Delayed puberty in males
Unless a patient is examined carefully, the earliest signs of puberty ie. testicular vascularisation and slight enlargement may well be missed. The commonest cause of delayed puberty is simple maturational delay but this is a diagnosis of exclusion and other common causes such as systemic or chronic illnesses need to be ruled out. In the normal healthy boy with no signs of puberty, a useful screening test is an 8am plasma testosterone level as a detectable level above 1 nmol/L will serve to indicate whether there has been the presence of nocturnal pulsatile LH secretion, the first endocrine event initiating puberty. In the absence of detectable testosterone levels, gonadotropin levels are the next appropriate investigations to perform as they are raised in primary testicular failure. The most difficult diagnostic problem is of low gonadotropin secretion which may be due to an idiopathic isolated deficiency, an intracranial lesion, an associated genetic defect (Kallman's Syndrome) or sometimes just extreme maturational delay.