1. Varicocele

• Often asymptomatic
• Dull dragging scrotal discomfort, worse on standing/exertion
• Infertility or abnormal semen parameters
• “Bag of worms” above the testis on standing and Valsalva
• Testicular hypotrophy, especially in adolescents

• Grade I: palpable only on Valsalva
• Grade II: palpable at rest
• Grade III: visible through scrotal skin
• Subclinical: demonstrable only on Doppler ultrasound

• Examine standing and supine, with Valsalva.
• Assess testicular volume and perform semen analysis if infertility is a concern.
• Scrotal color Doppler: dilated veins with reflux.
• A new right-sided, non-reducible, or persistent supine varicocele warrants evaluation for retroperitoneal pathology.

• Persistent pain despite conservative measures
• Infertile couple with a clinical varicocele, abnormal semen parameters, and potentially correctable female fertility
• Adolescent with progressive testicular hypotrophy

• Observation, scrotal support, NSAIDs for minor symptoms
• Microsurgical subinguinal varicocelectomy is commonly preferred due to lower recurrence/hydrocele risk.
• Alternatives: inguinal or laparoscopic ligation, radiological embolization.

2. Peyronie Disease

• Repetitive minor penile trauma during intercourse in a genetically susceptible man
• Abnormal wound healing with collagen deposition and plaque formation
• Associated with Dupuytren contracture and diabetes in some patients

1. Active or acute phase: penile pain, evolving curvature and plaque.
2. Stable or chronic phase: pain usually resolves; curvature remains stable for at least 3-6 months.

• Palpable firm plaque, commonly dorsolateral
• Curvature during erection
• Painful erection in active disease
• Penile shortening, hourglass deformity
• Difficulty with intercourse and psychological distress

• Mainly clinical: history, examination, measurement/documentation of erect curvature.
• Penile duplex Doppler ultrasound may identify plaque/calcification and assess erectile hemodynamics, particularly before intervention.

• Counselling and partner involvement.
• Observe if deformity is mild and intercourse remains satisfactory.
• Active phase: analgesia, risk-factor control, selected traction therapy. Oral agents have limited supporting evidence.
• Intralesional treatment may be considered for suitable stable curvature, depending on local availability and indication.
• Surgery only after stable disease when intercourse is impaired:
  • Plication for adequate penile length and less severe curvature
  • Plaque incision/excision with grafting for severe curvature or complex deformity
  • Penile prosthesis, with modelling or straightening, if significant erectile dysfunction coexists.

3. Orchialgia / Chronic Scrotal Content Pain

• Idiopathic
• Epididymitis/orchitis, post-vasectomy pain syndrome
• Varicocele, hydrocele, spermatocele
• Trauma, prior inguinal or scrotal surgery
• Testicular tumour
• Referred pain: ureteric calculus, inguinal hernia, lumbar radiculopathy, hip disease
• Pelvic-floor dysfunction and chronic pelvic pain syndrome

• Acute severe pain: exclude testicular torsion urgently.
• Palpable mass or persistent unilateral pain: exclude testicular malignancy.
• Fever, dysuria, urethral discharge: assess infection.

• History: onset, trauma, surgery, urinary/sexual symptoms, radiation of pain.
• Examine abdomen, inguinal canal, scrotal contents, prostate and pelvic floor when appropriate.
• Urinalysis and culture if infection suspected.
• Scrotal ultrasound with Doppler to exclude mass, torsion, varicocele, etc.
• Consider CT if ureteric colic or referred retroperitoneal pathology is suspected.

1. Treat an identified cause.
2. Conservative: reassurance, scrotal support, activity modification, NSAIDs.
3. Neuropathic pain agents where indicated and pelvic-floor physiotherapy for pelvic-floor tenderness/dysfunction.
4. Spermatic-cord block can be diagnostic and prognostic.
5. Refractory, well-localized pain with response to cord block: microsurgical denervation of the spermatic cord may be considered.
6. Epididymectomy or orchiectomy only in highly selected refractory cases. Orchiectomy is a last resort and may fail because pain can be neuropathic or referred.

4. Male Infertility

• Pre-testicular: hypogonadotropic hypogonadism, hyperprolactinaemia, systemic illness, exogenous testosterone/anabolic steroids.
• Testicular: varicocele, cryptorchidism, mumps orchitis, torsion, chemotherapy/radiation, genetic disorders such as Klinefelter syndrome.
• Post-testicular: obstruction of epididymis/vas/ejaculatory ducts, congenital bilateral absence of vas deferens, ejaculatory dysfunction.
• Lifestyle/environmental: smoking, alcohol/drugs, obesity, heat exposure, toxins.

• Evaluate both partners simultaneously.
• Reproductive/medical/sexual history and examination: testicular size, vas deferens, epididymis, varicocele, secondary sexual characteristics.
• Semen analysis: at least two samples if the first is abnormal.
  • Semen defects: oligozoospermia, asthenozoospermia, teratozoospermia, azoospermia.
• Hormones, especially FSH and morning testosterone, in azoospermia, oligozoospermia, small testes, or symptoms of endocrine disease.
• Genetic testing in severe oligozoospermia or azoospermia, as indicated.
• Scrotal ultrasound only when clinically indicated.

• Correct reversible causes: stop testosterone/anabolic steroids, manage systemic/endocrine disease, optimize weight and lifestyle.
• Treat clinical varicocele in appropriately selected infertile men.
• Obstructive azoospermia: reconstructive surgery or surgical sperm retrieval.
• Hypogonadotropic hypogonadism: gonadotropin therapy to induce spermatogenesis.
• Assisted reproduction:
  • IUI for selected mild defects
  • IVF or ICSI for severe sperm abnormalities or failed conventional therapy
  • Surgical sperm retrieval with ICSI in azoospermia

5. Erectile Dysfunction (ED)

• Vasculogenic: hypertension, diabetes, dyslipidaemia, smoking, atherosclerotic cardiovascular disease
• Neurogenic: spinal cord injury, multiple sclerosis, diabetic neuropathy, pelvic surgery
• Endocrine: hypogonadism, hyperprolactinaemia, thyroid disease
• Psychogenic: anxiety, depression, relationship difficulty
• Drug-induced: some antihypertensives, antidepressants, antipsychotics, opioids
• Structural: Peyronie disease

• Sexual, medical, medication, psychosocial, and cardiovascular history.
• Focused examination: blood pressure, BMI/waist, peripheral pulses, genital and neurological examination.
• Investigations: fasting glucose/HbA1c, lipid profile, and morning total testosterone. Other hormone tests when clinically indicated.
• Use a validated questionnaire, such as IIEF-5, to grade severity.

1. Lifestyle and risk-factor modification: exercise, weight reduction, smoking cessation, glycaemic/BP/lipid control; manage depression and relationship factors.
2. PDE5 inhibitors are first-line therapy: sildenafil, tadalafil, vardenafil, avanafil.
   • Require sexual stimulation.
   • Contraindicated with nitrates because of potentially profound hypotension.
3. Address testosterone deficiency if confirmed and clinically relevant. Testosterone alone is not a general ED treatment.
4. Second-line options:
   • Vacuum erection device
   • Intraurethral alprostadil
   • Intracavernosal injection therapy, such as alprostadil
5. Penile prosthesis for severe refractory ED or when other treatments are unsuitable.