A Quick Reference Guide to Male Reproductive Health Disorders

Despite the importance of reproductive health in relation to overall well-being, many people avoid discussing it due to stigma, cultural norms, fear of judgment, lack of awareness, privacy concerns, and apprehension about medical intervention. Yet several reproductive health conditions significantly impact not only a male patient's physical health but also their emotional and psychological well-being. Let's take a moment to shed some light on some common reproductive disorders and encourage patients to have open, crucial conversations about all aspects of their overall health and wellness. 

For this particular series, we'll focus on reproductive health disorders related to male bodies, distinguishing them from gender considerations for the purpose of diagnosis. In males, the reproductive tract includes external organs such as the penis, scrotum, and testicles, as well as internal organs like the prostate, epididymis, and various glands and ducts. 

Erectile Dysfunction 

Erectile dysfunction (ED), also more commonly known as impotence, is estimated to affect up to 75% of males over the age of 70. There's quite some variation in this number across ages and regions, but it also has the potential to be even higher due to a lack of reporting. There's a stigma surrounding ED, and many patients are uncomfortable discussing their concerns, perhaps due to embarrassment, being a private individual, or even thinking ED is a normal part of the aging process. (Note: it's not!) In addition, clinicians and caregivers may be contributing to the stigma through a lack of screening protocols, a lack of knowledge, or even a provider's discomfort with the topic.

For those who wish to engage in penetrative intercourse, the ability to have satisfactory sexual intercourse is essential. ED occurs when an individual is unable to get or maintain a firm erection for satisfactory sexual intercourse. There are several different causes for ED, including organic, psychosocial, and mixed causes. Organic causes are typically secondary to other conditions, like type 2 diabetes, high blood pressure, high cholesterol, or multiple sclerosis. ED can also occur as a result of certain surgical procedures done as treatment for bladder or prostate cancer or from the use of medications such as anti-hypertensives and antidepressants. Psychosocial causes include factors like fear of failure and mental health conditions like depression, anxiety, and stress. A mix of organic and psychosocial causes can also cause ED.  

Signs and symptoms include the inability to get or maintain a firm erection during sexual intercourse. However, there's some variation to this. Some individuals may be able to get an erection, just not during every sexual encounter. On the other hand, an individual might be able to get an erection but can't maintain it throughout intercourse, while others may be unable to get an erection at all. 

Diagnosis begins with a patient history and physical examination, with the history including a detailed sexual history and a physical exam that includes evaluation of both the patient's mental health and reproductive organs. A clinician can use this information to guide their next steps, which may include tests to rule out secondary conditions. 

For example, if diabetes is suspected, a hemoglobin A1C may be ordered. If a medication is suspected to be the culprit, the clinician may review the dosage and type of medication. If other conditions are suspected, such as cancer, additional tests can help aid in diagnosis, such as biopsies or other blood tests. The clinician may perform a more in-depth mental health evaluation if there's a psychosocial component. There are also tests specific to ED, like penile biothesiometry, which indirectly evaluates the nerve function of the penis, as well as penile ultrasounds, which can assess for any obstructions to blood flow around the penis.  

Treatment is a shared decision-making process between the patient and their clinician, and options depend heavily on the cause. For underlying conditions, treatment may include antidiabetic medications for diabetes or changing an antidepressant to another option less likely to cause ED. For individuals with psychosocial causes, counseling or additional medication can be beneficial. In some cases, a clinician may prescribe medication to help establish and maintain an erection, such as sildenafil or tadalafil. 

Benign Prostatic Hyperplasia 

Let's take a look at benign prostatic hyperplasia (BPH), also known as an enlarged prostate. Unlike ED, BPH is considered a normal part of aging. In fact, patients younger than 40 are rarely affected by BPH, yet up to a third of male patients over 65 are affected. Enlargement of the prostate comes from an increase in the number of cells inside, causing it to increase in overall size. It's important to note that this isn't a cancerous process but rather a benign process that can manifest some irritating signs and symptoms. 

No one is quite sure exactly what causes this proliferation of cells, but some risk factors include obesity, being over 40, having a family history of BPH, and having certain conditions such as diabetes or metabolic syndrome. Smoking, alcohol use, high caffeine intake, and lack of routine physical activity are other contributing risk factors.  

Signs and symptoms of BPH can include a weak, interrupted, or difficult-to-start urine stream or being unable to empty the bladder fully. There may also be urinary frequency or urgency, potentially having to wake in the night to urinate. A lot of these are also symptoms of other, more serious conditions like prostate cancer, so it's crucial to have them evaluated by a clinician. 

Diagnosis begins with a history and physical examination, which may include a digital rectal exam (DRE) so that a clinician can directly feel the size, shape, and firmness of the prostate through the rectum. Additionally, there may be lab tests like a urinalysis, post-void residual, and prostate-specific antigen (PSA) done to aid in diagnosis and help rule out other causes. 

If symptoms are manageable, patients may be asked to participate in active surveillance, or "watchful waiting," where the individual and the clinician monitor symptoms and begin treatment when it becomes necessary. Individuals may also benefit from lifestyle modifications, including restricting fluids closer to bedtime, following a toileting schedule, maintaining an active lifestyle, and avoiding alcohol and caffeine. 

For those experiencing unmanageable symptoms, treatments include medications and even surgery, in some cases, in addition to lifestyle modifications. Medications can include prazosin or tamsulosin, which relax specific muscles of the bladder, making it easier to urinate, or finasteride or dutasteride, which help slow the growth of or shrink the prostate. If symptoms become severe, surgical options can include procedures to help shrink the prostate, pull the prostate away from the urinary tract, or even remove part or all of the prostate.  

Epididymitis 

Up next is epididymitis, which is an inflammation of the epididymis. The epididymis is a coiled-up tube attached to and sits behind each testicle, where it stores and helps mature sperm. In younger individuals, epididymitis is usually caused by a bacterial infection, specifically sexually transmitted infections (STIs) such as chlamydia and gonorrhea. In older patients, it's more likely to be caused by a backflow of urine from the urinary tract and secondary to factors like BPH or anatomic variations.  

Signs and symptoms of epididymitis manifest as unilateral testicular pain and swelling. Initially, the pain may even start in the abdomen or side of the ribs, progressively moving into the testicular area. There can also be irritating urinary symptoms like frequency, urgency, painful urination, and penile discharge.   

Epididymitis is a clinical diagnosis, meaning it's made using history and physical examination findings. If the cause is suspected to be an infection, a urinalysis, urine culture, and/or STI testing can be done to identify the responsible pathogen. If the diagnosis is uncertain or if there's suspicion of anatomic variants, diagnostic tests can be done to further evaluate the condition, including ultrasounds and CT scans.  

Treatment depends on the cause. If the cause is bacterial, antibiotics are often prescribed and tailored using cultures obtained during diagnosis. If the cause isn't related to an infectious process, supportive measures can be recommended, including rest, icing the affected testicle, taking non-steroidal anti-inflammatory (NSAID) medications, and even scrotal support. 

Varicocele 

Let's move on to another condition closely related to the testicles, called a varicocele. The testicles are held by the scrotum, a pouch of skin that also contains blood vessels. A varicocele is when these blood vessels, specifically the veins in the scrotum, become enlarged and swollen. We're not quite sure exactly how this happens, but it's thought varicoceles occur when blood flow through veins in the scrotum backs up, leading to enlargement. It might be due to anatomic variations such as a faulty antireflux valve, allowing backward blood flow, or angulation of the veins, making blood flow more difficult. In rare cases, varicoceles may be secondary to another condition, such as blood clots, kidney disease, or cancer. 

Signs and symptoms are typically not present! Varicoceles are commonly asymptomatic and found incidentally. If there are symptoms present, it's typically a vague discomfort described as an ache, heaviness, or throbbing. Sometimes, patients may feel a soft lump or bump, often described as a feeling like a 'bag of worms'.  

Diagnosis is typically made clinically using patient history and physical examination findings. If the diagnosis is uncertain, it can be confirmed using ultrasound, showing the direction of blood flow and any enlargement in the veins. Treatment is typically supportive and involves scrotal support or over-the-counter medications if discomfort is present. Surgical removal of the varicocele is a possibility if it's large and causes symptoms. If a varicocele is caused by another condition, the focus of treatment is on the underlying condition. 

Interestingly, there's a correlation between varicoceles and infertility, which leads us to our next reproductive health condition.

Infertility 

Infertility is the inability to achieve pregnancy after twelve or more months of regular, unprotected intercourse. It's thought that the abnormal blood flow seen with varicoceles disrupts factors such as testicular temperature, tissue oxygenation, and hormonal balance (among other factors), leading to a reduced number of sperm produced that are less motile and oddly shaped, leading to infertility in some cases. Other causes of infertility include conditions like testicular or pituitary cancers that lead to hormonal dysfunction, certain genetic conditions like Klinefelter syndrome, exposure to pollutants or toxins, obstruction of the reproductive tract, and medication use, like chemotherapy, that damages sperm-producing cells.  

To diagnose infertility, a patient history and physical examination are done to identify any potential conditions inducing infertility. Then, specific infertility tests can be done, including sperm analysis, hormone levels, and genetic testing. Additionally, imaging tests like ultrasounds can be done to evaluate the anatomy and function of reproductive organs.  

Treatment depends on the cause of infertility. Interestingly, some individuals with infertility will still conceive without any intervention, though it typically takes at least 2 years. Other treatments may include lifestyle modifications like avoiding tobacco and alcohol, eliminating environmental or toxic exposures, eating a balanced diet, and exercising routinely. Some medications can be prescribed, though more research into their use and efficacy is needed.  

Peyronie Disease 

Last up, we have Peyronie (pronounced "pay-roh-nee") disease, which is an abnormal curvature of the penis that occurs with erections. It gets its name from a French surgeon, François Gigot de la Peyronie, who first described the condition in the 18th century. Peyronie disease is caused by fibrous plaque that forms within a portion of the corpus cavernosa, which are spongy columns that run along the shaft of the penis and fill with blood during erections. It's unclear why this happens, but risk factors include connective tissue disorders such as Dupuytren contracture, diabetes, penile injury or trauma, or a family history of Peyronie disease.  

Initially, signs and symptoms include a new or increased curvature in the penis during erections which may be accompanied by pain, shortening of the penis, a palpable fibrotic plaque felt on the penile shaft, as well as difficulty getting or maintaining an erection.  

Peyronie disease is diagnosed clinically using the patient's history and physical examination information. No further work-up is typically required unless the diagnosis is uncertain or there's concern for an underlying condition. Additional tests can include blood tests, such as a hemoglobin A1C to check for diabetes or an ultrasound to evaluate the anatomy of the penis. 

Over time, Peyronie disease may resolve on its own. However, in some cases, symptoms can progress and require intervention. Treatments can include traction therapy, where tension is applied to the penis to help limit loss of length and minimize curvature. Additional treatments include oral or injectable medications, and in chronic, severe cases, surgery may be considered.  

Why Open Conversations About Male Reproductive Health Matter

Breaking the stigma surrounding male health concerns is essential for fostering a supportive environment where male patients feel empowered to seek help and discuss their experiences. Navigating the complexities of reproductive health disorders can be daunting, but knowledge is power. It's important to remember these issues are common and can be addressed through open dialogue with healthcare providers. By understanding these conditions, patients can take proactive steps toward improving their overall health and quality of life. Let's cultivate a culture of awareness and acceptance, encouraging men to take charge of their health and well-being. 

References

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