7.2 Male Sexual & Reproductive Health: STIs, Infertility, Contraception & Sexual Dysfunction
Key Takeaways
Urethritis in men is treated empirically for gonorrhea and chlamydia (ceftriaxone 500 mg IM plus doxycycline 100 mg twice daily for 7 days), and partners within 60 days need evaluation or expedited partner therapy.
Acute epididymitis from likely STI is treated with ceftriaxone plus 10 days of doxycycline; men who practice insertive anal sex also need coverage for enteric organisms, such as levofloxacin.
Varicocele is the most common correctable cause of male infertility, and exogenous testosterone or anabolic steroids suppress spermatogenesis and can cause azoospermia.
PDE5 inhibitors for erectile dysfunction are contraindicated with nitrates because of profound hypotension, and erectile dysfunction is a marker of cardiovascular disease.
The USPSTF recommends against routine testicular cancer screening and leaves PSA screening at ages 55–69 to shared decision-making.
Why Male Health Is on a Women's Health Exam
NCC's outline lists "Sexual and Reproductive Health for Males" (sexuality, contraception, infertility, STIs) within the gynecology domain. WHNPs treat partners through expedited partner therapy (EPT), evaluate couples with infertility, and counsel on shared contraceptive decisions.
STI Syndromes in Men
| Syndrome | Typical Presentation | CDC-Recommended Management |
|---|---|---|
| Urethritis | Dysuria, urethral discharge, itching | Test by NAAT (first-catch urine); empiric ceftriaxone 500 mg IM (1 g if 150 kg or more) plus doxycycline 100 mg twice daily for 7 days; consider M. genitalium or trichomoniasis if symptoms persist |
| Acute epididymitis | Gradual unilateral scrotal pain and swelling, tender epididymis | Likely gonorrhea or chlamydia: ceftriaxone 500 mg IM plus doxycycline 100 mg twice daily for 10 days. Insertive anal sex: ceftriaxone plus levofloxacin for 10 days. Enteric organisms only (for example, after urinary instrumentation): levofloxacin alone |
| Proctitis (receptive anal sex) | Rectal pain, discharge, tenesmus | Ceftriaxone plus doxycycline for 7 days (21 days if lymphogranuloma venereum is suspected) |
| Genital ulcers | Painful ulcers suggest HSV; a painless indurated ulcer suggests syphilis | Test for HSV (PCR) and syphilis (serology); treat by etiology |
| Trichomoniasis | Often asymptomatic urethritis | Metronidazole 2 g orally once (the 7-day course is for women) |
Partner management: Partners from the previous 60 days should be evaluated. Where permitted by state law, EPT gives the patient medication for the partner; for gonorrhea, EPT for the partner is cefixime 800 mg orally once (plus doxycycline if chlamydia is not excluded). Retest everyone with gonorrhea or chlamydia at 3 months.
Prevention for Men Who Have Sex with Men
- Screen for gonorrhea and chlamydia at every exposed site (urethral, rectal, pharyngeal) at least annually, along with syphilis and HIV; screen every 3–6 months when risk is higher.
- Offer HIV PrEP, hepatitis A and B vaccination, and HPV vaccination through age 26 (shared decision-making to 45).
- Doxycycline post-exposure prophylaxis (200 mg within 72 hours after condomless sex) is recommended for men who have sex with men and transgender women with a bacterial STI in the past year.
Male Infertility
Male factor contributes to about 40%–50% of infertile couples, so a semen analysis belongs in the first visit (collected after 2–7 days of abstinence; see the infertility section for WHO 6th-edition limits).
| Cause | Features |
|---|---|
| Varicocele | Most common correctable cause; left-sided "bag of worms"; impairs sperm through raised scrotal temperature |
| Exogenous testosterone or anabolic steroids | Suppress pituitary LH and FSH, shutting down spermatogenesis and causing azoospermia; recovery after stopping can take months |
| Primary testicular failure | Small testes, high FSH; includes Klinefelter syndrome (47,XXY) and Y-chromosome microdeletions |
| Hypogonadotropic hypogonadism | Low FSH, LH, and testosterone (Kallmann syndrome, pituitary disease, opioids) |
| Obstruction | Normal testes and FSH with azoospermia; congenital bilateral absence of the vas deferens points to CFTR variants, so test the female partner for cystic fibrosis carrier status |
| Lifestyle | Heat exposure, smoking, heavy alcohol or cannabis use, obesity, and some medications |
Men with low testosterone who want future fertility should not receive testosterone; clomiphene, hCG, or anastrozole (off-label) can raise endogenous testosterone while preserving sperm production.
Male Contraception
- Condoms (external): the only male method that also prevents STIs; typical-use failure about 13% per year.
- Withdrawal: Typical-use failure about 20% per year.
- Vasectomy: Highly effective permanent method; not effective until a post-vasectomy semen analysis at 8–16 weeks shows azoospermia or rare nonmotile sperm.
- No hormonal male method is FDA-approved; combination gels such as nestorone/testosterone remain in clinical trials.
Erectile Dysfunction and Other Concerns
- Erectile dysfunction (ED) is a sentinel marker of cardiovascular disease, because penile arteries are small and endothelial dysfunction shows there early. Assess blood pressure, lipids, glucose, smoking, depression, and medications such as thiazides, beta-blockers, SSRIs, and antiandrogens.
- PDE5 inhibitors (sildenafil, tadalafil, vardenafil) are first-line. They are contraindicated with nitrates (and riociguat) because of profound hypotension; use caution with alpha-blockers. An erection lasting more than 4 hours (priapism) is an emergency.
- Hypogonadism: Diagnose only with symptoms plus two early-morning total testosterone levels below about 300 ng/dL (AUA).
- Premature ejaculation: Behavioral techniques, topical anesthetics, or off-label daily or on-demand SSRIs.
Preventive Screening for Men
| Topic | Recommendation |
|---|---|
| Testicular cancer | USPSTF recommends against routine screening of asymptomatic men (grade D); teach men to report any testicular mass |
| Prostate cancer | PSA screening at ages 55–69 is an individual decision (grade C); not recommended at 70 and older (grade D) |
| HIV, hepatitis B and C, syphilis | Same universal adult and risk-based screening as for women |
| HPV vaccination | Through age 26; shared decision-making for ages 27–45 |
Working with Couples
- In infertility care, evaluate both partners at the first visit: a semen analysis is inexpensive and noninvasive and can redirect the entire workup.
- When treating a woman for an STI, ask about partners, offer expedited partner therapy where state law permits, and advise abstinence until both partners finish treatment.
- Shared contraceptive decisions work best when both partners understand failure rates, vasectomy as an option, and the need for condoms to prevent STIs.
The 30-year-old male partner of a patient with infertility has a semen analysis showing azoospermia. He is muscular and reports injecting testosterone from a gym contact for 2 years. His testes are small and soft. What is the most likely explanation?
Exogenous testosterone suppressing pituitary gonadotropins and spermatogenesis
Congenital bilateral absence of the vas deferens from a CFTR gene variant
A large left varicocele raising scrotal temperature and impairing sperm production
Retrograde ejaculation into the bladder from diabetic autonomic neuropathy
A 34-year-old man with no medical problems presents with 3 days of right scrotal pain and swelling that began gradually, mild dysuria, and a tender, swollen epididymis. The testis lies in normal position, and the cremasteric reflex is present. He reports a new female partner and no anal intercourse. What is the recommended treatment?
Levofloxacin 500 mg orally once daily for 10 days
Emergency surgical exploration for testicular torsion
Azithromycin 1 g orally once plus scrotal elevation
Ceftriaxone 500 mg IM once plus doxycycline for 10 days
A 58-year-old man who takes sublingual nitroglycerin as needed for stable angina asks his partner's WHNP whether he can try sildenafil for erectile dysfunction. What is the best response?
Sildenafil is safe as long as he takes it at least 30 minutes after his last nitroglycerin dose.
Tadalafil is preferred because its long half-life means it does not interact with nitrates.
PDE5 inhibitors are contraindicated with nitrates because of severe hypotension; refer him to cardiology.
He should switch from nitroglycerin to a beta-blocker so that sildenafil is then safe to use.
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