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right. Hello of once. This is a slide again. Mind oblique. Um, I can see that there's a good number of people here of the movement, but I'm just going to give it another five minutes just to allow enough people to join. So we'll be starting at five past eight. You, Kate. Time. All right. Okay, so I think we'll go ahead and start. So I think you have room for joining us again. This is one of the urology Siris sessions undermined a bleep on day. Today's topic is going to be covering no urinary tract symptoms. So I'm gonna hand over to Anthony just now. Who's gonna be discussing the topic with you all today? Thank you very much. Thanks. Can everyone hear me? Okay. And can you see my slides? Is that a yes? Yeah, that's fine. Okay. Um hello, everyone. My name's Anthony. I'm an f y too. Doctor. In leads on, uh, thank you so much for joining us today. I just like to take a few moments to tell you about lower urinary tract symptoms. Feel free to ask any questions throughout the presentation. Just write them down in the common books and then Zack will pass them over to me. I'm happy to stop the presentation to answer any questions you might have. So let's start off with the case. A 75 year old man attends your clinic and describes a two month history off urinary frequency hesitancy nocturia poor flow on dribbling. What term would you use to describe the symptoms? And we've got prostitism high pressure, Chronic urinary retention. BP, BPH on blower urinary tract symptoms. Feel free to, uh, answer in the common box, and I'll give you a hint. This is not a trick question affect. So if you guys just pop the answers in the chart box and I'll relay this toe, Anthony Great. Okay, so again, a love eat. And that's the correct answer. Um, so lower urinary tract symptoms is they turn to describe Ah, a, um, a few types of symptoms that are related to the inability of the bladder to either store urine or avoided properly. It can occur in both men and women and in men the greater the age, the greater the incidents of them. They are most commonly in men related to benign prostatic hyperplasia, but they can occur in women as well, especially women over the age of 40 and they're usually caused by UTI. So now it is important to remember that whenever you hear the term lower year and a tract symptoms, you don't immediately think of the prostate and on, um, an enlarged prostate, causing them because they can be caused by pathology of the prostate, as well as the bladder, urethra or other pelvic organs on sometimes even neurological disease. Ah, especially conditions that are affecting the nerves that innovate the bladder. Uh, but they can be also spinal cord lesions, a mess and things like that. But we'll get into that in a moment. So whenever you are taking a history from a patient with such symptoms, it's important to distinguish between the two main types of lower urinary tract tract symptoms. Storage and voiding symptoms, and the way to think wrap your head around them is essentially stories. Symptoms are symptoms that show when the bladder can't keep the urine in, for instance, frequency. Instead of storing the urine, the bladder keeps voiding nocturia, which is avoiding at night urgency when you're unable to store urine long enough and keep having to go to the bathroom or incontinence when the bladder is just unable to store the urine voluntarily and avoids, uh, without the patient's control. When you think about voiding symptoms, that's mainly symptoms related to the inability off the patient to expel urine. Things like hesitancy. Um, intermittency. So starting and stopping of the stream straining terminal dribbling on incomplete emptying and essentially a sensation off incomplete emptying and things that can make these symptoms worse are often caffeine. Use excess alcohol, uh, or drinking plenty of fluids before going to bed so we can distinguish between the different types of causes of lower urinary tract symptoms in males and females in males. Like I've said, benign prostatic hyperplasia, Ah is by far the most common cause. They can be also caused by chronic prostatitis or a UTI on in females. It's most commonly caused by they are most commonly caused by UTI is but sometimes can be a sign of menopause or a, uh, side effect rather of menopause. But things like malignancy off the bladder or prostate weakness off the detrusor muscle, or it's instability. And that's the muscle that controls contraction of the bladder when voiding urethra strictures or external complaint compression from, Ah, a tumor in the surrounding area or ethical and, uh ah, there's mistaken in the slide should be a pelvic tumor or fecal impaction. I apologize, uh, or sometimes, like I said, neurological conditions like spinal cord lesions or ah, injury to the spinal cord or M s. These are common to both males and females. So that's one of the reasons why the old times for lots, which was prostitism, uh, has been abandoned. Just because ah, clinicians should not tend to think about the prostate immediately when they encounter these, there's a range of symptoms, a range of conditions that can cause them. And that's essentially the main, uh, the main take home message from from this Slide. So going on to our second case, we have a 63 year old man that comes in with urinary frequency and urgency, but also some pain in his lower abdomen. For the last four months, you do a urine dipstick and you find that it's positive for blood. But he has never noticed any blood in his urine, so meaning that he's never had any frank hematuria. So what's the likely diagnosis in this case. Yeah, just give it a second. Guys on a pop star answers in the box. Okay, we go on, we we got B. Thanks. Um sees. Okay, the correct answer is be this is a very classic, uh, almost MCQ style question, uh, in which bladder carcinoma in situ is ah is the correct answer. Uh, it is a type of cancer of the bladder, um, which is very small. However, it can grow very rapidly and is one of the most, if not to the most aggressive type of bladder cancer. Um, so it's important. Not like I said to think about the prostate. Always when you have these symptoms on the thing here that gives it away is the, um is the pain the super pubic pain coming from the bladder on also ah hematuria's on the dipstick, which suggests that the cancer is leaking. The carcinoma is leaking blood into the urine. Um, it's it's quite an important case that is associated with lots but isn't related to the prostate. Whenever you have a patient with such symptoms, it's important to take a good history and examine them properly when asking them about the sort of symptoms that they've been having. Ah, it's important to elicit old avoiding and stories symptoms. Um, you should know. You should ask about how long these have been going on for, uh, have they changed in the last few months or days? Um, is there a particular time of day that they are affected by the symptoms that most do they have any coping strategies? Have they tried anything? Has anything helped? Have they seen anyone in the past about it? It's important also to evaluate the effect of these symptoms on the patient's quality of life. One of the ways we can do that is to use the, uh, international prostate symptoms score, which I'll go into a little bit of detail in a moment we should screen for associative features such a see materia. The second case illustrated that quite well, ah, ask for super pubic pain or perhaps colicky pain, which could be an indication of a bladder stone or a kidney stone. Important task for past medical history. Um, and this is whether the patient uses caffeine or excessive or large amounts of alcohol on whether they've had any urological, uh, encounters in the past either in clinic. Or maybe they've had some surgeries or investigations performed. Importantly, medications such as anti cholinergics on anti histamines and bronchodilators can exacerbate these symptoms. Eso It's important to keep an eye out for these in a medication history, and then they are free. They are free main examinations that are key really in these situations. And that's in an abdominal examination allowing you to rule out a super pubic swelling, which could be enlarged and full bladder. UH, which would be dull to percuss. You should examine the external genitalia. Um, look for any abnormalities. Anything unusual on in is important, especially in men to perform a digital rectal examination, which gives you a good idea of the size of the prostate and can also hint at the pathology causing the symptoms. And we'll get into that in a little bit later. Very Anthony. I was just going to interrupt you that, and we have a question from re on on a cloud about the question that we had upped. Okay, eso they were asking, Why is is it in or cell carcinoma less likely than carcinoma in situ? That's a really good question. I believe that the transitional cell carcinoma doesn't often manifest with super pubic pain. I'm not 100% sure. Um, but, uh, carcinoma in situ is the most likely want to be related with specifically super pubic pain on, um, on hematuria. That's great. Okay, thank you. So the international prostate symptoms score is a tool that we can use to assess the impact of lower urinary tract symptoms on the quality of lives of patients. On the right hand side, you can see the scoring system. It's essentially a set of questions on. Patients are asked to give a score from 0 to 5 on, Do you count up the points and then the some of the points gives you an idea whether of whether the symptoms are mild, moderate or severe. There was a systematic review, however, that came out a couple of years ago that said that, um, this scoring system alone is not good enough to diagnose bladder outlet obstruction, so meaning that just because he scored highly doesn't mean that necessarily this is a bladder out outlet obstruction on. That's because there are all these conditions that we mentioned that could be causing them, however, is a really good tool to assess quality of life on patients and also with progression of the of the disease of of the disease causing these symptoms and management initiated, you can you can perform the score multiple times. Dysesthesia. There's any change if there's improvement or worsening or the situation hasn't changed the tour. So how to investigate a patient with such symptoms? You should do a full set of bloods, especially including a full blood count, which could hit it at a luring infection if the white cells are raised. Using these are important to rule out an A K I, for instance, and enlarge prostate could be a ah, a cause of a post renal AKI on, But it's it could be useful to perform a prostate specific antigen test importantly prior to D. R E. Because this examination can elevate these levels off the PSA, you should dip the urine, Um, just to rule out some other causes of these symptoms, Hematuria would suggest maybe there's a bladder cancer or a stone. Nitrates and Lucas sides would suggest the using these on then, if there If there's glucose, Uh, perhaps the patients got diabetes that you don't know of. And and sometimes in fact, diabetes can mimic symptoms of lower urinary tract, lower urinary tract symptoms. Um, things like Knocked iria can be a sign of diabetes. Uh, the urine should be sent for a culture on. It's important to do a post void residual volume scan, which is essentially a bladder scan after the patient's being asked, um, the past year and you could do a flow rate, which is quite a specific, um, specialist test. Uh, you wouldn't usually do on the ward. It would probably the patient have to go down to the urology, um, departments. But these two examinations a PVR V and the flow rate would can give you a good example of what's going on. Um, so, um, if the patient's having these symptoms, but they've got a low post void residual volume, so they managed to avoid the bladder entirely. Maybe they've got something like an overactive bladder, and there's nothing really wrong with the athletes. But if the post void volume is high on, the flow rates is poor. Maybe there's something obstructive, uh, in the way that's causing the urine not to avoid properly like BPH and then, depending on what you find, you might consider an ultrasound, a CT or an MRI. For instance, if you're suspecting the spinal cord lesion or M s, And then these specialists investigations, uh, you wouldn't usually encounter them. Like I say on the ward, it's something you might observe in if you're doing a rotation replacement in the urology with the urology team. So at the top in the topic to you can see an example of urodynamics studies, which is essentially a test in which a, uh uh water is pumped into the bladder to inflate it. And then multiple sensors measure its ability to stretch and then eventually avoid the urine out on. But you can learn things that I like, what the foot flow rate is, what the pressure of the detrusor muscle is on, what the storage capacity of the bladder is. Ah, a urologist might consider doing a flexible cystoscopy, which is a test in which you pass a very thin camera up the wreath row on. You can see an image from a flexible cystoscopy in the image below. So on the left hand side image, but a that is a normal prostatic urethra just on the border, looking up into into the bladder, the border between the urethra and the bladder on you can see quite a nice Lumen just around this internal urethra sphincter opening Where is on the right hand side that air that new medicine completely obscured by the enlarged prostate lobes coming into the view from laterally on both sides. Onda Um, if you're suspecting that the patient might be in chronic retention or hematuria auras got recurrent infections, you might consider some extra image in like a CT or an ultrasound. So once you've established the cause, they're different options. From management of these patients, you can opt for a conservative regimen of management first. Ah, by, uh, encouraging to regular fluid intake, perhaps reducing intake of fluids before bedtime. Um, if patients have got voiding symptoms S so these are these symptoms difficulty getting the urine out. Ah, urethra milk and technique might be might be useful, especially in patients that I've got post micturition dribble or double voiding with patients are asked. Avoid twice in quick succession. Pelvic floor exercises can be useful, and also there are other bladder training techniques like timed voiding your prompt avoiding. Uh, you might up for some medications, such as anti cholinergics. The first line medications are usually oxybutynin on told tear it in which help relax the but the truth or muscle. You have to be mindful that have quite a few side effects that just dryness and essentially, ah, a lot of these typical anti cholinergics side effects, and they are contraindicated in the few situations. So it's always good to look at the DNF before you prescribed them. An alternative is mirabegron, which is a bit of free adrenergic agonist. It's got a safer side effect profile, and it's got less contraindications. Ah, so that's another alternative. You can also use alpha blockers such as tamsulosin. You may have encountered that on the ward's. It is medication to manage symptoms, mainly by relaxing the muscles of the approximately urethra on. Then you go. So got finasteride, which is in five alpha reductase inhibitor. Essentially, it works to reduce the size of the prostate, but it takes a little bit longer Teo work. You might consider some lube Jurietti, X or Desmopressin. There is some evidence suggesting that it might reduce notorious impatiens, and essentially, it's important to, you know, identify the cause and then treat it. And that usually would be, uh, you know, it would warrant the referral to the urology team to guide this form of management. What the patient needs a cystoscopy original cystoscopy to remove the bladder tumor. Or, if the cause of spray static, does the prostate have to be removed, or maybe just decreased in size by with a T u r P, which is a transurethral resection of the prostate. If you're ever in, sure, just speak to the urology team. If left untreated, the urine can be stored excessively in the bladder. This inability to avoid and can call it to cause it to be stagnating. And that can cause UTI or bladder calculi, which can be seen in the image on the top. Uh, if the patient is not chronic obstruction, the bladder wall may become thicker on distends Onda. Also, that might lead to overflow incontinence, which is essentially in the patient patients. Bladder has filled in so much that, um, the pressure inside the bladder, uh, just causes the urine to rush out about any voluntary control of the patient. And obviously, any obstructive causes of these symptoms can lead to obstruction of the renal level on because we know Hydronephrosis has seen in the picture on the bottom or renal failure eventually from the high pressure and sometimes in progressively ph PSA quite quickly developing patients might present with acute urinary retention. And then it's important to catheterize thumb. Are there any questions? Zack, So far, I'll just have a look, and then we'll have any questions so far that they'd like to put in the box. Maybe just give a couple of minutes and type. And, well, if if anyone has any questions, feel free to type on, then you can stop me sick, I guess if anything comes up, Um, so the first case is an 82 year old man that's being explored, suffering from bed wetting for the best three months, a new examine his abdomen and find that he's got this tense, non tender mass, Uh, just above his pubic symphysis. What do you suspect is the diagnosis, right? So well, you guys type in the answers. I'll just mention a question. Actually, they just popped up. Do some test. Would you start tamsulosin and finasteride at the same time you can do, you absolutely can do. And we'll get into that closer to the end of the presentation of Got a few slides about that essentially, Ah, they work in different ways. Uh, you might if you feel that the patient might benefit from immediate relief of symptoms because their symptoms would be so bad, you might consider tamsulosin, which acts within a few days and relaxes, Um, some of the muscles in the pelvic region that contained alpha receptors on, um, you might get, you know, resolution of symptoms or improvement. Within a few days. Finasteride takes a little bit longer. It takes about six months to act on. Do you might consider it in patients, for instance, that you know you have examined you feel that they've got a bigger prostate. Their symptoms are not terrible. You so. But it would be good to eventually get this prostate to reduce in size. But there's I don't believe there's any contraindications to start them at the same time on. Do you see them commonly on the war is being prescribed at the same time. That's great. Okay, good clubs in cycle for whoever answered that question. So and with regards to the keys, we've got one person and said, Be an end of majority of bands to be for this question. Yes, that's that's correct. So it is high pressure, chronic urinary retention. This gentleman has clearly being having symptoms. Perhaps not since, uh, maybe maybe lower unit trip tract symptoms were not so bad for him, but he's definitely had some form of obstruction for quite some time. And his bladder is just constantly filled with urine on, then at night, when his muscles relax them. Unfortunately, this bedwetting occurs and often if you if you see these patients that you will be able to feel their bladder, um, very easily on examination. But it won't be tender Onda. You might place a catheter to drain the urine on. Sometimes you can drain up to two liters of urine from these bladder's. So the most common cause, like we said of lower urinary tract symptoms, is a benign prostatic hyperplasia, Uh, which is, in fact, also the most common cause off run a prostatic enlargement Onda bladder outflow, obstruction eso lots of times, but let's try to entangle some of them. So be P. H. Is a histological diagnosis. You have to take a sample of the prostate, look at it under a microscope or have the histology look at it on. It's a form of non cancerous hyperplasia off the glandular epithelia and stromal tissue off the prostate. Most important is it's non cancerous is just overgrowth of the prostate. It happens in all men. It's expected. It's estimated that 90% of men over 80 have BPH. Um, BP is, by the way, just a large prostate, regardless of the cause, on a bladder, out for obstruction is something causing the bladder toe struggle, avoiding regardless of the cause. So, uh, the pathophysiology of BPH is that testosterone is converted to dyhydrated testosterone, which is the more active version by an enzyme called five offer reductase, which is the enzyme that's being inhibited by finasteride Onda. That DTH constitutes as about 90% of androgens in the prostatic tissue and eventually stimulates the the prostatic tissue to swell with age. Risk factors include, like I said, a judge, but also family history, especially having a first degree. Let it relative that has had BP h makes you more prone to it on da men of a free in African or Caribbean ethnicity are more likely than Caucasian men. Uh uh, or Asian mento have BPH. Obesity is also a factor, and if you examine this prostate on a digital rectal examination, it will be enlarged. But it will be smooth. Uh, usually firm. It'll be symmetrical on. You can use finger wits. Teo indicate enlargement more than to suggest that eso a workable the patients. Very similar as previously. You do the d r e you, uh, you can encourage the patient to a bladder diary, essentially just them writing down every time they've passed. You're in what time it happened, Where there any problems, How much that they pass was did it? It's essentially a diary. You conduct the urine, do a post void residual volume. Uh, you can you can consider it's a good idea to to do a prostate specific antigen on, ideally before during the d. R E. Like we mentioned, and then you might consider an ultrasound on. But sometimes you might be able to see the prostate Ultrasounds on enlargement is classified as a prostate greater than 30 mills, and then you might refer patients to euro dynamic studies, which is, which are the tests that we mentioned previously in the specialist section? If the patient has no symptoms, you just watching weights, Andrea, Assess. Every now and then, you should review the medications on, uh, encouraged to do the have a diary and then you might offer lifestyle advice. Like we said, obesity is a risk factor. Um, on here Is that slight I was speaking about you might consider times a low PSA in about 30 to 40% of patients will respond Ah, by having some form of, ah, um, having the symptoms improved within a few days on. Then finasteride takes much longer, but eventually helps the prostate shrink. And then, if indicated, you might consider options off uh, removing the prostate or shrinking it's in size. For instance, the tur peak or a holiday, which is another form off ablation of the prostate. Um, just as an interesting point. Ah T U R p, which is this Ah, procedure. You can see on the right hand side. Essentially a, um a rigid. Uh, cystoscope has passed into the urethra on at the end of it. You can see. I don't know if you might be able to see if I use a laser pointer. Um, just over here you might see a tip of the, um of the urethra scope off the cystoscope, which essentially heats up very high temperature. And the urologist is able to scrape out the prostate from the inside on because the flow to be better, uh, complications of that are quite common. The UTI is patients come back after a few days with the really bad's, this area or, you know, deranged inflammatory market and sometimes even sepsis, our septic, uh, symptoms. And then just for anyone interested in surgery, um, this this sometimes comes up in questions. Something called a T u R P syndrome. It's not very common nowadays. It used to be more common in the past when hyper or smaller fluid was used for irrigation of the prostate during the procedure. And then this hyper smaller fluid would leak into the exposed, um, venous bets on cause a, um, hyponatremia and patients would essentially present after the procedure. With would develop symptoms of hyponatremia so they would become confused or nauseous that that might be agitated or have some visual symptoms. Uh, management is essentially just managing the fluid overload on careful treatments of the hyper Nutri Mia, making sure that you don't correct it too quickly. But, like I said, it's not very common nowadays because saline or other irrigation can be used, thanks to the invention and use of bipolar. Oh, on just the last few slides about prostate cancer, which is the most common cancer in males in the UK Ah, accounting about 26% on diet is estimated that 80% of men with it will survive over 10 years from from diagnosis ah ah, similar to BPH. It can be stimulated by the dihydrotestosterone. Uh, 95% of all cancers of all prostate cancers are a dental carcinomas on 75% of those arise in the peripheral zone on then, some of them in transitional and central zone is important to remember that it's the peripheral zone, and I'll show in the next slide. Why, uh, the purple's are being the most common region for these over that occurrence. The two main types are acid er, doctor, a dental carcinomas acid or coming from the glandular sales there are more common on doctor coming from the ducts. They grow faster and missed metastasize more commonly, uh, similar risk factors to DPH age, of course, ethnicity. African and Africa Ribi in men essentially are almost twice a likely to get prostate cancer than Caucasians on family history plays a part, especially the BRAC, a one and bracket two genes. Ah, obesity, diabetes, smoking and exercise. Common side effects. Common risk factors for multiple Uh uh range of other cancers as well On then, this picture on the right hand side just illustrates the point from the previous slide. We've got a sagittal cross section here of the pelvic organs, so the left sides of the picture is interior. The right side is posterior, and then the bladder seats. It's superior Lee over the prostate, and the urethra in this image is in fairly on. You can see this green zone being the peripheral zone, which is located towards the kind of posteroinferior inferior side of the prostate on. That's important because if you perform a digital rectal examination, you might be able to palpate some of the cancers. Allegedly. Tumors greater than North 0.2 mils can be palpable on, but, um, you might feel a irregularity in the prostate. Any sort of hard A symmetry, um should raise your suspicions as to the cause. It might be that the cause might be prostate cancer. Uh, sometimes you might hear a description off a, um, prostate would probably with cancer as craggy. Um, on. Actually, they are very, very often hard to feel, um feels on they're extremely hard. And if he if you compare it with of BPH of the differences is massive on this examination, and then in terms of ps A, it's a useful, uh, useful investigation for monitoring off prostate cancer. Ah, Grace. BSA could indicate that there is a wonder lying prostatic cancer somewhere. Ah, in there. But it's not very specific. As someone has had a recent d r E or does lots of exercise such as, for instance, bike riding has got maybe prostatitis uh uh Or has it Jack you lated? Recently, the PS PSA might be elevated on. It's important. It's very. It's a useful investigations to monitor as well the progress of the cancer patients who have had received treatment for it might come back for PT PS. PSA is at a later date to see if there's been any change on, then if a patient suspected toe have cancer, a biopsy would be taken, the most common one being a transparent. He'll biopsy being a series of biopsies taking from, ah, the majority of the prostate in a very, uh, unified and systematic manner. Onda um that is done under a general anesthetic. But it's quite safe in terms of a risks of infection after the procedure on DA, it is now more common than a transrectal ultrasound guided biopsy ah, which used to be the gold standard. In the past, it was performed a local anesthetic with the help of an ultrasound probe, which was placed inside the rectum. However, because obviously you're taking samples with multiple needles that passed through the rectum into the prostate, there was quite a risk high risk of infection on sepsis, and these biopsies will allow the urology. The history histology is to have a look at the tissues under their microscope on give the tissues a Gleason score, which is very important in stratification of patients and prediction of outcome. Essentially, on the right hand side of the top, you can see the various ways in grades in which the's prostatic cells can be differentiated, the more differentiated, the higher the great and the histology still have a look at the slide. L will find the most commonly represented grades on the second most common represented grade and give a score. So a patient that's called most common, most commonly great free cells and then some great for will have a score of free plus four, which equates to seven. But a patient that might have only great five cells might have a five plus five score, which is, incidentally, the highest score. Um, on that the prognosis then is poorer, and you can use the P the Gleason score in conjunction with levels of the PAS A on the ah the tumor node metastases, um, method off assessment of cancers to evaluate prognosis on risk of recurrence on the table. On the right hand side, the bottom kind of gives an idea of what the level of risk is given the outcomes of the other investigations. So if somebody has a low risk, because there s a is low and, uh, the Gleason score is free plus plus free, for instance, uh, you might just offer active surveillance. The patient would come in for a blood test every three months to measure their P S A. And then every six months a year. That might have a examination of the prostate. Um, and a biopsy might be offered every 1 to 3 years. If on these investigations the's monitoring investigations, there is some evidence of progression of the cancer treat. Radical treatment might be offered on down. That's radical treatment is mawr. It must be discussed in patients that have had intermediate or high risk disease diagnosed. The most common treatment being a radical prostatectomy, which is removal of the prostate, the seminal vesicles, the surrounding tissues around the prostate. And sometimes you might also consider removal of the lymph nodes around the area. On that can be done a PSA robotic case or as a laparoscopic case very rarely. As an open case. Read your therapy and brachytherapy also plays a role. Brachytherapy is essentially specialist method in which these tiny beads that I believe are radioactive are inserted inside the prostate, and then they just, um, it. I believe radiation around the area toe uh, to to eradicate the disease patients metastatic disease would be offering chemotherapy on top of the radical prostatectomy treatment. Uh, or sometimes they might have anti hormonal agents. And the patients that have had's the full set of radical treatments. But there is evidence that their disease come back, come back. The specialist medications such as Docetaxel and Capas it Taxol or even cortical steroids might be offered. So that's it? That's my last line. Um, thank you for attending and joining in a recession. Does anybody have any questions? Thank you very much, Antony, I'm just having a quick look through the box here. I think there was one question that I didn't pass on TV just until the end of the session. So it was actually about the question that we asked last if you could maybe go back. Um, yeah. Oh, sorry. And in the meantime of anyone else does have any questions, please. Problem in the box. And old are really those two. Once we're done with this one. Yeah. So this is the question and dean of color is just asked, How do we differentiate between B and E? Okay. Okay. Excellent question. Dean, Uh, you would not be able to, um, diagnose a different diverticulums very easily. Ah, other than through a flexible cystoscopy, I believe some bladder different diverticular. Essentially, these small out pouchings of the bladder, um, caused by hyper pressure inside the bladder on, um, they wouldn't cause these symptoms. But these that particular very rarely, I believe, are so huge to, um to cause a super pubic mass. Uh, I believe that most of these are found, incidentally, on a flexible cystoscopy, which is just a very small camera synkaryon pass into the bladder, um, to have a look, and then you might have a look inside the bladder. You might see a small diverticular, um, or a couple on the other side. Um, but treatment is just Ah, you don't treat them usually unless there any complications. Um, you don't really do anything about them. So it's in this question. It's a little bit of a red herring. You don't Oh, you wouldn't really see unless it's, um, very specialized urology that I is a way above my head. Um, you wouldn't really see a patient. And I don't know the wars there any that, uh, you examine. You might think Oh, this is a classic bladder. Different diverticula were eight. Is that right? Is that an okay? Answer? Yeah. So it says thank you. That sounds good. Thank you very much. I don't think they're any other questions just now, so I think we'll probably just move on to the last slide. Perfect. So thank you very much. Again, everyone think you, Anthony, for the great presentation. Obviously, we really appreciate everyone's feedback or we've gotten so far in the series and we're hoping that you guys can continue to do so. So please feel free to go ahead and use the QR code provided in this slide on down will take you to the feedback form, which you can fill out, and I'll give you a certificate as well for your portfolios. If you do happen to remember any other questions leader on feel free to email, Theodore s provided for urology, and we'll be happy to get a response sent across to you guys. Assume is possible. And, um, I am going to copy the link for the feedback form into the chat box as well. Just in case the QR code isn't working for you guys for some reason. So thank you again on day. Be sure to join us next time I next session is gonna be the one before the last of the series, and it's gonna be on urinary incontinent, so hopefully should be quite interesting. So you think you ever want to have a good night? And happy New Year is well hurried. Thank you.