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Priapism as a complication of high dose testosterone therapy: A medication error [Case report and a review of literature]


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Priapism is defined as a prolonged, sustained penile erection without sexual stimulus. It rarely occurs in children, but may result in erectile dysfunction and sexual aversion behaviors as one gets older. Testosterone therapy is safely used in children with hypogonadism, delayed puberty, and micropenis. We report a rare case of testosterone-induced priapism in an 8-year-old boy with a micropenis, after receiving an incorrect dose of 500 mg of testosterone injection; his mother (a paramedic) administered it. The patient was managed with observation and cold compresses; without any surgical intervention. This case suggests that hormonal injections be administered by either registered nurses or physicians, "but not by relatives."
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International Journal of Medical and Health Research
International Journal of Medical and Health Research
ISSN: 2454-9142
Impact Factor: RJIF 5.54
Volume 4; Issue 2; February 2018; Page No. 17-21
Priapism as a complication of high dose testosterone therapy: A medication error
[Case report and a review of literature]
1 Elaf Alzarnougi, 2 Abdulmoein Eid Al-Agha, 3 Yara Kano
1 King Abdulaziz University Hospital, Jeddah, Saudi Arabia
2 Professor of Pediatric Endocrinology, King Abdulaziz University Hospital, P.O.BOX 80215, Jeddah, Saudi Arabia
3 King Abdulaziz University Hospital, Jeddah, Saudi Arabia
Priapism is defined as a prolonged, sustained penile erection without sexual stimulus. It rarely occurs in children, but may result in
erectile dysfunction and sexual aversion behaviors as one gets older. Testosterone therapy is safely used in children with
hypogonadism, delayed puberty, and micropenis. We report a rare case of testosterone-induced priapism in an 8-year-old boy with
a micropenis, after receiving an incorrect dose of 500 mg of testosterone injection; his mother (a paramedic) administered it. The
patient was managed with observation and cold compresses; without any surgical intervention. This case suggests that hormonal
injections be administered by either registered nurses or physicians, "but not by relatives."
Keywords: priapism, testosterone, micropenis, medication error
The United State Institute of Medicine reports that To Err is
Human’ in November 1999, which focused on preventable
medical errors in order to build a safer health system and
making patient safety the preeminent issue in health care.
Over time, the concept of patient safety increased, and it
became clear that the prescribing, dispensing, and
administration of medications is the key of preventable
medical errors [1]. The National Patient Safety Agency
revealed the fact of those medication errors could occur at
each stage of the medication treatment process. Children were
more prone to these errors than adults. Medication errors in
pediatrics have been estimated to be 3-37% during
prescribing, 5-58% during dispensing, 72-75% during
administration, and 17-21% during documentation [2].
Testosterone is a hormone used in children with micropenis,
hypogonadism, constitutional delay of growth and puberty,
hypospadias, and disorders of sexual differentiation. It is
considered safe in both adults and children, with proper doses
maintained, so that monitoring is recommended [3].
Kaplowitz studied the value of testosterone therapy in males
with delayed puberty. He noted increased frequency of
erections, but it was not excessive in any patient. This appears
to be the case for the majority of patients, but it is important to
be aware that priapism could occur during testosterone
therapy [4-6].
Priapism is a prolonged complete or partial penile erection
lasting more than four hours, but unrelated to sexual stimulus.
There are three categories of priapism: ischemic priapism,
which is considered the most common type in children,
stuttering priapism (intermittent), and nonischemic priapism
Priapism after administration a high dose of testosterone has
been rarely reported in literature. There were 21-reported
cases of priapism associated with testosterone therapy in
English literature. Two cases were due to administering a high
dose, whereas the rest were therapeutic doses [3, 5, 8-18]. We
reported a case of an 8-year-old boy with micropenis and
priapism, secondary to a high dose of testosterone in a
medication administration error.
Case Report
An 8-year-old Yemeni boy was born prematurely after a 28-
week gestation to no consanguineous parents. He is one twin
in a pair of dizygotic twins, born with a birth weight of 1200 g
and good Apgar scores. Presented to the Pediatric Endocrine
Clinic with a history of micropenis (stretched penile length
was equal to 3.7 cm, which is below the 10th percentile for
ages plotted on the penile length chart). Testicular volume was
2 ml on both sides. No family history of micropenis or
hypogonadism existed. His height was 110 cm (-3.71 standard
deviation below the normal) and his weight was 16.5 kg (-3.02
standard deviation below the normal). He was otherwise
healthy with no dysmorphic features and unremarkable
systemic examinations. His initial work-up revealed a serum
testosterone level of 0.087 nmol (normal 8.4-28.7 nmol/L),
while follicle-stimulating hormone (FSH) and luteinizing
hormone (LH) were 0.2 (normally less than 2). Bone age
according to Greulich and Pyle was that of a 7-year-old
(delayed for chronological age). He had no risk factors for
priapism: no history of trauma, sickle cell disease, or
The patient was prescribed intramuscular testosterone
injections of 50 mg, but received an accidently high dose of
500 mg by his mother who, as mentioned, is a paramedic
personnel. Two hours after the injection, he started to have
International Journal of Medical and Health Research
painless prolonged erections for six hours in duration, but
which resolved spontaneously and recurred again within
hours; he continued to experience multiple erections, with six
of them being more than 4 hours long (ranging from 6 to 12
hours), and accompanied by nocturnal erections. Both testicles
became engorged, with a feeling of heaviness, discomfort, and
darkness of scrotum color. His genital examination revealed a
stretched penile length of 6 cm [Figure 1], with each testicular
volume increased to 3 ml on both sides, along with pubic hair
starting to appear at stage 2.
Fig 1: Erected patient's penis with penile length of 6 cm.
Our investigations were done to monitor precocious puberty
(post high dose of testosterone) revealed that his serum
testosterone was 23.54 ng/dL, LH 0.29 IU/L and FSH 0.11
IU/L. Testicular ultrasound showed prepubertal testicles size
[Figure 2]. Complete blood count (CBC) and coagulation
profile were otherwise normal with no evidence of anemia,
polycythemia, thrombocytopenia, or thrombocytosis. Sickling
test was negative.
Fig 2: Ultrasound of testicles showed right testicles measures 1 x 0.8
x 1 cm and left testicle measures 1.4 x 0.8 x 0.8 cm.
There is no antidote for testosterone, so he was managed with
cold penile compresses to decrease blood flow, daily
monitoring of frequency and duration of erections, as a
surgical shunt was planned if erections became worse; his
erections were less frequent, however, along with shorter
duration over time.
This case suggests a strong association between a high dose of
testosterone administration and development of priapism. This
patient did not have a previous history or risk factors for it.
Causes of priapism can involve sickle cell anemia, leukemia,
malignancies, and trauma. Drugs have also been considered,
but rarely has this been the situation. The World Health
Organization (WHO) Uppsala Monitoring Centre received
122 reports of priapism from 1968 to 1987, containing 138
suspected drugs, although testosterone was not one of them [8].
Testosterone hormone is important for penile erections.
Androgen receptors exist in large quantities in the immature
phallus, including the erectile tissue, but decrease with age
and present in low quantities in an adult phallus [19].
Androgens aid erection initiation by increasing nitric oxide
synthase expression and activity. Increased nitric oxide causes
cavernosal artery and sinusoidal smooth muscle relaxation, yet
it also enhances phosphodiesterase type-5 that works on
restoring the resting smooth muscle contractility [3]. The exact
mechanism by which testosterone administration causes
priapism is not clear yet.
In this reported case, priapism was obvious due to medication
administration error. The patient was given a high dose of
testosterone (500 mg) instead of the correct 50 mg by his
mother (a paramedic) who erroneously read the written
prescription. This is consistent with two other reported cases
who developed priapism after a high dose of testosterone due
to medication administration error. The first case was reported
by Zargooshi, in a patient with hypogonadotropic
hypogonadism, who had an increased dose from 250 to 500
mg. His conclusion was that testosterone-induced priapism is
dose-dependent [13]. Ichoka reported a second case of
testosterone-induced priapism in a patient with Klinefelter
syndrome. The patient was given the third injection by
mistake 12 days after the second injection, but the interval
between the two injections was too short. Accumulation of
testosterone enanthate, in addition to the supraphysiologic
local testosterone level, could be the cause of priapism. Ichoka
suspected that the sudden exposure to testosterone after a long
period of deprivation could have caused priapism, via an
increase in local sensitivity to testosterone [15]. This hypothesis
was supported by other cases in the literature as well [Table
1]. Shergill reported a case of priapism after testosterone
injection in a patient with Kallmann’s syndrome [10], while
Whalen reported two cases of priapism in patients receiving
gonadotropin-releasing hormone (GnRH) for
hypogonadotropic hypogonadism [9]. Zelissen reported a case
of testosterone-induced priapism in a patient with idiopathic
hypogonadotropic hypogonadism [8].
From previous reported cases, priapism can happen as a side
effect of testosterone therapy itself, especially in patients
deprived of testosterone, or as a complication of high doses.
The 21 cases found in a literature review [Table 1] found that
most of them were in adolescence between 12 and 23 years.
Four of them were above thirty, but no one was in the
International Journal of Medical and Health Research
childhood range, as was this indexed case. From these 21
patients, only one of them was documented to have
micropenis, although no one was taking testosterone for
isolated micropenis, as in this case. The onset of priapism
after testosterone administration ranged from 2 to 10 days. In
this patient, it started 2 hours after injection and continued for
6 hours, and resolved spontaneously; after that, he continued
to have night and day erections with multiple episodes of
priapism for one week until he sought medical advice.
To date, there is no antidote for testosterone overdose.
Regarding priapism management and medical evaluation, it is
recommended for any erection lasting more than 4 hours.
Management and prognosis varies among cases. Initial
management aims to determine the type of priapism and
achieve detumescence. With the current treatments available,
antiandrogens are seen as the optimal management of
testosterone-induced priapism. However, they are relatively
contraindicated in males who have not reached sexual or
skeletal maturation. Opiate analgesia is required in ischemic
priapism. Cold packs are also considered analgesic, and
causing vasoconstriction and decreasing penile blood flow as
that was effective in this indexed case. Aspiration of blood
from the corpus cavernosum, along with irrigation, is the
initial treatment in ischemic priapism. If not effective, an
intracorporal injection of phenylephrine in a small dose should
be performed. Last choice if the previous measures are not
effective is surgery, with distal or proximal shunts being
performed [6].
Follow-up of patients was not documented in most reports.
Key reported a case of priapism after a therapeutic dose of
testosterone for delayed puberty, who developed impotence
one year after puberty [5].
Although a relative of the patient may work in the medical
field, it is not advisable for that person to give the injection, as
frequent errors can happen as a function of an emotional
connection. For children, parents must be counseled before
testosterone administration about its side effects - e.g., pubic
hair appearance, frequent erections, and priapism, especially if
given in too high a dose. Monitoring is needed for early
puberty induction in these cases by regular examination of
testicular size and Tanner’s pubertal staging, in addition to
biochemical monitoring of pubertal hormones and ultrasound
monitoring of testicular size; this would naturally include
serum testosterone levels returning to normal for his age.
Table 1: Reported cases of testosterone induced priapism
Agent used
Age of the
Risk factors
Onset from
12 year old
Resolved spontaneously
enanthate and
Sickle cell
3 patients:
20, 20 and
31 year old
Previous Priapism
before starting the
All these cases needed
surgical intervention
as a mixture of
its ester
Renal Failure
2 patients,
age not
Not mentioned
as a mixture of
its ester
Renal Failure
Not mentioned
Sickle cell
19 year old
Resolved after drug
Fabry's disease
17 year old
Accumulation of
in autonomic ganglia.
At the 17th
day of
shunt had to be
Idiopathic hypo-
20 year old
Three days
after third
shunt. Recurrent one day
later and a second shunt
operation was necessary.
as a mixture of
its ester
Delayed Puberty
15 year old
7 Days after
first injection
Shunt operation was
planned. At induction of
anesthesia, penis
detumescence occurred.
Key LL5
Delayed Puberty
14 year old
Manipulation of the
erected penis
5 days after
first injection
Responded to irrigation
But one year later, after
puberty, he developed
14 year old
& 13 year
Following the
initial dose
Responded to amyl
nitrite therapy.
International Journal of Medical and Health Research
Table 2: Reported cases of testosterone induced priapism
Agent used
Age of the
Risk factors
Onset from
32 year old
Responded to injection of
1:100,000 epinephrine
solution followed by
38 year old
Shunt procedure was
Sickle cell
14 year old
7 Days after
Respond to terbutaline +
topical nitropaste
13 year old
8 Days after
Treated with aspiration
23 year old
The patient
increased the dose
the fourth
Corporeal glandular shunt
was performed
18 year old
10 Days
after first
Treated with aspiration but
recurred within 24 hours. So,
shunt was performed
delay of growth
and puberty
14 years old
2 Days after
Treated by repeated aspiration
and irrigation with
41 year old
The interval
between 2nd & 3rd
injection was short
8 Days after
Treated by aspiration and
injection of adrenaline
delay of growth
and puberty
15 year old
7 Days after
treated with insertion of
bilateral T-shunts. After 24
hour Bilateral mid corporal
corporotomies were
Sickle cell
14 year old
3 Days after
Treated with hyper hydration
and analgesia.
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... Androgen replacement therapy has been occasionally reported to trigger priapism in the literature. The presumed mechanism is via testosterone-induced upregulation of nitric oxide (NO) synthase, which increases cavernosal artery and smooth muscle relaxation [44][45][46][47]. ...
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Purpose of Review Priapism is a rare condition that has different presentations, etiologies, pathophysiology, and treatment algorithms. It can be associated with significant patient distress and sexual dysfunction. We aim to examine the most up-to-date literature and guidelines in the management of this condition. Recent Findings Priapism is a challenging condition to manage for urologists, since the etiology is often multi-factorial and the suggested treatment algorithms are based on small studies and expert anecdotal experience, perhaps due to the rarity of the disorder. Summary Ischemic priapism of less than 24 h can be managed non-surgically in most cases with excellent results. Ischemic priapism of more than 36 h is frequently associated with permanent erectile dysfunction. Management of prolonged priapism with penile shunting still may result in poor erectile function, so penile prosthesis can be discussed in these scenarios.
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Background: Priapism has been linked to many commonly prescribed medications, as well as recreational drugs and toxins. Although the incidence of priapism as a result of medication is small, the increasing use of antidepressants, antipsychotics, and recreational drugs may lead to more cases of pharmacologically-induced priapism in the future. Aim: To provide a comprehensive, up-to-date review of the most common causes of pharmacologically induced priapism and discuss incidence, pathophysiology, and basic management strategies. Methods: A review of the available literature from 1960 to 2018 was performed using PubMed with regards to pharmacologically induced priapism. Main Outcome Measure: We reviewed publications that outlined incidence, pathophysiology, and management strategies for various pharmacologic causes of priapism: antidepressants, antipsychotics, antihypertensives, methylphenidate, cocaine, heparin, gonadotropin-releasing hormone, propofol, spider bites, and other miscellaneous causes. Results: An understanding of the pathophysiology behind common pharmacologic causes of priapism can assist in the development of better treatment strategies and prevent future episodes of priapism. By understanding the potential risks associated with the use of medications with α-blocking or sympathomimetic properties, physicians can reduce the likelihood of priapism in their patients, especially those with other medical conditions that put them at increased baseline risk. Early corporal aspiration and injection of phenylephrine reduces additional complications related to priapism. In select patients, early placement of a penile prosthesis may prevent further morbidity. Conclusion: By developing a greater understanding of common pharmacologic causes of priapism, physicians can promptly identify and manage symptoms, leading to decreased patient morbidity. Scherzer ND, Reddy AG, Le TV, Chernobylsky D, Hellstrom WJG. Unintended Consequences: A Review of Pharmacologically Induced Priapism. Sex Med Rev 2018;XX:XXX‒XXX.
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Background Medication errors are a significant global concern and can cause serious medical consequences for patients. Little is known about medication errors in Middle Eastern countries. The objectives of this systematic review were to review studies of the incidence and types of medication errors in Middle Eastern countries and to identify the main contributory factors involved. Methods A systematic review of the literature related to medication errors in Middle Eastern countries was conducted in October 2011 using the following databases: Embase, Medline, Pubmed, the British Nursing Index and the Cumulative Index to Nursing & Allied Health Literature. The search strategy included all ages and languages. Inclusion criteria were that the studies assessed or discussed the incidence of medication errors and contributory factors to medication errors during the medication treatment process in adults or in children. Results Forty-five studies from 10 of the 15 Middle Eastern countries met the inclusion criteria. Nine (20 %) studies focused on medication errors in paediatric patients. Twenty-one focused on prescribing errors, 11 measured administration errors, 12 were interventional studies and one assessed transcribing errors. Dispensing and documentation errors were inadequately evaluated. Error rates varied from 7.1 % to 90.5 % for prescribing and from 9.4 % to 80 % for administration. The most common types of prescribing errors reported were incorrect dose (with an incidence rate from 0.15 % to 34.8 % of prescriptions), wrong frequency and wrong strength. Computerised physician rder entry and clinical pharmacist input were the main interventions evaluated. Poor knowledge of medicines was identified as a contributory factor for errors by both doctors (prescribers) and nurses (when administering drugs). Most studies did not assess the clinical severity of the medication errors. Conclusion Studies related to medication errors in the Middle Eastern countries were relatively few in number and of poor quality. Educational programmes on drug therapy for doctors and nurses are urgently needed.
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Although children are at the greatest risk for medication errors, little is known about the overall epidemiology of these errors, where the gaps are in our knowledge, and to what extent national medication error reduction strategies focus on children. To synthesise peer reviewed knowledge on children's medication errors and on recommendations to improve paediatric medication safety by a systematic literature review. PubMed, Embase and Cinahl from 1 January 2000 to 30 April 2005, and 11 national entities that have disseminated recommendations to improve medication safety. Study selection: Inclusion criteria were peer reviewed original data in English language. Studies that did not separately report paediatric data were excluded. Two reviewers screened articles for eligibility and for data extraction, and screened all national medication error reduction strategies for relevance to children. From 358 articles identified, 31 were included for data extraction. The definition of medication error was non-uniform across the studies. Dispensing and administering errors were the most poorly and non-uniformly evaluated. Overall, the distributional epidemiological estimates of the relative percentages of paediatric error types were: prescribing 3-37%, dispensing 5-58%, administering 72-75%, and documentation 17-21%. 26 unique recommendations for strategies to reduce medication errors were identified; none were based on paediatric evidence. Medication errors occur across the entire spectrum of prescribing, dispensing, and administering, are common, and have a myriad of non-evidence based potential reduction strategies. Further research in this area needs a firmer standardisation for items such as dose ranges and definitions of medication errors, broader scope beyond inpatient prescribing errors, and prioritisation of implementation of medication error reduction strategies.
Abstract OBJECTIVE: We review the English literature between 1980 and 2013 and summarize the clinical classification, aetiology, physiology, and pathophysiology of paediatric priapism. We propose a clinical guideline for the management of priapism in children. PATIENTS: Male patients aged ≤ 18 years. RESULTS: Priapism, a prolonged penile erection lasting >4 h, is a rare condition in childhood. There are 3 widely accepted types of priapism: 1) ischaemic priapism, the commonest type seen in children; 2) stuttering priapism, recurrent, self-limiting prolonged erections; and 3) non-ischaemic priapism, rare in children, usually due to trauma. Neonatal priapism has also been described. Ischaemic priapism is a urological emergency causing fibrosis of the corpora cavernosa, subsequent erectile dysfunction and penile disfigurement. The commonest causes of priapism in children are sickle cell disease (65%), leukaemia (10%), trauma (10%), idiopathic (10%), and pharmacologically induced (5%). CONCLUSIONS: Priapism in children must be assessed urgently. Rapid resolution of ischaemic priapism prevents permanent cavernosal structural damage and is associated with improved prognosis for potency later in life. Stuttering priapism requires careful counselling for episodic management. Chronic prophylaxis may be obtained using α-adrenergic sympathomimetics, phosphodiesterase type 5 inhibitors and, in sickle cell disease, hydroxyurea. Non-ischaemic and neonatal priapism may generally be treated less urgently.
Abstract Priapism is rare in children and may result in erectile dysfunction and sexual aversion behaviours. Testosterone therapy is commonly regarded as safe in children and is widely used in constitutional delay of growth and puberty, hypogonadism, hypospadias and micropenis. We report two cases of priapism in teenage boys with constitutional delay of growth and puberty after a change in the formulation of depot testosterone. One case required surgical intervention and the other was preceded by stuttering priapism. These cases illustrate the importance of patient and/or parent counselling before testosterone administration and consideration of lower doses in at-risk patients.
Priapism describes a persistent erection arising from dysfunction of mechanisms regulating penile tumescence, rigidity, and flaccidity. A correct diagnosis of priapism is a matter of urgency requiring identification of underlying hemodynamics. To define the types of priapism, address its pathogenesis and epidemiology, and develop an evidence-based guideline for effective management. Six experts from four countries developed a consensus document on priapism; this document was presented for peer review and debate in a public forum and revisions were made based on recommendations of chairpersons to the International Consultation on Sexual Medicine. This report focuses on guidelines written over the past decade and reviews the priapism literature from 2003 to 2009. Although the literature is predominantly case series, recent reports have more detailed methodology including duration of priapism, etiology of priapism, and erectile function outcomes. Consensus recommendations were based on evidence-based literature, best medical practices, and bench research. Basic science supporting current concepts in the pathophysiology of priapism, and clinical research supporting the most effective treatment strategies are summarized in this review. Prompt diagnosis and appropriate management of priapism are necessary to spare patients ineffective interventions and maximize erectile function outcomes. Future research is needed to understand corporal smooth muscle pathology associated with genetic and acquired conditions resulting in ischemic priapism. Better understanding of molecular mechanisms involved in the pathogenesis of stuttering ischemic priapism will offer new avenues for medical intervention. Documenting erectile function outcomes based on duration of ischemic priapism, time to interventions, and types of interventions is needed to establish evidence-based guidance. In contrast, pathogenesis of nonischemic priapism is understood, and largely attributable to trauma. Better documentation of onset of high-flow priapism in relation to time of injury, and response to conservative management vs. angiogroaphic or surgical interventions is needed to establish evidence-based guidance.
Anaemia is a common complication of chronic kidney disease. Of the various contributory factors, the most important is an inappropriately low circulating concentration of erythropoietin, a hormone largely produced by the peritubular cells of the kidney. Chronic anaemia causes debilitating symptoms, particularly if severe, including tiredness and lethargy, muscle fatigue, reduced exercise capacity and breathlessness on exertion. There are adverse consequences for a number of physiological systems, particularly those of the heart and brain. The anaemia of kidney disease tends to develop once the glomerular filtration rate falls below 60 ml/minute, and anaemic patients with a lesser degree of renal impairment should be screened carefully for another cause of anaemia. Synthetic erythropoietin therapy has transformed the management of renal anaemia; it induces an increase in haemoglobin concentration and prevents the need for repeated blood transfusions, particularly in dialysis patients. Many patients receiving erythropoietin therapy will require supplemental iron, and this is often given intravenously. Several new strategies for stimulating erythropoiesis are currently in development, including prolyl hydroxylase inhibition (HIF stabilizers), erythropoietin gene therapy, and modulation of hepcidin activity.
• A brief course of testosterone injections is known to be an effective treatment for boys with constitutional delayed puberty. In this study, data from seven boys at least 14 years old who received testosterone enanthate (100 mg intramuscularly monthly for four months) were analyzed to see if linear and testicular growth responses could be useful diagnostically in excluding growth hormone deficiency (GHD) and isolated gonadotropin deficiency, two conditions that are often difficult to distinguish from constitutional delayed puberty. During four months of testosterone therapy, growth rate increased from 4.0±1.0 cm/y to 10.7±2.3 cm/y, and was greater than 8 cm/y in all patients. Since testosterone-induced stimulation of linear growth is largely GH-mediated, the large increase in growth rate in all boys is considered indicative of GH sufficiency. Testis length, which did not increase during testosterone therapy, increased by 0.6 to 0.8 cm in every patient (from 2.7 ± 0.3 cm to 3.4 ± 0.4 cm) over the following four months, indicating normal gonadotropin secretion and normal pubertal progression; in contrast, the increase in serum testosterone concentrations after discontinuation of testosterone treatment was more variable. It is concluded that the growth response to a four-month course of testosterone is helpful in excluding GHD in boys with delayed puberty, and an additional four months of follow-up is sufficient to document the onset of puberty, thereby eliminating the possibility of isolated gonadotropin deficiency. (AJDC 1989;143:116-120)