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Um Can I get this into full screen or does that you know the right right sided toolbar? Yeah, you can click on. There's two arrows at the top. Ok. Fine. Oh, sorry. In fact hover over the bottom of your um slide show window, you can go view view full screen to make it fully fills full screen. Sorry, say that one more time. Um So if you just hover a bit above where our faces are um just over your actual blood shower, a view full screen tab will come up and that will go fully full screen. I see that um hover your mouse over the bottom of your presentation. Yeah. Yeah. Uh It doesn't matter so I can't see it. Mm Or maybe it's just me. I um mute myself off and then whenever you wanna make a start, uh you've got up 15 people start trickling now. Um But then yeah, I'll leave it to you if you want to introduce yourself and then take it away. Ok. Um So hi everyone. My name is. I'm currently in F one working at Broomfield Hospital in Essex. So welcome to this mind, the bleep lecture on urology. I've just finished my first rotation on urology. So it was, I think last Wednesday we all changed over. So I'm currently on pediatrics, but I've done four months of urology and J search. So, yeah, I'm gonna run you through um a, a brief overview. So I think we've got about an hour. It probably will run over slightly, but everything's recorded if you wanna leave and view it back in your own time. Um So we're gonna run over some, um some of the main urological emergencies, um which you will see both on the wards and the ones they tend to ask you about um, in your exams and your ay, um then we'll go over the two most common types of urological malignancy, which is um testicular and prostate cancer and that should carry us over through to the hour. I won't be going over more of the renal aspects. So things like AK I UTI not going to go over, but I think they will be covered in one of the other lectures. And um um if you, um there's also a feedback, there will be a QR code. Um I'll get it up at some point in the middle of the um um lecture. And um yeah, if you complete it, you get a certificate um to show that you attended. Ok. Um So moving on. So, um there, there are sort of four, there's 1/5 1 which I haven't included um which is prior prism. But other than that, there are four main neurological emergencies you need to be aware of. So, the first one is urinary retention, um There's also hematuria, um renal stones. So, urinary tract calculi and then testicular torsion. Um So, with urinary retention, it can be classified into three sort of um types. Um So the first one is just an acute retention. Um Usually this is for patients who are presenting for the first time in retention. Um And it's um as the word described. So it's a sudden sort of onset, there's also chronic, which can be due to um other medical conditions. So the main one is benign prostatic hyperplasia. So that can lead to a sort of the subtle insidious build up over time. And then there's also acute and chronic, which is where they might have chronic retention and then because of something else, a new disease process or anything like that causes an acute on chronic flare up. Um So yeah, so it's a sudden inability to voluntarily pass urine. And I think it's worth noting that often in questions or in oy scenarios, they can throw you off by saying the patient is passing urine or in the history of when you're asking the patient, they might say, yeah, I went to the toilet today and if you don't then flare that up with how much it can often throw you a bit off track. So, yeah, just to remember, they can be passing small amounts of urine. But urinary retention is normally about the actual amount of urine in the bladder, not whether they're passing urine at all or not. And it's typically in men. So the incident is about 13 to 1 men to women. And the classic patient is an older man, greater than 60 years and the incidence increases with age. So fortunately, if you are a man, you have quite a high chance of going into urinary retention at some point in your life. Um So the etiology behind it. So um in terms of sort of a mechanical aspect, so there can either be an obstruction from something outside of the urethra causing the obstruction and the retention of something inside. So the most common one and the one which you're bound to get a question or two in your SBA S is B ph other ones to note. So, constipation. So a lot of stools in the bowels can cause that compression, especially in men, the urethra is really long and it goes through the prostate. So there's quite a large chance that if there's enlargement of other organs around that area that can cause compression of this area there also. So just being pregnant and having fibroids can also possibly cause urinary retention inside the tube. So, um urinary um so renal stones, um if it gets lodged, I'm not sure if you can see my mouth. Um can someone just like drop me a message and see if you can see my mouse. Maybe not. OK. Fine, thank you. Um So if you just look on the diagram. So at the neck of the bladder, if a renal stone lodges in there and it's large enough to block the flow of urine, that can also cause retention. Similarly, if there's hematuria and there's a stasis of blood in the bladder over time that can, you know clot and if that lodges in that area, it can again cause retention. And then lastly, um an another one of the most common ones inside the tube is urethral stricture where there's a narrowing of the urethra, there's connective tissue build up which essentially prevents the flow of urine with your new retention. Um There are some important um red flags you have to look out for. So you want to rule out a neurological cause. Um So the main ones are MS called equina and diabetic neuropathy. Um So we'll discuss in a moment about how you can rule that out. And then just to mention, these are often questions which come up in the S PA is actually where there's quite a sort of vague picture. But then you see they've just been started on a new tricyclic antidepressant or something like that. So, and just bearing in mind, yeah, so all of those drugs um can be associated with causing urinary retention, especially in the elderly. Um Also, I should have mentioned that at any point. I, um, I will be momentarily checking the, um, chat function here. So if you do have any questions, just drop them in the chat and I'll try and get to them when I can. Ok. So the typical presentation, so as I mentioned, it's usually an elderly male and it's quite a subacute onset. So normally around on the wards, they come in saying, you know, I've got about four hour history, they thought the pain would go and it's just got worse, but it's normally lower abdominal discomfort pain. So in the suprapubic area and the patients often come in quite distressed, as you can imagine because they have the, the feeling of a full bladder, they want to pass you in, but they can't. Um and elderly patients can often come in quite delirious just because they're being knocked off their baseline, they're more likely more prone to it. So just making sure that, you know, if an elderly patient is coming in and confused, you want to ensure that they are passing urine just to rule that out from a urology perspective. I mean, there's plenty of other causes, even a uti but yeah, just making sure that's one of the things you consider and the signs on examination. So obviously, you can see the picture on the right. Um It's quite obvious in that one that he's got a distended bladder because he has a low BMI and I think it must be like over a liter of urine in that bladder, but normally it's not as obvious. So it's really important that you do the other aspects of your examination rather than just looking. Obviously. So what I mean by that is palpating and percussing. I would say having examined quite a few patients who've come in with retention, the most obvious one to me probably was percussion. You do really hear that it's dull to percussion and it just sounds different to when you're percussing anywhere else on the tummy. So making sure that that's something you consider. So you've got a palpable descended bladder and suprapubic tenderness, which is non peritonitic and the pressure and the discomfort will increase, the discomfort will increase on pressure. So, in terms of your investigations, um, I mean, I think at the moment, what I'll do is I'll just list them out. But if you do, if you guys want to suggest any before I go into the next slide, feel free to. Um, but with retention, it's usually a clinical diagnosis, um, there's no sort of gold standard test as such. Um But if you know, if the clinical picture is fitting with retention, and um, you suspect that the first thing you usually do, which we're going to discuss again is put a catheter into the patient. But in terms of the investigations before that, um, you want to do apr exam and a full neurological exam and to rule out some of those neurological causes we spoke about earlier. And in women, you also want to do a vaginal examination as well. Um If there's a suspicion of fibroids or anything like that, um I wouldn't say it's common practice. I mean, most of the time it did happen, but sometimes there's no sort of symptoms suggesting a uti, especially in elderly patients, it's urinalysis can be a bit unreliable. So, and also it might not be possible until after you catheterize the patient if they're not passing urine, but a uti can often cause retention in the elderly. So doing a urine sample just always say a urine sample when it's anything to do with the urine. So, urinalysis and culture and um importantly here. So the main thing I would say, the main investigation you do before brain catheter in is just doing a bladder scan. So this is an ultrasound bladder scanner and um they can be quite unreliable. Um You get very varying results like I remember one time it said 200. So CC is milliliters 200 CC and then it said like 500 something. So it can be quite unreliable. But usually if the clinical picture suggests retention and there's anywhere between 250 to 300 mL in the bladder, um then it usually confirms retention. Um You also want to do you know your full work up of blood. So full blood count um user knees in particular and C RP. And this is just to check if there's any, um you know, any deterioration because of the, because the urine isn't flowing, it can cause build up and backlog into the kidneys. And this can cause, you know, high pressure, chronic retention, which is essentially where everything is just building up and it causes hydronephrosis. So you really want to make sure that you're doing that because if there's hydronephrosis, it can suggest different management rather than just putting a catheter in. And um I mean, the same as with most things, psa is not particularly useful as is typically elevated in retention. So importantly, with retention, the patient isn't always for admission. And often you see patients who come in, they might have a catheter inserted and then they're not actually admitted, you sort of keep them in like a surgical emergency ward is what it's called an hospital, sort of like an intermediate ward. And then once the retention resolves the signs improve, they just go home. So they're not actually being admitted. And the main indications for patients to stay overnight and warrant further investigations, et cetera is if they've got a significant volume in the bladder and what I mean by that is usually over a liter. And if they've got deranged kidney functions because it suggests something else is going on because being honest, if they're just on retention, the kidney function shouldn't be that deranged. So Yeah. And um so the main thing you want to do is relieve that retention. So put a catheter in and you want to record the volume. So I think as part of your oly skills, there's all the things you want to do when you put a catheter in to record the volume you put in the balloon, record the volume that's come out of the catheter, the color, the size, etcetera. But the main thing is recording it over 15 minutes. Sorry. And um yeah, so anything less than 200 mL does not suggest acute retention. Anything over a liter is particularly alarming. You want to admit the patient and anything over 400 you want to keep the catheter in situ. The main reason why um anything greater than a liter is particularly alarming is that patients often go into something called post obstructive diuresis. And this is essentially because of the chronic sort of build up of urine in the bladder without passing it, sort of throws it. You don't really need to know too much about this, but it throws the kidney off. Essentially, I think something with the medullary gradient, you don't need to know it. But essentially, once the retention is relieved, the kidney just overproduces urine and can cause the patient to become quite dehydrated and deteriorate. So you want to admit them for at least for at least 24 hours to observe and if they're producing, so the value is over 200 mL of urine an hour for more than two hours you need to replace. So you start input, output an input output chart, record all the volumes going in and out and then you want to replace 50% of the urine output with IV fluids. Um So you do see that happen on the wards. Um It's not that common but it's something to bear in mind. Um And as mentioned, the management really does depend on um the underlying cause. Um Right. Ok. So the most common cause is B ph um So benign prostatic hyperplasia and um I've just listed some of the um management there because this is the most commonly asked, I mean, the most commonly seen cause and a question which can be asked. Um So important things to know is that alpha receptor antagonists work fairly quickly. So it's what patients will be started on pretty much immediately if it's suitable and it causes relaxation of the bladder and urethral smooth muscle. So it just helps the urine to flow through. Um If there's a big prostate sort of encircling and, you know, squeezing on the urethra, it helps to relax it. Um The second line is five alpha reductase inhibitors. So things such as finasteride, dutasteride and essentially what they do is stop D HT from causing further enlargement of the prostate. And over time, it can actually help to shrink the prostate a bit. Um But importantly, this is sometimes it doesn't even start working for 4 to 6 months. So I think a common pitfall is that people see Finasterides and then they think, OK, you know what? That's something to do. B ph just pick the answer, but it might be suitable in the long term, but not necessarily immediately in terms of management of the patient. And then the final thing if they're not, you know, they're not responding to medical management is surgical management. Um most commonly is ATU RP. So, transurethral resection of prostate and um yeah, so just something to bear in mind. So in terms of the management of the catheter, once a patient's retention is resolved, we normally talk the patient. So we try them without a catheter, we don't just send them home because they might go into retention again. So, um what we're looking for here is you wanna see them um voiding successfully. Um And once they do void, you would do a bladder scan again and see how much urine is left. Usually, if there's less than 200 mils, we're not concerned and usually you want to see them successfully void about 2 to 3 times over 24 hours. And then you can send them home if there is evidence of um some chronic lower urinary tract symptoms. Um If there's evidence of a large prostate which you've seen on and which you've felt on pr you would usually start them in sin and then talk them after 72 hours. So you'd admit the patient and then lastly, multiple talks can be attempted. I think the most common thing you see on the wards, especially because the unwell patients are the ones on the wards are patients being talked multiple times. So not as relevant in your exams, but because they fail their talks, they go on to intermittent self catheterization or long term catheterization. And, um, you don't need to worry too much about these. It's just that one is where the catheter obviously stays in situ permanently and they might need to be seen by the district nurses or sort of community team who can help change the catheter et cetera or intermittent self catheterization, which is where the patient is taught how to do it and they can do it themselves. And as mentioned before, surgery um may be appropriate. Um So I've got a question um there for you, I think, um hopefully it's not too difficult. Um But yeah, I'll give you a couple of minutes. OK. I'll give you another minute or so and then we'll go through it. Um Also, I think in the poll, I can see it says Alfuz supposed to be Alfuzosin. But yeah. OK. Um So the correct answer actually is a um So Azo, um so it's a bit of a, I had a bit of a red herring in the Doxazosin. Um So obviously, um so tamsulosin Alfie Zoen they're all from the same, the same class of um medication. So they're all alpha receptor antagonists. So I think you can see from the ending of OC. So it's like if you are thinking of one of those, it will be either A or C and the reason I didnt doxazosin. So obviously, it's an SBA doxazosin, even though it is from the same, it has the same mechanism. It's pretty much only used to treat hypertension. If you look on the B NF or alfuzosin, it will talk about B PH. Whereas Doxazosin, it's more for resistant hypertension and it does have an indication for B PH, but it's pretty much not used for that. So in terms of an SBA scenario, it would be alfuzosin. Um just something to bear in mind because obviously everyone knows tamsulosin. Um But yeah, it is basically the same medication and sometimes it can just be dependent on what's available on the wards in terms of which one you give. So, Sildenafil commonly known as Viagra is used to treat erectile, dysfunction, Finasterides. So this is a second line treatment I've touched upon it briefly, but um in terms of relieving the patient's symptoms in the short term, um actually relieving them, it would be A and not D because Finasteride would more help to improve them, you know, in the next few months, not relieve the symptoms at the moment. And then I've just put some of the side effects from Bisoprolol. It's not used to treat anything to do with B Ph. Ok. So here's the next question. So a 69 year old woman presents to presents to Ed, complaining of an inability to pass urine for the last 36 hours on examination. You notice she has some suprapubic discomfort, which she rates five out of 10. You take a thorough history and she has had no other significant urinary symptoms. You notice however, that she has been started on a new medication, which of the following medications are most likely to lead to a presentation. And this is um you know, quite a classic sort of question to do with um retention. Ok. One more minute. Ok. So, um well, on to most of you, um So the correct answer was the amitriptyline. So that's a tricyclic. Um So if you remember some of the, um the list before I said the drug causes a retention. So, amitriptyline is usually the one to look for in this scenario. It's the most common one by far. So Finasteride, it wouldn't necessarily cause retention if anything, it can help improve it, but it can cause sexual dysfunction, ramipril. So it's not used in the context of um retention. Um It can cause um side effects such as a dry cough, hyperkalemia, and headaches. Uh Donepezil um can cause urinary incontinence, nausea, vomiting, syncope and citalopram causes more gi symptoms rather than urinary symptoms, hypernatremia and QT interval, prolongation So that's the main QT. When you see Citalopram, you should always think about the QT interval. There you go. So, um this next one, if you guys could um suggest some questions in the chat, so we're going to be doing this as more of an osk scenario. Um So essentially, um yeah, just um just chuck any thoughts in it doesn't matter if it's right or wrong and we'll go through it step by step. So a 53 year old gentleman attends A&E presenting with vis visible hematuria. He says he has noticed dark red blood in his urine for the last two days alongside difficulty passing urine. You are asked to see this patient take a detailed history and decide on what investigations will be required as well as possible management plans. So in terms of questions at this point, say you're, you're taking a detailed history, this is what you got given as your ay station scenario. What questions are you thinking you need to ask? Yeah. So definitely any pain um both um referred pain and um if there's any pain, any pain in passing urine. Yeah. Really nice. So you wanna know if he's passing clots? Um If he's got any other lot symptoms, um any systemic um symptoms or symptoms suggesting malignancy. Yeah. Medication really well done. So you wanna know if he's taking any anticoagulants? Um because sometimes he, he may just have been started on that which is causing the bleeding and it's really important that you stop those anticoagulants. If he is bleeding. How long? And has it happened previously? Yeah. Really nice blood in stools as well. Great. Ok, so I've written, um, so just some common questions that you would ask. So, yeah. So when you first notice this has the color changed sometimes quite often, actually, patients notice, you know, sort of streaks or a light tinge in their urine and then it can worsen over the next few days. And that's when they then present. Um if he's able to pass any urine at all. So if you remember back a couple of slides, we spoke about clots, lodging in the bladder, there's something called clot retention. Um So this is one thing you want to make sure it doesn't happen because if they've got hematuria and retention is just, you know, not great. It's almost two in one. So just knowing if they're passing urine at all, any clots in the urine, any dysuria, any other symptoms, any pain, anywhere else, this can suggest, you know, if there's anything further up in the urinary system, so involving the kidneys. So flank pain, um and then any recent trauma as well. Yeah. So one of you touched on bleeding during or after the stream. So I'll go to discuss that. It's quite a soft indicator, but it can sort of indicate where the pathology, let's say lies whether it's lower down in the uni tract or a higher up? So we'll go into that really well done. So, um, some other important, um, so I'll go back a slide. Um, what other, in terms of the further history? So, not the presenting complaint, but the rest of the history, I hope I didn't give too much away. Has anyone got any important questions that they might want to ask? So, in terms of drug history, family history, social history. Yeah. So, um, weight loss. But that's more to do with the, I guess. No, actually, you know, you're right. It's more of the history of the presenting complaint. But, yeah, weight loss, um, suggesting malignancy, mainly anticoagulation, history of cancer. Yeah. Nice. So, this is often something which they almost, if you see like rubber dye leather, any sort of industrial work you need to think about, you know, well, what we're going to go on to talk about but essentially bladder cancer because it increases your chances of having a smoking, especially as well and schistosomiasis. So that's often people who have got a history of traveling. So either going to South America or I think Southeast Asia and Africa as well. So if they swim in lakes or rivers there and then they come back. So I went on holiday about two months ago, a month ago and now I've got hematuria. You want to be thinking about that as well? So, um, I've put some of the common things there. So, he's not got a relevant, um, past medical history. Um, he takes, um, a tablet for his BP and he's got no family history, no history of hand at all. But in the social history, you see that he, he's smoking 20 cigarettes a day. So he's got a 35 pack year. Um, and he's, um, hasn't been traveling anywhere other than Ibiza. Um, in the last 10 years I'm surprised they haven't got b of that. Um, and he's also working as a plumber. So really the only risk factor we're thinking of is in his history is the smoking. He's got no sort of occupational risks. He's got no travel risks, no family history. Um, he's not on any anticoagulants or anything and um, he's got no relevant past medical history and yeah, so I touched on trauma earlier, but you definitely would want to rule out if there's been any trauma as well. So, what examinations and investigations would you like to perform? Nice. Yeah. So anything urology or renal you wanna to urine dip blood like without fail for everything? Yeah, so bladder scan, um um well done. So you would do a bladder scan in this scenario. Um So cystoscopy. So I'll go on to talk about that. Um It's not something you would just resort to at the moment. I'm talking more about your bedside investigation. So say this is a real scenario where you see the patient because realistically we're not going to be as F ones, we're not going to be the ones doing the cystoscopy. So, what we would do before as asked all the first steps or as F twos before discussing with your senior? Yeah, so you would consider ordering Act KB. Yeah. Um ok. Yeah, so those are good suggestions. Uh So first of all, so, um, no one actually mentioned this. Um, you would examine the patient always as part of your clerking. It's, you know, history and examination. So um you want to do an abdominal exam, you know, the main thing is to check if there's any flank tenderness, um check if there's a distended bladder. Um So bladder is palpable. So it's slightly distended. So you're thinking about a retention picture again here, some suprapubic tenderness again suggesting that but otherwise unremarkable genitalia exam is unremarkable and pure exam is unremarkable. So I've just got a picture there just to show you it's almost like it's just a really small thing the bladder going. So, I mean, it's not really important. I don't think it really comes up in your exams, but it's literally always down the wards and every patient pretty much has one. But yeah, you do urinalysis, MC NS bloods and bladder scan. So well done, we got all of those. So, um I just want to go through the typical presentations for someone who comes in with hematuria. So, off the top of my head, I thought the three main ones which might come up are so painless hematuria, which is always the main thing you're thinking in the back of your mind is malignancy. So, ruling out, well, you can't rule out immediately, but you're thinking about bladder cancer, it could also be renal cancer as well. They're the two most common, um, then clot retention. So the stasis of blood clotting and blocking the neck of the bladder. Um, so they will have a mixed picture of hematuria or hematuria with reduced flow and maybe not even passing urine anymore at all because the clots you know, got bigger. And um yeah, so it can be a mixed picture. And then the last one is hematuria with systemic symptoms. And I'll go on to talk about what you're thinking about in the next slide with those ones. But yeah, to confirm. So especially in an osk scenario, a thorough history is important. And I think, I mean, loads of presentations or aspects of the history are important. But I mean, with this one, especially you can see how family history, social history. So the occupational history, all of those things are really important and they can really help to tease out what might be going on. Um So someone mentioned whether the bleeding is throughout the stream or at the end of the stream. So if it's throughout the stream, you're thinking it's more of a renal or bladder cause usually, but again, this is this is not a hard and fast rule. It's just something to think about. And if it's only at the end of the stream, you're thinking it's more, um, a bit lower down. So the bladder neck, the prostate or urethral, um, a urethral cause. Well, you want to do a thorough systems review, especially to rule out malignancy. Um, you wanna check all those risk factors. So I've written there, coal tar asphalt, um, industrial dyes, I think leather as well and rubber. Um And then lastly, drug history is very important, especially in terms of the management. The first thing you always do as an f one, if someone comes in with hematuria on the ward round is you cross off any anticoagulants because that's just gonna cause them to bleed more. And if the hemoglobin's going down, they're only going to deteriorate further. So, examinations you want to do an abdominal genital and pr exam and then I'll just mentioned some of some further questions you might ask. So, um the main thing there is if they're a catheter user, if they intermittently self catheterize, um if they've had any previous surgical or urological history as well. So um to someone I think said renal stone as well. So just uh um some information on hematuria. So now it's called or the preferred term is non visible and visible, rather micromacro cop. Um So non visible is where as you can see in the picture. So you can't actually see it with the naked eye, but on urine dipstick, you can see it. So you might get one or two plus on Dipstick. And it's sort of just there in 2.5% of the population. So it doesn't usually mean that something's going on. And that's because it can be caused by menstruation, sexual intercourse, vigorous exercise. And then ut obviously you want to treat and, um, the reason why, so we're not particularly worried about non visible hematuria. Um If they're greater than 45 especially in a young patient, if they're greater than 45 years, there's about a 3% chance that it's due to a malignancy. And most of the time in the general population, we don't have any clue as to why they're coming up with nonvisible hematuria. So calls are only identified in 10% um visible. Um So really small amount of blood can cause visible hematuria. So that shows how little blood is causing non visible. And again, it's still quite a low risk of malignancy. So 15% in those greater than 45 and with visible usually, I mean, not usually they are always investigated and about 50% of the time you identify the cause. So I think in terms of hematuria, if you just try and remember this slide, I know there's quite a lot. Um but especially the medical ones because I feel like from a renal aspect, they do like to ask about these conditions quite a lot. Um So yeah, we're not going to go into those today, but just remembering that all of these can cause hematuria and with malignancy, it can be anywhere. So in the urinary tract, so it can be the kidneys, the bladder, the prostate or the urothelial lining. Um And then also another cause of hematuria, which you might often forget is that catheterization can cause hematuria. So often when you're catheterizing a patient on the wards, you might notice that they initially had some bleeding. And you're like, well, me the first few times I was like, oh my God, they've got hematuria. And then you notice that actually, you know, it was just because there is some minor aspect of trauma to catheterizing a patient. Um But, you know, after that, it immediately resolves. Um So this is really important to get down there. I'm not sure if any of you are aware of this, but there's a really good handbook by Macmillan Cancer, which essentially summarizes all the cancer referral guidelines. You need to know and you do need to know those for your finals in terms of hematuria. So, an urgent two week way is warranted. So, if the patient is greater than 45 and essentially, they have unexplained visible hematuria or hematuria that persists after the treatment of a uti. Um So, um and then if they're greater than or equal to 60 they've got non visible hematuria, but with a raised white cell count or pain on urination and then you would do a six week wait. So a non urgent referral um if the patient is greater than 60 has assist and recurrent uti s. So, um in terms of if you get this as an osk scenario, for example, and you're trying to advise a patient, you know, it's a young patient, they have normal bloods, no protein urea and they're normotensive. Um They don't need to be admitted into hospital. They can be managed in the primary care setting. And sometimes you do see um I guess you can call it trigger happy or overly concerned. Um GPS who send the patient in and then we immediately discharge them cos they don't actually need to be admitted. Um So investigation. So once you've done that two week wait or six week wait. So I think someone correctly said cystoscopy. Um So that is what you would then do. So obviously, you've got the bedside, you follow the cancer referral guidelines and then you either would do a flexible cystoscopy plus or minus biopsy. Um So biopsy obviously will, it is the gold standard to confirm the presence of a malignancy and essentially it's just a tube. Um It almost looks like a, a weird sort of video game controller from the outside. They just sort of control the tube and they will enter through the urethra into the bladder and they can visualize it, take a biopsy and to histology to see if it is a malignancy. And if they're concerned that there might be something going on further up in the upper urinary tracts, then you'll do a ct urogram with contrast or an ultrasound urinary tract if it's a young patient or pregnant patient. Um So in this, um in the case, we had, um so the patient, um I think I touched upon it earlier, the patient had clot retention because he wasn't passing urine. Um He had a distended bladder and um he's obviously got hematuria in that the most crucial acute management you would do is put something called a three way catheter in. So you see a lot of patients having this on the wards, essentially, it's the same as a normal catheter, but there's one more connector. So there's a connector for the balloon, there's a connector to the drainage bag and then there's also the connector for irrigation and wash out. Essentially. All this means is that wash out is where you use saline, you just push it into the catheter and then pull it out and do it multiple times. It's just washing out the bladder. And sometimes if they've got really bad hematuria, you might start them on irrigation, which is where there's a continuous flow of saline in the bladder. Um just to help wash it out and prevent clots from forming um other things to consider. So, as part of managing a patient in an acute scenario. Often patients can have a really low hemoglobin. So then you'd want to do a blood transfusion if they've got a palpable flank mass. So you're thinking of sort of a renal tumor there or flank tenderness, difficult to manage bleeding, anything where you're just thinking, ok, this isn't your bog standard hematuria. You want to do a CT urogram. And um I mean, I think you, you might as well not even remember this, but sometimes urine cytology can suggest there's a tumor but just because it's negative, it doesn't rule out. So it's not really helpful. OK. Um So, um so that's hematuria. So now we've got a question before we go on to our next topic, which is renal stones. Um So if you have a look at this, OK, I'll give you another minute or so for the last few responses. OK. So really well done. So I think most of you got this one correct. So the correct answer is analgesia and increased fluid intake. So I will go through renal stones. Um But just for those of you who got it, right? Just in general. Yeah. So this is a classic renal zones, picture colicky lo to grow in pain, sudden onset. So they ordered the um appropriate investigations which is C TK up and it shows a very small stone, um quite distally and the V EJ. So the patient has um is afebrile heart rate is, he's slightly tachycardic but being on his, that's most certainly because of the pain. Um, so, and just giving the analgesia to manage the pain because it's a small stone quite distal in the urinary tract, it's very likely to pass. So you wouldn't want to do any intervention at the first stage. So the correct answer is d so, um, um, so, um, sorry about that. So, um, just to go through it. So, um um stones, so in our lifetime, men are slightly more like to have them than women, 11% and 7% respectively. And usually a patient presents quite young with the first episode and if you've had it previously, you're more likely to have it again. Um So usually you see patients in their thirties and forties coming in and it's pretty rare that the first episode is when they grade down 50. And it's essentially because of the just concentration of urine and then crystals forming within that when it's mixed with other products of the urine such as magnesium and phosphate. You don't need to know too much about the pathophysiology. But essentially, um it will help to explain some of the risk factors in a moment, but just think of really concentrated urine which doesn't have much water. Um Yeah, that's how I used to think of it anyways. And um the classic picture is loin to groin. When you see loin to groin, you will instantly renal colic will shoot into your heads. So just explain some of the and um so migration of the stain will cause pain and the loin pain is from intercostal nerves. You don't need to know too much about this. Um And the groin pain is the result of genito femoral and ilio ilioinguinal nerve stimulation. So, in terms of etiology, um so remember I said very ultra concentrated urine. So um um if a patient is very dehydrated or they don't have a good fluid intake, um there's also reduced urinary frequency. So the urine is just sitting there. So imagine like really concentrating urine just constantly sitting there allowing effectively. I don't know if this is the actual thing like physiology behind it, but um allowing the urine to almost concentrate and giving it time to concentrate um that will um help increase the chances of stones forming. Um So stasis of, I think that um that is the um the physiology co stasis of urine increases the chance of it happening. And um you're more likely to um also have it if you have chronic hydronephrosis and hydroureter. So that's just increased pressure in both the um in the kidneys and the ureter because of a blockage down the line and a backlog of urine. Um So genetic predisposition. So you want to make sure you're asking about a family history of renal stones, they're not sure entirely why, but there's probably multiple reasons why. But you always want to know, because if there's a first degree family member who has a history of renal stones, it does make you more likely. Um And then I'll just put um in terms of the um type of stone, most stones are calcium um related. So, calcium oxalate is the most common um around 40%. Um There's also um struvite stones. So these are mainly caused by proteus or other micro organisms such as ureaplasma uretic. So, if there's ever something associated with microorganisms, you're thinking struvite and this is the main infective cause of a stag on Calculi. A stag on Calculi. If you search up, you'll see what it is. It's essentially when the renal stone grows really big and grows into more than two of the individual pelvis of the kidney. And it causes a massive sort of blockage and hydronephrosis and patients tend to deteriorate quite quickly. It's really rare that is rarely seen in, in the woods. But something to note and the other thing is that um most stones can be seen, they're radioopaque, they can be seen on x rays of varying degrees. Um But uric acid stones aren't, they're radiolucent. Um So something to um bear in mind. Um Some of the questions I ask and the answer at the end just because I'm running a bit behind time. Um So in terms of the presentation. So, um so I often where the stone is, can really influence the clinical picture. So if it's just a simple stone and it's not obstructing. They might experience some pain as the stone migrates. They might be completely asymptomatic. They might have some hematuria. Um But these patients tend, generally tend to be quite well. There's also um obstructing renal stones. So, depending on where it is. So you can see in the um the um diagram. So you've got the um the calices, the, then the pelvic stones and then it goes to the P UJ. So the pelvi ureteric junction stones is what I think is more commonly caused as than the actual ureteric stones. And then the V UJ. And as I mentioned earlier, the more distal the stone is so the closer it is to the bladder, the less concerned you are about it because it's more likely to pass because it's already passed so much of, um, it's already gone through so much of the ureter. Whereas a stone which is, you know, staying the P EJ right at the entrance of the ureter, you're really worried that it's going to um cause a backlog and hydronephrosis. And um, if a stone enters the bladder, uh ii mean nine times out of 10, they're really well asymptomatic and you would tell the patient that the stone is likely to pass. Um So in terms of investigations at the bedside, you would do bloods again to check for inflammatory markers. User needs to check for any deranged kidney function. And this is a common cause of post renal AKI. So yeah, something you would make sure you do. You also want to check in a practical setting, you would check clotting and group and safe because sometimes these patients can be for theater, either for managing of the obstruction or later down the line for management of the stones. You'd also want to do a urine dip and in terms of imaging, um CT K UB non contrast is first line. Um as mentioned earlier, you would consider an ultrasound scan for pregnant women, um Children or if you're suspecting hydronephrosis. And um you want to um this is mainly used in the context of follow up, but an abdominal X ray is often used where when a patient is going home, you would do an abdominal X ray and then when they're coming back. So imagine a picture where the patient is likely to pass their stone. You would take an abdominal X ray and discharge them if they, you know they're clinically. Well, there's no concerns no deranged kidney function and then they would come back in 2 to 4 weeks and you would take another abdominal X ray. And this is just to ensure that the stone is passed essentially. Um And you usually advise the patient to be wary of the stone passing and if they can collect it um that they do so that it can be recovered for analysis. Um So just some, some statistics to show you that most of the time um most stones pass. So 80% of stones less than five millimeters pass without any treatment. So just simple analgesia increased fluid intake. Um as mentioned, the more distal it is the greater chance it will pass. Um And then as the stones get bigger in size, as you can imagine, it's much less likely that it will pass. We're more concerned with stones above 8 to 10 millimeters. Um And the general sort of rule is that patients are generally medically managed. Um if they're quite well um for 2 to 4 weeks and if it still hasn't resolved, then at that point, you think the patient does need surgical intervention. So, um the sort of red flags you're looking for. So in that question, I painted a picture of a patient who pretty much had no red flags clinically. Well, afebrile observations were all normal minus a slightly high heart rate. Um If you're seeing someone with deranged user deranged kidney function, um assist pain after 48 hours, they've got a history of bilateral stones in the past or solitary kidney. So there's a real chance that the patient could deteriorate because they've either only got one functioning kidney or they've previously had stones in both kidneys. So it effectively knocked out both kidneys occupational hazards. So the main occupation which is classically used in SBA S as a pilot and or if you want to just make sure that, you know, it's a really big stone, the patient is currently well, but you want to make sure that they don't deteriorate. That's when management intervention is necessary pretty promptly. So, from a conservative point of view, so this is for all patients. Um, the first line which you need to know for your exams is IM nsaids. So you usually take clo fenac upon admission. And, um, I mean, the hospital I work at doesn't even use IM. It only uses P RFAC. But what you need to know for your exams and the guidelines is IM and then afterwards, nsaids again, plus po paracetamol is first line and you would use IV paracetamol for NSAIDS are contraindicated. Um You can also use opioids if you know, for various reasons, they can't take any of the nsaids or paracetamol or it's not managing the pain. Well, um you would also want to use um want to encourage IV fluids. Um So encourage good fluid intake. You can also start the IV fluids. Um Buscopan is sometimes given a bit of an off label use. It helps to stop spasms in the bladder, it's thought so it can help to manage pain and tamsulosin is sometimes used. Um It's again another off label use. You don't really need to worry about it. So the typical presentation for conservative management is pain management with analgesia stone less than eight millimeters and no signs of infection or AK I so just remember that, um, that sort of picture you wouldn't want to do an intervention. So that's what the question previously was sort of suggesting. Ok. So with renal stones, um, there's two sort of aspects to it. The first is the inpatient aspect and then there's the outpatient, um, more often than not patients do not actually have their stone dealt with as an inpatient, they just have the obstruction cleared because what we're concerned about is that the kidneys, the they're not draining into the bladder, the urine is not draining into the bladder and then it's causing deranged kidney function. Patients could go into AK I and you know, deteriorate further. So what we want to do is one of two things. So the first is, and this is by far, the most common intervention is a ureteric stent, sometimes called a JJ stent. Um, it's um, um, I'll, I'll show a picture of it in a moment, but essentially, it just helps keep the ureter open. So everything can actually flow and drain. Um The second is an ir guided percutaneous nephrostomy. And that's um where a tube is put directly into the kidney coming out into the skin. And that's when you know, there's hydronephrosis or um there's an infected picture and you just need to get rid of everything that's in the kidney to help, you know, just improve the patient's condition. So those are the two options that are commonly used for obstruction relief and then the management of the stone. Um You can see it there. So shock wave is for smaller stones, it's not invasive, um important to know it's contraindicated in pregnancy. Um And it can be quite painful for the patient. Um There's also ureteroscopy and laser, which is for larger stones and then percutaneous nephrolithotomy. But they're all quite sort of long words. So I'll go through it. So the first one on the left here is the JJ stent. You can see it in the right ureter. And um I think the important thing to know is that the stone is not within the stent, it sort of pushed the stone to the side and it's allowing everything to flow next to the stone, bypassing the stone effectively. Um And yeah, you, you might see that in an abdominal X ray, you most likely have an O I think compared to an SBA, but it's just something to know. It, it's got quite characteristic um look and then this is the nephrostomy tube. Um It just helps to drain everything. Like if you think about if there's infection going on, pus everything out of the kidney. And um often you see patients with two nephrostomy in if they have bilateral stones with hydronephrosis. Ok. So again, on the left, I think once you know what it looks like, you sort of understand why you pick one over the other. So this is shock wave. It's for smaller stones it's less invasive and essentially, it's just using like concentrated shock waves to break up the stones and then they can pass in much smaller pieces freely through the urinary system. Um Sorry. So the second picture here is ureteroscopy and laser. This is where you put a urethroscope through the urethra up into the urinary track and where you find stones, it's almost like think of it as almost like a gun, laser gun where you find a stone, you just literally blast the stone with laser. It's quite cool actually when you see it in the theater. Um And then this one is percutaneous nephro omy. This is reserved for really complex cases where these managements essentially have not dealt with the stone. So this is very much second line. So whenever you see that percutaneous nephro lymph toomy, you're thinking of a really complicated situation where they need to actually go in through the skin directly into the kidney to break up the stones. So, yeah, so I think the most common thing is people that confused with nephro. So I'll just get the thing up again. Nephrolithotomy versus nephrostomy. Just remember one is for obstruction relief um to put the tube in the, you put a tube into the kidney to help drain it. And the other is where you actually go in and break up the stones. Ok. So I've got another question for you. Now, um I'll try and get through the rest as quickly as possible. It will probably be about another 1520 minutes. Um. Mhm. Ok. I'll give you another couple of minutes. Not many people have answered, if you're not sure. Just guess. Ok, let's give it 10 more seconds. Ok. So, um, really well done to most severe, um, oh, error. Oh, it's come back. Um, can someone just let me know if you can still see my screen? Cos it said there was a technical error? Thank you. Um So yeah, right down to most of you, the correct answer is c um So the way I think the best way to go about this is deciding if the patient needs an intervention or not. So ie is it conservative or the active management? And then from that, looking at the management and deciding, you know, is this a sort of an obstruction relief ie inpatient thing or is it something they're going to come back for as an outpatient? So, um you can see here that the patient is um clearly got a very large stone um very proximal in the P UJ and there's signs of obstruction and right hydronephrosis. So this is pretty bond or sort of, you know, presentation needs intervention. Um The next thing you want to think about from the conservative aspect is analgesia. Um First line is I am Diclofenac and um po paracetamol um as well. So already you can rule out um Well, anything which isn't, there's no indication to suggest Oramorph. Um You wouldn't go straight to IV paracetamol because there's no contraindication to nsaids. So you can rule out two of them um from the remainder. So, Ureteroscopy and Laser, that's more of a management for stone, of management of the stone itself and that isn't the. So, um, so I understand. So I'll go through the explanation, then I'll answer that actually. So, um yeah. So, um, you wouldn't go straight to ureteroscopy and laser because you wanna manage the obstruction first rather than managing the stone itself. And um ureteroscopy and laser and percutaneous nephrolithotomy are both um um options which manage the stone in terms of I think someone comment saying emergency ureteric stenting. So that might be, that may well be the best option. I think in, in this situation, you often see if there's a really bad obstruction or hydronephrosis with worsening kidney function with such a large stone. You just want to drain the kidney anyways because the stenting will not cause it won't improve the symptoms as quickly as hydro nephrosis will also on top of that, stenting has other things to consider such as really bad stent pain symptoms. So, and also stenting is not an option in this, in this SBA question. So the single best answer here is C which is iron, diclofenac, po paracetamol and the emergency ir guided nephrostomy insertion. So I would say the best tip I can think of is deciding which ones are for Stone management. And which ones for obstruction relief because obstruction relief is always more important because a stone can sit there as long as there's no obstruction. And although there will be pain, you're not really concerned about anything else. Um, so if you could just take a moment to, I'll leave this up for about a minute or so, I'll show it again at the end. But, um, if you could just do some feedback, we don't know how to improve our sessions if we don't get feedback. So, yeah, if you could just do it, so we know. Thank you and you get a certificate as well. So, yeah. OK. Um I'll come back to it, so I'm just gonna run through. So the final, the final of the emergencies. So testicular torsion. Um So there's not too much to know about testicular torsion. Actually, I think it's quite a small sort of in terms of the condition itself. It's not, it's not as big as any of the other emergencies, essentially. Just think of, you know, quite a young male, usually 1011 or early teenage years and it can be spontaneous. So it can just happen just because it can happen because of trauma and, but the most common sort of pathophysiological cause um to think about is something called the bell clapper deformity. And I've put a diagram on the right if you see where the tunica vaginalis is um in a normal testicle, it's not highly. So it doesn't attach very high along the sort of spermatic cord. Um But in Bell Kappa, it attaches very hard. So it almost like effectively fixes everything into one sort of ball which can then twist rather than everything being not collective held within the tunica vaginalis. Then if that makes sense, you don't really need to know about the cause, but it's just remembering why it's just because of the high insertion, makes it more likely to twist and then go into torsion. Um And when the testicles go into torsion, it essentially stops the blood flow in the pampiniform plexus. And um um it can cause a testicle to die, um pretty quickly and become necrotic. Um So you within 4 to 6 hours, which is why it's such an emergency. Um So the classic presentation is a sudden on severe testicular pain. Patients are often nauseous, they can vomit, the pain is poorly localized. So, um in the, in the like SBA or os history, they'll just say they've got some lower tummy pain or some abdominal pain. Um And the early signs to look out for is a tender elevated testicle and a thickened cord on examination. Um There's also a loss of the cremasteric reflex where when you sort of um brush the inside of the thigh, it will cause a rising of the testicles and it's also Pran negative. Um So I think some people often get confused with calling it pres negative or positive. Pr negative is torsion, pres positive is epididymal oritis, which I'll talk about in a moment. Um So p pres negative means that if you lift the testicle on the side of the pain with your hand, it doesn't cause the pain to improve. So it's still just as painful even though you've lifted it up and sort of supported it. Um and late signs of scrotal erythema and edema. So this is very much a clinical diagnosis, literally on the wards, they're like torsion straight to the management. You don't, after you've done your examination, that's it. You don't do an ultrasound or anything like that because of how much of an emergency situation it is. Um you would go straight into the management, which is obviously analgesia to manage the pain. And um so there's two options you have here. Um So the first thing is you try to manually untwist the testicle. Um It sounds pretty simple, but actually, it's a lot harder to do in practice. Um It's like it's almost fixed in that position. And if you try to untwist it slightly, it'll just twist again. So more often than not in these patients, they go straight to theater for surgical exploration. So, you know, obviously doing everything for theater prep. So you want to do clotting group and save etcetera. But um in um under um in the um you'd obviously untwist the testicle, um if the testicle goes back to its normal color. And um you can see that blood flow is flowing through the testicle, it's not necrotic. Um You do something called an orchidopexy um which is basically where you fix the testicle to the scrotum so that it prevents it from twisting. Um And you do it bilaterally because um bell clapper is usually bilateral anyways. But if one testicle is um likely to tort and twist, um the other one is also more likely. So you just wanna prevent the risk of that happening at all. And if the testicle is necrotic, you do an orchidectomy. Um and just from an immune response, even you might think like why do you have to remove it? Um et cetera, but the body will, will start an immune response against the testicle and then it will also attack the other testicle as well. So that's why you just remove it straight away um to prevent all of that. And you wanna keep, at least, you know, if you have to move on, keep the healthy testicle. So the next thing is testicular cancer. Um So I think this is a bit more difficult torsion, I think is fairly straightforward testicular cancer in the SBA S. But it's just, there's a lot to remember. I think personally, essentially 90% are germ cell tumors and of them, mostly semin 10% are non germ cell tumors and there's various different risk factors. The main one is Um So the testicle is not descending um after birth. So you have about, you normally say about six months for the testicles to descend if they haven't descended already. But it only becomes a concern, I think after a year. But um yeah, so the testicle not descending a family history of it, obesity, having a mumps infection in the testicles. So, mumps, orchitis or preexisting, infertility. Um So in terms of the metastasis of um testicular cancer, um you don't need to know um too much about it, just that the lungs are normally the most common place and um that it can metastasize to all the lymph in the lymphatics. It travels up via the paraaortic nodes at L1 L2. So you might see that mentioned. Um But just knowing that's how it enters the lymphatics through the paraaortic nodes, then it most likely will metastasize to the lungs. Um The I've put the staging there. I think you should just be aware of it. I think once you read it, you don't tend to forget this one. because it's quite discrete, it's the testicle, then the retroperitoneal lymph nodes, right, the paraaortic nodes. Then if it's, so that's one and two, then if it spreads above the diaphragm, it's three and then if it leaves the lymphatics and goes into other organs, then it's a stage four. The presentation is fairly ambiguous. Um It's just a painless lump on the testicle, pain is rare, they could present with a coexistent hydrocele or gynecomastia in men because um they secrete beta HCG. Um So in terms of the investigations you would do, so you want to obviously check for these tumor markers. So beta HCG um so a seminoma um and teratoma um can both um cause um the release of this. Um you also want to check a FP. Um So usually a teratoma only and you can also check LDH, which is suggesting that the seminoma has become metastatic um ultrasound testes is the gold standard diagnostic um of choice. And the management is surgical exploration plus orchidectomy. So, if there's a tumor, you want to immediately remove it before it metastasizes. Um So stage one. So this is something I've simplified it, I think to the level you need to know it at which is if it's a seminoma because it's got a high chance of metastasis. You give a um after you do the surgical exploration and orchidectomy, you're give an adjuvant. So that adjuvant means after the initial treatment alongside that you give a single dose of chemotherapy and para aortic radiotherapy as that's the most likely place, it will um enter in the lymphatics and the teratoma because it doesn't necessarily metastasize much less likely. So one of the germ cell, if it's a non germ cell, you would watch and wait and you do repeat CT in three and uh three months and a year. Um So that's why it's important to know Seminoma is more likely to metastasize. Teratoma is not and that decides your management and then if it's anything, any sort of metastasis or if it's gone anywhere else, then you do chemo and radio as well. So I don't think he needs to get bogged down in all this chemo. There are different types of chemo and radiotherapy. I think that's a bit above what you need to know for five minutes. Um So lastly, um common testicular pathologies you need to be aware of. So Hydrocele, um I've just written sort of like spark notes because I don't want to go into this too much. Um They're usually quite small topics in, in of itself, but a hydrocele, the main thing to remember is that it transilluminate if you shine a light to it, it can be present in um other things such as um torsion cancer and epididymal orchitis and um ultrasound testes is a diagnostic tool. Um It's usually non tender as well. Um Actually, um sorry, I forgot to mention um with a hydrocele. Um you often see the words um in a question that it's possible to get above it, which means that you are able to palpate something above the Hydrocele and that's in comparison to a um um a hernia or um I think um yeah, mainly a hernia actually where you're not able to because there's something protruding down so you can't palpate anything above it and that's an inguinal hernia. Um So the other thing um to know is a varicocele. Um it's uh essentially enlarged testicular veins. Um It can, it can cause subfertility. Um But usually it isn't a problem. Um It's nearly always on the left hand side and just because it involves the veins, just think, ok, ultrasound, test these cos that's what you always do for testes. But then you're also on Doppler studies to see the blood flow. Um, and you don't usually do anything for these. And then the last thing is epididymal orchitis. You want to always rule out torsion because they often present with pain. So, um, it's always rule out torsion before anything else. Um, and it's usually caused by S TI S in young men and in older men who might not, um, being sexually active is often due to a UTI and E coli is the main microorganism causing it and it usually presents as one sided pain and swelling and it can also cause discharge, which is suggesting of an ST, ok, so we're going on to the final topic now. So it shouldn't be too long. Um, so just the SBA to sort of introduce the topic. Mhm. I'll just give you another minute or so to get the final responses in. Ok. So well done most of you. So the correct answer is the, um, so we'll go through it, but essentially a, uh, slightly enlarged prostate is a normal variant. It's not concerning um especially if the um if the enlarged prostate is causing no symptoms. Obviously, in this patient, they have symptoms but an enlarged prostate in, in of itself is not concerning. Um the second. So when you hear the word foggy, tender, warm prostate, you always wanna think prostatitis, um especially the wet boggy, um soft to regular size, prostate, central sulcus present is normal again. So prostate is almost split to two sides with a central sort of crease or sulcus. Um So if you can feel that it means that, you know, there's no sort of abnormal anatomy. Um So yeah, normal. Um So d is the correct answer because there's a small nodule felt and the prostate is firm. So normally they say in apr exam when you feel the prostate, it should feel like the tip of your nose. So quite soft if you have a feel. So if it's start to feel a bit firmer, then that's not a normal sort of findings. So, yeah, so firm prostate also suggests a possible tumor. And um the final um I put that as a bit of a red herring. So PSA, I mean, the findings of the examination were all normal, which is by far more reliable than PSA itself, but the PSA is elevated for the um age range. So 60 to 69 is 0 to 4.5 but it could be for a whole host of reasons, um, what you're going to but, you know, exercise, especially cycling, previous pr examination, for example, so that in itself compared to option DD is by far more correct answer. So that's why the answer is d that makes sense. So I just got one more question here. Um, and then we'll go through, um, the next topic which is, um, prostate cancer. Ok. So, um, those of you haven't put an answer just, I guess, guess we can't really work this one out either though. You don't. Um, but yeah, I'll be moving on in about a couple of seconds. Ok. So, um, well done to most of you. So, um, yeah, I guess you can't really work it out. It's either something, you know, or you don't. Um, the correct answer is multiparametric MRI. So this has replaced um, transect or sun guided biopsy as the, mm as the first line management for well, first line investigation for suspected prostate cancer. And I'm going to talk about what happens, but usually after the multiparametric MRI, you might, you will do a biopsy of which one of the ways you can do it is through a trust. But what this means is that it's less invasive and the patient can get the cancer confirmed, let's say, and then has a biopsy rather than having a biopsy as the first line, which has its side effects. So, we're well done to most of you. So, prostate cancer is the most common male cancer. And it's the second biggest killer for men after lung cancer. There are various risk factors. So, I mean, you can see them, they're increasing age, a Caribbean ethnicity, family history, obesity and the presentation, I mean, a lot of the time it is asymptomatic. Um, especially if you think about um, the anatomy, a small nodule on the outside of the prostate, not really affecting the urethra is not going to cause any symptoms, especially early on no systemic symptoms of cancer. So often it's asymptomatic. If it's, you know, the, the prostate's really sort of enlarged, become firm, um really restricting the urethra, then it can cause lots of symptoms and also some hematuria and um erectile dysfunction as well because the nerves which um are involved in sexual function are in the sort of posterior aspect of the prostate. You don't need to know too much about it. But if there's tumor growing around the nerves, it's obviously going to affect it. And then obviously the general symptoms of metastatic disease. Um So at the bedside, there's two options we have. Um there's not really much more than that. The first is dre um So, um apr exam, um, digital rectal exam, whatever you want to call it. Um So those are the three sort of main ways you'll see a prostate being described in your S VA S. So the main things to think of are how it feels and the texture So, whether it's smooth or cragged, often you see the word craggy or regular used. Um How hard it is, whether it's soft or firm, soft is good. Remember the tip of your nose, I've heard some people say, you know, tip of your nose good. It feels like you're forehead, it not good. Um, prostatitis is an infection of the prostate. It's enlarged, tender, warm and foggy. So just think of loads of pus in there like a bag or something. That's how I remember it. And then if it's a tumor, it can be firm asymmetrical because the tumor might be growing along the sulcus. You have the loss of the sulcus. So you should be able to feel that ridge the whole way through and then you might have hard nodules itself, any of those signs for the cancer. One were in a two week wait referral for suspected prostate cancer. Um So the PSA is interesting, I'm sure you might be aware of that. You might have PSA counseling as one of your stations. Essentially, there's not a national screening program as such for, for PSA what men can do if they're over the age of 50 is request a PSA if they want. And usually if you just go to the GP and request one, they will do it. But it's important to know that, you know, it's quite unreliable and can be influenced by many other factors. So it's got a 75% false positive and a 15% false negative. So it all shows how unreliable it is and there's lots of other things. So PSA is made by um the cells in the prostate. So if it's getting bigger, if it's getting inflamed, anything like that, it will release PSA. Yeah. So BPH prostatitis uti, vigorous exercise, especially cycling. So that's like the classic description they'll give and then obviously the PSA is a bit more unreliable then and then recent sexual activity or handling of the prostate. So dre or prostate stimulation as well. So technically speaking, on the Macmillan guidelines, if the patient asks for a PSA level and the levels above the age specific range, it warrants an urgent two week wait. But this is the issue with the prostate because many people suspect that it's actually overtreating where the cancer maybe would not have progressed, they didn't have any symptoms. And now because of that you're treating it and they're having the side effects of the treatment. So, yeah, so technically speaking, um if you look on the guidelines, um it warrants a two week wait. So as I mentioned before, multiparametric MRI is first line and I think someone was asking a question about like a scale earlier, but there's not really much you need to know about it, especially at the level for finals. Essentially, it's just a a ranking of how likely the result of the MRI shows a tumor. So one is very low five is a definite cancer and then the rest are in between. And if the score is three or more on the like scale, you, you would do a prostate biopsy. So one option is a trust, the other is transperineal. But the reason why, well, it's better for patients that we have the multiparametric MRI rather than going straight to biopsy is that there is a risk of any with any procedure, pain, bleeding infection, but also specifically to the prostate urinary retention and erectile dysfunction. And then if there are any metastasis metastases, um if you wanna check for that, you do an isotope bone scan. Um Just one final thing to mention about the Gleason School, you don't need to know about it too much. But I think it's definitely helpful to at least understand how the school is calculated and that a very low school is good and a high school is bad. So essentially what they do is they um on the biopsy, they score based on how much dysplasia or how different the cell is to a normal prostate cell, they score the most common type of cell and then the second most common type of cell and add them up. So if the most common type of cell was a one ie closest to normal and the second was a five ie, there's a few cells which are really different, but most of the cells are normal. The combined score B6 and with that taken into account. A six is considered a low risk and eight plus is a high risk. So I think that's all you need to know about the Gleason score. If you understand that it's just the two most common types of cells. Low score is good. So obviously a one and a one perfect. It suggests there's no tumor but five and a five or 10 is a very high risk, sorry, a five and a four. And then, yeah, so um I think with the staging and the nodes just understanding, there's not really that much to it, but I think often people do ignore it, just cos they think they don't really need to know it. But if you just read it once you should understand roughly what it means and what it suggests. OK. Um So the management, so we're going to talk about the management. This is the final question I believe. Um So, yeah, if I'll give you a couple of minutes and then we'll go through it, give you guys another 20 seconds, go through it. OK? So this one was a bit more of an even split well done to those of you who put C so we'll go, we'll go through the management. Um Just looking at the S pa the patient, the picture it pains is that this patient has a very high chance of a tumor which will metastasize something. A Gleason score of 10 is quite high. Um Well, very high. So, yeah, so at that point, we were thinking, ok, so watchful waiting is not, um probably is not the right answer which none of you put is really well done. Um This needs intervention and I've um put the explanations there. So TU RP is specifically for the treatment of BPH. Um Goserelin is um used. Um So it's hormonal treatment. Um and all hormonal treatment is only used in metastatic cancer. Um So you're really just torn between C and D and where there's no indication suggesting that laparoscopic surgery is not. Um you know, it's contraindicated. Usually that's always the best option because it just has a better patient outcome, less invasive, lower risk of sexual dysfunction. So hold on to those of you who put the, I mean, sorry, we just go through it now. So the management. So if it's a localized cancer, so usually questions will say, and if not, they'll give you the staging and you have to know for yourself. But it says here, the cancer is localized to the prostate. So if it's localized for T one T two, normally it's active surveillance and watchful waiting if the Gleason score is really high. Um then you'd consider, well, you would do either a route or an open radical depending on what the indications are. Um But Ed is a very, sorry, I think I muted for a second. Um Eed. So erectile dysfunction is a very common complication, um, for, um, that procedure and, um, you do see patients who have had it, um, losing their sexual function. Um, radiotherapy is also sometimes used in localized prostate cancer. You don't need to know too much about this. It's way above or any of our pay grades. But, um, proctitis is a common side effect of radiotherapy and there's also an increased risk of bladder, bladder colon and rectal cancer. So, already you're seeing why if there was a, let's say a patient had a raised psa had no symptoms, nothing showed a slightly localized prostate cancer. And then the patient chose, he would like treatment on it. And in, in an otherwise, you know, not a very, let's say the patient didn't have much in the way of a problem with his prostate cancer. He now may increase his risk of bladder colon and rectal cancer, which could cause other symptoms. So this is a sort of fine line which you have to navigate with psa counseling. Um then with localized advanced prostate cancer. So T three T four, it's prostatectomy again, hormonal therapy. Um So anti androgen. So it can be used for T three T four as well. I think I said earlier, it's just metastatic and then radio therapy again. And then if it's metastatic, you give hormonal therapy and then chemotherapy, I think the only type of chemo you give is DOCEtaxel. So yeah, so that's the management. I think if you just simplify it into those so active surveillance or surgery for localized surgery and hormonal slash radio for T three T four and hormonal and chemo for metastatic. It will take you most of the way there. Um, ok, so thank you very much for listening. Um Hopefully it was a bit of a whistle stop tour, but um hopefully you've got a better understanding of some of your, some of the main sort of urological conditions that come up in your S PA S and your ay if you do have any questions and please do, let me know, I think some of the questions I have been asked are a bit above my level of knowledge. So I might have to get back to you on that. Um But um yeah, um if you have any questions, let me know if you have any questions about F One as well. Um I can lead drop my email below if anyone does. Um Yeah, thank you for joining and hopefully you joined some of the other talks as well.