14.4 Men's Health and Sexual Function

BPH medical therapy already lives in Section 14.1. This section is the rest of the official Reproductive system in men: the acute scrotum, STIs, erectile dysfunction, hypogonadism, preference-sensitive prostate screening, scrotal masses, and infertility. Domain II names torsion in minutes. Domain IV refuses the sildenafil-plus-nitroglycerin pair and refuses testosterone for “tired.”

The acute scrotum

Testicular torsion is a time-critical ischemia diagnosis. The classic patient is an adolescent or young adult with sudden, severe unilateral pain, nausea or vomiting, a high-riding or transversely oriented testis, and an absent cremasteric reflex. Prehn’s sign (relief with elevation) is unreliable and does not rule torsion in or out. If clinical suspicion is high, go to the emergency department now — urology will detorse. Doppler ultrasound is useful when it will not delay the trip; it is not a reason to watch a twisted testis through a 4 p.m. outpatient slot. Viability falls sharply after about 6 hours.

Epididymitis is more gradual, often with dysuria or urethral discharge, a tender epididymis posterior to the testis, a preserved cremasteric reflex, and sometimes a positive urinalysis. Treat by age and risk. In sexually active men, especially younger than about 35, cover gonorrhea and chlamydia: ceftriaxone 500 mg IM plus doxycycline 100 mg twice daily for 10 days. In men older than about 35, and in those with urinary-tract obstruction or instrumentation, cover enteric organisms (a fluoroquinolone such as levofloxacin is the usual outpatient choice). Insertive anal sex needs both gonorrhea/chlamydia and enteric coverage. Supportive care is scrotal elevation, NSAIDs if the kidney allows, and partner treatment when an STI is the cause.

Torsion of the appendix testis is common in school-age boys. Pain is often more focal at the upper pole; the blue-dot sign is specific when you see it. If you cannot confidently separate this from true torsion, image or refer — the cost of missing torsion is a testis. Once torsion is excluded, care is supportive.

STI in men, ED, and PDE5 inhibitors

Screen men based on risk, not on a birthday. Urine NAAT diagnoses gonorrhea and chlamydia in urethral infection. In men who have sex with men, add pharyngeal and rectal NAAT when those sites were exposed — a urine test alone misses them. Offer HIV and syphilis; treat partners; use expedited partner therapy where law allows. Gonorrhea treatment is the same ceftriaxone dose used in women, with doxycycline when chlamydia is not excluded. There is no routine HPV screening test in men; vaccinate by age and risk. Do not treat “chronic prostatitis” with a month of ciprofloxacin because a man is tired and his PSA is 3.2.

Erectile dysfunction is a cardiovascular and psychosocial history before it is a pill. Vascular / organic ED is usually gradual, occurs with all partners, and comes with lost morning erections and a plaque burden (diabetes, smoking, hypertension, known ASCVD). It is a coronary-risk equivalent conversation: if he cannot perfuse a penis, ask whether he can walk a flight of stairs, and treat lipids, glucose, blood pressure, and tobacco. Psychogenic ED is often sudden, situational, and morning erections are preserved. Many men have mixed disease. Screen for depression, performance anxiety, alcohol, SSRIs, spironolactone, and 5-ARIs.

PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are first-line drugs after you have taken a nitrate history. Never combine a PDE5 inhibitor with any nitrate — prescribed nitroglycerin, isosorbide, or recreational amyl nitrite (“poppers”). The pairing causes refractory hypotension. If he has taken sildenafil, wait 24 hours before a nitrate; if tadalafil, wait 48 hours. Counsel to seek emergency care for chest pain and to tell EMS about the PDE5. Use caution with alpha-blockers (separate the doses, start low). Priapism beyond 4 hours is an emergency. Do not prescribe PDE5 therapy to a man who is not cleared for sexual activity after a recent infarction or who has unstable angina.

Hypogonadism, prostate screening, masses, and infertility

Do not start testosterone because a man is tired. Diagnose hypogonadism only when there are compatible symptoms and a low morning total testosterone, then repeat it. Draw between about 7 and 10 a.m. Recheck free testosterone when SHBG is likely abnormal (obesity, aging, opioids, liver disease). LH and FSH separate primary (testicular — high LH/FSH) from secondary (pituitary/hypothalamic — low or inappropriately normal LH/FSH) disease; secondary hypogonadism can be a pituitary mass, opioid effect, or a sleep-apnea problem and is not an automatic gel prescription. Before testosterone, have a shared decision about the prostate (baseline PSA and DRE discussion), check hematocrit (testosterone causes erythrocytosis), and ask about fertility. Exogenous testosterone suppresses spermatogenesis. A man who wants children needs reproductive urology or endocrine care with hCG or a selective estrogen-receptor modulator, not a testosterone cypionate start. Monitor on therapy: hematocrit, PSA trajectory, and symptoms. Untreated sleep apnea, a hormone-sensitive prostate cancer under active treatment, a high hematocrit, and a desire for near-term fertility are stops.

Prostate-cancer screening is preference-sensitive. USPSTF gives PSA-based screening a C recommendation for men aged 55–69: offer it after a conversation about overdiagnosis, biopsy infection and bleeding, and treatment harms (incontinence, ED). It is not an automatic annual laboratory. USPSTF gives it a D after age 70. Higher-risk men (African American men, those with a first-degree relative with aggressive prostate cancer) may choose to start the conversation earlier, still as shared decision, not as a mandate. A nodular prostate or a rapidly rising PSA is a diagnostic referral, which is a different pathway from screening.

Scrotal masses get a calm exam and an ultrasound. Transillumination helps: a hydrocele lights up and feels cystic around the testis. A varicocele is a “bag of worms,” usually on the left, worse standing, better recumbent; a new right-sided varicocele raises concern for retroperitoneal pathology. An inguinal hernia may reduce and can carry bowel sounds. A firm, nontender, non-transilluminating testicular mass is cancer until imaging says otherwise — same-week ultrasound and urology, tumor markers as the specialist directs, not a 3-month sports-physical follow-up. Any mass you cannot name confidently is an ultrasound, including in the man who is embarrassed and “pretty sure it has been there for years.”

Infertility is a couple diagnosis. Evaluate after 12 months of timed unprotected intercourse if the female partner is younger than 35, and after 6 months if she is 35 or older — sooner when there is known oligomenorrhea, cryptorchidism, chemotherapy, or azoospermia risk. Obtain a semen analysis (2–7 days of abstinence, repeat if abnormal) rather than running only a female workup. History includes mumps orchitis, torsion, undescended testes, heat, anabolic steroids, and testosterone use. Exam includes habitus, gynecomastia, testis size, and varicocele. Do not start empiric clomiphene in primary care without a plan and a semen result. Refer reproductive endocrinology or urology when the analysis is abnormal or when time is short.

FNP traps: sending torsion home for an afternoon ultrasound; treating a 22-year-old’s epididymitis with ciprofloxacin only; pairing tadalafil with a nitrate because “he only uses the spray occasionally”; starting testosterone for a single afternoon level of 280 ng/dL and fatigue; ordering PSA on every 72-year-old “just to be complete”; and working up only the female partner for infertility.