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Yeah. Yeah, you OK. Hello everyone. I think I'm live now. Is that right side? Ok. Awesome. So, uh thanks for joining us this evening. Uh My name is Husan. I'm an F one working in Southampton and I just finished uh placing in urology. Uh That's why I say I'm teaching you on acute urological emergencies. So you count this a lot um as an YN NE D. Um I also uh it's part of your UK MLA content map. So without further ado I'll get started. OK. So our learning objectives for today is we're going to learn to diagnose the emergencies, inform some appropriate differentials. We will learn a little bit about the anatomy behind the pathologies and then formulate some management plans. Um And follow up. Um So at times in this presentation, I'll ask some questions if you'd like to speak up or just put your answers in the chat. That would be great. Uh Right. So diving into our first case, um I pretend you are an F one working in Ed and you, of course, see a 46 year old lady called Marie Schrader and she is with abdominal pain and a little bit about the history. It's right flank pain. It's been on and off for the past few months. But all of a sudden it's worse. It goes from right loin to groin. She is a bit nauseous. She's got some chills. She is quite sweaty past medical history. Um, nothing too relevant. She has 15 pack years. So, what do you think, uh, the differential diagnosis could be for this lady if you'd like to put it in the chat, we'll speak up renal colic. Yep, that's a good, that's a good one. Anything else? Ok. Ok. That's fine. Real colic. Pyelonephritis. Yeah. Could be that as well. Um, yeah, but if I move on as a right up there renal colic, uh, one thing we're worried about, um, a lot is she could have renal colic and one of her stones might have become obstructed and, or infected. So, that's a big thing to worry about. Also, generally you want to consider general surgery presentations like appendicitis bilary colic or cholecystitis. And also just because she is a woman, you worry about ectopic pregnancy or, and ovarian torsion. So now that we have our differential, we go in to examine our patient and just looking at her s we can see she's tachycardic hypotensive and febrile. She's got a fever or examination, she's tender in her right flank, but otherwise her abdomen is soft. She's got present bowel sounds. And so pretty much the only thing is that she's got, um, pain in her right flank. So, knowing this, what investigations do you think we should order or what should we do next? Ok. I put in the chat. No. Ultrasound K. That's right. Um, we're thinking of a stone, so ultrasound would be useful. E knees. Yep, that's good. We want to check your EGFR pregnancy test. That is a really, really good one. because we want to rule out any guy causes like a torch, um, ovarian, um, sorry, ectopic pregnancy. So that is good. Anything else, any other scans, er, considered decompression? I obstructive with nephrostomy. Yeah. So if she was obstructed, that's something we do. Um, but we first got our investigations, urine dipstick and culture. Absolutely. Um, it seems like she's got an infection, she's got a fever, non contrast CT K UB. That's it. Um, that's one of the main things I was getting at. So those are all really, really good investigations. If we go from least invasive to most invasive, we do some full bloods. Um, using these, the main thing we are checking for is her EGFR kidney function. A VBG because if she has the lactate, it's likely she's septic um, group and save, which is what you use to cross match blood because most likely we need to take her to the theater as it's likely she'll have sepsis. We take some blood cultures. You mentioned urine dip and urine cultures as well, which is really good um pregnancy test to rule out an ectopic pregnancy. And the main imaging we want is ultrasound or CT K UB because we're ultimately looking most likely for a stone. Um I don't know in my hospital, it's really hard to get ultrasounds on time. So normally you go straight to CT KUB, but they're both right answers. So here is the C TK UB. Uh for this lady, it's a Cron slice. So it's as if you put a crown on somewhere and you cut them straight down that way. So we're seeing her face on, uh and her pain is on the right side. So would anyone like to just have a look and let me know if they see anything that stands out to them? No. OK. OK. You take stone. Yep. Absolutely. Would you say it's on the left side or the right side? Nice obstruction in the right ureter dilated ureter on the right right sided. Excellent. That's really, really great. So if you can see, I don't have a pointer, but if you look on the right side, you see this very bright white thing like a, like a circle kind of like this. And that's the stone. And as you can see it's in the ureter and everything above the stone is very wide, including if you look at the right kidney compared to the left, it just looks a lot bigger. So most likely this is an infected obstructed stone that is causing upstream hydro nephrosis. And that is why we do C TK UB. So, they are non contrast because we are just mainly looking for stones. So, really well done now that we've seen she has a stone in her. Right. She's got an infection. She's slightly septic. It's obstructed. How should we manage this patient? Like, if you come up with a management plan, what would you do? No. Mhm. Ok. Diclofenac. That's true. That's the best way to manage pain is difficulty with Pr Diclofenac, analgesia. That's correct. Anything else you wanna do? I have antibiotics? Yep. Uh So with this, we're definitely worried like an infective obstructed stone is an emergency purely because all the pus will collect above the stone and there's no other way it's gonna come out itself and it's likely gonna get stuck and get worse. So we want to treat it firstly like it's sepsis. So we give IV fluids and IV antibiotics, as you've mentioned regarding her pain, you always want to keep patients comfortable. And typically Pr Diclofenac is the best of that. Um You know, typically when patients come into hospital, we always think of morphine, but Diclofenac helps the best with like renal colic pain or stones. And most likely with this lady, we will need to take her to theater. So you want to make a nil by mouth and she's going to be for Urs and stent insertion. So Urs urethroscopy, it is basically an endothelial procedure where we are going to go in through the urethra with a scope, get up to the bladder, um, and get into the urethra. And that way we can see the stone, uh potentially with a laser, we can break it apart and pull it out or if it is small enough, we just fish it out. And that way you remove the source of the infection, you remove the obstruction. And then just because there has been a stone, there is going to be a lot of infection and pus, we are going to put in a stent and a stent. It is like a hollow tube that's rubbery. And in urology, the JJ stents, so they kind of loop around the kidney and they loop in the bladder and this just helps keep the ureter open, like keep it open so you can drain out all the pus and your kidneys can drain well. And once we have the stone, we can set it up for analysis. So we can understand its composition and that helps influence follow up and management. Has anyone ever heard of ES WL or extracorporeal shockwave? With the tripsy? I hadn't before II started urology. Yes. Awesome. Do you think we could have done ES Wl for the L for this lady in this case? Oh, good. Ok. I don't think so. That's correct. Um ESWL is useful. Basically, it's using ultrasound waves to break down the stone. So if someone comes in with renal colic and they are otherwise stable. You can take them to this like um you can do this procedure where basically you use an X ray to locate the stone and then you just put like an ultrasound probe outside. So it's not invasive and it just breaks the stone into particles and they can pee it out. But in this case, this lady had an infection, she was septic and she had a big drop in her EGFR. So it's not really appropriate in this situation. Yeah. So mainly she has a fever drop in for anyone with a stone will have like a slight drop. But if there's anything significant, like from above 90 to 50 you'd wanna do something more surgically invasive. So typically anyone comes in with stones and you are thinking OK, is it renal colic? Do I need to do anything more? Can it cause stricture if it is in the urethra? Uh You mean the stone I imagine? Is that a question? Yeah. So not immediately, not acutely. If you leave there for a while, the inflammation can cause a stricture. But in the first couple of hours, we wouldn't be too worried about it if it's um that's only if it's really obstructed. But if it's just someone's passed like a one millimeter stone in the ureter, there's no real drop in EGFR, there's no infection. It's unlikely if I answer to your question. And so in that case, you can let them pee it out. I hope to answer your question. Um, but back to it, um, the only time you want to intervene in stones is if there is an infection, a significant obstruction and uncontrolled pain and uncontrolled pain would literally be. You've tried diclofenac and morphine and it just won't work. But the key thing is infection and obstruction. And in terms of follow up with anyone who comes in with a stone, whether you take them to theater or you don't, you always want to follow them in stone clinic. And this is where like a urologist who specializes in stones can review the makeup of the stone or their diet and give them tips on how to avoid getting stones. And let's say, um you did your surgery and you moved one stone, but there were still others left. You can later bring them back for the procedure called a fural or flexible urethroscopy and laser tripsy. And it's where you can pull out the stent. You can use a laser uh to break up all the remaining stones into dust and you can either leave in the stent for a bit longer or pull it out. But our main learning points from this. If someone comes in with right flank pain, it's low to grow. And you think it's renal colic, always check for inflammatory markers because if it is infected and obstructed, you'll need to intervene the intervention for it would be a stent in anyone with renal colic. Pr diclofenac is normally the best analgesia. All right, before we move on to the next case, anyone have any questions? No. OK. If not, we'll move on to our second of three cases. You guys are doing great. So you go back to Ed and your next patient is called Walter White and he's a 19 year old male and he's come in with testicular pain and that's all you've been told. You've been told as a patient with testicular pain, you have to go see them. What could be in a differential diagnosis for testicular pain. It's quite broad. So just let me know what you think torsion. Excellent. Um The main thing we hear about torsion, epididymal orchitis, excellent. Um infection hydrocele. Yep, potentially torsion again. So you've got torsion, you've got epidermitis mumps, I guess. So. Um anything else we worried about? Varicocele? Yep, Varicocele Hydrocele? Um Yeah, those are pretty much most of them. So main thing as you guys pointed out is testicular torsion. You can also get something called a hydatid of or gag torsion, which I'll talk about a bit later on infection. We covered epidermitis, epidermal orchitis. You can also get cellulitis quite a big one as well as trauma. And two last things which you can sometimes miss out is renal colic if it's a very distant stone, like just above the bladder can present with testicular pain or also if they have an sti um, you can get pain like that nonetheless. We go and we find, you know, Mister White and we take a history from him and we find out that his pain, it was sudden onset. It's excruciating 10 out of 10. He didn't have any trauma. Uh, he's also been vomiting. His paracetamol isn't helping. He's got no discharge, um, from a social history. He hasn't had any recent sexual contact. So, from this, what do we think it most likely is now that we've taken the history. Yep, torsion. So this screams uh torsion even before we get to the examination. So your typical findings, um, when someone comes in with a torsion is that the pain is unreal, like they will be frozen in pain. They are going to struggle to talk to you and more specifically on examination, you can find that one testicle is riding high slightly higher than the other. When you try examine them, they are going to fight you. It's going to be really bad and chromatic reflex will be absent. That's where you typically stroke the inner thigh and the stroke and surround the testicles would shrink. But for the most part, um, a torsion is just, that are frozen in pain and it's just a really bad pain. So now that we know it's a torsion, how do we treat a to like, what do we do next? Mhm I what? Yup. That's correct. Emily. Um, surgery the main way you treat a torsion is you have to take them to theater. You can do an ultrasound beforehand. If you're a bit unsure, you can do an ultrasound. Um But again, I do not know in my hospital, I don't know if it is every a ultrasound, it just takes forever. So you might as well just take him straight to theater, um, fixation of both sides. That is correct. Um Typically if someone has a torsion, you open it up and the, the testicle is all twisted, you will just fix the other side for good measure just to make sure they do not present with it again. Manual detorsion if early presentation, otherwise surgical, to be honest, I've never um heard of that being done before. Um and I asked my registrant and she said it's normally just um surgery. So I'd still say that um it would be surgery right off the bat if I am honest. Um Yeah, let's get into a bit of the anatomy. So in a torsion, you have your spinal cord which has your veins and arteries and when it gets twisted in itself, you lose your blood supply and you get ischemia of your testicle and it starts dying and that's bad because you know, it affects reproduction. So that is why you need to operate as soon as possible. And like you mentioned before, fix both sides, um in terms of follow up, it's quite simple. So this is like a day case procedure. So you can send them home with some painkillers. There's no need for them to be in the hospital and you can give them a scro support. But otherwise, um, it's quite quick. Now, the thing is what do we do? Like, let's say you're the F one and Ed and they come in and, you know, it's a, it's again a young person, they've got testicular pain but it doesn't seem that bad and it's a bit slower on. So it wasn't all of a sudden and you kind of do the comma reflex. Can you rule out a torsion like that? What would you guys think? Can you rule out a torsion just from this history? So I'd say no a torsion, like if in case you're a bit less convinced about the history, it's always good to get an ultrasound. But if it takes too long, you should always call urology. So just a safety thing is if you're an F one or an F two or an working in, it's, it's, if it, if you're a bit unsure about it, it's normally the job of the urologist, the registrar to rule it out. So in case you ever worried, just call the reg I mentioned earlier about the hydatid of Morgagni torsion, which is a bit of a fancy name. But basically, it's an embryological remnant from something called the malarian duct and it can present in a very similar way to a regular torsion like vomiting and acute onset pain. Um, but if you look on ultrasound, um, you'll just see that it's not the actual testicle on the spermatic cord. It's just the appendage. And the big thing with the MG agony torsion is it's conservative management. You don't need surgery, you can just give them analgesia and some bed rest. Um, so that's a big thing. Um, and that's why it's helpful to get an ultrasound if you can. So I'll only point for this case, always think of a torsion with testicular pain. It's less likely in elderly people, but anyone young comes in, always think of torsion. Um If you do diagnose a torsion or it takes too long to get an ultrasound scan, you need surgery to fix um the testicle that's torted and also the bilateral one. And if you're a bit unsure about it, there's no harm in calling urology. Ok? And one last thing, it is a graph I got just to show you the importance of time in testicular torsion. So if you take them to theater um within the 1st 12 hours, you have a 90% survival rate of the testicle. But actually the longer you get um the lower the survival rate. So that's why anyone with a torsion, let's say you are working in Ed and someone comes in to them to the hospital as soon as possible and just see them first and try to get the 3rd 1st. But yeah, that should be the end of our second case. Um, moving on to our third case and last one does the pain not persist with the hydatid or agne torsion. So it will persist. Um, but pretty much you'll just give them analgesia and bed rest. Um The, yeah, you wouldn't really take them to theater for pain. The only reason you do it with a torsion is to, you know, um enable them still to, you know, produce sperm and the testicle doesn't die. But notice it is true that pain would persist with the acne one. Hope to answer your question. All right. Uh Moving on to our final case. Keeping with the breaking bad theme, we have a 66 year old male called Tuco Salamanca and he presents to Ed with retention. What do you know, could cause retention? Like what are some causes of urinary retention? Prostate cancer? That's correct. BPH. BPH is the main one. or BPH. Yep. That's correct. Medication. That's right. Like anticholinergics. Um Yeah, bladder stone obstructing the urethra that could happen, but a bit less rare. But you're right. The main thing, pelvic trauma. Yeah, that's correct. Sometimes if you read about traumatic cases like motorcycle crashes, you can get um your, your urethra seven. But the main thing we worry about in men is BPH. So when your prostate gets enlarge with age and it just blocks your urethra typically, sometimes you can get someone who has a uti and they present, you can have stricturing the medication. Another one is hematuria and clot retention where someone is bleeding, the blood forms clots in their bladder and it blocks the orifice. And so they go into retention. So a solution for pretty much anyone who comes in with retentions, you put in a catheter in the medication, you mentioned trauma. Sometimes if they severed the urethra, you put in a suprapubic catheter, which comes just, you know, in the bottom of the abdomen. And that's something you call urology for. So it seems quite simple and it seems like we could end our session here, but sometimes it's a bit more complicated then just putting in a catheter. So let's say Tuco comes in and you speak to him and he says that I had some blood in my urine. It was frank, I had it for about a day. And then all of a sudden, I just find it difficult to pee I was having juice that put it out. I just can't pee anything and it hurts a lot. Um We find out he has atrial fibrillation. He takes Apixaban and Bisoprolol and he is a retired businessman in the pharmaceutical industry. So, you know, like I mentioned earlier, oops, um you, you put in a catheter, which you'll do. Is there anything else we'd like to do regarding his medication in case you didn't see my other slide Yes. Yeah. Alright. So we stop as a Pix ban, we are typical management. We stop as a pix ban, we put in a catheter regardless um anyone who comes in with hematuria. You always worry about dropping the HP and whether they will need a transfusion. So it is worth getting a full blood count just to check your HB and a group and save while are at it. And also I am glad I can kind of show you if there is a stone inside or any clots. Uh The reason I mentioned a three way catheter or a diagram of it is said to be three way catheters are a lot wider and they have three holes. Um So later on, you can do irrigation which I'll get on to. But I just want to show you a picture of a three way versus two way. OK. So we have put in a three way catheter, we stopped. His HB is fine and initially we drained some hematuria. Um but it is once again stopped like the catheter, nothing is coming out. So, what should we do? Now, does anyone know that someone comes in with hematuria? We put a cast through it and it just stop training flush. That's correct flush or bladder washouts. So basically what's happened is he's got like sting blood in his bladder. It's formed clots. And so you just have clots sitting at the office of the bladder and like Paul mentioned you do flushes or bladder washouts. And the way you do this is you unplug um, the bag from like a cat bag from the catheter. You get a really big syringe like have on the right like 60 mils and you get a pot with saline with sterile water and you literally just fill up the syringe, plug it into the catheter and you push it through and then aspirate and that way you're kind of forcing out the cars and then when you aspirate, you're pulling them out. So this is something you can do in F one and F two. If someone shows you how to do it, um you can give it a good amount of force to dislodge, the, cater to dislodge the clots and you pretty much keep doing this until you get rid of all the clots and that way your bladder can drain. So once you've done your mind, your bladder washout and you move all the clots, you might find that the urine is still bloody, uh It's still got blood in it. And that is why we set up something called irrigation. And this is why we need a three way catheter. Essentially, there are two diagrams here, but you essentially set up a big bag of saline. You run a tube down into one of the ports of the catheter bag and this kind of continuously irrigates the bladder so that if there is a source of bleeding, it can just wash it out and the, and help you then get clear urine. So that's something that happens, which you typically won't do the nurse and the ward will. But it's something to know that if you've done bladder washouts and it's still not clear, you need to set up some irrigation. So you do your washout, you do your irrigation, the urine becomes clear talk or trial without catheter where basically you just pull out the catheter and they pass it and then restarting Apixaban in a few days. So it's all done. A side note about the Apixaban. This is typically a surgical decision. So this patient would be under urology. So it's something your registrar or consultant would normally decide. But yeah, we we we we found our patient. They were in retention. We did some washouts. We made a plan for something that picks bad and everything is good. Is there anything else you think we need to do or can we just forget about this patient? So we organize any follow up. Is there anything you're worried about in a 66 year old male that comes in with hematuria? Yeah. Yeah. Cystoscopy. Why do you wanna do cystoscopy? Like what are we worried about bladder cancer? Yeah, that's excellent. Um bladder cancer. So pretty much um anyone who presents with hematuria is bladder cancer until proven otherwise. And so what we want to do is put them on a two week wait for flexible cystoscopy, which is where the urologist will take like a little camera and put it up the urethra and have a look at the bladder and it is a day case procedure without anesthetic. And also another thing they do, I don't know if it's just my hospital but you do a CT urogram. So, that is a CT scan, um, with, when you, the phase you try and get is when the contrast is in the bladder, um the urethra and the kidney and that can just rule out a malignancy higher up. Yeah. Yeah. Yeah. But our learning points from this case is if someone comes in with a co retention and the catheter stops straining, you have to do bladder washouts. Anyone with hematuria or anyone with bleeding in general who presents to a surgical ward, you want to check their HB just to make sure you don't need to transfuse them and anyone with Frank hematuria, you need to rule out bladder cancer. So in summary, um from our three cases, anyone comes in with testicular pain, you have to think of a torsion when someone comes in with flank pain and you are worried about a stone. You always need to make sure or think in the back of your mind. Is it infected? Is it obstructed? Do I need to put in a stent? And anyone who comes in with bladder cancer? No, sorry. Anyone who comes in with hematuria, you need to rule out bladder cancer and that's the end of the teaching session. I hope you enjoyed it. Um I appreciate your feedback. So, if you scan the QR code, but yeah, does anyone have any questions that should be most of like acute urology presenting to a ward? So, um yeah, I hope it helps. Yeah. Uh You're welcome. Um Yeah, thanks. I for putting in our feedback. Um I'm just gonna share uh the link to my next session in January which would be on B Ph Paul hematuria. Could this be a renal problem upstream rather than the bladder? Yeah, absolutely. And that's why we are doing the CT urogram because the CT urogram will look at the kidneys because potentially you could get hematuria from uh renal cell cancer or ureteric cancer. So, yeah, it could be upstream. Definitely, it could be even further lower stream. It could be like trauma to the urethra. Oh, thanks guys. So I hope you enjoyed it. Hope it was useful. I shared the link to my next session. I'm just gonna share the link to the next surgical session. It's on general surgery next week. Um And it covers a lot of key topics like acute abdomen. So I'd recommend signing up for that too. Yes, you're welcome the problem. Yeah, you're welcome. No, it ok. Ok. Ok. No. Ok. Ok. Oh, you're welcome, Paul. Thanks for coming. Yeah. No problem. Mhm. No. Yeah. Ok. Yeah. Ok. Then everyone. Um, if there are no more questions, um, I'll call tonight. I hope you enjoyed and have a good evening.