Men’s Health & Andrology Center
The arteries that fill an erection are narrower than the ones feeding the heart, so they silt up first. The tablet is often right. It is rarely the whole answer.
About This Center
The arteries that fill an erection are narrower than the arteries that feed the heart. Narrow vessels silt up before wide ones do, which means that in a great many men an erection problem is the first symptom of a circulatory disease that has not yet reached the chest, and which is why the appointment is worth making rather than putting off for another two years. A service that hands over a tablet and closes the file has treated the least important thing the man came in with.
Often the tablet is the right answer. It is almost never the whole answer. Both halves matter.
Free consultation
Tell us how it started, and send any blood results you hold
The single most useful thing you can tell us is whether the change came on gradually over months or suddenly, since a gradual decline points towards blood vessels and nerves while an abrupt change more often points elsewhere. Say whether morning erections still occur, because that one answer separates several possibilities before any test is done. Send whatever bloods you have, particularly glucose or HbA1c, cholesterol, testosterone with the time of day it was taken, and any kidney or liver results. List every medication and every supplement, including anything bought online, since blood pressure drugs, antidepressants and some prostate medications all affect this and so does anything containing testosterone. Tell us whether you smoke, how much you drink, and whether you hope to father children, because that last question changes the treatment more than almost anything else on this page.
The erection as a signal
An erection is a vascular event. Blood arrives faster than it leaves, the tissue expands, and the mechanism depends on arteries widening on demand and on the lining of those arteries releasing the chemical that tells them to. That lining is the first thing damaged by high blood sugar, by smoking, by high cholesterol and by high blood pressure, and the vessels supplying the penis are smaller in calibre than the coronary arteries. The consequence is a matter of plumbing. A given amount of narrowing produces a noticeable effect in a small vessel long before it produces one in a larger vessel. So the man who notices that erections have become less reliable over the past two years is frequently reporting the earliest usable symptom of a process that will eventually present as chest pain or worse, and he is reporting it at a point where something can still be done about it. That timing is the opportunity.
This is not an argument for alarm.
It is an argument about what the appointment is for. A consultation that establishes the diagnosis, writes a prescription and ends there has answered the question asked and ignored the question implied. A consultation that also checks blood pressure, blood sugar, cholesterol and weight, and acts on what it finds, has used a symptom most men are reluctant to raise as the entry point to the rest of their health. That is the whole argument for a men's health service existing as a service rather than as a prescription counter. Ask what else was checked.
What the assessment looks for
Andrology assessment is mostly conversation and blood tests, and the tests are chosen by what the conversation found. Each of the following changes something. Nothing here is filler.
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| What is checked | What it can reveal, and what changes as a result |
|---|---|
| Glucose and cholesterol | Undiagnosed diabetes and undiagnosed high cholesterol are found regularly in men attending for this complaint, and finding either changes what happens next far more than the erectile treatment does. Blood pressure is measured at the same appointment for the same reason. |
| Morning testosterone | Measured before nine in the morning and repeated on a second day before anything is concluded, since levels swing widely and a single afternoon sample means little. Where it is genuinely low, the pituitary hormones are checked as well, because the cause changes the treatment. |
| The medication list | Some blood pressure drugs, most antidepressants, certain prostate medications and anything containing testosterone all affect this directly. A drug that can be swapped is the cheapest and fastest intervention available and it is missed whenever nobody asks for the whole list. |
| Sleep, mood and relationship | Sleep apnoea, depression, work stress and difficulties within a relationship all produce the same complaint and none of them responds to a vascular treatment. Asking about them is part of the assessment and no preliminary to it. |
| Examination and, when indicated, ultrasound | Examining the testes and the penis finds varicocele, small testes, plaques from Peyronie disease and occasionally a testicular lump that nobody was looking for. Ultrasound of the penile blood flow is used when the answer would change the treatment, and never as a routine. |
Treatment, and what else it does
Tablets that treat erectile dysfunction work by amplifying the same signal the artery lining sends when it wants a vessel to widen. They are effective, they are well tolerated and they have been in use long enough that their safety profile is well understood.
What is less widely known is that their effect does not stop at the pelvis. That part is newer.
What a daily tablet did to the heart rhythm
Eighty-two men with a mean age of 47 and non-organic erectile dysfunction took daily tadalafil and were assessed with twenty-four hour heart monitoring before and after. Erectile scores improved from 15 to 23 and 74.4 percent met the threshold for early response. Measures of heart rate variability, which reflect how well the nervous system regulates the heart, improved across the group, with the standard deviation of heart intervals rising from 42.39 to 52.39 milliseconds and the balance between the two arms of the autonomic nervous system shifting favourably. The striking part is that these changes appeared equally in the men whose erections improved and in those whose erections did not, which suggests the drug is doing something to autonomic regulation independently of its effect on erection. Only 1.1 percent stopped the treatment, and the reason was indigestion. The study had no placebo group and ran for only 28 days, so it points at a mechanism without proving one.
That finding sits neatly on top of the argument this page began with. A treatment aimed at one symptom appears to be acting on the same vascular and autonomic machinery that underlies the wider problem.
It is not a reason to take a tablet you do not need, and it is a reason to stop thinking of the treatment as cosmetic. It is not a lifestyle drug.
Where tablets fail or cannot be used, the ladder continues.
- Vacuum devices, which work mechanically, cost nothing to try and suit some men very well once somebody has shown them how.
- Injections into the penis, self-administered, which are highly effective and which most men have never had explained to them properly by anybody.
- A penile implant, where nothing else works, which is a reliable operation with high satisfaction in properly selected men and a considered decision rather than a last resort taken in haste.
- Shockwave therapy, which is advertised widely and whose evidence remains weaker than its marketing, so we set out what is known and do not lead with it.
Testosterone, honestly
Two things are true about testosterone treatment at the same time, and most of what is written about it picks one and ignores the other. Both belong in the same conversation.
The first is that it is safer than a decade of anxiety suggested.
A European expert panel reviewed the evidence including the large randomised placebo-controlled TRAVERSE trial and concluded that testosterone therapy does not significantly increase the risk of major adverse cardiovascular events. The same review noted a useful secondary benefit in correcting anaemia. Their consensus was that the treatment is safe from a cardiovascular standpoint when prescribed to appropriately selected patients and monitored regularly, with particular attention to the blood count, and that treatment plans should be individualised.
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| Approach | How it works, and what it costs you |
|---|---|
| Testosterone from outside | Gel, injection or pellet. Effective at raising the level in the blood and at relieving symptoms in genuinely deficient men. It switches off the brain signal to the testes, so sperm production falls and in some men stops altogether. Wrong choice for a man who wants children. |
| Stimulating the testes instead | Human chorionic gonadotropin, or a selective oestrogen receptor modulator, works by pushing the man's own production upward rather than replacing it. Testosterone rises and sperm production is preserved or restored. This is the route for anybody whose family is not complete. |
| Treating the cause first | A large proportion of low readings in men under fifty are functional, meaning driven by obesity, untreated sleep apnoea, alcohol, opioid medication or poorly controlled diabetes. Correcting those raises the level without any hormone at all, and it is tried before treatment is started. |
| Sperm storage beforehand | Where testosterone from outside is genuinely the right treatment and children may still be wanted, freezing a sample first costs one appointment and removes the worst outcome entirely. It is offered as a matter of course and declined by many, which is fine as long as it was offered. |
Read the qualifying clause rather than the headline. Appropriately selected, and monitored regularly. That is the part the clinics dispensing testosterone on the strength of one afternoon blood test and a symptom questionnaire have quietly dropped, and it is the part that makes the safety finding true.
Least often mentioned to a man in his thirties is the second truth.
Testosterone given from outside switches off the signal from the brain that tells the testes to work. A review of what it describes as a pandemic of testosterone abuse sets out the consequences, which are suppression of the hypothalamic-pituitary-gonadal axis, a fall in the testosterone concentration inside the testis itself, impaired sperm production, shrinkage of the testes and, in a proportion of men, complete absence of sperm in the ejaculate. It adds that chronic use causes oxidative stress and DNA damage in sperm cells. Most importantly, recovery of fertility after stopping is often prolonged and in many cases incomplete.
What the review actually describes
A 2025 review of what its authors call a pandemic of testosterone abuse sets out the mechanism in order. Testosterone taken from outside suppresses the hypothalamic-pituitary-gonadal axis. The concentration of testosterone inside the testis itself falls, even while the level in the blood rises, and that internal concentration is what sperm production depends on. Spermatogenesis is impaired, the testes shrink, and in a proportion of men no sperm at all appear in the ejaculate. Chronic use additionally causes oxidative stress and DNA damage within sperm cells. Recovery after stopping is often prolonged and, the authors state, in many cases incomplete. Management involves stopping, then pharmacological treatment with human chorionic gonadotropin or selective oestrogen receptor modulators, and assisted reproduction where infertility proves refractory.
So the question that should be asked before any prescription is written is whether the man wants children, now or ever. Where the answer is yes, or is uncertain, there are treatments that raise testosterone without shutting down the testes, and the review names the pharmacological options used to restore function afterwards including human chorionic gonadotropin and selective oestrogen receptor modulators. Where that conversation has not happened before treatment starts, it happens later under much worse circumstances. Ask the question early.
When the problem is fertility
Roughly half of couples having difficulty conceiving have a male factor contributing to it, and yet the man is frequently the last person in the pair to be examined properly, sometimes after his partner has already been through several rounds of investigation. The starting point is a semen analysis, and it needs repeating, because a single sample varies enough that decisions built on one result are built on sand. A physical examination follows, along with hormone tests, and in the right circumstances genetic testing. Varicocele, meaning enlarged veins draining the testis, is the commonest correctable cause and the question of whether repairing it helps has been argued about for years. A systematic review and meta-analysis addressed a specific version of that question, which is whether repair before assisted reproduction changes the outcome. Nine observational studies were included, and the answer divided by technique. For intrauterine insemination there was no difference in clinical pregnancy, at an odds ratio of 1.01. For intracytoplasmic sperm injection, men who had undergone repair beforehand showed a significantly higher fertilisation rate, a higher clinical pregnancy rate at an odds ratio of 1.38, and a higher live birth rate at an odds ratio of 2.07.
Those authors were careful about their own conclusion, noting that all nine studies were observational, that sample sizes were small and populations heterogeneous, and that larger prospective studies are needed. Taken with that caution, it says something practical. A man being sent to assisted reproduction with an untreated varicocele may be being sent one step too early, and the question of whether repair first would improve the odds deserves asking before the cycle is booked. Sequence matters here.
The other things men come with
Erections and fertility are the two headings that bring most men through the door, and several other conditions belong in the same service because they are managed by the same people. One appointment, not three.
Premature ejaculation is common, responds well to a combination of medication and behavioural technique, and is frequently left untreated because nobody raises it. Peyronie disease, meaning a plaque of scar tissue causing curvature and often pain, is treated differently in its early inflammatory phase than in its later stable one, so the timing of the assessment matters a great deal.
Lower urinary tract symptoms from prostate enlargement overlap with sexual symptoms, and some of the drug treatments themselves affect ejaculation, which is worth knowing before starting them. Testicular pain and lumps are examined promptly and imaged the same day, since a painless lump in a young man is the presentation nobody should be waiting on.
Vasectomy and vasectomy reversal both belong in a service that also handles fertility, since the decision and the reversal are two ends of one conversation.
The connecting thread is that these problems overlap. A man with prostate symptoms, poor erections and low mood has one appointment, not three, and treating any of the three in isolation risks making another worse. They travel together.
What we do not offer
Any page describing a men's health service in this part of the world has to address penile enlargement, because it is advertised heavily and men arrive having read about it. The honest position is worth setting out plainly.
A review in the urological literature surveys the whole history of the field, from ancient methods through to current techniques, meaning injectable fillers and grafting for girth, and ligament release, penile disassembly and sliding elongation for length.
Its conclusion is the sentence that matters.
While these strategies can significantly increase length or girth, complications remain a concern, and so do inconsistent psychological outcomes and patient satisfaction, even after measurable gains in size. Read that twice.
Read that carefully, because it is not the usual objection. It is not merely that the operations carry risk. It is that men whose measurements demonstrably improved were frequently still not satisfied, which tells you the dissatisfaction was rarely about the measurement in the first place. A high proportion of men seeking these procedures have anxiety about a body that falls within the normal range, and an operation performed on a normal organ to treat a perception is a poor exchange. So we measure, we explain what the normal range actually is, and we offer a psychological consultation to men for whom that conversation is the treatment. Where a genuine anatomical problem exists, meaning Peyronie disease with significant curvature, buried penis, or the reconstructive needs that follow trauma or cancer surgery, that is different and is treated surgically. Cosmetic enlargement of a normal organ is not something we do, and any unit that offers it without first measuring and without offering that conversation is selling rather than treating. The measurement is not the problem.
What a first visit involves
Men delay this appointment for years, sometimes for a decade, and a good deal of that delay comes from not knowing what will actually happen in the room, which is a reason that disappears once somebody describes it plainly.
A conversation, in a room with a door
Twenty to thirty minutes, covering how the problem started, what still works, medications, alcohol, sleep, mood and whether children are wanted. Nothing here is embarrassing to a urologist and everything here is the diagnosis. A partner is welcome and is often useful.
Examination and blood pressure
Brief, and it includes the abdomen, the pulses in the legs and the testes. Blood pressure and waist measurement are taken because of everything set out at the top of this page. Digital examination of the prostate is done where the symptoms or the age make it relevant, and explained first.
Morning bloods, and a second set
Taken before nine, and testosterone is repeated on a separate morning before any conclusion is drawn from it. Glucose, cholesterol, kidney and liver function and blood count go alongside. Where fertility is the question, semen analysis is arranged and repeated as well.
A plan with two halves
One half treats the symptom you came about. The other half addresses whatever the assessment turned up, which is frequently blood pressure, blood sugar, weight, alcohol or sleep. Both halves are written down, and the second half is the one that changes how long you live.
Where an operation is indicated, meaning a penile implant, a varicocele repair, correction of Peyronie curvature or a vasectomy reversal, it is planned as a separate visit once the assessment is complete. Nothing surgical happens on the first day.
Coming to Istanbul
How long you need to stay in Istanbul depends entirely on what is being done. For assessment and medical treatment alone, three to five days covers the consultation, two separate morning blood draws, imaging where needed and a follow-up appointment to go through the results in person. For a varicocele repair or a vasectomy reversal, seven to ten days. For a penile implant, ten to fourteen, since the early wound and infection risk is the thing being watched and it is not something to manage from another country. A good deal of this can begin before you travel. Send the results you already hold and we will tell you what is missing, and much of the assessment is a conversation that translates well to a video consultation. Where the answer turns out to be a medication swap and a cardiovascular workup, we will say so and you may not need to come at all, which is an outcome we count as a success rather than a lost booking. Not every enquiry needs a flight.
Flying home is straightforward after assessment alone and needs a little planning after surgery, since clot risk is raised by any operation combined with a long flight, so compression stockings are worn, you move about the cabin, and after an implant we clear you to fly rather than leaving it to the calendar.
Discretion is taken seriously and stated plainly.
Appointments are made under your own name in an ordinary urology clinic, correspondence goes only where you direct it, and nothing is sent to an address or an employer without your instruction. Interpreting is arranged in advance in English, Arabic, Russian, French and German. You go home with the full blood results, a written diagnosis, the prescription with doses, and a plan naming which parts your own doctor should follow up and when. Keep the file.
What moves the cost
This field attracts headline offers, and a headline attached to a treatment nobody has yet established you need is not a quotation. What moves the figure is clinical.
- Whether the answer turns out to be medical or surgical, which is not known until the assessment is complete.
- How much of the blood work is done here rather than already available from home to an acceptable standard.
- Whether penile ultrasound with blood flow assessment is needed, or a scan of the testes.
- Whether semen analysis is required, how many samples, and whether genetic testing follows.
- For surgery, which operation, since an implant, a varicocele repair and a vasectomy reversal are entirely different undertakings.
- Which implant device, where one is used, since the models differ mechanically.
- Whether a psychologist or a sexual medicine consultation forms part of the plan.
- Whether treatment of something found incidentally, meaning diabetes, hypertension or sleep apnoea, is arranged here or at home.
Ask any written quotation five questions. Does it include the full assessment or only the treatment. Does it include repeat testosterone and repeat semen testing where those apply. Does it cover treatment of a complication, naming infection of an implant specifically, since that is the one that matters. Does it include the follow-up appointments and for how long. And what happens to the figure if the assessment concludes that the treatment you enquired about is the wrong one.
Units that have a clear answer to that last question is a unit worth dealing with. Ask all five.
Follow-up once you are home
What needs following depends on what was found, and the point of writing it down is that most of it can be done by any doctor anywhere.
Where testosterone treatment was started, the blood count, the testosterone level and the prostate marker are checked at three months, six months and then annually, and the blood count is the one that most often forces a change of plan. Where the assessment found high blood pressure, diabetes or high cholesterol, those are followed on their own schedules and they matter more than the symptom that brought you in. That is the real finding.
Four documents make that practical, and you should leave with all of them.
- The full blood results with the dates and times of the samples, since a testosterone level without a time attached cannot be interpreted by anybody later.
- A written diagnosis naming what was found and what was excluded, which prevents the same tests being repeated from scratch elsewhere.
- The prescription with doses and the monitoring schedule attached to it, particularly where testosterone is involved.
- Where an implant or any device was placed, the manufacturer, the model and the size, which any future surgeon will need and which you will be asked for at airport security.
Our team stays reachable for you and for your own doctor afterwards, and where a result comes back that nobody is sure how to read we would rather interpret it than have it guessed at. Send it over.
Frequently asked questions about men's health and andrology
Why does an erection problem mean my heart needs checking?
Is testosterone treatment safe for the heart?
Will testosterone affect my ability to have children?
Do the daily tablets do anything besides treat the symptom?
Should a varicocele be repaired before fertility treatment?
Do you perform penile enlargement surgery?
Why does testosterone need testing twice?
How long should I plan to be in Istanbul?
Written by the Biruni Hospital medical editorial team.
Reviewed by Dr Yunus Emre Yavuz, Urology and Andrology.
References
- Zitzmann M, Rastrelli G, Murray RD, et al. Cardiovascular safety of testosterone therapy, insights from the TRAVERSE trial and beyond, a position statement of the European Expert Panel for Testosterone Research. Andrology. 2026;14(1):294-302.
- Kumar N, Kakoti S, Chung E. Pandemic of testosterone abuse, considerations for male fertility. Arab Journal of Urology. 2025;23(3):183-189.
- Yıldız G, Kunak T. Daily tadalafil administration improves cardiac autonomic regulation in men with non-organic erectile dysfunction, a prospective heart rate variability study. Sexual Medicine. 2026;14(4):qfag029.
- Palani A, Cannarella R, Saleh R, et al. Impact of varicocele repair on assisted reproductive technique outcomes in infertile men, a systematic review and meta-analysis. The World Journal of Men's Health. 2025;43(2):344-358.
- Moore KT, Fu MZ, Lichtbroun BJ, Leitner DV. Penile enhancement surgery, the short and the long of it. Urology. 2025;197:226-231.
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