Get 25 Genitourinary questions straight from The Final Step.
Podcast: Play in new window | Download
Urethritis
- Inflammation or infection of the urethra, usually from a sexually transmitted infection (STI).
- Most common pathogens: Chlamydia trachomatis and Neisseria gonorrhoeae.
- Can also result from chemical irritation or catheter use.
Risk Factors
- Multiple or new sexual partners
- Unprotected intercourse
- Prior STI history
- Men under 35 years old
Clinical Presentation
- Dysuria, burning, or itching at urethral meatus
- Urethral discharge:
- Clear or mucoid → Chlamydia
- Thick yellow-green → Gonorrhea
- Urethral redness or irritation
- The question stem would likely describe a young sexually active man with dysuria and discharge after unprotected sex.
Diagnostics
- NAAT (nucleic acid amplification test): Urethral swab or first-catch urine → most sensitive for Chlamydia and Gonorrhea.
- Urinalysis: Pyuria without bacteriuria (“sterile pyuria”) — WBCs in urine but no bacterial growth due to intracellular organisms like Chlamydia.
- Consider Trichomonas vaginalis or Mycoplasma genitalium if persistent symptoms.
- Screen for HIV and syphilis.
Treatment
- Empiric therapy for both C. trachomatis and N. gonorrhoeae:
- Ceftriaxone 500 mg IM single dose
- plus Doxycycline 100 mg PO twice daily for 7 days
- If doxycycline contraindicated → Azithromycin 1 g PO single dose
- Treat all sexual partners.
- Abstain from sexual activity for 7 days after treatment.
- Retest at 3 months due to high reinfection rate.
Exam Keys
- Dysuria + urethral discharge = Urethritis (STI until proven otherwise).
- Gonorrhea: Purulent yellow-green discharge.
- Chlamydia: Clear or mucoid discharge.
- Sterile pyuria: WBCs present but no bacterial growth → Chlamydia.
- Always treat both pathogens empirically.
Urinary Tract Infection (Cystitis)
- Infection of the bladder (lower urinary tract) most often caused by Escherichia coli.
- Common in women due to short urethra and proximity to anus.
- Classified as uncomplicated (healthy, nonpregnant women) or complicated (men, pregnancy, diabetes, obstruction, catheters).
Risk Factors
- Female sex, sexual activity, diaphragm or spermicide use.
- Postmenopausal estrogen loss, pregnancy, diabetes.
- Indwelling catheters or urinary obstruction (BPH, stones).
Clinical Presentation
- Dysuria, frequency, urgency, suprapubic pain, hematuria, cloudy urine.
- No systemic symptoms (no fever, chills, or flank pain).
- If fever or costovertebral tenderness → think pyelonephritis.
- The question stem would likely describe a young woman with burning urination, frequency, and no fever.
Diagnostics
- Urinalysis: Pyuria, positive leukocyte esterase, and nitrites (Gram-negative organisms).
- Urine culture: >100,000 CFU/mL of a single organism confirms diagnosis.
- Urine dipstick: Often sufficient in uncomplicated cases.
- Men or recurrent infections: Consider ultrasound to assess for obstruction or stones.
Treatment
- Uncomplicated: Nitrofurantoin, Trimethoprim-Sulfamethoxazole (TMP-SMX), or Fosfomycin.
- Pregnancy: Amoxicillin-clavulanate or nitrofurantoin (avoid TMP-SMX near term).
- Complicated or male patients: Fluoroquinolones (ciprofloxacin, levofloxacin).
- Encourage hydration and frequent voiding.
- Asymptomatic bacteriuria: Treat only in pregnancy, before urologic procedures, or within 3 months of renal transplant.
Exam Keys
- Dysuria + frequency + no fever = Cystitis.
- Fever or flank pain = Pyelonephritis.
- Positive nitrites = E. coli.
- Men or recurrent infections → evaluate for obstruction or stones.
Pyelonephritis
- Infection of the kidney and renal pelvis caused by ascending bacteria from the bladder.
- Most common pathogen: Escherichia coli.
- Represents an upper urinary tract infection (UTI).
Risk Factors
- Female sex, pregnancy, recurrent cystitis.
- Urinary obstruction (stones, BPH), vesicoureteral reflux.
- Diabetes, neurogenic bladder, indwelling catheters, immunocompromise.
Clinical Presentation
- Fever, chills, flank pain, and CVA tenderness (hallmark triad).
- Dysuria, urgency, and frequency.
- Nausea, vomiting, and malaise in moderate to severe cases.
- Older adults may present atypically with confusion or weakness.
- The question stem would likely describe a febrile patient with flank pain, CVA tenderness, and urinary symptoms.
Diagnostics
- Urinalysis: Pyuria, positive leukocyte esterase, positive nitrites, and WBC casts (upper tract finding).
- Urine culture: Confirms organism and guides therapy.
- CBC: Leukocytosis with left shift.
- Imaging (CT or renal ultrasound): Only if complicated infection, suspected obstruction, stones, or no improvement after 48–72 hours.
Treatment
- Outpatient (mild, stable): Oral fluoroquinolone (ciprofloxacin or levofloxacin) for 5–14 days.
- Inpatient (severe, vomiting, pregnant, or complicated): IV ceftriaxone, fluoroquinolone, or piperacillin–tazobactam.
- Switch to oral when afebrile and tolerating PO.
- Encourage hydration and follow-up urine culture after completion.
Exam Keys
- Fever + flank pain + WBC casts = Pyelonephritis.
- Cystitis = dysuria/urgency without fever or flank pain.
- WBC casts confirm upper tract involvement.
- Most common pathogen = E. coli.
- Hospitalize if pregnant, vomiting, or septic.
Epididymitis
- Inflammation or infection of the epididymis, usually unilateral.
- Caused by retrograde bacterial spread from the urethra or bladder.
- Most common cause of scrotal pain in adult men.
Risk Factors
- Sexually active men <35 → Chlamydia trachomatis or Neisseria gonorrhoeae.
- Men >35 or with urinary obstruction → E. coli or other coliform bacteria.
Clinical Presentation
- Gradual onset of scrotal pain and swelling (vs. torsion = sudden).
- Pain localized posteriorly to the testis (epididymis).
- Scrotal erythema and warmth; possible hydrocele.
- Fever and dysuria may occur.
- Positive Prehn sign: Pain relief with scrotal elevation.
- Cremasteric reflex preserved (absent in torsion).
- The question stem would likely describe a young man with dysuria and gradual testicular pain, improved with elevation.
Diagnostics
- Urinalysis: Pyuria and bacteriuria possible.
- NAAT: Detect C. trachomatis and N. gonorrhoeae in younger men.
- Scrotal ultrasound: Enlarged, hypervascular epididymis with increased blood flow (rules out torsion).
- Urine culture: For older men or suspected coliform infection.
Treatment
- Men <35 (STI-related):
- Ceftriaxone 500 mg IM single dose plus Doxycycline 100 mg PO twice daily for 7 days.
- Men >35 or urinary obstruction:
- Levofloxacin 500 mg PO daily for 10 days (covers E. coli).
- Scrotal elevation, NSAIDs, and rest for symptom relief.
- Treat sexual partners and screen for STIs when appropriate.
Exam Keys
- Gradual unilateral scrotal pain + Prehn sign + intact cremasteric reflex = Epididymitis.
- Sudden severe pain + absent reflex = Testicular torsion.
- <35 years: STI pathogens (Chlamydia, Gonorrhea).
- >35 years: E. coli or urinary pathogens.
- Always rule out torsion first.
Orchitis
- Inflammation or infection of the testis, often associated with epididymitis (epididymo-orchitis).
- Most common cause: viral (especially mumps).
- May also result from bacterial infection, usually secondary to epididymitis.
Risk Factors
- Postpubertal males with recent mumps infection (unvaccinated).
- Extension from epididymitis (bacterial cause).
- Sexually active men, urinary tract obstruction, or indwelling catheter.
Clinical Presentation
- Unilateral testicular pain and swelling.
- Testicular tenderness, erythema, and warmth.
- May follow parotitis by 4–7 days if due to mumps.
- Fever, malaise, and fatigue may occur.
- The question stem would likely describe a postpubertal male with recent parotitis who now has unilateral testicular pain and swelling.
Diagnostics
- Clinical diagnosis in classic mumps cases.
- Urinalysis and culture: If bacterial cause suspected.
- Ultrasound with Doppler: Increased blood flow differentiates from torsion.
- Mumps serology if uncertain or unvaccinated.
Treatment
- Viral (mumps): Supportive care — rest, scrotal elevation, NSAIDs, and ice packs.
- Bacterial: Treat same as epididymitis.
- Ceftriaxone 500 mg IM single dose plus Doxycycline 100 mg PO twice daily for 7 days (<35 years, STI-related).
- Levofloxacin 500 mg PO daily for 10 days (>35 years or urinary pathogens).
- Analgesics and supportive care for pain and swelling.
Exam Keys
- Unilateral testicular pain and swelling after mumps = Orchitis.
- Viral = supportive care; bacterial = antibiotics.
- Rule out torsion with ultrasound in any acute scrotal pain.
Prostatitis
- Inflammation or infection of the prostate gland.
- May be acute or chronic and either bacterial or nonbacterial.
- Most common urologic diagnosis in men under 50.
Types
- Acute bacterial: E. coli most common.
- Chronic bacterial: Recurrent infection by the same organism.
- Chronic pelvic pain syndrome (nonbacterial): Most common overall; culture negative.
Risk Factors
- Urinary tract infection or instrumentation (catheterization, cystoscopy).
- BPH causing obstruction.
- Unprotected intercourse or history of STIs.
- Dehydration or prolonged sitting (e.g., cycling).
Clinical Presentation
- Acute bacterial:
- Fever, chills, malaise.
- Dysuria, frequency, urgency, perineal or low back pain.
- Tender, warm, “boggy” prostate on exam (avoid vigorous massage).
- Chronic bacterial:
- Recurrent UTIs with the same organism.
- Dull perineal discomfort, irritative voiding symptoms.
- Often afebrile.
- Chronic pelvic pain syndrome:
- Perineal pain and voiding symptoms for ≥3 months; cultures negative.
- The question stem would likely describe a man with fever, dysuria, and a tender prostate on exam.
Diagnostics
- Urinalysis and culture: Pyuria and bacteriuria in bacterial types.
- Prostatic massage: Contraindicated in acute prostatitis (may cause bacteremia).
- Post-massage urine or expressed prostatic secretions: Helpful in chronic bacterial cases.
- CBC: Leukocytosis in acute cases.
- PSA: Often elevated during infection — do not screen during acute phase.
Treatment
- Acute bacterial:
- Ciprofloxacin or TMP-SMX for 4–6 weeks.
- Hospitalize and start IV antibiotics (e.g., ceftriaxone, fluoroquinolone) if severe or septic.
- Avoid prostatic massage.
- Chronic bacterial:
- Fluoroquinolone or TMP-SMX for 6–12 weeks.
- May require suppressive low-dose antibiotics.
- Chronic pelvic pain syndrome:
- Alpha-blockers (tamsulosin), anti-inflammatories, warm baths, and pelvic floor therapy.
- Encourage hydration and stool softeners to reduce straining.
Exam Keys
- Fever + dysuria + tender “boggy” prostate = Acute bacterial prostatitis.
- Recurrent UTIs, dull pain, afebrile = Chronic bacterial prostatitis.
- Pain ≥3 months, negative culture = Chronic pelvic pain syndrome.
- Avoid prostatic massage in acute cases (risk of sepsis).
- E. coli is the most common bacterial cause.
Fournier Gangrene
- Necrotizing fasciitis of the perineum and genital region, rapidly progressive and life-threatening.
- Polymicrobial infection involving both aerobic and anaerobic bacteria.
- Most commonly affects men with diabetes, immunosuppression, or recent perineal trauma.
Risk Factors
- Diabetes mellitus (most common).
- Alcoholism, obesity, immunocompromise.
- Recent perineal, genital, or rectal surgery or trauma.
- Urethral stricture, indwelling catheter, or perirectal infection.
Clinical Presentation
- Rapidly progressing pain, swelling, and erythema of the scrotum, perineum, or lower abdomen.
- Pain out of proportion to physical findings is an early clue.
- Skin discoloration, crepitus (gas under the skin), and foul-smelling necrosis as infection advances.
- May develop fever, tachycardia, hypotension, or sepsis.
- The question stem would likely describe a diabetic male with severe perineal pain, swelling, and crepitus.
Diagnostics
- Clinical diagnosis — do not delay treatment for imaging.
- CT scan: May show subcutaneous gas, fascial thickening, or fluid tracking along fascial planes.
- Labs: Leukocytosis, elevated CRP, possible metabolic acidosis or acute kidney injury (AKI).
- Blood and wound cultures to guide antibiotic therapy.
Treatment
- Emergency surgical debridement — cornerstone of management; multiple surgeries often required.
- Broad-spectrum IV antibiotics:
- Carbapenem or piperacillin–tazobactam plus clindamycin (to inhibit toxin production) plus vancomycin (for MRSA coverage).
- Aggressive IV fluids and hemodynamic support.
- Tight glycemic control.
- Hyperbaric oxygen therapy may be considered as an adjunct.
Exam Keys
- Diabetic male + perineal pain + crepitus = Fournier gangrene.
- Pain out of proportion is the classic early sign.
- Immediate surgical debridement + broad-spectrum antibiotics are lifesaving.
- Do not delay surgery for imaging.
- High mortality without prompt recognition and intervention.
Full Transcript (click to expand)
Hello and welcome to the Physician Assistant Exam Review Podcast. This is episode 144. We’re going to continue GU with infectious disease. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review, where we have been reviewing medical content for PA students, MD students, pharmacy students, NP students for the past almost 15 years now. It’s crazy. This week, we’re going to be talking about specifically the genitourinary system and infectious disease that relates to the genitourinary system.
And we’re going to be moving through that topic. But I want you to always understand that that’s not our sole focus here. Our focus is the entire learner, the entire test taker. So we do cover medical content. But our other focus is advanced learning strategies, test taking techniques, peak performance, especially as it relates to anxiety and going into your exams. That’s really what we tend to focus on here.
All right. As we move through November, this is going to be this is episode 144. At the very beginning of November, I’m wrapping. We’re getting about halfway through the November cohort of 33 Days to Pass the PANCE are absolutely rocking it. It’s a ton of fun. We’re working on going through questions right now and how that’s going to work, which is so much fun. And to see the development of the students as we move through this practice.
If you want a small taste of what we do, I’m going to be putting together a PA student reboot package for Black Friday is what I decided on. I’m putting it together now. I’ve been slowly working on it. Really excited about how it’s coming together. It is going to cover the things we talk about, learning strategies, test taking techniques and peak performance in a way that you’re going to be able to implement right away. That’s really the goal here. So not to take any extra time out of your day, not to add anything to your day, but just to give you something that you can really focus on to improve what you’re doing.
Now, you can, there’s no way to get information on it right now because I’m not done putting it together yet. But when it is available, the first people who are going to hear about it are those on the email list. You can get on that by going to physicianassistantexamreview.com/daily, D-A-I-L-Y, because you get information from me on a daily basis there. Tips, tricks, philosophies, questions, promotions, all sorts of stuff comes out on a regular basis for students who are in there.
All right, so let’s jump in to our discussion of the GU system and our infectious disease. We’ll start with our priming questions. What’s the most likely cause of fever, flank pain, and white blood cell casts? Some of these may seem like low-hanging fruit and easy for some of you guys. Hopefully, they all will be by the time we finish. What’s the most likely cause of fever, flank pain, and white blood cell casts? What diagnosis should you suspect in a man with dysuria and urethral discharge, but sterile urine?
What diagnosis should you suspect in a man with dysuria, urethral discharge, but sterile urine? Which condition presents with a tender, warm, boggy prostate and fever? What life-threatening infection causes perineal pain, crepitus, and skin necrosis in a diabetic male? What life-threatening infection causes perineal pain, crepitus, and skin necrosis in a diabetic male? We’re going to begin with urethritis. So we’re going to go through UTIs first, which is going to be urethritis, cystitis, and pyelonephritis. They’re all urinary tract infections.
Urethritis and cystitis are considered lower urinary tract infections, and pyelonephritis is considered an upper urinary tract infection. But when we say UTI, it’s just kind of an all-encompassing idea. Urethritis is an inflammation or infection of the urethra, usually from an STI. The most common pathogens, do you know what they are? Guesses at the most common pathogens? Chlamydia and Neisseria gonorrhea. You can also get chemical irritations or catheter use can cause urethritis.
Risk factors. Multiple or new sexual partners, unprotected intercourse, prior STI history, and men under 35 years of age. Again, to me, don’t memorize this list. Understand how it gets built and why it’s there. Clinical presentation. Dysuria, burning or itching at urethral meatus, urethral discharge. So this is a way you can tell these things apart a little bit, at least in an exam.
I don’t work in the ER or in the clinic, so I haven’t experienced these to tell you how valuable they are in the clinic, but I can tell you on the exam you may see them. A clear mucoid discharge generally makes you think chlamydia. A thick yellow green discharge makes you think gonorrhea. You can also get urethral redness or irritation. So, the question stem here, what it’s going to look like, what it’s going to present to you, is likely going to be a young, sexually active man with dysuria and discharge after unprotected sex. Something like that. Maybe not all those pieces, but you get the idea.
Diagnostics, you’re going to do a urethral swab or first catch urine. It’s the best test for chlamydia and gonorrhea. You’re going to do urinalysis.
Now, you can get a sterile pyuria, which is no bacteria, but there are white blood cells present. This is usually chlamydia because it’s an intracellular organism, right? You’re also going to think about trichomonas and mycoplasma if persistent symptoms, if things drag on. You’re going to screen for HIV and syphilis, and you’re going to begin empiric therapy because this is most likely chlamydia or gonorrhea. So we can start with ceftriaxone, 500 milligrams. A single IM dose will do. Or I’m sorry, in addition to that, doxycycline, 100 milligrams PO twice daily for seven days.
Now, generally speaking, I’m not a big fan of spending time on the, for treatments, the dosages and the timeframes. I think it’s, generally speaking, for most students, it takes a lot of effort to retain that kind of stuff. It’s something you can easily look up later when you need it. So to me, this isn’t a place to spend a ton of time, except in this case. There are a handful of cases across the blueprint where it really makes sense, and this is one of those. Ceftriaxone, 500 milligrams, single IM dose, add doxycycline, 100 milligrams, PO twice daily for seven days. If they can’t take doxycycline, you can add azithromycin, one gram PO, single dose.
I think that’s useful. You’re also going to want to treat sexual partners here, avoid sex for seven days after treatment. I think that’s reasonable. Then retest after three months due to high reinfection rate.
Exam keys. So this is where we talk a little bit about how this looks on your test. We break it down really tight. So here we have dysuria plus discharge equals urethritis. It’s an STI until proven otherwise. So when I do these exam keys, it doesn’t mean it’s 100% accurate. It means what’s going to get us most of the way to the right answer most of the time.
That’s the goal here. Not a 100, not perfect. Most of the way with the least amount of work. That’s what these exam keys are for. So, purulent yellow green discharge, think gonorrhea. Clear mucoid discharge, think chlamydia. Sterile pyuria, think chlamydia.
And then make sure you’re covering both organisms empirically. Then we’re going to move on to cystitis. Cystitis is just an infection of the bladder, so this is a lower urinary tract infection. Generally, what’s the most common cause here? Take a minute and think. E. Coli.
It’s more common in women due to short urethra and proximity to the anus, and it may be secondary to urinary stasis, catheter use, or poor hygiene. Risk factors are female, sexually active, pregnancy, diabetes, indwelling catheter. Catheters, right, obviously are pathways for infection. Urinary obstruction, like BPH or stones. Clinical presentation here. Most people are pretty clear on what a cystitis might look like. Dysuria, frequency, urgency, suprapubic pain.
You can get hematuria and cloudy or foul-smelling urine. Definitely see that in patients on the floor. No systemic symptoms here. So you’re not really getting fever, chills, or flank pain. If those are present, you’re going to be thinking more like a pyelonephritis, which we’re going to get to in a second. Here, the stem is going to say something like a young woman with burning with urination frequency, but without a fever or anything else going on. For diagnosis, urinalysis.
You can get pyuria. Urine culture, looking for that organism. Urine dipstick might be sufficient. And in men with recurrent infections, you’re going to want to look for an ultrasound to evaluate for obstruction or stones. Or something else going on here.
Get 25 Genitourinary questions straight from The Final Step.
