You are 'phoned by a Community Physician asking for advice on the further
investigation of a 63 year old male patient complaining of erectile
dysfunction. The patient's serum testosterone has been measured: it was
58.5 nmol/L (male reference range 9 - 41 nmol/L).
This Case provoked 31 replies, and a wide range of opinion with some
further comments.
5 participants queried therapeutic testosterone; [+1.8]
8 queried covert use of testosterone/ other androgens; [+1.8]
4 queried other drug therapy. [+0.8]
4 queried a high SHBG; [+1.8]
4 queried assay interference; [+0.3*]
3 specifically queried a non-endocrine pathology; [-0.3]
3 queried a psychological problem; [-0.6]
2 thought that there was unlikely to be a biochemical or endocrine cause;
[-0.5]
2 thought the testosterone was probably normal; [-1.1]
2 stated that the patient did not have hypogonadism; [+0.4]
2 queried a blood circulatory problem; [-0.3]
1 queried varicose veins.[-1.3]
9 participants would measure SHBG; [+1.8]
9 would measure glucose/ check for diabetes; [+1.3]
6 would check LFTs; [+0.3]
5 would check thyroid function; [+0.8]
4 would check LH/ FSH; [+0.3]
2 each would check
renal function; [0.0]
FSH; [0.0]
prolactin; [-0.3]
oestradiol; [-0.3]
the testosterone; [+1.0]
the testosterone by another method; [+1.0]
lipids; [-1.0]
1 each would check
PSA; [-1.1]
HCG; [-0.8]
clotting studies; [-1.3]
LH [-0.3]
The Viagra hype is obviously getting to us (for non-UK participants; Viagra
is expected to be approved for UK use in September) and the following
comments were added:
Is he trying to get Viagra on the NHS?
HypoViagraism?
Viagra unlikely to be indicated;
Viagra is a possible therapy;
If Viagra is prescribed let me know if it works;
You might wish to adjust the Viagra dose one way or another;
Viagra overdose?
I particularly liked 'perhaps he should not recently married that 21 year
old' (thank you, Graham).
In my own Department, the increase in demand for male testosterone
measurements over recent weeks has been striking. This particular Community
Physician said that he had a considerable increase in male patients
complaining of impotence, and he was basically just measuring testosterone
on them all and telling them to come back in September.
This particular patient was apparently fit and healthy with no other
pathology. No drugs had been prescribed; but the CP wondered whether he
might be on some form of testosterone supplementation. I suggested a repeat
testosterone with an FSH as some form of check as to whether the free
testosterone was physiologically normal. If we had an in-house SHBG, I
would have added this as well (but we don't, so I didn't, and can't claim a
score for it!).
The mean score for CME/CPD participants in this Case was 3.1 (range -0.2 -
6.2).
Thank you for all your good wishes for my holiday - for those who have
asked, I am sure I will be spending a very wet week in the Lake District.
Enjoy your August, all of you - the next Case will arrive in September.
Gordon Challand
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