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🩺 Urinary Tract Infection (UTI) OSCE

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Urology

Candidate Instructions 📋

You are a final-year medical student in General Practice. A 28-year-old woman presents with urinary symptoms. Take a focused history, perform a relevant examination, and discuss your differential diagnoses and initial management plan. You are not required to perform an intimate examination.

🧬 Background

Urinary tract infections (UTIs) are among the most common bacterial infections in adults.
Caused in 70–90% cases by E. coli, followed by Klebsiella, Proteus, and Enterococcus.
Women are at higher risk due to a shorter urethra, sexual activity, and pregnancy-related changes.
Complications include pyelonephritis, sepsis, and recurrent UTIs.

Key History Points 📝

⏱️ Duration: Onset, frequency, progression.
🚽 Lower UTI symptoms: Dysuria, frequency, urgency, nocturia, suprapubic pain, haematuria.
🌡️ Systemic: Fever, rigors, flank pain, nausea/vomiting → pyelonephritis.
🧬 Past history: Childhood UTIs, recurrent infections, renal disease, structural abnormalities, catheter use.
💊 Drug history: Recent antibiotics, resistance, allergies.
👩 Women: Pregnancy, LMP, contraception, new partner (STI risk).
🧓 Elderly: Confusion, falls, incontinence, frailty.

Examination Focus 👀

🫀 Obs: Temp, HR, BP, SpO₂ (check for sepsis).
🫁 General: Pallor, hydration status, toxic appearance.
🩺 Abdomen: Suprapubic tenderness.
🧍 Renal angle tenderness: Suggests pyelonephritis.

Differentials ⚖️

✅ UTI: Cystitis, pyelonephritis.
🧬 STIs: Chlamydia, gonorrhoea, urethritis.
👩 Vaginitis: Candida, BV, trichomonas.
💎 Stones: Loin-to-groin pain, haematuria.
🚨 Other: Malignancy (persistent haematuria), interstitial cystitis.

Investigations 🔬

🧪 Urine dipstick: Nitrites, leukocytes, blood (useful in <50 yrs, but not reliable in elderly/pregnant).
🧫 MSU culture: Confirm pathogen, sensitivities.
🧪 Bloods: FBC, U&E, CRP if systemic unwell.
🫁 Pregnancy test: Always in women of childbearing age.
🧪 STI testing: If sexual history suggests risk.

💊 Management

Group	Antibiotic Choice	Notes
👩 Non-pregnant women (simple cystitis)	Nitrofurantoin 100 mg MR BD × 3 days or Trimethoprim 200 mg BD × 3 days (if low resistance risk)	Give safety-netting advice: return if fever, rigors, flank pain, worsening symptoms.
🤰 Pregnancy	Nitrofurantoin (avoid at term) Cefalexin 500 mg BD × 7 days	❌ Avoid trimethoprim (esp. 1st trimester).
👨 Men / complicated UTI	Nitrofurantoin, Trimethoprim, or Cefalexin × 7 days	Longer course due to higher risk of prostatitis.
🔥 Pyelonephritis	IV Co-amoxiclav / Gentamicin / Cefuroxime	Hospital admission, sepsis management, imaging if obstruction suspected.

🚨 Red Flags (Hospital Admission)

Systemic features: rigors, fever >38°C, vomiting.
Signs of sepsis or shock.
Pregnant women with suspected pyelonephritis.
Catheter-associated sepsis.
Obstructed kidney (stone + infection = urological emergency).

Examiner’s Marking Guide 📋

History covers LUTS + systemic + red flags.
Examination: abdomen + renal angle + vitals.
Considers key differentials (STIs, stones, gynae causes).
Investigations: urine dip, MSU, pregnancy test, bloods if unwell.
Safe management: empirical antibiotics, fluids, safety-netting.
Special considerations: pregnancy, elderly, recurrent UTIs.

💡 Teaching Pearl: – Urosepsis should always be suspected if there is fever + hypotension + confusion. – Asymptomatic bacteriuria → only treat in pregnancy or before urological surgery. – Chronic/recurrent UTIs may need prophylaxis (e.g., nightly nitrofurantoin, post-coital antibiotics).

🧑‍⚕️ Case Examples — Urinary Tract Infections (UTI)

Case 1 (Simple Cystitis in Young Woman): 🚺 A 22-year-old student presents with dysuria, urinary frequency, and suprapubic discomfort. She is afebrile, with no systemic features. Dipstick shows leukocytes and nitrites. Diagnosis: Uncomplicated cystitis. Teaching point: Treat empirically with 3 days of nitrofurantoin; no imaging needed if symptoms settle.
Case 2 (Pyelonephritis): 🔥 A 35-year-old woman reports fever, rigors, vomiting, and left-sided flank pain. She has costovertebral angle tenderness. Bloods show leukocytosis and raised CRP; urine culture grows E. coli. Diagnosis: Acute pyelonephritis. Teaching point: Requires systemic antibiotics (often IV), IV fluids, and hospitalisation if septic or unable to tolerate PO therapy.
Case 3 (Catheter-Associated UTI in Elderly): 🧓 An 81-year-old man in a care home with a long-term Foley catheter develops fever, acute confusion, and malodorous urine. Dipstick is not diagnostic; culture grows Klebsiella. Diagnosis: Catheter-associated UTI. Teaching point: Treat only if symptomatic, change the catheter, and give antibiotics guided by culture. Review ongoing catheter need.
Case 4 (Pregnancy): 🤰 A 30-year-old primigravida at 24 weeks gestation is asymptomatic but has bacteriuria detected on routine antenatal screening. Diagnosis: Asymptomatic bacteriuria in pregnancy. Teaching point: Always treat in pregnancy (e.g., with cefalexin) due to risk of pyelonephritis and preterm labour; repeat MSU post-treatment to confirm clearance.
Case 5 (Recurrent UTI in Postmenopausal Woman): 🌸 A 67-year-old woman presents with her 4th episode of dysuria and frequency in 6 months. Dipsticks and MSU cultures confirm recurrent E. coli UTIs. Diagnosis: Recurrent UTI post-menopause. Teaching point: Consider vaginal oestrogen, lifestyle measures (hydration, timed voiding), and prophylactic antibiotics if persistent.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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