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Come back to the screws, Scolds and Suspicious Teaching Series. Um My name is Scott. We're going to be going over urology today. Um Thank you for everyone who came to the session in person. Uh, unfortunately, when we were doing it a week or two ago, uh I had some technical difficulties and I couldn't get the, the slides and the, and the audio to match up. So, um, I just thought I'd do this video and upload it today just so that anybody who was there and anybody else who wants to catch up with urology can do that. So in terms of topics we're going to be covering today, we're going to be doing a couple of cases. Uh, the first one is going to be looking at urinary retention and the second hematuria and we'll be looking at the etiology. So the causes of those presentations, we'll be looking at initial investigations that you as a, as a resident doctor would be thinking of putting in place when you get those presentations to you. And we'll also be looking at management of those presentations and some common causes of those presentations. Um, and we'll split that up into initial management. So management that we put in place by, by you guys and also the definitive management. So things that um consultants senior registrars most likely be doing potentially with your help. Um but to treat the underlying cause, OK. After that, we'll look at catheter issues. So this is something that will be the bane of the life of a urology junior, but also will affect people on non urology placements. And it's a really good uh handy tips to know for anybody doing foundation placements. Ok. So if we start with case one, then looking at Mr Menendez, a 71 year old male who presents with suprapubic pain and an inability to pass urine for the last eight hours. He's been having issues with increased urinary frequency and poor stream for many months but hasn't sought help as he assumed he was just getting old. A bladder scan shows a volume of 1100 MS if you want to just take the next 20 seconds or so, to look at those answers and think about which one most likely describes the patient's presentation. We look at the that room. So this this presentation is most likely acute on chronic urinary retention. If we look at the next slide, we can see a little bit why. So urinary retention is split into different categories. Uh acute and chronic, really the classic one. So acute urinary retention is this new onset inability to pass urine and this leads to significant residual volumes. So anything over sort of 500 mils would be considered urinary retention, that's past the capacity of the bladder. But in acute urinary retention, you'd expect it to be less than 800 mils really. And you'd expect the patient to be in quite significant pain. Chronic urinary retention is a little bit different and that's due to the longstanding inability to completely empty the bladder. So you get significant residual volumes over 800 mils. And that's because that residual volume has built up over a long period of time. But you also get minimal pain because it's taken a long time for that residual volume to build up the bladder gets desensitized over that time. So the actual pain that the patient's feeling is not in keeping with the amount that they've actually got in their bladder acute on chronic is a combination of the two. So it's when somebody has this chronic urinary retention picture. So that a long standing in to completely void, which has led them to get these significantly high volumes. So over 800 mils, but there's been an acute change, which now means that they're not able to empty their bladder. So there's been a sudden increase in that residual volume. So you'd expect them to have really high volumes, but you'd also expect them to have pain because they're, the residual volume in their bladder has increased rapidly over a short period. Of time. So if we look back at our chart, Mr Mendez, you can see that he's had, he's got pain, but he's also got this large volume uh in his bladder. And you can see that he's been having some, some symptoms of poor, um poor emptying of the bladder over a long period of time. So that residual volume was built up and most likely there's been a sudden acute change, which has meant that he's now not able to open his bladder. And there's been an increase in the volume, a rapid increase in the volume that's, that's left in his bladder. So if we think about the initial management that we might want to put in place for a patient presenting like this. So presenting with pain or an increased bladder, increased bladder size, then the first thing you want to do is get a bladder scan and that's gonna tell you about the volume of urine that's in the bladder. Like we said before, anything over 500 mils would be considered urinary retention. Um And over 800 mils would make you suspicious for chronic picture. You'd want to put a catheter in the patient. Um Not only does this let you relieve the pain and, and give the, the relief that the patient wants. It also lets you again characterize how much volume and what, what, what the urine looks like. So, is it blood stained? Uh is there clots? Is that, that bread bloods, SF PCC RPF PC and C RP are really important to look for signs of infection, which is a common cause of urinary retention. And is that you've characterized the performance of the kidneys. So you can see whether the patient has a, an AK I with this urinary retention if there is significant retention. So, again, anything over sort of 800 mils, you'd want to be thinking about getting an ultrasound scan of the kidneys. And that's to look for hydro nephrosis and also hydroureter. And what those basically are is where the pressure in the bladder has built up to such an extent that um the normal antireflux mechanism of the ureters uh kind of fails and you get this backing up of fluid firstly into the ureters and then all the way back to the kidneys. So when you do an ultrasound scan, you can see that swelling that increase in volume due to the fluid that's stored in those areas. Uh And if this happens over a period of time, then it can lead to scarring in the ureters, scarring in the kidneys, which can lead to long term issues. So, chronic kidney disease, strictures, et cetera, et cetera. Um You'd also want to consider giving IV fluids if somebody has significant retention. And the reason for that is that if somebody does have this high pressure urinary retention, so where the fluid backs up all the way to the kidneys, when you release that pressure, the mechanism uh of the kidneys filtering has already changed due to those pressures. So when you release that pressure, you get this diuresis effect, this high output diuresis. Um So you can get urine output of over 200 mils per hour. Um And if that happens for, you know, more than an hour or two, then you're going to want to think about replacing it. Otherwise, the patient can flip into a pre renal AKI. Um So if you do have that high output diuresis post uh obstruction, then you want to replace sort of 50% of what they're putting out. So if over a couple of hours, they've put out 500 mils, then you might want to start giving them IV fluids at a rate of 250 MS an hour. For example, you also want to assess for the cause of the obstruction. So after you've done that initial management and you've relieved the patient and you've further characterized the obstruction, you want to think about what the actual cause was initially. And there's two things you might consider for that. One is a, a urine microscopy culture and sensitivity. You also might want to do a urine dip for younger patients as well. Um And APR exam is really useful. So you're in M CS is to look for UTI S and APR exam is to look for other causes. So if we think about doing APR exam on Mr Mendez, which of the following do you think you're feeling for in the context of his urinary retention? So, are you feeling for anal tone and perianal sensation? Are you feeling for prostate size and texture, presence of stool in the rectum or all of the above? Again, I'll just give you 20 seconds just to think about that. And then we'll look at the answer, have a look at the answer then. So the answer is that you'd still want to do all of the above. So when conducting APR exam on the patient, in the context of urinary retention, you want to feel for all of those things. And the reason for that relates to the causes of urinary retention, which are actually quite broad. So commonly, people think about obstructive causes. So BPH prostate cancer, urethral strictures and clots. And obviously, you want to feel for the size and shape of the prostate when conducting APR exam to assess the signs of BPH and prostate cancer. So, a feeling for an enlarged craggy prostate and prostate cancer or just a globally enlarged prostate in BPH UTI S are quite a common cause and hopefully, they will be picked up on our M CS, the presence of stool in the rectum when conducting APR exam relates to constipation, which is noted as a cause of urinary retention. So severe constipation and that build up of stool in the rectum. The idea is that it puts pressure on the urinary system which blocks the outflow, I think in reality, this is actually quite a rare cause. Uh and definitely, you know, a diagnosis of exclusion uh rather than something that you'd go straight to as being the cause. Um But it is something that's listed in the textbooks that's causing urinary retention, neurological causes, so called equina syndrome. Um upper motor neurone diseases like MS Parkinson's and more niche things like D SD. Uh So to true distinct to dyssynergy, which is effectively where there's a lack of synergy between the, the contraction of the bladder and the opening of the outlet. Um Obviously, in this context, thinking about urinary retention, anal tone um and sensitivity is, is really important in Cadarena syndrome. So definitely if you have a patient who's presenting with the urinary retention, but also maybe complains of back pain, any sort of sciatica, any sort of anesthesia, then corner has got to be the top thing that you're trying to rule out there a medical emergency. And that's compression of those lower motor neuron nerve roots within the spinal cord. And one of the side effects of that compression is that they lose their anal tone and their anal sensitivity. So you want to assess for that when doing apr examination, um go there. So list of of things. So any sort of signs of prostate enlargement, any stool in the rectum and anal tone and sensitivity. So they're all things that you want to assess when doing APR exam because they all relate to potential causes of urinary retention. A couple of other causes of urinary retention on the bottom of the SLS there. So pelvic prolapse, I'm sorry, cystocele, rectocele, uterine pelvic prolapse just depending on what part uh of the urinary system or, or, or your uh um other part of the body that has prolapsed beneath the pelvic floor and they can put pressure again on the on the urinary outlet system. So cause an obstruction, basically of your of urinary output, pelvic masses are another common cause and and very common uh in females presenting with um urinary retention. So, thinking about ovarian uterine masses that can again put pressure on the system. Thinking of this question then, so upon conducting apr exam, you find that Mr Mendez has an enlarged, symmetrically smooth prostate. So thinking about the common cause of that, which we just spoke about what percentage of men over the age of 50 do you think are affected by the condition most likely in this patient? So think about what you think the most common cause is of this presentation. And then thinking about what percent of men are affected by that condition over 50 just give you 10 seconds. Ok. So it's actually 40% of men. Um So the most likely diagnosis in this case, in somebody with urinary retention, the symmetrically smooth prostate would be BPH benign prostatic hyperplasia. And it's really common. So 40% of men, over 50 90% of men, over 80 have some degree of B ph BPH. For those who don't know, it is pretty much as the name says. So the benign growth of prostatic tissue and that tends to push outwards. Uh and this is quite a common cause of urinary um retention. Um oftentimes it causes lower uh urinary tract symptoms. So storage symptoms, which can include sort of um urgency. So having to go to the toilet quite quickly, not your ear. So having to go to toilets more often overnight, uh urinary incontinence, and that's because of the build up of urine in the bladder because of incomplete voiding, um which leads to those symptoms of storage symptoms. And you can also get some voiding symptoms. So that's things like a slow stream or uh hesitancy when starting to urinate straining, splitting of the stream or dribbling. After completing uh after completing urine, uh urinating, you can also get sort of post micturition symptoms. So, like we said, dribbling or or sensation of incomplete emptying, but commonly lower in the urinary tract symptoms for any cause of which BPH is a very common cause. It is split into those storage symptoms and those voiding symptoms. The medical management of BPH is split into two really. So there's an alpha adrenoreceptor antagonist. So tamsulosin and they work very fast. So they act to relax the bladder neck. So give more of a high volume area for urine to flow out by relaxing that bladder neck. And then five alpha reductase inhibitors such as Finasteride. And they work over a period of months and they prevent the conversion of testosterone to a more active form dihydrotestosterone, which is generally the thing that drives that prostatic growth. So a lot of parts of our body as we start to get older and older, they actually start responding to testosterone in the same way. But the prostate doesn't do that. It doesn't switch off as we get older and it keeps that conversion going, which is why commonly as men get older, they start to get issues with this prostatic growth causing um you know, some sort of symptoms. Um so we can use Finasteride that five alpha reductase inhibitor to block that conversion of testosterone to the more active form, thereby preventing and slowing that growth of the prostate. But like we said, that's a slow acting thing. So that works over a period of months. Whereas Tamsin should see an effect within a few days to relieve those symptoms. Surgical management then is something that's offered to patients who have tried medical, medical management but haven't had uh haven't had relief of their lower urinary tract symptoms uh or to patients who have sort of high pressure retention. So that's thinking back to um what we said earlier where that, that pressure builds up in the system and you start to get this hydro nephritis hydroureter uh with increase in volumes of fluids stored in those places and that can cause that long term damage. Um In terms of options for surgical management, there are minimally invasive treatments. So, steam treatment is a new one which is effectively um it's effectively killing the, the tissue of the prostate using steam. Uh and it's a more softer, less invasive treatment. I've never seen that used and commonly still, the most common management is something called a Terp, which we'll look at now. So Terp stands for transurethral resection of the prostate. And the way this works is using something called a resectoscope which you can see in the image there. So this tool here is called a resectoscope. And you use a uh rigid cystoscopy which allows you to access the prostate and then you can remove uh part of that prostatic tissue using electrocautery complications that you can get from TP uh include sexual dysfunction, hemorrhage. So, bleeding, post procedure, urethral strictures, which are quite common because you've got this large tube down the down the urethra, which can cause irritation. And there used to be something called Turp syndrome, which is now thankfully, quite rare. The reason that the people got that was that a glycine solution was used to irrigate the bladder. So once you've in inserted your cysto uh cystoscope, you want to put fluid into the bladder and into the system, want to keep it washed out. But also just to enlarge and help you visualize the area. Uh In the past, monothermal was used to cauterize the tissue, which meant that you couldn't use solutions that conducted electricity. So you couldn't use things like Hartman's or sodium chloride solution, which is why they used this glycine solution because they were using uh a solution that was severely hypotonic that then got absorbed. It caused issues with Terp syndrome. So, you know, hyponatremia, for example, would be a common side effect of having this um this operation, uh particularly if these operations went on for a long period of time. Thankfully, now, when using the resectoscope, they use diathermy to cauterize the tissue, which means that you don't have to be so concerned about using a a solution that uh carries an electric charge. So you can use those sodium chloride as solutions to, to irrigate uh the bladder um which you know, takes away from, from that um Turp syndrome happening. OK. Just a closer look at the resectoscope then. So you can see that it's got this sort of hook on the end of it and that's where the electric current passes, that allows you to take away that tissue around the prostate. There's also another attachment, which is a roller ball attachment and they use that after they've taken away the tissue just to cauterize the tissue and stem the bleeding. Uh and this is just uh just to outline the parts um the parts of the urethra. So when inserting you insert the rigid cystoscope first and then use the resectoscope through that and you're gonna put it through the penile part of the urethra through the membranous. And you're going to be looking at this prostatic part and that's where you're going to take away the tissue from. Ok. Question four. Then, so if you were concerned that Mr Mendez may have prostate cancer after your initial investigations, what would be the most appropriate initial imaging to ascertain a formal diagnosis? So obviously, in real life, just because you've done apr exam and you felt, you think that the prostate feels smooth, not craggy, but you're pretty sure it's enlarged and you've got this patient presenting with lower urinary tract symptoms. Um and this now acute retention, you're still gonna be concerned that actually maybe this isn't bh maybe this is something more sinister. Which one of these investigations do you think that, that you would do? Um I think it's fair to say that, you know, you can assume in this situation that a PSA so that's a simple blood test, prostate specific antigen has already been done. Uh And that it's raised, but you're still not certain about what the diagnosis is because as, as you, you know, you may well know PSA is a really useful tool um for ruling out prostate cancer, but it's not overly specific. So loads of things raise it. So prostate cancer BPH would cause a raised psa, vigorous activity, et cetera, et cetera, all cause a raised PSA. So I assume that this patient has a raised PSA, but you're still not sure about whether it's, you know, something sinister like prostate cancer or something more benign. Just give you 10 seconds then to think about which one of those investigations you'd do. Ok. So it's actually an MRI and it's something called a multiparametric MRI scan. And that just allows you to, to look at the prostate more closely and identify any abnormal areas of tissue. And once you've done that, you're going to want to do a biopsy if you are still concerned about prostate cancer. And that MRI scan is really useful because it allows you to see and target areas of abnormal prostatic tissue. And there's two ways that you can biopsy the prostate. So there's a trans uh sorry Transrectal approach, uh and a transperineal approach. So, the transrectal approach you can see on the right hand side and that's where an ultrasound probe is inserted into the rectum. And the biopsy needle is inserted through the rectum as well to allow you to sample areas of prostatic tissue. This has now gone out of favor. And the reason for that is because going through the rectum into the prostate uh has a higher likelihood of introducing infection into the prostate. So it's now favoring this uh transperineal approach where again, a probe is inserted into the rectum to allow you to visualize the prostate. But the actual biopsy needle goes through the perineum. Uh And there, there's different ways that you can go about um biopsying the prostate. The first is to do a targeted approach, uh which is where you, where you use your MRI scan in your your ultrasound probe to, you know, help you identify what might be abnormal areas of tissue and then you can biopsy from those areas more common though people do a grid like template approach though using the MRI Yes, to identify where it might be abnormal, using the ultrasound probe to identify where the prostate is, but just sampling it in a systematic manner. And that allows you to get more of a global picture of the prostate health and and any sort of um abnormal tissue that might be in there after doing that. Then since you've got your prostate, you um send it off to the micro lab um to the Histoplasma Gleason score is using two sections of tissue. So the two most abnormal sections of tissue, I think um and they look at how well differentiated they are so poorly differentiated tissue suggests that it's, you know, significantly different from the normal glandular um makeup of the prostate tissue. Whereas well differentiated tissue uh suggests that it's still quite similar to that glandular structure that we see in healthy prostate tissue. Um And using that they can calculate a score with more poorly differentiated tissue So further away from the normal structure scoring higher. Uh and that suggests a more high risk disease. The hist lab can also look at whether or not you've got an invasive prostate cancer. Um So that's spreading acro across the muscular layer. Um And you can use uh you know, a CT scan to, to, to, to assess whether it's metastatic or not. Overall though the treatment of prostate cancer depends on that Gleason score risk, psa your CT scan, looking at whether or not it might be metastatic or, or local. Uh And from that, you can determine, you know, where it is, is it in situ, is it invasive? Is it metastatic and get a risk of that prostate cancer? Um And then the treatment of that varies and it's, it's always determined by those factors of the disease that we've just discussed, but also patient factors as well. So how old are they, how healthy are they, what do they do for work? What's important to them? And do they want to undergo a procedure or actually would they prefer something more hands off? Um Just to kind of talk you through, you know, some sections of this slide II think it's really difficult to learn a slide like this because like I said, the the actual treatment will vary so much depending on all those factors. Um But a couple of things to kind of highlight is that in low risk in situ cancer commonly active surveillance is done. So, particularly in older patients in low risk prostate cancer, you will get growth of the prosthetic tissue. But actually, it will be quite a slow rate. Oftentimes and most patients who have this, particularly in older age won't experience any sort of symptoms or difficulty with this throughout their life. Certainly not compared to more radical approaches um of alleviating that prostate cancer. So that will probably cause more symptoms than just living with it. And most of the times, you know, it's not the prostate cancer which actually kills them, it's something different. So, active surveillance is an option in those patients um in patients that are maybe healthier or have a faster growing or invasive form of prostate cancer, more radical treatments. So, prostatectomy, so removal of the prostate and radiotherapy or hormonal therapy would be more common options and chemotherapy as well if it is metastatic. Um Unfortunately, radical prostatectomy does have quite a lot of side effects. So that's removal of the prostate uh commonly um incontinence. Um and I don't know, difficulty controlling their bladder. I is probably the most um most pressing side effect of having that treatment. Ok. So we can move on to the second case then. So thinking now about hematuria, I'm thinking about Miss Jackson, uh an 8 to 2 year old female presenting to the surgical assessment unit with a new onset severe visible hematuria. She has no other symptoms at present and has had a news of zero bloods on admission are mild anemia. So, hemoglobin 100 and seven and your in is highly positive for blood only. What is the first step in the management of this patient to put yourselves on the shoes? Are they resident doctor in the surgical assessment unit presented with this patient? What was the first thing that you're gonna think about doing in that situation? I'll just give you 15 seconds just to think about that. Ok. We'll look at the answer for that then. So one of those things that you want to do as, as a resident house officer is think about setting up a bladder irrigation and a three way catheter. Ok. So blood transfusion in this situation is not so important because it's a mild anemia. So 100 and seven, generally, you use ac of around 70 or 80 depending on the health of the patient. Obviously, the patient at the minute is quite far above that. You might want to consider getting bloods including in the group and save just in case the patient's anemia continues to drop. But at this point in time, you wouldn't be too concerned about setting up a transfusion. Uh A CT scan of the urinary tract is something that you might consider further down the line. But initially, it was not what you'd want to do. And a suprapubic catheter, which is a catheter inserted through the skin into the bladder. So through the abdomen into the bladder wouldn't be warranted in this case because we've not tried to put a urinary catheter in place yet. So a normal urethral catheter. So if we have a look at what a freeway bladder um a freeway catheter with bladder irrigation entails, then, so you can see that we've got an irrigation bag up here filled with just normal saline and that comes down into a three way catheter. So you've got the free ends of this one as an inlet for this irrigation bag, one as an outlet for urine and also this irrigation solution. And then this third one here which just allows you to inflate the balloon of the um of the catheter. So similar to a normal two way catheter where you've got the balloon on the outlet, but you've also got an inlet here for the irrigation band. So there's a three way catheter. And the reason that you want to set up this irrigation is to one help to wash out that blood from the, the the bladder, but also to help avoid clots. So, one of the main things you want to avoid in this situation is clots forming within the bladder getting stuck in the bladder neck or the urethra and then causing them to go into acute urinary retention. So you want to do this this irrigation system to help avoid that commonly, people that present with hematuria, the bleeding is actually stopped. So the bleeding inside the bladder is actually stopped on its own accord. By the time they'll get to hospital, all you want to do then is help to flush out the blood that's already in the bladder and help to avoid that clotting process. Sometimes it might be that the bleeding hasn't stopped, but most of the time actually, it has stopped on its own, the same patient. Then MS Jackson, after doing routine bloods and a urine dipstick, what are the recommended first line investigations for visible hematuria? So which of these would you think about booking for this patient? Ok. Just give me five more seconds. Ok. So you'd want to get them a CT kub. So a ct of the urinary tract and a flexible cystoscopy. Um CT gives you the best sort of visualization of the urinary tract. And it's particularly important to let you see stones which are a really common presentation of hematuria, particularly if the patient has pain. And the cystoscopy allows you to visualize in and around the bladder for any issues that you might have going on in there. And we'll look a little bit at what they might be the causes of hematuria in a minute. But thinking about why you would want to do a, a flexible versus a rigid cystoscopy. So a flexible cystoscopy can be done under local anesthetic and that's a cystoscopy. So a scope that goes into the bladder and bends as the name would suggest you can take little um biopsies if you, if you want to use a flexible cystoscopy, but you're really limited in what you're able to do. So really, that's just a tool for visualization. So that's, you know, a first line investigation to visualize what might be in the bladder. A rigid cystoscopy is different. So that's thinking about what we looked at when we were looking at how a turp is performed. That's a sort of rigid metal cystoscope that goes in the urethra. Um and then allows you to perform more complex um biopsies or to remove tissue. So, in the same way that we remove part of the prostate, you can do that same thing with that rigid cystoscope. So that's really is an intervention. It does allow you to visualize it as well, but you have to have a general anesthetic or a spinal anesthesia for that to be uh conducted. So it's really a more in depth um you know, an in depth procedure than just doing a flexible cystoscopy. So you'd usually do the flexible first just to visualize the area and characterize it. And then if you do need to do any intervention, then you would do a rigid cystoscopy after that, uh looking at the others, an ultrasound and an abdominal X ray are just less useful, particularly for looking at stones than what A CT Kub is. So, normally a CT Kub would be done rather than those looking at causes of hematuria, then just like an AK you can split them into renal prerenal. Postrenal causes uh a couple to pick out that are important for urology from renal would be things like renal stones, renal tumors, um which are, you know, reasonably common. Um And most of the post renal causes really would fall uh under a um urology, um uh you know, patient uh outlook. So, just picked out, you know, the key ones really, the key cause of hematuria that are really important to urology. So, renal tumors, renal curricula. So renal stones, bladder tumors are quite common. You can also get bladder stones as well. Prostate tumors. BPH can be a cause of hematuria, particularly if there's been, if the patient requires uh catheterization, um intermittent, potentially at home catheterization, then they can get bleeding quite commonly. After that UTIs are a really common cause and you know, hopefully should be picked up in that first initial investigations. When we're doing the urine, the urine mcs, the bloods, we should get signs that they've got an infection. It's also really important obviously to ask about whether they have symptoms of the uti and post procedure is a common cause of hematuria. So, any sort of procedure that we've talked about, sort of TP, etc, etc things where you in certain cystoscopes, commonly after those procedures, you can get bleeding or even just catheterization. It's not uncommon for patients to have bleeding after a catheter and patients who have long term catheters or intermittent catheterization at home and do it themselves commonly present with bleeding after attempts of catheterization has proved difficult. So, question seven. Then on further questioning of Missus Jackson, who's a cis gender female, she says that she has lost 5 kg in the past six months and has been feeling more tired than usual. She also has the sensation of needing to urinate post voiding on examination, her abdomen feels soft and is non tender. What is the most likely cause of her symptoms? So I'll just give you 10 seconds to think about that. Ok. So obviously, all these things listed here can cause hematuria. But I think given the history of weight loss, a long period of lower urinary tract symptoms. So needing to urinate post voiding and feeling more tired. So these B type symptoms are secondary symptoms of which indicate that there might be a tumor or some sort of cancer process. The most likely diagnosis here is bladder cancer uti is obviously definitely still an option but wouldn't cause all of the symptoms that the patient is presenting with renal colliculi. You would ex usually expect to present with pain, which the patient doesn't have in this instance. And prostate cancer as this patient is ac gender female, obviously, they don't have a prostate. Um So that would allow you to rule that out. Also important to note that even though you've done your examination and the abdomen is nice and soft. You can't feel any masses, that's pretty common for bladder cancer. So it's quite difficult to feel about a mass when doing an abdominal examination. And, and, you know, normally that's a really late sign or a sign of a really large mass, uh, that are present. If you can feel something symptoms of bladder cancer, then commonly a painless hematuria, that is the classic sort of sign of a bladder cancer is that painless hematuria, recurrent UTIs and lower urinary tract symptoms, which again, thinking back to earlier are those storage and voiding symptoms that we spoke about. Clinical examination is often remarkable, as we just said. And late stage disease is when you start to see this weight loss left these these secondary symptoms of tumor. So it was a worrying sign that we could see these in MS Jackson. The investigations that you'd want to do for this story spoke about flexible cystoscopy and you can see the cystoscope here and you can see how it bends to allow you to get into the bladder rigid cystoscopy. As we mentioned before is for further characterization. Then that's the kind of solid metal pole. And we'll see that in a minute staging CT, which you mentioned earlier to allow you to. Oh, sorry. No, we didn't. We got a CT KB earlier. Sorry. But the staging CT is, is uh a scan of, of, you know, the whole body just to check that there's no metastasis anywhere and also the local area just to check whether or not there's spread into the muscle, spread into the lymph nodes of that bladder cancer. Urine cytology is a test that you can do where you effectively get the, the cells from the urine. Um But it's not commonly done because the actual information that it can give you is quite poor. So it's not got great sensitivity or specificity. So it's, it's rarely done. Normally, you would just go straight to a flexible cystoscopy in terms of the management of bladder cancer. Again, just like prostate cancer, it depends on the cancer and also on patient um patient factors. Um But commonly, you can think about the bladder cancer as being split into local non muscle invasive, local muscle invasive and sort of locally advanced or metastatic disease. So that's when it's spread beyond the bladder. If you've got non muscle invasive, then you're going to think about doing something called a transurethral resection of the bladder tumor. So a turp very similar to a turp but turp um and uh adjuvant chemotherapy, which you can put into the bladder and we'll talk about these a bit more in a minute. Um Muscle invasive, you're going to want to do a radical cystectomy. So that's removal of the bladder and then for locally advanced or metastatic disease, chemotherapy or, or potentially just palliative care are the options that you'd want to do for those patients and consider for those patients, depending again on patient factors. Um Again, what, what approach do you use to treat bladder cancer would go to uh MDT meeting and it would be, you know, decided by multiple people what's best for that patient and what's best for this disease. And then think about what the best approach would be really. Um So if we think about a, the management of the non muscle invasive first, so this is the Tur BT, you're getting back the resectoscope that we use for a Turp. And this is our rigid cystoscopy uh here. So, this metal tubing which you put in through the urethra with a camera on the end to begin with. And then that allows you to insert your resectoscope down there and you can just remove this epithelial uh growth. Uh So this epithelial tumor um and you might want to use adjuvant chemotherapy. So, put chemotherapy into the bladder afterwards to help treat that uh local epithelial non malignant tumors. Um if they are malignant, so they have invaded, passed that lamina propria into the muscular layer, then you can't just do that superficial removal approach. Now, you've got to remove the whole bladder. So that's a radical cystectomy. Um And the way they do that commonly nowadays is using the robotics, um robotic surgical assistance that you might have seen. And the reason for that is that the bladder is obviously right down in the pelvis, it's quite difficult to get out. Um So by having those arms and that different way to visualize it helps you operate in such a tight and difficult to get out area. And the patient outcomes from using the robot are actually much, much better than, than just a human doing it on their own. It also means you can do it sort of laparoscopically much easier. Um So recovery is, is somewhat better for those patients in terms of the options after doing a cystectomy, um you can either form an eel conduit, which is where you take part of the ileum and thread the ureters into that and then form a urostomy on the skin. So effectively, the the urine drains from the ureters into your ileal conduit and then out into a urostomy bag. That's the most common thing that happens after these procedures. Sometimes people can do a bladder reconstruction. So that's again where they take part of the ileum. Um and reform what is a bladder and plum it back into the normal outlet system. But sometimes I think patients can have difficulty with urinary incontinence after doing that. And you know, it's actually quite a difficult procedure to perform and do well. So like we said, most of the time, it's the ileal conduit with the urostomy that tends to get done for those patients. Ok. So we'll move on now from looking at that presentation of, of uh hematuria and the cause that we identified as bladder cancer. And we'll think about how we can troubleshoot some catheter conundrums. So this is something that, like we said, is useful for everybody that's doing foundation placements, not just people that are on a urology or a gen specific placement. And the reason for that is that such a high proportion of hospital patients are catheterized. So it's estimated that around one in five hospital patients are catheterized at any one time. So it's something that, you know, commonly get bleeps about even on medical wards, starting off, looking at the different types of catheters then. So the most common are these uh you know, urinary catheters, foley catheters of which you can get a two way. So this is probably the classic one that you've seen. Um most of the time before and learned in med school about how to insert and whatnot. And that's where you've got two channels, one for draining and one for blowing up the balloon. You can also get a freeway bladder, a catheter, which is what we talked about earlier. And you can see down on the bottom right here and that's where you've got this third channel that allows for irrigation. So it allows you to put uh that solution going for over a period of time, which then comes out the drainage channel and allows you to wash out the bladder over a long period of time. Um The size of these is measured in Frenchies with one Frenchie equating to 10.33 millimeters. And usually you would use a 16 or a 14 Frenchie, maybe an 18 Frenchie in, in adults, you might have to use a larger one to drain blood clot and the smaller ones obviously are used in Children. So anything from 6 to 12, French, another type of catheter that you see, probably more. So if you are on a urology placement is a suprapubic catheter. And that's what we mentioned earlier where there's a catheter inserted into the abdominal wall and straight into the bladder. And that's oftentimes done if there's, you know, issues with control of the bladder. So it's a long term solution for people who have got issues with control of the bladder or if there's a long term outlets um issue, which means that you can't insert, um, a normal phony catheter team and tip catheters are the things that you can see here and they are like normal catheters and usually are two way. Um But they've got this sort of slightly curved, slightly pointed tip on the end and that helps you to hook around past the prostate. So for people that have got an enlarged prostate, for any reason that's making catheterization difficult, you can try and use one of these Q tips and help to guide that past the prostate and we'll talk a little bit about that later on indications for a catheter. Then why might my patient have a catheter urinary incontinence. Incontinence is the common one. But oftentimes you might want to consider pads or a convene convene is, is, um, the thing that's on the right here and it's sort of a bit like a sort of short condom almost in males where you put it on the tip of the penis. Um, and then it straps on kind of tightly and then that allows the urine to drain without any sort of insertion of anything into the urethra. Um So it's, you know, usually less painful for patients. Um and also a lower chance of spreading any sort of infection, you can also get a female convene now, but it's not something that I've seen commonly used, but um hopefully, over time, it will become more widespread. So that's one reason you'd want to use a catheter is that urinary incontinence is probably the most common reason that you see in, in hospital that it's used. Uh The second reason is to monitor urinary output. So if the patient has an AK or commonly in sepsis, where you have to monitor, monitor urine output closely, um then you, you would think about putting a catheter in just because it allows you to closely monitor the urine output in a way that you're not really able to, if a patient doesn't have a catheter, urinary retention. So that's one that we spoke about earlier. If patients go into urinary retention, you want to put the catheter in to relieve the symptoms let the urine flow out. Um And the relief that they get from that is sort of instant and enormous. Um And if you want to wash out cloths or debris, then you might want to do a washout, you also might want to think about doing irrigation like we spoke about earlier and we can talk a little bit about the difference between a washout and irrigation later on in the slides as well. So after you've put in your catheter, what do you want to document um the usual things that you document whenever you sort of writing in a patient's notes. So your name, your role, the date, the time you want to put those down, uh the indication for doing the catheter in the first place. So that's one of those things that we just spoke about. Um And if you did do a bladder scan, so I think you had any sort of urinary retention you want to put down the volume and what that showed as well, uh confirm that you got consent from the patient. Obviously, it's an invasive procedure and in a sensitive area. So it's something you want to discuss with the patient beforehand and confirm that they're happy with chaperone details, the volume of saline that you injected into the catheter bloom, any complications that arose from doing the catheter, what was drained after you put in the catheter? So the volume that was drained, what it looked like, were there any clots? What was the color, et cetera? OK. A few tips then for inserting catheters. So sometimes it can be difficult to insert catheters. I know we've all learned at one point in time on those models where they just fly in. But when you actually start doing them on patients a bit more, you realize that actually it's quite difficult in some patients to insert them, but a few tips that are really useful. The first one is to always hold the penis upwards in male patients. So if you see this image on the right, you see that the penis or the urethra tract has two bends in it at rest. So there's this pre pubic angle band and the infra pubic angle bend. If you lift the penis and hold it away from the body, so up right and to it away from the body, then you straighten out this pre pubic angle. So then you've only got one bend to get around rather than having to try and get around two bends. If you just let the penis sit naturally on the body and try and insert it that way. If you do hit some resistance at the prostate, then you can ask the patient to cough and that sometimes just freeze up a little bit of room around the prostate, which allows you to get around this and and get through the prostate only have one attempt at trying to get the catheter in. So if you're really struggling to get the catheter in, don't try and force it. And the reason for that is that the most common place that people get stuck when inserting catheters is this sort of area here. So you've gone around this pre pubic angle or you've strained it out and gone down, but you're struggling to get around this infrapubic angle and you can start to create a false lumen in this section of tissue here, which can cause bleeding pain. But also the more that you sort of stab at it, if you're finding difficulty, the deeper you can make that passage. So just have one attempt using reasonable force but not excessive force. And if you're struggling to get it passed, then don't keep forcing the issue. A tier tip or a cord tip. What we spoke about earlier, that curve tip catheter is a really useful tip. If you feel like you are getting caught at the bend and not able to get past the prostate. And the way you use that is to always put the tip pointing up towards the patient's nose. When you insert it by putting it in up towards the patient's nose, it acts as a hook which helps you get around this angle initially. And if it can just hook into the prostate a little bit better, then it helps you glide through and get into the bladder. Use, the correct size catheter is a good tip. Um using two large catheters can cause strictures which can cause, you know, irritation and infection, but also long term issues. Um and all of that is just because of inflammation, that's, that's being caused by the, by the catheter being there. If it is too large within the urethra, that being said, if you have a patient that's in acute urinary retention, then it seems kind of counterintuitive. But if you're struggling to get the, the catheter pass the prostate, then you can use a slightly larger catheter. So maybe just increase the size to prevent you of what you think you should use. And that can help you get around that, uh get around the prostate because it gives you a bit more rigidity. So the larger catheters are a bit more rigid than the smaller catheters. So by just using, uh, you know, a couple of french up in size, the patient who's got acute urinary retention, it can allow you to drain out all that urine and give them that instant relief. If you're struggling to get past the prostate, you might want to not think about leaving that catheter in there over the long term, if it is slightly too large for the urethra, but for the short term, it can certainly help you get past the prostate issue. Ok? T number five, then don't overinflate the blue 10 mils is absolutely fine to, to inflate the ballon. If you put too much in, then it can cause the bladder to go into these spasms, which can actually cause retention or they can cause bypassing of the urine. And for those who don't know what bypassing is, sort of what it sounds like, but it's effectively where you've got the catheter in and it's in the bladder, but there's spillage of the urine passes. So, rather than draining through the catheter into the bag, it's just spreading around the catheter, edges out through the bladder neck, through the urethra. Um And effectively you're getting leaking incontinence around your catheter. Ok. So if you go into these spasms, it can help promote that happening as well. Um always replace the foreskin in males to avoid paraphysis. So if you, if you accidentally forget to pull that foreskin back down after you've done the procedure, then you can get inflammation of the tip of the penis and the edge of the foreskin, which can make it really difficult to pull back down and also very painful. So, some common bleeps that you might get there. And the first two that we're going to look at are quite similar, but a patient's catheter isn't draining. It is a really common one that you'll get from nurses on the ward and the things that you want to consider. Uh in this instance, some of them you can ask them to do over the phone and some of them you might have to go and see the patient but I would certainly think about asking to get a bladder scan and asking about the hydration status. So that's to assess whether or not the patient is producing urine. So if you scan the bladder and there's nothing in there, then that's probably why the catheter's bag isn't draining anything. Um, the hydration status. So, are they actually drinking enough? Are they potentially in a pre renal AKI? And that's why they're not producing urine, which is why your catheter bag isn't draining in the first place if that's all? Ok. And actually they do have bladder in the urine. They are drinking plenty. Their s are all reassuring for the fact that they are producing urine or have been producing urine. Well, they're not in an AK. Uh, then you want to think about, well, what is the cause of this blockage of the catheter? The first one which is really easy to get to stop? Is are there any kinks on the outlet? So just trace that, that catheter all the way from the tip to the bag and make sure that it's, uh, you know, a nice open lumen for the urine to drain out. Um, try and deflate the balloon, push it all the way in and then reinflate it. So sometimes the bladder, the position of the tip of the catheter inside the bladder can make a difference either because it can sometimes slip down slightly. But more commonly the, the opening hole can sort of get pushed up against the bladder which can block the inflow of urine. So, just by deflating the balloon moving about, pushing it all the way in again, can help to open up those holes and then allow the drains to start again. Try and flush the bladder. So that's what we see on the right hand side here. And you can flush the catheter even with a two way catheter. So you don't need a three way catheter to flush. And that's effectively just taking some saline solution 20 miles or so and putting it into the normal outlet tract and when you want to push it through and you might wanna pull back as well on the, um, syringe to pull out any sort of clots or debris that might have been blocking that catheter and causing that, um, that, um, blockage in the first place. So you get 20 miles in a syringe, push it in, pull back out and see if that relieves any sort of blockage. Um, if, if you've done all these things and you haven't managed to get the catheter draining again, then you want to try changing the catheter and see if that helps. So, take out the catheter and reassert a new one, one thing to mention as well. And so in terms of the causes, if we just think about what the causes might be, so we said that the cause of, of calf to not draining would be prerenal cause. So you're not producing enough urine, you're going to do hydration status of your bladder scan to assess that blockages, which could be debris clots they can cause it. So you won't want to think about flushing to investigate for those and to help prevent those. Um, catheter has not been in the right place or bladder spasms as well. So that's where you want to think about deflating your balloon, moving the catheter and reinflating it, making sure you've got the right amount of fluid in that balloon. Not too much that you might be causing bladder bladder spasms. And then the other thing that commonly causes, um, catheters not today properly is uti, so you might want to think about doing a, um, a urine dip if you do have any urine, um, still in the bag or, um, or a, um, just some blood just to assess for any signs of any infection. Ok. My is my patient's catheter is bypassing. Same sort of things really is what causes a blockage. So, bypassing is when, rather than draining through the catheter, it's draining around the edges and out through the urethra for what's left of the urethra. You really want to do the same sort of thing. So check for any kinks, deflate, push, etc, try and flush it, change the catheter if that's not working and the causes for that are exactly the same really as, as, as not draining at all. Aside, from the fact that you now know they are producing urine. So you don't have to be too concerned about prerenal causes of this lack of, of urine production. Um OK. Third beat them. So my patients ripped out their catheter and now it's bleeding. Um always painful to think about. Um but not uncommon, particularly in older patients who experience some delirium. And the first thing you want to do if it's bleeding is to hold the tip of the penis away from the body and apply pressure. Um Same sort of idea as if you would have a nose bleed. Do you want to stem the bleeding and allow that blood to clot initially after the bleeding? So the the acute bleeding phase has stopped. Do you want to check, are they able to pass urine? Ok. If they are not able to pass urine, then you might need to think about reinserting the catheter. And you also want to think about why did they rip it out in the first place? So did they rip it out because it was painful? In which case, you might want to think about what size catheter you're putting in again or did they rip it out? Because there was an aspect of delirium, which case you might want to do a screen, a confusion screen to assess for what the cause of that delirium might be. Um But overall, the main thing you want to do in these patients is stem the bleeding and then think about do we need to reinsert another catheter? And if the, if they're not able to pass in the urine after a few hours, then the answer to that question is yes. Ok. And the last one, then there's blood streamed urine in my catheter bag. So we looked a little bit about this earlier when we talked about the initial management of hematuria. And the first thing you want to do if, if a nurse speaks to you and says this is just says, is it actually hematuria. So patients who are severely dehydrated, have a high bilirubin or uncertain medications like the can have this sort of orange tint to their urine, um which is a sort of pseudo presentation for hematuria. So you want to think about those things first, but if it is dark red or uh you know, a rose color, then usually it is going to be hematuria. In which case you want to think about? Firstly, when was the catheter inserted? So, post catheter insertion, some bleeding is not uncommon because of that irritation to the urethra and to the prostate. So if it hasn't even been in certain a short period of time ago, then you might think, well, that's probably why and that's ok. You want to take bloods to assess for any sort of urinary tract, um urinary tract infections. So FBC looking at white cells, CRP, we'd also probably want to do S while you're there, just to check that the kidneys are all. Ok? Is the catheter still draining? So, if the catheter is still draining, then you might want to um keep that catheter in. Um And just think about preventing any sort of clot formation. So, again, you'd want to think about doing a wash out and an irrigation potentially, if the bleeding is quite severe, if the catheter isn't draining, then you're probably going to want to remove that catheter and reinsert another one or after doing a washout and irrigation if that hasn't worked, ok? If it is more bleeding than what you just think is attributable to catheter insertion or an explained course like a uti, then you probably want to make a referral to urology to assess that patient properly and go through the work up like we did for hematuria previously with the patient who presented. But certainly the first things to do in this case is check. Is it definitely bleeding? When was the catheter inserted? Is this the cause? Is the catheter still draining? Do we need to do a wash out and consider an irrigation? And think about a urology referral? OK. Just to cover what we've looked at in this session. So we've looked at a couple of cases. The first one being urinary retention with Mr Menendez. The second one being hematuria with Miss Jackson and we've looked at the ati. So some common causes, some initial investigations that you might do the initial management that you might do along with definitive management for some presentations of those cases as well. We've also looked at some common catheter issues and some ways that you can troubleshoot those on the. Thanks for coming guys. Thanks for persevering. After the initial session had the technical difficulties. I'd really appreciate it if you could scan a QR code here and give some feedback on metal. Um Any questions pop them down below and we will respond to them in due time. Thank you very much.