Updated guidance — January 2026:
NICE refreshed its suspected-cancer referral guideline (NG12, last updated 12 January 2026). For the urinary tract it keeps age-specific PSA thresholds for prostate-cancer referral (50–59: >3.5; 60–69: >4.5 µg/L) and now adds unexplained appetite loss — alongside unexplained weight loss — as a symptom that should prompt assessment for several cancers, including bladder and renal. Practical upshot: don't dismiss "off my food and dropping weight" in an older patient — think malignancy and investigate. Source: NICE NG12, Suspected cancer: recognition and referral (last updated 12 Jan 2026).
Renal & Urology for GPs: Your Essential Guide
Waterworks, filtration units and the occasional plumbing emergency — decoded over a cuppa.
☕ Tea-Friendly Learning
⏰ For GP Trainees Short on Time
🚩 Red Flag Focused
Last Updated: 16 June 2026 · Verified against NICE CKS, NG12, NG109, NG112, NG118, NG123, NG203 & BNF
Executive Summary: What You'll Master Today
Because you have 47 other things to do before lunch — and that's just the morning list.
What This Page Covers:
- •History & examination
- •Investigations & the PSA test
- •Differential frameworks
- •Acute kidney injury
- •Chronic kidney disease
- •Urinary tract infections
- •Benign prostatic disease
- •Haematuria & proteinuria
- •Urological cancers
- •Urinary tract stones
- •Overactive bladder & incontinence
- •Red flags not to miss
Quick Facts at a Glance:
3 in 4
men with a raised PSA have no cancer found
1 in 6
prostate cancers occur with a "normal" PSA
ACR ≥3
mg/mmol = clinically important proteinuria (NICE)
~10–15%
lifetime risk of a kidney stone
PSA counselling figures: widely-cited approximations (≈75% of raised PSAs not cancer; ≈15–20% of cancers have normal PSA). ACR threshold: NICE NG203. Stone lifetime risk: ~14% (urolithiasis epidemiology).
📥 Downloads
path: URORENAL
- BPH & LUTS Management Pathway.pdf
- chronic kidney disease management - affinity care 2022.pptx
- CKD - Progression & Complications.pptx
- CKD Annual Review - checklist.docx
- CKD Criteria & Targets - quick reference guide.docx
- CKD Diagnosis Staging and Comprehensive Assessment.pptx
- CKD Discussions with Patients - explanations.docx
- CKD Management in Primary Care.pptx
- Continence Top Tips.docx
- Foods Which Irritate the Bladder.pdf
- Haematuria & Proteinuria.pptx
- medications to be careful with in CKD - affinity care 2022.pptx
- Prescribing in CKD & SADMAN.pptx
- Prostate Examination - what should it feel like.pdf
- Prostate Symptom Score - IPSS.pdf
- Prostate, BPH and PSA - everthing you wanted to know.pptx
- PSA Counselling Guide.pdf
- PSA Counselling.docx
- PSA Values.pdf
- UTI Antibiotic Prophylaxis.docx
This shortcode is replaced automatically by WordPress.
🌐 Web Resources
- NICE CKS — Kidney Disease & Urology
Primary-care summaries for all the topics on this page.
- NICE NG12 — Suspected Cancer Referral
2WW thresholds for renal, bladder, prostate & testicular cancer.
- NICE NG203 — Chronic Kidney Disease
Assessment, ACR categories & management.
- NICE NG109 / NG112 — UTI Prescribing
Lower UTI and recurrent UTI antimicrobial guidance.
- NICE NG118 — Renal & Ureteric Stones
Analgesia-first approach and medical expulsive therapy.
- BNF
Definitive source for doses, cautions and interactions.
- Think Kidneys — AKI Resources
Sick-day rules and AKI prevention materials.
- BAUS Patient Information
British Association of Urological Surgeons leaflets.
- CRUK — Suspected Cancer Referral
Practical primary-care referral tools.
- RCGP eLearning
UTI and kidney-care learning modules.
📚 Quick Navigation
💡
Visible blood = explain it, every time. Visible (frank) haematuria in anyone ≥45 without a clear UTI is a 2-week-wait referral for bladder/renal cancer. Try the line: "The colour is almost always something simple, but blood in the urine is one we never just watch — I'd like to arrange a quick camera test to be safe." (NICE NG12)
🎯
Never blame the warfarin. Anticoagulants or antiplatelets do not explain away haematuria — they unmask underlying pathology. Investigate exactly as you would for anyone else.
⚠️
The "triple whammy" makes kidneys cry. ACE-inhibitor/ARB plus a diuretic plus an NSAID is a classic recipe for AKI — especially in a dehydrated, intercurrently-unwell older patient. Spot it on the repeat screen before they get ill.
💊
Check the U&E 1–2 weeks after starting an ACEi/ARB. A fall in eGFR of up to 25% (or creatinine rise up to 30%) is expected and you can continue. Beyond that, stop and rethink (renal artery stenosis?). (NICE NG203)
🩺
ACR, not the dipstick, quantifies proteinuria. Use a urine albumin:creatinine ratio on an early-morning sample. A confirmed ACR ≥3 mg/mmol is clinically important — and it sharply raises cardiovascular risk, not just kidney risk. (NICE NG203)
🔑
PSA is a smoke detector, not a diagnosis. Counsel before you take blood: avoid ejaculation, vigorous cycling and a recent DRE for 48 hours, and postpone PSA for ≥1 month after a proven UTI. Use NICE age-specific thresholds to refer, not a single magic number.
🏥
Sudden, severe testicular pain is the clock starting. Treat as torsion until proven otherwise — phone the on-call urologist, don't wait for a scan. Salvage falls fast after 6 hours.
📋
Painful, unable to pass urine + a palpable bladder = retention. Catheterise for relief, then hunt the cause (BPH, constipation, drugs, infection, cord compression). Document the residual volume drained.
Dysuria (painful urination)
Essential questions
- •Onset & timing: sudden vs gradual; linked to intercourse
- •Where in the stream: start, throughout, or end
- •Associated: frequency, urgency, discharge, haematuria
- •Sexual history: new partner, STI risk
- •Systemic: fever, rigors, loin pain (think pyelonephritis)
- •Recurrence pattern and recent antibiotics
Differential lens
- •Infective: bacterial UTI, STI (chlamydia, gonorrhoea)
- •Non-infective: interstitial cystitis, chemical irritation
- •Structural: stone, tumour, stricture
- •Hormonal: atrophic vaginitis (post-menopausal)
🛑 Don't auto-diagnose UTI in: men, recurrent episodes, or anyone with visible haematuria — these need a proper work-up, not just a script.
Lower urinary tract symptoms (LUTS)
LUTS (lower urinary tract symptoms — the everyday term for bladder and outflow symptoms) split into three buckets. Asking about all three keeps you systematic.
Storage
- •Frequency (>8/day)
- •Nocturia (>1/night)
- •Urgency & urge leakage
Voiding
- •Hesitancy
- •Poor / intermittent stream
- •Straining to void
Post-micturition
- •Incomplete emptying
- •Post-void dribble
- •Score with IPSS (0–35)
IPSS: the International Prostate Symptom Score — a 7-question tool (each 0–5) plus a quality-of-life question — quantifies severity and tracks response to treatment.
Scrotal / testicular symptoms
Pain / swelling — time-critical
- •Onset: sudden (torsion) vs gradual (epididymo-orchitis)
- •Age: torsion peaks in adolescents & young men
- •Nausea/vomiting: points to torsion
- •Fever + dysuria: points to infection
Lumps — structured assessment
- •Separate from / part of testis? epididymal vs testicular
- •Transilluminates? cyst/hydrocele vs solid mass
- •Consistency: hard, craggy = worry; soft, fluctuant = reassuring
- •Growth rate & heaviness/dragging
🛑 Any hard, non-tender testicular lump in a young man: suspected-cancer pathway referral and an urgent ultrasound — don't "review in 2 weeks".
Erectile dysfunction (a cardiovascular warning sign)
- •Pattern: gradual loss (vascular) vs sudden with preserved morning erections (often psychogenic)
- •Vascular risk: diabetes, hypertension, smoking, lipids — ED can pre-date IHD by 3–5 years
- •Drugs: beta-blockers, thiazides, SSRIs, finasteride
- •Bloods: fasting glucose/HbA1c, lipids, morning testosterone
⚠️ Reframe it: "ED is often the body's early warning light for the blood vessels — so checking your heart risk is part of treating it." It's a chance to prevent an MI, not just restore function.
Digital rectal examination of the prostate
DRE = digital rectal examination. You're judging size, surface and consistency — and you can usually tell benign from sinister by feel.
What benign feels like
- •Smooth, symmetrical, rubbery (like the firm pad at the base of your thumb)
- •Median groove preserved
- •BPH: smoothly & symmetrically enlarged
What worries you
- •Hard, craggy or nodular
- •Asymmetry / loss of median groove
- •Fixed, "woody" gland
🚩 Refer on a suspected-cancer pathway if the prostate feels malignant
🚩
Hard, irregular or nodular gland on DRE — refer regardless of PSA (NICE NG12).
🚩
PSA above the age-specific reference range — refer (see Investigations).
First-line tests in the room
Cheap, fast and often decisive — but each has traps.
Reading it well
- •Leucocytes + nitrites: support UTI (nitrites = Gram-negatives)
- •Blood: confirm not contamination/menstruation; quantify haematuria clinically
- •Protein: if positive, confirm with a urine ACR (don't rely on the strip)
- •Glucose: opportunistic diabetes clue
Pitfalls
- •Negative nitrites do not exclude UTI (some organisms don't reduce nitrate)
- •Don't dip the over-65s/catheterised for UTI — asymptomatic bacteriuria is common and shouldn't be treated
- •Vitamin C can cause false-negative blood/glucose
✅ NICE NG109: in women <65 with ≥2 key symptoms (dysuria, new nocturia, cloudy urine) treat empirically — a dipstick isn't needed if the clinical picture is clear.
- •U&E + eGFR: baseline renal function; essential before/after starting ACEi/ARB and for any AKI/CKD question
- •Urine ACR: the test for proteinuria (see Haematuria & Proteinuria)
- •FBC: anaemia (CKD, malignancy), raised WCC (infection)
- •HbA1c & lipids: cardiovascular/renal risk stratification
- •PSA: only after counselling and with correct pre-test conditions (next tabs)
eGFR (estimated glomerular filtration rate): a calculated marker of kidney function from creatinine, age and sex. One low reading isn't CKD — you need it sustained over >3 months.
NICE age-specific PSA referral thresholds (NG12)
NICE refers on a 2-week-wait pathway if PSA is above the age-specific reference range, or the DRE feels malignant. There is no single "magic number" for symptomatic men.
| Age (years) | Refer if PSA above (µg/L) |
|---|---|
| <40 | Use clinical judgement |
| 40–49 | >2.5 |
| 50–59 | >3.5 |
| 60–69 | >4.5 |
| 70–79 | >6.5 |
| ≥80 | Use clinical judgement (no age range — most have a focus of cancer; only diagnose if palliative treatment likely) |
Source: NICE NG12 (age-specific thresholds, defined 2021; guideline last updated 12 Jan 2026). Note: some screening trials/PCRMP use a flat 3 ng/mL for asymptomatic 50–69 men — a separate context from NG12 symptomatic referral.
Raise PSA falsely (so prep the patient)
- •Ejaculation / vigorous exercise (cycling) — avoid 48h
- •Recent DRE, catheterisation, UTI/prostatitis
- •Prostate biopsy — wait ~6 weeks
- •BPH and increasing age (physiological)
Practical pre-test rules
- •No ejaculation/heavy exercise for 48h
- •Postpone ≥1 month after a treated UTI
- •Do the PSA before the DRE, or wait a week
💊 Prescribing pearl — finasteride & PSA: 5α-reductase inhibitors (finasteride, dutasteride) roughly halve the PSA after ~6 months. Double the measured value to interpret it on treatment.
The smoke-detector script: "The PSA test is like a smoke alarm — useful, but it goes off for non-fires too. About 3 in 4 men with a raised result turn out not to have cancer, and it can occasionally miss one. There's no right or wrong choice — it's about what feels right for you."
Cover the trade-offs
- •False positives (≈75%) → MRI ± biopsy, anxiety
- •False negatives (≈15–20%) → normal PSA doesn't fully reassure
- •Overdiagnosis: many cancers never cause harm
- •Treatment harms: incontinence, erectile dysfunction
Who to consider testing (offer + counsel)
- •Any LUTS, ED, or visible haematuria (with DRE)
- •Asymptomatic men ≥50 requesting it (informed-choice, PCRMP)
- •Earlier discussion if Black ethnicity or family history
- •Consider life expectancy >10 years
Counselling figures are widely-used approximations; thresholds per NICE NG12. Screening of asymptomatic men is not a national programme (UK NSC).
Painful
- •UTI: dysuria, frequency, urgency
- •Stone: loin-to-groin colic, restless
- •Prostatitis: perineal pain, fever, LUTS
- •Trauma/instrumentation
Painless (think malignancy first)
- •Bladder cancer: age, smoking
- •Renal cancer: mass, weight loss
- •Prostate cancer: LUTS, raised PSA
- •Glomerular disease: proteinuria, hypertension
⚠️ Golden rule: painless visible haematuria is malignancy until proven otherwise — even on anticoagulants.
Pre-renal (commonest)
- •Hypovolaemia: D&V, bleeding, sepsis
- •Reduced effective volume: HF, cirrhosis
- •Drugs: ACEi/ARB, NSAIDs, diuretics
Intrinsic
- •Acute tubular necrosis (ischaemia/toxins)
- •Glomerulonephritis / vasculitis
- •Interstitial nephritis (drugs)
Post-renal (obstruction)
- •BPH / prostate cancer
- •Stones, ureteric tumour/stricture
- •Pelvic mass, clot retention
Bedside trick: always feel for a palpable bladder and ask about the stream — a simple obstruction (post-renal) is the most reversible cause and a catheter can be curative.
Acute pain (emergency lens)
- •Torsion: sudden, young, vomiting, high-riding
- •Epididymo-orchitis: gradual, dysuria, fever
- •Torted appendix testis: "blue dot"
Lumps (structural lens)
- •Hydrocele: transilluminates, can't get above
- •Epididymal cyst: separate, behind testis
- •Varicocele: "bag of worms", left-sided
- •Tumour: hard, within the testis
🛑 New left varicocele that doesn't drain on lying down: can signal a left renal tumour obstructing the renal vein — image the kidneys.
KDIGO criteria (any one)
- •Creatinine rise ≥26 µmol/L within 48 hours
- •Creatinine ≥1.5× baseline within 7 days
- •Urine output <0.5 mL/kg/h for 6 hours
How it shows up in GP-land
- •Usually silent — found on routine/sick bloods
- •Reduced urine output, oedema, breathlessness
- •Uraemic clues: nausea, confusion, itch
KDIGO: Kidney Disease: Improving Global Outcomes — the international body whose creatinine/urine-output criteria define and stage AKI.
🚩 Treat as an emergency — same-day admission
🚩
Rapidly declining eGFR with signs of acute nephritis: oliguria, haematuria, new oedema, acute hypertension.
🚩
AKI with hyperkalaemia, fluid overload or uraemic features — discuss with medicine/nephrology now.
🚩
Suspected obstruction (anuria, palpable bladder, known pelvic malignancy) — needs urgent imaging ± catheter.
ACE inhibitors and ARBs reduce intraglomerular pressure — that's how they protect kidneys long-term — so a small eGFR dip on starting is expected.
Always recheck U&E + eGFR 1–2 weeks after starting or up-titrating.
✅ Continue: if eGFR falls <25% (or creatinine rises <30%) from baseline. Recheck and carry on.
🛑 Stop & investigate: if eGFR falls ≥25% (or creatinine rises ≥30%) — exclude volume depletion/NSAIDs, consider renal artery stenosis, and discuss with nephrology.
💊 Potassium rule (NG203): don't start an ACEi/ARB if K⁺ >5.0 mmol/L; stop if K⁺ ≥6.0 mmol/L once other causes addressed.
Source: NICE NG203 (CKD) & CKS.
🛑 The "triple whammy": ACE-inhibitor/ARB + diuretic + NSAID (or COX-2). Each alone is fine; together, in a dehydrated patient, they tip the kidney into AKI.
Reduce renal perfusion
- •NSAIDs / COX-2 inhibitors
- •ACE inhibitors / ARBs
- •Diuretics (volume depletion)
Directly nephrotoxic / accumulate
- •Aminoglycosides (e.g. gentamicin)
- •Iodinated contrast
- •Metformin (lactic acidosis risk if AKI)
| Stage | Serum creatinine | Urine output | Primary-care action |
|---|---|---|---|
| 1 | 1.5–1.9× baseline or ≥26.5 µmol/L rise | <0.5 mL/kg/h for 6–12h | Find & treat cause, hold culprit drugs, recheck |
| 2 | 2.0–2.9× baseline | <0.5 mL/kg/h for ≥12h | Lower threshold to admit; discuss nephrology |
| 3 | ≥3.0× baseline or ≥354 µmol/L | <0.3 mL/kg/h ≥24h or anuria ≥12h | Urgent hospital admission |
🧠 Mnemonic: SAD MAN — the meds to pause on "sick days"
SSGLT2 inhibitors — the "-flozins" (dapagliflozin, empagliflozin)
AACE inhibitors — the "-prils" (ramipril, lisinopril)
DDiuretics — furosemide, bendroflumethiazide
MMetformin
AARBs — the "-sartans" (losartan, candesartan)
NNSAIDs — ibuprofen, naproxen, diclofenac
⚠️ Sick-day rule script: "If you're vomiting, have diarrhoea, or are feverish and not keeping fluids down, pause these tablets for the day or two until you're eating and drinking normally again — then restart. If in doubt, ring 111 or the surgery."
✅ Heart-failure caveat: don't blanket-advise "drink 3 litres" in HF — they may need fluid restriction (~1.5–2 L) and daily weights. Individualise.
Sick-day guidance: Think Kidneys / NICE CKS. Always re-confirm doses against the BNF for the individual patient.
Definition (NICE NG203): abnormalities of kidney function/structure for >3 months — typically eGFR <60 mL/min/1.73m² (on ≥2 readings ≥90 days apart), or markers of damage at any eGFR (e.g. ACR ≥3 mg/mmol, persistent haematuria, structural disease).
⚠️ Not a diagnosis in itself: always look for the cause (diabetes, hypertension, obstruction, glomerular disease).
🛑 Why it matters: CKD is a powerful cardiovascular risk multiplier — most people with CKD die of cardiovascular disease, not of needing dialysis.
✅ In frailty/older age: eGFR falls with normal ageing. Don't over-label or over-medicate — individualise around comorbidity, function and life expectancy (NICE: don't manage CKD by age alone).
Source: NICE NG203, CKD assessment & management.
Classify by both GFR (G) and ACR (A) categories — the two together multiply risk.
| GFR stage | eGFR | Meaning | Typical monitoring* |
|---|---|---|---|
| G1 | ≥90 | Normal/high (+ damage marker) | Yearly |
| G2 | 60–89 | Mild ↓ (+ damage marker) | Yearly |
| G3a | 45–59 | Mild–moderate ↓ | ~Yearly |
| G3b | 30–44 | Moderate–severe ↓ | ~6-monthly |
| G4 | 15–29 | Severe ↓ | ~Every 3–6 months |
| G5 | <15 | Kidney failure | Frequent / specialist |
| ACR category | Urine ACR (mg/mmol) | Meaning |
|---|---|---|
| A1 | <3 | Normal–mild |
| A2 | 3–30 | Moderately increased |
| A3 | >30 | Severely increased |
*Monitoring frequency is tailored to the individual's G/A categories and rate of change (NICE NG203). Example: eGFR 50 + ACR 35 = CKD G3aA3.
People with CKD risk factors deserve a "kidney health check" — and it's just three things:
eGFR
filtration function (from creatinine)
U&E
creatinine & electrolytes
Urine ACR
albumin:creatinine ratio
⚠️ Don't forget these high-risk groups: diabetes, hypertension, cardiovascular disease, recurrent stones/BPH, gout, multisystem disease (e.g. SLE), and — easily missed — anyone recently discharged after an AKI (every AKI nudges CKD onwards).
🩸 Blood pressure: aim <140/90; aim <130/80 if diabetic or ACR ≥70 mg/mmol.
🧪 Albuminuria: reducing ACR slows progression; ACEi/ARB is the lever.
💊 ACE inhibitor or ARB — when to offer (NG203):
- •Hypertension + ACR >30 (A3): offer ACEi/ARB
- •Diabetes + ACR ≥3: offer ACEi/ARB
- •ACR ≥70 (non-diabetic): offer ACEi/ARB and refer to nephrology
- •First-line example: ramipril (titrate to highest tolerated licensed dose) or ARB e.g. losartan / candesartan. Don't combine ACEi + ARB.
✅ SGLT2 inhibitors & statins: dapagliflozin is now licensed/recommended to slow progression in eligible CKD (e.g. with albuminuria). Offer atorvastatin 20 mg for cardiovascular protection in CKD (no cholesterol target set). Confirm individual eligibility/dose against NICE TA/NG203 and the BNF.
💊 Metformin by eGFR (BNF/NICE):
- •eGFR ≥45: usual dosing (max 1 g twice daily)
- •eGFR 30–44: review dose; reduce (commonly ~500 mg twice daily) and avoid if risk of sudden deterioration
- •eGFR <30: stop — risk of lactic acidosis (metformin is renally cleared)
⚠️ Review the repeat list: before adding anything acute, ask "could this hit the kidneys?" (NSAIDs, nephrotoxins, dose-by-renal-function drugs). Consider a pharmacist medication review.
Empower the patient: "Tell any clinician or pharmacist that your kidneys aren't at full strength — it changes some doses and which painkillers are safe."
🚩 Refer to nephrology (NICE NG203)
•
ACR ≥70 mg/mmol (unless known to be diabetes already appropriately treated).
•
ACR >30 mg/mmol with haematuria.
•
Sustained eGFR fall ≥25% with a category change within 12 months, or ≥15 mL/min/year.
•
5-year risk of needing dialysis ≥5% (4-variable Kidney Failure Risk Equation) — broadly maps to eGFR <30 / G4–G5.
•
Poorly controlled hypertension on ≥4 agents, suspected genetic kidney disease, or suspected renal artery stenosis.
Plan 6–8 weeks ahead. Use the British Islamic Medical Association (BIMA) risk tool. Respect that many who could be exempt will still wish to fast.
🛑 "Must not fast" (very high risk): dialysis; CKD G4–G5; CKD G3–5 with cardiovascular disease.
⚠️ "Should not fast" (high risk): unstable CKD (rapidly falling GFR, fluid overload, frail); electrolyte abnormality; on fluid restriction.
✅ Individual decision (low risk): stable CKD G1–3 — discuss tolerance and adjust med timing to Suhoor/Iftar.
Source: BIMA Ramadan compendium; align medication advice with the BNF.
💊 First-line (NICE NG109):
- •Nitrofurantoin 100 mg modified-release twice daily for 3 days (or 50 mg four times daily) — avoid if eGFR <45.
- •Trimethoprim 200 mg twice daily for 3 days — avoid if used in the last 3 months or local resistance is high.
- •Second-line (no improvement/resistance): pivmecillinam or fosfomycin per local microbiology.
Send an MSU if…
- •Pregnant, recurrent, treatment failure, or atypical
- •Aged ≥65 or catheterised with new systemic symptoms
When NOT to treat
- •Asymptomatic bacteriuria in non-pregnant adults/elderly
- •A positive dipstick alone in someone with no symptoms
Source: NICE NG109 (lower UTI antimicrobial prescribing); confirm doses for the individual against the BNF.
💊 Men with lower UTI (NICE NG109): treat for 7 days.
- •Trimethoprim 200 mg twice daily for 7 days, or nitrofurantoin 100 mg MR twice daily for 7 days (avoid if eGFR <45).
- •If features of prostatitis, nitrofurantoin won't reach the prostate — use a fluoroquinolone (e.g. ciprofloxacin) or trimethoprim per CKS acute prostatitis and treat longer.
⚠️ Any UTI in a man is "complicated": send an MSU before antibiotics, and consider obstruction/structural cause. Recurrent UTI or any visible haematuria → urology referral.
Complicated = structural/functional abnormality, immunocompromise, stones/obstruction, catheter, pregnancy — these often need longer courses and culture-guided therapy.
🛑 Treat asymptomatic bacteriuria in pregnancy: it reduces pyelonephritis and preterm risk — the one group where you do treat a positive culture without symptoms.
💊 Choices in pregnancy (NICE NG109):
- •Nitrofurantoin (not at term — risk of neonatal haemolysis)
- •Amoxicillin (only if culture confirms susceptibility) or cefalexin as alternatives
- •Avoid trimethoprim in the 1st trimester (folate antagonist; teratogenic risk)
Source: NICE NG109; always confirm pregnancy-specific dosing against the BNF.
Recurrent = ≥2 in 6 months or ≥3 in 12 months. Work up the cause and try non-antibiotic measures first.
Non-antibiotic measures (first)
- •Adequate fluids; treat constipation
- •Vaginal oestrogen for post-menopausal women
- •Review spermicide/diaphragm use
- •Consider D-mannose/cranberry (limited evidence)
Prophylaxis (NICE NG112)
- •Single-dose on trigger exposure: trimethoprim 200 mg or nitrofurantoin 100 mg
- •Daily: trimethoprim 100 mg at night or nitrofurantoin 50–100 mg at night
- •Methenamine hippurate 1 g twice daily — non-antibiotic alternative (NG112, 2024; seek specialist advice)
- •Review at ~6 months
Source: NICE NG112 (recurrent UTI, amended 2024); confirm doses against the BNF.
Prevention
- •Catheterise only when necessary; remove ASAP
- •Aseptic insertion; closed drainage system
Treatment
- •Treat only if symptomatic — never the dip alone
- •Consider changing a long-term catheter before/at antibiotic start
- •Culture-guided; typically 7 days (longer if upper-tract features)
⚠️ Smelly/cloudy catheter urine alone is NOT a UTI. Look for genuine systemic features (fever, rigors, new delirium, suprapubic/loin pain) before reaching for antibiotics.
Assess
- •IPSS score (0–35) + quality-of-life question
- •DRE: size, symmetry, consistency, nodules
- •Frequency-volume chart if nocturia prominent
- •Bladder scan for post-void residual (if available)
Investigate
- •Urine dipstick (exclude infection/haematuria)
- •U&E (exclude obstructive nephropathy)
- •PSA — after counselling, if life expectancy >10y
✅ Reassure: "An enlarged prostate is extremely common as men get older and is not cancer — we treat it because of the bother it causes, and we can usually improve things in steps."
Conservative measures first (fluid timing, caffeine/alcohol, treat constipation, review anticholinergics), then medication by symptom pattern and prostate size.
💊 First-line — alpha-blocker (bothersome moderate–severe LUTS):
- •Tamsulosin 400 micrograms modified-release once daily. Alternative: alfuzosin 10 mg MR once daily.
- •Onset: days–weeks. Watch: postural hypotension, retrograde ejaculation, and intra-operative floppy iris syndrome — warn before cataract surgery.
💊 Add/second-line — 5α-reductase inhibitor (enlarged prostate, >30 mL or PSA >1.4 ng/mL):
- •Finasteride 5 mg once daily. Alternative: dutasteride 0.5 mg once daily.
- •Onset: 3–6 months; shrinks the gland and cuts retention/surgery risk. Halves PSA — double the reading to interpret.
- •Side effects: reduced libido, ED, gynaecomastia.
Combination (alpha-blocker + 5-ARI): for moderate–severe LUTS with an enlarged gland (NICE CG97). Prescribe as separate drugs rather than a fixed-dose combination product. Add an antimuscarinic if storage symptoms persist (see Incontinence).
Source: NICE CG97 (LUTS in men) & CKS; doses per BNF.
Refer (often urgent)
- •Acute or chronic urinary retention
- •Obstructive nephropathy (rising creatinine)
- •Recurrent UTIs or bladder stones from poor emptying
- •Recurrent/troublesome haematuria
Consider referral
- •Failed/insufficient medical therapy
- •Bothersome symptoms (IPSS high) with poor QoL
- •Patient prefers definitive (surgical) treatment
- •Large persistent post-void residual
⚠️ Suspicious DRE or PSA above the age threshold? That's a suspected-cancer pathway referral (see Urological Cancers), separate from a routine BPH referral.
The big idea: haematuria is a symptom, not a diagnosis. Your three jobs: (1) spot emergencies, (2) exclude reversible causes (UTI, contamination, menstruation), and (3) apply NICE thresholds to decide urology (cancer) vs nephrology (glomerular) vs monitor.
Visible (macroscopic / "frank") haematuria = blood you can see. Higher cancer risk than non-visible.
First confirm it's urinary blood
- •Exclude menstruation/PV bleeding, beetroot, rifampicin
- •Timing: initial (urethral) / terminal (bladder neck/prostate) / throughout (bladder/upper tract)
- •Send MSU; check FBC, U&E/eGFR (within 3 months)
Pain helps localise
- •Painful: UTI, stone, clot colic
- •Painless: malignancy until proven otherwise
🚩 2-week-wait referral (NICE NG12)
🚩
Aged ≥45 with unexplained visible haematuria without UTI, OR visible haematuria that persists/recurs after successful UTI treatment → bladder and renal cancer pathway.
Non-visible (microscopic) haematuria = blood on dipstick only. Confirm it's real and persistent before acting.
Confirm & classify
- •Persistent = ≥2 of 3 positive dipsticks over a few weeks
- •Exclude UTI, menstruation, recent vigorous exercise
- •Symptomatic (s-NVH) vs asymptomatic (a-NVH)
- •Check BP, U&E/eGFR and a urine ACR every time
Don't be misled
- •Never blame anticoagulants — investigate anyway
- •Young adult + cola urine after a sore throat → think glomerulonephritis (nephrology, not urology)
🚩 2-week-wait referral (NICE NG12)
🚩
Aged ≥60 with unexplained non-visible haematuria AND either dysuria or a raised WCC → bladder cancer pathway.
•
Non-urgent bladder cancer referral: ≥60 with recurrent/persistent unexplained UTI.
Use ACR, not the dipstick (NICE NG203): a urine albumin:creatinine ratio on an early-morning sample is the test. A reagent strip should not be used to quantify proteinuria.
| ACR (mg/mmol) | Category | What to do |
|---|---|---|
| <3 | A1 (normal–mild) | Reassure; usual risk-factor care |
| 3–30 | A2 (moderate) | Confirm on a repeat early-morning sample; clinically important proteinuria |
| >30 | A3 (severe) | Treat & monitor; ACEi/ARB if hypertensive; consider referral |
- •Confirm: if initial ACR 3–70, repeat on an early-morning sample; if ≥70, no repeat needed.
- •Clinically important proteinuria = confirmed ACR ≥3 mg/mmol.
- •Treat (NG203): ACEi/ARB if hypertension + ACR >30; if diabetes + ACR ≥3; if non-diabetic + ACR ≥70 (and refer).
⚠️ Nephrotic-range red flag: heavy proteinuria with oedema and low albumin (nephrotic syndrome) — urgent nephrology. Frothy urine + leg swelling deserves an ACR the same week.
Source: NICE NG203 (CKD assessment & management).
🔀 Haematuria — urology, nephrology or monitor?
START: Confirmed urinary haematuria (UTI/contamination excluded)
↓
❓ Meets a NICE NG12 cancer threshold?
YES ↓NO ↓
2-week-wait urology
(visible ≥45; or ≥60 NVH + dysuria/↑WCC)
(visible ≥45; or ≥60 NVH + dysuria/↑WCC)
Check ACR, eGFR, BP → if proteinuria/declining eGFR/uncontrolled BP, refer nephrology; else monitor in primary care
✅ Nephrology (not urology) flags: haematuria with significant proteinuria (ACR >30 + haematuria, or ACR ≥70), declining eGFR, uncontrolled hypertension, or systemic features (rash, joints — think vasculitis).
If no threshold is met: haematuria alone doesn't need referral — but keep monitoring BP, eGFR and ACR in primary care; don't just discharge it.
Source: NICE NG12 (cancer referral) & NG203 (nephrology referral). When sources differ, NICE takes precedence.
🃏 Aide-mémoire — tap to reveal the threshold
Visible haematuria
tap for the rule →
≥45, unexplained, no UTI (or persists/recurs after UTI) → 2WW urology (bladder + renal).
Non-visible haematuria
tap for the rule →
≥60 + unexplained NVH + dysuria or raised WCC → 2WW urology.
Clinically important proteinuria
tap for the number →
Confirmed urine ACR ≥3 mg/mmol (NG203). Use early-morning sample; A3 = >30.
Nephrology referral on ACR
tap for the rule →
ACR ≥70 (unless treated diabetes), or ACR >30 with haematuria.
Recognise
- •Often incidental on imaging done for something else
- •Classic triad (late, uncommon): flank pain, mass, haematuria
- •Paraneoplastic: ↑Ca²⁺, polycythaemia, pyrexia, weight loss
- •New left varicocele not draining when supine
Risk factors
- •Smoking, obesity, hypertension
- •Dialysis-acquired cystic disease; von Hippel–Lindau
🚩 2WW referral (NICE NG12)
🚩
Aged ≥45 with unexplained visible haematuria without UTI, or visible haematuria persisting/recurring after UTI treatment.
Recognise
- •Painless visible haematuria is the hallmark
- •Irritative LUTS without infection; recurrent UTIs (esp. men)
- •Non-visible haematuria with dysuria/↑WCC in older patients
Risk factors
- •Smoking (the dominant risk — roughly half of cases)
- •Occupational: aromatic amines (dyes, rubber, paint)
- •Age, male sex, prior bladder cancer
🚩 2WW referral (NICE NG12)
🚩
≥45 with unexplained visible haematuria (no UTI), or visible haematuria persisting/recurring after UTI treatment.
🚩
≥60 with unexplained non-visible haematuria and dysuria or raised WCC.
•
Consider non-urgent referral: ≥60 with recurrent/persistent unexplained UTI.
Recognise / when to test
- •Often asymptomatic — found via PSA/DRE
- •Consider PSA + DRE if: any LUTS, erectile dysfunction, or visible haematuria
- •Bone pain/back pain → think metastatic disease
Risk factors
- •Age; Black ethnicity; family history (incl. BRCA)
- •Most common cancer in UK males
🚩 2WW referral (NICE NG12)
🚩
PSA above the age-specific reference range (40–49 >2.5; 50–59 >3.5; 60–69 >4.5; 70–79 >6.5 µg/L).
🚩
DRE feels malignant (hard, irregular, nodular, asymmetrical) — refer regardless of PSA.
What happens next: the modern pathway is usually multiparametric MRI first, then targeted biopsy if suspicious — so you can tell men a raised PSA doesn't mean an immediate biopsy.
| Cancer | Classic clue | NICE 2WW trigger |
|---|---|---|
| Renal | Often incidental; flank pain/mass/haematuria (late) | ≥45 unexplained visible haematuria (no UTI) |
| Bladder | Painless visible haematuria; smoker | ≥45 visible haematuria; or ≥60 NVH + dysuria/↑WCC |
| Prostate | LUTS / abnormal DRE / raised PSA | PSA above age range, or malignant-feeling DRE |
| Testicular | Painless hard testicular lump (young men) | Consider 2WW + urgent USS (see Red Flags) |
✅ Safety-net script: "Most causes of these symptoms are not cancer, but it's important we rule it out quickly. If anything changes — more blood, weight loss, new pain — come back sooner; don't wait for the appointment."
Source: NICE NG12 (last updated 12 Jan 2026). Remember the 2026 addition: unexplained weight loss and appetite loss in older patients should prompt cancer assessment (incl. bladder/renal).
💊 Analgesia — NSAID first (NICE NG118):
- •Offer an NSAID by any route as first-line for the pain of suspected renal colic (e.g. diclofenac), unless contraindicated.
- •IV paracetamol if an NSAID is contraindicated or not giving enough relief.
- •Opioids only if both an NSAID and IV paracetamol are contraindicated or insufficient.
- •Do not offer antispasmodics (e.g. hyoscine butylbromide) for stone pain.
Confirm & assess
- •Urgent non-contrast CT-KUB is the imaging of choice (arranged via secondary care).
- •Microscopic haematuria is common — its absence does not exclude a stone.
- •Check U&E (AKI), FBC/CRP (infection) and pregnancy test where relevant.
Medical expulsive therapy (MET)
- •Offer an alpha-blocker (tamsulosin 400 micrograms OD) for distal ureteric stones <10 mm to aid spontaneous passage.
- •Most small stones pass within ~4 weeks; arrange follow-up imaging and refer if no progress.
Source: NICE NG118 (renal & ureteric stones); doses per BNF.
🚩 Admit / discuss with urology TODAY
🚩
Fever or signs of sepsis with an obstructing stone — an infected, obstructed kidney is a urological emergency needing emergency decompression.
🚩
AKI or anuria, or a stone in a solitary or transplanted kidney, or bilateral obstruction.
🚩
Pregnancy with suspected stone, or uncontrolled pain/vomiting despite adequate analgesia.
⚠️ Think sepsis: fever + loin pain + a known/suspected stone = treat as obstructed infected system until proven otherwise. Don't sit on it.
Source: NICE NG118.
General advice (all stone-formers)
- •Fluids: aim for a urine output of ~2–2.5 L/day (drink ~2.5–3 L, more in hot weather).
- •Add fresh lemon juice to water; reduce fizzy/sugary drinks.
- •Don't restrict dietary calcium — keep it normal (low calcium can worsen oxalate stones).
- •Reduce salt; keep to a balanced, non-excessive protein intake.
Targeted (by stone type, usually specialist-led)
- •Calcium oxalate: potassium citrate or a thiazide may be considered for recurrent stones.
- •Uric acid: alkalinise urine; address purine intake/risk factors.
- •Struvite: treat the underlying infection.
- •Lifetime risk is roughly 10–15%, and recurrence is common — prevention matters.
Source: NICE NG118 (prevention of recurrence).
Stress incontinence
- •Leak on cough, sneeze, laugh, exercise, lifting — no preceding urge.
- •Mechanism: weak urethral sphincter/pelvic floor support.
- •Risk factors: childbirth, menopause, obesity.
Urgency incontinence / OAB
- •Sudden compelling urge, then leak; with frequency & nocturia.
- •Mechanism: detrusor overactivity.
- •Triggers: key-in-door, running water, cold.
Mixed incontinence: treat the predominant symptom first. A bladder diary (≥3 days) is the single most useful tool — get one before prescribing. Exclude UTI, and check for retention/overflow in men and frail older people.
For OAB / urgency (NICE NG123)
- •Bladder training for ≥6 weeks as first-line.
- •Reduce caffeine; modify (not over-restrict) fluids; treat constipation.
- •Weight loss if BMI >30.
For stress incontinence (NICE NG123)
- •Supervised pelvic floor muscle training for ≥3 months as first-line (≥8 contractions, 3× daily).
- •Refer to a specialist continence physiotherapist where possible.
✅ Worth saying: "These exercises and bladder retraining are not a soft option — done properly they're as effective as anything we'd prescribe, and they have no side effects."
Source: NICE NG123 (urinary incontinence & pelvic organ prolapse in women) & CKS.
💊 OAB — antimuscarinic (second-line, after bladder training):
- •Choose one with the lowest acquisition cost, e.g. oxybutynin (immediate-release), tolterodine, or darifenacin. Review at ~4 weeks.
- •Do NOT offer immediate-release oxybutynin to frail older people — anticholinergic load worsens falls and cognition. Counsel on dry mouth, constipation, blurred vision.
💊 Mirabegron (beta-3 agonist):
- •Use only if antimuscarinics are contraindicated, ineffective, or have unacceptable side effects — useful when anticholinergic burden is a concern.
- •50 mg once daily; reduce to 25 mg OD if eGFR 15–29; avoid if eGFR <15.
- •Check BP before and during treatment — contraindicated in severe uncontrolled hypertension.
Postmenopausal women: offer intravaginal (topical) oestrogen for OAB symptoms with vaginal atrophy. For stress incontinence where surgery is declined/unsuitable, duloxetine may be considered (specialist-guided, not first-line). Refer stress incontinence not responding to conservative measures.
Source: NICE NG123 & CKS; doses per BNF.
Recognise
- •Sudden severe unilateral scrotal pain, often with nausea/vomiting.
- •High-riding testis, horizontal lie, absent cremasteric reflex; no relief on elevation.
- •Peaks in adolescents and neonates, but assume torsion at any age until excluded.
Act
- •Refer immediately for emergency surgical exploration — do not delay for imaging.
- •Salvage is time-critical: best within ~6 hours of onset.
🚨 Rule of thumb: acute scrotal pain is torsion until a senior clinician proves otherwise. A normal-looking testis does not exclude it.
Recognise
- •Painless hard, non-tender testicular lump or change in size/consistency.
- •Commonest solid cancer in men aged ~15–45.
- •Heaviness/dragging; occasionally gynaecomastia.
Act (NICE NG12)
- •Consider a suspected-cancer pathway referral (2WW) for a non-painful enlargement or change in shape/texture of the testis.
- •Arrange a direct-access urgent ultrasound in parallel.
Source: NICE NG12 (suspected cancer recognition & referral).
Recognise
- •Sudden inability to pass urine with a painful, palpable, distended bladder.
- •Common precipitants: BPH, constipation/impaction, UTI/prostatitis, anticholinergics/opioids, post-op.
- •Painless retention with high residuals can cause obstructive AKI — check U&E.
Act
- •Catheterise to relieve the obstruction and record the residual volume.
- •Treat the cause; start an alpha-blocker before a trial without catheter in men with likely BPH.
- •Watch for post-obstructive diuresis; same-day urology if AKI, infection, or recurrent retention.
⚠️ Always exclude: in retention with back pain, saddle anaesthesia or bilateral leg symptoms, think cauda equina — that's a separate emergency requiring immediate MRI and referral.
🚩 Never attribute visible haematuria to anticoagulation alone. Patients on warfarin/DOACs still need investigating on the same pathway — anticoagulants unmask underlying urological disease rather than explain it.
- •≥45 with unexplained visible haematuria (no UTI, or persisting after treatment) → 2WW (bladder + renal).
- •≥60 with non-visible haematuria + dysuria or raised WCC → 2WW (bladder).
Source: NICE NG12. See the Haematuria & Proteinuria section for the full pathway.