Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the European Association of Urology.

Sexual and Reproductive Health

European Association of Urology

Publication Date: Apr 1, 2026

Page Last Updated: May 19, 2026

Followup

Fully counsel symptomatic hypogonadal men who have been surgically treated for localized prostate cancer (PCa) and who are currently without evidence of active disease considering testosterone therapy (TTh), emphasising the lack of sufficient safety data on long-term follow-up. Weak
Restrict TTh to patients with a low risk of recurrent PCa after surgery*. Testosterone therapy should start after at least one year follow-up with prostate-specific antigen (PSA) level < 0.01ng/mL and no evidence of recurrence. Weak
Advise patients that safety data on the use of TTh in males treated for breast cancer are unknown. Strong
Advise patients on active surveillance or treated with non-surgical curative intent that safety data on the use of TTh are unclear. Weak
Consider further diagnostic testing in PCa-naive patients if there is a significant rise or increase in PSA velocity or total PSA. Strong
Evaluate total PSA in PCa survivors at three, six and 12 months during the first year of testosterone therapy, and annually thereafter. Strong
Assess cardiovascular (CV) risk factors before commencing TTh. Strong
Assess men with known cardiovascular disease (CVD) for CV symptoms before initiating TTh and monitor these men with close clinical assessment and evaluation during treatment. Strong
Treat men with hypogonadism and pre-existing CVD, venous thromboembolism or chronic cardiac failure who require TTh with caution, by careful clinical monitoring and regular measurement of haematocrit (not exceeding 54%) and testosterone levels. Weak
Exclude a family history of venous thromboembolism before starting TTh. Strong
Monitor testosterone and haematocrit at three, six and 12 months after testosterone therapy initiation, and thereafter annually. A haematocrit > 54% requires TTh adjustment or withdrawal and venesection if required. Reintroduce testosterone therapy at a lower dose once the haematocrit has normalised and consider switching to topical testosterone preparations. Strong
Evaluate patients with polycythaemia vera and those with a higher risk of developing elevated haematocrit every three months during the first year of testosterone therapy, and at least every six months thereafter. Strong

Treatment of ED

Fully inform patients of the mechanism of action and the ways in which phosphodiesterase type 5 inhibitors (PDE5Is) should be taken, as incorrect use/inadequate information is the main causes of a lack of response to PDE5Is. (Strong)
Direct the patient to Cognitive Behaviour Therapy as a psychological approach (include the partner), when indicated, combined with medical treatment to maximise treatment outcomes. (Strong)
Discuss with patients undergoing active treatment for prostate cancer the risk of sexual changes other than erectile dysfunction (ED), including sexual desire reduction, changes in orgasm, anejaculation, Peyronie’s like disease and penile size changes. (Strong)
Initiate lifestyle changes and risk factor modification prior to, or at the same time as, initiating ED treatments. (Strong)
Use PDE5Is as first-line therapy for the treatment of ED. (Strong)
Use intracavernous injections as an alternative first-line therapy in well-informed patients or as second-line therapy. (Strong)
Use topical/intra-urethral alprostadil as an alternative first-line therapy in well-informed patients who: (Weak)
- do not wish to have or are not suitable for oral vasoactive therapy;
- do not wish to have intracavernous injections;
- in patients who prefer a less-invasive therapy.
Use low intensity shockwave treatment (LI-SWT) with/without PDE5Is in patients: (Weak)
- with mild vasculogenic ED;
- as an alternative therapy in well-informed patients who do not wish to have or are not suitable for oral vasoactive therapy;
- who are vasculogenic ED patients that are poor responders to PDE5Is.
Use vacuum erection devices in well-informed patients requesting non-invasive, drug-free management of ED. (Weak)
Use supplements with L-arginine or ginseng daily in men with mild ED who refuse pharmacological treatment after counselling them that the improvement of EF could be mild. (Weak)
Implant a penile prosthesis if other treatments fail or depending upon patient preference. Patients should be fully informed of the benefits and harms associated with the procedure. (Strong)
Inform patients that available data are inadequate to support any specific regimen for penile rehabilitation (Weak)
Start pro-erectile treatments at the earliest opportunity after radical prostatectomy/pelvic surgery and other curative treatments for prostate cancer. (Weak)

Treatment of Ischaemic Priapism

Start management of ischaemic priapism as early as possible (within four to six hours) and follow a stepwise approach. Strong
Perform corpus cavernosum aspiration and washout until fresh red blood is obtained as first treatment step. Strong
Replace blood aspiration with intracavernous injection of a sympathomimetic drug as the first step in priapism secondary to intracavernous injections of vasoactive agents. Strong
Perform intracavernous injection of a sympathomimetic drug in priapism that persists despite aspiration. Strong
Repeat aspiration and intracavernous injection of a sympathomimetic drug in cases that persist despite prior aspiration and intracavernous injection of a sympathomimetic drug, before considering surgical intervention. Strong
Treat ischaemic priapism associated with sickle cell disease in the same fashion as idiopathic ischaemic priapism. Do not use exchange transfusion as a primary treatment. Provide other supportive measures but do not delay initial treatment to the penis. Strong
Proceed to surgical treatment only when blood aspiration and intracavernous injection of sympathomimetic drugs have failed. Strong
Perform distal shunt surgical procedures first and combine them with tunnelling if necessary. Weak
Peno-scrotal decompression may be used as An alternative first-line option instead of distal shunting (with or without tunnelling). Weak
Discuss penile prosthesis implantation in cases of delayed presentation (> 48 hours) and in cases refractory to injection therapy and distal shunting. Weak
Delay implantation of a penile prosthesis if a shunt has been performed, to minimise the risk of infection and erosion of the implant. Strong
Decide on which type of implant to insert based on:
- • patient suitability;
- • surgeons’ experience; and
- • availability and cost of equipment.
- If a malleable penile prosthesis is implanted, it can be exchanged for an inflatable penile implant. Strong

Diagnostic Work-Up of Male Infertility

Include a parallel assessment of the fertility status, including ovarian reserve, of the female partner during the diagnosis and management of the infertile male, since this might determine decision making in terms of timing and therapeutic strategies (e.g., assisted reproductive technology (ART) versus surgical intervention). (Strong)
Examine all men seeking medical help for fertility problems, including men with abnormal semen parameters. (Strong)
Take a complete medical, reproductive and family history, assessment of lifestyle and behaviour risk factors, physical examination and semen analysis. (Strong)
Counsel infertile men or men with abnormal semen parameters on the associated health risks. (Weak)
Assess testicular volume with a Prader’s orchidometer or testicular ultrasound (US). (Weak)
Perform semen analyses according to the latest edition of the WHO Manual for the Examination and Processing of Human Semen. (Strong)
Perform at least two consecutive semen analyses if the baseline analysis was abnormal. (Strong)
Do not routinely use reactive oxygen species (ROS) testing in the diagnosis and management of the male partner of an infertile couple. (Weak)
Perform sperm DNA fragmentation (SDF) testing in the assessment of couples with recurrent pregnancy loss from natural conception and failure of ART or men with unexplained infertility. (Strong)
Consider the use of testicular sperm for intra-cytoplasmic sperm injection (ICSI) in patients with high SDF in ejaculated sperm as experimental. (Weak)
Perform a hormonal evaluation including serum total testosterone and Follicle Stimulating Hormone/Luteinising Hormone at least in all cases of oligozoospermia and azoospermia. (Strong)
Offer standard karyotype analysis and genetic counselling to all men with azoospermia and oligozoospermia (spermatozoa < 5 million/mL) for diagnostic purposes. (Strong)
Provide long-term endocrine follow-up and appropriate medical treatment to men with Klinefelter syndrome. (Strong)
Perform Y-chromosome microdeletion testing in men with sperm concentrations of ≤ 1 million sperm/mL. Consider it in men with sperm concentrations of < 5 million sperm/mL. (Strong)
Inform men with Yq microdeletion and their partners who wish to proceed with ICSI that microdeletions will be passed to sons. (Strong)
Do not perform testicular sperm extraction in patients with complete deletions that include the AZFa and AZFb regions. (Strong)
Test men with structural abnormalities of the vas deferens (unilateral or bilateral absence with no renal anomalies) and their partners for cystic fibrosis transmembrane conductance regulator gene mutations. (Strong)
Provide genetic counselling in all couples with a genetic abnormality found on clinical or genetic investigation and in patients who carry a (potential) inheritable disease. (Strong)
Perform scrotal US in patients with infertility, as there is a higher risk of testis cancer. (Weak)
Discuss invasive diagnostic modalities (e.g., US-guided testicular biopsy with frozen section versus radical orchidectomy versus surveillance) in infertile men with US-detected indeterminate testicular lesions, especially if additional risk factors for malignancy are present in a multidisciplinary team setting. (Weak)
Perform transrectal US if a partial or complete distal obstruction is suspected. (Strong)

Recommendation Grading

Level	Type of Evidence
1a	Evidence obtained from meta-analysis of randomised trials
1b	Evidence obtained from at least one randomised trial
2a	Evidence obtained from one well-designed controlled study without randomisation
2b	Evidence obtained from at least one other type of well-designed quasi-experimental study
3	Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4	Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Strength	Description
S	Strong recommendation
W	Weak (conditional) recommendation

Document Overview

Document Title: Sexual and Reproductive Health

Authoring Society: European Association of Urology

Document Publication Date: Apr 1, 2026

Page Last Reviewed/Updated: May 19, 2026

Document Type: Guideline

Country of Publication: European

Full Text Freely Available: Yes

Full Text Guideline: d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Sexual-and-Reproductive-Health-2026.pdf

Source Citation: Salonia, A., Boeri, L., Capogrosso, P., Corona, G., Dinkelman-Smith, M., Falcone, M., Gül, M., Kadioğlu, A., Martinez-Salamanca, J. I., Minhas, S., Serefoğlu, E. C., Verze, P., Cocci, A., Fuglesang Jensen, C., Kalkanli, A., Morgado, L. A., Milenkovic, U. & Russo, G. (2026). EAU Guidelines on Sexual and Reproductive Health . In EAU. https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Sexual-and-Reproductive-Health-2026.pdf

Document Scope, Criteria, and Use Cases

Document Objectives: The European Association of Urology (EAU) Sexual and Reproductive Health Guidelines aim to provide a comprehensive overview of the medical aspects relating to sexual and reproductive health in adult men.

Scope: Diagnosis, Management, Prevention, Treatment

Diseases/Conditions (MeSH)

D060728 - Reproductive Health

D000074384 - Sexual Health

Keywords: Reproductive Health, sexual health

Target Patient Population: Adult men

Target Provider Population: Urologists, endocrinologists, and other healthcare providers who treat adult men.

Inclusion Criteria: Male, Adult, Older Adult

Health Care Settings: Ambulatory, Laboratory Services

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Sexual and Reproductive Health

Summary of Recommendations

Male Hypogonadism

Evaluation and Screening

Treatment of Classical and Late-Onset Hypogonadism

Testosterone Therapy Outcome

Choice of Treatment for LOH

Followup

Management of Erectile Dysfunction

Evaluation

Treatment of ED

Disorders of Ejaculation

Premature Ejaculation

Diagnosis

Treatment of PE

Haemospermia

Low Sexual Desire and Male Hypoactive Sexual Desire Disorder

Penile Curvature

Congenital Penile Curvature

Peyronie’s Disease

Diagnosis

Conservative Treatment of Peyronie’s Disease

​​​​​​Surgical Treatment Of Peyronie’s Disease

Penile Size Abnormalities and Dysmorphophobia

Definition, Epidemiology and Classification

Diagnosis

Management

Non-Surgical Management of Short Penile Size

Surgical Treatments

Surgical Treatment of Adult Acquired Buried Penis

Surgical Treatment of Congenital Intrinsic Penile Shortness

Surgical Treatment of Acquired Penile Shortness

Girth Enhancement

Priapism

Ischaemic (Low-Flow Or Veno-Occlusive) Priapism

Diagnosis of Ischaemic Priapism

Treatment of Ischaemic Priapism

Treatment of Stuttering Priapism

Non-Ischaemic Priapism

Diagnosis

Treatment

Male Infertility

Epidemiology and Aetiology

Diagnostic Work-Up of Male Infertility

Special Conditions And Relevant Clinical Entities

Cryptorchidism

Germ Cell Malignancy and Testicular Microcalcification

Varicocele

Male Accessory Gland Infections

Non-Invasive Male Infertility Management

Hormonal Therapy

Invasive Male Infertility Management

Obstructive Azoospermia

Non-Obstructive Azoospermia

Recommendation Grading

Document Overview

Document Scope, Criteria, and Use Cases

Surgical Treatment Of Peyronie’s Disease