Genitourinary Guidance Material

Implementing Rules (IRs), Acceptable Means of Compliance (AMCs) and Guidance Material (GM) on genitourinary conditions

The following are the requirements for the medical certification of aircrew, including guidance material issued by the UK CAA Medical Department in relation to the genitourinary system.

Implementing Rules

Acceptable Means of Compliance

Guidance Material

MED.B.035 Genitourinary System

(a) Applicants shall not possess any functional or structural disease of the renal or genitourinary system or its adnexa which is likely to interfere with the safe exercise of the privileges of the applicable licence(s).

 

 

 

 




Abnormal Urinalysis 

(b) Urinalysis shall form part of every aero-medical examination.  The urine shall contain no abnormal element considered to be of pathological significance.

Class 1
(a) Abnormal urinalysis
Investigation is required if there is any abnormal finding on urinalysis.

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:
1. Any single episode of visible haematuria
2. Any single episode of symptomatic non visible haematuria (in the absence of a urinary tract infection (UTI) or other transient cause)
3. 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.
NB: Trace haematuria can be considered as negative although not in the presence of significant proteinuria (see below).

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.
(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

UK CAA Abnormal Urinalysis flow chart




Implementing Rules

Acceptable Means of Compliance

Guidance Material

Renal/Genitourinary Disease


(c) Applicants with any sequela of disease or surgical procedures on the kidneys or the urinary tract likely to cause incapacitation, in particular any obstruction due to stricture or compression shall be assessed as unfit.

Class 1
(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) The requirement for dialysis is disqualifying.

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.





(d) Applicants with a genitourinary disorder, such as:
(1) renal disease;

Class 2
(a) Renal disease
Applicants presenting with renal disease may be assessed as fit if blood pressure is satisfactory and renal function is acceptable.  The requirement for dialysis is disqualifying.

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 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.

Refer to Medication for benign prostatic hypertrophy

Refer to 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*

Minimum time between dose and flying

SidenafilViagra12 hrs
VardenafilLevitra12 hrs
TadalafilCialis36 hrs

* Other trade names are used outside the UK

Notes for pilots:
1) You should discuss the appropriate dose with your GP/AME.
2) PDE5 inhibitors should never be taken in conjunction with any other medication without first discussing potential interactions with your GP/AME.
3) Choose an extended off duty period to try the medication for the first time in case of side effects.
4) 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.
5) 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.

Apomorphine
12 hours should elapse after use before flying/controlling.




Implementing Rules

Acceptable Means of Compliance

Guidance Material

Urinary Calculi


(2) one or more urinary calculi, or a history of renal colic; may be assessed as fit subject to satisfactory renal/urological evaluation.

Class 1
(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) A fit assessment with a multi-pilot limitation may be considered whilst awaiting assessment or treatment. 
   (4) A fit assessment without multi-pilot limitation may be considered after successful treatment for a calculus. 
   (5) With residual calculi, a fit assessment with a multi-pilot limitation may be considered.

Class 2
(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 a safety-pilot limitation may be considered.
   (4) After successful treatment the applicant may be assessed as fit.
   (5) For parenchymal residual calculi, the applicant may be assessed as fit.


UK CAA Renal Stones flow chart




Implementing Rules

Acceptable Means of Compliance

Guidance Material

Renal/Urological Surgery


(e) Applicants who have undergone a major surgical operation in the urinary apparatus involving a total or partial excision or a diversion of its organs shall be assessed as unfit and be re-assessed after full recovery before a fit assessment can be considered.  Applicants for a class 1 medical certificate shall be referred to the licensing authority for the reassessment.

Class 1
(d) Renal/Urological surgery
   (1) Applicants who have undergone a major surgical operation on the urinary tract or the urinary apparatus involving a total or partial excision or a diversion of any of its organs should be assessed as unfit for a minimum period of three months or until such time as the effects of the operation are no longer likely to cause incapacity in flight.  After other urological surgery, a fit assessment may be considered if the applicant is completely asymptomatic and there is minimal risk of secondary complication or recurrence. 
   (2) An applicant with compensated nephrectomy without hypertension or uraemia may be considered for a fit assessment. 
   (3) Applicants who have undergone renal transplantation may be considered for a fit assessment if it is fully compensated and tolerated with only minimal immuno-suppressive therapy after at least 12 months.  Applicants may be assessed as fit with a multi-pilot limitation. 
   (4) 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.  Applicants may be assessed as fit with a multi-pilot limitation.

Class 2
(c) Renal/Urological surgery
   (1) Applicants who have undergone a major surgical operation on the urinary tract or the urinary apparatus involving a total or partial excision or a diversion of any of its organs should be assessed as unfit until such time as the effects of the operation are no longer likely to cause incapacity in flight.  After other urological surgery, a fit assessment may be considered if the applicant is completely asymptomatic and there is minimal risk of secondary complication or recurrence presenting with renal disease may be assessed as fit if blood pressure is satisfactory and renal function is acceptable.  The requirement for dialysis is disqualifying. 
   (2) An applicant with compensated nephrectomy without hypertension or uraemia may be considered fit. 
   (3) Renal transplantation may be considered if it is fully compensated and tolerated with only minimal immuno-suppressive therapy after at least 12 months. 
   (4) Total cystectomy may be considered if there is satisfactory urinary function, no infection and no recurrence of primary pathology.


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 aregular annual renal report.  Class 1 holders require also require an annualcardiology assessment, including an exercise ECG.  The Class 1 certificate will be restricted with OML.