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Bradford VTS The GP Training website for everyone, not just Bradford Created by Dr Ramesh Mehay (est. 2002)
Updated Guidelines 2026:
  • β€’ NICE NG28 (type 2 diabetes, updated 18 Feb 2026): for adults with type 2 diabetes and CKD with eGFR above 30, offer modified-release metformin plus an SGLT2 inhibitor. With eGFR 20–30, offer dapagliflozin or empagliflozin plus a DPP-4 inhibitor; below 20, consider a DPP-4 inhibitor. Metformin remains contraindicated below eGFR 30. Upshot: diabetic kidney patients should now almost all be on an SGLT2 inhibitor unless there's a reason not to.
  • β€’ NICE NG12 (suspected cancer, updated 15 Apr 2026): new non-site-specific rule β€” aged 60+ with unexplained weight loss of more than 5% over 6 months: assess, then offer urgent investigation, a suspected cancer pathway referral, or a non-specific symptoms pathway referral. The urological referral thresholds (PSA, haematuria, testis) are unchanged.
  • β€’ Also worth knowing (UK National Screening Committee, 28 May 2026 β€” not NICE): no population PSA screening. Targeted screening is recommended only for men aged 45–61 with a BRCA2 variant and a relevant family history (PSA every 2 years) β€” it isn't running yet; governments must first accept it.

Sources: NICE NG28 (Feb 2026); NICE NG12 update information (Apr 2026); UK NSC final recommendation reported by Cancer Research UK (28 May 2026).

Renal & Urology for GPs: Your Essential Guide

Every surgery has at least one "wee" problem a day β€” this page helps you spot the ones that are bigger than they look.

β˜• Tea-Friendly Learning ⏰ For GP Trainees Short on Time 🚩 Red Flag Focused

Last Updated: 19 September 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

Quick Facts at a Glance:

3 in 4
men with a raised PSA don't have cancer
1 in 3
adults aged 75+ have CKD stage 3–5
13–18%
of hospital admissions involve AKI
50%
of stone formers get another within 10 years

Sources: NHS PSA test page; Health Survey for England 2016 (34% of over-75s CKD G3–5, cited in NICE NG203 scope); NICE NG148 context; Wilcox et al, BJGP 2020.

πŸ“₯ Downloads & Resources

Useful downloads and trusted web links for renal & urology

πŸ“₯ Downloads

🌐 Web Resources

πŸ“š Quick Navigation

🧠 Brainy Bites 🩺 History & Exam πŸ”¬ Investigations & PSA 🧩 Differentials πŸ’§ UTIs 🩸 Haematuria & Proteinuria ⚑ Acute Kidney Injury 🫘 Chronic Kidney Disease πŸͺ¨ Urinary Stones 🚹 Male LUTS & BPH 🚽 Bladder & Incontinence πŸŽ—οΈ Urological Cancers 🚩 Red Flags πŸ’ͺ You've Got This πŸ“₯ Downloads

🧠 Brainy Bites: Essential Renal & Urology Wisdom

The stuff seasoned GPs wish someone had told them sooner

πŸ’‘
Blood you can see is never "just" anything. Unexplained visible haematuria at 45+ is a suspected cancer pathway referral β€” even if the patient is on warfarin or a DOAC. Anticoagulants unmask disease; they don't explain it. Try: "It's usually something simple, but blood in the urine is one thing we never just watch."
⚠️
Hunt the "triple whammy" on the repeat list. ACE inhibitor/ARB + diuretic + NSAID is a classic AKI recipe, especially in a dehydrated older patient with D&V. The cheapest AKI prevention is a two-minute repeat-medication review.
πŸ’Š
The 25/30 rule after starting an ACEi or ARB. Recheck U&E in 1–2 weeks. An eGFR fall under 25% (or creatinine rise under 30%) is expected β€” carry on. Beyond that, look for dehydration or NSAIDs and think renal artery stenosis. (NICE NG203)
🎯
CKD is really a heart disease with kidney paperwork. Don't run QRISK in someone with eGFR under 60 or albuminuria β€” NICE says they're already high risk. Offer atorvastatin 20 mg, control BP and, in diabetes, an SGLT2 inhibitor.
🩺
ACR, not the dipstick, measures protein. A urine albumin:creatinine ratio (ACR) on an early-morning sample is the test. Remember three numbers: 3 (clinically important), 30 (severe, A3), 70 (refer nephrology).
πŸ”‘
PSA is a smoke alarm, not a fire. About 3 in 4 men with a raised PSA don't have cancer, and about 1 in 7 men with cancer have a normal PSA. Counsel before the needle, and check no ejaculation or vigorous exercise in 48 hours, no UTI in the last month.
πŸ₯
Acute scrotal pain = torsion until proven otherwise. Refer immediately for surgical exploration β€” don't wait for a scan. The testis has a stopwatch attached, and it isn't generous.
πŸ“‹
Men get UTIs for a reason. Every male UTI is treated for 7 days, not 3, and deserves an MSU. If he's febrile with perineal pain, think prostatitis β€” nitrofurantoin won't reach the prostate.

1️⃣ History & Examination Tips

Must-ask questions and exam structure for the commonest urinary presentations

Focused histories and the examination

Open one at a time β€” each gives you the questions, the traps, and what to say.

Essential questions
  • β€’Onset & timing: sudden vs gradual; linked to intercourse?
  • β€’Associated: frequency, urgency, new nocturia, cloudy urine, visible blood
  • β€’Vaginal or urethral discharge/itch: points away from UTI
  • β€’Sexual history: new partner, STI risk
  • β€’Systemic: fever, rigors, loin pain, vomiting (think pyelonephritis)
  • β€’Pregnancy, catheter, recent antibiotics and past cultures
Differential lens
  • β€’Infective: bacterial UTI, STI (chlamydia, gonorrhoea), prostatitis
  • β€’Non-infective: bladder pain syndrome, chemical irritants
  • β€’Structural: stone, tumour, urethral stricture
  • β€’Hormonal: genitourinary syndrome of menopause (vaginal atrophy)
πŸ›‘ Don't auto-label "UTI" in: men, pregnancy, recurrent episodes, catheters, or anyone with visible haematuria β€” they need cultures and a proper think, not just a script.

LUTS (lower urinary tract symptoms) is the umbrella term for bladder and outflow symptoms. Sort them into three buckets so you don't miss anything.

Storage
  • β€’Frequency
  • β€’Nocturia
  • β€’Urgency Β± urge leakage
Voiding
  • β€’Hesitancy
  • β€’Poor or intermittent stream
  • β€’Straining
Post-micturition
  • β€’Incomplete emptying
  • β€’Post-void dribble
Tools that do the work for you: the IPSS (International Prostate Symptom Score β€” 7 questions scored 0–5, total 0–35: 0–7 mild, 8–19 moderate, 20–35 severe) and a frequency–volume chart / bladder diary (a 3-day record of drinks, voids and leaks). The diary separates nocturnal polyuria (making too much urine at night) from a small, twitchy bladder. (NICE CG97)
⚠️ Always ask about drugs: diuretics, anticholinergics (retention), opioids, and caffeine/alcohol. And ask about constipation β€” a loaded rectum is a surprisingly common bladder saboteur.
Scrotal pain or swelling
  • β€’Onset: sudden (torsion) vs gradual (epididymo-orchitis)
  • β€’Nausea/vomiting: leans towards torsion
  • β€’Fever, dysuria, discharge: leans towards infection
Lumps β€” structured examination
  • β€’Can you get above it? If not, think inguinal hernia
  • β€’Separate from the testis? epididymal cyst β€” usually benign
  • β€’Transilluminates? fluid (hydrocele/cyst) vs solid
  • β€’Within the testis and hard? treat as cancer until proven otherwise
Erectile dysfunction β€” a vascular warning light
  • β€’Pattern: gradual loss suggests vascular cause; sudden onset with preserved morning erections suggests psychological
  • β€’Risk factors: diabetes, hypertension, smoking, lipids β€” ED can come before heart disease
  • β€’Drugs: beta-blockers, thiazides, SSRIs, 5Ξ±-reductase inhibitors
  • β€’Check: HbA1c, lipids, cardiovascular risk, morning testosterone where indicated (NICE CKS)
βœ… Reframe it kindly: "Erection problems are often an early sign about the blood vessels, so checking your heart health is part of treating this β€” it's a chance to prevent problems, not just fix one."
  • β€’Abdomen: palpable (and dull-to-percussion) bladder = retention; ballotable kidney = mass or hydronephrosis
  • β€’Obs: temperature, pulse and BP β€” sepsis and hypertension both matter here
  • β€’Genitals: phimosis, meatal stenosis, testicular lumps; in women, vaginal atrophy and prolapse

DRE (digital rectal examination) β€” you're judging size, surface, symmetry and consistency. Always offer a chaperone and document it.

What benign feels like
  • β€’Smooth, symmetrical, rubbery (like the tip of your nose)
  • β€’Central groove still present
  • β€’BPH: smoothly and evenly enlarged
What worries you
  • β€’Hard, craggy or nodular
  • β€’Asymmetry, lost central groove
  • β€’Tender and boggy with fever = acute prostatitis (examine gently)

🚩 Red Flags β€” Do Not Miss

🚩

Prostate feels malignant on DRE β€” suspected cancer pathway referral, whatever the PSA (NICE NG12).

🚩

Painless distended bladder β€” chronic retention; check U&E for obstructive kidney injury.

2️⃣ Investigations & the PSA Test

Urine testing, kidney bloods, and the PSA conversation done properly

First-line tests in the room

Cheap, fast and often decisive β€” but each has traps.

Reading it well
  • β€’Nitrite + leucocytes: support UTI (nitrite comes from Gram-negative bacteria)
  • β€’Blood: exclude menstruation and contamination; 1+ or more needs follow-up (NICE NG203)
  • β€’Protein: confirm and quantify with a urine ACR β€” not the strip
  • β€’Glucose: an opportunistic diabetes clue
Pitfalls
  • β€’Negative nitrite doesn't exclude UTI β€” some organisms don't make it
  • β€’Don't dip over-65s or catheterised patients to diagnose UTI β€” bacteria in the bladder are common and harmless there (UKHSA)
  • β€’Treat the patient, not the strip β€” asymptomatic bacteriuria isn't treated, except in pregnancy
βœ… Women under 65 (UKHSA diagnostic tool): 2 or more of dysuria, new nocturia or cloudy urine makes UTI likely β€” treat without needing a dipstick. With 1 or none, the dipstick helps decide.

Sources: UKHSA "UTI: diagnostic tools for primary care"; NICE NG203 (haematuria testing).

  • β€’U&E + eGFR: baseline before and 1–2 weeks after starting an ACEi/ARB, and for any AKI/CKD question
  • β€’Urine ACR: the test for proteinuria β€” early-morning sample preferred (NICE NG203)
  • β€’FBC: anaemia (CKD, cancer), raised white count (infection)
  • β€’HbA1c & lipids: cardiovascular and renal risk
  • β€’Calcium: in anyone with kidney stones (NICE NG118)
eGFR (estimated glomerular filtration rate): a calculated estimate of kidney filtering from creatinine, age and sex. One low value isn't CKD β€” you need it sustained for more than 3 months. Avoid eating meat in the 12 hours before the test, as it can falsely raise creatinine (NICE NG203).
⚠️ Interpreting a sudden drop: compare with previous results. A fall in eGFR plus an acute illness is AKI until proven otherwise (see AKI section).

NICE age-specific PSA thresholds for referral (NG12)

For men with possible symptoms, refer on a suspected cancer pathway (the old "2-week wait") if PSA is above the age-specific range, or the prostate feels malignant.

Age (years)Refer if PSA above (Β΅g/L)
Under 40Use clinical judgement
40–492.5
50–593.5
60–694.5
70–796.5
80 and overUse clinical judgement β€” most men this age have a focus of cancer; diagnose only if it's likely to need treatment
Things that falsely raise PSA
  • β€’Ejaculation or vigorous exercise in the last 48 hours
  • β€’Urine infection β€” wait at least 1 month after treatment
  • β€’DRE in the last week; prostate biopsy in the last 6 weeks
  • β€’BPH, prostatitis, catheterisation, increasing age
Things that falsely lower it
  • β€’5Ξ±-reductase inhibitors (finasteride, dutasteride) roughly halve PSA after about 6 months
πŸ’Š Prescribing Pearl: on finasteride or dutasteride, double the measured PSA before comparing with the thresholds β€” or you'll miss cancers.

Sources: NICE NG12 (thresholds defined 2021; guideline last updated Apr 2026); GPnotebook summary of NG12; NHS PSA test pre-test advice.

The smoke-alarm script: "The PSA test is like a smoke alarm β€” useful, but it sometimes goes off when there's no fire. About 3 in 4 men with a raised result don't have cancer, and about 1 in 7 men with cancer have a normal result. There's no right or wrong choice β€” it's about what matters to you."
Cover the trade-offs
  • β€’False alarms lead to MRI Β± biopsy and worry
  • β€’False reassurance: a normal PSA doesn't rule cancer out
  • β€’Overdiagnosis: many cancers found would never have caused harm
  • β€’Treatment harms: incontinence and erection problems
Who to test (with counselling)
  • β€’Symptoms: any LUTS, erectile dysfunction or visible haematuria β€” PSA + DRE (NICE NG12)
  • β€’No symptoms but asking: informed choice after balanced information
  • β€’Higher risk: Black men, family history, BRCA2 β€” discuss earlier
⚠️ Screening status (UK NSC, May 2026): no population screening. Targeted 2-yearly PSA screening is recommended only for men aged 45–61 with a BRCA2 variant and a relevant family history β€” awaiting government sign-off, so not yet available.
βœ… What happens after referral: most pathways now do an MRI first, then a targeted biopsy only if needed β€” so "raised PSA" doesn't mean "straight to biopsy". That reassures many men.

Sources: NHS PSA test page (3 in 4; 1 in 7); NICE NG12; UK NSC final recommendation, 28 May 2026 (via Cancer Research UK).

πŸƒ Aide-mΓ©moire β€” tap a card to flip

3️⃣ Differential Diagnosis Frameworks

Mental scaffolds so nothing important falls through the gaps

Three frameworks worth memorising

Each one maps straight onto a management decision.

Painful
  • β€’UTI: dysuria, frequency, urgency
  • β€’Stone: loin-to-groin colic, can't keep still
  • β€’Prostatitis: perineal pain, fever
  • β€’Trauma or instrumentation
Painless (think cancer first)
  • β€’Bladder cancer: older, smoker
  • β€’Kidney cancer: mass, weight loss
  • β€’Prostate: BPH or cancer
  • β€’Glomerular disease: with protein, high BP
⚠️ Golden rule: painless visible haematuria is cancer until proven otherwise β€” anticoagulated or not.
Pre-renal (commonest)
  • β€’Dehydration: D&V, bleeding, sepsis
  • β€’Heart failure, cirrhosis
  • β€’Drugs: ACEi/ARB, NSAIDs, diuretics
Renal (intrinsic)
  • β€’Acute tubular necrosis
  • β€’Glomerulonephritis / vasculitis
  • β€’Drug-induced interstitial nephritis (e.g. PPIs)
Post-renal (blockage)
  • β€’Prostate enlargement or cancer
  • β€’Stones, strictures, pelvic mass
  • β€’Blocked catheter, clot retention
Bedside trick: always feel for a bladder and ask about the stream. A blockage is the most reversible cause β€” sometimes a catheter is the cure.
ConditionKey cluesAction
TorsionSudden severe pain, vomiting, high-riding testisImmediate surgical referral
Epididymo-orchitisGradual pain, fever, dysuria/dischargeAntibiotics per STI/UTI likelihood (CKS)
HydroceleTransilluminates, can get above itUltrasound if testis not palpable
Epididymal cystSeparate lump above/behind testisReassure; ultrasound if unsure
Varicocele"Bag of worms", usually left, goes on lyingReassure; image if new or doesn't drain
Testicular cancerHard, painless lump in the testisSuspected cancer pathway + urgent ultrasound
πŸ›‘ New varicocele that doesn't empty lying down: can mean a kidney tumour pressing on the vein β€” image the kidneys.

4️⃣ Urinary Tract Infections (UTI)

Right drug, right duration, right patient β€” with good antibiotic stewardship

UTI by patient group

All doses are adult oral doses from NICE's antimicrobial prescribing guidelines. Check the BNF for renal/hepatic impairment and your local resistance data.

πŸ’Š Non-pregnant women 16+ β€” NICE NG109:
  • 1stNitrofurantoin 100 mg modified-release twice a day for 3 days (or 50 mg four times a day if MR unavailable) β€” only if eGFR β‰₯45.
  • 1stTrimethoprim 200 mg twice a day for 3 days β€” only if low risk of resistance (e.g. not used in the past 3 months).
  • 2ndPivmecillinam 400 mg initial dose, then 200 mg three times a day (3 days in total) or fosfomycin 3 g single-dose sachet β€” if no improvement after 48 hours or first choice unsuitable.
Send an MSU if…
  • β€’Pregnant, male, recurrent UTI, or treatment failure
  • β€’Atypical symptoms or visible haematuria
  • β€’Suspected pyelonephritis or recent resistant organisms
Self-care & back-up options
  • β€’Paracetamol or ibuprofen for pain; drink enough to avoid dehydration
  • β€’NG109 allows a back-up (delayed) prescription for non-pregnant women with milder symptoms
⚠️ Nitrofurantoin and kidneys: avoid if eGFR under 45. NICE notes it may be used with caution at eGFR 30–44 only for uncomplicated lower UTI with suspected or proven multidrug-resistant bacteria, if benefit outweighs risk.

Source: NICE NG109 (lower UTI: antimicrobial prescribing), tables 1–2.

πŸ’Š Men 16+ with lower UTI β€” NICE NG109 (7 days):
  • 1stTrimethoprim 200 mg twice a day for 7 days, or nitrofurantoin 100 mg MR twice a day for 7 days (eGFR β‰₯45).
  • 2ndNo improvement after 48 hours: consider an alternative diagnosis (prostatitis, pyelonephritis, STI) and use culture results.
πŸ›‘ Nitrofurantoin doesn't reach the prostate. If he has fever, perineal/rectal pain or a tender prostate, treat as acute prostatitis instead.
πŸ’Š Acute prostatitis β€” NICE NG110 (review at 14 days):
  • 1stCiprofloxacin 500 mg twice a day for 14 days then review (or ofloxacin 200 mg twice a day).
  • AltIf a fluoroquinolone is unsuitable: trimethoprim 200 mg twice a day for 14 days then review.
  • 2ndAfter specialist advice: levofloxacin 500 mg once a day or co-trimoxazole 960 mg twice a day, each for 14 days then review.
⚠️ Fluoroquinolones (MHRA, Jan 2024): only use when other recommended antibiotics are inappropriate β€” risk of disabling, long-lasting tendon, nerve and psychiatric effects. Warn the patient and stop at the first sign of tendon pain.
Every male UTI deserves a "why?": send an MSU before antibiotics, and refer to urology if UTIs recur, don't settle, or come with visible haematuria.

Sources: NICE NG109 table 3; NICE NG110; MHRA Drug Safety Update, Jan 2024.

Pyelonephritis (kidney infection) = fever, loin pain, rigors, nausea/vomiting Β± lower urinary symptoms. Send an MSU and consider admission.

πŸ’Š Non-pregnant adults 16+ β€” NICE NG111:
  • 1stCefalexin 500 mg twice or three times a day (up to 1–1.5 g three or four times a day if severe) for 7–10 days.
  • AltCo-amoxiclav 500/125 mg three times a day for 7–10 days β€” only if culture shows susceptibility.
  • AltTrimethoprim 200 mg twice a day for 14 days β€” only if culture shows susceptibility.
  • AltCiprofloxacin 500 mg twice a day for 7 days β€” only if the others are unsuitable (MHRA warning above).

🚩 Red Flags β€” Do Not Miss

🚩

Signs of sepsis (confusion, low BP, high heart or breathing rate), vomiting, or pregnancy β€” refer to hospital the same day.

🚩

Fever + loin pain with a known or suspected stone β€” possible infected obstructed kidney: emergency urology.

Source: NICE NG111 (acute pyelonephritis: antimicrobial prescribing).

πŸ›‘ Treat asymptomatic bacteriuria in pregnancy: the one group where a positive culture without symptoms is treated β€” choose from nitrofurantoin, amoxicillin or cefalexin based on culture results (NICE NG109).
πŸ’Š Pregnant women 12+ with lower UTI β€” NICE NG109 (7 days, send MSU first):
  • 1stNitrofurantoin 100 mg MR twice a day for 7 days (eGFR β‰₯45) β€” avoid at term (risk of neonatal haemolysis).
  • 2ndAmoxicillin 500 mg three times a day for 7 days (only if culture shows susceptibility) or cefalexin 500 mg twice a day for 7 days.
⚠️ Trimethoprim in pregnancy: not a NICE choice here β€” it's a folate antagonist and should be avoided, particularly in the first trimester (BNF).

Sources: NICE NG109 table 2; BNF (trimethoprim, pregnancy).

Recurrent UTI = 2 or more in 6 months, or 3 or more in 12 months. Look for a cause first β€” refer men, and anyone with visible haematuria or suspected structural problems.

πŸ”€ NICE NG112 β€” the stepwise ladder (non-pregnant women)

START: Behavioural & hygiene advice (fluids, don't delay voiding, wipe front-to-back); treat constipation
↓
❓ Post-menopausal? Consider vaginal oestrogen. UTIs linked to a trigger (e.g. sex)? Consider single-dose antibiotic on exposure
↓
❓ Still recurring? Consider methenamine hippurate as a non-antibiotic alternative (2024)
↓
Still recurring? Trial of daily antibiotic prophylaxis; review at least every 6 months
πŸ’Š Prophylaxis doses (NG112 / BNF):
  • SingleAfter a trigger: trimethoprim 200 mg or nitrofurantoin 100 mg (eGFR β‰₯45) as one dose.
  • Non-abxMethenamine hippurate 1 g twice a day; review within 6 months, then every 12 months. Seek specialist advice first in pregnancy, men, or recurrent upper/complicated UTI.
  • Daily 1stTrimethoprim 100 mg at night or nitrofurantoin 50–100 mg at night (eGFR β‰₯45).
  • Daily 2ndAmoxicillin 250 mg at night or cefalexin 125 mg at night.
βœ… Self-care honesty: cranberry and D-mannose have limited or uncertain evidence β€” fine to try if the patient wants, but don't let them replace the ladder above.

Sources: NICE NG112 (recurrent UTI, amended 2024, visual summary); methenamine dosing as used in the ALTAR trial reviewed by NICE; BNF.

Prevention
  • β€’Catheterise only when needed; remove as soon as possible
  • β€’Aseptic insertion; keep a closed drainage system
  • β€’No routine antibiotic prophylaxis
Diagnosis & first steps
  • β€’Treat only if symptomatic β€” never on a dipstick
  • β€’Catheter in over 7 days? Change it promptly (don't delay antibiotics) and take the sample from the new one
πŸ’Š CAUTI β€” NICE NG113 (non-pregnant adults 16+):
  • No upper1st: nitrofurantoin 100 mg MR twice a day (eGFR β‰₯45) or trimethoprim 200 mg twice a day (low resistance risk), each for 7 days. 2nd: pivmecillinam 400 mg then 200 mg three times a day (7 days in total).
  • UpperFever/loin pain: cefalexin 500 mg twice or three times a day for 7–10 days; alternatives as for pyelonephritis.
⚠️ Smelly or cloudy catheter urine is not a UTI on its own. Look for real signs: fever, rigors, new confusion, suprapubic or loin pain. Nitrofurantoin and pivmecillinam aren't suitable for a blocked catheter or upper UTI.

Source: NICE NG113 (catheter-associated UTI: antimicrobial prescribing).

πŸƒ Aide-mΓ©moire β€” how many days?

5️⃣ Haematuria & Proteinuria

Who needs urology, who needs nephrology, and who needs neither

Blood and protein in the urine

Haematuria is a symptom, not a diagnosis.

Your three jobs: (1) spot emergencies, (2) exclude simple causes (UTI, periods, contamination), and (3) apply NICE thresholds to choose urology (possible cancer) vs nephrology (kidney filter disease) vs monitor.

Visible haematuria = blood the patient can see. Higher cancer risk than non-visible.

First confirm it's really blood from the urinary tract
  • β€’Exclude periods and vaginal bleeding; beetroot and rifampicin colour urine red
  • β€’Send an MSU; check FBC and U&E/eGFR
  • β€’Clots or heavy bleeding? Risk of clot retention
Pain helps localise
  • β€’Painful: UTI, stone, clot colic
  • β€’Painless: cancer until proven otherwise

🚩 Suspected cancer pathway referral (NICE NG12)

🚩

Aged 45+ with unexplained visible haematuria without UTI, or visible haematuria that persists or recurs after successful UTI treatment β†’ bladder and kidney cancer pathway.

Non-visible haematuria = blood on the dipstick only. Use a dipstick rather than microscopy, and act on 1+ or more (NICE NG203).

Confirm & classify
  • β€’Persistent = 2 out of 3 positive dipsticks (NICE NG203)
  • β€’Exclude UTI, periods and recent heavy exercise
  • β€’Every time: BP, eGFR and urine ACR
Don't be misled
  • β€’Anticoagulants don't explain it β€” investigate anyway
  • β€’Young adult with cola-coloured urine after a sore throat β†’ think glomerulonephritis (nephrology, not urology)

🚩 Suspected cancer pathway referral (NICE NG12)

🚩

Aged 60+ with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test β†’ bladder cancer pathway.

β€’

Consider a non-urgent bladder cancer referral at 60+ with recurrent or persistent unexplained UTI.

Use ACR, not the dipstick (NICE NG203): the urine albumin:creatinine ratio (ACR) on an early-morning sample is the test for proteinuria.
ACR (mg/mmol)CategoryWhat to do
Under 3A1 β€” normal to mildly increasedUsual risk-factor care
3–30A2 β€” moderately increasedConfirm on early-morning sample; this is clinically important
Over 30A3 β€” severely increasedTreat, monitor more often; ACEi/ARB if hypertensive
70 or more(within A3)Refer nephrology (unless explained by treated diabetes)
  • β€’Confirm: if the first ACR is 3–70, repeat on an early-morning sample; if 70 or more, no repeat needed.
  • β€’Clinically important proteinuria = confirmed ACR of 3 or more.
⚠️ Nephrotic picture: heavy proteinuria plus leg swelling and low albumin = urgent nephrology. "Frothy urine and swollen ankles" deserves an ACR the same week.

Source: NICE NG203 (CKD: assessment and management).

πŸ”€ Haematuria β€” urology, nephrology or monitor?

START: Confirmed urinary haematuria (UTI and contamination excluded)
↓
❓ Meets a NICE NG12 cancer threshold?
YES ↓NO ↓
Suspected cancer pathway to urology
(visible at 45+; or non-visible at 60+ with dysuria / raised WCC)
Check ACR, eGFR, BP β†’ proteinuria, falling eGFR or high BP? Refer nephrology. Otherwise monitor in primary care
βœ… Nephrology (not urology) clues: haematuria with significant protein (ACR over 30 plus haematuria, or ACR 70+), falling eGFR, high BP, or systemic features such as rash or joint pain (think vasculitis).
No threshold met? Haematuria alone doesn't need referral, but don't just discharge it β€” keep an eye on BP, eGFR and ACR.

Sources: NICE NG12 (cancer referral) and NG203 (nephrology referral).

πŸƒ Aide-mΓ©moire β€” tap to reveal the threshold

6️⃣ Acute Kidney Injury (AKI)

Spot it early, stop the culprits, and know who needs hospital today

AKI in primary care

Usually silent, often drug-related, frequently preventable.

Definition β€” any one of (NICE NG148)
  • β€’Creatinine rise of 26 Β΅mol/L or more within 48 hours
  • β€’Creatinine rise of 50% or more within the past 7 days
  • β€’Urine output under 0.5 mL/kg/hour for over 6 hours
Who's at risk?
  • β€’Age 65+, CKD, heart failure, liver disease, diabetes
  • β€’Previous AKI; cognitive impairment (can't keep drinking)
  • β€’Nephrotoxic drugs; sepsis; urinary obstruction
How it shows up: usually found on bloods during an acute illness. Look for reduced urine, new swelling or breathlessness, and uraemic clues β€” nausea, itch, confusion.
StageCreatinineUrine outputPrimary-care action
11.5–1.9Γ— baseline, or rise of 26 Β΅mol/L or moreUnder 0.5 mL/kg/h for 6–12 hFind and treat cause; stop culprits; recheck in 24–48 h
22.0–2.9Γ— baselineUnder 0.5 mL/kg/h for 12 h or moreLow threshold to admit; discuss with medicine
33Γ— baseline, or 354 Β΅mol/L or moreUnder 0.3 mL/kg/h for 24 h, or anuria for 12 hHospital admission

Staging per KDIGO criteria, as used by the NHS England AKI algorithm and NICE NG148.

What you do
  • β€’Assess hydration, sepsis and obstruction (feel for a bladder)
  • β€’Dipstick the urine β€” blood/protein hints at kidney inflammation
  • β€’Pause nephrotoxic and "sick-day" drugs
  • β€’Recheck U&E promptly; review all drug doses by eGFR
After recovery
  • β€’Recheck eGFR and ACR β€” AKI raises future CKD risk
  • β€’Restart held medicines deliberately, with a blood-test plan
  • β€’Code the AKI so the next clinician knows

🚩 Red Flags β€” same-day admission / specialist discussion

🚩

Hyperkalaemia (potassium 6.0 mmol/L or more), fluid overload, or uraemic symptoms.

🚩

Signs of kidney inflammation: blood and protein on dipstick with rapidly falling eGFR, new swelling or high BP β€” possible glomerulonephritis.

🚩

Suspected obstruction (anuria, palpable bladder, known pelvic cancer), or AKI stage 3, or sepsis.

Source: NICE NG148 (AKI: prevention, detection and management).

ACE inhibitors and ARBs relax the outflow vessel of the kidney's filter β€” that's how they protect it long-term β€” so a small eGFR dip on starting is expected. Recheck U&E 1–2 weeks after starting or increasing the dose.

βœ… Continue unchanged: eGFR fall under 25% or creatinine rise under 30% from baseline.
πŸ›‘ Fall of 25%+ (or creatinine rise of 30%+): look for other causes (dehydration, NSAIDs). If none, stop or reduce, and consider renal artery stenosis/nephrology advice.
πŸ’Š Potassium rule (NICE NG203): don't start an ACEi/ARB if potassium is above 5.0 mmol/L; stop it if potassium is 6.0 mmol/L or more after other causes are addressed. Never combine an ACEi with an ARB for CKD.

Source: NICE NG203, recommendations on renin–angiotensin system antagonists.

πŸ›‘ The "triple whammy": ACEi/ARB + diuretic + NSAID. Each alone is usually fine; together, in a dehydrated patient, they tip the kidney into AKI.

🧠 Mnemonic: SADMANS β€” medicines to pause on "sick days"

SSGLT2 inhibitors β€” the "-flozins" (dapagliflozin, empagliflozin): also ketoacidosis risk
AACE inhibitors β€” the "-prils" (ramipril, lisinopril)
DDiuretics β€” furosemide, bendroflumethiazide, indapamide
MMetformin β€” lactic acidosis risk if kidneys struggle
AARBs β€” the "-sartans" (losartan, candesartan)
NNSAIDs β€” ibuprofen, naproxen, diclofenac
SSulfonylureas β€” gliclazide: hypoglycaemia risk when not eating
⚠️ Sick-day script: "If you're vomiting, have diarrhoea, or have a fever with sweats and shaking, pause the tablets on this list. Restart once you've been eating and drinking normally for 24–48 hours. If in doubt, ask your pharmacist, the surgery or 111."
βœ… Individualise it: give the advice with a written list of their medicines. People with heart failure may still need fluid limits and daily weights β€” don't blanket-advise "drink loads". NICE NG28 (2026) specifically asks for clear sick-day rules, including how to restart, for everyone with type 2 diabetes.

Sources: Think Kidneys / NHS England AKI programme; NICE NG148; NICE NG28 (2026). The mnemonic is a teaching aid, not NICE wording.

7️⃣ Chronic Kidney Disease (CKD)

A cardiovascular disease that happens to involve the kidneys

CKD from diagnosis to referral

Most people with CKD are managed entirely in general practice β€” this is your territory.

Definition (NICE NG203): abnormal kidney structure or function present for more than 3 months. In practice: eGFR under 60 on repeat testing at least 3 months apart, or markers of kidney damage at any eGFR β€” such as ACR of 3 or more, persistent haematuria, or structural disease on imaging.
⚠️ CKD isn't a diagnosis in itself: look for the cause β€” diabetes and high BP most often, but also obstruction, glomerular disease, polycystic kidneys and drugs.
πŸ›‘ Why it matters: CKD raises cardiovascular risk so much that NICE says don't use a risk calculator (like QRISK) if eGFR is under 60 or there's albuminuria β€” treat as high risk (NICE NG238).

What untreated CKD leads to

  • β€’Hard-to-control blood pressure β†’ heart attack, stroke, heart failure, peripheral arterial disease
  • β€’Hypoglycaemia risk β€” the kidneys normally clear insulin and some diabetes drugs
  • β€’Fluid retention, anaemia, and bone and mineral problems in later stages
  • β€’Drug accumulation β€” many doses need adjusting as eGFR falls
βœ… In frail older people: eGFR falls naturally with age. Don't let the label drive over-treatment β€” use age, frailty and patient priorities to guide care. You might say: "Your kidneys are working less than when you were young, which is common at your age. We'll keep an eye on them and make sure your medicines suit them."

Classify using both eGFR (G) and ACR (A) β€” for example, eGFR 50 and ACR 35 = G3aA3. Risk rises with both.

GFR categoryeGFR (mL/min/1.73mΒ²)Meaning
G190 or moreNormal or high (CKD only if damage markers present)
G260–89Mildly reduced (CKD only if damage markers present)
G3a45–59Mildly to moderately reduced
G3b30–44Moderately to severely reduced
G415–29Severely reduced
G5Under 15Kidney failure

How often to check eGFR (tests per year, NICE NG203)

GFR categoryACR A1 (under 3)ACR A2 (3–30)ACR A3 (over 30)
G1–G21 or fewer11 or more
G3a112
G3b1–222 or more
G4223
G5444 or more
⚠️ Tailor it: test more often if eGFR is falling fast, during intercurrent illness, or after medication changes. The table is a starting point, not a rule.

Source: NICE NG203 (classification; monitoring frequency table). Replaces the old fixed "3-monthly / monthly" schedules in the previous page.

Offer testing β€” eGFR (from creatinine) plus urine ACR β€” to people with risk factors. Just two tests do the job.

Test people with (NICE NG203)
  • β€’Diabetes, hypertension, cardiovascular disease
  • β€’Previous AKI
  • β€’Structural renal tract disease, recurrent stones, prostate enlargement
  • β€’Multisystem disease (e.g. lupus), gout
  • β€’Family history of kidney failure or hereditary kidney disease
  • β€’Incidental haematuria or proteinuria
  • β€’Long-term nephrotoxic drugs (e.g. lithium, calcineurin inhibitors, long-term NSAIDs)
Don't test just because of
  • β€’Age, sex, ethnicity or obesity alone, without another risk factor
Easily missed group: anyone discharged after an AKI β€” every AKI nudges long-term kidney function downwards, so check eGFR and ACR afterwards.
🩸 BP target β€” ACR under 70: clinic systolic under 140 (target range 120–139) and diastolic under 90.
🩸 BP target β€” ACR 70 or more: clinic systolic under 130 (target range 120–129) and diastolic under 80.
⚠️ Correction to the old page: NICE NG203 (2021) removed the separate "diabetes = 130/80" CKD target. Targets now depend on ACR, not diabetes status. Individualise in frailty (NICE NG136).

Lifestyle β€” what to say

  • β€’Exercise, healthy weight, stop smoking β€” the same advice that protects the heart protects the kidneys
  • β€’Salt: keep to under 6 g a day, as for high blood pressure
  • β€’Protein: don't offer low-protein diets β€” NICE advises against restricting protein below 0.6–0.8 g/kg/day
  • β€’Painkillers: avoid regular over-the-counter NSAIDs; check with a pharmacist before buying remedies
  • β€’Diabetes: individualised HbA1c targets β€” usually 48 or 53 mmol/mol, relaxed in frailty (NICE NG28)

Sources: NICE NG203 recs 1.6.1–1.6.2 (BP) and lifestyle recommendations; NICE NG28; NICE NG136. Replaces older non-UK dietary and glucose targets from the previous page.

πŸ’Š ACE inhibitor or ARB β€” when to offer (NICE NG203):
  • β€’Diabetes and ACR over 3
  • β€’Hypertension and ACR over 30
  • β€’ACR 70 or more, whatever the BP (and refer)
  • 1stRamipril β€” start 1.25–2.5 mg once daily, titrate to the highest licensed dose tolerated (max 10 mg once daily). In renal impairment the BNF caps it at 5 mg daily if eGFR 30–60 and starts at 1.25 mg if eGFR under 30.
  • 2ndIf an ACEi isn't tolerated (e.g. cough): losartan 50 mg once daily, increased to 100 mg once daily if needed (start 25 mg if volume-depleted).
βœ… SGLT2 inhibitors β€” kidney protection beyond glucose:
  • β€’Dapagliflozin 10 mg once daily (NICE TA1075, 2025) as an add-on to an optimised ACEi/ARB if eGFR 20 to under 45, or eGFR 45–90 with ACR 22.6 or more or type 2 diabetes β€” diabetic or not.
  • β€’Empagliflozin 10 mg once daily (NICE TA942) is the alternative; use the least expensive suitable option.
  • β€’Full eligibility, starting checklist and safety advice: see the Gliflozins (SGLT2i) tab.
Statins (NICE NG238): offer atorvastatin 20 mg for primary or secondary prevention to everyone with CKD. Increase the dose if non-HDL cholesterol falls by less than 40% and eGFR is 30 or more; agree higher doses with a renal specialist if eGFR is under 30.
⚠️ Also on the menu (specialist-guided): finerenone (NICE TA877) for CKD stage 3–4 with ACR 3+ and type 2 diabetes, as an add-on to optimised standard care. Watch potassium.

Sources: NICE NG203; NICE TA1075 (Jul 2025); NICE TA942; NICE TA877; NICE NG238; BNF / SPC (ramipril, losartan).

Gliflozins (SGLT2 inhibitors) in kidney disease β€” the 2026 picture

Gliflozins were designed to lower glucose by making the kidneys pass sugar in the urine. The surprise was that they also slow kidney decline and protect the heart β€” even in people without diabetes. That's why NICE now uses them for CKD, heart failure and type 2 diabetes.

The one-line summary: most adults with CKD on an optimised ACE inhibitor or ARB should be considered for dapagliflozin or empagliflozin 10 mg once daily β€” and almost everyone with type 2 diabetes and CKD (eGFR 20+) should now be on one (NICE TA1075, TA942, NG28 2026).

Who qualifies? Three NICE routes

RouteWhoKey conditions
CKD β€” TA1075 (dapagliflozin, 2025) & TA942 (empagliflozin, 2023)Adults with CKD, with or without diabetesAdd-on to highest tolerated ACEi/ARB (unless contraindicated) and eGFR 20 to under 45, or eGFR 45–90 with ACR 22.6+ or type 2 diabetes. Use the least expensive suitable option.
Type 2 diabetes + CKD β€” NG28 (Feb 2026)Adults with type 2 diabetes and CKDeGFR over 30: modified-release metformin + SGLT2i. eGFR 20–30: dapagliflozin or empagliflozin + DPP-4 inhibitor. Continue for heart/kidney benefit even if not helping glucose.
Heart failure β€” TA679/TA773 (HFrEF) & TA902/TA929 (HFmrEF/HFpEF)Symptomatic chronic heart failure, any ejection fractionHFrEF (EF 40% or less): add-on to optimised standard care. HFmrEF/HFpEF (EF over 40%): in addition to standard care. Many CKD patients also qualify here.

Sources: NICE TA1075 (Jul 2025), TA942 (Dec 2023), NG28 (Feb 2026), TA679, TA773, TA902, TA929.

Which drug, what dose?

πŸ’Š Dosing for CKD (UK SPCs / BNF):
  • 1stDapagliflozin 10 mg once daily, long term. No dose change for kidney function. Don't start if eGFR is under 15 (experience starting under 25 is limited). Starting dose 5 mg only in severe liver impairment.
  • 2ndEmpagliflozin 10 mg once daily, long term. Don't start if eGFR is under 20. If eGFR is under 60 the dose stays at 10 mg (the 25 mg dose is for glucose control with eGFR 60+ only).
  • BothNo routine lower "stop" threshold is set in the SPCs β€” as eGFR nears 15 or dialysis approaches, take renal advice rather than stopping reflexively.
⚠️ In type 2 diabetes: glucose-lowering fades below eGFR 45 and is likely absent in severe impairment β€” so add other glucose-lowering drugs if needed, but keep the gliflozin for organ protection. If on insulin or a sulfonylurea, consider reducing that dose to avoid hypos (SPC).

πŸ”€ Starting a gliflozin in primary care β€” checklist

START: CKD confirmed, on highest tolerated ACEi/ARB (unless contraindicated); eGFR and ACR within NICE criteria
↓
❓ Any reason to pause? Volume depletion, acute illness, type 1 diabetes, previous ketoacidosis on an SGLT2i, very low-carb/keto diet
YES ↓NO ↓
Correct dehydration first; seek specialist advice (type 1 diabetes or prior DKA = don't start in primary care)
Start 10 mg once daily; review diuretic dose (especially loop diuretics, age 75+); recheck U&E in a few weeks β€” a small early eGFR dip is expected

🚩 Safety β€” MHRA advice every prescriber should know

🚩

Diabetic ketoacidosis can happen with near-normal glucose ("euglycaemic DKA"). If someone on an SGLT2i has nausea, vomiting, abdominal pain, breathlessness or feels very unwell β€” test ketones, even if glucose looks fine (MHRA 2016).

🚩

Stop during major surgery or acute serious illness in hospital and check ketones, preferably in blood. Restart once ketones are normal and the patient is stable (MHRA 2020).

🚩

Fournier's gangrene (necrotising infection of the genitals/perineum) β€” rare but life-threatening. Severe genital or perineal pain, redness or swelling with fever: stop the drug and refer urgently (MHRA 2019).

β€’

Foot care: a lower-limb amputation signal was seen with canagliflozin; not shown with dapagliflozin or empagliflozin but may be a class effect β€” keep up diabetic foot checks (MHRA 2017).

βœ… What to tell the patient: "This tablet helps protect your kidneys and heart, not just your sugar. It makes you pass a little sugar in your urine, so keep the genital area clean and dry, and tell us about any thrush. If you're vomiting, have diarrhoea, or can't eat or drink, stop it until you're eating and drinking normally for a day or two. And if you ever feel very sick, breathless or have tummy pain, get checked straight away and mention this medicine."

πŸƒ Aide-mΓ©moire β€” gliflozins

Sources: NICE TA1075, TA942, NG28 (2026), TA679, TA773, TA902, TA929; Forxiga and Jardiance UK SPCs (emc); MHRA Drug Safety Updates 2016, 2017, 2019, 2020.

πŸ’Š Type 2 diabetes with CKD β€” NICE NG28 (updated Feb 2026):
  • eGFR >30Modified-release metformin + an SGLT2 inhibitor (introduce one at a time, metformin first). SGLT2 inhibitor alone if metformin unsuitable.
  • eGFR 20–30Dapagliflozin or empagliflozin + a DPP-4 inhibitor.
  • eGFR <20Consider a DPP-4 inhibitor; if unsuitable, pioglitazone or insulin.
  • NextNeed more glucose-lowering? Consider adding a DPP-4 inhibitor; then pioglitazone, a sulfonylurea or insulin.
πŸ›‘ Metformin by eGFR (UK SPC / BNF): eGFR 45–59: maximum 2 g a day; eGFR 30–44: maximum 1 g a day (don't usually start new here); eGFR under 30: stop β€” it builds up and can cause lactic acidosis. Check eGFR at least yearly, every 3–6 months if declining.
⚠️ Correction to the old page: the "contraindicated if creatinine over 150 or eGFR under 40" rule is out of date. The current cut-off is eGFR 30, with dose caps from 45 downwards.
Review the whole repeat list: before adding anything, ask "could this hurt the kidneys, or need a lower dose?" β€” NSAIDs, nitrofurantoin (eGFR under 45), gabapentinoids, DOAC doses, lithium. Tell the patient: "Mention to any pharmacist or doctor that your kidneys aren't at full strength β€” it changes which painkillers are safe."

Sources: NICE NG28 (Feb 2026, CKD track); UK metformin SPC renal dosing table; BNF.

🚩 Refer to nephrology (NICE NG203)

β€’

5-year risk of needing dialysis over 5% on the 4-variable Kidney Failure Risk Equation (KFRE) β€” this replaced the old "eGFR under 30" trigger.

β€’

ACR 70 or more β€” unless known to be caused by diabetes and already appropriately treated.

β€’

ACR over 30 with haematuria.

β€’

Sustained eGFR fall of 25% or more with a category change within 12 months, or a fall of 15 or more per year.

β€’

Hypertension uncontrolled despite 4 or more drugs at therapeutic doses.

β€’

Known or suspected rare/genetic kidney disease, or suspected renal artery stenosis.

βœ… Can't decide? Many units offer advice-and-guidance β€” a quick message often avoids an unnecessary referral and keeps care local.

Plan 6–8 weeks ahead. Many people who could be exempt will still choose to fast β€” respect that and make it safer.

πŸ›‘ Very high risk β€” advise not to fast: dialysis; CKD G4–G5; CKD G3–5 with cardiovascular disease.
⚠️ High risk β€” advise not to fast: unstable CKD (rapidly falling eGFR, fluid overload, frailty); electrolyte problems; fluid restriction.
βœ… Lower risk β€” individual decision: stable CKD G1–3. Discuss tolerance and move doses to Suhoor (pre-dawn) and Iftar (sunset).
Practical tips: review sick-day drugs (SADMANS), check U&E before and during if higher risk, and agree when to break the fast (dizziness, reduced urine, vomiting).

Source: British Islamic Medical Association (BIMA) Ramadan guidance and published nephrology risk stratification. NICE does not cover fasting β€” this is specialist/consensus guidance.

πŸƒ Aide-mΓ©moire β€” CKD numbers

8️⃣ Urinary Tract Stones

Pain relief first, spot the septic blocked kidney, then prevent the next one

Renal & ureteric colic

The patient who can't lie still, pacing your consulting room.

πŸ’Š Pain relief ladder β€” NICE NG118:
  • 1stAn NSAID by any route (e.g. diclofenac) unless contraindicated. NG118 doesn't state a dose β€” use the BNF dose for the route you choose.
  • 2ndIntravenous paracetamol if NSAIDs are contraindicated or not enough (hospital setting).
  • 3rdOpioid only if both of the above are contraindicated or ineffective.
  • Don'tDon't offer antispasmodics (e.g. hyoscine butylbromide) for stone pain.
Confirm & assess
  • β€’Low-dose non-contrast CT within 24 hours is the imaging of choice (ultrasound first in pregnancy and children)
  • β€’Dipstick blood is common, but its absence doesn't rule out a stone
  • β€’U&E, FBC/CRP, calcium; pregnancy test where relevant
  • β€’Older patient with "first renal colic"? Consider a leaking aortic aneurysm
Medical expulsive therapy (MET)
  • β€’Consider an alpha-blocker for distal ureteric stones under 10 mm (NICE NG118)
  • β€’Usually tamsulosin 400 micrograms once daily β€” off-label for this use; NG118 doesn't set a duration, so agree review with urology
  • β€’Small stones often pass on their own β€” watchful waiting is reasonable if pain is controlled

Source: NICE NG118 (renal and ureteric stones: assessment and management); BNF.

🚩 Red Flags β€” admit / urology today

🚩

Fever or sepsis with a suspected stone β€” an infected, blocked kidney needs emergency drainage (stent or nephrostomy).

🚩

AKI, anuria, a single or transplanted kidney, or stones on both sides.

🚩

Pain or vomiting uncontrolled despite adequate analgesia; pregnancy.

⚠️ The dangerous triad: fever + loin pain + known or suspected stone = infected obstructed system until proven otherwise. Antibiotics alone won't fix a blocked, infected kidney.
Everyone who's had a stone (NICE NG118)
  • β€’Drink 2.5–3 litres of water a day (more in heat)
  • β€’Add fresh lemon juice; avoid fizzy drinks
  • β€’Salt no more than 6 g a day
  • β€’Don't restrict calcium β€” keep a normal 700–1,200 mg a day
  • β€’Consider stone analysis; check serum calcium
Recurrent calcium oxalate stones
  • β€’1st: consider potassium citrate for recurrent stones that are mainly (over 50%) calcium oxalate
  • β€’2nd/targeted: consider a thiazide if there's also hypercalciuria β€” after salt is cut to 6 g a day
  • β€’NG118 doesn't give doses β€” usually specialist-led; check the BNF, and watch potassium/eGFR
βœ… Motivating line: "Half of people who've had one stone get another within 10 years β€” but drinking enough water is the single most effective thing you can do to stop it."

Sources: NICE NG118 (prevention of recurrence); recurrence figure from Wilcox et al, BJGP 2020.

9️⃣ Male LUTS & Benign Prostatic Enlargement

Assess, reassure, and step up treatment logically

Lower urinary tract symptoms in men

BPH (benign prostatic hyperplasia) is common, but not every male LUTS is the prostate.

Assess (NICE CG97)
  • β€’History: storage vs voiding vs post-micturition; drugs; fluids
  • β€’IPSS score and how bothered he is
  • β€’Abdomen, genitals and DRE
  • β€’Frequency–volume chart if storage symptoms or nocturia
Test
  • β€’Urine dipstick (blood, glucose, infection)
  • β€’U&E if chronic retention, recurrent UTI, stones or kidney concern suspected
  • β€’PSA after counselling (LUTS is an NG12 indication)
βœ… Reassure: "An enlarged prostate is very common as men get older and isn't cancer. We treat it because of the bother it causes, and we can usually improve things step by step."
  • β€’Fluids: sensible amounts, less in the evening; cut caffeine and alcohol
  • β€’Bladder training for storage symptoms; urethral milking for post-void dribble
  • β€’Review drugs β€” anticholinergics, diuretic timing; treat constipation
  • β€’Containment products (pads, sheaths) while other treatment starts
Nocturnal polyuria (producing over a third of daily urine at night): CG97 suggests considering a late-afternoon loop diuretic; desmopressin is an option but check sodium β€” hyponatraemia risk rises with age.
Drug classWhen (NICE CG97)1st choice2nd choiceOnset & watch-outs
Alpha-blockerModerate–severe voiding LUTSTamsulosin 400 micrograms MR once dailyAlfuzosin 10 mg MR once dailyDays–weeks; review at 4–6 weeks. Dizziness, postural drop, ejaculatory change; warn before cataract surgery (floppy iris)
5Ξ±-reductase inhibitorProstate estimated over 30 g or PSA over 1.4 ng/mL, at high risk of progressionFinasteride 5 mg once dailyDutasteride 500 micrograms once daily3–6 months to work. Halves PSA. Reduced libido, erectile dysfunction
CombinationBothersome moderate–severe LUTS + large prostate/PSA over 1.4Alpha-blocker + 5-ARI (e.g. tamsulosin + finasteride)Best at preventing progression and retention
AntimuscarinicStorage (OAB) symptoms persist after alpha-blockerSee Overactive Bladder section for choices and dosesCheck post-void residual concerns
πŸ’Š Prescribing Pearl: men on finasteride or dutasteride β€” double the PSA before comparing with age thresholds. And if he's already on doxazosin for BP, don't add a second alpha-blocker.

Sources: NICE CG97 (last reviewed Dec 2024); BNF / regional formulary doses.

Refer β€” urgent or soon
  • β€’Acute retention; chronic retention with kidney impairment
  • β€’Recurrent UTI, bladder stones, visible haematuria
  • β€’Suspected cancer (see Urological Cancers)
  • β€’Suspected neurological cause
Consider referral
  • β€’Bothersome symptoms despite medical treatment
  • β€’He'd prefer a definitive (surgical) option
  • β€’Stress incontinence in men
⚠️ Two separate pathways: a malignant-feeling prostate or a PSA above the age threshold is a suspected cancer referral β€” don't bury it in a routine BPH letter.

πŸ”Ÿ Overactive Bladder & Incontinence

Name the type, start conservative, and prescribe carefully in older people

Urinary incontinence

Common, under-reported, and very treatable β€” ask about it.

Stress incontinence
  • β€’Leaks on cough, sneeze, laugh, exercise, lifting β€” no warning urge
  • β€’Weak urethral sphincter and pelvic floor support
  • β€’Risk factors: childbirth, menopause, obesity, chronic cough
Urgency incontinence / overactive bladder (OAB)
  • β€’Sudden strong urge, then a leak; frequency and nocturia
  • β€’Caused by an overactive bladder muscle (detrusor)
  • β€’Triggers: key in the door, running water, cold
Mixed incontinence: treat the main symptom first. A bladder diary for at least 3 days is the most useful single tool (NICE NG123). Always exclude UTI and check for a palpable bladder (overflow), especially in men and frail older people.
For OAB / urgency (NICE NG123)
  • β€’Bladder training for at least 6 weeks β€” gradually lengthen time between voids
  • β€’Cut caffeine; sensible fluids (not too much, not too little)
  • β€’Weight loss if BMI over 30; treat constipation
For stress incontinence (NICE NG123)
  • β€’Supervised pelvic floor muscle training for at least 3 months β€” at least 8 contractions, 3 times a day
  • β€’Refer to a specialist continence physiotherapist
  • β€’Weight loss if BMI over 30
βœ… Worth saying: "These exercises aren't a soft option β€” done properly they work as well as tablets, with no side effects. Think of it as physio for your bladder."

Source: NICE NG123 (urinary incontinence and pelvic organ prolapse in women).

πŸ’Š OAB β€” antimuscarinic (after bladder training), NICE NG123: choose the lowest-cost suitable drug and review at 4 weeks.
  • 1stOxybutynin (immediate-release) 5 mg two or three times a day, maximum 5 mg four times a day; older people start at 2.5 mg twice a day. Not for frail older women (NICE NG123).
  • 1st altTolterodine 2 mg twice a day (1 mg twice a day if side effects).
  • 2ndSolifenacin 5 mg once daily, increased to 10 mg once daily if needed.
⚠️ Anticholinergic burden: these drugs can worsen memory, confusion and falls in older people, and cause dry mouth, constipation and blurred vision. Add up the total anticholinergic load before prescribing. Avoid in narrow-angle glaucoma.
πŸ’Š Mirabegron (beta-3 agonist), NICE TA290: only if antimuscarinics are contraindicated, ineffective or not tolerated. 50 mg once daily; 25 mg once daily if eGFR 15–29; avoid under 15 (SPC). Check BP before and during treatment β€” avoid in severe uncontrolled hypertension.
Post-menopausal women: offer vaginal oestrogen for OAB symptoms with vaginal atrophy. For stress incontinence, duloxetine is not first-line β€” only an option if surgery is declined or unsuitable (specialist-guided).

Sources: NICE NG123; NICE TA290; BNF and SMC dosing data; mirabegron SPC.

🚩 Refer urgently / specialist review

🚩

Visible haematuria (45+), or non-visible haematuria with dysuria/raised WCC (60+) β€” suspected cancer pathway.

🚩

Palpable bladder after voiding, suspected neurological disease, or a pelvic mass.

β€’

Persistent pain, recurrent UTI, previous continence or cancer surgery/pelvic radiotherapy, or symptomatic prolapse at or below the vaginal opening.

βœ… Refer non-urgently: stress or mixed incontinence that hasn't improved after supervised pelvic floor training, or OAB despite drug treatment (for options such as botulinum toxin).

1️⃣1️⃣ Urological Cancers

Your job is recognition and the right pathway β€” treatment lives in secondary care

Kidney, bladder, prostate and testis

All thresholds are from NICE NG12 β€” unchanged in the April 2026 update.

Recognise
  • β€’Often found by chance on a scan done for something else
  • β€’Loin pain, mass and haematuria together is a late, uncommon picture
  • β€’Unexplained weight loss or appetite loss; raised calcium; high haemoglobin
  • β€’New left varicocele that doesn't empty lying down
Risk factors
  • β€’Smoking, obesity, hypertension
  • β€’Long-term dialysis; inherited syndromes (e.g. von Hippel–Lindau)

🚩 Suspected cancer pathway (NICE NG12)

🚩

45+ with unexplained visible haematuria without UTI, or visible haematuria persisting/recurring after UTI treatment.

Recognise
  • β€’Painless visible haematuria is the classic sign
  • β€’Storage symptoms without infection; recurrent UTIs in older people
Risk factors
  • β€’Smoking β€” the biggest single risk factor
  • β€’Work exposure to aromatic amines (dyes, rubber, paint)
  • β€’Older age, male sex, previous pelvic radiotherapy

🚩 Suspected cancer pathway (NICE NG12)

🚩

45+ with unexplained visible haematuria (no UTI), or visible haematuria persisting/recurring after UTI treatment.

🚩

60+ with unexplained non-visible haematuria and either dysuria or a raised white cell count.

β€’

Consider a non-urgent referral: 60+ with recurrent or persistent unexplained UTI.

When to offer PSA + DRE (NICE NG12)
  • β€’Any LUTS β€” nocturia, frequency, hesitancy, urgency, retention
  • β€’Erectile dysfunction
  • β€’Visible haematuria
  • β€’Bone or back pain, weight loss β€” think metastases
Risk factors
  • β€’Increasing age
  • β€’Black ethnicity
  • β€’Family history; BRCA2 variants

🚩 Suspected cancer pathway (NICE NG12)

🚩

PSA above the age-specific threshold: 40–49 over 2.5; 50–59 over 3.5; 60–69 over 4.5; 70–79 over 6.5 Β΅g/L.

🚩

Prostate feels malignant on DRE β€” refer whatever the PSA.

What happens next: most men now have a prostate MRI first, and a targeted biopsy only if the MRI is suspicious.
Recognise
  • β€’Painless, hard lump or change in shape/texture of the testis
  • β€’Most common in young to middle-aged men
  • β€’Dragging heaviness; occasionally breast enlargement
Act (NICE NG12)
  • β€’Consider a suspected cancer pathway referral for non-painful enlargement or change in shape/texture of the testis
  • β€’Consider direct-access ultrasound for unexplained or persistent testicular symptoms
πŸ›‘ Don't "review in a few weeks": a hard lump within the testis in a young man needs referral now, even if he's embarrassed and keen to leave.
CancerClassic clueNICE NG12 trigger
KidneyOften incidental; haematuria, weight loss45+ unexplained visible haematuria (no UTI)
BladderPainless visible haematuria; smoker45+ visible haematuria; or 60+ non-visible + dysuria/raised WCC
ProstateLUTS, ED, abnormal DRE, raised PSAPSA above age threshold, or malignant-feeling DRE
TestisPainless hard lump in a young manConsider suspected cancer pathway Β± direct-access ultrasound
⚠️ New in April 2026 (NG12): aged 60+ with unexplained weight loss of more than 5% over 6 months β€” assess, then urgent investigation, suspected cancer pathway, or non-specific symptoms pathway. Urological cancers are among the possibilities.
βœ… Safety-net script: "Most causes of this aren't cancer, but it's important we check quickly. If anything changes β€” more blood, weight loss, new pain β€” come back sooner; don't wait for the appointment."

Source: NICE NG12 (recommendations by site; update information April 2026).

1️⃣2️⃣ Red Flags & Emergencies

The few presentations where minutes or a same-day referral change the outcome

Must-not-miss urology and renal emergencies

If in doubt, pick up the phone.

🚩 Red Flags β€” Do Not Miss

🚩

Acute scrotal pain β€” torsion until proven otherwise: immediate surgical referral.

🚩

Fever + loin pain + stone β€” infected obstructed kidney: emergency urology.

🚩

Painful, palpable bladder and unable to pass urine β€” acute retention: catheterise.

🚩

Retention with back pain, saddle numbness or leg weakness β€” cauda equina: immediate emergency referral.

🚩

AKI with potassium 6.0+, fluid overload, anuria or sepsis β€” same-day admission.

🚩

Visible haematuria at 45+ β€” suspected cancer pathway, anticoagulated or not.

Recognise
  • β€’Sudden, severe one-sided scrotal pain, often with nausea/vomiting
  • β€’High-riding testis lying horizontally; absent cremasteric reflex
  • β€’Most common in adolescents, but possible at any age
Act
  • β€’Refer immediately for surgical exploration β€” don't delay for a scan
  • β€’The chance of saving the testis falls with every hour β€” ideally surgery within about 6 hours (NICE CKS scrotal pain)
πŸ›‘ A normal-looking testis doesn't exclude torsion. Intermittent torsion can come and go β€” take a history of previous similar episodes seriously.
Recognise
  • β€’Can't pass urine, with a painful, distended, palpable bladder
  • β€’Triggers: BPH, constipation, UTI/prostatitis, anticholinergics, opioids, after surgery or anaesthetic
Act
  • β€’Catheterise and record the residual volume drained
  • β€’Check U&E; treat the trigger (e.g. constipation, stop culprit drugs)
  • β€’Men with likely BPH: offer an alpha-blocker before a trial without catheter (NICE CG97)
  • β€’Same-day urology if AKI, infection, clots or failed catheterisation
⚠️ Painless retention is sneaky: chronic high-pressure retention can silently damage the kidneys. Watch for a big post-drainage urine output (post-obstructive diuresis) and rising creatinine.
  • β€’Assess for sepsis in anyone with UTI plus fever, confusion, low BP, high heart or breathing rate, or mottled skin (NICE NG51 sepsis risk stratification)
  • β€’Older people may just seem "off legs" or newly confused
  • β€’Known stone, catheter or prostate enlargement makes obstruction more likely
πŸ›‘ Action: high-risk sepsis β†’ 999 / immediate hospital transfer. An infected blocked kidney needs drainage, not just antibiotics.
🚩 Never blame the anticoagulant. Patients on warfarin or DOACs still follow the NICE NG12 pathway β€” anticoagulants reveal hidden disease rather than cause the bleeding.
  • β€’45+ with unexplained visible haematuria β†’ suspected cancer pathway (bladder + kidney)
  • β€’60+ with non-visible haematuria + dysuria or raised WCC β†’ suspected cancer pathway (bladder)

Source: NICE NG12. See the Haematuria & Proteinuria section for the full pathway.

πŸ’ͺ You've Got This!

A final word of encouragement before you head back to the coalface

You've Got This! πŸ’ͺ

Remember: you don't need to be a nephrologist or a urologist to give excellent kidney and bladder care. You just need to know when to worry, when to treat, and when to refer.

You can confidently manage most UTIs, CKD monitoring, BP and statins, sick-day advice, and first-line treatment for prostate and bladder symptoms. Refer the ACR of 70, the falling eGFR, the raised PSA and the stone that won't pass. And the one thing never to miss: painless visible blood in the urine β€” however "obvious" the explanation seems.

β˜• Now go reward yourself with that well-deserved coffee

Bradford VTS is a FREE resource made with ❀ by Dr. Ramesh Mehay and others.

Β© 2026 Renal & Urology Clinical Guide β€” educational resource for healthcare professionals. Always check current NICE guidance and the BNF before prescribing.

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