General urology and andrology: haematuria, LUTS and the male patient
What the exam tests
General urology and andrology covers the office-based core: haematuria pathways, lower urinary tract symptoms (LUTS), erectile dysfunction, male hypogonadism and male-factor infertility. Questions usually give a clinical scenario and ask for the next investigation, or why a plausible management option is wrong.
Core rules
- Visible haematuria in anyone over 45, or in a younger patient with persistent unexplained findings, needs urgent referral for CT urography plus cystoscopy. Non-visible haematuria is first rechecked after treating infection; only persistent cases in higher-risk patients proceed.
- Glomerular bleeding suggests dysmorphic red cells, proteinuria and no clots; urological bleeding tends to clot and to be unilateral.
- LUTS split into storage (frequency, urgency, nocturia) and voiding (hesitancy, poor stream, terminal dribble). Always include a bladder diary, post-void residual and DRE.
- Erectile dysfunction is most often vasculogenic. PDE5 inhibitors are absolutely contraindicated with nitrates; testosterone is contraindicated in active prostate or breast cancer and in untreated polycythaemia.
- Male infertility: two semen analyses at least three months apart; WHO 2021 lower reference limits include volume 1.4 mL, concentration 16 million/mL, progressive motility 30% and normal morphology 4%.
Worked example
A 62-year-old man reports two episodes of painless visible haematuria while taking apixaban. He is afebrile and dipstick shows blood only. Reasoning: anticoagulation does not explain haematuria and must not delay referral. He needs an urgent suspected-cancer pathway referral for CT urography and flexible cystoscopy.
Traps
Blaming haematuria on anticoagulants; ordering cystoscopy alone without upper tract imaging; diagnosing hypogonadism from a single afternoon total testosterone; checking PSA immediately after prostate biopsy rather than waiting about six weeks.