Cases/Renal and Urology

Her Fourth Urine Infection This Year — Free SCA Practice Case

Woman with her fourth urine infection this year

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Denise Kerrigan

Age

58 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation.

Reason for Encounter

"This is my fourth water infection this year. I'm fed up with it — I need something to stop them coming back."

Medical Records

●PMH: Nil significant. Menopause at 51.
●Medications: None regular.
●Allergies: NKDA.
●Recent notes: Four episodes of urinary tract infection in the past 11 months, each treated with nitrofurantoin. Cultures: three of the four confirmed E. coli sensitive to nitrofurantoin; one episode treated empirically without a sample. No imaging or specialist input to date.

Patient Script

For the friend playing the patient role

Character Overview: You are Denise, a 58-year-old woman who works in a school office. You have had four water infections in the past year — burning when passing urine, going frequently, urgency, and cloudy urine — each settling with antibiotics. You are frustrated and worn down by them, and they are affecting your work and your confidence about going out. You went through the menopause at 51 and, if asked, you have vaginal dryness and discomfort during sex, which you have never mentioned to anyone because you were embarrassed. You are currently well with no symptoms. You have never seen blood in your urine. You want something to stop the infections recurring, and you have read online about taking a low-dose antibiotic every day.

Opening Sentence: "Hello Doctor. This is my fourth water infection this year — well, the last one cleared up, but I'm sick of them coming back. I've read you can take a low-dose antibiotic every day to prevent them. Can I have something to stop this happening again?"

History if Asked (Data Gathering Phase)

●The episodes: "Burning when I go, needing to go all the time, urgency, cloudy urine. Four times this year. Each time antibiotics sorted it."
●Currently: "I'm fine at the moment — no symptoms right now."
●Impact: "It's wearing me down. I've had time off work, and I get anxious about being away from a toilet."
●Samples: "I think I gave samples most times, though once they just gave me antibiotics over the phone."
●What she wants: "Something to prevent them. I've read about a daily low-dose antibiotic."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

●Ideas: Denise believes she needs a daily preventive antibiotic, having read about it. "I think what I need is a daily antibiotic to keep them away."
●Concerns: She is worn down and worried the infections will keep recurring indefinitely, and — if explored — that there might be something seriously wrong causing them. "I'm worried this is just going to keep happening, and part of me wonders if something's actually wrong."
●Expectations: She expects preventive treatment. "I want something that stops them coming back."

If Asked — Recurrent-UTI Work-Up and Red-Flag Screen

The patient answers these only when directly asked.

●If asked about visible blood in the urine (during or between episodes): "No, I've never seen blood in my urine." (Important — a suspected-cancer trigger in this age group if present.)
●If asked about fever, rigors, flank/loin pain, or vomiting (upper tract): "No — they've always been the lower, burning sort, no fevers or back pain."
●If asked about whether samples were sent/confirmed: "I gave samples most times. Once it was done over the phone without one."
●If asked about vaginal dryness, soreness, or pain during sex (genitourinary syndrome of the menopause): "Well… yes, actually. I'm dry and it's uncomfortable during sex. I've been too embarrassed to mention it." (Key — points to vaginal atrophy.)
●If asked about whether episodes relate to sex: "Sometimes they do seem to come on after sex, now you say it."
●If asked about incomplete bladder emptying, poor stream, or hesitancy: "I don't feel like I'm not emptying properly."
●If asked about incontinence or prolapse symptoms: "A bit of leaking when I cough, nothing major, and no dragging sensation."
●If asked about bowels/constipation: "I can be constipated, yes."
●If asked about fluid intake: "I probably don't drink enough water — a lot of tea and coffee."
●If asked about spermicide, contraception, or hygiene products: "No spermicide; I do use scented bubble bath."
●If asked about diabetes, immunosuppression, or a history of stones/catheters: "No diabetes that I know of, nothing like that, no stones or catheters."

Responses to Management (The Negotiation Phase)

●If the Doctor explains the work-up (confirming culture, checking glucose, examining): "So you want to be sure they really were infections and check a few things first? That makes sense." (The tested point is a proper recurrent-UTI work-up rather than moving straight to prophylaxis.)
●If the Doctor raises vaginal oestrogen — the key intervention: "Oestrogen cream? For water infections? I'd never have connected the dryness with the infections." (The tested point is recognising and treating vaginal atrophy as a driver of recurrent UTI in postmenopausal women.)
●If the Doctor discusses self-care and non-antibiotic measures: "So drinking more, sorting the constipation, and stopping the scented bubble bath?" (The tested point is non-antibiotic prevention advice.)
●If the Doctor discusses antibiotic prophylaxis and its criteria: "So a daily antibiotic is an option, but not the first thing, and there are downsides?" (The tested point is explaining prophylaxis criteria, options such as single-dose post-coital prophylaxis, and antimicrobial-resistance considerations — with review.)
●If the Doctor safety-nets and explains referral: "What would mean I need to be looked at properly by a specialist?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Define Recurrent UTI and Confirm the Diagnosis

●Recurrent UTI is ≥2 episodes in 6 months or ≥3 in 12 months. Crucially, confirm episodes with urine culture — some apparently recurrent UTIs are not infections at all (e.g. overactive bladder, atrophic vaginitis, or interstitial cystitis), and culture also guides antibiotic choice.

Screen for Red Flags — Haematuria

●In an adult of this age, unexplained visible haematuria, or haematuria persisting after treatment of a UTI, triggers urgent suspected-cancer referral (NICE NG12). Always ask about haematuria during and between episodes.

Genitourinary Syndrome of the Menopause — the Key Modifiable Factor

●In postmenopausal women, vaginal atrophy is a major and frequently missed driver of recurrent UTI. Topical vaginal oestrogen reduces recurrence and also treats dryness and dyspareunia, with minimal systemic absorption. Ask sensitively — many women will not volunteer these symptoms.

Look for Behavioural and Mechanical Contributors

●Assess intercourse as a trigger, incomplete bladder emptying, incontinence/prolapse, constipation, fluid intake, spermicide, and irritant products, plus predisposing conditions (diabetes, immunosuppression, stones, catheters).

Non-Antibiotic Prevention First

●Advise adequate fluids, treating constipation, avoiding irritants, and post-coital voiding; cranberry products/D-mannose may be discussed for non-pregnant women, acknowledging the limited evidence. Consider other options such as methenamine hippurate.

Antibiotic Prophylaxis — Criteria and Stewardship

●Where non-antibiotic measures fail, options are single-dose prophylaxis linked to a trigger (e.g. post-coital) or daily prophylaxis, after discussing antimicrobial resistance and adverse effects, with a planned review (e.g. at ~6 months). Prophylaxis is a considered step, not a first response to a request.

Referral and Safety-Netting

●Refer for red flags/haematuria, suspected structural or functional abnormality, stones, recurrent upper-tract infection, or failure of management. Safety-net for pyelonephritis (fever, loin pain, rigors, vomiting).

Common Candidate Mistakes in This Case

●Going straight to daily antibiotics: prescribing on request without work-up, criteria, or review.
●Missing vaginal atrophy: not asking about menopausal genitourinary symptoms, and so omitting vaginal oestrogen.
●Not asking about haematuria: overlooking a suspected-cancer red flag in a woman of this age.
●Assuming all episodes were UTIs: failing to check that episodes were culture-proven.
●No plan for future episodes or follow-up: leaving her without a strategy or review.

Free MRCGP SCA practice case for GP registrars covering Her Fourth Urine Infection This Year — Renal and Urology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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