Is men's health high yield on the PEBC exam?

Yes. Erectile dysfunction and benign prostatic hyperplasia are common, and the PDE5 inhibitor and nitrate interaction is a classic high-yield safety point. The exact mix is randomized from one sitting to the next, but men's health is consistently worth focused preparation.

What men's health topics should I focus on for the PEBC?

Focus on the PDE5 inhibitors and the nitrate contraindication, and on benign prostatic hyperplasia, where the key is separating the alpha-blockers from the 5-alpha-reductase inhibitors by speed and mechanism. The relevant cautions are common targets.

Which references should I use for men's health on the PEBC?

Use the Canadian Urological Association guidance for erectile dysfunction and benign prostatic hyperplasia. The PEBC expects the Canadian approach to drug selection and the key safety interactions.

How should I study men's health for the PEBC?

Lock in the PDE5 inhibitor and nitrate rule, separate the BPH drug classes by speed and mechanism, and know the alpha-blocker cautions.

PEBC Men's Health Practice Questions

Men's health is a focused, high-yield area on the PEBC exam. Erectile dysfunction and benign prostatic hyperplasia are the core topics, and most questions test drug selection and a couple of classic, high-stakes safety interactions.

The questions below sample each of those areas. Answer one and the breakdown shows where all four options stand, including the interaction or mechanism that decided it.

Written and reviewed against current Canadian guidelines and references.

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All 4

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How to approach a PEBC men's health question

1For erectile dysfunction, the PDE5 inhibitors are first-line, and the absolute rule is no PDE5 inhibitor with nitrates because of the risk of severe hypotension.
2For BPH, separate the alpha-blockers (fast symptom relief) from the 5-alpha-reductase inhibitors (slow, and they shrink the prostate over months), and know when each is used.
3Watch for the alpha-blocker cautions: orthostatic hypotension and intraoperative floppy iris syndrome during cataract surgery.
4Remember the overlap: tadalafil is used for both erectile dysfunction and BPH.
5Anchor on the Canadian Urological Association guidance for therapy selection.

Practice questions

Tap an answer to see why each option is right or wrong.

Question 1Erectile Dysfunction

A patient's wife asks the pharmacist whether testosterone replacement therapy alone would cure her husband's ED. Which of the following is the most appropriate response?

Incorrect · Answer: D

PEBC Yield: Highcounselling

Testosterone monotherapy is not effective for ED in most cases. Inadequate testosterone is not a common cause of ED, and replacement alone rarely restores erectile function.

PDE5 inhibitors remain first-line regardless of testosterone levels. Testosterone is added adjunctively when PDE5i response is inadequate and testosterone deficiency is documented.

Testosterone does not replace PDE5 inhibitors. Even with normalized testosterone levels, erectile function typically requires PDE5i therapy. Testosterone addresses libido and hormonal factors, not the vascular mechanics of erection.

D) (Correct)

Correct — testosterone is adjunctive only, used in combination with a PDE5 inhibitor when testosterone levels are low and PDE5i response is suboptimal. It may improve libido and enhance PDE5i responsiveness but is never monotherapy for ED.

Question 2Erectile Dysfunction

Which of the following adverse effects is unique to vardenafil among the PDE5 inhibitors?

Incorrect · Answer: B

PEBC Yield: HighADR-recognitionintraclass-differentiation

Headache and flushing are class effects shared by ALL PDE5 inhibitors (sildenafil, vardenafil, tadalafil). They are not unique to any one agent.

B) (Correct)

Correct — QTc prolongation is a unique adverse effect of vardenafil. ECG monitoring may be warranted, especially in patients taking other QTc-prolonging medications. Mnemonic: 'Vardenafil starts with V — V-shaped QTc on ECG.'

Myalgias are a unique adverse effect of tadalafil (not vardenafil). Mnemonic: 'Tadalafil — Ta-da gymnast pulls a muscle.'

Nasal congestion is a class effect of all PDE5 inhibitors due to vasodilation of nasal vasculature.

Question 3Erectile Dysfunction

A 55-year-old male with ED and BPH with lower urinary tract symptoms (LUTS) asks about a medication that could address both conditions. Which of the following is the most appropriate recommendation?

Incorrect · Answer: A

PEBC Yield: Highdrug-selection

A) (Correct)

Correct — tadalafil is the only PDE5i approved for both ED and LUTS/BPH when used as daily dosing (2.5-5 mg daily). The daily regimen provides continuous smooth muscle relaxation in both penile and prostatic/bladder neck tissue, addressing both conditions simultaneously.

Vardenafil PRN addresses ED only. It has no indication for BPH/LUTS.

Sildenafil PRN addresses ED only. It does not have approval or evidence for daily dosing to manage LUTS/BPH symptoms.

Alprostadil is a second-line agent for ED that does not address BPH/LUTS. It requires injection or intraurethral administration and is reserved for PDE5i failures.

Question 4Erectile Dysfunction

A patient has tried sildenafil 100 mg for ED on 4 separate occasions without satisfactory results. He asks to switch to tadalafil. Which of the following is the most appropriate recommendation?

Incorrect · Answer: C

PEBC Yield: Highdrug-selectionswitching-therapy

Four trials is insufficient to declare failure. The guideline recommendation is to attempt at least 8 trials of a PDE5i before switching to a different agent.

Co-using two PDE5 inhibitors simultaneously is NOT recommended. This causes additive vasodilation and increases the risk of hypotension, headache, and other adverse effects without proven additional benefit.

C) (Correct)

Correct — a PDE5i should be tried for at least 8 attempts before switching to a different agent. Early failures may be due to incorrect timing, food interactions, insufficient arousal, or dosing issues. Four trials is premature for declaring failure.

Alprostadil is second-line, reserved for patients who have failed PDE5i therapy. The patient has not completed an adequate trial of any PDE5i yet.

Question 5Erectile Dysfunction

KB is a 63-year-old male with ED, hypertension on amlodipine 5 mg daily, and dyslipidemia. He eats fast food most days (burgers, pizza, fries) and is unwilling to change his diet. Which of the following PDE5 inhibitors is most appropriate?

Incorrect · Answer: C

PEBC Yield: Highdrug-selectionintraclass-differentiation

Sildenafil's absorption is significantly reduced by fatty meals. In a patient who eats high-fat food most days and is unwilling to change, sildenafil's efficacy would be unpredictable.

Vardenafil's absorption is also reduced by fatty meals. The same food interaction limitation applies as with sildenafil.

C) (Correct)

Correct — tadalafil has NO food interaction, making it the ideal PDE5i for a patient with a high-fat diet who is unwilling to modify eating habits. It can be taken regardless of meal timing without affecting absorption or efficacy.

Starting sildenafil with dietary counselling is reasonable in theory, but the patient has explicitly stated he is unwilling to change his diet. Choosing tadalafil avoids the issue entirely.

Question 6BPH

J.P., a 60-year-old male with BPH, reports worsening urinary symptoms after starting an OTC cold product containing pseudoephedrine. Which mechanism best explains this exacerbation?

Incorrect · Answer: B

PEBC Yield: Highrisk factorsdrug-induced LUTS

Pseudoephedrine does not cause prostatic enlargement. It worsens symptoms acutely by increasing smooth muscle tone, not through glandular growth. Only DHT-mediated processes increase prostate size.

B) (Correct)

Pseudoephedrine is an alpha-adrenergic agonist that tightens smooth muscle in the prostate and bladder neck, worsening dynamic obstruction and exacerbating voiding symptoms in men with BPH.

Increased urine production is the mechanism by which diuretics worsen LUTS. Pseudoephedrine does not significantly increase urine output. This would apply to furosemide or hydrochlorothiazide.

Reduced bladder contractility is the mechanism of opioids and anticholinergic agents, not decongestants. This is tempting because it also worsens voiding symptoms.

Question 7BPH

G.R., a 72-year-old male on tamsulosin for BPH, is scheduled for cataract surgery next month. His ophthalmologist contacts the pharmacy. What perioperative concern is associated with tamsulosin use?

Incorrect · Answer: A

PEBC Yield: Highalpha-blockerscataract surgeryIFIS

A) (Correct)

Tamsulosin is specifically associated with intraoperative floppy iris syndrome (IFIS), which can complicate cataract surgery. The ophthalmologist should be informed of tamsulosin use preoperatively so surgical technique can be adjusted.

Postoperative urinary retention is a general surgical concern, not specifically linked to tamsulosin. Alpha-blockers improve urinary flow and would reduce, not increase, retention risk.

Tamsulosin does not increase intraocular pressure. This would be a concern with anticholinergic agents in narrow-angle glaucoma, not alpha-blockers.

Corneal edema from fluid retention is not an established adverse effect of tamsulosin. This is a plausible-sounding but clinically inaccurate distractor.

Question 8BPH

D.S., a 55-year-old male started on silodosin for BPH, returns after 2 weeks reporting absent ejaculate during intercourse. He is concerned about this change. What is the most appropriate pharmacist response?

Incorrect · Answer: C

PEBC Yield: Highalpha-blockersadverse effectsretrograde ejaculation

Tadalafil does not treat retrograde ejaculation and should not be combined with alpha-blockers due to hypotension risk. This is a dangerous recommendation.

The absent ejaculate is not due to subtherapeutic dosing. Increasing the dose would worsen this side effect. This response misidentifies the problem as lack of efficacy.

C) (Correct)

Retrograde ejaculation (dry ejaculation) is a common and expected adverse effect of silodosin. It is not harmful but should be discussed with patients, especially those concerned about fertility. It resolves upon discontinuation.

Switching to finasteride is inappropriate because finasteride also causes sexual dysfunction (impotence, decreased libido) and has a slow onset of 6-12 months. The current effect is expected, not a treatment failure.

Question 9BPH

C.D., a 59-year-old male on tamsulosin for BPH, is prescribed tadalafil 5 mg daily for concurrent erectile dysfunction. The pharmacist reviews the combination. What is the primary safety concern?

Incorrect · Answer: C

PEBC Yield: Hightadalafilalpha-blocker interaction

Tadalafil and tamsulosin do not antagonize each other. Both improve BPH symptoms through complementary mechanisms. However, the additive vasodilatory effect creates a safety risk.

Retrograde ejaculation is primarily associated with alpha-blockers (especially silodosin), not tadalafil. Adding tadalafil does not significantly increase this risk beyond what tamsulosin already causes.

C) (Correct)

Combining tadalafil with alpha-blockers carries a risk of severe hypotension because both agents lower blood pressure through smooth muscle relaxation. If both are needed, very close blood pressure monitoring is required.

Neither tadalafil nor tamsulosin increases urinary retention risk. Both actually improve urinary flow through different mechanisms. Urinary retention is a concern with antimuscarinics, not these agents.

Question 10BPH

S.H., a 66-year-old male on tamsulosin for BPH, reports persistent urgency and nocturia despite 8 weeks of therapy. His voiding symptoms have improved. What is the most appropriate next step?

Incorrect · Answer: D

PEBC Yield: Highantimuscarinicsstorage symptomsadd-on therapy

Alpha-blocker dose escalation does not address storage symptoms. The voiding symptoms have already improved, indicating adequate alpha-blockade. The remaining symptoms require a different mechanism.

Desmopressin specifically treats nocturnal polyuria (excessive nighttime urine production) and does not address urgency. Discontinuing tamsulosin would cause voiding symptoms to recur.

Switching to dutasteride removes the fast-acting symptom relief and does not address storage symptoms. Dutasteride treats prostatic enlargement, not urgency and nocturia from bladder overactivity.

D) (Correct)

When storage symptoms (urgency, frequency, nocturia) persist after alpha-blocker monotherapy, adding an antimuscarinic like tolterodine is appropriate. Alpha-blockers address voiding obstruction; antimuscarinics suppress bladder overactivity causing the residual storage symptoms.

Want the full bank?

These are a sample. The full bank adds full-length cases and timed mock exams.

Sample full case

One patient with several linked questions, the format the real exam uses for case clusters.

KS is a 68-year-old retired engineer who comes to your pharmacy for a routine medication review. He takes metformin 1000 mg PO BID for type 2 diabetes diagnosed 10 years ago (last A1C 7.1%), ramipril 10 mg PO daily for well-controlled hypertension (today 128/78 mmHg), and rosuvastatin 10 mg PO at bedtime. He gardens most mornings and recently completed his annual flu vaccination. Over the past 12 months his benign prostatic hyperplasia symptoms have escalated: International Prostate Symptom Score worsened from 10 to 18, nocturia is now 3 to 4 times nightly, and he reports hesitancy, weak stream, and incomplete emptying. Urology documented prostate enlargement on digital rectal exam and ultrasound, with volume 65 mL (up from 42 mL three years ago). PSA is 3.2 mcg/L. He has no allergies and denies recent UTIs.

Question 1BPH

Which medication is most appropriate to add?

Incorrect · Answer: B

PEBC Yield: Highbph-pharmacotherapy5-alpha-reductase-inhibitoralpha-blocker-vs-5ariprostate-volume-reduction

Doxazosin is a NON-uroselective alpha-1 blocker. It relaxes smooth muscle in the bladder neck and prostatic urethra and can improve flow within days to weeks — but it does NOT reduce prostate volume or modify long-term progression. Compared with uroselective alpha-1A blockers (tamsulosin, silodosin), doxazosin carries more orthostatic hypotension and first-dose syncope risk due to systemic vasodilation. In KS — large prostate (65 mL) with progressive volume growth — alpha-blocker monotherapy treats symptoms but leaves the volume-driven progression untreated. Source: Canadian Urological Association BPH guidelines 2018.

B) (Correct)

Correct. Finasteride is a 5-alpha-reductase inhibitor (5-ARI) that blocks conversion of testosterone to dihydrotestosterone (DHT) in the prostate. Clinical pearl: PSA over 1.5 mcg/L correlates with prostate volume over 30 mL and identifies men who derive most benefit from 5-ARI therapy. KS meets both criteria (PSA 3.2, volume 65 mL). 5-ARIs reduce prostate volume by roughly 20 to 25% over 6 to 12 months and lower long-term risk of acute urinary retention and BPH surgery (MTOPS, PLESS trials). PSA caveat on therapy: finasteride lowers PSA by about 50% within 6 months — when monitoring for prostate cancer on a 5-ARI, DOUBLE the measured PSA to compare against pre-treatment baseline. Source: CUA BPH 2018; Health Canada Proscar monograph.

Tamsulosin is a uroselective alpha-1A blocker — strong symptom relief for obstructive LUTS with less orthostatic risk than doxazosin. Like all alpha-blockers, it does NOT shrink the prostate or slow volume progression. Tamsulosin fits a goal of rapid symptom relief; it is often combined with a 5-ARI in patients who need both (e.g., Combodart = dutasteride/tamsulosin). For a large gland with progressive volume growth, monotherapy alpha-blocker is incomplete.

Solifenacin is an antimuscarinic for overactive bladder (OAB). BPH patients commonly have OAB overlap symptoms (urgency, frequency) — which makes antimuscarinics LOOK attractive — but anticholinergic effects (decreased detrusor contractility) can precipitate or worsen URINARY RETENTION in men with bladder outlet obstruction. KS already has hesitancy and incomplete emptying — solifenacin would worsen these. Clinical pearl: antimuscarinics can be used in selected BPH patients only AFTER outlet obstruction is adequately treated; never as initial monotherapy in a man with obstructive LUTS.

Question 2BPH

Four weeks after starting the add-on selected by urology, KS calls the pharmacy frustrated that his nocturia and weak stream feel unchanged. He has been taking the medication daily and has not started an alpha-blocker. He asks whether the medication has failed and whether he should stop it. Which counselling response best sets expectations for this drug class?

Incorrect · Answer: C

PEBC Yield: Hightreatment-timelinefinasteride-onsetadherence-counsellingcombination-therapy-combat

Six weeks is too soon for a 5-ARI to show meaningful benefit. This timeline fits an alpha-blocker (symptom relief within days to weeks via smooth-muscle relaxation), NOT a volume-reduction drug that works through hormone-mediated tissue change. Choosing 6 weeks reflects confusing 5-ARI pharmacology with alpha-blocker pharmacology.

Three months is when early reassessment typically occurs in clinical practice (first follow-up visit). Some patients notice modest symptom change, but it is too early to promise meaningful symptom improvement or substantial volume reduction. Counselling at 3 months should focus on adherence and managing expectations, not declaring failure.

C) (Correct)

Correct. 5-ARIs (finasteride, dutasteride) work by lowering intraprostatic DHT, which causes gradual epithelial regression of prostate tissue. Counselling timeline (CUA 2018; Health Canada monograph): meaningful symptom improvement typically takes ~6 months, with prostate volume reduction (~20-25%) and the progression benefit (lower retention risk, fewer surgeries) developing over roughly the first 12 months. An alpha-blocker is often added concurrently to provide rapid symptom relief during this slow-onset window — combination therapy (5-ARI + alpha-blocker) is supported by MTOPS for moderate-severe symptoms with enlarged glands.

This is too pessimistic. First meaningful symptom change should not require 12 months in responders, and prostate volume reduction is detectable well before 18 months. Telling a patient to wait 12-18 months risks losing adherence. Source: MTOPS trial, PLESS trial.

Question 3BPH

At KS's 3-month follow-up, he says he is willing to continue therapy but wants a more practical counselling summary before the next refill. He asks which changes should prompt him to call rather than quietly stopping the medication, and whether this drug has the same dizziness concern as older prostate medications. Which counselling point is most appropriate?

Incorrect · Answer: D

PEBC Yield: Highfinasteride-adrssexual-dysfunctionbph-drug-class-distinction

Persistent GI upset is not the characteristic 5-ARI adverse-effect pattern. Choosing this reflects generic adverse-effect guessing rather than class-specific counselling. Mild dyspepsia can occur with any oral medication but is not a 5-ARI signal.

Orthostatic dizziness and first-dose syncope are classic ALPHA-BLOCKER counselling points (especially doxazosin and terazosin, less so with uroselective tamsulosin). NOT 5-ARI effects. Confusing the two BPH drug classes is the common error this distractor tests.

Gynecomastia and breast tenderness CAN occur with 5-ARIs (~1-2% incidence) but are less common than sexual adverse effects and do NOT reliably resolve while therapy continues. New or progressive breast changes should be REPORTED (not dismissed) because rare male breast cancer signal exists. So 'usually resolves' is the wrong half of this option.

D) (Correct)

Correct. Sexual adverse effects — decreased libido, erectile dysfunction, ejaculatory changes — are the most common and clinically important 5-ARI counselling points (~10-15% incidence in finasteride trials vs ~5% placebo; ejaculatory changes ~3-5%). KS should know these may occur, that they're generally reversible on discontinuation in the majority of patients, and to report bothersome or persistent symptoms. Also remind him that PSA interpretation changes on therapy (double the measured PSA when monitoring for prostate cancer). Source: Health Canada Proscar monograph, CUA 2018.

Question 4BPH

Four months into therapy, KS develops a typical upper respiratory tract viral infection with nasal congestion, rhinorrhea, low-grade fever, and mild myalgia. He asks for an over-the-counter recommendation to manage his symptoms. Which of the following OTC medications should KS avoid?

Incorrect · Answer: A

PEBC Yield: Highotc-counsellingbph-avoid-listalpha-agonist-urinary-retentionpseudoephedrine-contraindications

A) (Correct)

Correct. Pseudoephedrine is the STRONGEST avoid for KS — it carries a DOUBLE-HIT mechanism in this patient: (1) BPH effect — as an alpha-adrenergic agonist it contracts smooth muscle in the bladder neck and prostatic urethra, precipitating or worsening urinary retention. KS already has hesitancy and incomplete emptying, so this is clinically high-risk. (2) HTN effect — pseudoephedrine elevates blood pressure (typically 5-15 mmHg systolic) and heart rate via systemic sympathomimetic action. Either effect alone is a caution; together they make pseudoephedrine specifically cautioned-to-avoid. Source: Health Canada pseudoephedrine monograph (BPH and HTN warnings).

Saline nasal spray mechanically clears nasal passages without any alpha-agonist, anticholinergic, or systemic effect. Safe in BPH and HTN. First-line non-pharmacologic option for nasal congestion.

Naproxen at OTC dose (220 mg q8-12h PRN) for short-course cold symptoms is a CONDITIONAL avoid — not as severe as pseudoephedrine. Mechanism: NSAIDs cause modest BP elevation (~3-5 mmHg on average) by reducing prostaglandin-mediated vasodilation, and they can blunt the antihypertensive effect of ACE inhibitors (KS is on ramipril). Renal-effect risk exists but is small for short low-dose courses in a patient without baseline CKD. Bottom line for ranking: BP impact alone, no BPH mechanism. Pseudoephedrine is the stronger avoid because it hits BOTH the BPH AND HTN axes. Source: CMAJ NSAIDs-and-hypertension reviews; Health Canada naproxen monograph.

Acetaminophen is the first-line OTC antipyretic-analgesic for adults with cardiovascular comorbidities. It does not affect BP or interact meaningfully with BPH. Safe and preferred for KS's fever and myalgia. Counsel max 3000-4000 mg/day depending on risk factors.

Full-length cases like this, across every PEBC domain, live in the question bank.

Frequently asked questions

Is men's health high yield on the PEBC exam?: Yes. Erectile dysfunction and benign prostatic hyperplasia are common, and the PDE5 inhibitor and nitrate interaction is a classic high-yield safety point. The exact mix is randomized from one sitting to the next, but men's health is consistently worth focused preparation.
What men's health topics should I focus on for the PEBC?: Focus on the PDE5 inhibitors and the nitrate contraindication, and on benign prostatic hyperplasia, where the key is separating the alpha-blockers from the 5-alpha-reductase inhibitors by speed and mechanism. The relevant cautions are common targets.
Which references should I use for men's health on the PEBC?: Use the Canadian Urological Association guidance for erectile dysfunction and benign prostatic hyperplasia. The PEBC expects the Canadian approach to drug selection and the key safety interactions.
How should I study men's health for the PEBC?: Lock in the PDE5 inhibitor and nitrate rule, separate the BPH drug classes by speed and mechanism, and know the alpha-blocker cautions.