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© The Canadian Journal of Urology™; 18(Supplement 1); April 2011
6
syndrome symptoms,
32
and reduction in body fat.
38
Many types of t es tos t erone therapy are
available in Canada, including pills (testosterone
undecenoate [Andriol]), gels (AndroGel, Testim),
patches (Androderm), and injections (testosterone
cypionate [Depo-testosterone], testosterone enanthate
[Delatestryl], each with its benefits and potential side
effects.
When choosing which testosterone replacement
therapy to prescribe, the physician should adopt
the ASTEP approach, which stands for “availability,
safety, tolerability, efficacy and preference.” Typically,
a patient taking testosterone replacement therapy
properly will perceive a benefit after 3 months.
Regular patient follow up is very important after
initiation and continued testosterone replacement
therapy. This therapy is associated with a wide range
of potential side effects including activation site effects
(irritation, redness, and rash), acne, enlarged prostate,
change inmood, depression, sleep disturbances, breast
enlargement, hair loss, baldness, headache, increased
serumprostate-specific antigen (PSA) levels, increased
red blood cell (RBC) count, prolonged or painful
erections, aggression or aggressive behavior, breast
pain, weight gain, and dizziness.
39-42
Other potential
side effects include fluid retention, worsening of sleep
apnea, and polycythemia.
3
To date, no study has shown that replacing
testosterone in a hypogonadal male and elevating
testosterone levels to the eugonadal range increases the
risk of aggravating benign prostatic hyperplasia (BPH)
or lower urinary tract symptoms (LUTS), or increases
the risk of developing prostate cancer. However, if the
patient has underlying prostate cancer, testosterone
replacement therapy may unmask the prostate cancer
earlier. The physician may detect a small rise in PSA
secondary to the testosterone-stimulated clinically
significant prostate cancer. If the cancer is identified
at an early stage, the patient has the best chance of
obtaining a cure.
Morales et al summarized the relationship between
testosteroneandtheprostate, as follows. Inhypogonadal
men who receive testosterone replacement therapy,
prostate volume increases, but only to the size expected
for eugonadal men. Recent placebo-controlled studies
have reported that there were no significant differences
in prostate volume, PSA, andLUTS in themen receiving
testosterone replacement therapy versusmen receiving
placebo. Testosterone promotes the growth of an
established prostate cancer, but it has not been shown
to promote the development of prostate cancer.
43
Hoffman and colleagues showed that among men
who were diagnosed with prostate cancer, those
with lower testosterone levels had a greater risk of
developing a more aggressive form of prostate cancer,
as demonstrated by their higher Gleason scores (8-10).
44
The addition of testosterone replacement therapy
may provide a more controlled and favorable response
in hypogonadal men who are not responding to
oral hypoglycemic agents,
23
PDE-5 inhibitors,
45
or
antidepressants.
46,47
Conclusion
ED is related to low testosterone levels. Testosterone
is essential for a normal erection because of its impact
on nitric oxide production. Some men with low
testosterone levels can have normal erections, and some
men with normal testosterone have poor erections.
Therefore, it is important to assess a patient for both
conditions. Simultaneous therapy with testosterone
replacement therapy and PDE-5 inhibitors is safe
and appropriate in the right situations. If a man has
symptomatic hypogonadism, testosterone replacement
therapy is both safe and very effective in improving his
physiologic, psychologic, and physical life.
Disclosure
Dr. Jack Barkin is an active urologist and Chief of Staff
at the Humber River Regional Hospital in Toronto.
He sits on the medical advisory board for Abbott,
AstraZeneca, Bayer, Boehringer-Ingelheim, Eli Lilly,
GlaxoSmithKline, Merck Frosst, Paladin, Pfizer, sanofi-
aventis and Solvay. He has done the clinical research
onAndrogel, Avodart, Casodex, Cialis, Detrol, Flomax,
Hytrin, Levitra, Xatral, Proscar and Viagra. He has
spoken all over the world for all of the companies
outlined.
References
1. NIH Consensus Conference. Impotence. NIH Consensus
Development Panel on Impotence.
JAMA
1993;270(1);83-90.
2. FeldmanHA, Goldstein I, HatzichristouDG, Krane RJ, McKinlay
JB. Impotence and itsmedical and psychosocial correlates: results
of theMassachusettsMaleAging Study.
J Urol
1994;151(1);54-61.
3. Morales A, Lunenfeld B; International Society for the Study of
the Agin Male. Investigation, treatment and monitoring of late-
onset hypogonadism in males. Official recommendations of
ISSAM. International Society for the Study of the Aging Male.
Aging Male
2002;5(2):74-86.
4. Safarinejad MR. Prevalence and risk factors for erectile
dysfunction in a population-based study in Iran.
Int J Impot Res
2003;15(4):246-252.
BARKIN