Every obese male with type 2 diabetes should be screened for hypogonadism

Hypogonadism is a clinical syndrome complex which consists of symptoms with or without signs and biochemical evidence of testosterone deficiency. The symptoms of testosterone deficiency are non-specific which can make the diagnosis difficult. Symptoms which are most commonly associated with testosterone deficiency are reduced or loss of libido, absent morning erections and erectile dysfunction.1 Other common symptoms include tiredness, fatigue, impaired physical endurance, loss of vitality, lack of motivation and mood disturbance. Erectile dysfunction Erectile dysfunction (ED) is a common complication in diabetic men with some reports finding up to 70% have the condition. The pathogenesis of ED in diabetic men is multi-factorial and can be due to a combination of these which include vasculopathy, neuropathy, psychological issues and testosterone deficiency. The presence of hypertension, smoking and higher waist circumference are associated with ED in diabetic men.2 Lower testosterone positively correlates with worsening IIEF (International Index of Erectile Function) in diabetic men. 2 Not all diabetic men with ED have testosterone deficiency but evidence shows that it is present in a significant number. NICE guidelines recommendation is to ‘review the issue of erectile dysfunction annually’.3 The European Association of Urology (EAU) guidelines on ED state that measurement of testosterone is a minimum requirement in the diagnostic evaluation. 4 Penile Doppler ultrasound has shown that basal systolic velocity and dynamic peak velocity after administration of a phosphodiesterase type 5 (PDE-5) inhibitor are significantly reduced in hypogonadal diabetic men when compared to eugonadal men with diabetes.5 Failure to respond to sildenafil is associated with low testosterone in diabetes. 6 Animal work has found that castration leads to reduction in vascular smooth muscle content in the corpus cavernosum, reduced elastic fibres and increased collagen in the tunica albuginea, fat deposition between the tunica and corpus cavernosum and reduced nerve sheath thickness in the cavernosal nerve.7 Prevalence of hypogonadism