1. 🧼 Opening the Consultation

• Wash or sanitise hands
• Introduce yourself: "Hi, my name is (Name), one of the physician associates"
• Confirm the patient's full name and date of birth
• Gain consent: "Would it be okay if I asked you some questions about your urinary symptoms?"
• Acknowledge that some questions may be personal: "Some of the questions involve sexual and genital symptoms because other conditions can sometimes feel very similar to a urine infection"
• Establish whether the patient appears acutely unwell, confused, dehydrated or in severe pain

2. ❓ Presenting Complaint

• Begin openly:
  • "What brought you in today?"
  • "Can you tell me what urinary symptoms you've been experiencing?"
• Establish whether this is:
  • A first episode
  • A recurrent problem
  • A recurrence shortly after recent treatment
  • A change in longstanding urinary symptoms
• If the patient says…	You should consider…
  "It burns when I pass urine"	Lower UTI, but also consider urethritis, STI or vulvovaginal irritation
  "I'm going much more often than normal"	Lower UTI, but consider diabetes, overactive bladder and other urinary causes
  "I've suddenly started getting up at night to urinate"	New nocturia can support a diagnosis of lower UTI
  "My urine looks cloudy"	Can support lower UTI when accompanied by urinary symptoms
  "I've got pain in my side and feel feverish"	Pyelonephritis / upper UTI
  "There's blood in my urine"	UTI is possible, but stones and urological malignancy must also be considered
  "I have discharge as well as burning"	Consider STI, urethritis or vulvovaginal infection rather than assuming UTI
  "I feel like I can't empty my bladder properly"	Urinary retention, obstruction, prostate disease or neurogenic bladder

3. 🩺 History of Presenting Complaint

• Onset: "When did the symptoms first start?"
• Dysuria: "Does it sting or burn when you pass urine?"
  Dysuria is one of the key symptoms supporting lower UTI, but it can also occur with urethritis, STI, genital irritation and genitourinary syndrome of menopause.

• Frequency: "Are you passing urine more frequently than usual?"
• Urgency: "Do you suddenly feel that you need to get to the toilet urgently?"
• Nocturia: "Are you waking during the night to pass urine more than you normally would?"
  New nocturia is one of the key symptoms used when assessing suspected uncomplicated UTI in women under 65.

• Urine appearance: "Have you noticed that the urine looks cloudy or different from usual?"
  Cloudy urine may support the diagnosis when accompanied by urinary symptoms. Smell alone is not sufficient to diagnose a UTI.

• Suprapubic pain: "Do you have any discomfort or pressure low down in your abdomen?"
• Haematuria: "Have you noticed any blood in your urine?"
  • Visible or only found on testing?
  • Blood throughout the stream?
  • Clots?
  • Has it happened before?
  Haematuria can accompany UTI but should not automatically be attributed to infection, particularly if it persists or recurs after successful treatment.

• Incomplete emptying: "Does your bladder feel empty after you've passed urine?"
• Urinary stream:
  • Weak stream?
  • Hesitancy?
  • Intermittent flow?
  • Straining?
  Obstructive symptoms may indicate bladder outflow obstruction or prostate disease and increase the possibility of a complicated infection.

• Progression: "Are the symptoms getting better, getting worse or staying about the same?"
• Previous treatment: "Have you taken anything for this already, including antibiotics?"

4. 🌡️ Screen for Upper UTI / Pyelonephritis

• Flank or loin pain: "Do you have pain in your back or side underneath your ribs?"
  Kidney or flank pain alongside urinary symptoms raises concern for upper urinary tract infection.

• Fever: "Have you felt feverish or measured a temperature?"
• Rigors: "Have you had episodes of uncontrollable shaking or chills?"
• Nausea or vomiting: "Have you felt sick or been vomiting?"
• Systemic illness: "Do you feel generally very unwell compared with a normal urine infection?"

5. 🔍 Exclude Other Genitourinary Causes

• Vaginal symptoms where relevant:
  • Vaginal discharge
  • Vaginal irritation
  • Itching
  • Abnormal vaginal bleeding
  • Dyspareunia
  • Pelvic pain
  Vaginal discharge makes uncomplicated UTI less likely and should prompt consideration of vaginitis, cervicitis or STI.

• Urethral discharge: "Have you noticed any discharge from the urethra?"
  Urethral discharge with dysuria should raise suspicion of urethritis or an STI.

• Genital lesions: ask about ulcers, blisters, sores or new genital skin changes
• Pelvic pain: "Do you have any lower abdominal or pelvic pain?"
• Renal colic symptoms:
  • Sudden severe flank pain?
  • Pain radiating towards the groin?
  • Unable to keep still?
  • Visible haematuria?
  Colicky flank-to-groin pain with haematuria should raise suspicion of a urinary tract stone rather than uncomplicated cystitis.

6. ♂️ Prostate Symptoms Where Relevant

• Ask about:
  • Perineal pain
  • Pelvic pain
  • Rectal discomfort
  • Penile pain
  • Painful ejaculation
  • Difficulty passing urine
  • Urinary retention
  • Fever or rigors
  Urinary symptoms with fever, pelvic or perineal pain and obstructive symptoms should raise suspicion of acute prostatitis rather than an isolated lower UTI.

7. 🤰 Pregnancy & Relevant Gynaecological History

• Pregnancy possibility: "Is there any possibility you could be pregnant?"
• If relevant, establish:
  • Last menstrual period
  • Known pregnancy
  • Gestation
  • Any vaginal bleeding
  • Pelvic or abdominal pain
  Pregnancy changes UTI management because of the increased risk of complications. A urine culture is important when UTI is suspected during pregnancy.

• Postmenopausal symptoms:
  • Vaginal dryness
  • Burning
  • Dyspareunia
  • Recurrent urinary symptoms
  Genitourinary syndrome of menopause can cause dysuria, urgency and recurrent urinary symptoms that may mimic UTI.

8. 🔁 Previous & Recurrent UTI History

• "Have you had urine infections before?"
• Establish:
  • How many episodes?
  • When was the last episode?
  • Were cultures positive?
  • Which antibiotics were used?
  • Did symptoms completely resolve?
  • Any known resistant organisms?
• Recurrent UTI: ask whether there have been:
  • 2 or more episodes within 6 months, or
  • 3 or more episodes within 12 months
  This meets the usual definition of recurrent UTI and changes the assessment and longer-term management approach.

• Possible triggers:
  • Sexual intercourse
  • New sexual partner
  • Spermicide use
  • Menopause
  • Incomplete bladder emptying
  • Urinary catheterisation

9. ⚠️ Complicated UTI Risk Factors

• Pregnancy
• Male urinary tract
• Urinary catheter
• Known urinary obstruction
• Urinary retention
• Renal or ureteric stones
• Neurogenic bladder
• Structural urinary tract abnormality
• Recent urinary tract instrumentation
• Diabetes
• Renal impairment
• Immunosuppression
• Previous multidrug-resistant organism
• Recent hospital admission
• These factors increase the likelihood of treatment failure or more serious infection and may change investigation, antibiotic choice and follow-up.

10. 🚩 UTI Red Flag Screen

11. 🧠 Recognising Common Urinary Patterns

12. 📋 Past Medical History

• Previous UTIs or pyelonephritis
• Kidney or ureteric stones
• Previous urinary retention
• Prostate disease
• Urinary tract abnormalities
• Previous urological surgery
• Urinary catheter use
• Diabetes
• Chronic kidney disease
• Neurological disease affecting bladder function
• Immunosuppression
• Previous STI
• Previous urological malignancy

13. 💊 Drug History & Allergies

• "What medications are you currently taking, including anything you've bought yourself?"
• Ask about:
  • Recent antibiotics
  • Previous antibiotics used for UTIs
  • Immunosuppressive medication
  • Diabetes medication
  • Medicines affecting urinary flow where relevant
• Previous antibiotic resistance: "Have you ever been told that a urine infection was resistant to certain antibiotics?"
• Allergies: establish the drug and the exact reaction

14. 👨‍👩‍👧‍👦 Family History

• Recurrent kidney stones
• Polycystic kidney disease where relevant
• Significant renal disease
• Urological malignancy

15. 🏠 Social & Sexual History

• Fluid intake: "Roughly how much do you drink during a normal day?"
• Smoking: current or previous
  Smoking history is particularly relevant when assessing unexplained or persistent haematuria because of its association with urological malignancy.

• Alcohol: amount and frequency
• Sexual history where clinically relevant:
  • Sexually active?
  • New sexual partner?
  • Unprotected intercourse?
  • Previous STI?
  • Current genital or urethral discharge?
  A sexual history is particularly important when dysuria occurs with discharge, genital symptoms or a new sexual exposure.

• Contraception where relevant: particularly spermicide use
• Occupation and daily impact: assess whether symptoms are affecting sleep, work and normal activities

16. 💬 ICE - Ideas, Concerns & Expectations

• "Do you have any thoughts about what might be causing these symptoms?"
• "Is there anything in particular you're worried this could be?"
• "What were you hoping we could help you with today?"

17. 🧾 Summarise & Explain Next Steps

"So, you've had (duration) of urinary symptoms including (dysuria/frequency/urgency/nocturia). You have also noticed (associated symptoms), with no (fever/flank pain/vomiting or other red flags). This is your (first/recurrent) episode, and relevant background includes (PMH, pregnancy status, recent antibiotics or resistance history)".

"I'd like to check your observations and examine you where appropriate. Whether we need a urine test or culture will depend on your symptoms, age, pregnancy status, previous infections and whether there are any signs of a more complicated infection".

18. 🔬 Investigations – Think Targeted

• Women under 65 with uncomplicated symptoms: symptoms themselves can provide useful diagnostic information.
• Three particularly useful symptoms:
  • Dysuria
  • New nocturia
  • Cloudy urine
  In women under 65, two or more of these symptoms make UTI more likely. With only one key symptom, a urine dipstick can help increase diagnostic certainty.

• Urine dipstick: when appropriate, assess nitrites, leukocytes and blood in the context of the clinical history.
• Adults aged 65 and over: do not routinely use urine dipsticks to diagnose UTI.
  Asymptomatic bacteriuria becomes increasingly common with age, making positive dipsticks less reliable. Diagnose using appropriate urinary and systemic clinical features instead.

• Men with suspected UTI: obtain a midstream urine sample for culture before antibiotic treatment where possible.
• Pregnancy: send a midstream urine sample for culture before antibiotic treatment where possible.
• Suspected pyelonephritis: obtain urine for culture before antibiotics where possible, but do not delay treatment in an unwell patient.
• Recurrent or resistant infection: urine culture is particularly important to identify the organism and sensitivities.
• STI suspected: arrange appropriate chlamydia, gonorrhoea or other STI testing depending on the history.
• Pregnancy test: where pregnancy is possible and this will alter management.
• Renal function: consider U&E and eGFR in complicated infection, renal impairment, significant systemic illness or where renal function will influence management.
• Blood tests: consider FBC, CRP and renal function where pyelonephritis, sepsis or significant systemic illness is suspected.
• Imaging: not routinely required for straightforward lower UTI. Consider imaging where obstruction, stones, structural abnormality, recurrent complicated infection or another urological pathology is suspected.
• Do not treat asymptomatic bacteriuria routinely in non-pregnant adults simply because bacteria are present in the urine.
  Pregnancy is an important exception because asymptomatic bacteriuria during pregnancy is treated due to the increased risk of complications.

19. 👴 UTI in Older Adults - Important Pitfall

• Do not diagnose a UTI simply because an older patient:
  • Is confused
  • Has smelly urine
  • Has cloudy urine
  • Has a positive urine dipstick
• Look for new local urinary symptoms such as:
  • Dysuria
  • Urgency
  • New urinary incontinence
• Assess for systemic infection:
  • Fever or low temperature
  • Rigors
  • Haemodynamic instability
  • New significant deterioration
• Older adults commonly have bacteria in the urine without infection. Consider other causes of delirium or deterioration rather than automatically attributing symptoms to UTI.

🎓 Present Back to Examiner (PA Format)

"This is a (age)-year-old (man/woman) presenting with a (duration) history of urinary symptoms including (dysuria, frequency, urgency or nocturia). Associated features include (relevant positives), with no (flank pain, fever, rigors, vomiting or other important red flags). This is their (first/recurrent) episode and relevant background includes (pregnancy status, PMH, urinary abnormalities, recent antibiotics and previous culture results). My leading differential is lower UTI, with (pyelonephritis/STI/urethritis/renal stone/prostatitis or other diagnosis) also considered. I would check observations, perform a focused abdominal and urinary examination and arrange urine testing or further investigation according to the clinical presentation".

📚 Key References

• UKHSA and NHS England – Diagnosis of urinary tract infections: quick reference tools for primary care. Updated 2025.
• NICE NG109 - Urinary tract infection (lower): antimicrobial prescribing.
• NICE NG111 - Pyelonephritis (acute): antimicrobial prescribing.
• NICE NG112 - Urinary tract infection (recurrent): antimicrobial prescribing.
• NICE NG12 - Suspected cancer: recognition and referral. Updated 2026.