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1. UTI - Definition, pathogens, lower vs upper tract features, diagnosis, treatment (including pregnancy-specific management).
2. Hematuria - Gross vs microscopic, clinical significance (up to 25% signal cancer), pseudohematuria, localizing the source by stream timing and clot shape, evaluation protocol.
3. Urinary Catheterization - Types (intermittent, indwelling Foley, suprapubic), indications, technique tips, and complications (especially CAUTI).
4. Urinary Stones - Types (calcium oxalate most common; struvite/staghorn; uric acid; cystine), clinical features (renal colic), diagnosis (CT KUB gold standard), and management.
5. Prostate Cancer - Epidemiology, risk factors, Gleason grading, PSA screening, diagnosis, and treatment by stage.
6. Bladder Cancer - Epidemiology, risk factors (smoking #1), pathology (90% urothelial), symptoms (painless hematuria), diagnosis (cystoscopy + biopsy), and treatment by stage.
7. BPH vs Prostate Cancer (detailed) - A full side-by-side comparison covering zone of origin, DRE findings, PSA, symptoms, metastasis, histology, and treatment - with two clinical diagrams from Bailey and Love's Surgery.

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OSCE Cases - Urology & Genitourinary Medicine

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🏆 OSCE Frequency Ranking (Most to Least Likely)

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CASE 1 - UTI in a Young Woman ⭐⭐⭐ (HIGHEST YIELD)

Station Instructions (to student)

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Simulated Patient Script

• Dysuria for 2 days (burning, stinging)
• Urinary frequency - going every 20-30 minutes
• Urgency - has to rush to the toilet
• Suprapubic discomfort
• No fever, no back/flank pain, no nausea/vomiting
• No vaginal discharge, no external burning (rules out vulvovaginitis)
• Sexually active, new partner 1 week ago
• Last menstrual period: 2 weeks ago, regular cycles
• Not pregnant
• No allergies
• No previous UTIs
• No medical history

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Mark Scheme

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Model Answer

• Urine dipstick: leucocytes + nitrites positive
• MSU for culture and sensitivity (before starting antibiotics if possible)
• Pregnancy test (urine hCG) - to exclude pregnancy before prescribing

• Nitrofurantoin 100 mg modified-release BD for 5 days (first-line)
• Alternative: trimethoprim 200 mg BD for 7 days (if local resistance < 20%)
• Adequate hydration (2L+ water daily)
• Analgesia: paracetamol for suprapubic discomfort

• Urethritis (chlamydia) - especially with new partner
• Vaginitis
• Interstitial cystitis

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CASE 2 - UTI in Pregnancy ⭐⭐⭐ (HIGHEST YIELD)

Station Instructions

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Key History Points

• Asymptomatic bacteriuria in pregnancy
• No dysuria, no frequency (no symptoms)
• First antenatal visit, 14 weeks pregnant
• No allergies, no previous UTIs in this pregnancy

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Mark Scheme

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Key Teaching Point

1. 30% progress to pyelonephritis
2. Risk of preterm labour and low birth weight
3. USPSTF Grade A recommendation to screen at 12-16 weeks

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CASE 3 - Elderly Man with LUTS: BPH vs Prostate Cancer ⭐⭐⭐ (HIGHEST YIELD)

Station Instructions

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Simulated Patient Script

• Poor urinary stream, takes time to start
• Intermittent stream (stops and starts)
• Sensation of incomplete emptying
• Nocturia x3 per night (wakes up 3 times)
• No fever, no dysuria, no haematuria
• No bone pain, no weight loss
• No previous urological history
• Father had prostate cancer (age 74)
• Non-smoker, no medications

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Investigation Results (shown to student)

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Mark Scheme

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Model Answer

• PSA > 10 ng/mL
• Free:total PSA ratio of 8% (< 25% is suspicious)
• DRE: hard, irregular nodule

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CASE 4 - Painless Hematuria in a 58-Year-Old Smoker ⭐⭐⭐ (HIGH YIELD)

Station Instructions

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Simulated Patient Script

• Painless, total (entire stream) haematuria
• No clots passed
• No dysuria, no fever
• No flank pain
• Smoker: 30 pack-year history
• Occupational exposure: worked in chemical dye factory for 20 years
• No anticoagulants, no recent urological procedures
• No recent trauma
• Weight loss of 4 kg in 2 months
• No family history of urological cancers

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Mark Scheme

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Model Answer

• Age > 50 + male gender
• Painless total haematuria
• Heavy smoking history (30 pack-years)
• Chemical dye industry exposure (aromatic amines)
• Weight loss

1. Urine dipstick + MSU (exclude UTI first)
2. Urine cytology (high specificity for high-grade TCC)
3. FBC, U&E, creatinine
4. CT urogram (upper tract + bladder)
5. Cystoscopy + biopsy = gold standard

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CASE 5 - Renal Colic ⭐⭐ (HIGH YIELD)

Station Instructions

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Simulated Patient Script

• Sudden onset severe left loin-to-groin pain
• Colicky in nature (comes and goes in waves)
• Pain score 9/10
• Nausea and vomiting
• Cannot find a comfortable position (rolling around)
• Haematuria: pink-tinged urine today
• No fever, no rigors (not infected)
• Not pregnant
• Previous similar episode 2 years ago (passed a stone spontaneously)
• Drinks only 1 glass of water per day, lives in a hot climate
• No medications, no allergies

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Mark Scheme

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Model Answer

• Urine dipstick: haematuria (90% of cases)
• Non-contrast CT KUB: gold standard (>95% sensitivity)
• FBC, U&E, calcium, uric acid, creatinine
• Urine culture (if febrile)
• Stone analysis if passed

• IV/IM diclofenac 75mg (NSAIDs are first-line for analgesia)
• IV morphine if NSAIDs insufficient
• IV hydration
• Tamsulosin 0.4 mg daily (alpha-blocker as medical expulsive therapy for stones < 10mm)
• Stones < 5 mm: 95% pass spontaneously
• Stones 5-10 mm: ureteroscopy or ESWL
• Stones > 10 mm or staghorn: PCNL

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CASE 6 - Prostate Cancer Counselling / PSA Discussion ⭐⭐ (HIGH YIELD - COMMUNICATION STATION)

Station Instructions

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Mark Scheme

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Key Phrases to Use

• "A raised PSA can be caused by several things - an enlarged prostate, inflammation, or in some cases a cancer. We need more tests to find out which is causing this."
• "This test on its own does not tell us you have cancer."
• "We are going to refer you to a specialist - a urologist - who will arrange a scan and possibly a biopsy of the prostate."

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CASE 7 - Urinary Catheterization Practical Station ⭐⭐ (PRACTICAL SKILLS)

Station Instructions

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Mark Scheme

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Common Mistakes in OSCE

• ❌ Inflating the balloon before urine drains (causes urethral trauma)
• ❌ Forgetting to replace foreskin
• ❌ Not using anaesthetic gel (lidocaine) especially in men
• ❌ Incorrect catheter size (14-16 Fr standard; 12 Fr if urethral stricture suspected)
• ❌ Using a curved Coude tip for BPH without documentation

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CASE 8 - Upper UTI / Pyelonephritis ⭐⭐ (HIGH YIELD)

Station Instructions

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Simulated Patient Script

• Fever 38.9°C, rigors
• Right-sided loin/flank pain - constant ache
• Nausea and vomiting, unable to keep fluids down
• Dysuria and frequency started 5 days ago (lower UTI preceded upper UTI)
• No haematuria
• Sexually active, using contraceptive pill, not pregnant
• No previous UTIs
• No allergies

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Mark Scheme

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Overall OSCE Tips for These Topics

The "Spot Diagnosis" Clues to Memorize

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What Examiners Are Looking For

1. Red flag recognition: painless haematuria, weight loss, bone pain, PSA > 10 = urgent referral
2. Differentiating BPH vs cancer: DRE findings + PSA + free PSA ratio
3. Safe prescribing: correct antibiotic, correct dose, correct duration, check for contraindications (e.g. TMP-SMX in 3rd trimester pregnancy)
4. Communication: breaking bad news, PSA counselling, explaining cystoscopy or biopsy
5. Investigations in the right order: dipstick → MSU → imaging → endoscopy/biopsy
6. Safety netting: always tell patients when to come back urgently

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Renal Colic - Complete Lab Tests & Treatment Options

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Pathophysiology (Quick Recap)

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PART 1 - LABORATORY INVESTIGATIONS

A. Immediate / Emergency Labs (Every Patient with Renal Colic)

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B. Extended / Metabolic Workup (For Recurrent Stones, First Stone in Young Patient, Bilateral Stones, Family History)

This is done after the acute episode resolves, on the patient's normal outpatient diet. Do NOT collect 24-hour urine during the acute hospitalization.

24-Hour Urine Collection (Comprehensive Stone Screen)

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C. Crystal Morphology on Urine Microscopy (Quick Reference)

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PART 2 - IMAGING

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PART 3 - TREATMENT OPTIONS

Step 1: Acute Pain Management (IMMEDIATE PRIORITY)

The first priority is adequate analgesia.

1. NSAIDs - FIRST LINE

2. Opioids - SECOND LINE / ADJUNCT

3. Antiemetics (for nausea/vomiting)

4. IV Hydration

• Give IV fluids if patient cannot tolerate oral intake.
• Note: There is NO evidence that aggressive high-volume IV fluid therapy speeds stone passage or improves outcomes - give enough to maintain hydration only.

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Step 2: Medical Expulsive Therapy (MET) - To Help Stone Pass

Alpha-1 Blockers - RECOMMENDED for distal ureteral stones < 10 mm

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Step 3: Watchful Waiting / Observation (Conservative Management)

Spontaneous Passage Rates by Stone Size

Spontaneous Passage Rates by Location

• Adequate pain control
• No infection
• No significant obstruction
• Normal or preserved renal function on the affected side

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Step 4: Surgical / Interventional Treatment (When Conservative Fails)

Indications for Intervention

• Stone > 10 mm (unlikely to pass spontaneously)
• Failure to pass after 4-6 weeks observation
• Intractable pain not controlled by analgesia
• Persistent vomiting / unable to maintain hydration
• Impaired or solitary kidney with obstruction
• Infection + obstruction = UROLOGIC EMERGENCY (see below)
• Bilateral ureteral obstruction

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Interventional Options

1. Ureteroscopy (URS) + Laser Lithotripsy

• Flexible ureteroscope passed up the urethra → bladder → ureter
• Holmium-YAG laser fragments the stone
• Basket extraction of fragments
• Used for stones in ureter or kidney < 2 cm
• Stone-free rate HIGHER than ESWL and lower retreatment rate
• A JJ stent may be left post-procedure to keep the ureter open

2. Extracorporeal Shock Wave Lithotripsy (ESWL)

• Focused high-energy shock waves directed at the stone from outside the body
• Fragments the stone into smaller pieces that pass spontaneously
• Used for stones < 2 cm in kidney or proximal ureter
• Non-invasive; done under sedation/anaesthesia
• Stone density on CT (Hounsfield units) predicts ESWL success - harder stones (e.g. calcium oxalate monohydrate, cystine) respond poorly
• Lower stone-free rate than ureteroscopy but less invasive

3. Percutaneous Nephrolithotomy (PCNL)

• A tract is dilated from skin directly into the renal collecting system
• Stone removed directly through the tract
• Used for stones > 2 cm, staghorn calculi, ESWL-refractory stones, multiple stones, hard stones
• Most invasive of the three but most effective for large stones
• Risk: bleeding, infection, urine leak

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Comparison of Interventional Methods

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Step 5: EMERGENCY - Infected Obstructed Stone (Sepsis + Obstruction)

This is the most dangerous scenario in urolithiasis - a true urologic emergency.

Recognition

• Fever + loin pain + signs of sepsis (tachycardia, hypotension, rigors)
• CT showing stone + hydronephrosis
• Positive urine culture or leukocytosis

Management (IMMEDIATE)

1. IV broad-spectrum antibiotics: Ceftriaxone 1 g IV (or piperacillin-tazobactam if septic)
2. IV fluid resuscitation
3. Urgent urologic consultation
4. Emergency drainage - either:
   • Ureteral stent (JJ stent placed cystoscopically) OR
   • Percutaneous nephrostomy (nephrostomy tube placed radiologically under USS/fluoroscopy)
5. Definitive stone treatment (ureteroscopy or PCNL) is deferred until infection is treated and patient is stabilized

⚠️ Do NOT attempt to remove the stone in an infected system - drain first, treat later.

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Step 6: Stone-Specific Prevention (Long-Term Treatment)

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Summary Algorithm

RENAL COLIC
│
├── IMMEDIATE: Analgesia (IV NSAID ± opioid) + Antiemetic + IV fluids
│
├── IMAGING: Non-contrast CT KUB (gold standard)
│           Ultrasound in pregnancy/children
│
├── LABS: Dipstick → MSU/culture → Creatinine → FBC → Ca/Urate → βhCG
│
├── Stone < 10mm + No infection + Pain controlled
│   └── CONSERVATIVE: MET (Tamsulosin 0.4mg/day) + analgesia x 4-6 weeks
│       ├── Passed → Strain urine, send stone for analysis
│       └── Not passed → Ureteroscopy or ESWL
│
├── Stone > 10mm or failed conservative → ESWL / Ureteroscopy / PCNL
│
└── FEVER + OBSTRUCTION = EMERGENCY
    └── IV antibiotics + Urgent ureteral stent OR nephrostomy

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Pregnant Woman with Back Pain + Fever + Dysuria

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What Is Happening?

• Fever (>38.5°C)
• Back/flank pain (costovertebral angle tenderness)
• Dysuria (lower urinary tract symptoms preceding the upper tract infection)

This is one of the most serious medical complications of pregnancy and a common cause of septic shock in pregnant women.

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Why Is Pregnancy a Special Risk?

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Causative Organisms

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Why This Starts as Dysuria (Lower Tract Infection)

• Up to 30% of pregnant women with untreated asymptomatic bacteriuria develop pyelonephritis
• Treating bacteriuria early is a USPSTF Grade A recommendation

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Dangerous Complications in Pregnancy (Why This Must Be Treated Aggressively)

⚠️ ARDS predictors: Heart rate >110/min, temperature ≥103°F in first 24 hours, use of ampicillin alone, tocolytic use, fluid overload. Watch for tachypnea and oxygen desaturation.

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Next Step Management

Step 1: Immediate Assessment

Clinical Examination

• Vital signs: Temperature, HR, BP, RR, SpO₂ (pulse oximetry mandatory)
• Costovertebral angle (CVA) tenderness: Punch/percussion tenderness over the flank = hallmark of pyelonephritis
• Abdominal examination: Uterine fundal height, uterine irritability/contractions
• Assess hydration status: Dry mucous membranes, skin turgor, urine output

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Step 2: Investigations

Urine Tests (MANDATORY)

Blood Tests

Imaging

CT scan: Avoid in pregnancy unless absolutely necessary (radiation risk). Ultrasound is preferred.

Obstetric Monitoring (≥24 weeks gestation)

• CTG (Cardiotocography): Monitor fetal heart rate and uterine activity
• Uterine contractions in pyelonephritis are common and can progress to preterm labour

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Step 3: Hospitalisation Decision

General rule: Most pregnant women with acute pyelonephritis should be hospitalised for at least 12-24 hours of observation even if initially mild. This is because of the risk of rapid deterioration, preterm labour, and ARDS.

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Step 4: Treatment

A. IV Fluid Resuscitation (CRITICAL)

• Start isotonic crystalloid (Normal saline or Hartmann's solution) IV
• Target urine output: 30-50 mL/hour or more
• Aggressive hydration reduces renal dysfunction rate from 20% → 7%
• ⚠️ Balance fluid carefully: Over-hydration risks pulmonary oedema especially with associated capillary injury → monitor SpO₂ throughout

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B. Antibiotic Therapy

Parenteral (IV) Regimens - For Moderate to Severe Disease

❌ Avoid: Fluoroquinolones (ciprofloxacin, levofloxacin) - contraindicated in pregnancy (cartilage toxicity) ❌ Avoid: TMP-SMX in first trimester (folate antagonism → neural tube defects) and third trimester (kernicterus risk) ❌ Avoid: Aminoglycosides as first choice (nephrotoxicity, fetal VIII nerve damage) ❌ Avoid: Ampicillin alone - high E. coli resistance rates

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Oral (Outpatient) Regimens - Step-Down or Mild Cases

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C. Antipyretic Therapy

• Paracetamol (acetaminophen) 1 g orally/IV every 6-8 hours
• Use cooling blanket if very high fever
• Important: Reduce fever promptly because:
  • Hyperthermia is teratogenic (especially in first trimester)
  • Increases fetal metabolic demands
  • Drives uterine contractions

❌ Avoid NSAIDs (ibuprofen, diclofenac) in pregnancy - cause premature closure of ductus arteriosus (especially third trimester)

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D. Monitoring During Admission

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E. If No Improvement After 48-72 Hours

• Suspect: urinary obstruction, resistant organism, perinephric/renal abscess
• Repeat renal ultrasound or consider MRI (non-radiation alternative to CT in pregnancy)
• Review culture sensitivities and adjust antibiotics accordingly
• Urology and nephrology consultation

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F. Preterm Labour Management

• Rehydrate first (contractions may resolve with hydration)
• If contractions persist → tocolysis:
  • Nifedipine (calcium channel blocker) - first choice tocolytic
  • Indomethacin (NSAID) - usable before 32 weeks
  • ⚠️ Use tocolytics cautiously in sepsis due to synergistic cardiovascular effects (vasodilation + sepsis = risk of severe hypotension)
  • ⚠️ Magnesium sulphate: Caution in severe sepsis (cardiovascular interactions)

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Step 5: After Recovery - Prevention of Recurrence

• Test of cure: Repeat urine culture 1 week after completing antibiotics and again monthly throughout pregnancy
• Suppressive antibiotic therapy for the rest of pregnancy if recurrent UTI:
  • Nitrofurantoin 50-100 mg at night (avoid near term - third trimester)
  • Cephalexin 125-250 mg at night
• Encourage high fluid intake (>2 L/day)
• Regular antenatal attendance and urine screening at every visit

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Summary Flowchart

Pregnant woman + Fever + Back/flank pain + Dysuria
│
▼
DIAGNOSIS: Acute Pyelonephritis in Pregnancy
│
▼
IMMEDIATE STEPS
├── Vital signs (HR, BP, Temp, RR, SpO₂)
├── Urine dipstick → MSU for C&S (before antibiotics)
├── FBC, creatinine, electrolytes, CRP
├── Blood cultures (if septic)
├── Renal USS (not CT)
└── CTG if ≥24 weeks
│
▼
IV Fluid Resuscitation (target UO >30 mL/hr)
+
IV Ceftriaxone 1-2 g daily (first-line)
+
Paracetamol (fever reduction)
+
Antiemetics
│
▼
Hospital admission (12-24 hours minimum)
Continuous SpO₂ monitoring (ARDS risk)
Fetal monitoring (preterm labour risk)
│
▼
Afebrile + stable for 24-48h?
├── YES → Step down to oral antibiotics → discharge
│         Complete 10-14 day course
│         Repeat urine culture in 1 week
└── NO → Renal USS for abscess/obstruction
          Review antibiotic sensitivities
          Urology consultation

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70-Year-Old Intoxicated Man with Urinary Retention

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What Is Happening? (Clinical Diagnosis)

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Why Alcohol Caused/Precipitated This

BPH is present in 80% of men in their 70s. AUR occurs in 10% of men in their 70s and up to 33% of men in their 80s. Alcohol, bed rest, medications (anticholinergics, opioids, antihistamines), constipation, and surgery are classic precipitating triggers.

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Two Types of AUR - Important Clinical Distinction

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Key Clinical Features

• Suprapubic pain (often severe - "cannot pass urine despite desperate urge")
• Distended bladder palpable above the pubic symphysis (dull to percussion)
• Restlessness and distress
• No urine output for hours despite feeling urgently full
• Overflow incontinence may occur in chronic/painless retention (dribbling small amounts despite full bladder)
• Note: Intoxicated patients may be less aware of pain - the bladder may be enormous before presentation

⚠️ A distended palpable bladder above the umbilicus = large volume retention (often >500 mL, sometimes >1-2 litres). If untreated → acute renal failure from back-pressure.

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PART 1: Diagnostic Tests

A. Bedside / Immediate Assessment

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B. Urine Tests

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C. Blood Tests

⚠️ Important: In chronic painless retention (often seen with neurogenic bladder or slowly progressive BPH), renal failure can be present at presentation without the patient being aware. Always check creatinine.

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D. Imaging

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E. After Stabilisation - Further BPH Work-Up

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PART 2: Immediate Next Steps (Management Tactics)

STEP 1: IMMEDIATE - Catheterisation (RELIEVE RETENTION NOW)

This is the first and most urgent step - do NOT delay while waiting for test results.

Urethral Catheterisation

If Urethral Catheterisation Fails

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STEP 2: MONITOR DRAINAGE - Beware Post-Obstructive Diuresis

Post-Obstructive Diuresis (POD)

• Mechanism: After relieving back-pressure, kidneys suddenly excrete the accumulated solutes (urea, sodium, water) - urine output can be 200-500 mL/hour
• Risk: Rapid fluid/electrolyte loss → hyponatraemia, hypokalaemia, hypomagnesaemia, dehydration, hypotension
• Management:
  • Hourly urine output monitoring
  • IV fluid replacement if urine output > 200 mL/hour (replace ~50-75% of output with normal saline or Hartmann's)
  • Serial electrolytes every 4-6 hours until diuresis settles
  • Do NOT clamp the catheter periodically - no evidence this prevents POD or haematuria

⚠️ If >3 litres drained at catheterisation: admit and monitor for POD.

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STEP 3: ADDRESS THE ALCOHOL + ACUTE ISSUES

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STEP 4: START ALPHA-BLOCKER THERAPY (Before TWOC)

❌ Do NOT start 5-alpha reductase inhibitors (finasteride, dutasteride) acutely - they take 3-6 months to reduce prostate size and have no benefit in the short term.

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STEP 5: TWOC - Trial Without Catheter (3-5 Days Later)

What Is TWOC?

• Remove the catheter after 3-5 days (median 5 days in clinical practice)
• Patient attempts to void spontaneously
• Check post-void residual with bladder scanner after voiding attempt

TWOC Success Rates

Factors Predicting TWOC Failure

• Age > 70 (this patient's age!)
• Large volume drained at catheterisation (≥ 1 litre)
• Severe LUTS (high IPSS score)
• Spontaneous AUR (vs precipitated - alcohol is precipitated, which is better)
• Large prostate volume

TWOC Options After Catheter Removal

• Bladder scanner check: If post-void residual > 200 mL → another episode of AUR likely → repeat TWOC or consider surgery
• Clean Intermittent Self-Catheterisation (CISC): Patient catheterises himself every 4-6 hours; reduces infection risk vs indwelling catheter; preferred by urologists but patients are often reluctant

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STEP 6: DEFINITIVE MANAGEMENT OF UNDERLYING BPH

Medical (Long-Term BPH Management)

Surgical (When Medical Fails / TWOC Fails)

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STEP 7: COUNSEL + ADDRESS ALCOHOL

• Alcohol is a clear precipitating factor - counsel about reducing/stopping alcohol
• Address alcohol dependence if chronic (AUDIT score, CAGE questionnaire)
• Alcohol causes: diuresis (bladder overdistension) + sympathetic tone increase + CNS sedation - triple mechanism for AUR

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Summary Algorithm

70yr old drunk man + unable to void + distended bladder
│
▼
DIAGNOSIS: Acute Urinary Retention (AUR)
Most likely cause: BPH + precipitated by alcohol
│
▼
STEP 1: IMMEDIATE → Urethral catheterisation
        • Coude catheter (18-20 Fr) for BPH
        • Lidocaine gel first
        • Record volume drained
        • Fails? → Suprapubic catheter / urology consult
│
▼
STEP 2: MONITOR → Post-obstructive diuresis
        • Hourly urine output
        • IV fluids if UO >200 mL/hr
        • Electrolytes q4-6h
        • Creatinine baseline
│
▼
STEP 3: BLOODS + URINE
        • Creatinine, eGFR, electrolytes, FBC
        • Urine dipstick + MSU
        • PSA (note: interpret 4-6 weeks post-catheter)
        • Renal USS (hydronephrosis?)
        • DRE (prostate assessment)
│
▼
STEP 4: Start TAMSULOSIN 0.4mg daily
        (increases TWOC success rate)
│
▼
STEP 5: TWOC at 3-5 days
        61% success → discharge on tamsulosin
        Fail → repeat (up to 3 attempts)
        All fail → TURP or laser prostatectomy
│
▼
STEP 6: Address ALCOHOL (precipitating factor)
        Counsel / refer to addiction services

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Young Woman in ER: Fever + Hematuria + Difficulty Urinating (Past Few Days)

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First - What Is the Clinical Picture Telling You?

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Step 1: Immediate Assessment in the ER

Rapid ABC + Triage

⚠️ If she is tachycardic + hypotensive + febrile = sepsis → immediate IV access, blood cultures, IV antibiotics within 1 hour (Sepsis 6 protocol)

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Step 2: Focused History (Key Questions)

About the Hematuria

• Is it visible (gross) or only found on dipstick (microscopic)?
• Is it the whole stream, initial, or terminal?
• Are there clots? What shape? (Worm-shaped = upper tract; cuboid = bladder)
• Is it painless or painful?

About the Dysuria / Voiding Difficulty

• Burning on urination? (cystitis/urethritis)
• Urgency, frequency?
• Inability to void / incomplete emptying?
• Suprapubic pain or cramping?

About the Fever

• How high? Gradual or sudden onset?
• Any rigors (shaking chills)? → Strongly suggests bacteraemia/sepsis
• Loin/flank pain? (upper UTI)
• Costovertebral angle pain?

Background History

• Last menstrual period - MANDATORY (exclude pregnancy)
• Sexual history - multiple partners, new partner, unprotected sex → STI risk
• Previous UTIs - recurrent UTI history?
• Recent upper respiratory tract infection → IgA nephropathy trigger
• Medications: analgesics, cyclophosphamide (drug causes haemorrhagic cystitis)
• Family history: renal disease, deafness → Alport syndrome
• Rash, joint pain, oral ulcers → Lupus nephritis (SLE)
• Trauma - any recent injury?
• Contraception - diaphragm use increases UTI risk

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Step 3: Physical Examination

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Step 4: Investigations

Urine Tests (MOST IMPORTANT - Order Immediately)

Microscopy Decision Tree

Urine microscopy result
│
├── Dysmorphic RBCs + RBC casts + proteinuria
│   → GLOMERULAR DISEASE (IgA nephropathy, GN, SLE, Goodpasture)
│   → Nephrology referral + further serology
│
├── Round (non-dysmorphic) RBCs + WBCs + bacteria
│   → INFECTION (cystitis / pyelonephritis)
│   → Urine culture + antibiotics
│
└── Round RBCs only (no WBCs, no bacteria)
    → STRUCTURAL/UROLOGICAL cause (stone, tumour, trauma)
    → CT KUB + urology

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Blood Tests

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Imaging

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Step 5: Working Diagnosis Framework

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Scenario A: Urine = WBCs + bacteria + round RBCs, CVA tenderness, HIGH fever (38.5°C+), rigors

1. Admit to hospital (young woman with fever, hematuria, and days of symptoms = not mild)
2. IV access + blood cultures + urine culture (before antibiotics)
3. IV ceftriaxone 1 g daily - first-line (broad spectrum, covers E. coli; ampicillin resistance is high)
4. IV fluid resuscitation - maintain urine output > 30 mL/hour
5. IV paracetamol for fever and pain
6. IV antiemetics (ondansetron 4 mg IV) if nausea
7. Renal USS - exclude abscess or obstruction
8. Monitor: vitals, urine output, temperature chart, creatinine
9. Step down to oral antibiotics when afebrile for 24-48 hours
10. Total antibiotic course: 10-14 days (co-amoxiclav, ciprofloxacin, or TMP-SMX oral - guided by culture sensitivities)
11. Repeat urine culture 1 week after completing antibiotics

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Scenario B: Urine = WBCs + bacteria + round RBCs, SUPRAPUBIC pain, LOW fever, no CVA tenderness

• Oral antibiotics if no systemic toxicity:
  • Nitrofurantoin 100 mg BD x 5 days (first-line)
  • Trimethoprim 200 mg BD x 7 days (if local resistance < 20%)
  • Co-amoxiclav 625 mg TDS x 7 days (if above not suitable)
• High fluid intake (> 2 L/day) to flush bladder
• Analgesia: paracetamol; phenazopyridine (bladder analgesic) if available
• Repeat urine culture in 48 hours if not improving
• If no improvement after 48h → IV antibiotics + re-evaluate for upper tract involvement

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Scenario C: Dysmorphic RBCs + RBC casts + significant proteinuria, recent URTI, young patient

• Young patient (15-35 years, male predominance but occurs in women)
• Haematuria appearing 24-72 hours after a sore throat or upper respiratory infection ("synpharyngitic haematuria")
• Low-grade fever
• Cola/brown coloured urine (not bright red)
• No or minimal oedema
• Possible mild proteinuria

• Nephrology referral
• Serology: IgA levels, complement C3/C4, ANA, anti-dsDNA, ANCA, ASO titre
• 24-hour urine protein / urine PCR
• Monitor BP (hypertension worsens prognosis)
• Renal USS
• Renal biopsy is required for definitive diagnosis (shows IgA + IgG deposits in mesangial cells on immunofluorescence)
• No curative treatment; ACE inhibitors for proteinuria; steroids in selected cases
• Most patients maintain stable renal function; ~25% develop renal insufficiency over decades

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Scenario D: Positive βhCG (pregnant) + above symptoms

• Admit immediately
• IV ceftriaxone + IV fluids + obstetric consultation
• Monitor fetal heart rate if ≥ 24 weeks
• Avoid NSAIDs, fluoroquinolones, TMP-SMX in 3rd trimester
• Full management as per pyelonephritis in pregnancy protocol

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Scenario E: Vaginal discharge + cervical excitation + fever + dysuria

• Send: endocervical swab for gonorrhoea culture + NAAT for chlamydia
• Urine NAAT for chlamydia/gonorrhoea
• Treat empirically: Ceftriaxone 500 mg IM (single dose) + azithromycin 1 g oral (single dose) or doxycycline 100 mg BD x 14 days for chlamydia
• Contact tracing

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Step 6: Red Flags That Change the Urgency

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Summary: ER Management Algorithm

Young woman + Fever (past few days) + Hematuria + Dysuria
│
▼
IMMEDIATE
├── Vitals + sepsis screen
├── IV access if febrile/tachycardic
├── Urine dipstick + MSU (BEFORE antibiotics)
├── βhCG (mandatory)
└── Pelvic exam ± STI swabs if indicated
│
▼
BLOOD TESTS
FBC, CRP, creatinine, electrolytes, blood cultures (if febrile)
│
▼
URINE MICROSCOPY (KEY DECISION POINT)
│
├── Round RBCs + WBCs + bacteria
│   → UTI/Pyelonephritis
│   → Urine culture + antibiotics
│   ├── CVA tenderness + high fever → ADMIT + IV ceftriaxone
│   └── Suprapubic only + mild → Oral nitrofurantoin, discharge
│
├── Dysmorphic RBCs + RBC casts + proteinuria
│   → Glomerulonephritis (IgA, SLE, post-infectious)
│   → Nephrology referral + serology + renal USS
│   └── Consider renal biopsy
│
└── Round RBCs only (no infection)
    → Structural (stone, tumour)
    → Renal USS / CT KUB
    → Urology referral

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Quick Reference - Common Diagnoses at a Glance

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