Genitourinary guidance material (GM)

1. Urinalysis shall form part of each aero-medical examination. Applicants shall be assessed as unfit where their urine contains abnormal elements considered to be of pathological significance that could entail a degree of functional incapacity which is likely to jeopardise the safe exercise of the privileges of the license or could render the applicant likely to become suddenly unable to exercise those privileges.
2. Applicants with any sequelae of disease or surgical procedures on the genitourinary system or its adnexa likely to cause incapacitation, in particular any obstruction due to stricture or compression, shall be assessed as unfit.
3. Applicants with a diagnosis or medical history of the following may be assessed as fit subject to satisfactory genitourinary evaluation, as applicable:
   1. renal disease;
   2. one or more urinary calculi, or a medical history of renal colic.
4. Applicants who have undergone a major surgical operation in the genitourinary system or its adnexa involving a total or partial excision or a diversion of their organs shall be assessed as unfit. However, after full recovery, they may be assessed as fit.
5. The applicants for a class 1 medical certificate referred to in points (c) and (d) shall be referred to the medical assessor of the licensing authority.

CLASS 1 - AMC1 MED.B.035

(a) Abnormal urinalysis
Investigation is required if there is any abnormal finding on urinalysis.

CLASS 1 - AMC1 MED.B.035

(b) Renal disease

1. Applicants presenting with any signs of renal disease should be assessed as unfit. A fit assessment may be considered if blood pressure is satisfactory and renal function is acceptable.
2. Applicants requiring dialysis should be assessed as unfit.

CLASS 2 - AMC2 MED.B.035

(a) Renal disease

Applicants presenting with renal disease may be assessed as fit if blood pressure is satisfactory and renal function is acceptable. Applicants requiring dialysis should be assessed as unfit.

CLASS 1 - AMC1 MED.B.035

(c) Urinary calculi

1. Applicants with an asymptomatic calculus or a history of renal colic require investigation.
2. Applicants presenting with one or more urinary calculi should be assessed as unfit and require investigation.
3. Whilst awaiting assessment or treatment, a fit assessment with an OML may be considered.
4. After successful treatment for a calculus a fit assessment without an OML may be considered.
5. Applicants with parenchymal residual calculi may be considered for a fit assessment with an OML.

CLASS 2 - AMC2 MED.B.035

(b) Urinary calculi

1. Applicants presenting with one or more urinary calculi should be assessed as unfit.
2. Applicants with an asymptomatic calculus or a history of renal colic require investigation.
3. While awaiting assessment or treatment, a fit assessment with an OSL may be considered.
4. After successful treatment the applicant may be assessed as fit.
5. Applicants with parenchymal residual calculi may be assessed as fit.

CLASS 1 - AMC1 MED.B.035

(d) Renal and urological surgery

1. Applicants who have undergone a major surgical operation on the genitourinary system or its adnexa involving a total or partial excision or a diversion of any of its organs, should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.
2. After other urological surgery, a fit assessment may be considered if when the applicant is completely asymptomatic and there is only minimal risk of secondary complication or recurrence.
3. Applicants with compensated nephrectomy without hypertension or uraemia may be considered for a fit assessment.
4. Applicants who have undergone renal transplantation may be considered for a fit assessment with an OML if it is fully compensated and tolerated with only minimal immuno-suppressive therapy after at least 12 months.
5. Applicants who have undergone total cystectomy may be considered for a fit assessment with an OML if there is satisfactory urinary function, no infection and no recurrence of primary pathology.

CLASS 2 - AMC2 MED.B.035

(c) Renal and urological surgery

1. Applicants who have undergone a major surgical operation on the genitourinary system or its adnexa involving a total or partial excision or a diversion of any of its organs, should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.
2. After other urological surgery, a fit assessment may be considered when the applicant is completely asymptomatic, and there is only minimal risk of secondary complication or recurrence.
3. Applicants with compensated nephrectomy without hypertension or uraemia may be assessed as fit.
4. Applicants who have undergone renal transplantation may be considered for a fit assessment if it is fully compensated and with only minimal immuno-suppressive therapy.
5. Applicants who have undergone total cystectomy may be considered for a fit assessment if there is satisfactory urinary function, no infection and no recurrence of primary pathology.

Haematuria

Please note revised terminology for haematuria: now called ‘visible’ and ‘non-visible’ (otherwise referred to as ‘microscopic’ or ‘dipstick positive’ haematuria). Urine dipstick of a freshly voided urine sample containing no preservative is considered a sensitive means of detecting the presence of haematuria. Routine microscopy for the confirmation of dipstick positive haematuria is not necessary.

SIGNIFICANT HAEMATURIA is defined as:

• Any single episode of visible haematuria.
• Any single episode of symptomatic non-visible haematuria (in the absence of a urinary tract infection (UTI) or other transient cause).
• Persistent asymptomatic non-visible haematuria (in the absence of UTI or other transient cause).

‘Persistent’ is defined as: 2 out of 3 dipsticks positive for non-visible haematuria.

Please note that trace haematuria can be considered as negative although not in the presence of significant proteinuria as defined in the proteinuria section on this page.

Proteinuria

Trace proteinuria is acceptable except in the presence of trace haematuria. When trace proteinuria and trace haematuria are both present, a repeat test is indicated. (Please note: 24-hour protein collection for the assessment of proteinuria is no longer recommended). Urine protein: creatinine ratio (PCR) or albumin: creatinine ratio (ACR) is preferred. ACR has the greater sensitivity.

SIGNIFICANT PROTEINURIA is defined as: ACR>30 or PCR>50

The Abnormal Urinalysis flow chart offers further guidance.

IgA Nephropathy/Thin Basement Membrane Disease

Applicants are requested to submit an annual renal review to confirm blood pressure level and no evidence of proteinuria or impaired renal function. A creatinine clearance below 20ml/min is unacceptable for medical certification. If the review is acceptable, the applicant can be assessed as fit for unrestricted certification.

Chronic Renal Disease

Applicants require regular renal review. In the absence of nephrotic syndrome and its associated thrombotic potential, and in the absence of uncontrolled hypertension, unrestricted certification may be permitted. A creatinine clearance below 20ml/min is unacceptable for medical certification. An albumin level below 35g/l is also disqualifying.

Polycystic Renal Disease

The diagnosis of autosomal dominant polycystic kidney disease requires an Operational Multi-pilot Limitation (OML) for class 1 certificate holders. Berry aneurysms need to be excluded by means of Magnetic Resonance Angiography and cardiac valve disease (including aortic root dilatation) by means of an echocardiogram. Abdominal aortic aneurysm also needs to be excluded.

There is further information and guidance available for Medication for benign prostatic hypertrophy and Medication for the treatment of bladder instability.

Acceptable treatment and medication for Erectile Dysfunction
Phosphodiesterase Type 5 (PDE5) inhibitors

The main aeromedical concerns are the side effect profile of these drugs which includes colour vision changes in the blue/green and purple spectrum and sudden hearing loss.

Generic name UK trade name (other trade names are used outside the UK) and minimum time between dose and flying:

• Sildenafil Viagra 12 hours
• Vardenafil Levitra 12 hours
• Tadalafil Cialis 36 hours

Notes for pilots:

• You should discuss the appropriate dose with your GP/AME.
• PDE5 inhibitors should never be taken in conjunction with any other medication without first discussing potential interactions with your GP/AME.
• Choose an extended off duty period to try the medication for the first time in case of side effects.
• Side effects that are important for flying include changes in blood pressure, visual disturbance including a change in colour vision, headaches, musculoskeletal pain and a sustained erectile effect with the potential for distraction from the flying task.
• You should not obtain this medication other than by prescription to ensure product quality (the contents of medication obtained in other ways, in particular over the internet, cannot be assured).

Renal Stones

The Renal Stones flow chart offers further guidance.

Renal Transplant

Applicants who have undergone a renal transplant are assessed as unfit. Medical certification can be considered 12 months post-transplant. Renal function must be stable with no underlying systemic disorder that is likely to cause sudden change and blood pressure must be within normal limits. The use of approved anti-hypertensive drugs is permitted. Any steroid dosage must be below 10mg/day. Levels of anti-rejection drugs must be within therapeutic range to minimise side effects. Cardiovascular risk must be assessed by a cardiologist to include an exercise (stress) ECG. To maintain certification, applicants are required to provide an annual renal report. Class 1 holders also require an annual cardiology assessment, including an exercise ECG. The Class 1 certificate will be restricted with OML.

The donation of a kidney in an individual with otherwise normal renal function and an unremarkable post-operative recovery is compatible with unrestricted Class 1 certification.