Testosterone Deficiency (2018)

See Original Guideline

Includes parts of Chapter 23 from 11th edition of Campell's

Androgen deficiency (AD)

• The term androgen/testosterone deficiency is preferred over hypogonadism
• Unlike female menopause, which is a universal process associated with aging, the exact rate of testosterone decline and presenting symptoms are highly variable in men
• True prevalence of AD in the adult male is unknown as a result of inconsistent definitions used in the literature; population-based studies suggest prevalence 2-39%

Pathophysiology

• Causes classified as primary vs. secondary
  • Primary: caused by testicular failure
  • Secondary: caused by the disruption at the hypothalamic–pituitary–gonadal (HPG) axis level

• • Primary (hypergonadotropic hypogonadism) causes (5):
    1. Congenital causes (DUNKY XX):
       1. Down syndrone
       2. Undescended testis
       3. Noonan’s
       4. Kleinfelters
       5. Y-microdeletions
       6. XX-male
    2. Iatrogenic causes (e.g., bilateral orchiectomy, testicular radiation, chemotherapy)
    3. Testicular trauma
    4. Infection (orchitis)
    5. Auto-immune
  • Secondary (hypogonadotropic hypogonadism) causes (8):
    1. Congenital causes (e.g. Kallman syndrome (congenital deficiency of GnRH))
    2. Pituitary or suprasellar tumors
    3. Pituitary infiltrative disorders (e.g., hemochromatosis, tuberculosis, sarcoidosis, histiocytosis)
    4. Pituitary apoplexy
    5. Medications (i.e. chronic opioid exposure)
    6. Hyperprolactinemia
    7. Severe chronic illness
    8. Systemic illnesses associated with AD:
    • • Diabetes
      • Obesity
      • HIV
      • Myocardial infarction
      • Stroke
      • COPD
      • Respiratory illness
      • Cancer
      • Sepsis
      • Chronic liver disease
      • Chronic kidney disease; renal transplantation appears to reverse the hormonal abnormalities associated with ESRD
      • Rheumatoid arthritis
      • Burn injury
      • Traumatic brain injury
      • Surgical stress

Diagnosis and Evaluation

• Clinical diagnosis of testosterone deficiency requires BOTH:
  1. Low testosterone levels combined WITH
  2. Symptoms or signs that are associated with low serum total testosterone.
  • A patient is considered testosterone deficient and a candidate for testosterone therapy only when he meets both criteria
  • UrologySchool.com summary:
    • Recommended (2):
      1. History and Physical exam
      2. Laboratory confirmation of low testosterone
         1. Total morning testosterone < 300 ng/dL on 2 separate occasions
      3. Questionnaire not recommended