Illustrative story · A fictional composite written for education. It does not describe a real patient or a reported treatment result.
Erectile dysfunction
When erections become unpredictable
He is in his early fifties and has had high blood pressure for a few years. Over the past year, his erections have become less firm, and sometimes he loses them before intercourse. A friend suggested a tablet, which he bought without a prescription. It worked on some occasions and not others, and he felt uneasy taking something no doctor had checked.
Slowly, he started avoiding intimacy, saying he was tired. His wife began to wonder whether something was wrong between them. He hasn’t mentioned it to his family doctor; it feels too personal, and he isn’t sure whether it is just age.
Read more: assessment, options and what to know
What a specialist may look at
- How and when the change started, whether morning erections still occur, and whether the problem happens in every situation.
- General health: blood pressure, blood sugar, cholesterol, weight, smoking, alcohol, sleep and stress.
- Current medicines, as some can affect erections.
- A short, validated questionnaire to describe erectile function clearly.
- Blood tests where appropriate, such as blood sugar or HbA1c, cholesterol, and an early-morning testosterone level.
- A physical examination, which needs an in-person visit.
Possible pathways options to discuss, not a predicted result
- Improving heart and blood-vessel health (activity, weight, stopping smoking, sugar and blood-pressure control), which matters for erections as well as overall health.
- Prescription oral medicines, with guidance on how to take them correctly and safely.
- Vacuum erection devices.
- Medicines given by injection into the penis or placed in the urethra, taught carefully by the specialist.
- Psychosexual counselling, alone or alongside medical treatment, with the partner involved if both wish.
- For some men, when other options are unsuitable or unsatisfactory, a penile implant (see the last story).
Current guidelines support choosing among these together, based on your health, preferences and priorities, rather than following a rigid sequence. Some newer treatments, such as low-intensity shockwave therapy, have limited or evolving evidence and guidelines differ on them. Others, such as platelet-rich plasma (PRP) or stem-cell injections, are still considered experimental. If these come up, the uncertainties are discussed openly.
Worth knowing
- Erection problems can sometimes be an early sign of blood-vessel or heart disease. That is a reason to look at your overall health, not just the symptom.
- Some erection medicines are dangerous when taken with nitrate medicines used for chest pain. Take them only on a doctor’s prescription.
- Some “herbal” or “power” products sold for sexual performance have been found to contain undeclared prescription drugs.
- Don’t stop blood-pressure or other prescribed medicines on your own; discuss any concerns first.
Online or in person?
History, reports, test planning and options can be discussed online. Physical examination and procedures happen in person.
Questions you might bring
Could my blood-pressure medicine be involved? Which tests do I actually need? What are the side effects of each option?
Illustrative story · A fictional composite written for education. It does not describe a real patient or a reported treatment result.
Low libido & low testosterone
When desire fades and energy dips
He is in his mid-forties, with a demanding job. For about eighteen months he has had little interest in sex. He feels tired most afternoons, has gained weight around his waist, and his wife says he snores heavily. He notices fewer morning erections.
An online advertisement promised that a “testosterone booster” would restore his energy, and someone at his gym suggested testosterone injections. He is tempted, but he and his wife are also hoping to have a second child.
Read more: assessment, options and what to know
What a specialist may look at
- Desire, erections, energy, mood, sleep, weight, alcohol, stress and the relationship. Low desire has many possible causes.
- Medicines that can lower desire or hormone levels.
- Testosterone measured on two separate mornings. Levels vary through the day and from day to day, so a single test is not enough to diagnose deficiency.
- If testosterone is low, further hormone tests (such as LH, and prolactin where relevant) to understand why.
- Before any testosterone treatment, a blood count and, where appropriate for age, a prostate blood test (PSA).
- Whether you plan to have children, which is central to choosing a treatment.
Possible pathways options to discuss, not a predicted result
- If testosterone is normal, other causes are explored: sleep, mood, stress, the relationship, medicines and general health.
- If a specific cause is found, such as a hormone imbalance from the pituitary gland, it is addressed directly.
- Weight loss, regular exercise and treatment of sleep apnoea may help hormone levels and energy in some men.
- Testosterone therapy may be considered when deficiency is confirmed and symptoms are present, and when fathering a child isn’t planned. It needs regular monitoring of hormone levels, blood count and PSA.
- For men who want to preserve fertility, other medicines that encourage the body’s own testosterone production may be discussed in selected cases. Some are used outside their original licensed indication, and this is explained.
Worth knowing
- Testosterone therapy, anabolic steroids and similar products can reduce or stop sperm production. Recovery after stopping may take months and is not guaranteed.
- “Testosterone booster” supplements generally lack good evidence, and some products contain undeclared substances.
- Low testosterone is diagnosed from symptoms and repeated blood tests together, never from an online checklist.
Online or in person?
History, test planning, report review and treatment discussion can happen online. Examination, if needed, is in person. Whether a particular medicine can be prescribed after an online consultation depends on the clinical situation and India’s telemedicine rules.
Questions you might bring
Is my tiredness definitely hormonal? How would treatment affect our plans for another child? How often would I need monitoring?
Illustrative story · A fictional composite written for education. It does not describe a real patient or a reported treatment result.
Male infertility
When pregnancy doesn’t happen and attention falls on one partner
He and his wife, in her early thirties, have been trying to conceive for about eighteen months. She has already had several tests, and at family gatherings the questions are mostly directed at her.
He assumed that because sex and ejaculation feel normal, his fertility must be fine. When the gynaecologist asked for a semen analysis, the report showed a low sperm count and reduced movement. He felt embarrassed, searched online, and found frightening and contradictory information.
Read more: assessment, options and what to know
What a specialist may look at
- How long you have been trying, sexual frequency and timing, and both partners’ history.
- Past illnesses (such as mumps affecting the testes), surgery, medicines, smoking, alcohol, heat exposure, and any use of testosterone or bodybuilding steroids.
- A repeat semen analysis if the first is abnormal, after the recommended 2–7 days of abstinence, in a reliable laboratory. One abnormal report is not a final diagnosis.
- Examination of the testes and scrotum, for example for a varicocele (enlarged veins) and testis size. This must be done in person.
- Hormone tests, and an ultrasound when indicated.
- Genetic tests for men with a very low or zero sperm count, where guidelines recommend them.
Possible pathways options to discuss, not a predicted result
- Stopping smoking, limiting alcohol, keeping a healthy weight, avoiding excess heat, and stopping any testosterone or steroid use.
- Treating identifiable causes, for example repair of a varicocele that can be felt on examination when semen results are abnormal, or medication for specific hormone problems.
- If no sperm are found in the semen: further tests and, in selected men, surgical sperm retrieval combined with IVF/ICSI.
- Coordinating with your partner’s gynaecologist or fertility specialist, so neither partner’s assessment is delayed and decisions take both of you into account.
Worth knowing
- In around half of couples facing infertility, a male factor contributes. Assessing both partners together is standard practice.
- Normal erections and ejaculation don’t tell you anything about sperm quality.
- Sperm take about three months to develop, so changes from lifestyle or treatment take time to show in results.
- Male infertility can occasionally point to other health problems worth checking, which is one more reason for a specialist assessment.
Online or in person?
Reviewing reports, explaining results and planning tests can begin online. Examination, ultrasound and procedures are in person.
Questions you might bring
Should I repeat the test, and where? Is a varicocele relevant for us? How does my result affect our options as a couple?
Illustrative story · A fictional composite written for education. It does not describe a real patient or a reported treatment result.
Chronic pelvic pain (CP/CPPS)
When pelvic pain keeps returning despite treatment
He is in his mid-thirties. For about a year he has had an aching pain between the scrotum and the back passage, discomfort in the lower abdomen, and pain after ejaculation. He passes urine often, and long hours sitting at his desk make it worse.
He has taken several courses of antibiotics from different clinics; each helped briefly, or not at all. He worries it might be cancer, or an infection he could pass to his wife. He is sleeping poorly, feels anxious, and nobody has given him a clear explanation.
Read more: assessment, options and what to know
What a specialist may look at
- A detailed picture of the pain: where it is, what triggers it, and how it affects urination, sex, sleep, mood and work. A validated symptom score may be used to track it.
- Urine tests and cultures, sometimes taken before and after a prostate examination, to check properly for infection.
- Tests to rule out other conditions where relevant, for example sexually transmitted infections, blood in the urine, and urine flow and bladder emptying.
- Examination of the abdomen, genitals, prostate and pelvic floor muscles, which are often tender or tight. This is done in person.
- Mapping which areas contribute in your case (urinary, muscular, psychological, sexual, nerve-related or infection), because the plan is built around them.
Possible pathways options to discuss, not a predicted result
- A clear explanation of the condition, which is often helpful in itself.
- A combined plan suited to your symptom pattern, which may include pelvic floor physiotherapy, medicines to ease urinary symptoms in some men, medicines that change how nerves process pain, psychological support such as cognitive behavioural therapy, attention to sexual concerns, and acupuncture, which some guidelines include.
- Antibiotics only when there is evidence or a strong suspicion of infection, rather than repeated courses.
Worth knowing
- In most men with these symptoms, no ongoing bacterial infection is found.
- The condition is not contagious and is not considered a precancerous condition.
- The pain is real even when tests are normal. Muscles, nerves and stress can all play a part.
- Symptoms often fluctuate. The aim of treatment is to reduce symptoms and improve daily life, and progress is usually gradual.
Online or in person?
History, report review and an initial plan can begin online. Examination, including the pelvic floor and prostate, is in person, and pelvic floor physiotherapy is arranged locally.
Questions you might bring
Do I really need more antibiotics? Is my partner at any risk? Which parts of the plan can I start myself?
Illustrative story · A fictional composite written for education. It does not describe a real patient or a reported treatment result.
Peyronie’s disease
When the penis begins to curve
He is in his late fifties and has diabetes. A few months ago he noticed that his erections had started to bend upwards and to one side. Erections are sometimes painful, and he can feel a firm lump along the shaft. Intercourse has become difficult.
He is frightened the lump might be cancer. Online he has found creams, oils and vitamin capsules that promise to “straighten” the penis, and he is too embarrassed to raise it with his regular doctor.
Read more: assessment, options and what to know
What a specialist may look at
- Whether the condition is still active or has become stable. Pain and a curve that keeps changing suggest the active phase; a curve unchanged for at least about three months suggests the stable phase.
- Examination of the plaque (the firm area of scar tissue) and of penile length. This is done in person.
- Erection quality, since erectile difficulty is common alongside Peyronie’s disease.
- Before any procedure, measuring the curve during an erection produced in the clinic, sometimes with an ultrasound scan.
Possible pathways options to discuss, not a predicted result
- If the curve doesn’t interfere with sex, treatment may not be needed; monitoring is a reasonable choice.
- In the active phase: pain relief and monitoring. A penile traction device may help some men.
- Injections into the plaque may be considered for selected men. Availability of some of these medicines in India may be limited, and this is discussed honestly.
- Once the condition is stable, if the curve makes intercourse difficult: surgery to straighten the penis (by shortening the longer side, or by grafting), or a penile implant if erections are also poor.
Worth knowing
- Peyronie’s disease is a benign scarring condition. It is not cancer and it is not infectious.
- In many men the curve stops changing, although it doesn’t usually disappear on its own.
- The AUA advises against most oral supplements and vitamins for Peyronie’s disease, because evidence of benefit is lacking.
- Avoid forceful bending, massage or unproven creams.
- Feeling low or anxious about the condition is common and worth talking about.
Online or in person?
History and early guidance can begin online. Examination and curvature assessment need an in-person visit. Please don’t send photographs on WhatsApp; if photos would help, you’ll be told how to share them securely.
Questions you might bring
Is my condition still active? Is waiting reasonable? What could surgery change, and what are its risks?
Illustrative story · A fictional composite written for education. It does not describe a real patient or a reported treatment result.
Penile implants
When other treatments haven’t been suitable
He is in his early sixties and has had diabetes for many years. His erection problem has gradually worsened. Tablets no longer help much. Injections worked, but he found them uncomfortable and felt they took away all spontaneity.
His wife is supportive, but both feel frustrated. A relative mentioned an “operation” for erections. He is hopeful and anxious at once: is it major surgery, will it look different, will anyone know?
Read more: assessment, options and what to know
What a specialist may look at
- Which treatments have been tried, how they were used, and why they didn’t suit him. Sometimes an option is worth revisiting first.
- Overall fitness for surgery and anaesthesia.
- Diabetes control, since blood sugar affects the risk of infection.
- Any curvature, scarring or previous surgery.
- What both partners expect and hope for.
- A physical examination, which is done in person.
Possible pathways options to discuss, not a predicted result
- Revisiting less invasive options if they haven’t been fully tried.
- Inflatable implants: fluid-filled cylinders with a small pump inside the scrotum, allowing a softer resting state and a firm state.
- Malleable (semi-rigid) implants: bendable rods that are simpler to use but always remain firm.
- Implant surgery is a hospital procedure. The device is used only after healing, usually some weeks later, with instruction.
Worth knowing
- The implant is placed entirely inside the body and is not usually visible to others.
- In most men, sensation, orgasm and ejaculation are not changed by the implant itself.
- The decision is irreversible. Once an implant is placed, natural erections and other erection treatments usually no longer work.
- An implant doesn’t make the penis longer, and some men perceive it as shorter.
- Risks include infection, mechanical failure and the need for further surgery.
- Costs vary with the device and hospital; ask for an itemised written estimate.
Online or in person?
An online consultation is a good place to understand the options and ask questions. A decision about surgery is made only after in-person assessment and counselling, ideally with your partner.
Questions you might bring
Which type might suit me? What does recovery involve? How would my diabetes affect the risks?
