Testosterone replacement therapy (TRT) is prescribed to men with clinically confirmed testosterone deficiency in the UK, regulated by the MHRA and guided by NICE recommendations. Whilst TRT can influence prostate function and lower urinary tract symptoms, many men wonder: can testosterone treatments cause incontinence? Understanding the relationship between testosterone therapy and urinary function is important for patients considering or currently receiving treatment. This article examines the evidence regarding TRT and incontinence, explores related urinary effects, and provides guidance on when to seek medical advice for urinary symptoms during testosterone treatment.

Understanding Testosterone Replacement Therapy in the UK

Testosterone replacement therapy (TRT) is a medical treatment prescribed to men with clinically confirmed testosterone deficiency, also known as hypogonadism. In the UK, TRT is regulated by the Medicines and Healthcare products Regulatory Agency (MHRA) and prescribed according to guidelines from the National Institute for Health and Care Excellence (NICE CKS) and specialist endocrinology societies.

Testosterone deficiency occurs when the testes produce insufficient amounts of this essential hormone, leading to symptoms such as reduced libido, erectile dysfunction, fatigue, decreased muscle mass, mood changes, and reduced bone density. Diagnosis requires both biochemical confirmation through blood tests showing consistently low testosterone levels (typically measured on two separate morning occasions) and the presence of relevant clinical symptoms. In borderline cases, measurement of sex hormone binding globulin (SHBG) and free testosterone may be considered.

TRT is available in several formulations in the UK, including:

• Transdermal gels and solutions (e.g., Testogel, Tostran, Testavan) applied daily to the skin

• Intramuscular injections such as testosterone undecanoate (Nebido) administered every 10–14 weeks, or testosterone esters administered every 2–3 weeks

The choice of preparation depends on patient preference, lifestyle factors, and clinical considerations. TRT works by supplementing the body's natural testosterone, restoring levels to the normal physiological range. This helps alleviate symptoms of deficiency and may improve quality of life, sexual function, body composition, and bone health.

TRT is not appropriate for all men with low testosterone. Contraindications include androgen-dependent tumours (including prostate cancer), male breast cancer, uncontrolled heart failure, severe hepatic or renal impairment, and untreated severe sleep apnoea. TRT also suppresses sperm production and should be avoided in men trying to conceive. Regular monitoring by a GP or endocrinologist is essential, including blood tests (testosterone levels, full blood count, PSA where appropriate), blood pressure checks, and clinical assessment of response and side effects.

Can Testosterone Treatments Cause Incontinence?

There is no established direct causal link between testosterone replacement therapy and urinary incontinence in the current medical literature or regulatory guidance from UK authorities. Incontinence is not listed among the common or recognised adverse effects of TRT in the British National Formulary (BNF) or product information approved by the MHRA.

Urinary incontinence—the involuntary leakage of urine—has multiple potential causes in men, including benign prostatic hyperplasia (BPH), overactive bladder, neurological conditions, pelvic floor dysfunction, and post-surgical complications. The relationship between testosterone and lower urinary tract function is complex and not fully understood. Some research suggests testosterone may have a protective or neutral effect on bladder function, though evidence is limited and mixed.

However, testosterone therapy can influence the prostate gland, which may indirectly affect urinary symptoms in some men. Testosterone stimulates prostate growth, and men on TRT may experience modest increases in prostate size or prostate-specific antigen (PSA) levels. In men with pre-existing benign prostatic hyperplasia, this could potentially worsen lower urinary tract symptoms (LUTS) such as urgency, frequency, or weak stream—though not necessarily incontinence itself.

If incontinence develops during TRT, it is more likely coincidental or related to other factors rather than a direct effect of the testosterone. Age-related changes, concurrent medications, underlying bladder or prostate conditions, or other health issues should be considered. Any new onset of incontinence warrants proper medical evaluation to identify the underlying cause, rather than automatically attributing it to testosterone treatment. Your GP or specialist can conduct appropriate investigations to determine the reason for urinary symptoms and recommend suitable management strategies.

Assessment of lower urinary tract symptoms (e.g., using the International Prostate Symptom Score) before starting TRT is advisable, particularly in men with existing urinary symptoms or known BPH.

Other Urinary Side Effects of Testosterone Therapy

While incontinence is not a recognised side effect of testosterone replacement therapy, TRT can affect the lower urinary tract and prostate in other ways that patients and clinicians should be aware of.

Prostate enlargement and lower urinary tract symptoms (LUTS) are the most relevant urinary considerations with TRT. Testosterone stimulates prostate tissue, and some men may experience:

• Increased urinary frequency (needing to urinate more often)

• Nocturia (waking at night to urinate)

• Urgency (sudden, strong need to urinate)

• Hesitancy (difficulty starting urination)

• Weak urinary stream

• Sensation of incomplete bladder emptying

These symptoms are more common in older men or those with pre-existing benign prostatic hyperplasia. UK clinical guidance recommends baseline assessment of prostate symptoms before initiating TRT and regular monitoring during treatment, including digital rectal examination and PSA testing where clinically indicated.

Elevated PSA levels may occur with testosterone therapy, reflecting prostate stimulation. Whilst modest increases are expected and generally benign, significant or rapid rises require investigation to exclude prostate cancer. Product information recommends PSA monitoring at baseline, after 3-6 months of treatment, and then at least annually, with more frequent monitoring in older men or those at higher risk.

Urinary retention—the inability to empty the bladder—is a rare but serious potential complication, particularly in men with significant pre-existing prostatic obstruction. This requires urgent medical assessment via your GP, NHS 111, or A&E.

Other recognised side effects of TRT include erythrocytosis (increased red blood cell production with haematocrit potentially >54%), fluid retention, acne, mood changes, and worsening of untreated sleep apnoea. Regular monitoring of full blood count, PSA (where appropriate), and clinical review are essential to identify and manage any adverse effects promptly.

If you experience any suspected side effects from testosterone treatment, report them to your healthcare provider and consider reporting via the MHRA Yellow Card scheme (yellowcard.mhra.gov.uk).

When to Seek Medical Advice About Incontinence

Any new or worsening urinary incontinence should be evaluated by a healthcare professional, regardless of whether you are receiving testosterone replacement therapy. Incontinence is not a normal part of ageing and often has treatable underlying causes.

Contact your GP promptly if you experience:

• Involuntary leakage of urine (stress incontinence with coughing/sneezing, or urge incontinence with sudden need)

• Significant changes in urinary frequency or urgency

• Difficulty starting urination or weak stream

• Sensation of incomplete bladder emptying

• Blood in the urine (haematuria) – visible blood in urine often requires urgent referral under the NICE suspected cancer pathway

• Pain or burning during urination

• Recurrent urinary tract infections

Seek urgent same-day medical attention (via GP, NHS 111 or A&E) if you develop:

• Inability to pass urine (urinary retention)

• Severe lower abdominal pain with inability to urinate

Call 999 or go immediately to A&E if you experience:

• Sudden onset of incontinence with leg weakness, numbness, or loss of bowel control (potential cauda equina syndrome)

• Severe symptoms with systemic illness or inability to travel safely

Your GP will conduct a thorough assessment including medical history, physical examination, and likely urinalysis. Further investigations may include:

• Bladder diary to record fluid intake and urinary patterns

• Post-void residual volume measurement (ultrasound to check bladder emptying)

• Urodynamic studies to assess bladder function

• Prostate examination and PSA testing

• Referral to urology or continence services for specialist assessment

If you are on TRT and develop urinary symptoms, inform your prescribing doctor. They will assess whether the symptoms are related to treatment, require dose adjustment, or indicate an unrelated condition needing investigation. Do not stop TRT without medical advice, as abrupt discontinuation can cause symptom recurrence. Effective treatments exist for most causes of incontinence, including pelvic floor exercises, bladder training, medications, and in some cases, surgical interventions. Early assessment improves outcomes and quality of life.

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