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right. Hi, everyone. I'm just going to give it another five minutes to give enough people to join, and then we can start at five past eight. Okay, so that's five minutes past eight. So we're going to go ahead and start now. Welcome back to the Weekly, uh, urology theories presented by mind the bleep. Um, today's topic is going to be covering chronic urinary retention, and that's after last week's session on acute urinary retention. So just a quick message from one of our sponsors before we go ahead and start, If you don't mind showing me the next slide, please. Great. So basically, we've partnered with COPD me, and they're providing. They're allowing us to provide hundreds of COPD accredited webinars at the moment. Um, there are some applications can actually be found on all platforms, including android and apple. And they're specifically designed for people who are registered with the GMC or the NM see, or any other health care professionals. Really? So we've managed to get quite a decent discount, um, 50% off. So it only costs 8 lbs for the whole year, and you can use their application essentially to upload all your teaching material and teaching COPD basically. So if you're interested in that, go ahead and use the QR code provided. So without further ado, I'm going to go ahead and hand over to our wonderful presented today and I'll let you introduce yourself. Hi, everyone. My name is sciatica and I am a urology s t five in Glasgow in the west of Scotland. Rotation. Um so today I'll be talking to you about chronic urinary retention, and I hope not to overlap too much about acute urinary retention from last week's talk. Um, just give you a good overview, but also give you some information about what you might want to think about when you see patients in clinic that come in with lower urinary tract symptoms. And I'll talk to you a little bit about catheters as well, just to give you an overview of what urology is like as well. So calling you on your attention. Um, it means that you're able to basically pass urine, but you often retain it, Um, or you can pass urine or he gets a bit of discomfort. But not all the time. It is the painless inability to avoid and it could be categorized as low or high pressure. So low pressure, chronic urinary retention. Often you have normal using these, and there's no hydronephrosis is on an ultra side. Those with high pressure, you often have a drop in their e g f r. And you often find hydronephrosis if you do an ultrasound of the urinary tract. Often these large volumes are greater than 800 it's quite a large residual volume. And what I mean by residual volume is if a patient is able to pass urine to still hold on to, say, like 800 mils or another kind of volume. But it's what that's left in the bladder after the avoid. That's what's also often called acute and chronic. Retention is a painful inability to void with catheterization volumes over about 800 mils. Common cause is is useful to bear in mind all the causes of acute urinary retention. Um, common causes of chronic you know retention include those underlying causes for bladder outlet obstruction so often it's most commonly found in men. So those with an enlarged prostate having stricter disease as well, or one of the commonest things to bear in mind. So the manager of chronic urine retention is quite similar to those patients presented with acute urinary retention. You assess the patient in a B C D approach and would like to catheterize them, especially if they're in chronic high pressure retention with reduced e g f r. You also have to think about if you can insert a catheter you recently or super pubic clean. Uh, specifically, if it's very difficult to insert, you're if you have a large prostate or a very tight stricture, and then often you might think about, um, inserting a suprapubic catheter. Suprapubic catheter should ideally inserted by neurology trainees, and it wouldn't be expected if your ms who are in foundation to need to do that. The key here is to record how much volume comes out once the catheter inserted and look to record. If there's any evidence of diabetes, is and we'll look at what dialysis means and what we do about it. Sometimes you can get something called decompression bleeding, so if you think about it, if your bladder stretched and you put the catheter in and then it kind of collapses, and that causes some bleeding, so sometimes when you have chronic urinary retention, public catheter, and initially it drains clear urine. Um, and afterwards and it gets quite red and bloody or immature Ick. You should always take a focal neurological history. Um, it can give you a clue as to probably what's causing the chronic urinary retention. You examine the patient, examine your abdomen and look at the external genitalia. Um, and if they're man would examine the prostate as well. And investigations are similar to that of acute urinary retention. So you want to do a urinary ultrasound, especially if they have deranged urine electrolytes? Um, some patients. Sorry. Will have, um So I guess what I want to say is you can always test check the PSSA in patients, but you have to bear in mind that in retention it will be high. But if you feel someone's prostate and it feels grossly abnormal, um, I have previously done a PS PSA on patients and respect them being chronic urine retention. You often can just check again in a couple of weeks down the line to see if it's fallen. So in low pressure, chronic retention, you can offer someone intermittent self catheterization. What that means is, um, patients are given these kind of small kind of disposable catheters kind of once once only, and they can insert it themselves like an I/O catheter, especially if they're having high residual volume. But they're still able to pass urine. They can also be offered a long term catheter, and those men can be offered a transurethral resection of the prostate. There's also you procedures are out there that are minimally invasive as well that are alternatives to a T. R K, and I'll briefly touch on those as well. So there's three different options for low pressure. Chronic retention. But those with high pressure, chronic retention, the safest thing to do is give them a long term catheter or offer them transurethral resection of the prostate or some other measures that are going to talk to you about If you allow a patient to do intermittent self catheterization, there is a chance that that may not be able to empty the bladder that well all the time, and those with high pressure attention as we talked about we'll have impaired renal function, so that's why we try and avoid that. So for those of you haven't seen this is what a transurethral resection of the prostate looks like. Um, hopefully this video will work, so that's just going through the urethra. You can see the prostate is enlarge so often when you go in with the telescope, you'll look and see if you can find the ureteric offices and you want to make sure that you don't respect them. That's the right left there. So the look here just basically takes a chip of prostate out, and that's how you resect the prostate. And as you can see, there's some bleeding and things. Um, but that's what the T u R P would look like. And this is just a simulation model of it. So there's many alternatives and these are being offered. Um, just depends on where you really work. Um, certainly your left eye has become quite popular as an alternative to T. R. P s main reason being those who undergo t. R. P s, um they have problems with ejaculation and erections, and this avoids that. So I thought I would show you what your left was. The urolift system is a proven, minimally invasive technology designed to relieve urinary symptoms and improve quality of life with minimal side effects for men with an enlarged prostate caused by the nine prostatic hyperplasia, or BPH, the urolift system procedure begins by inserting an implant delivery device into the urethra and attached. Endoscope provides visibility to the obstructive prostate on reaching the area blocked by the enlarged prostate. The obstructive prostate tissue is moved aside following a trigger. Press the device inserts of fine 19 gauge hollow needle across the prostate and deploys the implant through the needle. The implant is a nylon suture fixed in place with a thin metal tab at each end, depending on the prostate size and blockage. Severity. The doctor insert several more implants the same way I Typically 4 to 6 implants are placed into the prostate. The outer capsule of the prostate is firm and provides a solid anchor, which allows the implants to lift and hold the enlarged prostate tissue out of the way so it no longer blocks the urethra. As the sutures are shorter than the prostate death, the prostate laterally compresses. This reduces pressure on the urethra and provides immediate, visible results so urine can flow freely. It's a mechanical solution to a mechanical problem. The minimally invasive procedure requires no cutting, heating or tissue removal. This procedure avoids erectile and ejaculatory dysfunction. It typically also means minimal downtime, mild to moderate side effects and a quick return to normal activity. So, as you can see, unlike the T. U r P, this is kind of like a day case procedure, Um, and it's almost like a curtain where the two loaves of prostate or just kind of pushed to the site. We've recently had, like a training module, um, with Scotland colleagues on how to do this procedure, and the team from your left actually showed us. And it's actually looks quite fun, certainly not available at the moment in the West of Scotland, and it might not be available everywhere else. But it's, um, it's something that's new that we probably should just briefly know about as an alternative to turn up. The other things that can be offered are lasers for creating that channel again, and that can be used by a whole or a green light laser and fortunately for steam can be used as well to create that channel. And that's often called resume. So we talked about how to look at the diuresis and what is diabetes is so diabetes is. The definition is if you document someone's urine output if they're passing almost 200 miles per hour over the last two consecutive hours, that is considered that the patient is diuresing following catheterization, and this is what symbolizes Guess it was commonly associated with chronic high pressure attention. So it happens in about 0.5 to 78% of patients with chronic depression extensions. Quite a lot. Um, quite a few mechanisms underlying the cause of this, So excretion of retained water and salt can cause this. There's a osmotic diuresis, um, secondary to high levels of urea. You get production of lots of diuretic and naturalistic peptides. This causes the loss of concentration gradient, which means that reduced urine flow through the obstructive kidney, and this impairs the tribulation function. There's also an impaired response to the collecting ducts to a D. H, and there's an imbalance of sodium regulating hormones. So all of these factors cause you to produce lots and lots of urine. So how do we manage this? You have to document the urine output very accurately. That's one of the key things to do. So strict urine, early volumes record their BP and daily weights to ensure that they're not becoming flu depleted. It's good to look at their drug charts, um, to make sure that you know So they're never toxins are withheld. Looking at whether they're on diuretics, try and withhold them and optimize your antihypertensives. For those with chronic hypertension, you want to do an option of the urinary tract as this could show hydronephrosis and monitor their renal function to see, um, if they're renal function improves falling catheterization. So to replace, um, how urine output in those patients with chronic high pressure attention, you'd replace basically 50% of the previous hours urine output with sodium chloride, and you calculate that by looking at the hourly volumes of the flu balance chart. So it's a little bit about, uh, male lots. Um, this is quite common neurological problem that you'll see in clinics, and it includes a variety of symptoms, including storage and avoiding lots. So storage lots include things like frequency, which is like going back and forth to the toilet urgency, having that quick desire to suddenly go to the toilet and nocturia when you're sleeping away and you're waking up because you have a desire to pass urine. Avoiding lots includes the headstones, a poor stream kind of straining to pass urine intermittent. Same. Prolong the duration. So taking a really long time to pass urine and the feeling that you're not really quite empty, your bladder and can also get some dribbling. The key with all of these things, take a focal neurological history. So you want to work out if they have storage or avoiding the lower urinary tract symptoms and the duration and extent of both, and see how how much it's affecting their lifestyle. You want to ask what kind of red flag symptoms such as Frank Hematuria, which is blood in the urine and the weight loss or a loss of appetite? Um, there could be an underlying sinister cause for why this person is presenting with lower urinary tract symptoms. Other things to mention would be your ankle injury or instrumentation. There's a risk that they could have developed stricture disease, any pelvic surgery which could impair the nerves, which means that they may not be able to into their bladder so well. Same with neurological disorders such as, UM, M s and also diabetes. It's good to look at what medications paper patients are on already gives you an idea as to what's worked for them, what's not worked for them and see what else can be added. You have to take a focused lifestyle history, especially looking at the fluid intake, whether they smoke and what they do for a living, because these factors will impact how they go from day to day life examination. Generally, you would look for evidence of fluid overload signs of your anemia. Um, if they have a neurological condition to look for tremor, their gait, your exam in their abdomen and you see you can feel a bad ER or palpate their kidneys. It's quite hard to do that always, but often if they are very slim, that is possible. You look at the external genitalia, especially, um, if you are doing an examination, you always have a chaperone present and document. If there's any evidence of diagnosis or any prenatal stenosis, and you obviously try and examine the prostate as well, and it says the size and consistency of it and make sure it feels benign. Initial assessments. You do an I. P s score and you want to do a fluid volume chart. Want to dip their urine to exclude any infection? And you want to check the A renal function and check the PSSA and explain to them why you're doing the PSSA and what PS A looks at and conditions where it can be raised. And those are all important things to mention to the patient. You do have flu and scan, uh, to look at how the patients voiding, and you can check afterwards, um, their bladder scan to see how much they're retaining and record your post void residual volume. Here is the IPSS questionnaire, um, and asks you several questions and it categorizes your sense of incomplete emptying frequency intermittency urgency, a weak stream straining and nocturia. And I also ask you about the quality of life and as you can see their scores for all of them, management wise, like simple lifestyle factors, would offer to the patient or conservative measures, so you'd ask them to cut down on the caffeine intake, look at how much they drink daily. Other things would include double voiding or ureter milking, especially if they have lots of dribbling. Medical therapy includes commencing patients on tamsulosin and finasteride. Uh, they work in different ways, so Tamsulosin relaxes the small muscles in the prostate and bladder so that the urine can flow freely and finasteride essentially shrinks the size of the prostate. And finasteride often takes a bit longer to work. Uh, tamsulosin. I'm sure it was covered in acute unit retention by, ideally, you want to give someone, um, two doses of tamsulosin before you take the catheter out to see if they can pass urine goes with chronic high pressure retention. You wouldn't want to use tamsulosin because you don't want to take the catheter out, and you have to obviously offer them either a long term catheter or surgery that would, um, kind of the inside of your prostate to create better channel to flow, to allow or better flow of urine. So these are some things about catheters because you will commonly see them in hospitals. They all have different tips and different sizes, and the size is correlate. Um, sorry. The colors correlate to the different size of catheters. You can see the pediatric ones that are from six to about 10 French adult ones range from 12 to 20 to those that present with clot retention. I think that's one of the topics that's covered later on, um, in the month and series, you get really large catheters, and they have, like, a three way channel right here. You get catheters with kind of pointed tips, and those are called QD or team and catheters. And this is like a fantastic catheter that I discovered in one of the hospitals I was working. It's very good if your prostate is very enlarge and it just goes straight, and so they're wonderful for those with the enlarged prostate, and the catheters that you often see in the wars are kind of our standard to away catheters. We connect this end, too catheter bag, and that's your billing port so you can get short term and long term catheters. This is an example of what short term catheter looks like. Often They're this kind of brown kind of yellow color, and they're PTFE quoted, and they last for about 28 days. Often kind of. The long term catheters are kind of clear. Um, they're quoting is from silicon higher gel, and they can be used almost up to about three months. So this is a three way catheter. Just bring this down here. So these are the three ports on the freeway catheters you've got. The same port is a two way for the balloon. You've got a drainage channel where you connect to a catheter bag, and this is a port that special for a three way. This is where the irrigation comes in. So when I say irrigation, there's fluid running into the catheter kind of washing out the bladder, and then it comes out and it's drained. And this should be used only for short term, especially someone who's having lots of frank hematuria and lots of clots. So this is a tipped catheter, so you can see the curve here. And like I said, it's great for BPH. Sometimes it can be used in the urethra or those with false passage is as it just avoids that area and gets into your bladder. There's some difficult catheterization tips and tricks, which hopefully quite useful if you start working on the ward's. So generally, um, I used to instill a gel in females would probably use 12 or 14 French catheter. Um, in males, I go a bit bigger and use, uh, 16 or 18 French. If you're unable to insert a catheter. You recently, uh, I would go and do a suprapubic catheter. Or, if available, I'll try and do a flexible cystoscopy, which is a telescope test inside your bladder to see what's causing it and see if I can insert a catheter. That way, if you have an enlarged prostate, you can try using a firmer catheter, a larger size catheter, a tipped catheter and the flexible cystoscopy here. This is what it looks like, and that's a guidewire there. So what you do is you insert the telescope into the bladder, you put a guidewire through the telescope, um, and then cut the tip of your catheter and almost just put it on top and push on top of the guidewire so that it goes into the bladder. So this is this metal thing is called an introducer. Um, they look quite scary and should only really be used by urologists. Um, they can be used in a large prostates as well, and they do a similar thing to like the tip catheters, where they kind of go beyond the large prostate and get into your bladder. But they're quite dangerous. Um, there's lots of injuries that can be caused by them if they're not used correctly. And so if you get to that point where it's very hard to catheterize and you should always call your friend the urologist, so those that have a fimosis there's different ways to go about it. Sometimes you can try gently stretch the foreskin, but the definitive kind of treatment for that would be to try and give them a dorsal slit in the short term so that you can gain access through the urethra meatus. And once you go home, they can. They can be listed for an elective circumcision. If they have the right pharmacy, you can try and use a small catheter and get something to give you a hand as well. Um, just to try and see if we can open up the force that as much as possible if you have a risk of stricture, it's quite difficult to obviously insert a catheter so freely we can try smaller catheter to see if you can go through the stricture. But what I found very useful is to use a flexible cystoscopy and a guidewire. And you use these kind of disposable dilators you can see here. They're kind of blue shape. Um, they're kind of typical Blue Shield kind of cooks dilators. And what you do is you feed the dilator over the guidewire and that just stretches, um, the stricture. And afterwards, you just pop the catheter over the GUIDEWIRE. Insert it that way. So this is what a suprapubic catheter would look like inside someone that if you put one in, uh, indications if you're in, you're in retention, and you can't insert you recently, Um, those with m s are year around. Um, I would prefer sometimes the have a suprapubic catheter for comfort as well. Those with lower urinary tract or pelvic trauma. Uh, super pubic catheters are inserted, especially. I have really bad, uh, your initial injury, those with neuropathy disorders, often the external catheters, and they found that it's sometimes easier to have a super pubic catheters. So things to think about before inserting a suprapubic catheter and like super pubic catheter should really be inserted by urologists. Um, if you can't feel the bladder. It I would say it's unsafe to insert a catheter, but often if you have a friendly urology, a radiologist handy. Sometimes they can help you do an ultrasound guided suprapubic catheter. But unless you can feel the bladder sometimes is very difficult to do that without having direct vision of it. If you're an anticoagulant or have a coagulopathy, there's a risk of bleeding because you're cutting into the skin. Um, and there's a chance that can cause bleeding. If you have bladder cancer, you'd want to avoid that. If you have an abdominal scars or adhesions, um, there's a chance that that could have some bowel kind of kind of going on to the scar. And sometimes that can cause bowel injury. So you just have to be mindful of that. Those with ascites is quite difficult, especially because it means that you can't really always feel your bladder so that causes problems. And those with hernia mesh is so. This is the insertion of suprapubic catheter, what you should counsel patients on, and I guess one of the most serious complications is causing injury to your underlying or surrounding structures, and we can cause damage to your bone and important blood vessels so supported to counsel patients about that risk. But also the common things, such as infection bleeding, may get some bladder pain or spasms. You may still leak a little bit from the urethra, and you can have the development of bladder stones later down the line. So this is what a suprapubic catheter set looks like, and this is the one we typically use where I work at the moment. Um, it looks quite fancy years, but it's it's absolutely wonderful. It comes with a 16 French catheter. Here it comes with two syringes, one syringe to do some aspirating and one syringe to fill up the catheter balloon. And this is a scalpel here to make a decision on the skin. Um, and that's unusual for aspirating, and it comes with a guidewire and a trocar. You will try and insert some local anesthetic before you do the procedure and have some dressings in a catheter bag of candy. And I'm just going to play you a video of what a suprapubic catheter insertion looks like. Right, So this is the kit that I just showed you and This is what we typically use. Um, you would set up the training like this and make sure everything's kind of arrange in a way that it's like one after the other. You know what you're using. So that's the guidewire here, and it has, like a soft, fluffy end and a harder end, and it's got little markings as well to show you how far to put inside the bladder. So this is before. Sometimes people will do. If it's possible to work out why you can't get into the bladder really thrilling to palpate the bladder and then two finger. It's, um, with Publix emphasis. You would want to put a cut, that's what The scalp here and then you'd use the long needle. Just aspirate, um, to make sure that you are in the bladder and this bit here is why you measure two fingerbreadths so that you're avoiding hitting the bone and anything above there. That's where you want to be hitting the bladder. So then you put your guide wire through that needle and always make sure that it's a really nice soft floppy end that's put in and then you take the needle out over the guidewire. And then you use the trocar basically to form the tract. So you twist gently over the guidewire and you point slightly down to the feet. Um, it's slightly 90 degrees, but just pointed to the feet. Um, and you often feel like give, and then you know that you're inside the bladder. Then what you do is remove the guidewire with the inner sheath, and that's when you put your finger over, because then all the urine comes out, and afterwards you just put the catheter through that and then you didn't play the balloon. Um, some people will switch the catheter in initially just until things heal. Others just put some dressings on. And that's a suprapubic catheter. So I think that's my last slide and hope I've given you a generalized overview of what to do when you see patients with chronic retention, Um, and the two main types, which is low pressure and high pressure and how you manage both and the kind of common treatments that are available. And then the new things that are available for those that have an enlarged prostate that have chronic high pressure retention, Um, as well as some tips and tricks for catheterization When you when you're working on words, So go ahead. I'll give this back to sack. Amazing. Thank you very much dot Okay, that was really useful. Those are quite keen on the videos that you showed as well. Um, So would anyone like to pop any questions in the chat box before we go ahead and conclude? Just give me a couple of can send your wants to pop question. Yeah. Okay. So it doesn't seem like there's any questions at the moment, But if you do think of anything later on, uh, feel free to send us an email that webinars don't mind, please dot com and we'll be happy to answer them. Um, otherwise, thank you very much for attending. And be sure to fill feedback form so that you can get a certificate. And also, the feedback will be really useful for us. So we know that we're doing things right. So thank you very much again. And make sure you attend our next session on hematuria. Thank you. That. Would you like me to, uh, stop sharing