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Clot retention & its management!

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Summary

This on-demand teaching session is relevant to medical professionals and is designed to teach them about clot retention and how to manage it.

The session will provide an overview of the causes for clot retention, and how to assess, identify and manage patients who have it.

Through interactive activities of real-life scenarios, the speaker will guide medical professionals through the process of doing an effective bladder wash out, connecting a three-way catheter and infusing the bladder with sterile water and saline to evacuate the clots, as well as discuss investigations to conduct afterwards.

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Learning objectives

Learning Objectives:

  1. Understand what clot retention is
  2. Describe how clot retention occurs and what causes it
  3. Describe the clinical features of clot retention and understand how patients present with this
  4. Understand management of clot retention in real life settings
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Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

all right. Hi, everyone. I'm just going to give it another five minutes just to let everyone join in. And then we'll start at five past eight. Okay, so that's five past eight. So welcome, everyone back to another session in the mind of sleep Urology series. So today we're going to be talking about a clot retention and how to manage it. And before I go ahead and introduce today speaker, I'm just going to give out quick message from one of our sponsors. If you don't mind, just jump into the next slide, please. Um so essentially we've partnered with COPD. Me and they they're allowing us for providing us with hundreds of COPD accredited webinars. They have a really cool application, which you can find both android and IOS. And essentially, they have, like, a nice dragon drop interface that you can use on your phone, um, to allow you to record all your teaching sessions. And it's designed for anyone who is registered with either the GMC, the NM see or any other health care professional. Really? So they've given mind. The BLEEP uses a 50% discount if you use the QR code provided on this slide, it will give you basically an 8 lb per year membership, which, if you're interested in, go ahead and use. Now, um, so going back to our session today Speaker is going to be, um, Nikita, but who's an ST six, Um, in urology. And she currently works in Cambridge University hospitals. So without further ado, I'm going to go ahead and hand over to you. Thanks. Thanks for having me. Um, so I want to talk about a clot retention and its management. So the objectives of today's session are going to be first of all, what is clot retention? What causes it? How would you expect your patients to present? How would you manage it? Um, and then we're going to go through a case at the end. Um, try and make it interactive. Um, so what is clot retention? It's a sequel, beta bleeding in the urological tract. And it's an inability to urinate going to the volume of blood clot in the bladder. And if this happens, it's a true emergency because the patient can avoid, um so what really causes it so that the basis of it is that any cause of visible hematuria can potentially lead to clot retention. So when you develop a large amount of blood in the bladder that exceeds the ability of urinary your, uh, kidneys to prevent clot formation, it results into clot retention. So you're okay now, this is an enzyme that promotes clot license by converting plasminogen into plasma. None. Um, And then when these clots are accumulating the bladder, it results into retention of urine and the clots then physically blocks the urethra or the bladder neck. Um, and that's what clot retention is. So, as I said, any cause of visible hematuria really can result in to clot retention. Um, common causes include things like malignancy, BPH, um, trauma commonly on neurological world. You see this post operatively after bladder outflow, obstruction, surgery, um, or bladder cancer operations? Um, like a t u R p t. So presentation the patient will present with attention. So super pubic distention severe discomfort in the lower abdomen. If they're already catheterized, you'll start seeing bypassing of fluid around the catheter. Um, they might be dribbling some blood stained urine, or they might actually be passing urine with a few clots, and it's increasingly painful to pass urine. Um, so if you see a patient like this in any So obviously you go through your basic management to your A B c d. Make sure they're, um, stable, Um, first and send off bloods. Um, if they are unstable, you can do a A BG at that point, um, start fluids if they're hypertension, et cetera. But for managing the clot retention itself, you've got two goals. You want to relieve your out flow blockage and you want to prevent new clot formation. And the key to doing this is a three way catheter. Um, I'm not sure how many of you are familiar with this, but I'm just going to go through it anyway. So a three way catheter has an extra access a port, which is called the irrigation port. So normal catheter just has an outflow port in a catheter balloon. The third part, and this allows you to actually get fluid into the bladder, wash the bladder out and then get clots out through the outflow port. So, um, immediate management, once the patient has been stabilized appropriately, is to insert a large urethral catheter. Very commonly, we would end up using a 22 French catheter. Um, I haven't seen anything larger than that being used. Um, and it's a three way, um, you started irrigating with normal saline. Um, so the first thing you want to try and do is A to remove all the clots in the bladder bladder and establish a spontaneous drainage. And the way to do this is with what is called a catheter tip syringe, which looks like this, um, it's usually 60 mills and has a tip that's quite different. That goes into the catheter, and you were able to literally suck all the clots out. And once you've established some drainage from the bladder, you can start them on irrigation. Um, So, um, I'm going to go through this video because I think it's really important to know how to do an effective bladder wash out with a syringe. This is Dr Margolis. I'm going to try to explain how to irrigate a three way catheter using a piston syringe. As you can see, the syringe has a hole at the end. So we call this the catheter syringe in the UK, and whether you're doing a two hand or one handed using a three way catheter, meaning it has a opening at the end. That you can flush I/O of. This is generally the end that gets hooked to the leg bag or a drainage bag. The other part of the freeway is the continuous irrigation that you see hooked up on the right has some blood in it, which is not unusual when the irrigation is not running as it is in this patient. Eventually, when the clots are all cleared out, we can start that running. But it's never a good idea to run it until all the clots are clear. If you do, the patient is gonna have a risk of, uh, perforation of the bladder if you run the irrigation and there's no way for the fluid to get out. Generally we start with two syringes, just to be sure that we're not sucking against the bladder wall. When we do pull back. Patient probably has several 100 mL when they come in with retention and you put the catheter in so occasionally we will let it passively drain between installations of fresh syringes of sterile water. We do not use saline as it does not like the cells as well as sterile water does. And these clots are generally inches in diameter and need to be shredded in order to get out the rather narrow tip of the catheter. This is a plain 22 French latex catheter. It's not the one I typically use but didn't have a choice here. Normally, we use a cavalier catheter by rash, which is a clear plastic one with a rather large mouth. Uh, so essentially, I think you get the picture. You want to try and instill the sterile water. So for the washout, we usually use a large water sister of water. And then when you're hooking up irrigation, it's usually saline. Um, so you need your entire kit ready before you go to the patient's bedside. You want to, uh, take any sort of balls or sterile vessels you find in the ward, fill them up with the sterile water and then start instilling the bladder with the water. First, um, and then once you've had once, you've got a little bit of water inside about two syringe fulls is fine. Then you start, um, um, sort of sucking their plots out. And the reason is you don't want to catch the bladder wall if it's empty while trying to, um, flush the clots out. And then you continue to do this a few times until you start seeing as you saw in the end of the video, sort of a light pink or what we call a rose colored urine coming out. Which means you've removed majority of the clots, and that's when you can hook up irrigation. So this is a really important skill. A lot of the times, you would say the nurses are able to do this on the wall, which is excellent, but not everyone does it this way. And I think this is the most effective way of doing it. Um, some people tend to wash out with from from the irrigation port and then just let the clots passively drain out from the catheter port. And that's usually not as effective as doing it this way. So you want to make sure the irrigation port is actually the clamp it off or you've got, um, as you can see here, they just put a, um, the irrigation fluid and closed it off so you can do either or, UM so that's the first step of management. But however, if you find a patient that you've done all the initial bids and the bleeding is unsettling, um, then the next step in the management would require rigid hysteroscopy in an emergency setting in the operating room and a lot of actually plot evacuation. And again, all you're doing is trying to get the clots out of the bladder. And the reason is when the clot stay in the bladder, they're really irritate the bladder that cause more bleeding. And then the block, the catheter, they block the urethra. So you want to get rid of all the clots. And while you're doing this, um uh, in theater, you use an, uh, an instrument called Angeliq, which usually just suction out all the clots from the bladder. You can also use the bladder syringe at the end of the cystoscope to try to move the clots. And then, if you see any active sides of bleeding, you treat them at the same time. Um, is it Doctor Margolis? Okay, again. So once the urine is clear, you hook up irrigation. So if you've never seen this, this is how it's done. um, usually you've got preferably three liter bags of irrigation solution. Um, and the reason is because if it runs out, if it's a liter, it'll run out quite quickly and you'll be running around trying to get another bag, and the patient will clot off again. So better to have two bags by the bedside. Three liters each, uh, connected to the irrigation board. And you want to achieve this sort of rosy light pink urine. Um, and you make sure that it's infused via gravity. It's not on a pump or pressure, because if if, uh the blood that does get, um, clotted off or the catheter gets blocked and you're continuously infusing a vacation, you there's a risk of perforating the bladder, so you don't want that. So you want to just make sure it's infusing, um, through gravity rather than pressure. Um, so once you've managed these patients, uh, if the clot evacuation is treated, you want to investigate them, um, as a follow up, usually when the bladder is full of clots, so there's a dark material you're not going to be able to see much. Um, and the vast majority of such patients that urine will clear up, you'll send them home and then you'll bring them back for the material investigations. And your material clinic is usually, uh, express hysteroscopy and upper tract imaging either a CT scan or ultrasound, depending on risk factors. Um, so that's all for acute management of retention. Um, and then we're going to move on to our case. Um, so this is an 80 year old man quite commonly seen presenting like this Went to the GP after noticing some blood in the urine and difficulty emptying his bladder. Um, the GP was quite concerned, um sent him to any and admitted, and he was admitted to the hospital via any. The urine was positive for infection, but the blood the urine was quite bloody. So it's hard to say, um, whether what happened first. So we started on IV antibiotics and transfer transfused two units since admission. Um, so what? I'm told that people like this to be quite interactive, So if you could try and type into the chat box what additional history would be pertinent in such a patient? So there's a patient presenting with hematuria and likely infection. What else do you want to ask the patient. Okay, so we're just going to give it 30 seconds if you guys feel free to types and additional history in the chat box and I'll have a look and relay that to you. Okay, So I have any history of bladder cancer or BPH. And someone mentioned asking about the onset. Yeah, give it some more time. Family history, blood coagulation problems. Excellent. Yeah. So whoever said family history, um, why is that important? Just typing a response. So yeah. So to know if there's any risk factors, basically, Yeah. So you you're trying to rule out in your head. What? What is potentially causing the hematuria and clot retention. There are certain familiar, um, sort of medical diseases, for example, clotting problems that that could happen, and then some neurological diseases as well. Um, could be familiar. And yeah, so relevant. Yeah, absolutely. And to know if there's underlying factors like cancer or bleeding tendencies. Yeah, that's really important, because obviously, if someone has got a history of cancer, bladder cancer, for example, and they're having t u r p t s or regular cystoscopy checks, and they come with him a tree and then you sort of understand why they're presenting like that. So, yeah, that's quite important. And history of diabetes someone mentioned. I mean, yes, if the because they've got an infection. Diabetes. It's important to know if the sugars are under control, because that's sort of a holistic management of the infection. They won't get better if the sugar goes up to the roof. So, yeah, absolutely. And someone mentioned the last time they past year in order to Syria. Yeah, So infection. Obviously this year is a symptom, isn't it? So that's important the last time the past year and is important because that gives you somewhat of an idea how long they've been in retention. Um, so if it was like 24 hours ago, you know that they have in past urine in a day, and that means they are more than likely going to be in retention for for that much time. So they need an urgent catheter if they're not in pain and they don't tell you, it's that straight away, great. And then we have someone mentioned any history of catheter usage or traumatic caster in session's recently. Yeah, so anything that can potentially damage the urethra or the bladder Catheters can cause a lot of category action. Um, and that can then cause bleeding. So yeah, And as I was mentioning these patients who have indwelling catheter will present with sort of dark urine and lots of bypassing. And then you're thinking that they could be bleeding inside the bladder, which cause it has caused a lot to get stuck in the eye of the catheter. And just you need to change that to a to a three way catheter at that point. So yeah, that's important. Okay. And Dean has mentioned fevers. Claire mentioned anticoagulants as well. Yeah. So absolutely. I think you have all covered everything that I've written here. So I'm just gonna now go through it. So you have fevers or is a really important because you want to see if it's a UTI versus your sepsis. Um, have they had any flank pain? Abdominal pain? Um, any past medical history of said all of this. So the patient already has. The patient is known to have hypertension, he's obese, and he has actually got diet controlled diabetes. Um, past such the history. He had a bladder stone removal about five years ago, and he had what he described as a bladder neck surgery. I can't remember what it was exactly years and years ago. Um, medication wise, he's on an anti hypertensive, so, no, he doesn't have any coagulation or bleeding disorders. Um, that that we discussed. He doesn't have a family history of stones or any malignancy that we've discussed. Um, and apart from that social history, you want to know because of the risk of bladder cancer. So, uh, he's a nonsmoker, and there are no occupational risks. So occupational risks, to be honest, in the sort of an accurate situation, maybe not as important, but in a hematuria history, this is important because bladder cancer has an occupational risk factors. Um, so, yeah, you go through this sort of a standard history, um, and then you The next thing that you've done is examine the patient. Um, so for examining these patients, you want to look for abdominal tenderness, distention which which he has, and then you're looking for cost over chewable angle tenderness bilaterally. Um, why would you do that? Right. So your question was, why do we ask about Costa vertebral angle tenderness? Yeah, like why do you examine them? So the way to examine some someone's costovertebral angle Zar So right at the back here, um, in the general area of your kidneys and you kind of sort of press around around that area, and you just basically elicit any tenderness. There's some description of you can sort of punch that area as well, but usually just pressing that is enough. Um, why do you think it's important and such a patient? So we got a couple of response is saying to see if there is piling a phrase this. Yeah. Yeah, exactly. So if they have pyelonephritis, they be tender in that area. So if someone is presenting to you with the UTI and unwell, um or even otherwise, I always you always examine the cost of multiple angles to make sure there's no tenderness to rule out pollen. Arthritis. Um, it may not be president. Everyone, though, So if it's not present, doesn't mean they don't have it. Um, and then you're looking for the external genitalia. Uh, make sure that they don't have severe fibrosis, et cetera, before you're going in to catheterize them. If you're not comfortable with that situation, and you need help. So always examine the external genitalia. Um, And in retention in general, even though it's really hard to have a full blown retention with fimosis. But it's good to examine the external genitalia. Um, good. So, um, so based on this history, I'll go back to this. Um, what is your differential diagnosis of this eight year old man presenting with HEMATURIA to your any? He's lost enough blood to require blood transfusion. And this is his sort of background. What is your differential diagnosis? Okay, I'm just going to give them some time. So we have a couple of differentials here from Dean. Who? BPH Cancer Infection? Yeah. Another BPH malignancy. Yeah. Or bladder. 19 bph. So two. All the very intelligent people saying BPH, Why? Why is the top that the top differential? Um, I and there's a reason in the history, so that's very clever. I'll give some time for people to answer that question, but we've got a few more answers initially, So we've got prostatitis stones. Um, memory is just replied about bph saying his age. Mm. Yeah, absolutely. Something else in the past history that strikes you as a clue. Dean has replied with age and medical his past medical history. Yeah. Yeah, so sort of. You mean the metabolic syndrome prototype? Yeah, that that's a risk factor. Yeah, but there's something else. So I asked this a different way. Why do you get bladder stones? So Maria's replied bladder stone removal? Yeah. So can someone just tell? Tell us. How do you get a bladder stone? Is it the same reason why you get kidney stones? Okay. Michelle said no. Could one of you guys elaborate? Yeah. So bladder stones are not usually not the same etiology as a renal stone or ureteric stone there. In developed countries in adults, they're usually caused by bladder outflow obstruction. So it's something that doesn't let the urine drain as concentrated urine sat in the bladder. Um, that forms debris. The debris then calcified and forms a stone. So that's how you form a bladder stone. And, uh, previously, the thinking was, if someone has a bladder stone, you go and sort of treat their bladder outlet obstruction, which is in the vast majority of cases. Uh, bph. So you go and just do the BPH surgery at the same time. But now there's more and more evidence to say. You don't need to necessarily need to do this. Um, so sometimes they have had a stone removed. And if they're not experiencing any lawyer in tract symptoms, and they're emptying reasonably well, you don't need to do the BPH surgery in the scene sitting. Um, so yeah, that that is one of the clues in the history that he could have BPH, because he's previously years ago Had five years ago had a better stone removal. So it probably was due to a large, large prostate. Um, and then the other etiology for bladder stones, um, is sort of in developing countries and sort of malnourished kids. But I don't think you need to know about that. Um, so this Yeah, so absolutely right. Bang on with all your differentials. Um, don't forget trauma in elderly people who have come into any. They could have had a fall at home. Um, and you just check their flags for bruising and stuff. And sometimes they could have just by falling on on on their sides called a renal trauma. So that's what remembering that. Okay, any questions so far in the history or the differential. Anyone like to put a question in the chat box? Okay, Maybe we can keep them for for later. Um, so the next question is, how would you manage this patient now? So you've done your A B. C. D. S is quite stable. Now. He's not in research, is just in sort of the holiday. Um, and you have What is your next step? Can you let's see if you guys have any ideas. So someone said do lab tests. Do you have any specific lab tests that you like to do? You have blood and urine culture. You got to watch it with a three way cast. Good. So I'll start answering at the labs. You said? Absolutely. If someone can tell us what labs, and then I'll go on to the next bit. So you've asked for a urine sample, and he did provide one before that was infected. It looks really dark. And he he really struggled to pee. Um, um, he didn't have a temperature, so they didn't do blood cultures. Which, which was, I think reasonable. Um, so in terms of bloods, we have you seen these LFTs coag bone crp F B CS. And someone mentioned the bladder scan. Yeah, you could do a bladder scan. Absolutely. Uh, sometimes if they've got large clots ash in the bladder and you do a bladder scan, it may not, um, depict the actual picture. So, um, if someone is very visibly in clot retention, I don't always get a bladder scan, but yeah, I think I think that's reasonable. Um, yeah, all the bloods, correct. But I think the most important one is the fbc. You want to check their baseline hemoglobin at this stage? Um, and just to recollect, he has been transfused two units. So you're likely came in with a low H b, um, and then required two units of transfusion already. So yeah, fbc would would be important coag renal function and CRP because he has an infection. Um, you could do that if he's in a born profile at this stage. Um, um, may or may not be very helpful. Um, right now, um, because you know, you're not suspecting prostate cancer or something, um, as wonderful and weird at the moment, So yeah, the basic blood test. Um, So you've done the basic bloods and then you've checked the urine. It's bloody patient struggling to pay. So what would you do that Someone mentioned this already? That you would put a three week gap and then do a washout. So sorry, I'm just going to interrupt. Someone had a question. Um what about fibrinogen function? Yeah, I mean, you mean just a clotting profile. I mean, if if they're not on anticoagulants, um, you could I mean, if they're anticoagulants, I usually check the i n r. Um, something very specific. Suggested fibrinogen profile in this sort of emergency situation is probably not not relevant right now, but I I completely except that something that you want to explore at a later stage if they continue to bleed and you want to involve dermatology, and if there's anything wrong with the clotting factors, etcetera, you can correct that. But when you call down to assess the patient, who is going to be who is likely? The diagnosis is clot retention secondary to something that we haven't really investigated yet. The first step is to relieve the clot retention, so it's relevant, but not at this point. Okay, so I think your next question was What would you guys do next, after the involved investigations that we mentioned? So someone already say three way catheter, didn't they? Yeah. Yeah. So I think I'm just gonna show this, then. So, yeah, three with a catheter. Uh, and the bladder wash out was done, as you suggested, and then we just got lots and lots of clots out, Um, and started the patient on continuous bladder irrigation. So fairly straightforward her, um And then we already mentioned you start the patient on antibiotics because they've got an infection and they have received two units of blood. Um, and then So the next thing that happens is that you've checked his blood blood again, and his HPV is 90. His usual baseline. 120. And this is despite the two units of transfusion, he's probably been bleeding for a while. Um, his renal function is completely normal. Um, he continues to be, despite your wonderful washout and irrigation, the HB keeps dropping. Um, and this is like, two days later, after his admission. Um, you're not able to get on top of the hematuria just by doing the washouts and the irrigation on the ward. Um What? What would you do next? Okay, So what would your next steps be, guys? So let's recap. So he's 80. He's coming with hematuria severe Imitrex causing clot retention, requiring blood transfusion. Antibiotics. You put in a three way, you've done a washout. You've irrigated him for two days on the world. He's still bleeding, and the HPV is HP continues to drop. So what would you do now? So we have one. And I said blood transfusion. Since the hemoglobin is low and Dean has replied surgical intervention. Sorry. So we have blood transfusion. And then another answer was surgical intervention. Yeah, very good. So what surgical intervention would you do? I briefly mentioned this earlier, so someone said T U R P. Okay, Anything else or surgical intervention is one thing. Anything else that you think you want before you take the patient to theater? Someone says cystoscopy. Yeah. So the surgical intervention would be a cystoscopy. Um, and we can discuss that in a minute. Is there something else you want before you take the space into theater imaging? So someone said ct. Very good. So this is the CT scan. Um, can someone tell me What kind of see? See, this is I don't appreciate us, Really. It's not an easy question. Um, but you all are brilliant. So I think someone is going to come up with the answer. Okay, So while I get a chance for people to answer which type of CT is someone else replied CBI. I don't know what that continues. That irrigation. Yeah, but you've been doing that for two days, and it hasn't really responded. So you kind of need to change tactics or they'll continue to drop their h B, but yeah, absolutely. That that's what you would do on the world for sure. Great. So we have someone said Contrast ct and another one said urogram Excellent. Yeah, this is a urogram. And the reason is because you've got contrast in the genital urinary tract. So starting from the kidney down to the ureters and into the bladder, you can see the white bit, which is the contrast. Um uh, sorry Corona and actual films. Um, so obviously my next question is going to be What? Can someone tell me what you can see on the CT scan? So what can you guys see on the CT. Someone mentioned clot. Good. So basically, this sort of swirls sign is where the contrast is sort of accumulating around the clots. So, yeah, that's the those are clots. Um, this is the catheter balloon. Um, and just here you can see this sort of big mass, which could be anything. Really. Um, the other thing you want to look for is is there any hydronephrosis is that the kidney is obstructed, but I already mentioned that his kidney function was normal, so it's unlikely, But it's something that you want to check, so his kidneys are not obstructed. He doesn't have any hydronephrosis, but he does have clots like he quite rightly said. And that is the sort of a mass in the posterior wall of the sort of the wall of the bladder. Yeah, everybody appreciate that. And, yeah, his bladder wall is thickened. And that's not something unusual that you see in people who have an outflow obstruction to their bladders when someone's bladder isn't draining that well, and they have to do a lot of work to empty their bladder over time, the bladder wall gets quite thick. Um, and that's some sort of an imaging finding that can be reported and a lot of these scans. Um, so, yeah, there's a large enhancing mass on the posterior aspect of the bladder. Um, any thoughts on what? What should we be doing next? Or what this could be to see if anyone has an idea as to what we can do next. So sometimes I'll go with the previously when someone says it's just charge three. But what kind of cystoscopy are you going to do? And he thought it was Someone know the types of cystoscopies that that that are available. There's two main types, so someone said Flexible. Yeah, very good. So flexible is what you see in our patients. If you go to a clinic and you start watching a cystoscopy list, that's what you see. It's usually a 16 French, like its diameter of a standard catheter long kind of scope that's flexible. So the clue is in the name, and then that's one type. What's what's the other type? So, Dean said, rigid and flexi. Yeah, so rigid and plexi. So the problem with the flexible scope is because it's a small diameter relatively, um, there's only one channel for you to pass small instruments through. Usually with this kind of a clot in a mass, you're not going to be able to see anything or do anything. So what he needs is a rigid cystoscopy. Um, under an anesthetic. It's done on the emergency list. Um, so Richard Cystoscope diameter is about, on average, 20 to friendship. It varies very widely. Um, and essentially, what you do is you go into the bladder. Um, and you would take a look inside, and the first thing you'd see is massive clots in the bladder. So what you start doing is using better instruments like an Ellik to evacuate the clots, Um and then possibly, um, if necessary, depending on what you see, because you don't really know what this mass is. But you're assuming this could be a bladder tumor as you possibly get ready to resect this tumor if there is one. So you get the THC in to get all of that ready. But, yeah, the thing to take away from this is you put them on the emergency this for a cystoscopy and a clot evacuation plus minus whatever you find inside and you try and deal with that at that stage, Um, if it's actively bleeding, So, um, for this job, then they went in. They evacuated 400 cc of clot, but they didn't see a bladder tumor. But instead, like everybody predicted, he had a very large prostate. Very large introvert cycle median lobe, um, which So, basically, they got all the clot out, and at that stage, they just itemized the bleeding points. And then later on, he elected to have a t u r p for the management of his BPH benign hematuria. Um so BPH can cause significant hematuria. It's up to 12%. Um, growth, immature. Requiring transfusion with BPH cannot going up to 2% of patients. And this is because of new vascularity of the prostate. And the normal is what brings with it a lot of new blood supply. Um, and that's where you can also treat this. If it's not the bleeding. Isn't this bad? Um, or even otherwise, you can start them on finasteride, which is a five alpha reductase inhibitor. Um, and it does. It is known to sort of shrink the prostate over time, but can also help with reducing this new vascular ization and reducing the risk of hematuria. Or you can offer them, uh, bladder outflow, obstruction, surgery. Um, could be a t u r p Could be a whole lab, etcetera, depending on what your center has and how big the prostate is. Um, that's really it. So essentially the take home points for everyone when you see such a patient, um, identifying clot retention is really important. Um, so, uh, the patient will be clinically in retention pain, passing urine, not being able to empty the bladder part of the bladder passing blood, frank blood. Um, but sometimes you might be able to see clots, etcetera. So stabilize the patient. Um, and then the first thing you want to do is after you stabilize, the patient is put in a three week catheter. Do a good wash out. I cannot stress how important a good wash out is because if you haven't done a good wash out your left close behind, the patient can't keep bleeding. The catheter is going to keep blocking. You'll keep bypassing. So good wash out is absolutely key. Um, it's important to start off, maybe watch someone from urology, do it and then start practicing this. If you see many of these patients, um, then you make sure they're on irrigation. The irrigation doesn't run out. They don't clot off on the ward in the middle of the night sort of situation. And the majority of them, as I said, will recover and go home at this point in a couple of days. If they don't think of what to do next, don't wait around for a long period of time to think of ask questions can be imaged them can we should take in the theater. Um, and at all times, good medical management. So check their hemoglobin every day. Plotting profile, um, antibiotics that they've got an infection. Um, that's really it. If you are sending these patients home and you haven't taken a look in their bladder, do not forget to book them for follow up for the cystoscopy and upper tract imaging. Um, when you discharge them, sometimes people may forget to tell you to do that if you're enough one. But that's something that you should really, um, make sure it's done for that patient when they go home. Um, yeah, that's everything. I think that you would need to know at this level for hematuria rising clot retention. Um, any questions? I think that's my next side, right? So does anyone have any questions they like to put in the chat box? I have a question here. Are there any contraindications to a three way catheter? Um, I mean, I would always try, but yeah, if the patient has had a known urethral stricture, for example, um, or they have multiple false passage Is from a previous, difficult catheter insertion. Um, and you're not really happy to do it. You can call the neurologist with that. But the majority of the times, if you if you can put in a standard catheter, a three way catheter should go in. Um, if there's a stricture, um, and they are in clot retention. Call the urologist. Right. Okay. Um, what's happened? Look, any other questions, guys? So here's another one. If they are on anti coagulation, what would you do saying, say, in the setting of atrial fibrillation? Yeah. You just have to hold it. Um, a f is fine. Um, majority of the times. If you hold it for a couple of days, they're usual, right? You can put them on prophylactic, uh, daughter, parents and Ted's, um, and usually it's not a problem. Now, if someone has a metabolic heart valve or something like that, that that's a bigger problem. Um, and you have to involve, uh, cardiology and hematology. A lot of these patients need to be on their anticoagulants. So sort of a risk benefit discussion you have with the medics and the patient. Um, if they're bleeding really, really badly, sometimes you have to hold them for a day or so. Um, a lot of the times if they're high risk, we try and continue them if you can. Um, and for example, someone has a recent, um I, um And they're on dual antiplatelet. Treatment is really tricky situation to manage, and it happens sometimes. So, um, you try and start doing their bladder care, um, without stopping their anti platelet initially. But then, if it's not responding to your washouts and irrigation, it might be that you might have to stop their anti platelets after discussing with cardiology. Okay, so Maria has asked, Can you put a catheter for a patient with hyperspace ideas? Yeah. Um, it depends. What kind of hypospadias it is so as you hypospadias is a range, so it could be distal hypospadias going down to proximal. I'm hoping you never have to see a adult with the proximal hypospadias. Um, but yeah, if it's a distal hypospadias. Essentially, for those who don't know Hypospadias is bad, the urethra opening is on the undersurface or or the ventral part of the Penis. So it's sort of inside on the undersurface rather than on the tip. So if it's a glandular, a hormonal, um, urethral opening, then absolutely fine. But you need to know whether urethral opening is so if you can't find that and you keep sort of trying to go where they sometimes will have, like a depression at the tip of the glands where they should have the urethral opening. But it's not there, so you have to kind of look underneath, and that's where you would see it. But yeah, it's not a contraindication. You just need to know your way around that if you don't feel comfortable. Yeah, call quality. Religious. Sorry. I just realized I was on the that, um So someone asked Is there any contraindications to doing a wash out? Um, not really? So if someone is on top of retention Yeah, not. I don't think anything would stop me from doing a wash out if Unless you're not comfortable doing it, that's really the only thing. Um, I mean, a lot of people get really scared with a three way catheter and a washout, because first of all, the catheter looks massive and you feel like your stocking stuff out of someone's blood and patient will always be in agony. Um, but if you can put in a two week catheter, that technique for insertion of the three week after is exactly the same. Um, for a wash out. I mean, as long as you do what I said. And so that was the video said, Really, that you actually fill up the bladder a little bit and then start sucking on the closets. Absolutely safe to do. Okay. And the final question was from Dean, Is the management the scene for patients with a super pubic catheter? Um, good question. Um, so suprapubic catheter. You can't obviously put in a three way from this Repubic track. I'm sure you can, but the tractors of a certain size, um and that's not what you would usually do. So if someone with super pubic catheter has come in with hematuria and they're bypassing because that's how they present, Um, So if you can access the bladder, you literally I put in a three way. You literally, um, if you can't, if the urethra has been closed off or they've got a stricter or for whatever reason, you can't get into the urethra, then I would put in a the biggest to be you have in the suprapubic tract and then wash out the clots, um, and see what happens. Um, I mean, if it gets that bad, that you are starting to think that they need the three way through the superpubic. And there's no access to the urethra quality urology, Reg, because we'll figure it out usually. Um, but yeah, So these are the things you can do, but in a three way through the urethra, it's accessible. If not, put in a bigger super pubic and wash out the clots using a two way. Okay, great. I don't think we have any more questions at this point, but I'd actually like to ask the question myself before you finish. Um So do you use tranexamic acid at all in these patients? I've seen that quite common. Yeah, very controversial. So, um, so, just as a background, obviously tranexamic acid helps in clotting. Um, a lot of trauma surgery and other bits of bleeding like grinding example for menorrhagia comma use that The biggest problem with urology and using something traditionally is the fact that it can form clots and the clots that form after you've given someone trying something else that's quite dense, the very hard to wash out and break up. So a lot of people are quite hesitant, so it depends on the center. I worked in some centers are very, um, sort of lax about giving it, and in someone who has refractory the material that you've done everything possible and it's just not stopping. I think you can give tranexamic acid, and I've done it in some hospitals, and it's been absolutely fine. Um, it really depends on the center you work in and their policy because their data on this is really sparse and the evidence is really weak. So, to be honest, it depends on your boss, is how I would I would say it. Um, if I were the boss, that I probably if they have a factory bleeding there elderly. I've done everything possible. Yeah, I would then try tranexamic acid. 1 g. Uh, B d is what I've given before. Some people also give it stat, so they give, like, a 1 g IV. Um, and and And sometimes that works. Like I've seen it been given postop after a t u r B or a polyp if they're bleeding, Um, just just Actos, all right? Okay, thank you very much. I don't think anyone else has any questions, so I think we'll conclude. Thank you very much for everyone who's joining today. And thank you, Nikita. It was a really, really good session, in my opinion. 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