Andrology

Andrology is one of the most dynamic specialties of modern medicine, focusing on male reproductive system health and sexual dysfunctions. This discipline fundamentally approaches men’s health holistically and covers the diagnosis, follow-up, and treatment of all male-specific biological processes, from reproductive capacity and hormonal balance to sexual functions and structural anatomical characteristics. As a specialized branch of urology, it provides professional solutions for physiologically and psychologically based health problems that men of all age groups may encounter. Aiming to preserve the complex functioning of the male body, this scientific field brings together the most current medical methods to improve both the physical and social quality of life of individuals.

What Is Andrology and Which Diseases Does It Cover?

When urology is mentioned, general urinary system diseases involving the kidneys, urinary tract, bladder, and prostate in both women and men usually come to mind. Andrology, however, focuses its lens solely on male anatomy, physiology, and the reproductive system within this large and broad structure. This field covers male infertility, varicocele, azoospermia, erectile dysfunction, ejaculation problems, penile curvature, low testosterone, and certain male genital system diseases. Many issues that deeply affect men’s quality of life, self-confidence, mood, and family life and are sometimes difficult to discuss fall directly within the scope of andrology. Chief among these is the inability to have children, namely infertility, which is quite common in society.

In addition, the inability to achieve sufficient rigidity for healthy and satisfying sexual intercourse or to maintain this rigidity, known as erectile dysfunction, as well as problems that wear down a person psychologically, such as premature or delayed ejaculation, are also frequently encountered and treated conditions. Acquired penile curvature, known as Peyronie’s disease, congenital deformities, and physical and psychological changes that develop due to a decrease in the male hormone testosterone in the blood with advancing age are also examined in full detail within the scope of andrology.

When evaluating such conditions and diseases, the patient is not approached solely through a physical complaint. How active the patient is in daily life, how they eat, and how much stress they experience in their work and social life are of great importance. Previous surgeries, medications used continuously, habits such as smoking or alcohol consumption, and chronic conditions such as high blood pressure or diabetes are evaluated as a whole, like pieces of a puzzle. In this way, the main source of the problem is identified, and instead of superficial solutions, permanent, satisfying treatment options that genuinely improve quality of life are offered.

How Does the Male Infertility Process Work in the Andrology Approach?

A couple’s inability to achieve pregnancy after a full year of regular sexual intercourse without using any contraceptive method is defined in medicine as infertility. There is an incorrect and incomplete perception in society that this condition generally originates from women. However, in nearly half of couples who have difficulty having children, the problem is caused either entirely or to a certain extent by the male factor. The andrological perspective does not view this situation simply as a low sperm count or insufficient motility. It always considers the possibility that it may be the reflection of an underlying structural disorder, a hidden genetic problem, or a different systemic condition involving the entire body.

The evaluation process always begins with a highly detailed and sincere conversation, namely taking the medical history. Febrile infections such as mumps experienced during childhood that may affect the testicles, the failure of the testicles to descend into the scrotum at birth, known as cryptorchidism, severe blows to the area, or previous groin surgeries such as hernia repair contain very important clues. Whether there are similar reproductive problems in the family is also always questioned in terms of genetic predisposition. During the subsequent meticulous physical examination, the volume and consistency of the testicles and the condition of the sperm-carrying ducts are evaluated. Most importantly, the presence of varicocele, the most common cause of infertility and at the same time the cause most successfully corrected surgically, is checked. In light of the findings obtained from these physical examinations, the process then moves to laboratory tests, which are the most decisive step in establishing a diagnosis.

What Do Sperm Test (Spermiogram) Values Mean in Andrology Laboratories?

The sperm test performed under special conditions in andrology laboratories, commonly known as semen analysis or spermiogram, is the most basic and indispensable method for understanding male reproductive potential and health. The World Health Organization (WHO) establishes specific criteria so that laboratories around the world can perform evaluations according to the same standards and specialists can make correct decisions, and it updates these criteria in line with developments in medicine. For this highly sensitive test to provide accurate, reliable, and non-misleading results, it is a critical rule that the sample be given after at least two days and no more than seven days without any ejaculation, meaning after sexual abstinence. If this period is shorter than two days, the count may appear falsely low because sufficient sperm will not have accumulated in the testicles. Conversely, waiting longer than seven days causes the sperm to age inside, seriously impairing their motility and vitality. Therefore, when evaluating the test result, attention is paid not only to numerical values but also to the conditions under which the sample was provided, the abstinence period, and laboratory standardization.

The main parameters evaluated are as follows:

• Ejaculate volume, meaning the amount of semen
• Total Sperm Count
• Sperm Concentration, meaning the number of sperm per milliliter
• Total Motility
• Proportion of sperm moving rapidly forward (Progressive Motility)
• Normal Morphology (Structural shape of the sperm)
• Vitality (Proportion of live sperm)
• pH Level (Degree of acidity/alkalinity)
• Leukocyte Count (Inflammatory cells)

Each of these laboratory values has a different physiological meaning behind it. For example, semen volume below the standards may suggest reduced activity in the fluid-producing glands or a partial obstruction in the ducts. A low count directly indicates a capacity problem related to the production facility in the testicle. Motility is the energy that allows sperm, which will embark on a difficult journey, to move through the female reproductive tract and reach the egg. Morphology evaluates whether the head, neck, and tail sections of the sperm have a healthy structure; a proper shape is highly important for penetrating the outer membrane of the egg. The data obtained from this test are combined to determine the direction of the treatment plan. A decision is not made based on a single parameter; semen analysis results are interpreted together with the patient’s history, examination, and additional tests when necessary.

Why Do Andrology Specialists Request Advanced Tests and Hormone Tests?

If a significant reduction in the parameters is observed in the detailed sperm test, especially if the count is below ten million per milliliter, it becomes necessary to check the body’s general production mechanism and hormonal balance. There is an extremely harmonious and complex chemical communication network between the pituitary gland located at the base of the brain and the testicles in the human body. By examining the levels of the hormones that provide this communication in blood samples taken in the early morning, specialists try to understand where the system is malfunctioning. For example, if the signaling hormones produced by the brain, FSH and LH, are very high in the blood test, this indicates that the brain is constantly stimulating the testicles and sending the command to “produce sperm,” but the testicles cannot respond to this command due to insufficient capacity. This is directly a production facility problem. If the hormones remain completely within normal levels but not even a single sperm is present in the semen, the conclusion is that the production facility is functioning perfectly, but there is an obstruction in the highways, namely the ducts, that are supposed to transport the produced goods outside.

Sometimes, despite everything appearing completely normal in terms of count, motility, and shape, pregnancy cannot be achieved for a long time or, even if pregnancy occurs, it ends in recurrent distressing miscarriages. In such mysterious cases, the problem is thought to exist at a more cellular, microscopic level. DNA damage tests within the sperm itself come into play precisely at this point. If there are too many breaks or structural defects in the genetic code carried by the sperm, which will form half of the baby, healthy embryo development may unfortunately be disrupted even if the egg is fertilized. In addition, genetic chromosome tests, including karyotype analysis and Y chromosome microdeletion testing, must be performed in cases where the sperm count is extremely low or no sperm is found in the test. These tests serve as an invaluable guide for predicting the likelihood of finding sperm when microscopic surgical sperm retrieval is performed in the future.

What Is Varicocele in Andrology Practice and How Is Its Surgical Treatment Performed?

Varicocele is the abnormal enlargement, increase in diameter, and twisted, complex appearance of the veins located inside the scrotum that carry deoxygenated blood back to the heart, similar to varicose veins seen in the legs. It holds a very critical place in the field of andrology because it is the most common cause of male infertility that can be corrected surgically with the highest success rate. Blood cannot flow comfortably through these enlarged veins with damaged valves and begins to flow backward and pool. As a result of this pooling, the temperature of the area, which should normally be cooler than the body, increases. In addition, harmful waste products produced by the cells cannot be removed from the area. Over months and years, the increased temperature and accumulated toxic substances damage the structure of the sensitive sperm-producing cells, reduce DNA quality, and seriously undermine reproductive potential.

The solution to this structural problem is surgical, and the most successful method accepted as the gold standard in modern medicine today is “Microsurgical Varicocelectomy.” However, surgery is not necessary for every patient. Varicocele treatment is planned according to the patient’s complaint, desire to have children, semen analysis results, testicular volume, and the grade of varicocele detected during examination. During surgery, the problematic vascular network is reached through a very small, aesthetic incision made just below the groin. The most important key feature of this operation is the use of a special surgical microscope that provides high-level optical magnification. Thanks to the microscope, the tiny vessels in that area are magnified up to twenty times and seen in enormous detail. In this way, the arteries that keep the testicle alive and the lymphatic vessels that maintain fluid balance are clearly distinguished and carefully preserved, while only the damaged veins that cannot perform their function are tied off one by one and eliminated. Compared with older open surgery methods, the success rate of microsurgery is much higher. The possibility of the disease recurring in the future is quite low. In addition, the risk of unwanted complications such as fluid accumulation in the scrotum after surgery, known as hydrocele, or accidental damage to the artery is significantly reduced thanks to the microscope. Patients can usually walk home on the same day. The recovery process is quite comfortable, and the positive effects of the surgery on sperm production generally begin to appear clearly in tests performed from the third month onward. However, in some patients, improvement may occur later, and it does not mean a guarantee of pregnancy for every patient.

What Can Be Done When No Sperm Is Found in the Semen (Azoospermia) Within the Scope of Andrology?

The condition in which not a single live or dead sperm cell is found in the semen during laboratory tests is called azoospermia in medical terminology. Although this condition is usually a major shock and a source of deep sadness for patients receiving the test result, the chance of having biological children may still continue thanks to developing medical technologies and microsurgical methods. This problem fundamentally arises from two different causes in the body. Either there is an obstruction in the sperm-carrying ducts due to a previous infection or congenital absence, known as obstructive azoospermia, or sperm production capacity in the testicles has severely decreased or stopped, known as non-obstructive azoospermia caused by production failure.

If examinations and tests reveal that the problem is only an obstruction, sperm can be easily obtained from the testicles or from the storage area called the epididymis using relatively simple and short needle-based methods, TESA or PESA, because production inside continues normally. The sperm obtained through these minor procedures, which can even be performed under local anesthesia with the help of thin needles, are then used in in vitro fertilization treatment. However, the cases that require the main medical intervention and must be addressed with great care are production-related azoospermia cases in which sperm production is impaired. At this point, the most advanced technological method, a microsurgical operation called Micro-TESE, comes into play.

During this delicate procedure, while the patient is under general anesthesia, the internal tissue of the testicle is examined in great detail under an operating microscope, like the pages of a book being turned. The specialist scans the tissue for hours under the microscope, looking for tiny tubules that appear slightly fuller, opaque in color, and healthier than the others and therefore have the highest probability of containing sperm. Very small tissue samples of millimetric size are taken only from these healthy-looking points and immediately sent to the laboratory for examination. The greatest advantage of this method is that it does not blindly damage the internal structure of the testicle. Since much less tissue is removed compared with traditional older methods, the body’s testosterone hormone balance is preserved. The valuable sperm found as a result of this meticulous search can be used immediately on the same day to fertilize the partner’s eggs or safely stored for years by freezing them in special solutions for possible future treatments. However, finding sperm after micro-TESE is not guaranteed in every patient; the chance of success varies according to the underlying cause and the condition of the testicular tissue.

Which Methods Are Used to Treat Erectile Dysfunction in the Andrology Outpatient Clinic?

Erectile dysfunction is the inability to achieve sufficient penile rigidity required for sexual intercourse or, even if achieved, the inability to maintain it until the end of intercourse, and it has both physical and psychological dimensions. This condition not only impairs the quality of sexual life and causes communication problems between couples, but also provides very early and serious warnings about the body’s general vascular health. Since the blood vessels in the penis have a much smaller diameter than other vessels in the body, a silently developing problem such as atherosclerosis, high cholesterol, or vascular damage due to diabetes may show its first sign years before a heart attack as a decline in erection quality. Therefore, when evaluating complaints, not only the patient’s sexual life but also their general cardiovascular and metabolic health must be considered in detail.

To resolve this common problem, a stepwise treatment strategy progressing from simple to more advanced options is applied according to the patient’s expectations, age, and other diseases.

The main treatment options applied are as follows:

• Oral tablet treatments (PDE5 Inhibitors)
• Shock wave therapy applied to the penis (ESWT)
• Mechanical vacuum devices
• Direct injection treatments (Intracavernosal injection)

The first step is generally the easiest-to-use tablet treatments. These medications significantly accelerate blood flow and provide a high-quality erection by widening the blood vessels leading to the area when sexual stimulation begins. If medications are insufficient or there is age-related structural weakness in the vessels, shock wave therapy is a very good option. In this method, low-intensity sound waves are delivered externally to different points of the penis, creating mild microtrauma in the tissue and triggering the body to form new, healthy capillaries in that area. For people who cannot use medication, are troubled by side effects, or do not benefit from tablets, medications applied to the penis with very fine special needles shortly before sexual intercourse or devices that draw blood into the area with a vacuum are highly practical alternatives with high success rates.

What Is a Penile Implant in Andrology Surgery and What Are Its Types?

If the patient’s erectile dysfunction cannot be resolved with medications, injections, or milder methods such as shock wave therapy, if the spongy tissue inside the penis has largely lost its elasticity, or if the nerve network has been severely damaged due to causes such as advanced diabetes or prostate cancer surgery, one of the most effective and long-term options is penile prosthesis surgery, commonly known as a penile implant. These prostheses, which are sometimes misunderstood in society, are special medical silicone materials placed surgically and completely concealed inside the spaces in the penis that normally fill with blood to create an erection, making them absolutely invisible from the outside.

The types of prostheses preferred according to the patient’s manual dexterity and physical characteristics are as follows:

• One-piece malleable prostheses
• Two-piece inflatable prostheses
• Three-piece inflatable prostheses

Malleable models remain at a certain level of firmness continuously, and the person uses them by easily positioning them upright by hand when preparing for intercourse. They are extremely simple to use and do not carry a risk of mechanical failure because they do not contain a complex mechanism. Advanced inflatable models, on the other hand, are systems designed to closely resemble human physiology and natural anatomical structure. They operate with a small control pump system concealed inside the body in the scrotum. Before intercourse, the person squeezes this externally invisible pump several times, inflating the fluid-filled cylinders and achieving sufficient rigidity for sexual intercourse. When the procedure is finished, the system is unlocked using the same pump, the fluid returns to the reservoir, and the penis becomes completely soft and returns to its normal everyday appearance. After these operations, there is generally no loss in the sensation of touch in the penis, the ability to experience orgasm, or the ejaculation function necessary for having children; the main purpose is to support the lost erection mechanism.

How Is Premature Ejaculation Managed in the Field of Andrology?

Premature ejaculation is the occurrence of ejaculation involuntarily immediately before sexual intercourse begins or very shortly after penetration and the inability to control this condition. It is one of the most common sexual health problems among men regardless of age. This condition deeply undermines the man’s self-confidence and also prevents the partner from being satisfied, seriously wearing down the dynamics of the relationship and the couple’s psychology. From a medical perspective, it is generally considered not as an anatomical disease but as hypersensitivity and a control problem involving a reflex in the nervous system. In some men it exists throughout life from the first sexual experience, while in others it may develop later after stress or different illnesses.

Different approaches appropriate to the patient’s condition are available to resolve this problem. Sometimes behavioral therapies aimed solely at listening to the body and retraining reflexes may work. Recognizing the moment when excitement and sensation reach their peak during sexual intercourse and taking a short break, changing position, or applying light pressure to the tip of the penis may help prolong the duration and allow the body to become accustomed to the sensation. However, these techniques alone are often not sufficient, and medical support is required. Medications specially developed for the treatment of premature ejaculation significantly prolong the ejaculation reflex by regulating the levels of certain chemical messengers in the brain called serotonin. These medications are generally taken a few hours before planned sexual intercourse. In addition, locally applied delay creams, gels, or sprays can also be effective by reducing skin sensitivity at the tip of the penis and decreasing the intensity of external stimulation. However, the amount of such topical products must be adjusted very carefully; otherwise, they may cause complete loss of sensation, leading to loss of erection or causing the partner to experience localized numbness as well.

How Is Penile Curvature (Peyronie’s Disease) Treated from an Andrological Perspective?

Penile curvature, better known medically as Peyronie’s disease, is the formation of hard, calcified plaques or tissues on the strong sheath surrounding the internal structure of the penis and enabling it to stretch. These connective tissues, resembling a hard scar that forms while healing after a deep cut in the skin, prevent the part of the penis that fills with blood during an erection from stretching naturally. While the side that cannot stretch remains fixed, the other side continues to lengthen, causing the penis to bend. This leads to severe pain, palpable hardness in the penis, especially during the first months of the disease, and over time, curvature severe enough to make sexual intercourse impossible. The disease generally begins with an acute phase in which pain is present and change continues. During this initial period, the main goal is to relieve pain, suppress inflammation, and try to prevent the curvature from worsening further using various medications or intraplaque injections.

The definitive treatment decision is generally made during the chronic phase, when the pain has completely disappeared and the degree of curvature has remained stable for months. If this deformity or curvature greatly complicates sexual life, causes pain in the partner, or prevents intercourse, surgery becomes necessary. Different and highly delicate surgical techniques are applied according to the direction and degree of curvature and the patient’s existing erectile capacity. Sometimes the healthy tissue on the exact opposite side of the curvature is slightly folded with special sutures to achieve straightening, known as plication techniques. If the curvature is very severe and shortening of the penis is not desired, the hardened calcified tissue is completely removed, and patches taken from another vessel in the body or specially produced in a laboratory are aesthetically sutured into the resulting space, known as grafting techniques. If the patient also has a very severe and permanent erectile problem together with this disease, a penile implant is placed inside the penis during a single surgical session, aiming both to correct the deformity and to resolve the patient’s erectile dysfunction in the long term. In brief, the same treatment is not applied to every patient with Peyronie’s disease; the treatment plan is made by considering the degree of curvature, pain status, whether the disease is in the active or stable phase, and erectile function.

What Are the Symptoms of Age-Related Testosterone Deficiency (Andropause) in Andrology Follow-Ups?

With each advancing year of age, many changes gradually occur in the metabolism and hormonal cycle of the male body. One of the most important of these is the gradual decline over the years in testosterone, the hormone that gives the body male characteristics and provides energy. This condition, also known among the public as andropause or late-onset hypogonadism, does not occur suddenly and sharply like menopause in women. It is a much slower, insidious process that extends over years. Generally beginning from the mid-forties onward, this hormonal decline gradually lowers the person’s quality of life. When the person looks in the mirror, they can no longer find their former energy and begin to feel constantly exhausted, tired, and unmotivated toward daily life.

The main symptoms observed are as follows:

• Marked decrease in sexual desire (libido)
• Reduced frequency or disappearance of morning erections
• Persistent fatigue that does not improve with rest
• Loss of muscle mass and strength
• Decrease in bone mineral density (bone loss)
• Frequent awakening at night and sleep problems
• Unexplained depressive and irritable mood
• Difficulty concentrating and remembering at work

In people who apply to the outpatient clinic with such wide-ranging complaints, detailed blood tests are performed to check hormone levels in the blood. If the testosterone level is truly below the laboratory reference values and this situation corresponds with the complaints, replacement treatment, namely external hormone support, is initiated. With this treatment, administered in the form of special gels applied to the skin, weekly short-acting injections, or long-acting intramuscular injections given every few months, the building block that the body produces insufficiently is safely replaced from outside. However, this treatment requires very strict and disciplined physician follow-up. During treatment, the extent to which the blood has thickened, meaning the hematocrit level, and the condition of the prostate in terms of prostate cancer risk, using the PSA test, should be checked at regular intervals. Additional caution is required in men planning to have children because testosterone treatment may suppress sperm production.

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