12.3 Urology & Men's Health

12.3 Urology & Men's Health

Quick Answer: APC names urological conditions as exam content. Community-relevant material is benign prostatic hyperplasia medicines (alpha blockers and 5-alpha reductase inhibitors), overactive bladder and anticholinergic burden, urinary tract infection selection rules including nitrofurantoin's renal limits, and erectile dysfunction medicines with their absolute nitrate contraindication.

Benign prostatic hyperplasia (BPH)

Lower urinary tract symptoms in older men — hesitancy, weak stream, nocturia, incomplete emptying — are common and mostly manageable, but they overlap with conditions that must not be missed.

Alpha-1 blockers (tamsulosin, prazosin, silodosin, alfuzosin)

• Work within days to weeks by relaxing prostatic and bladder-neck smooth muscle; they relieve symptoms without changing prostate size
• Postural hypotension and first-dose effect — counsel to take at night, rise slowly, and be careful with the first dose or after a dose increase
• Additive hypotension with antihypertensives and with PDE5 inhibitors
• Intraoperative floppy iris syndrome — anyone taking or who has taken an alpha blocker must tell the ophthalmologist before cataract surgery. This is the single most examinable tamsulosin counselling point.
• Abnormal ejaculation is common with tamsulosin and silodosin, and is a frequent silent reason for non-adherence — raise it sensitively

5-alpha reductase inhibitors (finasteride, dutasteride)

• Shrink the prostate over time; expect 3–6 months before meaningful benefit — set that expectation or the patient will stop early
• Reduce PSA by roughly half. A PSA measured during therapy must be interpreted with that in mind, typically by doubling it. Failing to account for this can hide prostate cancer.
• Sexual adverse effects (reduced libido, erectile dysfunction, ejaculatory changes) and breast changes; report breast lumps
• Handling caution: women who are or may become pregnant should not handle crushed or broken finasteride tablets or leaking dutasteride capsules because of the risk to a male fetus
• Blood donation is generally deferred during and for a period after treatment

Combination alpha blocker plus 5-alpha reductase inhibitor is used for larger prostates with a view to reducing progression.

Refer, do not manage, when you see

Acute urinary retention, visible haematuria, fever with urinary symptoms, unexplained weight loss or bone pain, a rapidly worsening stream, or any first presentation without a medical assessment.

Overactive bladder

Anticholinergic burden is a genuine deprescribing concern. An older patient already on a sedating antihistamine, a tricyclic and an antipsychotic does not need oxybutynin added without review. Non-drug measures — bladder training, caffeine and alcohol reduction, pelvic floor exercises, timed voiding, and reviewing diuretic timing — come first and are examinable in their own right.

Urinary tract infection

Who can be managed and who must be referred

Agent-specific traps

• Nitrofurantoin — efficacy depends on renal secretion into urine, so it fails as renal function falls. AMH advises avoiding it below an eGFR of about 45 mL/min, with short courses used cautiously in the 30–44 range only for resistant lower urinary tract infection; note that some Australian product information still carries the older creatinine clearance of 60 mL/min contraindication. Check AMH in the exam rather than reciting one number. It may be used for cystitis in pregnancy but is avoided near term (from about 38 weeks) because of neonatal haemolysis risk. It does not treat upper urinary tract infection or urosepsis.
• Trimethoprim — a folate antagonist, so it is avoided in the first trimester; watch for hyperkalaemia risk with ACE inhibitors, ARBs, spironolactone and potassium supplements, and interaction with methotrexate.
• Urinary alkalinisers — commonly requested for symptom relief, but they should not be combined with nitrofurantoin because alkaline urine reduces its activity. Also unsuitable for people on sodium- or potassium-restricted diets depending on the product.
• Cranberry products — evidence for prevention is weak, they do not treat an established infection, and they interact with warfarin.

Erectile dysfunction

• PDE5 inhibitors are absolutely contraindicated with nitrates in any form — glyceryl trinitrate tablets, spray or patches, and isosorbide preparations — because of catastrophic hypotension. Also contraindicated with riociguat.
• Additive hypotension with alpha blockers means timing and dose care.
• Some sildenafil presentations are available as Pharmacist Only (Schedule 3) medicines under strict pharmacist assessment criteria; product scheduling changes, so confirm the current Poisons Standard entry and your jurisdiction's rules rather than memorising a pack.
• Erectile dysfunction can be an early marker of cardiovascular disease and diabetes. A man presenting for the first time deserves a cardiovascular conversation and medical review, not just a supply.
• Sudden vision or hearing loss during therapy requires immediate medical attention; an erection lasting more than four hours is a medical emergency.
• Medicines can cause the problem: thiazides, beta-blockers, SSRIs, finasteride and antipsychotics are common contributors and are worth reviewing before adding therapy.

Exam mindset

Urology stems test whether you can spot the referral trigger inside a routine request. Cataract surgery plus tamsulosin, a PSA result on finasteride, nitrofurantoin with a low eGFR, a nitrate patch with a request for sildenafil, and UTI symptoms in a man are all designed to see whether you check before you supply.

Screening, testosterone and the wider men's health conversation

Men present to pharmacies far less often than women, so the consultation you do get carries extra weight.

• Prostate cancer screening is a shared decision, not a routine recommendation. PSA testing has real benefits and real harms (over-diagnosis and over-treatment), and eligibility discussions belong with the GP. Your role is to explain that the test exists, that a 5-alpha reductase inhibitor suppresses the result, and to encourage the conversation rather than to advise for or against testing.
• Testosterone is a Schedule 4 medicine with PBS access restricted to defined clinical indications confirmed by pathology; it is not a treatment for ordinary ageing or tiredness. Counsel on application-site transfer risk for gels — cover the site, wash hands, and avoid skin contact with women and children — and on the need for ongoing monitoring including haematocrit and PSA.
• Opportunistic conversations are legitimate practice: a man collecting a BPH medicine can reasonably be asked about blood pressure, smoking, alcohol and bowel screening participation. This links Standard 3.6 directly to a urological consultation.