When should a patient with hypogonadism (low testosterone) be referred to a urologist?

From the Guidelines

Referral to a urologist for low testosterone is recommended when a patient has persistent symptoms of hypogonadism and consistently low testosterone levels confirmed by morning blood tests on at least two separate occasions, with levels below 300 ng/dL, as indicated by the American Urological Association guideline 1. When evaluating patients for low testosterone, it is essential to consider both the clinical symptoms and the laboratory results. The diagnosis of testosterone deficiency requires both a low testosterone measurement and the presence of select symptoms and/or signs, such as reduced energy, reduced endurance, diminished work and/or physical performance, fatigue, visual field changes, anosmia, depression, reduced motivation, poor concentration, impaired memory, irritability, infertility, reduced sex drive, and changes in erectile function 1.

Key Considerations for Referral

• Patients with a history of unexplained anemia, bone density loss, diabetes, exposure to chemotherapy, exposure to testicular radiation, HIV/AIDS, chronic narcotic use, male infertility, pituitary dysfunction, and chronic corticosteroid use should be considered for referral, even in the absence of symptoms or signs associated with testosterone deficiency 1.
• A targeted physical exam should be conducted to examine patients for signs associated with low testosterone, including evaluation of general body habitus, virilization status, body mass index or waist circumference, gynecomastia, testicular evaluation, varicocele presence, and prostate size and morphology 1.
• Before referral, a basic workup should include morning total testosterone levels, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and a complete metabolic panel.

Role of the Urologist

Urologists can provide specialized evaluation of the male reproductive system, manage testosterone replacement therapy, and address potential complications like effects on prostate health or fertility 1. Early referral is particularly important for younger men with low testosterone, as the condition may indicate underlying health issues requiring specialized management.

Additional Considerations

• Validated questionnaires are not recommended to define which patients are candidates for testosterone therapy or monitor symptom response in patients on testosterone therapy 1.
• The use of morning serum total testosterone levels is recommended to determine if testosterone deficiency is present in men with erectile dysfunction 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Referral to Urology for Low Testosterone

Men with low serum testosterone and symptoms of androgen deficiency may be diagnosed with testosterone deficiency 2. The following are indicators for referral to urology:

• Low serum testosterone levels
• Symptoms of androgen deficiency, such as:
  • Diminished libido
  • Erectile dysfunction
  • Depressed mood
  • Decreased sense of vitality
  • Increased fatigue
• Presence of metabolic syndrome and cardiovascular disease 2

Benefits and Risks of Testosterone Therapy

Testosterone replacement therapy (TRT) may improve sexual function, body composition, bone density, cognition, and sense of well-being 3, 4, 5. However, the benefits and risks of TRT are controversial, and the American Urological Association and European Association of Urology guidelines differ on several points of management 2. The risks of TRT include:

• Prostatic risks
• Cardiovascular risks
• Erythrocytosis

Monitoring and Treatment

Men receiving TRT must be monitored at regular intervals with:

• Digital rectal examination
• Blood testing for prostate-specific antigen
• Hematocrit or hemoglobin testing 3. The treatment effect of TRT on sexual activity, hypogonadal symptoms, and sexual desire can be maintained for up to 2 years 5.