Urinary Tract Infections — MCQs
A patient 45 years of age, non diabetic, presents with chronic pelvic pain of 1 year duration. She also complains of frequency, urgency and a sense of incomplete evacuation since 1 year without any significant finding on her past ultrasounds, urine examination and urine and high vaginal swab cultures. On pelvic examination there is no significant vaginal discharge. Cystoscopy is normal. Most probable diagnosis is
A 27-year-old man presents with clear urethral discharge and dysuria for 3 days. Gram stain shows numerous polymorphonuclear leukocytes without intracellular diplococci. What is the most likely pathogen?
Xanthogranulomatous infection is caused by:
Most common organism causing UTI:
A patient from the Ohio River valley presents with granulomatous prostatitis showing broad-based budding organisms on microscopy. What is the most likely infecting organism?
Struvite stones are primarily composed of which metal?
Ectopic ureter may be frequently associated with which of the following conditions?
Irregular scarred kidney with pelvic dilatation is seen with?
Which antibiotic is the most appropriate choice for treating a bedridden patient with catheter-related urinary tract infection (UTI) and pneumonia?
A woman presenting with symptoms of urinary tract infection was prescribed a drug that causes tendon rupture and arthropathy. What is the mechanism of action of the drug?
Urinary Tract Infections Indian Medical PG Practice Questions and MCQs
Question 1: A patient 45 years of age, non diabetic, presents with chronic pelvic pain of 1 year duration. She also complains of frequency, urgency and a sense of incomplete evacuation since 1 year without any significant finding on her past ultrasounds, urine examination and urine and high vaginal swab cultures. On pelvic examination there is no significant vaginal discharge. Cystoscopy is normal. Most probable diagnosis is
- A. Asymptomatic bacteriuria
- B. Cystitis
- C. Urethral syndrome (Correct Answer)
- D. Vulvovaginitis
Explanation: ***Urethral syndrome*** - The patient presents with classic symptoms of **urethral syndrome**, including chronic pelvic pain, frequency, urgency, and incomplete evacuation despite negative urine cultures and normal cystoscopy [1]. - This diagnosis is also supported by the absence of significant findings on ultrasound, urine examination, and vaginal cultures, ruling out common infectious or structural causes [1]. *Asymptomatic bacteriuria* - This condition involves the presence of bacteria in the urine without any associated symptoms and would not explain the patient's **chronic pelvic pain**, frequency, and urgency. - While urine cultures would be positive, the absence of symptoms differentiates it from the patient's presentation. *Cystitis* - **Cystitis**, or bladder inflammation, typically presents with similar symptoms to the patient, but would usually show signs of inflammation or infection in urine analysis (e.g., pyuria) or cystoscopy, which are absent here. - Her negative urine cultures also effectively rule out **bacterial cystitis**. *Vulvovaginitis* - **Vulvovaginitis** is an inflammation of the vulva and vagina, usually presenting with vaginal discharge, itching, or irritation, which is conspicuously absent in this patient [2]. - The patient's symptoms are primarily urinary and pain-related, not genitally localized to the vulva or vagina.
Question 2: A 27-year-old man presents with clear urethral discharge and dysuria for 3 days. Gram stain shows numerous polymorphonuclear leukocytes without intracellular diplococci. What is the most likely pathogen?
- A. Neisseria gonorrhoeae
- B. Trichomonas vaginalis
- C. Ureaplasma urealyticum
- D. Chlamydia trachomatis (Correct Answer)
Explanation: ***Chlamydia trachomatis*** - The presentation of **clear urethral discharge** and **dysuria** in a sexually active young man, coupled with polymorphonuclear leukocytes on Gram stain but **no intracellular diplococci**, is highly characteristic of **chlamydial urethritis**. - *Chlamydia trachomatis* causes **non-gonococcal urethritis** and is a common cause of sexually transmitted infections (STIs). *Neisseria gonorrhoeae* - This pathogen typically causes **purulent urethral discharge** and would show **intracellular Gram-negative diplococci** on microscopy, which were absent in this case. - Gonococcal urethritis is usually associated with more severe symptoms and a different Gram stain finding. *Trichomonas vaginalis* - While *Trichomonas vaginalis* can cause urethritis in men, it is less common than in women and typically presents with a **foamy, greenish discharge** and may be associated with **pruritus**. - *Trichomonas* is not visible on Gram stain; diagnosis requires **wet mount microscopy** showing motile trophozoites, making this less likely given the laboratory findings. *Ureaplasma urealyticum* - *Ureaplasma urealyticum* can cause **non-gonococcal urethritis**, but it is generally associated with **milder symptoms** or can even be asymptomatic. - While it's a possibility, *Chlamydia trachomatis* is a more common and prominent cause of the described clinical picture.
Question 3: Xanthogranulomatous infection is caused by:
- A. Nephrolithiasis
- B. Proteus Mirabilis
- C. All of the options (Correct Answer)
- D. Urinary obstruction
Explanation: ***All of the options*** - **Xanthogranulomatous pyelonephritis (XGP)** is a severe, chronic infectious process of the kidney, often associated with a combination of factors including **urinary tract obstruction**, specific bacterial infections, and the presence of kidney stones (nephrolithiasis) [1]. - **Proteus mirabilis** is a common cause of XGP due to its ability to produce urease, which hydrolyzes urea into ammonia, increasing urinary pH and promoting the formation of struvite stones, thus acting in concert with obstruction and stones [1]. *Nephrolithiasis* - While **kidney stones** are a major predisposing factor for XGP, they do not solely cause the infection; they primarily create an environment conducive to bacterial colonization and obstruction. - The presence of stones, particularly **struvite stones**, can lead to persistent infection and the characteristic inflammatory response seen in XGP. *Proteus Mirabilis* - **Proteus mirabilis** is frequently isolated in cases of XGP, but it typically acts in conjunction with urinary obstruction and/or nephrolithiasis [1]. - This bacterium contributes significantly to the pathophysiology by promoting stone formation and maintaining a chronic infectious state, but it is not the sole cause. *Urinary obstruction* - **Urinary tract obstruction** is a key predisposing factor that prevents proper drainage, leading to stasis and increasing susceptibility to infection [1]. - While essential for the development of XGP, obstruction alone does not directly cause the characteristic xanthogranulomatous inflammation without the presence of bacteria and often stones. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 939-940.
Question 4: Most common organism causing UTI:
- A. E. coli (Correct Answer)
- B. Klebsiella
- C. Streptococci
- D. Staphylococcus saprophyticus
Explanation: ***E. coli*** - **Uropathogenic *E. coli*** (UPEC) is responsible for 75-95% of all urinary tract infections (UTIs) due to its virulence factors like **fimbriae** that allow adherence to uroepithelial cells. - Its presence in the urethra colonizes the region and ascends to the bladder, making it the most common causative agent. *Klebsiella* - **Klebsiella pneumoniae** is a common cause of UTIs, especially in complicated cases or in patients with indwelling catheters, but it is not the most frequent overall. - It ranks significantly lower than *E. coli* in incidence. *Streptococci* - While certain **Streptococcus species** can cause UTIs, they are a less common cause compared to gram-negative rods like *E. coli*. - For example, **Enterococcus faecalis** (a Group D Streptococcus) can cause UTIs, especially in hospital-acquired infections, but *E. coli* is still more prevalent. *Staphylococci saprophyticus* - **Staphylococcus saprophyticus** is a common cause of UTIs in young, sexually active women but is not the most common organism overall across all demographics. - Its incidence is significant in specific populations but doesn't rival that of *E. coli* generally.
Question 5: A patient from the Ohio River valley presents with granulomatous prostatitis showing broad-based budding organisms on microscopy. What is the most likely infecting organism?
- A. Escherichia coli
- B. Histoplasma capsulatum
- C. Pseudomonas aeruginosa
- D. Blastomyces dermatitidis (Correct Answer)
Explanation: ***Blastomyces dermatitidis*** - This organism is endemic to the **Ohio River valley** and is known to cause **granulomatous inflammation**, including in the prostate. - Its characteristic morphology is **broad-based budding yeast** on microscopy, fitting the description. *Escherichia coli* - While *E. coli* is a common cause of **bacterial prostatitis**, it does not present as granulomatous inflammation. - It is a **bacterium**, not a fungus, and would not show broad-based budding organisms. *Histoplasma capsulatum* - **Histoplasma** is also endemic to the Ohio River valley and causes granulomatous disease, but its yeast forms are **small**, intracellular, and do not exhibit broad-based budding. - It is often associated with a history of exposure to **bat or bird droppings** and commonly affects the lungs. *Pseudomonas aeruginosa* - *Pseudomonas aeruginosa* causes **bacterial infections**, often in immunocompromised individuals or associated with catheter use, and is not a fungus. - It causes **acute inflammation**, not chronic granulomatous inflammation, and does not show broad-based budding.
Question 6: Struvite stones are primarily composed of which metal?
- A. Magnesium (Correct Answer)
- B. Calcium
- C. Sodium
- D. Potassium
Explanation: ***Magnesium*** - **Struvite stones** are primarily composed of **magnesium ammonium phosphate**, formed in the presence of urease-producing bacteria. - The presence of magnesium is a defining component of these **infection-related stones**. *Calcium* - **Calcium** is the primary component of the most common type of kidney stones, **calcium oxalate** and **calcium phosphate stones**. - These are typically unrelated to bacterial infections, unlike struvite stones. *Sodium* - **Sodium** is not a primary component of any common type of kidney stone. - While high sodium intake can increase the risk of stone formation, it does not directly form the stone matrix. *Potassium* - **Potassium** is not a characteristic component of kidney stones. - It plays a role in urinary pH regulation but is not directly incorporated into stone formation.
Question 7: Ectopic ureter may be frequently associated with which of the following conditions?
- A. Dysuria
- B. Paradoxical incontinence (Correct Answer)
- C. Bilateral hydroureter
- D. Oliguria
Explanation: ***Paradoxical incontinence*** - Ectopic ureters in females often insert distal to the external sphincter (e.g., vagina, vestibule), leading to **continuous leakage of urine** despite periods of normal voiding. This is known as paradoxical incontinence, where the bladder fills and empties normally, but urine also constantly dribbles from the ectopic opening. - In males, ectopic ureters usually insert proximal to the external sphincter (e.g., prostatic urethra, seminal vesicle) and therefore rarely cause incontinence but rather present with **ureteral obstruction** or **epididymitis**. *Oliguria* - **Oliguria** refers to a decreased urine output and is typically associated with **renal failure**, dehydration, or severe obstruction, not directly or frequently with an ectopic ureter itself. - An ectopic ureter may cause obstruction leading to **hydronephrosis** or renal damage, which could eventually lead to oliguria, but it is not the immediate or frequent direct association. *Dysuria* - **Dysuria** means painful urination, most commonly associated with **urinary tract infections (UTIs)**, urethritis, or bladder inflammation. - While an ectopic ureter can predispose to UTIs, dysuria is a symptom of infection rather than a direct, frequent consequence of the anatomical anomaly itself. *Bilateral hydroureter* - **Bilateral hydroureter** suggests obstruction of both ureters, often at the level of the bladder or urethra, or a systemic condition affecting both kidneys. - An ectopic ureter is usually a unilateral anomaly, causing **unilateral hydroureter** if it is obstructed, not typically bilateral.
Question 8: Irregular scarred kidney with pelvic dilatation is seen with?
- A. Chronic pyelonephritis (Correct Answer)
- B. Polycystic kidney
- C. Renal artery stenosis
- D. Tuberculosis of kidney
Explanation: ***Chronic pyelonephritis*** - Characterized by irregular scarring of the kidney and often leads to **pelvic dilatation** due to recurrent infections and obstruction [1]. - The damage from inflammation results in **cortical scarring** and can affect kidney function significantly over time [1]. *Renal artery stenosis* - Typically presents with **hypertension** and may lead to ischemic atrophy, but does not cause significant **pelvic dilatation**. - The kidney appears small and often asymmetric, but not typically irregular and scarred. *Tuberculosis of kidney* - Can cause damage to the kidney, but usually leads to **caseating granulomas** and can cause abscesses, not specifically irregular scarring with pelvic dilation. - Often presents with systemic symptoms such as fever and night sweats, along with hematuria. *Polycystic kidney* - Characterized by multiple cysts in both kidneys leading to enlarged kidneys, but does not typically present as **irregularly scarred kidneys**. - Usually associated with **hemodynamic issues** and hypertension but not pelvic dilatation in the sense of scarring or fibrosis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 937-939.
Question 9: Which antibiotic is the most appropriate choice for treating a bedridden patient with catheter-related urinary tract infection (UTI) and pneumonia?
- A. Amoxicillin
- B. Beta Lactam antibiotics with beta lactamase (Correct Answer)
- C. 3rd gen cephalosporins
- D. 2nd gen cephalosporins
Explanation: ***Beta Lactam antibiotics with beta lactamase*** - This combination provides a **broad spectrum of activity** against common pathogens causing both hospital-acquired UTIs and pneumonia, including those producing **beta-lactamase enzymes**. In many organisms, resistance is due to ̢-lactamase production, which can be overcome by the addition of ̢-lactamase inhibitors like clavulanic acid or tazobactam [1]. - Given the patient's bedridden status and catheter, there is a higher risk of **multidrug-resistant organisms**, making this broader coverage more appropriate. Ureidopenicillins combined with beta-lactamase inhibitors extend the spectrum to include Pseudomonas spp., which are often resistant to aminopenicillins [1]. *Amoxicillin* - **Amoxicillin** alone has a limited spectrum and is often ineffective against many hospital-acquired pathogens, especially those producing **beta-lactamase** [1]. - It would not adequately cover potential resistant bacteria in a bedridden patient with catheter-related infection. *3rd gen cephalosporins* - While **3rd generation cephalosporins** offer broader coverage than earlier generations, they may not adequately cover some **ESBL-producing organisms** or **Pseudomonas**, which are concerns in hospitalized, bedridden patients [1]. - They are suitable for many community-acquired infections but might be suboptimal for **nosocomial infections** without additional agents [2]. *2nd gen cephalosporins* - **Second-generation cephalosporins** have an even narrower spectrum compared to third-generation agents and would likely be insufficient for the broad range of potential pathogens in this clinical scenario. - They are typically used for specific indications and generally lack sufficient activity against many **gram-negative bacilli** and atypical pneumonia pathogens.
Question 10: A woman presenting with symptoms of urinary tract infection was prescribed a drug that causes tendon rupture and arthropathy. What is the mechanism of action of the drug?
- A. Ribosomal inhibition
- B. Cell wall synthesis
- C. Inhibition of folic acid synthesis
- D. DNA gyrase inhibition (Correct Answer)
Explanation: ***DNA gyrase inhibition*** - The description of a drug causing **tendon rupture** and **arthropathy** in the context of a urinary tract infection (UTI) suggests a **fluoroquinolone**. - Fluoroquinolones exert their bactericidal effect by inhibiting **bacterial DNA gyrase** (also known as topoisomerase II) and **topoisomerase IV**, thereby preventing DNA replication and repair. *Ribosomal inhibition* - This mechanism is characteristic of antibiotics like **aminoglycosides**, **tetracyclines**, and **macrolides**. - While some of these can treat UTIs, they are not typically associated with **tendon rupture** or **arthropathy** as major side effects. *Cell wall synthesis* - This is the mechanism of action for **beta-lactam antibiotics** (e.g., penicillins, cephalosporins) and **vancomycin**. - These drugs are common for UTIs but do not cause **tendon rupture** or **arthropathy**. *Inhibition of folic acid synthesis* - This mechanism is used by **sulfonamides** and **trimethoprim**, often combined as trimethoprim-sulfamethoxazole. - While effective for UTIs, these drugs are not known to cause **tendon rupture** or **arthropathy**.
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