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
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📥 Downloads
path: UROLOGY
- antibiotics - long term prophylaxis for uti.docx
- incontinence - continence top tips.docx
- incontinence - food and drinks which can irritate the bladder.pdf
- primary care urology.pdf
- prostate disorders - diagnosis.pdf
- prostate disorders.pdf
- prostate examination.pdf
- prostate problems - some cases.ppt
- prostate symptom score.pdf
- prostate symptom scoring.pdf
- proteinuria.ppt
- psa screening.pdf
- psa test counselling I.pdf
- psa test counselling II.pdf
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
Red flags: visible blood, loin pain + fever, inability to void
2. Diagnostic Approach & Investigations
Systematic approach to investigations and monitoring in primary care
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.
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
• 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))
• 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
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 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 |
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.
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.
Medical Targets for CKD
BP <130/80 mmHg
prescribe ACE inhibitor or ARBs to get it under control
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
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.
Tweaking the repeat medication list in CKD
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
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
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