LH, which is routinely measured by immunoassay, may help to establish the etiology of testosterone deficiency and can be an important factor in determining if adjunctive tests should be ordered (Appendix C - refer to the Appendix C section in the left menu). Their role in diagnosing testosterone deficiency is unclear, and they should not be used at the expense of a full patient evaluation, including laboratory testosterone measurement. Screening questionnaires are not an appropriate tool to identify candidates for testosterone therapy. Clinicians should inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer. Prior to offering testosterone therapy, clinicians should measure hemoglobin and hematocrit and inform patients regarding the increased risk of polycythemia. Serum prolactin levels should be measured in patients with low testosterone levels combined with low or low/normal luteinizing hormone levels. Given the clinical and commercial testosterone landscape, the American Urological Association (AUA) identified a need to produce an evidence-based document that informs clinicians on the proper assessment and management of patients with testosterone deficiency. Conditions such as hypogonadism may require medical treatments instead to bring testosterone levels back into balance. Body of evidence strength Grade B in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances but that better evidence could change confidence. Body of evidence strength Grade A in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances and that future research is unlikely to change confidence. Conditional Recommendations are non-directive statements used when the evidence indicates that there is no apparent net benefit or harm or when the balance between benefits and risks/burdens is unclear. IM injections involve injecting testosterone directly into the muscle tissue. SubQ injections involve injecting testosterone into the fatty tissue just below the skin. Subcutaneous (SubQ) and intramuscular (IM) are two common methods of administering testosterone injections. Testosterone injections are a common method of administering testosterone for individuals undergoing hormone replacement therapy – or for those looking to garner more gains. For testosterone injections, 23-gage, 1-inch and 25-gage, 1-inch needles are standard. The injection should go into the upper outer quarter, away from the spine and toward the hip bone. The gluteus maximus is ideal when someone else can administer the injection. Some patients prefer to use the shoulder/deltoid muscle due to familiarity with the muscle. The upper outer quadrant contains fewer nerve endings and blood vessels, making it safer for injection. Alternatively, the gluteal site (buttocks) typically provides the most comfortable injection experience with minimal post-injection discomfort from our experience. The thigh offers excellent accessibility for self-injection and contains adequate muscle mass for proper absorption. Following these preparation steps creates a foundation for safe and effective testosterone administration, while preventing both personal injury and environmental contamination. Rub the alcohol wipe in a circular motion outward from the injection site to ensure the area is clean. Before you inject, use an alcohol wipe to clean the injection site on your body. Continue doing this carefully until there is only testosterone within the syringe. The injection needle should be new and in its protective packaging. Then remove the drawing needle from the syringe and replace it with the injection needle. Conversely, a recent study exposing patient testes to radiation (3 patients 17Gy and 4 patients 24Gy) demonstrated normal testosterone levels up to 3 years after radiation exposure.147 A retrospective review of 399 men (mean age 37 years) with a mean total testosterone of 308 ng/dL found that 35% of patients had BMD at osteopenic levels and 3% had osteoporosis. Recent studies have explored the association between varicocele and low testosterone levels, and while there is no definitive evidence that varicocele presence is a cause of low testosterone, accumulating data suggest that ligation surgery might increase serum testosterone levels.
