Kidney and urology

As a GP your roll 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 medications, to reduce the risk of AKI 
• Manage of common urinary tract problems such as urinary tract infections (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

• There is increasing awareness that a significant proportion of AKI starts in the community, so GPs have a key role to play in its early identification and management
• Increased use of cystatin C based eGFR estimates may help reduce over-diagnosis in early stage CKD
• There is a growing awareness that many urological conditions are associated with obesity, inactivity and metabolic syndrome, which highlights the need for holistic assessment and care of patients with urological problems

For each problem or disease, consider the following areas within the general context of primary care:  

• The natural history of the untreated condition including whether acute or chronic 
• The prevalence and incidence across all ages and any changes over time  
• Typical and atypical presentations 
• Recognition of normal variations throughout life 
• Risk factors, including lifestyle, socio-economic and cultural factors
• Diagnostic features and differential diagnosis 
• Recognition of 'alarm' or 'red flag' features 
• Appropriate and relevant investigations 
• Interpretation of test results 
• Management including self-care, initial, emergency and continuing care, chronic disease monitoring  
• Patient information and education including self-care 
• Prescribing – understanding medication and dose changes in renal impairment 
• 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, 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, arthralgia

Common and important conditions  

• Acute Kidney Injury (AKI)  
• Cancer: bladder, kidney, penile, prostate, testicular, ureteric 
• Chronic Kidney Disease (CKD) including causes, classification, management, 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 (for example, 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 kidney 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 testes, varicocele 
• Urinary incontinence in men  
• Urinary incontinence in women: stress and/or urge incontinence. (Prolapse is covered in Topic Guide Gynaecology and Breast) 
• Urinary tract infections in children and in adults including lower urinary tract infection, pyelonephritis and persistent/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 Topic Guide Sexual Health).

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, eGFR, electrolytes, full blood count, prostate specific antigen (PSA), calcium, phosphate, parathyroid home (PTH) and Vitamin D 
• International Prostate Symptom Score (IPSS) to assess LUTS 
• Renal tract imaging including ultrasound and CTKUB 
• Secondary care investigations (such as cystoscopy, ureteroscopy, urodynamic studies and flow rate studies)  
• 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 prostate-specific antigen (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 and necessary adjustments 
• Nephrostomy and cystostomy care 
• Prescribing in kidney disease (for example dose adjustment in renal impairment) and an awareness of nephrotoxic medications 
• Renal transplantation and post-transplant care that is relevant to primary care

Nigel is a 37-year-old businessman who presents to you having recently had a 'well man' check through his employer's private health care 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's 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. 

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. The UK Renal Association website has an excellent UKeCKD Guide available on their website. These concise pragmatic guidelines can be referred to when managing patients identified with CKD.

Some GP specialty trainees 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. Trainees with paediatric placements may encounter childhood renal and urology problems.

Self-directed learning

You can find e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare and at RCGP Learning. The RCGP have a toolkit on Acute Kidney Injury. 

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.

Applied Knowledge Test (AKT) 

• Monitoring of chronic kidney disease 
• Drug therapy for prostatic cancer 
• Investigations for haematuria 

Clinical Skills Assessment (CSA) 

• Middle-aged man has abdominal and loin pain. Examination expected. 
• Woman with diabetes and hypertension is recalled urgently to discuss a sudden drop in renal function. She is recovering from gastroenteritis. 
• 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