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The Urology on-call Miss Bushra Abdelqader Urology ST4- Kingston hospital BSoT FY/Core trainee rep @Bushra_aq91 Bushra.abdelqader1@nhs.net @BSoT_UKUrology team • On call cover: • Referrals to surgical SHO 3 FY1s 2 SHO’s • SPRs 8-17 weekdays 8-1pm weekends • Handover unwell/ complex patients. 8 3 SPR’s consultants • old male patient has presentedar with painful penis and a problem Case 1 with foreskin for the past 6 hours, can you please see.Case 1Paraphimosis • Paraphimosis is a common urological emergency that occurs in uncircumcised males when the foreskin becomes trapped behind the corona of the glans penis. • This can lead to strangulation of the glans and painful vascular compromise, distal venous engorgement, edema, and even necrosis.ParaphimosisCase 2 • year- old lady who presented with abdominal pain and 45 fever, she has raised inflammatory markers. Can you please admit under Urology ? PyelonephritisCasNEWS • Hx: back pain for few weeks, right> RR 24 Sats 95% left- she saw her GP but was air thought to be MSK pain. Fever and rigors started 3 days ago associated BP 87/50 HR 130 with vomiting and feeling unwell. • PMHx: BMI 54, OSA, T2DM Temp 39.5Invistigations • ABG in A&E • Bloods : • PaO2 13 • Hb 130 • PH 7.23 • Platelets 465 • PaCO2 5 • WCC 25.6 • HCO3 15 • INR 1.5 • BE -6 • CRP 350 • Lactate 4 • Na 145 • K 5.9 • Cr 350 ( 80) • Urine Dip: Bld +ve, Leuk +ve, Nit • eGFR 18 ( >90) +ve • She was prescribed Co-Amox & Gent (given in A&E)Case 2 • Assessment: - History is very important – Think infected obstructed kidney - As with any septic patient A-E assessment, Sepsis 6. with focus on: - Antibiotics – to cover urinary source - Fluids - Catheter - Send CULTURES , bloods, CLOTTING - CT KUB ASAP - Stop nephrotoxic meds, stop anticoagulation (reverse) - Involve CCOT earlyCase 2 A Urological Emergency Resuscitate- Keep NBM Infected obstructed SEPSIS 6 Call Urology kidney Involve CCOT EMERGENCY de- obstructing the systemInfected obstructed kidney vJJ stent insertion: 1- Needs to be done under GA, usually on CEPOD. 2- A cystoscope is passed through the urethra into the bladder and the stent is inserted over a guide wire into the ureter up to the kidney. 3- The stent has to be changed every 3- months until cause of obstruction is treated.Infected obstructed kidney vNephrostomy: • It drains the kidney above the point of obstruction. • Anesthesia.e in interventional radiology under Local • The nephrostomy tube is passed into the kidney over a guidewire. • The nephrostomy has to be changed every 10 weeks.Infected obstructed kidney Stent VS Nephrotomy : • Depends on local availability of resources • IR Vs CEPOD • Patient factors: anti-coagulation, ? Fit for GAPyelonephritis • Some key points: • Common in younger women • Can be very sick • Features: • Ascending UTI • Fever, dysuria, flank pain, vomiting, very high CRP and WCC • When to CT: • If very unwell - ? Emphysematous Pyelo • Preceding colic type history • Needs 2 weeks of antibioticsCase 3 • You are the Fy2 in A&E, you are reviewing a 36 year old patient with 3 days history of left loin pain.Analgesia (NICE guidelines): - IV paracetamol - PR Diclofenac - Weak Opioids - For all stones ≺5mm, 68% Spontaneous passage rate - For stones measuring 5-10mm - 47% Spontaneous passage rate Safety net advice: Come back if – can’t control pain at home. Infection/fever + feeling unwellUrinary tract stones May seem basic but can be very complex patients. • Common – at least one referral per shift • Wh• Renalthe stone – • Ureteric – Upper/mid/lower/VUJ • (Bladder) • Si• 5mm or lessne • 6-10mm • 1-2cm • StaghornUrinary tract stones • Referral, what does the Urology SpR want to know: • Age and background • Does the patient have 2 kidneys • Is there any infection – fever and urine dip • Is there an AKI • CT scan – position and size of the stone? Presence of hydronephrosis • Question is – can this person go homeCase 4 • You are called by Pediatrics A&E, a 14-year-old male presented with 3 hours of left testicular pain, Can you please review ? Torsion T ESTICULAR T ORSION T ESTICULAR T ORSION Intravaginal torsion: longitudinal PRESENTATION Intravaginal torsion: longitudinal PRESENTATION rotation of the spermatic cord due to § Pain § Nausea PHYSICAL EXAM rotation of the spermatic cord due to PHYSICAL EXAM “bell-clapper deformity”. This results in § Pain § Nausea the absence of testicular blood flow o Sudden onset § May have Scrotumbell-clapper deformity”. This results in o Sudden onset § May have o Deep / visceral associated the absence of testicular blood flow Scrotum and is a surgical emergency. § Early presentation: o Deep / visceral associated § Early presentation: trauma may be normalurgical emergency. trauma normal bell-clapper torsion o Unilateral o Unilateral may be normal § Peak § Late: edematous, bell-clapper torsion § Peak § Late: edematous, o Testicular / incidence: indurated, o Testicular / scrotal scrotal incidence: indurated, 12-16 y/o, erythematous 12-16 y/o, erythematous o May radiate to o May radiate to unlikely before Affected testis unlikely before Affected testis inguinal or lower puberty inguinal or lower puberty abdominal areas § Tender abdominal areas § Tender § May be § High riding § May be § High riding o Potential prior Hx o Potential prior Hx awakened awakened § Horizontal lie of intermittent § Horizontal lie Bell-clapper deformity: Capacious of intermittent from sleep due Bell-clapper deformity: Capacious from sleep due § Cremasteric reflex § Cremastscrotal sac. Often bilateral. pains to pain absent scrotal sac. Often bilateral. pains to pain absent DIAGNOSIS TWIST Score DIAGNOSIS TWIST Score Primarily a clinical diagnosis. History and P/E often Symptom Points Primarily a clinical diagnosis. History and P/E often sufficient to bring straight into OR. Symptom Points Testicular swelling 2 Intravaginal torsion: longitudinalo OR. q U/A generally not indicated and not needed for diagnosis “bell-clapper deo Sudden § May havelts inL EXAM Testicular swelling 2 Hard testicle 2 and is a surgical emergenctraumal§ Early presentation:agnosis Colour Doppler Ultrasound normbell-torsioo Testicular /k § Late: edematous, Hard testicle 2 Absent cremasteric reflex 1 o May radiate topler Ultrasound If Dx is in question, U/S to determine presence inguinal puberty§ Tender testis o If Dx isawakene§ Horizontal lietermine presence Absent cremasteric reflex 1 or absence of blood flow: Nausea/vomiting 1 Bscrotal sac. Often bilateral.ain§absentsteric reflex § Decreased testicular perfusion or absence of blood flow: Nausea/vomiting 1 § Twisting of spermatic cord High riding testis 1 DIAGNOSIS§ Decreased testicular perfusion sufficient to bring straight into OR.Points P/E often High riding testis Usefulnes1 limited in small prepubertal testes with ↓baseline flow q U/A generally no§ TwistiHard testicl2ic cordor diagnosis ≤2 Points: 3-4 Points: ≥5 Points: If Dx is in question, U/S to determine presence DO NOT delay surgical management for imaging studies if low risk medium risk HIGH risk § Decreased testicular perfusionbertal testes with ↓baseline flow clinical findings are strongly suggestive. Usefulness limited in small prepubertal testes with ↓baseline flow ≤2 Points: 3-4 Points: ≥5 Points: clinical findings are strongly suggestive.iskstudies ifes if low risk medium risk HIGH risk clinical findings are strongly suggestive. DetorsiTestiGOAL: early surgical consultation with surgeon and in Detorsion Testis 4-6 ho97-100%erating room within 6 hours from onset of symptoms GOAL: early surgical consultation with surgeon and in >12 ho20-61%NEVER delay surgery on assumption of nonviability within… viability >24 ho0-14% based on clinically estimated duration of torsion operating room within 6 hours from onset of symptoms Detorsion Testi 4-6 hours 97-100% within… SURGICAL viabilityON GOAL: early surgical consultation with surgeon and in torseds orchiopexy (ftesticle explorationweeksry >12 hours 20-61% NEVER delay surgery on assumption of nonviability ≤6 hours testicle and orchiotesticle is sufficientwithin 6 hours from onset of symptoms viab4-6 hou siectomy (97-100%)pefor normal fertility >24 hours 0-14% based on clinically estimated duration of torsion Published May 2021 SaraA>12 hoursnd Dr. Mar20-61%us (Urologist, Indiana University) for www.pedscases.combility, University of ≤6 hours T ESTICULAR T ORSION Detorsion Testis GOAL: early surgical consultation with surgeon and in within… viability Intravaginal torsion: longitudinal PRESENTATION rotation ofo erating room within 6 hours from onset of symptoms “bell-clapper deformity”. This results inin § Nausea PHYSICAL EXAM 4-6 hours 97-100% the absence of testicular blood flow o Sudden onset § May have Scrotum and is a surgical emergency. o Deep / visceral associated § Early presentation: >12 hours 20-61% normal bell-clappertorsionery on assumption of nonviabilityauma may be normal ≤6 hours o Testicular / § Peak § Late: edematous, based on clinically estimated dura ion of torsionnce: indurated, >24 hours 0-14% o May radiate to unlikely before erythematous inguinal or lower puberty Affected testis abdominal areas § May be § Tender o Potential prior Hx awakened § High riding Bell-clapper deformity: Capacious of intermittent from sleep due § Cremasteric reflex scrotal sac. Often biSURGICAL EXPLORATIONns to pain absent DIAGNOSIS TWIST Score Primarily a clinical diagnosis. History and P/E often Symptom Points • Average recovery Is the sufficient to bring straight into OR. Contralateral yes q U/A generally not indicated and not needed for diagnosis Testicular swelling 2 time: 1-2 weeks torsed orchiopexy (fixati ) Hard testicleloration 2 Colour Doppler Ultrasound Absent cremasteric reflex 1 • One functional testicle If Dx is in question, U/S to determine presence and orchiopexy or absence of blood flow: Nausea/vomiting 1 testicle is sufficient viable? no Orchiectomy § Twisting of spermatic cordsion bHigh riding testisbilateral 1 for normal fertility DO NOT delay surgical management for imaging studies ifseline≤2 Points: 3-4 Points: ≥5 Points: clinical findings are strongly suggestive. low risk medium risk HIGH risk Detorsion Testis Published May 2021 within… viability GOAL: early surgical consultation with surgeon and in Sarah Park (Medical Student, University of Alber4-6 hoursPeter 97-100%e (Pediatric Urologist, University ofrom onset of symptoms ≤6 hours Alberta) and Dr. Mark Assmus (U>12 hours Indi 20-61%versity) for www.pedscases.comn assumption of nonviability >24 hours 0-14% based on clinically estimated duration of torsion SURGICAL EXPLORATION Is the yes Surgical detorsion and Contralateral • Average recovery torsed orchiopexy (fixation) testicle exploration time: 1-2 weeks testicle and orchiopexy • Otesticle is sufficient viable? no Orchiectomy (removal) bell-clapper often bilatefor normal fertility Published May 2021 Sarah Park (Medical Student, University of Alberta), Dr. Peter Metcalfe (Pediatric Urologist, University of Alberta) and Dr. Mark Assmus (Urologist, Indiana University) for www.pedscases.comT esticular torsion • History is Key. • Always examine the patient. • Urine Dip. • Keep NBM. • If in doubt – Torsion until proven otherwise. • For consent use BAUS information leaflet. • TWIST Score • Have all the information available before you call.Scrotal pain differentials • Hernias • Infection – usually red scrotum, hot, hard testicle, dip +ve for Nit & Leuk, gradual onset. R/O Abscess • Treatment: Abx as per micro guide, scrotal support, analgesia (very painful) • Trauma • Ureteric stone • Torsion of testicular appendages: Normally found on exploration S CROTAL P AIN History Physical Exam Investigations Management Incarcerated Torsion of Appendix Testis Inguinal Hernia q Sudden onset mild-severe pain q Uncommon to have N/V or previous episodes q Infants: irritable, crying, poor feeding ------------------------------------------------------------------------------------------ q “Blue dot sign”: palpable tender nodule at q ?Previously reducible mass q Vomiting, abdominal superior or inferior pole distension and/or constipation q Cremasteric reflex present /obstipation if intestinal q Scrotal erythema, edema, nontender testicle ------------------------------------------------------------------------------------------------------------------------------------------------------------------- q Firm, discrete, tender inguinal q Colour doppler ultrasound: normal or increased blood flow to testis, torsed mass extending to scrotum appendage shown as lesion of low ----------------------------------------------------------------------------------------- q Labs and imaging ------------------------------------------------------------------------------------------ of limited use Ø Supportive: analgesics, rest, scrotal support q Ultrasound occasionally Ø Should resolve in 5-10 days Ø Surgical removal of appendix testis rarely ----------------------------------------------------------------------------------------- Ø Emergent reduction Ø Most manually reducible, to OR if impossible in ER Ø Once reduced, timing of definitive Epididymitis surgical repair depending upon q Bimodal incidence: age and degree of illness • Childhood & sexually active q Gradual onset pain Testicular Torsion q Unlikely: Dysuria, frequency, discharge CANNOT MISS! q N/V more common with q Peak incidence: peri pubertal torsion q Pain: Sudden onset, moderate q No definitive discrimination to severe, unilateral with torsion q Occasional Hx of trauma or ---------------------------------------------------------------------- previous episodes of pain q Cremasteric reflex present q N/V common q Scrotal erythema, edema, q TWIST score Orchitis --------------------------------------------------------------------- ------------------------------------------------------------------------------------------ q High-riding testicle, horizontal lie q Occasionally bilateral q Urinalysis: may be normal q Cremasteric reflex absent testicular pain q STI testing: q Scrotal erythema, edema, testicular q May show systemic § Urine NAAT for tenderness manifestations of chlamydia and q May have reactive hydrocele underlying infection gonorrhea ---------------------------------------------------------------------------------------------§--Most common in pre- q Colour doppler ultrasound if low risk q Scrotal erythema, pubertal: coliforms and (low TWIST score) & Dx in question edema, tenderness, P. aeruginosa § Contraindicated if high likelihood shininess of overlying q Colour doppler ultrasound: and results in delay skin normal or ↑ blood flow q U/A generally not indicated and not ------------------------------------------------------------------------------------------------------------ q Viral: mumps, rubella, Ø No pyuria à no abx, --------------------------------------------------------coxsackie, and-------------------- supportive care Ø High likelihood (high TWIST score) parovirus common Ø Suspected STI cause: à immediate surgical exploration q Bacterial: brucellosis ceftriaxone IM x1 dose + § Surgical detorsion and ----------------------------------------------- orchiopexy if viable Ø Supportive: rest, doxycycline PO x10-14 days NSAIDs, ice packs Ø Suspected enteric cause: § 97% salvage if <6h from sx onset levofloxacin PO x10 days Ø Orchiopexy of contralateral testis Published May 2021 Sarah Park (Medical Student, University of Alberta), Dr. Peter Metcalfe (Pediatric Urologist, University of Alberta) and Dr. Mark Assmus (Urologist, Indiana University) for www.pedscases.com Case 5 • You are the on call SHO on a busy shit, you receive a call from A&E as they are referring an 80-year-old patient with haematuria “Known to urology”, this is the 4 haemturia referral of the day.Case 5 Hx: has been passing blood in the urine for a week, O/E: Looks in pain, EWS 1 the past 6 hours unable to (HR 100). Abdomen: Bloods pending pass urine, lower Palpable bladder, tender abdominal pain.Case 5 • Think Clot retention – Takes time to sort! • Catheterize – 3-way catheter – the biggest you can find 22-24Fr • Bladder washout – a good washout saves you bleeps later in the day/night. • Start irrigation once clots cleared. • needed.ticoagulation/ correct INR if • If evidence of UTI start Abx. • Resuscitate, bloods, G&S.Bladder washout How dark is the urine – if no clots, not in retention – check for UTI and GP should refer via 2WW (Flexible cystoscopy + upper tract imaging) Patients with catheters – most of the time Haematuria- the catheter is displaced, once a new troubleshooting catheter is put in the urine is clear – ALWAYS check catheter position. Irrigation will prevent further clot formation but will not clear existing clots for that you need a bladder washout otherwise catheter will keep blocking.Urinary retention • Acute Painful retention: Painful inability to void, with relief of pain following drainage of bladder. • Should be managed by A&E – catheter, treat cause and discharge with TWOC appointment. • High pressure Chronic retention: maintenance of voiding with a bladder volume >800 mls and raised intravesical pressure associated with hydronephrosis. First presenting symptom is bedwetting. • Insert a long- term catheter. • Document RV – VERY important. • Admit, hourly input/output monitoring. • Monitor for post obstructive diuresis • Daily U&Es • Not for TWOC until definitive treatmentCatheters Use Instillagel *2 in males Traction of the pens to stretch urethra. Use 14/16 Fr catheters – silicone if difficulty with latex Catheter Tips Don’t push if not sure If resistance at prostatic urethra – use curved tip If stricture- use smaller catheter Check when was inserted (New tract vs established tract). If establish tract – attempt re-insertion ASAP . Fallen Re-insert the same size, can try smaller if suprapubic fail. catheter Distract the patient – tense abdominal wall can cause difficulty. If unable to re-insert, establish indication for SPC ? Can urethral be inserted.Useful resources Bristol urological institute – Urology News- bladder Catheter troubleshooting washout GIRFT – BAUS BAUS Cauda Consensus – Consensus – equina Priapism Penile fractureChoose Urology Variety of Open , robotic and Good work/ life subspecialties endoscopic surgery balance 5 years training You can make an Operate seated Research Small community immediate opportunities difference to patients. Balance between Variety of patient surgical/medical groups/ ages. interventions. Questions ? @Bushra_aq91 Bushra.abdelqader1@nhs.net @BSoT_UK