Among men younger than age 40, a total testosterone level of less than 400 ng/dL was linked with hypogonadal symptoms.

Many men younger than 40 years with testosterone levels of 300 – 400 ng/dL still experience hypogonadal symptoms, a new study suggests. The standard threshold of below 300 ng/dL, based on studies in elderly men, may not apply to younger men.

“The notion that common and uniform concentrations of androgen levels can be applied to describe the increasing prevalence of testosterone-related symptoms in young men should be challenged on the basis of the conclusions from the present study,” stated lead researcher Larry I. Lipshultz, MD, of Baylor College of Medicine in Houston, and colleagues.

The investigators suggest a 400 mg/dL threshold can be used along with symptoms and a comprehensive general assessment to determine the underlying health problems in young male patients. It should not be used as the sole criterion to start testosterone replacement therapy.

For the study, they reviewed the charts of 352 men younger than age 40 who complained of “low testosterone” while attending an outpatient clinic in 2013 – 2014. Serum total testosterone levels were collected and analyzed. Patient responses to the Androgen Deficiency in Aging Male (ADAM) questionnaire about sexual, psychological, and physical symptoms were also assessed. Despite poor specificity, the 10-question ADAM questionnaire is validated for hypogonadism.

According to results published  online ahead of print in BJU International, the probability of hypogonadal symptoms increased at a total testosterone level of 400 ng/dL for young men. None of the 10 symptoms predicted a testosterone level below 300 ng/dL.

Sexual symptoms, such as erectile dysfunction (ED), often seen in elderly men, did not predict hypogonadism in these younger patients. Instead, low energy and sadness, along with decreased strength, lowered ability to play sports, and decline in work performance were associated with low testosterone. After multivariable analysis, lack of energy appeared to be the most important symptom.

“Young men are less likely to have organic factors contributing to ED, and our present data suggests that sexual symptoms often seen in elderly hypogonadal men are less important in diagnosing clinical hypogonadism in younger men,” according to the researchers.

1. Scovell, JM, et al. BJU International, 2015; doi: 10.1111/bju.12970.

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Renal colic will affect one in 10 men before the age of 60 years and is three times more common in men than in women.¹ It costs the economy of the US more than $5bn a year.²

The condition classically presents with sudden-onset loin to groin pain that is colicky in nature. Patients often complain of a sensation of not being comfortable in any position.

It is associated with haematuria (more commonly non-visible) in more than 90% of cases.³

Despite the extreme discomfort, examination of the patient is frequently unremarkable. Differential diagnoses are listed in box 1.

Availability of CT scans

Investigations that can be performed in primary care include urine dipstick testing, for the presence of Hb and to rule out an infective cause, and basic observations to determine the presence of pyrexia.

The gold standard investigation is non-contrast CT scan of the renal tract, which has a sensitivity of 90-97% and a specificity of 86-100% for detecting renal and ureteric calculi.⁴

There is nationwide variation in the availability to primary care doctors of CT scanning for the investigation of suspected renal colic.

In Berkshire, GPs have access to a dedicated CT time slot each day to investigate suspected renal colic and we have found this enables many more patients to be investigated and managed in the community by their GP.

It should be noted that in more than a third of patients who have a history consistent with renal calculi and microscopic haematuria, there will be no evidence of calculi on imaging,5 particularly in young female patients.

When to refer

When faced with a patient who has renal colic and is in extreme pain, it can be daunting to refrain from immediate referral to secondary care, but most patients will be comfortable with oral or PR analgesia and medical expulsive therapy. Not all require a same-day referral.

It is easier to divide patients into those who need to be seen as an emergency by the on-call team the same day (those with red flag symptoms who may warrant emergency treatment), patients who need urgent referral and should ideally be seen within a couple of weeks, and those who require routine referral.

We recommend following the guidance outlined in box 2 when deciding whether to refer patients for secondary care investigations and treatment.

Medical expulsive therapy

Spontaneous passage of kidney stones less than 5mm in diameter will occur 97% of patients when prescribed medical expulsive therapy. ⁶

Stones 5-10mm in diameter have a spontaneous passage rate of 76% with medical expulsive therapy and stones >10mm are unlikely to pass without non-pharmacological intervention.

Medical expulsive therapy consists of alpha-blockers or calcium- channel blockers, with evidence suggesting both are effective.⁷

The therapy offered in our institution is tamsulosin 400 microgram once daily. It should be noted that using the drug for this purpose is not licensed and this should be explained to the patient. It is not advised for pregnant patients.

Shock wave lithotripsy

Shock wave treatment is suitable for calculi >5mm in diameter in the renal pelvis, upper third of the ureter and occasionally, the lower third of the ureter. Contraindications include anticoagulants and pregnancy.

This treatment can be uncomfortable, although most patients tolerate the procedure. Availability of this treatment nationwide is variable.

Ureteric stenting

Ureteric stents are inserted cystoscopically under general anaesthetic for obstructing stones as an emergency, to drain infection from the kidney, to preserve renal function or to manage uncontrolled pain.

A further procedure is needed to remove the stent and the calculus.

Most patients tolerate ureteric stents, although most report 'stent symptoms' to a varying degree, including frequency, dysuria, loin pain and haematuria.

It can be tempting to treat this as a UTI, because the urine dip is nearly always positive for blood and leucocytes, but this rarely improves symptoms. It should be noted that in a minority of patients, these 'stent symptoms' can be debilitating.

Percutaneous nephrostomy

Percutaneous nephrostomy is a surgical procedure usually reserved for patients with an infected obstructed upper urinary tract.

Performed under local anaesthetic, usually by radiologists, a needle puncture is made into the affected kidney under ultrasound and fluoroscopic guidance, and the infected urine drained.

This has been demonstrated to have similar outcomes to cystoscopic ureteric stenting,8 but avoids the requirement for general anaesthetic.

Ureteric stents can be passed via the nephrostomy under local anaesthetic, in order to be able to remove the nephrostomy drain while ensuring the kidney is not obstructed.

Ureteroscopy

Ureteroscopy involves a ureteroscope being passed up the ureter via the bladder to the calculus, under general anaesthetic. The calculus is either removed in its entirety or fragmented and removed, usually by laser. A temporary ureteric stent may be left in after this procedure.

Nephrolithotomy

Percutaneous nephrolithotomy is reserved for large stones in the renal pelvis. This involves inserting a nephrostomy into the kidney under general anaesthetic and fragmenting then removing the stone.

Treatment pathways

It should be noted that practice and availability of treatment and investigations varies across the country and this article is intended to be used as a rough guide and to try to provide clarity on some areas where there is more than one treatment or referral option available.

There is, however, no substitute for clinical assessment and experience in managing these patients.

If there is concern about a patient or the most appropriate treatment option or pathway, the local urology department can normally address these queries.

• Mr Gill and Mr Britnell are SpRs in urology and Mr Kumar is a consultant urologist at Royal Berkshire NHS Foundation Trust

References

1. Curhan GC, Willett WC, Rimm EB et al. J Am Soc Nephrol 1997; 8(10): 1568-73.

2. Saigal CS, Joyce G, Timilsina AR. Kidney Int 2005; 68(4): 1808-14.

3. Perez JA, Palmes Mde L, Ferrer JF et al. Arch Esp Urol 2010; 63(3): 173-87.

4. Drake T, Jain N, Bryant T et al. Indian J Urol 2014; 30(2): 137-43.

5. Nadeem M, Ather MH, Jamshaid A et al. Int J Surg 2012; 10(10): 634-7.

6. Preminger GM, Tiselius HG, Assimos DG et al. J Urol 2007; 178(6): 2418-34.

7. Seitz C, Liatsikos E, Porpiglia F et al. Eur Urol 2009; 56(3): 455-71.

8. Goldsmith ZG, Oredein-McCoy O, Gerber L et al. BJU Int 2013; 112(2): 122-8.

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Two state-of-the-art dialysis centres to be built Trinidad & Tobago Express Two state-of-the-art dialysis centres will be constructed at earmarked areas at the Mt Hope Women's hospital and the San Fernando hospital at a cost of $120 million each. However, the construction cost will be borne by private companies- Comprehensive ...

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