Restoring Prostate Nerve Sensitivity and Testosterone in Secondary Hypogonadism
Your Situation Requires Stopping Testosterone First
You cannot accurately diagnose the type of hypogonadism or restore natural testosterone production while taking exogenous testosterone—you must discontinue testosterone therapy and allow a 2–4 week washout period before diagnostic testing can differentiate primary from secondary hypogonadism. 1
Your laboratory profile (low testosterone with normal LH and FSH) is misleading because exogenous testosterone suppresses the hypothalamic-pituitary-gonadal axis, artificially lowering or normalizing gonadotropins even in men who would otherwise show elevated LH/FSH if they had primary testicular failure. 1 The American Urological Association explicitly warns against attempting to diagnose hypogonadism type based on gonadotropin levels while a patient remains on testosterone therapy, as the results will be unreliable. 1
Understanding "Prostate Nerve Sensitivity"
The term "prostate nerve sensitivity" is not a recognized clinical entity in the medical literature provided. If you are referring to:
- Erectile function and sexual sensation: These are mediated by the pudendal nerve and cavernous nerves, not the prostate itself. 1
- Diminished libido and erectile dysfunction: These are the primary symptoms of hypogonadism that respond to testosterone therapy, with a small but significant improvement (standardized mean difference 0.35). 1, 2
- Lower urinary tract symptoms: Testosterone therapy has minimal to no proven benefit for urinary symptoms. 3
If you are experiencing erectile dysfunction or reduced libido, these symptoms may improve with appropriate testosterone management—but only after confirming true biochemical hypogonadism and determining whether you have primary or secondary disease. 1, 4
Diagnostic Algorithm After Testosterone Discontinuation
Step 1: Washout Period (2–4 Weeks)
- Stop all testosterone therapy immediately. 1
- Allow 2–4 weeks for exogenous testosterone to clear, permitting recovery of the hypothalamic-pituitary-gonadal axis in men with secondary hypogonadism. 1
- Injectable testosterone enanthate or cypionate returns to baseline by days 10–14 after the last injection. 1
Step 2: Repeat Morning Testosterone and Measure Gonadotropins
- Measure morning total testosterone (8–10 AM) on two separate occasions to confirm persistent hypogonadism (< 300 ng/dL). 1, 4
- Measure LH and FSH after confirming low testosterone. 1
Step 3: Measure Free Testosterone and SHBG
- Free testosterone by equilibrium dialysis is essential, especially in men with obesity or borderline total testosterone. 1, 4
- Low SHBG (as in obesity) can artificially lower total testosterone while free testosterone remains normal, indicating functional rather than true hypogonadism. 1
Treatment Pathways Based on Diagnosis
If You Have Secondary Hypogonadism (Low/Normal LH and FSH)
Gonadotropin therapy (hCG ± FSH) is the evidence-based first-line treatment for men with secondary hypogonadism who desire fertility restoration or wish to avoid permanent suppression of spermatogenesis. 1, 5
Gonadotropin Therapy Protocol
- Human chorionic gonadotropin (hCG) 1,500–3,000 units subcutaneously 2–3 times per week. 1
- Add recombinant FSH 75–150 units subcutaneously 2–3 times per week if sperm counts remain low after 3–6 months of hCG monotherapy. 1
- Expected outcomes: Restoration of both testosterone levels (to mid-normal range, 500–600 ng/dL) and spermatogenesis within 6–12 months. 1, 5
Gonadotropin therapy directly stimulates the testes, bypassing the suppressed pituitary, and is the only approach that restores both testosterone and fertility potential. 1 Testosterone replacement therapy is absolutely contraindicated if you desire fertility preservation, as it causes prolonged and potentially irreversible azoospermia. 1, 6
Alternative: Enclomiphene Citrate (Off-Label)
- Enclomiphene 25–50 mg orally three times per week stimulates endogenous testosterone production by blocking estradiol-mediated negative feedback on the hypothalamus. 1, 5
- Expected outcomes: Testosterone rises to mid-normal levels (500–600 ng/dL) within 6 weeks in obese men with secondary hypogonadism. 1
- Advantages: Preserves fertility, avoids exogenous testosterone suppression. 1, 5
- Limitations: Ineffective in primary hypogonadism (elevated LH/FSH), not FDA-approved for male hypogonadism. 1
If Fertility Is Not a Concern: Restart Testosterone Replacement
- Transdermal testosterone gel 1.62% at 40.5 mg daily is the preferred first-line formulation due to stable day-to-day levels and lower risk of erythrocytosis (15.4%) compared to injectable testosterone (43.8%). 1
- Intramuscular testosterone cypionate or enanthate 100–200 mg every 2 weeks is a more economical alternative (annual cost $156 vs. $2,135 for gel). 1
- Target testosterone levels: Mid-normal range (500–600 ng/dL), measured midway between injections (days 5–7) for injectable formulations. 1
If You Have Primary Hypogonadism (Elevated LH and FSH)
Testosterone replacement therapy is the only option, as the testes cannot respond to gonadotropin stimulation. 1
- Gonadotropin therapy and enclomiphene are ineffective in primary hypogonadism because the testes are intrinsically damaged and cannot produce testosterone even with maximal LH/FSH stimulation. 1
- Testosterone therapy permanently suppresses fertility in primary hypogonadism, as spermatogenesis is already impaired and exogenous testosterone will further suppress the hypothalamic-pituitary axis. 1
Expected Outcomes with Testosterone Therapy
Sexual Function (Primary Benefit)
- Small but significant improvements in libido and erectile function (standardized mean difference 0.35). 3, 1, 2
- Modest improvements in quality of life, primarily in sexual function domains. 3, 1
- Reevaluate at 12 months: If sexual function has not improved, discontinue testosterone to avoid unnecessary long-term exposure to risks without benefit. 1, 2
Minimal or No Benefit for Other Symptoms
- Little to no effect on physical functioning, energy, vitality, depressive symptoms, or cognition, even in confirmed hypogonadism. 3, 1, 2
- Energy and fatigue improvements are minimal (standardized mean difference 0.17). 2
- Depressive symptoms show less-than-small improvement (standardized mean difference −0.19). 2
Monitoring Requirements During Treatment
Initial Monitoring (2–3 Months)
- Testosterone levels: Target mid-normal range (500–600 ng/dL). 1
- Hematocrit: Withhold treatment if > 54%; consider phlebotomy in high-risk cases. 1
- PSA (men > 40 years): Urologic referral if PSA increases > 1.0 ng/mL in first 6 months or > 0.4 ng/mL per year thereafter. 1
Long-Term Monitoring (Every 6–12 Months)
- Testosterone levels, hematocrit, PSA, and symptomatic response (particularly sexual function). 1
Critical Pitfalls to Avoid
- Never restart testosterone if fertility is desired—this will immediately suppress spermatogenesis again. 1
- Never diagnose hypogonadism type while on testosterone therapy—gonadotropin levels will be misleading. 1
- Never assume age-related decline in young men—investigate for secondary causes of hypogonadism (pituitary adenoma, hemochromatosis, hyperprolactinemia). 1
- Never skip the investigation for reversible causes—obesity, sleep apnea, medications (opioids, glucocorticoids), and metabolic syndrome can all cause secondary hypogonadism. 1, 2
Addressing Obesity-Related Secondary Hypogonadism
If you have obesity (BMI > 30), weight loss through low-calorie diets and regular exercise should be attempted first, as this can reverse secondary hypogonadism by reducing aromatization of testosterone to estradiol in adipose tissue. 1, 2
- Hypocaloric diet: 500–750 kcal/day below maintenance requirements. 1
- Structured physical activity: Minimum 150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2–3 times weekly. 1
- Expected outcomes: Weight loss of 5–10% can significantly increase endogenous testosterone production in obese men with secondary hypogonadism. 1