Men's Health — GCC Nursing Guide

Why Men Seek Less Healthcare — Barriers

Behavioural Barriers

Stoicism: "tough it out" mentality
Embarrassment: discussing intimate symptoms
Time & work patterns: inflexible work hours, reluctance to take sick leave
Health literacy: limited awareness of screening benefits

Masculinity & Health-Seeking

Traditional masculine norms discourage vulnerability
Help-seeking perceived as weakness
Delayed presentation = advanced disease at diagnosis
Men less likely to have a regular GP
Risk-taking behaviour associated with masculine identity

Nursing Approach

Non-judgmental, private environment
Normalise screening conversations
Use opportunistic moments (e.g. BP check)
Brief intervention techniques
Male health champions/peer educators

Opportunistic Screening Checklist

Domain	Screening Method	Frequency / Threshold
Blood Pressure	Sphygmomanometer	Annual if >40; treat ≥140/90 mmHg
Weight / BMI	BMI + waist circumference	Waist >94 cm (men) = increased risk
Smoking	Brief advice + CO monitor	Every visit; NRT referral if smoker
Alcohol	AUDIT-C questionnaire	AUDIT-C ≥5 = hazardous use
Sexual Health	STI screen + HIV test	Annually if sexually active / at-risk
Mental Health	PHQ-9 / GAD-7	Any opportunity; atypical male presentation
Testicular Self-Exam	Education & technique teaching	Monthly from age 15
PSA Discussion	Informed consent counselling	Offer at 50 (45 if family history; 40 if Black ethnicity)
Cardiovascular Risk	QRISK3 calculator	40–74 years; treat if 10-yr risk ≥10%

Cardiovascular Risk — QRISK3

10-Year CVD Risk Assessment

Inputs: age, sex, ethnicity, smoking, SBP, cholesterol ratio, BMI, family history, deprivation, diabetes, AF, RA, CKD, migraine, SLE, mental illness, erectile dysfunction
ED is now a QRISK3 input — independent CVD risk factor

Risk Thresholds

10-yr Risk	Action
<10%	Lifestyle advice, re-screen in 5 years
10–20%	Discuss statin therapy (shared decision)
>20%	Statin + antihypertensive likely indicated

ED presenting at <50 yrs may be earliest sign of subclinical atherosclerosis — always assess cardiovascular risk.

Depression Screening — PHQ-9

Atypical Male Presentation

Men rarely present with classic "low mood" — ask about anger, irritability, substance use, risk-taking, work stress.

Male-Specific Symptoms

Increased anger / aggression
Alcohol or drug misuse
Risk-taking, reckless behaviour
Physical symptoms (headaches, fatigue)
Social withdrawal / overworking

PHQ-9 Scoring

Score	Severity	Action
0–4	None/minimal	Monitor
5–9	Mild	Watchful waiting, counselling
10–14	Moderate	Antidepressant / psychotherapy
15–19	Moderately severe	Antidepressant + psychotherapy
20–27	Severe	Urgent psychiatric referral

Male Suicide — Key Statistics

Male suicide rate is approximately 3× higher than female. Men account for ~75% of all suicides in most high-income countries.

Risk Factors

Untreated or unrecognised depression
Substance misuse (alcohol particularly)
Social isolation, relationship breakdown
Unemployment / financial stress
Previous attempt (strongest predictor)
Access to means

Nursing Assessment — Ask Directly

"Are you having any thoughts of harming yourself?"
Assess ideation, plan, intent, means
Use Columbia Suicide Severity Rating Scale (C-SSRS)
Safety planning if at risk

Prostate Cancer — PSA Awareness

PSA (Prostate Specific Antigen)

Age	PSA Upper Normal (ng/mL)
40–49	<2.5
50–59	<3.5
60–69	<4.5
70+	<6.5

Benefits of PSA Testing

Early detection of localised disease (potentially curable)
Monitoring of known prostate cancer

Limitations

Not cancer-specific — raised by BPH, prostatitis, vigorous exercise, catheterisation
False negatives possible
Risk of overdiagnosis and overtreatment
Informed consent discussion mandatory before testing

MRI (mpMRI) + biopsy used for formal diagnosis. PSA is a screening/monitoring tool only.

Testicular Self-Examination (TSE)

Technique — Monthly from Age 15

Perform after a warm bath or shower (scrotal skin relaxed)
Stand in front of a mirror
Examine each testicle separately with both hands
Place index and middle fingers under the testicle; thumbs on top
Gently roll the testicle between thumbs and fingers
Feel along the epididymis (soft, rope-like structure at back — normal)
Look and feel for: lumps, changes in size, hardness, or consistency, heaviness, dull ache

One testicle slightly larger or hanging lower is normal. Report any new lump or change to a doctor promptly.

When to Seek Medical Review

Any painless lump or swelling on the testicle
Change in size or shape
Dull ache in lower abdomen or groin
Feeling of heaviness in the scrotum
Sudden fluid collection (hydrocele)
Gynaecomastia (raised bHCG)

Testicular Cancer Epidemiology

Most common solid malignancy in men aged 15–35. Overall cure rate >95% if caught early.

Incidence & Risk Factors

Peak incidence: 25–35 years
Second peak: >60 years (lymphoma)
Undescended testis (cryptorchidism) — 4–8× risk even after orchidopexy
Family history — 6–10× risk
Contralateral testicular cancer — 2–5% risk
Klinefelter syndrome (mediastinal GCT)
White ethnicity higher than Black/Asian

Initial Investigations

Urgent scrotal ultrasound (same-day if suspected)
Tumour markers: AFP, bHCG, LDH
CT chest/abdomen/pelvis (staging)
Staging: TNM + IGCCCG prognostic classification
CXR (pulmonary metastases)

Testicular Tumour Types

Germ Cell Tumours (95%)

Seminoma (pure)

Peak age: 30–40 years
Slower growing, well-defined
Radiosensitive — radiotherapy used adjuvantly
AFP not raised (if raised = non-seminomatous element)
bHCG mildly raised in ~15%
Excellent prognosis — 5-yr survival >99% stage 1

Non-Seminomatous GCT (NSGCT / TGCT)

Mixed histology: embryonal, yolk sac, choriocarcinoma, teratoma
Peak age: 20–30 years
AFP raised — yolk sac element
bHCG raised — choriocarcinoma element
LDH — non-specific tumour bulk marker
Not radiosensitive — chemotherapy preferred

Non-Germ Cell Tumours (5%)

Leydig Cell Tumour

Rare, usually benign; gynaecomastia (excess oestrogen)

Sertoli Cell Tumour

Rare, usually benign

Testicular Lymphoma

Most common testicular tumour in men >60
Bilateral in 35%; systemic disease common

Tumour Markers Summary

Marker	Seminoma	NSGCT
AFP	Never raised	Often raised
bHCG	Mildly raised (15%)	Often raised
LDH	May be raised	May be raised
PLAP	Often raised	Variable

Orchiectomy Nursing Care

Surgical Approach

Inguinal orchiectomy — groin incision (not scrotal, to avoid lymphatic spread to inguinal nodes)
Spermatic cord ligated high at internal ring
Day case or overnight stay
Prosthesis can be inserted at same time or later

Post-Op Nursing

Wound check: inguinal incision
Drain management (if inserted)
Scrotal support / ice packs for swelling
Pain assessment (usually mild)
Haematoma monitoring

Psychosocial Care

Body image concerns — discuss prosthesis option
Fertility counselling pre-operatively
Impact on masculinity / sexuality
Partner involvement (with consent)
Support groups signposting
Remaining testicle capable of normal hormonal function

Testicular prosthesis: saline-filled silicone implant. Cosmetic only, no hormonal function. Offered to all patients.

Fertility Preservation

Sperm banking MUST be offered and completed BEFORE any chemotherapy or radiotherapy.

Semen analysis pre-treatment
Bank ≥2 samples (48h apart)
Cryopreservation: viable for decades
Pre-existing subfertility common in TC patients
RPLND can cause retrograde ejaculation

RPLND

Retroperitoneal lymph node dissection
Nerve-sparing technique preferred
Risk: retrograde ejaculation (sympathetic nerve damage)

BEP Chemotherapy — Nursing Monitoring

Regimen

Drug	Route	Key Toxicity
Bleomycin (B)	IV	Pulmonary fibrosis
Etoposide (E)	IV	Myelosuppression, secondary leukaemia
Cisplatin (P)	IV	Nephrotoxicity, ototoxicity, neuropathy

3–4 cycles; each cycle = 5 days, repeated every 21 days

Bleomycin — Pulmonary Toxicity

Bleomycin pulmonary toxicity (BPT) — potentially fatal. Cumulative dose-dependent.

Incidence: 10–20%; fatal in 1–3%
Monitor: baseline PFTs (DLCO), then each cycle
Symptoms: dry cough, dyspnoea, fever
CXR: bilateral interstitial infiltrates
Stop bleomycin if DLCO drops >25%
Avoid high FiO₂ — risk of pulmonary oxygen toxicity

Cisplatin Monitoring

Aggressive IV hydration pre & post (2–3L/day)
Urine output monitoring (≥100ml/hr)
Renal function: creatinine/eGFR each cycle
Audiometry: ototoxicity (irreversible tinnitus/hearing loss)
Peripheral neuropathy: numbness/tingling
Anti-emetics mandatory (highly emetogenic)
Electrolyte replacement: Mg²⁺, K⁺

Erectile Dysfunction — Overview

Prevalence: ~40% of men >40 years; increases with age. ED affects ~150 million men worldwide.

Vascular Causes

Atherosclerosis (most common cause)
Hypertension, dyslipidaemia
Diabetes mellitus (endothelial + neurological)
Smoking — vasoconstriction, endothelial damage
Obesity, metabolic syndrome

ED in men <50 = early marker of cardiovascular disease — arteries of penis (1–2mm) affected before coronary arteries (3–4mm)

Neurological Causes

Post-radical prostatectomy (nerve damage)
Multiple sclerosis
Diabetic autonomic neuropathy
Spinal cord injury / pelvic surgery
Parkinson's disease
Peripheral neuropathy

Hormonal Causes

Hypogonadism / low testosterone
Hyperprolactinaemia
Hypothyroidism
Hyperthyroidism

Psychological Causes

Performance anxiety
Depression (and antidepressants)
Relationship issues
Stress / burnout
Pornography-associated ED (young men)

Drug-Induced ED

SSRIs / SNRIs
Beta-blockers
Thiazide diuretics
Antihypertensives (multiple classes)
Finasteride / dutasteride
Opioids
Alcohol (chronic use)
Anabolic steroids — suppress LH/FSH

Assessment — IIEF-5

International Index of Erectile Function (5-item)

5 questions, each scored 1–5. Total score 5–25.

Score	ED Severity
22–25	No ED
17–21	Mild ED
12–16	Mild–Moderate ED
8–11	Moderate ED
5–7	Severe ED

History Points

Onset (sudden = psychological; gradual = organic)
Morning erections present? (absent = more organic)
Situational vs universal
Relationship issues
Medications review
Cardiovascular risk factors
Testosterone symptoms

Princeton Consensus — Cardiovascular Risk

Sexual Activity Risk Stratification

Risk	Criteria	Action
Low	Controlled HTN, mild stable angina, <3 CVD risk factors	PDE5 inhibitor safe, reassess in 6/12
Intermediate	≥3 CVD risk factors, moderate stable angina	Cardiac evaluation before treatment
High	Unstable angina, uncontrolled HTN, recent MI/stroke, NYHA IV HF	Defer sexual activity; stabilise CVD first

PDE5 inhibitors ABSOLUTELY contraindicated with nitrates (organic or recreational) — severe hypotension risk. Allow 24h (sildenafil/vardenafil) or 48h (tadalafil) washout.

PDE5 Inhibitors

Sildenafil (Viagra)

Dose: 25–100 mg prn
Onset: 30–60 min
Duration: 4–6 hours
Take on empty stomach (fatty food delays absorption)
Most studied

Tadalafil (Cialis)

Dose: 10–20 mg prn OR 2.5–5 mg daily
Onset: 30 min–2 hours
Duration: up to 36 hours ("weekend pill")
Not affected by food
Also licensed for BPH/LUTS

Vardenafil (Levitra)

Dose: 5–20 mg prn
Onset: 25–60 min
Duration: 4–6 hours
More selective for PDE5 vs PDE6 (retina)

Common Side Effects

HeadacheFacial flushingNasal congestionDyspepsiaBlue-tinge vision (sildenafil — PDE6)Myalgia (tadalafil)Hypotension

Contraindications

Nitrates (absolute) — GTN, isosorbide, amyl nitrate ("poppers")
Severe hepatic impairment
Recent stroke or MI (<90 days)
Low blood pressure (<90/50 mmHg)
Certain antifungals / HIV protease inhibitors (CYP3A4 interactions)
Retinitis pigmentosa (relative)

Second & Third Line Treatments

Vacuum Erection Device (VED)

Cylinder placed over penis; pump creates vacuum drawing blood in
Constriction ring applied at base to maintain erection
Ring left on max 30 minutes
No systemic side effects
Useful if PDE5 contraindicated or ineffective
Penile bruising, sensation change possible

Intracavernosal Alprostadil

Prostaglandin E1 — relaxes smooth muscle
Self-injection into corpus cavernosum
Onset: 5–20 min; duration: up to 1 hour
Effective in 80–90%
Risk: priapism (erection >4 hours — emergency)
Penile pain, fibrosis with repeated use
Also available as intraurethral pellet (MUSE)

Penile Implant (Prosthesis)

Inflatable (3-piece) or malleable (semi-rigid)
3-piece: reservoir (abdomen), pump (scrotum), cylinders
Highest satisfaction rates of all ED treatments
Irreversible — natural erections no longer possible
Surgical risks: infection, mechanical failure
Last resort after failure of conservative options

LUTS Assessment — IPSS Questionnaire

Storage Symptoms (Irritative)

Frequency: voiding >8×/day
Urgency: compelling desire to void that cannot be deferred
Nocturia: waking at night to void (>1× per night = significant)
Urgency incontinence: leakage associated with urgency

Storage symptoms may indicate overactive bladder (OAB), NOT always BPH. Consider anticholinergics.

Voiding Symptoms (Obstructive)

Hesitancy: difficulty initiating urination
Poor/weak stream: reduced urine flow
Intermittency: flow starts and stops
Incomplete emptying: feeling of residual urine
Straining: abdominal effort to void
Terminal dribbling: dribble at end of void

IPSS Severity Classification

IPSS Score	Severity	QoL Impact	Initial Management
0–7	Mild	Not usually bothersome	Watchful waiting, lifestyle
8–19	Moderate	Mixed impact	Medical therapy (alpha-blocker ± 5ARI)
20–35	Severe	Severely bothersome	Medical or surgical treatment

Investigations

Baseline Work-up

Test	Purpose	Key Values
Urinalysis / MSU	Exclude infection, haematuria	Rule out UTI, cancer
Serum PSA	Exclude prostate cancer	Age-specific (see Tab 1)
Uroflowmetry	Objective flow rate	Normal: >15 mL/s; obstruction: <10 mL/s
Post-void residual (USS)	Assess incomplete emptying	Normal: <50 mL; significant: >200 mL
Renal function (U&E)	Chronic retention → hydronephrosis	eGFR, creatinine
Frequency-volume chart	Voiding diary 3 days	Total volume, frequency, nocturia episodes

Indications for urgent referral: haematuria, raised PSA, palpable bladder, renal impairment, recurrent UTI, urinary retention.

Prostate Anatomy & BPH Pathophysiology

Prostate Zones

Transition zone: surrounds urethra — site of BPH
Peripheral zone: 70% gland — site of prostate cancer
Central zone: 25% gland — surrounds ejaculatory ducts

BPH Mechanism

Hyperplasia of stromal and epithelial cells
Androgen-dependent (DHT via 5-alpha reductase)
Mechanical obstruction (gland bulk) + dynamic obstruction (alpha-1 adrenoceptors in stroma/bladder neck)
Affects >50% of men by age 60; >80% by age 80

Medical Management of BPH

Alpha-1 Adrenoceptor Blockers

Tamsulosin (MR) 400 mcg daily — Most commonly used

Mechanism: relax smooth muscle in prostate stroma and bladder neck
Onset: within days (dynamic component)
SE: postural hypotension, dizziness, retrograde ejaculation (10–30%), rhinitis
Intraoperative floppy iris syndrome — alert ophthalmologist pre-cataract surgery

Other Alpha-Blockers

Doxazosin — also antihypertensive (non-selective)
Alfuzosin — fewer ejaculatory side effects
Silodosin — most selective; highest retrograde ejaculation rate

5-Alpha Reductase Inhibitors (5ARIs)

Finasteride 5 mg / Dutasteride 0.5 mg daily

Mechanism: inhibit DHT production → reduce prostate volume (20–30% over 6 months)
Onset: 3–6 months for symptom benefit
PSA halved within 6 months — double PSA to correct value
SE: decreased libido, ED, ejaculatory disorders, gynaecomastia
Teratogenic to male fetus — women must not handle crushed tablets

Combination Therapy

Alpha-blocker + 5ARI = better outcomes in prostate >40 mL
CombAT trial: dutasteride + tamsulosin superior at 4 years

Anticholinergics / Mirabegron (for storage symptoms)

For OAB component (urgency/frequency/nocturia)
Caution if PVR >200 mL (risk of acute retention)

Surgical Options for BPH

Procedure	Mechanism	Key Nursing Points
TURP (gold standard)	Resectoscope removes prostate tissue (monopolar/bipolar)	Catheter post-op, TURP syndrome (hyponatraemia — monopolar), retrograde ejaculation 90%
HoLEP (Holmium Laser)	Laser enucleates prostate lobes	Less bleeding, suitable for any prostate size, shorter catheter time, retrograde ejaculation common
Prostatic Urethral Lift (UroLift)	Implants hold lateral lobes apart — no tissue removed/destroyed	Day case; preserves ejaculation; not for median lobe; symptom benefit < TURP
Rezum (water vapour therapy)	Steam injections cause convective heat injury to prostate tissue	Day case; temporary catheter 3–7 days; preserves ejaculation in most; delayed response 3 months

Pre-operative nursing: catheter care, haematuria monitoring, fluid balance. Post-TURP: irrigate bladder, watch for clot retention, monitor sodium if monopolar diathermy used.

Hypogonadism — Symptoms

Classic Presentation

Fatigue and reduced energy
Decreased libido
Erectile dysfunction
Low mood / depression / irritability
Reduced muscle mass and strength
Increased body fat (especially visceral)
Anaemia (normochromic normocytic)
Osteoporosis / reduced bone density
Hot flushes and sweats
Reduced testicular size and consistency
Infertility / low sperm count
Gynaecomastia
Reduced body / facial hair
Cognitive changes (poor concentration)

Symptoms are non-specific — biochemical confirmation mandatory before initiating TRT.

Investigations — Hypogonadism

Hormone Panel

Test	Timing	Significance
Total Testosterone	Morning (07:00–11:00), fasting, repeated twice	<8 nmol/L = hypogonadism; 8–12 = borderline
SHBG	Same sample	Calculate free testosterone
LH	Same sample	High = primary; low/normal = secondary
FSH	Same sample	Marker of Sertoli cell function / fertility
Prolactin	—	Hyperprolactinaemia suppresses gonadotropins
FBC	—	Anaemia, haematocrit baseline
Bone density (DEXA)	If indicated	Osteoporosis risk

Classification

Primary hypogonadism: testicular failure → Low T + High LH/FSH (hypergonadotrophic)

Secondary hypogonadism: pituitary/hypothalamic → Low T + Low/Normal LH/FSH (hypogonadotrophic)

Causes of Hypogonadism

Primary (Testicular)

Klinefelter syndrome (47,XXY) — most common genetic cause
Mumps orchitis (post-pubertal)
Trauma / torsion
Chemotherapy (cisplatin, alkylating agents)
Radiotherapy to testes
Undescended testes
Autoimmune orchitis

Secondary (Pituitary/Hypothalamic)

Pituitary tumour (prolactinoma most common)
Haemochromatosis
Kallmann syndrome (anosmia + HH)
Opioid-induced hypogonadism
Anabolic steroid misuse (exogenous androgens suppress HPG axis)
Glucocorticoid excess (Cushing's)
Severe systemic illness

Age-Related / Other

Late-onset hypogonadism (ageing) — testosterone declines ~1%/year after 30
Obesity (aromatisation of T to oestradiol in adipose tissue)
Type 2 diabetes
HIV/AIDS
Severe sleep apnoea
Chronic renal / hepatic disease

Testosterone Replacement Therapy (TRT)

Formulations

Route	Product	Frequency	Notes
Gel	Testogel / Tostran	Daily (applied to shoulders/abdomen)	Transfer risk to partners/children; most physiological
Patch	Androderm	Daily (applied to back/thigh)	Skin reactions common
IM injection	Nebido (undecanoate)	Every 10–14 weeks	Stable levels; nurse-administered
IM injection	Sustanon 250	Every 2–4 weeks	Peaks and troughs common
Implant	Testopel pellets	Every 3–6 months	Subcutaneous; stable levels
Oral	Testosterone undecanoate	Twice daily with meals	Less potent; hepatotoxicity rare with modern forms

Monitoring on TRT

Parameter	Timing	Target / Action
Total testosterone	3 months, then 6-monthly	Target mid-normal range (15–25 nmol/L)
Haematocrit (Hct)	3 months, then annually	Stop if Hct >54% (polycythaemia risk)
PSA	3 and 12 months	Rise >1.4 ng/mL in 12 months → urology referral
Testicular size	Annually	Atrophy expected (suppress LH)
Lipid profile	Annually	TRT may affect HDL
Mood / libido / symptoms	Each review	Clinical response assessment

Absolute contraindications: prostate cancer, breast cancer, polycythaemia (Hct >54%), severe untreated sleep apnoea, planned paternity.

Fertility & TRT Considerations

TRT Suppresses Fertility

Exogenous testosterone suppresses LH and FSH via negative feedback on HPG axis
Results in reduced sperm production (azoospermia in many)
Testicular atrophy from lack of intratesticular testosterone
Recovery of spermatogenesis after stopping TRT: months to years (not guaranteed)

Any man desiring paternity should NOT receive standard TRT. Discuss and document before initiation.

Fertility-Preserving Treatment

Hypogonadotrophic hypogonadism (HH): Gonadotrophin therapy (FSH + hCG) stimulates spermatogenesis AND testosterone production
hCG: mimics LH — stimulates Leydig cell testosterone production
FSH (recombinant): stimulates Sertoli cells and spermatogenesis
Clomiphene citrate: blocks oestrogen negative feedback → increases endogenous LH/FSH/T
Sperm banking prior to any treatment affecting fertility

GCC-Specific Men's Health Context

Demographic Factors

Male predominant workforce in GCC (UAE, KSA, Qatar, Bahrain, Kuwait, Oman)
Large South Asian and Arab migrant worker population
Age profile skewed younger (20–50 years) — working age men
Occupational health conditions common in construction/manual workers
Limited access to preventive healthcare among low-income workers

Cultural Barriers

Masculinity norms even stronger in Arab and South Asian cultures
Urological symptoms (ED, incontinence) highly stigmatised — rarely disclosed
Strong preference for same-sex healthcare provider for intimate examinations
Family / social honour considerations affect disclosure
Mental health stigma — depression rarely acknowledged openly

Clinical Priorities in GCC

BPH very common in older Gulf nationals and long-term expats (high diabetes/metabolic syndrome prevalence)
Testicular cancer awareness campaigns extremely limited — late presentations more likely
Testosterone / anabolic steroid misuse — GCC gym culture; bodybuilding widely popular
Fertility pressure in Gulf marriages — hypogonadism presenting through infertility route
High rates of type 2 diabetes → vascular ED common
Consanguinity increases genetic conditions (e.g. Klinefelter's variants)

Anabolic Steroid Misuse — GCC

Testosterone and anabolic steroids purchased without prescription in some GCC settings
Suppression of HPG axis → secondary hypogonadism, infertility, testicular atrophy
Post-cycle therapy (clomiphene, hCG) often self-administered
Nurses should screen fitness-focused men for exogenous androgen use

DHA / DOH / SCFHS Regulatory Framework

DHA (Dubai Health Authority)

Regulates healthcare in Dubai emirate
DHA nursing licence required for practice
Men's health programmes under Primary Healthcare Corporation
Occupational health standards for migrant workers
DHA Health Record system — chronic disease monitoring

DOH (Department of Health — Abu Dhabi)

Regulates Abu Dhabi emirate (includes Al Ain, Al Dhafra)
HAAD legacy policies now under DOH
Thiqa and Daman insurance — men's health covered
Mandatory health screening for visa applicants
DOH clinical guidelines align with international standards (EAU, AUA, NICE)

SCFHS (Saudi Commission for Health Specialties)

Regulates healthcare professionals in Saudi Arabia
SCFHS nursing exam tests clinical knowledge including urology, men's health
Saudi Vision 2030 — focus on preventive care and men's health
SCFHS Exam: expect IPSS scoring, PSA interpretation, PDE5 contraindications

DHA / DOH / SCFHS Exam Preparation — Key Topics

IPSS Scoring — High Yield

Score Range	Classification	Management Implication
0–7	Mild	Watchful waiting, lifestyle modifications
8–19	Moderate	Alpha-blocker ± 5ARI; consider surgical if refractory
20–35	Severe	Urgent urology referral; surgical treatment likely

Exam tip: IPSS has 7 symptom questions (0–5 each = max 35) + 1 QoL question (0–6) scored separately. Nocturia question scored 0–5 based on times woken per night.

Testicular Cancer Markers — Key

Tumour Type	AFP	bHCG
Pure seminoma	Normal	Mildly raised (15%)
NSGCT (yolk sac)	Raised	May be raised
Choriocarcinoma	Normal	Very high
Teratoma	May vary	May vary

Exam tip: AFP raised = always non-seminomatous element present (even if pathology reports seminoma).

PDE5 Inhibitor Contraindications — Must Know

ABSOLUTE: Concurrent nitrates (any route) — organic nitrates (GTN, isosorbide), recreational nitrates (amyl nitrate "poppers"). Combination causes severe, potentially fatal hypotension.

Contraindication	Type
Nitrates (all routes)	Absolute
Recent MI or stroke (<90 days)	Absolute
Severe hypotension (BP <90/50)	Absolute
Severe hepatic impairment	Absolute
Concurrent alpha-blockers (caution)	Relative — additive hypotension
Retinitis pigmentosa	Relative

BPH Drug Classes — Key Side Effects

Drug Class	Key SE for Exam
Alpha-blockers (tamsulosin)	Retrograde ejaculation, postural hypotension, intraoperative floppy iris
5ARIs (finasteride)	Sexual dysfunction, reduced PSA (halves it), teratogenic
Anticholinergics	Dry mouth, constipation, urinary retention — caution if PVR >200 mL
Mirabegron (beta-3 agonist)	Hypertension — safer than anticholinergics in elderly

Exam tip: PSA is halved by finasteride/dutasteride — when interpreting PSA in a man on a 5ARI, double the measured value to get the "true equivalent" PSA.

Quick Reference — Clinical Thresholds

Normal Values

Urine flow rate: >15 mL/s (normal)
Post-void residual: <50 mL (normal)
Testosterone: >12 nmol/L (borderline), >15 nmol/L (normal)
Haematocrit on TRT: stop if >54%
IPSS: 0–7 mild, 8–19 moderate, 20–35 severe

Scoring Tools

IPSS: 0–35 (7 questions × 0–5)
IIEF-5: 5–25 (5 questions × 1–5)
PHQ-9: 0–27 (9 questions × 0–3)
AUDIT-C: 0–12 (3 questions; ≥5 men = hazardous)
C-SSRS: Suicide severity rating (6 categories)

Referral Red Flags

Painless testicular lump → urgent scrotal USS same day
Haematuria → 2-week-wait urology
PSA > age-specific upper limit → urology
Acute urinary retention → catheterisation + urology
IPSS >19 refractory to medication → surgical review
ED age <50 → cardiovascular risk assessment (QRISK3)
PHQ-9 >15 + suicidal ideation → urgent psychiatric review