Domain – Kidney and urinary health (guiding topics)

• Identify common conditions causing chronic kidney disease (CKD) in asymptomatic individuals. Plan for appropriate screening tests to aid early diagnosis, monitor and prevent progression of CKD.
• In collaboration with the patient, develop a management plan for CKD and consider comorbidities.
• Be aware of significant causes of CKD:
  • diabetes mellites
  • glomerulonephritis
  • hypertension
  • vascular disease
  • connective tissue disease
  • polycystic kidney disease
  • obstructive nephropathy
  • multiple myeloma
  • medication and other rare causes such as amyloidosis.
• Appropriately screen and manage patients presenting with acute kidney injury.
• Develop a patient-centred management plan in collaboration with the patient, family and non-GP specialist to support renal transplant recipients in the community.
• Conduct a detailed history, examination and assessment of patients presenting with haematuria and consider differential diagnoses including risk factors for malignancy. Arrange appropriate investigations to arrive at a diagnosis and formulate a patient-centred management plan, considering biopsychosocial aspects.
• Identify and distinguish between the different causes of haematuria:
  • transient haematuria:
    • trauma
    • exercise
    • vaginal atrophy
  • malignancy:
    • renal cell carcinoma
    • urothelial carcinoma including bladder cancer, prostate cancer
  • infections:
    • pyelonephritis
    • lower urinary tract infection
    • urethral caruncle
  • medical disease:
    • CKD
    • glomerulonephritis
  • congenital conditions:
    • polycystic kidney disease
  • obstructive disease:
    • urolithiasis
    • benign prostatic hyperplasia (BPH).
• Conduct a detailed history, examination and assessment of patients presenting with lower urinary tract symptoms (LUTS), including frequency, urgency, urethral discharge, flow disturbances.
• Identify and distinguish between the different causes of LUTS, including:
  • BPH
  • prostatitis
  • prostate cancer
  • urethral stricture
  • urethritis
  • urethral calculi
  • cystitis
  • bladder cancer or neurogenic bladder secondary to medical condition.

Causes of Lower Urinary Tract Symptoms (LUTS)

Cause	Key Features in Clinical Diagnosis	Investigations Specific to Diagnosis	Key Treatments
Benign Prostatic Hyperplasia (BPH)	– Hesitancy, weak stream, incomplete emptying, nocturia – Non-tender, enlarged prostate on DRE	– Digital Rectal Exam (DRE) – PSA levels – Ultrasound (post-void residual)	– Alpha blockers (e.g., tamsulosin) – 5-Alpha reductase inhibitors (e.g., finasteride) – TURP (Transurethral resection of the prostate)
Prostatitis	– Dysuria, pelvic pain, perineal pain – Fever, chills (acute) – Tender, boggy prostate on DRE	– Urinalysis and urine culture – Prostate-specific antigen (PSA) may be elevated	– Antibiotics (e.g., fluoroquinolones) – Alpha blockers – Anti-inflammatories – Sitz baths
Prostate Cancer	– Asymptomatic in early stages – LUTS symptoms if advanced – Hematuria, bone pain (metastasis)	– DRE (hard, irregular prostate) – PSA levels – Biopsy (transrectal ultrasound-guided) – Imaging (MRI, bone scan)	– Active surveillance (low-risk) – Surgery (prostatectomy) – Radiation therapy – Hormone therapy (androgen deprivation)
Urethral Stricture	– Weak stream, spraying of urine – Dysuria, recurrent UTIs	– Uroflowmetry – Cystoscopy – Retrograde urethrogram	– Urethral dilation – Urethrotomy – Urethroplasty
Urethritis	– Dysuria, urethral discharge – Itching, burning sensation	– Urinalysis – NAAT (Nucleic Acid Amplification Test) for STIs – Urethral swab and culture	– Antibiotics (e.g., azithromycin for Chlamydia, ceftriaxone for Gonorrhea) – Partner treatment
Urethral Calculi	– Severe, colicky pain radiating to the groin – Hematuria – Dysuria	– Non-contrast CT scan – Urinalysis – KUB (Kidneys, Ureters, and Bladder)	– Pain management (NSAIDs, opioids) – Alpha blockers (e.g., tamsulosin) – Lithotripsy or endoscopic removal
Cystitis	– Dysuria, urgency, frequency – Suprapubic pain – Hematuria (occasionally)	– Urinalysis – Urine culture	– Antibiotics (e.g., nitrofurantoin, trimethoprim/sulfamethoxazole) – Increased fluid intak
Bladder Cancer	– Painless hematuria – Irritative LUTS (frequency, urgency) – Pelvic pain (advanced)	– Urine cytology – Cystoscopy with biopsy – Imaging (CT urogram)	– TURBT (Transurethral resection of bladder tumor) – Radical cystectomy (advanced cases)
Neurogenic Bladder (secondary to medical condition)	– Urinary retention, incontinence – Frequency, urgency – History of neurological condition (e.g., spinal cord injury, MS)	– Urodynamic studies – Post-void residual measurement – MRI of the spine (if new onset)	– Clean intermittent catheterization – Anticholinergics (e.g., oxybutynin) – Botulinum toxin injections<br>- Sacral neuromodulation

• Conduct a detailed history, examination and assessment of patients presenting with dysuria and consider differential diagnoses, including:
  • urinary tract infection (UTI)
  • sexually transmissible infection (STI)
  • BPH
  • vaginal prolapse
  • trauma
  • calculus.
• In patients presenting with incontinence, identify and differentiate between causes such as:
  • urge, stress or mixed type incontinence
  • overactive bladder
  • cauda equina syndrome
  • neurogenic bladder.
• In collaboration with the patient, develop an incontinence management plan that includes pharmacological, non-pharmacological and surgical options.
• In patients presenting with flank, groin or abdomen pain identify causes, including:
  • urolithiasis
  • pyelonephritis
  • cystitis
  • malignancy
  • referred pain due to testicular torsion, epididymitis/orchitis.
• Screen paediatric patients presenting for newborn check or immunisation for:
  • hypospadias
  • cryptorchidism
  • labial adhesions in female babies
  • signs of hyper or under virilisations such as clitoromegaly or micro penis.
• Identify urosepsis and treat as per best evidence in significantly unwell individuals in the community and in residential aged care facilities.
• Screen for UTI with a mid-stream, clean catch or catheter sample in patients presenting with fever with no obvious cause.
• Be vigilant and screen asymptomatic individuals in high-risk populations for signs and symptoms of kidney or urological disease, including:
  • proteinuria and microscopic haematuria (polycystic kidney disease, glomerulopathies, CKD, malignancies)
  • asymptomatic bacteriuria (pregnancy)
  • hyperuricemia in CKD
  • prostate cancer.
• In babies and young children presenting with culture positive UTIs, screen for underlying conditions, including:
  • vesico-ureteric reflux
  • posterior urethral valve
  • congenital anomalies such as duplication or absence.
• In patients presenting with urinary retention, identify common aetiological factors and manage accordingly.
• Conduct a urine dipstick test as part of examination and information gathering.
• Perform clinical examination of external genitals and speculum examination of women presenting with LUTS to rule out vaginal atrophy and urethral caruncle, before organising extensive investigation.
• Competently insert an indwelling catheter and replace supra-pubic catheters to:
  • relieve distress in acute urinary retention
  • collect appropriate specimens, including for children.