The androgen receptor (AR) is part of a superfamily of nuclear receptors. The AR has a diverse set of downstream effects on male phenotype and sexual function, muscle mass and strength, bone density, hematopoiesis, cognition, and metabolism. Testosterone replacement therapy (TRT) to treat male hypogonadism utilizes exogenously administered testosterone to activate the AR. However, TRT is known to have potential risks, including erythrocytosis, dyslipidemia, prostatic hypertrophy, hepatotoxicity, impaired fertility, aromatization of testosterone to estrogen, and testicular atrophy. Selective androgen receptor modulators, also known as SARMs, are compounds that have shown tissue-selective activation of the AR. These compounds potentially offer the ability to treat hypogonadal conditions where activating the AR in the bone, muscle, or brain is desired while sparing undesired effects in tissues such as the prostate, liver, or bone marrow. Currently, there is a dearth of data in human subjects regarding the treatment of male hypogonadism with SARMs. However, from animal models and preliminary studies of SARMs in humans, there appears to be a possible role for SARMs in the hypogonadal man, and their efficacy and safety warrant further study.

In this chapter, we will review how men’s health has evolved into a distinct subspecialty of medicine and changed over the past two decades. There exists a large disparity between men and women when it comes to health. However, as the drivers for men seeking health care are changing, the urologist is in a unique position to help quarterback men’s health initiatives. Men’s health advocacy and the creation of men’s health centers are on the rise. Areas of advancement in the field include prostate cancer diagnosis and treatment, erectile dysfunction therapies, surgical treatment for chronic testicular pain, and new approaches to male factor infertility. The burgeoning field of men’s health has seen many advancements in the past two decades and will continue to make significant gains in the years to come.

Given the wide spectrum in practice standards and patterns, array of covered versus out-of-pocket conditions, and role of adjunct streams of revenue, the business landscape of men’s health is diverse. Fundamental to the fiscal success of many providers is the efficacy of direct to consumer marketing in the setting of inelastic demand for solutions to aging, erectile dysfunction (ED), and Peyronie’s disease; this has created enormous markets surrounding supplemental testosterone, online platforms for ED treatment, and out-of-pocket products such as platelet-rich plasma, stem-cell therapy, and shock wave treatments. The contemporary story of men’s health has been defined by the gender health gap; uncovering the link between coronary artery disease (CAD) and ED unveiled a touchpoint for establishing holistic men’s health. University and large hospital systems have the infrastructure to support comprehensive Men’s Health Centers and have therefore maximized the downstream revenue associated with prescriptions, long-term screening, and future hospitalizations.

Surgical correction of Peyronie’s disease remains the gold standard of treatment. The goals of surgery should be cosmetic improvement and the preservation or restoration of sexual function. Preoperative workup should include objective assessment of both curvature and erectile function, and shared decision-making with the patient to clearly understand expectations for surgery is critical, as there is a risk of penile shortening and erectile dysfunction with any Peyronie’s surgery. Peyronie’s surgeries fall into three broad categories: plication procedures, plaque incision and grafting, and placement of a penile prosthesis. While direct comparative studies are rare, plication surgeries are the most commonly performed, as they are technically simpler and have excellent satisfaction rates. Grafting techniques are most indicated for more severe cases. Prosthetic placement is appropriate for patients with concurrent erectile dysfunction, and placement alone can correct cases of mild curvature. Additional techniques to straighten the penis can be employed if needed.

A diagnosis of infertility in the male or female partner within a couple can cause significant stress, leading to sexual dysfunction in either or both partners. The causes of infertility and the related sexual dysfunction can be organic or psychosocial in nature but are frequently linked. Here, we discuss the interplay between infertility and sexual dysfunction, specifically in the man and the couple, and focus on psychosocial interventions for the couple as they struggle to build their family.

The worldwide prevalence of erectile dysfunction is estimated to impact 20% of men. The evaluation of the male with erectile dysfunction can serve as an opportunity to screen men for a variety of important cardiovascular risk factors. A typical visit consists of a detailed and comprehensive patient history and a focal physical exam. Patients should be put at ease and a therapeutic relationship established to move forward with a shared decision-making process regarding treatment. Considerations during the evaluation should be toward screening for underlying risks factors for erectile dysfunction, a detailed sexual history, utilization of validated questionnaires, determination of lifestyle and social history factors, basic laboratory testing, and a psychological assessment. The goal of the evaluation is to identify the underlying causes of erectile dysfunction that will allow the clinician to develop the best therapeutic strategy.

The internet constantly evolves and facilitates the development of new avenues for users to interact and communicate internationally. Social media and search engines represent the forefront of internet technologies that enable users to produce content, develop digital participatory networks, and share information across various topics. These internet tools are reshaping the continuum of care by enabling patients to acquire medical information, consult peers and healthcare practitioners, and even make treatment decisions without leaving their connected device. The consequences of circumventing traditional pathways to care are amplified in men’s health due to the fact that men frequently do not engage with the healthcare system and that erectile dysfunction and male infertility are stigmatized. The focus of this chapter is to evaluate the emerging online landscape for common men’s health conditions including male infertility, erectile dysfunction, hypogonadism, and Peyronie’s disease.

Although semen analysis is the main routine test used in the diagnosis of male infertility, it is considered to be poorly predictive of male fertility status. Only recently, research in sperm biology focused on the development of assays to evaluate sperm functions necessary to reach and fertilize the oocyte and to allow a correct embryo development. However, the clinical utility of the currently proposed tests/assays remains a matter of debate, especially after introduction of ICSI. Ideally, since fertilization proceeds in a cascade-like manner, the goal would be to develop a single test able to evaluate all the aspects involved in this process and introduce it in ART laboratories. Such test should be simple, cheap, and not requiring expensive technology. Unfortunately, this aim is still far from being achieved. In this chapter, we discuss the most promising tests assessing sperm functions, describing their validity, limits, and potential use in clinical practice.

Ejaculation is a complex physiologic phenomenon and may have been historically necessary to achieve pregnancy. The advent of successful assisted reproductive technologies (ART), such as intracytoplasmic sperm injection and surgical sperm removal, have become an area of interest in reproductive medicine research. As such, interest has shifted away from ejaculatory disorders in part due to the tremendous success of assisted reproduction. Ejaculatory disorders are poorly understood and frequently misdiagnosed. While sperm retrieval procedures are highly effective in achieving the goal of reproduction, accurate diagnoses and management of these disorders to minimize complexity of ART are required. Additionally, many of these symptoms induce distress in patients, despite having any concerns involving fertility, resulting in significant quality of life implications for them. The evaluation of this entity requires a careful and appropriate treatment strategy. A carefully planned workup is needed to determine an accurate diagnosis and treatment that can result in high levels of patient satisfaction.

Men with spinal cord injury often suffer from erectile dysfunction, ejaculatory dysfunction, infertility, and hypogonadism. Restoration of sexual and reproductive functions is a top priority and efficient treatment modalities exist. Erectile dysfunction can be treated with phosphodiesterase-5 inhibitors and if unsuccessful intracavernosal injections can be tried. When injections fail a penile implant can ultimately be an option. Anejaculation and the resulting infertility are treated in a stepwise approach with penile vibratory stimulation, electroejaculation and surgical sperm retrieval followed by assisted reproduction. Assisted ejaculation is an effective and safe procedure but carries a risk of autonomic dysreflexia, especially in men with injuries at the level of T6 or above. Autonomic dysreflexia is an unregulated and uncontrolled response of the sympathetic nervous system but it can be safely managed. Hypogonadism is more prevalent in men with spinal cord injury compared to the general population and testosterone replacement therapy can be beneficial for alleviating symptoms of low testosterone, but testosterone-related spermatogenic suppression needs to be considered in men who wish to initiate a pregnancy.

Over the last decade it has become increasingly clear that semen analysis is insufficient to diagnose male infertility. With 30% of infertile men diagnosed as idiopathic, the ethics of continuing to rely on outdated diagnostic parameters must be questioned. Sperm DNA damage is a strong biomarker of male infertility. It also correlates significantly with increased risk of miscarriage after both natural and ART conception. Thirdly, sperm DNA damage is a useful predictive tool for both IVF and ICSI live birth success. DNA fragmentation can occur as double or single strand breaks. Oxidative stress is a common cause of single strand breaks and can be prevented by endogenous and dietary supplemented antioxidants. In contrast, double strand breaks are caused by dysfunction during spermatogenesis, and are harder for oocytes to repair post fertilization. Greater awareness of the relevance of DNA damage and its origins could aid fertility choices and outcomes.

Paternal age is increasing with time. Increasing evidence suggests that a man’s reproductive health changes with age. A man’s fertility may decline as he ages with evidence of an association with unassisted and assisted conception. In addition, there are risks to the pregnancy and child for older fathers. While the definition of advanced paternal age remains uncertain, the consequences of paternal age are becoming more quantifiable.

Benign prostatic hyperplasia is the most common benign neoplasm in males in the United States. It is characterized by lower urinary tract symptoms: weak stream, urinary frequency, urgency, incomplete emptying, hesitancy, nocturia, and acute urinary retention. These symptoms are generally slowly progressive and left untreated can cause irreversible bladder damage. Diagnosis is mostly clinical and based on symptomatology; however, the use of some objective tests can be helpful. Treatment options include lifestyle modification as well as a variety of different pharmacologic agents.

Over the past 20 years, there has been growing interest in understanding the genomic integrity of human spermatozoa and the clinical relevance of sperm chromatin and DNA defects. We have learned that the etiology of human sperm DNA damage is multi-factorial and that sperm DNA defects are associated with abnormal semen parameters. While we have observed that tests of sperm DNA integrity are correlated with reproductive outcomes, use of these complementary biomarkers in the management of male infertility remains controversial. In this chapter, we review the etiologic factors associated with sperm DNA damage and the utility of these tests in clinical practice. We also review the treatment options for infertile men with sperm DNA damage.

More than one-third of American adults fail to achieve the 7–9 hours of sleep recommended by the American Academy of Sleep Medicine and the Sleep Research Society needed for optimal health and well-being. In addition to primary sleep disorders, such as sleep apnea, insomnia, and restless legs syndrome, many modern societal factors are also thought to contribute to chronic sleep deficiency, such as technology and work-related factors. Interruptions in the natural sleep–wake cycle can be associated with shift work and numerous chronic health conditions. A few studies have investigated the impact of nonstandard shift work on male reproductive health, and a compelling association between sleep and male urogenital health has been demonstrated. This chapter will review the literature on the effect of sleep and shift work on ED, LUTS, hypogonadism, male infertility, and how improved sleep quality can possibly improve common men’s health conditions.

Erectile dysfunction (ED) is a complex, multifactorial disease caused by multiple factors including difficulty with erection initiation, arterial filling, and occlusion to maintain turgor. It may be a manifestation of poor overall health or specific medical conditions. Treatment of underlying causative conditions may resolve ED. Medical treatment options for ED include oral medications, such as phosphodiesterase type-5 inhibitors, as well as locally acting agents and nonsurgical devices. Locally acting agents include alprostadil, which may be administered by intracavernosal injection, intraurethral suppository, or topical cream, as well as other intracavernosal injection agents. Vacuum erection devices are available. Surgical management options for ED include penile prosthesis placement or vascular surgery. Penile prostheses may be malleable or inflatable. Arterial vascular surgery has shown some efficacy in ideal candidates, but venous surgery is not recommended. Treatment options that are currently being studied and show promise include low-intensity extracorporeal shockwave therapy and regenerative treatments such as stem cells and platelet-rich plasma.

Approximately one out of every 15 men will exhibit subfertility or infertility, and some data suggest the incidence of male infertility is increasing. While a number of factors can cause male infertility, there is strong and growing evidence that genetic factors contribute to a significant proportion of cases. Several significant genetic factors have long been recognized as clinically relevant causes of male infertility including Klinefelter syndrome, microdeletions of the Y chromosome, and cystic fibrosis transmembrane conductance regulator mutations. Since the discovery of these factors in the 1950s, 1970s, and 1980s respectively, there has been a relative dearth in the discovery of additional clinically relevant genetic factors underlying male infertility until recently. However, with the application of emerging genome-wide genetic approaches, along with the collaborative efforts from a growing number of groups, male infertility genetics has experienced a renaissance of sorts in the past decade with significant new discoveries being reported frequently over recent years. This chapter will briefly review the history of male infertility genetics as well as some of the more recent discoveries and efforts beyond gene screening approaches that have and will continue to advance the field.

This chapter is a fictional account of several people talking about aspects of their lives that are impacted by variations in sex development at a support group meeting. In their exchanges about past, present and future medical encounters, the author draws out both the opportunities and the dilemmas presented by medicine. Through the characterizations, the author also teases out some of the most pertinent psychological themes in the field, such as how to decide about “normalizing” surgery for a child and how to talk about bodily differences in relationships. These themes are centralized in Chapters 9–14 and explored in the literature summaries and practice vignettes therein.

Chapter 6 summarizes the changes to medical care in recent years. There is now a greater recognition that the projected social and psychological challenges of genital variations cannot be fixed by surgery. The first international consensus statement on intersex was published in 2006. The statement makes a number of recommendations to improve care. Controversially however, a new term disorders of sex development (and, later, differences in sex development, or DSD) was introduced to replace intersex and hermaphroditism. Biotechnological developments have been advancing rapidly. More has been learned about “normal” and “abnormal” sex development. However, parents still struggle to talk to children about their bodily variations, young people still worry about getting into relationships, childhood genital surgery is still considered the only way out of stigmatization, psychological expertise is still a low priority in specialist services and the huge potential of peer support is not fully realized.