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Figure 4 Prostate volumes measured by transrectal ultrasound (TRUS). T, testosterone; TE, testosterone enanthate; TTD, testosterone transdermal system. (Reproduced from Meikle, A. W.; Arver, S.; Dobs, A. S.; Adolfsson, J.; Sanders, S. W.; Middleton, R. G.; Stephenson, R. A.; Hoover, D. R.; Rajaram, L.; Mazer, N. A. Urology 1997, 49, 191-196, with permission from Elsevier.)

Figure 4 Prostate volumes measured by transrectal ultrasound (TRUS). T, testosterone; TE, testosterone enanthate; TTD, testosterone transdermal system. (Reproduced from Meikle, A. W.; Arver, S.; Dobs, A. S.; Adolfsson, J.; Sanders, S. W.; Middleton, R. G.; Stephenson, R. A.; Hoover, D. R.; Rajaram, L.; Mazer, N. A. Urology 1997, 49, 191-196, with permission from Elsevier.)

6.22.6.2 Prostate Disease

6.22.6.2.1 Benign prostate enlargement

Both the transition and peripheral zones of the prostate enlarge as males age in response to testosterone.3,46

Androgen withdrawal or deficiency results in a significant reduction in prostate volume of both zones (Figure 4),47 but the age relationship to prostate size is maintained. Testosterone replacement therapy does not elevate serum concentrations of PSA above those expected in males of comparable age. Lower urinary tract symptoms (see 6.24 Incontinence (Benign Prostatic Hyperplasia/Prostate Dysfunction)) are strongly influenced by hereditary factors and prostate volume48; it follows that androgen replacement therapy is associated with symptomatic prostate symptoms.

6.22.6.2.2 Prostate cancer

Prostate cancer is an androgen-responsive cancer, but evidence that testosterone replacement therapy results in prostate cancer is lacking.3 An undiagnosed prostate cancer may grow in response to testosterone replacement therapy. Therefore, a PSA and digital rectal examination are recommended in males aged 40 or over before initiation of androgen replacement therapy for hypogonadism with surveillance at 6-month intervals initially and then based on age.

6.22.6.3 Other Considerations of Treatment of Androgen Deficiency

The main use of androgen replacement therapy is in the management of males with testosterone deficiency.

Reversible causes of the hypogonadism should be established and therapy directed toward the underlying cause.3 Hyperprolactinemia from a pituitary tumor can be treated with bromocriptine, which often corrects the testosterone deficiency. Other tumors of the pituitary or hypothalamus may cause other pituitary deficiencies and require surgical or irradiation therapy. Systemic acute and chronic illness and glucocorticoid therapy will cause hypogonadism; androgen replacement therapy may be considered in such patients. Androgen replacement therapy in aging males requires monitoring for diseases incident to age but may offer benefits in bone preservation, lean body mass, mood, and intellectual and sexual function.

For males desiring fertility, hormonal therapy to enhance spermatogenesis may be successful. Gynecomastia, lack of secondary sexual characteristics, or small testes might contribute to psychological problems or social embarrassment for some hypogonadal adolescent and mature males. Gynecomastia generally does not regress and may worsen during hormonal replacement therapy of hypogonadism, which can be treated with plastic surgery (reductive mammoplasty). Some patients with secondary or tertiary hypogonadism may experience testicular enlargement in response to gonadotropin therapy. Implantation of testicular prostheses is an option for males who have psychological concerns about testicular size.

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