Evaluation and Management of Male Hypogonadism and Sexual Dysfunction

Initial Diagnostic Approach

The European Association of Urology recommends measuring morning total testosterone, FSH, and prolactin levels to confirm hypogonadism before treatment, as this triad of symptoms strongly suggests hypogonadism 1, 2
The European Urology guidelines suggest measuring morning total testosterone on two separate occasions if the initial value is low, as testosterone levels fluctuate and diagnosis requires persistent deficiency 1, 2
Measuring FSH levels helps distinguish primary (elevated FSH) from secondary hypogonadism (low/normal FSH), according to the European Urology guidelines 1, 2
The Journal of Urology recommends measuring serum prolactin in all men with reduced libido and erectile dysfunction combined with low testosterone, as hyperprolactinemia can cause this exact symptom constellation 3
Checking SHBG levels is necessary if total testosterone is borderline, since elevated SHBG reduces bioavailable testosterone and can cause functional hypogonadism despite normal total testosterone, as stated in the European Urology guidelines 1, 2

Secondary hypogonadism (low testosterone with low/normal FSH) indicates hypothalamic-pituitary dysfunction and is potentially reversible with appropriate treatment while preserving fertility, according to the European Urology guidelines 1, 8
If prolactin is elevated, an MRI of the pituitary is necessary to evaluate for prolactinoma or other pituitary masses, as recommended by The Journal of Urology 3
Reviewing all medications for drugs that suppress the HPG axis, such as opiates, glucocorticoids, anabolic steroids, GnRH agonists/antagonists, is crucial in the diagnosis of secondary hypogonadism, as stated in the European Urology guidelines 1, 8

Treating the underlying cause of hyperprolactinemia, such as discontinuing prolactin-elevating medications or treating prolactinoma with dopamine agonists, is essential, as recommended by The Journal of Urology 3
Hyperprolactinemia directly suppresses libido and causes erectile dysfunction independent of testosterone levels, according to The Journal of Urology 3

Ejaculatory duct obstruction (EDO) presents with acidic semen (pH <7.0), volume <1.4 mL, azoospermia or severe oligospermia, normal testosterone, and palpable vas deferens, as described in the Praxis Medical Insights guidelines 6
Ordering TRUS or pelvic MRI is only necessary when clinical criteria for EDO are met, as stated in the Praxis Medical Insights guidelines 5, 6

Testosterone replacement therapy normalizes libido, improves erectile function, and enhances quality of life in men with secondary hypogonadism without fertility concerns, according to the European Urology guidelines 1, 8
Avoiding testosterone therapy if fertility is desired is crucial, as it suppresses spermatogenesis and can cause azoospermia, as recommended by The Journal of Urology 3

Obesity decreases testosterone and SHBG, worsens erectile function, and is a modifiable factor that worsens sexual function, as stated in the European Urology guidelines 2
Smoking is associated with reduced fertility and erectile dysfunction, and cessation is recommended, according to the Praxis Medical Insights guidelines 6

Karyotype analysis is mandatory for azoospermia or severe oligospermia (<5 million/mL), as recommended by the Praxis Medical Insights guidelines 5, 7, 6
Y-chromosome microdeletion analysis is necessary for azoospermia or sperm concentration <1 million/mL, according to the Praxis Medical Insights guidelines 5, 7, 6
CFTR gene testing for the female partner is mandatory if the male has CBAVD, as stated in the Praxis Medical Insights guidelines 5, 6