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right. Hi, everyone. I'm just gonna give it another five minutes so that as many people join as possible. So we'll start at five minutes past eight. Right? Okay, so that's eight and five minutes. So we'll go ahead and start. Thank you, everyone, for joining us today for the second episode of the Urology series. So today we're going to be talking about catheterization and acute urinary retention. Um, and this will be the second part of the 12 teaching series, basically. And urology, if you could give me the next slide, please. So before we go ahead and start, I'm just going to give a quick message for our sponsors. OCPD me basically, um a new portfolio company. And what they do is basically give us a handy drop down, um, interface for your career and development. Um, and it's suitable for anyone who works with the GM. See the n M. C. Or any healthcare professionals in general. So if you're interested in that, use QR code with minded sleep, and you can get 50% off, and now I'll go ahead and hand over to sign in. Who's going to present our subject today? Thank you. Zack. My name is Shannon, Uh, ST five urology registrar in Aberdeen. I'm currently out of program doing PhD, um, and I'm going to talk to you today about urinary tension and catheterization. So the objectives that I'd like to cover, uh, to know the causes of urinary retention know the indications for catheterization, uh, be familiar with different catheters and catheterization techniques and be familiar with catheter complications and post catheter care. So, um, catheterization is a key procedure. Um, you should all by the end of medical school, know how to perform a female and mail catheter catheter. Um, it's a very common procedure. As I said so in a study by shock Little, um, you know, over 250 NHS trust. About 13% of patients were catheterized. So that's over a million patients in a study looking at over nine million patients. So very common procedure. Everyone needs to know how to do it. Uh, and as expected, mail catheters are more common than female catheters. So if we think about cause of retention, I'd like you to think of the bladder as is a muscle that stores and pumps. Um, so if the muscle is overstretched, then it can fail to work. The best way to think of this is, um if you're trying to lift a weight, uh, say you're trying to lift away with your biceps. Um, if your biceps are straight out and they're stretched to the max, it will be harder to initiate that flexion. Uh, rather than if your arm is already halfway, uh, flexed. So if the muscles over stretched, it can fail to work. If there's not enough force in the muscle, then the bladder will not empty. And if there's too much outflow obstruction, then the bladder will not empty. And urine may even reflux up the ureters because there's nowhere else for them to go, and that causes something called hydronephrosis. So if we think of it, as I said, pump and, uh so storage and and pump, uh, so pump failure would be, um, if it's overfilled, overstretched muscle, like we said, Um, neurogenic. So any disease where the nerves don't talk to the bladder, such as multiple sclerosis? Um, detrusor failures of failure in the muscle itself and infections can irritate the bladder and the muscle. So you have pump failure. Um, of course, anesthesia. Very common reason why people go into retention is post anesthetic. And then, if we look at blockages, so outflow blockages. The obvious one here in men is BPH, but also cancer. Either of the prostate, bladder, urethra, Penis, vulvar for gyny cancer, anything that causes a mechanical blockage. In the outflow, you can get some weird and wonderful neurogenic things where the bladder and the sphincter are not in sync, so they both contract at the same time. That's very rare. A prolapse, um so, especially vaginal prolapse will kink the urethra and cause out flow blockage. A stone may get stuck and cause blockages there constipation and, of course, trauma as well. So a number of different causes. So the indications for catheterization. Obviously there's retention, which is we're talking about, and this can both be acute or chronic. Um, so as a general rule of thumb, acute retention tends to be painful. Where, as chronic retention is painless and chronic, retention happens more with men, for example, with BPH who over time their prostate has grown and their bladder has just learned to learn to stretch and stretch and stretch until they are retaining over a liter, but because their bladder stretched over time, they're not feeling pain as much. Another indication for catheterization is urine output monitoring, so especially for patients undergoing long surgeries or patients with sepsis. So if you've heard of the sepsis six, it's one of the things that you need to do. Monitor the urine output. Uh, we talked about pre emptive or surgical planning, but also, if you're doing any receptions in that area and you want to preserve the urethra, then the catheter is a good thing to have in, um, so you know where your landmarks are. Fistulas. So a connection between the colon and the bladder, colon for cycle or the vagina and the bladder vesicovaginal. Um so these are abnormal connections? Obviously, Um, and the best way to manage it is to put a catheter in initially so that urine isn't leaking out the vagina or leaking into the colon. Um, and in a similar way, certain, um, perforations in the bladder. You can actually treat with a catheter because the bladder stays nice and collapsed, and it gives gives the bladder a chance to heal and close up that hole. Um, administration of treatment. So for people with bladder cancer, sometimes we give them chemotherapy inside the bladder, and we do that using a catheter. A very rare reason is incontinence, uh, as a general rule, you don't catheterize someone for incontinence, but very, very rarely. Sometimes if it's causing them a lot of symptoms and bother, you do. So what are the different catheter types? Well, obviously we talked about some roots that you can put a catheter in. So there's the obvious one, which is urethral and, uh, sorry. There's a two, a catheter that you can put in. And this is from a simple Foley, which I'm sure you've all seen before. A yellow Foley catheter. It's called a two a day because it has two channels one, uh, to drain the urine out the other to inflate the balloon. Um, you can have a long term or silicon catheter, which is a bit more stiffer than a Foley and helps you navigate around big prostates. Um, you can get a code a tip, which is different from a straight tip again, this helps meander around a big prostate, which you might not be able to get through with with a straight tip. You can have three way urethral catheters, and this is where you have the balloon port, the drainage port and an irrigation port. Um, so this is for people who have blood in their urine. That's clotting inside their bladder, and you can put in a three way catheter to wash out and irrigate the bladder out. Um, it's also used when we're doing resection inside the bladder. Endoscopic resection. Um, and there's a lot of bleeding. Um, so post opportunity. We'll leave a three way catheter in to wash out the bladder so that the blood doesn't clot. Inside the bladder, you can have a suprapubic catheter, so that's a catheter that goes straight through the tummy and into the bladder, and it drains that way. Um, and this is for people who can't have a urethral catheter or, um, they need a long time catheter for life. And a urethral catheter is causing complications. Um, so that you will be put one through the tummy because it's a lot easier to manage. You can have an intermittent or a once only catheter, Um, and this is a catheter that the patient will use, Um, so we teach them how to do intermittent self catheterization. Um, and this is used for people. For example, who whose bladder doesn't empty? Who has a neurogenic bladder, for example, where the bladder just doesn't have the nerves connected to talent to squeeze, um, people with ms. For example, um, so they would use they would use that. And of course, with all these cats is there's different sizes, so they normally range from six, which is very, very small, often used in pediatric cases to 26 and the most common ones really. Realistically, that stopped on the ward on an adult urology ward will be from 12 French to 18 French for a two way catheter and 22 to 20 for for a three way caster. Um, so a lot of people try to find out what the size is when they're picking up the packaging. But if you if you remember the color at the end, so if you see in the top that Foley catheter is a red top on the balloon port, so that's an 18 French. So if you remember the colors and you don't need to look at the numbers and the common. You just need to remember a few, Uh, mainly the white is 12. Green is 14 oranges 16. Those are the most common. We use catheters. Um, so if you remember those, you don't need to look up the size so Catholic technique. Um, so I'm sure you'll learn hands on training how to put Catherine, but tips for especially for difficult catheterization in men. Obviously, you have to prepare everything on the trolley. It has to be aseptic technique, and my tip is to take everything out of the wrapping. So it's all there and ready. You've got your instill a gel, which is jelly with local anesthetic. That helps, um, and often when you take it out, it's quite stiff. The plunger is quite stiff. So my little trick is to pull back a little bit, and that just makes makes the plunger nice and loose. Um, then obviously you prepare the field and clean. Uh, so the best way, uh, to get the urethra nice and straight is to hold the Penis taught and straight. So basically point up to the ceiling as as as taught as you can, that straightens out the urethra and makes your life a lot easier. Instead, insert the instill a gel relatively quickly, and then you hold the urethra shut. If you don't, then all the jelly will just come up. Um, and then you take your catheter. If it's a man, I would say they need at least a 16 French unless they have a history of narrowing or strictures in the urethra, and then you need to go smaller. Insert the catheter slowly. You'll eventually reach a bit of resistance where the prostate is, at which point you'd drop your hand down to get around that curve that you see in that anatomy picture in the top, right, so you get you drop your hand to get around that curve. So you point the catheter up towards the ceiling, and then you push. Um, if you're using a code a tip. Remember, that's the bent tip. At the end. You have to ensure that the tip is always facing up and it doesn't spin around while you're putting it inside. There's often a line on one side to help keep your orientated with female catheterization, Um, fairly easier, But people still get into trouble. The urethra is always between the clitoris and the vagina unless they've had, um, major surgery down there or resections. Um, and in older ladies, the urethra might sort of migrate down more towards the anterior vaginal wall. So just be aware of that. What can go wrong with catheters? So the main problem is false. Passage is so This is a channel that's created extra anatomically, so not where it's supposed to be, and it's often beside the urethra. The main place where it happens is at that bend around the prostate, so you can see in that diagram where that caster is digging into, and it's not following the urethra. And if you look down a camera down the urethra with the camera, you'll see that there are two holes. The one in the middle is the true Lumen and the one at the bottom or to the side. The less darker one is the false passage where the catheter has just been digging in and in and creating a false space. Um, para pharmacist. So in uncircumcised men, someone will retract the foreskin, put the catheter in and forget to replace the foreskin, and that causes a constriction where the foreskin gets engorged, the glands get engorged and it's very painful, and it's unnecessary. So that's almost always the fault of the person who put the catheter in. Um, so that shouldn't really happen. Uh, urethral trauma, obviously, Uh, and bladder trauma. Uh, these are quite rare. Thankfully, um, with a super pubic catheter, though the complications are a bit more, um, bit more like a surgical procedure. So some people actually consent patients before putting in a suprapubic catheter. But the main complications with any surgical procedure, infection, bleeding and pain, there's also a risk. You can perforate the bladder, so if you're going through the tummy into the bladder, But, um, sometimes a loop of bowel can come down and and before you know it, you're skewing the bowel into the bladder. Um, normally, there's a space which is extraperitoneal. So where black bowel is is not present. Um, and that's just above the pubic pubic synthesis. So technically, bowels shouldn't be there, but sometimes it is, and that can lead to perforation, peritonitis and death. So there's about a 11 to 2% risk of death with super pubic catheter, so it's not just a routine procedure Um and, of course, damage to surrounding structures. There are some contraindications, so people, some people that cannot have a suprapubic catheter in. If they have bladder cancer, you can't put one in because it will cede. Uh, the tumor will cede up the catheter tract. If they've had previous laparotomy, there'll be more chance of scar tissue and more chance that one of those scar tissues is kinking, a loop of bowel in your way. If they're on a blood thinner and you put super pubic catheter in and it bleeds and bleeds and bleeds and then clots, that's not good. So that's relative contraindications. And if they have any vascular graphs that are going across the tummy, such as a femur femur, ephemeral crossover graft So you put your Catherine, it's draining urine. You're very happy with yourself. What next? Well, you need to consider a catheter sample for your analysis or microbiology. If you think there's been some infection that caused the retention, documentation is very, very important. You need to write down what the residual volume drained in, and you need to obviously give it time to drain. Um, so I would just give five minutes So by the time you've packed up your stuff, you put them all in the been gone and wash your hands and then started to write. That's about five minutes. You come back and see what's in the in the bag attached to the catheter you just put in. You need to document the color of urine. Um, I know that sounds silly, but you need to say if it's clear urine concentrated urine, smelly urine, puss filled urine if it's bloody urine. So hematuria. Um, all these things are really important. Uh, on the catheter packs. They're normally catheter stickers with patch number and things like that to try and stick them in the in the notes. And when you get senior enough, you have to try and think of the next step. So you put Caster in. What's next? Do they need it removed? Do they need it changed in the community? How will they empty it? You're just going to attach it to a leg bag or just have a flip flow valve at the end, So I need to think of the next step. Um, if your patient has a retention over 800 mils, then you need to monitor for something called post decompression diuresis and for Hematuria, and I'll explain a bit about that in a second. Um, if they do have a lot of urine, you have to ensure that the bag isn't full or bursting straight away. You'll need to drain it otherwise, because it will just mean that the bladder is still not empty. So you haven't really done your job and then just be just have some common sense and ensure the patient is safe and they won't pull up the bag or the catheter. So if you put the catheter in, don't put the bag on the other side of the bed that the patient's getting out of because they'll just roll out of bed for getting. They have a catheter in and target the catheter, and it might come out traumatically, so just be sensible. So in people with large volume retention, they get something called post decompression uh, problems. So it's normal for the urine to turn clear from clear to a rose or hematuria. So dark blood or red blood urine. And the reason for that is the capillaries in the bladder have been stretched so far. And then when you put the catheter in, the pressure is taken off suddenly, so they become quite leaky and they'll bleed up it. And that's why that's why initially, you get the clear urine that's been in the bladder and then as it as it shrinks and fresh urine is produced, you start to get that bleeding so it will turn from clear to the mature. That's normal. You don't need to do anything about that. It will clear with time. Uh, the only thing the only time you need to call a urologist is if it's starting to form clots, and it's blocking the catheter. Post decompression diuresis. So you get a diary, sis effect, which means that you produce a lot more urine than usual after decompressing large volume retention, and this is defined as more than 200 miles per hour. So you need to ask the nurse to monitor the output. This is obviously after you've recorded the residual volume. Um, so they need hourly in input and output. Um, and the diaries. This part is, in a sense, physiological up to a certain point, because the patient, while they've been in retention, has been retaining salt and water that has accumulated, especially during the period of renal failure. So they're going to want to clear that. So you get a diary, sis effect, you get lost. I don't know if you remember your diagram with the Net from, but it all works on a concentration gradient, and you'll get loss of that concentration gradient because there is diminished flow of, um, urine through the nephron. So if there's no flow, then the gradient won't won't be there, Um, and the third reason you get the diagnosis is because all the urea that has built up causes an osmotic effect. So to a certain extent you'll get physiological response. But you need to make sure that they don't get dehydrated by from diaries in too much. So you need to do a lying and standing BP to measure for for a postural drop. If that's present, then you'll need to treat them with replacement fluids because they won't be able to keep up the fluid intake orally to match how much they're losing. Um, and if you don't do that, they will get really dehydrated, and that's potentially fatal. So you normally start replacement fluids at 50% of what they're losing. So if a patient had one liter in the bladder that you drained and then over the next hour they peed out two liters, But they only drank one liter. Then, um, they're sorry they didn't drink as much. Then you need to replace one liter, uh, which is 50% of what they've lost. So the two liters they've lost and there's no way they'll be able to drink all of that, uh, in that amount, amount of time. And, of course, you need to monitor their urine electrolytes until the diarrhea settles and their renal renal function has improved. So there are some other advanced urological techniques that you should be aware of, but I wouldn't necessarily be asked to do. A bladder aspiration is simply where you stick a needle with a large, uh, syringe into the bladder to aspirate urine. Uh, this is a temporary solution just to get it's kind of like get out of jail free card. If there's someone in retention and you can't cast dries them and um, you know, it's very, very painful. You can you can aspirate at least 500 miles from the bladder and give them a little bit of relief. Of course, it's not a temporary solution because they'll just fill up again, but it can buy you time a catheter introducer. So that's the big metal rod you see in the bottom, right? So it's exactly that it's a metal rod that you put inside the catheter, and it just gives it a bit more firmness so that you can navigate around a big prostate and that end with a big prostate. Um, you know, and and and catheterize them that way. But that's a very dangerous tool in the wrong hands. Obviously, it's a big metal wire going up your urethra, Um, a guidewire. So we have these thin guidewires, which you can put in especially useful if there's a stricture or a tight hole in the urethra that you can't get a normal catheter through. So the guidewire will ensure it goes the right way, and you don't for many false passage is, um, or in patients with pharmacists, so that's a tight foreskin. Sometimes it's pin hole tight and and shut. So, um, you need a guidewire to navigate through and find the right Lumen. A flexible cystoscopy, um is sometimes needed. If you can't see what you're doing, or you can't see the the urethra, you can catheterize them. So you get the camera in and you can find the true Lumen and use a guidewire to catheterize the bladder. Um, and then some patients develop penoscrotal edema. So this is just like pitting edema. So especially in the hospitals where they sit with the bed slightly bent so that they're sacrum is is the lowest point, um, of gravity. So any edema they for most will go there so they'll get sacral edema. But it will also go to the Penis scrotal area. And the edema can mean that the foreskin kind of closes shut, and you can't see and they can't pee. So, um, but it's very simple. All you have to do is squeeze the edema of the way until they're four skins back to vaguely what it was. And then you can pull back a little bit and see the urethra, meatus and catheterize that way. So, in summary, we've talked about causes of retention. Uh, and we've thought of them as pump failure or outflow. Obstruction. Um, you know now that there are many more indications for catheterization apart from urinary retention. Um, there are multiple types of catheter, including single use, two a day and three way catheters with different sizes. And it's very, very important to understand the common complications of catheters and how to manage postcatheterization care. So thank you for listening. And, uh, I'll hand back to Zack to see if there are any questions. Thank you very much, Sam. That was really useful. I hope it was as useful to me as well to you guys as much as it was to me. Does anyone have any questions they'd like to pop in the chat box for cinnamon? Okay, so it doesn't seem like there's any questions at the moment, and that's fine. If you guys think of any other questions later on after the end of the session, feel free to just send us an email at the link just here, and we'll be happy to get back to you guys and reply promptly. Um, otherwise, we really appreciate your feedback. Um, it will help us deliver better sessions for you guys and make sure that we deliver whatever you guys want us to deliver. So, um, feel free to use the QR code on the right to give us some feedback and you'll get a certificate for that. And thank you again for all your attendance. And be sure to join us next time on chronic urinary retention. I'm going to pop the link for the feedback into the chat box as well. For those of you who would prefer to use the link. So thank you very much and have a good one. Thanks. Thank you.