










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Testosterone, lower urinary tract symptoms, 
BPH, hypogonadism

None declared. Received on April 22, 2022 
Accepted on June 12, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(5):296–302

DOI: 10.48083/POJQ7964

Relationship Between Serum Testosterone  
and Severity of Lower Urinary Tract Symptoms 
Among Malaysian Men

Suzliza Shukor, Fam Xeng Inn, Zulkifli Md Zainuddin

Department of Surgery, Faculty of Medicine, Hospital Canselor Tuanku Mukhriz, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Abstract

Background Lower urinary tract symptoms (LUTS) are commonly experienced among ageing males. The 
increasing prevalence of late-onset hypogonadism suggests a possible relationship between serum testosterone and 
severity of LUTS. This study examines the association between serum testosterone and severity of lower urinary tract 
symptoms among Malaysian men, as reflected by the International Prostate Symptom Score (IPSS).

Method A total of 163 men with LUTS were enrolled in a cross-sectional study in Hospital Canselor Tuanku 
Mukhriz, Malaysia. Full examination, IPSS, and serum total testosterone (TT) levels were evaluated. Categorical 
and continuous correlations were analyzed using chi-square test and age-adjusted Pearson’s partial correlation, 
respectively.

Result Mean age was 66.25 (SD = 7.05), with mean serum TT of 16.74 nmol/L (SD = 6.32). Twenty eight percent (n = 
46) had low testosterone levels. Severity of LUTS (mild, moderate, severe) was not found to be dependent on TT status 
(normal, low, severely low), (χ2 [4, N = 163] = 4.24, P = 0.37). Weak negative correlations between total IPSS and IPSS 
storage sub-score with serum TT levels were exhibited respectively (r = −0.17, P < 0.05; r = −0.17, P < 0.05).

Conclusion Among elderly Malaysian men, severity of LUTS and TT status were not found to be associated, despite 
a weak negative correlation between IPSS and serum testosterone levels. Nonetheless, with a high prevalence of 
hypogonadal ageing men, further research regarding serum testosterone measurement among this population may be 
valuable as part of a multimodal approach to treatment.

Introduction

Lower urinary tract symptoms (LUTS) are common among men above 50 years of age in Malaysia, with prevalence 
increasing at the rate of 8% per decade, so that up to 65.4% of men above 70 years of age are affected[1]. An age-related 
reduction in serum total testosterone is also frequently seen in this population and is viewed as one of the more 
important endocrine-related changes seen in ageing men[2,3].

While the relationship between ageing and serum testosterone and ageing with LUTS have been widely estab-
lished, studies that looked into the relationship between serum testosterone and LUTS have not been consistently 
reported[4-8].

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https://orcid.org/0000-0002-2854-7521
mailto:suzliza.shukor%40gmail.com?subject=SIUJ
https://orcid.org/0000-0002-1377-6436
http://SIUJ.org


The importance of testosterone in the general well- 
being of ageing men is readily acknowledged. Nonethe-
less, especially among those who are diagnosed with 
late-onset hypogonadism with concomitant LUTS, 
limited studies are available that highlight the effects of 
testosterone in the development of LUTS, and whether 
it could potentially be a surrogate tool to predict LUTS 
severity, and thus subsequently assist in the manage-
ment of LUTS among this population.

In the present study, we aim to elicit the relationship 
between serum total testosterone levels and severity of 
LUTS among ageing men with LUTS in Malaysia. We 
also aim to investigate the prevalence of hypogonad-
ism among the different ethnic groups that make up 
the South East Asian demographic, thus allowing better 
insight into the epidemiology and management of the 
condition among the population within this region.

Materials and Methods
The study involved multi-ethnic men aged 50 to 80 
years who presented with urinary tract symptoms to the 
urology outpatient clinic at a tertiary teaching hospital 
in Kuala Lumpur between May 2021 and January 
2022. Clinical data were obtained, including age, body 
mass index, waist circumference, and medical history. 
We excluded from the study men with a history of 
malignancy, liver cirrhosis, or urinary tract infections, 
as well as those who were previously diagnosed with 
hypogonadism, those who were taking hormones, 
antiandrogen, antifungal medications, or any urological 
medications (including alpha-blocker, anticholinergics, 
5-alpha-reductase inhibitors, and phosphodiesterase-5 
inhibitors), those who were previously treated surgically 
for BPH, and those who were diagnosed with other 
lower urinary tract problems such as urethral stricture. 
Men with abnormal digital rectal examination or raised 
prostate specific antigen levels (> 4ng/mL) were also 
excluded from the study.

Lower urinary tract symptoms were assessed using 
the validated International Prostate Symptoms Scor-
ing (IPSS) which comprises an 8-item questionnaire, in 
which the sum of the first 7 items yields an overall score 
ranging from 0 to 35. Based on the IPSS, LUTS sever-

ity is categorized as mild (0 to 7), moderate (8 to 18), 
or severe (more than 18) for categorical data analysis.  
The IPSS storage sub-scores were assessed through items  
2 (frequency), 4 (urgency), and 7 (nocturia) in the ques-
tionnaire, while IPSS voiding sub-scores were assessed 
based on summing the outcome from item 1 (incom-
plete emptying), 3 (intermittency), 5 (weak stream), and  
6 (straining).

All participants underwent uroflowmetry testing, with 
a minimal voiding volume requirement of 150 mL. 
They also underwent transabdominal ultrasonography 
to assess prostate size (4Mhz, Canon Aplio). Blood 
measurement of serum total testosterone (TT) was done 
between 8:00 a.m. and 10:00 a.m. following an overnight 
fast to minimize the effects of diurnal variation on 
hormonal levels. Based on the European Association 
of Urology (EAU) guideline on diagnosing late-onset 
hypogonadism, we categorized serum total testosterone 
status as “severely low” at a level of 8 nmol/L or less, as 
“low” at between 8 and 12 nmol/L, and as “normal” at 
more than 12 nmol/L.[9] 

Data analyses were done using SPSS sof tware 
(Version 22.0, Inc. Chicago, US). Continuous variables 
were presented as the mean ± standard deviation (SD) 
or median (interquartile range). Categorical data were 
presented as numbers and percentages. Categorical 
data on LUTS severity (“mild,” “moderate,” “severe”) 
and serum total testosterone status (“normal,” “low,” 
“severely low”) were analyzed using the chi-square 
test. Statistical comparisons of continuous variables 
comprising the International Prostate Symptom Score 
and serum testosterone levels were done using an 
age-adjusted Pearson partial correlation coefficient to 
minimize the possible confounding effect of age on the 
outcome. A P-value of < 0.05 was considered significant.

Results
A total of 163 men were enrolled in the study, with a 
mean age of 66.25 years (SD = 7.05). Of these, 6 (0.04%) 
had mild LUTS, 112 (68.71%) had moderate LUTS while 
the remaining 45 (27.6%) had severe LUTS (Table 1). 
The mean serum TT level was 16.74 nmol/L (SD = 6.32), 
and mean prostate volume was 43.25 cm3 (SD = 18.57). 
Further patient characteristics are summarized in 
Table 2 and Table 3.

Based on serum total testosterone level, 4.91% of 
men (n = 8) were found to have severely low testoster-
one, 23.31% (n = 38) had low testosterone, and 71.78% 
(n = 117) had normal testosterone. Of men from Indian 
ethnicity (n = 14), 35.72% (n = 5) had a testosterone level 
of less than 12nmol/L. Among Chinese men, 29.76% 
(25/84) had low to severely low testosterone, and among 
Malay men, 24.62% (16/65).

Abbreviations 
BPH benign prostatic hyperplasia 
IPSS International Prostate Symptoms Scoring 
LUTS lower urinary tract symptoms 
TRT testosterone replacement therapy
TT total testosterone

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As shown in Table 4, categorical data analysis using 
the chi-square test revealed that severity of lower 
urinary tract symptoms is independent of the serum 
total testosterone status, χ2 (4, N = 163) = 4.24, P = 0.37). 
Subsequent analysis based on the continuous variables 
using the Pearson’s partial correlation following age-ad-
justment showed a negative correlation between total 
IPSS and serum total testosterone level, although only a 
weak association was seen (r = −0.17, P < 0.05) (Table 5). 
Similarly, for the IPSS storage sub-score, a weak correla-
tion with serum total testosterone level was exhibited  

TABLE 1. 

Frequency table of severity of LUTS and serum total 
testosterone status 

Severity of LUTS

Mild Moderate Severe Total

Total 
testosterone

Normal 4 85 28 117

Low 2 23 13 38

Severely low 0 4 4 8

Total 6 112 45 163

TABLE 2. 

Patient characteristics 

Characteristic Mean ±SD
Interquartile 

range

Age (years) 66.25 ± 7.05 61–72

BMI (kg/m2) 25.83 ± 3.69 23.2–27.95

Waist circumference (cm) 89.09 ± 13.28 78–98

Diabetes mellitus (%) 47 (28.83%)

Hypertension (%) 72 (44.17%)

Total testosterone (nmol/L) 16.74 ± 6.23 11.55–19.89

PSA (ng/mL) 1.63 ± 1.08 0.8–2.31

Prostate volume (cm3) 43.25 ± 18.57 32–50.5

Total IPSS 15.77 ± 5.67 11–19

IPSS voiding sub-score 9.55 ± 3.97 6–8

IPSS storage sub-score 7.22 ± 3.09 4.5–7

Qmax (ml/s) 8.65 ± 2.04 2.35–10

Post residual volume (mL) 33.15 ± 43.56 0–50

BMI: body mass index; PSA: prostate specific antigen; IPSS: 
International Prostate Symptom Score; Qmax: peak flow rate

TABLE 3. 

Patient characteristics based on serum total testosterone 
status 

TT category
Normal 

 (n = 117)
Low 

(n = 38)
Severely 

low (n = 8)

Characteristic Mean ± SD

Age  
(years)

65.68 ± 6.79 67.14 ± 7.17 70.25 ± 9.35

BMI 
(kg/m2)

25 ± 3.26 27.46 ±  4.07 30.25 ± 1.62

Waist circumference  
(cm)

86.45 ± 12.04 93.79 ± 14.43 105.38 ± 6.25

Diabetes mellitus (%) 88 (75.21%) 25 (65.79%) 3 (37.5%)

Hypertension  
(%)

67 (57.26%) 19 (50%) 3 (37.5%)

Total testosterone 
(nmol/L)

19.35 ± 5.21 10.69 ± 2.53 7.27 ± 0.48

PSA  
(ng/mL)

1.58 ± 1.08 1.71 ± 1.10 1.84 ± 1.11

Prostate volume (cm3) 43.05 ± 19.15 42.68 ± 15.77 48.75 ± 23.53

Total IPSS 15.21 ± 5.94 16.87 ± 4.76 18.75 ± 4.20

IPSS voiding  
sub-score

9.11 ± 3.85 10.13 ± 2.90 6.94 ± 3.20

IPSS storage  
sub-score

6.94 ± 3.20 7.76 ± 2.66 8.63 ± 3.02

Qmax  
(mL/s)

8.63 ± 3.02 8.63 ± 2.14 9.01 ± 2.45

Post residual volume  
(mL)

33.28 ± 46.36 30.89 ± 33.36 41.88 ± 45.75

TT: Total testosterone; BMI: body mass index;  
PSA: prostate specific antigen;  
IPSS: International Prostate Symptom Score;  
Qmax: peak flow rate

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(r = −0.17, P < 0.05). Contrastingly, for the IPSS voiding 
sub-score, no significant correlation was seen with the 
serum total testosterone level (r = −0.12, P = 0.07).

Discussion
Lower urinary tract symptoms (LUTS) are commonly 
seen among ageing males and largely attributed to 
benign prostatic hyperplasia (BPH). The main etiologic 
factors that have been accepted to play a role in the 
pathogenesis of the condition are ageing and alterations 
in androgen levels[10,11]. Serum testosterone levels 
gradually decrease after the age of 40, and it is during this 
period that the onset of BPH usually occurs[3]. Although 
it has been well established that serum testosterone and 
its metabolite, 5-alpha-dihydrotestosterone, is vital for 
prostate growth, the mechanism of increasing LUTS 
occurrence in the later stages of life despite the declining 
androgen levels remains unclear. Xia et al. analyzed 
the correlations between prostate volume and serum 
testosterone level over a 4-year period and found a linear 

increase in prostate volume with the decrease in serum 
testosterone level, suggesting that prostate volume is not 
dependent on serum testosterone in the ageing male 
population[12]. Until now, the persistence of conflicting 
views on the effect of prostate volume on LUTS shown in 
previous studies highlights the complex nature of BPH 
and factors that may contribute to it[13,14].

Our study found that the severity of LUTS, as cate-
gorized according to the IPSS, and the serum TT status 
are independent of each other, which is consistent with 
previous studies reported by Crawford et al. and Liu et 
al.[4,6]. Similarly, a cross-sectional study by Schaztl et al. 
of 312 men above 40 years of age with untreated LUTS 
showed that hypogonadism had no impact on LUTS 
status and its clinical parameters, including IPSS and 
uroflowmetry[15]. This finding is in keeping with the 
saturation hypothesis, which surmises that incremen-
tal increase in testosterone level does not cause further 
androgen-stimulated prostate tissue proliferation due to 
the saturation of the available androgen receptors on the 
gland[16].

Interestingly, based on the continuous variable data 
analysis, we found negative correlations between serum 
total testosterone levels with total IPSS and IPSS storage 
sub-score, although only weak correlations were demon-
strated. Several possible mechanisms may explain the 
inverse association between testosterone and LUTS. The 
urethral and bladder epithelial cells have been found 
to contain a large amount of androgen receptors. One 
animal study showed that testosterone may have an 
effect in maintaining the pelvic ref lex activity of the 
autonomic nervous system, including the suppression of 
detrusor activity, which may play an important role in 
determining the severity of LUTS[17]. Other postulation 
includes the effect of testosterone on nitric-oxide-medi-
ated smooth muscle relaxation, which may result in the 
reduction of LUTS severity among those with a higher 
testosterone level[18]. Additionally, testosterone may 
also have a physiologic role in the maintenance of the 
vasopressin level, thus affecting the ability of the kidneys 
to concentrate urine, thereby improving storage symp-
toms such as nocturia[19]. Furthermore, testosterone has 
been demonstrated to enhance the anti-inflammatory 
effect in prostate, thus dampening the effect of chronic 
inflammatory process that has been postulated to be one 
of the major etiologies of LUTS/BPH development[20]. 
Similarly, the presence of metabolic syndrome, which 
is commonly seen among men with lower testoster-
one levels, may perpetuate this chronic inflammatory 
process, therefore further propagating the development 
of LUTS/BPH among men in this population[20,21].

Apart from lower urinary tract symptoms, the effects 
of low testosterone are diverse, encompassing mental, 
physical, and sexual functions. The prevalence of 

TABLE 5.  

Age-adjusted Pearson partial correlations between IPSS 
(total and sub-scores) and serum total testosterone level 

Coefficient 

IPSS -0.172*

IPSS-V -0.123 

IPSS-S -0.165*

* p < 0.05, ** p < 0.01, *** p < 0.001 Conditioned on variables: Age 
IPSS: International Prostate Symptom Score;  
IPSS-V: IPSS voiding sub-score; IPSS-S: IPSS storage sub-score

TABLE 4. 

Chi-square test of LUTS severity with serum total 
testosterone 

Value df
Asymptotic  
significance 

(2-sided)

Pearson  
chi-square

4.243a 4 0.374

N of valid cases 163

a  4 cells (44.4%) have expected count less than 5.  
The minimum expected count is 0.29.

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male hypogonadism in Malaysia has been reported 
as being between 17.5 and 18.5% among the general 
population[22,23]. Nonetheless, there is still a paucity 
of data available locally with regards to late-onset 
hy pogonadism among men with LUTS/BPH. In 
our cohort, the prevalence of hypogonadism among 
ageing men in Malaysia with LUTS was relatively high, 
accounting about 28%, with almost 5% having a severely 
low testosterone level. Disparities were also seen in the 
distribution among the multi-ethnic communities, 
and men of Indian ethnicity showed the highest 
preponderance of hypogonadism. Plausible causes of 
the disparity would include differences in genetic and 
epigenetic makeup and in socioeconomic background, 
which require further investigation. Its high prevalence 
indicates that thorough evaluation of ageing men 
presenting with LUTS, with or without late-onset 
hypogonadism syndrome, is vital as these symptoms are 
closely associated, regardless of testosterone level[24].

As the elderly population increases in Malaysia, the 
incidence of lower urinary tract symptoms with concur-
rent hypogonadism needs to be adequately addressed by 
clinicians, and consideration should be given to testos-
terone replacement therapy (TRT). In general, most 
guidelines still include precautions regarding TRT in 
men with BPH because of the belief it may aggravate 
the increase in prostate volume and thus hasten the 
progression of BPH, despite studies showing that exog-
enous testosterone has no effect on prostate volume or 
prostate specific antigen in older hypogonadal men[25]. 
In a systematic review by Cui et al. on 16 randomized 
controlled trials involving 1030 men, it was found that 
neither short-term nor long-term TRT increased the risk 
of prostate growth among hypogonadal men, thereby 
suggesting its safety among men with LUTS/BPH[26]. 
A 5-year prospective study by Yassin et al. that exam-
ined 261 hypogonadal men with LUTS receiving TRT 
found that TRT was associated with a significant LUTS 
improvement of 13.4% in hypogonadal men, suggest-
ing a potential beneficial effect of TRT among this 
cohort[27]. Kohn et al., in their meta-analysis of 14 
clinical trials involving 2029 men receiving TRT for 
late-onset hypogonadism, reported that IPSS changes 
were similar among men with mild to moderate LUTS 
receiving TRT versus placebo, indicating that TRT treat-
ment does not worsen LUTS among men with late-onset 
hypogonadism[28]. More recently, a systematic review 
by Lee et. al of 12 clinical trials to investigate the rela-
tionship between TRT and LUTS found that there was 
no significant worsening of LUTS following TRT and 

concluded there was not sufficient evidence to support 
warnings that TRT may worsen LUTS among men with 
hypogonadism[29].

The outcomes f rom our study high lighted t he 
complexity of the relationship between testosterone and 
the development of LUTS/BPH. More extensive research 
is required to improve the management of LUTS among 
ageing men.

Several limitations to our study were noted. A correlation 
between the IPSS and serum total testosterone levels 
was found, but there were only weak associations, and a 
larger sample size would strengthen the outcome of the 
study. As compared to a longitudinal study, the cross-
sectional study design prevents the ability to make causal 
inferences from the observed association. Our study 
included only one sampling of serum total testosterone 
per participant, which may provide an imperfect 
evaluation that may be inf luenced by individual and 
analytical errors, and the study did not include free 
testosterone measurement.

Conclusion
Our study found no significant relationship between 
the severity of LUTS with total testosterone status, 
although a higher IPSS, particularly those related to 
storage symptoms, was found to have a weak association 
with lower levels of serum total testosterone. Among 
Malaysian men with lower urinary tract symptoms, up 
to 28% may have concurrent testosterone deficiency, 
with males of Indian ethnicity having the highest 
preponderance of hypogonadism. As a high prevalence 
of low testosterone is seen among this population, 
more research is needed to elucidate the role of serum 
testosterone measurement among ageing patients 
with LUTS and its implication to the clinical practice, 
so as to better optimize the multimodal approach to 
its management. Further prospective research could 
include evaluating measurement of serum testosterone 
levels as possible biochemical predictor for LUTS 
progression and response to BPH therapy.

Acknowledgements
The study was performed in accordance with the ethical 
standards based in the 1964 Declaration of Helsinki 
and was approved by the local institutional ethics 
board (UKM FF-2021-082). Special thanks to Associate 
Professor Dr Rozita Hod for statistical consultation and 
Consultant Endocrinologist, Associate Professor Dr 
Norlaila Mustafa for research input.

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References

1. Teh GC, Sahabudin RM, Lim TC, Chong WL, Woo S, Mohan M, et 
al. Prevalence of symptomatic BPE among Malaysian men aged 50 
and above attending screening during prostate health awareness 
campaign. Med J Malaysia.2001 Jun;56(2):186–195.

2. Feldman HA, Longcope C, Derby CA, Johannes CB, Araujo AB, 
Coviello AD, et al. Age Trends in the level of serum testosterone and 
other hormones in middle-aged men: longitudinal results from the 
Massachusetts Male Aging Study. J Clin Endocrinol Metab.2002 Feb 
1;87(2):589–598.

3. Wu FCW, Tajar A, Beynon JM, Pye SR, Silman AJ, Finn JD, et al. 
Identification of late-onset hypogonadism in middle-aged and elderly 
men. N Engl J Med.2010 Jul 8;363(2):123–135.

4. Crawford ED, Poage W, Nyhuis A, Price DA, Dowsett SA, Muram D. 
Effects of testosterone level on lower urinary tract symptoms. Am J 
Mens Health.2016 Sep 1;10(5):440–442.

5. Liao CH, Chiang HS, Yu HJ. Serum testosterone levels significantly 
correlate with nocturia in men aged 40-79 years. Urology.2011 
Sep;78(3):631–635.

6. Liu CC, Huang SP, Li WM, Wang CJ, Chou YH, Li CC, et al. Relationship 
between serum testosterone and measures of benign prostatic 
hyperplasia in aging men. Urology.2007 Oct;70(4):677–680.

7. Martin SA, Haren MT, Marshall VR, Lange K, Wittert GA, Members 
of the Florey Adelaide Male Ageing Study. Prevalence and factors 
associated with uncomplicated storage and voiding lower urinary tract 
symptoms in community-dwelling Australian men. World J Urol.2011 
Apr;29(2):179–184.

8. Shim JS, Kim JH, Yoon YS, Choi H, Park JY, Bae JH. Serum testosterone 
levels are negatively correlated with international prostate symptom 
score and transitional prostate volume. Low Urin Tract Symptoms.2018 
May;10(2):143–147. doi: 10.1111/luts.12150. Epub 2016 Nov 5

9. EAU guideline. EAU Male Sexual and Reproductive health Guidelines. 
Edn. presented at the EAU Annual Congress Amsterdam 2022. ISBN 
978-94-92671-16-5.

10. Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human 
benign prostatic hyperplasia with age. J Urol.1984 Sep;132(3):474–479.

11. Partin AW, Oesterling JE, Epstein JI, Horton R, Walsh PC. Influence 
of age and endocrine factors on the volume of benign prostatic 
hyperplasia. J Urol.1991 Feb;145(2):405–409.

12. Xia BW, Zhao SC, Chen ZP, Chen C, Liu TS, Yang F, et al. Relationship 
between serum total testosterone and prostate volume in aging men. 
Sci Rep.2021 Jul 8;11(1):14122.

13. Agrawal CS, Chalise PR, Bhandari BB. Correlation of prostate 
volume with international prostate symptom score and quality of 
life in men with benign prostatic hyperplasia. Nepal Med Coll J.2008 
Jun;10(2):104–107.

14. Bosch JL, Hop WC, Kirkels WJ, Schröder FH. The International Prostate 
Symptom Score in a community-based sample of men between 55 
and 74 years of age: prevalence and correlation of symptoms with 
age, prostate volume, flow rate and residual urine volume. Br J Urol. 
1995;75(5):622–630. doi: 10.1111/j.1464-410x.1995.tb07421.x

15. Schatzl G, Brössner C, Schmid S, Kugler W, Roehrich M, Treu T, et al. 
Endocrine status in elderly men with lower urinary tract symptoms: 
correlation of age, hormonal status, and lower urinary tract function. 
The Prostate Study Group of the Austrian Society of Urology. 
Urology.2000 Mar;55(3):397-402.

16. Khera M, Crawford D, Morales A, Salonia A, Morgentaler A. A new 
era of testosterone and prostate cancer: from physiology to clinical 
implications. Eur Urol.2014 Jan;65(1):115-23.

17. Yassin A A, El-Sakka AI, Saad F, Gooren LJG. Lower urinary-tract 
symptoms and testosterone in elderly men. World J Urol.2008 
Aug;26(4):359–364.

18. Smet PJ, Jonavicius J, Marshall VR, de Vente J. Distribution of nitric 
oxide synthase-immunoreactive nerves and identification of the cellular 
targets of nitric oxide in guinea-pig and human urinary bladder by cGMP 
immunohistochemistry. Neuroscience.1996 Mar;71(2):337–348.

19. Shigehara K, Sugimoto K, Konaka H, Iijima M, Fukushima M, Maeda 
Y, et al. Androgen replacement therapy contributes to improving lower 
urinary tract symptoms in patients with hypogonadism and benign 
prostate hypertrophy: a randomised controlled study. Aging Male.2011 
Mar;14(1):53–58.

20. Rastrelli G, Vignozzi L, Corona G, Maggi M. Testosterone and benign 
prostatic hyperplasia. Sex Med Rev.2019 Apr;7(2):259-271.

21. Tsujimura A, Miyagawa Y, Takezawa K, Okuda H, Fukuhara S, 
Kiuchi H, et al. Is low testosterone concentration a risk factor for 
metabolic syndrome in healthy middle-aged men? Urology.2013 
Oct;82(4):814-819.

22. Kang WH, Siruhan M, Shree VN, Karupiah M, Sukor N, Kamaruddin 
NA. Prevalence of hypogonadism among male Type 2 diabetes mellitus 
patients in Pusat Perubatan Universiti Kebangsaan Malaysia. J ASEAN 
Fed Endocr Soc.2021 Dec 5;36:12–12.

23. Ho CC, Singam P, Hong GE, Zainuddin ZM. Male sexual dysfunction in 
Asia. Asian J Androl.2011 Jul;13(4):537–542.

24. Tsuru T, Tsujimura A, Mizushima K, Kurosawa M, Kure A, Uesaka Y, 
et al. International Prostate Symptom Score and quality of life index 
for lower urinary tract symptoms are associated with aging males 
symptoms rating scale for late-onset hypogonadism symptoms. World 
J Mens Health.2022 Jan 6. doi: 10.5534/wjmh.210171.

25. Raynaud JP, Gardette J, Rollet J, Legros JJ. Prostate-specific antigen 
(PSA) concentrations in hypogonadal men during 6 years of transdermal 
testosterone treatment. BJU Int.2013 May;111(6):880–890.

301SIUJ.ORG SIUJ  •  Volume 3, Number 5  •  September 2022

Relationship Between Serum Testosterone and Severity of LUTS 

http://SIUJ.org


26. Cui Y, Zhang Y. The effect of androgen-replacement therapy on 
prostate growth: a systematic review and meta-analysis. Eur 
Urol.2013 Nov;64(5):811-822.

27. Yassin DJ, El Douaihy Y, Yassin AA, Kashanian J, Shabsigh R, 
Hammerer PG. Lower urinary tract symptoms improve with 
testosterone replacement therapy in men with late-onset 
hypogonadism: 5-year prospective, observational and longitudinal 
registry study. World J Urol.2014 Aug;32(4):1049–1054.

28. Kohn TP, Mata DA, Ramasamy R, Lipshultz LI. Effects of testosterone 
replacement therapy on lower urinary tract symptoms: A systematic 
review and meta-analysis. Eur Urol.2016 Jun;69(6):1083-1090. doi: 
10.1016/j.eururo.2016.01.043.

29. Lee MH, Shin YS, Kam SC. Correlation between testosterone 
replacement treatment and lower urinary tract symptoms. Int 
Neurourol J. 2021 Mar;25(1):12–22.

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