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Uh I'm one of the nice to meet you guys. I'm one of the f ones currently in urology at Charing Cross. So I might meet you some of you guys this year might not. Um But I'm gonna give you a talk about renal neurology and full disclaimer. It's like about five minutes of renal and the rest of it is urology. Um But hopefully it'll be useful. Um Yeah, it's quite an interactive lecture. So please feel free to like message in the chat or and your mic and say something because otherwise it'll just be me here. So just feel free whenever you want to and ask questions whenever. Um So let's just start first with like a case presentation. So John Williams is like a 68 year old man who presents to Ed with an increased tiredness and swelling in his legs for the last three days. So, what questions would you ask if he presented? And you were the F one in Ed? And what are your main differentials at this moment? Like any other symptoms, any systemic symptoms? And maybe you thinking along like renal lines, any change in like his urine? Yeah, brilliant. Yeah. So he's talking about like an increased tiredness and he's got swelling in his leg. And then he's also saying that he hasn't really been peeing for the last three days. Is he again, less and less over the last three days? He said he's got some nausea, maybe a little bit of a metallic taste in his mouth, which he thinks is a bit weird. Um, but no fever, no vomiting, no recent infections. He did say that he had an episode of severe diarrhea a week ago, but he doesn't know if it's related because he thought he just got food poisoning. So, what are you thinking about now? Anything in particular? No, I do. You might want to find out if that was like, you wanna see if there's any blood in the urine. Yes, exactly. That's really good. Um, if he, you wanna do your, so you'd do a urine dip. I'm guessing from that as well. Maybe. Yeah. And look at it. But you could also do a urine dip if it showed two plus protein, one plus blood in the urine dip. Other things that you might wanna do, you may maybe want to do some general obs. You'd notice that his BP is a little bit high, like 100 and 65. His heart rate is a little bit high. Maybe like 98 100. His resp rate is normal. His temperature is normal. Um, is, that's normal. 96% on room air. He seems a bit tired, he seems slightly pale. Um, otherwise apart from some mating edema on his legs, there's not much there. Um, what do you, what's your main differential at this moment? Could it be nephrotic syndrome? Yeah, it could. We think a little bit that good. Not quite which type of kidney injury but we're gonna go with, this is probably some sort of AKI really? right. That protein, the urine is a nephrotic syndrome. But before we even know it's a nephrotic syndrome, we know he probably has an AK there's like three types of AK if you, I don't know if any of you guys have started a renal replacement. That's like one of the first things they always ask you was it could you describe an AK and you have to say prerenal renal and postrenal uh prerenal is like medicine, renal is renal and then post renal is always just based the whole of urology. Um So prerenal would be anything that falls the renal blood flow such as like dehydration, sepsis or anything that changes like vasomotor to the kidneys like a size and nsaids. So they can be also called renal. I um they can usually be reversed. Renal ones are ones that like damage the parenchyme itself. So most carly acute tuber necrosis that can be caused by like drugs. And then postrenal is anything that obstructs the outflow of urine that could be in the ureters or in the urethra and the bladder anywhere like that. Um So d I can add to medicate to this one. Anyway. Um Do you wanna, let's go through ment, I've got a couple of slides, I'm like, I just wanna see what you guys know are different causes of like a prerenal and a renal and a postrenal at. So the code is that at the top, if you want me, I can also read out the code. I kind of already spoiled it a little bit as well because I already told you guys, but that's OK. Oh I can't, I didn't actually open responding is off. Yeah, hold on. Sorry. A trans I have to admit I don't remember much about renal. So uh my actual side a little very simple but these are all really, really good answers. OK. I'll wait for like one more and I love it. That's OK. Um OK. Do you know you guys know any renal causes of an AK instead? He just said, yeah, this is really good. OK. And we want to like, yeah, basically anything like this autoimmune things that affect the kidneys, there's a large ones and then postrenal, like I said, urology, we can't think of any actual names of urological conditions like co it like what can cause obstruction or like, yeah, BVH kidney stones, tumor. Exactly. OK. I think that's probably enough for now. But everyone's really really right. Cancers, kidney stones of the contrast as well. I guess contrast could typically be like a drug kind of cause it could be a renal cause. Arguably. Yeah, prerenal anything that depletes volume. You're right. Nsaids, Arbs Acis as well. Uh vascular things cause renal problems. Ischemic nephrotoxic. And then urology is like strictures, kidney, kidney stones and order writing urology ones, but I'll talk about them later anyway. So back to the patient that we just talked about. So we know that John probably has a pre renal AKI, he said that he's had some recent food poisoning. So he's probably pretty like dehydrated from that. And then he could have some sort of underlying CKD. Um, we didn't really ask about his drug history, but he could have some sort of heart condition. He's taking an Ace inhibitor and ARB and then he's not really drinking much as well because it's food poisoning. So the best thing for him is basically just fluid resuscitation. You could take some bloods, maybe some see his electrolyte imbalances hold any sort of nephrotoxic medications. He could be taking Metformin Ace inhibitors. When you do the PSA you're going to learn a lot of different nephrotoxic medications. Um and what, what to do in those situations. But you can start now like this and then daily blood we'd like to monitor to check that his renal function is getting better before we can send him home. And you probably wanna monitor his fluid status So you can put in a catheter, do an infant output chart. Um Basically, the management of other Akis kind of depends on what the AKI is most pre renal ones will be just IV fluids and daily renal monitoring, um stopping the drugs and then treating the cause of the fluid depletion of the sepsis. So, like antibiotics, renal ones is a, a little bit more complicated like things like acute interstitial nephritis. You could do like steroids um to settle the inflammation as well. The Maryland nephritis is usually immune mediated things like lupus or IGA nephropathies. So that again is like immunosuppressive therapies and then postrenal is basically fixing the blockage. So that's pharmacologically surgically. Um If they're in retention, you want to treat the cause of the retention, which can be either BPH or infection or if they're sometimes people can get retention from like going and drinking a bunch of alcohol. So sometimes you just poke after and then one do them overnight and they're fine. So like everything and I said is true underlying cause. And then the complications are things like for all AKI S are electrolyte, balances, metabolic acidosis hypertension because it activates the rash system um or like makes it funny. Um And then it depends on the cause of the AKI can lead to other problems like uremia or building up of nephrotoxic substances leading to encephalopathy. There's a patient currently in ICU that um you have to remember that if they have an AKI that like kidney function just stops working. So one of the complications can be that if you give them a bunch of drugs, they don't clear out. So she's been given a bunch of things to make her sleep and she's not waking up because ok, ad fr is like seven. So things like that just to be aware of and just know to be careful about when you're treating them. And this is the summary slide and then I have one SBA so far. So it's a 45 year old who's come to um hospital with a history of rheumatoid arthritis. Sorry to her GP was fatigue, a decreased urine output, uh mild swelling in her legs over the past week, she was recently treated with Ibuprofen for joint pain. On examination, the BP is a little bit high. So 1 50/90 her serum creatinine is a bit raised. It's like uh baseline, it's a little bit over baseline. Um This is an American number because I couldn't find out how to DS VA S in England. Um Her urine analysis is 2.2 plus, her blood has two plus in protein and blood. Sorry, on white blood cell casts. Um her potassium is a little bit raised as well. So what do you think is the most likely cause of a kidney injury? I don't know if it's sort of a yeah, um acute interstitial nephritis basically because she's just used Ibuprofen, which is an NSAID. So, and the white blood cell casts is a sign of acute interstitial nephritis compared to the other one. the arthritis and acute tubular necrosis have different things like urine analysis is part of path and you never use it again. So it's not actually that important but just knowing that usually acute intestinal nephritis is the one that's caused by nsaids or ace I or Arbs usually. And then glomeru nephritis and acute tuber necrosis are caused by other factors. But you get really good renal teaching. But when you're in Hammersmith for your renal placement, so I didn't really cover renal, so you'll be fine. So let's imagine that John came in a couple of days later and didn't go into when he did. Um Instead he's presenting to Ed five days after those previous symptoms of swelling. A bit of tiredness um have begun. Instead, he presents a lot more seriously with confusion, generalized weakness, a decreased urine output, shortness of breath, even worse leg swelling and some severe fatigue. Instead you do his enase and his potassium comes back to 6.8. So what would you do as your first? So, next step, an ECG. Exactly. And if his ECG came back like this, what would you do? 10 mils of 10% calcium gluconate every 10 minutes and then insulin and dextrose infusion. Yeah. Oh, what I did the other day call the med and ask him to do it. Uh But yes, um if a cal uh potassium for the back of over six, just like you said, you check if there's ECG changes, if there is calcium gluconate 10% and then IV infusion of insulin and glucose over 5 to 15 minutes. Um Something I realized as well while you're doing this, you also need to monitor the glucose, the BMS regularly. So maybe every hour or every two depending on how mean you wanna be on stabbing the patient. Um And then you wanna maybe think about albuterol nebulizers and slow IV infusions and then something that holds the calcium um back into the cells like LAK uh sorry, like a calcium binder lama for like long term getting rid of calcium potassium and then if it's not getting better after all of this, you might need expert health or dialysis to send them to it. Um They had, then I made a slide on like different things that cause hyperkalemia. But you did, you guys just did pass. So I'm not actually going to tell you any of it. Um You get the slides, so I think it's fine. You can read it if you want. Um They're all the notes. OK. Here's another case instead. So I'm gonna talk, let's talk about Sarah Thompson. She's 43 and she comes to A&E after a two week holiday in Spain. She's complaining of a severe onset sudden right flank pain that radiates to the groin, what you ask next? Sure. You guys know it's just so could do. Um, so let's go through it. So if she was severe pain, nine out of 10, she's saying she can't find a comfortable position at all. So very suddenly, four hours ago, on the right area, it's getting worse, uh radiating on the lower abdomen, groin with ongoing, persistent and worsening pain. There's some nausea, some vomiting when she goes to the toilet, it really hurts and she's noticed some blood in her urine as well. Um She doesn't have any trauma. She's not recently hit herself in her blank area. She hasn't changed anything but she's not really drinking and she's just been on holiday somewhere very, very hot. Uh, whenever she moves, it gets worse. She's tried some paracetamol, it's not doing anything about it. So next thing you would do if you were in a patient scenario and they say, what do I do next? B using general examination, I'm guessing. So you do have, she's breathing a little fast. Her heart rate is a little high. Her BP is a little high for the pain. Her temperature is fine. Uh Her sats are normal. She looks really stressed. Her right right flank is really painful but there's no palpable masses. One thing you do need to make sure you check in anything like this is also feel for the abdominal aorta because um, a ruptured abdominal AORTA also presents with point to growing pain. And the worst thing you can do in Imperial trust, this is because it's on urology and Karen Cross. So if you presented to Mary, so that growing pain and you, they think it's an A um it's a stone and they send it to Charing Cross and a CT them in Charing Cross and you find out it's a ruptured AAA, they have to send them back to Saint Mary's. So just make sure you check, it's not a ruptured AAA first. Um and then blood test, you want to do a urine dip as well. So you can see that on the urine dip blood three plus and then her creatinine was in the normal range for her. Her white blood cell count is a little bit high electrolytes are normal limit. So, what imaging would you do next? You are, I don't know if I can actually see common CK UB. Yeah. Contrast on contrast, noncontrast. Yeah, you can see you don't basically don't need contrast in a CT K A kidney stone because you can see it. It's bright white, you can see it right there. It's quite clearly. This one it's in was one in the kidney and this one is one ureter. Um they're not usually painful when they're a kidney, but in the ureter, they start becoming quite painful. Um And there's also this time where sometimes the donors in the kidney but can like pop in and out of the junction into the ureter and then that causes quite a lot of pain, but it does still look like it's in the kidney when you scan it. Yeah. And there's different types of stones. The most common is calcium oxalate. You basically can only tell what type of stone it is when you send it off for testing. But you can kind of guess by sending off bloods like calcium and urate. And if they have a high calcium or high urine, you can guess, um you can see a stag clone colliculi, but that's the only one you can clearly see. And then judging by the stone analysis when they've passed it, you can then give them advice about things like diet to avoid stones in the future. So that's the useful bit of doing a stones analysis following it. And the management acutely, the management is pr and you don't really want to let them be in pain. But the management in the long term kind of depends on the size of the stone and the symptoms. It's quite clear if it's less than five millimeters, it's usually an expectant management and kind of discharge and pain relief. You can repeat the scans in outpatient a few weeks to make sure the stones passed. Um If not, you can offer for more invasive. If it's borderline five millimeters like a 4.5 you can be nice and offer them for other things, but if it's like two millimeters and they're telling you they excruciating pain, they're being dramatic, don't worry about it. And if it's over 20 millimeters, so a two centimeter stone is just huge, you definitely do some sort of thing to it. Usually if it's more than five, you definitely do something about it. It's a bit mean to send someone home with an eight millimeter stone. Um, the things you can do are Lithotripsy, which is the shockwave, high intensity sound waves, I'm pretty sure and they like, break up the stone into a little bit and then they can pass it or you can do a ureteric stent insertion, um, and plus minus the uroscopy where you put the stent into the ureter and it keeps it open and then it helps the stone pass by itself and then the stent has to be removed a couple of months later and you have to make sure that it is removed and they can't get lost. Follow up. The only downside of that one is that there are quite a few stent symptoms. Like there is some like blank pain from it. They can pass a bit of blood in the urine. It's quite uncomfortable to have a stent in there because it constantly rubs against the ureter. But it's got a lot less of a waiting time than Lithotripsy probably because it's less preferred. And I think apparently one of the Lithotripsy machines that turned ourselves by a couple of months ago. But in Hillingdon, metho tripsy provided. Uh yeah. And you can also do a uroscopy where they try and remove the stone when they insert the stent. It's got a quite a high fail rate in real life. So usually they just put a stent in and then let it go back. Well, and then if there is hydronephrosis on the CT kub or if they have any signs of an infection, you might also want to do a nephrostomy before you insert a stent or do any surgical management, which is basically where you put two tubes from the back into the kidneys to decompress the kidneys to let the fluid drain out. Um It's basically just to protect the kidneys before you do any, they have to wait for any further surgical management. And then if they've got an infection, then you can do some antibiotic coverage as well, which is usually Comox for urology and then de session lithotripsy afterwards when they can. Um And if it's a complex one, like a stag or follicular, you might want to do a nephrolithotomy, which is a little bit more invasive. This is the summary slide. So there is another ba when my fingers, which apparently um OK, I didn't see who was all right. OK. There's another one, I'll show you a question about. So there's a 60 year old man with PKD stage four hypertension, heart failure. He comes to generalized weakness. His heart rate is really low, quite irregular. His BP is 30 100 and 30/80. His ECG shows peak ta widened cures bradycardia. His labs results show a potassium of 7.1 is what's the most appropriate initial management? I just get the rest of it. You see a 761. Yeah, I'm glad. Yeah, let's see who won. Very nice. Ok, thanks. Goodbye. So here is another passage. So, Fred presents to the GP and he's got a six month history of worsening urinary issue. What kind of questions would you ask, Nick? What kind of symptoms has he been having? Yeah. So he thinks like, what kind of questions particularly about symptoms would you have? So, like the lower urinary tract symptoms? Like front tips? Yeah. What does that stand for? I don't have that one. Uh, like frequency urgency. Uh, nocturia, dysuria. Uh, I forgot what the age is. Intermittent. Um, something like that. Yeah. Oh, cool. He didn't have that. Yeah. Basically he's having all of those. He's got difficulty starting urination, weak urine stream frequency to urinate, especially at night. He needs to wake up 3 to 4 times a night to urinate and it's really affecting the sleep. He needs to really have a nap. So you can do Socrates symptoms started six months ago. They're getting worse. She's finding it difficulty to like, start urine. She's dribbling at the end and he feels like he doesn't fully empty his bladder and it's starting to affect his daily quality of life. He doesn't really have any pain while he goes to the toilet, he doesn't have any blood. He denies any fever, chills, weight loss. They're worse at night. They're worse after he drinks. He's got no history of any kidney stones. He's never had a brace. Psa no history of any uti, um, what do you think you would do next? Well, I would do an outdoor exam and that shows that is soft, non tender, there's no masses and PP palpate bladder. The next thing you might want to do in this situation is ad so the prostate's large, smooth, um non tender with no pulp nodules and no sign of asymmetry. You kind of wanna do an D in some of these situations because sometimes if someone's really constipated, it makes it really hard for them to pee and constipation is a really easy solution. So you may as well do it to find out if that's an easy way to fix whatever their problem is, the urine dip shows nothing significant. His PSA is a little bit elevated at 4.5 but sometimes when they get older that PSA just slowly gets higher anyway. So it's not very significant. And also I get, I think, you know what the condition is in PPH, it's a little bit high anyway. And then I don't know if you ever get to do this in a GP but a bladder ultrasound can show a po post void residual and a post void residual of 80 millimeters is a little bit high for like an average person. Usually for a normal person, you completely empty your bladder but anything above 100 I think it's like a 60% chance of obstruction or something a statistic. Um and basically what the management of BFH and I spoiled it because I didn't add any animations. But lifestyle wise, you would reduce your caffeine intake, no drinking of fluids two hours before bedtime. This would be the first thing you say to someone that's complaining of symptoms, lower urinary tract symptoms and the medical ones, you'd start with tamsulosin and then you, which is an alpha blocker. So it helps to relax the bad and neck muscles and that can help with improving urine flow. And if that doesn't work after a couple of months and they come back, still complaining of symptoms, you can consider adding Finasteride, which is a five alpha reductase inhibitor and that can help to reduce the prostate size. It doesn't act immediately. So you have to tell them that it's not going to work for like six months and you're not gonna notice any difference for a while in the long term. It can help to reduce the size of the prostate and improve things. Um You want to reassess the side effects. If the side effects worsen, you might want to repeat the PSA, remember you do not want to repeat the PSA when they come in with things like a UTI or after you've just done D ra because it's gonna be raised, do it at a separate time and tell them not to ride a bike to the GP. And you might also want to do a post void, residual bladder scan again and you might want to see his enase and see how his kidney is doing. But you need to me and go to safety net them if they ever have any difficulty going to the toilet and feel like they've got any urinary retentions, any pain in the abdominal area or feel like they haven't passed urine for a significant number, number of days. Well, one day I think is significant enough infection, any blood or clots in the urine when they pass, go to the toilet then to refer to urology. Uh Does anyone know any side of co management of B ph? Ok. Then I didn't trans transurethral resection exactly the couple more and they're quite niche other than like the 1st 21 of them is the one you said, which is ti got bored of writing the table, sorry. Uh They got more and more niche and then I thought you didn't actually need to know the end of them. Uh at which is what you just said. Have urethra or a section of the prostate is the most popular one as I've noticed. Um It works pretty well, which is assume is why it's pretty popular, but it does have a couple of problems that can cause erectile dysfunction and most most sexual symptoms, um it can cause TRP syndrome, which I wrote in the notes. So I'm not gonna actually explain because it's so rare and then also retrograde ejaculation, which you need to warn patients about if you actually offer them P RP just where the semen goes into the bladder and then they pee it out because it can be really freaky for men. So you need to tell them that that could happen. Uh understandably quite freaky. And then Holle which is whole laser Nucleation of the prostate, which can cause infertility, increased urinary frequency and urinary incontinence. Um It's got a shorter stay than A TP. And it's good if the patients on blood thinners, they basically urethra resection is where they get the diathermy and they just go crazy on the prostate and a whole lot is um where they use a laser to make the prostate smaller. Um So you can see why one of them has a lower stay in the hospital and then resume imperil. Absolutely loves. It's like the steaming of the prostate. Uh It means that they don't really have any sexual dysfunction. So it's referred in younger men or old men with big prostates that have young wives, things like that. Um I think it's an interesting concept because the way that works is the steam basically causes the cells to necrose over time. So it can lead to a lot of pain uh for a couple of months while the prostate cells necrose um and it can also increase the urinary frequency urges or a little while after. And also there's like a 5 to 10% acre um reoperation rate. So they end up having a up a whole lot later on. And then there's a Euro lift where they basically use staples to keep the prostate out of the way it can lead to retention. It's not really great for great, really big prostates. And there can be incrustation which is like a stone formation, calcium formation on the implant. But again, it doesn't really have sexual side effects and it's quite minimally invasive. The PA is where they embolize the arteries and that shrinks the prostate. A high fu is a really high intensity ultrasound like in here. Um But similar to like everything else just shrinks the prostate and the cryotherapy to resume treats the prostate with cold instead of steam and tuna, which is a really, really niche. One is like an interstitial radiofrequency needle that causes heat induced coagulation, necrosis. Yeah. So there's quite a few uh the one that the problem with the PA is post embolization syndrome, which is um like pain, difficulty urinating and it's quite irritating. It lasts less than a week. It can be treated with nsaids and antibiotics. So it's not lasting very long. So that one, it sounds really bad but it doesn't, it's not as bad as some of the other side effects. Yeah. So S BPH, it's quite simple if you think about it and there's a lot of surgeries where you don't actually need to worry about anything about them. They wouldn't ask you about anything. It's not a whole, or at, if they were going to ask you about them, it's a bit mean, it's a bit niche. So that's another S VA so this is a 35 BP. Um With the youngest age, you need to like where someone could have BPH 50, ok. Like sixties. Ok. So not like someone. No, because you were saying like, you know, the guy cycling in, I was like, are we thinking like forties or like sixties? 16? Ok. Thank you. Don't worry, people should not get it that young. Um It's, they think it's because of like testosterone changes as like a man gets older that can cause the BPH G um prostate gang bigger. So it's quite a gradual thing. So it's not really something that can happen that young. Um OK, here's an SBA 35 year old man presents to Ed with sudden onset left leg pain ring into the groin, the sharp colicky and he hasn't been able to move anywhere comfortable. He's got nausea, he hasn't vomited, he doesn't have a fever. His urine shows microscopic hematuria but no infection. What's the most appropriate initial investigation? Maybe the time is that I tried to catch you guys out. Oh, I didn't put the answer. I'm so sorry. It is a non class V every time. I'm so so sorry. Yeah, my bad. I don't know if I can edit it now, but this one is right. Sorry. I feel like on the, I, I'm getting old. Ok, five years later, re now, now 73 and presents to Ed with severe abdo pain. He's been having increased problems with his lower urinary tract symptoms and he decided to manage his BPH at the time with just tamsulosin, which is um just a pharmacological management. And he says he hasn't passed any urine for two days. How would you manage him? Now, any idea? I think a bladder scan and then maybe a catheter, but it might be kind of hard to catheterize. Yeah, definitely a catheter. Um, you could do a bladder scan is a good idea. If you can get a bladder scan fast enough, you should definitely do a bladder scan. But sometimes it's really hard to find an ultrasound scan. And a and it's a bit mean if someone hasn't peed in two days to just be wandering around finding an ultrasound scanner. But if you can and it shows 2 L in his bladder, I understand that it's gonna be slightly harder to catheterize him. But it's basically the only thing you can do at this moment. You don't take a history, you find out if he has any allergies because sometimes catheters of latex and that's it. And then the first thing you do before you continue any rest of the history is put a catheter in him. And one thing is you need to do after you put a catheter in is document how much is drained after catheter insertions, it would be useful yet to find out how much is actually left and you can monitor input output straight away and then take the rescue history after inserting the catheter because they're going to be in so much pain. And the most relieving thing you can do at this moment is to put a catheter in. No one's going to want to talk about their like family history and their parents like cardiac history while they haven't peed for two days and they got 21.2 L in their bladder. And then after you've done the catheter, you might wanna do a urine dip and a culture because um sometimes infection can be a cause of urinary retention, things like that find underlying cause. And then you'd want to monitor his input output for things like post obstructive diuresis and replace 50 to 80% of the fluid lost. So and like post obstructive diuresis is basically what can happen after an acute drainage and decompression of a distended bladder that's been distended for a little while um where basically they start losing about 200 mL or more of urine for at least two hours or more than 100 mil per hour. And um they think it's something about like and sodium transport egfr damage to the Nephron. Uh Yeah, but you know, um but anyway, all you need to know is you need to re give him the fluid lost from him. Peeing out so much, so quickly. That's basically acute urinary retention. Um It gets more complex when it becomes chronic urinary retention as it's just um where that the acute urin retention isn't solved so long that the bladder muscles start relaxing and then it becomes chronic and then they start being able to hold more on their bladder. So, um over time and the bladder becomes more relaxed and that can cause problems with an underactive bladder and things like that as well. So a urine, urine retention is quite a medical emergency. Ok. Here's another by acute case. So this is David, he's 16 years old and he's presenting to Ed and with this sharp severe onset pain in his left testicle, it's constant, it's unbearable and it's radiating to his left abdominal area. What would you do? Testicular examination? Yeah. Uh Anything in particular in a testicular examination that you would really focus on. So I think you'd wanna rule in or out to. So you'd be looking at whether um there's like a chroma reflex, whether it um it. I've forgotten the other signs. But, yeah, like that kind of thing. Exactly. Yeah, you could do Socrates as well. But, uh, basically you need to check if there's any trauma beforehand because they hit there. That's not, you're gonna know that the cause is, but it just stick to a torsion. Definitely. And like you said, the steric reflex, which will be absent torsion, but it'll be present in basically every other testicular pain thing. So it's a really useful thing to cancel out. Most other things s pre sign where you lift a testicle and it doesn't relieve the pain, um which is different because you can use an epidermitis and then it does relieve the pain. Um Usually the patient will if it's to and then you could see a urine dip, but it's not really significant. Uh You could do an ultrasound scrotum with a Doppler to check for blood flow, but I've never seen one of those been able to find acutely on the NHS. So the most de definitive and the preferred management is a surgical exploration and fixation. And you've got about six hours to maximize the chance of testicular salvage and the complications would be infertility, free infection, things like that. And then some other causes of scrotal pain would be things like testicular trauma. And usually the history will tell you for anything like that. You need to check for scrotal hematoma like um so you need to do quite a thorough testicular exam for that. You can do an ultrasound testing for this. If it's currently required, you can check for any testicular rupture, which is in the testicular exam. But if not, we can manage this quite conservatively. Uh p gangrene which will present with things like fever malaise and depending how severe it is some moderate to severe pain. There's some swelling in the genital area, anal areas, there can be pretus skin necrosis, hemorrhagic bully and it can lead to sepsis and septic shock. So it's good. You need to manage this quite urgently. Like surgical debridement, send the tissues for histology and culture, some like antibiotics, skin grafts. You might also want to send any pus and sampling in culture as well. So you can give the correct antibiotics and then epididymal orchitis. That's quite similarly to torsion with um quite severe pain sometimes. But usually they can also have some fever, some dysuria, some hematuria, you can have some urethral discharge on past med. They love to ask about it and use the assumption that they're old. It's usually a uti caused by E coli if they're young boys because of an sti um do have some real life too, but don't always be too judgmental. They can always surprise you. Um And then the other thing that can present with scrotal pain is testicular cancer, which is usually painless, but it can be acute pain because of internal hemorrhage. It can have palpable masses in the scrotum. But basically, when you suspect it in a patient, this is usually when you find like a lump in someone that's 20 to 40 years old, then you definitely do A B HCG and AFP because they are really good uh spotting for like testicular cancers. And the management of this would be a radical inguinal orchidectomy and adjuvant chemotherapy. Then um a scrotal in basically um has a couple of different presentations, but they're not very, I think uh you've got Hydrocele. I decided not to do this. It was like different cases because uh scrotal is the most exciting thing to present. Um Hydroceles, uh painless fluctuant swelling, transilluminate if someone presents and they like 20 to 40 year old with a Hydrocele or if you can't really palpate the testes, you might want to do an ultrasound because that can suggest malignancy. But because they're usually presenting a little bit older, they're like, um but if they don't mean anything and then they can be congenital hydrocele, well, which happen in neonates and they regress spontaneously or caused by patent processes, vaginalis, but that's pete. So I don't think you need to cover this year and basically, you can manage them and surgically manage them. They grow really, really big, but you don't really do anything about them anyway. Varicocele is when they use in the exam. So this is a bag of worms or a dragging sensation. Um and it can disappear when they lie flat, it can cause infertility, it can cause testicular atrophy because of increasing the temperature in the scrotum. Um So if someone presents with a varicocele or a history of varicocele and fertility issues, you should do a semen analysis and then refer to urology, but you don't really need treatment for them. You can do surgical management with embolization by interventional radiology or you can do surgical management of ligation of spermatic veins. Yeah. And then there's epididymitis, which is usually in an uti or sti like I just said in inguinal hernias, which are the direct or indirect ones where um they can get into the test needs via the external ring. And you can tell that it's an inguinal hernia in a testicular exam because you can't get above it. That's kind of the words that they'll say in SB and then you, they can also be exacerbated by coughing and they can disappear on lying flat. So the things that you need to do is assess for the strangulation obstruction, but you'll know these because they'll be really painful. And then you would need a treated surgery surgically. But if not, you don't really need to do anything about it. And yeah, epididymal cysts which are benign fluid filled, transilluminate just like hydroceles. Um which is basically when you shine a torch through and you can see it and you can see them a lot in middle aged men. You don't really need to do anything about it. Surgery can usually cause infertility. So it's avoided in younger men. Yeah. And otherwise the other, other thing that I can think of is any sort of urological presentation you might need to know about is hematuria. So the most common cause of hematuria is a uti but it can also be cause of many other things like renal cancer, bladder cancers, BPH. It can be medical causes like glomeris is the IV nephropathies. The post infectious ones, it can be HSP good pasture, a bunch of things. And when someone does present with hematuria, if you uh uh an F one next year, um if you want to ask about things like how much blood they have, is it Frank hematuria or is it hematuria mixed with urine? You might hear urology on your urology placement. You might hear them say, say things like is it rose or is it Frank Rose is basically either you can compare it to the wine, which is what they like doing. They even say like is it a mellow or is it like a rose or you can do it where basically if you can see it is urine, then you can write it rose. But if you can't see any urine on it, it's basically you can't tell that it's urine mixed with blood and it looks like just blood. It's not Rosie, it's how people can write it. Um So it's a bit, there's a bit of difference to it. But you can also ask about timing. So if it's the whole stream, he mature, then you assume it's upper tract. But if it's the end of the stream, so all of the rest of the urine is clear at the very end, it goes red. It can be a sign of like severe bladder irritation and there's other fun risk factors of bladder cancer, like schist of psoriasis. But you also need to ask about a smoking history. And depending on whether you think it's in the upper urine tract or the lower urinary tract, you'd be thinking about maybe doing a cystoscopy. And this is what you'd see in a cystoscopy. It's basically urethra in a little camera. And then if it's upper urinary tract, you do a ct urogram where you inject dye into the bladder and you scan it and you see what leads and you can also do an ultrasound of kidneys to tell the same thing. And it's a little bit cheaper, it's a bit less invasive. So you might want to do that first. And the management of anyone that presents here with like hematuria is by treating underlying cause if they present with severe hematuria retension, you put in a three way catheter, it's a little bit different, dirty way. The only way is there another entrance. So when you do your paces and they ask you what it is, it's literally the same as a two way, but it has three bits to it. And then you do a bladder wash out and you do irrigation, you do it overnight. You see if it's clear, if it's clear, you can send them home, you can stop anything like Apixaban and blood thinners and transfuse them if they're required. And that's pretty much it. And then I mentioned the underlying causes earlier. So you basically treat any of those. I have two more S pa s but sorry, the stroke wasn't very quick. So no, no, any questions ready. So I didn't actually say what it was, but we just went through it. Yeah, do not take, you don't need to take a PSA because um he's presenting with less symptoms and um I should have showed you. Um, he did a dre on him on that day and his prostate is enlarged. I was, I was, I was so put it in the L I'm so sorry. Um Yeah, make sure you don't do ad R on a man that after doing um and then measure his PSA but otherwise yes, you would do a PSA on him later on in that day. I probably want to make sure that he's not doing anything beforehand. That's like causing a race psa like a UTI or thing. Ok. Next one. So a 20 year old man per 28 year old man presents the ed with severe right sided scrotal pain began three hours ago. He denies any fever, urine symptoms is a testicles, swollen as an absent chro reflex. What's the most appropriate next step and stop? Brilliant. Any question, urology is a little bit simple. It's just pee, you don't really need to think too hard about it. If there's a stricture, you put a stent in it, the stone, you put a stent in it. If it's blocked, you put nephrostomy in the back, um, block to skip the blockage. That's pretty much the whole thing. So hopefully your old, you won't be too hard. And also I remember I never learned that much on my urology placement. So hopefully this will actually help you. So you don't actually need to worry about your urology placement. But yeah, that's everything I think about urology that you'll ever need to know. There's some niche urological cancers management of those is to cut it out and do chemo. Yeah. Anything else? If not just had a good time? No worries. Thank you. Uh You can answer questions of mentally.