NEEDS ASSESSMENT

Over the last two decades there has been a growing awareness of the impact of testosterone deficiency (TD), also called hypogonadism, on men’s health. Though the condition of TD was once associated primarily with obvious and severe medical conditions, today we recognize that TD affects a large number of otherwise healthy adults, and is particularly prevalent among men with common chronic medical conditions such as diabetes, obesity, and chronic pulmonary disease. Another emerging concept is that TD affects much more than sexuality. TD has been shown to be associated with impaired mood, sense of vitality, diminished energy, chronic fatigue, loss of muscle mass, truncal obesity, the metabolic syndrome, and osteoporosis.

Although many of the issues associated with TD relate to general medicine, the urologist has an important role in the diagnosis and treatment of TD. Since the sexual symptoms are often the presenting symptoms that drive the patient to seek medical attention, the urologist is often the first person with an opportunity to diagnose the condition. As the specialist most closely involved with male-specific health issues, it is important for the urologist to become familiar with current evidence regarding the impact of TD on men’s health. In this issue, authors will review the various signs and symptoms of TD, who is a candidate for treatment, considerations in choosing forms of testosterone therapy, the risks of treatment, and how to monitor the man receiving testosterone therapy.

Additionally, benign prostatic hyperplasia (BPH) is one of the most common diseases in the aging male, and it can be associated with bothersome lower urinary tract symptoms (LUTS) that affect quality of life by interfering with normal daily activities and sleep patterns. The prevalence of histopathologic BPH is age-dependent, with initial development usually after 40 years of age. By 60 years of age, its prevalence is greater than 50%, and by age 85 it is as high as 90%. As with histologic evidence, the prevalence of bothersome symptoms also increases with age.

Approximately one-half of all men who have a histologic diagnosis have moderate to severe LUTS. Additionally, it is estimated that approximately $1.7 billion is spent annually on BPH prescription drug treatment. As in years past, approximately 5%, or 96 of more than 2100 abstracts at the 2008 national meeting of the American Urological Association (AUA), covered the areas of LUTS and BPH in the areas of Basic Research, Epidemiology and Natural History, evaluation and Markers, Medical and Hormonal Therapy, and Surgery and New Technology, much of the latter being occupied with a discussion of new and old lasers for the treatment of BPH. This publication will also review current AUA guidelines and ongoing research for treating BPH.

PROGRAM OVERVIEW

There are several choices for treatment once a decision has been made to begin testosterone therapy. They include oral medications; intramuscular injections; testosterone patches, gels, and pellets; long-acting injections;and a buccal form of testosterone. It should be noted that there is universal agreement that oral forms of testosterone available in the US should not be used for treatment of TD due to the potential for severeliver toxicity, including life-threatening peliosis hepatis. A safe form of testosterone, however, called testosterone undecanoate, is available in a number of countries outside the US and is currently under review by the US Food and Drug Administration. There are a number of other oral medicationsthat are used to treat TD that are not themselves testosterone products and not associated with liver toxicity. Among the risks of testosterone replacement therapy is BPH. The concerns regarding growth of the benign prostate parallel those of prostate cancer; however, there is little evidence indicating that testosterone therapy produces clinically significant changes in LUTS. In patients who have moderate symptoms, drugs are often used to control BPH. The main options are a-blockers, 5-a reductase inhibitors, and anticholinergics. a-blockers make urination easier by relaxing the muscleswhere the bladder narrows toward the urethra. Several forms of a-blockers have been approved for treatment of BPH by the US Food and Drug Administration. 5-a reductase inhibitors shrink the prostate gland, but may only cause noticeable improvements for men with significantly enlarged prostates and may take months to be effective. Anticholinergics are used to increase the bladder’s capacity, inhibit involuntarycontractions, and delay the urge to urinate. In some patients, a combination of several drugs may be more beneficial than one drug alone.

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