A systematic PubMed review (2020–2026) maps the urological and andrological footprint of GLP-1 receptor agonists — semaglutide, liraglutide, and the dual GIP/GLP-1 agonist tirzepatide — across seven domains. The agents deliver up to 22% body-weight reduction and, in obesity-related hypogonadism, raise total testosterone while improving erectile function. Nephroprotective signals include reduced albuminuria and slowed eGFR decline. Epidemiological data hint at lower prostate cancer risk, and weight loss confers indirect benefit for stress incontinence and overactive bladder. The critical counterweight: non-diabetic obese men on semaglutide face a 4.5-fold elevated risk of new-onset erectile dysfunction — a paradox demanding mechanistic investigation.
The finding reframes GLP-1 RAs from cardiovascular-metabolic drugs into agents with meaningful genitourinary biology. The testosterone-boosting effect aligns with established evidence that visceral fat suppresses the hypothalamic-pituitary-gonadal axis, so weight loss restoring androgen levels is biologically coherent. The ED paradox, however, is harder to reconcile and may involve semaglutide's effects on penile vascular tone, autonomic signaling, or libido-dampening appetite suppression pathways — none yet well characterized. Critical limitations: this is a narrative review, not a meta-analysis, and the ED risk signal derives from observational data vulnerable to confounding. Data in women are nearly absent. For prescribing clinicians, the takeaway is practical — baseline andrological assessment before initiating GLP-1 RAs and perioperative caution around delayed gastric emptying are immediately actionable. Overall, this is a confirmatory-plus synthesis that elevates an underappreciated clinical dimension of blockbuster drugs.