EAU 2025 Guidelines: Sexual and Reproductive Health

What This Guideline Covers

The EAU 2025 Sexual and Reproductive Health guideline provides evidence-based recommendations across 33 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

• Check for concomitant diseases, drugs and substances that can interfere with testosterone production/action.
• Measure total testosterone in the morning (07.00 and 11.00 hours) and in the fasting state, with a reliable laboratory assay.
• Repeat total testosterone on at least two separate occasions when < 12 nmol/L and before starting testosterone therapy.
• Use 12 nmol/L total testosterone (3.5 ng/ mL) as a reliable threshold to diagnose late onset hypogonadism (LOH).
• Measure sex hormone-binding globulin and free-testosterone calculation when indicated.
• Analyse luteinising hormone and follicle- stimulating hormone serum levels to differentiate between the different types of hypogonadism.
• Measure prolactin (PRL) levels if low sexual desire (or other suggestive signs/ symptoms) and secondary hypogonadism is present.
• Perform pituitary magnetic resonance imaging (MRI) in secondary hypogonadism, with elevated PRL or symptoms specific of a pituitary mass and/or presence of other anterior pituitary hormone deficiency.
• Screen for LOH only in symptomatic men.
• Do not use structured interviews and self- reported questionnaires for systematic screening for LOH as they have a low specificity.

Testosterone therapy outcome

• Do not use testosterone therapy in eugonadal men.
• Use testosterone therapy as first-line treatment in hypogonadal patients with mild erectile dysfunction (ED).
• Use conventional medical therapies for severe depressive symptoms and osteoporosis.
• Do not use testosterone therapy to improve cognition vitality and physical strength in ageing men.

Late-onset hypogonadism choice of treatment

• Treat, when indicated, organic causes of hypogonadism (e.g., pituitary masses, hyperprolactinemia, etc).
• Improve lifestyle and reduce weight (e.g., obesity); withdraw, when possible, concomitant drugs that can impair testosterone production; treat co-morbidity before starting testosterone therapy.
• Fully inform patients about expected benefits and adverse effects of any treatment option. Select the testosterone preparation in a joint decision process, and fully inform patients of the risks and benefits.

Safety and monitoring in testosterone treatment

• Advise patients that safety data on the use of testosterone therapy in men treated for breast cancer are unknown.
• Assess cardiovascular risk factors before commencing testosterone therapy.
• Assess men with known cardiovascular disease (CVD) for cardiovascular symptoms before testosterone therapy and with close clinical assessment and evaluation during treatment.
• Exclude a family history of venous- thromboembolism before starting testosterone therapy.
• Monitor testosterone, haematocrit at three, six and twelve months after testosterone therapy initiation, and thereafter annually. A haematocrit > 54% requires testosterone therapy adjustment or withdrawal and venesection if required. Re-introduce testosterone therapy at a lower dose once the haematocrit has normalised and consider switching to topical testosterone preparations.
• 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.
• Evaluate total PSA in PCa survivors at three, six and twelve months during the first year of testosterone therapy, and annually thereafter.

Diagnosis of erectile dysfunction

• Take a comprehensive medical and sexual history in every patient presenting with erectile dysfunction (ED). Consider psychosexual development, including life stressors, cultural aspects, and cognitive/ thinking style of the patient regarding their sexual performance.
• Use a validated questionnaire related to ED to assess all sexual function domains (e.g., International Index of Erectile Function) and the effect of a specific treatment modality.
• Include a focused physical examination in the initial assessment of men with ED to identify underlying medical conditions and comorbid genital disorders that may be associated with ED.
• Evaluate laboratory tests, including glucose and lipid profile and total testosterone, to identify and treat any reversible risk factors and lifestyle factors that can be modified.
• Include specific diagnostic tests in the initial evaluation of ED in the presence of the conditions presented in Table 1.

Treatment of erectile dysfunction

• Direct the patient to Cognitive Behaviour Therapy as a psychological approach (include the partner), when indicated, combined with medical treatment to maximise treatment outcomes.
• Discuss with patients undergoing active treatment for prostate cancer about 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.
• Initiate lifestyle changes and risk factor modification prior to, or at the same time as, initiating ED treatments.
• Use PDE5Is as first-line therapy for the treatment of ED.
• Use intracavernous injections as an alternative first-line therapy in well- informed patients or as second-line therapy.
• Implant a penile prosthesis if other treatments fail or depending upon patient preference. Patients should be fully informed of the benefits an harms associated with the procedure.

Diagnostic evaluation of premature ejaculation

• Perform the diagnosis and classification of premature ejaculation (PE) based on medical and sexual history, which should include assessment of intravaginal ejaculatory latency time (IELT) (self- estimated), perceived control, distress and interpersonal difficulty due to the ejaculatory dysfunction.
• Include physical examination in the initial assessment of PE to identify anatomical abnormalities that may be associated with PE or other sexual dysfunctions, particularly erectile dysfunction.
• Do not perform routine laboratory or neuro- physiological tests. They should only be directed by specific findings from history or physical examination.

Treatment of premature ejaculation

• Treat erectile dysfunction (ED), other sexual dysfunction or genitourinary infection (e.g., prostatitis) first.
• Use either dapoxetine or the lidocaine/ prilocaine spray as first-line treatments for lifelong premature ejaculation (PE).
• Use off-label oral treatment with daily selective serotonin re-uptake inhibitor (SSRIs) or daily/on-demand clomipramine as a viable alternative for second-line treatments.
• Use off-label tramadol with caution as a viable on-demand third-line treatment alternative to on-demand/daily antidepressants (SSRIs or clomipramine)
• Use PDE5Is alone or in combination with other therapies in patients with PE (without ED).

Investigation and management of haemospermia

• Perform a full medical and sexual history with detailed physical examination.

Treatment of low sexual desire

• Perform laboratory tests to rule out endocrine disorders.

• Provide testosterone therapy if LSD is associated with signs and symptoms of testosterone deficiency.

• Use the Nesbit procedure or plication techniques with or without neurovascular bundle dissection (medial/lateral) for satisfactory curvature correction.

Diagnosis of Peyronie’s disease

• Take a medical and sexual history of patients with Peyronie’s disease (PD), include duration of the disease, pain on erection, penile deformity, difficulty in vaginal/anal intromission due to disabling deformity and erectile dysfunction (ED).
• Perform a physical examination, including assessment of palpable plaques, stretched or erect penile length, degree of curvature (self-photography, vacuum-assisted erection test or pharmacological-induced erection) and any other related diseases (e.g., Dupuytren’s contracture, Ledderhose disease) in patients with PD.

Non-operative treatment of Peyronie’s disease

• Offer conservative treatment to patients not fit for surgery or when surgery is not acceptable to the patient.
• Fully counsel patients regarding all available treatment options and outcomes before starting any treatment.
• Do not offer oral treatment with vitamin E, potassium para-aminobenzoate (potaba), tamoxifen, pentoxifylline, colchicine and acetyl esters of carnitine to treat Peyronie’s disease (PD).
• Use nonsteroidal anti-inflammatory drugs to treat penile pain in the acute phase of PD.
• Offer intralesional therapy with Collagenase Clostridium Histolyticum to patients with stable PD and dorsal or lateral curvature > 30o, who request non- surgical treatment, although the placebo effects are high.
• Do not offer intralesional treatment with steroids to reduce penile curvature, plaque size or pain.
• Do not use intralesional platelet-rich plasma or hyaluronic acid, either alone or in combination with oral treatment, to reduce penile curvature, plaque size or pain outside the confines of a clinical trial.
• Do not offer ESWT to improve penile curvature and reduce plaque size.

Surgical treatment of Peyronie's disease

• Perform surgery only when Peyronie’s disease (PD) has been stable for at least three months (without pain or deformity deterioration), which is usually the case after twelve months from the onset of symptoms, and intercourse is compromised due to the deformity.
• Assess penile length, curvature severity, erectile function (including response to pharmacotherapy in case of erectile dysfunction [ED]) and patient expectations prior to surgery.
• Do not use the sliding techniques as there is a significant risk of life changing complications (e.g., glans necrosis).
• Do not use synthetic grafts in PD reconstructive surgery.
• Use penile prosthesis implantation, with or without any additional straightening procedures (modelling, plication, incision or excision with or without grafting), in PD patients with ED not responding to pharmacotherapy.

Classification of short penile size

• Perform a detailed genital examination in all men and particularly in men with BMI > 30, lichen sclerosis or penile cancer history and complaints of urinary/sexual difficulties or poor cosmesis to exclude the presence of an adult acquired buried penis (AABP) condition.
• Inquire on the presence of body dysmorphic disorder/penile dysmorphic disorder in patients with normal-sized penis complaining of short penile size.

Diagnosis of short penile size

• Take a comprehensive medical and sexual history in every patient presenting complaining of short penile size.
• Refer patients with BDD for mental health counselling.

Non-surgical management of short penile size

• Consider psychotherapy when psychopathological comorbidities are detected, or when aversive relationship dynamics may underlie the request for penile augmentation.
• Use endocrinological therapies to restore penile size in boys with micropenis or disorders of sex development.
• Do not use testosterone therapy or other hormonal therapies to increase penile size in men after puberty.

Recommendations surgical treatment

• Extensively counsel patients on the benefits and complications of AABP surgery.

• Initiate lifestyle changes and modification of risk factors, particularly weight loss, to minimise AABP surgical complications and to optimise surgical outcomes.

• Perform surgery for AABP in high volume centres.

• Extensively discuss possible complications related to SLR, ventral phalloplasty and suprapubic lipoplasty/liposuction/ lipectomy.

• Do not recommend penile prosthesis implantation, penile disassembly or sliding technique to patients seeking penile lengthening options.

• Counsel patients extensively regarding the risks and benefits of penile girth enhancement techniques.

• Do not use silicone, paraffin and petroleum jelly (Vaseline) to address penile girth enhancement.

• Do not use hyaluronic acid, soft tissue fillers and autologous fat injection to address penile girth enhancement in men with penile dysmorphic disorder.

• Do not use grafts in penile girth enhancement as they are considered experimental.

• Do not use biodegradable scaffolds and subcutaneous penile implant (Penuma®) to address penile girth enhancement as they are considered experimental.

Diagnosis of ischaemic priapism

• Take a comprehensive history to establish the diagnosis which can help to determine the priapism subtype.
• Include a physical examination of the genitalia, perineum and abdomen in the diagnostic evaluation.
• Include a full blood count, white blood cell count with blood cell differential, platelet count and coagulation profile for laboratory testing. Perform directed further laboratory testing depending upon history and clinical and laboratory findings. Perform a complete evaluation of all possible causes of priapism in children.
• Perform a haemoglobinopathy screen in patients with low flow priapism who are at high risk of sickle cell disease or thalassemia.
• Analyse the blood gas parameters from blood aspirated from the penis to differentiate between ischaemic and non- ischaemic priapism.
• Perform colour duplex ultrasound of the penis and perineum before aspiration to differentiate between ischaemic and non- ischaemic priapism.

Treatment of ischaemic priapism

• Start management of ischaemic priapism as early as possible (within four to six hours) and follow a stepwise approach.
• Decompress the corpus cavernosum by penile aspiration and washout until fresh red blood is obtained as first treatment step.
• Replace blood aspiration with intracavernous injection of a sympathomimetic drug as the first step in priapism secondary to intracavernous injections of vasoactive agents.
• Perform intracavernous injection of a sympathomimetic drug in priapism that persists despite aspiration.
• 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.
• 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 (intravenous hydration, oxygen administration with alkalisation with bicarbonate, blood exchange transfusions), but do not delay initial treatment to the penis.
• Proceed to surgical treatment only when blood aspiration and intracavernous injection of sympathomimetic drugs have failed.
• Delay implantation of a penile prosthesis if a shunt has been performed, to minimise the risk of infection and erosion of the implant.
• 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 later for an inflatable penile implant.

Treatment of stuttering priapism

• Manage each acute episode according to the treatment recommendation for ischaemic priapism.

Diagnosis of non-ischaemic priapism

• Take a comprehensive history to establish the diagnosis, which can help to determine the priapism subtype.
• Include a physical examination of the genitalia, perineum and abdomen in the diagnostic evaluation.
• Include a neurological examination if neurogenic non-ischaemic priapism is suspected.
• Include complete blood count, with white blood cell differential, and coagulation profile for laboratory testing.
• Analyse the blood gas parameters from blood aspirated from the penis to differentiate between ischaemic and non- ischaemic priapism.
• Perform colour duplex ultrasound of the penis and perineum to differentiate between ischaemic and non-ischaemic priapism.
• Perform selected pudendal arteriography when embolisation is planned for non- ischaemic priapism.

Treatment of non-ischemic priapism

• Perform selective arterial embolisation when conservative management has failed.

• 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).

• Examine all men seeking medical help for fertility problems, including men with abnormal semen parameters.

• Take a complete medical reproductive and family history, assessment of lifestyle and behaviour risk factors, physical examination and semen analysis.

• Perform semen analyses according to the latest edition of the WHO Manual for the Examination and Processing of Human Semen.

• Perform at least two consecutive semen analyses if the baseline analysis was abnormal.

• 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.

• Perform a hormonal evaluation including serum total testosterone and Follicle Stimulating Hormone/Luteinising Hormone at least in all cases of oligozoospermia and azoospermia.

• Offer standard karyotype analysis and genetic counselling to all men with azoospermia and oligozoospermia (spermatozoa < 5 million/mL) for diagnostic purposes.

• Provide long-term endocrine follow-up and appropriate medical treatment to men with Klinefelter syndrome.

• 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.

• Inform men with Yq microdeletion and their partners who wish to proceed with ICSI that microdeletions will be passed to sons.

• Do not perform testicular sperm extraction in patients with complete deletions that include the AZFa and AZFb regions.

• 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.

• 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.

• Perform transrectal US if a partial or complete distal obstruction is suspected.

• Do not use hormonal treatment for cryptorchidism in post-pubertal men.

• Perform simultaneous testicular biopsy, for the detection of intratubular germ cell neoplasia in situ (formerly carcinoma in situ), if undescended testes are corrected in adulthood.

• Offer adult men with unilateral undescended testis and normal hormonal function/spermatogenesis orchidectomy.

• Do not perform testicular biopsy, follow- up scrotal ultrasound (US), measure biochemical tumour markers, or abdominal or pelvic computed tomography, in men with isolated TM without associated risk factors (e.g., infertility, cryptorchidism, testicular cancer, and atrophic testis).

• Perform inguinal surgical exploration with testicular biopsy or offer orchidectomy after multi-disciplinary team meeting and discussion with the patient, if there are suspicious findings on physical examination or US in patients with TM with associated lesions.

• Manage men treated for TGCT in a multi- disciplinary team setting with a dedicated late-effects clinic and survivorship program, since they are at increased risk of developing hypogonadism, sexual dysfunction and cardiovascular risk.

• Perform sperm cryopreservation prior to planned orchidectomy or before additional neoadjuvant or adjuvant oncological therapies.

• Offer onco-testicular sperm extraction (onco-TESE) at the time of radical orchidectomy in men with testicular cancer and azoospermia or severe abnormalities in their semen parameters.

• In adolescents offer surgery for varicocele associated with a persistent small testis (size difference of > 2 mL or 20%), which should be confirmed on two subsequent visits performed six months apart.

• Do not treat varicocele in infertile men who have normal semen analysis and in men with a sub-clinical varicocele.

• Treat infertile men with a clinical varicocele, abnormal semen parameters and otherwise unexplained infertility in a couple where the female partner has good ovarian reserve to improve fertility rates.

• Refer sexual partners of patients with accessory sex gland infections that are known or suspected to be caused by sexually transmitted diseases for evaluation and treatment.

• Inform infertile men about the detrimental effects of obesity, low physical activity, smoking and high alcohol intake on sperm quality and testosterone levels. Therefore, advise infertile men to improve life style factors to improve their chances of conception.

• Induce spermatogenesis in men with congenital or acquired hypogonadotropic hypogonadism who wish to conceive by effective drug therapy (hCG; human menopausal gonadotropins; recombinant FSH; highly purified FSH).

• Do not use testosterone therapy for the treatment of male infertility.

• Provide testosterone therapy for symptomatic patients with primary and secondary hypogonadism who are not considering parenthood.

• Perform microsurgical vasovasostomy or epididymovasostomy for azoospermia caused by vasal or epididymal obstruction in men with female partners with good ovarian reserve.

• Use sperm retrieval techniques, such as microsurgical epididymal sperm aspiration (MESA), testicular sperm extraction (TESE) and percutaneous techniques (PESA and TESA) either as an adjunct to reconstructive surgery, or if the condition is not amenable to surgical repair, or when the ovarian reserve of the partner is limited or patient preference is not to undertake surgical reconstruction and the couple prefer to proceed to ICSI treatment directly.

• Confirm a diagnosis of non-obstructive azoospermia (NOA) in two consecutive semen analyses, when no sperm are found after centrifugation.

• Perform a comprehensive assessment, including detailed medical history, hormonal profile, genetic tests and scrotal ultrasound to investigate the underlying aetiology and associated co-morbidity in patients with NOA.

• Genetic counselling is mandatory in couples with genetic abnormalities prior to any assisted reproductive technology.

• Perform surgery for sperm retrieval in men who are candidates for assisted reproductive technology (i.e., ICSI).

• Do not perform surgery for sperm retrieval in patients with complete AZFa and AZFb microdeletions, since the chance of sperm retrieval is zero.

• Do not perform fine needle aspiration (FNA) and testicular sperm aspiration (TESA) in patients with NOA.