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Hello and very warm welcome to Ulster University Surgical Society's revision series. It's so good to have you with us today. We will be looking at urology core conditions that can be found in the second year core conditions list. Just a quick disclaimer that the UU Surgical Series is a peer lead revision series for educational purposes. Only, the design and delivery of these materials is carried out by medical students and as such shouldn't be taken as professional medical advice. And whilst the materials have been designed as accurately as possible, it's possible that some of the materials may be out of date by the time it content is accessed. So we're learning objectives for today or firstly to review the fundamentals of urological anatomy as it relates to the core conditions, then we'll review the definition presentation and management of each of these core conditions. And then at the end, we'll have a go at some single best answer questions and on the right tier are some of the conditions that come up on the two-year core conditions list. Today, we're going to take a slightly different approach that we might have taken in other sessions where we would have tackled all the anatomy in the first half and the core conditions in the second half of the session. As urology spans a lot of different organs. We're going to look at the anatomy in isolation for each of these and the core conditions. Almost in little sections. We'll tackle the kidney anatomy and core conditions, the bladder, anatomy and conditions and so on and so forth. So, the study of urology focuses on the renal tract, which is the kidney, ureters, bladder and urethra, and then specifically the male reproductive organs. So, starting at the top, the kidney is a pretty good place to begin. So, if we were to do in-depth anatomy for each of these organs, it could become a very long session. Indeed. And it's more important that we stick to the absolute basics. Um and just give enough information that's useful for learning the conditions. So here on the left is the growth structure of the kidney as if it's been sliced down the middle, giving you an internal view and the major structures you need to be aware of are working from outside. In you have the cortex tissue, the medulla tissue and the medulla tissue is arranged into these renal pyramids or medullary pyramids. These triangular structures. Here, each of these drain into minor calluses. The minor calluses drain into major calluses. The major calluses drain into the renal pelvis which drains into the ureter. Ok. And the flow of urine is such that blood comes in through the renal artery. It feeds into the functional unit of the kidney, which is the Nephron. Hopefully, you'll remember this from first year anatomy and nephrology and the blood is filtered. The waste products are taken out and the urine drains via this collecting system and into the ureter. On the right, I've included the, the vascular supply supply to the kidneys. Here's your main vascular motorways. If you like going down the body, the abdominal aorta here in the red, the inferior vena cava in the blue. Here, the kidneys are supplied by right and left renal arteries which come out at approximately the levels of L1 L2 and are drained by, you guessed it, the renal veins you can appreciate with the orientation here of the IVC and the AORTA that the right and left renal arteries and right and left renal veins are going to be different lengths. So because the aorta is further to one side or it's closer to the left kidney, the left renal artery is shorter and the right renal artery is longer and then the opposite is true for the left and right renal veins. So I want to include a little bit about the ureter as well because it will become important. A little later on. The ureter originates from the renal pelvis in the kidney and then there's an abdominal part of the ureter and it descends down into the pelvis and connects and drains into the bladder. And here's a cross section of the ureter. It's kind of got this almost star shaped lumen and the layers going from superficial. The deeper this muscular layer on the outside, there's a lamina propria on the inside and then the epithelium that faces the lumen on the innermost surface. And the way that that the ureter works is quite like the peristalsis of the bile. It contracts in a coordinated fashion to, to squeeze urine down the tube. Um This, this movement is sometimes called vermiculation. It's it's the word that means wormlike because as you see the, the ureter kind of writhing in this way, it almost looks like a worm. Ok. I've added this in constriction points in the and this becomes clinically important when we start thinking about renal stones in a little moment. There are a couple of areas of the ureter where there are natural constrictions and these are the areas that are susceptible to obstruction by, by kidney stones. So some of the narrowing areas going from the top is this area here called the pelvic uric junction or the P UJ. Then moving on down. There's another natural constriction point here called the pelvic brim. Now, this is where the ureter enters the pelvis and there's a crossing of the internal iliac vessels here and where the crosses those vessels is another little point where a stone can get lodged if you're unlucky and then the third main constriction point is the vu the Vesico ric junction, that area where urine enters from the, from the ureter into the bladder. So this is important to know, I know that we've had a, a brief discussion about the constriction points in the ureter that sets us up nicely for the topic of renal stones. Now, I noticed that renal stones isn't actually part of the core conditions list to you, But I thought it was, it was almost impossible to have a urology revision session without touching on the subject briefly. Um It's, it's just the the precursor to so many problems. So I think it's important that we just discuss it for a moment. So this is renal stones, stones in the renal tract. Um Some of the other names you'll hear are renal calculi, urolithiasis and nephrolithiasis. And they can come in several different types. The most common is calcium oxalate stones. You can get stones made out of calcium phosphate, uric acid struvite. Um An interesting type is a Staghorn calculus where the stone actually molds and forms according to the shape of that, that renal pelvis and those calluses that we, we showed in a few slides a few slides ago and it forms this Staghorn looking thing. Um And again, here are some, some of the sites you might find stones. So in those calluses, you might find them bobbing around in the renal pelvis. And then you might find them stuck in places like the P UJ and the V UJ. And that's when it starts causing problems and by problems, I mean urinary obstruction, um, urine can't get past this blockage. It becomes static, it becomes a harbor for bacteria and an infection and the backup of urine can lead to an acute injury. And here's just another diagram showing where those stones might be located or obstructed. So, in a nutshell, the basis for formation of these stones is over saturation or over concentration of the urine. Um And some of the risk factors of these, you might have guessed would be dehydration, extremes of exercise. So maybe too little or too much exercise, obesity, high dietary salt, highly acidic drinks. Um and there's a couple more, but these are the main ones that you'll, you'll find in the general population. How do these patients present? Well, interestingly, they might not even know the stone is there and they'll be completely asymptomatic until a stone becomes obstructed in one of those sites that we discussed in the last slide. And when this happens, these patients will present with a sudden onset of excruciating pain. They'll describe it as low to groin and that's where it starts in the back or in the flank. And it's kind of moving a diagonal pattern down towards the groin on one side. It's usually so painful that it's associated with nausea and vomiting. If the stone is causing trauma in the renal tract, there might be hematuria, blood in the urine. Typically, you don't see it with the naked eye and, but this would be picked up on a urine dipstick. And if it's been lodged there for a while and it's starting to cause urinary stasis, there might be an infection starting to bruise as well. So they might have fever, they might be, have chills, they might be exhausted. So this patient comes in. How are you going to investigate them? The first couple of basic things you're going to do is a urine dipstick and a culture. And that might show you some of that microscopic blood. If there's infection in the urine, it, it might be present there as well. Um You'll want to take a set of routine bloods, full blood count, CRP U and ES. But really if you're suspecting stones, what you want is some imaging. Ok. The gold standard for diagnosing renal stones is what we call a noncontrast ct kidney ureter bladder or K UB. And the reason you do it is non contrast is that because the stone might be radioopaque and it will come up as, as as white. And if you put contrast agent into the renal tract, it will also turn up white as well. So by using contrast, you might actually mask if, if there's a stone there. So noncontrast CT K UB, you might, if you're concerned that um there's complete obstruction of urine, you might do an ultrasound of the renal tract to assess for hydronephrosis, which is sort of an enlargement of the kidney secondary to um urinary obstruction and backflow. But that's more measuring complications. Nonconscious C TK UB is what you need to remember. So, the patients come in, you've performed act K UB, you've seen the stone obstructing. How are you going to manage these patients? So, first of all, it is really, really painful. So, painkiller is a must and some of the most effective options would be im or erectile diclofenac, which is an NSAID. If they're really dehydrated, you might offer fluid replacement that might be oral, just encouraging them to drink. And in turn, this might help the stone pass spontaneously if they're feeling really sick, an antiemetic like cyclizine would be appropriate. And if there's evidence of infection, you'd really want to start them on antibiotics. Some of the definitive options however, are indeed surgical. So some of the common ones you might see in placement are extracorporeal shockwave, lithotripsy. This is sending shock targeted shock waves that break those bigger stones into smaller pieces, allowing them to come out in the urine. If you have really big ones that are maybe resistant to shock wave therapy, you might insert a camera and this is called uteroscopy and you can target the stone directly with the laser. And if you're on placement and you get a chance to see this, it is quite cool. I'd recommend it. Um Another option that is more invasive is a percutaneous nephrolithotomy. And this is where you insert a camera via the back directly into the kidney and stones can be removed there and you can leave a drain in place called a nephrostomy that helps the kidney decompress and release some of the urine that's been backed up. So we've had a brief overview on stones and now I want to move on and talk about the second of the kidney core conditions, which is renal cancer. The most common form of a renal tumor is a renal cell carcinoma. And here's some of the risk factors. Now, smoking is a big one. It will double the risk exposure to carcinogens. Maybe in the workplace is a risk factor. Dialysis has shown to be a big risk factor for, for these patients. And of course, some of the other things like high BP, obesity and anatomical disorders like polycystic kidneys, these are just some types to be aware of. Don't worry about these too much. Um It just, it just, it's important to, to be aware of some of these things and especially willms tumor, which is um one that presents in Children typically under five years old. How do these patients present? Again? These are often asymptomatic and they'll be picked up incidentally on, on act scan for something else. The kidneys are retroperitoneal organs which means they have a large space to grow in before they start causing symptoms or obstructing something serious. Um, sometimes if they do have symptoms, you know, there'll be hematuria, blood in the urine, they'll have flank pain, there'll be a palpable flank mass and then they'll have some maybe systemic symptoms like lethargy and weight loss. So, how are you going to investigate these patients? A lot of the same investigations apply. Your analysis is always a good place to start on a blood profile. But the gold standard for diagnosing a renal cell carcinoma, it's a CT abdomen pelvis with contrast. And there's some discussion about the role of biopsy in in renal cancer and this probably will be performed. But CT abdo pelvis with contrast is usually sufficient later on. After the diagnosis, you might perform stuff like a CT chest for staging and looking for evidence of metastases in other parts of the body. And speaking of staging for renal cell carcinoma, they use the TNM staging which hopefully you will remember from um the last session on on breast cancer. Some, some centers will use the American Joint Committee of cancer staging which uses four stages. Don't worry about this too much. Um, rule of thumb is that stage one is, is a smaller tumor confined to the renal capsule. Stage two is a slightly bigger cancer that's invading the renal capsule on the outside of the kidney, but it's still confined to the organ. Stage three is where it's the cancer is maybe extending into the nearby vasculature such as the renal vein or the vena cava or it's maybe spread to one or two local lymph nodes and then stage four very serious cancers. They're extending beyond the kidney into the lymphovascular system and maybe the nearby adrenal gland or they'd maybe metastasize to a different organ altogether. And on metastases, here are some of the places that renal cancer will spread to. Firstly, it'll go into the surrounding renal fascia and tissue, then next into the renal vessels into the renal vein and the IVC. Then looking at more serious metastasis, it will travel on the lymphatics and other sites include bones, liver, brain, and lungs. So that's why we might perform some um CT chest, for example, for, for staging purposes. So you've performed a CT abdomen pelvis. With contrast, you've diagnosed this patient with renal cancer. What are your options for managing and treating the patient then? So your first line things are surgical options and you've got a couple of choices. You can do a partial nephrectomy, which as the name suggests is removing just the diseased section of the kidney and leaving the remaining functional kidney in situ. Or you can perform a radical nephrectomy which is removing the entire kidney surrounding tissues, lymph nodes, maybe some adrenal glands as well. Those two are the mainstay of surgical options. I've added these ones in as well just as an fyi there's also a percutaneous cryotherapy which freezes the cancer cells using nitrogen and there's also radiofrequency ablation and that's doing the same thing only using an electrical current. So that's when patients are fortunate enough to have been caught in the early stages of disease or local stages of disease for metastatic disease. However, you have to think about other options. So you might perform the nephrectomy plus one of something else. So you might add in immunotherapy or some of these newer drugs like biologics to attack the metastases. But what you might actually do is perform a metastasectomy which is removal of an isolated metastasis. So if you've done a staging scan and you've noticed there are metastasis in the brain or lung and you, you determine that those can be removed safely with their own separate procedures. That's an option too. Go like saying with any cancer, patient management should involve an MDT input. It's dependent on so many things, cancer stage, patient health and patient preference. So um take this this revision as like the basics and overview, but appreciate that on placement. You're going to see a G a great variety of different management plans. So that rounds off our overview of the renal conditions. Now, we jump into some of the bladder conditions. So what's the bladder for the bladder is to store urine and also to end the expulsion of urine. Ok, to contract and get rid of urine, looking at the bladder wall, working from the inside, out on the inside facing the lumen, we have the transitional epithelium, which could be a common exam question. Outside of that, we have the lamina propria. Then outside of that, there's a muscular layer. This is the detrusor muscle and on the outermost layer is a is a layer of fatty connective tissue. Now looking at the growth structure of the ureter, it's got this trigone triangular shape which marks the boundaries for the ureteric me, the opening of the ureter and where urine drains in from the kidney, the bladder then drains into the urethra. So we're looking briefly at the neurovascular supply to the bladder. In terms of arterial blood supply, the bladder gets most of its blood from the superior vesicular arteries, which are branches of the internal iliac artery. Any time you hear vesicular, it's usually to do with the bladder. There's some additional blood supply, uh which differs between males and females. In the males. There'll be some additional supply from the inferior vesicular arteries and then the vaginal arteries in females. Then for the innervation. Now, innervation for the bladder, there's a couple of things going on at any one time, the bladder receives sympathetic input from the hypogastric nerve. This is responsible for relaxing that trusion muscle or on the outside of the bladder. And when the muscle is relaxed, then that promotes retention of urine. The other side of that is the parap sympathetic system, which is the pelvic nerve and that's responsible for contracting the detrusor muscle. And that's what initiates the squeeze of the bladder and initiates the urination. Then there's somatic input as well from the pudendal nerve which maintains control of the external urethral sphincter and voluntary urination. Now, we have what's called the bladder stretch reflex. Um It's something we're born with. And what happens is as the bladder fills with urine, there are receptors in the wall of the bladder that sense the stretch of the bladder wall. Ok. And what happens is the bladder fails, the sensory nerves sense this information, send this information to the spinal cord. And then the reflex is that the parasympathetic system kicks in the detrusor is contracted and the urine is expelled and this is an involuntary thing. And this is, this is what you'll notice in infants before they've been toilet trained and they'll, they'll not have control of urination. It does as infants go through toilet training, we sort of learned how to override this reflex and, and grow out of it a little bit. You have to consider this in the cases of spinal injuries or perhaps neurodegenerative diseases, um where the brain is, is no longer able to override this reflex. So this is worth thinking of if, if someone comes in with involuntary urination that there might be a neurological cause and it might be something to do with that bladder stretch reflex. But this is just something interesting to know. I know just a couple of quick facts on the urethra. You can see here we're looking at the male urethra which is approximately 15 to 20 centimeters long and it's divided into three parts. So there's the prosthetic part, the membranous part and the penile or the bulbous part. And that just denotes what, what other structures the urethra is traveling through. Um the length of the urethra in males is, is really relevant. It's particularly relevant for catheterization and perhaps some of you in your placement will have had an opportunity to do this already. Um You can see on this diagram on the right, there are a couple of angles, there's the prepubic angle and the infrapubic angle. And these are areas where a catheter just might need a little more encouragement to, to, to navigate the tract. Um And it's important to make note of note of these lengths because male and female catheters are different and you do not want to put a female catheter, which is obviously shorter into a male urethra because you would end up inflating the balloon somewhere in the, in the urethra. And the patient would let you know about it because it would be really, really painful. The female urethra is much shorter. It's only four centimeters passes through the pelvic floor muscles and opens onto the perineal vestibule, which is just anterior to the vaginal opening. The length of the female urethra is relevant because it is shorter and this leaves females more susceptible to urinary tract infection simply that it is a shorter space and there is, there's a closer, more confined space for bacteria to accumulate and it's a shorter distance for bacteria to drive off from the opening into the bladder. I know that we've teed up urinary tract infection that brings us to the first condition. This is such a common presentation. Um I think maybe in, in my study so far, it's been the thing I've seen the most of and this is infection at any point between kidney ureter bladder and urethra. Some important terminology to be aware of. If someone talks about pyelonephritis, this is infection in the kidney tissue, someone talks about cystitis, that's inflammation of the bladder. The top cause of urinary tract infection is, is e coli and more often than not, it's, it's via local spread from the anal opening. E coli is part of the normal gut flora, but the anal opening is very close to the urethral opening and this is just local spread. Some of the things you'll see in hospital might be infection that stems from an indwelling urinary catheter. And this is again a surface for bacteria to cling to. So how do these patients present? And this, this list of symptoms is really something that you should become familiar with as um particularly if you're in general practice placement or if you want to go into general practice later down the line, you'll encounter these symptoms. A lot. Typically they will have dysuria, so painful urination, they'll have suprapubic pain or lower abdominal pain. Maybe in pilot arthritis, they'll have some pain in the loin or in the back. They might report needing to, to urinate more frequently or more urgently. They might report a really file smell from the urine and particularly in elderly patients, urinary tract infections, a big cause for confusion. Some things to be aware of in your assessment are just high fever. So, thinking of a temperature of over 38 degrees loin pain, um and renal angle tenderness would be more indicative of pyonephritis over a lower uti maybe like a cystitis. So these are just things to keep an eye out for. So how do you investigate these patients? The the mainstay of investigation, particularly in the community is urine dipstick and some of the evidence that you're looking for that would suggest infection or nitrites leucocytes or maybe red blood cells in the urine. And more often than not, you send this urine away for microscopy and culture to, to just double check what the organism is and make sure you're targeting your antibiotics appropriately. Now, there's some stewardship involved with antibiotics. You need to be, you can't hand them out to everyone. So a couple of general rules, if the urine contains nitrates or leucocytes or red blood cells, you go ahead and you treat this as a uti, you don't wait for culture. Um but culture might inform your decision or make you change your mind on antibiotics. If you have dipped a urine and there are only leucocytes present, but there are no nitrites, there are no red blood cells. Then typically you wouldn't offer an antibiotic. These leucocytes are just less specific for urinary tract infections. But if you are going to treat as a, as a uti, then antibiotics is the mainstay. You, you follow your local guidelines and high levels of sensitivity just because this is a very common illness. But one of the ones you'll, you'll see loads in general practice and in the hospital are trimethoprim nitrofurantoin, maybe called ICV. So if you, if you even remember these three, that would be, that would be enough duration wise for simple uti s3 days is usually enough. Um, maybe 5 to 10 days if you are immunosuppressed or, or if, if you've got a lower baseline kidney function and typically for men, pregnant women or any catheter related uti S, you'll, you'll go for a seven day course. And that's just because these tend to be more serious infections. Now, moving along to bladder cancer, this is cancer that typically arise from the, arises from the endothelial lining of the bladder. And if you remember from the anatomy a few slides ago, the most that epithelium is transitional cell. So, naturally, the most common type of bladder cancer is a transitional cell carcinoma. And here are some of the other types too um risk factors. Smoking as with most cancers is a, is a big risk factor. And exposure to aromatic hydrocarbons such as like an industrial dye can be um a big risk factor. That's something that might slip into exam questions to see if you can associate it with bladder cancer and previous pelvic radiation, maybe for other surgeries is also a risk factor. These patients present more often than not with painless hematuria. So blood in the urine that doesn't hurt as it's coming out. This is a red flag thing that warrants a two week weight referral, an urgent referral to see a a urologist, um and painless hematuria should be treated as bladder cancer until proven. Otherwise, other things that the patient might tell you is that they have recurrent uti s um increased frequency, urgency, the feeling of incomplete voiding. So when they go, they're emptying, but they feel like they could maybe get a little bit more, it just won't come and then some of the systemic signs of cancer like weight loss and fatigue. So if the specialist thinks it's necessary, what you're gonna do for these patients is cystoscopy. This is, this is a camera test that can visualize the inside of the bladder. If there's a suspicion lesion there, you might remove it there and then, or if it's too big, take a biopsy and send it to the labs for investigation. And then later on, if you think you've confirmed that this is cancer and you suspect that there might be muscle invasion, you might perform act to stage the cancer. No, like kidney cancer, you can use the, the C NM staging for, for bladder cancer too. And here's just some examples of, of what the T and M staging might look like in the bladder context. Please don't worry about learning this off by heart. It's probably useful enough that, you know, T and M staging is, is the system that's used. But for example, here are, if we just take tumor, T one is a cancer that's maybe started to grow into the connective tissue. Ta is the level before that where it's maybe just in the innermost layer. Um It's a very superficial one, T two. The cancer is maybe growing into the connective tissue T three. It's maybe starting to invade the muscular layer that detrusor muscle and T four is as always the most serious one where it's invaded beyond the bladder and is maybe traveling to other organs. So management of these cancers is something you'll see quite frequently on your urology placements. Hopefully, some of you have had the opportunity to see these operations already. And for nonmuscle disease or invasive disease, the standard procedure is what's called the transurethral resection of bladder tumor or TPT procedure. And this uses a cystoscope and you can, if you can see it's, it's quite difficult to see here. There's a small sort of U shaped hook that can transfer heat and you can use this to burn off and shave off the tumor from endothelial li lining of the bladder. It's quite a satisfying procedure. Um, especially if it's only a superficial thing that can just be nicked off. This is often given alongside chemotherapy, intravesical, which means directly into the bladder. Um One of the things you might see used is chemotherapy called mitoMYcin C. And after the procedure or after the tumor has been removed, this might just be injected into the bladder. So that's for noninvasive disease. In the case of where the cancer has maybe invaded the muscle, you might have to consider a radical cystectomy which is removing the bladder and that obviously means that the kidneys are still going to produce urine and you're going to have to re divert that, that urine somewhere else that might either be with the urostomy. Um where the ureter is brought out to the surface of the skin, kind of like an ileostomy or you might use a piece of bile to reconstruct the bladder, a new bladder altogether. And in muscle invasive disease, you might need some, some systemic chemotherapy with that as well. For, for metastatic cancer. The the surgical options might be limited to chemotherapy and symptom relief is is what you're aiming for and there would be palliative care input there. There's a worse prognosis for that. And just on prognosis, typically for superficial cancers, the prognosis is quite good for bladder cancer. Um As always, it's dependent on cancer staging, the patient's underlying health and the decision of the MDT. But superficial disease like TI S TA or, or T one typically has a good prognosis. So there is an overview of the bladder conditions that you're going to see most in placement and indeed in exams and we've got some more good stuff to go. I want to take a, a pause here and just to say urology has a lot of information in it. It covers a lot of anatomy and a lot of conditions. Try not to get too overwhelmed by all this information. Don't try and commit at all to memory right? This moment, this is just an introduction to the subject and something that you can hopefully come back to if you need a refresher at your revision. So why don't you take a couple of minutes to stretch your legs? Have a break and join me again for prostate conditions? Ok. So the prostate, the prostate is a small gland commonly referred to as the size of a walnut. And it's an important gland. It, what it does is secretes proteolytic enzymes into the semen. What this does is break down the clotting factors in the semen and allows it to remain in a liquid state as it moves through the female reproductive tract and allows for fertilization in terms of position. You can see from this diagram that it sits just inferior to the neck of the bladder, but superior to the external urethral sphincter and anteriorly to the rectal ampulla. And if you were to slice it up and look at the tissue under a microscope, you would notice three different zones. So most of the prostate is made up of the peripheral zone right about 70%. Um And it sort of shrouds around the two other zones. As you can see, the transitional zone represents a very small part, maybe only 5 to 10% and the central zone 25%. And hopefully, you can appreciate from this diagram, the position of those zones in relation to the urethral course, it almost hugs around the outside of, of the urethra. So you can imagine when the prostate is enlarged in any way that that urethra become compressed and then the neurovascular supply of the prostate is as follows. The arterial surprise via the prosthetic branches of internal iliac artery. The venous drainage is via the prosthetic plexus which drains into the internal lilac veins and the innervation is via the inferior hypogastric plexus. So the first of our prostate conditions is prostatitis, which you might have guessed is inflammation of the prostate. This can be an acute thing or it could be a chronic thing. When you suffer from this. For for many months, these patients will typically present with in the chronic, they'll present with pain, um painful urination, maybe some urinary frequency or the opposite retention might present with erectile dysfunction or pain and ejaculation. They might have blood in the sperm. They might also have painful bowel movements. Remember we talked about the close relation to the rectal ampulla and on examination, they will have a chronically enlarged prostate. In the acute setting, the symptoms will be similar, but there might be some more systemic infective symptoms like fever, myalgia, nausea, fatigue, and in serious cases, they might present a septic, which you wouldn't get with the chronic picture. So you'll investigate these patients with a urine dipstick, urine microscopy culture and sensitivities. Usually you'll do um S ti testing on these patients as well as one of the causes can indeed be sexually transmitted chlamydia and gonorrhea can be culprits. And if they are presenting acutely with, you know, they're very systemically unwell, you'd do blood cultures and initiate your sepsis, sepsis. Six, most likely then to manage these patients in the acute setting. If they're really unwell, they might need admitted to hospital for urgent IV antibiotics. Some of the, the courses you might give are Ciprofloxacin, ofloxacin. Um along with pain relief and supportive care like fluids if needed. The chronic prostatitis patients, they're usually treated with alpha blockers um to, to try and shrink the size of the prostate. You can see here from the picture the effect that prostatitis has on the urethra, it will compress and cause those urinary symptoms if the prostate is so large that it's, it's causing painful bowel movements. You might, these chronic patients might have laxatives as well. It's not something I've seen much, but it's, it's important to be aware of this condition. So now we move on to quite an important urology condition. This is benign prostatic hyperplasia or BPH for short and BPH is extra proliferation of the strong and epithelial cells in the prostate which causes the prostate to enlarge and the symptoms that come with it. So this is really common. It affects approximately half a man in their fifties and up to as many as, as much as 90% of men in their eighties. So it really does affect a lot of people and given what we said about the prostate's position in relation to the urethra, you can understand that these patients might present with painful urination and more likely per flow because of urinary, urinary outlet, obstruction, dribbling that sensation of complete emptying, really having to strain to, to urinate, getting up in the middle of the night, to urinate and running an exam. Um, digital rectal exam, you'll typically feel a large prostate and it's important, um, to be able to differentiate between what feels like a benign prostate and what feels like a be a malignant prostate benign are typically smooth, uniform. Um, they are large but um are more often than not slightly softer. Some people describe it as almost buggy, whereas a cancerous prostate is really hard. It's asymmetrical in shape. Um, it's craggy and irregular, um, and does feel very different on top of a digital rectal exam, you'd want to do an abdominal exam as well. If, if the patient's telling you they haven't urinated in quite some time, you'd want to feel their suprapubic area just to make sure there isn't a palpably distended bladder investigating these patients. You start with urine dipstick, you'd measure urinary output and you might to, to help your diagnosis measure psa prostate specific antigen. Although something that's important to note about this is that it's not specific. And what that means is that it can be raised by any number of things. You know, a raised psa doesn't, doesn't diagnose B ph and it could cause false positives which cause the patient to worry and stress out about it. So a PSA might be raised by prostate cancer. It could be raised by prostatitis or a uti it could be raised by exercise that is traumatic to the pers, like sitting on a bicycle saddle and inter intercourse and ejaculation can, can raise it as well. So it's really not relied on too much. So when it comes to managing these patients, then the objective is to relieve those urinary symptoms. And we do that with a couple of drugs that are worth remembering and these are the mainstay of prostate medical management. The first class is alpha blockers. A common one is tamsulosin. And what these do is help the smooth muscle of the prostate relax and um and just reduce the activity of it. And the longer term relief then is using a class of drugs called five alpha reductase inhibitors. Now, these help convert testosterone into another form called dihydrotestosterone. And what this does is gradually shrink the prostate in size. So in a, in a prostate that has been chronically enlarging, these are, these are useful for long term symptom relief in really problematic cases or if it's really the patient's wish and it's, it's, you know, taking away from their quality of life significantly. There are surgical options you might see in your placement, a transurethral resection of the prostate or a terp. That's the most common one. As you can see in the diagram on the right, the objective is to um use a cystoscope to go in and you scrape away from the inside of the urethra, a portion of the bladder or the prostate tissue um to maintain the patency of the urethra. Some of the other options are listed here, but um they're, they're less common but just useful to be aware of. So we discussed earlier the importance of being able to differentiate B PH from prostate cancer, which is gonna what we're going to look at now. So, prostate cancer in 95% of cases originates from the cells of the peripheral zone, which makes sense given that it is the largest of the zones and accounts for 70% of the prostate's tissue. Some of the risk factors for prostate cancer are age over 75. Um, Black African or Caribbean ethnicity, family history of prostate cancer, obesity, diabetes, mellitis and smoking. And quite often these patients are asymptomatic, um, or it's, it's confused for just non troublesome B ph, but some symptoms that might make you think more seriously that this could be a cancer or blood in the urine ed, bone pain, lethargy, weight loss and anorexia. And those last few are the ones that would make you think maybe there's metastatic disease going on here examining these patients as always, the digital rectal examination is a good place to start. And as we discussed, um before some of the things that make you think more towards cancer rather than BPH would be asymmetry of the prostate. Um fixed hard irregular masses, apologies that that should say nodularity where there's um harder nodules in the prostate and loss of the central sulcus, which you would be able to feel in, in a normal or a benign prostate. Again, investigating these patients, you can use a PSA and it's not diagnostic. A raised PSA does not mean you have prostate cancer, but it might just be used to inform next steps or to measure the effectiveness of treatment really to kick off the diagnostic process. You might do a multiparametric MRI which can identify an irregular prostate and give you an image of that. But gold standard is taking a biopsy of the prostate and typically you'll take a couple of different tissue samples. Grading prostate cancer is based on histological appearance. So when you take those samples of tissue and you look at them under the microscope, and the grading system is the Gleason system and this, this could come up, come up in an exam. So it's, it's useful just to remember Gleason for prostate cancer. But you don't use the histological appearance on its own. You do that alongside psa measurement. Um and the stage of the cancer, the stage as with the other cancers we've discussed today is calculated using the TNM staging system. If you one to stage like like the other cancers, you would do a CT Chest Abdel vs, you're looking at the prostate itself, but looking for evidence of metastasis, just an example again of how the, the T might be informed in the T and M for prostate. So at one cancer in the prostate might just be too small to even fail on rectal exam T two. It may be a small cancer but contained within the prostate. T three will start extending beyond the prostate. And T four is where there's metastasis to nearby organs. You have a few different options with managing these patients. Sometimes you opt for the surveillance approach where you monitor the PSA every couple of months and every time you do that, you'd maybe perform a rectal examination and you can watch him wait, taking a biopsy every, every few years and maybe he might get an MRI to, to keep an eye on it as well. But there are some surgical options where you can remove the entire prostate. This is called a radical prost ectomy. You might take the seminal vesicles as well and some of the pelvic lymph nodes if there's evidence of spread and rarely um II, don't think it's done much anymore. But in the past, you might have seen more removal of the testicles as well. This is an example of surgical castration. Um Prostate cancer responds to androgens such as testosterone. So, by removing the source of testosterone production in the meals, you can almost starve the cancer of of what helps it grow. Hormone therapy has the same sort of idea it would be used in patients where there's metastatic disease. And you're trying to, to starve that cancer of testosterone, which is, which is helping it grow. So you might use androgen receptor blockers or gonadotrophin releasing hormone agonists just want to add in again that this is just an overview of some of the options out there. Each patient will be managed differently. It involves the MDT and depends on the stage and grade of cancer, the patient's health and of course, the patient's preferences. So now we move on to our fourth and final anatomical area which is the testicle. Ok. So the testicle and epidermis are paired structures in the male scrotum which serve the purpose of firstly producing and, and storing sperm. And there's also a role in hormone production as well. Looking at a, a cross section of the testicle here, the seminiferous tubules on the inside is where the majority of sperm production takes place. And the testicles drain out into the epididymis which has had a body and a tail which then further drains to the vast deference. Looking over here, then immediately outside the testicle, you have the cremaster muscle. Now, the cremaster muscle function is to raise and lower the scrotum and therefore the testicles in order to regulate the temperature. So, sperm, the ideal temperature for sperm development is around 34 degrees, which is a couple of degrees below body temperature, which is why the sperm or the testicles are outside the body cavity and the temperature of the testicles is regulated by increasing or decreasing the exposed surface area of, of the surrounding tissue. So, um if the the body is too cold, the cremaster works to contract and in warm environments, the cremaster relaxes to um to, to relax the scrotum. Another important instruction then is the spermatic cord. Um it carries a couple of things from the body to the testicle, but the most important ones are the blood supplies of the testicular artery which um arises directly off the abdominal aorta. The piniform plexus, which is a, a network of veins around the testicular artery which which drain blood from the testicle and the vast defer as we've discussed which, which carries sperm from the testicle and epididymis. So, her first condition is epididymis and orchitis, which you might have guessed is inflammation of the epididymis testicle and the common causes of this, it's usually caused by a local spread of another infection. So for example, a uti of the bladder might quite easily spread to the epididymis or, or the testicle enteric causes would include e coli um maybe clsa pseudomonas and then some of the nonenteric or more of the, the sexually transmitted causes might be chlamydia or the syria gonorrhea. Sometimes mumps is a cause for orchitis and this is something that can come up in exams where um a patient presents with testicular pain and they've had a history of parotid swelling, um indicative of a mumps infection. In the past, the typical presentation, these, these patients will come either with testicular pain, usually unilateral or describing a dragging, heavy sensation. There might be swelling and erythema around the testicle. And when you palpate this on exam, it's going to be tender, particularly over the epididymis on the posterior part of the testicle. In sexually transmitted causes like chlamydia or gonorrhea, you might expect some urethral discharge. And if the infection has spread and they've become systemically unwell, there might be fever and ry gos and chills. So you'll do a full examination. But some of the specific tests to be aware of um to exclude more serious things like testicular torsion are firstly, the chroma reflex, you test this by taking an item like maybe a piece of cotton wool or the end of a tendon hammer to brush against the inside of the thigh. And the chroma reflex is such that when you do this, the the scrotum will be elevated. This reflect is intact in cases of epididymitis and isn't intact in serious things like torsion. So this is a good differentiator. Another test you can do is pre test and a positive pr sign is when you elevate the scrotum, when the patient is lying flat on their back. And if elevation of the scrotum relieves the pain, this is a positive pre sign. If it's, if it does not relieve the pain, this is a negative pre sign, positive pre signs more suggestive of epididymitis and a negative pre sign would make you or make you suspect something more serious like a torsion. So to investigate these patients, first and foremost, you're going to try and find an underlying cause. So if you suspect a uti you would do a urine dip and microscopy. If the history is suggestive of a sexually transmitted cause, for example, maybe a patient's telling you they've had multiple sexual partners or unprotected sex, you might do nucleic acid amplification tests to identify the gonorrhea and the chlamydia do a full blood count and a CRP, if they're systemically unwell, you might send off for blood cultures, you could perform a us Doppler of the testicles which would show in epididymitis and orchitis increased vasculit or increased blood flow to the area as part of the inflammatory process. And then if you, if the history was suggestive of orchitis, secondary to mumps, you could send away for for mumps, antibodies and then manage, managing these patients first and foremost, is supportive care. So it's sore, don't be afraid to, to give these patients some analgesia. And then after your investigations have informed the underlying cause, then you would treat it. So for the enteric organisms, typical choices would be floxacin or levofloxacin. If you've identified, on the other hand, a sexually transmitted cause such as gonorrhea or chlamydia. Um in, in the case of chlamydia, you would give a single intramuscular shot of cetra axone with a course of doxycycline afterwards. And if you've identified gonorrhea or you think it's the most likely cause you would give those first two plus azithromycin. Now, we talked about testicular torsion as an important differential for testicular pain and this is one of the emergency conditions and what it is is twisting of the spermatic cord plus its contents with rotation of the testicle leading to vascular compromise, a cut off of the blood supply to the testicle, causing the testicle to slowly die. A couple of risk factors for testicular torsion. The common one is what's called a bell clapper deformity. This is um by direct your attention to the testo. Here, the gubernaculum on the outside of the testicle is, is responsible for helping the orientation and keeping that vertical eye of, of the testis sometimes in a proper deformity. This is, is anchored to the testicle abnormally or it's it's not present. And the, the testis might sit in a transverse or a sideways, horizontal lie in the scrotum and it can move more freely which leaves it susceptible to that spermatic cord and all those blood vessels twisting around in itself. Cryptorchidism is the the term for undescended testes, which is a risk factor younger age. So in between 12 and 25 is when you'll find this most commonly, um previous history of torsion is indeed a risk factor or testicular trauma such as contact sport. So these patients present with a severe testicular pain. It's usually on one side, it will come on suddenly, it will be so painful that it's associated with nausea and vomiting. And when you examine these patients, there will usually be a horizontal testicular lie and it will be raised on the affected side. So imagine you are over here, you're looking at the paired testicles, the normal side will will be hanging slightly lower. And because of the twisting of the cord, the affected side might be riding a little bit higher and the testicle itself will be in this transverse orientation. We discussed the the cremasteric reflex reflex typically in torsion. This is absent, which helps you differentiate it from, from epididymitis or orchitis and pre sine will be negative. Remember that pre sign is when the pain is elevated on upon elevation of the scrotum. Ok. So that will not be the case with torsion. So how do you officially diagnose this? Well, given the clinical picture more often than not, you'll be able to diagnose this clinically and it will be obvious. Um but if you're still in doubt, you can use the Doppler ultrasound to confirm the disturbance of vascular supply. And remember that's another way to differentiate between epididymitis, epididymitis and orchitis be that um increased vascularity. Whereas with torsion, it will be decreased because there will be less blood flow to the testicles to rule out an infection. You might want to perform a urine dip and a couple of those routine things. But this shouldn't delay urology, referral and emergency treatment. Why? Because torsion is a surgical emergency, ok. Every minute that passes, you're at risk of the testicle dying and it being unsalvageable. These patients need to be treated with emergency scrotal exploration and bilateral orchidopexy. This is fixation of the testicles. So you would untwist the spermatic cord and if it's ok and it's viable and it's going to survive, then you would just fix it to reduce the chance of that happening. Again. The reason I've, you know you do bilaterally is because even though the other testicle hasn't been impacted, you might if, if you have torsion on one side, you might be at risk of having it on the other side in the future. So, while you're in theater, while um, the scrotum is being explored, it just makes sense to fix both of them at the same time. If, unfortunately, it, it's treated maybe too late or the torsion is severe and the infarction has, has set in and it's, it's, the testicle has started to die, then removal of the testicle might be required. This is called an orchidectomy. And some of the the complications of torsion are, as we've said, true total testicular infarction, maybe future infertility, chronic pain, um a repeated episode of torsion and obviously the risks that go with surgical treatment. So the last testicular condition I want to look at is testicular cancer. Um and it's cancer that typically arises from the germ cells, which are the sperm producing cells of the testicle and they can present as either a primary cancer. So, originating um first from the testicle or secondary cancer. So it's a cancer in another part of the body and it has metastasized and has been found in the testicle. So just to give you an overview of the types with this little diagram, so you can have germ cell tumors which make up 95% of testicular cancers and non germ cell tumors, which is a smaller portion within germ cells. Then you can have seminoma um and non-seminomatous germ cell tumors within the non germ cell group, you can have Leydig cell tumors and sertoli cell tumors. And hopefully, those terms are um are familiar to you from, from your embryology. It can get confusing but the gist is that germ cell tumors are usually malignant ones. Non germ cell tumors are usually benign and that's the most important bit. So the risk of factors for testicular cancer are undescended testicles, um history of male infertility and a family history. And these patients will typically present with a testicular lump. It's characteristically unilateral, it's not sore but like other cancers, it feels firm, fixed, irregular. Um And when you shine a light through this, this doesn't transilluminate. So it's an opaque structure and this helps you differentiate it from some other testicular things like varicoceles and hydroceles. How would you investigate these patients? Well, you would do a scrotal ultrasound to try and locate gross abnormalities in the scrotum. You can measure some tumor markers in the blood. So alpha fetoprotein beta HCG um LDH, these are quite nonspecific things. Um So, so don't worry about learning these too much. And then one of the most things that's commonly for is ct abdomen with contrast and that helps with the staging and trying to identify any metastases. Key thing to remember with testicular cancer is that you don't typically perform a biopsy, which seems unusual because you do so many different certain types of other cancers. But with the testicle. There's some evidence that suggests that punching into the tissues or the testicle causes cancer, seeding, it causes cancer cells to break away and seed into other parts of the testicle. So, biopsy isn't performed and that's something that um that might be tested in exams. So we said that CT is used to stage testicular cancer. The royal Marsden staging system is what's used. And stage one means the cancer is isolated to the testicle. Stage two, is when it spreads to infra infradiaphragmatic lymph nodes. So any nodes below the diaphragm in stage three, they, this means that the cancer has spread to nodes above the diaphragm. And stage four, there's metastasis and involvement of other organs and usually with testicular cancer, the metastases sites are to the brain, liver and lungs. Remembering Royal Marston is a good, is a good start for testicular cancer. I wouldn't worry too much about learning the ins and outs of the stages to memory. So how would you manage? You've got a couple of options, surgical, you could perform orchidectomy, you simply remove the testicle and the cancer goes with it. Um Chemotherapy might be offered as an adjuvant to surgery to try and shrink the cancer or as a standalone therapy where that's, that's all you would be receiving. And then in more advanced maybe metastatic disease, radiotherapy might be offered as well. Follow up for testicular cancer patients will involve regular examinations of, of the scrotum maybe CT scans and chest x rays to um keep an eye on the primary cancer and to check if there's any metastases to the lungs and to assess um the efficacy of some of those medical treatments, you might monitor the tumor markers. So well done. If you've made it this far, there is one more condition I want to discuss. And it's something that the T year curriculum wants you to be able to recognize as a urological emergency. Acute urinary retention isn't really a condition as such. It's more a presentation. So it's when there's a new onset inability to pass urine and there's a couple of causes for this and some of them, we've, we've actually talked about today. So they can be obstructive causes where urine just cannot get past a mechanical blockage. So, in the example of B ph or urethral strictures from previous surgeries, maybe prostate cancer and constipation. These can just be causes that block the urethra off and stop the urine from passing. Then there can be neurological causes. So maybe there is nerve damage to the bladder from previous pelvic surgery. Um, some medications can cause um neurological dysfunction and and can cause you to lose control of, of urination and then some degenerative neurological conditions. Um, upper motor neurone diseases in particular like Parkinson's and MS. So how do they present they typically present with acute pain um in the lower abdomen or the supra pubic region and of course, the inability to urinate and these patients tend to get very full. They'll describe this feeling like they're going to blow if, um, if they fill up any more on examination of distended bladder. And here's an example of that. Now, this is quite a, they're not always as obvious as this. This is just a very skinny individual, um, where you can see a, a very enlarged bladder. Um, if they're unwell or infection has set in, they may also have fever Riggers, chills, lethargy and confusion, particularly in the elderly. This this can make people quite confused. So you'll start by examining these patients, you do a full general exam, um, signs of an infection, et cetera. You'd look for neurological causes and look for that distended bladder. As we showed in the previous slide. You'd also do a rectal examination to look for a couple of things. You um might find an enlarged prostate is the cause and you would treat it appropriately or you might find impacted stool indicative of constipation, which could also be compressing the urethra. Then some of the the actual tests you could perform are a post void bladder scan. So the patient, you ask the patient to empty their bladder if possible. Um And then you would, you would scan using ultrasound and this would show a level of retained urine volume and that would indicate that there is an outlet obstruction somewhere. You do routine bloods like FB CCR pu and e and after um you'd catheterize these patients, you would dip the urine from that and, and culture it to see if there's an infection. Um as a result of urinary stasis later on. After the acute stage, you could ultrasound the abdomen and pelvis and see if there's evidence of hydronephrosis. Um which if you remember is swelling of the kidney because it's of a, of a backflow of fluid. So the management when the problem is that they cannot urinate or there's an obstruction, then the solution is immediate catheterization and you get the catheter in as quick as possible because they have that feeling they're going to blow and you measure what comes out. And I've heard from urologists that when you can do this successfully for patients, they thank you so much and you are the hero of the day because it is just immediate relief. Then once you've, you've sorted out the immediate problem of, of a full bladder, you want to identify and treat the underlying cause. So for example, did you find that it was BPH that had caused the outlet obstruction? In that case, you would treat the BPH. So using drugs like tamsulosin, as we, as we discussed earlier was the cause an infection or, or is infection a result of urinary stasis. Well, then we'll give antibiotics, let's say it was total obstruction by stones um or something. Then you might need to take these patients to theater and decompress the kidney by inserting a tube in through the back and letting the, the urine, the urine back flow out directly from the kidney itself. And that's why you've performed things like the ultrasound to look for hydronephrosis. But these are all immediate things for definitive management. You would continue out or monitoring their urinary output and these patients have a catheter in, they'll maybe be in the hospital for a few days and when you feel it's ok and the kidneys are working, all right, you could try the patient without a catheter to see if they can pass urine spontaneously. Um And if they can and the urologist is happy. That's great. So you can discharge these patients. But if they go into retention again, they might require rec catheterization. So folks that brings us to the end of the session. Thank you so much for watching. I appreciate that it was a long one and that urology covers a lot of content. Um Just I would encourage you to use this as an overview and there are a couple of places you can go to get some more detail and more information. Your I OD urology session covers some more and some of the conditions covered today. And, and I encourage you to, to use this session in tandem with, with the I OD materials too. And some other useful resources that I just like to use for my own personal study are BMJ. Best practice the nice, um, clinical knowledge, summaries teach me surgery. Zero to finals smed. They're all good. Um, and I have some questions to, to test your knowledge. I can finish up by doing some single best answer questions and hang around if you want to do those. So pause the video at this point. Have a read through the question and have a go at answering and I will rejoin you in a couple of seconds. All right. So the question is asking you about a male who is hobbling into accident and emergency and he's complaining of a sharpshooting pain that travels between the back and the lower abdomen. This is kind of what you would identify as that typical loin to groin pain. And hopefully in that first sentence, you're already getting some ideas of what's going on here. Then the pains come on suddenly he has not been able to get comfortable and has been to the toilet once and it was a normal color. OK. So hopefully given that part of the question, you're starting to think of renal stones. And then the question is asking what's the gold standard investigation for diagnosing the likely condition and well done if you answered the C TK UB, without contrast, remember without contrast is important because if we were to use contrast, it could potentially um mask the presence of the stones so well done if you got that right. OK. Pause the video and eye for a few seconds and have a think about this one. All right. So this is asking about an 80 year old patient on who's been on the ward for treatment of BPH. Um, so we've got a known history of an enlarged prostate and one morning he's complaining of an inability to pass urine and he's in severe pain and can get comfortable. So hopefully you're thinking, ok, he's in acute urinary retention and he, there is, there's a risk factor of BPH there. So we might already have an idea on the cause. So the questions answering, given the likely diagnosis, which of the following options is the most appropriate for immediate management of this patient. And it's important to read the question carefully because really you could do all of these things, but the question wants the immediate management and well done if you identify the correct thing to do as insertion of a urinary catheter. Ok. So here is one more positive video now and have a go at this one, right? So this question is asking about a young gentleman who has come in with pain and a swollen red, right? Testis. And the key bits of information here are that the chroma reflex is intact, that there is a positive pre sign and that he is not sexually active. Ok. So you're already thinking this whatever it is probably isn't, um, sexually transmitted. And we're ruling out hopefully with intact reflexes and positive pre signs you've ruled out something really serious like torsion and the 10 day history of a gradual onset would support that as well. So you've got a couple of options here. Um Hopefully your key, your key differential is epididymis or orchitis. And the question is asking for the most appropriate management for the patient. So hopefully you've ruled out a. So because torsion is, is less likely you've ruled out b because, well, we need to do something for this patient. He's um quite a lot of discomfort. So you're left with a couple of other options. And the correct option is e pain relief and ofloxacin well done if you got that right, the reason that it is E and not C or D is that the, the cause is likely bacterial? Ok. And we would treat that with pain relief and of course, of, of floxacin or levofloxacin, um, the cefTRIAXone or cefTRIAXone or Azithromycin would be reserved for sexually transmitted causes or nonenteric causes like chlamydia or gonorrhea. Well done if you got that right. Well, folks, thank you so much for watching. I hope it was a useful recap. Sorry that it was a little longer than other sessions. But as you know, urology is a large topic and we were only able to cover the fundamentals today. So I'd encourage you to engage with the I OD resources and some of the other resources mentioned to supplement your learning and maybe you'll be able to revisit this as you come up to exams for a quick refresher. Our next session will be prerecorded as well and will be released onto metal on Wednesday, the 28th of February. It's going to cover ent and ophthalmology core conditions together, those were originally separate sessions, but for two year ophthalmology only has one or two core conditions. So we thought we could merge it into one session. It promises to be a good one. I hope you'll join us for it and until then take care.