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OK. OK. Hi, everyone. Uh I'm, I'm, I'm one of the Urology registrars here in Kingston. And I'm also the foundation for trainee. Um B is the trainee representing body of the British Urological Association. So, if you have any questions or anything, please email me or follow us on Twitter. Um So today I tried to include to think about the most common stuff that you will see on the urology on call mostly as an, but it would also be helpful for everyone who cover the wards. Um It's really hard to cover all the urological emer emergencies in less than an hour. So I didn't include the rare emergencies. I just included the common, common things and how to troubleshoot. Uh Just to give you an idea about the urology team here at Kingston. So we have three F ones, two s one of them is Act two. And the other is Act one. There's three registrars myself and Oliver and we have eight consultants um as you know, go to the surgical eo 24 7, we have us the register from 8 to 5 or six on week days and 8 to 1 over weekends. Um, we are, um, brought it to do other activities. So it's not just on call and doing the ward round. Sometimes we're assisting in theater, sometimes doing clinics at the same time as being on call. Uh, we would really appreciate it if you hand over any complex or unwell patients. Um, I wouldn't mind being called at 730 just by the night. You were saying just so, you know, there's this patient that you need to know about, especially if someone needs to go to theater early in the morning and I'm sure and, and wouldn't mind as well. So, um I've made it into cases just to make it a bit more interesting. Please stop me if you have any questions. Uh So you're on call 3 a.m. 30 year old male patient presents with a painful penis and a problem with the foreskin for the. Can you please see you get the call from A&E triage? They're not sure what's happening. You argue for 10 minutes and then you just decide to go and see the patient yourself. Um Which to be honest, I would cases um you go to the patient and this is what you find any ideas for that. Mm Paraphysis. Yes. Yes. So, as you can see, this is the thymo band. So this is where the tight foreskin is and this is all edema and swelling. Um What happens is um the patient retracts the foreskin and they're unable to pull it back. And if they leave it for a period of time, this is probably longer than six hours. But this is what I could find and Google and then the edema and swelling starts to get worse. And sometimes it's a nightmare, it's reduced. So it is one of the urological emergencies. You have to sort it out when you go and see the patient. Um So just to give you some background. So, fimosis a common neurological emergency, it's uncircumcised men uh or kids for skin becomes strapped behind the corona of the penis. The main concern is that it can cause necro necrosis of the glans penis. And this is what you can see in this picture. Uh The other common presentation that you will have is um patients on board. So they get catheterized in A&E and no one pulls the skin, the foreskin back. They have it for days, complain of pain, everyone thinks it's from the catheter. So again, if you call to see if, if you call to prescribe analgesia for someone who has pain in the penis after catheter insertion, just go and look at them because it might be part immun system uh symptoms that you need to reduce it. It depends on how swollen it is. My go to technique is I try to reduce the swelling. So you apply pressure to where the edema is and slowly increase the pressure. Obviously, if the patient is shouting in pain and it's not allowing to, you allowing you to touch him. You probably would need to call us. So we can do a penile block. Uh, but if, if they're relatively tolerating it, then it just needs time and patience. You can apply Dextro Saline. Uh you can give antibiotics and use a, a needle to pierce it and get the fluid out. But again, I wouldn't do that without a block. It's just not nice for the patients. And then once you're happy that the edema has come down. So I use this technique. So you, you put your two fingers below the tic band and you push the glands in and pull the, the foreskin out until it goes in. And again, you need to apply steady pressure slowly because it can be quite painful. Um, it's just if you use intell, it becomes very slippery and you just can't, you can't do anything. So it's really important to get the swelling down. So pressure, keep the pressure up, uh and slowly increase the pressure and then pull it up and push the glands in. Um, they can be sometimes very difficult to reduce. Um, if we can do a penile block, it's easier because they, they're not in much pain. And again, it depends on the duration. If it's in hours and you haven't done it before. It's, it's not a bad idea to give us a call earlier and say I haven't done it do you mind coming with me and we can just supervise. Are you doing it? So that is for any questions. So with, with that penile block and then if it doesn't work with a penile block, they can, they can, we can do an emergency dosage slip or emergency circumcision on CPO. Uh but most of the time with a block, we can reduce it. So penile block is we uh we use local anesthetic and we, we apply it to block the, the nerves go into the penis. So you just give them local anesthetic. And some we can do circumcisions under a penile block. Some sometimes you can do a gland if it's done correctly. So it's just not of the penis completely in the tip of the penis. Um We wouldn't expect you to do it unless you've seen it done before. So we would come here and inject local anesthetic and then I would do a certain function block as well within your capacity with the onco just identifying it's a paramo trying to reduce it and then time is really crucial. The longer it stays, the harder it is to reduce. And then the sorry in a case like this with necrosis then needs any sort of Yeah. Um you might just once you use it that can often heal, we might get an opinion. But if, if that is the case, then you probably wouldn't send the patient home and, and let us see them. Once you've reduced the para FBS, you need to ask the patient, how many times have they had this problem? Just thinking long term, do we need to see them in clinic or do we list them for a circumcision? And I think if it's daytime on call and we are around, just ask, ask us to see the patient. If you're concerned, then we can just book them for a circumcision and just get it done instead of duplicating that point. Obviously, it depends how hectic and busy it is questions. So if you, if you're out of hours and you like in the evening, let's say, or the weekend, you try to reduce that. You can and, and like you is it, then you just call the on call and be like, yeah, because if you, the longer you leave it, the harder it is to reduce. So it's one of those emergencies that yes, it's not life threatening, but it's time, time dependent. So you want to identify it as early as possible and then try and reduce it. Uh You can Google the mouse uh paraphysis. Um I think they have uh information leaflet and it just tells you what other maneuvers you can do. But this is what I uh there has been a few patients in A&E they applied Dextro saline and it just, the swelling came down. But my experience with it, it just makes it slippery and more difficult. So it's just pressure but patients because it takes time. So you and you, you, you, you're increasing the pressure slowly as the patient tolerates it. So you just hold and squeeze gradually gradually. How long would you hold for 20 minutes or? Yeah, I think, I mean, when you're there, I don't, I don't keep track of time but it's just you, you and if you think it's not, the swelling is not reducing, you've tried, nothing is working. It's fair to call anyone, either us or the consultant overnight. As long as you see the patient very quickly, you just don't leave, leave it because it will get worse with time and then safety net to the patients, especially the kids. If it comes back again and they can't pull the foreskin into the anatomical position, they need to come straight to A&E and not leave it for hours because that would make it even more difficult. Sometimes they're embarrassed. They don't wanna come. Uh The second case is again, you're a night. I don't know why I chose nights as the theme. But uh again, we see this a lot on it might cause you get referred to 45 year old lady presented with abdominal pain, fever, raise inflammatory markers and any I've seen her, they think she has pyonephritis. Can you admit under urology? And one of the things that I want to highlight with these patients is when you take the referral, try to get as much in, I'm sure you all do that but try and get as much information from them as possible because A&E is busy hectic um and things can be missed. So when, when you finally go to see this patient amongst the 10 other referrals that you have, uh she actually has been having back pain for a few weeks. Went to the GP, they thought it might be musculoskeleton gave her some codeine. Um but three days ago, she started having fevers and felt really unwell uh with vomiting. Um So she called an ambulance and came to A&E um the respiratory 2495 she's hypertensive tachycardia and temperature is 39.5. Um And then you look at her past medical history, she's diabetic BMI 54 and uh has obstructive sleep apnea and CPAP. So, um what should you be thinking when you see all of these sepsis? Yeah. So should be bringing your head that this, this is a potentially a very sick patient and you just need to get it sorted. The other thing is in the history is very key is that she had pain for a few weeks and then she had the fever which you keep, which should always raise your um make you think that could this be a stone that she had the colic? And now it's an infected obstructed kidney and it's, it's one of the absolute emergencies. And we do if you've been around long enough doing urology, you will see really sick patients with infected obstructed kidneys going to ICU. Um, and they deteriorate very quickly and they can get better very quickly as well when we treat them. But it's one of those conditions that you just need to always have it in the back of your head. When you hear pyonephritis pain and very unwell patients, uh, you look at her bloods again. She has an AK I EGFR 18 from 90 CRP is 350 lactate is for positive urine that which sometimes you don't have all of it. Um and gentle were given in A&E in the morning again. She's been waiting for maybe 78 hours to be seen and then she was referred and by the time you got to see her, um so all of this should raise the alarms for infected ru the kidney. The key thing to do with management is sepsis. So do your sepsis six properly give them, give fluids. Catheter is important scent cultures because a lot of these patients with stones, they sometimes have some resistant bugs. So if we don't send scent cultures, we don't have any basis in treating them if they get worse um clotting and if there is inr is high or if they're on warfarin or if they take Edoxaban, please make a plan to either stop it, hold it or reverse if they need Vitamin K or anything and arrange for repeat inr in the morning, CT K UB overnight. I think they do. This is one of the indications where they would agree to do act K UB overnight stop nephrotoxic and anticoagulation and involve see early. I think everyone would want to know about a patient this sick. Um even if it means that we're not doing anything in the morning and how we once the sepsis is treated and the patient is stable enough, then we can think about the obstructing the kidney, which is the main treatment. It's like an abscess and you just need to drain it. And there are two ways we can do that. So this is a CT scan. So sorry, would you, would you consult if the patient is really sick? Yeah. Just, yeah. Yeah, I would. Um and uh and this is someone I would call the judge in the morning and say just so, you know, there's this patient I've admitted she either he or she needs sent or nephrostomy. Just so, you know, so we go and see her in the morning first thing. Um So it's a, it's an absolute urological emergencies, resuscitate and keep them by mouth. Do your sepsis. Six, inform the on call urologist and go to see her really early and then they, she will need emergency obstruction of the system. Sometimes if there are no rods and they're really septic and going to ICU, the consultant might need to come and do a center overnight or a nephrostomy. So, um and we have done that before um just to give you a bit of background how we treat them. So, the ster, if it's uh if it's obstructed because of a stone or a tumor or anything that will not be treated in the acute admission, we will mainly treat the sepsis. And that would be either with a stent, which is mostly what we do at Kings stent or with a nephrostomy. And which one you do? It really depends on the patient. Can they have a G A? Can they lie? Supine? Do you have available interventional radiology? Do you have a urologist who can do a stent? Is there x-ray? So it really depends in Kingston, we mostly do uh stents if we can and then if we can't, we do nephrostomy, the benefit of a stent or a nephrostomy, you can do it in patients who are anticoagulated. The main issue is they need to have a AG you can sometimes do it with a flexi um to insert the stent and then after they're treated, we bring them back to treat the stone that that's beyond being on cold. But again, key key messages is make sure you get the history like from the referral, take the uh the information that you need. So you know when to see the patient because a poly nephritis probably can wait, just a non uncomplicated poly nephritis while if someone is infected and septic, you might ask them to do the CT while you were waiting. Um Can you add um for the, because we are referred stone patients with kidney stones all the time and apart from infected. So, which is, you know, uh one of the reasons we have to see them and probably the one that we have to see more urgently like the other um indications or types of uh stones we would accept because uh usually um I asked them like a specific questions to see if they fall into those categories. Because most time they can go, they can go home with kidney and we don't have to be involved. They can go the stone pathway for any uh usually what it is they find on the C can be some sort of nephrosis hydroureter. And uh they are say they are called need to refer based just on that patient. Not, I think there's no way of avoiding that because a lot of CT S get reports urethra and we wouldn't expect you to make a decision on that. So it's always the safest thing to call or if you're not sure overnight. Um It's really hard. So normally we would, if you see from the on course, we would look at the CT and say, oh, this is not significant. I'm happy for this patient to go home. There's no way around it. It's just the way they report CT S. So unless you have you learn the skill of reading the CT scans for, for, for stones, then you won't be able to make that decision. But I, I've come back to stones because I have a, a separate slide for uh stones. Uh I'll just put a few sl one slide on pyonephritis. It's com common in younger women. They can be very sick. Just think about CT ing the patient. If they have really high inflammatory markers are very unwell. It can be, especially diabetic obese patients. It can be emphysema, pinar nephritis, which is again another emergency which I haven't talked about because it's, it is rare or if they have an infected kidney and they need two weeks of antibiotics and you admit them as with anyone with infection, if they're unwell and they can't take oral antibiotics. Um, next one is your typical concerns. I think you get so many of these calls. Yeah, daytime, nighttime, 36 year old patient, three days history of left lung pain. There is um this is what I can find on the internet. Is this what they use at a they perform? I think they have like a pen said they should be able to discharge the patient from any if it's a simple ureteric adrenal stone and refer to the stone pathway, they should only call you, call you with complicated ones who might need admission. Just key things to highlight the nice guidelines for analgesia and renal colic. IV paracetamol. Pr Diclofenac just make sure that they give pr diclofenac when, when the patients have renal colic, the pain is so bad that they vomit. So the absorption or the pr diclofenac works like magic. And then you can go to weak opioids and then, or you probably would notice they would usually say patient has been given morphine and the pain is steady there. They haven't given diclofenac. So make sure you give diclofenac. If you're sending the patient home, send them home with diclofenac. Uh or roughly for all stones, less than five millimeters, there's only 70% chance of passage, regardless where the stone is stones for 5 to 10. It's around 50% spontaneous passage rate. Again, it depends if the stone is uh proximal. Um this stones in the kidney, they rarely cause acute problems. So these can be seen as a routine um outpatient stones in the ureter, that's when we, when we need urgent outpatient referrals. And that's why they have these, the, the colic pathway where you refer them to the clinic. And it depends where the stone is, but roughly the more distal the stone closer to the bladder, the smaller it is the, the more likely it is to pass on its own. You just need to give them analgesia and safety net. It's really important to document that you've given them safety net advice to return. If pain is worsening despite analgesia, they have fever or they become unwell or they're just vomiting and not feeling great. So they need to come back. Um Yeah, if, if the it's reported as hydronephrosis or stranding, then you, you probably will need to discuss it with us. And we look at the CT and make and make a decision whether the patient can go home or not. But what we want to know when, when we get the call is Asian background. Does the patient have two kidneys? And what's the renal function? Is there infection? So the urine dip and fever, is there an AK again CT scan, we normally look at it. The size and location of the stone is the pain controlled. And that what we're trying to decide is can this patient go home and you may have seen if you're on call with me if, if, if it's visible on this count, I sometimes refer them for shock wave lithotripsy directly and just put them in clinic instead of duplicating the appointment. It just gives the patient something if, if they're interested. So again, if it's daytime and you're not sure if it's a big stone, just give us a call and, and we can advise you but just have all the information. How quickly do they get? Um it should be within 2 to 3 weeks. So all these stone prefers get triaged by the consultant or us. And then depending on where the stone is and we look at the scan and we either defer them for shock wave treatment at them or so it's useful if we're on call just to see the patient and get that treatment started, which are what I tend to do. And I'm sure it's necessarily need to. You can just, no, that's where it becomes. Yeah, you can give them oral Comox. But I would discuss that with the, with the. Yeah. Um, another thing is because they, they are usually given the which is not good. Like so if they tell you it's not very effective, no, it's not. You, you can give it with spasms but it's mainly the diclofenac that helps with the pain. Um And you will see that they would be desperate to try anything during colic patients. It's one of the most painful conditions. Um First case, I think it's what you're all scared of. So you're called by pediatrics, A&E 14 year old unilateral testicular pain, three hours. Can you review the patient again? Anyone with testicular pain within the age group? So kids and like early twenties, I go and see them go and see them immediately and just make a decision, make sure they do a urine dip and ask them to give the patient little by mask because the amount of patients we go and see and they're having a sandwich is just um um if this is that is ok, if the R function is ok and if they don't have any other contraindications, so I found this very useful. I found it on Twitter. It's called uh it's, it's done by um a website called Pe Cases and they do like a pathway for torsion anticipator pain. And I think it's just worth having it on your phone. I have the QR code for it at the end. Um And it just gives you what's the pain findings on examination, which I'm sure you all know. Um and then diagnosis for di and twist score. So you've been told that we're now using twist score. So if you're calling us or the consultant, we would expect that you have the twist score handy, you're in dip and then examine the patient. And I think the more patients you examine and the more patients you see, the more you will know what it's like to have torsion. But your mindset when seeing someone with torsion, if there's no other differential diagnosis and you can't rule it out, then they probably would need an explanation, especially in teenagers and early patients in their early twenties. So it will be sudden onset pain, severe. It's really important to know the timeline and just document it clearly and document when you've seen them. So medically, um you've covered your bases, you want the urine depth, sexual history and any history of trauma and then examination, usually it's very tender. Sometimes you can't feel the horizontal light. It's just when you touch them, they will jump and I normally look at the patient when they come from the waiting room, they sometimes limp. The ones who have torsion from the pain while if someone is walking and or a kid is running into the examination room, you're slightly a bit more assured that this is not unlikely to be torsion, nausea and vomiting is very important and then do the twist score. Um And if we can't rule it out clinically, then they will need to be to have testicular um scrotal exploration. Uh We use b leaflets for the patients. But now with e consent, it's much easier if you need to consent, the patient to make sure that you mark the side that we're um exploring as well. Um intraoperatively if we find that it's we untwist it and put it back in an position and see if it goes back to normal color. If it does, then we do orchidopexy and fix the other side. If not, then orchidectomy and fix the other side. Um You will find different evidence for fixing negative explorations. Some people would say just put it back on the scrotum. Others would say you've already explored the scrotum. Once more I fix, it depends. Um So history is really important. Always examine the patient, get a urine dip early, keep them in by mouth if in doubt it's torsion until proven otherwise. And then use the twist score. I think there will be um a pathway coming for testicular torsion soon it's not ready yet. So once it is recirculated, these are the main things. It's one of those difficult. Um, you have to see the patient and assess one by one. If you think it can be torsion, you call the boss. If you think it's clearly something else they have fever, it's red, it's hot, um, positive urine there. It's been there for days, then it's unlikely to be torsion. But if it's a short history, acute sudden onset pain and the examinations are very tender, then we have to explore it. Um again, differentials, it can be hernias, infection, trauma, and especially in young men, ureteric stones, they do get referred pain if the stone is distant. So if all is negative and they have hematuria on the urine, that may be worth getting a CT again, I find this when I was in sri found it very useful. I had it on my phone. So it has all the differentials on it. It's really nice and colorful. Most of the time this you find it when you explore the patient. But on examination, it's really hard to, to know the difference between the 22. So you, you end up most of the time exploring them because you think it's testicular torsion. And normally when we explore them, we take off the appendage with like scissors or the isolated. Yeah, it's really hard. So if, if you, if you, if it's definitely that and you have an ultrasound and the testicle is fine and you can feel the core and you can feel the testicle, then you can justify not exploring them. But most of the times you end up exploring them and finding it on exploration in terms of it's the same. Yeah, it's the same presentation as torsion. He I think this is the pain of our hematuria. Um So if we would tell you that this is more than 50% of our in patients most of the time. So you're on call, busy shift, sorry, it's shift. Uh You receive a call from A&E that referring an 80 year old patient with hematuria. Yeah, patient is known to urology of course. Um and this is the fourth hematuria referral of the day. So what do you do? So I just wanted to improve. I don't know if the colors are what? So this is, this is dark urine. So on my screen, it's showing differently. So I contrast the light. Oh Yeah, maybe. So you see this is hematuria, this is proper active hematuria. So this is where we get really worried and involved. Um This you can see the tubing is clear. This is probably close to your P or to your BT. So the tubing is clear, but what's here is hematuria. So this is rose. Um again, this is dark, I'd say this is dark urine, there's no clots, it looks more brownish and this is rose color. So you take a bit of history. So has been passing blood in the urine for a few weeks, see some clots and for the past six hours, he's been unable to pass urine with lower abdominal pain. He looks in pain a bit tachycardic. And you, you've examined the abdomen, there's palpable bladder clots are pending. So the key is to think this patient is in clot retention and, and I think the issue with these patients for you guys is that they take a lot of time to manage. Even though it's a simple, it's a sim relatively simple presentation. So you go and see them insert a three way catheter. The biggest catheter you can find. So always take a 22 French in this hospital in other places, they have 24 but the biggest here is 22 and take a curve tip with you as well. If you need it, once you put three, the the six is the urology theater and you can find the curve tip and yeah, just grab it. Um Once you put the catheter in, you inflate the balloon, uh these catheters can take up to 15 minutes. So I would normally put 30 minutes in the balloon for two way catheters. Uh and then you have the two channels. So, so there's the, this is the balloon, this is the irrigation channel and this is the main channel, the biggest channel. And the idea is if you put an A team. Just remember that it, there would be a challenge for the balloon and channel for IG. So it ends up being a small catheter. So at least the 22 French, if you can, if you can get it in, once the catheter is in, you need to do a decent washout. Don't depend on any or the nurses to do it. A decent washout. We use one or 2 L of wash out to get the clots out. And the idea is these patients will have lots of clots in their bladder. If you start the irrigation, that will not clear, the clots irrigation will only prevent further clots from forming. So you need to clear whatever is in their bladder. So sometimes you put it in and you just aspirate and it's loads of clots coming out and you just keep aspirating until you can't anymore. And then you start a wash out. Are you all happy doing bladder washouts? So, can you pass the? So this is what you use, either sterile water, you can find it on a or Alex, just take it down with you to A&E um And then you have the bladder syringe and you need a sterile pot or anything. You put the water in here and you fill up the syringe. And the key is to keep track of how much you're putting in and how much you're taking out if it's going in and out easily. And the urine looks clear. Then the bladder doesn't have any clots in it. If you push it in and you withdraw and there's only 10 minutes coming out. It means there's a clot. So you just need to maneuver your catheter and turn it around. So you can wash out the bladder and, and you can just take lots of clots out. Once you're happy and satisfied that the ate, that the bladder is clear and your family wash out, then you start the aggregation and that will probably prevent you from getting bleeped overnight because the catheter will keep blocking if a proper washout is not done and the patient will be in discomfort, especially if they're left in A&E waiting for bed. So it's really, really important to do a decent workout. And you see in the war when we come and see all of these patients, we take more stuff with us and do it on, on the ward and just treat it as any bleeding, do clotting poop and save if they have an HB drop. If they've been bleeding for a while, we've had a few patients just before Christmas who needed transfusions. And one of them had the period of a scro from hematuria. So sometimes it can be severe. Um and it would be more like this color. If it's, if it's active, this is active bleeding. And then you, you need to think why they have hematuria in the acute phase is there, infections start them on antibiotics or is it prostate? We would do ad re on everyone. So if you, you want, you can do one and then it just stay fluids, blood sample can say. But the most important thing is to tell the patient as well if they don't have dementia that if your bladder starts to feel full and you're in pain, you need to call the nurses to stop the irrigation because what you don't want is the catheter blocking and the irrigation keeps going in and not coming out. So they, they just need to be aware of in and out. Ok. So this is for the ones in clot retention. So this is the catheter, the freeway. Um Are you all happy with three ways? Yeah. And then we have uh 63 ways COVID. If you, if you put the three ray in and at the prostate, you feel resistance just don't push it, take it out and try with the code and with the code tick, you, you, you always want the, the curve facing upwards and once you put it in, there's no way of knowing. So you either need to orientate yourself with the balloon port or the white line and you see some catheters, the line is on the side, some catheters, it's below. So once it's in, just make sure you're orientated where it is and just push it all the way down. I always use two Instagel for men. Any cancer. Do you do the wash out? Is it, um, you go out from the drainage then? Yes, from the drainage. So you sp up the third channel and then you push in through the drainage and out, in and out, in and out until you get all the clots out the drain. And, no, no, it's, it's the, it's through the same channel. You just do it in and out and get the clots out. It's just important to keep track of how much you're putting in and out because you don't want to be filling the bladder with a liter and you're not getting anything out. So, if you try a couple of 100 minutes and you can't get it out, then you're not getting anything. Ok. There's the green that you find it on the words, um, that's green, it's green, same one they use for an, uh, so, um, you don't like TX A. So I think it makes the clots a bit sticky. Yeah. So, TX A, it's, I personally would want to know that the bladder is, is clear of clots because it can make clots, um, very sticky. So, if you've done, it's not first line and evidence is a bit you about it. So we do sometimes give it if, if we've done a war out patient is still bleeding. But if you think there's still clots in there, then I wouldn't give you, we'll see the patient first um and that is mainly clot retention. That's the main reason why we admit patients other hematuria. So, non visible hematuria, visible hematuria where the patient can still pass urine. They don't have any clots, they don't need admission. They just need uh either to be treated and a two week wait referral, which can be done by the GP and they get a flexible cystoscopy and a CT urogram. So when you get the referral and how dark is the urine is there clots is the patient in retention. Do they have a uti that could be why uh patients with catheters? And I'm sure you've all seen this before. Uh if there is very, you go and see the patient and it's very dark old streak of blood in the catheter and the bag is empty. You just think that the catheter is not in the right place. And most of the time you put in a three way and the urine is clear, it's a bit of a clinical judgment. So if you, if you go and see the patient and then this, this much of the catheter is out, the catheter is not in, in the bladder. So, and if it doesn't move, you take it out and most of the time I just take my chances and put a two way and it's clear and then you can just turn them down and get them out across if it's just that um always check the catheter position and then irrigation will prevent further clots from forming, but it will not clear existing clots. So you still need to do a bladder wall out and again, do it yourself, please because it just saves you and the patient catheter blockage and it just can be a nightmare. Uh Any questions about hematuria hypertension? I didn't go into details about the like pathophysiology and all of that because you can read that I just went into clinical. But if you have any questions, I'm happy to answer them a few sides on acute retention. So, acute painful retention, it's inability to void. And usually once you pass the catheter, they'd be extremely happy patients and not so much in pain should be managed by A&E normally they have pathways, they put the catheter in. If it's BPH, they start them with the same constipation, give them um laxatives and book them for appointment in two weeks. Uh just put a few things about high pressure, chronic retention because that's the other thing where you get cold. So if a patient comes in for any reason or, and they put in a catheter, more than a liter is drained um from their catheter at the, at the first instance. And then the adrenal function is the range and this is high pressure chronic retention. And they all of them mostly need admissions mainly because we look at their hourly input output, they get diuresis. So after the kidneys are decompressed. They start producing lots of urine because they're now decompressed and that can lead to dangerous electrolyte disturbances. So we always admit them and say hourly input output monitoring. They're producing more, roughly more than 250 to 300 MS of urine per hour for two hours. And this is post obstructive diuresis and they need I viv fluids or oral fluids. Most of the time we give them IV and we replace 50% of the losses. So it's a lot of work for the nurses because they need to check every hour how much urine has come out and then adjust the fluids based on that. So you, most of the time you will need to explain it to the nurse. You said um they use the knees and these would be not for top until definition of treatment because if you drop them, they would retain again. Any questions about hypertension in general do ad re always in, in women. Why do you get that class of someone? They do? Sometimes they have strictures or they have cystoceles. And it's, it's not as common as in men, but we've seen a few recently where they've had chronic high pressure, chronic retention and you, if you scan them, you would find bilateral hydronephrosis as well and that's all from the pressure and it tends to resolve after um catheterizing them. So even if all the bloods are completely normal, if they're more than 1000 mils, if their bloods are completely normal and they have more, 1000 meds and you catheterize them, A&E shouldn't defer them unless they're di, or they think it's, it depends if it's painful or painless, chronic retention is normally painless. So they're not in pain or if it's acute painful retention and it's 1.1 L and it's completely relieved. It's only for six hours. Sometimes there's acute and chronic. But, uh, but mainly for chronic retention, it's large volume, more than a liter. Hydronephrosis or an AK I how long, how long do you monitor for post obstructive diaries? Is that something? Say, say you see a patient at 8 p.m. Yeah. And you sort them out. Um If, if they have api would admit them, if they have a de and function, I would admit them and monitor for diuresis. If only it was high, it was high. 40 because I had a patient like that. He just had some uh I think it's sodium just a Yeah. But he did have a, so what was the volume? It was, it was a lot. It was like over 1000. Yeah. So was it painful, painless? It was pain. Yeah. Yeah. So that's where it becomes acute on chronic. So the, the key with chronic high pre chronic, high pressure retention is completely painless. And sometimes they're picked up on CT S they come with abdominal masses and they get a CT and then they refer it to, it's painless um with an AK I or, or deranged adrenal function and diuresis, they need admission and they start di hours afterwards. And that's why it's really important for whoever catheterizes the patient to document the residual volume because that makes a difference whether they can be talked or not. Ok. Uh So catheters, we have different sizes uh and different shapes of catheters. So we have um Lasix catheters, which are mostly short term. So if you're sending someone with high pressure, chronic retention, you need to think about what catheter type they have because they're going to have it until they have the T RP or hold it. So you can, you need to change it or look them for change of catheter quite soon. Then we have two way and three way catheters and then we have open ended catheters as well, which I brought you. Um And we use these for difficult catheterization. You see tip is not there and pass uh through it and then straight tip and co again. So code T is very useful for enlarged prostate. So you have, you have the prostate and if you go in with a straight tip, it just hits the bottom, right. If you go in with a curve tip, the idea is that it slides over the enlarged prostate, but you need to make sure it's facing, facing up, there's so much resistance and you can't get it in stop and so on. Um, and then again for, um, for Hematuria, it's really important to get the biggest catheter you can find because a lot of the times they have 18 and we go in the water in the morning and we have to change it to 22. So, um, I know a lot of the time A&E insert it if you are doing it, just put a big one, uh, top tips for catheters. So use two instills in me. I always do that. It does not only that, it gives lubrication, but if you put two intels in and they go in nicely, you nicely distended, the urethra and you know, your catheter is gonna go in. It's very unlikely once. If you, if the intell goes into the catheter doesn't go in traction of the penis to send the urethra, don't be scared. Uh pull it all the way up and then straighten it when you're about to go to the prostate, I use 1416, uh sitting in in men and the silicone catheters can be a bit stiffer and less fiddly than the uh Lasix one. So if you can't get a Lasix one, maybe probably with the silicon, it's just easier to put in, if not sure. Don't push if resistant prosthetic urethra use curve tip and if the catheter is not going in at all and you feel like you're hitting a wall that's a stricture and you need to stop, not create those passages. You can use 12 or even pediatric 1010 French, if someone is in acute retention due to a stricture, just a small fine. Um And then if they, if, if you, you probably would be called the consultant overnight and they might ask you to aspirate, which is needs to be a full bladder, use a green needle and you just put it above the sepsis pubis and aspirate urine to make the patient comfortable in the morning. Um The other thing that you probably you would be called about is falling cal again, I would go and see these patients quickly because if you get it back in, it's like pulling out p tubes and all these tubes. If you get it back in, you spare the patient a lot of trouble. So go and see them check when it was inserted. If it's a new tract, you pro you can try and put it back in. But if it's been inserted a week or so ago, very uncommon. Normally these are patients with established tracts. They probably have bladder stones or some sort of infection or bladder spasm. The, the catheters keep coming up, um, try and put it back in. So again, clean, put in a gel. If they're still leaking from the truck, that's a good sign. It means that there's still a chance to push, to push it back in, reinsert the same size or smaller if you can't get uh the same size in the key thing is to distract these patients because the most of the times you can't get it in because of tense abdominal muscles. So if you, if you talk with them and distract them and you just push it in while you're talking to them, a lot of the time it goes back in. If you can't be, insert it, check why it was put in. Can they have the urethral catheter put in or is it just for incontinence or were they in retention or is it a completely obliterated urethra? Um if they're comfortable and you can't get it in, I probably wouldn't call the consultant. But if they're in pain and you can't catheterize them, reduce to, they're in acute retension, you probably would need to call someone. And again in the morning, it's nice to know about them because we can go and try first thing and if you can get it in relief for everyone, if not, uh but time is really important. So, um ideally A&E should try and put it back in when they come through the door and if not just call you because a lot of the time they don't need blood, they don't need anything. If you put it back in, you can just send them back to a care home or wherever that is. Um These are some I thought used for resources. So while I was preparing this Bristol Urological Institute, they have a lot of documents about was and cat troubleshooting. So I just put the link. Um and then I've included some of the other emergencies. So, priapism, which is a painful reduction of the penis. Um We don't see it very frequently, but if you get the referral, you can just look at the v consensus and it just tells you how to patient say for penile fracture and then Corina, which ideally shouldn't come to you. But if someone comes in with back pain retention, you should think about and you have uh have released a new document to a to get referral and MRI S, they're working the links because I did them two weeks ago and then bladder wash out how to do it. There was a good urology. I saw some recently with um really vague ventral slip due to long term catheter. I do anything that we, we sometimes get them to have a ubic catheter. So you see it a lot with long term catheters, they get ventral hi. Um and it can be uncomfortable. It depends how fit the patient, why they have the catheter. Sometimes you can offer them ubic catheter because II just Reche him. Yes, they can get it in. Yeah. Unless they're symptomatic and quite painful or if it's like a 90 year old, probably relieve it. It was, he was like a nursing home. But if it's someone more more, then you can get them in clinic and we can think about. OK. Uh I put some slides about why you can choose urology as a car. Yeah. So we, we do have a variety of subspecialties. We have open robotic and endoscopic operating we have, by the way. Yeah, it's five years training as to other surgical specialties. So we finished training at seven. You, you can operate seat for a lot of this stuff, especially the endoscopic uh surgeries. There's lots of research opportunities. It is a small community and our own courses are busy and hectic. I'm sure you all know that. But sometimes you a lot of the times you make a difference, immediate difference to the patients. We have a variety of patient groups. So we see the 90 year olds with hematuria and the 1412 year old group with testicular torsion and it has a bit of a balance between surgical and medical interventions. We do manage the patient as a whole sometimes a lot of times. Uh yeah, especially like the ne bladders. Yeah, it's reconstruction. It has a lot. So if you want to be a cancer surgeon, yeah, there's so much you can do if you want to be a reconstructive surgeon and manage function in patients. There's a lot to do. There's a lot in between. There's so many sub specialties. Think about it come and do a surgery with us. Um If you have any questions, please email or ask for phone or us or anyone and you said earlier about looking them in for a change. How do you do that? Uh, so as far as I know you can correct me because you've been here longer, uh, if it's done in the community all the time, then you can just ask the nurses to do the community referral for the change of catheter. If it's a new or difficult catheter, you can do the cr clinic and just write on it, change your catheter and put the size. Ok. So it's the same. Yeah. Yeah. It's just you, you just write on it and in general you can send an e-mail to the, like the generic urology. It may, they are pretty healthy. They're very for everything. Yeah. Yeah. And they're pretty in terms of the, so usually you use the silicon two way catheters for sics and it depends what, what they have. So, they would tell you, I have, uh, 1618, the same, the same, same catheter. I didn't go into how to change it because of time. But, uh, they mainly if, if, if they're coming. So if you want to change a catheter on the ward, come in the flexi clinic if you want to change the catheter on the wall, um, then fill the bladder with a bladder strech 200 minutes just to know that your, that the bladder is full and you take it out, put in cel and put the new one in and you can change gloves in between. Um, or if you have someone with you, someone can sit out and you just put the new one in and as if urine is draining, you only need to put it beyond the balloon. Like for the skin, depending on that, uh, says if we can arrange, um, penile penile block like uh, lessons, yeah, we can, we can show you, but with penile blocks you have to do it and yeah, supervise and make sure that it works and cause if you do one and it doesn't work, then we can. Yeah, definitely don't try to. Yeah, we, we won't expect you to do that.