Managing testosterone (and its deficiency)

 

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This came up when I searched for “low testosterone”…I don’t think that’s the issue here. 

Very few men are brave enough to ask me, a woman, about “man troubles,” but when they do, I want to give them good counsel.* So, this post is really more like “here’s what I read on the Internet, hopefully it’s a helpful summary”:

Testosterone deficiency. Andropause. Male menopause. Low T. These are the terms your patient may have read about, and they want to know if you think they have it, and furthermore, if you think they need testosterone replacement therapy.

Is testosterone deficiency a real thing?

Short answer: yes, but you have to be strict in how you diagnose it. This is bolded in Up To Date, and whenever something is bolded in Up To Date, it’s important. This Science-Based Medicine article makes a convincing argument that testosterone deficiency has been oversold by the pharmaceutical industry in order to peddle patches, injections, etc. for profit.

What is the range of normal for testosterone in males?

300-1000 ng/dL.

How is testosterone deficiency diagnosed? 

Testosterone deficiency cannot be diagnosed in a single visit. Let me repeat that: it will take at least 2-3 visits/lab draws to make a diagnosis. That’s because testosterone levels fluctuate, and that is a normal thing!

Diagnosis requires repeatedly low morning-level testosterone levels PLUS factors like low libido, loss of morning erections, gynecomastia, loss of body hair, loss of bone density, or small testes.

Vague symptoms, like fatigue, depression, anemia, and loss of muscle strength are NOT enough on their own and should receive a broader workup.

What about in older men? I heard it’s different. 

Kind of? There is no one clear answer. It seems reasonable to treat older men for truly low testosterone levels, like <200 ng/dL who are having symptoms. Data shows that it does improve mood, energy, and sexual function. But there are no big studies of long-term side effects, so if one day it’s found that testosterone secretly causes cancer or dementia, you’ll be glad you were conservative.

Who can NOT receive testosterone?

Patient with severe prostatic hypertrophy, PSA >4.0, history of prostate cancer, erythryocytosis, uncontrolled heart failure. Some people say sleep apnea–this is not totally clear, but may be more of a co-variate. Obesity can lower testosterone levels, and is also associated with sleep apnea.

Before starting anyone on testosterone, make sure to do a prostate exam and PSA level. If the PSA is markedly elevated, you might need to make sure he doesn’t have prostate cancer first…

What are the different kinds of testosterone replacement? 

  • Transdermal: most people consider this the easiest method of administration, but it can be more expensive
  • Injections: can be given every 1-3 weeks depending, but the farther apart the injections are the more labile someone’s symptoms might be
  • Pills are an option, but have been linked with higher rates of hepatic disease
  • Sublingual formulation
  • Nasal gel
  • Subcutaneous implantable pellets (seriously, when there is money to be made, the possibilities are infinite)

What are the side effects of testosterone replacement?

  • Acne: the patch in particular can cause a nasty localized rash, although I think this is more like a contact dermatitis
  • Headaches
  • Hepatitis
  • Polycythemia: rare, but shows up on board questions
  • Fluid retention
  • Hypercholesterolemia
  • Insulin resistance:
  • Infertility: this is not immediately apparent to people, and you should ask your patient if they are planning on conceiving prior to prescribing testosterone. Interestingly, testosterone has been explored as a contraceptive agent.

Labs should be monitored regularly: CBC, LFTs, lipid panel. Testosterone levels can be checked every few months for efficacy, too.

How is testosterone for transgender patients prescribed? Are there any caveats to be aware of? 

Technically, using testosterone for gender transition is off-label. Shameless social justice plug: some friends and I made a document about caring for vulnerable populations, including transgender patients, and you can find more information there.

Testosterone is prescribed in any of the forms described above at similar doses. Many providers will cite “other endocrine dysfunction” instead of “gender identity disorder” or “gender dysphoria” as this is less stigmatizing.

The patient expects to experience deepening of the voice, male pattern hair growth, clitoromegaly, and atrophic vaginitis, among other things. However, breast tissue atrophies less than most people expect. Typical side effects also apply.

* This information is relevant to adults, not to children or adolescents.

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When does someone need a long term chronic urinary catheter?

I asked this question after meeting a patient with spinal cord injury who intermittently self-cathed who had repeated bouts of acute prostatitis. Would a long term Foley help him?

A urinary catheter is considered “chronic” when a patient maintains a need for a catheter >4 weeks.

Here are the two situations in which long term urinary catheter placement might be indicated:

  • inability to void urine
  • incontinence that affects daily function

These issues might be more common in people with underlying conditions:

  • spinal cord injury
  • cauda equina syndrome
  • multiple sclerosis
  • stroke
  • prostatic enlargement that cannot be surgically improved
  • pelvic surgery (such as hysterectomy, colectomy, etc)

Note: None of these are ABSOLUTE indications to place a long term catheter. Because long term catheters are associated with higher risk of infection, they should only be used when intermittent catheterization has not been working or the patient is unable to manage intermittent catheterization.

Unfortunately, there might be other reasons for my patient to have recurrent prostatitis, and a long term catheter would not necessarily help.

A related question is, how frequently do chronic indwelling catheters need to be exchanged? Medscape has an article on this; the conclusion is that it may be 2-6 weeks depending on the patient, and reasons to exchange are obstruction, either by encrustation or mucus, symptomatic infection, or leakage around the catheter. Catheters should NOT be exchanged unless there is a reason to do so–otherwise, patients are put at higher risk of infection.

* ** When assessing a patient with a chronic indwelling urinary catheter, ask yourself, what is the indication for this catheter? Would it be possible to remove it? Patients are not necessarily doomed to a catheter forever; they should be subjected to multiple trials of void if possible.

I also ran across a condition I’d never heard of before: Fowler’s Syndrome, an uncommon cause of urinary retention in younger (<30 years) women.

What is an artificial bladder sphincter? (and do you have to manage it specially?)

Consider this: about 15% of men who undergo radical prostectomy will have urinary incontinence! An artificial bladder sphincter is a device that consists of a cuff around the urethra, a pump in the scrotum, balloon to hold fluid (acting as a buoy).The patient activates the sphincter to relax so they can pee, and the cuff closes by itself in 3-5 mins.

from http://www.nlm.nih.gov/medlineplus/ency/presentations/100115_3.htm
from http://www.nlm.nih.gov/medlineplus/ency/presentations/100115_3.htm

In my experience, the sphincter doesn’t have to be specially managed if a patient is admitted to the hospital for other reasons. You should let them use it as they do at home–unless of course, they were admitted with a UTI or concern for urinary issues, in which case you can always call their urologist!