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Male menopause after unilateral inguinal herniorrhaphy

A man aged 56 began to experience severe episodic flushing and sweating one month after a right inguinal herniorrhaphy. These episodes lasted several minutes and were described as sudden drenching perspiration occurring twenty or more times a day and severe enough to wake him at least ten times every night. There was no relation to food or exercise, he had no history of chest pain or syncope and there were no ictal phenomena; he was on no regular medication, was a non-smoker and drank little alcohol; he was married with two children. During a witnessed episode no abnormalities were observed in pulse, blood pressure or temperature. Routine blood investigations, including thyroid function tests, were normal and screening for phaeochromocytoma and carcinoid syndrome was negative. Although the herniorrhaphy had apparently been uncomplicated the patient reported that the right testis had become swollen and painful postoperatively (he had believed this to be the expected discomfort after a hernia repair). Once the pain had subsided, the right testis seemed to him smaller than it had been before surgery. He also disclosed that, as a child, he had experienced an episode of acute pain in the left testis which had resolved spontaneously. Examination of the scrotum revealed an atrophic left testis and a soft right testis, volumes 3 mL and 15 mL, respectively, when measured by Prader's orchidometer. Biochemical investigations confirmed the presence of hypogonadism: serum testosterone 1.0 nmol/L (normal range 10.5-31.0), luteinizing hormone 27.5 mU/mL (212 mU/mL) and follicle stimulating hormone 54.4 mU/mL (1-12). On direct questioning he said there had been no change in shaving frequency or loss of body hair but his libido had declined and he complained of lethargy. Within 4 hours after receiving testosterone replacement via intramuscular injection (Sustanon 250 mg), the sweating episodes had resolved and they did not recur for two weeks. Lifelong testosterone replacement is to be provided by subcutaneous testosterone implants.