EAU Guidelines on Sexual and Reproductive Health in Men

Overview

This Guidelines summary of the European Association of Urology’s (EAU) guideline on sexual and reproductive health provides recommendations covering sexual and reproductive health in adult men, including hypogonadism, erectile dysfunction, disorders of ejaculation, low sexual desire, and male infertility.

The recommendations in this summary only cover information that may be relevant to primary care; refer to the full guideline for specialist recommendations and further information.

Male Hypogonadism

Diagnostic Evaluation of Late-onset Hypogonadism 

• Check for concomitant diseases, drugs, and substances that can interfere with testosterone production/action [strong recommendation]
• Measure total testosterone in the morning (between 07.00 and 11.00) and in the fasting state, with a reliable laboratory assay [strong recommendation]
• Repeat total testosterone on at least two separate occasions when <12 nmol/l and before starting testosterone therapy [strong recommendation]
• Use 12 nmol/l total testosterone (3.5 ng/ml) as a reliable threshold to diagnose late-onset hypogonadism (LOH) [strong recommendation]
• Consider sex-hormone-binding globulin and free testosterone calculation when indicated [strong recommendation]
• Calculated free testosterone of <225 pmol/l has been suggested as a possible cut off to diagnose LOH [weak recommendation]
• Analyse luteinising hormone and follicle-stimulating hormone serum levels to differentiate between primary and secondary hypogonadism [strong recommendation]
• Consider prolactin (PRL) measurement if low sexual desire (or other suggestive signs/symptoms) and low or low-normal testosterone is present [strong recommendation]
• Perform pituitary magnetic resonance imaging (MRI) in secondary hypogonadism, with elevated PRL or symptoms specific of a pituitary mass and/or presence of other anterior pituitary hormone deficiency [strong recommendation]
• Perform pituitary MRI in secondary severe hypogonadism (total testosterone <6 nmol/l). [weak recommendation]

Screening Men with Late-onset Hypogonadism

• Screen for LOH (including in those with type 2 diabetes) only in symptomatic men [strong recommendation]
• Do not use structured interviews and self-reported questionnaires for systematic screening for LOH, as they have low specificity. [strong recommendation]

Testosterone Therapy

• Do not use testosterone therapy in eugonadal men [strong recommendation]
• Use testosterone therapy as first-line treatment in patients with symptomatic hypogonadism and mild erectile dysfunction (ED) [strong recommendation]
• Use a combination of phosphodiesterase type 5 inhibitors (PDE5Is) and testosterone therapy in more severe forms of ED, as it may result in better outcomes [weak recommendation]
• Use conventional medical therapies for severe depressive symptoms and osteoporosis [strong recommendation]
• Do not use testosterone therapy to reduce weight and enhance cardiometabolic status [weak recommendation]
• Do not use testosterone therapy to improve cognition vitality and physical strength in ageing men. [strong recommendation]

Choice of Treatment for Late-onset Hypogonadism

• Treat, when indicated, organic causes of hypogonadism (for example, pituitary masses, hyperprolactinemia) [strong recommendation]
• Improve lifestyle and reduce weight (for example, obesity); withdraw, when possible, concomitant drugs that can impair testosterone production; treat comorbidity before starting testosterone therapy [weak recommendation]
• Fully inform patients about expected benefits and adverse effects of any treatment option. Select the testosterone preparation in a joint decision process, only with fully informed patients [strong recommendation]
• The aim of testosterone therapy is to restore serum testosterone concentration to the therapeutic range for young men [weak recommendation]
• Use testosterone gels rather than long-acting depot administration when starting initial treatment, so that therapy can be adjusted or stopped in the case of treatment-related adverse effects. [weak recommendation]

Risk Factors in Testosterone Treatment

• Fully counsel symptomatic hypogonadal men who have been surgically treated for localised prostate cancer (PCa) and who are currently without evidence of active disease and are considering testosterone therapy, emphasising the benefits and lack of sufficient safety data on long-term follow up [weak recommendation]
• Restrict treatment to patients with a low risk for recurrent PCa (that is, preoperative prostate-specific antigen [PSA] <10 ng/ml; Gleason score <7 [International Society for Urological Pathology grade 1]; cT1-2a)^[A] and treatment should start after at least 1 year follow up with PSA level <0.01 ng/ml [weak recommendation]
• Advise patients that safety data on the use of testosterone therapy in men treated for breast cancer are unknown [strong recommendation]
• Assess cardiovascular risk factors before commencing testosterone therapy [strong recommendation]
• Assess men with known cardiovascular disease (CVD) for cardiovascular symptoms before testosterone therapy and with close clinical assessment and evaluation during treatment [strong recommendation]
• Treat men with hypogonadism and pre-existing CVD, venous thromboembolism, or chronic cardiac failure—who require testosterone therapy—with caution, by careful clinical monitoring, and regular measurement of haematocrit (not exceeding 54%) and testosterone levels [weak recommendation]
• Exclude a family history of venous thromboembolism before starting testosterone therapy [strong recommendation]
• Monitor testosterone and haematocrit at 3, 6, and 12 months after testosterone therapy initiation, and thereafter annually. A haematocrit >54% should require testosterone therapy withdrawal and phlebotomy. Reintroduce testosterone therapy at a lower dose once the haematocrit has normalised and consider switching to topical testosterone preparations [strong recommendation]
• Evaluate patients with polycythaemia vera and those with a higher risk of developing elevated haematocrit every 3 months during the first year of testosterone therapy, and at least every 6 months thereafter [strong recommendation]
• Evaluate total PSA in PCa survivors at 3, 6, and 12 months during the first year of testosterone therapy, and annually thereafter. [strong recommendation]

For information on epidemiology and prevalence of sexual dysfunction and disorders of male reproductive health, refer to the full guideline.

Erectile Dysfunction

Diagnostic Evaluation of Erectile Dysfunction

• Take a comprehensive medical and sexual history in every patient presenting with ED. Consider psychosexual development, including life stressors, cultural aspects, and cognitive/thinking style of the patient regarding their sexual performance [strong recommendation]
• Use a validated questionnaire related to ED to assess all sexual function domains (for example, the International Index of Erectile Function) and the effect of a specific treatment modality [strong recommendation]
• Include a focused physical examination in the initial assessment of men with ED to identify underlying medical conditions and comorbid genital disorders that may be associated with ED [strong recommendation]
• Assess routine laboratory tests, including glucose and lipid profile and total testosterone, to identify and treat any reversible risk factors and lifestyle factors that can be modified [strong recommendation]
• Include specific diagnostic tests in the initial evaluation of ED in the presence of the conditions presented in Table 1. See Table 2 for indications for specific diagnostic tests. [strong recommendation]

Table 1: Cardiac Risk Stratification

Table 2: Indications for Specific Diagnostic Tests for Erectile Dysfunction

Treatment of Erectile Dysfunction

• Assess all patients for inadequate/incorrect information about the mechanism of action and the ways in which drugs should be taken, as they are the main causes of a lack of response to PDE5Is [weak recommendation]
• Use cognitive behaviour therapy as a psychological approach (include the partner) combined with medical treatment to maximise treatment outcomes [strong recommendation]
• Initiate lifestyle changes and risk factor modification prior to, or at the same time as, initiating ED treatments [strong recommendation]
• Treat a curable cause of ED first, when found [weak recommendation]
• Use PDE5Is as first-line therapeutic option [strong recommendation]
• Use topical/intra-urethral alprostadil as an alternative first-line therapy in well-informed patients who do not wish or are not suitable for oral vasoactive therapy [weak recommendation]
• Use topical/intra-urethral alprostadil as an alternative first-line therapy, in well-informed patients, who do not wish to have intracavernous injections or in patients who prefer a less-invasive therapy. [weak recommendation]

For more treatment recommendations, including recommendations on intracavernous injections, low-intensity shockwave treatments, PDE5Is, vacuum erection devices, and penile prostheses, refer to the full guideline.

Disorders of Ejaculation

Premature Ejaculation

Diagnostic Evaluation of Premature Ejaculation

• Perform the diagnosis and classification of premature ejaculation (PE) based on medical and sexual history, which should include assessment of intravaginal ejaculatory latency time (IELT; self-estimated), perceived control, distress, and interpersonal difficulty due to the ejaculatory dysfunction [strong recommendation]
• Use either stopwatch measured IELT or self-estimated IELT in clinical practice [weak recommendation]
• Use patient-reported outcomes in daily clinical practice [weak recommendation]
• Include physical examination in the initial assessment of PE to identify anatomical abnormalities that may be associated with PE or other sexual dysfunctions, particularly ED [strong recommendation]
• Do not perform routine laboratory or neurophysiological tests. They should only be directed by specific findings from history or physical examination. [strong recommendation]

See the full guideline for an algorithm for the management of PE.

Assessment of Premature Ejaculation

• Consider sexual history and psychosexual development [strong recommendation]
• Consider anxiety and interpersonal anxiety; focus on control issues [strong recommendation]
• Include partner if available; check for the impact of PE on the partner. [strong recommendation]

Treatment of Premature Ejaculation

• Psychosexual approach: use behavioural, cognitive, and/or couples' therapy approaches. Consider mindfulness exercises [weak recommendation]
• Treat ED, other sexual dysfunction, or genitourinary infection (for example, prostatitis) first [strong recommendation]
• Use either dapoxetine or the lidocaine/prilocaine spray as first-line treatments for lifelong PE [strong recommendation]
• Use off-label topical anaesthetic agents as a viable alternative to oral treatment with selective serotonin reuptake inhibitors (SSRIs) [strong recommendation]
• Use off-label tramadol with caution as a viable on-demand alternative to on-demand SSRIs [strong recommendation]
• Use PDE5Is alone or in combination with other therapies in patients with PE (without ED) [strong recommendation]
• Use psychological/behavioural therapies in combination with pharmacological treatment in the management of acquired PE [weak recommendation]
• Use hyaluronic acid injection with caution as a treatment option for PE compared to other more established treatment modalities. [weak recommendation]

Management of Recurrent Haemospermia

• Perform a full medical and sexual history with detailed physical examination [strong recommendation]
• Screen men aged ≥40 years with persistent haemospermia for prostate cancer [weak recommendation]
• Consider noninvasive imaging modalities (transrectal ultrasound scan and MRI) in men aged ≥40 years or men of any age with persistent or refractory haemospermia [weak recommendation]
• Consider invasive methods such as cystoscopy and vesiculoscopy when the noninvasive methods are inconclusive or in patients with recurrent haemospermia. [weak recommendation]

Low Sexual Desire

Table 3: Common Causes of Low Sexual Desire in Men

Treatment of Low Sexual Desire

• Perform the diagnosis and classification of low sexual desire (LSD) based on medical and sexual history, which could include validated questionnaires [weak recommendation]
• Include physical examination in the initial assessment of LSD to identify anatomical abnormalities that may be associated with LSD or other sexual dysfunctions, particularly ED [weak recommendation]
• Perform laboratory tests to rule out endocrine disorders [strong recommendation]
• Modulate chronic therapies that can negatively impact toward sexual desire [weak recommendation]
• Provide testosterone therapy if LSD is associated with signs and symptoms of testosterone deficiency. [strong recommendation]

For recommendations on penile curvature, penile size abnormalities and dysmorphophobia, and priapism, refer to the full guideline.

Male Infertility

Epidemiology and Aetiology

• Male fertility can be impaired as a result of:
  • congenital or acquired urogenital abnormalities
  • gonadotoxic exposure (for example, radiotherapy or chemotherapy)
  • malignancies
  • urogenital tract infections
  • increased scrotal temperature (for example, as a consequence of varicocele)
  • endocrine disturbances
  • genetic abnormalities
  • iatrogenic factors (for example, previous scrotal surgery)
  • immunological factors
• Investigate both partners simultaneously to categorise the cause of infertility [strong recommendation]
• Infertility should be evaluated after 6 months of attempted conception when the female partner is aged >35 years [weak recommendation]
• Examine all men seeking medical help for fertility problems, including men with abnormal semen parameters for urogenital abnormalities. [strong recommendation]

Diagnostic Investigation of Infertility

• Include a parallel assessment of the fertility status, including ovarian reserve, of the female partner during the diagnosis and management of the infertile male, since this might determine decision making in terms of timing and therapeutic strategies (for example, assisted reproductive technology versus surgical intervention) [strong recommendation]
• Take a complete medical history, physical examination, and semen analysis, as they are the essential components of male infertility evaluation [strong recommendation]
• Use Prader’s orchidometer-derived testicular volume as a reliable surrogate of ultrasound-measured testicular volume in everyday clinical practice [weak recommendation]
• Perform semen analyses according to the most recent World Health Organization Laboratory manual for the examination and processing of human semen (6th edition) indications and reference criteria, or according to the previous version (5th edition) until a formal and complete adoption of the newly released parameters will be implemented [strong recommendation]
• Perform a full andrological assessment in all men with couple infertility, particularly when semen analysis is abnormal in at least two consecutive tests [strong recommendation]
• Include counselling for infertile men or men with abnormal semen parameters of the associated health risks [weak recommendation]
• Perform a hormonal evaluation including serum total testosterone and follicle-stimulating hormone/luteinising hormone in cases of oligozoospermia and azoospermia. [weak recommendation]

For more recommendations on diagnostic investigation, refer to the full guideline.

Male Accessory Gland Infections

• Treating male accessory gland infections may improve sperm quality, although it does not necessarily improve the probability of increasing conception [weak recommendation]
• Refer sexual partners of patients with accessory sex gland infections that are known or suspected to be caused by sexually transmitted diseases for evaluation and treatment. [strong recommendation]

Noninvasive Male Infertility Management

• In men with idiopathic oligo-astheno-teratozoospermia, lifestyle changes including weight loss and increased physical activity, smoking cessation, and alcohol intake reduction can improve sperm quality and the chances of conception [weak recommendation]
• No clear recommendation can be made for treatment of patients with idiopathic infertility using antioxidants, although antioxidant use may improve semen parameters [weak recommendation]
• No conclusive recommendations on the use of selective oestrogen receptor modulators in men with idiopathic infertility can be drawn [weak recommendation]
• No conclusive recommendations on the use of either steroidal (testolactone) or nonsteroidal (anastrozole and letrozole) aromatase inhibitors in men with idiopathic infertility can be drawn, including before testicular sperm extraction. [weak recommendation]

For information on late effects, survivorship, and men’s health, as well as specialist recommendations on the topics covered in this summary, refer to the full guideline.

Footnote

[A] As for EAU risk groups for biochemical recurrence of localised or locally advanced prostate cancer. See the EAU’s prostate cancer guidelines (2023).