Androgens Do Not Improve Weak Urinary Stream and Are Not Indicated for This Symptom
Androgens (testosterone) should not be used to treat a weak urinary stream in adult males, as they have no demonstrated benefit for lower urinary tract symptoms and may theoretically worsen obstructive voiding symptoms. The appropriate first-line treatments for weak stream are alpha-blockers like tamsulosin, 5-alpha-reductase inhibitors like finasteride, or phosphodiesterase-5 inhibitors like tadalafil 1.
Why Androgens Are Not the Answer
No Evidence for Urinary Benefit
- The only guideline mention of androgens in the context of urinary symptoms relates to their use for hot flashes in men on androgen deprivation therapy—not for treating weak stream 2.
- Androgens are indicated solely for testosterone deficiency (hypogonadism) in males, not for lower urinary tract symptoms 3.
Theoretical Risk of Worsening Symptoms
- Benign prostatic hyperplasia (BPH) requires androgens for development, and surgical/chemical castration reduces prostate volume 2.
- While testosterone replacement in hypogonadal men does increase prostate volume (mainly in the first 6 months), most studies show no significant worsening of voiding symptoms in men receiving testosterone for legitimate hypogonadism 2, 4.
- However, the 2009 American Urological Association guidelines note that "individual men with hypogonadism may occasionally have increased voiding symptoms with testosterone-replacement therapy" 2.
What the Evidence Actually Shows in Hypogonadal Men
- In a retrospective study of 120 hypogonadal men receiving testosterone replacement, the mean change in American Urological Association Symptom Index (AUASI) was -1.07 points (essentially no change), with 45.8% having less than 3-point change in either direction 4.
- Only 22.5% had worsening of symptoms by 3+ points, while 31.7% actually improved 4.
- Another review suggested that testosterone levels may have beneficial effects on urinary function through effects on bladder smooth muscle, nitric oxide synthase, and pelvic blood flow, but this remains investigational 5.
The Correct Approach to Weak Urinary Stream
First-Line Pharmacologic Therapy
- Alpha-blockers (tamsulosin) improve symptoms by 3-10 points on the International Prostate Symptom Score and facilitate bladder emptying by decreasing bladder outlet resistance 1.
- 5-alpha-reductase inhibitors (finasteride, dutasteride) are effective in men with clinically enlarged prostates and prevent progression to urinary retention and need for surgery 2, 1.
- Phosphodiesterase-5 inhibitors (tadalafil) also improve lower urinary tract symptoms by 3-10 points 1.
- Combination therapy (alpha-blocker plus 5-alpha-reductase inhibitor) is more effective than monotherapy, lowering progression risk to less than 10% compared to 10-15% with monotherapy 1.
Behavioral Interventions
- Pelvic floor physical therapy, timed voiding, and fluid restriction can improve symptoms 1.
When to Consider Surgery
- Transurethral resection of the prostate or holmium laser enucleation are highly effective for refractory cases, improving symptoms by 10-15 points 1.
Critical Clinical Caveat
If a patient with weak urinary stream also has documented hypogonadism (low testosterone with symptoms), testosterone replacement is appropriate for the hypogonadism itself—not for the weak stream. In this scenario, testosterone replacement is unlikely to significantly worsen urinary symptoms based on available evidence 4, 5, but the weak stream should be treated with the standard therapies outlined above 1.