What should I do about testicular atrophy and erectile dysfunction with normal sperm count and testosterone levels?

Testicular Atrophy and Erectile Dysfunction with Normal Laboratory Values

You need immediate scrotal ultrasound to measure precise testicular volumes and assess testicular architecture, followed by measurement of FSH, LH, prolactin, and estradiol to identify occult endocrine dysfunction that standard testosterone testing may miss. 1

Understanding the Disconnect Between Symptoms and Laboratory Values

Your situation presents a critical diagnostic challenge: physical testicular atrophy and erectile dysfunction despite apparently normal testosterone (42 nmol/L, approximately 1210 ng/dL) and excellent sperm count (100 million/mL). This disconnect suggests several possibilities that require systematic investigation.

Why Current Sperm Count May Be Misleading

• Sperm production reflects testicular function from 2-3 months ago, not current function, since the complete spermatogenesis cycle takes 64-74 days. 2 Your current excellent sperm count represents what your testes were producing when they were potentially larger and healthier.

• Testicular atrophy may be recent or progressive, meaning the impact on sperm production won't appear in semen analysis for another 2-3 months. 2

• You need repeat semen analysis in 2-3 months to determine if the testicular shrinkage is actually affecting sperm production. 2

Essential Immediate Workup

Imaging Studies

Scrotal ultrasound is mandatory to objectively quantify testicular volumes and assess internal architecture. 1 Physical examination with orchidometer provides estimates, but ultrasound is superior for:

• Precise volume measurement (normal testicular volume >15 mL; reduced <12 mL) 3
• Detection of testicular microcalcifications, which occur in 18-fold higher rates in men with testicular dysfunction and increase cancer risk 1
• Assessment of testicular homogeneity versus dysgenetic patterns 1
• Identification of occult testicular tumors, as infertile men have 1.91 times higher risk of testicular cancer 1

Comprehensive Hormonal Evaluation

Your testosterone level alone is insufficient. You require a complete hormonal panel including: 1

• FSH (follicle-stimulating hormone): Elevated FSH >7.6 IU/L indicates impaired spermatogenesis and can detect testicular dysfunction before sperm count declines. 1, 4 This is the most sensitive early marker of testicular failure.

• LH (luteinizing hormone): Low or low-normal LH with your symptoms suggests possible pituitary dysfunction. 1

• Prolactin: Men with low/normal LH must have prolactin measured to screen for prolactinomas or other pituitary tumors. 1 Elevated prolactin can cause both testicular atrophy and erectile dysfunction.

• Estradiol: Elevated estradiol can cause erectile dysfunction and should be measured in all men with ED. 1

• Sex hormone-binding globulin (SHBG): Your total testosterone may be normal, but if SHBG is elevated, your free (bioavailable) testosterone could be low, explaining erectile dysfunction despite normal total testosterone. 4

Critical Pituitary Evaluation

If your testosterone is truly >1000 ng/dL (42 nmol/L) with testicular atrophy, this is paradoxical and concerning. 1

• Men with testicular atrophy typically have LOW testosterone, not high testosterone. 1
• High testosterone with testicular atrophy suggests exogenous testosterone use (which causes testicular shrinkage) or a testosterone-secreting tumor. 5
• If total testosterone is <150 ng/dL with low/normal LH, you need pituitary MRI regardless of prolactin levels to exclude non-secreting pituitary adenomas. 1

Erectile Dysfunction Evaluation

Cardiovascular Risk Assessment

Erectile dysfunction is a sentinel marker for cardiovascular disease and should trigger comprehensive cardiovascular evaluation. 1

• Measure blood pressure, waist circumference, BMI, and obtain fasting lipid panel and glucose. 1
• Obtain resting electrocardiogram. 1
• ED often precedes cardiovascular events by 3-5 years; addressing cardiovascular risk factors improves both cardiac and erectile outcomes. 1

Testosterone's Role in Erectile Function

• Testosterone is essential for erectile function, and even "normal" levels may be insufficient for some men. 6 Testosterone increases nitric oxide synthase and PDE5 expression, both critical for erections. 6

• 36% of men presenting with sexual dysfunction have hypogonadism, and testosterone deficiency is a common cause of PDE5 inhibitor failure. 1

• If you've tried PDE5 inhibitors (sildenafil, tadalafil) without success, this strengthens the indication for comprehensive hormonal evaluation including free testosterone. 1, 6

Differential Diagnosis to Exclude

Testicular Cancer

• Testicular atrophy with normal sperm count is unusual and raises concern for space-occupying lesions. 1
• Ultrasound is essential to exclude testicular tumors, which can present with atrophy of surrounding normal tissue. 1

Varicocele

• Can cause progressive testicular atrophy and erectile dysfunction. 1
• Diagnosed on physical examination (palpable dilated veins) and confirmed by ultrasound. 1
• Treatment improves fertility in men with clinical varicocele and abnormal semen parameters. 1

Klinefelter Syndrome or Other Genetic Disorders

• If FSH is elevated (>7.6 IU/L) with testicular atrophy, karyotype testing is indicated to exclude Klinefelter syndrome (47,XXY). 1
• Klinefelter presents with small firm testes, elevated FSH, and variable testosterone levels. 1

Cryptorchidism History

• History of undescended testicles increases risk of testicular cancer 3.6-7.4 fold and causes progressive testicular dysfunction. 1
• Even corrected cryptorchidism carries ongoing risks requiring surveillance. 1

Management Algorithm

Immediate Actions (Week 1)

1. Scrotal ultrasound with testicular volume measurement 1
2. Comprehensive hormonal panel: FSH, LH, prolactin, estradiol, SHBG, free testosterone 1, 4
3. Cardiovascular risk assessment: BP, lipids, glucose, ECG 1
4. PSA if over age 40 1

Follow-up at 2-3 Months

1. Repeat semen analysis to assess impact of testicular atrophy on sperm production 2
2. Repeat hormonal evaluation to establish patterns 2
3. Reassess testicular volumes to determine if atrophy is progressive 2

Specialist Referrals Based on Findings

• Endocrinology referral if: Elevated prolactin, abnormal LH/FSH patterns, or paradoxically high testosterone with atrophy 1
• Urology referral if: Testicular masses, severe atrophy, or abnormal ultrasound findings 1
• Male reproductive specialist if: FSH >10 IU/L or progressive decline in testicular function 4
• Cardiology evaluation if: Significant cardiovascular risk factors identified 1

Common Pitfalls to Avoid

• Do not assume normal testosterone and sperm count exclude significant pathology. Testicular atrophy with these findings is paradoxical and demands investigation. 1

• Do not wait for sperm count to decline before investigating. By the time sperm count drops, you've lost 2-3 months of testicular function. 2

• Do not treat erectile dysfunction with PDE5 inhibitors alone without hormonal evaluation. Testosterone deficiency causes PDE5 inhibitor failure in many men. 1, 6

• Do not dismiss testicular atrophy as "normal variation." Progressive testicular atrophy always warrants investigation for malignancy, endocrine disorders, or vascular pathology. 1, 3