Hypogonadism, lower urinary tract symptoms (LUTS), and prostate cancer (PCa) often coincide in older men. For years testosterone replacement therapy (TRT) has been contraindicated in men with PCa due to the fear of disease progression, and TRT has been thought to exacerbate male LUTS. Recent studies on the association between testosterone and the prostate have questioned these paradigms. Currently, there is no evidence to suggest an increased risk of developing PCa after TRT in men without previous PCa. Similarly, it seems that there is no increased risk of PCa recurrence when looking at men receiving TRT after radical prostatectomy. Studies investigating TRT in men with active PCa and those who have undergone other modalities of curative treatment, including external beam radiation therapy, are too scarce to draw conclusions. Clinical epidemiological studies suggest that TRT can be safely administered to patients with mild to moderate LUTS, however, there is a lack of evidence to support TRT in men with severe LUTS. Sufficiently powered trials with longer follow-ups are needed to determine the exact relationship between TRT, LUTS, and PCa.