--- module: 052-02 language: en chapter: 52 title: "Male Reproductive and Sexual Health" module_title: "Androgen physiology, sexual function, fertility, and male genital emergencies" source_sha256: 8fe332d5d81517c2e2c0e1017b5bfba14234f6c630579480cfcb0343bf446690 --- # Androgens, sexual function, fertility, emergencies ## Integrated assessment ### Libido, erection, ejaculation, fertility are separable #### Normal erections with impaired spermatogenesis ### Establish anatomy, goals, satisfactory function ## Androgen axis and diagnosis ### Pulsatile releasing hormone; continuous suppresses ### Testosterone mostly protein-bound #### Binding globulin altered by age, obesity, liver #### Total level can misrepresent available hormone ### Symptoms plus consistently low timed testosterone #### Morning sample, repeated when well ### High gonadotropins: primary testicular failure ### Low or normal gonadotropins: central suppression #### Check prolactin, iron, opioids, steroids, obesity ## Testosterone therapy and fertility ### Only when deficiency established ### Erythrocytosis, acne, oedema, sperm suppression ### Anabolic steroids: prolonged secondary hypogonadism ### Fertility wish: restore endogenous drive #### Correct weight, sleep, opioids, prolactin #### Specialist gonadotropins or receptor modulation #### Spermatogenesis takes months to recover ### Ask about children before treatment begins ## Erectile function ### Nitric oxide raises cyclic guanosine monophosphate #### Cavernosal smooth muscle relaxes #### Sinusoids compress subtunical veins, trapping blood ### Sympathetic tone: detumescence and emission ### Early vascular marker: small penile arteries ### Morning erections do not prove psychogenic cause ### Phosphodiesterase five inhibitors need stimulation #### Nitrates absolutely incompatible #### Failure: review, not unsafe escalation ### Injections and intraurethral therapy ### Vacuum ring must not remain indefinitely ### Psychological therapy does not mean symptoms unreal ## Ejaculation ### Sympathetic emission, bladder-neck closure ### Serotonergic drugs delay ejaculation ### Alpha blockade or pelvic surgery impairs closure #### Retrograde: dry orgasm, sperm in urine ### Premature: pattern, poor control, distress ## Priapism ### Ischaemic: rigid corpora, soft glans #### Stagnant hypoxic blood in a closed compartment #### Necrosis then fibrosis with time #### Aspiration, alpha-agonist, surgical escalation ### Systemic care must not delay decompression ### Non-ischaemic: perineal arterial injury ### Stuttering priapism needs prevention plan ### Seek help once erection persists, not at four hours ## Acute scrotum ### Treat as torsion until proven otherwise #### Venous then arterial block, infarction in hours #### No single sign or feature excludes it #### Explore without imaging delay, fix both testes ### Epididymitis: gradual, overlaps with torsion #### Nucleic-acid tests, culture, partner treatment #### Persistent swelling may be tumour ### After torsion: viability, atrophy, fertility #### One normal testis often suffices, not guaranteed ## Fournier gangrene and testicular mass ### Necrotising perineal and genital fascial infection #### Pain beyond visible change, crepitus, shock #### Immediate surgery; CT must not delay ### Solid intratesticular mass is malignant #### Trans-scrotal biopsy disrupts lymphatic staging #### Inguinal orchidectomy diagnoses and treats #### Sperm cryopreservation before gonadotoxic therapy ## Prostate ### Bulk, dynamic tone, bladder adaptation ### Alpha blockers act quickly on tone ### Reductase inhibitors lower antigen levels #### Reinterpret during cancer assessment ### Retention, infection, high residual: procedures ### Screening is a preference-sensitive sequence #### Mortality benefit versus overdiagnosis ## Male infertility ### Evaluate in parallel with partner ### Semen varies: abstinence, fever, collection ### Low volume: collection error, obstruction, retrograde ### Azoospermia: absent production or obstruction ### Absent vas: cystic-fibrosis implications ### Targeted, non-moralising lifestyle advice #### Stop exogenous testosterone and steroids ### Insemination, in-vitro fertilisation, donor, adoption