GPAtlas🧭 When to suspect
Urological cancers in primary care are largely an exercise in pattern recognition and correct referral: the GP's job is to recognise the cardinal presentation, do the right first-line test, exclude infection before acting on haematuria or PSA, and refer by the correct route. Four pictures account for most of the work – prostate (lower urinary tract symptoms, erectile dysfunction, or visible haematuria, and an abnormal prostate on examination), bladder and renal (visible haematuria is the cardinal sign), testicular (a non-painful lump or change in the testis), and penile (a mass or persistent ulcerated lesion).
The single most useful habit is to treat unexplained visible haematuria as urological cancer until proven otherwise, and to recognise that a painless testicular lump or a hard, nodular prostate each earns a referral on their own.
| Cancer | Cardinal presentation in primary care | Key referral action |
|---|---|---|
| Prostate | LUTS (nocturia, frequency, hesitancy, urgency, retention), erectile dysfunction, or visible haematuria; hard, nodular or asymmetrical prostate on DRE | PSA + DRE; refer 2WW if DRE feels malignant or PSA is above the age threshold |
| Bladder / renal | Visible haematuria – the cardinal sign | 2WW if aged ≥ 45 with unexplained visible haematuria (no UTI), or visible haematuria persisting/recurring after UTI treatment |
| Bladder | Non-visible haematuria with dysuria or a raised white cell count | 2WW if aged ≥ 60 |
| Testicular | Non-painful enlargement or change in shape/texture of a testis | 2WW; consider urgent direct-access ultrasound |
| Penile | Penile mass or ulcerated lesion (STI excluded), or a persistent lesion after STI treatment | 2WW |
Prostate cancer referral is driven by an age-specific PSA threshold. DRE and PSA act as independent triggers: refer if either is abnormal, and never rely on a normal DRE to exclude cancer.
| Age (years) | Refer (consider 2WW) if PSA above |
|---|---|
| Below 40 | Use clinical judgement |
| 40–49 | More than 2.5 |
| 50–59 | More than 3.5 |
| 60–69 | More than 4.5 |
| 70–79 | More than 6.5 |
| 80 and over | No age-specific threshold – individualise (see Special Notes) |
Thresholds are in micrograms/litre (numerically equal to ng/mL) and apply to men with possible symptoms of prostate cancer.
Source: NICE NG12 · NICE NG131
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