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  • Question 1 - A 45-year-old man with a lengthy history of frequent urination at night and...

    Correct

    • A 45-year-old man with a lengthy history of frequent urination at night and dribbling at the end of urination comes in with a fever, chills, and muscle soreness. He is experiencing pain in his perineal area and has recently developed painful urination, increased frequency of urination, and a strong urge to urinate. During a rectal examination, his prostate is extremely tender.
      According to NICE, which of the following antibiotics is recommended as the initial treatment for this diagnosis?

      Your Answer: Ofloxacin

      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.

    • This question is part of the following fields:

      • Urology
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  • Question 2 - A 57-year-old woman with a long history of frequent urination and difficulty emptying...

    Correct

    • A 57-year-old woman with a long history of frequent urination and difficulty emptying her bladder completely presents with a high fever, shivering, and body aches. She is experiencing pain in her pelvic area and has recently developed painful urination, increased frequency of urination, and a strong urge to urinate. During a rectal examination, her prostate is extremely tender. Due to a previous adverse reaction, he has been advised against taking quinolone antibiotics.
      According to NICE, which of the following antibiotics is recommended as the first-line treatment for this patient's diagnosis?

      Your Answer: Trimethoprim

      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.

    • This question is part of the following fields:

      • Urology
      45.4
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  • Question 3 - A 35-year-old woman presents with intense one-sided abdominal pain starting in the right...

    Incorrect

    • A 35-year-old woman presents with intense one-sided abdominal pain starting in the right flank and extending to the groin. 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 is NOT a factor that increases the risk of developing urinary tract stones?

      Your Answer: Higher socio-economic class

      Correct Answer: Excessive citrate in the urine

      Explanation:

      There are several known risk factors for developing urinary tract stones. These include anatomical abnormalities in the renal system, such as a horseshoe kidney or ureteral stricture. Having a family history of renal stones, hypertension, gout, or hyperparathyroidism can also increase the risk. Immobilization, relative dehydration, and certain metabolic disorders that increase solute excretion, like chronic metabolic acidosis or hypercalciuria, are also risk factors. Additionally, a deficiency of citrate in the urine, cystinuria (a genetic aminoaciduria), and the use of certain drugs like diuretics or calcium/vitamin D supplements can contribute to stone formation. Residence in hot and dry climates and belonging to a higher socio-economic class have also been associated with an increased risk.

    • This question is part of the following fields:

      • Urology
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  • Question 4 - A 30-year-old woman comes in with intense pain in her right flank and...

    Incorrect

    • A 30-year-old woman comes in with intense pain in her right flank and microscopic blood in her urine. After evaluation, you diagnose her with renal colic.
      What is the ONE category of medication that has been proven to improve the passage of kidney stones in cases of renal colic?

      Your Answer: Loop diuretics

      Correct Answer: Calcium channel blockers

      Explanation:

      NSAIDs are known to have a relaxing effect on the ureter, but a randomized controlled trial found no difference between NSAIDs and a placebo in terms of this effect. Currently, only two classes of drugs, calcium channel blockers and alpha-blockers, are considered effective as medical expulsive therapy (MET). Calcium channel blockers work by blocking the active calcium channel pump that the smooth muscle of the ureter uses to contract, resulting in relaxation of the muscle and improved stone passage. Alpha-blockers, on the other hand, are commonly used as the first-line treatment to enhance stone passage. They reduce the basal tone of the ureter smooth muscle, decrease the frequency of peristaltic waves, and lower ureteric contraction. This leads to a decrease in intraureteric pressure below the stone, increasing the chances of stone passage. Patients treated with calcium channel blockers or alpha-blockers have been shown to have a 65% higher likelihood of spontaneous stone passage compared to those not given these medications.

    • This question is part of the following fields:

      • Urology
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  • Question 5 - A 42-year-old man comes in with a 4-day history of sudden left-sided scrotal...

    Correct

    • A 42-year-old man comes in with a 4-day history of sudden left-sided scrotal discomfort and a high body temperature. During the examination, the epididymis is sensitive and enlarged, and the skin covering the scrotum is reddened and warm to the touch. Lifting the scrotum alleviates the pain.

      What is the MOST PROBABLE diagnosis?

      Your Answer: Epididymo-orchitis

      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.

      To distinguish

    • This question is part of the following fields:

      • Urology
      15.1
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  • Question 6 - A 3-year-old boy is brought in by his father with symptoms of fever...

    Incorrect

    • A 3-year-old boy is brought in by his father with symptoms of fever and irritability. He also complains of lower abdominal pain and stinging during urination. A urine dipstick is performed on a clean catch urine, which reveals the presence of blood, protein, leucocytes, and nitrites. You diagnose him with a urinary tract infection (UTI) and prescribe antibiotics. His blood tests today show that his eGFR is 38 ml/minute. He has no history of other UTIs or infections requiring antibiotics in the past 12 months.
      Which of the following antibiotics is the most appropriate to prescribe in this case?

      Your Answer: Amoxicillin

      Correct Answer: Trimethoprim

      Explanation:

      For the treatment of young people under 16 years with lower urinary tract infection (UTI), it is important to obtain a urine sample before starting antibiotics. This sample can be tested using a dipstick or sent for culture and susceptibility testing. In cases where children under 5 present with fever along with lower UTI, it is recommended to follow the guidance outlined in the NICE guideline on fever in under 5s.

      Immediate antibiotic prescription should be offered to children and young people under 16 years with lower UTI. When making this prescription, it is important to consider previous urine culture and susceptibility results, as well as any history of antibiotic use that may have led to resistant bacteria. If a urine sample has been sent for culture and sensitivity testing, the choice of antibiotic should be reviewed once the microbiological results are available. If the bacteria are found to be resistant and symptoms are not improving, a narrow-spectrum antibiotic should be used whenever possible.

      For non-pregnant women aged 16 years and under, the following antibiotics can be considered:
      – Children under 3 months: It is recommended to refer to a pediatric specialist and treat with an intravenous antibiotic in line with the NICE guideline on fever in under 5s.
      – First-choice in children over 3 months: Nitrofurantoin (if eGFR >45 ml/minute) or Trimethoprim (if low risk of resistance*).
      – Second-choice in children over 3 months (when there is no improvement in lower UTI symptoms on first-choice for at least 48 hours, or when first-choice is not suitable): Nitrofurantoin (if eGFR >45 ml/minute and not used as first-choice), Amoxicillin (only if culture results are available and susceptible), or Cefalexin.

      Please refer to the BNF for children for dosing information. It is important to consider the risk of resistance when choosing antibiotics. A lower risk of resistance may be more likely if the antibiotic has not been used in the past 3 months, if previous urine culture suggests susceptibility (but was not used), and in younger people in areas where local epidemiology data suggest low resistance. On the other hand, a higher risk of resistance may be more likely with recent antibiotic use and in older people in residential facilities.

    • This question is part of the following fields:

      • Urology
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  • Question 7 - A 45 year old female presents to the emergency department with complaints of...

    Incorrect

    • A 45 year old female presents to the emergency department with complaints of painful urination, frequent urination, and a strong odor during urination. The patient's temperature is 37.7ÂșC. All observations are within normal limits. A urine dipstick test shows ++ nitrites, ++ leukocytes, and + blood. The patient reports no allergies.

      What is the most suitable treatment regimen for this patient's lower urinary tract infection?

      Your Answer: Nitrofurantoin 100 mg (modified-release) twice daily for 3 days

      Correct Answer: Trimethoprim 200 mg twice daily for 7 day

      Explanation:

      When treating men for uncomplicated urinary tract infections (UTIs), a 7-day course of antibiotics is typically recommended. Unlike women, men are advised to take a longer course of antibiotics, with a preference for 7 days instead of 3. The National Institute for Health and Care Excellence (NICE) suggests the following as the first-line treatment, although local microbiology departments may make adjustments based on antibiotic resistance patterns: Trimethoprim 200 mg taken twice daily for 7 days, or Nitrofurantoin 100 mg (modified-release) taken twice daily for 7 days. If prostatitis is suspected, a quinolone antibiotic like ciprofloxacin may be used, and treatment duration is usually 2-4 weeks.

      Further Reading:

      A urinary tract infection (UTI) is an infection that occurs in any part of the urinary system, from the kidneys to the bladder. It is characterized by symptoms such as dysuria, nocturia, polyuria, urgency, incontinence, and changes in urine appearance and odor. UTIs can be classified as lower UTIs, which affect the bladder, or upper UTIs, which involve the kidneys. Recurrent UTIs can be due to relapse or re-infection, and the number of recurrences considered significant depends on age and sex. Uncomplicated UTIs occur in individuals with a normal urinary tract and kidney function, while complicated UTIs are caused by anatomical, functional, or pharmacological factors that make the infection persistent, recurrent, or resistant to treatment.

      The most common cause of UTIs is Escherichia coli, accounting for 70-95% of cases. Other causative organisms include Staphylococcus saprophyticus, Proteus mirabilis, and Klebsiella species. UTIs are typically caused by bacteria from the gastrointestinal tract entering the urinary tract through the urethra. Other less common mechanisms of entry include direct spread via the bloodstream or instrumentation of the urinary tract, such as catheter insertion.

      Diagnosis of UTIs involves urine dipstick testing and urine culture. A urine culture should be sent in certain circumstances, such as in male patients, pregnant patients, women aged 65 years or older, patients with persistent or unresolved symptoms, recurrent UTIs, patients with urinary catheters, and those with risk factors for resistance or complicated UTIs. Further investigations, such as cystoscopy and imaging, may be required in cases of recurrent UTIs or suspected underlying causes.

      Management of UTIs includes simple analgesia, advice on adequate fluid intake, and the prescription of appropriate antibiotics. The choice of antibiotic depends on the patient’s gender and risk factors. For women, first-line antibiotics include nitrofurantoin or trimethoprim, while second-line options include nitrofurantoin (if not used as first-line), pivmecillinam, or fosfomycin. For men, trimethoprim or nitrofurantoin are the recommended antibiotics. In cases of suspected acute prostatitis, fluoroquinolone antibiotics such as ciprofloxacin or ofloxacin may be prescribed for a 4-week course.

    • This question is part of the following fields:

      • Urology
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  • Question 8 - A 55-year-old man on treatment for a urinary tract infection returns after 48...

    Incorrect

    • A 55-year-old man on treatment for a urinary tract infection returns after 48 hours because his symptoms have not improved. Unfortunately, the sensitivities from the urine sample that was sent to the lab are still unavailable. He has a history of chronic kidney disease, and his blood tests today show that his eGFR is 40 ml/minute. He has been taking trimethoprim 200 PO BD for the past two days.
      Which of the following antibiotics is the most suitable to prescribe in this situation?

      Your Answer:

      Correct Answer: Pivmecillinam

      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.

    • This question is part of the following fields:

      • Urology
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  • Question 9 - A 35-year-old woman comes in with complaints of painful urination and frequent urination....

    Incorrect

    • A 35-year-old woman comes in with complaints of painful urination and frequent urination. A urine dipstick test shows the presence of blood, protein, white blood cells, and nitrites. Based on these findings, you diagnose her with a urinary tract infection and prescribe antibiotics. Her recent blood tests indicate that her estimated glomerular filtration rate (eGFR) is greater than 60 ml/minute.
      Which antibiotic would be the most suitable to prescribe for this patient?

      Your Answer:

      Correct Answer: Nitrofurantoin

      Explanation:

      NICE provides the following recommendations for the treatment of non-pregnant women with lower urinary tract infections (UTIs):

      1. Consider prescribing a back-up antibiotic or an immediate antibiotic for women with lower UTIs, taking into account the severity of symptoms, the risk of complications, previous urine culture results, previous antibiotic use, and the woman’s preferences.

      2. If a urine sample has been sent for culture and susceptibility testing and an antibiotic prescription has been given, review the choice of antibiotic when the microbiological results are available. Change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not improving.

      3. The first-choice antibiotics for non-pregnant women aged 16 years and over are nitrofurantoin (100 mg modified-release tablets taken twice daily for 3 days) or trimethoprim (200 mg tablets taken twice daily for 3 days), if there is a low risk of resistance.

      4. If there is no improvement in lower UTI symptoms after at least 48 hours on the first-choice antibiotic or if the first-choice antibiotic is not suitable, the second-choice options are nitrofurantoin (100 mg modified-release tablets taken twice daily for 3 days), pivmecillinam (400 mg initial dose followed by 200 mg three times daily for 3 days), or fosfomycin (3 g single sachet dose).

      5. The risk of resistance to antibiotics may be lower if the antibiotic has not been used in the past 3 months, previous urine culture suggests susceptibility, and in younger people in areas with low resistance rates. The risk of resistance may be higher with recent antibiotic use and in older people in residential facilities.

    • This question is part of the following fields:

      • Urology
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  • Question 10 - A 32-year-old woman comes in with right-sided flank pain and nausea. A urine...

    Incorrect

    • A 32-year-old woman comes in with right-sided flank pain and nausea. A urine dipstick shows microscopic hematuria. She is later diagnosed with renal colic.
      Which of the following stone types is the least frequently seen?

      Your Answer:

      Correct Answer: Cystine stones

      Explanation:

      Urinary tract stones form when the concentration of salt and minerals in the urine becomes too high. These stones can be classified into five types based on their mineral composition and how they develop.

      The most common type of stone is the calcium stone, which can be further divided into calcium oxalate and calcium phosphate stones. These account for 60-80% of all urinary tract stones.

      Another type is the struvite or magnesium ammonium phosphate stone, making up about 10-15% of cases. Uric acid stones, also known as urate stones, occur in 3-10% of cases.

      Cystine stones are less common, accounting for less than 2% of urinary tract stones. Finally, there are drug-induced stones, which are caused by certain medications such as triamterene, protease inhibitors like indinavir sulphate, and sulfa drugs. These account for approximately 1% of cases.

      By understanding the different types of urinary tract stones, healthcare professionals can better diagnose and treat patients with this condition.

    • This question is part of the following fields:

      • Urology
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SESSION STATS - PERFORMANCE PER SPECIALTY

Urology (3/7) 43%
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