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Hello, everyone. Um Can you please let me know if you can hear me in the chat box? Ok, perfect. Um So we'll be starting with um urological emergencies, which is today's topic. Um If you guys have any questions, um, just put them in the chat box and I'll try and answer them. Um So these will be some of the topics that we're covering today. Unfortunately, we won't be covering all of them, but we are covering most of them. Um The questions the session will be question based. Um And then we'll learn a bit more about them. So this is the first scenario, feel free to have a read, put the answer that you've got in the chat box. So the case is, um, there's a 45 year old male who's presented to the Ed with excruciating left-sided pain. What do you think is the likely diagnosis? Um So when you start looking at somebody like this in the Ed, what do you think you would um, do first? So you would start by doing a bit of Socrates, you ask them a bit more question and yes, this is going to be, you will be able to access the slides later at the end of this session. Um And so what you're gonna do is you're gonna start by asking questions when you see such a patient and in your A&E. Um, and you'll do a Socrates. So when you've done a Socrates, you've found out the patients told you they've got excruciating, left-sided flank pain, which is radiating to the groin and they've described the pain as intermittent pain and it's very sharp. Um You decide to ask a few more questions and then you find out that there's uh no hematuria that's associated with this. Um But the patient says he's feeling a bit nauseous. And so as you've mentioned, this is renal colic and it is due to uh renal stones. So we'll see a bit more about renal stones. So this is a really nice um slide that you can find on osmosis, which I think summarizes everything regarding renal stones pretty well. Um So renal stones as we know they'll occur if there's a lot of um dehydration, usually if there's certain types of crystals that are excessively um accumulated. Um And there could be other dietary factors as well which will um he cause renal stones. Um So the type of stones, um there's largely um two types. So there's calcium based and non calcium based. So the most common stones will be um which is about 80% will be uh calcium oxalate. Um And then the next, most commonly found would be calcium phosphate, um, calcium because if you've got a high amount of calcium in your body due to dietary factors or other things. Um Or if you have a low urine output as well, they are the two high highest risk factors for these type of stones. Other types you will see is uric acid stones. Um these are not usually visible on x rays. Um You'll have struvite which is actually produced by a bacteria. So it's associated with infection. Um, and then you have cystine, uh, stones which is associated with something called cystinuria. Um, and that's basically an autosomal recessive, um, disease, which sort of predisposes you to having these, um, other type which isn't mentioned here will be a staghorn, um, calculi. Um, as you can see it on the right there in the kidney. Um, it shows you two tiny small stones. So those that's the area exactly where the staghorn calculus would be formed. Um, and it's called as a staghorn calculus because it looks like, uh, deer antilla. Um, so that's why a deer stag mm Staghorn. Um And you can definitely see those on a plain x as well. Um, most commonly a staghorn, uh, calculi will be formed, um, because of stones that are made of strew white. Um, so you would see patients with recurrent, uh, UTIs will have them very often. So what happens is the bacteria, um, in your kidneys is hydrolyzing um the urea that's present in the urine and it's turning it into ammonia and that's what causes this, um, strew white to form. Um And as you can see that, um the, the kind of presentation that you will see depends on where the stone is present. So if it's present in the renal pelvis, then typically, if it's smaller and if it's not staghorn, you will not have any symptoms in particular. But once it starts moving down into the ureter, there's going to be spasm of the smooth muscles um, in your ureter. And that's going to cause this classic, um, renal colic pain that patients, uh, talk about. You also have nausea and vomiting present. Um, if the stones are in the bladder, um, you will have this, uh, sensation of urgency or wanting to empty out your bladder. Um, but actually, there is, there's nothing to empty out. It's just the stones pressing against the bladder. And, um, that's what causes this sort of discomfort. Um, ok. So that's all about, uh, renal stones, um, as for the treatment. So what you can before the treatment, you're gonna do some investigations as well. So you do a urine dipstick that will help you see if there's any hematuria. Um, in case there's any stones. Um, however, a normal, uh, urine dipstick doesn't automatically, um, rule out the presence of any stones, but it can be helpful to identify any infection. So, therefore you do a urinalysis. Um You can do blood test to check for any signs of infection, check for renal function. Um also can do it um to check for any calcium levels. So, if it's high risk calcium, then you automatically know that they might, that's what um is causing the renal stones. And you can then um correct that you do an abdominal X ray as we talked about um before the calcium based stones will show up on there, but the uric acid stones will not because they're radio loosened. Um And then you can also do a CT Kub, which is the classic one that we always go for. And that is the choice of diagnosis for uh uh renal stone. So if you have a colicky patient in your exams or in your sys and the first uh line investigation, you should be offering is a CT Kub and the urinalysis and blood tests and other things can come later. Um for um uh treatment purposes, you can give them nsaids. So the most famous one is you give I uh im diclofenac. Um You could also be giving them IV paracetamol if they uh can't tolerate nsaids. Um you could give opioids as well, but that's not typically done and it's not routinely used for this sort of col pain management. Um If they have nausea and vomiting, you might wanna give them antiemetics. If there's any infection, you give them antibiotics. Um And if they uh have small stones, then you can give them tamsulosin and tamsulosin will just help loosen everything um and help pass the uh stone spontaneously. Um Other thing that we do normally is if it's less than five millimeters, then uh we're going to do something called watchful, waiting, basically, wait for it to pass and hopefully, um you don't need any interventions. However, if the stones are bigger than that, um especially if they're about 5 to 10 millimeters, you're gonna go for something more invasive. So, as you can see in this diagram, uh something like lithotripsy um is an option that you can uh opt for. Um OK. So let's move on to the next case, you can have a read and put your answers um in the chat box. So again, you've got a 17 year old male this time and he's got an urgency with l uh he's sorry, he's presented urgently and he's got unilateral testicular pain. Um So if you think about the diagnosis, what do you think um is happening over here? Um So you decide to ask a few more questions um to this 70 year old patient. Um And you do a bit of Socrates. So you find out that this pain has started quite suddenly, you find out there's no history of trauma and you find out the pain is not relieved by rest when you examine this patient. Um You find out that the affected testicle is quite swollen and it's very tender. Does that help with um the answers for anybody? A sudden onset pain? No history of trauma. What do you think is the causative diagnosis? Right. So, it would be a testicular torsion? Ok. And in testicular torsion you're going to have absent uh cremasteric reflexes. Ok. So let's talk about testicular torsion further. So, testicular torsion is going to, it's basically what it sounds like is a twisting of your spermatic cord. Um It is a urological emergency. So you shouldn't, if you are suspicious, you shouldn't um wait around for anything, any sort of confirmation, you should immediately uh raise it to a senior and have them go in um for surgery. Um Any delay in treatment can also cause ischemia. It can cause necrosis of the testicle and that can further cause either subfertility or complete loss of fertility. Um uh typically your patient that you see will be a teenage boy and, but actually testicular torsion can occur in any age. Um, something that might help you in the history is maybe there's a recurrent symptom um of intermittent testicular torsion. So they might be complaining of pain onset every now and again, which resolves and that happens frequent enough and then now it's become really bad. So that would help you sort of um narrow things down. Um If you've got um a patient like this who's in severe pain, you're not gonna exactly go and examine them first time. So you're gonna ask them a few questions, ask them what triggered it, maybe it's while they were playing sports. So just ask them about what they were doing at the time. Um Normally it's quite acute and it's normally also unilateral, it's not bilateral. Um So that should also help you narrow down your diagnosis. Sometimes they'll come in with abdominal pain and vomiting as well. Um But sometimes they can come in with a ABDO pain only and no other pain. So, whilst you're doing abdo pain, if everything is nice and soft and you're still not understanding what exactly is going on, then you might want to further expand into a testicular exam or even a digital rectal exam to cover other things. Um So if you do start examining, you'll find a firm swollen testicle, you'll find that it's more elevated. Um You'll find the cremasteric reflex is not present and you'll find that there's an abnormal eye. So, as you can see in the diagram here, um is going to be quite often um be horizontal rather than how it is normally. Um And it would be rotated in a weird way where the epididymis which is usually sort of flying at the back of the testicle is um now not going to be sort of posteriorly uh present anymore. If you have any doubts, you should immediately seek um urological senior support and ask them for their opinion. Ok. Um So you can see something about bell clapper deformity, basically. Um bell clapper deformity is one of the causes of testicular torsion. Um What happens is that the testicle is normally fixed at the tunica vaginalis. And in this deformity, the fixation that's present between the testicle and the uh tunica vaginalis is not present. So it's sort of free floating um in the scrotal sac um and normally will just hang in a ver particular uh vertical position. And so it's a sort of free floating, it's both horizontal, sorry. Um And that just make, makes it easier for it to twist around, um quite easily and sort of rotate. So it's gonna turn around on itself, sort of stop, cut off the blood supply and then that's gonna um kick off everything um for managing testicular torsion, you will uh keep the patient by mouth as soon as you figure out that it is testicular torsion. Um You uh give them any analgesia that might be required, get urology immediately. Um And then they're gonna do a surgical exploration of the scrotum. Normally can do an A uh which is basically where you correct the um testicle and put it back into its original position or they might do an orchidectomy, which is where they will remove the entire testicle. Um But that's only if the surgery has been delayed and there's nothing else we can do only when will they remove it. So, it's usually a last-minute option. Um Sometimes you might consider doing a scrotal ultrasound if you aren't quite sure about what's going on. Um, but if you try and go through any of these sort of investigations and delay surgery, then you shouldn't be going for it. You should be going for surgery first. Um, however, if you do end up going for ultrasound, um, what you will see is a whirlpool sign which is basically the spherical, um, sort of tornado appearance, um, of the spermatic cord and the blood vessels. That's just the Hallmark image you'll see. Ok. Right. So this is the, um, further information on investigations. So as I mentioned, it's a 4 to 6 hour window. Um, you could do an ultrasound and you can also rule out infections, um, by doing other basic beds whilst they prepping for surgery. And, yeah, and as you can see that there's a, uh, if you see them within this 4 to 6 hour window, the success rate of the surgery is much higher. But if you perform it, um, anytime after even 12 hours later, um, then it can cut down significantly. Ok. So here's our next case. So we've got a 60 year old male this time, he's present presenting with a sudden inability to pass urine. So what do you think is the likely cause? And how would you approach this patient this time? Um, as we've discussed in all the other questions so far, you're going to go to this patient when you see them and start doing a Socrates. So when you do the Socrates, you find out that this patient's um pain is, um this symptom is uh accompanied by lower abdominal discomfort. Then you ask them if they've got any history of recent infections and they deny any infections. So, what do you guys think it is? Feel free to put your answers in the chat box cause a 60 year old male not able to pass urine, no signs of infection but lower abdominal discomfort. Ok. So the answer would be uh prostatic hypertrophy. So it's gonna be b um it's not that deep, to be honest, this question. Um The main reason for it to it could be other reasons. It can be bladder stones, it can be other, other thing options over there. But just because a male patient of a specific sort of age group is presenting with these sort of symptoms, um then that just makes it more likely. So it's just the clinical presentation makes um prostatic hypertrophy the most um obvious sort of most common cause um in the sort of patient demographic. So we've got another question this time. It's a 60 year old uh female who's presenting with this uh similar symptoms, they aren't able to pass urine. Um but it's accompanied by abdominal discomfort as well. She's also saying there's no recent infections. So you start figuring out what's going on with her. Um And you find out a few more things about what's going on with her this time. Um Because you aren't really sure what's happening. So you decide to do a bit more, put, put a bit more effort this time. Um You start taking a Socrates, you find out the pain. Where is it? It's in the suprapubic region. Does it go anywhere? No, it doesn't go anywhere. Um And then you ask if they, when was the last time they were able to pass urine. So she's telling you that um she's not been able to pass urine in the last 24 hours despite the sensation of needing to avoid. Ok. So it's definitely um urinary retention. Now, what's go, what else could be going on? So you decide to put in a bit more effort and also ask about the past medical history for this patient. Find out this patient has uh hypertension, hypercholesterolemia and depression. Um You decide to do an examination, find that the suprapubic region is got a palpable bladder and is quite tender. So, with all of this information that I've given now, um what do you guys think is the most likely cause um of this patient? So this is different from the last question where it was a 60 year old male. Now, this time we have a 60 year old female. Um Any answers anybody. Yes. Right. So the answer is d it's amitriptyline. Um Amitriptyline is a Trisil antidepressant, um which is an anticholinergic. So, what happens is your acetylcholine neurotransmitters are sending signals to your bladder to contract and void. Um But you've got the um tricil an antidepressant here with the anticholinergic uh effect and it's blocking the acetylcholine transmission. So, your bladder is not contracting and that's what's causing this um, woman's um urinary retention this time. Um So there you go. That's your answer for this one. So here's just a few more um causes of urinary retention. Um We're quite short on time. So we aren't covering all of them. Um But always try and think about it broadly. If, if it's obstructive, is it caused by inflammation or infection? Is it neurological? So, always ask them questions about that if they can, uh if they've still got the sensation down below, that's a very important question. And if all else fails, definitely go into the medication history. Um typically the medicines causing this would be anticholinergic uh drugs. So, keep that in mind. Ok. So as for symptoms of acute urinary retention, um you can see it typically be sort of acute pain that's come on. Uh suddenly it's not gonna be a chronic history, it'll typically be suprapubic pain. Um They'll also come in with quite a bit of discomfort, as you can imagine. Um Normally there's an urge present but they aren't able to um void their bladder. Um You'll feel a suprapubic tenderness and usually you can feel uh bladder as well. You can consider doing ad re or acute urinary retention uh symptoms because it might be caused by either the prostate or it could be fecal infection. Maybe they're constipated. So you should think about that. If they've got any uh fever, then you should consider if this uh is being caused by infection. So you can further do um um some more bloods to figure that out. Um If they've been recently catheterized, maybe that's what's um causing an issue, maybe the catheter is blocked, maybe there's a clot retention, maybe there's some hematuria. So always think about those things when you guys are doing your oy or when you see these patients in as an F one or as a doctor, just, I don't know what level you guys are at the moment. Um So further investigations that you'll do is a bladder scan. So always remember um in the bladder scan, if it's less than 400 mils, that's normal. If it's anything more and especially anything more than a liter, then you definitely have a high amount of urine. Uh So that means urgently looked at, looking at, um and if you can't sort it out, definitely seek see your attention. So you'll do the bloods, look for any infections, check for renal function and because there's going to be a consequence um of all of this urine sort of backing up into your kidneys as well. Um And then you can do an ultrasound as well. So that will help look for any signs of any hydronephrosis. So, on the back of the urine can cause that. How do you treat this? Um So number one would be to catheterize and make sure that you are measuring the volume of the urine when, when you're catheterizing them, be both before and after. So when you're doing your bladder scans, and then you need to look into how much is left in there as uh as well as how much you've got out um into the catheter bag. Now, um, the second one would be to sort of start looking for medications. So you can start with tamsulosin. It's gonna help relax the bladder, start the flow of urine. Um, you can also in medications, look at anything that can be reversed as we've discussed before. There's any active infections, then you can start treating them, send them for urine culture immediately. So you can have more specific, um, drugs that you can deal with, um, to help with the infections. And then you can also do an uh output monitoring, um, after that. So this is what I was talking about earlier, um, about the kidney function worsening. So the inter there's an intermedullary concentration gradient and that's going, that's what's affected when, um, there's going to be a long period of urinary retention. Um, basically that worsens ak because the water is leaving, um, the blood very quickly um into the urine. And that's why your AKI gets worse, the kidney functions get um, much worse. And, um, so you need to be really careful if, also, if they've got a higher loss of, um, urine output, then, um, you need to make sure that you're also replacing them cause that will also, um, worsen your renal function. Ok. Next case. So here we've got a, for 35 year old female and she's come in with visible blood in her urine. And this time you decide to um not put in that much effort, but you ask her a few questions, you just ask her when she's noticed it and she tells you that it's just in the last two days. Um And you ask if there's any pain when she's urinating and she denies any pain. So, what do you think um your next step should be and put it in the top? Right? Um So your next next step is going to be urinalysis. So, anything related to urine, if it's not obvious enough, definitely go for urinalysis first. Um So you've done your urinalysis. Um You've figured out that there's a lot of blood in there and now you need to know what to do. Um So the most common cause of a uti is going to be um something called um sorry, the most common cause of uh hematuria is going to be a uti um other causes would also be um any sort of cancer. So, renal cancer, bladder cancer, prostate cancer, um renal stones and um benign prostatic hyperplasia also causes that will um that are very commonly known for hematuria. There's other less common causes. So things like trauma, um sort of medical causes like hematuria with um that you see typically in glomerulonephritis, um um in H US in um good pastures disease, for example. So those would all be um medical causes, as you can see in this nice um flow chart here. Um You can either divide hematuria in urological and non neurological causes. So, if it's urological, you would think about, is it coming from the upper tract? Is it coming from the lower tract? If it's nonneurological, we've discussed just now some medical causes, there's some pseudo hematuria causes as well. Pseudohematuria is going to be when um the urine is red or brown and it's not um um present, there's no hemoglobin um present. Um Can anyone tell me about any famous causes um for this sort of pseudohematuria where that's coloration of the urine, but it's not caused by hemoglobin? Ok. Um So, rifampicin or metildopa are um very famously. Um yes, menstruation as well, very good, but menstruation will show you hemoglobin. Um But it is important, that's a very good point. It is important to um ask your patient where the blood is coming from and if it's present on wiping, then where exactly. So definitely that's an issue that comes up a lot of the times where they think something's wrong and it's just, they've started their period but um a lot of women are quite smart as well. So, definitely. Um Right. So, rifampicin and methydopa will be very common causes of um sort of drugs that cause um pseudohematuria. Um There's other things like hyper bilirubin, um myoglobinuria, um some foods as well. So, uh things like um Beru rhubarb, the very um typical sort of um examination questions as well that they will, they um will um ask you it's something very typical that we learn in med school as well, don't we? Um So yeah, you can ask them about those things as well. Um Otherwise, broadly, hematuria is divided into visible and non visible hematuria. So visible will be definite as it's saying, um just color of the urine that you can see. Um non visible hematuria is you've done a urinalysis and that's why you see there's rbcs present, but um you can't really see it. The non visible hematuria is further divided into symptomatic and asymptomatic. Um So if it's symptomatic, then you'll typically have suprapubic pain and some sort of renal colic, things like that. Um If it's asymptomatic, um then you basically just don't have any um typical symptoms that come with it. Ok. Um So when you have a patient like this, um with hematuria, what you need to do is um start by quantifying what degree of hematuria is present. Um So you need to ask them is what kind of color. Is it, is it pink, is it dark red? So, um, that would help you figure out how much blood is present exactly. Um, if it's new blood, if it's old blood, if, ask them if there's any clots coming out as well. So that would tell you that there's a significant amount of bleeding. It's enough that there's clots in there. Um, you can ask them about the timing as well. When is it red? Is it red throughout? Is it total hematuria? Um, cause that would tell you that, um, the cause of your hematuria would be something like, um, uh coming from the bladder or, um, it could be an upper tract source as well. Um But if it's just terminal hematuria, then it could be just because of some bladder irritation. Um, if it's bright pink, orange or dark brown colored urine, then you would think about nonneurological hematuria, um, causes because that's not normally, um, based stereotypical of urological ones. Um, you can also ask them about any typical symptoms. So you can ask them about any lower urinary uh tract symptoms. Um, if they've got any fever, I guess suprapubic pain, flank pain, weight loss, you have the typical ones. Um, you can also ask them about any recent trauma because that would contribute to hematuria as well. Um, while you're taking the history, make sure you ask them about um, smoking because as you know, smoking is, um, very significantly um associated with, um, bladder cancers, um, and other sort of urological malignancies as well. Ask them about where they work, maybe they're exposed to industrial carcinogens. Um, and that would increase risk of cancers as well. Um You can ask them if they've been somewhere recently. Um, and maybe they've caught some schistomysis from some somewhere. Um, and that would cause um, non neurological medical causes of hematuria. Um So you would definitely do an abnormal examination if they've got any abdominal pain. Um But you also might want to do ad again for the sim similar reasons. So you can um, see if there's anything else that's going on. Maybe there's a prostate cancer. Um So you might want to do that. Ok. And then you might wanna also take a drug history. Maybe they're on blood thinners. Uh Maybe they're on Warfarin. The I nr is um deranged and they aren't aware. Um So you would look for that if there are any antiplatelets or antithrombotic uh medications. However, having said that if they are on any blood thinners, that doesn't necessarily um exclude the other causes of hematuria automatically, they might be on blood thinners and everything's fine, but they're still bleeding because of some other reason. Ok. So, other than urinalysis, um, if there is um other causes that you're concerned about, then you'll do a PSA um you'll do basic bloods, your FP CS use and E LFT S, all of those, you'll do um clotting screen is one that you would also want to do. Um Then you would uh want to consider doing a flexible cystoscopy. Um And the other option would be to um so sorry for a flexible cystoscopy. Um You're basically trying to see what the lower urinary tract um looks like. Um And it's typically the hallmark for hematuria. So you do it for basically most um hematuria situations. Um Then you also think about um doing uh upper urinary tract imaging. Um So you can do things like ultrasound. Um So typically, if it's noninvasive uh non visible hematuria, you'll go for an ultrasound. Um You could think about a ct urogram that's typically done for visible hematuria cause you'll get more definitive imaging of the renal tract through that. Um For management, typically, you'll, as we've discussed so far, treat the underlying pathology, see what's um going on. If there's any anticoagulation, you try and review that any clotting disorders that you might have picked up, then you fix that. If there's any blood transfusions that you require, then you do that. Um some patients might um have a lot of significant hematuria which is causing a lot of clots. And as you can imagine that that can cause further issues, like it can obstruct the bladder outflow. Um So you admit them with urology and they started on a three way catheter, um which we'll talk about in a little bit as well. And basically you wash out the bladder through this um threeway catheter um to make sure that the clots don't stain or they don't form. So it depends on if it's significant amount of hematuria, then you would consider that um in some very rare cases of um visible hematuria. If the patient needs multiple blood transfusions, things like that, you would think about doing a rigid cystoscopy and you could do it with or without um general anesthesia. Sometimes you just do it with a spinal. Um And then you go in basically and try to control the bleeding that's present. OK? And then here's the urological referral criteria, that's just for your knowledge um that if you were in sort of GP land and you would use these to um go forward. So make sure that you are familiar with it, especially for your ay because you are um sort of going to look at these um as red flags when you're um doing your um stations. So make sure, you know, if it's any unexplained visible hematuria, if it's um persisting a, even after you've treated them uh with uti s, um anything that you can't explain that should a always raise red flags um and help you with your referrals. Ok. Next scenario. So you have a 28 year old male present this time. Um and they've come in with the swelling of the penis. So, swelling of the penis is not really enough. So you decide on asking, um, that you're gonna ask them a few more questions. Um, you do a Socrates and you find out that the pain is quite sudden it's caused, um, them severe pain. You decide to ask, when did this happen? Exactly. And they tell you that this happened after, um, some sexual activity. Um, and he's heard a popping sound. So, as, um, unser as that sounds, um, your typical patient will be, um, sort of like this. So I know I've kind of given it away but any, any answers, what do you guys think is there's a popping sound? Ok. So sexual activity and hearing a popping sound is the hallmark signs of a penile fracture. Ok. Um And typically, what's happened is um you're gonna look for a sudden onset severe pain. Um and you're gonna look for swelling, the popping sound and sexual activity again, as I mentioned, that's all indicative of penile factor and you basically will need to immediately take them into surgery, right? So, um a penile fracture is quite rare, to be honest, you won't see it every day. Um But it does require, it's an urological emergency as well. So it requires you to have a very quick surgical intervention so that you can restore the function of the penis. Um While this can happen at any age, they predominantly between 3040 years is when you see this happening the most. Um And somehow for some reason, um there's damage occurring on the right side of the penis very commonly as well. Um So, penile fracture would be the traumatic uh rupture of the corpus cavernosa and the tunica alia um in an erect penis. So it won't typically happen in a flaccid one. it's going to be caused by blunt trauma. Um So normally the penis for whatever reason, has deviated violently, sort of away from its access. And when we typically the partners on top, that's penetrative intercourse, um or even forceful masturbation, sometimes if they've fallen from bed um from um whilst they've got an erect penis, all of those kind of things will sort of um to be typical of a, a penile fracture. Um So you would, you might consider um maybe sporting or other sort of um blunt force traumas to um the flaccid penis um might be considered a penile fracture, but it's typically not. Um Normally, um there's uh other things that can happen in that case, which, which would be a rupture of the veins that are present in the penis or do any dorsal artery or veins. Um or if there's rupture of the suspensory ligaments. But both of these um typically, in these kind of scenarios, if, if there's no popping sound, then you're not considering it in as a penile fracture. Um what's causing it whilst they're having in intercourse is basically, there's thrusting into the pubic symphysis and or the perineum of the partner and that's basically what causes the um deviation from the axis in them, the fracture um moving on. So, whilst you're examining, the patient will typically have a penile swelling, they will have a discoloration. And the colloquial uh term they use is an aubergine sign. Um And typically, it's deviated towards the opposite side of where the lesion is. So you might also see uh something called a rolling sign, which is when uh there's a firm. Um but immobile hematoma that's uh present on the uh shaft of the penis. Um So that's basically what you're calling a rolling sign. There might um also be a butterfly shaped hematoma in uh in the perineum. And if that's the case, then you might want to think about a urethral injury as well. Ok. So that's not a real picture of a penile factor and just in case somebody is wondering, um ok, so for investigations, most of the cases will be diagnosed clinically. Um patients who are suspected of having a penile fracture will have normal routine preop bloods um that you will do um there's something called a cavernosography um which can be used. Um If you're thinking that the this may or may not be a penile fracture or maybe they've come in quite late. So it's a delayed presentation um or even whilst you're already on the table and there's your mid surgery and so you might want to use it then as well. Um to identify the site of rupture. Um But um it's been associated with um complications of priapism and also fibrosis um of the corpus cavernosum. So you don't typically see it being used. Um So any form of ultrasound can be used because it's cheap. Um It's noninvasive it, but at the same time it's user dependent. So you don't use it typically as well. Um If the patient has symptoms that suggest they've got a urethral injury, so you would look for if they've got any um blood in the meatus, if they've got any difficulties in um avoiding. Um So you would also want to do a retrograde uh urethrography. Um In some case, some certain centers, this is quite routinely done. Um Even if there's no urethral symptoms and they've just come in with a penile fracture, they will do it. So, for management, you'll give them analgesia for pain, give them antiemetics if they've got any nausea or vomiting symptoms because of the pain. Um Surgical exploration, typically you'll do it um with a circumferential incision and then the penis is essentially degloved um all the way up to uh the base of the penis. Um If there's any hematoma, can you evacuate the hematoma before um you identify that where the tear uh has happened and uh start repairing it. Um And you use absorbable um sutures to repair. Um Following this, you would ask the patient to um abstain from all sexual activities. Um for about 66 to 8 weeks, post surgery. Um, and this involves all sexual activity because you don't want to exacerbate, um, the, uh, the situation, um, as long as they've presented with sort of, within a week of the surgery, they can go, uh, through sort of surgical ex exploration and be managed successfully. But if they've presented beyond, um, one week, then you don't usually go, go for the surgical option, you just go for monitoring. Um And you do that as an outpatient. And you basically, while when you're monitoring, you're looking for signs of erectile dysfunction, you're looking for um pioner disease, which we'll be talking about um soon as well. Um But most people as you can imagine show pretty quickly and pretty immediately. So, and that's never really the case. Um Some complications that you might want to think about that sort of come up with penile fractures um would be penile curvature. Um and also penile paresthesia or dyspareunia, which is basically um painful erections. Um So that's why it's very important if you do see this rare phenomenon happening whilst you're at work um that you make sure um that they're urgently seen. Ok. So now we have 1/6 case, feel free to have a read. It's a 60 year old male, he's presenting with severe genital pain. Um So again, you decide to do a bit more sleuthing to figure out where this pain is coming from. Um You ask them about um the background history, if they've got anything. So you find out that they're diabetic and you decide to do an examination of the penis cause they're starting to appear quite significantly unwell. Um And you're quite concerned. So when you're doing your examination, you find out that there's significant swelling and redness in the perineal region, what do you think is happening here? Mm If you want to put your options in the chat box? OK. So I've given this away e earlier and it is foreigner gangrene. So what do you think you're gonna do trying to deal with this? What's your next steps, do you think? Ok. So let's just talk a bit more about foreigner's gangrene. So, foreigner's gangrene is a type of um necrotizing fasciitis. Um So, necrotizing fasciitis is sort of an umbrella term and foreigner's gangrene is a type of it. Um but it's just necrotizing fasciitis that's affecting the perineum specifically. Um other differentials you could think about would be epididymal orchitis and testicular torsion um for the type of presentation that we just discussed. So um for gangrene um is quite rare as well, but it is another urological emergency. It has a high mortality rate of 20 to 40%. Um necrotizing fasciitis as a group is normally um is going to be very rapidly spreading necrosis um of your subcutaneous tissue and your fascia. Um So the same way that you would treat necrotizing fasciitis is you use the same principles to um treat foreigner gangrene as well. Um Foreigner's gangrene can be either moni monomicrobial or polymicrobial. Um So things like uh group, a streptococcus um E coli are very common. Um So it could be one of them, it could be multiple organisms. So you need to treat them accordingly. So there's something um there's an naturally anatomical barriers that are present which um prevent the spread of infections. So you can see the dartos um fascia um around the penis and the scrotum in the diagram there. Um You can see something called the caulis fascia of the perineum and the scarpa fascia as well of the anterior abdominal wall. Um So these will act as ana anatomical barriers. And basically what that means is that the test is an epididymis aren't commonly affected because of these barriers um by fasciitis. So it doesn't spread all the way. Um So typical risk factors you can see is diabetes, excess alcohol intake if they're not eating properly. So, poor nutrition, um a lot of steroid use um and also certain types of hematological um malignancies and also recent traumas will cause these issues. So, for our patient in the last question, um because he had diabetes that makes him more um at risk for foreigner gangrene. Ok. So for diagnosis, um typically it's clinical, um patients will normally be observed and monitored. Um and they'll basically look out for any signs of disease progression. Um if you have, uh, if you are suspicious of, um, any patient who has for gangrene, again, they are for immediate surgical exploration. Um, so you do typical your routine bloods, all your bases. F PC CRP clotting ETS, you do blood cultures as well. Um, if there's no obvious risk present, then you might want to consider doing, um, HBA1C to see, maybe they've got a background of diabetes that they weren't aware of or if they are aware, then you just look at the BMS and try and correct the um if they've got any deranged um BMS and then you can also do CT imaging and that will basically show you facial swelling and um soft tissue gas. Um but CT imaging is typically not very specific. Um So you sh again need to go for surgical management rather than waiting for CT. But in case you're doing, you are doing CT, um then you can use it to help you sort of not just figure out which structures are affected um that can, that are involved and that might become foreigner gangrene, but you can also help assess the retroperitoneum um to which this sort of um necrotizing tissue can spread. Um in your CT, you'll also see asymmetrical thickening of the fascia as you can see in the image there. Um Subcutaneous emphysema is the hallmark of um sort of foreigners, gangrene in the CT scan, you'll see um fluid collections, abscesses. Um So, but it's not necessarily present in all cases. Um for management as we've talked is urgent surgical debridement. Um and they shouldn't be delayed. So, debridement is quite extensive usually. And it, it's not all done in one session. Sometimes it's done in multiple session. It all depends on how much of the tissue is um being affected, but you are supposed to remove all of the necrotized tissue uh completely. So it's definitely something that's done very thoroughly um to make sure. Um and the tissue that's removed, you send it for histology and culture. Um Or if there's any pus that you found um in the abscesses, then you send that for culture as well. Um And that will just help you with your treatment with antibiotics and uh figure out the sensitivities. Um But whilst you've sent these for cultures, you're waiting for the culture results to come back. Meanwhile, you'll start them on broad spectrum antibiotics. Um so that you can cover both gram positive, gram negative, um also aerobic and anaerobic bacteria. Um As we've mentioned, um before, it can be caused by multiple organisms or one single organism. So you basically want to cover yourself really well. Um you might want to transfer them to a high dependency setting. So, depending on where you are, um you, that might be an HD or an it is because they'll require more 1 to 1 monitoring and care. Um So, um once your cultural and uh sensitivities are back, you can start tailoring the antibiotics, um, a bit more, a lot of the times there's more surgical rooks even after you're done. Um, and there's more debridement that's required until they're free of all the necrotic tissue. Um, you sort of want to close up everything afterwards. So you, that's called a secondary closure and you do that with skin grafts, that's usually a really long process as well. Um So you would want to involve your plastic surgeons really early on. Um postoperatively. The outcome really depends um on how far the disease had spread and how much of the tissue was involved. Um A lot of the times um you might also do a partial or total orchidectomy. Um That just depends on how much um the process uh sort of went along um as well. OK. Next case. So we've got a 42 year old male that's presenting to the ed and he's got a painful, prolonged um erection and that's persisted for several hours and this time there's no sexual stimulation um that's involved. Um So you need to sort of think about what anatomical structures um would be involved here. Any suggestions, please put them in the top box. OK. So, um in this case, it's going to be corpus cavernosum as we've discussed um before that's causing this. So, as you can see here, the part of the penis um is found by the corpus cavernosum, which is the two large um um anatomical structures and then the corpus spongiosum as well. But mainly it's the corpus cavernosum that um helps the penis be uh more erect. So, if you think about um what's happening here is a type of priapism and can somebody tell me about what they know about what priapism is? Right. So, priapism is going to be what's happening to this man here, an unwanted prolonged, painful um erection of the penis, which is not associated with sexual desire. And, and it's usually more than four hours, that's the um typical definition that we use. Um Right. So, um and for this um question non is ischemic priapism. Um So, um ischemic priapism again is a type of priapism which is a urological emergency. Um Normally you need immediate um sort of uh management for this as well. So, let's just go into what we're talking about. So, um right. So there's something called low flow or ischemic priapism and there's uh something called high flow or non ischemic priapism. Um So, ischemic priapism is normally going to um occlude um the venous um flow um but non ischemic is going to be um arterial flow. So, what's happening in the ischemic? One is there's blockage of the venous strain, uh venous drainage. So, um that's what's causing it. Um Typically, it's called the causes for this will be iatrogenic. It might be because of sickle cell disease. Um This might be caused by different sort of hematological disorders as well. Um And then you've got, um, and then you've got the um non ischemic, which is, um as we mentioned, arterial um cause. Um So what's happening here is there's rapid entry but slow exit and that's why it's not ischemic. So it's not like it's causing any problems, um, long term. Ok. Um, so for non ischemic causes, um you might want to think about, um, if there's a history of any, um, penile or perineal trauma, um, you might want to think about spinal cord, um, injury as well. Um, and that's where you would have sort of, um, any damage to the vasculature. Um, and that would affect, um, if it's iatrogenic, um, you might want to think about, um, if they're on any drug therapy. Um, so any papaverine or, um, alprostadil that's typically used for impotence. Um, so you might want to think about that. The background of sick, sickle cell disease is, um, very important. Um, and other hematological disorders would be things like, um, any, uh, leukemia, any thalassemia, maybe they have any, um, pelvic malignancies, but that's quite rare as well. Um, and other medications that cause, um, priapism would also include, um, antipsychotics cause there's several of them and the side effect, uh, would cause this, um, it can also be anticoagulants, antidepressants. Um, so why is it an emergency? Exactly because your blood is collecting in the corpus, um, cavernosa. Um, if there's venous stasis and there's going to be ischemia and if you don't treat it and it might cause impotence as well. So things that you do for priapism, you're gonna do a corporeal um, blood gas, you normally do a routine blood as well to help you identify what's happened. Um Either you can take this whilst the episode is happening or you can take it as a as a follow up, but you do your FBC CRP. Um your esr you do coag screen um bone profile. Um We can also do hemoglobin, um electrophoresis. You can also check for um drug screens, uh do a drug uh screening. So maybe they've taken something and that's what's causing it. Um So you might want to have a look at that. Um if it's a non ischemic cause and you might want to do further workup of your potential sort of spinal injury if they have any. Um And you might want to do a Doppler ultrasound to help you um further identify if it's um uh in what's going on. Exactly. So when you're doing uh corporeal blood gasses, if it's acidotic, um it's going to be ischemic. That's the main thing that you should uh remember. Um Either way the initial management is always going to be um mainly through corporeal aspiration, which is what's um happening in this diagram. Um And that helps um sort of most cases to um sort this out. Um Normally you would also give them some ice packs, um, to help, uh, with things. But, um, n normally that doesn't really help things in the long term. Um, but a lot of patients that have come in, um, and if that's what they've tried, uh, doing, um, some, a lot of the times they've tried to sort of physically exert themselves, they've tried, um, masturbation as well to help, um, with the symptoms. But none of those really work. Um So corporeal aspiration um is required. So when you do that, that's when you get the corporeal blood gas sample. Um and that helps you sort of identify your cause as well. Um What they're doing in the in the diagram is basically, they use a large bore needle, you insert it on the lateral edge of either one of the um corpus cavernosum. Um And a lot of the times you have to do it for both as well. Um After you've done sort of uh enough aspirates for your diagnosis for the blood gas, um you might need to do further rounds of aspirations. Um Sometimes you do a wash out as well to help you. Um you look for basically around 10 to 15 mils of static bloods at least, and you keep replacing that with a normal saline until um your aspirate is bright red. Um If there's no response after the aspiration, then you go for um intracavernosal injection of uh something called a sympathomimetic um agent. So basically phenylepherine. So you might want to try that. Um You might wanna go for surgical management. So if these maneuvers are all ineffective, then you go for a surgical shunt, um which you put in between the uh corpus cavernosa and the glands. Um And the shunts will basically help to also um release any fluid that's present and um help you uh with the symptoms for about 90% of the cases. Um If the pri has lasted 24 more than 24 hours, they don't re regain the ability for intercourse again. Um And in such cases, you might wanna consider penile um prosthesis. So again, for those reasons, this is a urological emergency um which requires you to promptly act on it. Ok? Next case. So we've got a 12 year old male this time who's come into the ed um and he's also got swelling of the penis. So what do you think is the most likely cause? Here you are, well, water a sorry about that. Ok. So you um asked this person, um this patient a few more questions to try and figure out what's happening. Um And he's telling you that for um a medical procedure that he's had recently, he's had to undergo catheterization. Um And so you decide to do a little examination, you find out that there's some edema of your, of the glands and the foreskin is retracted as well. So, what do you think is a cause now, you might have an uh no. So the answer is paraphysis. So this is very typical, um the combination of sort of pain swelling. Um There's a history of recent catheterization um that would suggest that uh this is paraphysis. Um So when you are catheterizing, make sure that you um put the foreskin back into its normal position after you've uh retracted it. Um So, paraphysis essentially means the inability to pull forward a retracted skin over the glands. Um penis. Um So you will have the um typical um sign of a tight constricting band that's present. So, if you're being ever called into or to have a look at um the sort of a patient, um then this is sort of the hallmark sign a tight constricting band. Um and that's basically what's preventing the retraction um over the penis. If the p pyrosis um remains, the glands start becoming more and more edematous. Um because the venous return is reduced and that starts causing some vascular engorgement of the distal penis starts causing a lot of edema there. So you need to again, treat this quickly. Um If it's not treated, it might lead to penile ischemia. If there's any infection there already, it might worsen infection as well. So something like foreigner gangrene is what you would be looking out for then. Um So therefore, it's another urological emergency and you need to urgently make sure that you reduce it. So, and as we mentioned. Um an indwelling urethral catheter is typically a high risk factor. If they've already got uh sis, then that will uh aggravate this as well. Um If they've got poor um hygiene, if they've got any prior history of having fimosis, tho those would all be things that um sort of exacerbate this. Um If there's any paraphysis, you reduce it as soon as possible. Um If there's any delays, then as I mentioned, worsening of swelling and then you won't be able to reduce it um before you're reducing it, um make sure you've given them plenty analgesia because this is quite painful. Um A lot of the times a penile block is given, um we are um an anesthetic um but this is not always necessary. So it depends on how bad things are and once you've reduced the uh foreskin, um then you need to start considering if they might need something more definitive this time. So maybe a circumcision uh might be necessary and that you might arrange it quite urgently as an outpatient. Um So for diff, there's different methods of reducing it. So there's manual pressure that you can use to um the glands uh and then that can help in sort of use the pressure and then reduce the edema. So you're essentially squeezing gently but um constantly. Um and you're going to help sort of um reduce the edema by doing that. And so you have to use a, a lubricant jelly to help you as well. Um You can also use a dextro soaked gauze. So, Dextro is a sugar that can help you with an osmotic effect. Um and basically draw out the fluid um from the glands and that can help reduce the edema as well. Um And you can also try using ice packs cause that can help you with reducing the swelling. Um The Dundee um technique basically, um you use a needle to puncture into the glands, penis, you squeeze into the area, you allow it to sort of start draining out. Um So you'll get some um edematous fluid drainage and then you try and reduce the glands penis after. So that's what you call the Dundee technique. Um And that's typically what I've seen you is the most um in practice as well. Um If this um all of this fails, um then you go for something called a dorsal slit. So that's what you can see in this image here. You put in a small incision to the prep in the 12 o'clock position. Um And then try and reduce it a lot of the times you might wanna go for um an emergency um surgery as well. OK. So we've finished most of our questions and is now we will now discuss a bit about some very common catheter issues that you see as um f one doctors. So this might be very useful no matter what specialty you're starting with or where you're going. And very commonly, very often nurses come up to you to try and ask you about what, um, difficult catheters or various issues. So, very commonly, they'll ask if somebody, some catheter is not draining, maybe some catheter is, um, sort of not functioning, it stopped working. So you look at the catheters. Um, so these are the three types of catheters. The, um, you can see one way, two way and three way catheters um in the diagram next to you. So the one way catheter is typically your indwelling catheters, the two way catheters, what you see in um medical practice more often. So that's probably the, the one that you've all seen um in practice. And that's the one that you do your ay for. Uh So, you know how that one works. Um You've just got your one opening for the urine and you've got another small opening to the right um for the um balloon to inflate and then you've got your three-way catheters, which you will mostly only see um if there's um any heavy bleeding. So a lot of the POSTOP um patients um will have it, um especially if they've had any sort of uh cystoscopies. So any flexi or rigid s sigmoidoscopies uh might have caused trauma if they've gone through any tumor, uh removal, things like that. And if there's high bleeding, high hematuria, even if, as we mentioned before, any patient that's come in with a lot of hematuria will use a three way catheter. So most of it is your normal, there's a port in the center for the urine. There's a port in the right for your um, balloon to be inflated and to the left, this one is basically attached to this massive um is 2 L bag of saline. It's really huge. Um And basically there's saline that's flowing down from it um into the bladder and then sort of washing it out and it's free flowing and then it comes out through the urinary port in the center. Um So that's what you refer to as uh bladder irrigation. So, it's, it's a continuous cycle of sort of washing your bladder out through um by irrigating it essentially. So, the first thing you're gonna do when a nurse comes up to you about a catheter that isn't working is you'll check if there's any external blockages. So you check if it's twisted, if it's kinked, if it's been clamped somehow or maybe it's under the patient or it's been um uh stepped on maybe um or a chair or a table is sort of um blocking it, things like that. Um Then you look, if there's nothing wrong externally, everything's fine. Um Then you start looking for more uh any obvious internal blockages. So a lot of the time you'll see a lot of sludge and debris that starts accumulating that's normal. Um And if they've got bleeding, then sometimes the bleeding, um, can clot and block the catheter as well. In that case, you might want to, um, uh, change your catheter and get a new one in and if there's nothing wrong internally as well, then you might want to discuss with the nurse and I ask her to help you do a bladder scan. Um, that will help you figure out what the cause is, is it a blocked catheter or is it that there's actually no urine output at all? Because that might also be an issue. Um If um everything's fine, then as well, you can just ask the nurse to flush the catheter, see if there's any resistance. If there's some resistance, then you know, there's a blockage in there somewhere. Um, a lot of the times doing this flush can help you dislodge um the clot, but this can then uh further go and get blocked somewhere else. So again, you might just want to um change the catheter. So considerations when you are changing catheter, you might wanna go for a larger lumen or you might wanna go for a three way catheter. And as I mentioned, three-way catheter will help you sort of um irrigate everything and, and release um any sort of blockages or any clots that might be present. Um Additionally, if you notice any leakages um in the catheter, uh if the patient is, has been lying down and you catheterize them, everything's working fine. But suddenly they get up to go to, um, go for a walk or get a cup of tea or something. Um, and it starts leaking. Then you might also want to go for a larger lumen. Right. Um, the other issue, if they've, um, uh, sorry if they've told you, um, that the catheter is leaking, um, then you can look for any blockages. Um, if the lumen is too small, you go for a bigger lumen. Um Also you will check for inflation. Uh if is the balloon fully inflated. So you can, um, deflate it completely and then try and reinflating it um completely. If they've got a leg bag, you need to make sure that no matter if they're sitting or lying or standing that this leg bag is below their bladder level. So that will also help um to prevent it from leaking, right? So this is the end of our session today. Thank you so much for being here. If there's any questions, please feel free to put them in the chat box and I'll be happy to answer them and I'll stay until the end until all of you have left. So feel free to fill in the feedback and leave. Thank you guys.