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OK, show mixed time. Um So again, I'm Hannah. I was an F one here. Now, I am an F two. I lost, I did urology as one of my jobs last year. So I have a little bit of knowledge and um I started like this is all sponsored by the MDU which is for the fi so similar to all the other sessions. We're gonna start with the basic anatomy again, doing a cahoot and then going on to uh some, a couple of presentations thinking about the operations for some of them. And then I've got a s at the end again. So it's starting with the heat. OK. Let me just share. OK. OK. Oh, sorry. Um That which that sounded something again. There is a prize for those in person. OK. So first question. Mhm. There we go. So this is true. False. Which kidney is high is the right kidney higher. It's um so we have a leader at the moment. So yeah, so the um the yeah is fine. And then if you look at that picture closely enough, the answer was on that. So yeah, they all come off, they all directly which again should help you with so effectively, where are the lymph nodes that drain the kidney? So similar to the arterial supply, we'll go back to the aorta. OK. Are they intraperitoneal or retroperitoneal? Yeah. So they are retroperitoneal structures in the back? OK. Now this one got me confused. So the ureters um travel above and then, so the next question I think I've got no, I've got image here. So you can see that the te comes below the testicular artery and then above the internal IAC um OK. And that should help you with the next question, right? So this is where if you've heard of the water under the bridge, that's where this one is. So it's to do with the ovarian or testicular artery um where the ureter um goes underneath if this is your uterine, uh your Yeah, uterine artery. Um whereas with the internal iliac, it's the other way around. Yeah, which is not one of the three locations where the ureters are out there. Now, one that should be. So the prosthetic part would be part of the urethra. Yeah, I always remember urethra has is a and that's one. And so I think it's just one tube rather than ureters. That was my way of somehow remembering it. So we got another little image. Yeah. So that trigone is just kind of at the bottom of the um bladder and they kind of enter each side of this. So like the and the where the ureter is enter. Mhm Most common area for prostate cancer to originate from? Listen. So this one is the peripheral zone and then for the next one, so it's cancer is from the peripheral zone of the prostate. But then where does B ph what bit is in large in BP that wants you transitional. So those two I can get quite confused sometimes but transitional is the B ph and peripheral is your cancers in my case? OK. And the winner today is and first place? OK. Ok. Mhm. So now on to OK. The main bit at the talk. So we're gonna go through three different presentations today. The first one is urosis or effectively renal stones. One of the most common things you're gonna see on urology referrals when you're in S au first question, what are the four types of stones? Can anyone name any of those? Which one? Yeah. And what's the most common type of stone you're gonna get? What made up of? Yeah. So that was your calcium today? Um get that one up. And so it's stone, which is your colon and then any other one of the commonly called gap? Yeah, that one and then your last one is your cystine, which is the most rare type. So to go through them a bit, calcium are the most common. They're the ones which you're gonna get because you're very dehydrated. Um And yeah, most common, they're you're gonna be able to see them on x rays. If they're large enough, the struvite are generally ones associated with infection, um, particularly, um, klebsiella infection. So that's where you're gonna get your, as you said, then your uric acid. I mean, these patients are the ones who also get gout. Um, they are the ones who eat lots of meat. Um, and then finally with cystine, those kind of genetic, if you're not absorbing of cystine appropriately. So they're less common. You generally won't see them. I think the cystine is going also not visible on X ray. I think they're the ones who aren't regular, um, opaque. But I think, uh, your slides are possibly frozen online or still on the first slide. Ok. It's right. It's kind of ok. I hope that's working a bit better now online. Yeah, we're on risk factors now. Are they? Ok. So that's all that, um, any, anyone name, any risk factors? I mentioned one of them, any risk factors for stones? Sorry, red meat. Yams. What about your calcium ones? I mentioned anything about that. Dehydration. Yeah. Um, so male or female who get some more male. Yeah. So 3 to 1. Um, how old are people generally? Yeah. Kind of 40 to 60 middle age. Yeah. Um, and then generally Caucasian diet related. So again the meat, um, dehydration, obesity and then some medications can increase your risk. Um, so if you think of something like diuretics where you're gonna pee out your walk, you're gonna end up a bit dehydrated. So, what if you were to do nothing? I, you might pass them yet. It might be painful but you might pass them. Um, and the other thing is you could, there could be an associated infection because if you're blocking that tube, it could be obstructed. You could end up with hydronephrosis. Um, and kidney failure. How do these patients present? Yeah. No, in pain. Exactly. Um, it will be colicky and colicky basically means it's coming and going. Um, so yeah, the pain will come in waves. Um, they may have some blood in the urine. It may be visible or, um, microscopic and then they may be vomiting because of the pain. Um, so anything other than flight tenderness? See what you thought that. So you're gonna examine them and find, yeah, we could have the bladder. Um, if it's infected, you may get some sepsis, it might be writhing in pain. Again, you're gonna a hematuria. If it's not macroscopic, it might be microscopic. Um, which is one of quite a common sign in that then to go through. Um, as we've done and all the other, how you review them, what you'd be looking for, what you do to make them safe and how you'd actually confirm the diagnosis. So, what are your actions? Someone's come in with renal colic, what are you gonna do to treat them? And it has already been confirmed that work. So, if it's already been confirmed, that's your highest suspicion. What are you gonna do? Yeah. So, dehydration. So, you're gonna get some fluids? Yeah. What kind of analgesia? Yeah, definitely said that can affect your kidneys. What else is really good for it? Diclo. Exactly. Um, and that's really quite a good way of finding out if someone's actually in pain, whether they're willing to use some pr medication because there'll be lots of, will find it out. Um But Diclofenac works and nsaids work quite well for this type of pain. Um They might be vomiting. So you're gonna get an antiemetic look at their urine output. Um And then you can do your blood um to check it actually how their kidney function is and what they need to do anything else, whether it's actually there's an infection on it as well. So, what is your most common uh modality to look for stones? CT KB. Can you see the side on this side? Um And it looks to be a bit of hydronephrosis as well because that kidney is a bit larger than that one. Um The other thing you'll often hear the urologist ask about is a scouting x-ray or to get an abdominal X ray to confirm whether you can see it on just an x-ray. So if you can see the slowing just on a plain X ray, it means that when they're coming back in a couple of weeks time to review them. You won't need to do a CT and you can just do an X ray. But if you couldn't see it on the X ray on the scaling X ray, which was like the first, often in CT S, they sometimes sometimes don't where they take a x-ray just to plan out when they're gonna, um, do that kind of where they figured out the abdomen. They, um, you'd sometimes do a CT Scan, x-ray, abdominal x-ray. So what could this be confused for someone's saying they've got really bad pain here. What could it be? Mhm. Goes out of here. What if they've got uh kind of, uh, leucocytes, nitrates and blood in their urine. Anything else going on white cells are up on their bloods. What else could it be? Uti and what, what kind of the next step from the UTI? Yeah. So really compound arthritis is the other thing which I remember in a GP place. And then warning me about is when you're considering a uh renal stone, you also need to rule out a triple because apparently the pain because it's kind of that front to back pain. Um, is an important one to look out for. As you said, the biliary bowel obstruction, pneumonias, lower lobe pneumonia can also kind of cause pain around there. So just keeping your kind of ideas a bit wide even if you're on a surgical placement. Um, and then, I don't know if anyone's noticed the referral pathways. So renal stones. So if you're an ed, renal stones will go to urology. But pyonephritis goes to medics and then if it's like an affected stone that then can go to urology because I urology won't deal with someone if they don't need to operate and a stone would require operation. Um And that's an important differentiation. So if you're an ed doctor, how are you gonna pick who you refer to? What in your patients? What you've done in Ed so far? How are you gonna pick which way you're gonna go and refer them to history? So for example, if you've done a CT K UB already, which you may have done in, then you know that that can go to um urology. But if you're in GP, what else can you use to figure out which way you're gonna go? How might the patient present differently in pyonephritis versus renal colic? Sorry. Yeah, they might be, they might be hemodynamically unstable in the ps and yeah, so you're gonna be able to the urine. So this is as you kind of get F one to F two, I'm a G in GP at the moment and you have such limited, even if you want blood, it will be at best next week, probably in a month's time. So you're not gonna have the same things you would in to get instant answers. You're gonna have to use a different kind of knowledge, I'm thinking about kind of if their BP is high, you're gonna want to send them in anyway. So that's most of renal colic. So in terms of you're looking for patients with or groin pain, hematuria and um flank tenderness, you're gonna give them IV fluids. Um Diclophenac as the um analgesia, look at their renal function, check for infection and then confirm with a CT KUB, the other thing to know. So in terms of the management from a urology side of things, um, they can either they all know the treatments, how you actually we, what size of a stone, I suppose. First of all, you would put, you'd need to treat at what point does the stone go from, but you'll probably be past that to, ok, maybe we do need to do something. It's about five or six millimeters is a kind of cut off. Um, and any, what kind of treatments can you do for these stones? Lithotripsy. Yeah, exactly. Um, you can also do kind of, um, stents and that's what if you're worried about. And so urologist will get out of bed in the middle of the night for an infected obstructed kidney. So that means that they've got a stone, there's infection like, like ap nephritis, but then that's gonna back flow up into the kidney. Um, and with that, they'll generally either do a nephrostomy or they'll put a stent in. So the stent being kind of just going up and allowing both the kind of urine to pass the stone, they won't necessarily take out the stone unless it's quite easy to take out at that point. Or they'll do a nephrostomy and be able to drain the kidney that way. And in an attempt to kind of save the kidney because they probably have a really bad AKI at the same time. Ok. So that's stones. Any other questions on stones? You need to be like that. So this is what we do that or is that nothing? Yeah, you can do that. Absolutely. But that would generally be something. Uh you kind of if it's infection obstructive, I do, you generally don't do that at that point. You do that kind of two weeks down the line when you notice stones still there, you'll put them in. Um I think there's like I remember because I did, I was on around you over Christmas and they kind of said they were debating which way as the urology, read the consultant having a discussion about what they prefer a stent or Lithotripsy and they kind of, they had different views for the stent. Obviously, you then need to have the stent taken out at a later date, but Lithotripsy doesn't always work. I think it was that kind of argument. So I think the consultant referred a stent um because it was more successful, um even if you needed to go back twice. But yeah, you can also kind of do effectively lithotripsy or laser um by cystoscopy. So you're kind of going inside and you're actually on the stone from the inside rather than just going from the outside, right. So, next one to testicular torsion, this um Germany is a testicular ischemia from a rotation of the testes. It's um commonly happens with something called a bell clapper. Have you heard of that before? So that's where actually the testes lies horizontal rather than its normal thing. Most commonly, you're gonna see it either in the newborn stage or in kind of puberty to early twenties. And the difference is, you know, which one is more common at which time. So the extra vaginal which is outside the tunica tunica, um vaginal is this one you're gonna get in neonates. So they're the ones you're gonna be born with. Whereas the intravaginal, those are the ones for the boys who are gonna present with that. So just a quick bit, obviously, it's unlikely to be seeing this. But these are the babies who were born with what looks like a necrotic testing. Um And it's very kind of black. Generally you'd end up removing it rather than doing too much about it. The thing to note with torsion is after a period of time, it's not painful. Once it effectively dies, it's not gonna be painful. So if you've got someone who's kind of presented a bit slowly, even if it's a teenage boy who's been a bit embarrassed, presented a few days later, he said, oh, it was painful but actually now it's not, you know, kind of thinking that might be a bit too late or it's not torsion in that case. Um So intravaginal torsion. So this, as I said, is within the tunica vaginalis. So this, this T vaginalis. Um does anyone know the layers of the testes or anyone know an acronym for knowing them? So there's a acronym I read when I was rising part of my exams. So um some damn Englishman called it the Testes. So, skin um uh external um uh external spermatic fascia, cremasteric fascia, internal um spermatic fascia, um call it the aa al tunica vaginalis, vaginalis al um So that's where V are, that's the treatment for vaginal. Um The left testes is more common and that's probably because of the difference in height and maybe it's a bit longer. Um OK. Anything of any risk factors? What's gonna cause you to be more likely to have a torsion trauma. Yeah. Trauma could do it. Not the Bell C Yeah. Yeah. Um Anything else? What age? Yeah. Um If you don't have, if you've had an undescended testing, that's more likely cos it's kind of a bit freer if it's in your abdomen. Um Sexual arousal activity, it can be more common. Although I've never heard someone actually present saying that because they've probably been too embarrassed um during exercise and active cremasteric reflex. So, that's kind of where it's maybe overly active. So, does anyone know what the cremasteric reflex is? Yeah. Um, to where you effectively grow up on the thigh, it causes the muscles to, um, contract cold weather, family history. And those are the main ones that probably the most common ones. What else could it be? Boy coming in with a painful testicle. What else could it be? Infection? Yeah. Yeah. Yeah. Yeah, exactly. Um, so that's, yeah. Um, gastro appendicitis can be referred into the testing. Um, it could be a, to, uh, that's the one you're talking about. The, um, epididymal epidermal, that's gonna be your most common differential that's gonna cause you a painful test. Um, and I think I'd say the epididymal orchitis, the men who came in with that looked like they were in the most pain out of a lot of other patients. I've seen, they look, yeah, I felt very sorry for them. Um, inguinal hernia. And as you said, any of those have any questions about any of those? Ok. How will they present, how to suggest the things? But what is your typical patient gonna present, like sudden onset? Yeah, excruciating pain. They may be vomiting. Exactly. Um, and what are you gonna find on exam? 5, 19. Yeah. So, do you know what that's called? Yeah. Friends. Exactly. Um, it may be razor, it may be high riding again because of the twists in it. It might be pulled further up, it might be a bit swollen, there might be a change in color, um, very tender to touch negative friends test, as you said and an absent remister reflex. So your two special tests, as we've kind of spoken about are your cremasteric reflex. So that's this and the test won't move if it's torted, but it will move in orchitis and similar with friends in friends that are limiting the testee will relieve the pain in epi orchitis. And you'll see urologists often suggesting that patients like kind of tight underwear when they've got, um, orchitis because it kind of holds it a bit higher. So, what's this like? Ok. Yeah. So that's what it's called. This is called the blue dot sign. And then she said it's of the taut hi, this appendix of the test. Um, it's not a surgical emergency. So it's not, you wouldn't have to rush them to theater because it's not gonna injure the testee. But I don't know, I don't know about your, but I'd be a bit cautious if I was certain it was just the, um, the appendage that was not the whole testing investigation wise. What do you think about investigating caution? Yeah. So you can do ultrasound and in that you're gonna see the whirlpool sign, which is this kind of looks like the flow of blood, but you're only gonna do investigations if there's any uncertainty, but generally you're gonna take them to theater and getting an ultrasound out of the radio. One year, you gonna need a specialist radiologist who can do testicular ultrasounds and then you're gonna have to debate with them why you think it's worthwhile doing this rather than taking them to theater. Um And so this is your, this, you can kind of see that this, this is all twisted and you'll often see in the op note, it'll say how many times it's twisted. So they do actually count. Um, I don't know why it makes a difference. Um, and you do your incision through the midline, um, of the scrotum and then you can from there, you can look at both testes so you can check both. Um, and then you effectively fix it at three points. Um, and you will, you do. Yeah. Um, you don't always fix both sides and it's important to document clearly whether you, what has been fixed. Um, I think if it's a bell deformity, you'll probably fix both sides. But otherwise I know the patients have been referred in where the mum's been like, oh, he had some sort of scrotal surgery. I'm not sure whether they fixed it and then he was in pain again and I mean, he had to be brought back to theater because we weren't sure whether both testes were fixed and the chance of him getting a torsion on the other side. So that's testicular torsion. So you're gonna, they're the ones in extreme pain, it's gonna be sudden onset. They may be vomiting. You're gonna get urgent urology review because there's a six hour window from when they present to getting them to theater to um, untaught it here. The general surgeons do that overnight. The urologist won't come in to do um, a orchidopexy. Um, but every hospital might be different whether say.