A Veteran Presenting for Low Testosterone and Lower Urinary Tract Symptoms
Case Presentation: A 76-year-old patient presented with decreased libido, repeated low testosterone levels, and lower urinary tract symptoms. He had a history of a left nephrectomy approximately 17 years prior for presumed renal cell carcinoma (RCC) subsequently complicated by chronic kidney disease stage 4, benign prostatic hypertrophy, erectile dysfunction, and a 50-pack-year history of smoking. His medications included tadalafil, tamsulosin, oxybutynin, and losartan.
There are a multitude of causes of pituitary apoplexy, including alterations in coagulopathy, pituitary stimulation (eg, dynamic pituitary hormone testing), and both acute increases and decreases in blood flow.10 This patient likely had an ischemic event due to changes in vascular perfusion, spurred by both his blood loss intraoperatively and ongoing hematuria. Management of pituitary apoplexy is dependent on the patient’s hemodynamics, mass effect symptoms, electrolyte balances, and hormone dysfunction. The decision for conservative management vs surgical intervention should be made in consultation with both neurosurgery and endocrinology. Once the patient is hemodynamically stable, the next step in evaluating this patient should be repeating his hormone studies.
►Dr. Bhatnagar: An assessment of pituitary function was consistent with values obtained preoperatively. After multidisciplinary discussions, surgery was deferred, and hydrocortisone was reinitiated to reduce inflammation caused by bleeding into the mass. As the ophthalmoplegia improved, this was transitioned to dexamethasone.
Twelve days after admission, he was discharged to a subacute rehabilitation center, with improvement in his ophthalmoplegia and stabilization of his creatinine level and urine output.
