Recurrent urinary tract infection — structured oral station (12 minutes)

Opening prompt — "Take a focused history from this patient."

Model response — say it in this order: ^[1][6]

• "I would take a focused urinary tract history: dysuria, frequency, urgency, suprapubic pain, haematuria, incontinence, fever, flank pain; previous UTIs, last episode, organism and sensitivities, and how each was treated."
• "I would take a sexual and contraceptive history — spermicide use, diaphragm, new partner, post-coital pattern — because in this age group these are the dominant modifiable risk factors."
• "I would ask about menopause status, lactation, exogenous oestrogen, genitourinary symptoms, and about fluid intake, voiding habits and post-coital voiding."
• "I would screen for diabetes, recurrent thrush, prior pelvic surgery, neurogenic bladder, and the impact on sleep, work, sexual function and mood."
• "I would ask about the result of any imaging or cystoscopy, and any family history of UTI."^[1]

Examiner is listening for: pattern (post-coital, spermicide-related), risk-factor identification, exclusion of structural abnormality, and the impact question. ^[1]

Probe 1 — "Her urine cultures are repeatedly E. coli with sensitivity to nitrofurantoin, trimethoprim and fosfomycin. What now?"

• "This is recurrent uncomplicated UTI — defined as two or more culture-confirmed infections in six months, or three or more in twelve. In her age group and with her history, this is re-infection, not persistence — she has different triggers each time and structurally normal urinary tract is the default assumption."
• "The next step is to confirm the cultures are correctly collected and labelled, repeat a urine culture with sensitivities on a clean-catch mid-stream, and arrange renal ultrasound and post-void residual if she has any features of voiding dysfunction. Cystoscopy is reserved for refractory, complicated or persistent disease."^[1][6]

Probe 2 — "What would you prescribe for this acute episode?"

• "First-line agent is nitrofurantoin 100 mg modified-release orally twice daily for 5 days — provided local resistance is under 25% and she has reasonable renal function."
• "Alternatives are trimethoprim 300 mg orally daily for 3 days (if local resistance is under 30%) or fosfomycin 3 g orally as a single dose."
• "I would explicitly avoid fluoroquinolones as first-line for uncomplicated cystitis because of resistance and the WHO AWaRe 'Watch' classification; tendon rupture and aortic dissection are also class effects."^[1]

Probe 3 — "How would you prevent recurrence?"

• "Three non-antibiotic options. First, cessation of spermicide and diaphragm — spermicide depletes vaginal Lactobacilli and increases periurethral E. coli colonisation. Second, cranberry — high-proanthocyanidin content (≥36 mg/day PAC commonly used in trials); inhibits E. coli fimbrial attachment to uroepithelium, with modest effect (Fu 2017 meta-analysis — RR 0.74, 26% rUTI reduction). Third, methenamine hippurate 1 g orally twice daily — converted to formaldehyde in acidic urine; the ALTAR trial showed it was non-inferior to low-dose antibiotic prophylaxis."
• "I would also discuss Uro-Vaxom (OM-89) as an immunostimulant immunoprophylaxis option — modest evidence from older German RCTs and modern retrospective series."
• "Antibiotic prophylaxis: post-coital prophylaxis is the most efficient strategy in her case because her UTIs cluster around intercourse. A single dose of nitrofurantoin 50–100 mg, OR trimethoprim 100 mg, OR cephalexin 250 mg, taken within two hours of intercourse."^{[1][2][3][4][6]}

Probe 4 — "Why not continuous antibiotic prophylaxis?"

• "Continuous prophylaxis is an option, but post-coital prophylaxis is the most efficient strategy in young sexually active women because it minimises total antibiotic exposure and targets the trigger. Continuous prophylaxis is reserved for women whose recurrences are unrelated to intercourse or who have very frequent episodes despite post-coital prophylaxis."
• "Whichever strategy is chosen, review every 3 to 6 months; document triggers, response and side effects; and reassess ongoing need."^[1][6]

Probe 5 — "She is distressed and asks whether she will have to take antibiotics forever."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Move to her eye level, use her name, and be honest: "Most women with recurrent UTI find a prevention strategy that works for them — for you, the most efficient single step is to stop the spermicide and switch to a non-spermicide contraceptive, then add cranberry or methenamine, and use a single-dose post-coital antibiotic if needed."
• "We will not put you on long-term antibiotics unless we have to. We will review every few months and stop prophylaxis after a sustained remission."
• Acknowledge the impact on her life, validate her experience, name a contact for flares, and provide written information.^[1]