Andrology and Male Sexual Health
Andrology questions test your handling of erectile dysfunction, testosterone deficiency, male infertility, Peyronie disease, priapism and ejaculatory disorders. The examiners favour pharmacodynamics, contraindications and the correct sequence of treatment escalation.
Erectile dysfunction
- Assess with the IIEF-5, cardiovascular risk (Princeton consensus) and targeted investigations: glucose, lipids, testosterone, prolactin if indicated.
- PDE5 inhibitors are first line and require sexual stimulation. Absolute contraindication: any nitrate or nicorandil. Also avoid with riociguat and caution with alpha-blockers.
- Second line: vacuum erection device, intracavernosal alprostadil, low-intensity shockwave in selected cases. Third line: penile prosthesis, including after radical prostatectomy failure.
Testosterone deficiency
- Confirm with two fasting morning total testosterone samples; treat below 12 nmol/L, and measure free testosterone when SHBG is abnormal.
- Contraindications: prostate or breast cancer, haematocrit above 54 percent, untreated severe LUTS or retention, uncontrolled heart failure, active fertility desire.
- Monitor haematocrit at 3, 6 and 12 months, plus PSA and DRE in older men.
Male infertility
- WHO 2021 lower reference limits: volume 1.4 mL, concentration 16 million/mL, total sperm number 39 million, total motility 42 percent, progressive motility 30 percent, normal morphology 4 percent.
- Obstructive azoospermia: low volume, low FSH, normal testicular volume; consider CFTR testing and congenital bilateral absence of the vas deferens. Non-obstructive: high FSH, small testes, micro-TESE.
- Treat clinical varicocele with abnormal semen parameters; avoid varicocelectomy for subclinical varicocele.
Peyronie disease, priapism, ejaculation
- Stable Peyronie disease with curvature under 60 degrees and adequate rigidity: plication. Severe curvature or shortening: grafting. Collagenase is an option in some health systems.
- Ischaemic priapism: aspiration and irrigation, then phenylephrine 200 micrograms every 5 minutes with blood pressure monitoring, then shunt surgery; prosthesis after prolonged episodes.
- Premature ejaculation: behavioural therapy, topical lidocaine, dapoxetine; SSRIs are off-label.
Worked example
A 42-year-old presents 6 hours after intracavernosal alprostadil with a rigid, painful erection. This is ischaemic priapism until proven otherwise; cavernosal blood gas would show hypoxia and acidosis. Aspirate 20-30 mL, irrigate with saline, and give phenylephrine 200 micrograms every 5 minutes up to about 1000 micrograms within an hour while monitoring blood pressure. Failure mandates a surgical shunt, and he must be counselled about erectile dysfunction risk rising steeply after 24 hours.
Traps that cost marks
Prescribing a PDE5 inhibitor to a man on nitrates; using phenylephrine in high-flow priapism; expecting testosterone to correct erectile dysfunction in a eugonadal man; using older WHO 2010 semen limits; operating on subclinical varicocele; ignoring haematocrit on testosterone therapy.