Classification and symptoms of hypogonadism

The time of onset of testosterone deficiency is of greater importance for the clinical symptoms than localization of the cause. Lack of testosterone or testosterone action during weeks 8 to 14 of fetal life, the period of sexual differentiation, leads to the development of intersexual genitalia (see Chapter 3). Lack of testosterone at the end of fetal life results in maldescended testes and small penis size. In later life the onset of testosterone deficiency before or after completion of puberty determines clinical appearance (Table 13.2).

If testosterone is lacking from the time of normal onset of puberty onwards, eunuchoidal body proportions will develop, i.e. arm span exceeds the standing height and lower length of body (from soles to symphysis), exceeds upper length (from symphysis to top of the cranium) and bone mass will not develop to its normal level. The distribution of fat will remain prepubertal and feminine, i.e. emphasis of hips, buttocks and lower belly. Voice mutation will not occur. The frontal hairline will remain straight without lateral recession, beard growth is absent or scanty, the pubic hairline remains straight. Hemoglobin and erythrocytes will be in the lower normal to subnormal range. Early development of fine perioral and periorbital wrinkles are characteristic. Muscles remain underdeveloped. The skin is dry due to lack of sebum production and free of acne. The penis remains small, the prostate is underdeveloped. Spermatogenesis will not be initiated and the testes remain small. If an ejaculate can be produced it will have a very small volume. Libido and potency will not develop. A lack of testosterone occurring in adulthood cannot change body proportions, but will result in decreased bone mass and osteoporosis. Early-on lower backache and, at an advanced stage, vertebral fractures may occur. Once mutation has occurred the voice will not change again. Lateral hair recession and baldness when present will persist, the secondary sexual hair will become scanty and, in advanced cases, a female hair pattern may again develop. Mild anemia may develop. Muscle mass and power decrease. The skin will become atrophied and wrinkled. Gynecomastia may develop. The prostate will decrease in volume while the penis will not or only minimally change its size. Spermatogenesis will decrease and as a consequence, also the size of the testes, which will become softer. Libidoand sexual arousability will decrease or disappear while potency will be less affected.

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