Life with IBD
Most patient-facing information about ulcerative colitis (UC) treats symptoms and treatment side effects as gender-neutral. While the core symptoms of UC (bloody diarrhea, abdominal cramping, urgency, fatigue) are the same regardless of sex, the downstream effects of the disease and its treatments on male sexual health, testosterone levels, and fertility are real clinical concerns that rarely get addressed in plain language. Men with UC also tend to delay seeking care and are less likely to disclose sensitive symptoms, particularly those involving rectal bleeding or bowel urgency, partly due to cultural expectations around masculinity and stoicism. If you are a man with UC, or you suspect you might have it, this article covers what gender-neutral resources leave out.
UC Symptoms Men Are Less Likely to Report
The hallmark symptoms of ulcerative colitis, including rectal bleeding, frequent loose stools, abdominal pain, and fatigue, affect everyone with the disease. But research into healthcare-seeking behavior consistently shows that men are less likely to engage with the healthcare system for lower gastrointestinal and rectal symptoms. A 2025 systematic review found that men face multiple barriers to help-seeking, including poor prior relationships with the healthcare system, cultural attitudes that frame medical visits as a sign of weakness, and a general lack of health programs targeted specifically at men. When your primary symptom involves blood in your stool or sudden bowel urgency, these barriers become especially significant. Delayed diagnosis means more time for inflammation to progress, and UC that goes untreated can lead to complications including toxic megacolon and increased surgical risk. If you are experiencing rectal symptoms that are new, persistent, or worsening, getting evaluated promptly is one of the most protective steps you can take.
How UC Medications Affect Male Fertility
One of the most well-documented, male-specific concerns in UC treatment involves sulfasalazine, an older but still commonly prescribed 5-aminosalicylic acid (5-ASA) drug. Sulfasalazine causes oligospermia (low sperm count), reduced sperm motility, and a higher proportion of abnormal sperm forms. The mechanism involves the sulphapyridine component of the drug, which appears to be directly toxic to developing sperm cells. A separate study in the journal Andrologia found that men treated with sulfasalazine for extended periods also showed lower serum testosterone levels alongside abnormal semen quality.
The important finding for men considering their fertility is that these effects are reversible. When sulfasalazine is withdrawn, semen quality typically improves within two to three months, and multiple pregnancies have been documented following discontinuation. For men who are planning to have children, gastroenterologists often recommend switching from sulfasalazine to mesalamine or another 5-ASA formulation that does not contain sulphapyridine. This is a conversation worth having before you are actively trying to conceive, not after months of difficulty.
Testosterone, Inflammation, and Sexual Function
UC can affect testosterone levels through several pathways, and the relationship between disease activity and male sexual function is stronger than many patients realize. A 2023 study published in Andrologia found that UC severity shows an inverse correlation with both semen parameters and testosterone levels, meaning that as disease activity increases, testosterone tends to decrease. The inflammatory cytokines that drive UC (including TNF-alpha and interleukins 1 and 6) can directly inhibit testosterone production in the Leydig cells of the testes. Zinc deficiency, which is common in IBD due to malabsorption, further compounds this effect because zinc is required for normal testosterone synthesis.
An estimated 15 to 25 percent of male IBD patients experience sexual dysfunction, compared to about 5 percent of men in the general population. This includes erectile dysfunction, reduced libido, and difficulty with orgasm. Long-term corticosteroid use, which is common during UC flares, can independently reduce sexual function. A systematic review and meta-analysis confirmed that IBD is significantly associated with elevated risk of sexual dysfunction in men. If you are experiencing changes in sexual function, raising this with your gastroenterologist is worthwhile because treatable factors like active inflammation, low testosterone, or medication side effects may be contributing.
Surgical Risks for Male Sexual Function
For men with UC who require surgery, the most common procedure is proctocolectomy with ileal pouch-anal anastomosis (IPAA), sometimes called J-pouch surgery. Because this surgery involves removing the rectum and working in close proximity to the pelvic autonomic nerves that control erectile function and ejaculation, there are specific risks to be aware of. Studies report that male IPAA patients are roughly twice as likely to experience sexual dysfunction as male IBD patients who did not undergo the procedure, with postoperative erectile dysfunction reported in roughly 2 to 10 percent of cases and retrograde ejaculation in approximately 1.5 to 4 percent.
However, the picture is more nuanced than these numbers suggest. A prospective study on sexual function after proctectomy found that many patients actually reported improved sexual function after surgery, likely because eliminating severe disease activity improved their overall quality of life, energy levels, and confidence. The key factors that increased risk of postoperative sexual dysfunction were older age, cardiometabolic comorbidities, and major depressive disorder. If surgery is being discussed as part of your treatment plan, asking your surgeon specifically about nerve-sparing techniques and expected recovery timelines for sexual function is reasonable and appropriate.
Bringing These Topics to Your GI Appointment
Many men with UC never raise sexual health or fertility concerns with their gastroenterologist, and many gastroenterologists do not proactively ask. Closing that gap starts with being willing to bring specific information to your appointments. Track your symptoms and medication side effects with Aidy so you can bring specific data to conversations with your GI about treatment adjustments. When you can show a record of when symptoms changed relative to a medication switch, or document patterns in fatigue and libido alongside disease activity, you give your care team something concrete to work with. This makes it far easier to have productive conversations about whether your current treatment plan is serving your full health, not just your GI tract.