EURURO Vol. 72 No. 2

164 320

Platinum Opinion
European Association of Urology Position Statement on the Role
of the Urologist in the Management of Male Hypogonadism and
Testosterone Therapy
Vincenzo Mirone Frans Debruyne Gert Dohle Andrea Salonia Nikolaos Sofikitis
Paolo Verze Mikkel Fode Christopher Chapple
on behalf of the URO-TRAM working grou
a Urology Department, University of Naples Federico II, Naples, Italy; b Urology Department, Andros Clinic, Arnhem, The Netherlands; c Urology Department,
Erasmus University Medical Center, Rotterdam, The Netherlands; d Division of Experimental Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Milan,
Italy; e Urology Department, Medical School, University of Ioannina, Ioannina, Greece; f Urology Department, Zealand University Hospital, Roskilde, Denmark;
g Urology Department, Herlev and Gentofte Hospital, Herlev, Denmark; hRoyal Hallamshire Hospital, Sheffield, UK
Testosterone is a crucial sex hormone important for the
health and development of men of all ages. Low androgen
levels in utero can lead to genital abnormalities, and
disruption during childhood alters pubertal development.
Low androgen levels after puberty and throughout adult-
hood can affect quality of life (eg, reduced libido, sexual
dysfunction, and mood and cognitive function ), alter
physiology (eg, infertility, lower muscle mass and bone
mineralization [osteopenia or osteoporosis]), and adversely
affect metabolism (changed fat metabolism, muscle
strength, physical activity, and function). These effects
relate to every man and are therefore of strong urological
interest. While late-onset hypogonadismmay be treated by
testosterone therapy (TTH), the indications and risks for
TTH are yet to be fully defined . To define the role and
responsibilities of the urologist, the EAU has considered all
the available data and formulated this position statement.
Issues encountered in urological daily practice include
erectile dysfunction (ED), lower urinary tract symptoms
(LUTS), prostate cancer (PCa), male fertility, and potential
risks related to TTH. Urologists should have the skills to
recognize, diagnose, and treat disorders associated with
male hypogonadism. They should be aware of the indica-
tions and contraindications for TTH.
1. Libido and ED
Sexual dysfunction symptoms are the most predictive
determinant sign of potential male hypogonadism: 23–36%
of men with sexual dysfunction are hypogonadal In
hypogonadal men, TTH increases sexual desire Like-
wise, testosterone plays an important role in the physiology
of erection and ED Androgen ablation results in
impaired relaxation of the smooth muscle of the corpora
cavernosa, and adequate levels of circulating testosterone
are necessary for restoring penile erections in hypogonadal
men. The reported effects on erectile function and male
sexual behavior are positive overall; however, a certain
degree of discrepancy exists in randomized trials
Testosterone plays a role in sexual function via multiple
molecular processes. (1) Testosterone stimulates nitric
oxide synthase to facilitate NO production, leading to
smooth muscle relaxation (via the nitric oxide/cyclic
guanosine monophosphate signaling pathway). (2) Testos-
terone establishes and maintains the structural and
functional integrity of the penis. (3) Testosterone has a
major role in the development, maintenance, function, and
plasticity of the cavernous nerve and pelvic ganglia
. TTH also has beneficial effects on ED because of the
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* Corresponding author. Urology Department, University of Naples Federico II, Via S. Pansini 5, Naples 80131, Italy. Tel. +39 081 7462611;
Fax: +39 081 5452959.
E-mail address: (V. Mirone).
1 The remaining members of the URO-TRAM working group are listed in Appendix A.
0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.