Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay, perfect. That's great. Thank you very much guys. Okay, we will start just now then. So this is the second session in the mind the Bleep Surgical Series uh session. Um It's common urology in Fy one. So here's just a bit about the other members kind of organizes mind the bleep and you should have a read but what they do and what they get up to and visit the website, which um three guys already do. Um And yeah, just some other things about F One membership and Wesley an and the M D U. So yet as I said, I am Cameron Green ho I good school screen. I am I graduate from University of Aberdeen. I graduated um two summers ago. So I'm now in Fy two in the second block of Fy two. I integrated Physiology from 2018 to 2019. I currently work in N H S Lanarkshire, which is just outside of Glasgow, finished the GP job lock last and I'm on a medical job, I'm currently on infectious diseases and then my final job is general surgery um of F two. And then I'm hoping to the application process, apply for um I have applied for court surgical training in 2023. Uh Sorry, I have applied for a C D F. I'm going to then apply for a court surgical training following that. Hopefully. And I enjoy playing hockey, running and meet up with friends. So like to have a bit less as well. Outside of mention, she's gonna do one more double Chinese in case I missed something onto the page. Oh gosh, so yes. Um just checking. Ok, perfect. Just let me know if um throughout just turn your mic but if there's any kind of issues um with uh so fine. Um okay. So, so the structure of today's webinar is we will look at basic urology history taking and what you include and what's useful when you're doing this and what's useful for kind of final you're off ski type scenarios and then also looking at common urology presentations and particularly ones that you'll deal with as an F Y one. Obviously, you have people to escalate too, but the kind of initial management of what you should do what you would do um and any kind of initial management plan you would make and things like that in this uh situation. So uh one of the speakers wasn't able to turn up tonight. I'm gonna do this myself. So I think at the end we can same questions at the end and I'll have please stay around and ask answer some questions then and we can just go through just now. So again, if you, if you manage to tune into the first session on surge question, taking like basically any other history you use the the acronym Socrates. So you want to know site flick urology kind of is it super pubic is abdominal? Is it loin pain? So is it underneath the kidney kind of areas onset? Did it come on today? Has it been coming on? Has it been lasted for a week? You had it for a number of months. When did this start character? How would you describe it? Is it a kind of sharp pain? Is it a dull achy pain? Um, you want to know what it feels like and does it radiate anywhere? Does it start in the kind of kidney area up in the loin? And does it radiate down towards your groin or is it no radiation just in one specific area? It just stays there and associated symptoms. You've been having some weight loss recently or you're having some fevers, some Riggers, you've gone off, gone off your food. You want to know you've got kind of constipation at the same time. You want to know what else is going on, timing as well. So it doesn't come on at specific points today. Does it come on when you're, when you're peeing or does it, is there a certain thing that triggers it and exacerbate the leaving factor as well? So, exacerbates anything make it particularly worse. Is positional movement make it worse. Does eating, there's drinking, make it worse and does any make it better? What you're doing to make yourself feel a little bit better in terms of the pain you're having or the, the issue you're having. Have you noticed anything you do might actually improve what's going on the severity for this? I like to just say one between 1 to 10, 1 being fine. 10 being awful. How would you rate the pain you're having or the problem you're having? So kind of starting with quite a common thing you see is hematuria. So it's the presence of blood in your urine and it's one of the most common presenting complaints in urology can be a sign of many different things. So it's can categorize into visible. So, macroscopic, you can see it with the, with the naked eye or non visible microscopic, see under microscope, hematuria and obviously nonvisible can be picked up on a, on a dipstick or a med stream specimen urine sample. Um And some, some you're all just especially I work my stead a bit of your old. You work last year when you phone one of the reg is or anyone they like to know what color is this hematuria and it's, I suppose it's not correct, but sometimes they might ask you, does it look like rose? A wine does look like Meryl kind of slightly darker wine or is it right? Peanut. Is it really, really dark? And uh, this is probably not the best way to do it. But if something is looking kind of like severe for like, for example, the darker hematuria, the right, you know, then it probably would warrant an admission for an inpatient and for, for management as an inpatient. And a lot of times when, when A G P makes a urology referral or when they're kind of referred from, from A and E. Um it's important to know the kind of two week wait referral if your age 45 over and your GP would, would refer you for kind of urgently if they've had unexplained visible hematuria without a uti or visible hematuria, that process that occurs even after successful treatment of a uti. So you might have had antibiotics and, and it's still not gone away or if your age 16 over and have unexplained nonvisible hematuria's, you can't see it and either dysuria, so pain when you're peeing or a raised white cell count on a blood test. So that's also a way. Um Okay. So that's what we know about hematuria. So next. Mhm uh Sorry, something's just got on with my power point. It's going to open up again. I apologize. Um So perfect. Uh And I apologize but this guy's um so make sure I'm sharing my screen, God. So I'm sharing my screen. Um Here we go, share. So go on here. So Yeah, so we'll start from here again, apologize about that guys. Um And so there we go. So common cause of hematuria. Um So when you're, when you're the examiner and ask, you might ask you where, where is this like, what do you think that, where, what might be the cause of this hematuria? And it's kind of nice to break it down into different anatomical areas and thinking what might be the cause of it. So, in the kidneys, you might be thinking kind of pelvi calcio area. So the renal pelvis, you might thinking cancerous or transitional carcinoma or a stone might be their pre reno, you might think they do they have a clotting disorder or rhabdomyolysis or reno you might have Gomory, nephritis, acute tribulus necrosis or a cancer or a trauma ureters. Again, you may be thinking again, is it a stone causing a blockage or is it uh some like transitional cell carcinoma, cancer? Bladder again, cancer stones. Is it information in the bladder, cystitis or radiation cystitis, post chemo or a post radiotherapy? Sorry, or is it a uti prostate? Thinking, is it malignant or is it um benign prostatic hyperplasia or is it information of the prostate prostatitis? Then you re thrax coming further down. Is it again a cancer? Is it trauma? Good thing thing when you have hematuria's, it could also be a vaginal cause of it. So you need to be ruling out vaginal bleeding as the cause of this. And then pseudo hematuria is another thing to think about which is actually isn't hematuria at all. Could be eating beetroot or you might be on treatment such as reef ampicillin. So it's important to be aware of those things. So, any kind of common urology history and especially with regards to hematuria, you want to know the present to complain and the history don't complain. When did it start? As the, as the changing, has the hematuria change in color over time? It's gotten darker. Have you ever peed out clots is important thing to know. Is it mixed with the urine or is it separate entity? Does it look like it's mixed in or is it completely separate? And when you're peeing at the time of onset of micturition, is it continuous? Does it, is it always there when you're peeing or is it just at the start? Just the end of it? You wanna know? Is there pain involved? Is it stinky or is it sore to p and is there associated abdominal pain or up in your kidneys? Flank pain? You had any symptoms of anemia. Have you been short short of breath recently? Um Are you feeling tired? Which should show that you're having quite a significant blood loss, the weight loss kind of night sweats? Other red flags. And I don't know about the past medical histories. They ever had some of this before they on meds? Are they on any anticoagulants? Are they on warfarin or they on prostate medications? Are they on tamsulosin? Are they on Rifamycin or they're on chemo? And you want to know about their family and social history as well? So, what their occupation is, have you ever worked with chemicals? You might be thinking potentially down the line of a bladder cancer or they smoke again, increasing the rest of bladder cancer. They recently traveled and again, you just want to know a lot about what's going on. And then when you're wanting to know how to manage visible, so somebody got significant amount of hematuria. So they've got Catherine bagging already or you just from their history, they told you they have lost a lot of blood from hematuria. You want to kind of as an F one, you probably should be thinking about these different things. You want to do an 80 assessment. So assessing the acutely unwell patient, um so early breathing circulation disability, everything else. So I'm sure you'll all be quite um you'll know this quite well before you finish medical school, but kind of working to an eighth is what you're doing most kind of emergency situations. So you want to know you need to apply oxygen. Are there sats coming down, do they have access if they're going to need some couple units of blood, if their hemoglobin is dropping. Um So making sure they've got IV access. You want to take their buds, you want to know fill vodka and you want the hemoglobin is they're dropping, their kidney function is creatinine really higher. Is there? They've got quite bad kidney damage. They're clocking okay. And maybe in this situation you want to do a group and same just in case they do need blood again, monitoring your BP. You want to know you're gonna have to put fluid resuscitation in is the BP dropping. They might need some fluids. And then particularly where I was last year, a three way catheter can be quite important in uh in someone with the kind of hematuria and a lot of it. And then if you've got a catheter in, you want to get a urine sample or if they can a midstream can take a full history, examine the patient, admit the patient. And obviously you're an F Y one. You want to inform seniors, you don't want to let this lie. You want to let other people know about it. You can't manage this yourself. You want to just alert people that something is going on and you want to make them um aware of it and something sometimes in some with hematuria, you probably do as an F 01, but sometimes you need to start continuous irrigation the bladder with the three week after and bladder washouts in the wards. And in case of hematuria, the sooner this is done the better. So putting in a three way Catherine irrigating it can potentially prevent clot formation in the bladder and reduce the risk of needing an emergency bladder wash out in theater. And then at that stage, you want to know what's going on. So further investigatory work, you want to know image, you want to have imaging of the uh poor upper reno tracks. And then so and they also might deflect school cystoscopy as well. Um So the two most kind of common imaging modalities um here are ultrasound scan, the kidneys, your term bladder or a CT scan. With contrast. Obviously, there's advantages advantage, ultrasound, it's fast obtain and you can do it no matter what the patient's renal function is. However, it's kind of user dependent and it's possible to miss small things like tumors or stones. And then CT scan did a greater sensitivity and specificity, but they do involve radiation um annual contrast, which can worsen someone renal function if they've already got poor renal function can also lead to anaphylaxis. So, before they run a CT scan, I always, I think you should always inform, inform a senior and and in the case of a CT and you might ask for a CT urogram um as well to see what's going on and the contrast and this highlights the kidneys, your term bladder. Um So it's important to kind of think about the initial management, but then also thinking about how you can, what you'd be doing after this. And I think in an off ski situation. Uh Some of the questions I've had in the past or what can a further investigate your work would be after you've seen this patient or what would the next initial stage? So something insane having kind of the common scans involved in your heads, an ultrasound scan or a CT scan with contrast is always very important. And also just being aware that having a patient, usually with this kind of ct scan of contract should have a decent renal function prior to this. It's always ensuring you're checking the use of these before this. Um So next thing which is quite common, you see a lot as an F one done as an F two. Really even in medical jobs as well is acute urinary retention. So um what it is, it's an acute kind of stop of the urinary flow resulting in a painful distended bladder. And this will often present with kind of not been able to piece and your ear and also super pubic pain, which needs to be and it can also be palpable is when your pain pressing down in the abdominal exam, you can, can cause a lot of pain when you're pressing down there. And then you need to kind of think it's that acute or chronic, acute will be usually quite painful where chronic is pain, less chronic retention will also be very large volumes and chronic also be quite slow onset, often with a long history of lower urinary tract symptoms. Um So, yeah, it's pretty important to be aware of that and the sinus symptoms. So, if someone would think you, you're in your attention would be that they have difficulty passing your, they're not able to do it. They've got some abdominal pain when you're pressing down or some super pubic pain as well important to always make sure you're pressing down superpubic li they might be restless, they might have had some kind of proceeding lower, you know, track symptoms that you, that they had. So maybe some frequency prior to this or maybe some hesitancy. Um and they may have suffered with painful peeing fishery or hematuria or, or, or kind of constipation even prior to this. So a lot of times if someone is constipated, it can lead to acute urinary retention, being aware of that as well as a potential cause. And then so examination wise, you want to do an abdominal exam and making sure, sorry, the tender should be publicly. Have you got palatable bladder? Is it that full? You can actually feel the bladder and, and here in a, in a male patient, you'd want to know if they got enlarged prostate on, on digital rectal exam. And, and, and if someone I think your intentions important and it's actually very important to always check neurological abnormalities, they got weakness in their legs have they have they got kind of other sensation changes. And in that sense, you want to rule out called a quite a syndrome as well. So you wanna make sure they got any kind of um, saddle, um, kind of loss of sensation and things like that. So, a pr exam is quite important in this situation along with a neuro exam. So, and someone with an acute your attention in your history, you want to know the how it presented history, presenting complaint sent to complain how long duration, acute or kind of slow onset painful, describe how it is. Tell me what it feels like any urinary symptoms prior to this hematuria. And you want to know if they've got anything else going on in the morning, they got an infection brewing or the infection markers. Like, are they constipated any recent surgery on the abdominal wall? So you want to just make sure you're doing this and then uh and a history taking that the examiner might say to you, what examination would you do in this situation? I think in this, you probably wanna do a abdominal, an external genitalia and a digital right to exam and then made kind of thing. And acute retention. I'd want to rule out would be called that quite a syndrome. So it's always something to be wary of and someone with acute urinary retention. Yes, I've just kind of flagged that out here. Um So it's important to be aware of all of these things. Um So then the causes of acute urinary retention So you wanna urological causes? So they got in a, in a male and older male, potentially a benign prostatic enlargement. Have they got a block catheter? That's because is that need to be flushed? Did they have a trial without catheter? Have they been getting better? And the consultant surgery, trial without catheter, get, get the nurses take it out and it's just not work that's failed, failed. What have you got some clot retention? Is there some clots in the bladder? They got a potential tumor and then, then their prostate and the bladder and the urethra, they got a stricture in the urethra. You want to look at g eye cause as well. They constipated, they got an infection going on and they got malignancy and they got inflammatory bowel disease. You see, or crones you had previous abdominal wall surgery and then yes, systemics infection is the other pain going on medications as well. Are there on any anti cholinergic drugs? And then neurological as well? You want to look at cardiac weena. Has there been a spinal cord injury that you're not, you're not aware of that, a fall or something like that. Again, Barry, probably when I've never really seen myself, but it could be a cause if they got M S, all these things are important to be aware of add, managing your attention initially. So again, as I said, so you do, you do 80 approach, you want to get IV access want to get bloods, including a full blood count, renal function, the fluids to resuscitate them. This one a catheter to way is probably appropriate. You know, hematuria. If there is a history of hematuria, then you maybe consider a three way. And then if there's a Catherine, you want to get the residual volume that drains from the catheter initially and send the catheter urine sample. Take history examined again as, as it always is inform your senior, this isn't normal to see someone's unwell. You want to inform the senior and again for diuresis, if they're draining a lot of fluids and you want to replace the fluid loss is if they're needed and and you want to monitor their electrolytes and using these are very important this situation and you want to know if there's been any hematuria is their hemoglobin stable as well. So the next we're gonna move on to is testicular torsion again. So you want to see in this situation. Um So test like your storage and what is it? Firstly, it's uh when the spermatic cord twists, cut off the blood supply to the testicle, which can result in a scheme, it necrosis and possibly the loss of the testicle. Um So you want to kind of just be aware that this is quite, this is serious. And if a kind of young male or a male of any age really presents with painful pain in the testicle region, you want to really rule out torsion differentials. You might think about epididymo-orchitis, this um in this situation to an infection of the epididymis. Um But yeah, tourism is something you want to be very, very aware of. And this picture also kind of shows you what's going on in the right hand side. So sounding symptom Torgyan, so sudden onset is that you're paying it came on all of a sudden painful, painful testicle and it might relate their back or their or their kidney area. Most commonly, it's between males and kind of the ages of 10 to 30 and that kind of correct kind of any age including in pre pubertal Children. So, you're on pediatrics, a job there, you might be thinking about this can be associated with local trauma. They've been kicked in the area in the testicle region or have they been hit with a ball or something like that. Um uh in some cases, they might have had a self resolving episode of groin pain, maybe not, probably not as severe, but sometime before this, maybe a couple weeks before this, this started and they might just be nauseous and having vomiting and on exam, you might have, they might have an extremely tender testicle, too high riding, it rides up in the abdomen and it's fixed and it might be swollen if it's quite severe, might be discolored. Um which maybe would say that it's a scheme ick. Um And you just wanna look into that a bit more thoroughly. Um, so in the history again, because it's really history taking when it comes down to it. So, when did it happen? So when, what time did it come on at that happened suddenly, or has it gotten worse over time? And does the pain radiate anywhere? Where is it going to go into a full pain history? Socrates, as we've done their previous trauma to the area, have they just come from a, from a rugby match have been hit with a hockey ball, any similar episodes? Well, then in this situation, you probably would be thinking as a, as a differential is in ST I. So then the recent unprotected sex, you like to get sexual health history. Have you had any penile discharge? And is it painful in there peeing of any fevers recently or UTIs even? Are they, are they prone to UTI S um or any recent catheterization of the, of the urinary tract? So you want to just be aware of all these different things when you're thinking about towards and, and again, as we kind of look at as this talk is aimed at fy one and kind of management in these situations when you first start, if you have got urology job, as always, 80 assessment is great for the notes to do initially when you first um see the patient and, and document it. So are their stats decreasing? They need oxygen, do they need IV access, putting catheters so I can um get some blood, get some bloods, full blood count. What's the hemoglobin looking like? Um what's the renal function like they got high creating in our, their electrolytes off? You want another CRP? Is there an infection going on and their clotting factors as well? Give them fluids if needed, take a full history exam. Um You want to do a urine dip. So if there is kind of a sign of infection in urine dip, um then you might be maybe thinking maybe it's not torching, maybe it is kind of a version on the lines of epididymo-orchitis. This um as the kind of cause of this acute testicular pain. Um Again, as I've always said, as an F Y one, if you're doing all these things, you're looking great before you phone the senior or even give the senior call and then do all these things. But inform your senior a chap, this patient probably would be needed if it is too urgent to be taking the surgery. And so they need to be kept nil by mouth and making the theater and aesthetic teams aware of this. Sometimes you after you do an ultrasound of this test is in this situation. And no, it's only done if it's requested by the urologist, it cannot rule out definitively if it's testicular torsion and then it's probably wasting time when the patient needs to go to theater for exploration. Um And then any theater. If you're interested in this, they usually perform an exploration of the scrotum. So they untwist the testicle, they wrap it um and saline solution to see if it reaper reaper fuses. If it doesn't, then they do an orchidectomy, which is basically removal of the testicle as it's non viable. If it re perfuse is then they do an orchiopexy. So they fix the state, the test is back in the scrotum and bilaterally. Okay. So, moving on to the next part, which we're going to look at the obstructed infected kidney. And so an obstructive kidney. And in fact, the kidney can result in kind of rapid development of urosepsis was septic shock. It's very important to be aware of all this, very serious and it can result in the loss of kidney function and it can be painful, patient's so it should be picked up early. Um The most common cause of an obstructed. In fact, the kidney is a stone that's come out of the kidneys start to travel down the ureter towards the bladder and and it can kind of commonly get stuck at three locations. So the pelvi you're a Terek junction at the top of the ureter. Um as the your or then at the where the ureter across is the iliac vessels or the physical, you're a Terek junction at the very bottom of the ureter. Um So an obstructive kidney will result in your urinary stasis, which can also lead to infections brewing. Um and it can lead to increasing the intrarenal pressures which it can result only cause renal damage. And so therefore, in this kind of situation, you want to find a way of draining the kidney quickly if it is infected and obstructed. Um So things to ask in the history of something like this is so again, presenting complaint, history, gentle complain, systematic pain history, Socrates, when did the symptoms start the onset any previous episodes of this before any known stones that you're aware of that's been picked up in the past and any other urological issues you've had and you have that you have a lot of UTIs. Do you, do you often get go to your G P from any uti infections? Any red flags, any weight loss, um family history, social history, as always are they do they, do they have a good fluid intake? Stones can often because people who drink less than I think it's 1.2 liters a day. So you want to be aware of this. Is this an older person doesn't really drink very much? And then obviously you want to follow up with a third abdominal examination and any kind of relevant examination they think might be necessary. Um And then so the side of the symptoms and infected obstructive kidney. So have they got a fever, they got rigors, they're shaking, they got line two groin pain. So pain that starts in the kidney area there. Loin radiates down their side, into their groin or even into their back or again, if they have abdominal pain and have they had any recent hematuria there? Obs you want to get, if you could get the nurses to help you, have they got tachycardic to look at their news chart and the Avenues in Scotland. I'm not sure about England, but it's the National area warning score. So, are they tachycardic? Do they, um are they breathing heavily? They tap you up to Chiappe Nick? And, and then you want to know is, are they septic at this point? If, if there's instruction, have they got other symptoms of sepsis or the hypertensive is a BP dropping. They got new af that's, that's not really, they've never had before. They're not known to have a f what's a urine output. Um If there's a catheter bag there or even just generally, if they told you they're not peed in a couple of days, you want to know what's going on there. And then, so the initial management of uh infected obstructive kidney. Um So as I said, always kind of 80 approach. When, when you say, for example, the nurse calls you, this patient's not doing great. You want an 80 S S mint and in this situation, you think there's an obstruction, you want to do the steps to six just to rule out and kind of treat that as well. So are there, satch dropping again. Oxygen. Have they got IV access? They need some fluids. Make sure there's car dealers in. Get some bloods. This situation. If you think it's an obstruction, you maybe think let's get some cultures. And if there's an infection going on, get a lactate, what's their organ perfusion looking like? Full blood count, renal function? CRP. And then you want to get a urine and calcium level as well for potential stones. Um urine dipstick as always think urology, urine urine dipstick, send a sample for culture and sensitivity is very easy thing to do. If it's a woman with this kind of abdominal pain of child bearing age, you want to think, let's get a pregnancy test. It's always rule out pregnancy. Something I got asked in one of my final loss kid was in with abdominal pain. What's the most important test? Initially, pregnancy test? And then in this situation, you wanna says that urine output and the fluid status, how much they drink and how much they're paying out and start antibiotics according to kind of any sensitivities they've got back not available, then just follow your local guidelines, whatever trust you're working in when you start and admit the patient inform your senior as always is always thing to do. Anyone above you just let them know what's going on. They'll probably give you some advice. You probably if you're doing what this is gonna saying, you're probably doing all the right things, but just to make sure that you're aware of what's going on and letting the senior know. And then again, in this situation, want to keep the patient now by mouth, unless you're told otherwise and you want to get some imaging as well. So unless it's contraindicated, you'd like to get a C T K U B initially. Um So a CT kidney ureters bladder and it's an ideal kind of imaging mode to look for an obstructing stone that might be causing this infected obstructed kidney. And then kind of for the two kind of temporary treatment options for draining and infected obstructed kidney. And it would be kind of an insurgent of a stent. A Euro tear extent, usually performed the theater and involved in the placement of a tube into the ureter which blended the kidney and the bladder and holds it in place. And then the urine is basically able to drain through this and around the stent into the bladder. And then the secondary temporary procedure would be an insertion of a nephrostomy kind of similar to this end. But the tube is passed through the skin on the patient's back or flank, which is then directly into the kidney to drain urine from the kidney into a bag which is then stuck to the patient's skin. You often see this on wards with even on medical word, you see patient's like this. Um and then you want to treat the court's underlying issue as well. So then moving on to something called Sarafem Asus. And so what is it? So part pharmacists and is when the foreskin and uh manoa is retracted behind the glands, penis and cannot be replaced again. So it's result you see a tight ring of tissue around the penis and this is an emergency and you should really be aware, this isn't to be mistaken with fimosis, which is just a tight sports skin which is difficult to retract. You really wouldn't be able to retract this at all. Um And it can sometimes lead to kind of venus occlusion, a Dema around the around the area of the penis and it can eventually to compromise the blood supply to the glands and the foreskin, which is a scheme ick causing ischemia, which is quite serious. Um So the signs and symptoms to be aware of this. So if you're, you're forced range retracted behind the glands, penis, there's some penile odoema looks quite swollen around the head of the penis, potential discoloration, you might see some kind of signs of ischemia and even necrosis and it's been there for if it's happened for a while, might be painful or in some cases, it might just go unnoticed by the patient. And it can also be seen in cath drives patient's where the foreskin hasn't been retracted. Um So just to be aware of that, um so it does require urgent reduction and if left alone, it can lead to being a seclusion leading to Dema of the tissues and then leading to necrosis, resultant lee. Um so far ways to reduce the power fimosis. Um And the aim of all this is to reduce the swelling in the tissues, which would then allow you to replace the foreskin back to its original position. Um So it's relatively rare. The patient require emergency surgical intervention here. But sometimes they might use can ice method where they apply like lidocaine and ice and wait for the for the swelling to go down. And, and sometimes they might require surgical interventions which be done by urologists and she could circumcision. Um So all patient should be followed by the urology team in this situation. Um As a circum circumstances would likely be required to invent this um occurring again in the future. Um So now we will go on to talking about kidney stones. Um So they're very common and you'll probably diagnose if you in your career. And so kind of test your renal colic is quite common in um medical school examinations, especially kind of final years. The patient, if you have actors in your university, they might kind of give a renal colic history. Um and then Kenny stones can be diagnosed. And so real clock is kind of this intermittent kind of dull achy pain that they have in their flank and their loin area around the kidneys. Um So be aware when someone is presenting like this. You might be thinking is there a stone causing this? Um so can be diagnosed using kind of different types of imaging. So you might need to x ray of the kidneys, ureter bladder's, but then some of them, only 60% of stones are actually radio peak. So then you can, you can sometimes miss someone actually um ultrasound of the kidney Uritin bladder can be useful m texting stones and like hydronephrosis, but it might struggle to see small stones in the ureters. So it's probably not the ideal one. And then you may have heard of intravenous. You're a grams where they give a patient radiopaque contrast which and watch it's rain to the urinary tract using x rays to look for kind of any filling defects or obstruction that might represent a stone. The gold standard. Though, investigation in this um of a first presentation of renal colleague would be a C T K U B. So kidney, your it'd bladder, it's non contrast, quite a low dose of CT and which can pick up basically about 100% of stones. It's non contrast. So therefore, you don't have to worry about the patient renal function or the risk of kind of contrast allergies. And they're also quite quick scans, easy to performing readily available in acute setting. And and CT KBS can tell you the size of a case of the stone, how hard the stone is, whether any signs of stone blocking the ureter cause an obstruction of kind of urine flow from the kidney and presenting on a scan has hydronephrosis, which is a swollen kidney. Um, so yes, the signs and symptoms and you're looking for in someone with, presented with a kidney stone would be loin two groin pain. So, pain around the kidney area and they're loin raiding all the way down there side into their groin area. And some people might even describe it as the worst pain you've ever felt. They're just not be able to sit still. Um, they might be kind of result also quite nauseous that showing warm clammy and sweaty. You look at their observations, you might have some tachycardia and their heart rate might be going up and they might even have some hematuria in their, in their history as well. So that they got visible hematuria, they can see themselves or is it nonvisible? Where is it microscopic? And then the in this situation isn't infected kind of stones. So you want to know signing symptoms of infection might include, are they pyrexic? They got temperature, their heart rate going? Are they, are they tachycardic? Are they breathing quickly? Is the respiratory rate up? What by their CRP? And they're white cells, you want to know they're full blood count is our white cells off for the inflammatory markers raised. And if they got any kind of result in sequela of infections such as H O fibrillation, they've never had before. So you want to be aware of that. So they're always a different types of stones that form in the, in the urinary tract. Um So, calcium oxalate stones are up to 80% of all renal calculi and they're radiopaque uric acid as well, they're radio lucent. Um So it's important to be aware of this. Um And then there are some kind of predisposing factors to having a stone stone formation. Um I've kind of made them put them into intrinsic and extrinsic factors and, and I'll briefly explain what they kind of Riley re pre disposed individual to forming urinary calculi, their stones. So set in essence the cause of urinary stones. This kind of super saturation of the urine with one or more components which form stones to kind of intrinsic factors. Age. They're quite common in the ages between 20 and 50. More common in males, approximately 1.5 to 1 ratio. Um in males, testosterone cause increased oxalate production, predisposing to calcium oxalate stones in females. Hi Henry, higher urinary citrate which inhibits calcium oxalate stone formation. Um So yeah, then genetics, it's it's an increased risk in Caucasian Asian populations. You have a family history, you might have familiar renal tubular acidosis, you might have had hypercalciuria. Um because of this might include hyperparathyroidism. You might have gout, you might have hyperuricemia as well or maybe like a mile a preventive disorder. So just be aware of these think at anatomically, they might have a horseshoe kidney or they might have a paella ble ureteric junction obstruction. So, just kind of think of anything that might cause urinary status or delayed emptying of urine again. Uti s um, can predisposure to that and they might have medications again that might lead to stone production. So, are they on loop diuretics? Are they on any steroids which can predispose to calcium stones? Have they had any chemo recently for, for a malignancy which might have hyperuricemia and then extrinsic factors. Again, there, women like a western lifestyle if they have in a hot climate can predispose into it. They got poor fluid intake. Are they in their eighties? And they really don't monitor how much they drink. Are they drinking less than maybe a liter of fluid a day? That would be a risk. And they got a century lifestyle. They work in a hot environment again, you think about their diet and they got a high protein diet can lead to excessive pure and excretion causing uric acid stones. Are they a weightlifter? They drink a lot of protein. They got high salt. Um So low calcium as well. It's kind of you as you wouldn't, you'd expect, you wouldn't really expect it. But there's a higher risk of calcium stone which and someone has a hypocalcaemia and just being aware of all these things and how to so kind of management of it. So in reno stones can be managed on an elective basis. But there's sometimes indications for an emergent, er Venn Shin. And it's important to be aware of this when you start fy once or their signs of infection. Have they got, are they Pyrexic? Have they got high white seller CRP. They got just a single functioning kidneys there a reason why they only got one function kidney have they got off renal impairment? So they got any kind of abnormal used knees. Is there an obstruction of the kidney? Um And you want to just look as into the, into the history of the at the previous kind of I T U admission's do two stones, just be aware of all these things. And in these situations, if you're looking at kind of surgical management, you might want to think about stenting or nephrostomy. Um and again, and then if, if it's not an emergency situation, the kind of other kind of treatment you might have conservative management. So you might just, the stones can pass on their own, depending on the size. They might need a bit of kind of pain ready to go home with a follow up scan a few weeks later. And sometimes they might give alpha blockers such as tamsulosin um to kind of help pass a stone and, and then you might get other kind of things again, as in an oxy situation, probably won't be, you won't be asked about it, but you might use extracorporeal shockwave lithotripsy. So should be performed in a clinic with some pain relief and shock waves break up the stones, which helps them to pass it easier. Just being aware of the kind of other ways that can help with stone management. Um So now we're moving on to talk about, about the prostate. So moving on to kind of males. Um, so in prostate, you're looking at lower urinary tract symptoms. Um So the longer you're a tract symptoms, I'm sure you probably all are aware of them are collective symptoms which are common, examined and kind of medical school, um final exams and they're also extremely common. So kind of whatever, especially you working, you'll probably come across patient suffering from these. I like to kind of break it down and I kind of already tract symptom history. So divided into storage symptoms and voiding symptoms of storage, the bladder itself, any problems there are avoiding actually peeing yourself where the symptoms coming from. So storage can it can be caused by sore symptoms can be caused by an abnormality of the bladder function. So obviously, it's functions to store urine, a low pressure and then you wanted to contract when you're actually peeing. Whereas voiding symptoms are caused by an obstruction of the bladder outflow. So they've been large prostate or urethral stricture. Um She's taken a good to kind of lower urinary tract symptom history can have it diagnosed the cause of the patient symptoms and also it can square quite high if there's a station like this and then you're off skis. Um So things to ask you sit in your history of someone with kind of prostatic symptoms. So you want to know the lower in your track symptoms. Um So story symptoms. Um I'll kind of go here. So you're gonna have they got frequency, are they going to the toilet a lot more often than normal? They got urgency. Can they just not when they need to go? They need to go and they can't wait. Um They got urgent continence again like when they just suddenly need to go and they let go and they're, they're continent they got nocturia. So are they going to the toilet in the middle of the night which is abnormal for them? Or even are they even like wetting the bed? They can't even make it to the bathroom? Um So that's kind of storage symptoms and voiding symptoms. You're thinking is there any hematuria but in the urine or any pain this Sharia when they're peeing and they got hesitancy? Is it for a man? Are they going to the toilet? It's difficult to kind of commence peeing. Is there an issue there when they're peeing is a kind of really weak kind of poor flow and not like them? Um and, and or are they having kind of incomplete voiding issues? So are they going to the toilet and then when they finish peeing. They actually don't think that the bladder is empty properly. So you wanna be aware of that. So once you've explored the patient's learner tract symptoms, you're gonna need to complete a thorough history. So obviously, including red flags, you want to do an abdominal examination is are palpable bladder. If they're not emptying their bladder quickly, you might want to look at the external genitalia there from Asus and doing a digital rectal exam as well, especially in the males is feeling the size, the shape and the consistency of the prostate gland. Um Other investigations, again, a bit more advanced, you might look at your flow, um, a tree and post void residual volume of your within the bladder. So asking the nurses on the ward or yourself even to use a bladder scan to see if the patient's in retention after they've gone through toilet as there's still a significant amount of you. And even once they've gone, um usually sometimes in the G P setting, you might look at the PS A, the prostate specific antigen and the renal function basics. Again, urine dipstick testing, midstream urine sample, sending that off for culture and sensitivities. Um, you might consider an ultrasound scan, um as well. So just being aware of all these things. So kind of common causes avoiding lower, you know, track symptoms. So the kind of process of peeing be benign prostatic hyperplasia, they got a large prostate that's pushing against um their bladder that's caused him to have this kind of difficult peeing issue. They got prostate cancer. Is there a stricture in, in their, in their urethra? They got pharmacist as well and then kind of common cause of um, storage, lower your new tract symptoms. So they got an overactive bladder. Have they got infection and they got cystitis or information of the bladder or they got kind of intra bladder pathology going on? Is there a tumor or is there a kind of stone? Is there any bladder calculi? Um which I'm sorry to say we'll start it again. 26. Um worry about this. Um Yeah, share my screen again. So. Mhm All right, what I say. Uh So I'm just going back to it so much here. Um So what's so much going again? Share my screen and here we go. Sorry about that. We're back to it. Um So we're moving on then to benign prostatic enlargement. Um So just play from the slide. So, so it's a benign prostatic enlargement. It's benign increase in the number of epithelial cells. So, hyperplasia. So it's also called benign prostatic hyperplasia. Um A stromal cells as well. So increase the number of cells when the prostate gland. Um So it can called, you might hear it as benign prostatic enlargement or you might hear it as benign prostatic hyperplasia. BPH. Um So in on a digital rectal exam in this situation, you'd probably feel a soft but in large gland, you probably shouldn't be feeling any craggy masses or anything like that. You'd be feeling something that's soft and just a bit bigger. Um, it's incredibly common and unfortunately, most older men are, men even will have benign prostatic hyperplasia during the course of their life. However, not every single male will develop lower, you know, tract symptoms as a result of this and the size of the gland doesn't actually always correlate with the degree of symptoms that the patient may be experiencing. Um so often kind of lower in your tract symptoms as a result of BPH will progress over time becoming more disruptive until a patient actually seek medical attention or develops even and kind of work a style your your attention after a trigger event. So you might have mild, moderate or severe lorna tract symptoms. So mild might be managed conservatively. Um whereas moderate ones, you might think about using alpha blockers and such as tamsulosin quite common. But the kind of side against side effects, this can cause hypertension dizziness to be aware of these and other class of drugs is five alpha reductase inhibitors such as Finasteride. Um but storage symptoms are still persisting, maybe adding an anti cholinergic um severe lower Neurotrack symptoms. You might think about surgical intervention or long term catheter surgical options. Quite common search procedure as a transurethral section, the prostates with terp um to help deal with the symptoms that they're having. Um in men with this situation, you want to be looking at P S A. So they got the prostate specific antigen. It's an enzyme produced by the prostate, which is used to kind of liquefy semen. So it's a useful indicator, prostate size. However, there are many other factors that can cause a raise PS A including UTIs, prostatitis, your your attention, catheterization, ejaculation, etcetera, just been aware of those other cause. It's not always a great test in that sense. And obviously, a P S A level must be done caught in correlation with a digital rectal exam and taking a good history and taking a good examination differently BPH and prostate cancer. Um So obviously, prostate cancer, we'll talk a little bit about it is adenocarcinoma of the prostate is the most common type in men in the UK. Um and signs and symptoms of prostate cancer may include such as a lawyer in your symptoms, similar to BPH hematospermia. You might some blood in the semen. Um You might just incidentally found with a raised P S A by your G P and be sent in for further imaging. But on digital rectal exam, which is the difference between benign prostatic hyperplasia, you have an abnormal digital rectal exam, you'd have a hard nodular craggy feeling prostate. You might even have some bone pain or back pain, which you might think down the line. You might be thinking, have they got Mex or any other kind of signs of metastatic spread. But in most kind of situation, I raised PSEA will likely kind of prompt the referral to urology page may be said for MRI or biopsy, the prostate to rule out a malignant cause of the raised PSE as opposed to BPH. Um So yeah, just to be aware of that, my laptop is done again. I'm sorry, it's like gone. So uh then moving on um finally, so we will share my screen here and then moving on to lumps and bumps you might find. Um so as a male testicular lumps and bumps and so in your finals situation in previous exams, university, they often give you a kind of a a dummy of artistic your scrotum and you didn't want to do a kind of clinical exam of the lump. So plastic models will often exist for this. But you could also be expect to take a kind of clinical history from a patient or an actor before proceeding to examine the model in a kind of final 50 or scenario. Um Just important take a thorough clinical history as it might drastically change your differential diagnosis. Um for example, changing your suspicion as to whether a lump is malignant or not. Um So just being aware of that. So things to ask your history, when did it, when you first notice, when did you first notice this lump? Has it changed in size over time? Is it painful? Is it tender? And if it's if you're seeking, seeing the word pain, you're hearing pain, you want to do Socrates, any other symptoms? They got fever pain in their peeing loan, you know, tract infections. Have they got some discharge from the penis? Um Have they had any recent unprotected sexual contact? Any history kind of sub fertility issues or previous to stick your cancer? You want to take a good family history in a good past medical history here as well. Um An important examination. If you, if they give you like a dummy model of a testicular testicle in the scrotum, you want to say kind of the site of the lump, where is it is on the left or right testicle? How big is it? And if you can describe it with your fingers, is it the shape of it? Is it, is it a kind of large, is it small? Um the surface of it? Is it kind of craggy? Is it a hard craggy mass you're feeling or is it kind of soft? And there's not no kind of weird weirdness to it? And how is the skin around on the testicle? Is there any skin changes? Um and can you palpate any lymph nodes around the area would be something you'd probably further do? It may be a bit more advanced from a medical student perspective, but you want to be looking at things like that and is it tender when you're touching it or is it warm to touch. Can you trans illuminate it? So that moves on to kind of talking about hydro seals, which is like an accumulation of fluid within the area called the tunica vaginalis. And so you can be primary or secondary. A secondary would be a sign of malignancy, trauma, infection torsion. Um So sinus symptoms of a hydrocele would be a fluctuance, scrotal swelling, trans illuminate. Herbal swelling should be shine a light on it, trans illuminates and you've been unable to palpate. The test is separate from the swelling, be stuck together and you can't, you can get above it. So you can manage to put your fingers above this area, which would help to rule out a hernia. And so making aware of that treatment options included conservative management, surgical repair, um or aspiration. If they're not suitable for uh um if they're not suitable for a surgical procedure, then baracus eels are dilation of the test, take your veins, which can either happen on one side or other side. Unilaterally, bilaterally often feels like a bag of worms. When you're, when you're palpating, they might feel a dragging sensation in the area which make them feel quite a key and it can be identified. An ultrasound of the test is um a good thing to be aware of for written finals, is kind of being aware of the new left sided barkus, even adults. And as renal cancer is involved, the left reno vein can can cause obstruction of the left spermatic vein causing a left sided barking seal. And where compared to the right testicular pain, which trains directly into the inferior vena cava. Again, treatment option, conservative surgical management as well and epididymo-orchitis another one. So it's a common neurologic presented presentation. It's often difficult to differentiate from a sort of test that we discussed earlier. Um causative organisms such as E coli can do it. But also you can have to rule a sexually transmitted infection such as chlamydia, gonorrhea. Um if left untreated, the patient can become septic and develop an abscess. So, symptoms of this may have proceeding symptoms of a uti lord your tract infection symptoms or laundry tract symptoms, discharge painful scrotal area, feverish and then a sign signs of this examination will be a hot swollen red hemiscrotum, testicular testicles and epididymal are very tender to touch and the epididymal in the cord might feel quite thickened. So again, when you're doing this, you wanna know time of onset to change over time, radiation of pain, pain history, Socrates, sexual history, any discharge peeing symptoms, previous UTIs and a kind of urological history, previous roto surgery. And so in the management of this would be ruined out, the tourism of the tests would be the first thing to do. Getting onto the case, the urologist letting senior management. No. And and then you might want to start my antibiotics if it's an S T I M getting kind of good micro advice in this situation, be good and usually course of antibiotics for epididymo-orchitis and given for about 10 to 14 days and then reviewed by the G P following this. Um after this. And finally, lastly, the thing we're going to move on to is talking about urinary incontinent. So this is a common presentation urology. Um Females being twice as likely to develop incontinence as men. I've had previous Oscar stations on incontinence. Risk factors of this include so quite a long list. But age older females, gender anatomical disorders like officially childbirth, pregnancy can increase the risk of em incontinence. Any abdominal pelvic prostate surgery. Obviously the other one, diabetes, smoking, obesity, frequent UTIs are all factors for it in your history. Basic as I'm sure all were taking kind of Socrates to it. Any urgency frequency dysuria, they use incontinence pad and if they are, how many using that day or night, um are they taking a bladder diary and discussing their fluid intake habits? So when do they drink, they drink just before bed, drinking a lot of alcohol or coffee, caffeine, taking obstetric issue for females looking at their bowel function. Um any sexual dysfunction you might be having and I kind of want to know the next kind of psychosocial impact their symptoms is embarrassing for them that they're having to run to the toilet during um work or whenever are they out with their friends? You want to be aware of this and neurological issues can often cause disorders. You want to do a good neuro exam as well um in these symptoms. So I kind of four different types there. Stress urge mixed and overflow. So stress is the involuntary leakage of urine on efforts. So for example, sneezing or coughing, um and in this situation, you'd want to use conservative management such as weight loss exercise, pelvic floor training, they might use this kind of surgical tape procedure. And in this and urges the involuntary leakage of urine accompanied by immediately or proceeded by urgency. So a sudden desire to need to go and p caused by overactive detrusor muscle in the bladder. And the treatment could be conservatively. So reducing caffeine or alcohol, you might use anti muscarinic medication such as oxybutynin and sometimes it might even need Botox injections. In this situation. Mixed is the involuntary leakage of urine associated with effort, kind of coughing or sneezing accompanied by immediately proceeded by urgency. So, a strong desire to go to the toilet and then you've got, lastly, you've got overflow. So involuntary leakage of urine when the bladder's abnormally distended with large volumes of urine, um often do two bladder outflow obstruction. So men with chronic retention and the management would be kind of treat the bladder outflow obstruction. Um Long term catheters, perhaps or intermittent self catheterization. Um And that is the end of the presentation. Has anyone got any questions T T score? Is it commonly used, I'm not actually sure what the T T score is. Um I could be being very stupid there, but um I'm unsure. Um So I'm going to send you guys the feedback form as well, which would be great if you guys can send back, we can send that just now. Um So you guys please take a minute to kind of fill out the feedback form and it would also be able, you'll get to claim your attendance certificate as well. I've got some new messages, I think. Um Yeah, so two seconds. So I can see the question about the three way catheter. Um So I actually had written this up to six. So I found a good explanation of what the purpose of it is. So, so the kind of three way pathway casters are used for bladder washouts. Um So patient's who are catheterizing have kind of hematuria. So significant hematuria can lead to blocking of the castor and clots forming in the bladder and this may proceed precipitate kind of further bleeding. So avoid it, avoid this, careful watching the color hematuria and early intervention is essential. Um So you have a three way catheter in place. You have three channels, one for inflation of the balloon of the catheter, one for drainage of the urine and one for connection of irrigation fluids is getting rid of these clots, which is um when someone's got quite significant hematuria. So a three week after is quite, is quite useful in someone that has got um significant chemistry for performing things such as bladder washouts. Um Is there an easy way to know when to prescribe tamsulosin? Very finasteride from what I know. Not really. I think it's more of an advanced kind of urology decision slash GPS often trial them and see how patient's get on. I don't think it ever in that kind of off ski scenario we asked which one to prescribe or, um, you might guess in finals, but usually it wouldn't be a choice between the two of them, but just kind of knowing what it there used for an patient's with benign prostatic hyperplasia is a good thing to know. Um Okay. Well, thank you very much guys for joining an attending. Um, and the next session will be on the 23rd, which will be common orthopedics and I'll be taken by someone that is doing an orthopedic job at the moment. So, if you all would be great to see you guys there. And again, thanks for joining any questions. Let us know and I hope that was beneficial. Thanks guys.