Clinical History and Physical Examination
For general information on the clinical history, physical examination, and laboratory tests involved in a male presenting with infertility, please site. Here we review those points specifically relevant to the diagnosis of hypogonadism.
The evaluation of a patient with suspected hypogonadism begins with a detailed and complete history and a physical examination. The medical history should focus on pubertal development, testicular descent, loss of body hair, decrease in shaving frequency, and past and current chronic medical illnesses. In patients presenting with infertility, information should be obtained on previous mumps orchitis, sinopulmonary complaints, sexually transmitted diseases, genitourinary tract infections, and previous surgical procedures such as vasectomy, orchiectomy, and surgery around the vas deferens. Social history should include tobacco and alcohol intake, exposure to toxic chemicals, hot baths and saunas, irradiation, anabolic steroids, cytotoxic chemotherapy, and drugs that may cause hyperprolacrinemia. A detailed sexual history should be obtained, including questions on libido, frequency of intercourse, and erectile and ejaculatory functions. In addition, the fertility status of the female partner, and the type and extent of past investigations of the female partner and the patient himself should be ascertained.
The physical examination includes a general medical examination. The clinical manifestation of androgen deficiency depends on the age of onset, with different clinical findings at different ages:
■ Early fetal life: ambiguous genitalia (testicular agenesis, androgen biosynthetic defects, or androgen resistance)
■ Late fetal development and in the neonate: micropenis
■ Adolescence: delayed pubertal development with eunuchoid features
■ Adulthood: loss of secondary sex characteristics, decreased sexual function, and infertility
Height, extremity span, and the ratio of upper to lower body segments will determine if a patient is eunuchoidal. Androgen deficiency may lead to increased body fat and decreased muscle mass. Obesity itself will lead to lowered testosterone levels. Loss of pubic, axillary, and facial hair, decreased acne and oiliness of skin, and fine facial wrinkling are features suggestive of low androgen concentrations. Gynecomasria may be present when there is a decreased androgen-to-estrogen ratio. During the physical examination, the stage of development (Tanner’s classification) of the gonads and phallus is ascertained. Examination of the scrotum should include palpation of the vas deferens and epididymis and the identification of other scrotal abnormalities such as varicocele, hydrocele, and hernia. Testis size can be measured by either the Prader or Takihara orchidometers, which consist of a series of plastic ellipsoids with a volume from 1 to 30-35 mL. A tesris volume of less than 15 mL in an adult Caucasian man is regarded as small; testicular size may be slightly less in normal Asian populations. A decreased tesris volume usually indicates a decreased mass of the seminiferous tubules since they account for 80% of the mass of normal-sized testes. Alternatively, testis size can be measured by calipers. The length of the testis in eugonadal men ranges between 3.6 and 5.5 cm and the width between 2.1 and 3.2 cm.