MET3 Revision: Urology III

Question 1

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

Question 2

A 34-year-old female presents to her General Practitioner after noticing sudden-onset hair growth, particularly in the facial region. She is becoming increasingly embarrassed by this. She is keen to have the problem sorted. Blood tests were performed, with the only abnormality being a testosterone level of 10.4 nmol/l l (reference range 0.8–3.1 nmol/l).

What is the next step in her management? [1]

Answer 2

A 34-year-old female presents to her General Practitioner after noticing sudden-onset hair growth, particularly in the facial region. She is becoming increasingly embarrassed by this. She is keen to have the problem sorted. Blood tests were performed, with the only abnormality being a testosterone level of 10.4 nmol/l l (reference range 0.8–3.1 nmol/l).

Refer to Endocrinology as a suspected cancer referral

This patient’s history of sudden-onset hair growth and her raised testosterone level necessitates an urgent referral for suspected malignancy.

Question 3

A 38-year-old male arrives at the Emergency Department complaining of intense left flank pain that extends to the groin area. The presence of blood in the urine, as indicated by urinalysis, raises suspicion of a renal stone. An ultrasound scan of the kidneys, ureters, and bladder (KUB) reveals a likely stone in the left ureter.

What is the most appropriate imaging modality to visualise a ureteric renal stone?

Non-contrast computed tomography (CT) KUB

Micturating cystourethrogram

Magnetic resonance imaging (MRI) KUB

Plain radiography KUB

Intravenous urography (IVU)

Answer 3

A 38-year-old male arrives at the Emergency Department complaining of intense left flank pain that extends to the groin area. The presence of blood in the urine, as indicated by urinalysis, raises suspicion of a renal stone. An ultrasound scan of the kidneys, ureters, and bladder (KUB) reveals a likely stone in the left ureter.

What is the most appropriate imaging modality to visualise a ureteric renal stone?

Non-contrast computed tomography (CT) KUB

Micturating cystourethrogram

Magnetic resonance imaging (MRI) KUB

Plain radiography KUB

Intravenous urography (IVU)

Question 4

A 30-year-old male has a right inguinal mass. On examination, the left testis is palpated in the scrotum and is of normal size, but the right testis cannot be palpated in the scrotum. An ultrasound scan shows that the inguinal mass is consistent with a cryptorchid testis.

What is the most appropriate treatment?

Put it into the scrotum surgically (orchidopexy)

Remove it (orchidectomy)

Remove it along with the opposite testis (bilateral orchidectomy)

Start the patient on testosterone

Perform a chromosome analysis

Answer 4

A 30-year-old male has a right inguinal mass. On examination, the left testis is palpated in the scrotum and is of normal size, but the right testis cannot be palpated in the scrotum. An ultrasound scan shows that the inguinal mass is consistent with a cryptorchid testis.

What is the most appropriate treatment?

Remove it (orchidectomy)

Orchidectomy of the undescended testis is the most appropriate option since it eliminates the risk of subsequent development of seminoma

Question 5

Which of the following stone type appears as smooth, can be large and radio-opaque on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

Answer 5

Which of the following stone type appears as smooth, can be large and radio-opaque on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

Question 6

Which of the following stone type appears as smooth, brown & radiolucent on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

Answer 6

Which of the following stone type appears as smooth, brown & radiolucent on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

Question 7

Which of the following stone type appears as a spiky & radio-opaque on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

Answer 7

Which of the following stone type appears as a spiky & radio-opaque on x-ray?

Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine

Question 8

Which drug classes increase the chance of urinary tract calculi? [5]

Answer 8

allopurinol (treat gout)
loop-diuretics
antacids
acetazolamide
corticosteroids
aspirin

Question 9

What causes an increased risk of infection from urinary tract calculi? [1]

Answer 9

If voiding impaired

Question 10

How does pain present in urinary tract calculi?

How does pain presentation differ if the stone is
- Obstructing the kidney [2]
- Obstructing mid ureter [1]
- Obstructing lower ureter [2]
- Obstructing bladder or urethra [3]

Answer 10

Obstructing the kidney:
- felt in loin;
- between rib 12 and lateral edge of lumbar muscles

Obstructing mid ureter:
- mimics appendicitis / diverticulitis

Obstructing lower ureter
- may lead to symptoms of bladder iritability and pain in scrotum, penile tip or labia

Obstructing bladder or urethra:
- pelvic pain
- dysuria
- strangury

Question 11

What differential will CT-KUB help to exclude? [1]

Answer 11

Ruptured AA

Question 12

How does pain present in urinary tract calculi?

Answer 12

Excruciating pain that spreads from loin to groin that can cause nausea and vomiting in colicky fashion

Question 13

Describe the analgesic therapy offered for urinary tract calculi [1]

Answer 13

IM diclofenac
IV paracetamol 2nd line

Question 14

Describe the treatment algorithim for a patient who has a confirmed obstructed kidney stone? [2]

Answer 14

1.urgent decompression:
- ureteric stent past the obstruction and achieve drainage.
- a percutaneous nephrostomy tube can be placed by interventional radiology.

2. urgent antibiotics

Question 15

Calcium phosphate stones are commonly found in which structure? [1]

Answer 15

Bladder - found with urinary stasis

Question 16

Calcium phosphate stones are clinically associated with which 3 conditions? [3]

Answer 16

Hyperparathyroidism
Medullary Sponge Kidney (MSK)
Distal Renal Tubular Acidosis (Type 1)

Question 17

How are urate stones formed? [1]
How do they appear? [1]

Answer 17

Yellow
Acidic urine forms stones; uric acid entering urine

Question 18

Struvite stones are associated with what type of infection? [1]

Answer 18

Bacterial infection; (form when bacteria meet a surface and make urine more alkali; Mg binds and builds up): UTI

Question 19

When lasering a kidney stone is smells of egg. Which type of renal stone is this? [1]

Answer 19

Cysteine

Question 20

Describe the free theory of stone formation [4]

Answer 20

Free theory:
- Unsaturated urine increases in concentration; goes beyond the solubility product, at which point the urine becomes saturated
- Above this level, the urine is saturated but crystals are prevent from forming by inhibitors
- Above the formation product, crystals form spontaneously
- Stone formers sit at both the metastable and spontaneous regions; they have less inhibitors

Question 21

Describe the formation of stones via fixed theory [2]

Answer 21

Normally, need high energy to form crystal lattice

But, if have rough surface, e.g. from urate crystals, then energy required to form lattice is lower

Question 22

Describe how uric acid stones are formed [2]

Answer 22

Urate stones are formed from both theories:

Free theory:
- Urate has pK value of 5.4 (crystals will form when pH meets pK value); urate crystal formation is pH dependent

Fixed theory:
- Prescence of urate crystals forming acts as a nidus for stone formation

Question 23

Answer 23

Question 24

What is a Randall’s plaque? [1]

Where do they form? [1]

Answer 24

Wn attachment site over which calcium oxalate stones form, begins in the basement membranes of thin limbs of the loop of Henle.

Question 25

Label A

Answer 25

Question 26

What is a Duct of Bellini? [1] How are stones formed here? [2]

Answer 26

The duct of Bellini represents the most **distal portion of the collecting duct.** * Stones formed within the tubules * Duct of Bellini narrows * **Stones gets “stuck” at papillary surface**

Question 27

Name a stone inhibitor [1] and how it works [1]

Answer 27

**Tamm Horfshall Protein (aka uromodulin)** Bind to crystal structures and prevent from binding to renal epithelial cells

Question 28

How do you differentiate between a bowel colic and uteric colic [1]

Answer 28

**Ureteric colic pain** - usually comes and goes with a background of pain completely between bouts **Bowel colic** - pain comes and **goes**, going away completely between bouts

Question 29

State reasons why hypercalciuria [4] and hyperoxaluria [3] may be occurring and thus causing calcium stones

Answer 29

Hypercalciuria: - **Hyperparathyroidism** - **Excess Ca2+ intake** - **Increased Ca2+ gut absorption** - **Poylcystic ovaries or medullary sponge disease** Hyperoxaluria: - **High diet in oxalates** - **Low dietary Ca2+** (leading to decreased binding to oxalate) - Increased intestinal resorption (e.g **Crohns**)

Question 30

Name 3 foods high in oxalate [3]

Answer 30

spinach tea rhubarb

Question 31

Important differential diagnoses? [6]

Answer 31

AAA: older patients Bilary colic (presents more with RUQ pain) Ectopic pregnancy Pyelonephritis MI Pneumonia

Question 32

What (non-radiological) investigations would you conduct for renal stones? [3]

Answer 32

**Urine dipstick:** - 80% have **blood** - check for **infection** (nitrates; leukocytes) - **urine** **pH** (will indicate urate stones if low) **MSU** - check for microbiology culture and sensitivity **Bloods**: - **serum urea, electrolytes** - **FBC** and **CRPs** - Check **calcium** and **urate** levels

Question 33

Which radiological investigations would you conduct for renal stones? [5]

Answer 33

**1. CT-KUB - Non-contrast Computerised Tomography** - GOLD STANDARD - can measure how hard stone is (can determine treatment), position and size 2. If CT-KUB is postive; then perform **KUBXR** to look at **stone position** **3. Ultrasound:** - Shows kidney stones and renal pelvis dilatation well but ureteric stones can be missed - useful in pregnant and younger recurrent stone-formers (no radiation risk) 4. IVU (intravenous urogram) - Rarely used 5. MRI - used for pregnancy

Question 34

Which anti-emetics are prescribed for kidney stones? [3]

Answer 34

Anti-emetics to prevent vomiting: **metoclopramide, prochlorperazine or cyclizine**

Question 35

State 4 surgical interventions for kidney stones [4]

Answer 35

**Extracorporeal shock wave lithotripsy (ESWL)** **Ureteroscopy and laser lithotripsy** **Percutaneous nephrolithotomy (PCNL)** **Open surgery**

Answer 36

**Extracorporeal shock wave lithotripsy (ESWL):** * ESWL involves an **external machine that generates shock waves** and **directs them at the stone under x-ray guidance**. The shockwaves break the stone into smaller parts to make them easier to pass. **Ureteroscopy and laser lithotripsy:** * A **camera is inserted via the urethra, bladder and ureter**, and the stone is identified. It is then **broken up using targeted lasers**, making the smaller parts easier to pass. **Percutaneous nephrolithotomy (PCNL):** * PCNL is performed in theatres under a general anaesthetic. A **nephroscope** (small camera on a stick) is **inserted via a small incision at the patient’s back**. The scope is inserted through the kidney to assess the ureter. **Stones can be broken into smaller pieces and removed**. A nephrostomy tube may be left in place after the procedure to help drain the kidney. **Open surgery:** - Open surgery can be used to access the kidneys and remove the stones. This is rarely needed as other, less invasive, methods are usually effective.

Question 37

A 48-year-old women presents with recurrent loin pain and fevers. Investigation reveals a staghorn calculus of the left kidney. Infection with which of the following organisms is most likely? Staphylococcus saprophyticus Proteus mirabilis Klebsiella E-Coli Staphylococcus epidermidis

Answer 37

A 48-year-old women presents with recurrent loin pain and fevers. Investigation reveals a staghorn calculus of the left kidney. Infection with which of the following organisms is most likely? Staphylococcus saprophyticus **Proteus mirabilis** Klebsiella E-Coli Staphylococcus epidermidis Infection with Proteus mirabilis accounts for 90% of all proteus infections. It has a **urease producing enzyme**. This will tend to favor **urinary alkalinisation which is a relative per-requisite for the formation of staghorn calculi.**

Question 38

State the medical expulsive therapy that can be used for treating kidney stones [2]

Answer 38

Medical expulsive therapy: - **nifedipine** - **tamulosin** (alpha blocker)

Question 39

Describe the treatment plan for a renal stone < 10 mm that fails to pass despite initial conservative management [3]

Answer 39

Offer **shock wave lithotripsy (SWL)** Consider **ureteroscopy** if SWL is contraindicated, fails, or is not indicated because of anatomical reasons Consider **percutaneous nephrolithotomy** (PCNL) if SWL and ureteroscopy are not suitable options or have failed.

Question 40

Name two AEs of shock wave litrotripsy [2]

Answer 40

The passage of shock waves can result in the **development of solid organ injury.** Fragmentation of larger stones may result in the **development of ureteric obstruction**

Question 41

What is the first line treatment for pregnant person with stone? [1]

Answer 41

If the patient has no evidence of infection, the specialist will arrange **ureteroscopy**. Ureteroscopy has been demonstrated to be safe in pregnancy.[74]

Question 42

Describe the treatment plan for a renal stone > 20 mm [1]

Answer 42

**Percutaneous nephrolithotomy**

Question 43

A 32-year-old female with a history of Crohn’s disease presents for review with left loin pain consistent with renal colic. On examination she has a large midline abdominal scar suggestive of previous small bowel resection. Plain abdominal X-ray reveals multiple renal calculi. What type of renal calculi fit best with this clinical picture? Uric acid stones Cystine stones Calcium oxalate stones Calcium carbonate stones Magnesium carbonate stones

Answer 43

A 32-year-old female with a history of Crohn’s disease presents for review with left loin pain consistent with renal colic. On examination she has a large midline abdominal scar suggestive of previous small bowel resection. Plain abdominal X-ray reveals multiple renal calculi. What type of renal calculi fit best with this clinical picture? Uric acid stones Cystine stones **Calcium oxalate stones** Calcium carbonate stones Magnesium carbonate stones **Increased urinary oxalate may be genetic (primary oxaluria), idiopathic or enteric (either due to severe bowel inflammation and malabsorption or to extensive small bowel resection, as is the case here).**

Question 44

Namet two contraindications for shockwave lithotripsy? [2]

Answer 44

**Pregnancy** and **coagulopathy**

Question 45

Which of the following best describes *radiolucent, so they are not seen on X-ray.* [2] Uric acid stones Cystine stones Calcium oxalate stones Calcium carbonate stones Magnesium carbonate stones

Answer 45

Which of the following best describes *radiolucent, so they are not seen on X-ray.* **Uric acid stones** **Cystine stones** Calcium oxalate stones Calcium carbonate stones Magnesium carbonate stones

Question 46

Which of the following are related to urinary tract infections Uric acid stones Cystine stones Calcium oxalate stones Calcium carbonate stones Magnesium carbonate stones

Answer 46

Which of the following are related to urinary tract infections Uric acid stones Cystine stones Calcium oxalate stones Calcium carbonate stones **Magnesium carbonate stones**

Question 47

What imaging modility is first line for non-pregnant patients for suspected kidney stones? MRI XR-KUB CT-KUB US

Answer 47

What imaging modility is first line for non-pregnant patients for suspected kidney stones? MRI XR-KUB **CT-KUB** US | Pregnant: US

Question 48

What imaging modility is first line for pregnant patients for suspected kidney stones? MRI XR-KUB CT-KUB US

Answer 48

What imaging modility is first line for pregnant patients for suspected kidney stones? MRI XR-KUB CT-KUB **US**

Question 49

What is the first line treatment for pregnant person with stone? [1] Open surgery Percutaneous nephrolithotomy (PCNL) Ureteroscopy (URS) Shockwave lithotripsy (SWL)

Answer 49

What is the first line treatment for pregnant person with stone? [1] Open surgery Percutaneous nephrolithotomy (PCNL) **Ureteroscopy (URS)** Shockwave lithotripsy (SWL)

Question 50

What is the first line treatment for pregnant person with stone size of less than 2cm? Open surgery Percutaneous nephrolithotomy (PCNL) Ureteroscopy (URS) Shockwave lithotripsy (SWL) Watchful waiting

Answer 50

What is the first line treatment for pregnant person with stone size of less than 2cm? Open surgery Percutaneous nephrolithotomy (PCNL) Ureteroscopy (URS) **Shockwave lithotripsy (SWL)** Watchful waiting

Question 51

What is the first line treatment for pregnant person with stone size of < 5mm? Open surgery Percutaneous nephrolithotomy (PCNL) Ureteroscopy (URS) Shockwave lithotripsy (SWL) Watchful waiting

Answer 51

What is the first line treatment for pregnant person with stone size of < 5mm? Open surgery Percutaneous nephrolithotomy (PCNL) Ureteroscopy (URS) Shockwave lithotripsy (SWL) **Watchful waiting**

Question 52

What is the first line treatment for person with stone size of 12 mm? Open surgery Percutaneous nephrolithotomy (PCNL) Ureteroscopy (URS) Shockwave lithotripsy (SWL) Watchful waiting

Answer 52

What is the first line treatment for person with stone size of 12 mm? Open surgery Percutaneous nephrolithotomy (PCNL) Ureteroscopy (URS) **Shockwave lithotripsy (SWL)** Watchful waiting

Question 53

What is the first line treatment for person with stone size of 24 mm? Open surgery Percutaneous nephrolithotomy (PCNL) Ureteroscopy (URS) Shockwave lithotripsy (SWL) Watchful waiting

Answer 53

What is the first line treatment for person with stone size of 24 mm? Open surgery **Percutaneous nephrolithotomy (PCNL)** Ureteroscopy (URS) Shockwave lithotripsy (SWL) Watchful waiting

Question 55

State the 4 most common causes of UTIs

Answer 55

Escherichia coli (E. coli) Proteus mirabilis Klebsiella pneumoniae Staphylococcus saprophyticus

Question 56

Haematogenous spread of UTIs is more often seen with uncommon urinary microorganisms such as [3]

Answer 56

Haematogenous spread is more often seen with **uncommon urinary microorganisms** such as **Staphylococcus aureus, Candida albicans and Mycobacterium tuberculosis.**

Question 57

Pyelonephritis has a similar presentation to lower urinary tract infections plus the additional triad of symptoms of which symptoms? [3] Which sign also indicates pyelonephritis? [1]

Answer 57

**Symptoms:** * **Fever** * **Loin or back pain** (bilateral or unilateral) * **Nausea or vomiting** AND * **Renal angle tenderness on examination**

Question 58

Explain which investigations should be given for UTIs? [2]

Answer 58

**Urine dipstick:** - **Nitrates** suggest **bacteria** in urine (E. coli breaks down nitrates into nitrites) - **Leukocytes** - **Haematuria** **Midstream urine sample:** - sample sent for **microscopy, culture and sensitivity** testing will determine the infective organism and the antibiotics that will be effective in treatment. **FYI**: **Where only nitrites are present, it is worth treating as a UTI.** Where only leukocytes are present, a sample should be sent to the lab for further testing. Antibiotics may be considered where there is clinical evidence of a UTI.

Question 59

What is the management of lower UTIs causing **uncomplicated cystitis**: (include length of time) First line? [2] Second line? [3] Length of treatment? [1]

Answer 59

**3-5 day** course of standard antibiotics to local guidance: First line: * **Nitrofurantoin** * **Trimethoprim** Second line: * **co-amoxiclav** * **cephalosporin** * **ciprofloxacin**

Question 60

A patient presents with recurring UTIs. You have investigated using urine dipstick and MSU. What are the next most appopriate steps for investigation? [2]

Answer 60

**USS renal tract or CT KUB** (kidney, ureter, bladder)

Question 61

Describe the differing length of treatment time for different patient populations for UTIs [3]

Answer 61

**3 days** of antibiotics for **simple lower urinary tract infections in women** **5-10 days** of antibiotics for i**mmunosuppressed women, abnormal anatomy or impaired kidney function** **7 days of antibiotics** for **men, pregnant women or catheter-related UTIs**

Question 62

NICE guidelines (2018) recommend the which first-line antibiotics for 7-10 days when treating **pyelonephritis** in the community? [5]

Answer 62

**Cefalexin** **Co-amoxiclav** (oral or IV if more serious; if culture results are available) **Trimethoprim** (if culture results are available) **Ciprofloxacin** (keep tendon damage and lower seizure threshold in mind) **IV Gentamicin** (if severe)

Question 63

How long should antibiotic treatment of pyelonephritis be provided for? [1]

Answer 63

7-10 days

Question 64

Urinary tract infections in pregnancy increase the risk of w which pathologies? [3]

Answer 64

pyelonephritis premature rupture of membranes pre-term labour.

Question 65

Urinary tract infection in pregnancy requires [] days of antibiotics. All women should have an what additional investigation? [1]

Answer 65

Urinary tract infection in pregnancy **requires 7 days of antibiotics.** All women should have an **MSU** for microscopy, culture and sensitivity testing.

Question 66

Why should nitrofurantoin be avoided in the 3rd trimester of pregnancy? [1] Why should trimethoprim be avoided in the 1st trimester of pregnancy? [1]

Answer 66

**Nitrofurantoin**: * should be **avoided in the third trimester** as there is a risk of **neonatal haemolysis** **Trimethoprim**: * should be avoided in the first trimester as it works as a **folate antagonist.** Folate is essential in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly **neural tube defects** (e.g., spina bifida). It is not known to be harmful later in pregnancy but is generally avoided unless necessary.

Question 67

Which conditions should trimethoprim be avoided in? [1]

Answer 67

**Renal impairment**

Question 68

Those with HLA-[] blood group antigen - tend to have recurrent UTIs

Answer 68

Those with **HLA-A3** blood group antigen - tend to have recurrent UTIs

Question 69

State 4 categoriesand examples of risk factors for UTIs

Answer 69

**Increase in bacterial innoculation**: * sexual activity * urinary incontinence * faecal incontinence **Increased binding of uropathogenic bacteria**: - spermicide use - decreased oestrogen - menopause **Decreased urine flow** **Increased bacterial growth:** - DM - I/S - Stones - Obstruction - Pregnancy

Question 70

If vaginal discharge is present, what is your most likely differential? [1]

Answer 70

PID

Question 71

Which pathogen is the most common cause of UTI? [1] Name two other causes

Answer 71

**E. coli** **Staph. saprophyticus** **Klebsiella pneumoniae**

Question 72

How do you manage UTIs in non-pregnant women? [2]

Answer 72

If 3+ symptoms of cystitis and no vaginal discharge: - 3 day course of **trimethoprim** or **nitrofurantoin** - If fails, take a MSU and send for culture

Question 73

How do you manage UTIs in pregnant women? [1] Which drugs should be avoided [3] and in which semesters? [3]

Answer 73

**Get expert help**: associated with **pre-term babies** Avoid: * **trimethoprim & ciprofloxacin** in **trimester 1** * **nitrofurantoin** in **3rd trimester**

Question 74

How do you manage UTIs in men: - If lower UTI [2] - If suspected prostatic involvement [1]

Answer 74

If lower UTI: * **7 day course** of **trimethoprim or nitrofurantoin** If suspected prostatic involvement: - **Ciprofloxacin** - **Cefalexin** (the typical choice)

Question 75

The typical duration of antibiotics is: [] days of antibiotics for simple lower urinary tract infections in women [] days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function [] days of antibiotics for men, pregnant women or catheter-related UTIs

Answer 75

The typical duration of antibiotics is: **3 days** of antibiotics for simple lower urinary tract infections in women **5-10 days** of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function **7 days** of antibiotics for men, pregnant women or catheter-related UTIs

Question 76

What risk does giving nitrofurantoin in 3rd trimester risk? [1]

Answer 76

Nitrofurantoin should be avoided in the third trimester as there is a risk of **neonatal haemolysis (destruction of the neonatal red blood cells).**

Question 77

What risk does giving trimethoprim in 1st trimester risk? [1]

Answer 77

Trimethoprim should be avoided in the first trimester as it works as a **folate** **antagonist**. Folate is essential in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly **neural tube defects** (e.g., spina bifida). It is not known to be harmful later in pregnancy but is generally avoided unless necessary.

Question 78

Two things to keep in mind with patients that have significant symptoms or do not respond well to treatment are? [2]

Answer 78

Two things to keep in mind with patients that have significant symptoms or do not respond well to treatment are: **Renal abscess** **Kidney stone obstructing the ureter, causing pyelonephritis**

Question 79

NICE guidelines (2018) recommend which first-line antibiotics for 7-10 days when treating pyelonephritis in the community? [4]

Answer 79

**Cefalexin** **Co-amoxiclav** (if culture results are available) **Trimethoprim** (if culture results are available) **Ciprofloxacin** (keep tendon damage and lower seizure threshold in mind)