Urinary Tract Infections — MCQs
A 25 year old female, presents to the clinic with dysuria, urinary frequency and urgency. After a laboratory workup a diagnosis of cystitis is made. Which is the first line drug for the treatment for this patient?
What is the definition of persistent diarrhea in infants based on duration?
A one-year-old male child presented with a poor urinary stream since birth. The initial investigation of choice for evaluation is:
A 6-year-old boy came with a history of recurrent urinary tract infections. Imaging was done and showed retrograde flow of urine from the bladder into the ureters. What is the most likely diagnosis based on the imaging findings?
A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?
A 3-year-old boy presents with fever, dysuria and gross hematuria. Physical examination shows a prominent suprapubic area which is dull on percussion. Urinalysis reveals red blood cells but no proteinuria. Which of the following is the most likely diagnosis -
A 10-year-old child with a history of frequent micturition and fever since 2 years presents to the pediatric OPD. On examination, it was normal. What would be the MOST APPROPRIATE diagnostic modality for this child?
Which of the following statements about Eagle-Barrett syndrome is false?
A 4-year-old girl presented with urinary infection caused by E. coli, pus cells in the urine, dilation of the left ureter with hydroureter, and a micturating cystourethrogram showing a filling defect in the bladder. What is the likely diagnosis?
After splenectomy, the most common infection is:
Urinary Tract Infections Indian Medical PG Practice Questions and MCQs
Question 1: A 25 year old female, presents to the clinic with dysuria, urinary frequency and urgency. After a laboratory workup a diagnosis of cystitis is made. Which is the first line drug for the treatment for this patient?
- A. Cephalexin
- B. Norfloxacin
- C. Amoxicillin
- D. Nitrofurantoin (Correct Answer)
Explanation: ***Nitrofurantoin*** - **Nitrofurantoin** is the most widely recommended first-line antibiotic for uncomplicated **cystitis** due to its excellent efficacy against common urinary pathogens, especially **E. coli**. - It achieves high concentrations in the urine and has a low rate of resistance, making it an excellent choice for this condition. - It is preferred over other antibiotics due to antimicrobial stewardship principles and minimal impact on gut flora. *Cephalexin* - While generally effective against some urinary pathogens, **cephalexin** is typically reserved as a second-line agent for uncomplicated cystitis, particularly if there are contraindications to or resistance to first-line agents. - Its broad-spectrum activity may contribute to increased resistance development if used routinely as first-line. *Norfloxacin* - **Norfloxacin** is a **fluoroquinolone** that, while effective for UTIs and sometimes used in regional practice, is generally not recommended as the preferred first-line for uncomplicated cystitis due to concerns about increasing antibiotic resistance and potential for serious side effects (e.g., tendinitis, QT prolongation, CNS effects). - Current antimicrobial stewardship guidelines recommend reserving fluoroquinolones for more complicated urinary tract infections or when other first-line options are not suitable. *Amoxicillin* - **Amoxicillin** is generally not recommended as a first-line agent for cystitis due to high rates of **bacterial resistance**, particularly among **E. coli** strains, which are the most common cause of UTIs. - Its efficacy against common urinary pathogens is often lower compared to other first-line options.
Question 2: What is the definition of persistent diarrhea in infants based on duration?
- A. 14 days
- B. More than 14 days (Correct Answer)
- C. Less than 14 days (Acute diarrhea)
- D. 7 days
Explanation: ***Correct: More than 14 days*** - Persistent diarrhea is defined as diarrhea lasting **more than 14 days** according to WHO and standard pediatric guidelines - This classification is crucial for differentiating it from acute diarrhea and guiding management strategies - Persistent diarrhea carries increased risk of **malnutrition, dehydration, and micronutrient deficiencies** - Requires different management approach including nutritional rehabilitation and evaluation for underlying causes *Incorrect: 14 days* - Diarrhea lasting **exactly 14 days** is at the boundary but does not meet the criterion for persistent diarrhea - The definition requires duration to **exceed** 14 days, not just reach it *Incorrect: Less than 14 days (Acute diarrhea)* - Diarrhea lasting **less than 14 days** is classified as **acute diarrhea** - Acute diarrhea typically has different etiology (mostly viral) and is generally self-limiting - Management focuses on rehydration and rarely leads to the severe nutritional complications seen in persistent cases *Incorrect: 7 days* - 7 days is well within the acute diarrhea range - Has no special significance in the classification of diarrhea duration - Most acute diarrheal episodes resolve within 5-7 days
Question 3: A one-year-old male child presented with a poor urinary stream since birth. The initial investigation of choice for evaluation is:
- A. USG bladder
- B. Voiding cystourethrography (VCUG) (Correct Answer)
- C. Uroflowmetry
- D. Intravenous urography
Explanation: ***Voiding cystourethrography (VCUG)*** - A **one-year-old male child with poor urinary stream since birth** is highly suggestive of **posterior urethral valves (PUV)**, the most common cause of bladder outlet obstruction in male infants. - **VCUG is the investigation of choice** for diagnosing PUV as it directly visualizes the posterior urethra during voiding and can demonstrate the characteristic findings: dilated posterior urethra, valve leaflets, bladder trabeculation, and vesicoureteral reflux. - While it involves catheterization and radiation, in this classic presentation, VCUG provides definitive diagnosis and is essential for surgical planning. *USG bladder* - Ultrasound is a useful **non-invasive screening tool** that can detect secondary findings such as hydronephrosis, bladder wall thickening, and increased post-void residual. - However, **USG cannot visualize the urethral valves** themselves and cannot definitively diagnose PUV. - In practice, many centers may perform ultrasound first, but it must be followed by VCUG for definitive diagnosis in this clinical scenario. *Uroflowmetry* - This test measures the **rate of urine flow** and requires patient cooperation with voiding. - A **one-year-old child cannot reliably follow instructions** to perform uroflowmetry. - It is more useful in older, cooperative children and adults. *Intravenous urography* - **Intravenous urography (IVU)** involves contrast administration and multiple X-rays to visualize the urinary tract. - It has been largely **replaced by ultrasound and CT urography** due to better imaging quality and safety profile. - IVU does not adequately visualize the urethra or diagnose urethral pathology like PUV.
Question 4: A 6-year-old boy came with a history of recurrent urinary tract infections. Imaging was done and showed retrograde flow of urine from the bladder into the ureters. What is the most likely diagnosis based on the imaging findings?
- A. Vesicoureteric reflux (VUR) (Correct Answer)
- B. Urinary bladder diverticulum (UBD)
- C. Vesicocolic fistula (VCF)
- D. Urinary bladder hernia (UBH)
Explanation: ***Vesicoureteric reflux (VUR)*** - VUR is defined by the **retrograde flow of urine from the bladder into the ureters**, which directly matches the imaging finding described - This is the **most common cause of recurrent UTIs in children**, as reflux allows bacteria to ascend from the bladder to the kidneys - Diagnosed by **voiding cystourethrogram (VCUG)**, which shows contrast refluxing into ureters during micturition - Graded from I to V based on severity; can lead to **reflux nephropathy** and renal scarring if untreated *Urinary bladder diverticulum* - An **outpouching of the bladder wall** through weakened muscle layers - May predispose to UTIs due to urinary stasis within the diverticulum, but does **not cause retrograde flow into ureters** - Imaging would show a **saccular projection** from the bladder, not ureteral filling *Vesicocolic fistula* - An **abnormal communication between bladder and colon**, typically from inflammatory bowel disease, malignancy, or trauma in adults (rare in children) - Presents with **pneumaturia (air in urine)**, fecaluria, and recurrent UTIs - Would not demonstrate **retrograde ureteral flow** on imaging *Urinary bladder hernia* - Protrusion of bladder through a **hernial defect** (inguinal, femoral, or abdominal wall) - Presents as a **reducible mass** that may increase with Valsalva - Does not cause **ureteral reflux** and has a distinct clinical and radiological presentation
Question 5: A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?
- A. Reflux nephropathy
- B. Polycystic kidney disease
- C. Chronic glomerulonephritis (Correct Answer)
- D. All of the options
Explanation: ***Chronic glomerulonephritis*** - The combination of **microscopic hematuria, proteinuria, and RBC casts** is pathognomonic for **glomerular disease**. - **RBC casts** specifically indicate glomerular bleeding and are highly specific for **glomerulonephritis**. - **Hypertension** in chronic glomerulonephritis results from sodium retention, fluid overload, and activation of the renin-angiotensin-aldosterone system. - The absence of acute features suggests a **chronic** process rather than acute post-streptococcal glomerulonephritis. *Reflux nephropathy* - While reflux nephropathy can cause hypertension and proteinuria, it typically presents with a history of **recurrent urinary tract infections**, which is explicitly absent in this case. - **RBC casts are NOT a feature** of reflux nephropathy; urinalysis may show proteinuria and occasionally WBCs/bacteria if infection is present. - Diagnosis requires imaging (VCUG, DMSA scan) showing vesicoureteral reflux and renal scarring. *Polycystic kidney disease* - **Autosomal dominant PKD** rarely presents with symptoms in childhood; it typically manifests in the 3rd-4th decade. - **Autosomal recessive PKD** presents in infancy/early childhood with enlarged kidneys and renal failure. - While PKD can cause hematuria (from cyst rupture), **RBC casts are not characteristic** as the pathology is cystic, not glomerular. - Diagnosis is made by ultrasound showing multiple bilateral renal cysts. *All of the options* - This is incorrect because the **specific urinalysis findings** (particularly **RBC casts**) point definitively to **glomerular pathology**. - RBC casts are the hallmark of glomerulonephritis and are not seen in reflux nephropathy or polycystic kidney disease. - The clinical presentation with specific laboratory findings allows differentiation between these conditions.
Question 6: A 3-year-old boy presents with fever, dysuria and gross hematuria. Physical examination shows a prominent suprapubic area which is dull on percussion. Urinalysis reveals red blood cells but no proteinuria. Which of the following is the most likely diagnosis -
- A. Acute glomerulonephritis
- B. Posterior urethral valves (Correct Answer)
- C. Urinary tract infection
- D. Teratoma
Explanation: ***Posterior urethral valves*** - The combination of **fever**, **dysuria**, **gross hematuria**, and a **prominent, dull suprapubic area** (suggesting a distended bladder) in a young male child points to an obstructive uropathy. - **Posterior urethral valves** are the most common cause of lower urinary tract obstruction in male infants and young children, leading to bladder outlet obstruction, urinary retention, and potential hydronephrosis. *Acute glomerulonephritis* - While it can cause hematuria, it typically presents with **proteinuria**, **edema**, and **hypertension**, which are not present in this case. - The prominent, dull suprapubic area is not a characteristic finding for acute glomerulonephritis. *Urinary tract infection* - A **UTI** can cause fever and dysuria, but significant **gross hematuria** and a **prominent suprapubic area** (indicating bladder distention) are less typical initial presentations. - While possible, the strong evidence of obstruction makes another diagnosis more likely. *Teratoma* - A **teratoma** is a tumor, which might present with a mass, but the constellation of acute symptoms including fever, dysuria, and a distended bladder points away from a primary diagnosis of teratoma. - Teratomas in the urinary tract are rare and usually present with non-specific symptoms or a palpable mass rather than acute obstructive signs.
Question 7: A 10-year-old child with a history of frequent micturition and fever since 2 years presents to the pediatric OPD. On examination, it was normal. What would be the MOST APPROPRIATE diagnostic modality for this child?
- A. 3D MCU (Correct Answer)
- B. MR UROGRAM
- C. 3D CT UROGRAM
- D. IVP
Explanation: ***3D MCU (Micturating Cystourethrogram)*** - **Gold standard** for diagnosing **vesicoureteral reflux (VUR)**, the most common cause of recurrent UTIs in children - In a child with **2-year history of recurrent UTIs** (fever + frequent micturition), VUR is the primary concern that needs to be ruled out - MCU provides **dynamic imaging** during bladder filling and voiding, allowing direct visualization of **reflux** and assessment of **bladder and urethral anatomy** - **Standard of care** recommended by IAP (Indian Academy of Pediatrics) and major pediatric nephrology guidelines - Though it involves ionizing radiation, the **diagnostic benefit far outweighs risks** in this clinical scenario - Cost-effective and widely available in Indian healthcare settings *MR Urogram* - Provides excellent anatomical detail of the **upper urinary tract** (kidneys, ureters) without radiation - However, it is **NOT the first-line investigation** for recurrent UTI workup in children - Does not adequately assess **dynamic VUR** like MCU does - More expensive, requires sedation in many children, and less accessible - Reserved for specific indications like suspected anatomical anomalies after initial screening *3D CT Urogram* - Excellent for detailed anatomical evaluation but involves **high radiation dose** - Not appropriate as first-line investigation in a **chronic, non-acute pediatric case** - Reserved for complex cases where MR is contraindicated or for acute complications *IVP (Intravenous Pyelogram)* - **Obsolete modality** that has been replaced by ultrasound, MCU, and modern cross-sectional imaging - Provides limited functional and anatomical information - Higher radiation exposure with inferior image quality compared to modern techniques - Not used in current pediatric practice
Question 8: Which of the following statements about Eagle-Barrett syndrome is false?
- A. Pulmonary hypoplasia
- B. Bilateral undescended testes
- C. Scapular hypoplasia (Correct Answer)
- D. Also known as prune belly syndrome
Explanation: ***Scapular hypoplasia*** - **Scapular hypoplasia** is not a characteristic feature of Eagle-Barrett syndrome. The syndrome primarily affects the abdominal wall, urinary tract, and testes. - The classic triad of Eagle-Barrett syndrome includes **partial or complete absence of abdominal wall musculature**, **urinary tract abnormalities**, and **bilateral cryptorchidism**. *Pulmonary hypoplasia* - **Pulmonary hypoplasia** can be a severe complication of Eagle-Barrett syndrome due to reduced fetal lung development. - This is often secondary to **oligohydramnios** caused by severe urinary tract abnormalities, restricting chest wall movement and fetal breathing. *Bilateral undescended testes* - **Bilateral undescended testes (cryptorchidism)** is a hallmark feature of Eagle-Barrett syndrome. - This is thought to be related to the abdominal wall defect and/or connective tissue abnormalities impacting testicular descent. *Also known as prune belly syndrome* - Eagle-Barrett syndrome is indeed **also known as prune belly syndrome**, a descriptive term referring to the wrinkled appearance of the abdominal wall in affected neonates. - This characteristic appearance is due to the severe hypoplasia or absence of rectus abdominis and oblique muscles.
Question 9: A 4-year-old girl presented with urinary infection caused by E. coli, pus cells in the urine, dilation of the left ureter with hydroureter, and a micturating cystourethrogram showing a filling defect in the bladder. What is the likely diagnosis?
- A. Sacrococcygeal teratoma (a congenital tumor)
- B. Ureterocele (a cystic lesion in the ureter) (Correct Answer)
- C. Posterior urethral valves (a condition in males)
- D. Vesicoureteral reflux (urine backflow into the ureters)
Explanation: ***Ureterocele (a cystic lesion in the ureter)*** - A **ureterocele** is a congenital malformation where the **distal ureter balloons into the bladder**, creating a filling defect on a micturating cystourethrogram (MCUG). - Its presence can lead to **obstruction** and **stasis**, causing recurrent **urinary tract infections (UTIs)**, **hydroureter**, and **hydronephrosis**. *Sacrococcygeal teratoma (a congenital tumor)* - A **sacrococcygeal teratoma** is a tumor typically found at the base of the spine and is usually **palpable externally** or identified prenatally. - While it can cause urinary symptoms due to compression, it would not directly present as a **filling defect within the bladder** on an MCUG. *Posterior urethral valves (a condition in males)* - **Posterior urethral valves** are obstructive membranes found in the **male urethra**, almost exclusively affecting boys. - This condition is unlikely in a 4-year-old girl and typically causes global bladder and upper tract dilation rather than a discrete filling defect from a ureteral anomaly. *Vesicoureteral reflux (urine backflow into the ureters)* - **Vesicoureteral reflux (VUR)** is the **abnormal backflow of urine from the bladder into the ureters** and often presents with UTIs and hydroureter. - However, VUR itself does not create a **filling defect in the bladder** on an MCUG; rather, the contrast would be seen flowing up the ureter.
Question 10: After splenectomy, the most common infection is:
- A. E. coli
- B. Klebsiella
- C. Streptococcus pneumoniae (Correct Answer)
- D. Haemophilus influenzae
Explanation: ***Streptococcus pneumoniae*** - The **spleen** is crucial for filtering encapsulated bacteria and producing opsonizing antibodies, making individuals **asplenic** or functionally asplenic highly susceptible to infections by **encapsulated organisms**. - *S. pneumoniae* is the most common cause of **overwhelming post-splenectomy infection (OPSI)**, leading to rapid onset **sepsis** and high mortality. *E. coli* - While *E. coli* is a common cause of infections, particularly **gram-negative sepsis** or **urinary tract infections**, it is not an encapsulated bacterium and thus not the primary opportunistic pathogen post-splenectomy. - The spleen's role in clearing *E. coli* is less central compared to encapsulated organisms. *Klebsiella* - *Klebsiella* species are also encapsulated bacteria, but *S. pneumoniae* is statistically the most frequently implicated organism in OPSI. - While *Klebsiella* can cause severe infections, particularly **pneumonia** and **bacteremia**, it is less common than *S. pneumoniae* in the context of post-splenectomy sepsis. *Haemophilus influenzae* - **Encapsulated strains of *Haemophilus influenzae***, particularly type B (Hib), can cause severe infections in asplenic patients, including **meningitis** and **epiglottitis**. - However, with widespread Hib vaccination, its incidence has significantly decreased, and *Streptococcus pneumoniae* remains the most prevalent cause of OPSI.
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