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Here and definitely not to panic when your called about a block catheter. So those are going to be some of the things that we go through tonight. Thank you very much for joining me this evening. And if you have any questions, feel free to pop them in the chat, similarly, I'll be asking a few questions myself throughout the presentation. So I would really appreciate uh some some answers in the chat box if you happen to know the answer or if you just want to have a go, which I fully encourage. So this is the rough session plan. We're going to be defining describing hematuria, which once again is as simple as it sounds, we're going to be looking at some of the causes of hematuria, how that can help us to investigate it further. Well, then be looking at a few case based discussion's about causes of hematuria, different presentations that fairly textbook, they may not necessarily always present in this way, but there's some common causes of hematuria that are important to think about. And then we'll have to think about treating hematuria and finally looking at Cath to trouble trouble shooting like I mentioned. So by the end of this session, this is what I hope to achieve with you guys tonight, have a systematic approach to investigating and managing him a trea and increase confidence when managing catheters because that's going to be important. So for all the lovely members in the chat, how do we describe hematuria and what's the difference between macro and microscopic hematuria? Just pop any answers in the chat and I'll give it a bit of time just to let the answers feed through blood and urine. Excellent divya. Yeah. Any other? So like I say it is that simple. So that is how we describe define hematuria. So what's the difference between Macron microscopic? So yeah, macro that means that there's visible blood and then micro, if one of them is visible, micro's are cold bleeding, see micro is kind of blood that you might not necessarily be able to see, but it is present in the urine. And actually sometimes when we're handing over to a urology registrar, for example, or to a urology F one even sometimes it would be helpful to have a sort of color chart much like this one where we can describe the color of the hematuria. And that's everything from sort of what's classically described to as a rose on the left, to a sort of muddy brown on the right with read Frank hematuria sort of in the middle towards the right. You can also have clots in with that as a whole spectrum of descriptions of hematuria. Um And it just gives you an idea of a rough idea, at least of, first of all, how much blood there is in the urine, but also how long that urine has been sort of sat there. Um And also an idea of where it's coming from. You know, generally speaking, if you have bright fresh red blood, it's more likely to be coming from a more distal source. So one closer to the urethra. Uh so perhaps the bladder, whereas a bit darker, you might think that it may have come from a little bit higher up. Although that's not necessarily always the case for those of you who are rose drinkers, I think describing rose as hematuria is enough to probably put you off it for life. So this is how we can categorize. The cause is you see him mature, you start to think okay, where is this coming from? So are a couple of ways that you can kind of differentiate the cause is on the left. You've got these four here. So you can think about the anatomy where the blood might be coming from. You can think about the medical causes. So that that's medical as opposed to surgical and then there's iatrogenic. So things that we've done to cause the hematuria and often those two can be interrelated. And then you've got this thing called pseudo hematuria. Does anyone know what pseudo hematuria might include. Yes. So, bells gone for very common alarming cause of hematuria. Well, pseudo hematuria that people might not expect. And, yeah, stuff. Exactly revamp isn't. So, there are certain drugs that can change the color of your urine which might make it look like, uh, hematuria but isn't actually blood. So beetroot well known for, um, not only changing the color of urine but also still some people can the steak, heavy diet of beetroot for a bit of blood in the stool. And it can be quite worrying and revamp acing. Although it classically dies urine and other bodily secretions, orange, it can be easy to see how that might be mistaken for blood. When you think that there's this whole spectrum here, an orange can kind of fit in there and you have got myoglobin, your ear as well. So that's pseudo hematuria looks like hematuria that isn't necessarily hematuria. But that doesn't mean that it's not necessarily pathological either. So then uh anatomical, how we classify it. So on the right here, you can see we've got urological upper tract and lower tract. I tend not to make that differentiation. When I'm working, I tend to just start the kidneys work my way down through the, your Etta's into the bladder and then through the urethra. And obviously, the anatomy is going to be a bit different depending on if you've got a male or a female patient. So if you've got a male patient. Obviously, you need to include the prostate into, into your kind of flow chart of where the, where the blood might be coming from. And then in terms of medical, sorry, I should have said that. Does anyone know it was things that haven't been mentioned here, what might fit into sort of medical causes of hematuria? And we can, we can include iatrogenic causes in here as well. Yes, the cancer is a big one. Um mm cancer sir. Stones. Yeah. Pailin nephritis. So coagulopathy, she's, that's yeah, that's probably a big one that I include in that um prostate cancer, stones, pilon arthritis, you, you can easily classify them in medical. I tend to use work through those in anatomical because I think okay, what's going to be affecting the kidneys could be an infection. What's affecting the ureters could be a stone for example, but how you choose to classify them, how it's helpful for you is going to be the way that you remember it. So don't just take what I'm saying and and try and apply it if it doesn't work in your practice. Um So yeah, coagulopathy, these and for people who are on blood thinning medication, those are two that I kind of fit into the medical and iatrogenic and there's also another cause of iatrogenic hematuria that we will come onto a little bit later. Um You might also and this is something that I've come across very commonly is you might have a kind of anatomical structural issue such as a malignancy that's actually made a little bit worse by the anticoagulants that we might be giving someone for, uh, you know, for whatever reason for a F for PE for DVT. So, although this will help, sometimes it can be multifactorial, so it's just a case of keeping an open mind and doing a sort of thorough investigation into the cause is as always the first thing that you're gonna do when you're asked about reviewing someone with hematuria is, you're going to take a history. So what kind of features of a presenting complaint are you going to look at? What are the, what the points that you want to pick out of a presenting complaint and what systems might, you want to dig a little bit deeper into pop your answers in the chat. So yeah, you want to get, uh that's good stuff and you want to get an idea of sort of when they're noticing the hematuria, you want to know if they're having any pain from anywhere because that's gonna sort of when we talk about, you know, the anatomical causes of hematuria, that's gonna point you into a good direction of where the pathology might be coming from. So, yeah, again, the color. So it's a bit like we spoke about earlier. If they're having a small amount of bleeding from somewhere distill, it might be a bit more rosey. However, if it's deeper into the, deeper into the bladder, to the ureters. If it's sitting around there, it might be a bit darker. So, again, yeah, really good. Talking about weight loss. So, thinking about b symptoms. So, any signs that there might be an underlying malignancy. So, associated fevers. Yeah, because that's good. That's really good. So, that's going to be point pointing in the direction of sort of infections. And again, that can be anywhere from the prostate if they're male bladder infection or further up into the kidneys as well. Yeah, nausea, vomiting. So those are kind of features that we might associate with infective causes. But similarly, the pain from renal calculi is can be quite severe and can induce a sort of nauseated feeling and also some vomiting. And of course, we're talking about the urinary tract. So you want to be discussing any urinary tract symptoms with them, uh whether that's symptoms associated with UTI S. So, burning, stinging, uh polyuria urgency, just, yeah. So exactly alligator this area. And you also want to be thinking about signs and symptoms that might point you towards prostate malignancy or prostate pathology, even whether it's malignancy or otherwise. And what sort of prostate symptoms do people complain of with relation to their urinary tract frequency, urgency, nocturia? Excellent. Yeah, you can also get some hesitancy feeling of incomplete emptying. So you wanna, when you're assessing these patient's just get a really good idea of what they're, what's normal for them because, and then also, well, what's normal of them quite, quite often they've, they've been sat on these kind of symptoms and just that, uh, stiff upper lip attitude of saying, oh, you know, I get, I get up about every hour in the night, but that's normal for me, you know, quite obviously getting up every hour in the night to go for a week is not normal and might be pointing towards an underlying prostate problem if they're, they're sort of an older gentleman. So, in the past medical history, so what features might you want to ask about in the past medical history that might help you determine the cause of the hematuria? Yeah, any history of malignancies. So, any bladder cancer, renal cancer, prostate cancer. These are all things that are likely to cause hematuria and it's given the elastic nature of the blood. You know, it's that transitional cell, um, the way that it stretches and then contracts when it fills and empties, it just leaves the bladder very prone place to bleed. So, we've got cancer, which we spoke about a little bit whether they've had any history of any uh stones, passing stones in the past history of recurrent uti S, that's really important uh diabetes as well because that might influence whether you think that this frequency that they're having is coming from an infection or a metabolic endocrine cause. Yeah, really good. Whether they've had radio radiotherapy to the pelvis because that's gonna potentially affect their, their sphincters, catheter use. Yeah. So, any history of any long term catheters, whether they have to self catheterize for whatever reason they've recently been talked here because they might have lost some of that control that they usually had over their bladder. That's something that we frequently see. So, those are all really, really great, great bits of input. Thank you very much. So, drug history. What kind of medications do we want to be aware of? So, yeah, Sampson, what we spoke about earlier that can cause a bit of sort of pseudo hematuria. So, yeah, nsaids, blood thinners, anti platelets, anticoagulants, anything like that, that might, uh, might exacerbate some hematuria. You also want to get an idea of whether they're already known to urology services. So there's a good chance that if somebody is on, um, Finasteride or tamsulosin, then they've already got, you know, they're met. Well, yeah, they already have some sort of prostate history, most likely, uh family history. Obviously, we need to think about any sort of history of malignancies in the family and then social history. There's a few funny little uh kind of textbook examples of social history that we need to be aware of, particularly in terms of previous professions and I don't know, habits, recreational activities, that kind of thing. I don't know. Um, so what kind of features of the social history might point us towards a course for hematuria amylin die exposure. Yeah. So there's a couple of kind of like I say, fairly classic uh examples of things that predispose people to urological malignancies. So aniline dies as one and I think the other, the other quoted one is uh working in rubber factories. I think it is. And of course, it's really important to get a good idea of their smoking history as well because smoking is another, I mean, it's a predisposing factor for malignancies, but especially true for urological meat, um urological malignancies also. So let's move on some case based discussion's some case things. Um We've got a 38 year old male that has attended their G P. He said, I think I have some blood in my way now, just based on that snapshot, what kind of things jump to mind causes for hematuria that you've come across. And I know that's not very much information, but if you think they've attended the GP and if you look at their age that might help point you towards certain pathologies more than other pathologies, BPH. Okay. So we're thinking BPH, because it's more of a chronic problem maybe. So, that's why they're at the G P. Um BPH, probably less common in gentlemen, of uh of this age, be a trauma, trauma and renal stones have both been offered up, I think. Yeah, the again, trauma potentially may be more likely to attend the emergency department and renal stones as well. It's something that they could attend to the GP with, especially if they're just having lots of smaller stones. Um, so a UTI again, yeah, 38 year old male attending the G P with the UTI quite uncommon still because you tend to tend to get UTI S more oftenly in females, but not unheard of certainly. And when it is in males, it's a bit more of a problem because generally speaking, the anatomy is more protective against UTI S. But those are all really good suggestions. So let's get a bit more information from a history and examination. And you've also got a bit of an ultrasound scan there um for people for budding radiologists. So, otherwise he's been a symptomatic. So he's just noticed this bleeding a few weeks ago. It's kind of rose to red colored hematuria on examination, there's a palpable abdominal mass and this 38 year old man has got BP of 100 and 68/96. What do we think the diagnosis might be? So, we got prostate cancer. So, with a palpable abdominal mass, it's always something to think about. So, yeah, excellent polycystic kidneys more often than not autism, all dominant polycystic kidney disease. Although I believe there is an autism or assess it version as well, but A D P K D is um is what I was going for here because this is a fairly young gentleman with a symptomatic hematuria and it's the BP, that kind of gives away the diagnosis as well as this very polycystic looking ultrasound. I couldn't have told you had I not googled that what part of the body we're looking at? I'm not that well versed with ultrasonography yet. It's on my list of things to do. Um but just wanted to for people who may have looked at this before, just give them a bit of the aide memoire into autosomal dominant polycystic kidney disease. Very rare, but it is a cause, an important cause of hematuria. Does anyone know one of the complications of A D P K D? Uh that's really important to screen for? Yeah. So it's a very annual aneurysm. Exactly. Mustafa. So people with A D P K D are more prone to having berry aneurysms. I think more commonly on the anterior communicating artery in the circle of Willis. Don't quote me on that. Look it up yourself. Um Yeah. So if, if someone has a barrier aneurysm there at risk of a uh subarachnoid hemorrhage. Exactly. So case to 26 year old female attends a and a and she thinks she has a water infection. What's, what's this making people think of? So, got uti yep, any advances on UTI. So again, we've got likely uti given age and gender. Yeah. So we've got important demographic factors here. We've got the sort of more acute presentation. We've also got some kind of ideas, concerns expectations. Bubbling away here. So, bladder stones is, yeah, that's equally reasonable because they can present fairly similar E S T I. So that's, um, yeah, that's a good one to think about because they'll often share a very similar symptom profile will be feeling unwell. They'll be having this sort of pain, potentially disarray there. So definitely something to keep in mind when you're thinking about source control when you're treating an infection. So, a bit more of a history and an examination. So she's had infections in the past, but it's never been like this. She's got fevers, feeling shaky, been unwell for a few days, being nauseated and vomited. She's got abdominal and back pain, non examination. She's got pretty good going left flank pain with a temperature of 38.4 degrees. So what do we think the diagnosis is? Mhm. So again, I mean, I was going for an acute pyelonephritis but I think yeah, renal calculi is like perfectly reasonable to put in your differentials. Um With that in mind, how are we going to best differentiate between whether this is a renal calculi which could to be fair cause a bit of a urological emergency if the calculi gets stuck, stuck in the Euro to and causes an infected obstructed kidney. So what kind of thing would help us to decide whether this is a stone that's become impacted, causing a bit of a infective backlog of urine and sloth and other nastiness or whether this is a straightforward pylon arthritis. How could we differentiate between the two? Is there anything we might want to order maybe? Yeah. So okay. So we've got, we've got suggestions of ultrasound and CT C T K U B. Yeah. So all of these perfectly reasonable. However, I would point out one thing this is a 26 year old female. So we do need to think about radiological burden in everyone. You know, we need to be using the Alara rules as low as reasonably allowable in terms of radiation doses. But specifically in women of childbearing age, we do want to be careful with, with ordering too much intensive radiology. So an ultrasound is probably what they go for first just based on the fact that it would probably give you a pretty good idea of what the diagnosis is with a lower radiological burden. However, if you were to order a CT K U B, so you want to know what kind of signs might point towards pylon arthritis because if you've got an infected obstructed stone, the chances are you're likely going to see some big old kidneys with some hydronephrosis and potentially some hydroxyurea to uh a proximal to the stone. But so you'll know the CT findings for pylon arthritis or something that might point towards inflammation on CTS. And this is applicable for uh for pilot nephritis appendicitis, any kind of inflammation. So I think the staff is given the game weight. Yeah, so fat stranding. So it's this kind of linear collection of uh capacity around the kidney. So it's perinephric fat stranding and what that basically is is just a Dema kind of swimming in between all these different layers here. So, if you had an infected obstructed kidney, this kidney would probably be much larger, let's say it's a stone on the left and you'd have a big dilated ureter here, similarly, probably be quite big and bulky. Um And it would just, you know, just look a bit fatter. Whereas here you've, you've got this kind of perinephric fat stranding. Obviously, this is bilateral. Um If you've got a pyelonephritis on one side, it would just be on one side. Okay. 62 year old gentleman attends a and a, he says my, we've been a bit off recently. What's that? Making people think of what diagnoses? Yep, prostate cancer. BPH. So you don't really know what he means by a bit off. That might be in color. It might be in terms of smell. It might be in terms of, it's been a bit off. It's been just a bit slough e horrid, bit brown, not sure. So we could probably dig into that could be infected maybe. So, here's a bit of a history and examination. So again, yeah, diabetes. It might just be that it's, it's just a bit, it's got a bit more frequent. So he's been feeling off for a few weeks. He's had some malaise some weight loss and he's felt fatigued. He gets short of breath more easily than he used to. And actually on some deeper digging, he's, he's had some chest pain with a bit of cough and a bit of hemoptysis as well. And also noticed this blood in his urine on examination, you notice that he's got quite swollen hands and feet, but he's put that down to the fact that it's 30 degrees outside on examination, you hear crackles on auscultation of the chest. What are we thinking in terms of diagnosis? So, metastatic prostate prostate cancer. Yeah. So that's that, that would be an important differential to rule out, wouldn't it? Definitely because he's having hematuria, which would make you think about prostate cancer and he's got these kind of chest symptoms. It's got CKD as well. Yeah. And then we've got Goodpasture syndrome, glomerulonephritis. Yeah. So you can have any number of memory alone of nephropathy. These and of course, we can differentiate those into nephrotic and nephritic. And they've both got different profiles in terms of what you might see in the urine. Um Good Passengers syndrome, which is what I was going for here. Um Again, not, not that common, but you know, there are some, it's just a demonstration of how though it might seem like, you know, something quite straightforward going on a bit of blood in the urine and a bit of a cough. Actually, you know, you, you, you see the examination, hands and feet have felt swollen. Why are his hands and feet swollen if he's got good pastures syndrome? Good postures disease. Yeah. Any ideas. So with good postures, it's a nephritic picture. So uh you get hematuria, there's a triad and now it's completely escape my brain, but you get hematuria and you also get a bit of protein, your ear as well because what happens is you have auto antibodies which are attacking the type three collagen in the basement membrane. And that's both in the kidneys and the glomerulus and also in the lungs. So when you get a breakdown of that barrier, you get the cough, you get the hemoptysis because you get blood coming up as the barrier is broken down and you also get the blood in your urine because your glomerulus has broken down. You're getting the blood's not staying in the circulation, it's going into your urinary tract and you also lose, so you're losing blood through your urine, but you're also losing proteins. So when you lose those proteins from your blood, you don't have that oncotic pressure, keeping the fluid in. So it tends to pull in the extremities to start with because you don't have, you know, it's all about those earth Stalin forces. So the next case, I think we've got three more. So four to take 42 year old male attends a and a. So think about what pathologies might be affecting someone in this age group and why they might be coming in acutely. And he says, and I'm not sure how he knows, but he says this pain is worse than childbirth. What we're thinking, what might be going on. Yep. So renal calculi, ureteric colic. So, yeah, abigail was bang on the money with your renal calculi. This is a kind of typical history, uh sudden onset of abdominal pain coming in waves. So that's where you have that kind of colic colicky pain because you have a, you have a hollow viscous that's trying to um Peristyle, trying to do Paracelsus, you've got that stone there. So it's trying to push that stone through and that's where that kind of pain that comes in waves comes from. So you have pain that can sort of be there for four out of 10. But when that paris dialysis happens, you get waves of 10 out of 10 pain. And of course, you've got this sort of classic loin, two groin loin, two groin pattern of pain that really analgesia struggles to touch it, especially sort of paracetamol ibuprofen, get a bit of blood in the urine and you'll have that abdominal pain as well with some renal angle tenderness, perhaps to, in terms of management, there's a couple of medications that would help this gentleman. One of them is an analgesia and the other one is a medication that's used in urology quite frequently, but not necessarily um indicated for you know, it would be an off label use when you're using it for a, you're a Terek Stone. Does anyone know what two medications I'm talking about? Who? So, in terms of CCB, uh, not short, see CBS is, see, CBS. Is that calcium channel blockers? So, uh, so close with Finasteride. So calcium channel blockers isn't one that I've come across personally. But if you've seen them used in practice, you know, um, let me know sort of in what context you've seen them use because that's quite interesting. It's something I can look into. Um But yeah, so perverts coming with tamsulosin. So, yeah, tamsulosin is something that we usually use in urology for people with BPH. Um So it's actually got some evidence that it would help in your A Terek colic. So it can just help with that, you know, ease that kind of smooth muscle contraction that's going on and causing the pain and can just help people to pass stones a bit more easily. The analgesia that I was talking about is actually diclofenac. So it's a, it's a non steroidal anti inflammatory drug. Um And usually we give it rectally so it's 50 mg, tds rectally and it's been shown to be it's really effective. Um It can pretty much take someone's pain away more or less completely. Um Or at least have a really big impact on it. Of course, there's also risks of using a NSAIDS, but they're, they're very very effective helping with renal colic. So, just a little bit about renal stones because they're very common. If they're five millimeters or under, they should pass by themselves. And of course, you can give them pain relief and, um, tamsulosin. And that's even in females, by the way, tamsulosin, that's been shown to help with your rhetoric stones. Um, because it's generally one of those medications that we associate with just being for men essentially, but that's not the case. It can be used here. Uh Although discuss with your urologist first, I should probably say, don't just go prescribing it off your own back. Um If they're over five millimeters, then there needs to be some discussion about management that we can get into a little bit later. A noncontrast ct CT K U B will highlight the stones because that's if you're using a contrast CT, then all that contrast is just going to pull and you, you might see a bit of a level and if there's a complete obstruction, but otherwise it might mask a smaller stone. Um And then if there's hydronephrosis, then that's when you need to start thinking about stenting where they place a tube that essentially goes from the bladder all the way up to the renal pelvis. And it just helps urine bypass that stone. Or um in certain instances, they might think about nephrostomy where they usually interventional radiology in such a tube into the kidney just to help it drain much like an ileostomy or colostomy into a bag just on the flank. And importantly, infected obstructed kidney is one of the neurological emergencies. And once someone goes to I are, they have a nephrostomy put in. It's often complicated by septic shower. Has anyone come across that phrase before septic shower? Is anyone willing to go out on a limb under? Uh if they, if they feel confident, knowing what septic shower is sharing with the rest of the group on the chat. So we got shock, septic shock. So it's, it's a bit more specific than that. So, septic shower. So let's say someone's got an infected obstructive kidney. Yeah. So did he has got it. So infected obstructed kidney and nephrostomy is or stent or some other technique is used to relieve that obstruction and what you get is all that kind of infected matter that's just been sat there then gets flooded into the system. So you have this kind of deterioration, which is essentially, yeah. So it's sepsis following relief of an obstruction, infected obstruction and it's just letting all those pathogens go a bit wild and you get this inflammatory response and you essentially treat it in the same way as sepsis. So, follow your sepsis six and escalate. But if someone's come back from IR and they start to deteriorate, they've got a temperature, they've got a new oxygen requirement. This is a sort of thing that you, you know, it's relatively sort of common. So we've got a 69 year old male that attends his GP, his, we've been a bit dark. So, again, think about the age group, think about the acuity of the presentation and think about what this might mean. Just pop your answers in the chap. So, the girls sit prostate cancer. So it's a bit more of a history and an examination. So, urine's been a bit dark for weeks. It's not been painful. It's not always dark, but it's, it's just been a bit off otherwise. Well, in himself, no dysuria, no frequency, no urgency, no nocturia. He's an ex smoker of 40 years, retired handyman and on examination, there's nothing really in terms of anything on the systems review. So again, it's a bit like we spoke about earlier. Devious said it bladder cancer is something that we think about, but equally as relevant prostate cancer. So this kind of painless hematuria point you towards more malignant etiology of the blood in the urine. And we can talk a bit about how we'd investigate and manage that a bit later. And then finally, so this is the last case before we move into sort of investigations and management and then we'll do a bit, a little bit of cafta troubleshooting after that. So you're working urology, you've been asked to review a patient admitted, recently treated as your oh sepsis. Got pretty good going AKI he feels much better. Now, it's still a bit unwell, which can probably be expected. He's never had hematuria before and he was catheterized due to a sepsis because you want to get a good, uh, recording of urine output. But urine is now draining rose in color. What do we think happened here? Any ideas? So, obviously, given his age, you don't necessarily want to, um, you don't want to overlook the fact that there might be a more sinister pathology going on here. Um, but if he's recently had a catheter inserted and it's draining rose, so it's, you're thinking it's probably not, you know, not a great deal of blood, that's just a bit of blood. It doesn't take much blood to tenge er, and fairly rosy in color. So it could be cancer, but more than it's probably more likely that it's associated with the catheter. So, insertion of the catheter can just on its own cause hematuria. Um, obviously, for this gentleman, you probably want to get a full work up nevertheless, because you don't want to miss anything that might be underlying it so acute on chronic urinary retention secondary to BPH. So, and actually this is, this is, this has raised a really good point as well. So if someone's been in high pressure, chronic retention, the bladder gets really, really full, we're talking a liter plus here. Um, it might not necessarily be painful as soon, but it could cause an AKI of three and a bit of your oh sepsis. Once a catheter goes in and that bladder contracts down, there's every possibility that they might get a bit of hematuria. Just, just simply from that because the blood has been so distended, so stretched out that, that contraction, you know, the vessels can be a bit friable. You can get some bleeding into the bladder just because it's been so distended for so long. So, actually could be catheter associated here. But just as equally this could be to do with a sort of high pressure, chronic tension that's recently been relieved by a catheter. And that's just caused a bit of bleeding in the bladder. Again, you would investigate them all in exactly the same way, especially for someone of this age. So when it comes to investigations, I always follow this, I followed this for my Aussies when I was a medical student and I still follow it as a junior doctor because it just helps me to make sure that I'm ticking the boxes. So what kind of bedside tests would help us to, uh, investigate hematuria? Very simple, very straightforward urine dipstick. That's going to give you an idea of whether there's blood there, but also, uh leukocytes nitrites some protein as well. And these can all sort of kind of make you think about causes too because if there's protein and blood, then you might think about the critics syndromes, you can kind of go from there, but it's a good place to start, we've got an offering a flexible cystoscopy. Now, I would probably put up further down the tree and more specialist investigations in terms of bloods. So we've had abigail saying use the knees. So yeah, using these are excellent. Um, that one of my, one of the most commonly ordered invest blood investigations in urology, um F B C as well because if someone's got hematuria, especially if they've got quite a lot of quite frank red hematuria, you want to make sure that this isn't affecting their hemoglobin levels. So, using these, because using these can be knocked off in all sorts of urological pictures, FBC because you want to monitor not just the hemoglobin, but also if you're thinking there's an infective cause for this white cells, neutrophils in a similar breath, also, CRP is going to give you an idea of inflammation, isn't it? And then you got P S A, if you're thinking that there might be a bit of an underlying prostate problem going on, let's say you've done A P R and there's a kind of asymmetric, asymmetric, bulky, hard feeling prostate, you're gonna want to get A P S A and then, yeah, coagulation. Exactly. So, if someone's bleeding, you want to get a good idea of if they're actually able to clock by themselves. So, yeah, your creatinine is going to be part of your use and he's, and that's gonna help, uh, just sort of, uh, that's gonna help you determine sort of the severity of the case as well. So you got some good blood tests go in there. What imaging, we've already spoken a little bit about this. There's a whole host of imaging that you can do and that's everything from ultrasound to see T K U B CT Urogram. Uh There's some nuclear imaging studies that you can do that, that will demonstrate how quickly uh the urine is draining as well. Um MRI, so MRI has its place as well. Um Particularly if you're thinking of sort of underlying uh prostate malignancies. Um The list is a bit endless. We won't go too much into it, but really ultrasound and CT is going to be your mainstay of imaging. You can get ABDO X rays, you can get X ray KUBS as well. Um And these, all these all have different indications and generally speaking, I just let the, the, the urology consultants sort of um lead the way on the imaging because like I say, it can get a bit weird and wonderful because if someone's got a stent in and they want to make sure the stents in the right place, you can get an ABDO X ray to check that. Um Yeah, very complicated. What I would say is ultrasound and CT are going to be the two. Just remember if you're thinking stones, you can certainly wig and you can order a CT noncontrast K U B with alongside. So that's, you can have a CT urogram with a noncontrast phase to check for stones. So you can get a good idea of um, the flow through the kidneys from the urogram as well as a good idea of if there's any calculi from the CT KUV noncontrast specialist investigations. So this is when we talk about flexible cystoscopy. So if we go back to this gentleman, so, yeah, Uro Dynamics studies, that's, that's kind of in the sort of weird and wonderful special investigations. But if we go back to this gentleman, the chances are he's going to get a CT uh ct urogram plus a flexible cystoscopy because although you're fairly confident that this is associated with the catheter, you don't want to miss that underlying malignancy. So, although you may not be too concerned, a flexible cystoscopy, direct visualization of the bladder is going to be your sort of gold standard for ruling out malignancies. So, in terms of management, again, much like this, this is something that I use. Danowski. Is it something that I use in practice today? Start with conservative? Think about medical and if it's indicated surgical so conservative, it's as simple as staying hydrated. Um I mean, again, it will depend a lot on the causes. So for stones, if we focus on stones conservative will be ensuring appropriate analgesia, it's prescribed plus um adequate hydration for medical. You know, you might think about tamsulosin here and then surgical's when you think about stents, um, and lithotripsy and all that kind of stuff here. I'm not going to go too deep on the management for, you know, every single one of the cases that we looked at. But there are some sort of, yeah, there are some general things that we can think about in urology when we're managing hematuria. So, catheterization, urology is sometimes frustratingly simple. Sometimes it is just a case of you're dealing with multiples of tubes. So you've got a urethra, it's got some blood coming out of it. What you want to do, you want to put another tube in the tube that you've got, and that's going to give you a few different treatment options after that, depending on what catheter you put in. So a catheter is not only going to help you monitor output and monitor the extent of the hematuria because you've got that sort of collection bag that you can monitor, but you can also use a catheter for blood to wash out. Um So glad to wash out is something that if you haven't done it before might seem a bit daunting, but it is very straightforward. You basically get a catheter tip syringe, which I've got a picture of a little bit later and you get some sterile water, you fill up the catheter, not catheter, you fill up the syringe with sterile water where the catheter would correct. Connect to a collection bag. You sort of, you, you clamp the catheter, so that urine is not going to go everywhere when you disconnect them. So clamp the catheter disconnect, connect your syringe, unclip the catheter and then with a fairly good amount of force, not too forceful, but you want to be fairly, um you want to give it a fair amount of pressure because what you want is for the water to go up the catheter, potentially remove any blockages that might be blocking the catheter if that's what you've been called for, um and give a good amount of turbulent flow around the bladder. So let's say you've got a 50 mil syringe, you've injected 50 million to the bladder, you then want to aspirated that same 50 mil and just dispose of that fill up the syringe again and keep doing that until the urine that you're uh the fluid that you're aspirating starts to clear up a bit. And you can do that as many times as you need to essentially bladder irrigation. Does anyone know how bladder irrigation differs from bladder wash out? But any ideas have any of you seen when you've been on the wards, the massive massive bags of fluid. Yeah. So to do bladder irrigation, you need a three way catheter and exactly like you say, Moustapha, it's this kind of continuous fluid. So I'll show you a little picture of a three way catheter a bit later on and explain it. Um But when someone's having hematuria, if bladder washouts aren't settling it. It's really dark red. Then you might want to change the, well, if they've got a catheter in situ already, then you might want to change it to a three way. Or if they don't have a catheter, you might just want to insert a three way and begin bladder irrigation. We can talk about a little bit about three way catheters just shortly because they can seem a bit intimidating. Um For some reason, the nurses at Wigan on allowed to do three way catheter insertions, they're exactly the same as two way except in one very important way which we'll discuss when we get onto three way catheters medication review. So that's just looking at things like we've spoken about already like the anticoagulants, analgesia. If you're in pain, obviously, you want to manage their pain relief IV fluids. Now, why am I saying that you need to be careful with IV fluids and this is specific to urology? So let's say, for example, someone has an AKI of three and they've come in with high pressure, chronic retention. Why do you need to be careful with IV fluids? Anyone have any ideas catheter associated? So it's kind of to do with catheter. So you've got an A K I three. How do we, how do we categorize AKI? How do we categorize acute kidney injuries based on there cause does anyone know you're a sepsis? So kind of kind of a game. So, Yeah, we've got pre intra and post renal causes of AKI. So you're prerenal causes or obviously, things like dehydration shock, uh sepsis would come into that. You've got your intrarenal causes of AKI. And those are fairly multiple acute tubular necrosis, acute institution of nephritis, and all the causes of those two things, whether it's drug induced, whether it's caused by the dehydration and then you've got post renal causes of AKI. And if let's say someone's got high pressure, chronic retention, that would be a post renal cause of AKI. Now, the way that you treat a post renal cause of AKI is you remove the cause in a prerenal cause give them all the fluids they need because that's why their kidneys are unhappy because they haven't got enough fluid coming in to be able to do their job or to be able to be um uh they're just not getting the circulation to them. So that's why they've got damage in a post renal cause. As soon as you put that catheter in, you're helping to relieve the cause of that post renal AKI. So really a K I S that post renal, once you remove that blockage, they resolved by themselves, there's not necessarily that need for, you know, what can, can potentially be quite aggressive IV fluids. And actually, what you end up doing is, you know, with someone with a post renal cause of AKI, if you give them tons of fluids, they're just gonna diaries it straight off, they're gonna just have a, have a urine output that exceeds or matches the amount that you're putting in and you're going to put them into a negative fluid balance. So you need to be a bit careful in those situations. If they've got a stone or infected, obstructed kidney, you can think about stents or nephrostomy, but it's not realistically, you're gonna be um, you as a sort of nurse F one F two, uh probably even not to call a surgical trainee. You know, you can definitely get involved with it, but it's going to, that's going to be a sort of registrar consultant led decision as is trans urethral resection of prostate. If it's, if the pathology is coming from the prostate or trans urethral resection of bladder tumor, if they've got a bit of a tumor in the bladder that's causing uh some bleeding and then nephrectomy is, you know, when you've got sort of renal tumor's or also more dominant polycystic kidney disease, that's when we can think about taking kidneys out that are causing problems. So, really the domain that sort of, at my level, at least is everything here. We've make sure that they catheterized, they're being irrigated. We've reviewed their medications, they've got good amounts of analgesia in place if they need it and they've got IV fluids, if they need it again, if you've got all that in place, then the urology reg slash consultant that you speak to is going to be pretty happy with you to have put all that in place. So catheter troubleshooting again, something that is fairly common. Um At least when I started as a F one, which seems like ages ago now, but really it was only four months. Um One of my first out of hour shifts, classically shift end ended at 11 at about half past 10. I'm asked to come and review a catheter. Excellent timing, just, just enough time to sort of go and deal with it. But realistically, this was almost definitely going to keep me in past my going home time of 11 PM. Nevertheless, Mr X Y Z X Y has a catheter in but it's not changed. It's not draining, you've been asked to come and change it. What do you do? What are your initial thoughts in this situation? You've been asked to come and change the catheter? Are you going to go and change it? What do you need to know and apologies. We have run a little bit over the our um this is the last little bit. Yeah, so yeah, great. You want to know how long it's been there? You want to know if this is a new catheter or if they have a long term catheter in place. So I really like that, that contribution, then the staff to try to do a wash indications for the catheter. Exactly. This is really important. Now, this is, this really is important. You're asked to come and see them, you're asked to come and change their catheter. If this person has had a trans urethral reception of prostate in the last few days and they're asking you to come and change the catheter. You absolutely under no circumstances should, especially if they're POSTOP, post T U R P because the chances are everything's going to be very sensitive around the prostate, realistically, it's going to be a reg who has the final say in whether this gets changed. I would, if someone is post T U R P, I would always ask the reg before changing the catheter. So, indications catheter. So we've spoken a bit about that fluid input. Yeah. So that's, that's a really good point as well. Like if, if they're in a sort of negative fluid balance. So if they haven't been taking much in, it might just be that there's nothing in the bladder. So what you can, so when you're washing out, you can, you know, think about, you know, if you're putting 50 mils in, you're getting 50 mils out, but you're not really getting that much more than, um, it might just be that there's nothing in the in the bladder to drain. You can think about looking at the Robs, you know, if they're Tacky Kartik, if they're hypertensive at that point, that's probably why they've got a pretty rubbish fluid out. So, I really, I really like the uh finding out about the indications for the catheter. That's really excellent and then also try to do a wash. So why is the catheter in? Is it safe to remove it? We've spoken a little bit about that with their potential, recent history of prostate disease and reception was the insertion difficult. Are you going to be able to do it? Was this a catheter that had to be put in, in theater? If this was in difficult insertion that had to be done in theater, if you go and take that catheter out, you're probably not going to be able to get one in. So keeping the catheter in in these kind of situations is for the best because you've got access already, you don't want to lose that because if someone goes into retention, that can be, that can be pretty bad news. And then again, is this a long term catheter? So these are all just like good questions to think about before you start thinking about changing the catheter. So just like my staff said, first step is usually wash out, you've got a catheter in, it might be blocked, doing a wash out, might just relieve that blockage if there's Frank hematuria. So really dark red with plots, then it might be appropriate to change it to a three way, like I said, and then a difficult insertion. So this is this is where it gets a bit sort of what's a difficult insertion. So if it was done in theater, obviously don't think about doing it. But if they've got history of benign prostatic hypertrophy, um then you might need to think about using different catheters. So we'll talk a little bit about Cody tip catheters and in terms of size, if you're having difficulty inserting a green catheter, so that's kind of a sort of midrange, average sized catheter. Do you think if you're having difficulty inserting it, you should try a size up or a size down? So, would you go for a smaller catheter or would you go for a bigger catheter? Yeah, exactly further. Yeah, you go up. So bell further, spot on a larger catheter is gonna be more rigid and it's going to give you a bit more tension to just be able to help it through the prostate and into the bladder. Other little tricks or a Cudi tip, which again, I'll show you if you haven't come across it before in a second. And there are also some, some techniques that you can use with normal catheters do not, do not under any circumstances. Try to twist a Cudi tip catheter. You'll see why when you see it. But with a normal two way silicon or latex catheter, sometimes just applying a bit of a bit of a rotational force, just helps it to uh navigate the prostate a bit easier. So the last, the first thing should not just go down and remove it. Always look at the indications, see if you can wash it out. If there's hematuria, change it to a three way. And then we can think a little bit about difficult insertions there. So this is just a quick sort of guide to catheters. Never come across one of these ones on the right and practice. These are the two that I've only ever come across need to ask someone about this. Um So this is a two way catheter too way because you've got things can come in, things can go out down that same channel. So if someone's got one of those in place, it's blocked, you can stick your catheter tip, syringe on to the end of here, inject a bit of sterile water and then aspirated back out. And of course, this is the, the port for the balloon that sits in the bladder. A three way is a bit different. So you've got one port here much acts in exactly the same way as this one. We've also got this port here. So this is where you can attach the irrigation. So what you do is you have a big two liter bag of fluid that's continuously running up this channel through one of these into the bladder. And then the bladder drains back out through this one in terms of inflating the balloon. Does anyone know how a three way catheter differs from a two way catheter? Any ideas? So, fluids thinking along the right track. So in a two way catheter, you inject about 10 mils of water into this port to allow the balloon to fill in a three way catheter. It's not quite 50 mil, Mustafa. Uh it's between uh sort of 20 to 30 mil. So you just have to inject a bit more. And of course, with catheter insertion documents, just always, always, always, always, always document the indication and how much fluid you put in that balloon that's going to sit in the bladder because 20 to 30 mils, that's not a very definite figure is it if you put 20 mills in. Now, let's say you've put 30 mils in, someone comes along to remove that catheter and they think, oh, it's a three way, I'll take 20 out. There's still going to be 10 mils of fluid in that balloon. And so that removing that catheter is either not going to be possible or it's gonna be incredibly painful for the patient. So really may be careful to make sure how much fluid you have injected into that port when you're documenting your catheter insertions. So this is a Kooky tip, we'll run through it quickly. Appreciate that. We've run a little bit over. So thank you very much for bearing with me, but I just wanted to run through a couple more things. So this is a Kooky tip catheter. So it's slightly curved in one direction at the end and that is a rigid sort of non malleable curve. So these, uh, remember earlier when I said about that twisting motion that you can apply to normal cafta's just to help it. Why do you think you don't want to twist this when you're inserting it? The answer is as simple as you think it is if that's a rigid curve. So it's designed to go down the urethra and then if someone's got an enlarged prostate, it just helps to um two to sort of scooch it around that, that bend in the prostatic urethra to get to the bladder. If you twist that, yeah, it's gonna cause some residual trauma, rotation, that's gonna be pretty painful. So generally speaking, if I'm inserting a cutie tip catheter or try and have someone else there, just to make sure that the orientation of the catheter is as it was when it went in because it's really important to keep those in the same plane. So this for people who haven't come across it before, this is a catheter tip syringe. So that and it's going to be a bit different. So a normal syringe will have a sort of screw top attachment here for, for needles. But this is specifically designed to insert into this port here. Does anyone know what this is one of the most useful bits of equipment in urology? So this is a spigot for rectal examination. Not quite. No, this is a spigot. So this is a bit of plastic that kind of acts as a cork. Uh So let's say someone's got lots and lots of clots and hematuria and they're three way catheter isn't draining. You're going to get your catheter tip syringe and you're gonna, you know, start trying to irrigate and aspirated through that middle channel. However, you've got this other port here and you have disconnected the irrigation bag and what this is, is essentially an open port. So if you're, if you're um washing out with the syringe with the uh with the water going into this middle channel, what's going to happen is that's just gonna come straight back down this other channel and start spraying everywhere wildly, which is not ideal. It has happened to me. I would not recommend it. Always remember a spigot when you're going to go and wash out a bladder with a three way in because you just want to make sure that whatever you're injecting in here and washing out in the bladder isn't just gonna come spraying directly back at you out of the third port. And that is that thank you very much for bearing with me. Um Catheters can be a little bit sort of, it can be a bit intimidating when you first come across them, but there, there's there as simple as you think they are. Um I hope that this session is giving you sort of a good idea of approaches to hematuria with ideas for potential investigations and management. Um, I will put a bit of feedback into the, uh, where is it? I'll put some feet of linked to the feed back into the chat in just a second. Yeah. Oh, it's there already. I think so. Yeah, if you'd like to leave some feedback, tell me what could be improved, what you enjoyed, what you, what, you know, what you'd like to see added to the session, things that you like to spend a bit more time on that would be really useful for me going forward is not just for this session, but for my sessions generally. So that's anything from content to structure. Um Also, if you have any questions, I'll stick around for a bit now just to answer ready. Um I'll put it onto a more sort of pleasant slide. Gosh, they're all of it. Yeah, let's let's have, let's have a good look at some fat stranding. Um So could you repeat what you need to be careful with IVF? So yeah, we can go back over that quickly. Uh Definitely, where are we? Uh So just for uh toler. Um so IV fluids, so be careful. So like I said, you have, so let's say someone's got an AKI and they're in high pressure, chronic retention. This is a post renal cause of an acute kidney injury. So the cause for the acute kidney injury is coming from after the kidney and you have that high pressure system in the bladder, which is causing a backlog of fluid to the kidneys. And that's just causing them to become damaged and dysregulated. Once you've relieve that obstruction, and the bladder is emptying and the kidneys are able to drain through the ureters through the bladder and out of the body again. Once you relieve that obstruction, uh, the AKI should resolve because you've removed the offending sort of culprit for the acute kidney injury. If you give them tons of fluids, like you would in a prerenal cause of AKI. In that instance, all that fluid that you're giving them is just gonna flood through the kidney and they're actually gonna just diaries it off. So you'll end up with a negative fluid balance. So that's why you need to be careful in a post renal cause by all means give them a bit of maintenance fluid, but you don't want to treat them quite as aggressively with fluid because it's very easy. You know, you see an A K I three and you think, oh goodness, this person needs some fluid um fairly urgently. Um But it's not always a good idea in post renal causes because it's, it's not gonna have any positive effects. Basically, I hope that clarifies it a little bit. Let me know if it hasn't looking, I can go over it a little bit more. Hopefully, that's all right. So please can, I sort of say what a midterm. So, so midterm Catholic. So sort of a midrange catheter size. So I keep meaning to learn exactly how big an 18 French or A I go by color. So I I use green for go so green and this is, this is again, is local to the trust that I'm working at. Um So it might not, it might not be the same for wherever you're working. But my trust green or green can see this is the thing I should know. The size is I'm a very uh I'm not a great urology f one. I feel like the consultants. If they were watching me now, they'd be shaking their head. They'd be very disappointed, but green for go and then I think orange is the next size up, but it will say on the packaging essentially. So, whatever catheter you use wherever you are. Um I think for sort of 14, 16 French is a kind of typical catheter size 12 is a bit of a smaller catheter and then anything upwards from there. Um So your eighteens, your twenties, that's when you're getting into some fairly um yeah, fairly thick catheters. Just remember that three way catheters are inherently going to be a bit thicker. So a 22 French three way catheter has to accommodate not only the catheter port, but also the port for irrigation as well as the port for the balloon. So they're inherently going to be a bit bigger. So something like a 22 French three way catheter is going to be equivalent to a probably like a 6 to 14 to 16 to 18 to a catheter because it's all based on the tube. The outside tube, not the, not the drainage tube in the middle gets a bit complicated. Um, but I think, yeah, sort of 14 to 16. French is kind of a typical everyday catheter and there's, yeah, there's a wonderful link there to explain it from Devier. Thank you very much. Anyway, if there are no other questions, I hope you'll have a wonderful Wednesday evening. Um, and I'll see you in a couple of weeks time. I think I've got a session coming up on the 15th. Thank you very much, Angus and everyone have a great evening. Thank you. Bye.