 443
Christopher K Rayner & Michael Horowitz

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Contents

Section VIII: Cardiovascular and Respiratory System 463

35. Atherosclerotic risk assessment of androgen therapy in aging men 465
David Crook
36. Male aging: changes in metabolic, inflammatory, and endothelial
indices of cardiovascular risk 473
Ian F Godsland
37. Androgens: Studies in animal models of atherosclerosis 487
Peter Alexandersen
38. Androgens and blood pressure in men 501
Guy Lloyd
39. Androgens and arterial disease 511
Carolyn M Webb & Peter Collins
40. Androgenic influences on ventilation and ventilatory responses to
oxygen and carbon dioxide during wakefulness and sleep 517
Christopher P Cardozo
41. The role of androgens in respiratory function 521
Ann M Spungen

Section IX: Central Nervous System and Psyche 529

42. Changes in libido/sex life 531
Syed H Tariq
43. Depression 539
Margaret-Mary G Wilson
44. Testosterone, depression and cognitive function 551
John E Morley
45. Modern antidepressants 561
Margaret-Mary G Wilson
46. Sleep disorders 575
Hosam K Kamel
47. Cognitive changes in aging 683
Syed H Tariq & John E Morley

Section X: Skeletal System 609

48. Bone loss and osteoporotic fracture occurrence in aging men 611
Steven Boonen & Dirk Vanderschueren

Section XI: Sensory Organs 619

49. Aging and the eye 621
Ali R Djalilian & Hamid R Djalilian
50. Aging and inner ear dysfunction 631
Emiro Caicedo, Diego Preciado, George Harris & Frank Ondrey
51. Smell and taste 645
Weiru Shao & Frank Ondrey

Section XII: Skin and Hair 659

52. Healthy skin aging 661
Walter Krause

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Contents

53. Skin disease caused by changes in the immune system and infection 677
Isaak Effendy and Karen Kuschela
54. Skin changes caused by venous diseases 691
Eberhard Rabe & F Pannier
55. Aging of Hair 697
Ralph Trüeb & Rolf Hoffmann

Epilogue 709
56. Hormone treatment and preventative strategies in aging men:
whom to treat, when to treat and how to treat 711
Louis JG Gooren, Alvaro Morales & Bruno Lunenfeld

Index 731

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Contributors

Angela Marie Abbatecola Marc R Blackman, MD

Department of Geriatric Medicine National Center for Complementary &
and Metabolic Diseases Alternative Medicine
Il University of Naples National Institutes of Health
Italy Bethesda, MD
USA
Peter Alexandersen, MD
Center for Clinical & Basic Research Laurent Boccon-Gibod, MD PhD
Vejle, Denmark Professor
CHU BICHAT
HJ Armbrecht PhD University of Paris VII, Paris
Professor of Biochemistry & France
Molecular Biology
Geriatric Research, Education & Steven Boonen, MD PhD
Clinical Center Leuven University Center for Metabolic Bone Diseases
St. Louis VA Medical Center Katholieke Universiteit Leuven
St. Louis, MO, USA & Belgium
St. Louis University
School of Medicine, MO Simon RJ Bott, FRCS
USA Trustees of the London Clinic Ltd
London
Nikiforos Ballian
UK
Johns Hopkins University
School of Medicine
Alberto Briganti
USA
Department of Urology
William A Banks, MD Vita-Salute University
GRECC, VA Medical Center Milan
St. Louis & Division of Geriatric, Italy
Department of Internal Medicine
St. Louis University School of Medicine, MO Gerald B Brock MD FRCSC
USA St. Joseph's Health Centre
London
Martin Bergmann Canada
Institut fur Veterinär-Anatomie
Histologie und Embryologie Emiro Caicedo, MD
der Justus-Liebig-Universität Giessen University of Minnesota
Germany Minneapolis, MN
USA
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Contributors

Christopher P Cardozo MD Thorsten Diemer

VA Medical Center Poliklnik für Urologie und Kinderurologie
Bronx, NY, USA and Zentrum für Chirurgie, Anästhesiologie
Associate Professor of Medicine und Urologie, Universitätsklinikum
Mount Sinai School of Medicine Giessen und Marburg GmbH
New York, NY Standort Giessen
USA Justus-Liebig-Universität Giessen
Germany
Shanon Casperson, DTR
Ali R Djalilian, MD
Oscar A Cepeda, MD National Eye & Health Institute
Fellow, Division of Geriatric Medicine Bethesda, MD
Department of Internal Medicine USA
St. Louis University School
of Medicine & GRECC VA Medical Center Hamid R Djalilian, MD
St. Louis, MO UCI Medical Center
USA University of California
Irvine, CA, USA
Richard YT Chen
Associate Consultant (Endocrinology) Isaak Effendy MD
Department of Medicine Department of Dermatology
Changi General Hospital Municipal Hospital of Bielefeld
Singapore Germany

Xi Chen, MD PhD Dariush Elahi, MD

Department of Neurology Johns Hopkins University
St. Louis University School of Medicine & School of Medicine
St Louis VA Medical Center, MO USA
USA
Andrea Gallina
Peter Collins MD FRCP FESC Department of Urology
National Heart & Lung Institute Vita-Salute University
London Milan
UK Italy

David Crook, PhD Spas V Getov

St. Bartholomew’s & Royal London School of Medicine Academic F2 SHO in Stroke Medicine
London Brighton and Sussex University Hospitals
UK UK

Federico Dehò Sidney Glina, MD PhD

Department of Urology Head of Department of Urology
Vita-Salute University Hospital Ipiranga, and Director of Instituto H Ellis
Milan São Paulo
Italy Brazil

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Contributors

Ian F Godsland, PhD Rafi T Kevorkian, MD

Faculty of Medicine Assistant Professor
Imperial College London Division of Geriatic Medicine,
St Mary’s Hospital Department of Internal Medicine
London St. Louis University School of Medicine &
UK GRECC VA Medical Center
St. Louis, MO
George Harris, BS
USA
Axel Heidenreich, MD
Klinikum der Philipps- Roger S Kirby MA MD FRCS (UROL) FEBU
Universitat Marburg Professor, the Prostate Centre
Germany London
UK
Jerome M Hershman, MD
West Los Angeles VA Medical Center Walter Krause, MD
Los Angeles, CA Philipps University Marburg
USA Medical Center
Marburg
Rolf Hoffmann, MD Germany
Dermaticum
Freiburg Karen Kuschela
Germany Department of Dermatology
Municipal Hospital of Biekfeld
Michael Horowitz Biekfeld
University of Adelaide Germany
Department of Medicine
Royal Adelaide Hospital Charles P Lambert PhD
Australia Assistant Professor
University of Arkansas for
Seema Joshi, MD Medical Sciences
St. Louis University Medical Center Little Rock, AR
St. Louis, MO USA
USA
Richard W Lee
Hosam K Kamel MD MPH Academic F2 SHO in Stroke Medicine
Director, Geriatrics & Brighton and Sussex University
Extended Care Hospitals
St. Joseph’s Mercy Health Center UK
Hot Springs National Park, Arkansas
USA Kok Bin Lim
Singapore General Hospital
Pierre I Karakiewiz Singapore
Cancer Prognostics &
Health Outcomes Unit Guy Lloyd, MD FRCP
University of Montreal, Quebec East Sussex NHS Trust
Canada UK

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Contributors

Mahmoud Malas Diego Preciado, MD PhD

Johns Hopkins University Assistant Professor
School of Medicine George Washington University School of Medicine
USA Children's National Medical Center, DC
USA
Francesco Montorsi, MD
Professor Eberhard Rabe
Department of Urology Professor of Dermatology
Vita-Salute University Klinik und Poliklinik für Dermatologie
Milan, Italy University of Bonn
Germany
John E Morley MB BCH
Divison of Geriatric Medicine C Rajkumar
St Louis University School of Medicine, Chair in Geriatrics and Stroke Medicine
MO, USA and VA GRECC Brighton and Sussex Medical School
Medical Center, St Louis, MO UK
USA
Vincent Ravery, MD PhD

Sergio Musitelli Professor

Hospital Bicat
Michael Oettel Paris, France

Frank Ondrey MD PhD Christopher K Rayner

University of Minnesota School of Medicine University of Adelaide
Minneapolis, MN Department of Medicine
USA Royal Adelaide Hospital
Australia
Feliztas Pannier
Dermatology Clinic and Polyclinic Andrea Salonia, MD
Rheinischen Friedrich Wilhelms Department of Urology
Universitat Vita-Salute University
Bonn Milan, Italy
Germany
Mary H Samuels, MD
Giuseppe Paolisso, MD Oregon Health and Science University
Department of Geriatric Medicine and Portland, Oregon
Metabolic Diseases USA
Il University of Naples
Italy Fred Sattler, MD
Professor of Medicine & Biokinesiology
Michaël Peyromaure, MD Keck School of Medicine
Service d'Urologie University of Southern California
Hospital Cochin Los Angeles, CA
Paris USA
France

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Contributors

Claude C. Schulman, MD Ralph Trüeb, MD

University Clinics Brussels Department of Dermatology
Belgium University of Zurich
Switzerland
Weiru Shao, MD
Director, Division of Otology & Neurotology Randall J Urban, MD
Tufts- New England Medical Center Professor
Boston, MA University of Texas Medical Branch
USA Galveston, TX
USA
Melinda Sheffield-Moore, PhD
Associate Professor Dirk Vanderschueren, MD PhD
University of Texas Medical Branch Katholieke Universiteit Leuven
Galveston, TX Belgium
USA
Alex Vermeulen, MD
Shirley Shidu Yan, MD
Professor Emeritus
Department of Pathology
University Hospital Ghent
College of Physicians & Surgeons
Belgium
Columbia University
New York Adrian Wagg, FRCP
USA Senior Lecturer in Geriatric Medicine
Ann M Spungen, PhD University College London Hospital
Associate Professor of Medicine UK
and Rehabilitation Medicine
Carolyn M Webb PhD
Mount Sihai School of Medicine
New York, NY, USA, and
Wolfgang Weidner, MD
Co-chair VA cooperative Study
Direktor der Klinik und Poliklnik
VA Medical Center
für Urologie und Kinderurologie
Brunx, NY
Zentrum für Chirurgie
USA
Anästhesiologie und Urologie
Syed H Tariq, MD FACP Universitätsklinikum Giessen und
Assistant Professor of Medicine Marburg GmbH
Division of Geriatic Medicine Standort Giessen
St. Louis University Medical Center Justus-Liebig-Universität Giessen
St Louis, MO, USA & GRECC Veterans Affairs Germany
Medical Center
St. Louis, MO Michael John Wheeler
USA Professor
Department of Chemical Pathology
David R Thomas, MD FACP AGSF Guy’s & St. Thomas Foundation Trust
Division of Geriatric Medicine St. Thomas Hospital
St. Louis University Health Sciences Center London
St. Louis, MO UK
USA

xvii