PLAB 2 Urology: Mastering Common OSCE Scenarios

As you prepare for the PLAB 2 exam, it's crucial to be well-versed in a wide range of medical specialties. Urology, though sometimes overlooked, is a high-yield area often featuring in OSCE stations. From benign prostatic hyperplasia to acute renal colic, understanding common urological presentations is key to acing your practical assessment. This guide will equip you with the knowledge and approach needed to confidently navigate these scenarios.

Why Urology is Important for PLAB 2

Urological conditions are highly prevalent in primary and secondary care settings. As a doctor practicing in the UK, you'll frequently encounter patients presenting with urinary symptoms, loin pain, or issues related to reproductive health. The PLAB 2 exam tests your ability to take a focused history, perform relevant examinations, formulate a differential diagnosis, and propose an appropriate management plan – all skills directly applicable to urological presentations.

High-Yield Urological Conditions for PLAB 2

Let's delve into some common conditions you might encounter:

1. Benign Prostatic Hyperplasia (BPH)

Scenario: A middle-aged to elderly male presenting with lower urinary tract symptoms (LUTS).

Key History Points:

• Storage Symptoms: Frequency (day/night), urgency, nocturia, incontinence.

• Voiding Symptoms: Hesitancy, poor stream, straining, terminal dribbling, incomplete emptying.

• Complications: UTIs, haematuria, acute urinary retention.

• Red Flags: Weight loss, bone pain (consider prostate cancer).

• Impact on Life: Sleep, daily activities.

Examination:

• Abdominal Examination: Palpable bladder (if retention).

• Digital Rectal Examination (DRE): Assess prostate size, consistency, and any nodules (smooth and enlarged in BPH).

Investigations (to mention):

• Urine dipstick (rule out infection/haematuria).

• Blood tests: U&Es (renal function), PSA (discuss pros and cons with patient).

• Urine flow rate, post-void residual volume (if specific investigations are asked).

Management:

• Conservative: Lifestyle advice (fluid intake, caffeine/alcohol reduction), watchful waiting.

• Medical: Alpha-blockers (e.g., Tamsulosin) for symptom relief, 5-alpha-reductase inhibitors (e.g., Finasteride) for prostate shrinkage.

• Surgical: Referral for TURP (Transurethral Resection of the Prostate) if symptoms severe or complications arise.

• Safety Netting: Advise on symptoms to look out for (e.g., inability to pass urine, fever, worsening pain).

2. Urinary Tract Infections (UTIs) & Pyelonephritis

Scenario: A patient (often female) presenting with dysuria, frequency, and urgency. Or a patient with fever and loin pain.

Key History Points:

• Symptoms: Dysuria, frequency, urgency, suprapubic pain, haematuria (cystitis). Loin pain, fever, chills, nausea, vomiting (pyelonephritis).

• Risk Factors: Sexual activity, incomplete bladder emptying, history of UTIs, diabetes, pregnancy, post-menopausal.

• Red Flags: Sepsis symptoms (tachycardia, hypotension, altered mental status), signs of obstruction (e.g., inability to pass urine), severe loin pain with fever.

Examination:

• Abdominal: Suprapubic tenderness (cystitis), costovertebral angle tenderness (pyelonephritis).

• General: Assess for signs of sepsis (fever, tachycardia, hypotension).

Investigations:

• Urine dipstick (nitrites, leukocytes, blood).

• Midstream urine (MSU) for culture and sensitivity.

• Blood tests: FBC, U&Es, CRP (if suspecting pyelonephritis/sepsis).

Management:

• Uncomplicated Cystitis: Oral antibiotics (e.g., Nitrofurantoin, Trimethoprim) for 3-5 days. Analgesia.

• Pyelonephritis: Oral or IV antibiotics depending on severity, hydration, analgesia. Hospital admission if unwell or sepsis suspected.

• Safety Netting: Advise on fluid intake, complete antibiotic course, return if symptoms worsen or new symptoms develop.

3. Renal Colic (Urolithiasis/Kidney Stones)

Scenario: Sudden onset, severe, spasmodic loin pain radiating to the groin.

Key History Points:

• Pain Characteristics: Sudden, severe, colicky, radiating from loin to groin/testicle/labia.

• Associated Symptoms: Nausea, vomiting, restlessness, haematuria (visible or non-visible), dysuria, frequency.

• Risk Factors: Dehydration, family history, previous stones, certain dietary habits.

• Red Flags: Fever with loin pain (suggests infected obstructed kidney - urological emergency), anuria, signs of acute kidney injury.

Examination:

• General: Patient may be restless, in distress.

• Abdominal: Loin tenderness (minimal, usually no peritonism).

Investigations:

• Urine dipstick (haematuria).

• Blood tests: U&Es, FBC, CRP.

• Imaging: CT KUB (Kidney, Ureter, Bladder) is the gold standard for stone detection. Ultrasound can be used initially but is less sensitive for ureteric stones.

Management:

• Analgesia: NSAIDs (e.g., Diclofenac) are first-line unless contraindicated, then opioids (e.g., Morphine).

• Hydration: Oral or IV fluids.

• Referral: Urgent urology referral if signs of infection with obstruction, anuria, or acute kidney injury. Otherwise, monitor for spontaneous passage of smaller stones, alpha-blockers may aid passage.

• Safety Netting: Advise on straining urine, collecting stone for analysis, return if fever/worsening pain/inability to pass urine.

General Approach to Urology Stations in PLAB 2

1. Structured History Taking: Always use a systematic approach (SOCRATES for pain, PQRST for symptoms, ICE, past medical history, drug history, social history, red flags).

2. Focused Examination: Only perform relevant examinations. For urinary symptoms, abdominal examination is usually key, and a DRE if BPH/prostate issues are suspected.

3. Investigations: Explain why you are ordering each test and what you hope to find.

4. Management Plan: Offer a multi-faceted approach including conservative, medical, and surgical options where appropriate. Always explain risks and benefits.

5. Safety Netting: Crucial for all patients. Ensure they know when and how to seek further medical help.

6. Communication Skills: Empathy, active listening, clear explanations, shared decision-making are paramount.

Tips for PLAB 2 Success in Urology

• Know Your Red Flags: Identifying immediately life-threatening conditions (e.g., infected obstructed kidney, sepsis, prostate cancer) and knowing when to urgently refer is critical.

• Practice DRE: While you won't perform it on a real patient, know the steps and what you're looking for.

• Master LUTS: Understand the difference between storage and voiding symptoms and how they relate to conditions like BPH and OAB (overactive bladder).

• Be Patient-Centered: Discuss investigations like PSA sensitively, acknowledging patient concerns and preferences.

By focusing on these common urological scenarios and refining your systematic approach, you'll be well-prepared to tackle any urology station that comes your way in the PLAB 2 exam. Good luck!