Prostate

224

Practical Urology: EssEntial PrinciPlEs and PracticE

in another study on aging men, and it was sug-

and testosterone administration results in lipol-

gested that early diagnosis and treatment of

ysis. Testosterone replacement in hypogonadal

hypogonadism might prevent hip fractures in

men with abdominal obesity enhances triglycer-

an aging population.48 Additional potential con-

ide turnover in abdominal adipose tissue.54

tributing mechanisms are increased mechanical

loading via anabolic effects on muscle.

Cardiovascular System

of impotence,increased sweating,mood changes,

check the reference range for serum testoster-

fat mass, dry skin and anemia.59 Other symp-

one in the laboratory they use to help them

toms are even less specific and include reduced

interpret the results. Normal reference ranges

erectile strength, fatigue, mood disturbances

for serum total testosterone in adult men is gen-

comprising of irritability, frustration, lack of

erally considered to be 300–1,000 ng/dL (10–

motivation and depression. Medical history

35 nmol/L). Levels of <250 ng/dL (8.7 nmol/L)

should be focused on the presence of pituitary

suggest that the patient is likely to be hypogo-

disease, primary testicular disease, exposure to

nadal,whereaslevelsof >350 ng/dL(12.7nmol/L)

radiation, failure to develop at puberty and

suggest that the symptoms may not be due to

osteoporosis. Physical examination may detect

androgen deficiency. Some recent publications

signs of hypogonadism such as lack of second-

suggest using cut-off values of between 200 and

ary sexual characteristics and fine wrinkling of

400 ng/dL.61 When morning serum total testos-

facial skin. In middle-aged to older men, the

terone levels are <250 ng/dL, luteinizing hor-

symptoms become even less specific because of

mone (LH) and follicle stimulating hormone

the higher frequency of co-morbid conditions.

(FSH) levels should be checked. LH and FSH lev-

Three questionnaires are most widely recog-

els are elevated in primary hypogonadism but

nized as improving diagnostic specificity: the

are normal or low in secondary hypogonadism.

St. Louis University Androgen Deficiency in

If testosterone,LH,and FSH levels are low,serum

Aging Males (ADAM) (Table 17.2), the Mass-

prolactin should be checked to exclude a prolac-

achusetts Aging Survey (MMAS), and the Aging

tin-secreting pituitary tumor. The International

Male Survey (AMS) (Table 17.3).

Society of Andrology (ISA), International

Society for the Study of the Aging Male (ISSAM),

Biochemical Assessment

and European Association of Urology (EAU)

guidelines recommend that levels <231 ng/dL

Clinicians should optimize the determination of

(8 nmol/L) are representative of hypogonadism

serum testosterone levels by drawing the blood

and in such cases testosterone replacement may

sample in the morning (between 7 and 10 a.m).

therefore be appropriate while levels above a

Although circadian rhythms in serum testoster-

threshold of 346 ng/dL (12 nmol/L) are nor-

one are less marked as men age, the reference

mal.23 Borderline levels of total testosterone

ranges are usually obtained in the morning in

should be followed up by measurement of free

younger men. In addition, physicians should

or bioavailable testosterone. If these levels are

yes

no

(1)

do you have a decrease in libido (sex drive)?

yes

no

(2)

do you have a lack of energy?

yes

no

(3)

do you have a decrease in strength and/or endurance?

yes

no

(4)

Have you lost height?

yes

no

(5)

Have you noticed a decreased enjoyment of life?

yes

no

(6)

are you sad and/or grumpy?

yes

no

(7)

are your erections less strong?

yes

no

(8)

Have you noticed a recent deterioration in your ability to play sports

yes

no

(9)

are you falling asleep after dinner?

yes

no

(10)

Has there been a recent deterioration in your work performance?

Symptoms

Score

1

2

3

4

5

1.

decline in your feeling of general well-being

(general state of health, subjective feeling)

2.

Joint pain and muscular ache (lower back pain,

joint pain, pain in a limb, general back ache)

3.

Excessive sweating (unexpected/sudden episodes

of sweating, hot flushes independent of strain)

4.

sleep problems (difficulty in falling asleep,

difficulty in sleeping through, waking up early

and feeling tired, poor sleep, sleeplessness)

5.

increased need for sleep, often feeling tired

6.

irritability (feeling aggressive, easily upset about

little things, moody)

7.

nervousness (inner tension, restlessness, feeling

fidgety)

8.

anxiety (feeling panicky)

9.

Physical exhaustion / lacking vitality (general

decrease in performance, reduced activity,

lacking interest in leisure activities feeling of

getting less done, of achieving less of having to

force oneself to undertake activities)

10.

decrease in muscular strength (feeling of

weakness)

11.

depressive mood (feeling down, sad, on the verge

of tears, lack of drive, mood swings, feeling

nothing is of any use)

12.

Feeling that you have passed your peak

13.

Feeling burnt out, having hit rock-bottom

14.

decrease in beard growth

15.

decrease in ability/frequency to perform sexually

16.

decrease in the number of morning erections

17.

decrease in sexual desire/libido (lacking pleasure

in sex, lacking desire for sexual intercourse)

Have you got any other major symptoms?

yes

no

if yes please describe: