Testosterone Deficiency

Diagnostic criteria

Low total testosterone levels (300 ng/dL)- on 2 occasions and Symptoms and/or signs of testosterone deficiency

Tests

Testosterone: Early morning- times 2

LH

Prolactin: If low/normal luteinizing hormone levels

Estradiol: If breast symptoms or gynecomastia

Hemoglobin and hematocrit

PSA: In men over 40 years of age 

Testosterone Therapy

Indications:

Men with low testosterone levels 

and clinical symptoms of hypogonadism

Absolute contraindications:

Prostate cancer

PSA > 4 ng/mL

Nodules/induration on digital rectal examination

Breast cancer

Polycythemia (hematocrit > 54%)

Relative contraindications:

Baseline hematocrit > 50%

Desire for fertility

Severe lower urinary tract symptoms

Other cautions:

Testosterone should not be given for 3-6 months after cardiovascular events.

Treatment Goal:  To achieve a total testosterone level in the middle tertile of the normal reference range.

Intramuscular Testosterone Injections

Testosterone Cypionate 

IM- 50- 200mg every 7 -14 days. Initial dose:  50-100 mg

Testosterone  Enanthate 

 Same as above agent

Injection Site: Gluteal muscle or lateral upper thigh 

Most Frequent Adverse Effects

Local site reactions 

Abnormally elevated hemoglobin 

Transdermal Testosterone Gel

Androgel 1% 

Dose:50 to 100 mg daily to shoulders, and upper arms

Most Frequent Adverse Effects

Local site reactions

Transference 

HCG Injection

Indications: Hypogonadotrophic hypogonadal patients with fertility issues 

Dose:1,500-5,000 IU  two to three times weekly (M/W/F) to a maximum of 10,000 IU/week administered intramuscularly or subcutaneously.

Anastrozole (Arimidex)

0.5- 1 mg PO, 3/week (M/W/F)

Clomiphene (Clomid)

Start with 25 mg  PO, 3 times per week (M/W/F) and slowly titrate up to 50 mg once a day as needed.

Follow-up 

Testosterone levels: 2 to 3 months after therapy is initiated and then every 6-12 months

PSA:Increased PSA level greater than 1.4 µg/L within 12-month period of testoster­one treatment or PSA level greater than 4.0 µg/L need urologic evaluation

Hematocrit, hemoglobin: An increase in hematocrit to greater than 52-54% should lead to cessation of treatment 

FSH Injection

Indication: Patients who are receiving HCG and would like to conceive

Reasoning: Induction of testosterone synthesis by hCG alone may lead to suppression of FSH

FSH Injection :75–150 IU, SC injection, 2–3 times/ wk

hMG Injection:75 IU , SC injection,  2–3 times / wk

Hematospermia

Step 1: UA, DRE, PSA, per indications

Step 2- Persistent hematospermia (>2 months) needs further workup. This includes:

Infectious workup (urine culture, GC urethritis, non- GC urethritis, TB) if indicated

Semen analysis- may be considered

Coagulation studies

TRUS or MRI

Cystoscopy

Seminal vesicle endoscopy- has been considered by some urologists.

Premature Ejaculation

Topical Therapies

EMLA Cream (Lidocaine 2.5%/prilocaine 2.5%):20 to 30 minutes pre-intercourse

Selective Serotonin Reuptake Inhibitor

Fluoxetine (Prozac): 20-40 mg/day

Paroxetine (Paxil):10, 20, 40 mg/day or 20 mg 3 -4 h before sex 

Sertraline (Zoloft): 50 to 200 mg/day or 50 mg 4 to 8 h before sex 

Second Line Treatment

Tramadol: On demand: 20-100 mg 

Notice- Also refer the patient to mental health professional with expertise in sexual health.

Concomitant Erectile Dysfunction

Erectile dysfunction should be treated first.

Delayed Ejaculation

Treat erectile dysfunction.

Address low testosterone if present.

Address medications that may contribute to delayed ejaculation.

Refer to mental health professional with expertise in sexual health.

Peyronie’s Disease

Oral Medications

Non-steroidal anti-inflammatory drugs

For pain management

Intralesional Injections

Collagenase (Xiaflex)

The only FDA-approved medication for Peyronie's disease

Disease should be stable.

May be used in patients with penile curvature >30° and <90°, and intact erectile function with or without the use of medications.

Steps:

1- Inducing penile erection: A single intracavernosal injection of 10 or 20 micrograms of Alprostadil

2- Identifying the target area

3- Waiting for penis to become flaccid

4- Injecting 0.58 mg XIAFLEX into the target plaque

 5- Repeating the injection in 1 to 3 days 

6- Performing  penile modeling procedure 1 to 3 days after the second injection 

Up to four treatment cycles may be administered. 

Each treatment cycle may be repeated at approximately six-week intervals. 

If the curvature deformity is less than 15 degrees after the first, second or third treatment cycle, treatment should be stopped. 

Patient should  not have sex or any other sexual activity between the first and second injections of a treatment cycle.

Patient should not have sex or have any other sexual activity for at least 4 weeks after the second injection..

Interferon α-2b 

Verapamil

Surgery: Prerequisite:

Peyronie’s disease should be stable for at least three months (without pain or deformity deterioration)

Surgical options:

Tunica plication: If

Rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy) 

There is adequate penile length

Curvature < 60° 

There is no special deformities (hour-glass, hinge)

Plaque incision or excision and/or grafting:  If

Rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy)

There is not adequate penile length

Curvature > 60º 

There is special deformities (hour-glass, hinge)

Penile prosthesis : If

Rigidity is not adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy)

Inflatable penile prosthesis is recommended in Peyronie's disease.

Congenital Penile Curvature 

Nesbit surgery/ Other plication techniques

Priapism 

Diagnosis

CBC- diff

Coagulation profile

Corporal aspiration and blood gas analysis

Ischemic priapism: 

pO2 (mmHg) <30

pCO2 (mmHg) >60

pH < 7.25

Duplex ultrasound

To differentiate between ischemic and non-ischemic priapism as an alternative or adjunct to blood gas analysis.

Treatment of Ischemic Priapism

Post-treatment with combination of aspiration, irrigation, and alpha adrenergics erectile preserves in 70-92% of patients.

AUA Core Video 

Supplies:

ABG Needle

25 Gauge Needle for Penile Block

16 Gauge Angiocatheter Needle X 2

Empty Syringes (10 cc and 60 cc)

Sterile Saline

Betadine

1% Lidocaine without Epinephrine

Phenylephrine Vials with concentration of 100- 500 mcg/mL

Cardiac Monitor

First step

Therapeutic aspiration (with or without irrigation) - Aspirate the corpora cavernosa until fresh red blood is obtained.

Intracavernosal  phenylephrine injection

First, decompress by penile aspiration.

Dilute it with normal saline.

Concentration of 100 to 500 mcg/mL is needed.

Inject 1 mL every 3 to 5 minutes for approximately one hour.

Lower concentrations in smaller volumes is needed in children and patients with severe cardiovascular disease.

Blood pressure and electrocardiogram monitoring are needed in patients with high cardiovascular risk.

Second step

Corporoglanular shunt

Normal erectile function is preserved in 33.3- 50% of patients with distal shunt.

Options:

Winter: using large biopsy needle 

Ebbehøj: using scalpel 

Al-Ghorab: excising a piece of the tunica albuginea at the tip of the corpus cavernosum.  Snake procedure may be added.

AUA Core Video 

Third step; Proximal shunt. Options are:

Quackels

Grayhack 

Forth step

Penile prosthesis

Consider it if :

Priapism episode is > 36 hours after onset.

Other interventions have failed.

Notice: A duration >36 hours is invariably associated with a degree of corporal fibrosis and erectile dysfunction

Treatment of Priapism in Sickle Cell Anemia

Follow above steps.

Oxygen 

Intravenous hydration

Alkalization with bicarbonates

Blood exchange transfusions

Treatment of Recurrent Priapism

Medical treatment

Gonadotropin-releasing hormone (GnRH) agonists

Antiandrogens

Hormonal agents should not be used in pediatrics.

Intracavernosal self-injection

Phenylephrine

If patient fails or rejects systemic treatment.

Treatment of Non Ischemic Priapism

First step: Observation

Second step

Selected pudendal arteriogram and superselective arterial embolization

Autologous clot and absorbable gel are preferred to coils and chemicals, which are permanent.

Third step: Surgery