Signs of Testicular Failure (Hypogonadism)
Testicular failure presents with a constellation of sexual, physical, and psychological symptoms that vary based on age of onset and severity, with the most specific indicators being reduced libido, erectile dysfunction, and decreased spontaneous morning erections in adults. 1
Sexual Symptoms (Most Specific)
The European Association of Urology identifies three highly specific sexual symptoms that should prompt evaluation: 1
- Reduced libido – decreased sexual desire is one of the most reliable indicators 1
- Erectile dysfunction – inability to achieve or maintain erections sufficient for sexual activity 1
- Decreased spontaneous/morning erections – loss of nocturnal or early morning erections is particularly indicative 1
Less specific sexual symptoms include: 1
- Reduced frequency of sexual intercourse
- Reduced frequency of masturbation
- Delayed ejaculation
Physical Symptoms
Physical manifestations of testicular failure include: 1
More specific physical signs:
- Decreased vigorous physical activity 1
- Difficulty walking more than 1 km 1
- Decreased ability to bend 1
- Hot flushes 1
- Decreased energy and physical strength 1
Additional physical findings:
- Decreased muscle mass and increased visceral adiposity 2
- Gynecomastia (breast tissue development) 3
- Reduced body hair (facial, pubic, chest, axillary) 4
Psychological Symptoms
Mental and cognitive changes associated with testicular failure: 1
- Low mood or mood deflection 1
- Decreased motivation 1
- Fatigue 1
- Concentration or memory difficulties 1
- Sleep disturbances 1
- Depressed mood 2
Age-Specific Presentations
In prepubertal or peripubertal males (congenital/developmental): 1
- Cryptorchidism (undescended testes) – present in 21.9% of congenital cases 5
- Micropenis 5
- Severely reduced testicular volume (mean 3.4 mL in congenital hypogonadism vs 20.8 mL in acquired) 5
- Absent or incomplete development of secondary sexual characteristics 4
- Delayed or absent puberty 6
In adult-onset (acquired) testicular failure: 1
The presentation is typically less severe than congenital forms, with normal testicular volume in 70% of cases (mean 20.8 mL) and 70.4% having achieved spontaneous fertility before disease onset 5
Laboratory Confirmation Pattern
Primary testicular failure (hypergonadotropic hypogonadism) is characterized by: 1, 7
- Low testosterone levels (below normal range) 1
- Elevated LH and FSH – the pituitary attempts to compensate for testicular failure 1, 7
- Low sperm counts (azoospermia or oligospermia) 1
This hormonal pattern definitively distinguishes primary testicular failure from secondary (hypothalamic-pituitary) hypogonadism, where LH and FSH would be inappropriately normal or low 7
Critical Pitfalls to Avoid
Do not assess testosterone during acute illness – levels are artificially suppressed and unreliable during any acute medical condition 3
Do not rely on single testosterone measurement – the European Association of Urology requires two separate morning (8-10 AM) total testosterone measurements on different days to confirm diagnosis, as diurnal variation is significant 3
Do not overlook drug-induced causes – multiple medications can cause testicular failure including: 1
- Glucocorticoids
- Opioids
- Antiandrogens (cyproterone acetate, spironolactone, flutamide, bicalutamide)
- 5α-reductase inhibitors (finasteride, dutasteride)
Recognize that screening questionnaires lack specificity – while they have clinical value, they cannot be used alone for systematic diagnosis and must be combined with biochemical confirmation 1