Can testosterone be prescribed for patients with Benign Prostatic Hyperplasia (BPH)?

Testosterone Therapy in Patients with BPH

Testosterone therapy is generally not contraindicated in patients with benign prostatic hyperplasia (BPH), but requires careful monitoring and consideration of individual risk factors. 1

Safety of Testosterone in BPH Patients

• Multiple studies show that testosterone therapy (TTh) is safe and does not significantly worsen lower urinary tract symptoms (LUTS) or increase prostate volume in most men with BPH, except in those with severe symptoms 1
• The European Association of Urology guidelines confirm that TTh does not worsen LUTS or significantly increase prostate volume in men with mild to moderate BPH 1
• A recent randomized clinical trial demonstrated that 24 weeks of testosterone therapy in men with BPH and metabolic syndrome did not worsen urinary symptoms and actually improved markers of prostate inflammation 2

Important Considerations Before Prescribing

• PSA levels should be measured in men over 40 years of age prior to starting testosterone therapy to exclude prostate cancer 1
• If PSA is elevated at baseline, a second test is recommended to rule out spurious elevation 1
• If two PSA tests raise suspicion for prostate cancer, further evaluation including reflex testing and possibly prostate biopsy should be considered before initiating testosterone 1
• Hemoglobin/hematocrit should be measured at baseline, as testosterone therapy can increase these values 1
• Patients should be assessed for cardiovascular disease risk factors before starting therapy 1

Monitoring During Treatment

• Regular monitoring of PSA, hemoglobin, hematocrit, liver function tests, and lipid concentrations is necessary during testosterone therapy 3
• If hematocrit exceeds 54%, intervention such as dose reduction or temporary discontinuation is warranted 1
• Patients should be monitored for worsening of BPH symptoms 3

Contraindications

• Testosterone therapy is contraindicated in men with:
  • Carcinoma of the breast 3
  • Known or suspected prostate cancer 3
  • Men currently trying to conceive (as it can cause azoospermia) 1

Dosing Considerations

• The goal of testosterone therapy should be to achieve total testosterone levels in the middle tertile of the normal reference range (450-600 ng/dL) 1
• Starting with lower doses and titrating up as needed is recommended, especially in men with BPH 1
• Clinicians should use the minimal dosing necessary to normalize testosterone levels and improve symptoms 1

Benefits of Testosterone Therapy

• In hypogonadal men with mild erectile dysfunction (ED), testosterone therapy can be used as first-line treatment 1
• For more severe ED, a combination of phosphodiesterase type 5 inhibitors (PDE5i) and testosterone therapy may be more effective than PDE5i alone 1
• Testosterone therapy may improve anemia, bone mineral density, lean body mass, and depressive symptoms in hypogonadal men 1

Potential Risks and Side Effects

• Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism 3
• Increased risk of myocardial infarction and stroke in some postmarketing studies 3
• Edema with or without congestive heart failure in patients with preexisting cardiac, renal, or hepatic disease 3
• Sleep apnea may occur in those with risk factors 3

In conclusion, testosterone can be prescribed for patients with BPH who have documented testosterone deficiency, but requires careful patient selection, appropriate monitoring, and consideration of individual risk factors. The decision should be made after thorough evaluation and discussion of potential benefits and risks with the patient.