Male Reproductive Medicine, Andrology, and Sexual Medicine
Testosterone deficiency
Confirm with two morning total testosterone measurements, adding free testosterone when values are borderline. Treat only symptomatic, biochemically confirmed hypogonadism. Testosterone therapy is contraindicated in active prostate or breast cancer, haematocrit above 50 percent, uncontrolled heart failure, and in men seeking fertility, because exogenous androgen suppresses spermatogenesis.
Male infertility
Semen analysis follows two to five days of abstinence and abnormal results are repeated. In azoospermia, low ejaculate volume with normal FSH and normal testicular volume suggests obstruction such as congenital bilateral absence of the vas deferens or ejaculatory duct obstruction, prompting CFTR testing and transrectal ultrasound. High FSH with small testes suggests non-obstructive failure, warranting karyotype and Y-chromosome microdeletion testing. Varicocele is correctable in selected cases.
Erectile dysfunction and priapism
PDE5 inhibitors are contraindicated with nitrates. Ischaemic priapism beyond four hours is an emergency: corporal aspiration, irrigation, and intracavernosal phenylephrine, with shunt surgery if refractory. High-flow priapism after perineal trauma shows arterial inflow and is managed expectantly or by embolisation.
Traps
Prescribing testosterone to an infertile man; measuring FSH without interpreting testicular volume; missing the four-hour priapism window; forgetting that haematocrit must be monitored on therapy.
Worked example
A 34-year-old with azoospermia, low-volume ejaculate, normal FSH, and palpable vasa should be evaluated for ejaculatory duct obstruction, not assumed to have testicular failure.