The role of the GP in kidney and urological health
As a GP your role is to:
- identify and manage chronic kidney disease (CKD), and understand the interventions that can delay its progression and reduce the associated increased cardiovascular morbidity and mortality
- identify and manage acute kidney injury (AKI), including taking early action, such as stopping medication, to reduce the risk of AKI
- manage common urinary tract problems such as urinary tract infection (UTI), renal stone disease and benign prostatic conditions
- be alert to possible indicators of urinary tract malignancy
- know when to refer and when not to refer, avoiding futile investigation and escalation and encouraging supportive care.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care
- prognosis.
Symptoms and signs
Urinary
- Dysuria
- Haematuria
- Lower urinary tract symptoms (LUTS):
- storage symptoms: frequency, nocturia, urgency
- voiding symptoms: hesitancy, poor stream, terminal dribble
- post-micturition symptoms: post-micturition dribble, sensation of incomplete emptying
- Oliguria, anuria, polyuria
- Proteinuria
- Strangury
- Urinary incontinence – stress, urgency and mixed
- Urinary retention – acute and chronic
Genital
- Abnormal digital rectal examination
- Erectile dysfunction
- Haematospermia
- Penile problems, including deformity and skin lesions
- Perineal pain
- Scrotal pain, swelling and lumps
- Testicular pain, swelling and lumps
Abdominal
- Abdominal and loin masses, including palpable kidneys and bladder
- Abdominal and loin pain
Systemic
- Anaemia
- Fever and rigors
- Hypertension
- Oedema
- Pruritus
- Thirst
- Systemic symptoms of vasculitis, for example, rash and arthralgia
Common and important conditions
- AKI
- Cancer: bladder, kidney, penile, prostate, testicular, ureteric
- CKD, including causes, classification, management (including cardiovascular risk reduction), monitoring and indications for referral
- Congenital abnormalities of the urinary tract
- Haematuria (visible or non-visible)
- Inherited kidney diseases such as polycystic kidney disease, Alport syndrome
- Intrinsic renal disease (such as glomerulonephritis)
- Overactive bladder syndrome
- Penile problems such as malignancy, paraphimosis, Peyronie’s disease, phimosis, priapism, balanitis, skin disorders
- Prostatic problems such as acute and chronic prostatitis, benign prostatic hyperplasia, prostatic carcinoma
- Proteinuria (including microalbuminuria)
- Renovascular disease (renal artery stenosis)
- Systemic conditions causing renal disease, for example, connective tissue diseases, diabetes mellitus, glomerulonephritis, hypertension, malignancy such as multiple myeloma, nephrotic syndrome
- Testicular problems, including epididymitis, hydrocele, orchitis, sperm granuloma, torsion, tumours (such as seminoma and teratoma), undescended and maldescended (undescended) testes, varicocele
- Urinary incontinence in men
- Urinary incontinence in women: stress and/or urge incontinence. (Prolapse is covered in the Gynaecology and breast health topic guide)
- UTIs in children and adults including lower UTI, pyelonephritis and persistent or recurrent infection
- Urinary tract obstruction, including acute and chronic retention; causes including prostatic and other structural abnormalities (strictures, congenital renal tract abnormality such as posterior urethral valves, duplex systems)
- Urolithiasis (stone disease): renal colic, management of stones including lithotripsy and ureteric stents
(Erectile dysfunction and sexually transmitted infection are covered in the Sexual health topic guide.)
Examinations and procedures
- Abdominal examination to include bladder and kidney palpation
- Assessment of fluid balance status
- Digital rectal examination, including prostate size, tenderness, nodules
- Genital examination
- Urine dipstick testing
Investigations
- Blood tests, including creatinine, estimated glomerular filtration rate (eGFR), electrolytes, full blood count, prostate-specific antigen (PSA), calcium, phosphate, parathyroid hormone (PTH) and vitamin D
- The Kidney Failure Risk Equation
- International Prostate Symptom Score (IPSS) to assess LUTS
- Renal tract imaging including ultrasound and computed tomography of the kidneys, ureters and bladder (CTKUB)
- Secondary care investigations (such as cystoscopy, ureteroscopy, urodynamic studies, flow rate studies and multiparametric magnetic resonance imaging (MRI))
- Urine tests, including biochemistry, microscopy, culture and sensitivities, quantification of urinary albumin and protein
Service issues
- Call and recall systems to ensure patients with CKD receive appropriate monitoring
- Circumcision for religious or cultural beliefs, including ethical issues
- Debate around the role of the PSA blood test as a screening test for prostate cancer
- Local continence services and arrangements for management of long-term urinary catheters
- The role of chaperones in intimate examinations
Additional important content
- Being aware that the patient’s physiology and anatomy may be different from the patient’s gender
- Catheters: types, indications, management, problems such as bypassing, infection, self-catheterisation, use of catheters in paraplegic patients
- Conservative management of end-stage renal failure, including management of anaemia
- Dialysis: peritoneal and haemodialysis, including complications that may be encountered in primary care (such as infection of catheter sites, fluid balance disturbance)
- Methods to estimate and measure glomerular filtration rate (GFR), including their limitations
- Nephrostomy and cystostomy care
- Prescribing in kidney disease (such as dose adjustment in renal impairment) and an awareness of nephrotoxic medications
- Renal transplantation and post-transplant care that is relevant to primary care
Case discussion
Tim Atkinson is a 37-year-old businessman who presents to you having recently had a ‘well man’ check through his employer’s private healthcare provider. At this check he was found to have 2+ blood and 3+ protein on his urine dipstick and was advised to see his GP to follow this up. He is otherwise fit and well and asymptomatic. Abdominal examination is normal, and his blood pressure is 155/93. The urine dipstick shows persistent proteinuria and non-visible haematuria. He tells you his mother had a renal transplant five years ago but he is not sure about the reason for this. You arrange some blood tests, which show he has an eGFR of 46ml/min/1.73m2.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | What are my thoughts on the private sector providing ‘well person’ checks? What difficult issues might be raised by the results from these checks? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | Knowing more about his mother’s kidney problem might be very helpful here, but raises issues regarding medical confidentiality – how can I explore this ethically? How would I respond to health enquiries from an employer who provide screening for employees? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | What do I need to find out about this patient’s ideas, concerns and expectations regarding his health? What strategies could I use to explore how much Tim already knows about kidney disease given the family history of a kidney transplant? How can I explore how this family history might be impacting on his own concerns? How do I explain to the patient what the cause of his abnormal urine dipstick and blood results might be? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What is the significance of an eGFR of 46ml/min/1.73m2? What other investigations might I want to carry out? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What factors affect the accuracy of urine dipstick testing? How would I assess fluid balance status? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How do I decide whether or not referral to secondary care is indicated and if so to which specialty (urology or nephrology) and with what urgency? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What are the indications for referral to secondary care for investigation of haematuria, proteinuria or reduced eGFR? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | It is possible this represents an inherited kidney disease and will have implications for Tim’s relationships with his mother, wider family and children. How would I explore this with him? What issues might arise when considering whether someone with a genetic condition should be advised to inform their relatives that they may have inherited the condition? What if they decline to inform their relatives? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | If I decide to refer Tim to the local kidney unit, how can I collaborate with them to provide high-quality care for him? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | Where can I find out more about CKD and AKI? How do I maintain my knowledge of rare conditions such as inherited kidney disease? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What systems can help with effective primary care monitoring and recall of patients with chronic diseases such as CKD? What role do information technology (IT) systems have in helping patients engage with their chronic disease management? What issues are raised by these systems? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | What impact might kidney disease have on a patient’s life? What is the place of ‘well person’ checks? What ethical issues are raised by these? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | How can we promote increased awareness of kidney disease among our local population? Are there any communities locally who may be at higher risk of kidney disease? |
How to learn this area of practice
Work-based learning
- General practice is where the vast majority of patients with kidney and urological health issues present. GPs have a key role in identifying and managing the majority of patients with CKD.
- Some GP registrars will have dedicated hospital placements with renal medicine or urology teams, where the management of acute or complex cases can be observed.
- Kidney problems are very common among medical inpatients; nearly all hospital training posts will bring some exposure to CKD and AKI in particular. GP registrars with paediatric placements may encounter childhood renal and urology problems.
Self-directed learning
You can find eLearning module(s) relevant to this topic guide at elearning for healthcare and at RCGP eLearning.
The RCGP has a toolkit on AKI on its website.
Learning with other healthcare professionals
CKD is a chronic disease and has significant overlap with other chronic conditions, in particular diabetes, hypertension and vascular disease. Experience gained with specialist nurses working in these fields will often include experience of managing CKD.
District nurses are particular experts on catheter management and will be able to give tips and advice on this area.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Monitoring of CKD
- Diagnosis of penile or scrotal pathology
- Investigations for haematuria
Simulated Consultation Assessment (SCA)
- A middle-aged man has abdominal and loin pain. Examination expected
- A woman with diabetes and hypertension is recalled urgently to discuss a sudden drop in renal function. She is recovering from gastroenteritis
- A young woman with multiple sclerosis wants to discuss worsening urinary incontinence
Workplace-based Assessment (WPBA)
- Observed clinical examination and procedural skills (CEPS) on a prostate examination in a man with a raised PSA
- Learning log reflecting on a teenager who delayed several months before attending with a testicular swelling
- Audit – looking at the prescribing of long-term antibiotics for patients with recurrent UTIs