Testosterone therapy is an increasingly popular and highly marketable industry amongst male patients, so much so that testing and treatment with TTh has increased fourfold in the last 20 years [5]. This growth in interest is reflected in the steady increase in Google searches for testosterone replacement therapy over the last decade [6]. Therefore, it is essential that providers familiarize themselves with the various TTh resources available in order to tailor their patient counseling and guide them toward credible and coherent PEMs if additional information is needed.

As shown by existing Health Information National Trends Survey (HINTS) data, patients are increasingly relying on the Internet to seek health information [7]. This behavior has inevitably increased during the coronavirus pandemic likely due to a surge in digitalization and information-gathering [8]. In addition, as highlighted by Beck et al., online health information could potentially influence health behaviors, especially in young adults [9]. This highlights the increasing need for quality and readability of online patient education materials. Health literacy is critical for patients, in fact, poor health literacy is associated with worse health outcomes and increased health care costs [10, 11]. Despite this, the information presented to patients online have been widely proven to be above the average health literacy level for Americans [12].

Our study demonstrates similar concerns regarding TTh where all included sources are estimated to be at the college level, with academic sources requiring the highest level of understanding (at or near the level of a college senior). Literature within Urology as well as other medical fields including colorectal surgery, anesthesiology, and ophthalmology have shown PEMs above the advised reading level [13,14,15,16]. McBride’s work in 2016 demonstrated this clearly with search results online [3]. Unfortunately, our results demonstrate that despite advances in medical therapy, and published findings of advanced readability, patient information has not been revised to be more readable for the average patient. This suggests that many patients focused medical materials that we continue to create and disseminate are more advanced than the recommended level of understanding and not as helpful as we may intend [17]. Patients unable to comprehend resources designed for them are therefore left to their own research which we can demonstrate may not be helpful at improving comprehension or understanding of complex medical issues, especially TTh.

To ensure that all web-based PEMs are coherent, straight-forward, and easily accessible would be impossible given the vast number of sources and the dynamic nature of the internet. Even in the academic webspace, this would require a multidisciplinary approach, extensive reviewing, and significant time and dedication. However, this presents an opportunity for improved authorship with audience appropriate documents and information. Editing and or authoring documents in a way so that they are as easily accessible and understandable to a wide audience is likely to bridge the gap of misunderstanding and misinformation best. This can be achieved through multiple strategies including but not limited to the elimination of jargon, use of simple phrasing and reducing overall sentence or paragraph length.

This study has certain limitations despite using multiple different assessment methods. Usage of Google as a primary search engine fails to accurately capture results from patients’ searches on alternative search engines or trusted websites. Google was chosen because it comprises the highest web usage amongst the general population and therefore reasonably illustrates what the majority of the patient population encounters. To objectively evaluate TTh search results, readability tools were used to analyze the text and provide the “grade level” that is needed for someone to engage with the material [18]. These tools are not without fault, as they can only evaluate based on quantitative characteristics of the text, like word count, number of syllables, or sentence length. For example, a shorter word such as a medical jargon may be more difficult to understand than a longer but simpler word. Therefore, a more comprehensive review of readability of patient education materials should consider the medical jargon used as well as account for images and content organization [19]. In addition, readability does not correlate with comprehension.