Why Clinical Guidelines Matter for Your Health
When you search online for “best urologist near me” or “ED treatment clinic”, you are probably looking for a doctor who will provide the most effective, evidence-based care. But how do you know if a urologist is actually following the best available medical evidence? This is where clinical guidelines come in.
The American Urological Association (AUA) publishes comprehensive guidelines for the management of men’s health conditions including erectile dysfunction (ED), Peyronie’s disease, priapism, male infertility, and ejaculatory disorders. These guidelines are based on systematic reviews of the highest-quality medical research. When a urologist follows AUA guidelines, you can be confident that you are receiving care that has been proven to work.
However, not all urologists follow these guidelines consistently. A new study by Fastenau and colleagues (2025) surveyed urologists in the New York section of the AUA to measure how closely they adhere to evidence-based recommendations for men’s health. The findings reveal important gaps in guideline adherence – gaps that directly affect patient outcomes. The full text is available here: adherence to AUA guidelines study by Fastenau and colleagues (2025)
What the Study Did
The researchers designed an anonymous questionnaire covering five areas of men’s health: erectile dysfunction, Peyronie’s disease, priapism, male infertility, and ejaculatory disorders. For each area, they selected two to four specific AUA guideline recommendations. The survey was sent to 945 members of the New York section of the AUA. A total of 82 urologists responded – an 8% response rate, which is typical for physician surveys.
Of the respondents, 79.2% were male, 57.3% had completed fellowship training, and 51.2% practiced in academic institutions. Fellowship specialties included male infertility/andrology (19.1%), urologic oncology (29.8%), female pelvic medicine (10.6%), pediatrics (10.6%), robotic surgery (10.6%), and others.
The key question for patients is: when you visit a urologist for a men’s health problem, are you getting care that follows the best evidence? The study provides both reassuring and concerning answers.
What Urologists Do Well
The survey found high adherence to AUA guidelines in several important areas.
Erectile dysfunction workup. 89.9% of urologists see patients with ED at least sometimes in their practice. 83.1% check early morning testosterone levels, which is a core AUA recommendation. Testosterone deficiency is a major cause of ED, and identifying it changes treatment men with low testosterone may benefit from replacement therapy rather than (or in addition to) PDE5 inhibitors like sildenafil or tadalafil.
Male infertility evaluation. Among urologists who treat infertility, 84.9% perform semen analysis the cornerstone of infertility testing. 79.2% obtain follicle-stimulating hormone (FSH) and testosterone levels, which help distinguish between testicular failure and hormonal causes of infertility.
Premature ejaculation. 75% of urologists recommend daily selective serotonin reuptake inhibitors (SSRIs) for premature ejaculation. SSRIs are the first-line evidence-based treatment and have been shown in multiple randomized trials to significantly increase intravaginal ejaculatory latency time.
These findings suggest that for common conditions like ED and infertility, most urologists are following the evidence.
Problem Areas: Where Adherence Falls Short
However, the study also identified significant gaps in guideline adherence, particularly for conditions that are less common or where recommendations are based on expert opinion rather than high-level evidence. These gaps matter because they directly affect patient outcomes.
| Subspecialty | ED Guidelines | Peyronie’s Guidelines | Infertility Guidelines | Ejaculatory Disorders |
| Andrology/Male Infertility | High | High | High | High |
| General Urology | Moderate | Low | Low | Moderate |
| Urologic Oncology | Moderate | Low | Low | Low |
| Female Pelvic Medicine | Low | Low | Low | Low |
Source: Fastenau et al. 2025
This table tells an important story. Fellowship-trained andrologists specialists in men’s sexual and reproductive health have high adherence to guidelines across all conditions. General urologists and oncologists, who see men’s health conditions less frequently, have lower adherence, especially for complex conditions like Peyronie’s disease and infertility. For a patient, this means that the type of urologist you see significantly affects whether you receive evidence-based care.
Three Critical Gaps in Guideline Adherence
Key Gaps Identified
- Mental health referral for ED. 42.9% of urologists said they “rarely” refer men with ED to mental health professionals, and 20% said they “never” do. This is despite decades of research showing a strong bidirectional link between ED and depression. ED causes psychological distress, and depression is a direct cause of ED. The AUA guidelines recommend assessment of psychological factors and referral when indicated. Patients who do not receive mental health support may have worse outcomes from ED treatment.
- Diagnostic testing for Peyronie’s disease. Half of urologists (50%) “never” perform an in-office intracavernosal injection test for Peyronie’s disease. This test involves injecting a medication that causes an erection, allowing the urologist to fully assess the penile deformity, plaque, and any pain associated with the erect state. Without this test, patients may receive inaccurate assessments of curvature severity, leading to suboptimal treatment planning. Additionally, 59% of urologists “never” offer oral therapies – which is actually appropriate because vitamin E, tamoxifen, and other oral agents have been shown to be ineffective and are not recommended by the AUA. However, the fact that some urologists still offer these ineffective treatments means patients may waste time and money on therapies that do not work.
- Management of non-ischemic priapism. For non-ischemic priapism (a rare condition where the penis is erect but blood is still flowing normally), 54% of urologists “never” perform Doppler ultrasound during initial evaluation, and 52% “never” offer observation and conservative management – which is actually the correct approach for non-ischemic priapism since it is not a medical emergency. More concerning, 57% “never” offer repeat embolization over surgical ligation for persistent non-ischemic priapism, despite evidence that embolization preserves erectile function in 85% of patients compared to only 50% with surgery. Patients seen by urologists unfamiliar with these guidelines may undergo unnecessary surgery and lose erectile function as a result.
Why Some Urologists Deviate from Guidelines
The study authors offer several explanations for why even well-trained urologists sometimes fail to follow evidence-based recommendations.
Lack of specialized training. Urologists who completed general urology residency but no fellowship in men’s health (andrology) are less comfortable with conditions like Peyronie’s disease, priapism, and infertility. They see these conditions infrequently, so they never develop the routine of performing specific diagnostic tests or offering guideline-recommended treatments. This is reflected in Table 1, where general urologists and oncologists had much lower adherence than fellowship-trained andrologists.
Perceived invasiveness of tests. The intracavernosal injection test for Peyronie’s disease involves an injection into the penis. Some urologists avoid this test because they believe patients will find it too painful or uncomfortable. However, a 2022 study cited by the authors found that patients rate the anticipated pain much higher than the actual pain median pre-injection anticipated pain was 5 out of 10, but post-injection perceived pain was only 1 out of 10. The test is well tolerated, but some urologists still avoid it.
Lack of integrated mental health services. Many urology practices do not have established referral pathways to mental health professionals. Even when urologists recognize that a patient with ED could benefit from psychological support, they may not know who to refer to or may assume the patient will not follow through. This systems-level barrier reduces adherence to the guideline recommendation for mental health assessment in ED.
Disagreement with expert opinion guidelines is another factor influencing adherence. Some AUA recommendations are based on “expert opinion” rather than randomized controlled trials. The evidence for using α1-adrenoreceptor antagonists for premature ejaculation after first-line therapy failure is limited, so many urologists choose not to prescribe these medications. While this is understandable, it does represent deviation from the written guideline.
Three Key Takeaways for Patients Seeking Men’s Health Care
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- Seek fellowship-trained specialists in men’s health (andrology). The study clearly shows that andrology-trained urologists have significantly higher adherence to AUA guidelines for all men’s health conditions not just ED, but also Peyronie’s disease, infertility, and ejaculatory disorders. When searching for “best urologist for ED near me” or “Peyronie’s disease specialist”, look for fellowship training in male reproductive health or sexual medicine.
- Ask about mental health integration. Only 37.1% of urologists in the study “often” or “always” refer ED patients to mental health professionals. A clinic that has established relationships with psychologists or sex therapists and routinely screens for depression and anxiety will provide more comprehensive care. The connection between ED and depression is bidirectional, and treating only the physical aspect without addressing psychological factors leads to worse outcomes.
- Avoid clinics that offer unproven “oral cocktails” for Peyronie’s disease. The AUA guidelines explicitly state that oral therapies such as vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, and L-carnitine are not effective for Peyronie’s disease. Yet 59.3% of surveyed urologists said they “never” offer these treatments meaning 40.7% offer them sometimes, often, or always. If a clinic offers you vitamin E or L-carnitine for penile curvature, they are not following evidence-based guidelines, and you should seek care elsewhere.
Why Guideline Adherence Matters for Patient Outcomes
Guideline adherence is not an abstract academic concept. It directly affects whether you get better.
For ED. A urologist who checks morning testosterone will identify hypogonadism as a cause of ED. Treating low testosterone with replacement therapy may restore erectile function without the need for PDE5 inhibitors, or may make PDE5 inhibitors more effective when used together. A urologist who skips testosterone testing may treat you with sildenafil or tadalafil indefinitely without addressing the root cause.
For Peyronie’s disease. A urologist who performs an intracavernosal injection test will accurately document the degree of curvature, plaque location, and any hourglass deformity. This information guides treatment decisions whether to observe, offer collagenase injections, perform penile plication, or place an inflatable penile prosthesis. A urologist who skips this test may underestimate curvature severity or recommend inappropriate treatment.
For non-ischemic priapism, following guidelines can determine whether erectile function is preserved or lost. A urologist who follows AUA guidelines will offer observation and conservative management initially, with embolization for persistent cases. Embolization preserves erectile function in 85% of patients. A urologist who deviates from guidelines may proceed directly to surgical ligation, which preserves erectile function in only 50% of patients. The difference between following and not following guidelines is the difference between keeping your natural erections and losing them.
How the Fastenau Study Compares to Previous Research
This is the first study to specifically measure adherence to AUA men’s health guidelines. Previous research on guideline adherence in urology has focused on other areas.
A 2019 study from Indonesia (Rahman et al.) examined adherence to benign prostatic hyperplasia (BPH) guidelines and similarly found significant gaps, particularly in preoperative testing and documentation. The authors concluded that educational interventions were needed to improve guideline adherence.
The Fastenau study adds several important insights specific to men’s health. First, it identifies that fellowship training in andrology is a strong predictor of adherence. Second, it highlights that guidelines based on expert opinion (rather than randomized controlled trials) have lower adherence rates. Third, it quantifies the specific gaps in mental health referral, Peyronie’s diagnostics, and priapism management that had not been previously documented.
Why Choose a Men’s Health Clinic That Follows AUA Guidelines
At Adult & Pediatric Urology (APUMN), our board-certified urologists and fellowship-trained specialists in men’s health strictly follow the American Urological Association (AUA) clinical guidelines for erectile dysfunction, Peyronie’s disease, priapism, infertility, and ejaculatory disorders. Unlike general urology practices where adherence to guidelines for complex conditions like Peyronie’s disease or non-ischemic priapism may be as low as 50% (per the Fastenau study), our team has specialized training in sexual medicine and reproductive health. We perform indicated diagnostic tests including in-office intracavernosal injection for Peyronie’s assessment, prescribe only evidence-based therapies (no vitamin E or ineffective oral cocktails), and collaborate with mental health professionals to address the psychological dimensions of ED. When you search for “best men’s health clinic near me” or “urologist following AUA guidelines”, choose APUMN where guideline adherence meets compassionate, comprehensive care.
Summary for Patients
The Fastenau study reveals a clear pattern: urologists with fellowship training in men’s health (andrology) consistently follow AUA guidelines across all conditions. General urologists have lower adherence, especially for less common conditions like Peyronie’s disease and priapism. This means that where you seek care directly affects whether you receive evidence-based treatment.
If you have erectile dysfunction, Peyronie’s disease, priapism, infertility, or ejaculatory problems, your best chance for a good outcome is to see a urologist who specializes in men’s health and who follows AUA guidelines. Ask the questions listed above. Avoid clinics that offer unproven oral therapies for Peyronie’s or that never refer ED patients to mental health professionals. And remember that guideline adherence is not just a bureaucratic requirement it is a direct measure of whether your doctor is giving you the best available care.
Author
Jerome P. Keating, M.D
