renal – Bradford VTS

UROLOGY & RENAL MEDICINE FOR GPs

A comprehensive clinical guide for primary care practitioners

☕ Tea-Friendly Learning

⏰ For GP Trainees Short on Time

🚩 Red Flag Focused

February 9, 2026

📋 Executive Summary

What This Page Covers:

• Data-gathering & examination tips for urinary/renal presentations
• Diagnostic approach & investigations (triage, tests, monitoring)
• Differential diagnosis frameworks for common presentations
• Common conditions GPs manage confidently (AKI, CKD, UTIs, BPH)
• Red flags & conditions not to miss (malignancy, retention, sepsis)
• WPBA-ready structures and consultation skills

Quick Facts at a Glance:

3 out of 4

men with raised PSA don't have cancer

1 in 6

men with cancer have a normal PSA

50%

of men over 50 have BPH (90% over 80y)

10-15%

lifetime prevalence of kidney stones

🧭 Quick Navigation

Jump to the section you need

1. Data-Gathering & Examination Tips

Must-ask questions and structuring for key urinary presentations

Dysuria (Painful Urination)

Essential Questions

• Onset: sudden vs gradual, timing with intercourse
• Location: start, during, or end of urination
• Character: burning, stinging, sharp pain
• Associated symptoms: frequency, urgency, discharge
• Sexual history: new partner, STI risk factors
• Previous episodes: recurrent UTI pattern
• Systemic features: fever, rigors, loin pain
• Medications: recent antibiotics, immunosuppression

Differential Approach

• Infectious: bacterial UTI, STI (chlamydia, gonorrhoea)
• Non-infectious: interstitial cystitis, chemical irritation
• Structural: stones, tumour, stricture
• Hormonal: atrophic vaginitis (post-menopausal)

When not to assume UTI: men <65, recurrent episodes, haematuria
Red flags: visible blood, loin pain + fever, inability to void

Haematuria Assessment

Visible Haematuria (Macroscopic)

• Timing: initial, terminal, or throughout stream
• Colour: bright red, dark red, cola-coloured
• Clots: presence suggests significant bleeding
• Pain: painful (stones, infection) vs painless (malignancy)
• Associated: LUTS, loin pain, weight loss

2WW criteria: age >45 years (unless obvious UTI)

Non-visible Haematuria (Microscopic)

• Persistent: >2 positive dipsticks 2-3 weeks apart
• Exclude: menstruation, UTI, vigorous exercise
• Proteinuria: suggests glomerular disease
• Hypertension: check BP, consider renal disease
• Family history: polycystic kidneys, hereditary nephritis
• Medications: anticoagulants, cyclophosphamide

Lower Urinary Tract Symptoms (LUTS)

Storage Symptoms

• Frequency: >8 times/day
• Nocturia: >1 time/night
• Urgency: sudden compelling desire
• Urge incontinence: leakage with urgency
• Causes: overactive bladder, UTI, stones

Voiding Symptoms

• Hesitancy: delay in starting
• Poor stream: reduced force/calibre
• Intermittency: stop-start flow
• Straining: abdominal effort needed
• Causes: BPH, stricture, neurological

Post-micturition

• Incomplete emptying: sensation of residual urine
• Post-void dribbling: continued leakage
• IPSS scoring: quantify severity (0-35)
• Quality of life: impact assessment

Scrotal/Testicular Symptoms

Pain/Swelling - Time Critical

• Onset: sudden (torsion) vs gradual (epididymitis)
• Age: bimodal (neonates, adolescents) for torsion
• Nausea/vomiting: suggests torsion
• Fever: suggests infection
• Urinary symptoms: dysuria with epididymitis
• Sexual activity: STI risk factors
• Trauma history: recent injury or vigorous activity

Lumps - Routine Assessment

• Duration: slow-growing vs rapid change
• Consistency: hard (malignancy) vs soft (cyst)
• Separate from testis: epididymal vs testicular
• Transillumination: hydrocele vs solid mass
• Associated symptoms: pain, heaviness, dragging
• Family history: testicular cancer (rare but relevant)

Erectile & Sexual Function

Erectile Dysfunction (NICE CKS)

• Onset: gradual (vascular) vs sudden (psychological)
• Morning erections: preserved suggests psychological
• Relationship factors: partner, stress, depression
• Cardiovascular risk: diabetes, hypertension, smoking
• Medications: antihypertensives, antidepressants, diuretics
• Lifestyle: alcohol, recreational drugs, cycling
• Psychological: anxiety, depression, relationship issues

Digital Rectal Examination (DRE)

Prostate Size Assessment

• Normal: 20g (walnut size), smooth surface
• Mild enlargement: 20-40g, symmetrical
• Moderate: 40-80g, palpable median groove
• Severe: >80g, obliterated median groove
• Document: size estimate, symmetry, surface

Prostate Consistency

• Normal: firm, rubbery, like thenar eminence
• BPH: smooth, symmetrically enlarged
• Malignancy concern: hard, irregular, nodular
• Prostatitis: tender, boggy, warm
• Advanced cancer: fixed, woody hard

Red Flags for 2WW Referral:
• Hard, irregular nodule (any age)
• Fixed to surrounding structures
• Asymmetrical enlargement with hard areas
• PSA >4ng/ml + abnormal DRE
• Age-adjusted PSA concerns
• Rapid PSA rise (>20% annually)

2. Diagnostic Approach & Investigations

Systematic approach to investigations and monitoring in primary care

Urine Dipstick Testing

Key Parameters

• Protein: trace, 1+, 2+, 3+, 4+
• Blood: non-haemolysed vs haemolysed
• Leucocytes: suggests infection/inflammation
• Nitrites: gram-negative bacteria
• Glucose: diabetes screening
• Specific gravity: concentration ability

Interpretation Pitfalls

• False positives: contamination, menstruation
• False negatives: dilute urine, vitamin C
• Nitrites: negative doesn't exclude UTI
• Proteinuria: confirm with ACR if persistent
• Haematuria: exclude contamination first

PSA Test Counselling & Shared Decision Making

What to Say to Patients (Evidence-Based Phrases)

"The PSA test isn't perfect - it's like a smoke detector that sometimes goes off when you're just cooking."

"About 3 out of 4 men with a raised PSA don't actually have cancer - these are called false positives."

"The test can also miss some cancers - about 1 in 6 men with cancer have a normal PSA."

"Let's discuss what matters most to you - some men prefer to know, others prefer not to worry unless symptoms develop."

Key Counselling Points (PSA Consensus 2024)

• Balanced information: pros and cons of testing
• Individual choice: no right or wrong decision
• False positives: 75% of elevated PSAs are not cancer
• False negatives: 15-20% of cancers have normal PSA
• Overdiagnosis risk: many cancers never cause problems
• Treatment side effects: incontinence, erectile dysfunction
• Life expectancy: consider if >10 years

PSA Accuracy by Age Group

Age Group	False Positive Rate	False Negative Rate	Key Points
40-60 years	~80%	~10%	Highest false positive rate, lowest cancer prevalence
60-80 years	~70%	~15%	Optimal screening age group
80+ years	~60%	~20%	Screening generally not recommended

Key Message: False positives are much more common than false negatives across all age groups. For every 1000 men screened for 13 years, only 1-2 deaths from prostate cancer are prevented, but 240 men will have false positive results requiring further investigation.

Age-Adjusted PSA Reference Ranges

Normal PSA Ranges

Age	Upper Limit (ng/ml)
40-49	<2.5
50-59	<3.5
60-69	<4.5
70+	<6.5

2WW Referral Thresholds

• NICE 2024: PSA ≥3.0 ng/ml (any age)
• Age-adjusted approach: use age-specific ranges
• Rapid rise: >20% annually (any level)
• Abnormal DRE: regardless of PSA level
• High-risk groups: lower threshold consideration

Factors Causing PSA Elevation (False Positives)

Sexual Activity & Exercise

• Ejaculation: avoid 48 hours before test
• Sexual intercourse: avoid 48 hours before test
• Masturbation: avoid 48 hours before test
• Vigorous exercise: especially cycling, rowing
• Heavy lifting: avoid 48 hours before test
• Prolonged sitting: long car/bike rides

Medical Causes

• BPH: benign prostatic hyperplasia
• Prostatitis: acute or chronic inflammation
• UTI: urinary tract infection
• Recent DRE: within 1 week
• Catheterisation: recent procedure
• Prostate biopsy: within 6 weeks
• Age: naturally increases with age

Pre-test Instructions: Advise patients to avoid ejaculation, vigorous exercise (especially cycling/rowing), and recent prostate manipulation for 48 hours before PSA testing to prevent false positive results.

PSA Test Limitations & Patient Education

What PSA Can't Tell Us

• Cancer vs BPH: both can raise PSA
• Aggressive vs slow-growing: PSA level doesn't predict behaviour
• Location: doesn't show where cancer is
• Spread: doesn't indicate metastases
• Treatment need: many cancers never need treatment

Consequences of Positive PSA

• Repeat PSA: in 6-8 weeks
• MRI scan: multiparametric prostate MRI
• Possible biopsy: if MRI suspicious
• Anxiety: psychological impact
• Overdiagnosis: finding harmless cancers
• Overtreatment: unnecessary side effects

Balanced Counselling Script

"The PSA test is a useful tool, but it's not perfect. It's like a car alarm - sometimes it goes off when there's no real problem. About 3 out of 4 men with a raised PSA turn out not to have cancer after further tests. On the flip side, it can occasionally miss cancers too. The decision to have the test is entirely yours - there's no right or wrong choice. What matters is what feels right for you, considering your age, health, and personal values. Would you like to discuss what the next steps would be if your PSA was raised?"

3. Differential Diagnosis Frameworks

Systematic approaches to common urological and renal presentations

Symptom-Based Framework

Painful Haematuria

• UTI: dysuria, frequency, urgency
• Stones: renal colic, loin-to-groin pain
• Acute cystitis: suprapubic pain
• Prostatitis: perineal pain, fever
• Trauma: recent injury, catheterisation

Painless Haematuria

• Bladder cancer: age >45, smoking
• Renal cancer: mass, weight loss
• Prostate cancer: LUTS, raised PSA
• Glomerulonephritis: proteinuria, hypertension
• Anticoagulants: warfarin, DOACs

Pre-renal, Intrinsic, Post-renal Framework

Pre-renal (70%)

• Hypovolaemia: dehydration, bleeding, D&V
• Hypotension: sepsis, cardiogenic shock
• Reduced effective volume: heart failure, cirrhosis
• Medications: ACE-I, ARBs, NSAIDs, diuretics
• Renal artery: stenosis, thrombosis

Intrinsic (25%)

• Acute tubular necrosis: ischaemia, nephrotoxins
• Glomerulonephritis: RPGN, vasculitis
• Interstitial nephritis: drugs, infection
• Vascular: HUS, TTP, malignant hypertension
• Tubular obstruction: myeloma, rhabdomyolysis

Post-renal (5%)

• Bladder outlet: BPH, prostate cancer
• Ureteric: stones, tumours, strictures
• Bladder: neurogenic, blood clots
• Urethral: strictures, phimosis
• External compression: retroperitoneal mass

4. Acute Kidney Injury (AKI)

Recognition, management and prevention of AKI in primary care

AKI Definition & Recognition

KDIGO Criteria (Any of the following)

• Creatinine rise: ≥26 μmol/L within 48 hours
• Creatinine rise: ≥1.5x baseline within 7 days
• Oliguria: <0.5ml/kg/h for 6 hours

Clinical Presentation

• Often asymptomatic: detected on blood tests
• Reduced urine output: oliguria/anuria
• Fluid retention: oedema, breathlessness
• Uraemic symptoms: nausea, confusion, itch

AKI - When to Suspect

Anyone with a rapidly declining eGFR and/or signs of acute nephritis:
• Oliguria
• Haematuria
• Acute hypertension
• Oedema

These patients should be regarded as a medical emergency and admitted to hospital

I've started an ACE inhibitor or ARB and the eGFR has fallen

What to do if ACE inhibitor or ARB reduces eGFR further...

ACE inhibitors and ARBs cause a reversible reduction in glomerular blood flow (that's how they work!). As a result GFR can decline when treatment is initiated.

After starting an ACE inhibitor or ARB, you should always do a U&E and eGFR 1-2 weeks later.

✓ CONTINUE ACE inhibitor or ARB

If the reduction is less than 25% within 2 months of starting therapy

✗ STOP ACE inhibitor or ARB

If the reduction in GFR is more than 25% below the baseline value.
Refer to a nephrologist.

Which meds can cause AKI?

Drugs that can cause AKI

Watch out for the triple whammy that can cause an AKI:
• BP drugs (ACE inhibitor or ARB)
plus
• Diuretics
plus
• Pain killers (NSAIDs or COX2 inhibitors (except low dose aspirin))

AKI Staging & Severity

Stage	Serum Creatinine	Urine Output	Action
Stage 1	1.5-1.9x baseline or ≥26.5 μmol/L increase	<0.5 ml/kg/h for 6-12h	Monitor closely, treat cause
Stage 2	2.0-2.9x baseline	<0.5 ml/kg/h for ≥12h	Consider nephrology referral
Stage 3	3.0x baseline or ≥354 μmol/L	<0.3 ml/kg/h for ≥24h or anuria ≥12h	Urgent hospital referral

Prevention - Sick Day Rules & SADMAN

Preventing AKI - The Sick Day Rules

Tell the patient...

When you are unwell with any of the following…

• Vomiting or Diarrhoea (unless only minor and mild)
• Fevers, sweats and shaking (unless only minor and mild) – this can often happen with common cold/flu, chest infections, water infections

Then STOP taking the medicines I have written down for you

Restart these when you are well (after 24-48 hours of eating and drinking normally)

If you are in any doubt, contact the pharmacist, doctor, nurse or call 111.

Medicines to STOP on sick days (mnemonic SADMAN)

SGLT-2 inhibitors: medicine names ending in "flozins" like canagliflozin, empagliflozin, dapagliflozin

ACE inhibitors: medicine names ending in "pril" like ramipril, lisonopril, enalapril, captopril, perindopril

Diuretics: e.g. medicine names ending in "ide" like furosemide, bendroflumethiazide, bumetanide

Metformin (which is a medicine for diabetes)

ARBs: medicine names ending in "sartan" like losartan, candesartan, valsartan, irbesartan

NSAIDs: anti-inflammatory pain killers like ibuprofen, diclofenac, naproxen, ketoprofen

Also tell the patient: Other Measures...

• Take some rest

• Drink plenty of sugar-free fluids. Aim to drink at least three litres (five pints) a day, UNLESS YOU HAVE HEART FAILURE – see box on right.

• Try to keep to your normal meal pattern, but if you are unable to, see box on right.

• Avoid too much caffeine as this could make you dehydrated.

• Take painkillers in the recommended doses as necessary.

• Contact your GP to see if treatment with antibiotics is necessary.

• If you are vomiting uncontrollably, contact your GP or call 111

SPECIAL CASES... Oral fluids in patients with Heart Failure

Ask your Heart Failure nurse or GP or ring 111 about how much fluid you should drink.

You may need to stick to around 1.5-2 litres.

Weigh yourself every day.

If you suddenly gain more than 2Kg in 3 days, contact the emergency doctor or call 111.

If you cannot eat your normal meals...

You can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as yoghurt, milk and other milky drinks, fruit juice or sugary drinks such as Lucozade, ordinary cola or lemonade.

You may find it useful to let fizzy drinks go flat to help keep them down

If you are a diabetic on insulin or diabetes medication...

Keep taking your insulin or diabetes medications even if you are not eating. HOWEVER, stop metformin and blood pressure medication if you are dehydrated.

Test your blood four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.

Test your urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.

Testing for ketones

When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.

If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control.

Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.

5. Chronic Kidney Disease (CKD)

Comprehensive CKD management and monitoring in primary care

Defining CKD & Why it's important to treat

DEFINITION

Chronic Kidney Disease (CKD) is indicated when eGFR < 60 ml/min/1.73m² for >3m with or without kidney damage (so you need at least 2 GFRs)

It can also be in people with eGFR > 60 if... they have markers of kidney damage that are persistent for >3m (= micro or macro albuminuria).

CKD in itself is not a diagnosis. Attempts should be made to identify the underlying cause of CKD.

Did you know...

CKD is a stronger risk factor for future coronary events and all-cause mortality than diabetes.

WHY IS CKD IMPORTANT

If untreated a patient is more likely to have

• Hypertension that is difficult to control, which then leads to...

• IHD, HF, PVD, Stroke, which may then lead to...

• greater risk of cardiovascular MORTALITY

• hypoglycaemic events (kidneys excrete insulin usually)

• ankle swelling and fluid retention

• hip fractures (changes in calcium metabolism/vit D deactivation)

CKD in the elderly - what to do?

Renal function goes down as we age. It is a naturally ageing process and does not necessarily equate with morbidity and mortality in the elderly. Therefore the care of elderly people with CKD requires an individualised approach taking into account comorbidities, functional status life expectancy and health priorities.

CKD Staging & Classification

Stage	eGFR (ml/min/1.73m²)	Description	Monitoring Frequency	Action
G1	≥90	Normal/high (with kidney damage)	Annual	Monitor, treat comorbidities
G2	60-89	Mild decrease (with kidney damage)	Annual	Monitor, treat comorbidities
G3a	45-59	Mild-moderate decrease	6-monthly	Monitor, optimize treatment
G3b	30-44	Moderate-severe decrease	4-monthly	Consider nephrology referral
G4	15-29	Severe decrease	3-monthly	Nephrology referral, prepare for RRT
G5	<15	Kidney failure	Monthly	Renal replacement therapy

If eGFR is <45
People with moderate or severe CKD is defined as eGFR <45 mL/min/1.73 m² or persistently having a urine ACR >25 mg/mmol (males) or >35 mg/mmol (females))

They are considered to be at the highest risk of a cardiovascular event (>15% probability in five years). Failure to recognise the presence of moderate to severe CKD may lead to a serious under-estimation of cardiovascular disease (CVD) risk in that individual.

The Kidney Check in CKD - 3 things to check

Individuals with risk factors for CKD should undergo a Kidney Health Check every 1-2 years.

ALSO DON'T FORGET...

• Patients with structural renal disease - recurrent calculi or BPH

• Multisystem disease which might involved the kidneys e.g. SLE

• Gout

• Incidental haematuria or proteinura

BUT MOST IMPORTANTLY

Don't forget those discharged from hospital who had an AKI - every AKI will lead to a further worsening of CKD

ALL OF THESE PATIENTS NEED AT LEAST ANNUAL TESTING

eGFR

Estimated Glomerular Filtration Rate

Creatinine (U&E)

Urea & Electrolytes

ACR (urine)

Albumin:Creatinine Ratio

Lifestyle changes for CKD

Nutrition

• Consume a varied diet rich in vegetables, fruits, wholegrain cereals, lean meat, poultry, fish, eggs, nuts and seeds, legumes and beans, and low-fat dairy products.

• Limit salt to <6g /day (≤100mmol/day).

• Limit intake of foods containing saturated and trans fats.

• Limit intake of foods containing added sugars.

• Drink water to satisfy thirst.

• Avoid high calorie sweetened carbonated beverages at all costs.

• Dietary protein no lower than 0.75 g/kg body weight / day.

Weight

• Ideal BMI ≤25

• Waist circumference (MEN): <94cm (<90cm in Asian men)

• Waist circumference (WOMEN): <80cm (including Asian women).

Physical Activity

• Be active on most, preferably all, days every week.

• Accumulate 2 ½ to 5 hours of moderate intensity physical activity or 1 ¼ to 2½ hours of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week.

• Do muscle strengthening activities on at least 2 days each week.

Smoking

Stop smoking using counselling and, if required nicotine replacement therapy or other medication.

Alcohol

• Limit intake to ≤2 standard drinks per day to reduce risk of alcohol–related disease or injury over a lifetime.

• Do not drink >4 standard drinks on any single occasion

Protect your heart - CKD cardiovascular risk

Medical Targets for CKD

BP <130/80 mmHg

prescribe ACE inhibitor or ARBs to get it under control

What if ACE inhibitor or ARB reduces eGFR further?

ACE inhibitors and ARBs cause a reversible reduction in glomerular blood flow (that's how they work!). As a result GFR can decline when treatment is initiated.

After starting an ACE inhibitor or ARB, you should always do a U&E and eGFR 1-2 weeks later.

If the reduction is less than 25% within 2 months of starting therapy, CONTINUE ACE inhibitor or ARB

If the reduction in GFR is more than 25% below the baseline value, STOP ACE inhibitor or ARB. Refer to a nephrologist.

Glucose

• Blood glucose levels (BGL): 6-8mmol/L fasting; 8-10 mmol/L postprandial.

• HbA1c: generally ≤53 mmol/mol (range 48-58); ≤7% (range 6.5-7.5).

• Needs individualisation according to patient circumstances e.g. disease duration established vascular complications important comorbidities life expectancy

Albuminuria

aim for 50% reduction in urine ACR.

prescribe ACE inhibitor or ARBs to get it BP under control and slow the progression of albuminuria

What if ACE inhibitor or ARB reduces eGFR further?

ACE inhibitors and ARBs cause a reversible reduction in glomerular blood flow (that's how they work!). As a result GFR can decline when treatment is initiated.

After starting an ACE inhibitor or ARB, you should always do a U&E and eGFR 1-2 weeks later.

If the reduction is less than 25% within 2 months of starting therapy, CONTINUE ACE inhibitor or ARB

If the reduction in GFR is more than 25% below the baseline value, STOP ACE inhibitor or ARB. Refer to a nephrologist.

Lipids

Use statin or statin/ezetimibe combination in people ≥50 years with any stage of CKD, or in people <50 years with any stage of CKD in the presence of one or more of

• coronary disease

• previous ischaemic stroke

• diabetes or estimated high cardiovascular risk (>15% over 5 years

No target serum cholesterol level recommended.

FBC - anaemia

keep to Hb 100-115g/L

If low, consider a trial of iron supplementation maintaining:

• Ferritin >100 µg/L.

Specialist may need to initiate erythropoietin stimulating agent (ESA).

Once ESA commenced, maintain:

• Ferritin 200-500 µg/L; TSAT 20-30%.

Potassium

Level K+ ≤6.0 mmol/L.

Vaccinations

Influenza and invasive pneumococcal disease vaccination recommended for all people with diabetes and / or ESKD.

Tweaking the repeat medication list in CKD

THE DOCTOR

Medication adjustments are often needed in people with CKD and without them kidney function can be further compromised.

If you prescribe anything acute, look up to see whether it can have an effect on the kidney function.

Could it cause an acute kidney injury? (see the "medicines that can cause acute kidney injury" tab.

EMPOWER THE PATIENT

Educate your patients to flag their kidney status with other providers and ensure your patient is aware that having CKD can affect prescribing of medications.

THE PHARMACY TEAM

Consider referral to a pharmacist for a Medication Review and Medication Optimisation.

Drugs that can cause AKI

The Triple Whammy

Watch out for the triple whammy that can cause an AKI

• BP drugs (ACE inhibitor or ARB)

plus

• Diuretics

plus

• Pain killers (NSAIDs or COX2 inhibitors (except low dose aspirin)

Diabetic meds

If eGFR>45 - can use metformin up to max dose 1g bd

If eGFR lower than this, risk of lactic acidosis

If eGFR<45 - reduce metformin to 500mg bd

If eGFR<30 - stop metformin.

In diabetes, Please remember

Metformin is very effective, reduces cardiovascular risk, retards weight gain and is not usually associated with hypos – but is contra-indicated if Creatinine > 150 (or eGFR < 40) in CCF or significant hepatic dysfunction. Metformin has to be stopped if eGFR fall below 30! Reason: Metformin is renally cleared and accumulates when kidney function is severely impaired (eGFR <30), leading to increased risk of metformin-associated lactic acidosis (MALA) due to impaired lactate clearance and drug accumulation.

Ramadan & Fasting Advice for Renal Disease

Fasting & Ramadan

Fasting is an obligation for competent, healthy adult Muslims although there are exemptions. Many of those who could seek exemption might still want to fast. It is important to respect this but it is advisable to start planning 6-8 weeks before Ramadan to avoid adverse outcomes e.g. patient self-adjustment of medication.

The fast of Ramadan lasts from dawn to sunset for a period of 29 or 30 days. It follows the lunar calendar so is brought forward by about 10 days each year.

Fasting people generally eat two meals a day: often a smaller meal before dawn (Suhoor) and a larger one after sunset (Iftar). No fluids or food are taken during daylight hours. This includes water and most medication.

Who is exempt from fasting?

• Acute or chronic illness

• Travellers

• Pregnant/breastfeeding*

• Menstruating/postpartum bleeding

• Children

• Mentally unwell/lacks capacity

*Consensus by Islamic scholars that it is permissible not to fast if there is threat of harm to mother/child

Permissible interventions

• Blood tests

• Vaccinations

• Asthma inhalers*

• Ear drops*

• Eye drops

• Transdermal patches

*Difference of opinions exist. Encourage patients to contact their local imam, or BIMA for advice.

Should I advise my patient NOT to fast?

BIMA have an interactive traffic light tool that help to classify patients into low/moderate risk, high risk, and very high risk at www.britishima.org/Ramadan-compendium in chapter 6.

Patients in the two higher tiers should be advised that they 'must not fast' and 'should not fast' respectively.

Consider advising these patients to fast in the shorter winter months.

MUST NOT FAST - V. HIGH RISK

• All those on dialysis

• CKD stage 4-5

• CKD 3-5 with cardiovascular disease

SHOULD NOT FAST - HIGH RISK

• CKD 1-3 but unstable disease (rapidly declining GFR/fluid overload/frail)

• CKD with electrolyte abnormality

• Those on fluid restriction

INDIVIDUAL DECISION - LOW RISK

• CKD 1-3 with stable renal function

WHAT IS THEIR ABILITY TO TOLERATE IT

6. Urinary Tract Infections (UTI)

Evidence-based UTI management and antimicrobial stewardship

Uncomplicated UTI (Women)

First-Line Treatment

• Nitrofurantoin: 100mg BD x 3 days
• Alternative: Trimethoprim 200mg BD x 3 days
• Pregnancy: Nitrofurantoin (avoid at term)
• No routine: follow-up urine culture

When NOT to Treat

• Asymptomatic bacteriuria: elderly, catheterised
• Pregnancy exception: treat asymptomatic bacteriuria
• Contaminated sample: mixed growth
• Dipstick only: in asymptomatic patients

Complicated UTI

Definition

• Men: always considered complicated
• Structural abnormalities: stones, obstruction
• Immunocompromised: diabetes, steroids
• Pregnancy: risk of pyelonephritis
• Catheterised patients: indwelling catheter

Treatment

• Duration: 7 days minimum
• 1st line: Nitrofurantoin 100mg BD
• Alternative: Trimethoprim 200mg BD
• Send MSU: before starting antibiotics
• Follow-up: ensure clinical improvement

Recurrent UTI Management

Non-antibiotic Measures

• Fluid intake: 1.5-2L daily
• Post-coital voiding: within 15 minutes
• Cranberry products: may reduce recurrence
• Avoid: spermicides, diaphragms
• Topical oestrogen: post-menopausal women

Antibiotic Prophylaxis

• Indication: ≥3 UTIs in 12 months
• 1st line: Trimethoprim 100mg ON
• 2nd line: Nitrofurantoin 50mg ON
• Duration: 6 months initially
• Review: 3-monthly, consider stopping

Catheter-Associated UTI (CAUTI)

Prevention

• Avoid unnecessary: catheterisation
• Remove early: as soon as possible
• Aseptic technique: insertion and care
• Closed drainage: maintain system integrity
• Daily hygiene: meatal cleaning

Treatment

• Symptomatic only: don't treat asymptomatic bacteriuria
• Change catheter: before starting antibiotics
• 1st line: Nitrofurantoin 100mg BD x 7 days
• Alternative: Trimethoprim 200mg BD x 7 days
• Severe: consider IV antibiotics

7. Benign Prostatic Disease (BPH)

Comprehensive BPH assessment and management strategies

BPH Assessment & Diagnosis

Clinical Assessment

• IPSS score: quantify symptom severity (0-35)
• Quality of life: impact on daily activities
• DRE: prostate size, consistency, nodules
• Post-void residual: bladder scan if available
• Flow rate: uroflowmetry if available

Investigations

• Urine dipstick: exclude UTI, haematuria
• U&E: baseline renal function
• PSA: if life expectancy >10 years
• Frequency-volume chart: if nocturia prominent

Medical Management Options

Conservative

• Lifestyle: reduce evening fluids
• Bladder training: scheduled voiding
• Avoid: caffeine, alcohol before bed
• Medications: review anticholinergics
• Constipation: treat if present

Alpha-blockers

• Tamsulosin: 400mcg OD (1st line)
• Alfuzosin: 10mg OD (alternative)
• Onset: rapid improvement (days-weeks)
• Side effects: dizziness, retrograde ejaculation
• Caution: cataract surgery

5α-reductase Inhibitors

• Finasteride: 5mg OD
• Indication: prostate >30g
• Onset: slow improvement (3-6 months)
• PSA effect: reduces by ~50%
• Side effects: erectile dysfunction, gynaecomastia

When to Refer for Surgical Management

Absolute Indications

• Acute urinary retention: failed trial without catheter
• Recurrent retention: multiple episodes
• Renal impairment: due to bladder outlet obstruction
• Bladder stones: secondary to obstruction
• Recurrent UTIs: due to incomplete emptying

Relative Indications

• Failed medical therapy: persistent bothersome symptoms
• Patient preference: definitive treatment
• Large post-void residual: >300ml consistently
• Severe symptoms: IPSS >19 with poor QoL

8. Urinary Tract Stone Disease

Acute management and prevention strategies for renal stones

Acute Stone Management

Pain Management

• 1st line: Diclofenac 75mg IM or 100mg PR
• Oral NSAIDs: Ibuprofen 400mg TDS
• Opioids: if NSAIDs contraindicated
• Avoid: buscopan (no evidence of benefit)
• Paracetamol: adjunct therapy

Medical Expulsive Therapy

• Indication: stones 5-10mm in ureter
• Tamsulosin: 400mcg OD x 4 weeks
• Nifedipine: alternative option
• Follow-up: 2-4 weeks
• Refer if: no progress at 4 weeks

Stone Prevention Strategies

General Measures

• Fluid intake: 2.5-3L daily (urine output >2L)
• Dietary sodium: <6g daily
• Dietary protein: 0.8-1.2g/kg daily
• Calcium intake: normal dietary calcium
• Weight management: maintain healthy BMI

Stone-Specific Advice

• Calcium oxalate: reduce oxalate-rich foods
• Uric acid: alkalinise urine, reduce purines
• Cystine: high fluid intake, alkalinise urine
• Struvite: treat underlying infection

Emergency Referral Criteria

• Sepsis: fever + stone + obstruction
• AKI: rising creatinine
• Anuria: complete obstruction
• Intractable pain: despite adequate analgesia
• Solitary kidney: with obstruction
• Bilateral obstruction: rare but serious

9. Overactive Bladder & Incontinence

Comprehensive continence assessment and management

Types of Incontinence

Stress Incontinence

• Triggers: cough, sneeze, exercise, lifting
• Mechanism: urethral sphincter weakness
• Risk factors: childbirth, menopause, obesity
• No urgency: leakage without warning

Urge Incontinence

• Mechanism: detrusor overactivity
• Symptoms: sudden urge followed by leakage
• Triggers: key in door, running water
• Associated: frequency, nocturia

Conservative Management

Lifestyle Measures

• Weight loss: if BMI >30
• Fluid management: 1.5-2L daily
• Caffeine reduction: <100mg daily
• Constipation: treat if present
• Smoking cessation: reduces cough

Pelvic Floor Training

• Supervised: physiotherapist referral
• Duration: 3 months minimum
• Technique: 8-12 contractions TDS
• Biofeedback: if available

Bladder Training

• Scheduled voiding: gradually increase intervals
• Urge suppression: distraction techniques
• Bladder diary: 3-day record
• Duration: 6 weeks minimum

Medical Management

Overactive Bladder

• 1st line: Oxybutynin 2.5mg BD (start low)
• Alternative: Tolterodine 2mg BD
• Long-acting: Solifenacin 5mg OD
• Side effects: dry mouth, constipation, confusion
• Contraindications: narrow-angle glaucoma

Post-menopausal Women

• Topical oestrogen: vaginal cream/pessary
• Duration: 3 months trial
• Benefits: improves urethral function
• Safe: minimal systemic absorption

10. Red Flags & Conditions Not to Miss

Life-threatening conditions requiring urgent recognition and referral

Bladder Cancer

Key Warning Signs

• Painless visible haematuria: age ≥45
• Non-visible haematuria: age ≥60 + dysuria/raised WCC
• Recurrent UTIs: especially in men
• Irritative symptoms: frequency, urgency without infection
• Pelvic mass: advanced disease

Risk Factors

• Smoking: 4x increased risk
• Occupational: dyes, rubber, chemicals
• Age: peak 60-70 years
• Male: 3:1 male predominance
• Previous bladder cancer: high recurrence

2WW Referral: Age ≥45 with visible haematuria (no UTI) OR Age ≥60 with non-visible haematuria + dysuria/raised WCC

Testicular Cancer

Local Signs

• Painless lump: hard, non-tender
• Testicular enlargement: asymmetrical
• Heaviness: dragging sensation
• Change in consistency: harder than normal
• Hydrocele: secondary to tumour

Metastatic Disease

• Abdominal mass: retroperitoneal lymph nodes
• Respiratory symptoms: pulmonary metastases
• Gynaecomastia: β-hCG secretion
• Back pain: retroperitoneal mass

Peak age: 20-40 years. Any testicular lump in young men = 2WW referral

Testicular Torsion

Clinical Features

• Sudden onset: severe scrotal pain
• Nausea/vomiting: often prominent
• High-riding testis: horizontal lie
• Absent cremasteric reflex: affected side
• No relief: with elevation

Age Distribution

• Bimodal peaks: neonates and adolescents
• Peak age: 12-18 years
• Bell-clapper deformity: predisposing factor
• Bilateral risk: prophylactic fixation

EMERGENCY: Immediate surgical exploration. Salvage rate: 90% if <6 hours, 50% if 6-12 hours, 10% if >24 hours

Acute Urinary Retention

Clinical Features

• Inability to void: complete or partial
• Suprapubic pain: severe, constant
• Palpable bladder: dull to percussion
• Restlessness: patient in distress
• Previous LUTS: often present

Common Causes

• BPH: most common in elderly men
• Medications: anticholinergics, opioids
• Constipation: faecal impaction
• Infection: prostatitis, UTI
• Neurological: spinal cord lesions

Immediate action: Catheterisation (urethral or suprapubic). Same-day urology referral if recurrent.