How does testosterone therapy affect patients with Benign Prostatic Hyperplasia (BPH)?

Testosterone Therapy in Patients with Benign Prostatic Hyperplasia (BPH)

Testosterone therapy is generally safe for patients with BPH as multiple studies have failed to demonstrate exacerbation of voiding symptoms during testosterone supplementation, and complications such as urinary retention have not occurred at higher rates than in controls receiving placebo. 1

Effects of Testosterone on Prostate Tissue and BPH Symptoms

Testosterone therapy affects the prostate in the following ways:

• Prostate Volume: Testosterone replacement therapy (TRT) does increase prostate volume significantly during the first six months of treatment, mainly bringing hypogonadal men's prostate size to levels equivalent to men without hypogonadism 1

• Urinary Symptoms: Despite increases in prostate volume:

  • Urine flow rates remain stable
  • Post-void residual volumes show no significant changes
  • Prostate voiding symptoms typically do not worsen 1

• Symptom Improvement: In some hypogonadal men with BPH, testosterone therapy may actually improve lower urinary tract symptoms (LUTS) 2

  • A randomized controlled study showed significant decreases in International Prostate Symptom Score (IPSS) after 12 months of testosterone treatment
  • Maximum flow rate and voided volume also improved in the testosterone treatment group

Clinical Considerations for Testosterone Therapy in BPH Patients

Monitoring Requirements

• PSA Monitoring:

  • Serum PSA levels should be measured prior to starting testosterone therapy in patients over 40 years 1
  • Continued PSA monitoring should follow standard guidelines for men without testosterone deficiency

• Hematocrit Monitoring:

  • Check hematocrit prior to initiating treatment
  • Re-evaluate hematocrit 3-6 months after starting treatment, then annually
  • If hematocrit becomes elevated, stop therapy until it decreases to an acceptable level 3

Potential Risks and Precautions

• Risk of Worsening BPH: The FDA label for testosterone products states that "patients with BPH treated with androgens are at an increased risk for worsening of signs and symptoms of BPH" 3

• Individual Variation: While most studies show no significant worsening of symptoms, clinicians should be aware that individual men may occasionally experience increased voiding symptoms with testosterone therapy 1

• Prostate Cancer Risk:

  • No evidence links testosterone therapy to the development of prostate cancer 1
  • Patients should still be evaluated for prostate cancer prior to and during treatment with androgens 3

Algorithm for Managing Testosterone Therapy in BPH Patients

1. Before Starting Therapy:

   • Measure baseline PSA (mandatory in men over 40)
   • Perform digital rectal examination
   • Assess baseline urinary symptoms using IPSS
   • Check hematocrit levels

2. During First 6 Months:

   • Monitor for changes in urinary symptoms
   • Be aware that prostate volume typically increases during this period
   • If significant worsening of urinary symptoms occurs, consider:
     • Dose reduction of testosterone
     • Addition of alpha-blockers (such as doxazosin) 4

3. Long-term Monitoring:

   • Annual PSA testing
   • Annual hematocrit measurement
   • Periodic assessment of urinary symptoms
   • For patients with larger prostates, consider combination therapy with a 5-alpha reductase inhibitor for long-term management 4

Common Pitfalls and Caveats

1. Misinterpreting Prostate Growth: The increase in prostate volume with testosterone therapy does not necessarily correlate with worsening urinary symptoms - this apparent paradox is explained by the poor correlation between prostate volume and urinary symptoms 1

2. Overlooking Benefits: Testosterone therapy may improve erectile dysfunction when combined with PDE5 inhibitors 1, which can be particularly beneficial for BPH patients who often have concurrent erectile dysfunction

3. Ignoring Individual Response: While population studies show minimal impact on urinary symptoms, individual responses vary - close monitoring is essential, especially in the first 6 months

In conclusion, testosterone therapy is generally safe in men with BPH, with studies showing no significant worsening of urinary symptoms despite increases in prostate volume. In some cases, testosterone therapy may even improve LUTS in hypogonadal men with BPH. Proper monitoring of PSA, hematocrit, and urinary symptoms is essential for safe management.