Urology & Renal Medicine for GPs

🩺 Urology & Renal Medicine for GPs: Your Survival Guide

Kidney-friendly knowledge - no stones left unturned (and we promise that's the last pun)

☕ Tea-Friendly Learning ⏰ For GP Trainees Short on Time 🚩 Red Flag Focused

Date Updated: January 13, 2026

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:

• 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 (CKD, AKI, UTIs)
• Red flags & conditions not to miss (malignancy, retention, sepsis)
• WPBA-ready structures and consultation skills

Quick Facts at a Glance:

15%

of UK adults have CKD

50%

of UTIs are recurrent

2WW

for visible haematuria >45yrs

6hrs

max for testicular torsion

Quick Navigation

📋 Data-Gathering & Examination 🔍 Diagnostic Approach 🧠 Differential Diagnosis 💊 Common Conditions 🚩 Red Flags 📚 Resources & Downloads

1️⃣ Data-Gathering & Examination Tips

Focused Symptom Histories (Urinary)

Must-ask questions and structuring for key urinary presentations

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

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)
• 2WW criteria: age >45 years (unless obvious UTI)
• Associated: LUTS, loin pain, weight loss

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

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

Oliguria (<400ml/24h)

• Pre-renal: dehydration, hypotension, heart failure
• Renal: AKI, glomerulonephritis, interstitial nephritis
• Post-renal: obstruction (stones, BPH, tumour)
• Medications: NSAIDs, ACE inhibitors, diuretics

Polyuria (>3L/24h)

• Diabetes: mellitus (glucose) or insipidus
• Hypercalcaemia: malignancy, hyperparathyroidism
• Chronic kidney disease: concentrating defect
• Medications: diuretics, lithium

Initial GP Assessment

• Fluid balance: input/output chart
• Observations: BP, weight, fluid status
• Dipstick: glucose, protein, specific gravity
• Blood tests: U&E, glucose, calcium

Transient vs Persistent

• Transient causes: fever, exercise, UTI, heart failure
• Orthostatic: positive when upright, negative supine
• Persistent: >2 positive tests 1-2 weeks apart
• Quantification: ACR (albumin:creatinine ratio)
• Significant: ACR >3mg/mmol (microalbuminuria)

Underlying Causes

• Diabetic nephropathy: most common cause
• Hypertensive nephropathy: chronic BP elevation
• Glomerulonephritis: often with haematuria
• Systemic disease: SLE, vasculitis, myeloma
• Follow-up: repeat ACR, eGFR, BP monitoring

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

Mixed & Other Types

• Mixed: combination of stress + urge
• Overflow: chronic retention with dribbling
• Functional: mobility/cognitive impairment
• Neurological: MS, spinal cord lesions

Focused Symptom Histories (Genital)

Key questions for genital and sexual health presentations

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

Other Sexual Symptoms

• Haematospermia: usually benign, exclude infection/stones
• Penile pain: Peyronie's disease, priapism, balanitis
• Perineal pain: prostatitis, pelvic floor dysfunction
• Premature ejaculation: primary vs secondary causes
• Loss of libido: hormonal, psychological, medication

Abnormal DRE Findings (NICE Prostate Cancer Guidelines)

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)

Sensitive History-Taking Tips

Communication Approach

• Privacy: ensure confidential environment
• Normalise: "Many men experience...", "It's common to..."
• Direct questions: avoid euphemisms, be clear
• Non-judgmental: maintain professional demeanor
• Partner involvement: ask if appropriate

Documentation Standards

• Objective findings: size, consistency, symmetry
• Functional impact: IPSS score, quality of life
• Risk factors: family history, medications
• Patient concerns: ICE (ideas, concerns, expectations)
• Safety-netting: when to return, red flags

Systemic/Renal Symptom Histories

Renal + systemic symptom prompts for comprehensive assessment

Loin/Abdominal Pain or Masses

• Renal colic: severe, colicky, radiates groin/genitals
• Pyelonephritis: constant ache + fever + rigors
• Renal mass: dull ache, may be asymptomatic
• Polycystic kidneys: bilateral masses, family history
• Renal infarction: sudden severe pain + haematuria
• Associated symptoms: haematuria, LUTS, weight loss
• Timing: relationship to posture, movement, eating
• Radiation: back to front, down to groin

Fluid Retention & Oedema (NICE Heart Failure)

• Distribution: dependent (cardiac) vs facial (renal)
• Timing: worse evening (cardiac) vs morning (renal)
• Pitting: degree (1-4+) and recovery time
• Associated breathlessness: orthopnoea, PND
• Weight gain: rapid (>2kg/week) vs gradual
• Abdominal distension: ascites vs bladder
• Medication history: NSAIDs, steroids, CCBs
• Dietary sodium: recent changes, processed foods

Uraemic Symptoms (KDIGO CKD Guidelines)

• Pruritus: generalised itching (phosphate retention)
• Nausea/vomiting: uraemic toxins, especially morning
• Metallic taste: altered taste sensation, food aversion
• Fatigue: anaemia, metabolic acidosis, sleep disturbance
• Restless legs: mineral imbalance, worse at night
• Cognitive changes: concentration, memory problems
• Muscle cramps: electrolyte imbalance
• Bone pain: CKD-mineral bone disorder

Systemic Disease Features

• Vasculitis (ANCA): rash, arthralgia, ENT symptoms, neuropathy
• SLE: malar rash, photosensitivity, joint pain, mouth ulcers
• Myeloma: bone pain, recurrent infections, hypercalcaemia
• Diabetes: polyuria, polydipsia, weight loss, infections
• Hypertension: headaches, visual disturbance, chest pain
• Amyloidosis: heart failure, neuropathy, macroglossia
• Sarcoidosis: lung symptoms, skin lesions, eye problems
• Infective endocarditis: fever, new murmur, embolic phenomena

Constitutional Symptoms

• Fever/rigors: infection, systemic inflammation, malignancy
• Weight loss: malignancy, chronic disease, uraemia
• Night sweats: infection, malignancy, vasculitis
• Anaemia symptoms: fatigue, breathlessness, pallor, palpitations
• Bone symptoms: pain, fractures (CKD-MBD, myeloma)
• Bleeding tendency: uraemic bleeding, thrombocytopenia
• Recurrent infections: immunosuppression, diabetes, myeloma
• Visual changes: hypertensive retinopathy, diabetes

Thirst & Polyuria Assessment

• Diabetes mellitus: glucose-induced osmotic diuresis
• Diabetes insipidus: central (pituitary) vs nephrogenic
• Hypercalcaemia: stones, bones, groans, psychiatric moans
• Chronic kidney disease: concentrating defect
• Psychogenic polydipsia: psychiatric history, normal sodium
• Medications: diuretics, lithium, demeclocycline
• Quantify intake: litres per day, nocturia frequency
• Fluid preference: water vs other drinks

Family History Red Flags (Genetic Kidney Disease)

Polycystic Kidney Disease

• ADPKD: family history, bilateral cysts
• Associated: liver cysts, intracranial aneurysms
• Complications: hypertension, CKD, stones
• Screening: USS family members >18 years

Hereditary Nephritis

• Alport syndrome: hearing loss, eye problems
• Thin basement membrane: benign familial haematuria
• Pattern: X-linked, autosomal recessive/dominant
• Presentation: haematuria, proteinuria, CKD

Other Genetic Conditions

• Fabry disease: pain, skin lesions, cardiac
• Tuberous sclerosis: angiomyolipomas, seizures
• Von Hippel-Lindau: renal cell carcinoma
• Diabetes: family history, early onset nephropathy

Examination Techniques & Documentation

Systematic examination approach with documentation standards

Abdominal Examination

Inspection

• Distension: bladder, ascites, masses
• Scars: previous surgery, trauma
• Skin changes: bruising, discoloration
• Visible masses: renal, bladder

Palpation

• Kidneys: bimanual ballottement
• Bladder: suprapubic dullness
• Masses: size, consistency, mobility
• Tenderness: renal angle, suprapubic

Fluid Balance Assessment

Volume Status

• Blood pressure: lying and standing
• JVP: fluid overload assessment
• Capillary refill: <2 seconds normal
• Mucous membranes: hydration status

Oedema Assessment

• Peripheral: ankles, legs, sacral
• Pitting: grade 1-4, recovery time
• Distribution: dependent vs facial
• Weight changes: rapid vs gradual

Genital Examination

Male Examination

• Inspection: lesions, discharge, swelling
• Testicular: size, consistency, masses
• Epididymis: tenderness, swelling
• Hernias: inguinal, scrotal

DRE Technique

• Position: left lateral, knees to chest
• Prostate size: normal 20-25g
• Consistency: firm, smooth, symmetrical
• Abnormalities: nodules, asymmetry

Documentation Standards

Examination Findings

• Systematic approach: inspection, palpation, percussion
• Objective findings: size, consistency, location
• Normal findings: document what was normal
• Abnormalities: detailed description
• Patient comfort: examination tolerated well
• Chaperone: offered and accepted/declined

Clinical Correlation

• History correlation: findings support symptoms
• Differential diagnosis: examination narrows options
• Red flags: concerning findings highlighted
• Further assessment: investigations needed
• Management plan: examination-guided decisions
• Follow-up: re-examination timing

Special Examination Techniques

Renal Examination

• Bimanual palpation: one hand anterior, one posterior
• Ballottement: kidney mobility assessment
• Renal angle tenderness: costovertebral angle
• Kidney size: normal not palpable

Bladder Assessment

• Percussion: dullness above pubis
• Palpation: smooth, rounded mass
• Post-void residual: USS measurement
• Catheter assessment: if present

Scrotal Examination

• Transillumination: hydrocele vs solid
• Cremasteric reflex: neurological assessment
• Testicular lie: horizontal suggests torsion
• Varicocele: "bag of worms" feeling

WPBA-Ready Mini-Structures

Templates for assessments and learning opportunities

CEPS-Style Urology Review Template

Raised PSA Consultation Structure

• ICE: "What are your main concerns about the PSA result?"
• Explanation: PSA significance, false positives/negatives
• Risk factors: age, family history, ethnicity, DRE findings
• Options: repeat test, referral, active monitoring
• Shared decision: patient preference, risk tolerance
• Safety-netting: new symptoms, follow-up plan
• Documentation: decision rationale, patient understanding

LUTS Assessment Structure

• IPSS scoring: quantify severity and bother (0-35)
• Impact assessment: work, sleep, relationships, QoL
• Red flags: retention, haematuria, infection, masses
• Examination: DRE, abdominal, post-void residual
• Management options: lifestyle, medication, surgery
• Follow-up: symptom monitoring, re-assessment timing
• Referral criteria: failed medical management, complications

Learning Log Prompts (RCGP Curriculum)

Delayed Presentation Testicular Swelling

• Reflection: Why might patients delay seeking help?
• Learning: Differential diagnosis approach, examination skills
• Communication: Sensitive questioning techniques
• Safety: Red flag recognition and urgent referral pathways
• Follow-up: Patient education and reassurance strategies
• Systems: Practice protocols for urgent urology referrals

Recurrent UTI in Elderly Woman

• Complexity: Multiple contributing factors, polypharmacy
• Investigation: When to investigate further, imaging decisions
• Management: Prevention strategies, antibiotic stewardship
• Safeguarding: Hygiene, care needs assessment, capacity
• MDT working: Community nursing, continence services
• Quality improvement: Practice UTI management protocols

Audit Templates (QI Framework)

Recurrent UTI Antibiotic Use

• Standard: NICE guidance on UTI management (NG109)
• Data collection: Antibiotic choice, duration, resistance patterns
• Analysis: Appropriateness of prescribing, culture correlation
• Improvement: Education, guidelines, decision support tools
• Re-audit: Measure improvement in practice, resistance rates
• Outcomes: Patient satisfaction, symptom resolution

CKD Monitoring Compliance

• Standard: Annual eGFR/ACR monitoring (NICE CG182)
• Population: Patients with CKD stages 3-5, diabetes
• Measures: Monitoring frequency, BP control, ACE-I use
• Interventions: Recall systems, patient education
• Outcomes: Progression prevention, CV risk reduction
• Cost-effectiveness: Delayed dialysis, reduced admissions

Consultation "Adds Value" (SCA-Style Assessment)

ICE & Impact Assessment

• Ideas: Patient's understanding of condition
• Concerns: Fears about cancer, sexual function
• Expectations: Treatment preferences, outcomes
• Work impact: Lifting, driving, time off
• Sleep disturbance: Nocturia frequency, quality
• Sexual function: Erectile function, relationships
• Social impact: Activities, confidence, embarrassment

Shared Decision Making

• Present options: Conservative, medical, surgical
• Discuss risks/benefits: Numbers needed to treat
• Patient preferences: Risk tolerance, lifestyle factors
• Written information: Patient leaflets, websites
• Time to consider: Non-urgent decisions
• Follow-up planned: Review decision, monitor response
• Document rationale: Decision-making process

Safety-Netting Excellence

• Specific symptoms: "If you develop..."
• Timeframe: "If no improvement in..."
• When to seek help: Urgent vs routine
• How to access care: GP, OOH, A&E
• Follow-up arrangements: Proactive vs reactive
• Written summary: Key points, actions
• Patient understanding: Confirm comprehension

2️⃣ Diagnostic Approach & Investigations

Clinical Triage & Urgency Assessment

Systematic approach to prioritising urological and renal presentations

🚨 Same Day Action Required

• Testicular torsion: sudden severe pain, nausea, high-riding testis
• Acute retention: unable to void, palpable bladder, severe pain
• Priapism: prolonged painful erection >4 hours
• Fournier's gangrene: severe perineal pain + systemic illness
• Infected obstructed kidney: stone + fever + loin pain
• Severe AKI: stage 2-3, oliguria, hyperkalaemia >6.0
• Paraphimosis: retracted foreskin, venous congestion

⚡ Urgent (2WW) Referral

• Visible haematuria: age >45 (unless obvious UTI)
• Suspected malignancy: hard prostate nodule, testicular mass
• Persistent non-visible haematuria: age >60
• Recurrent UTI in men: structural abnormality concern
• Acute scrotum: if torsion excluded but concerning features
• Progressive AKI: rising creatinine despite treatment
• Nephrotic syndrome: proteinuria + oedema + hypoalbuminaemia
• Rapidly progressive GN: AKI + haematuria + proteinuria

📅 Routine Referral (Weeks)

• LUTS not responding: to initial management
• Recurrent UTI in women: >3 episodes/year
• Persistent proteinuria: ACR >30mg/mmol
• CKD progression: eGFR decline >5ml/min/year
• Erectile dysfunction: not responding to PDE5 inhibitors
• Incontinence: failed conservative management
• Renal stones: recurrent episodes, large stones
• CKD stage 4-5: eGFR <30, pre-dialysis planning

🏠 Self-Care + Review

• Simple UTI: young women, typical symptoms
• Mild LUTS: IPSS <8, minimal bother
• Stress incontinence: mild, recent onset
• Stable CKD: stages 1-3a, well controlled
• Benign scrotal lumps: small, long-standing
• Transient proteinuria: associated with illness
• Mild hypertension: <160/100, no target organ damage
• Asymptomatic bacteriuria: elderly, catheterised

Decision-Making Framework

Life-Threatening?

Retention, sepsis, torsion → Same day

Cancer Risk?

Haematuria, masses → 2WW

Specialist Needed?

Complex cases → Routine

GP Manageable?

Simple conditions → Self-care

Core Urine Testing in Primary Care

Dipstick interpretation, MSU indications, and abnormal result triggers

Dipstick Interpretation Framework

Blood (Haematuria)

• Trace/1+: may be insignificant, repeat
• 2+/3+: significant, needs investigation
• False positives: menstruation, exercise, myoglobin
• Action: repeat if trace, investigate if persistent
• Microscopy: confirms true haematuria

Protein

• Trace: may be normal, repeat
• 1+: 30mg/dl, consider ACR
• 2+/3+: significant proteinuria, needs ACR
• False positives: concentrated urine, alkaline pH
• Quantify: ACR more accurate than dipstick

UTI Dipstick Interpretation (Evidence-Based)

Dipstick Pattern Performance (Likelihood Ratios)

Individual Markers

• Leucocytes + only: LR+ ~1.4 (weak evidence)
• Nitrites + only: LR+ ~6.5 (strong evidence)
• Both Leuc + Nitrites +: LR+ ~8.0 (very strong)
• Leuc + Nitrites + Blood +: LR+ ~9.1 (excellent)

Clinical Translation

• Leucocytes alone: UTI "equally likely" as other causes
• Nitrites alone: Strong bacteriuria evidence
• Both positive: PPV ~93% in symptomatic women
• Triple positive: PPV ~94%, very high specificity

⚠️ Critical Age-Related Guidance

• Adults >65: Do NOT use dipsticks to diagnose UTI
• Care homes: Routine dipstick screening is poor practice
• Catheterised patients: Dipsticks unreliable
• Reason: High prevalence of asymptomatic bacteriuria

Detailed Marker Interpretation

Leucocytes (White Cells)

• Positive: inflammation/infection/contamination
• Sterile pyuria: leucocytes without bacteria
• False positives: vaginal discharge, contamination
• Clinical context: symptoms matter more than result

Nitrites

• High specificity: few false positives
• False negatives: short bladder dwell, non-producers
• Gram-positive bacteria: don't produce nitrites
• Best single marker: for gram-negative UTI

When to Send MSU (NICE Guidelines)

• Recurrent UTI: >2 episodes in 6 months
• Treatment failure: symptoms persist after antibiotics
• Complicated UTI: men, catheterised, immunocompromised
• Pregnancy: all positive dipsticks
• Children: all suspected UTIs
• Pyelonephritis: before starting antibiotics
• Sterile pyuria: leucocytes without nitrites
• Catheter-associated: symptomatic patients only

Abnormal Results - Further Assessment

• Persistent haematuria: 2WW referral if age >45
• Significant proteinuria: ACR, eGFR, BP check
• Glucose: diabetes screening, HbA1c
• Ketones: diabetic ketoacidosis risk
• Specific gravity: concentrating ability assessment
• pH: stones (alkaline), acidosis (acidic)
• Bilirubin: liver disease, haemolysis
• Urobilinogen: liver function, haemolysis

Dipstick Pitfalls to Avoid

Sample Issues

• Contaminated sample
• Delayed testing (>2 hours)
• Concentrated/dilute urine
• Improper storage

Patient Factors

• Menstruation
• Recent exercise
• Dehydration
• Medications (rifampicin)

Technical Issues

• Expired strips
• Incorrect timing
• Poor lighting
• Cross-contamination

UTI Culture Interpretation & Asymptomatic Bacteriuria

Evidence-based approach to culture results, mixed growth, and care home management

Mixed Enteric Growth - Clinical Decision Making

Usually Contamination (80-90%)

• Poor sampling: perineal flora contamination
• Delayed transport: bacterial overgrowth
• Action: Do NOT treat with antibiotics
• Repeat sample: if clinically indicated
• Look for other causes: dehydration, constipation

True Mixed Infection (~10-25%)

• Evidence: ~22% yield single pathogen on repeat
• Higher risk: catheterised, frail, instrumentation
• If symptomatic: repeat MSU promptly
• If unwell: treat clinically, discuss microbiology
• Context matters: symptoms + clinical picture

Asymptomatic Bacteriuria (ASB) - Evidence-Based Management

Definition & Prevalence

• Definition: bacteria in urine without urinary symptoms
• Care homes: >30% of residents
• Elderly women: very common, increases with age
• Often transient: resolves spontaneously
• Not harmful: colonisation, not infection

Why NOT to Treat ASB

• No clinical benefit: evidence shows no improvement
• Antibiotic harms: C. diff risk, side effects
• Antimicrobial resistance: drives resistance patterns
• Missed diagnoses: other causes of symptoms
• Cost: unnecessary healthcare utilisation

Exceptions (DO Treat)

• Pregnancy: follow pregnancy ASB guidance
• Pre-urological procedures: invasive interventions
• These are specific exceptions: not routine practice
• Immunocompromised: specialist advice needed

🏠 Care Home UTI Management Revolution

❌ STOP These Harmful Practices

• Routine dipstick screening: drives overtreatment
• "Dip and treat" protocols: treats colonisation
• Treating cloudy/smelly urine: not diagnostic
• Dipsticks in >65s: unreliable, guidance advises against
• Treating confusion alone: multiple causes

✅ Evidence-Based Approach

• Symptom-led assessment: new dysuria, frequency, urgency
• Minimum criteria: ≥2 new urinary symptoms
• Systemic illness: fever, rigors, hypotension
• Alternative causes: dehydration, constipation, meds
• Loeb criteria: structured assessment tools

📊 UTI Natural History - Supporting Delayed Prescribing

Spontaneous Resolution Evidence

• Uncomplicated cystitis: 25-33% resolve in 7-10 days
• Placebo studies: 28% symptom cure by 1 week
• Extended follow-up: 37% clear by 5-7 weeks
• Quality evidence: well-designed RCTs
• Applies to: otherwise well women with cystitis

Clinical Applications

• Delayed prescribing: reasonable for uncomplicated cases
• Patient education: "1 in 3 resolve naturally"
• Safety netting: when to start antibiotics
• Reduces resistance: fewer unnecessary prescriptions
• Shared decision making: informed patient choice

🔬 Sterile Pyuria Investigation Algorithm

Definition: Pyuria + Negative Culture

White cells in urine with negative bacterial culture - systematic approach needed

1️⃣ First-Line Assessment

• Repeat MSU: proper clean-catch technique
• Recent antibiotics? can sterilise culture
• Basic screen: U&E, eGFR, ACR, BP
• Dipstick: blood, protein assessment
• Confirm asymptomatic: no urinary symptoms

2️⃣ Targeted Investigations

• STI screen: if <35, new partner, risk factors
• TB screen: 3x early morning urine AFB
• Travel history: schistosomiasis screen
• FBC/CRP: if systemically unwell
• Drug history: interstitial nephritis

3️⃣ Specialist Assessment

• USS: if persistent + haematuria
• Urology referral: haematuria + age criteria
• Common causes: stones, interstitial nephritis
• GSM/atrophy: post-menopausal women
• Interstitial cystitis: chronic pain syndrome

Core Blood Tests and Monitoring

Which tests help in CKD/AKI assessment and how results influence urgency

Essential Renal Function Tests

eGFR (CKD-EPI Formula)

• Normal: >90 ml/min/1.73m² (with normal kidneys)
• CKD Stage 1: >90 + kidney damage
• CKD Stage 2: 60-89 + kidney damage
• CKD Stage 3a: 45-59 (mild-moderate decrease)
• CKD Stage 3b: 30-44 (moderate-severe decrease)
• CKD Stage 4: 15-29 (severe decrease)
• CKD Stage 5: <15 (kidney failure)

Creatinine Interpretation

• Baseline: establish individual normal range
• AKI criteria: rise >26μmol/L in 48hrs or >50% in 7 days
• Factors affecting: muscle mass, age, ethnicity, diet
• Limitations: late marker, normal until 50% function lost

Proteinuria Assessment (KDIGO)

ACR (Albumin:Creatinine Ratio)

• Normal: <3 mg/mmol
• Microalbuminuria (A2): 3-30 mg/mmol
• Macroalbuminuria (A3): >30 mg/mmol
• Monitoring: annually in diabetes/hypertension
• Progression risk: higher ACR = faster CKD progression

PCR (Protein:Creatinine Ratio)

• Normal: <15 mg/mmol
• Significant: >50 mg/mmol
• Nephrotic range: >300 mg/mmol
• Use: when ACR not available or non-diabetic proteinuria

Supporting Blood Tests

Full Blood Count

• Haemoglobin: anaemia in CKD (EPO deficiency from eGFR <30)
• White cells: infection, inflammation, immunosuppression
• Platelets: bleeding risk, HUS/TTP, drug effects
• Target Hb: 100-120 g/L in CKD

Bone & Mineral (CKD-MBD)

• Calcium: hypercalcaemia causes, CKD-MBD monitoring
• Phosphate: elevated in CKD stages 4-5
• PTH: secondary hyperparathyroidism (target 2-9x normal)
• Vitamin D: deficiency common, supplement if <75 nmol/L

Other Key Tests

• HbA1c: diabetes control (<53 mmol/mol target)
• Lipids: cardiovascular risk (statin if CKD)
• Bicarbonate: metabolic acidosis (<22 mmol/L)
• Potassium: hyperkalaemia risk with ACE-I/ARB

Results Influencing Urgency

Same Day Action

• eGFR <15 with uraemic symptoms
• Creatinine rise >50% acutely
• Hyperkalaemia >6.0 mmol/L
• Severe acidosis pH <7.2
• Pulmonary oedema

Urgent (Days)

• eGFR 15-30 (stage 4 CKD)
• Rapid eGFR decline >5ml/min/year
• ACR >70 mg/mmol
• Hyperkalaemia 5.5-6.0 mmol/L
• Severe anaemia Hb <80 g/L

Routine Follow-up

• Stable CKD stages 1-3
• Controlled diabetes with microalbuminuria
• Mild anaemia (Hb 100-110)
• Well-controlled mineral bone disease

Imaging Pathways (Primary Care Perspective)

When ultrasound is first-line, when CT KUB is considered, and secondary care imaging

🔊 Ultrasound - First Line

Primary Care Indications

• CKD assessment: kidney size, structure, cortical thickness
• Recurrent UTI: structural abnormalities, post-void residual
• Haematuria investigation: initial imaging (before CT)
• Suspected obstruction: hydronephrosis, bladder distension
• Palpable mass: renal/bladder masses, prostate size
• AKI investigation: exclude obstruction

What USS Shows

• Kidney size: normal 9-12cm length
• Cortical thickness: <1cm suggests CKD
• Hydronephrosis: pelvicalyceal dilatation
• Masses/cysts: size, echogenicity, complexity
• Bladder: wall thickness, masses, residual volume
• Prostate: size estimation, median lobe

📡 CT KUB - When Considered

Indications

• Suspected renal colic: acute severe loin pain
• Stone disease: recurrent episodes, family history
• Haematuria + normal USS: exclude small stones
• Unexplained AKI: rule out obstruction
• Complex UTI: structural assessment needed
• Trauma: suspected renal injury

Advantages

• Stone detection: all types visible
• No contrast: safe in renal impairment
• Quick acquisition: 5-10 minutes
• Anatomy: clear structural detail

Limitations

• Radiation: 3-5 mSv exposure
• Soft tissue: limited detail without contrast
• Small lesions: may miss <5mm stones

🏥 Secondary Care Imaging

Specialist-Initiated

• CT with contrast: mass characterisation, staging
• MRI: complex masses, young patients, pregnancy
• IVU/CTU: urothelial imaging, collecting system
• Nuclear medicine: differential function assessment
• Angiography: vascular causes, intervention
• Cystoscopy: direct bladder visualisation

Functional Studies

• DMSA scan: differential renal function
• MAG3 renogram: drainage assessment, obstruction
• Urodynamics: bladder function, pressure studies
• Isotope GFR: accurate function measurement

GP Imaging Decision Framework

Start with Ultrasound if:

• First presentation of symptoms
• Chronic/recurrent problems
• Need to assess kidney size/structure
• Pregnancy (radiation-free)
• Children (first-line imaging)
• Suspected bladder pathology
• CKD assessment
• Post-void residual measurement

Consider CT KUB if:

• Acute severe loin pain (renal colic)
• Known stone former with recurrence
• Haematuria with normal ultrasound
• Suspected obstruction not seen on USS
• Complex clinical picture
• Urgent assessment needed
• Failed conservative stone management
• Planning surgical intervention

When to Refer Before Imaging

Urgent Referral First

• Visible haematuria (2WW pathway)
• Suspected malignancy
• Acute retention
• Severe AKI
• Testicular torsion
• Priapism

Specialist Imaging Needed

• Complex masses requiring contrast
• Functional assessment needed
• Interventional procedures planned
• Paediatric imaging
• Pregnancy-related imaging
• Vascular assessment

LUTS Scoring & CKD/AKI Monitoring

IPSS assessment, CKD progression monitoring, and AKI recognition triggers

IPSS (International Prostate Symptom Score)

Scoring System (0-35)

• Mild (0-7): watchful waiting, lifestyle advice
• Moderate (8-19): consider treatment options
• Severe (20-35): treatment usually indicated
• Quality of life: separate 0-6 scale (bother score)
• Reassessment: 4-6 weeks after treatment changes

Assessment Areas

• Incomplete emptying sensation
• Frequency (<2 hours between voids)
• Intermittency (stop-start stream)
• Urgency (difficult to postpone)
• Weak stream
• Straining to start
• Nocturia (times per night)

Clinical Use

• Baseline assessment: quantify symptoms objectively
• Treatment monitoring: response to therapy
• Referral decisions: severity + bother score
• Shared decisions: patient involvement in management
• Audit tool: practice LUTS management quality

CKD Identification & Monitoring

Recognition Criteria (NICE CG182)

• eGFR <60: for >3 months (stages 3-5)
• Kidney damage: ACR >3mg/mmol + normal eGFR
• Structural abnormalities: on imaging
• Persistent proteinuria: >2 positive tests
• Persistent haematuria: after excluding UTI

Monitoring Frequency

• Stage 1-2: annually if stable
• Stage 3a: annually
• Stage 3b: 6-monthly
• Stage 4: 3-monthly
• Stage 5: 6-weekly (pre-dialysis planning)
• Rapid decline: >5ml/min/year = more frequent

Progression Risk Factors

• Diabetes: poor glycaemic control (HbA1c >53)
• Hypertension: uncontrolled BP (>140/90)
• Proteinuria: ACR >30mg/mmol
• Smoking: accelerates decline
• NSAIDs: nephrotoxic medications
• CVD: shared risk factors

AKI Recognition Triggers

Common Primary Care Contexts

• Intercurrent illness: D&V, sepsis, pneumonia
• Dehydration: poor oral intake, excessive losses
• Medications: ACE-I, ARB, NSAIDs, diuretics
• Contrast exposure: CT scans, angiography
• Surgery: major procedures, blood loss
• Obstruction: BPH, stones, catheter blockage

AKI Criteria (KDIGO)

• Creatinine rise: ≥26μmol/L in 48 hours
• Or: ≥1.5x baseline in 7 days
• Or: urine output <0.5ml/kg/hr for 6 hours
• Stage 1: 1.5-1.9x baseline or +26μmol/L
• Stage 2: 2.0-2.9x baseline
• Stage 3: ≥3x baseline or ≥354μmol/L

Escalation Thresholds

• Same day: AKI stage 2-3, oliguria, hyperkalaemia
• Urgent: AKI stage 1 + risk factors
• Actions: stop nephrotoxics, fluid assess, treat cause
• Monitor: daily U&E, fluid balance, urine output

Cardiovascular Risk in CKD

Risk Assessment

• CKD = CVD equivalent: high risk category
• QRISK calculator: includes CKD as factor
• Target BP: <140/90 (or <130/80 if ACR >70)
• Statin therapy: indicated in most CKD patients
• Aspirin: if established CVD

Monitoring Parameters

• Blood pressure: every consultation
• Lipids: annually
• HbA1c: if diabetic (3-6 monthly)
• Smoking status: cessation support
• Weight/BMI: lifestyle advice
• Exercise tolerance: cardiac symptoms

Prescribing Safety in Kidney Disease

Dose Adjustment Principles

• eGFR <60: check all medications in BNF
• Renally excreted drugs: reduce dose/frequency
• BNF guidance: specific CKD recommendations
• Start low, go slow: especially elderly

Nephrotoxic Awareness

• NSAIDs: avoid if possible, short courses only
• ACE-I/ARB: monitor creatinine 1-2 weeks
• Contrast: pre-hydration if eGFR <60
• Aminoglycosides: level monitoring essential

3️⃣ Differential Diagnosis Frameworks

Dysuria Differential Diagnosis Framework

Systematic approach to painful urination by age, gender, and clinical features

Young Women (16-50 years)

• Most common: Bacterial cystitis (E.coli 80%)
• STI-related: Chlamydia, gonorrhoea, herpes
• Post-coital: honeymoon cystitis, trauma
• Hormonal: pregnancy-related, contraceptive effects
• Behavioural: poor hygiene, bubble baths, tight clothing
• Recurrent pattern: >3 episodes/year suggests underlying cause

Men (Any Age)

• Prostatitis: acute/chronic, bacterial/non-bacterial
• STI: urethritis (chlamydia, gonorrhoea)
• Structural: BPH, urethral stricture, stones
• Balanitis: poor hygiene, diabetes, candida
• Epididymitis: usually secondary to UTI/STI
• Red flag: any UTI in men needs investigation

Elderly Women (>65 years)

• Atrophic vaginitis: oestrogen deficiency
• Recurrent UTI: incomplete emptying, prolapse
• Catheter-related: biofilm, encrustation
• Medication-induced: chemotherapy, immunosuppression
• Functional: mobility issues, cognitive impairment
• Malignancy: bladder cancer (painless haematuria more common)

Non-Infectious Causes

• Interstitial cystitis: chronic pain, frequency, sterile urine
• Chemical irritation: soaps, spermicides, douches
• Radiation cystitis: pelvic radiotherapy history
• Drug-induced: cyclophosphamide, ketamine abuse
• Autoimmune: Behçet's, SLE, reactive arthritis
• Psychological: anxiety, depression, somatisation

Diagnostic Clues

• Sudden onset + fever: acute pyelonephritis
• Gradual onset + discharge: STI
• Post-coital timing: honeymoon cystitis
• Recurrent pattern: structural abnormality
• Sterile pyuria: TB, stones, interstitial nephritis
• Haematuria + dysuria: stones, malignancy

Investigation Strategy

• First episode (women): dipstick + empirical treatment
• Recurrent/men: MSU + culture
• STI risk: NAAT testing (chlamydia/gonorrhoea)
• Sterile pyuria: TB culture, cytology
• Haematuria: imaging + cystoscopy referral
• Treatment failure: culture + sensitivity

Haematuria Differential Diagnosis Framework

Systematic approach by source, age, and associated features

Glomerular Causes

• IgA nephropathy: episodic haematuria with URTI
• Thin basement membrane: benign familial haematuria
• Alport syndrome: hearing loss, family history
• Post-infectious GN: recent streptococcal infection
• ANCA vasculitis: systemic features, rapid progression
• SLE nephritis: systemic lupus features
• Goodpasture's: pulmonary-renal syndrome

Urological Causes

• Bladder cancer: painless, age >50, smoking history
• Renal cell carcinoma: flank mass, weight loss
• Urothelial cancer: occupational exposure, smoking
• Prostate cancer: hard nodule, raised PSA
• Renal stones: colicky pain, family history
• BPH: LUTS, enlarged prostate
• Trauma: recent injury, catheterisation

Other Causes

• UTI: dysuria, frequency, nitrites positive
• Exercise-induced: marathon running, contact sports
• Menstruation: timing with cycle
• Anticoagulants: warfarin, DOACs, aspirin
• Sickle cell disease: papillary necrosis
• Polycystic kidneys: family history, hypertension
• Factitious: psychiatric history, inconsistent

Age-Stratified Risk Assessment

<40 Years

• Most likely: UTI, stones, glomerular disease
• Malignancy risk: Low (<1%)
• Investigation: Conservative unless persistent
• Family history: Important for hereditary nephritis

40-60 Years

• Intermediate risk: Stones, BPH, early malignancy
• Malignancy risk: Moderate (5-10%)
• Investigation: USS + cystoscopy if persistent
• Risk factors: Smoking, occupational exposure

>60 Years

• High risk: Malignancy until proven otherwise
• Malignancy risk: High (15-25%)
• Investigation: Urgent 2WW referral
• Even if UTI: Investigate after treatment

LUTS Differential Diagnosis Framework

Lower urinary tract symptoms by mechanism and gender

Men: Obstructive Causes

• BPH (most common): age >50, gradual onset, symmetrical enlargement
• Prostate cancer: hard nodule, asymmetrical, raised PSA
• Prostatitis: acute/chronic, pain, fever, tender prostate
• Urethral stricture: trauma history, poor stream, recurrent UTI
• Bladder neck stenosis: previous surgery, young men
• Neurological: MS, spinal cord injury, diabetes

Women: Storage Symptoms

• Overactive bladder: urgency, frequency, nocturia
• UTI: dysuria, suprapubic pain, cloudy urine
• Interstitial cystitis: chronic pain, sterile urine
• Pelvic organ prolapse: bulge, incomplete emptying
• Atrophic vaginitis: post-menopausal, oestrogen deficiency
• Bladder stones: pain, haematuria, infection

Neurological Causes

• Multiple sclerosis: detrusor-sphincter dyssynergia
• Spinal cord injury: level determines pattern
• Diabetic neuropathy: poor sensation, overflow incontinence
• Parkinson's disease: detrusor overactivity
• Stroke: loss of cortical inhibition
• Cauda equina: saddle anaesthesia, retention

Medication-Induced LUTS

• Anticholinergics: tricyclics, antihistamines, antipsychotics
• Alpha-agonists: decongestants, some antihypertensives
• Diuretics: frequency, nocturia, urgency
• Calcium channel blockers: oedema, nocturia
• Opioids: constipation, urinary retention
• Alcohol: diuretic effect, nocturia

Systemic Conditions

• Diabetes mellitus: polyuria, neuropathy, infections
• Heart failure: nocturia, dependent oedema
• Sleep apnoea: nocturia, poor sleep quality
• Hypercalcaemia: polyuria, polydipsia
• Chronic kidney disease: concentrating defect
• Diabetes insipidus: massive polyuria

Assessment Strategy

• IPSS questionnaire: quantify severity (0-35)
• Bladder diary: 3-day frequency-volume chart
• Post-void residual: USS or catheter
• Flow rate: uroflowmetry if available
• DRE: prostate size, consistency, nodules
• Dipstick: exclude UTI, haematuria

CKD Causes & AKI Differential

Systematic approach to kidney disease by mechanism and reversibility

Common CKD Causes (UK Primary Care)

• Diabetic nephropathy (30%): microalbuminuria → proteinuria → CKD
• Hypertensive nephropathy (25%): chronic BP elevation
• Glomerulonephritis (15%): IgA, FSGS, membranous
• Polycystic kidney disease (10%): family history, bilateral cysts
• Interstitial nephritis (5%): drugs, infections, autoimmune
• Obstructive uropathy (5%): stones, BPH, malignancy
• Unknown/multifactorial (10%): elderly, multiple comorbidities

AKI: Pre-renal Causes (70%)

• Volume depletion: D&V, bleeding, burns, diuretics
• Hypotension: sepsis, cardiogenic shock, anaphylaxis
• Reduced effective volume: heart failure, liver failure
• Renal vasoconstriction: NSAIDs, ACE-I, contrast
• Hepatorenal syndrome: advanced liver disease
• Abdominal compartment: surgery, trauma, ascites

AKI: Intrinsic Renal (25%)

• Acute tubular necrosis: ischaemia, nephrotoxins
• Acute interstitial nephritis: drugs (NSAIDs, PPIs, antibiotics)
• Glomerulonephritis: ANCA vasculitis, anti-GBM, lupus
• Vascular: malignant hypertension, HUS/TTP, emboli
• Rhabdomyolysis: muscle breakdown, myoglobin
• Tumour lysis syndrome: chemotherapy, high cell turnover

AKI: Post-renal Causes (5%)

• Bladder outlet: BPH, prostate cancer, stricture
• Ureteric: stones, clots, external compression
• Retroperitoneal fibrosis: drugs, malignancy, idiopathic
• Neurogenic bladder: spinal cord lesions, diabetes
• Catheter blockage: blood clots, debris, kinking
• Bilateral obstruction: required for AKI (unless single kidney)

Drug-Induced Nephrotoxicity

• NSAIDs: reduced GFR, interstitial nephritis, papillary necrosis
• ACE-I/ARB: functional AKI, hyperkalaemia
• Aminoglycosides: dose-dependent tubular toxicity
• Contrast agents: osmotic nephropathy, especially if dehydrated
• Chemotherapy: cisplatin, methotrexate, ifosfamide
• Herbal remedies: aristolochic acid, heavy metals

Diagnostic Approach

• History: medications, recent illness, family history
• Examination: fluid status, BP, rash, lymphadenopathy
• Urinalysis: proteinuria, haematuria, casts
• Imaging: USS kidneys, bladder scan
• Blood tests: FBC, U&E, LFT, immunology if indicated
• Specialist referral: rapid progression, unclear cause

4️⃣ Common Conditions GPs Should Manage

CKD Identification, Monitoring & Management

Comprehensive primary care approach to chronic kidney disease

CKD Identification (NICE CG182)

• eGFR <60: for >3 months (stages 3-5)
• Kidney damage: ACR >3mg/mmol + normal eGFR
• Structural abnormalities: on imaging
• Risk factors: diabetes, hypertension, CVD, family history
• Annual screening: diabetes, hypertension, age >60
• Confirm: repeat tests 2-3 weeks apart

Monitoring Frequency

• Stage 1-2: annually if stable
• Stage 3a: annually
• Stage 3b: 6-monthly
• Stage 4: 3-monthly
• Stage 5: 6-weekly (pre-dialysis planning)
• Rapid decline: >5ml/min/year = more frequent

Progression Prevention

• BP control: <140/90 (or <130/80 if ACR >70)
• ACE-I/ARB: first-line if proteinuria or diabetes
• Diabetes control: HbA1c <53 mmol/mol
• Statin therapy: all CKD patients (atorvastatin 20mg)
• Smoking cessation: accelerates progression
• Weight management: BMI 20-25

Cardiovascular Risk Management

• CKD = CVD equivalent: high risk category
• Aspirin 75mg: if established CVD
• Statin: atorvastatin 20mg (no monitoring needed)
• BP targets: <140/90 (<130/80 if diabetes + ACR >70)
• Annual review: lipids, HbA1c if diabetic
• Lifestyle: diet, exercise, smoking cessation

Complications Management

• Anaemia (eGFR <30): investigate if Hb <110 (men) or <100 (women)
• Bone disease (eGFR <30): check Ca, PO4, PTH, vitamin D
• Acidosis: bicarbonate <22 mmol/L, consider sodium bicarbonate
• Hyperkalaemia: dietary advice, review medications
• Fluid retention: loop diuretics, dietary sodium restriction
• Vaccination: annual flu, pneumococcal, hepatitis B

Referral Criteria

• eGFR <30: stage 4-5 CKD
• Rapid decline: >5ml/min/year or >15ml/min in 1 year
• ACR >70 mg/mmol: despite ACE-I/ARB
• Haematuria: persistent, especially if >45 years
• Hypertension: difficult to control (>4 drugs)
• Suspected genetic: family history, young age

UTI Management & Recurrent UTI Prevention

Evidence-based approach to urinary tract infections

Acute UTI Management (NICE NG109)

• Women (uncomplicated): nitrofurantoin 100mg BD 3 days
• Alternative: trimethoprim 200mg BD 3 days
• Pregnancy: nitrofurantoin 100mg BD 7 days
• Men: nitrofurantoin 100mg BD 7 days (+ MSU)
• Catheterised: only treat if symptomatic
• Elderly: same antibiotics, watch for delirium

Pyelonephritis Management

• Mild-moderate: cefalexin 500mg BD 7-10 days
• Alternative: co-amoxiclav 625mg TDS 7-10 days
• Severe/sepsis: hospital admission for IV antibiotics
• Pregnancy: always admit for IV treatment
• Follow-up: MSU 1 week post-treatment
• Imaging: USS if recurrent or complications

Recurrent UTI Prevention (Women)

• Definition: >3 episodes in 12 months or >2 in 6 months
• Lifestyle advice: adequate fluid intake, complete bladder emptying
• Post-coital voiding: empty bladder within 15 minutes
• Cranberry products: may help (limited evidence)
• Topical oestrogen: post-menopausal women
• Prophylaxis: trimethoprim 100mg ON or nitrofurantoin 50mg ON

When to Investigate Further

• Men: any UTI needs investigation (MSU + imaging)
• Recurrent UTI: >3 episodes/year in women
• Treatment failure: symptoms persist after appropriate antibiotics
• Haematuria: visible or persistent non-visible
• Unusual organisms: Proteus, Pseudomonas, Enterococcus
• Structural abnormality: suspected on history/examination

Antibiotic Stewardship

• Avoid quinolones: unless culture-directed
• Shortest effective course: 3 days for uncomplicated cystitis
• Local guidelines: follow antimicrobial formulary
• Culture-guided: for recurrent/complicated UTI
• Resistance patterns: monitor local epidemiology
• Patient education: complete course, symptom recognition

Special Populations

• Pregnancy: treat asymptomatic bacteriuria, 7-day courses
• Elderly: may present atypically (confusion, falls)
• Catheterised: only treat if symptomatic, change catheter
• Immunocompromised: longer courses, culture-guided
• Diabetes: higher risk of complications, monitor closely
• Spinal cord injury: different presentation, prophylaxis may be needed

🏠 Care Home UTI Protocol - Stop Overtreatment

Asymptomatic Bacteriuria (ASB) is present in roughly 1 in 3 (30%) of care home residents at any one time. ASB often "goes away" without antibiotics in care/nursing homes, but it is dynamic: many residents fluctuate positive → negative → positive over time (often with different organisms). So, MSSU in care homes: "positive urine" doesn't equal infection, and be careful - repeated dips/cultures just create noise and unnecessary antibiotics.

Evidence-Based Decision Algorithm

❌ NEVER Do These

• Routine dipstick screening: all residents
• Treat cloudy/smelly urine: not diagnostic
• Dipsticks in confusion: unreliable >65
• Treat asymptomatic bacteriuria: causes harm
• "Dip and treat" protocols: drives resistance

⚠️ Assess First

• New urinary symptoms: dysuria, frequency, urgency
• Minimum 2 symptoms: Loeb criteria
• Systemic illness: fever, rigors, hypotension
• Alternative causes: dehydration, constipation
• Medication review: new drugs, interactions

✅ Then Consider Treatment

• Clear urinary symptoms: + systemic features
• MSU if treating: proper sampling technique
• Empirical antibiotics: per local guidelines
• Review in 48-72h: clinical response
• Stop if improving: without positive culture

Care Home Staff Checklist

Before Calling GP

• Vital signs: temperature, BP, pulse, O2 sats
• Fluid intake: adequate hydration?
• Bowel function: constipation causing confusion?
• New medications: started in last 48h?
• Pain assessment: other sources of distress?
• Baseline function: change from normal?

Information for GP

• Specific symptoms: dysuria, frequency, urgency
• Timeline: when symptoms started
• Systemic features: fever, rigors, hypotension
• Functional change: mobility, cognition, appetite
• Recent changes: medications, procedures, illness
• Catheter status: if present, when changed

Treatment Thresholds (Evidence-Based)

Definite UTI - Treat

• New dysuria + systemic illness
• Fever + new urinary symptoms
• Rigors + suprapubic pain
• Hypotension + urinary symptoms
• Acute confusion + fever + urinary symptoms

Possible UTI - Consider

• ≥2 new urinary symptoms (Loeb criteria)
• New incontinence + urinary symptoms
• Catheter + systemic illness
• Discuss with GP: clinical judgement
• Trial of treatment: if high suspicion

NOT UTI - Don't Treat

• Confusion alone (no urinary symptoms)
• Cloudy/smelly urine alone
• Positive dipstick alone (>65 years)
• Asymptomatic bacteriuria
• Behavioural changes alone

Quality Improvement Measures

Audit Indicators

• Dipstick usage: % residents screened routinely
• Antibiotic prescribing: UTI indication documentation
• Culture correlation: treatment vs culture results
• C. diff rates: associated with UTI prescribing
• Symptom documentation: urinary symptoms recorded

Staff Education Topics

• ASB vs UTI: colonisation vs infection
• Symptom recognition: what constitutes UTI
• Alternative causes: dehydration, constipation
• Sampling technique: proper MSU collection
• Antibiotic stewardship: resistance implications

LUTS/BPH Assessment & Management

Comprehensive approach to lower urinary tract symptoms in men

Initial Assessment (NICE CG97)

• IPSS questionnaire: quantify severity (0-35) and bother
• DRE: prostate size, consistency, nodules
• Dipstick urine: exclude UTI, haematuria
• PSA: if life expectancy >10 years (after counselling)
• Post-void residual: USS if retention suspected
• Bladder diary: frequency-volume chart

Conservative Management

• Lifestyle advice: fluid management, avoid caffeine/alcohol
• Bladder training: scheduled voiding, pelvic floor exercises
• Medication review: diuretics, anticholinergics, decongestants
• Weight loss: if BMI >30
• Constipation: treat if present
• Watchful waiting: mild symptoms (IPSS <8)

Medical Management

• Alpha-blockers: tamsulosin 400mcg OD (first-line)
• 5-alpha reductase inhibitors: finasteride 5mg OD (large prostate)
• Combination therapy: both if prostate >30g
• Antimuscarinics: if storage symptoms predominant
• Beta-3 agonists: mirabegron if antimuscarinic unsuitable
• PDE5 inhibitors: tadalafil if concurrent ED

Red Flags for Urgent Referral

• Acute urinary retention: unable to void, palpable bladder
• Visible haematuria: especially if age >45
• Suspected malignancy: hard/irregular prostate, raised PSA
• Recurrent UTI: in men
• Renal impairment: rising creatinine
• Bladder stones: pain, infection, haematuria

Routine Referral Criteria

• Failed medical management: inadequate symptom improvement
• Patient preference: for surgical intervention
• Severe symptoms: IPSS >19 with significant bother
• Large post-void residual: >200ml consistently
• Complications: recurrent retention, stones, UTI
• Diagnostic uncertainty: atypical presentation

Follow-up & Monitoring

• Initial review: 4-6 weeks after starting treatment
• IPSS reassessment: quantify improvement
• Side effects: postural hypotension, ejaculatory dysfunction
• Annual review: symptoms, DRE, consider PSA
• Medication adherence: discuss benefits/side effects
• Lifestyle reinforcement: ongoing conservative measures

Incontinence Management (Primary Care Approach)

Comprehensive assessment and management of urinary incontinence

Initial Assessment (NICE CG171)

History Taking

• Onset & duration: sudden vs gradual, triggers
• Frequency & volume: bladder diary (3-7 days)
• Precipitants: cough, exercise, urgency
• Associated symptoms: dysuria, haematuria, prolapse
• Impact on QoL: social, sexual, psychological
• Medications: diuretics, ACE-I, anticholinergics

Physical Examination

• Abdominal: palpable bladder, masses
• Pelvic (women): prolapse, atrophy, pelvic floor
• Rectal: prostate size, faecal impaction
• Neurological: if indicated (reflexes, sensation)
• Cough test: demonstrate stress incontinence
• Post-void residual: USS if retention suspected

Types of Incontinence

Stress Incontinence

• Mechanism: urethral sphincter weakness
• Triggers: cough, sneeze, exercise, lifting
• Risk factors: childbirth, menopause, obesity
• Management: pelvic floor exercises, weight loss

Urgency Incontinence

• Mechanism: detrusor overactivity
• Symptoms: sudden urge, frequency, nocturia
• Causes: idiopathic, neurological, UTI
• Management: bladder training, antimuscarinics

Mixed Incontinence

• Combination: stress + urgency components
• Assessment: identify predominant type
• Management: treat most bothersome first

Conservative Management

Lifestyle Interventions

• Weight loss: if BMI >30 (5-10% reduction helpful)
• Fluid management: 1.5-2L daily, avoid excess
• Caffeine reduction: bladder irritant
• Constipation: treat if present
• Smoking cessation: chronic cough worsens stress UI

Pelvic Floor Muscle Training

• First-line: stress and mixed incontinence
• Technique: 8-12 contractions, 3x daily
• Duration: minimum 3 months trial
• Supervision: physiotherapist referral if available

Bladder Training

• Indication: urgency incontinence
• Method: scheduled voiding, delay techniques
• Goal: 3-4 hour voiding intervals
• Duration: 6 weeks minimum

Pharmacological Management

Urgency Incontinence

• First-line: oxybutynin IR 2.5-5mg BD/TDS
• Alternatives: tolterodine 2mg BD, solifenacin 5mg OD
• If contraindicated: mirabegron 25-50mg OD
• Side effects: dry mouth, constipation, cognitive
• Cautions: elderly, dementia, narrow-angle glaucoma
• Review: 4 weeks, continue if beneficial

Post-menopausal Women

• Vaginal oestrogen: if atrophic changes
• Preparations: cream, pessaries, ring
• Benefits: improves urgency, recurrent UTI
• Safety: minimal systemic absorption

Men with BPH

• Alpha-blockers: tamsulosin for LUTS
• Combination: antimuscarinic if storage symptoms
• Caution: risk of retention with antimuscarinics

When to Refer

Urgent Referral

• Suspected malignancy: haematuria, pelvic mass
• Neurological cause: new neurological signs
• Fistula suspected: continuous leakage
• Recurrent UTI: with structural abnormality

Routine Referral

• Failed conservative management: 6-12 weeks
• Significant prolapse: beyond introitus
• Voiding dysfunction: high post-void residual
• Patient preference: for surgical options
• Diagnostic uncertainty: complex presentation

Practical Management Tips

Patient Education

• Bladder diary: essential for assessment
• Normal frequency: 4-7 times per day
• Pelvic floor exercises: correct technique crucial
• Realistic expectations: improvement not cure

Follow-up

• Initial review: 6 weeks after starting treatment
• Medication review: 4 weeks, then 3-monthly
• Long-term: annual review if stable

Renal Stone Management (Primary Care Perspective)

Assessment, acute management, and prevention of renal stones

🚨 Acute Renal Colic Management

Clinical Presentation

• Pain: severe colicky loin-to-groin pain
• Radiation: flank to ipsilateral groin/genitalia
• Associated: nausea, vomiting, restlessness
• Haematuria: visible or non-visible (85%)
• No fever: unless concurrent infection

Immediate Management

• Analgesia: diclofenac 75mg IM/50mg PO (if no CI)
• Alternative: morphine 10mg IM + antiemetic
• Antiemetic: cyclizine 50mg IM/IV
• Fluids: normal maintenance, avoid overhydration
• Dipstick urine: haematuria, nitrites, leucocytes

Red Flags - Immediate Referral

• Fever + stone: infected obstructed kidney
• Anuria: bilateral obstruction or single kidney
• AKI: rising creatinine
• Uncontrolled pain: despite adequate analgesia
• Persistent vomiting: unable to tolerate oral fluids

Investigation & Imaging

Initial Tests

• Urine dipstick: haematuria (85%), infection
• MSU: if nitrites/leucocytes positive
• U&E: baseline renal function
• FBC: if infection suspected
• CRP: inflammatory marker

Imaging Strategy

• CT KUB: gold standard, no contrast needed
• Advantages: detects all stone types, size, location
• USS: pregnancy, children, follow-up
• Plain KUB: limited use (only radio-opaque stones)
• IVU: rarely used now

Stone Analysis

• Strain urine: collect passed stones
• Composition: guides prevention strategy
• Common types: calcium oxalate (80%), uric acid

Conservative Management

Medical Expulsive Therapy

• Indication: stones <10mm, distal ureter
• Tamsulosin: 400mcg OD for up to 4 weeks
• Mechanism: alpha-blocker relaxes ureteric smooth muscle
• Success rate: 70-80% for stones 5-10mm
• Follow-up: 2-4 weeks, imaging if no passage

Supportive Care

• Analgesia: regular NSAIDs if no contraindications
• Fluid intake: 2-3L daily to maintain good urine output
• Activity: normal activity, exercise may help passage
• Strain urine: to catch stone for analysis

When to Refer

• Large stones: >5mm unlikely to pass spontaneously
• Failed conservative: no passage after 4 weeks
• Recurrent episodes: frequent stone formation
• Complications: infection, obstruction, AKI

Stone Prevention Strategies

General Measures (All Stone Types)

• Fluid intake: 2.5-3L daily (urine output >2L)
• Dietary sodium: <6g daily (reduces calcium excretion)
• Calcium intake: normal 1000-1200mg daily (don't restrict)
• Protein: moderate intake 0.8-1g/kg/day
• Weight management: obesity increases stone risk

Calcium Oxalate Stones (80%)

• Oxalate restriction: spinach, rhubarb, nuts, chocolate
• Citrate increase: lemon juice, citrus fruits
• Thiazide diuretics: if recurrent (reduces calcium excretion)
• Potassium citrate: if low urinary citrate

Uric Acid Stones (10%)

• Urine alkalinisation: potassium citrate
• Target pH: 6.5-7.0
• Purine restriction: red meat, organ meats, seafood
• Allopurinol: if hyperuricaemia or recurrent stones

Struvite Stones (Infection)

• Complete stone removal: essential
• Eradicate infection: culture-directed antibiotics
• Long-term suppression: may be needed
• Urease inhibitors: specialist use only

Follow-up & Monitoring

First-time Stone Former

• Basic metabolic screen: U&E, calcium, phosphate, urate
• Stone analysis: if stone retrieved
• General prevention advice: fluid intake, diet
• Follow-up imaging: not routinely needed

Recurrent Stone Former

• Detailed metabolic screen: 24-hour urine collection
• Parameters: volume, calcium, oxalate, citrate, urate, pH
• Specialist referral: for complex cases
• Annual imaging: USS or low-dose CT

Patient Education

• Fluid intake: clear urine as target
• Warning signs: when to seek help
• Dietary advice: specific to stone type
• Medication compliance: if prescribed preventive therapy

Surgical Options (Specialist)

Treatment Modalities

• ESWL: extracorporeal shock wave lithotripsy
• URS: ureteroscopy with laser fragmentation
• PCNL: percutaneous nephrolithotomy (large stones)
• Open surgery: rarely needed now

Indications for Intervention

• Stone size: >5mm unlikely to pass
• Obstruction: with infection or AKI
• Persistent pain: despite medical management
• Patient preference: occupation, lifestyle factors

5️⃣ Red Flags & Conditions Not to Miss

Malignancy Red Flags & 2WW Criteria

Cancer warning signs requiring urgent referral

Bladder Cancer (NICE NG12)

• Age ≥45 + visible haematuria: without UTI or persists after UTI treatment
• Age ≥60 + unexplained non-visible haematuria: + dysuria or raised WCC
• Risk factors: smoking, occupational exposure (dyes, rubber, textiles)
• Associated symptoms: weight loss, suprapubic mass
• Recurrent UTI: especially in men
• Painless haematuria: more concerning than painful

Prostate Cancer (NICE NG12)

• Abnormal DRE: hard, irregular, fixed nodule (any age)
• PSA levels (age-adjusted):
• Age 50-59: ≥3.0 ng/ml
• Age 60-69: ≥4.0 ng/ml
• Age ≥70: ≥5.0 ng/ml
• PSA velocity: rise >20% annually
• Lower threshold: if African-Caribbean or family history

Renal Cell Carcinoma

• Classic triad (rare): haematuria + loin pain + abdominal mass
• Visible haematuria: especially if age >45
• Systemic symptoms: weight loss, night sweats, fever
• Paraneoplastic syndromes: hypercalcaemia, polycythaemia
• Incidental finding: renal mass on imaging
• Risk factors: smoking, obesity, hypertension, dialysis

Testicular Cancer

• Painless testicular lump: any age (peak 15-35 years)
• Testicular enlargement: unilateral, firm, non-tender
• Change in testicular consistency: harder or softer than normal
• Gynaecomastia: hormone-secreting tumours
• Back pain: retroperitoneal lymphadenopathy
• Risk factors: undescended testis, family history

Penile Cancer (Rare)

• Persistent penile lesion: ulcer, growth, or change in skin
• Non-healing ulcer: especially under foreskin
• Persistent discharge: foul-smelling, blood-stained
• Inguinal lymphadenopathy: hard, fixed nodes
• Risk factors: poor hygiene, HPV, smoking, phimosis
• Age: usually >50 years

Referral Pathways

• 2WW urology: suspected bladder, prostate, renal, testicular cancer
• Same day: testicular torsion vs tumour (if acute presentation)
• Urgent USS: testicular lumps, renal masses
• Patient information: explain urgency without causing alarm
• Documentation: clear rationale for referral
• Safety-netting: contact if symptoms worsen

Acute Urological Emergencies

Time-critical conditions requiring immediate action

🚨 Testicular Torsion

• Presentation: sudden severe testicular pain + nausea/vomiting
• Age distribution: bimodal (neonates + adolescents 12-18)
• Examination: high-riding testis, absent cremasteric reflex
• Time critical: salvage rate 90% if <6 hours
• Action: immediate surgical referral, do not delay for imaging
• Differential: epididymitis (gradual onset, fever, dysuria)

🚨 Acute Urinary Retention

• Presentation: inability to void + suprapubic pain + palpable bladder
• Causes: BPH, constipation, medications, neurological
• Immediate action: catheterisation (urethral or suprapubic)
• Post-catheter care: monitor for post-obstructive diuresis
• Investigation: identify and treat underlying cause
• Follow-up: trial without

🩺 Urology & Renal Medicine for GPs: Your Survival Guide

Executive Summary: What You'll Master Today

What This Page Covers:

Quick Facts at a Glance:

Quick Navigation

📥 Downloads

🌐 Web Resources

1️⃣ Data-Gathering & Examination Tips

Focused Symptom Histories (Urinary)

Essential Questions

Differential Approach

Visible Haematuria (Macroscopic)

Non-visible Haematuria (Microscopic)

Storage Symptoms

Voiding Symptoms

Post-micturition

Oliguria (<400ml/24h)

Polyuria (>3L/24h)

Initial GP Assessment

Transient vs Persistent

Underlying Causes

Stress Incontinence

Urge Incontinence

Mixed & Other Types

Focused Symptom Histories (Genital)

Scrotal/Testicular Symptoms

Pain/Swelling - Time Critical

Lumps - Routine Assessment

Erectile & Sexual Function

Erectile Dysfunction (NICE CKS)

Other Sexual Symptoms

Abnormal DRE Findings (NICE Prostate Cancer Guidelines)

Prostate Size Assessment

Prostate Consistency

Red Flags for 2WW Referral

Sensitive History-Taking Tips

Communication Approach

Documentation Standards

Systemic/Renal Symptom Histories

Loin/Abdominal Pain or Masses

Fluid Retention & Oedema (NICE Heart Failure)

Uraemic Symptoms (KDIGO CKD Guidelines)

Systemic Disease Features

Constitutional Symptoms

Thirst & Polyuria Assessment

Family History Red Flags (Genetic Kidney Disease)

Polycystic Kidney Disease

Hereditary Nephritis

Other Genetic Conditions

Examination Techniques & Documentation

Abdominal Examination

Inspection

Palpation

Fluid Balance Assessment

Volume Status

Oedema Assessment

Genital Examination

Male Examination

DRE Technique

Documentation Standards

Examination Findings

Clinical Correlation

Special Examination Techniques

Renal Examination

Bladder Assessment

Scrotal Examination

WPBA-Ready Mini-Structures

CEPS-Style Urology Review Template

Raised PSA Consultation Structure

LUTS Assessment Structure

Learning Log Prompts (RCGP Curriculum)

Delayed Presentation Testicular Swelling

Recurrent UTI in Elderly Woman

Audit Templates (QI Framework)

Recurrent UTI Antibiotic Use

CKD Monitoring Compliance

Consultation "Adds Value" (SCA-Style Assessment)

ICE & Impact Assessment

Shared Decision Making

Safety-Netting Excellence