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Question 1
Incorrect
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A 42-year-old patient comes in with a 3-day history of urgency, increased frequency of urination, and discomfort while urinating. Upon examination, she has no fever, mild tenderness in the suprapubic area, and no tenderness in the flank region. Her pregnancy test is negative and she has no medication allergies.
What is the MOST suitable course of action for management?Your Answer: The patient should be started on a 7-day course of oral amoxicillin
Correct Answer: The patient should be started on a 3-day course of oral trimethoprim
Explanation:Classical symptoms of a urinary tract infection (UTI) typically include dysuria, suprapubic tenderness, urgency, haematuria, increased frequency of micturition, and polyuria. The Scottish Intercollegiate Guidelines Network (SIGN) has developed comprehensive guidelines for the management of UTIs. According to these guidelines, if a patient presents with three or more classical UTI symptoms and is not pregnant, it is recommended to initiate empirical treatment with a three-day course of either trimethoprim or nitrofurantoin. For more detailed information, you can refer to the SIGN guidelines on the management of suspected bacterial urinary tract infection in adults.
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This question is part of the following fields:
- Urology
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Question 2
Incorrect
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A 35-year-old woman comes in with a 3-day history of mild discomfort while urinating. She also reports increased frequency of urination. She denies any urgency or excessive urination and has not observed any blood in her urine. On physical examination, her abdomen is soft and nontender.
What is the MOST suitable course of action for management?Your Answer: Start her on a 3-day course of oral trimethoprim
Correct Answer: Use a urine dipstick test to help in this patient’s diagnosis
Explanation:Classical symptoms of a urinary tract infection (UTI) typically include dysuria, suprapubic tenderness, urgency, haematuria, increased frequency of micturition, and polyuria. To effectively manage UTIs, SIGN has developed excellent guidelines. According to these guidelines, if a patient presents with mild symptoms of a UTI (experiencing two or fewer classical symptoms), it is recommended to use a dipstick test to aid in the diagnosis and treatment process.
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This question is part of the following fields:
- Urology
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Question 3
Correct
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A 35-year-old patient is worried because she has observed blood in her urine for the past few days. She is not currently experiencing her menstrual cycle, and there is no possibility of pregnancy. She has not had any recent fevers but has noticed some discomfort in her lower abdomen. Additionally, she has been urinating more frequently than usual. She is not taking any medications. During the examination, her abdomen is soft, with slight tenderness in the suprapubic region. There is no guarding or rebound tenderness, and she does not experience any renal angle tenderness. Her urine appears pinkish in color and tests positive for leukocytes, protein, and blood on the dipstick.
What is the SINGLE most likely diagnosis?Your Answer: Urinary tract infection
Explanation:This is a classical history for a simple urinary tract infection. The other possible causes mentioned can also result in frank haematuria, but they would be less likely based on the given history.
Bladder cancer typically presents with additional symptoms such as an abdominal mass, weight loss, and fatigue. Nephritis is more likely to cause renal angle tenderness and some systemic upset. It is often preceded by another infection.
Tuberculosis may also have more systemic involvement, although it can present on its own. Renal stones commonly cause severe pain from the loin to the groin and renal angle tenderness.
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This question is part of the following fields:
- Urology
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Question 4
Correct
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A 30-year-old man comes to the clinic complaining of pain in his right testis that has been present for the past five days. The pain has been gradually increasing and there is now noticeable swelling of the testis. Upon examination, he has a temperature of 38.5°C and the scrotum appears red and swollen on the affected side. Palpation reveals extreme tenderness in the testis. He has no significant medical history and no known allergies.
What is the most suitable treatment for this patient?Your Answer: Ceftriaxone plus doxycycline
Explanation:Epididymo-orchitis refers to the inflammation of the epididymis and/or testicle. It typically presents with sudden pain, swelling, and inflammation in the affected area. This condition can also occur chronically, which means that the pain and inflammation last for more than six months.
The causes of epididymo-orchitis vary depending on the age of the patient. In men under 35 years old, the infection is usually sexually transmitted and caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In men over 35 years old, the infection is usually non-sexually transmitted and occurs as a result of enteric organisms that cause urinary tract infections, with Escherichia coli being the most common. However, there can be some overlap between these groups, so it is important to obtain a thorough sexual history in all age groups.
Mumps should also be considered as a potential cause of epididymo-orchitis in the 15 to 30 age group, as mumps orchitis occurs in around 40% of post-pubertal boys with mumps.
While most cases of epididymo-orchitis are infective, non-infectious causes can also occur. These include genito-urinary surgery, vasectomy, urinary catheterization, Behcet’s disease, sarcoidosis, and drug-induced cases such as those caused by amiodarone.
Patients with epididymo-orchitis typically present with unilateral scrotal pain and swelling that develops relatively quickly. The affected testis will be tender to touch, and there is usually a palpable swelling of the epididymis that starts at the lower pole of the testis and spreads towards the upper pole. The testis itself may also be involved, and there may be redness and/or swelling of the scrotum on the affected side. Patients may experience fever and urethral discharge as well.
The most important differential diagnosis to consider is testicular torsion, which requires immediate medical attention within 6 hours of onset to save the testicle. Testicular torsion is more likely in men under the age of 20, especially if the pain is very severe and sudden. It typically presents around four hours after onset. In this case, the patient’s age, longer history of symptoms, and the presence of fever are more indicative of epididymo-orchitis.
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This question is part of the following fields:
- Urology
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Question 5
Incorrect
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the right flank and spreading to the groin. Her urine test shows blood. A CT KUB is scheduled, and the diagnosis is ureteric colic. The patient has a history of asthma and cannot take NSAIDs.
According to the current NICE guidelines, what is the recommended analgesic for this patient?Your Answer: Intravenous morphine
Correct Answer: Intravenous paracetamol
Explanation:Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with the presence of a urinary tract stone.
The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the lower back or flank and radiating to the groin or genital area in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.
People experiencing renal or ureteric colic are usually restless and unable to find relief by lying still, which helps to distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is an associated urinary infection. Some individuals may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.
In terms of pain management, the first-line treatment for adults, children, and young people with suspected renal colic is a non-steroidal anti-inflammatory drug (NSAID), which can be administered through various routes. If NSAIDs are contraindicated or not providing sufficient pain relief, intravenous paracetamol can be offered as an alternative. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective in relieving pain. Antispasmodics should not be given to individuals with suspected renal colic.
For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 6
Incorrect
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A 25-year-old pregnant woman comes in with dysuria, high body temperature, chills, and pain in her left side. During the examination, she experiences tenderness in the left renal angle and her temperature is measured at 38.6°C. The triage nurse has already inserted a cannula and sent her blood samples to the laboratory.
What is the MOST SUITABLE antibiotic to prescribe for this situation?Your Answer: Gentamicin
Correct Answer: Cefuroxime
Explanation:This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, she is showing signs of sepsis and is pregnant, which makes it necessary to admit her for inpatient treatment.
According to the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious illness or condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.
NICE also recommends considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected structural or functional abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).
For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and intravenous first-line options (if severely unwell or unable to take oral treatment) include amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.
For pregnant women, the recommended choice of antibacterial therapy is as follows: oral first-line option is cefalexin, and intravenous first-line option (if severely unwell or unable to take oral treatment) is cefuroxime. Intravenous second-line options or combining antibacterials should be considered if there are concerns about susceptibility or sepsis, and consultation with a local microbiologist is recommended.
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This question is part of the following fields:
- Urology
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Question 7
Incorrect
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A 68 year old female visits the emergency department with complaints of lower abdominal pain and a strong urge to urinate but an inability to do so. Upon examination, the patient's bladder is easily palpable and a diagnosis of acute urinary retention is made. To determine if any medications may be contributing to the condition, you inquire about the patient's drug history. Which of the following drug classes is NOT known to cause urinary retention?
Your Answer: Tricyclic antidepressants
Correct Answer: 5α-reductase inhibitors
Explanation:Urinary retention can be caused by various drug classes. One such class is 5α-reductase inhibitors like finasteride, which are prescribed to alleviate obstructive symptoms caused by an enlarged prostate. Some commonly known drugs that can lead to urinary retention include alcohol, anticholinergics, decongestants (such as phenylephrine and pseudoephedrine), disopyramide, antihistamines (like diphenhydramine and phenergan), and amphetamines.
Further Reading:
Urinary retention is the inability to completely or partially empty the bladder. It is commonly seen in elderly males with prostate enlargement and acute retention. Symptoms of acute urinary retention include the inability to void, inability to empty the bladder, overflow incontinence, and suprapubic discomfort. Chronic urinary retention, on the other hand, is typically painless but can lead to complications such as hydronephrosis and renal impairment.
There are various causes of urinary retention, including anatomical factors such as urethral stricture, bladder neck contracture, and prostate enlargement. Functional causes can include neurogenic bladder, neurological diseases like multiple sclerosis and Parkinson’s, and spinal cord injury. Certain drugs can also contribute to urinary retention, such as anticholinergics, opioids, and tricyclic antidepressants. In female patients, specific causes like organ prolapse, pelvic mass, and gravid uterus should be considered.
The pathophysiology of acute urinary retention can involve factors like increased resistance to flow, detrusor muscle dysfunction, bladder overdistension, and drugs that affect bladder tone. The primary management intervention for acute urinary retention is the insertion of a urinary catheter. If a catheter cannot be passed through the urethra, a suprapubic catheter can be inserted. Post-catheterization residual volume should be measured, and renal function should be assessed through U&Es and urine culture. Further evaluation and follow-up with a urologist are typically arranged, and additional tests like ultrasound may be performed if necessary. It is important to note that PSA testing is often deferred for at least two weeks after catheter insertion and female patients with retention should also be referred to urology for investigation.
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This question is part of the following fields:
- Urology
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Question 8
Correct
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A 45-year-old man with a long-standing history of benign prostatic hyperplasia dribbling presents with a fever, chills, and muscle aches. After taking a detailed history and conducting an examination, you diagnose acute bacterial prostatitis and decide to start antibiotics.
What is the recommended duration of treatment for this condition?Your Answer: 14 days
Explanation:Acute bacterial prostatitis is a sudden inflammation of the prostate gland, which can be either focal or diffuse and is characterized by the presence of pus. The most common organisms that cause this condition include Escherichia coli, Streptococcus faecalis, Staphylococcus aureus, and Neisseria gonorrhoea. The infection usually reaches the prostate through direct extension from the posterior urethra or urinary bladder, but it can also spread through the blood or lymphatics. In some cases, the infection may originate from the rectum.
According to the National Institute for Health and Care Excellence (NICE), acute prostatitis should be suspected in men who present with a sudden onset of feverish illness, which may be accompanied by rigors, arthralgia, or myalgia. Irritative urinary symptoms like dysuria, frequency, urgency, or acute urinary retention are also common. Perineal or suprapubic pain, as well as penile pain, low back pain, pain during ejaculation, and pain during bowel movements, can occur. A rectal examination may reveal an exquisitely tender prostate. A urine dipstick test showing white blood cells and a urine culture confirming urinary infection are also indicative of acute prostatitis.
The current recommendations by NICE and the British National Formulary (BNF) for the treatment of acute prostatitis involve prescribing an oral antibiotic for a duration of 14 days, taking into consideration local antimicrobial resistance data. The first-line antibiotics recommended are Ciprofloxacin 500 mg twice daily or Ofloxacin 200 mg twice daily. If these are not suitable, Trimethoprim 200 mg twice daily can be used. Second-line options include Levofloxacin 500 mg once daily or Co-trimoxazole 960 mg twice daily, but only when there is bacteriological evidence of sensitivity and valid reasons to prefer this combination over a single antibiotic.
For more information, you can refer to the NICE Clinical Knowledge Summary on acute prostatitis.
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This question is part of the following fields:
- Urology
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Question 9
Incorrect
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A 30-year-old woman who is being treated for a urinary tract infection comes back after 48 hours because her symptoms have not gotten better. Regrettably, the lab still hasn't provided the sensitivities from the urine sample that was sent. Her blood tests today indicate that her eGFR is >60 ml/minute. She has been taking nitrofurantoin 100 mg modified-release orally twice a day for the past two days.
Which antibiotic would be the most suitable to prescribe in this situation?Your Answer: Amoxicillin
Correct Answer: Fosfomycin
Explanation:For the treatment of women with lower urinary tract infections (UTIs) who are not pregnant, it is recommended to consider either a back-up antibiotic prescription or an immediate antibiotic prescription. This decision should take into account the severity of symptoms and the risk of developing complications, which is higher in individuals with known or suspected abnormalities of the genitourinary tract or weakened immune systems. The evidence for back-up antibiotic prescriptions is limited to non-pregnant women with lower UTIs where immediate antibiotic treatment is not deemed necessary. It is also important to consider previous urine culture and susceptibility results, as well as any history of antibiotic use that may have led to the development of resistant bacteria. Ultimately, the preferences of the woman regarding antibiotic use should be taken into account.
If a urine sample has been sent for culture and susceptibility testing and an antibiotic prescription has been given, it is crucial to review the choice of antibiotic once the microbiological results are available. If the bacteria are found to be resistant and symptoms are not improving, it is recommended to switch to a narrow-spectrum antibiotic whenever possible.
The following antibiotics are recommended for non-pregnant women aged 16 years and older:
First-choice:
– Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days (if eGFR >45 ml/minute)
– Trimethoprim 200 mg taken orally twice daily for 3 days (if low risk of resistance*)Second-choice (if there is no improvement in lower UTI symptoms on first-choice treatment for at least 48 hours, or if first-choice treatment is not suitable):
– Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days (if eGFR >45 ml/minute)
– Pivmecillinam 400 mg initial dose taken orally, followed by 200 mg taken orally three times daily for 3 days
– Fosfomycin 3 g single sachet dose*The risk of resistance may be lower if the antibiotic has not been used in the past 3 months, previous urine culture suggests susceptibility (although this was not used), and in younger individuals in areas where local epidemiology data indicate low resistance rates. Conversely, the risk of resistance may be higher with recent antibiotic use and in older individuals in residential facilities.
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This question is part of the following fields:
- Urology
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Question 10
Correct
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A 32-year-old woman comes in with one-sided abdominal pain starting in the left flank and spreading to the groin. Her urine test shows blood. She has a history of kidney stones and says that the pain feels similar to previous episodes. She describes the pain as less intense this time, but still uncomfortable. She also feels nauseous but hasn't vomited. She has no known allergies or sensitivities to medications.
According to NICE, which of the following pain relievers is recommended as the first choice for treating pain in kidney stone colic?Your Answer: Diclofenac
Explanation:Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with the presence of a urinary tract stone.
The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the lower back or flank and radiating to the groin or genital area in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.
People experiencing renal or ureteric colic are usually restless and unable to find relief by lying still, which helps to distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is an associated urinary infection. Some individuals may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.
In terms of pain management, the first-line treatment for adults, children, and young people with suspected renal colic is a non-steroidal anti-inflammatory drug (NSAID), which can be administered through various routes. If NSAIDs are contraindicated or not providing sufficient pain relief, intravenous paracetamol can be offered as an alternative. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective in relieving pain. Antispasmodics should not be given to individuals with suspected renal colic.
For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 11
Correct
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the right flank and spreading to the groin. She is also experiencing severe nausea and vomiting. Her urine dipstick shows the presence of blood. A CT KUB is scheduled, and a diagnosis of ureteric colic is confirmed.
Which of the following medications would be the LEAST appropriate choice to help manage this patient's pain?Your Answer: Buscopan
Explanation:Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the loin area caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with urinary tract stones. The pain typically starts in the flank or loin and radiates to the labia in women or to the groin or testicle in men.
The pain experienced during renal or ureteric colic is severe and comes in spasms, with periods of no pain or a dull ache in between. It can last for minutes to hours. Nausea, vomiting, and the presence of blood in the urine (haematuria) often accompany the pain. Many individuals describe this pain as the most intense they have ever felt, with some women even comparing it to the pain of childbirth.
People with renal or ureteric colic are restless and unable to find relief by lying still, which helps distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is a concurrent urinary infection. As the stone irritates the detrusor muscle, they may complain of dysuria (painful urination), frequent urination, and straining when the stone reaches the vesicoureteric junction.
To support the diagnosis, it is recommended to perform urine dipstick testing to check for evidence of a urinary tract infection. The presence of blood in the urine can also indicate renal or ureteric colic, although it is not a definitive diagnostic marker. Nitrite and leukocyte esterase in the urine suggest the presence of an infection.
In terms of pain management, non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for adults, children, and young people with suspected renal colic. Intravenous paracetamol can be offered if NSAIDs are contraindicated or not providing sufficient pain relief. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective. Antispasmodics should not be given to individuals with suspected renal colic.
For more detailed information, refer to the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 12
Correct
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A 42-year-old woman comes in with dysuria, chills, and pain in her left side. During the examination, she shows tenderness in the left renal angle and has a temperature of 38.6°C. The triage nurse has already inserted a cannula and sent her blood samples to the lab.
What is the MOST suitable antibiotic to prescribe for this patient?Your Answer: Cefuroxime
Explanation:This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.
According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.
NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).
For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.
For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option.
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This question is part of the following fields:
- Urology
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Question 13
Correct
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A 42-year-old woman comes in with dysuria, fevers, rigors, and pain in her left loin. During the examination, she experiences tenderness over the left renal angle, and her temperature is 38.6°C. The triage nurse has already inserted a cannula, and a complete set of blood tests has been sent to the lab.
What is the SINGLE most probable diagnosis?Your Answer: Pyelonephritis
Explanation:This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.
According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.
NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).
For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.
For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option.
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This question is part of the following fields:
- Urology
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Question 14
Incorrect
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A 3-year-old boy comes in with a high temperature and urine that has a strong odor. His mother is worried that he might have a urinary tract infection.
According to NICE, which of the following symptoms is indicative of a UTI in this age group?Your Answer: Haematuria
Correct Answer: Poor feeding
Explanation:According to NICE, the presence of certain clinical features in a child between three months and five years old may indicate a urinary tract infection (UTI). These features include vomiting, poor feeding, lethargy, irritability, abdominal pain or tenderness, and urinary frequency or dysuria. For more information on this topic, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.
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This question is part of the following fields:
- Urology
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Question 15
Correct
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A 21-year-old man comes in with a suddenly painful and swollen right testis and intense abdominal pain. The pain started while he was asleep, and he has experienced multiple episodes of vomiting. His cremasteric reflex is not present, and the testis is too sensitive to touch.
What is the SINGLE most probable diagnosis?Your Answer: Testicular torsion
Explanation:Testicular torsion is the correct diagnosis in this case. When a patient presents with sudden, severe, and acute testicular pain, testicular torsion should be assumed until proven otherwise. There are several historical factors that support this diagnosis. These include the pain occurring suddenly, being accompanied by vomiting, happening during sleep (as half of torsions occur during sleep), a previous history of torsion in the other testis, previous episodes that have resolved recently, and a history of undescended testis.
On examination, there are certain findings that further suggest testicular torsion. The testis may be positioned high in the scrotum and too tender to touch. The opposite testis may lie horizontally (known as Angell’s sign). Pain is not relieved by elevating the testis (negative Prehn’s sign), and the cremasteric reflex may be absent.
It is important to recognize that testicular torsion is a surgical emergency that requires immediate assessment and intervention to restore blood flow. Irreversible damage can occur within six hours of onset, so prompt treatment is crucial in this patient.
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This question is part of the following fields:
- Urology
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Question 16
Incorrect
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A 35-year-old individual presents with intense one-sided abdominal pain starting in the right flank and extending to the groin. They are also experiencing severe nausea and vomiting. The urine dipstick test shows the presence of blood. A CT KUB scan is scheduled, and a diagnosis of ureteric colic is confirmed.
Which of the following is NOT a reason for immediate hospital admission in a patient with ureteric colic?Your Answer: Signs of sepsis
Correct Answer: Frank haematuria
Explanation:Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with the presence of a urinary tract stone.
The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the flank or loin area and radiating to the groin or testicle in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.
The pain experienced during renal or ureteric colic is often described as the most intense pain a person has ever felt, with many women comparing it to the pain of childbirth. Restlessness and an inability to find relief by lying still are common signs, which can help differentiate renal colic from peritonitis. Previous episodes of similar pain may also be reported by the individual. In cases where there is a concomitant urinary infection, fever and sweating may be present. Additionally, the person may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.
It is important to seek urgent medical attention if certain conditions are met. These include signs of systemic infection or sepsis, such as fever or sweating, or if the person is at a higher risk of acute kidney injury, such as having pre-existing chronic kidney disease, a solitary or transplanted kidney, or suspected bilateral obstructing stones. Hospital admission is also necessary if the person is dehydrated and unable to consume fluids orally due to nausea and/or vomiting. If there is uncertainty regarding the diagnosis, it is recommended to consult further resources, such as the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 17
Incorrect
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the right flank and spreading to the groin. Her urine test shows blood. A CT scan is scheduled and confirms a diagnosis of ureteric colic. She was given diclofenac through an intramuscular injection, but her pain is still not well managed.
According to the latest NICE guidelines, what is the recommended next option for pain relief in this patient?Your Answer: Oral morphine
Correct Answer: Intravenous paracetamol
Explanation:Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with the presence of a urinary tract stone.
The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the lower back or flank and radiating to the groin or genital area in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.
People experiencing renal or ureteric colic are usually restless and unable to find relief by lying still, which helps to distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is an associated urinary infection. Some individuals may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.
In terms of pain management, the first-line treatment for adults, children, and young people with suspected renal colic is a non-steroidal anti-inflammatory drug (NSAID), which can be administered through various routes. If NSAIDs are contraindicated or not providing sufficient pain relief, intravenous paracetamol can be offered as an alternative. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective in relieving pain. Antispasmodics should not be given to individuals with suspected renal colic.
For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 18
Correct
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A 68 year old male presents to the emergency department with lower abdominal pain and a strong urge to urinate but an inability to do so. Upon examination, the patient's bladder is easily palpable, leading to a diagnosis of acute urinary retention. What is the most probable underlying cause?
Your Answer: Prostatic enlargement
Explanation:The most frequent reason for sudden inability to urinate in males is an enlarged prostate.
Further Reading:
Urinary retention is the inability to completely or partially empty the bladder. It is commonly seen in elderly males with prostate enlargement and acute retention. Symptoms of acute urinary retention include the inability to void, inability to empty the bladder, overflow incontinence, and suprapubic discomfort. Chronic urinary retention, on the other hand, is typically painless but can lead to complications such as hydronephrosis and renal impairment.
There are various causes of urinary retention, including anatomical factors such as urethral stricture, bladder neck contracture, and prostate enlargement. Functional causes can include neurogenic bladder, neurological diseases like multiple sclerosis and Parkinson’s, and spinal cord injury. Certain drugs can also contribute to urinary retention, such as anticholinergics, opioids, and tricyclic antidepressants. In female patients, specific causes like organ prolapse, pelvic mass, and gravid uterus should be considered.
The pathophysiology of acute urinary retention can involve factors like increased resistance to flow, detrusor muscle dysfunction, bladder overdistension, and drugs that affect bladder tone. The primary management intervention for acute urinary retention is the insertion of a urinary catheter. If a catheter cannot be passed through the urethra, a suprapubic catheter can be inserted. Post-catheterization residual volume should be measured, and renal function should be assessed through U&Es and urine culture. Further evaluation and follow-up with a urologist are typically arranged, and additional tests like ultrasound may be performed if necessary. It is important to note that PSA testing is often deferred for at least two weeks after catheter insertion and female patients with retention should also be referred to urology for investigation.
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This question is part of the following fields:
- Urology
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Question 19
Incorrect
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A 65-year-old woman presents with symptoms of painful urination and frequent urination. A urine dipstick test reveals the presence of blood, protein, white blood cells, and nitrites. She has a history of benign enlargement of the prostate and takes tamsulosin. The diagnosis is a urinary tract infection (UTI) and antibiotics are prescribed. Her blood tests show an eGFR of 38 ml/minute.
Which antibiotic would be the most suitable to prescribe in this situation?Your Answer: Nitrofurantoin
Correct Answer: Trimethoprim
Explanation:For the treatment of men with lower urinary tract infection (UTI), it is recommended to offer an immediate prescription of antibiotics. However, certain factors should be taken into account. This includes considering previous urine culture and susceptibility results, as well as any history of antibiotic use that may have led to the development of resistant bacteria.
Before starting antibiotics, it is important to obtain a midstream urine sample from men and send it for culture and susceptibility testing. This will help determine the most appropriate choice of antibiotic.
Once the microbiological results are available, it is necessary to review the initial choice of antibiotic. If the bacteria are found to be resistant and symptoms are not improving, it is recommended to switch to a narrow-spectrum antibiotic whenever possible.
The first-choice antibiotics for men with lower UTI are trimethoprim 200 mg taken orally twice daily for 7 days, or nitrofurantoin 100 mg modified-release taken orally twice daily for 7 days if the estimated glomerular filtration rate (eGFR) is above 45 ml/minute.
If there is no improvement in lower UTI symptoms after at least 48 hours on the first-choice antibiotics, or if the first-choice is not suitable, it is important to consider alternative diagnoses and follow the recommendations in the NICE guidelines on pyelonephritis (acute): antimicrobial prescribing or prostatitis (acute): antimicrobial prescribing. The choice of antibiotic should be based on recent culture and susceptibility results.
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This question is part of the following fields:
- Urology
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Question 20
Correct
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A 2-year-old boy presents with a high temperature and foul-smelling urine. His mother is worried that he might have a urinary tract infection.
Which of the following symptoms is NOT mentioned by NICE as indicative of a UTI in this age range?Your Answer: Haematuria
Explanation:According to NICE, the presence of certain clinical features in a child between three months and five years old may indicate a urinary tract infection (UTI). These features include vomiting, poor feeding, lethargy, irritability, abdominal pain or tenderness, and urinary frequency or dysuria. For more information on this topic, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.
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This question is part of the following fields:
- Urology
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Question 21
Incorrect
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A 65-year-old patient presents with dysuria, fevers, rigors, and left-sided loin pain. On examination, there is tenderness over his left renal angle and he has a temperature of 38.6°C. You suspect the most likely diagnosis is pyelonephritis.
Which of the following is not a reason to consider hospital admission in a patient with pyelonephritis?Your Answer: Significant tachycardia
Correct Answer: Failure to improve significantly within 12 hours of starting antibiotics
Explanation:This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.
According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.
NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).
For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.
For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option. If there are concerns about susceptibility or sepsis, it is advised to consult a local microbiologist for intravenous second-line
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This question is part of the following fields:
- Urology
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Question 22
Incorrect
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A 45-year-old man presents with a 4-day history of sudden right-sided scrotal pain and high fever. On examination, the epididymis is tender and swollen, and the overlying scrotal skin is red and warm to the touch. Lifting the scrotum provides relief from the pain. He has a history of epilepsy and takes phenytoin for it. He has no other significant medical history and no known allergies to medications.
What is the most suitable treatment for this patient?Your Answer: Levofloxacin
Correct Answer: Co-amoxiclav
Explanation:Epididymo-orchitis refers to the inflammation of the epididymis and/or testicle. It typically presents with sudden pain, swelling, and inflammation in the affected area. This condition can also occur chronically, which means that the pain and inflammation last for more than six months.
The causes of epididymo-orchitis vary depending on the age of the patient. In men under 35 years old, the infection is usually sexually transmitted and caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In men over 35 years old, the infection is usually non-sexually transmitted and occurs as a result of enteric organisms that cause urinary tract infections, with Escherichia coli being the most common. However, there can be some overlap between these groups, so it is important to obtain a thorough sexual history in all age groups.
Mumps should also be considered as a potential cause of epididymo-orchitis in the 15 to 30 age group, as mumps orchitis occurs in around 40% of post-pubertal boys with mumps.
While most cases of epididymo-orchitis are infective, non-infectious causes can also occur. These include genito-urinary surgery, vasectomy, urinary catheterization, Behcet’s disease, sarcoidosis, and drug-induced cases such as those caused by amiodarone.
Patients with epididymo-orchitis typically present with unilateral scrotal pain and swelling that develops relatively quickly. The affected testis will be tender to touch, and there is usually a palpable swelling of the epididymis that starts at the lower pole of the testis and spreads towards the upper pole. The testis itself may also be involved, and there may be redness and/or swelling of the scrotum on the affected side. Patients may experience fever and urethral discharge as well.
The most important differential diagnosis to consider is testicular torsion, which requires immediate medical attention within 6 hours of onset to save the testicle. Testicular torsion is more likely in men under the age of 20, especially if the pain is very severe and sudden. It typically presents around four hours after onset. In this case, the patient’s age, longer history of symptoms, and the presence of fever are more indicative of epididymo-orchitis.
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This question is part of the following fields:
- Urology
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Question 23
Incorrect
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A 30-year-old man comes to the clinic complaining of pain in his right testis that has been bothering him for the past five days. The pain has been increasing gradually and he has also noticed swelling in the affected testis. During the examination, his temperature is measured at 38.5°C and the scrotum appears red and swollen on the affected side. Palpation reveals extreme tenderness in the testis.
What is the most probable organism responsible for this condition?Your Answer: Escherichia coli
Correct Answer: Neisseria gonorrhoeae
Explanation:Epididymo-orchitis refers to the inflammation of the epididymis and/or testicle. It typically presents with sudden pain, swelling, and inflammation in the affected area. This condition can also occur chronically, which means that the pain and inflammation last for more than six months.
The causes of epididymo-orchitis vary depending on the age of the patient. In men under 35 years old, the infection is usually sexually transmitted and caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In men over 35 years old, the infection is usually non-sexually transmitted and occurs as a result of enteric organisms that cause urinary tract infections, with Escherichia coli being the most common. However, there can be some overlap between these groups, so it is important to obtain a thorough sexual history in all age groups.
Mumps should also be considered as a potential cause of epididymo-orchitis in the 15 to 30 age group, as mumps orchitis occurs in around 40% of post-pubertal boys with mumps.
While most cases of epididymo-orchitis are infective, non-infectious causes can also occur. These include genito-urinary surgery, vasectomy, urinary catheterization, Behcet’s disease, sarcoidosis, and drug-induced cases such as those caused by amiodarone.
Patients with epididymo-orchitis typically present with unilateral scrotal pain and swelling that develops relatively quickly. The affected testis will be tender to touch, and there is usually a palpable swelling of the epididymis that starts at the lower pole of the testis and spreads towards the upper pole. The testis itself may also be involved, and there may be redness and/or swelling of the scrotum on the affected side. Patients may experience fever and urethral discharge as well.
The most important differential diagnosis to consider is testicular torsion, which requires immediate medical attention within 6 hours of onset to save the testicle. Testicular torsion is more likely in men under the age of 20, especially if the pain is very severe and sudden. It typically presents around four hours after onset. In this case, the patient’s age, longer history of symptoms, and the presence of fever are more indicative of epididymo-orchitis.
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This question is part of the following fields:
- Urology
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Question 24
Correct
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A 70-year-old woman presents with painless haematuria and mild urinary urgency. Urine microscopy and culture are normal. An intravenous urogram (IVU) was also performed recently and was reported as being normal. On examination, you note that her bladder feels slightly distended. The rest of her examination was entirely normal.
What is the SINGLE most likely diagnosis?Your Answer: Bladder cancer
Explanation:Bladder cancer is the most likely diagnosis in this case, as patients with painless haematuria should undergo cystoscopy to rule out bladder cancer. This procedure is typically done in an outpatient setting as part of a haematuria clinic, using a flexible cystoscope and local anaesthetic.
Prostate cancer is less likely in this case, as the patient’s prostate examination was relatively normal and he only had mild symptoms of bladder outlet obstruction.
Bladder cancer is the seventh most common cancer in the UK, with men being three times more likely to develop it than women. The main risk factors for bladder cancer are increasing age and smoking. Smoking is responsible for about 50% of bladder cancers, as it is believed to be linked to the excretion of aromatic amines and polycyclic aromatic hydrocarbons through the kidneys. Smokers have a 2-6 times higher risk of developing bladder cancer compared to non-smokers.
Painless macroscopic haematuria is the most common symptom in 80-90% of bladder cancer patients. There are usually no abnormalities found during a standard physical examination.
Current recommendations state that the following patients should be urgently referred for a urological assessment: adults over 45 years old with unexplained visible haematuria not caused by a urinary tract infection, adults over 45 years old with visible haematuria that persists or recurs after successful treatment of a urinary tract infection, and adults aged 60 and over with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
For those aged 60 and over with recurrent or persistent unexplained urinary tract infections, a non-urgent referral for bladder cancer is recommended.
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This question is part of the following fields:
- Urology
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Question 25
Incorrect
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A 32-year-old male patient complains of a painless, solid lump in the body of his left testis. Upon examination, the lump is firm, located within the testis, and does not show transillumination.
What is the MOST LIKELY diagnosis for this patient?Your Answer: Varicocele
Correct Answer: Testicular cancer
Explanation:Testicular cancer is the most common form of cancer that affects men between the ages of 20 and 34. In recent times, there have been campaigns aimed at raising awareness about the importance of self-examination for early detection. Some risk factors for this type of cancer include having undescended testes, especially if it affects both testicles, which increases the risk by ten times. Additionally, individuals who have had testicular cancer in the past have a 4% chance of developing a second cancer.
The typical presentation of testicular cancer is a painless swelling in the testicles. When examined, the swelling feels hard and is located within the testis. It cannot be illuminated when light is shone through it. Approximately 60% of cases are seminomas, which are slow-growing and usually confined to the testis at the time of diagnosis. If seminomas are diagnosed at stage 1 (confined to the testis only), the 5-year survival rate is 98%. The remaining 40% of cases are teratomas, which can grow at a faster rate and often coexist with seminomas. In cases where the tumors are of mixed type, they are treated as teratomas due to their more aggressive nature. The main treatment for testicular cancer is surgery, with the possibility of additional chemotherapy and radiotherapy.
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This question is part of the following fields:
- Urology
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Question 26
Incorrect
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the left flank and extending to the groin. You suspect she may have ureteric colic.
What are the two types of drugs that can be used for conservative treatment as medical expulsive therapy?Your Answer: Beta-blocker and calcium-channel blocker
Correct Answer: Alpha-blocker and calcium-channel blocker
Explanation:Conservative management of ureteric stones may involve the use of medical expulsive therapy (MET), which can be achieved through the administration of either an alpha-blocker or a calcium-channel blocker. This treatment aims to facilitate the natural passage of the stone during the observation period.
Research has shown that in adults, both alpha-blockers and calcium channel blockers have been effective in improving the passage of distal ureteric stones that are less than 10 mm in size, when compared to no treatment. Additionally, alpha-blockers have shown to be more effective than placebo in promoting stone passage. Alpha-blockers have also demonstrated more benefits than calcium channel blockers in terms of stone passage, as well as some advantages in terms of hospital stay and pain management. However, there was no significant difference in the time it took for the stone to pass or the overall quality of life.
Currently, the National Institute for Health and Care Excellence (NICE) recommends alpha-blockers as the preferred choice for medical expulsive therapy. For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 27
Incorrect
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A 35-year-old woman presents with a ‘lump’ in her right breast. She is very worried that she may have breast cancer. On examination, she has a painless, well-defined mass that can be felt separate from the breast tissue. The mass is transilluminating.
What is the SINGLE most probable diagnosis?Your Answer: Varicocele
Correct Answer: Epididymal cyst
Explanation:Epididymal cysts are commonly observed in men who are over the age of 40. They often appear in multiple numbers and can be found on both sides. These cysts are typically well-defined, soft to the touch, and can be illuminated when light is passed through them. Since they develop in the epididymis, they can be felt as separate from the testis, which helps to differentiate them from hydroceles. In most cases, these cysts cause no significant issues and do not require any treatment. However, larger cysts can become bothersome and may need to be drained or surgically removed.
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This question is part of the following fields:
- Urology
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Question 28
Correct
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A 42-year-old woman comes in with dysuria, chills, and left-sided flank discomfort. During the examination, she exhibits tenderness in the left renal angle and has a temperature of 38.6°C.
What is the MOST suitable antibiotic to prescribe for this patient?Your Answer: Ciprofloxacin
Explanation:This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.
According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.
NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).
For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.
For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option.
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This question is part of the following fields:
- Urology
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Question 29
Correct
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A 35-year-old man presents to the Emergency Department feeling extremely ill. He was recently prescribed a course of trimethoprim for a suspected urinary tract infection by his primary care physician. Initially, he felt slightly better, but unfortunately, in the past 24 hours, he has developed severe pain in his lower back, chills, and has vomited up this morning's antibiotic. He denies any possibility of being pregnant. Upon examination, he has an elevated heart rate of 106 beats per minute and tenderness in his left flank.
What is the MOST appropriate next step in his management?Your Answer: Refer for admission for intravenous antibiotics
Explanation:This patient is clearly experiencing pyelonephritis with systemic involvement, which may indicate sepsis. According to NICE guidelines, it is recommended to admit individuals to the hospital if they exhibit any symptoms or signs that suggest a more serious illness or condition, such as sepsis. In cases of acute pyelonephritis, it is advisable to consider referring or seeking specialist advice for individuals who are significantly dehydrated or unable to consume oral fluids and medications, pregnant women, those at a higher risk of developing complications (e.g., individuals with known or suspected structural or functional abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression), and individuals who have recurrent episodes of urinary tract infections (e.g., two or more episodes within a 6-month period). Additionally, it is recommended to consider referral for men who have experienced a single episode without an obvious cause and women with recurrent pyelonephritis. For more information, please refer to the NICE Clinical Knowledge Summary on the management of acute pyelonephritis.
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This question is part of the following fields:
- Urology
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Question 30
Incorrect
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A 30-year-old woman on treatment for a urinary tract infection returns after 48 hours because her symptoms have not improved. She is currently 20 weeks pregnant. Unfortunately, the sensitivities from the urine sample that was sent to the lab are still unavailable. Her blood tests today show that her eGFR is >60 ml/minute. She has been taking nitrofurantoin 100 mg modified-release PO BD for the past two days.
Which of the following antibiotics is the most suitable to prescribe in this situation?Your Answer: Co-amoxiclav
Correct Answer: Cefalexin
Explanation:For the treatment of pregnant women with lower urinary tract infections (UTIs), it is recommended to provide them with an immediate prescription for antibiotics. It is important to consider their previous urine culture and susceptibility results, as well as any prior use of antibiotics that may have contributed to the development of resistant bacteria. Before starting antibiotics, it is advised to obtain a midstream urine sample from pregnant women and send it for culture and susceptibility testing.
Once the microbiological results are available, it is necessary to review the choice of antibiotic. If the bacteria are found to be resistant, it is recommended to switch to a narrow-spectrum antibiotic whenever possible. The choice of antibiotics for pregnant women aged 12 years and over is summarized below:
First-choice:
– Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days, if the estimated glomerular filtration rate (eGFR) is above 45 ml/minute.Second-choice (if there is no improvement in lower UTI symptoms with the first-choice antibiotic for at least 48 hours, or if the first-choice is not suitable):
– Amoxicillin 500 mg taken orally three times daily for 7 days (only if culture results are available and show susceptibility).
– Cefalexin 500 mg taken twice daily for 7 days.For alternative second-choice antibiotics, it is recommended to consult a local microbiologist and choose the appropriate antibiotics based on the culture and sensitivity results.
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This question is part of the following fields:
- Urology
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