Cases/Renal and Urology

Urine Infection in a Man — Free SCA Practice Case

Man with a urine infection

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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

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Materials for Candidate

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Patient Profile

Full Name

Rhydian Brightwell

Age

45 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Same day appointment booked by the patient.

Reason for Encounter

"Burning when I pass water for two days. Could I have some antibiotics, please?"

Medical Records

●PMH: Nil significant. No previous urinary problems recorded.
●Medications: None regular.
●Allergies: NKDA.
●Social: IT systems administrator. Married. Non smoker. Alcohol about 12 units a week.

Recent Notes

●Health check, 14 months ago: BP 124/78, BMI 27, eGFR above 90.

Patient Script

For the friend playing the patient role

Character Overview: You are Rhydian Brightwell, a 45 year old IT systems administrator for a firm of solicitors. You work from home three days a week and drive to the office on the other two. You live with your wife Annika, an accountant, and your two teenage children. You are practical, brisk and a little embarrassed to be calling about "something down below". You are rarely ill and do not like fuss. For two days you have had burning when you pass urine and have been needing to go all the time. Annika gets water infections now and then and the surgery always gives her a three day course of antibiotics, so you think you need exactly the same and would rather not take time out of a busy week to come in. Underneath, you are uneasy about the dull ache you have had between your legs since yesterday, because your father was treated for prostate cancer at 72. You say nothing about this unless asked what you are worried about. You answer questions plainly and in short sentences.

Opening Sentence: "Hello doctor. I've had burning when I pass water and I'm going all the time, for two days now. My wife gets a three day course of antibiotics for this, so could I just have the same? I'd rather not come in, I've got a lot on."

History if Asked (Data Gathering Phase)

●How it started: "Two days ago I noticed a sting when I passed water. By yesterday I was running to the toilet every hour or so. Nothing set it off, and I've not had any injury or been unwell before it."
●Urinary symptoms: "Burning every time, worst at the end. I need to go in a hurry. I'm up three times a night, which is new. The urine looks a bit cloudy and smells strong. There's no blood that I've seen."
●Stream and emptying: "Now you ask, the stream has been weaker and slower since yesterday and I have to wait a moment for it to start. It doesn't stop completely and I'm passing a fair amount each time. I haven't been unable to go at all."
●The ache: "A dull ache between my legs, behind my testicles towards my back passage. It started yesterday and it's there all the time, about a four out of ten. Sitting at my desk makes it worse. It's not sharp and nothing has come out."
●Pain on ejaculation: "Only if asked. Yes, it hurt when I ejaculated the other night. I hadn't thought about it."
●Fever and general health: "I haven't checked my temperature. No shivering, no sweats, no vomiting and no pain in my back or sides. I'm tired because I'm up in the night, but otherwise I feel well in myself."
●Penile or testicular symptoms: "No discharge from the tip, no lumps, no swelling and no redness. The testicles aren't tender, it's the area behind them that aches."
●Sexual history: "Only if asked. I've only ever been with Annika, nobody else, and she has no symptoms." If offered tests for infections, he is surprised but fine with it: "If you think it's worth doing, go ahead."
●Previous urinary problems: "None. I have never had a water infection and I have never had blood in my urine, stones or kidney trouble. No catheter, no camera test and no operation on my waterworks."
●Bowels: "Normal, if a bit sluggish this week. No pain on opening them."
●Diabetes and immune system: "No diabetes. I'm not thirsty or passing large volumes. I take no steroids and have no condition that weakens my immune system."
●Antibiotics and tablets: "I have not had antibiotics for years. I take nothing regularly. I have taken two ibuprofen over the past two days for the ache and it helped a little. I have no ulcers, asthma or kidney problems."
●Allergies: "None."

Ideas, Concerns, Expectations

Gating note: Rhydian does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

●Ideas: He thinks it is the same water infection that Annika gets, probably from sitting for hours at his desk and not drinking enough. "It must be the same as Annika's, I don't drink enough when I'm working."
●Concerns: He is worried about the ache between his legs and whether it is his prostate. His father was treated for prostate cancer at 72 and he has never been checked himself. He also does not want antibiotics that "do nothing" and leave him ill all week. "Dad had prostate cancer. When it's down there and aching, you wonder."
●Expectations: He expects a prescription for the same three day course as Annika, sent to the pharmacy without having to come in. "Just the same as my wife gets, and I'll pick it up on my way past."

If Asked: Medical History and Family History

Gating note: Rhydian answers each of these plainly when the doctor asks.

●Other health problems: "Nothing. I've never really been ill. My blood pressure was fine at my check last year."
●Family history: "Dad had prostate cancer at 72, treated with radiotherapy and he is fine now. Mum had a thyroid problem. No bowel or kidney problems that I know of."
●Alcohol and smoking: "I don't smoke. About a dozen units a week, mostly wine at weekends."
●Fluids: "A lot of coffee and not much water when I'm working. Maybe three or four cups of coffee and a glass of water."

Social History and Lifestyle Impact

●Work: IT systems administrator. Works from home three days a week and is in the office the other two. He sits at a desk for most of the day. He is on call this week for a system upgrade and says he cannot easily drop everything, but he accepts coming in once he understands why.
●Home: Lives with Annika and two teenagers, aged 14 and 16. Annika has had several water infections over the years.
●Availability to be seen: He is working from home today and tomorrow. He lives ten minutes from the surgery and could come in this afternoon or first thing tomorrow. He can bring a sample if asked, because he has not passed urine for about two hours.
●Impact: He is annoyed at being woken three times a night and finds it hard to concentrate.

If Asked: Examination and Samples

Gating note: Rhydian can describe only what he feels or reads off a home thermometer. He does not know how to examine himself.

●If asked about a thermometer: "We've got one at home but I haven't used it. I'll go and get it... it says 37.2."
●If asked to examine himself or press on his tummy: "A bit tender low down above my pubic bone, nowhere else. I wouldn't know what else to check."
●If asked about a urine sample: "I haven't passed urine for about two hours, so I could do one if I came in. I'd get the pot from reception."

Responses to Management (The Negotiation Phase)

●
If the doctor says he cannot have the three day course and explains why men are treated differently:
- ●Reaction: Surprised but not hostile. "Annika always gets three days. Why's it different for me?" Once told that in men the infection can involve the prostate and needs longer and a proper sample: "So it's not a bug on its own, it could be connected to the ache?" He accepts a clear explanation.
●
If the doctor asks him to come in and give a sample before antibiotics:
- ●Reaction: Reluctant, then agreeable. "Do I really need to come in? I'm on call." If told it is needed to check his temperature, examine him and send urine to the laboratory so the right antibiotic is chosen: "Fine. I can be there this afternoon. Do I need to hold on to a full bladder?"
●
If the doctor mentions the prostate or the length of the antibiotic course:
- ●Reaction: Alarmed by the length, then wants detail. "Seven days, or two weeks? That's a long time to be on tablets. What do they do to you?" Told about stomach upset, rash, and tendon problems or nerve symptoms for some antibiotics: "Right. I'll watch out for that." If prostate cancer is brought up, he asks about his father: "Does this mean I might have cancer too?" He is reassured by a clear, honest explanation that infection is far more likely at his age with these symptoms, and that checking for cancer is a separate matter.
●
If the doctor discusses painkillers, fluids and rest:
- ●Reaction: Practical. "Is ibuprofen all right with the antibiotic? And do I need to be off work?" Told paracetamol or ibuprofen can be used, to drink plenty and he can usually work if he feels able: "I can work from home. I'll move the on call if I have to."
●
If the doctor discusses follow up and the sample result:
- ●Reaction: Agreeable. "So the lab result tells you if it's the right antibiotic?" He is happy with a phone call or review in about two days. If the doctor mentions other tests for the prostate: "Do I need that blood test for my prostate now?" If told it is better left until the infection has cleared, he accepts that.
●
If the doctor gives safety netting:
- ●Reaction: Wants specifics. "Come back if it's worse, but worse how?" If told to seek same day help for a fever or shivering, pain in his back or side, vomiting, being unable to pass urine, or no improvement in two days: "Right, so if I can't pass water at all, that's an emergency. I'll tell Annika as well."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Rhydian is a 45 year old man with two days of dysuria, frequency and nocturia, plus a dull perineal ache, a weaker stream and pain on ejaculation. He asks for the three day course his wife receives. The station tests whether the candidate refuses a short course designed for women, sends a urine sample first, and recognises that these symptoms may mean the prostate is involved while excluding pyelonephritis and sepsis.
●The model plan has six parts. Take a history that finds the prostatic features and screens for fever, rigors and loin pain. Arrange a same day face to face assessment, because temperature, abdomen, loins, genitalia and prostate cannot be examined by telephone. Obtain a midstream urine sample for culture before the first dose. Start an effective antibiotic for longer than three days, chosen with the prostate in mind. Review at about 48 hours, with the culture result. Give specific safety netting.
●Acceptable alternatives: treating as acute prostatitis from the outset with a 14 day course, or treating as a lower urinary tract infection for 7 days with trimethoprim and a 48 hour review that moves to a prostatitis regimen if prostatic features are confirmed. Starting after the examination later the same day is also reasonable. All are accepted provided the sample is sent first, the course is longer than three days and nitrofurantoin is avoided once the prostate is suspected.

Why Men Are Not Given the Women's Course

●NICE guideline NG109 on lower urinary tract infection (antimicrobial prescribing) gives men their own table: trimethoprim 200 mg twice a day for 7 days, or nitrofurantoin 100 mg modified release twice a day for 7 days if eGFR is 45 or more. The three day courses apply to non pregnant women.
●NICE CKS (lower urinary tract infection in men, revised April 2025) lists prostatitis, pyelonephritis, epididymitis, urethritis and bladder or renal malignancy as conditions that can look like a lower infection.
●His assumption that he needs what his wife gets is reasonable, so the best answer explains the difference and does not simply refuse.

Sending the Sample First

●NG109 recommends that a midstream urine sample is obtained from men before antibiotics are taken and sent for culture and susceptibility testing. CKS adds that dipsticks should not be relied on to confirm the diagnosis in men.
●Culture matters here for three reasons. It confirms infection, guides a change of antibiotic if the organism is resistant and symptoms are not improving, and is needed if the picture proves to be prostatitis. NG109 advises reviewing the antibiotic when results return and changing it only if resistant and symptoms are not already improving.

Recognising Prostatic Involvement

●CKS (acute prostatitis, revised June 2024) says acute prostatitis should be suspected in a man with urinary infection symptoms plus perineal, penile or rectal pain, obstructive voiding symptoms, low back pain or pain on ejaculation. Bacteraemia features such as rigors, myalgia, fever and tachycardia suggest severe disease.
●Rhydian has perineal ache, a weaker stream and painful ejaculation, but no fever, rigors, vomiting, loin pain or retention. He is therefore a man with probable prostate involvement who is not septic.
●Examination should include temperature, pulse and blood pressure, a palpable bladder, loin tenderness, the genitalia and, where appropriate, a gentle digital rectal examination. A prostate that is tender, swollen or warm supports the diagnosis.
●Think also about urethritis from a sexually transmitted infection and epididymitis. Rhydian has one partner who is well and no discharge, but offering a screen is reasonable.

Antibiotic Choice and Duration

●For acute prostatitis in a man who is not septic and not in retention, NICE NG110 and CKS recommend an oral antibiotic for 14 days then review: ciprofloxacin 500 mg twice a day or ofloxacin 200 mg twice a day first choice, or trimethoprim 200 mg twice a day if a fluoroquinolone is unsuitable (NG110 advises seeking specialist advice). Levofloxacin and co-trimoxazole are second choices after specialist discussion. NG110 advises reviewing at 14 days and either stopping or continuing for a further 14 days.
●Fluoroquinolones carry MHRA restrictions (January 2024) because of disabling and potentially long lasting side effects, including tendon damage and nerve symptoms. The patient should be warned of these risks, and trimethoprim is the alternative where a fluoroquinolone is not appropriate.
●NG109 states that nitrofurantoin is not recommended for men with suspected prostate involvement because it is unlikely to reach therapeutic levels in the prostate. Rhydian's perineal ache is the cue. A candidate who gives nitrofurantoin has missed it.
●A candidate who treats as lower urinary tract infection with trimethoprim 200 mg twice a day for 7 days, with a clear plan to review at 48 hours and extend if the prostate is involved, is acting within guidance. A candidate who sends a 14 day course with a review is also correct.

Excluding Pyelonephritis and Sepsis

●Fever, rigors, loin pain, vomiting or feeling very unwell suggest pyelonephritis or bacteraemia. NG111 (acute pyelonephritis) advises referral to hospital for any symptoms or signs suggesting a more serious illness, such as sepsis. For uncomplicated cases, first choice oral antibiotics include cefalexin for 7 to 10 days, co-amoxiclav for 7 to 10 days if the culture is available and susceptible, or trimethoprim for 14 days if susceptible.
●Rhydian has no systemic features, and the temperature is 37.2 if checked. Sending him to hospital with no sign of sepsis or retention is an over response.
●Acute urinary retention and prostatic abscess are the complications of prostatitis. Both are reasons for same day hospital assessment, so the safety net must name inability to pass urine.

Follow Up, Referral and Reassessment

●CKS recommends follow up at about 48 hours to check the response and culture results. Admit or refer to hospital if there is no improvement 48 hours after starting treatment for suspected acute prostatitis, or at any time if retention, abscess or sepsis is suspected.
●CKS states that referral to urology is not routinely required for a man with one uncomplicated lower urinary tract infection. It should be offered for ongoing symptoms despite appropriate treatment, an underlying cause or risk factor, or two or more episodes in 6 months. Suspected urological cancer, for example visible haematuria, goes on a suspected cancer pathway.
●Rhydian's father had prostate cancer at 72. This raises the question of discussing prostate cancer risk and PSA testing in general, but not as an immediate test. NICE CKS (prostate cancer, diagnosis) notes that PSA can be raised by infection and prostatitis, and that a man should not have a PSA test with an active urinary infection or within the previous 6 weeks, so the test is deferred, not requested now. Reassurance that infection is the likely cause, with a plan to reassess if symptoms persist, is appropriate.

Self Care and Safety Netting

●Advise paracetamol, with or without a low dose weak opioid, or ibuprofen if suitable, and enough fluids to avoid dehydration (NG110 self care). Explain that acute prostatitis can take several weeks to settle even once the infection has been treated, and that side effects such as nausea and diarrhoea may occur.
●Specific safety netting for Rhydian: fever or shivering, pain in the back or side, vomiting, feeling very unwell, being unable to pass urine, or no improvement within 48 hours should lead to same day contact, NHS 111 or emergency care. "Come back if it gets worse" is not enough.

Communication Points

●Acknowledge his wife's experience, explain why men differ, and do not make him feel that he has done wrong; he is embarrassed about the site of the symptoms.
●His real worry is the ache between his legs and his father's cancer. Asking about ideas and concerns opens this. An honest, proportionate answer works better than blanket reassurance.
●Negotiate the visit around his on call week. Naming the reason (temperature, examination and sample so the right antibiotic is chosen) usually turns reluctance into agreement.

Common Mistakes in This Station

●Prescribing the three day course because he asks, or because it matches his wife's.
●Prescribing without sending a urine culture, or relying on a dipstick.
●Choosing nitrofurantoin after the perineal ache has been described.
●Not asking about the prostate, so missing the perineal ache, weak stream and painful ejaculation.
●Not asking about fever, rigors, loin pain, vomiting or inability to pass urine, so sepsis and retention are not excluded.
●Making the diagnosis and prescribing entirely by telephone with no examination arranged.
●Giving no follow up at 48 hours and no specific safety netting.
●Sending him to hospital with no sign of sepsis or retention, or arranging an urgent cancer referral for a typical infection.
●Missing his father's prostate cancer because ideas, concerns and expectations were never explored.

Mapped to the RCGP curriculum topic: Renal and Urology.

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