Guidelines on the management of sexual problems in men: the role of androgens continued

Treatment

Co-morbidities

• Men with diabetes mellitus, hyperprolactinaemia, metabolic syndrome, severe symptoms of lower urinary tract symptoms, significant erythrocytosis (haematocrit >50%), untreated obstructive sleep apnoea or untreated severe congestive heart failure, breast or prostate cancer should not be started on treatment with testosterone without appropriate assessment and treatment of these co-morbid conditions
• The use of testosterone in patients with locally advanced or metastatic prostate cancer is absolutely contraindicated. Severe symptoms of lower urinary tract symptoms due to benign prostate hyperplasia represent a relative contraindication

Types of interventions and treatments

• The combination of testosterone and phosphodiesterase-5 inhibitors (PDE5i) treatment should be considered in hypogonadal patients with erectile dysfunction who fail to respond to either treatment alone. It is suggested that men with hypogonadism and erectile dysfunction should be treated with testosterone prior to the introduction of a PDE5i
• Preparations of natural testosterone should be used for substitution therapy. Intramuscular, subdermal, transdermal, oral and buccal preparations are safe and effective. The treating physician should have sufficient knowledge and adequate understanding of the pharmacokinetics as well as of the advantages and drawbacks of each preparation. The selection of the preparation should be a joint decision of an informed patient and physician. Risks of transfer should be discussed in advance of starting treatment
• Any adverse events during treatment (especially elevated haematocrit or prostate carcinoma) require rapid discontinuation of testosterone substitution, short-acting preparations may be preferred over long-acting depot preparations in the initial treatment of patients with late-onset hypogonadism

Follow up and monitoring

• Once patients are on therapy, testosterone levels should be monitored to ensure normal concentrations are being achieved. The aim of therapy should be a total testosterone level of at least 15 nmol/l. Sustained supra-physiological levels should be avoided
• Erythrocytosis can develop during testosterone treatment, especially in older men treated with injectable testosterone preparations. Haematological assessment is indicated before treatment, then at 3–4 months and 12 months, and annually thereafter. To keep the haematocrit below 53% (48% if history of thrombosis), dose adjustments and/or periodic venesection may be necessary
• Assessment of treatment outcome and decisions about continuing therapy should be based on improvement in signs and symptoms of testosterone deficiency. Failure to benefit within a reasonable time interval (up to six months is adequate for libido and sexual function, muscle function and improved body fat) should result in discontinuation of treatment. Further investigation for other causes of symptoms is then mandatory
• Hypogonadal older men should be carefully monitored for prostate safety during treatment, at 3–6 months, 12 months, and at least annually thereafter. Confirmed PSA increments >1.4 ng/ml during any one-year period after initiation of testosterone therapy or a PSA velocity >0.4 ng/ml per year during sequential PSA measurements for periods of more than two years should warrant a urological evaluation and more intensive future surveillance for prostate cancer. The combined application of PSA and digital prostate examination improves the prostate cancer detection rate over either test alone

full guidelines available from…
British Society for Sexual Medicine, Holly Cottage, Fisherwick, Near Lichfield, Staffordshire WS14 9JL (Tel – )
http://www.bssm.org.uk/

British Society for Sexual Medicine. Guidelines on the management of sexual problems in men: the role of androgens. Wylie K, Rees M, Hackett G et al. Androgens, health and sexuality in women and men. Hum Fertil 2010; 13 (4): 277–297.

First included: June 13.