Diabetes mellitus (DM) is a metabolic condition most known for the body’s inability to produce or utilize insulin properly. If not managed carefully and holistically, including during treatment and care visits, DM can lead to further complications, such as sexual dysfunction (SD), of which 20-80% of diabetic women experiences symptoms. Sexual dysfunction experienced by diabetic women may include genital arousal disorder (caused by chronic hyperglycemia) or low self-esteem related to the overall impact of diabetes that may negatively affect sexual functioning. It’s assumed that as DM progresses, risk of SD increases.

Active surveillance (AS) refers to a low-risk, localized prostate cancer management technique, which involves monitoring the disease through prostate-specific androgen (PSA) tests, digital rectal exams, multiparametric MRIs, and biopsies. This technique minimizes complications associated with surgery and radiation, such as erectile dysfunction and incontinence, as surveillance can help detect disease progression early on. It’s estimated that one in six men will develop prostate cancer at some point in their lifetime.

Other conditions also tend to affect this population of men, such as hypogonadism, which can be explained as low testosterone levels. Low testosterone affects roughly 40% of men over the age of 45. Normally, testosterone replacement therapy (TRT), is the preferred treatment for managing hypogonadism. However, this may be avoided for those on AS for prostate cancer due to a belief that higher testosterone levels may contribute to the progression of prostate cancer. Nevertheless, recent research on the androgen saturation model suggests that prostate cancer progression is more likely at lower testosterone levels and less likely at higher levels.

Between 2009 and 2023, researchers at the Scott Department of Urology at Baylor College of Medicine in Texas aimed to evaluate the effects of TRT and prostate cancer progression in men on AS. They also hoped to contribute to the lacking available literature by providing clarity regarding the feasibility of TRT in these men.

A total of 43 men with a median age of 62 with a prostate cancer diagnosis were evaluated over at least a 12-month period while undergoing TRT. The average evaluation period was around 73 months. Of these men, 32 (74.4%) followed through with the evaluation period, five (11.6%) stopped because they felt they no longer needed TRT, three (7%) stopped due to cancer progression following biopsy, and one (2.3%) stopped due to an unrelated hospitalization.

Prior to starting TRT, the median testosterone serum level of the group was 272 nanograms per deciliter (ng/dL), and when measured after the start of TRT, that median level had jumped to 578.5 ng/dL. Seven men (16.3%) had testosterone levels below 250 ng/dL, which is the low testosterone threshold proposed by the androgen saturation model. All 43 men had normal testosterone levels (above 300 ng/dL) following the start of TRT.

Additionally, the median PSA level prior to starting TRT was 2.8 nanograms per milliliter (ng/mL), while after starting TRT the PSA levels dropped to 2.6 ng/mL, which researchers found to be an insignificant difference. However, seven (16.3%) of patients demonstrated a PSA increase of at least 1 ng/mL, and three of these seven patients had an elevated baseline PSA level of 3.5 ng/mL. Researchers believe that while PSA level increase with TRT is generally insignificant toward disease progression, elevated baseline PSA levels may be a risk factor for prostate cancer progression. This is in line with the androgen saturation model, in which higher testosterone levels are thought to be less likely to lead to disease progression.

Biopsy results were only available for 15 patients prior to and following the start of TRT. Of these 15 patients, 12 (80%) demonstrated no disease progression after an average of 44.28 months, three (20%) demonstrated an increase following an average of 79.5 months, and two (13.3%) had benign biopsy after an average of 9 months. One of these individuals had normal tissues after 12 years of TRT, while the other had normal tissues after 11 months. This data aligns with existing literature about prostate cancer, regardless of TRT.

Conclusion

Overall, results reflect the androgen saturation theory, which suggests that testosterone regulators (androgen receptors) are maximally saturated and able to function properly at a testosterone concentration of 240-250 ng/dL. In this study, only seven (16.3%) of men had baseline testosterone levels below this threshold and a significant increase in PSA following TRT. The other 83.7% had baseline testosterone levels above this threshold and virtually no significant increase in PSA levels following TRT.

Despite a small sample size and lack of generalizability, this study is still the largest retrospective single-center study of its kind. This allows future research to expand and specialize, focusing on larger patient groups and subgroups to fully understand the effects of TRT on the risk of prostate cancer progression.

Researchers say the results of this study contribute to existing evidence that TRT may be safe for men with low testosterone levels on AS for prostate cancer.

References:

• Applewhite, J., McCarter, J., Saffati, G., Kronstedt, S., Hinojosa-Gonzalez, D., La, T., Diejomaoh, R. M., Lipshultz, L. I., & Khera, M. (2025). Testosterone replacement therapy in men on active surveillance for prostate cancer. The Journal of Sexual Medicine, 22(3), 432–438. https://doi.org/10.1093/jsxmed/qdaf003  

Gender-affirming surgery is available to support transgender individuals in aligning their physical characteristics with their gender identity and alleviating gender dysphoria. Gender dysphoria occurs when an individual feels distressed by a disconnect from their own body due to their gender identity not aligning with their sex assigned at birth. For transgender women, gender-affirming surgery may consist of breast implants, facial feminization surgery, or vaginoplasty, and often all of them together.

Circumcision, where the foreskin of the penis is surgically removed, is an extremely common procedure performed in both pediatric and adult urology practices. Outside of religious reasons (common among pediatric patients), adults may choose to be circumcised for a variety of other reasons such as visual aesthetic, penile cancer, and to prevent infections.

Urinary tract infections (UTIs) occur when bacteria enter the urinary system through the urethra and spread to the bladder. Most UTIs remain in the bladder, but if they reach the kidneys, it can become a more serious health concern. Common symptoms include a burning sensation while urinating (dysuria), cloudy or pink urine, and frequent urges to urinate, regardless of bladder fullness. Over half of all women will experience at least one UTI in their lifetime, and up to 2.8% will develop recurrent UTIs (rUTIs), defined as three or more UTIs in a year or two or more within six months. Roughly 60% of rUTIs are linked to sexual activity, which may introduce bacteria into the urethra, while others result from hormonal changes due to menopause.

Artificial intelligence (AI) has allowed for a multitude of improvements in medicine. Particularly, in the field of urology, AI has been used extensively in the processes of diagnosis, treatment planning, assessing the effectiveness of surgeries, and more. Beyond that, AI has been integrated into a variety of medical fields for diagnosis, education, and patient care. Perhaps with further analysis as to the effectiveness and ethics of AI, sexual health may be able to reap the benefits as well.

Vulvodynia is a chronic condition that affects the vulva with no clear cause, causing pain, burning, or irritation that lasts at least three months. Researchers believe that the development of pain-related systems in those diagnosed with vulvodynia may be caused by alterations in the central nervous system and the peripheral nervous system. Specifically, previous research suggests the pain experienced from vulvodynia is a result of central sensitization, which is the hypersensitivity of areas in the brain that are responsible for acute pain processing.

Temporomandibular disorders (TMDs) revolve around chronic pain and other clinical conditions affecting the temporomandibular joint (TMJ), the muscles involved in chewing (mouth and jaw muscles), and other structures in that region. These disorders affect around 31% of adults and can present as pain in the TMJ, limited jaw movement (lock jaw), cracking or popping noises within the joint during jaw function, and more.

According to a 2024 empirical study, there are almost no other studies pertaining to the implications of TMDs in regard to sexual health or sexual functioning. However, this research review did highlight some key aspects of TMD in relation to sexual health based mostly on patient testimonies and patient educational resources.

Peyronie’s disease (PD) is a disorder in the penile tunica albuginea, which is just under the skin of the penis and surrounds the tissue that creates and maintains erections. It can cause penile deformity, namely curvature, and pain, and can negatively impact quality of life. This could be due to curvature severity, loss of length or girth, and even erectile dysfunction (ED). ED is quite common in patients with PD, ranging from 31.5% - 54.4% of patients in existing literature.

Multiple sclerosis (MS) is categorized as a progressive chronic inflammatory disorder that negatively impacts both physical and mental health, with around 2.8 million individuals affected globally. It has been found that sexual dysfunction occurs in males with MS (MwMS) nine times more frequently than with any other neurological disease. In fact, many MwMS see sexual dysfunction as the most detrimental part of their disease, which then negatively impacts other aspects of their health and quality of life. It has been suggested in previous research that a combination of psychological, physical, and social factors may contribute to the onset of sexual dysfunction. Namely, the presence of disability, depression, anxiety, fatigue, and hormonal imbalances can cause erectile dysfunction.

Beta blockers, most commonly used for heart problems and hypertension (low blood pressure), have notoriously been problematic for the erectile function of biological males, often increasing the risk of erectile dysfunction (ED), which is defined as the inability to maintain an erection long enough to engage in a satisfactory sexual experience and is a common issue in male sexual medicine.

Provoked vulvodynia is pain felt in the vulva for at least three months without a known cause. This can be triggered by touch or pressure in the vulva, possibly from both sexual and non-sexual stimuli. According to a 2019 study, about 10% of individuals across Europe are affected by provoked vulvodynia, which often results in pain during intercourse.