Testosterone Therapy and Benign Prostatic Hyperplasia

Pathophysiology and Effects of Testosterone Therapy

• The development of BPH involves the proliferation of prostatic tissue, which requires testosterone for development, and the pathophysiology involves the conversion of testosterone to dihydrotestosterone (DHT) by 5α-reductase enzymes, with DHT having a higher affinity for androgen receptors and being considered the more potent androgenic hormone 1
• Prostate volume increases significantly during testosterone therapy, mainly during the first six months of treatment, bringing the prostate size to levels equivalent to men without hypogonadism, but despite increased volume, urine flow rates, post-void residual volumes, and voiding symptoms typically do not worsen significantly 2
• The American Urological Association suggests that testosterone replacement therapy does not typically exacerbate voiding symptoms attributable to BPH, and complications such as urinary retention have not occurred at higher rates in men on TRT compared to those receiving placebo 2
• The apparent paradox between increased prostate volume and stable urinary symptoms is explained by the poor correlation between prostate volume and urinary symptoms, with individual responses varying 2

Management and Monitoring of BPH in Testosterone Therapy

• Testosterone therapy is generally safe for patients with BPH, as multiple studies have failed to demonstrate exacerbation of voiding symptoms during testosterone supplementation, and complications such as urinary retention have not occurred at higher rates than in controls receiving placebo 2
• The American Urological Association recommends that testosterone therapy does not significantly worsen urinary symptoms in men with BPH, despite increases in prostate volume 2
• Serum PSA levels should be measured prior to starting testosterone therapy in patients over 40 years, and continued PSA monitoring should follow standard guidelines for men without testosterone deficiency 3
• Hematocrit levels should be checked prior to initiating treatment, re-evaluated 3-6 months after starting treatment, and then annually 4
• Annual PSA testing, annual hematocrit measurement, and periodic assessment of urinary symptoms are recommended for long-term monitoring 4
• For patients with larger prostates, consider combination therapy with a 5-alpha reductase inhibitor for long-term management 4
• Testosterone therapy may improve erectile dysfunction when combined with PDE5 inhibitors, which can be particularly beneficial for BPH patients who often have concurrent erectile dysfunction 5
• The American Urological Association recommends measuring baseline PSA, performing digital rectal examination, assessing baseline urinary symptoms using IPSS, and checking hematocrit levels before starting therapy 4
• During the first 6 months, monitor for changes in urinary symptoms, be aware that prostate volume typically increases, and consider dose reduction of testosterone or addition of alpha-blockers if significant worsening of urinary symptoms occurs 4

Monitoring and Follow-up

• Close monitoring is essential, especially in the first 6 months, due to individual responses to testosterone therapy varying 2
• The increase in prostate volume with testosterone therapy does not necessarily correlate with worsening urinary symptoms, due to the poor correlation between prostate volume and urinary symptoms 2