History Taking · Foundation · Urology

Lower Urinary Symptoms in Pregnancy

Practise this PLAB 2 history taking station on Urinary Tract Infection in Pregnancy. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in general practice. Mrs Neha Singh, a 32-year-old woman who is 24 weeks pregnant, has come to see you with dysuria and frequency for the past three days. Please take a focused history and discuss safe management options during pregnancy.

Background notes: PMH: no renal disease, nulliparous until current pregnancy (24 weeks gestation)

What this station tests

  • Mandatory urine culture in pregnancy: unlike non-pregnant women, MSU must be sent before starting empirical antibiotics
  • Pregnancy-safe antibiotics: nitrofurantoin (avoid near term), amoxicillin, cefalexin. No fluoroquinolones, trimethoprim caution in first trimester
  • Test of cure: repeat MSU after completing antibiotics to confirm clearance, mandatory in pregnancy
  • Pyelonephritis risk: untreated bacteriuria progresses to pyelonephritis in 20 to 40% of pregnant women
  • Reassuring about fetal safety: antibiotics chosen are safe for the baby, treating is safer than not treating

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

UTI in pregnancy is always treated urgently because untreated bacteriuria progresses to pyelonephritis in 20 to 40% of pregnant women, risking preterm labour and adverse fetal outcomes. The candidate must choose pregnancy-safe antibiotics and send a mandatory urine culture. Mrs Singh is 32, 24 weeks pregnant with her first child, presenting with 3 days of dysuria and frequency. She is anxious about the baby. Open with: 'Mrs Singh, tell me about the symptoms, and I want to reassure you that we take this seriously in pregnancy and can treat it safely.'

Core approach

Confirm cystitis and exclude upper tract infection. Dysuria, frequency, urgency, suprapubic discomfort. No fever (critical: fever suggests pyelonephritis and needs hospital referral). No flank pain. No nausea or vomiting. No vaginal bleeding or discharge. No contractions or abdominal tightening. These features confirm lower UTI without upper tract involvement.

In pregnancy, urine culture is MANDATORY (unlike non-pregnant women where it is not required for uncomplicated UTI). Send MSU before starting antibiotics. Treat empirically without waiting for results because delay risks progression.

Antibiotic choice in pregnancy: nitrofurantoin is first-line (avoid in third trimester near term due to neonatal haemolysis risk, but safe at 24 weeks). Amoxicillin if sensitivities allow. Cefalexin as alternative. Trimethoprim is avoided in the first trimester (folate antagonist) but can be used later if needed. Critically: NO fluoroquinolones (ciprofloxacin) in pregnancy (cartilage toxicity).

Address her anxiety about the baby. She has read about infections in pregnancy online and is frightened. Reassure: 'A urinary tract infection is very common in pregnancy and is easily treated with antibiotics that are safe for the baby. The important thing is treating it now to prevent it spreading to your kidneys.'

Closing and safety netting

Prescribe nitrofurantoin 100mg MR BD for 7 days (longer course in pregnancy than non-pregnant). Send MSU for culture and sensitivity. Arrange test of cure: repeat MSU 7 days after completing antibiotics to confirm clearance (this is mandatory in pregnancy, not done in non-pregnant women). Explain why: 'In pregnancy, we always check the infection has completely cleared because untreated bacteria can cause kidney infection, which is more serious.'

Safety net: 'If you develop back pain, fever, vomiting, or any contractions, go to the maternity assessment unit immediately as these could indicate the infection is spreading.' Hydration advice. Follow-up: review culture result and test of cure.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for urinary tract infection in pregnancy. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Upper tract excluded (no fever, flank pain). Obstetric symptoms checked (no contractions, no bleeding). Gestation noted (24 weeks, affects antibiotic choice). MSU sent. Pregnancy-specific risk factors assessed.

Costs marks: Not excluding upper tract. Not checking obstetric symptoms. Not noting gestation for antibiotic choice.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Pregnancy-safe antibiotic (nitrofurantoin at 24 weeks). 7-day course. MSU sent before treatment. Test of cure arranged. Pyelonephritis safety netting with maternity assessment unit instruction.

Costs marks: Wrong antibiotic (fluoroquinolone). 3-day course. No culture. No test of cure. No pyelonephritis safety net.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Reassuring about fetal safety. Explaining why treating is important (prevents pyelonephritis). Addressing her online reading anxiety. Practical, clear safety netting.

Costs marks: Not addressing baby concern. Being alarmist about pyelonephritis risk. Not reassuring about antibiotic safety.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not sending urine culture. In pregnancy, culture is mandatory. Candidates who treat empirically without sending MSU cannot check sensitivities or confirm clearance.
  2. Not arranging test of cure. Repeat MSU after treatment is mandatory in pregnancy to confirm the infection has cleared. Candidates who treat and discharge without follow-up culture miss a key pregnancy-specific requirement.
  3. Prescribing a 3-day course. Pregnancy UTI requires a 7-day course, not the 3-day course used in non-pregnant women. Candidates who prescribe 3 days demonstrate guideline unfamiliarity.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this urinary tract infection in pregnancy station?

UTI in pregnancy is always treated urgently because untreated bacteriuria progresses to pyelonephritis in 20 to 40% of pregnant women, risking preterm labour and adverse fetal outcomes. The candidate must choose pregnancy-safe antibiotics and send a mandatory urine culture. Mrs Singh is 32, 24 weeks pregnant with her first child, presenting with 3 days of dysuria and frequency.

What does a strong performance look like to the examiner in this station?

Strong performances show: Upper tract excluded (no fever, flank pain). Obstetric symptoms checked (no contractions, no bleeding). Gestation noted (24 weeks, affects antibiotic choice). Weak performances: Not excluding upper tract. Not checking obstetric symptoms. Not noting gestation for antibiotic choice.

What is the biggest pitfall in this urinary tract infection in pregnancy station?

Not sending urine culture. In pregnancy, culture is mandatory. Candidates who treat empirically without sending MSU cannot check sensitivities or confirm clearance.

How should I prepare for urinary tract infection in pregnancy if I have never seen it in practice?

Structure beats experience here. Focus on pregnancy-safe antibiotics: nitrofurantoin (avoid near term), amoxicillin, cefalexin. No fluoroquinolones, trimethoprim caution in first trimester. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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