Dr. Ron’s Research Review – April 11, 2018

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This week’s research review focuses on testosterone testing in erectile dysfunction.

A recent article argues that routine hormone analysis (testosterone) is an essential part of the initial screening of men with erectile dysfunction. (Gore and Rajfer, 2004)
With a progressive decline in serum levels of testosterone with age, the prevalence of hypogonadism increases from 7% in males aged 40 to 60 years to 20% in males aged 60 to 80 years. Likewise, the prevalence of ED increases with age, with approximately 50% of men aged 70 years affected.
Symptomatology often reveals patients decreased libido and atrophic testes low serum testosterone. Typically, these patients report decreased libido and on physical examination will have atrophic testes. If patients with normal desire and a normal genitourinary examination had not been screened, 40% of the patients that benefited from parenteral testosterone therapy would never have been diagnosed.
Additionally, ED secondary to hypogonadism can be a presenting complaint of pituitary disorders. Although the prevalence of hyperprolactinemia is low in the entire screening ED population, as many as 30% of patients with low serum testosterone have an associated elevation in serum prolactin.
A counterpoint is appears in the same issue. (Jack and Zeitlin, 2004)
Although it may appear that checking a simple testosterone level is an inexpensive and convenient screening tool, screening the testosterone levels of all patients with ED is very costly and unnecessary. One of patients’ and physicians’ greatest misconceptions is that hypogonadism is the cause of many cases of ED. Hypogonadism alone is in fact a very rare cause of ED, and serum testosterone must be extremely low in and of itself to cause ED. Still, a majority of physicians and physician references advocate checking the serum testosterone level in men with ED. This is impractical for a variety of reasons.
One of the problems with testosterone screening is that testosterone levels are variable within any given individual at any given time, and there is no immediate cut-off for any individual to determine where the appropriate “normal” range stops and the clinically significant levels set in.  In two studies, overall, less than 2% of all patients screened went on to benefit from testosterone replacement therapy.

Dr. Ron


 

Articles

The role of serum testosterone testing: routine hormone analysis is an essential part of the initial screening of men with erectile dysfunction.
            (Gore and Rajfer, 2004) Download
As oral phosphodiesterase-5 inhibitor therapy has become the first-line treatment of erectile dysfunction (ED), common approaches in the evaluation of ED have been largely abandoned. Not only is routine hormone analysis no longer widely recommended, but most specialists perform serum testosterone level testing only in the most complex cases of ED. This article explores the rationale for including serum testosterone analysis as part of the initial screening of patients with ED. The use of routine serum testosterone testing is advocated for its efficacy in the diagnosis and treatment of hypogonadism and pituitary disorders associated with ED.

The role of routine serum testosterone testing: routine hormone analysis is not indicated as an initial screening test in the evaluation of erectile dysfunction.
            (Jack and Zeitlin, 2004) Download
A 60-year-old male physician is self-referred to your office for evaluation of his erectile dysfunction, which has been worsening for 5 years. He reports his erections rarely achieve fullness for penetration, and he is unable to ejaculate. He has tried sildenafil citrate (Viagra(R); Pfizer Inc, New York, NY) with mild success in the past. He has a strong libido and feels healthy. He rarely exercises, but is on his feet most of the day at work. He has been healthy his whole life and never seeks a doctor's attention. He has no other medical problems. His only medication is a baby aspirin once a day. His physical examination, including genitalia, is normal. As part of his initial visit, should his serum testosterone level be checked by his urologist

 

References

Gore, J and J Rajfer (2004), ‘The role of serum testosterone testing: routine hormone analysis is an essential part of the initial screening of men with erectile dysfunction.’, Rev Urol, 6 (4), 207-10. PubMed: 16985604
Jack, G and SI Zeitlin (2004), ‘The role of routine serum testosterone testing: routine hormone analysis is not indicated as an initial screening test in the evaluation of erectile dysfunction.’, Rev Urol, 6 (4), 203-6. PubMed: 16985603