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OK, so, um welcome to the next talk in the Concha final series. Today, we're gonna be covering urology with Doctor Swain and Doctor Brew. Um And with, they don't need more introduction than that. They are experts at an F one level in urology. Um So I'll hand over to James now, I'm by no means an expert in urology, cos I'm currently on orthopedics. So forgive me, if I get any of this wrong, then let's crack on and make a start. So the learning objectives for tonight are the ones that you've already been sent. It's to understand the most commonly occurring urological presentations and conditions required for medical finals. And also um when you start clinical practices, fy ones developing a structured approach to diagnosing and managing urological diseases, enhancing clinical reasoning skills and gaining insight into the key topics that often appear in finals. So let's move on to the MLA curriculum. And so I'm gonna take three topics and then Shana is also gonna take three topics. The ones that I'm going to be looking at is scrotal testicular pain and or lumps and swellings, bladder cancer and epitomized as well as bronchitis and then Chena will be looking at BPH, prostate cancer and urinary tract calculi a bit later on. So let's start with a poll to get our minds working. She got a 24 year old male who's presented to the sexual health clinic following a um unprotected sexual intercourse with a female partner. One week ago, he's got a dragging sensation in his left testicle associated with urethral discharge and fever. The doctor elicits a positive friends sign which of the following antibiotics is used to treat chlamydia, trach chlamydia. So put your answers into the poll. I've already given you the diagnosis. So it's just the management bit of sexual health as well as um urology tonight. So five people have responded and there's 20 people here. So keep guessing a few more people. How do I show you the answer? I can't remember now. Um So the answer is B Doxycycline. So most people got that right. So let's move on to the testicular anatomy. So at the back of each testicle is the epididymis and sperm are released from the testicle into the head of the epididymis connected at the top of the testicle, the sperm then travel through the head, then the body and then the tail of the epididymis and then they mature and are stored as, as they're, they're also um stored in the epididymis that then drains into the vas deferens. So that was just um a recap of the testicular anatomy. So, let's move on to a clinical presentation of epididymo orchitis. So that's kind of on the ma curriculum. It's split into two, but it can present as one condition. So, epididymitis is inflammation of the epididymis and orchitis is just inflammation of the testicle. Um whereas epididymal orchitis is typically an infection in the IPs later, epididymis and testicle, those are the most common causes. Most, the most common one that you'll see in clinical practice is e coli but be aware of the other um causes as well. So this is an eye slide just for revision recap. The clinical features being testicular pains, they might describe it as a dragging or a heavy sensation. There might be a swelling of the testicle and you might feel a swelling of the epididymis as well and they might have some urethral discharge, some systemic symptoms and positive friends sign. So a friend sign is when pain improves with elevation of the testicle. So the diagnosis is key with epididymal orchitis because you need to establish the cause. And in finals, the cause is probably going to be related to the the stem of the question, whether it's a sexually active young adult or an older adult with a low risk of a sexual history. So when you're thinking about the investigations you might want to do, if you've got a sexually active young adult, then you might want to do a naps for an sti or a midstream sample, urine for an older adult, he might also want to exclude mumps as well as um testicular torsion using an ultrasound scan. So, the management, so if they're acutely unwell with systemic symptoms, you're going to want to admit this patient and give them some IV antibiotics. If you're thinking that this is probably going to be an S TI as a cause of epididymal orchitis, then it's probably a good idea to refer them to the gum clinic for further management and tests. But if they're low risk of ST I because they're an older adult with a low risk of sexual history, then the most common and management is ofloxacin for 14 days as well as the other um supportive management such as analgesia, wearing supportive underwear, abstaining from sexual intercourse and rest and those are the complications as well. So let's move on to the second pole. So you've got a 14 year old. Uh No, that's the wrong one. Let's not. It is. Where is that one gone? We'll do this one. Then got a 14 year old boy presents to ed with sudden onset intense right sided testicular pain. And he's urgently referred to urology for assessment of suspected testicular torsion and on clinical examination, which of the following features is not likely to be present. I know the wrong. You can't, let's move on quickly to this one. Sorry, you couldn't see them cos I put the wrong one up. So which of the fun of features not likely to be present good. So most people are getting the right answer. So it is a positive friend sign. So we'll go through testicular torsion and then we'll go back to the um the other presentation. So, testicular torsion, the clinical features are the ones um I've got on the slides, it's often triggered by activity. So often when a child is playing sport, it's often unilateral pain, um with sudden onset abdominal pain, nausea, vomiting, and when you examine the patient, they're like for you to have a swollen test of testes, um which is retracted upwards, there's gonna be a loss of the cremasteric reflex and a negative friends sign. So the diagnosis is with ultrasound most typically, um which would show the whirlpool sign, which I've put a picture of there. However, it's important to know that no investigation should delay surgery. So the management is urgent urological um surgical exploration of this patient. So you need to refer this patient to the urology team, let them know by mouth, optimize their analgesia and then explore the scrotum in theater. Typically, the ideal gold standard is within 4 to 6 hours of the patient presenting to Ed or in the inpatient setting. And then you've got two options when you're in theater and you probably don't need to do this for exams. But it is a nice to know for when um you're in clinical practice. So you've got Orchidopexy. So that is if the torsion is present. Um but the testes is still viable, so they'll untwist the testicle and fix both of them into the scrotum. And then an orchidectomy is when they remove the testicle, if the surgery is delayed or if there are signs of necrosis. So let's just go back to, you've already seen the answer. So let's just go through it. A 92 year old nursing home resident presents to Ed complaining of a swollen penis. His long term catheter was recently replaced by district nurses on examination. The glands are significantly swollen and his foreskin is retracted. The ed doctor is unable to replace the foreskin but the catheter is draining. Well, I've actually got a case of this on my ward at the moment. So which is the next most appropriate management. So as it says, the answer is attempt manual reduction with suitable analgesia. All of those options are possible, but the next most appropriate management for the exam is to attempt manual reduction. So, phimosis and paraphimosis. So, phimosis is a tight foreskin which cannot be retracted over the glands. So you're typically typically gonna see this in a young child. Whereas a paraphimosis is typically caused by not replacing a retracted foreskin. Um commonly when you're doing a catheter, you need to pull back the foreskin inside the catheter. And the most common cause of paraformosus is just not retracting it, which causes pain and the swelling in the glands due to impaired venous return causing edema. So there's two different types of management. So if you, you, if you've got PSIS just put steroid creams on it. Um or if they're a young child, then you can consider them for a circumcision paraphimosis. On the other hand. So as I just said, the first line is to um apply manual pressure to the glands to reduce the edema with adequate analgesia. Um then you might want to consider needle puncture into the glands to reduce edema. I think they can do it on the ward um or a dorsal slit to cut the foreskin or you may need something for an emergency circumcision. So let's go to the next question. I'll try and put the right one up this time. So you've got a 67 year old lady um who's presented her GP with painless hematuria. The GP is suspecting bladder cancer and she's referred to urology on the urgent suspected cancer pathway. What is the gold standard investigation to confirm this diagnosis? So, a I don't know if you can see a um but it's urine microscopy culture and sensitivities. All blood count ct ke uh urinary biomarkers or cystoscopy. Ok. So half of the people have replied any other guesses. So how are we gonna confirm a diagnosis of transitional cell carcinoma of the bladder? Good. So most people have got the correct answer. So it's a cystoscopy. So, urine microscopy can be used to exclude infection but it wouldn't be diagnostic, full blood counts equally used to exclude anemia as a result of the cancer but are not diagnostic of the cancer itself. A CT which a few people put can help to stage the disease and help with planning a transurethral resection of the tumor. But it's only useful after diagnosis to help stage and plan treatment. Urinary biomarkers can be used as seen more commonly in research rather than practice. Um So cystoscopy is the diagnostic investigation of choice. So let's go through bladder cancer. So there are lots of different types of bladder cancer in terms of how it can be classified. So, transitional cell carcinoma is seen in approximately 90% of cases. If you're asked an exam, what's the most common classification of bladder cancer? It's most likely to be a transitional cell carcinoma which tends to be in the urothelium. So if you think back to the preclinical years, that's most likely to be in the renal pelvis, the ureter urethra and bladder 5% are caused by squamous cell carcinoma, which tends to be in the lining of hollow organs. And then there are some rarer causes as well such as adenocarcinoma, sarcoma, as well as small cell carcinomas. About 2% of cases. So the risk factors for bladder cancer are cigarette smoking, older age and that common one from textbooks of aromatic amines in dye rubber industries. So again, thinking about the question that they give to you in the exam and thinking about the stem. So, bladder cancer. So the clinical features are painless hematuria. That's the number one clinical feature that you need to be thinking about when you see patients in clinical practice as well as in exams that um also if you've got a patient with recurrent unexplained uti S and they're over the age of 60 that's another thing to be thinking about in the GP setting. Um I didn't want to put all the clinical features in there because there's just too many. But there are current nice guidelines that can go through that if you want to do some further reading. Um So the investigations, as I said, the investigation, diagnostic um of choice is a cystoscopy and then the CT scan can look for metastatic spread and stage the disease. So the treatment options, there are many, it needs an MDT approach as to all oncology patients. Um but you can do a turp, so a transurethral resection of a bladder tumor and that can be used for non muscle invasive bladder cancer. Um This involves removing the bladder tumor during the cystoscopy procedure. You can then use, you could use intra called chemotherapy, which um is when you give chemotherapy into the bladder through a catheter. And it's often used after the transurethral resection of the bladder tumor um to reduce the risk of recurrence. I like the next one. It's an intravesical BCG immunotherapy. So you get the BCG vaccine into the bladder and that's sought to stimulate the immune system which in turn attacks the bladder tumor. You could do a radical cystectomy that involves removing the entire bladder and um, or you could use chemotherapy and, or radiotherapy. Just thinking if you remove the entire bladder, you need to have a way of draining urine. So you can look into this in your own time. But just thinking of the most common one being a urostomy with an eye or conduit. Um But there are other ones which you can read up on later. So I'm going to hand it over to Shana to talk about prostate and kidney stones. Um All right, let's see if this works perfect. All right, let's go to the next one. Lovely. So first question to kick us off. Oh, lovely James to pull. Thank you, James. 60 year old male requests ap saa prostate specific antigen test from his G PPS. A level is reported as 12 and a digital rectal exam reveals a symmetrical but nodular prostate gland. He is referred for specialist serological evaluation. What is the most appropriate next stage investigation? Give you guys a few minutes. Yeah. All right. I see five responses. Give you guys a bit more time fab All right, well done. Most of you got guys. Got that. It is MRI. So let's go with that if you haven't noticed I'm American, by the way, that's my funny accent. Um Right. So we're gonna start off with prostate cancer. Um Sometimes in finals, we were told that Southampton is year fives, you can get sort of epidemiological questions. So most common cause of cancer in men is apparently prostate cancer. So just keep that in the back of your mind in case it comes up. Um Most often prostate cancer is androgen dependent, which basically it needs testosterone to sort of keep growing and keep fueling the cancer that's really important for it. Um And again, in case you need this quick fact, it's usually an adenocarcinoma. So that's the glandular tissue um in the peripheral zone to the outside of the prostate. That's the most common area that that's gonna grow um your common risk factors. So, thinking about your question, stem um increasing age. So older age, if there's a strong family history that goes from most cancers as well, so that can be a good clue. Um Black African or Caribbean origin is a risk factor. Apparently, I learned this while reading up to teach you guys tall stature is a risk factor, um and anabolic steroids. So again, anything that increases that testosterone is going to be a risk factor, hence why anabolic steroids are your risk factor there? Cool. So going through it more specifically your clinical features. So unfortunately, it can be quite asymptomatic. So it could be picked up in a PSA exam um or a prostate exam. Um So just keep that in mind as well. But I think typically what you guys might see in exams are your lower urinary tract symptoms. Um So these are gonna be your hesitancy, your frequency, weak flow, terminal dribbling, nocturia, intermittency, straining, incomplete, emptying any of those sort of key um L UT S symptoms, you're gonna be looking out for, you can also have hematuria, erectile dysfunction. And then with any sort of cancer diagnosis, always think to ask about those red flag symptoms as well. That can be really important. And if you feel a little bit stuck, particularly in an ay and you start asking some of those questions, sometimes it can bring everything together for you, which can be really, really helpful, moving on to investigations. So I just want to touch on the prostate specific antigen and the PSA exam really quickly, it's actually not diagnostic. Um and it can lead to quite a bit of sort of high positive, high false positive and high false negative results. Um So PSA is basically secreted by the end of epithelial, sorry, epithelial cells in the prostate and it's basically there to thin out the semen. So it is quite specific to the prostate. However, it's going to be raised in BPH, which we're gonna talk about shortly. Prostatitis uti, even things like really high rigorous exercise, um recent ejaculation and anything that sort of stimulate the prostate is going to increase your PSA. So it's specific to the prostate but it's not diagnostic um for prostate cancer. So it can sort of come up in counseling stations as well. And the as is counseling a patient on sort of the pros and cons of, of getting a PSA. Um So just keep that in the back of your mind, it could be something to practice as well just in case it comes up. Um So your more diagnostic ones are gonna be your prostate exam. So when you, when you do your digital rectal exam, you're gonna feel the prostate and then prostate cancer, the big one is you're gonna lose the central sulcus. So you should um sort of have two hemispheres of the prostate, you're gonna lose that central sulcus of it. Um It might feel quite firm, craggy, irregular. Um It could feel nodular, you could feel the nodules of the cancer. And if you feel any of this, that usually elicits a two week wait to urology. Um then your investigation of choice is your MRI, which most of you got correct. So, really well done and then if the MRI is positive, then you move on to your prostate biopsy and that can be done transrectally or transperineally. Um And when the biopsy comes back, the histology is based on something called Gleason grading system, um which basically tells you how poorly differentiated the tumor is. Um And then that sort of helps determine what your later treatment options are gonna be. Um So just, just so, you know, sort of that key word in case you come across it in exams and then your treatments again, like any sort of oncology diagnosis, you're gonna approach it with an MDT approach. That's always a really nice keyword to say. Um And if it's really early stages, it might be a watch and wait situation. Um And then you move on to your more sort of invasive invasive option. So you have your external beam radiotherapy. Um and just to know major side effect of that is proctitis, um which is inflammation of the rectum. Um and to sort of diagnose that look for pain, altered bowel habits, bleeding from the rectum, any different discharge, the patient is not used to. And you can usually treat this with predniSONE suppositories to help. So it's just sort of a key side effect of that that can come up from that treatment. You also have brachytherapy, which is where you insert radioactive metal seeds into the prostate and then that delivers sort of continuous radiotherapy. And then you have your hormone therapies and all the hormone therapies are trying to reduce those levels of androgens, those levels of testosterone to sort of help stop stimulating that cancer from growing further. Um And the most likely spread for prostate cancer. It can basically spread anywhere but the most likely is lymph nodes and bones. So, keep that in your mind as well. All right. Next question. 72 year old African man is reviewed in Urology clinic for slowly worsening urinary symptoms in combo with a raised psa level investigations reveal benign prostatic hyperplasia, which of the following class of drugs is the first line treatment for mild B PH. So you know the diagnosis of B PH, we're just asking what the first line treatment would be management wise. Give you guys a few more minutes, seconds, more minutes, fab really well done. Most of you got that as well, which is alpha-blockers. Um So just to know the alpha-blockers decrease the smooth, smooth muscle tone of the prostate and the bladder. And that's why they're first line. They're actually more for symptomatic relief. And then there's another treatment that we can, that we go into that sort of helps with the issue specifically. But that's your first line, right? So B PH, which stands for benign prosthetic hyperplasia, but that is a mouthful. So I'm gonna stick to B ph. Um So it's hyperplasia of the stromal and epithelial cells of the prostate. Um So unlike prostate cancer, the cells stay differentiated as the cells are supposed to be. Um they just keep multiplying. So your risk factors are increasing age, usually over the age of 50. Again, strong family history is always very relevant. Um And then you go into sort of more of your lifestyle. So sort of a sedentary lifestyle. Um OK, obesity and then your common sort of comorbidities of diabetes and cardiovascular disease as well. So you can see from that picture, you can see that prostate is really putting pressure on that urinary tract. And that's why you're gonna get those sort of the lower urinary tract symptoms. Cool. Ok. So, um your clinical features again, your l symptoms. So always keep those in mind. And w if you have an OSK station and you're thinking there might be sort of a urological cause, always ask at least I'd say three or four of these sort of lower urinary tract symptom questions cause that can really, really help you. And in really severe cases, they could be in urinary retention as well, which would need sort of immediate management. Um And they can actually grade all those symptoms into what's called the international prostate symptom score. IPSS. Again, I wouldn't think you need to know anything too deep about it, but just to know the word in case you come across it, that's what that is regarding. So if they have a high ipss score, they have a lot of those sort of the lower urinary tract symptoms. So then you'd start thinking about these sort of differentials. Um So investigation wise, you're gonna do your digital rectal exam once again. But this time when you feel for the prostate, um if you're thinking B Ph it's gonna feel smoother, it's gonna be still slightly soft, like a normal prostate should feel like it should still maintain its central sulcus but it's just gonna be enlarged, but it shouldn't have any of those nodules. You shouldn't lose that central sulcus like you would in prostate cancer. Um I would do an abdominal exam mainly to check to make sure you can, the bladder isn't palpable to make sure they're not in retention. Um And then the next thing you can do is a urinary frequency volume chart which is usually done for 72 hours. Um And it's basically asking the patient to record their daily fluid intake and their daily fluid output. And then um a very intelligent urologist can go through that chart and sort of see how they're doing symptomatically with that. Um I would do a urine dip, you wanna rule out infection and you wanna rule out any sort of hidden differentials like bladder cancer if there's a hematuria. Um And then you can do AP sa again, I would make sure you co them before you do. So. Um OK, moving on to the treatment options, I think these are where a lot of the questions can come for B ph. Um So short term sort of symptomatic relief is gonna be your alpha blockers, which is usually tamsulosin you'll hear. Um And then sort of for your long term relief because the tamsulosin kind of relaxes the smooth muscle and allows for symptomatic relief, but it doesn't necessarily sort of get to the central issue that's going on. So then you can move on to your five alpha reductase inhibitors if symptoms aren't relieved enough, which is usually finasteride. Um And these will actually help to hopefully decrease the size of the prostate itself. What they um So what that enzyme does five alpha reductase is it converts testosterone to dihydrotestosterone, which is basically a more potent form of testosterone. Um So obviously, that medication will inhibit that pros that process from happening. Um But that will take up to six months to work. So it's really important to counsel patients if you put them on Finasteride, that they need the alpha-blockers to sort of control their symptoms. And then they really need to take the time to let the Finra do its job and that will take quite a bit of time. Um And then your next sort of level up from that will be your surgical option, which is your terp transurethral resection of the prostate. So they basically put a scope into the urethra, they sort of firm form a diathermy loop. Um And then they remove the prostate tissue and that sort of allows more space for the urine to flow out. And your main side effects from TP are gonna be bleeding, infection, incontinence, urinary, incontinence, um, erectile dysfunction, retrograde ejaculation, urethral strictures. Um And with any sort of surgical input, you can always have a failure to resolve the symptoms as well. All right, we're nearly there. So, last question, 45 year old tree surgeon presents to ed with pain around the left flank which radiates to the left groin and started 12 hours ago. He also noticed blood in his urine but is afib and passing normal volumes of urine urinalysis revealed two plus blood leucocytes plus nitrates and negative. Which investigation would be most useful to confirm the diagnosis. Give everyone a few minutes. Ok, a couple more responses and then we'll move on fab. All right, well done. So most of you got that as well. Non contrast C TK UB, which stands for kidney ureters and bladder. So basically a good way, I like to think about that cause I used to get confused with that as well. Actually, um is the contrast kind of covers up the stones. So you can't see them and obviously you want to be able to see them to see if they're there. So that's why you use non contrast. So maybe that will help you if you get stuck. Like I used to. Um, so urinary tract calculi or kidney stones. Um So the most common place they like to form is in that renal pelvis. Um and they commonly obstruct, they get stuck at the vesicoureteric junction, which is basically a fancy word for when the ureter meets the bladder. That's the point at which they like to get stuck. So formed up top of the renal pelvis, they get stuck right where they try and get into the bladder. Um The one thing that likes to get asked are stone types. So the most common type of stone um that can form is a calcium um It can be calcium oxalate or ca calcium phosphate. Um And your risk factors for that are hypercalcemia. So think about sort of all your hypercalcemic um presentations like stones, grown's abdominal, no stones, bones, abdominal grown's that sort of um presentation um and low urine output. And then you have your other types of stones that can also form but are much less common, which are uric acid stones, struvite um stones which are your staghorn um stones. They, they take the shape of like the renal pelvis, which is why they're called staghorn and those are typically associated with infection. Um And then cystine stones and your overall risk factors are again, more lifestyle wise, obesity, poor diet, um being dehydrated most of the time, not drinking enough water. Um, a family history and if you get recurrent UTI S, ok. So your clinical features, sort of your classic presentation is gonna be loin to groin pain, often unilateral unless you're very unlucky and you have stones bilaterally. Um But I think that would be very unlucky. Um They're gonna be colicky in nature, so they're gonna come and go that pain and it's gonna be really severe. Oftentimes your patient is kind of gonna be like moving around, not being able to get comfortable. Um, maybe having some nausea and vomiting intermittently as well. Apparently it's extremely painful to have stones. Um, and then you can look for hematuria, nausea, vomiting and reduce urine output. We actually had a pediatric presentation of this not too long ago, which sort of threw everyone off. So you don't see it as much in pediatrics, but it was actually classic presentation when we got back to it. Um, so investigation wise, you can do a urine dip, you're mostly gonna see hematuria on that dip. Um You can do blood tests, you can check for your infection markers. Um You can check for hypercalcemia for those calcium stone presentations. Um First line is your non-contrast C TK UB within 24 hours which we chatted about. Um if you, your patient is a pregnant female or a child, you're probably gonna think about an ultrasound K UB instead. Um So you don't just to minimize the risk of radiation there. Um So your treatment options are mostly gonna be symptomatic control if the stone is small enough. Um And the best one is NSAID S I am Diclofenac um seems to sort of be the NSAID of choice for that. Um If you have nausea and vomiting can think about antiemetics, um if it's associated with any sort of infection, um then of course, you can think about your antibiotics as well as per micro guide. Um Oftentimes it is watchful waiting for the stone to pass with the needed analgesia. Um However, if the stone is over 10 millimeters or there's any sort of complications with the stone. Um, then you're gonna start thinking about surgery. Um, so there's lots of fancy words. Um, I can go through them but I think probably just having a read about all of them a quick read. So you sort of briefly know what they are and know that their surgical options should suffice for exams. Um, then your complications that can occur from stones are obstructions and that can lead lead to acute kidney injury. Um You can have an infection because of the stone which can lead to obstructive pyelonephritis. Um And then you can sort of have recurrent stones and that's when you wanna start thinking about some lifestyle changes. Um So for instance, if you often have calcium stones, you can intake sort of your oxalate rich foods, they say, which are spinach, beet, root nuts, rhubarb, and black tea. Um And then the uric acid stones, you can reduce the intake of purine rich foods which are kidney, liver, anchovy, sardines and spinach. Um So just start to think about your lifestyle changes really. Um And you can consider certain medications which I think I would say are quite a specialist. Um But you can try potassium citrate, um if you have ca calcium oxalate stones and raise your calcium and you can actually try thiazide diuretics. Um again, with calcium oxalate stones, but at that point, that would probably be specialist input to decide what's the best moving forward. But I think it's important just to know you can get recurrent stones and there are some options. Ok. Fab I think that is the end. Awesome. Sorry, I missed some questions. OK. F you guys got them for me. Thank you. All right. If there's any more questions for either James or I feel free to pop them in the chat. Thank you. Chat. Um Great. Um What am I trying to say? Great talk guys and thank you everyone that interacted with the chat. Um If anyone's got any more questions, please pop them in um or you can always um message our meal page. Ok. Um But yeah, thank you guys. That was a really good comprehensive overview of urology. I needed that for my finals. We had a urology station that I was not prepared for. It was nice. Um So yeah, we'll leave it like two minutes or so just to see if anyone's got any questions, but please do fill in the feedback form. It helps us improve um the for the future um sessions and also gives our lovely speakers feedback for that portfolios which you will all find out in F one is very important. Lovely. Oh, I think James's internet went for a second but he is still here if you have any questions for him. Ok.