Breast and Urology Lecture
Summary
This session targets medical professionals looking to gain helpful insights about breast and urology. Hannah, a medical expert, will discuss topics such as breast examination, anatomy, common presentations like breast pain and lumps, and the diagnosis of breast cancer. The session also accounts for real-life patient experiences, offers critical tips and tricks for breast exams, and highlights terminologies relevant to breast examination. This educating and engaging session is ideal for medical professionals wanting to strengthen their patient exam skills, improve patient communication, and expand their medical knowledge.
Learning objectives
- Understand the anatomy of the breasts and its relevance to clinical examinations
- Learn the appropriate medical techniques for conducting a breast examination and practice communication skills during such procedures
- Understand the presentations and potential causes of breast pain and lumps
- Identify the red flag criteria for breast pathology and learn when to refer patients for specialist reviews
- Understand the risk factors, signs, and symptoms for breast cancer and apply this knowledge in diagnostic considerations.
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Hi, everyone. Thanks for everyone who's joined in so far, we'll just give it another five minutes or so here and then make start. Thanks. So, uh hi, everyone and thanks for Jo. I have all this joined in so far. My name is I'm one of the peer share committee this year. Um And a big thanks to Hannah tonight who's gonna come on and talk about breast and urology with yourselves. So, um in about 20 minutes or so, I'm going to just drop the, the link into the feedback link into the group, into the, the, into the zoom chat here. So, and if you could all fill that out, it would be much appreciated, especially for Hannah. I was taking the time to prepare this presentation and just so that we can help improve peer share suppose for future years as well. So that's all I really have to say. I'm gonna pass you over to Hannah now. So I hope you all enjoy. That's great. Thank you. And can you hear me all? OK. Yeah. Yeah, perfect. Excellent. All right. I will just start going ahead then with um the first presentation which um is breast today, I'm covering breast and urology. Um So, um we will just get started on everything the way great. Any questions pop them in the chat box and I will try and get around to them. Um, either at the time or at the end depending on how this goes. Um But yes, so, first presentation today is all about breast. Um And in this, I'll cover a little bit about the anatomy and um sort of your breast examination for your osk. I know the fourth years I've got your osk first. So I've tried to fill in a little bit about um ay prep and some MC Qs at the end as well for both the breast and the urology presentation. Um then covering some conference presentations that are associated with um breasts and breast pathology. Um You sort of all important red flag criteria and your triple assessment um for any sort of lumps and bumps in the breasts, um your breast, your malignant breast disease and then sort of more benign stuff. So try to put the really important stuff at the beginning. And then as you're getting tired throughout the e evening, um some of the sort of less important stuff as we go along. Um So first of all chatting about breast anatomy, um you uh I don't know if you can see my cursor here, but um obviously you have the um doles um which all drain into the ducts and then uh through the nipple, most of it is just um sort of fatty tissue and behind that is your layer of muscle. So your pectoral muscles and then your ribs behind that um is a very sort of um simple um way of looking at things. So, um don't be worried if you can sort of feel um sort of hard structure sometimes. Um It can just be ribs behind the breast. So, um so, you know, when you're describing your lump, that's when you're getting down to like your tethering and things like that. So you should be able to differentiate between a lump and um just a rib and then looking at it from the front obviously. And the important thing with looking at this image on the right here is the actual shape of the breast. So you've got the round tissue at the bottom, which is fair enough. Um but don't forget about this area here going up towards the axilla. So the sort of tail of the breast. Um so when you are doing your breast exam, sort of feel right the way up into the armpit. Um because the breast tissue actually continues up into that area and then obviously filling into the axilla itself for your lymph nodes, um then just some tips and tricks for the breast exam. So when you are doing your initial inspection to see the whole breast, um you can either ask the patient themselves to lift the breast or um using the back of the hand then to lift the breast up. I know this is a really awkward one, especially for a lot of guys out there. Um So sometimes just asking the patient to do it can be as easy as anything else and then you don't get sort of accused of doing anything untoward. Um But I think that's the best way to sort of go around it either just, you know, explaining exactly what you're doing, you're going to lift up the breast tissue at the back of your hand. Um And that's a little bit less groppy or asking the patient just to do it themselves. Um When you're doing your palpation, if the patient has come to you because I think they have a lump, get them to point it out. Um It can be really difficult to sort of fail what the patient thinks they're failing. Um So that will allow you just to make sure that they're happy that you've sort of assessed the right spot and then it's not missing anything as well, especially in your ay. Um, if they can point it out for you, then that's always a win, especially when you're nervous on the day. Um, obviously start with the unaffected side first as well, just so you can feel everybody's breast tissue is slightly different and you have a mixture of the sort of more glandular tissue. And then as you get older, it becomes a lot more sort of fatty. So um the texture can change. So just so you get used to what one side felt like for that person, then um you can go on to test the, the side that they think there's more, maybe some pathology going on. And as I said before, in the sort of more anatomy based slide, don't forget to feel right up into the tail of the breast and into the axilla as well. Um I think the main thing with these stations is not more, not your technique per se, although it's very important, it's more about the communication. So, um sort of maintaining the patient's dignity throughout, you know, covering one side when you can and you don't need it to be exposed. Um And um sort of trying to keep them as dignified as possible, you know, making sure you've pulled the curtain around and simple things like that. Um When it comes to terminology, I think that's also very important for breast exams. So um avoid using the term like, well, I'm gonna feel like you would for an abdominal examination, I'm just gonna feel the tummy. Um It kind of sounds a little bit awkward. So this is one of the very few situations I would say, don't be too worried about using medical jargon, like today, I'd like to examine you. Um when you're explaining what you're going to be doing, um just to make it feel a little bit more clinical and a little bit less casual. Um And obviously the big thing with breast exams don't forget to ask for a chaperone. I know you'll see it in GP where they don't have a chaperone present, but for the purpose of these and things like that always happen. Great. So then there's two kind of common presentations when it comes to um, breasts, usually it's either pain or it's going to be a lump um of some description. Um Pain in general is not a big red flag when it comes to um breast pathology, a lot of the time it's sort of related to the menstrual cycle and related to sort of changes and fluctuations in hormones. Um So if you hear that a patient is just complaining of pain, that's sort of not something that we would be overly concerned about. So just note there, it's not a, a red flag in itself. Um Obviously, with any pain you want to do your Socrates history and then the differences you're thinking about it, as I say, it sort of cyclical, um sort of menstrual related hormonal changes with your um medications and then going on more for like inflammatory things like infections um or just normal breast changes associated with pregnancy with anything like that as well. Also think of like non breast related things. Um I remember seeing a patient in GP who had come in with breast pain um and turned out to be having a pee. So always think of like what else you've got under those structures. And so, and she described it on the phone as breast pain and it wasn't until she came in that we thought God, this is ap so definitely something to consider. So even things like costochondritis, especially in young people and, and as well as shingles because obviously you can get the sort of rash over the breast then and that's going to be quite painful. And so that's something else to consider. And then just for general pain management, when it comes to the breast, just like supportive underwear. Um and sort of simple analgesia are the big ones to go for um nice and simple. Um And then if you obviously, if you've discovered something else like an infection going on, then you can treat that accordingly with your antibiotics. Then when it comes to lumps, you've either got benign lumps or malignant lumps. And we're gonna go on to talk about these more details. So I won't touch on them too much. Now. Um So going on then for your red flag criteria, as I mentioned, pain itself is not a red flag criteria. Your big ones are being over the age of 30 with a new unexplained breast lump or being over the age of 50 with any form of sort of nipple changes. Um Another big one to consider is inflammatory changes in anybody who's not breastfeeding. Um is also a red flag and it's kind of, I think it gets overlooked a lot of the time because people focus on these top two. But it's definitely one to think about. Um, and sort of considering red flag then as, um, anybody over the age of 30 with an unexplained lump in the axilla, um, and sort of skin changes as well suggestive of breast cancer. And again, we'll go into that in a wee bit but that things like you're puckering of the skin um and sort of some rashes as well of the skin and any sort of non urgent referrals, just anybody under the age of 30 with an unexplained breast lump. Um So a lot of the time that would be sort of more due to like fibrocystic changes which just normal changes associated with breast tissue. Um or again, any sort of um cyclical changes associated more with hormones then to diagnose breast cancer, the risk factors that are associated with it um are like lifestyle. So big one with that would be smoking that comes up quite often as a risk factor in exams. And MC Qs. Um your genetics obviously with your BRCA one BRCA, two mutations, any sort of family history of breast or ovarian cancer, um any exposure to estrogen. So, um if you don't have any Children, um or if you had um you reached the, you started your periods at an earlier age, the early re and you're sort of late onset menopause and then other things like um sort of um worsen uh some, what do you call it? Uh like additional um estrogen that may be given in the form of the contraceptive pill. Um So, synthetic forms of estrogen. So your contraceptive pill or your HRT and then any form of ionizing radiation. So, don't forget things like um a lot of lung cancers are treated a lot with ionizing radiation. So, um important part of the history there, obviously, then a lot of breast cancers are picked up through the screening program. So um it's a mammogram every three years for women age 50 to 70. And then um just be aware of um some groups of patients which might have an annual mammogram as well. So anybody who's kind of high risk um would get uh an annual mammogram, then what happens um after you have done your red flag uh referral. So there's triple assessment pathway and you should have a pretty good idea about each of these steps involved. So there's the breast examination itself, which we've kind of spoken through there. So noticing any skin changes on your initial inspection, doing your examination, being able to describe the lump, which I'm sure you can all do a lot better than I can. Um And then um going on then to, to do your imaging and don't forget as well when your examination to feel up into the axilla. Um the imaging then. So it's a mammogram for anybody over the age of um 30 an ultrasound scan for anybody under the age of 30. And that's just due to the, the makeup of the, the breast tissue itself. So as you get a bit older, it tends to be um more sort of fatty tissue. Um compared to when you're younger, it's, it's more glandular. So different types of imaging helps to view three different um sort of densities of tissue. So that's why it's different. Um And then your biopsy. So you've got your fine needle aspirate, um which is a little bit more um useful and then your core um which it takes a sort of a larger sample and is better for a PA, there tends to be more core biopsy that they use rather than at the end, the short and the long and short of it is that you get an examination, you do some form of imaging and then a biopsy then going on to stage. Um You've got your TNM staging for um breast cancer. I wouldn't worry too much about the staging itself. I would just have a very, very rough idea um of the, what sort of translates as I wouldn't, I personally wouldn't learn it off. Um Because I think every different type of cancer has a different type of TNM staging. But um if you have a little bit of extra time, that's maybe something to look over. But as I say, I wouldn't get overly fussed about it for the purposes of exams then going on to manage your breast cancer. So there's a few different things that you can do. Um you can do surgical management. So you can do wide local excision for if you've got like a solitary node, um that's more in the periphery of the breast and can be sort of easily just taken out. Um And then you might also want to consider doing a mastectomy. So that tends to be for a sort of larger lesion or if there's multiple different lesions as well or a lesion, that's more central, you just um a mastectomy. So that takes off the entire breast tissue. Um And then depending on the um results of your sort of initial screening with your um imaging and whatnot, then you would want to consider doing a, an axillary node clearance. So, in the surgery itself, they can um sort of inject a dye into the, the um the tumor itself and then wherever it drains into that will be what's called your sentinel node. Um So that's the first lymph node that is drained by the, that drains the area where the tumor is. And they can, as I say, they can inject a dye into the tumor itself and they can sort of visually see um where the this a node is and decide then whether they're gonna remove it um or do axillary node clearance, if there's more than one node that's positive um on your sentinel lymph node biopsy, um or the, the the node stage of your TNM staging is 1 to 3, then they might do an entire like axillary node clearance where they take out all the axillary nodes are sort of um in the, the upper arm. And um that can have some sort of downsides in the long run. If you've ever seen somebody with a complete axillary node clearance, then they can get quite bad sort of lymphedema in that arm. Um So that can be sort of problematic going forward. You can take bloods from it and things like that and it can be all sort of swollen and puffy. So they try not to do that as much as possible. But obviously, um you want to remove any nose that might be affected just to prevent the rate of recurrence. You can also do adjuvant radiotherapy. So this is done on top of um the the surgery to remove the tumor. Um and um adjuvant chemotherapy as well just to shrink the the tumor before surgical removal. Um and then your hormonal therapies as well are also very, very common. So this would be this pink box here would be the thing that I would most focus on on this slide um because it comes up most commonly in exams. So you've got um if you've got estrogen or, or progesterone receptor positive breast cancers. And then these are the sort of medications you'll be using and it's dependent on your menopausal status. So, if you're premenopausal, so you haven't gone through menopause yet, then um you use tamoxifen and if you're after menopause and then you use an esto which is an aromatase inhibitor. Um this came up in our finals and it's quite a common um exam question when it comes to breast cancer. So that's something to focus on for her two receptor positive breast cancers, then you use trastuzumab, which is Herceptin. Um And for triple positive therapies, uh for triple positive breast cancers, then you can use the tamoxifen or the anastrozole depending on your menopausal status and the Herceptin. Um But if they're triple negative, then there's no form of hormonal therapy that you can give. So it tends to be associated with a more pro prognosis. Hopefully, that will make sense. But as I say, the thing to focus on on this slide would be the hormonal therapies. Um then moving on to benign breast lumps. Um as I mentioned before, you've got the fibroadenoma. So in exams, this sort of key thing to think about um when they're asking you about breast lumps is um is it really, really mobile? Um The fibroadenoma is what's known as your breast mouse. So it will sort of move around in the breast tissue, it's not painful and it tends to be associated with younger people and in general, they don't do an awful lot for them unless they are incredibly painful or sort of large in size as well. Um, and is causing some form of breast, um, sort of abnormality or asymmetry, then they'll do removal of them. But in general, they just get left alone because they're pretty benign, fibrocystic breast changes then are a sort of variant of normal. As I said, they're associated more with, um, changes in hormones throughout the menstrual cycle. Um It can be a wee bit painful and that you can get sort of lumps and bumps that appear and disappear um with the menstrual cycle. So, um that's something as well to bear in mind as a sort of benign cause of a breast lump. But um if you have any query about it, then I would refer on for triple assessment. Anyway, process cysts then are um sort of fluid-filled. So when you're feeling it, it'll see, it feels sort of uh it'll sort of fluctuate in size. Um And again, can be a little bit painful as well. They do require further investigation though, to exclude breast cancer as you can't tell just off of examination. Um So either way, like if you're referring home with that necrosis or breast cysts don't be worried that you've referred somebody for a triple assessment and they don't have cancer and you're worried that's a waste of resources. It can't be sort of been diagnosed any other way. So, don't panic about it. And as I say, the same goes with that necrosis. So that tends to be more associated with some sort of trauma to the region. Um and is quite firm and fixed to local structures, can get some sort of dimpling of the skin as well and nipple inversion. So that's what would sort of it cause you to be quite worried about them and refer them on for triple assessment. Um But it can just turn out to be fat necrosis. Um then with breastfeeding as well as something to think about. So, lactation, mastitis again is a really, really common exam question that comes up. Um And it's common that you, like, you'll say it when you're in clinical practice as well. Um It's more associated with unilateral breast pain. You can get overlying sort of erythema and inflammation, um and nipple discharge as well just from the clogged duct. Um And if it's quite severe, it can cause things like fever as well. Um You're getting infection of the milk duct effectively. Um So it becomes a bit blocked, then can get infected. It's usually that infected by staph aureus, which lives naturally on the skin. So it makes sense that that would be what's causing the infection and um to manage it. You are um encouraging regular breastfeeding to help sort of clear the blockage and the clogged duct here. Um If you um are, you know, applying suction onto that area then that help should help to, to remove the, the blockage and just um heat packs and warm showers again to try and loosen everything up and, and get things flowing again. Um, if there are any form of systemic symptoms, so things like fever, you're worried about sort of septic symptoms. You can give um antibiotics. It's flucloxacillin cause it's for staph aureus, um, or Erythromycin. If they're pen allergic nipple discharge, then is also a very common exam question that comes up. So, um there are sort of three causes of nipple discharge, um, mammary duct, ectasia, um where you get inflammation of one of the ducts that causes discharge, it's usually quite benign and um causes a sort of white gray green colored discharge. Um, smoking is a really big risk factor for it. Um and it can produce a sort of palpable lump as well. Um because of the sort of strange colored discharge that you can get with it and the fact that there is a palpable lump, you do want to refer the mom for triple assessment. And um again, common mcq microcalcifications can be seen and that sort of is an indication of mammary duct, ectasia don't do an awful lot for it. Um It's a lot about sort of um supportive management analgesia and um sort of supportive underwear, intraductal papilloma then is where you get a sort of warty lesion that grows within one of the breast ducts. And that can cause discharge. Again, it can be, it's benign, but it can become malignant. So it's something to keep an eye on. Um, this is more associated with your blood stained discharge. Again, can have a, a palpable lump and again, that's why you want to refer them on for triple assessment. Um, they can remove it as well just to send for histology and make sure that is exactly what it is and that it's not become malignant. Then, g lactea then is the production of sort of milk when you're not pregnant or breastfeeding. Um There's a few different causes of it mostly related to um high prolactin levels secreted by the pituitary gland and, and I've just listed some of the reasons why you might get that as well. Be aware that you can get this with men and women. Um So I don't think it's just sort of woman you can get it with and it's all about in terms of managing it. Um identifying the underlying cause and treating that appropriately. Bene can masia. Then I know this is sort of a breast talk. But um men have breast too and men can also get breast cancer. So don't forget that um gne masia is usually caused by an imbalance between the estrogen and progesterone in men. Um and can either be caused by high estrogen or low low testosterone. Um A big one to think about in men with gynecomastia that especially who are younger is um like testicular cancers. We're gonna go on to talk about them in the urology presentation, but it's definitely something to keep in the back of your mind. Um be also aware that some types of um lung cancer can also cause um tumors that secrete B HCD which causes um high estrogen levels. So definitely something to think about there as well and send them for uh a chest X ray, low testosterone then is also something to think about. Um and can be quite often, especially in younger people, be associated with mumps too. Um So um think about sort of the two causes high estrogen levels or low testosterone and consider things from there. Um in terms of exam land and MC Qs are sort of put in bold, the main things to think about. So your testicular cancers for your high estrogen levels and spironolactone um is a common cause of um gynecomastia in men um as it inhibits the testosterone production. So don't forget about medications as well. Marijuana is also a very common one that you'll see out and about um and anabolic steroids with people who are using steroids in the gym and stuff like that. So, um but yeah, as I say, in terms of exams, those ones I put in involved, there are the big ones to think about that includes the breast talk. Hopefully that's um sort of covered the main things I know that was a bit of a whistle talk to her, but I popped in a few MC Qs at the end here. Um So we can have a think about them when we chat through them. So I don't know if you want to put the answers in the chat function. Um So the first question there then is a six year old woman who presents with a rash on the right nipple has been gradually expanding over the last year to involve the areola. Um And she complains of itchiness and redness over the area over the last two weeks, she's also noticed an underlying mass in the same area and some bloody steam nipple discharge. She feels quite well other than this and has no other past medical conditions. What is the most appropriate management? Ok. So the answer here is triple assessment and I've just underlined sort of reasonings why. So it's a sort of older female um who's presented with skin changes. So if you go back to the previous eye looking at the red flag criteria, um it's anybody over 50 with um sort of skin changes are associated or any sort of changes in the nipple. So here they've got a rash in the nipple. There's also an underlying mass which would make you sort of suspicious of something malignant and blood stained nipple discharge, which requires further investigation. So the answer here is triple assessment. This is the same scenario and that was the most likely diagnosis. Great So I've got an answer there for b so projects disease of the nipple, which is great. Hold on. And then the final question, a 35 year old woman who has a painful lump in her breast. Her mother has breast cancer at the age of 65. She's currently 32 weeks pregnant with no past medical history. She's not taking any medication. She smokes five cigarettes a day on examination. There's a two centimeter lump in the right breast. It's tender on palpation and she has erythema of the overlying skin. What's the most appropriate management? Great and a couple of messages coming through there. So the answer is the triple assessment. So here, um this is kind of a little bit more of a difficult question but um as I said before, the criteria that often gets overlooked by a lot of people I think is the inflammatory best reactions. So here I know she is um pregnant, she's 32 weeks pregnant. So she's unlikely to milk production. She's unlikely to have something like a mastitis. Um She also has a history of smoking, which again is a risk factor for breast cancer. She's got a family history of breast cancer which again would make you more suspicious. Um And it sounds sort of inflammatory in nature, as I said, it's sort of tender, there's a lot of erythema with the overlying skin. Um So you would want to refer that on for triple assessment as well. Um, if it was a mastitis and she was sort of currently breastfeeding, um, you'd be, and um she had a bit of a fever or something like that. You'd be um, more along the lines of doing sort of simple analgesia, hot compresses, considering an antibiotic, that sort of thing. Um But as I say, because she has these risk factors, she is a little bit early and to be lactating then um would require that on for triple assessment as well. Great. So I will stop sharing there. I don't think there are any questions on breast pathology. If there are, then you can send me a wee message. But if not, that's fine and we can move on to then looking at um urology, right. So yes, it's gonna basically follow a very similar layout here. So I'll tell you about the anatomy. We'll look at the various sort of areas as well then of the male genital urinary tract. Um, we'll cover the prostate pathology associated with it, the testing and the kidneys and then going on to a wee bit about the bladder. But I know that you've had sort of like um kidney chats and renal chats before. Um So I'll only touch them on a little detail and the sort of important things associated with them. So to begin with the basic anatomy, um having a very quick flick through. So to follow the sort of course that sperm would go and it starts off in the testes. That's where the sperm are produced down here at the bottom. You then have your epididymis which overlaps the testes and just be aware of like the anatomy of it with your head, the body and then the tail just for your testicular exam. Do you want to comment on those? Make sure you're palpating all of them. Um that then leads into the uh ducts defer or the vas def, um, which travels um along and then connects with the, the urethra, um which drains from the pro uh which drains from the bladder. Um You get additional sort of fluids um coming from the prostate as well, which helps towards that ejaculation and then, um leading to the, the urethra, um I know you're sort of an asthma, the penis as well. Um And then obviously urethro meatus, um So quick, run through, I'm sure you all covered it in 1st and 2nd year. So it shouldn't be too bad. Um So just to be orientate you a wee bit, we're starting off um sort of here and chatting about the prostate and pathology associated with it. Once again, I've tried to put things that are more likely to come up in exams and MT Qs first. Um And then this sort of things are a little bit more boring towards the end, are not quite as important. Um So just beginning with B Ph very, very, very common, you'll see it out in community, you'll see it in the hospital. Um It's sort of associative with, um, older gentlemen who've got hesitancy. So, difficulty sort of initiating urination, weak flow when they do get going. Um, sort of urgency need, they need to go to the toilet. Now. Um, I feel that they need to go in a lot more frequency, uh, frequently they've got thing which is where they sort of, um, start and stop when they're going to the loo and then, um, can have problem with straining if they've got a sort of blockage, um, around the, the urethra. Then obviously, they've got a strain to be able to get past that and then they can get like a little bit of dribbling as well afterwards, um, to investigate it, then, um, you want to look for, um, do an abdominal exam, first of all to see if they've got a palpable bladder. If they do, this is a sign that they've got some chronic urinary retention. So, um, they, they, they've had problems with the prostate, sort of closing over and blocking the, the urethra for a long period of time. Um, and their, that's caused their bladder to sort of expand. Um, then you obviously wanna do your rectal exam to look and assess the, the prostate itself. Um, and, uh, in BPH, it should be nice and smooth and symmetrical. You should feel the central sulcus as well normally. Um, and it'll be nice and soft in texture, it'll just be a bit larger than you would expect. Um, you then wanna do urina to rule out any differentials. So you're thinking with these sort of symptoms, you're thinking of sort of uti symptoms, um, that sort of have a big crossover. So, from your analysis, nothing quick and easy. Um And that'll help you either rule it in or rule it out as a, a possible diagnosis and then doing your PSA now the PSA is a little bit of an unreliable test. So I would sort of try with caution as to how much you rely on it. Um It has a really high rate of false positives um and just be aware as well of the things that can cause uh a raised psa some of them sort of falsely raise if you've been doing a lot of um exercise and click cycling, um or any sort of recent um ejaculation or prostate stimulation. And that includes like performing ad re and then doing a PSA afterwards. So just consider that in the back of your mind. When you're interpreting the results, there's lots of different reasons why it can be raised and not necessarily always associated with them like cancer or something like that to manage it, then you um can do different um sort of medical treatments initially. So Tulin is an alpha blocker. So that helps to relax a smooth muscle. Uh and that can be useful if you've got um, sort of acute urary tension secondary to BPH. So if the prostate completely closes over the urethra, they're having problems with peeing. They haven't peed for ages. They've got a massive big palpable bladder. They're feeling really sort of uncomfortable. Um, you can give tamsulosin, um, and also insert a catheter just to, um, relax that smooth muscle and help sort of quickly relieve the symptoms. Um, just be aware that it can be associated with postural hypotension. So BPH is often associated with sort of older men. So just be aware of that and the risk of falls then associated also if you see somebody um in a, so Jerry Station and exams who's on tamsulosin and has come in with a fall. Um just have postural hypertension at the back of your mind and it might be a medication that you want to consider stopping. Um in that situation. Finasteride then is um a medication that's used to reduce the size of the prostate itself. So this is a little bit more longer acting than the Tamsin you can use in the combination. Um But it takes a, that wee bit longer to actually have a, a notable effect. Um It also is associated with sexual dysfunction um as a sort of side effect. So it's something to think about as well. Um And might be a, a reason that people stop taking their medication, but they're not necessarily gonna be open and honest and tell you about. So, um, if you have some form of counseling or something on that, um, then have that in the back of your mind as a, a sort of question to ask about it. Um, and then if the medications sort of fail, um, or they've been on them a long time and then they're getting problems with these, um, sort of symptoms again, then you can do a turp, which is your transurethral resection of the prostate where they insert a sort of um scope through the urethra and sort of shave away the inside of the prostate just to open up the urethra meatus again and allow um everything to flow naturally. Will that all make sense? Prostate cancer? Then um is uh another problem associated with the prostate, obviously, um risk factors, obviously, increasing age, family history, um different ethnicities and anabolic steroid use usually presents sort of similar to BPH. So if you, as I said, the symptoms are very similar, so it's something that you might want to rule out by doing your um PSA and that's why you're doing your dre as well um can be associated more so with hematuria. Um But as things like UTI S, so again, there's a massive crossover here because it can be kind of hard to, to identify what it is that's going along. Um But erectile dysfunction is associated with um prostate cancer and, and then you're getting into your, more of your symptoms associated with more chronic disease. So things like weight loss and bone pains as well is quite often associated with prostate cancer, especially in like lower back pain is a common one investigations. Then you're doing your dr obviously. So, um, this will show more of like a hard asymmetric sort of craggy, um, prostate with loss of the central sulcus. Um, craggy is obviously the key word that comes up in exams and you know, instantly from there, it's gonna be prostate cancer is the answer. Um, any raise psa so greater than four is then also associated with um prostate cancer. So it's um that you would want to refer that on then your red fla uh red flag referral, then you are sending them initially for an MRI. Um and then you're doing your biopsy afterwards and a lot of people get them mixed up. So MRI is first, um and then you're doing your biopsy because the biopsy is um quite uncomfortable. They sort of do it sort of through the um rectum and then into the prostate. And there's no point in doing that if they've already got um, like bony nets and it's gonna be and sort of palliative management, you don't really need a biopsy, then you don't need a, a tissue biopsy. So, um MRI first to look for any sort of evidence of any metastases and make sure it is um sort of a solitary lesion, then they'll do a biopsy and then they can do an eye toe bone scan if there's any doubt about anything as well. The big thing to know about prostate cancer then is your Gleason score. So this will assess how differentiated um the cells are. So the higher the score, the more poorly differentiated the cells are. So that translates as the high score means bad essentially. Um So the oh so the Gleason score is given us two numbers. Um and just be aware that the, you want the lower number to come first essentially, and that's associated with a better prognosis. So, although they add up to make the same number, a three plus four is better than having a four plus three because the level of differentiated cells then is there's more sort of cancerous cells or cancer pathological looking cells in the four plus three than there are in the three plus four. Hopefully, that makes sense. Um But, and then that can be used to assess your sort of risk um with the prostate cancer and um how bad it's looking essentially in terms of your management. If you're low risk, then they will just do surveillance for you. Um and just keep an eye on things and make sure that they aren't sort of developing too much further. You can then do um for more higher risk um sort of like things like your intermediate risk and you want to do external beam radiotherapy. Um So that's, and your brachytherapy. So there's sort of two different types of radiotherapy that they can do. Um, but just be aware that it can cause protis. So, inflammation of the rectum as a sort of, um, side effect or complication of them. Um, and your brachytherapy is where they go and, um, place the wee surgical clips and that'll give them something to sort of direct the, um, the radiotherapy beams at. Um, so they know where they're going with the prostate and then your hormonal therapies as well. They've got two different types of medication and just be aware of them essentially. Um So, similarly to your breast cancer, they can do more targeted hormonal therapy treatment um with prostate cancer as well and just be aware, there's no screening program as well for prostate cancer prostatitis then is um sort of inflammation of the prostate itself. Um It can cause sort of peroneal pain. So, between the sort of anus and the penis, that sort of the lar your skin um sort of in here um can become painful or um prosthetic pain itself can present as well, sort of similar to UTIs. A lot of these things can. Um So your dysuria, your frequency and your urgency associated with urination. Um and you can also get a favor because there's inflammation going on, but there's no infection here um on investigating. Um So you'd do ad re so your digital rectal exam. Um and you'll find a sort of enlarged, very, very, very tender prostate. Um You want your urinalysis just to rule out uti once again, you might want to consider sending it for cultures and sensitivities and consider as well. Things like chlamydia and gonorrhea, uh gonorrhea testing as well. Um To treat it. If there is an underlying infection, you can give antibiotics, but if not, it's just analgesia and it should settle on its own. So hopefully all that sort of prostate stuff makes sense. And we will now go down here to chat about the testicles and pathology associated with them. Now to testicular exams is not something that we had an awful lot of teaching on. But, um, Queens have recently bought a new sort of testicular model where they can like take off the testicles and put ones on with different um, pathologies with them and they can give you things like, you know, your porch to do your translumination. So, have a good idea. I wouldn't like, I wouldn't be surprised if it came up, um, especially with recent news cover of testicular cancers and um, trying to help engage more young men um, to attend, um, the doctor if they feel something a little bit abnormal. Um, but just your differentials for any form of sort of abnormality of the testicles, um, or any sort of lumps. So, hydroceles, obviously, they transilluminate. So that's the big thing that goes along with them as well for MCQ, these are very helpful, your varicoceles, your sort of bag of worms, um feeling. So that's like a varicus vein. Then of the, the, the the veins around the testicle, your epididymal cysts. So they'll be soft and sort of fluid filled. You'll feel um your testicular cancer then or more hard and irregular your epididymal orchitis. That's what I was saying earlier, you need to know your anatomy. So, um of the epididymis of your head, the body and the tail and you're feeling it um to assess for any tenderness or inflammation of the overlying skin. Um inguinal hernias then isn't also a very good differential for um any lump in the testicle. And the way that you're able to differentiate that from, say a hydrocele is that you're unable to get above the lump. So usually when you're doing your testicle exam, you want to feel up into the spermatic cord. Um but in an inguinal hernia, you will be able to feel the spermatic cord because it will all just be boil coming down in front of it. Um So make sure that you are trying to sort of bear these things in mind when you're performing the examination just to start ruling things out essentially. And then your testicular torsion as well is really, really painful and you get loss of the cremaster reflex when you sort of stroke up the inner thigh, then you get the um testicles sort of um retracting up. Um That won't happen then in testicular torsion cause all the muscles and all the nerves that innervate the muscles that allow it to sort of jump up, um are all twisted. So they don't function so well. And then when you are doing the um testicular exam, a really important test to be aware of is friends test. So this allows you to differentiate between your epididymal orchitis or your epididymitis and your testicular torsion. Um because they can both sort of a here is very sort of um tender, um acutely painful, um testes and they can be quite inflamed and things like that. So just to try and differentiate between the two and all the test is, is that you, it's really easy to do, you just elevate the testicle and see how that affects the pain. So, if there's a reduction in the pain, then that's your acute epididymitis. And if it's still sore, then it's a testicular torsion and that's your big urological emergency and that I'm sure you're all aware of. So, um it to go straight to surgery um to avoid losing the testicle altogether and it becoming all necrotic. Um So I think a lot of people weren't very aware of friends test when I was um going over test exams with people before. So, um definitely have a look over it as, as I say, it's not difficult to do and um comes up a lot in exams um and will allow you to differentiate between the two and MC Qs and things like that tips and again, are very, very similar to the breast exam. So try to maintain the patient's dignity throughout. Um, you know, keep things covered when they don't need to be out. Um And, and, but at the same time, you wanna be able to see as much as you can. So like have a look at those testicles and then, um you know, try and maintain people's dignity and um don't be excessive with it. Essentially. Um Another good thing to do is assess the patient lying down and standing up. So you can perform the test, testicular exam as normal when the patient is lying down, but then just get them to stand up right at the end of the examination just to make sure if there are any hernias that you do find them, um especially if the patient's a little bit older. Um make sure um to assess for inguinal hernias. Um And it'll remind you as well if you get them to stand up at the end to assess for them. Um Maybe you've forgotten when you're doing the actual examination itself. So hernias will be more prominent when they stand up. So if you aren't sure if there's like, if there's a lump present, you're not entirely sure um what it is, get them to stand up and then you'll be able to, if it gets bigger, essentially, it's a hernia. Um And again, similar to the breast exam. Don't forget a chaperone testicular cancers then are, um, once again, very common. Now use, um, know that it's affecting, it's one of very few cancers that affect younger men. Um, and, um, undescended testes is also a big risk factor. So that's why in pediatrics are really concerned if a baby is born with undescended testing, they want to keep a really close eye eye on it because, um, if they could do go on to develop a testicular cancer, but the testes is undescended, then nobody's ever gonna find out about it for ages. So that's why they're kind of keen on it and then any sort of family history of testicular cancers, um It presents as a sort of unilateral um So, painless lump is the key thing. So, like you might have painless jaundice for your pancreatic cancers. A painless lump is um a testicular cancer until proven otherwise. Um It's sort of hard, irregular. Um So similar things that you would find in any sort of cancer abnormality. Um And also don't forget to ask about, you know, your casual, your systemic symptoms. So weight loss, night sweats, fevers, that sort of thing, investigate. Then there's three blood tests. You do your alpha beta protein, your beta HC D and your LDH or they sort of screening blood for you, then wanna send them off for an ultrasound of the scrotum and um can then go on to assess for staging and things like that using a CT, there's a pretty low um threshold for a referral. Um So as long as you are happy enough that it's not a hydrocele or something like that and it's a young man who comes in with an uh unilateral painless lump. I would refer them on um red flag for testicular cancers. You'd rather refer people on and it not be cancer than not. And it is. um so just have a pretty low threshold for it. In terms of the cancers themselves, I won't go into this in too much detail. But um the main ones to be aware of are there's two different types. So there's germ cell tumors which arise from the sperm producing cells and nonsperm cell tumors effectively. So, the big one with your germ cell tumors are seminomas. Um and they're more associated with older men. Um whereas non germ cell tumors um are things like your teratomas. So you get them in females as well with their classic sort of um tumors that will grow like teeth and hair and all that sort of stuff. Um And they're associated more with the young men. Um The management then is an MDT approach, you can do ra radical or orchidectomy. So, removal of the testicle itself and then your radiotherapy chemotherapy stuff, just be very um cautious if you're going and doing some of these stations or um if you ever see somebody with testicular cancer um infertility is a really big one. So if you get this at an oxy station or something, then um definitely want to discuss um the fact that they're probably gonna have um a reduced fertility afterwards after treatment. So they might want to consider things like sperm banks and sperm donation programs really there. Um epididymal orchitis then. So epididymitis is just inflam inflammation of the epididymis, which is this structure here. Um and orchitis is inflammation of the testes. So you can get epididymitis on its own or you can get epididymo orchitis, but they are both very similar. Um So you'll never get both of them together in an M CQ. It'll be one or the other. Um but just be aware that they are slightly different. It's just more terminology more than anything else. Um So this is usually caused by an infection. So in older men, be aware of e coli, so similar to UT S in men, it's usually caused by e coli. Um that is what epi oritis is caused by. But in younger men, it's more associated with STIs or mumps. So think about chlamydia, gonorrhea. Um and then mumps as well is another common one. It presents with unilateral testicular pain again, which is, as I said before, when we're talking about friends test, it's relieved on elevating the testes and that's how you differentiate from the testicular torsion, as I said, with swelling of the testes as well. And um if it's a younger man, then you might get sort of, um, urethral discharge and then you're wanting to think more along your sort of gum route as well. Um, you can also, because it's infection, you can get systemic symptoms so your fever and things like that. In fact, uh, investigations, then you want to do, um, urine culture and sensitivities in case it is sort of e coli related. Um, and you wanna target your antibiotics appropriately. You can do your testing for your chlamydia and gonorrhea. So you're not testing in your charcoal swabs and then do, um, saliva pcr testing that you're suspecting things like bumps, but you're gonna have a feel of the lymph nodes as well when you're doing that. And then, um, you can do an ultrasound as well to help differentiate between other, um, sort of similar looking pathologies. Um, and then management is very, such as simple from our point of view, but it's just referring them on to gum if you think that they have some form of ST I and, um, treating the infection as per the antibiotic guidelines. So, obviously, it's gonna be different depending on whether it's an E coli infection or chlamydia or gonorrhea or whatever else. Great. And now very briefly going on to chat about the kidneys and bladder. So I've mainly just included the cancers here. So, um, renal cell carcinomas, um, are the big ones associated with the kidneys classified by tria the symptoms. So, hematuria, Frank, Frank pain and a palpable mass. Obviously, normally, when you are doing your ABDO exam, you're failing for the kidneys, you cannot feel them. Um, in renal cell carcinomas, you might well be able to the most commonly, um, what's called a clear cell carcinoma. Um, so that's quite uncommon things to come up in MC QS as well, came up in our finals, um, and just be aware that Wilms tumor or a type of renal cell carcinoma that are specifically associated with Children. So, any sort of palpable um sort of mass in the flanks of a child, um especially if they cross the midline, you're wanting to think about Wilms tumors. Um So keep that in the back of your mind. You don't wanna miss that to refer then for renal cell carcinomas. You doing anybody over the age of 45 with unexplained physical hematuria and they can have uti symptoms or um they can, they can not have uti symptoms and they can just persist after they've been treated for uti, obviously, hematuria is really common with uti S. So, um if you treat them for uti and the hematuria doesn't go away and then you'd be wanting to start thinking about referring them on for a red flag um to try and find out what could be going on. Um Another really common exam question is a patient presents with shortness of breath and um they get a chest X ray and there's loads of cannonball mets. So that's sort of key phrase. Um So that is associated with metastases of renal cell carcinomas classically. Um So the the tumor in the kidney then tends to spread to lungs, basically to manage it. Again, it's an MDT approach. You can go wrong by saying that especially in AY. Um and you want to do either partial removal um of part of the kidney or you can just remove the whole kidney. Um but just be aware, you don't actually have to remove the whole kidney. Depends on where the the tumor itself is at. And um how much of the kidney itself is affected kidney stones then are really another like another really, really common um question that comes up. So, um there are four different types of kidney stones. You can get, just be aware that um uric acid stones will not show up on abdominal x rays. Um But the rest of them should be radio opaque and show up. Um It has come up in. Um I think it was fine last year where they had a kidney stone station and were asked to um like what their kidney stones made of kind of thing. Um So just have a rough idea, calcium oxalate calcium phosphate, um uric acid and are the, the sort of big ones um presents typically with really, really, really extreme low to growing pain. Um People say it's birth and childbirth I don't know, but it's bad anyway. Um again, hematuria, um and things like nausea and vomiting just with the pain. Um to investigate it, you obviously want to do urinalysis, um to rule out any other causes of like infection. You're looking at your nitrates, things like that. Um do a bone profile as well to check for your calcium levels. Um As you can see, a lot of the stones are associated with high calcium. So um check that the, the blood calcium levels are not high and then um doing an abdominal X ray as well as I said, your acid stones won't show up on X ray, but all other types of stones should show up and should be radiopaque. So you should be able to see them and then um you can do a CT K UV as well just to look at the renal tract and see exactly where the stones are. Um Then for management, um the big one for MT Qs is giving pain relief. So that's your Pr Ri M Diclofenac, it's uh anti-inflammatory. So it can help sort of get the stone moving along. Um And depending on the size of the stone, then there's a few different interventions you can do. So if the stone is less than five millimeters, then you watch and wait and you just hope that the person to it themselves, um which they should and it's just all about, you know, keeping hydrating and keeping the kidneys functioning um for stones which are five millimeters to two centimeters, that's 20 millimeters. Um You wanna do Lithotripsy, um which is where they use um sort of ultrasound waves to break up the, the stone into sort of smaller fragments. And that makes it easier to pass and stops any obstructions along the route or uroscopy, which is where they can put like um stents in the ureter to then help things pass along a little bit easier. You can also do um percutaneous nephrolithotomy. Um If the stone is especially big, um which is where they go in through the skin um into the kidney to then retrace the stone if it's just not budging, um stones can quite often get sort of stuck at the renal pelvis, which is sort of a way up here. So, um you're not gonna be coming in from the bottom and sort of going all the way up. It's easier just to go through the skin then, um and then just be aware that there might be something that come up when you're interpreting um abdominal x-rays. So keep it at the back of your mind. Um And just here, we've got the Staghorn Calculi which is associated with your um through, right? Um And so that's something to be aware of. And then there is one here. Hopefully you can see my mi um there's one here as well um in the abdominal X ray. So, um and it looks like it's more sort of in the ureter descending toward the bladder there. So, um, if you see like a wee white thing, always compare it to the other side. And, um, obviously there's one here but there's nothing over here. So that's why you're thinking it's more sort of pathological. Um, and that's likely to be a sort of calcium based one because they're nice and radio opaque. You can see them with um x-ray kidney transplant then are a big thing as well. Um Especially over here, they performed a lot of them over COVID. So there's loads of patients walking around with um nice new kidneys. Um We, in our finals had somebody come up with um a fistula and we had to examine it. So, just be aware of that. Um I know how to examine um your arteriovenous fistulas, um usually in the arm. Um And then as well when you're doing your abdominal examinations want to look for your classic sort of hockey shaped scar in the flank region. And unlike um your sort of um host kidneys or the ones that you were naturally born with, you'll be able to palpate the kidney and they're usually in the right iliac fossa and then they get plumbed just straight into your um iliac vessels. Um And for some reason, they always like to choose the right, more so than the left. Um I don't know why that, um, if you see a big long scar like that, then that's something to consider. And if you see, feel a palpable mass there, then it could well be a new kidney beware as well with kidney transplants, which is strange, they don't take out the old ones, they just leave them in and pop new ones in wherever they can find space effectively. So you can get new kidneys popping up basically in most places in the abdomen. But classically, it's in the right. So there bladder cancer then um I think it's from the last slide. So we're nearly there. Um risk factors, big risk factor is um the sort of dyes and rubber. Um So classical in est you'll get somebody who's worked in some form of dye factory, um who presented with um a hematuria and weight loss. Um And you're starting to think already about bladder cancer, just be aware that schisis, um which is a parasite infection is also associated with bladder cancer and is one of these weird things that you'll see in but never in real life. Um So it's again something to bear in the back of your mind. Most bladder cancers though are what's called transitional cell carcinomas. So, if you remember from histology, the bladder um lining itself is transitional cells and that allows it to sort of expand and things like that. Um And that's a common type type of cancer, but squamous cell carcinomas as well can be associated with bladder cancers and they are the ones that are associated with your schizos, sosis, the sort of parasite infection. Um, as I mentioned, um, when I was talking about, you know, your classic M CQ question, it starts with plain hematuria. Um And your referral criteria is there as well. I'm going into too much detail, but it's quite self-explanatory, I think, um investigations then or cystoscopy to actually visualize the inside of the bladder. So they go in through the urethral um and into the bladder to have a look to see if they can visualize any cancers tom your management then is an MGT approach once again. And um they can sort of reset the tumor if it's nice and localized, hasn't spread anywhere at all. And that's your tt um Just be careful that um you don't mix that up with a turp. So your turp was your chance to use resection of the prostate and that was for your BPH. Um But your D is your transurethral resection of the bladder tumor. Um So just be careful with those terminologies. Again, they're very similar procedures. But obviously that one, they are going a wee bit further up to resect because they're going right the way into the bladder rather than just to the prostate. They can also do um chemotherapy, which again, they put in through the urethra directly into the bladder itself on the inside and, and immunotherapy as well, which is straight into the bladder too. And that's interestingly enough. The BCG. So, how that works is the BCG vaccine that they use for TB, um, sort of sticks to the, um, cancer cells and that will elicit an immune response causing in your own immune system to then attack the bladder and the cancer itself. It's quite interesting. You don't know much about it. I would have a read into it if you've got time. But I find it quite interesting and maybe that's just me being nerdy. Um, and then sort of as your final stages, you can do a radical cystectomy, um, or the urostomy. So that's where you're taking out the bladder altogether. And then similar that you would with the bile in like a bowel cancer or, um, your sort of Crohn's disease then, or your ulcerative colitis, then you can create a stoma. Um, and this will be sort of in the middle of the abdomen and it will have just like a wee smaller holes in what your body would. Um, and obviously the bag will be filled with urine rather than of, um, sort of fecal matter. So it's always important when you're doing any form of, um, stoma examination that you check the actual contents of the bag as well because, you know, for more liquid, um, matter in the bag, then that's more associated with your, um, like your small bile and then your colostomies, then are you sort of more dried out and solid matter. Um And then urostomy, sorry, obviously your liquid matter. Great. So we're just going to some quick M CT S. So this one, a 22 year old man has been experiencing increased shortness of breath and exertion for the last two months. He also feels that his clothes are looser than they used to be and has gone down about size over the last three months. He says that his testing feel different on self exam, which of the following tumor markers are most likely to be positive in this patient. No, it's not sure, not very well, but the answer there is be to HCG. Um So I've sort of underlined the reasons why again. So increased shortness of breath, um and his clothes are looser. So you're thinking that he's um got a wee bit of weight loss there. Um And the testing is a little bit different so that you're thinking sort of metastases of a testicular cancer to the lung is quite common. Um And um you'll be wanting to do your three checks. So your um HCD, your AFP and your ce um and great. Then a 20 year old man presents to A&E with severe pain in the left flank. ACR shows that he's recently been discharged from hospital following an upper urinary tract infection. An abdominal X ray shows the presence of a renal calculi in the left ureter. What's the most likely composition of the patient's kidney stone struvite? And that is because um of the upper uti so struvite is more associated with recent infections. Um And just remember as well as I said before, your uric acid is not gonna show up on X ray. So you can instantly rule that one out. The rest of them would show up on X ray, but your is the one that's more associated with recent infections. And then the final question, 78 year old man has recently been diagnosed with prostate cancer. He presents to um ed with lower abdominal pain. He's not passed around for the last 10 hours and is still unable to void on examination. He has a distended bladder which causes him severe discomfort when palpated, what bedside test can be done to confirm the diagnosis and hear the answer to the bladder scan. So, um the man's already been diagnosed with prostate cancer. So you're not too fast about trying to diagnose the prostate cancer itself. He's not pass urine for 10 hours, which is quite a long time. And um you can feel the bladder. So, obviously, you know, when, um you're doing your abdominal examinations, you can't usually feel the bladder. Um So that suggests that it's really quite distended and he's probably got a bit of chronic urinary retention. Um So you can sort of roughly quantify how much fluid is in the bladder itself by doing a bladder scan. Um, and that will allow you to sort of decide what your next steps are gonna be, it's probably gonna involve, um, putting in a catheter for sort of immediate release, um, of the, the urine and release some of the discomfort. And then, um, you can decide what you're going to do about the actual obstruction of the urethra itself. Ok. So I hope that that all makes sense. If you have, um, any questions, then please let me know. I will, the, I will pop the feedback link back into the group chat messenger again. And if you could fill that out, that'd be brilliant. Um, I put my emails on those slides as well. So if you have any questions about anything else, then, um, feel free to send it on. But if not, then that's ok. And I hope you all enjoy the rest of your evening and good luck for your exams.