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UROLOGY Surgical Teaching SeriesKINDLY SPONSORED BYAIMS Basic Anatomy Management of Acute Presentations Operation PrinciplesKEY ANATOMY Kahoot https://create.kahoot.it/my-library/kahoots/a2f55036-860f-4573-9d26- 59ce153e378cRENAL COLIC – UROLITHIASISPATHOGENESIS/ PATHOPHYSIOLOGY Calcium Stone Struvite Stone Uric Acid Stone Cystine StonePATHOGENESIS/ PATHOPHYSIOLOGY Calcium stones Struvite stones ­ 60-80% ­ 10-15% ­ Most calcium oxalate ­ Infective associated ­ Very insoluble ­ Staghorn calculi Uric acid stones Cystine stones ­ 5-10% ­ 1% ­ Associated with high protein diets ­ Hereditary ­ Associated with metabolic syndrome ­ Frequently recurRISK FACTORS Men : women, 3:1 Peak age 40-60 years Caucasian prevalence Diet Chronic dehydration Obesity Medication – aspirin, antacids, diuretics, antiretrovirals, antilepticsRENAL COLIC – NO INTERVENTION Stone normally passes ­ But very painful Associated infection/ hydronephrosis can cause permanent kidney scarring/ failurePRESENTATION – RENAL COLIC History Examination Loin to groin pain Flank tenderness ­ Colicky Possible sepsis – if infection ­ Sudden onset Writhing Haematuria Vomiting Haematuria on urine dip ­ 90% including microscopic INITIAL MANAGEMENT Review Patient Make Safe Confirm Diagnosis Hx + Exam Initial treatments + investigations Further investigation Escalate early if concerned Cover for scary differentials Rule out scary differentialMAKE SAFE – RENAL COLIC IVI Analgesia (PR diclofenac) Anti-emetic Monitor urine output Bloods – FBC, U+E, CRP , Coag ­ Renal derangement or evidence of infection warrant urgent urology reviewCONFIRM DIAGNOSIS – RENAL COLIC CT KUB Scout AXRPROBLEM What do you think the most common differential diagnosis is? • Pyelonephritis • AAA, biliary pathology, bowel obstruction, lower lobe pneumonia, or musculoskeletal related pain Renal stones – urology • But pyelonephritis – medics • But renal stone + infection warrants URGENT urology review You're and A&E doctors – how do you decide where to refer? You’re a GP – How do you decide where to refer? RENAL COLIC OVERVIEW Review Patient Make Safe Confirm Diagnosis loin to groin pain IVI CT KUB haematuria PR diclofenac flank tenderness Renal function ?infectionTESTICULAR TORSIONPATHOGENESIS / PATHOPHYSIOLOGY Testicular ischemia resulting from a rotational occlusion of the spermatic cord Most common 12-25 “Bell clapper” deformity predisposed (90% cases) ­ Found in 12% malesPATHOGENESIS/ PATHOPHYSIOLOGY Two main subtypesEXTRAVAGINAL TORSION Scrotal swelling, and dark discoloration of the scrotum ­ Clinically, the affected testis is usually firm and painless ­ The affected testis is usually necroticINTRAVAGINAL TORSION Occurs within the tunica vaginalis By far the most common type ­ Commonly occurs during puberty ­ Approximately 16% ED patient with acute scrotal pain ­ Peak incidence aged 13 years The left testis is more frequency involved Bilateral in 1-2%TESTICULAR TORSION – RISK FACTORS Undescended testicle Sexual arousal or activity Physical exercise An active cremasteric reflex Cold weather Family history of torsionDIFFERENTIALS Gastroenteritis Appendicitis Testicular torsion Torsion of hydatid of Morgagni Epididymitis/ epididymo-orchitis UTI Inguinal hernia HydrocelePRESENTATION – INTRAVAGINAL TESTICULAR TORSION History Examination ­ Extreme sudden onset testicular pain ­ Raised testicle ­ Vomiting ­ Swollen testicle ­ Extreme tenderness ­ Absent cremasteric reflex ­ Negative prehn’s signSPECIAL TESTS Cremasteric reflex Prehn signWHAT IS THIS SIGN AND WHAT DOES IT SUGGEST?BLUE DOT SIGN SUGGESTING LEFT TORTED HYDATID OF MORGAGNIINVESTIGATION Ultrasound (grey scale, colour or doppler) ­ whirlpool sign Only if there is diagnostic uncertainty and scrotal swelling is not of acute onsetTREATMENT ­Exploratory surgery within 6 hours of symptom onset if a torsiona high suspicion for ­raphe so that both testes can be examined ­If torsion is found bilateral orchodopexy is performed by fixing the testes to the inner call of the scrotum TESTICULAR TORSION OVERVIEW Review Patient Make Safe Confirm Diagnosis extreme testicular pain urgent urology review urgent urology review raised testicle urgent surgical exploration urgent surgical exploration vomitingQUESTIONSSIMATS PATIENT IN PAIN IN ED 60-year-old male patient with abdominal pain and fever NEWS - RR 20 Sats 99% OA HR 100 Temp 38.4 C BP 90/60BACKGROUND Under investigation for enlarged prostate. Has an indwelling catheter Previous MI DHx: atorvastatin, ramipril, bisoprolol, aspirin, tamsulosin No allergiesA – AIRWAYB – BREATHING RR Sats Auscultation Expansion Percussion Tracheal position ? CXRC – CIRCULATION Heart sounds Cap refill ECG Peripheries BP HR Cannula + BloodsVBG pH – 7.2 pCO2 – 5.5 pO2 – 12 HCO2 – 15 Lactate 5.9 Glucose – 5 Na2+ – 138 K+ - 3.4D – DISABILITY Pupils BM Temp GCSE – EXPOSURE Abdominal exam PR Look at limbsACUTE RETENTIONPATHOGENESIS/ PATHOPHYSIOLOGY A new onset inability to pass urine Causes ­ Benign Prostatic hyperplasia ­ Prostate cancer ­ Urinary tract infection ­ Constipation ­ Neurological ­ MedicationBENIGN PROSTATIC HYPERPLASIA Non-cancerous enlargement of the prostate Incidence ­ 40% men aged 50 ­ 90% men aged 80 ­ Symptoms in 25-50% people with BPHMAKE SAFE – URINARY RETENTION Catheter Urine dip Abx if infection suspected NB bladder scans are a good shout if unsure/ grey area ­ >500ml, catheter a good idea ­ >700ml, needs a catheterCONFIRM DIAGNOSIS – URINARY RETENTION Output monitoring ­ >1000ml need monitoring for post-obstructive diuresis If renal function deranged – USS kidneys ­ ?high pressure urinary retention (hydronephrosis) Determine cause ­ Including PR ACUTE RETENTION OVERVIEW Review Patient Make Safe Confirm Diagnosis Suprapubic pain. tenderness Catheter PR no urine output Urine dip +/- abx Output monitoring ?infection ?USSFEEDBACK Thank youTHANK YOU TO OUR SPONSORS: