Androgen Deficiency in Aging Male and huge prostatomegaly: Dilemma of management

A patient presented to us in Ramayyas Urology and Nephrology Hospital with complaints of erectile dysfunction and lower urinary tract symptoms. As per the detailed history there was history of decrease libido, difficulty in maintaining the erection and frequent mood alterations also.





On examination the patient had bilateral hydrocele and normal testes(size and texture).The prostate showed Grade 4 enlargement .
The investigation revealed huge prostatomegaly (187 gms) and Sr PSA 11.81 NG/ML. His testosterone was subnormal 1.63 ng/ml( below the reference range).So the patient had grade 4 enlargement of prostate with high PSA and ADAMS(Androgen Deficiency of Aging Male )





Having tried Vacuum erection device which he felt was not suitable for his use and having not satisfied with the effect of PDE-5 inhibitors ;he was given option of testosterone supplementation.But taking into consideration high PSA there was chances of occult carcinoma which needed to be excluded.
The prostatic enlargement of 187 gm and high PSA with uroflowmetry showing Maximum Flow rate of 12 ml/sec also pointed out to benign prostatic hyperplasia which would need treatment (medically-Dutasteride would have complicated the erectile dysfunction and alpha blocker - there was chance of retrograde ejaculation).The surgical treatment was deemed to be optimum.
The all options were discussed with the patient.Finally a decision was made to go for PROSTATE BIOPSY(A 14 CORE BIOPSY), bladder neck sparing laser evaporation of the lateral lobe(pt had bilobar prostatomegaly-the right lobe was predominantly enlarged that was removed.This was done with two views: trying to preserve anterograde ejaculation and prevention further complication because of prostate enlargement after testosterone supplementation) and bilateral hydrocelectomy.
The prostatic biopsy report was negative for malignancy.He was started on Viagra( continuous therapy to take care of endothelial dysfunction rather as on when needed basis and testosterone supplementation once biopsy is negative) and androgen replacement therapy with Zandrova(testosterone cream 5 gm sachet locally) daily on shoulder after bath .




From andrological point of view he will be under complete follow-up with regular PSA and evaluation of improvement of erectile dysfunction.