madman
Super Moderator
* Elevated haematocrit is common with TTh, typically occurring within 3–12 mo. Levels up to 54% appear safe, but higher values may increase CV risk [15].
* Treatment adjustments are required for haematocrit >54% (requiring withdrawal and phlebotomy in high-risk cases)
Fig. 1 – Diagnostic evaluation of late-onset hypogonadism. cFT = calculated free testosterone; LH = luteinising hormone; MRI = magnetic resonance imaging; PRL = prolactin; SHBG = sex hormone–binding globulin; T = testosterone; TT = total testosterone.
Objective
The objective of this study is to present a summary of the updated 2025 European Association of Urology (EAU) guidelines on sexual and reproductive health (SRH), focusing on hypogonadism, erectile dysfunction (ED), premature ejaculation (PE), and Peyronie’s disease (PD), providing practical recommendations on the clinical workup, with a focus on diagnosis, treatment, and follow-up.
The panel conducted an updated systematic review of new research published in 2021–2024 in Medline, EMBASE, and Cochrane Libraries. The guidelines’ recommendations focused on key clinical decisions that would impact patient care most. Each recommendation’s strength was evaluated based on three factors: the trade-offs between benefits and drawbacks of different treatment approaches, the quality and reliability of the available evidence, and the diverse preferences and values of patients.
Key Findings
Along with a detailed basic and advanced diagnostic approach for every condition, key recommendations emphasize the importance of appropriate indications and subsequent follow-up for testosterone therapy in patients with late-onset hypogonadism (LOH), a clinical condition in the ageing male combining low levels of circulating testosterone and specific symptoms associated with impaired hormone production and/or action. The decision-making algorithm for treating ED—defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance—aims to support personalised treatment tailored to individual patients, according to the invasiveness, tolerability, and effectiveness of the different therapeutic options and patients’ expectations. Hence, patients should be fully counselled with respect to all available treatment modalities. The EAU guidelines adopted the definition of PE, which has been developed by the International Society for Sexual Medicine. After the subtype of PE has been defined, patient’s expectations should be discussed thoroughly, and pharmacotherapy must be considered as the first-line treatment for patients with lifelong PE, whereas treating the underlying cause must be the initial goal for patients with acquired PE. An accurate baseline assessment of patients with PD should differentiate between acute and stable phases of the disorder. Surgical treatment for PD should be offered to patients having a penile deformity with a negative impact on sexual function: patients with concomitant ED should be offered penile prosthesis implantation.
This overview of the 2025 EAU SRH guidelines offers valuable insights into the diagnosis, treatment, and follow-up of LOH, ED, PE, and PD.
3.1.4. Safety and follow-up in hypogonadism management
3.1.4.1. Fertility issues.
TTh is contraindicated in men seeking fertility. For secondary hypogonadism, gonadotropin therapy can maintain testosterone levels while preserving fertility [3,16,17]
3.1.4.2. Male breast cancer.
Breast cancer growth is influenced by testosterone and its conversion to oestradiol (E2) [26]. Active or treated male breast cancer remains an absolute contraindication for TTh due to limited safety data.
3.1.4.3. LUTS/benign prostatic hyperplasia.
Several studies show that TTh is safe and does not worsen LUTS or prostate volume significantly [27–31] except in men with severe symptoms (IPSS >19), but with limited long-term data [10].
3.1.4.4. Prostate cancer.
Research shows no clear association between higher testosterone levels and PCa risk [32]. Moreover, meta-analyses of RCTs found no evidence of increased prostate-specific antigen (PSA) levels or PCa risk with TTh [32]. Recently, the TRAVERSE trial confirmed no difference in PCa incidence between the testosterone and placebo groups at a mean follow-up of 33.0 ± (standard deviation) 12.1 mo [13]. For PCa survivors, safety data remain limited. Meta-analyses suggest no increased recurrence risk, but evidence quality is poor [33]. TTh should be avoided in advanced PCa, and PCa survivors should be counselled thoroughly regarding the unknown long-term effects.
3.1.4.5. CV disease.
Hypogonadal men show an increased risk of CV disease (CVD) [34]. LOH associates with CV risk factors and increased mortality [35]. RCTs demonstrate some CV risk benefits from TTh, including reduced central adiposity and improved lipid profiles [36,37]. The TRAVERSE trial showed that TTh was noninferior to placebo for major adverse cardiovascular events (MACEs), though slight increases in atrial fibrillation, kidney injury, and pulmonary embolism were noted [13]. However, the latter findings are in contrast with previous trials showing no increased risk of venous thromboembolism or major arrhythmias [38]. Current evidence suggests neutral or beneficial effects on MACEs for up to 3 yr of therapy [39].
3.1.4.6. Cardiac failure.
TTh is contraindicated in severe cardiac failure but may benefit moderate cases with careful monitoring [40]. Moreover, there are data showing that untreated hypogonadism increases readmission and mortality in heart failure patients [41].
3.1.4.7. Erythrocytosis.
Elevated haematocrit is common with TTh, typically occurring within 3–12 mo. Levels up to 54% appear safe, but higher values may increase CV risk [15]. Management options include dose reduction, formulation change, or venesection. Parenteral formulations show a higher risk than topical ones [42]. The TRAVERSE study found a slightly higher incidence of pulmonary embolism for TTh than for placebo (0.9% vs 0.5%) [13]. However, multiple large studies and meta-analyses showed no increased risk of venous thromboembolism with TTh [38]. When thromboembolism occurred, it was often linked to underlying thrombophilia disorders [43].
3.1.4.8. Obstructive sleep apnoea.
Evidence suggests that TTh does not worsen obstructive sleep apnoea. Combined continuous positive airway pressure (CPAP) and testosterone gel therapy showed better outcomes than CPAP alone [44].
3.1.4.9. Follow-up.
Table 9 details the clinical and biochemical parameters to be checked during TTh. Follow-up monitoring is time dependent and varies according to the preparation used, although an initial evaluation is recommended at 3 mo when sexual symptoms typically improve(Table 9) [45]. Treatment adjustments are required for haematocrit >54% (requiring withdrawal and phlebotomy in high-risk cases) and significant PSA increase (Table 10).
* Treatment adjustments are required for haematocrit >54% (requiring withdrawal and phlebotomy in high-risk cases)
Fig. 1 – Diagnostic evaluation of late-onset hypogonadism. cFT = calculated free testosterone; LH = luteinising hormone; MRI = magnetic resonance imaging; PRL = prolactin; SHBG = sex hormone–binding globulin; T = testosterone; TT = total testosterone.
Objective
The objective of this study is to present a summary of the updated 2025 European Association of Urology (EAU) guidelines on sexual and reproductive health (SRH), focusing on hypogonadism, erectile dysfunction (ED), premature ejaculation (PE), and Peyronie’s disease (PD), providing practical recommendations on the clinical workup, with a focus on diagnosis, treatment, and follow-up.
Evidence AcquisitionThe panel conducted an updated systematic review of new research published in 2021–2024 in Medline, EMBASE, and Cochrane Libraries. The guidelines’ recommendations focused on key clinical decisions that would impact patient care most. Each recommendation’s strength was evaluated based on three factors: the trade-offs between benefits and drawbacks of different treatment approaches, the quality and reliability of the available evidence, and the diverse preferences and values of patients.
Key Findings
Along with a detailed basic and advanced diagnostic approach for every condition, key recommendations emphasize the importance of appropriate indications and subsequent follow-up for testosterone therapy in patients with late-onset hypogonadism (LOH), a clinical condition in the ageing male combining low levels of circulating testosterone and specific symptoms associated with impaired hormone production and/or action. The decision-making algorithm for treating ED—defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance—aims to support personalised treatment tailored to individual patients, according to the invasiveness, tolerability, and effectiveness of the different therapeutic options and patients’ expectations. Hence, patients should be fully counselled with respect to all available treatment modalities. The EAU guidelines adopted the definition of PE, which has been developed by the International Society for Sexual Medicine. After the subtype of PE has been defined, patient’s expectations should be discussed thoroughly, and pharmacotherapy must be considered as the first-line treatment for patients with lifelong PE, whereas treating the underlying cause must be the initial goal for patients with acquired PE. An accurate baseline assessment of patients with PD should differentiate between acute and stable phases of the disorder. Surgical treatment for PD should be offered to patients having a penile deformity with a negative impact on sexual function: patients with concomitant ED should be offered penile prosthesis implantation.
Conclusion and clinical implicationsThis overview of the 2025 EAU SRH guidelines offers valuable insights into the diagnosis, treatment, and follow-up of LOH, ED, PE, and PD.
3.1.4. Safety and follow-up in hypogonadism management
3.1.4.1. Fertility issues.
TTh is contraindicated in men seeking fertility. For secondary hypogonadism, gonadotropin therapy can maintain testosterone levels while preserving fertility [3,16,17]
3.1.4.2. Male breast cancer.
Breast cancer growth is influenced by testosterone and its conversion to oestradiol (E2) [26]. Active or treated male breast cancer remains an absolute contraindication for TTh due to limited safety data.
3.1.4.3. LUTS/benign prostatic hyperplasia.
Several studies show that TTh is safe and does not worsen LUTS or prostate volume significantly [27–31] except in men with severe symptoms (IPSS >19), but with limited long-term data [10].
3.1.4.4. Prostate cancer.
Research shows no clear association between higher testosterone levels and PCa risk [32]. Moreover, meta-analyses of RCTs found no evidence of increased prostate-specific antigen (PSA) levels or PCa risk with TTh [32]. Recently, the TRAVERSE trial confirmed no difference in PCa incidence between the testosterone and placebo groups at a mean follow-up of 33.0 ± (standard deviation) 12.1 mo [13]. For PCa survivors, safety data remain limited. Meta-analyses suggest no increased recurrence risk, but evidence quality is poor [33]. TTh should be avoided in advanced PCa, and PCa survivors should be counselled thoroughly regarding the unknown long-term effects.
3.1.4.5. CV disease.
Hypogonadal men show an increased risk of CV disease (CVD) [34]. LOH associates with CV risk factors and increased mortality [35]. RCTs demonstrate some CV risk benefits from TTh, including reduced central adiposity and improved lipid profiles [36,37]. The TRAVERSE trial showed that TTh was noninferior to placebo for major adverse cardiovascular events (MACEs), though slight increases in atrial fibrillation, kidney injury, and pulmonary embolism were noted [13]. However, the latter findings are in contrast with previous trials showing no increased risk of venous thromboembolism or major arrhythmias [38]. Current evidence suggests neutral or beneficial effects on MACEs for up to 3 yr of therapy [39].
3.1.4.6. Cardiac failure.
TTh is contraindicated in severe cardiac failure but may benefit moderate cases with careful monitoring [40]. Moreover, there are data showing that untreated hypogonadism increases readmission and mortality in heart failure patients [41].
3.1.4.7. Erythrocytosis.
Elevated haematocrit is common with TTh, typically occurring within 3–12 mo. Levels up to 54% appear safe, but higher values may increase CV risk [15]. Management options include dose reduction, formulation change, or venesection. Parenteral formulations show a higher risk than topical ones [42]. The TRAVERSE study found a slightly higher incidence of pulmonary embolism for TTh than for placebo (0.9% vs 0.5%) [13]. However, multiple large studies and meta-analyses showed no increased risk of venous thromboembolism with TTh [38]. When thromboembolism occurred, it was often linked to underlying thrombophilia disorders [43].
3.1.4.8. Obstructive sleep apnoea.
Evidence suggests that TTh does not worsen obstructive sleep apnoea. Combined continuous positive airway pressure (CPAP) and testosterone gel therapy showed better outcomes than CPAP alone [44].
3.1.4.9. Follow-up.
Table 9 details the clinical and biochemical parameters to be checked during TTh. Follow-up monitoring is time dependent and varies according to the preparation used, although an initial evaluation is recommended at 3 mo when sexual symptoms typically improve(Table 9) [45]. Treatment adjustments are required for haematocrit >54% (requiring withdrawal and phlebotomy in high-risk cases) and significant PSA increase (Table 10).
