Andrology , Infertility(Male Sexual Diseases)

🩺 What is Erectile Dysfunction?

Erectile dysfunction (ED) is the inability to achieve or maintain an erection firm enough for satisfactory sexual intercourse. It is one of the most common male sexual health problems, especially in men over age 40.

📊 Prevalence:

Affects up to 50% of men aged 40–70 to some degree

Becomes more common with age, chronic illnesses, and certain medications

🔍 Causes of ED:

ED can result from physical, psychological, or mixed factors:

1. Physical (Organic) Causes:

Vascular: Atherosclerosis (narrowing of arteries), high blood pressure

Neurological: Diabetes, spinal cord injury, multiple sclerosis

Hormonal: Low testosterone, thyroid disorders

Medications: Antidepressants, antihypertensives, cancer treatments

Penile disorders: Peyronie’s disease, trauma

Lifestyle: Smoking, obesity, excessive alcohol

2. Psychological Causes:

Stress

Anxiety (including performance anxiety)

Depression

Relationship problems

🧪 Diagnosis of ED:

Detailed history and physical exam

Questionnaires (e.g., IIEF – International Index of Erectile Function)

Blood tests – to check testosterone, blood sugar, lipids

Penile Doppler ultrasound – to assess blood flow (if needed)

✅ Management of Erectile Dysfunction:

1. Lifestyle Modifications:

Quit smoking

Lose excess weight

Exercise regularly

Limit alcohol intake

Manage chronic conditions (e.g., diabetes, hypertension)

2. Psychological Support:

Counseling or sex therapy (especially for anxiety or relationship-related ED)

Cognitive-behavioral therapy (CBT)

3. Medications (Oral PDE5 Inhibitors):

These are first-line treatments:

Drug	Notes
Sildenafil	Works in 30–60 mins
Tadalafil	Long-acting (up to 36 hrs)

Not to be taken with nitrates (can cause dangerous blood pressure drop)

4. Other Medical Treatments:

Penile vacuum erection device (VED): A cylinder that draws blood into the penis

Penile injections: Alprostadil or combination therapy (direct injection into penis)

Urethral suppositories: Alprostadil (MUSE)

5. Surgical Options:

Penile prosthesis (implant):

Malleable (semi-rigid) or inflatable types

Very effective when other treatments fail

Vascular surgery (rare): For specific cases of vascular blockage or injury

🔁 Follow-Up:

Regular evaluation for response and side effects

Treat underlying conditions

Address partner concerns and satisfaction

💡 Summary Table:

Treatment Type	Examples	Indications
Lifestyle changes	Diet, exercise, quit smoking	All patients
Medications	Sildenafil, Tadalafil	First-line therapy
Devices	Vacuum erection device	Non-responders to pills
Injections	Alprostadil	When pills are ineffective
Surgery	Penile implant	Severe or treatment-resistant ED
Psychological	Counseling, sex therapy	Psychogenic or mixed ED

💥 What is Premature Ejaculation?

Premature Ejaculation (PE) is a common male sexual dysfunction characterized by:

Ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress or relationship difficulty.

🧭 Types of Premature Ejaculation:

Lifelong (primary)

Present since first sexual experiences

Acquired (secondary)

Develops after a period of normal sexual function

📊 Prevalence:

Affects up to 20–30% of men worldwide

One of the most common male sexual complaints

🕒 Diagnostic Criteria (per ISSM):

Ejaculation that always or nearly always occurs within 1 minute of vaginal penetration (for lifelong PE)

Inability to delay ejaculation on all or nearly all occasions

Negative personal consequences: distress, frustration, avoidance of intimacy

Note: For non-vaginal sex (e.g., anal or oral), timing may vary, but lack of control and distress are key

.

🔍 Causes of Premature Ejaculation:

Lifelong PE:

Likely involves neurobiological factors

Low serotonin levels in the brain

Acquired PE:

Often linked to:

Performance anxiety

Erectile dysfunction (ED)

Stress or relationship issues

Prostatitis or other urological issues

✅ Management of Premature Ejaculation

1. Behavioral Techniques

Method

Description

Start-Stop Technique

Pause sexual stimulation just before ejaculation

Squeeze Technique

Partner squeezes the penis head to delay climax

Masturbation before sex

May reduce urgency and delay ejaculation during intercourse

These techniques require practice and partner cooperation.

2. Psychological Counseling / Sex Therapy

Beneficial for performance anxiety, relationship issues, or stress

Often used in combination with medication or behavioral methods

3. Medications

A. SSRIs (Selective Serotonin Reuptake Inhibitors)

Drug	Use	Notes
Dapoxetine	On-demand SSRI	Fast-acting, approved in many countries
Paroxetine	Daily use SSRI	Effective but may take weeks
Sertraline	Daily or on-demand	Similar to paroxetine
Fluoxetine	Daily use	Longer onset, less common for PE

Side effects: nausea, fatigue, reduced libido, delayed orgasm

B. Topical Anesthetics

Lidocaine-prilocaine creams or sprays

Applied to penis 10–15 minutes before sex

Reduces sensitivity and delays ejaculation

May reduce sensation for the partner if not washed off

C. PDE5 Inhibitors (e.g., Sildenafil, Tadalafil)

Useful if PE coexists with erectile dysfunction

May help improve control and confidence

4. Combination Therapy

Often, best results come from combining:

Behavioral methods

Psychological support

Medications (oral or topical)

🔁 Follow-Up:

Monitor effectiveness and side effects

Address expectations and partner satisfaction

Adjust treatment if PE is secondary to ED, prostatitis, or another condition

🧬 Summary Table:

Treatment Type	Example	Best For
Behavioral techniques	Start-stop, squeeze	Mild to moderate PE
Counseling/therapy	Sex therapy, CBT	Psychogenic or relational PE
Medications (oral)	Dapoxetine, SSRIs	Most men with moderate-severe PE
Topical anesthetics	Lidocaine-prilocaine	Quick onset, few systemic effects
PDE5 inhibitors	Sildenafil, Tadalafil	PE with coexisting ED

Penile Fracture: Definition, Causes, Symptoms & Management

A penile fracture is a traumatic injury to the penis that occurs when the erect penile shaft is forcefully bent, causing a rupture (tear) of the tunica albuginea—the tough fibrous layer surrounding the corpora cavernosa, which are the erectile bodies of the penis.

It is a urological emergency that usually requires immediate surgical repair.

🧠 Why Does It Only Happen When Erect?

The tunica albuginea is thin and stretched when the penis is erect, making it more vulnerable to rupture.

When flaccid, the tunica is thick and flexible, so injury is much less likely.

🚨 Causes of Penile Fracture:

Cause	Description
Vigorous sexual intercourse	Most common cause, especially with “woman-on-top” position
Masturbation accidents	Sudden bending or misaligned force
Rolling over in bed with an erection	Accidental trauma
Aggressive manipulation	Non-sexual injury or deliberate bending

❗ Classic Symptoms:

Audible “popping” or “cracking” sound

Sudden loss of erection (detumescence)

Sharp pain in the penis

Rapid swelling (resembling an “eggplant deformity”)

Bruising and discoloration

Possible blood at urethral opening or difficulty urinating (if urethra is injured)

🔍 Diagnosis:

Primarily clinical (based on history and physical exam)

Imaging (if needed):

Ultrasound or MRI for unclear cases

Retrograde urethrogram (RUG) if urethral injury is suspected (e.g., blood in urine or difficulty voiding)

🛠️ Treatment:

🔹 Surgical Repair (Gold Standard)

Performed under general or spinal anesthesia

Involves:

Exploration of the penis through an incision

Repair of the tear in the tunica albuginea

Repair of urethra if injured

Best performed within 24 hours to prevent complications

🔹 Conservative (non-surgical) management

Rarely used today due to high risk of complications (e.g., erectile dysfunction, penile curvature, painful erections)

⚠️ Complications if Left Untreated:

Permanent penile curvature

Painful erections

Erectile dysfunction

Penile fibrosis (scarring)

Urethral stricture or fistula (if urethra is damaged)

⏱️ Recovery:

Hospital stay: Usually 1–2 days

Sexual activity: Avoid for 6–8 weeks

Pain and swelling: Usually resolve in 1–2 weeks

Long-term outcomes are excellent with prompt surgical treatment

🧬 Summary Table:

Feature	Penile Fracture
Cause	Sudden trauma to erect penis
Key Sign	Popping sound + immediate loss of erection
Emergency?	Yes – requires urgent surgery
Complications if untreated	Curvature, ED, scarring, urethral injury
Treatment	Prompt surgical repair

🧬 Male Infertility: Definition and Management

🧔‍♂️ What is Male Infertility?

Male infertility refers to a man's inability to impregnate a female partner after 12 months of regular, unprotected sexual intercourse. It accounts for about 40–50% of all infertility cases in couples.

🧪 Normal Fertility Requires:

Healthy sperm production (spermatogenesis)

Proper sperm transport (through ducts and ejaculation)

Normal sperm function (motility, morphology)

Ability to deposit sperm in the vagina (normal erection and ejaculation)

📊 Causes of Male Infertility:

🔹 1. Pre-testicular Causes (hormonal or systemic)

Hypogonadotropic hypogonadism

Pituitary or hypothalamic disorders

Medications (e.g., testosterone supplements, steroids)

🔹 2. Testicular Causes (sperm production problems)

Genetic: Klinefelter syndrome, Y-chromosome microdeletions

Varicocele (enlarged veins in scrotum)

Undescended testicles (cryptorchidism)

Infections (e.g., mumps orchitis)

Chemotherapy/radiation

🔹 3. Post-testicular Causes (sperm transport issues)

Obstructive azoospermia (e.g., vasectomy, congenital absence of vas deferens)

Ejaculatory duct obstruction

🔹 4. Functional or Idiopathic

Erectile dysfunction

Retrograde ejaculation

Idiopathic (unknown cause, common in 25–30%)

🧫 Evaluation and Diagnosis:

History and physical exam (sexual, medical, surgical, family history)

Semen analysis – Key test (done at least twice, 2–5 days apart)

Parameter	Normal Value (WHO)
Volume	≥1.5 mL
Concentration	≥15 million/mL
Motility	≥40% total motile
Morphology	≥4% normal forms

Hormonal tests – FSH, LH, Testosterone, Prolactin

Scrotal ultrasound – To check for varicocele or other testicular issues

Genetic testing – For azoospermia or severe oligospermia

Transrectal ultrasound (TRUS) – If obstruction is suspected

🧰 Management of Male Infertility:

✅ 1. General Measures:

Lifestyle changes (weight loss, stop smoking/alcohol, reduce stress)

Avoid hot baths, tight underwear, environmental toxins

Stop anabolic steroids or testosterone supplements

🧴 2. Medical Treatment:

Condition	Treatment
Hypogonadism	Gonadotropins (hCG + FSH), clomiphene
Varicocele	Varicocelectomy (surgery or embolization)
Infections	Antibiotics
Erectile dysfunction	PDE5 inhibitors, counseling
Hormonal imbalance	Treat underlying endocrine disorder

🩺 3. Surgical Treatment:

Varicocelectomy – Improves sperm quality in men with clinical varicocele

Vasovasostomy/Vasoepididymostomy – Reversal of vasectomy or bypass obstruction

Testicular sperm extraction (TESE), Micro-TESE – For azoospermic men (used with IVF/ICSI)

🧫 4. Assisted Reproductive Techniques (ART):

Technique	When Used
IUI (Intrauterine Insemination)	Mild male factor infertility
IVF (In Vitro Fertilization)	Moderate to severe sperm issues
ICSI (Intracytoplasmic Sperm Injection)	Very low sperm count, motility, or morphology
Donor sperm	In cases of non-reversible azoospermia or genetic risk

🧬 Summary Table:

Cause Type	Examples	Management
Pre-testicular	Hormonal imbalances, pituitary issues	Hormonal therapy
Testicular	Varicocele, genetic causes	Surgery (varicocelectomy), ART
Post-testicular	Vasectomy, ejaculatory duct obstruction	Surgery or sperm retrieval + ART
Functional/Other	ED, retrograde ejaculation, idiopathic	Meds, ART, counseling