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Urological Cancers (Prostate, Bladder, Testicular, and Penile Cancers)

Reviewed and updated by practising UK GPs, overseen by our Clinical Advisory Officer. Last updated 17 Feb 2026.

🧭 When to suspect

Urological cancers in primary care are largely an exercise in pattern recognition and correct referral:

• Recognise the cardinal presentation.

• Do the right first-line test.

• Exclude infection before acting on haematuria or prostate specific antigen (PSA).

• 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.

• Penile: a mass or persistent ulcerated lesion.

Treat unexplained visible haematuria as urological cancer until proven otherwise; a painless testicular lump or a hard, nodular prostate each earns a referral on its 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 digital rectal examination (DRE)

• PSA + DRE

• Refer on the suspected cancer pathway if DRE feels malignant or PSA is above the age threshold
Bladder/renal Visible haematuria – the cardinal sign Suspected cancer pathway referral 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 Suspected cancer pathway referral if aged ≥ 60
Testicular Non-painful enlargement or change in shape/texture of a testis

• Suspected cancer pathway

• Consider urgent direct-access ultrasound
Penile Penile mass or ulcerated lesion (STI excluded), or a persistent lesion after STI treatment Suspected cancer pathway

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 suspected cancer pathway) 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.

Cardinal urologicalpresentationCord compression signs, orclot retention or unable topass urine?Same-day emergency admission•new back pain with neurology: urgent MRI•clot retention: catheterise/admitWhich presentation?Dipstick and MSU: exclude andtreat UTI first•recheck after treatment to confirmresolution•never attribute haematuria toanticoagulants aloneAged 45 or over withunexplained visiblehaematuria, or haematuriapersisting after UTItreatment?Suspected cancer pathway:bladder or renal canceralso aged ≥ 60 with non-visiblehaematuria + dysuria or raised WCCPSA + DRE after counselling•raised PSA: ~72-80% not cancer•normal PSA: ~7-15% still cancer•postpone PSA at least a month after aproven UTI•on finasteride/dutasteride: double themeasured valueAge-specific PSA referralthresholdBelow 40use clinical judgement40-49: more than 2.5consider suspected cancer referral50-59: more than 3.5consider suspected cancer referral60-69: more than 4.5consider suspected cancer referral70-79: more than 6.5consider suspected cancer referral80 and overno age-specific threshold:individualiseDRE hard, nodular orasymmetrical, or PSA abovethreshold?Suspected cancer pathway:prostate cancerDRE and PSA are independent triggers;refer if either abnormalCriteria not met•LUTS with normal PSA and benign DRE:local LUTS pathway•≥ 60 with recurrent unexplained UTI:non-urgent referralSuspected cancer pathway +urgent direct-accessultrasoundnon-painful enlargement or change inshape/texture of a testisSuspected cancer pathway:penile cancermass or ulcerated lesion with STIexcluded, or persisting after STItreatmentYESNOhaematuriaLUTS, ED or visible haematuriaYEStesticular lump or changepenile mass or ulcerYESNOHaematuria, PSA and the lump rulesOcean 🌊GPAtlas Ocean 🌊

Source: NICE NG12 · NICE NG131

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Inside the full topic 🔒 History🔒 Red Flags🔒 Examination🔒 Patient Explanation🔒 Investigations🔒 Management🔒 Non-pharmacological Treatment🔒 Pharmacological Treatment🔒 Special Notes🔒 Referral Pathways🔒 Take Home Messages

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