--- module: 052-01 language: en chapter: 52 title: "Male Reproductive and Sexual Health" module_title: "Foundations" source_sha256: 12322cc938c5545f101c67a0d281643e04536184ab2cf81885cbf9500a1a8aa8 --- # Male reproductive and sexual health ## Orientation ### Embarrassment and stigma delay presentation #### Inclusive language, confidentiality, permission ### Time-critical: torsion, Fournier, priapism ## Hormonal control and hypogonadism ### Pulsatile releasing hormone stimulates gonadotropins #### Luteinising hormone drives Leydig testosterone #### Follicle-stimulating hormone acts on Sertoli cells ### Testosterone and inhibin give negative feedback ### Primary: testicular failure, high gonadotropins #### Chromosomal, orchitis, torsion, chemotherapy, radiation ### Secondary: hypothalamus or pituitary #### Tumours, prolactin, opioids, steroids, obesity ### Diurnal and illness-related variation #### Repeat properly timed testing with context ### Replacement only for proven deficiency #### Suppresses spermatogenesis, erythrocytosis #### Not a treatment for fatigue or ageing ## Sexual history and examination ### Concerns, partners, practices, function, fertility ### Do not infer identity from partners or anatomy ### Onset, consistency, morning erections, situation ### Palpate testis, then epididymis and cord #### Normal testis smooth and firm, not hard ### Ultrasound more reliable than transillumination ## Erectile and ejaculatory dysfunction ### Nitric oxide, inflow, relaxation, venous occlusion ### Vascular, neural, endocrine, drug, psychogenic, mixed ### Small penile arteries: early cardiovascular marker #### Assess pressure, diabetes, lipids, smoking, fitness ### Phosphodiesterase five inhibitors amplify nitric oxide #### Need sexual stimulation #### Never with nitrates: profound hypotension ### Vacuum, intraurethral, intracavernosal, prosthesis ### Premature ejaculation: distress and poor control ### Delayed ejaculation: serotonergic drugs, neuropathy ### Retrograde: bladder outlet fails to close ## Priapism and penile disease ### Priapism: erection over four hours ### Ischaemic: painful, rigid compartment syndrome #### Blood disorders, injections, psychotropics #### Urgent aspiration and sympathomimetics ### Non-ischaemic: arterial trauma, less painful ### Paraphimosis: oedema compromises blood flow #### Urgent reduction ### Balanitis and Peyronie plaque ### Penile cancer: biopsy persistent lesions #### Smoking, phimosis, oncogenic papillomavirus ## Acute scrotal pain ### Torsion blocks venous then arterial flow #### No sign safely excludes torsion #### Explore and fix both sides without imaging delay ### Epididymitis: gradual, posterior tenderness #### Test urine and infections, treat partners ### Fournier gangrene: rapid perineal necrosis #### Pain beyond visible findings #### Resuscitation, antibiotics, immediate debridement ### Hydrocele and left-sided varicocele #### Right-sided or non-reducing: secondary obstruction ### Solid intratesticular mass is malignant #### Urgent ultrasound, no trans-scrotal biopsy ## Testicular cancer ### Younger adults, painless lump or heaviness ### Undescended testis and previous tumour ### Markers classify but can be normal ### Radical inguinal orchidectomy ### Highly curable with stage-adapted care ### Discuss sperm banking before treatment ## Prostate disorders ### Hyperplasia: androgen-dependent transition-zone growth #### Symptoms reflect tone and bladder, not size #### Alpha-one blockers relax outlet quickly #### Five-alpha-reductase inhibitors shrink over months #### Retention, infection, renal compromise: surgery ### Acute prostatitis: cultures, penetrant antibiotics ### Chronic pelvic pain: no repeated antibiotics ### Prostate-specific antigen rises with benign causes ### Screening is preference-sensitive #### Deaths prevented versus overdiagnosis and harm ### Magnetic resonance and risk-adapted biopsy ## Male infertility ### Evaluate both partners ### Production, obstruction, ejaculation, endocrine ### Repeat semen analysis because results vary ### Treat reversible factors #### Stop exogenous testosterone ### Insemination, in-vitro fertilisation, sperm injection