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take looking back. Yeah. So come back. Have room. That's all right. That's fine. They we've got Doctor Guy Brain, who's currently a clinical fellow in urology to deliver the first part off urology content this Siris, I'll just pass on to him quickly before I've done my shrill. Basically, the next to slide is just our social media platform. As you already know, just follow us on there for any updates on again. Thanks to empty you for sponsoring the theories, I'll just pass. You want a doctor grain for a brief introduction before we get back home With today's tutorial off the Thank you. So I'm guy on, as promised, I'm a single fellow in urology. Um, although what exactly? I mean, I'm still I'm tired of short. Apart from I see a lot. Penis is my dates. They work. Um, so I am some social leaders of here to want to take on that. Okay, so here, this should be your stuff followed by this is serious and talk on some stuff for you. So I am here to talk about your allergy. I would just go through some basic questions on answers covering a fair range of topics which hopefully you're getting us to outlandish force off that question every year old G. If there is any minutes to you know to for me, if you don't stand pop question of chap walk, you know, pop a mark for on. We could go through anything at any time. Just let me know so we'll just get right into a sports. So first question is on screen. Now we have a 56 year old man who's come in a vial. Emergency department. He's got right sided flank pain, a classic urologic. One Nice background is pretty soundly. He's got a quarter page it for several years from the C spine injury is that UTI is are on and off for many years now. Now I've got X ray on the next slide that will show you that I don't want you to. I hope you'll see on. We want to know the composition off. That abnormality is such a great results quickly because you should note that he's slightly tachycardic a little bit on the hyper side. Uh, the problem can't refill on his feet brought Okay, so leave that on screen for women's Who you can see exactly what the abnormality is. Well, if it's not distinctly obvious, do you have you know, So they got Those are the options. Is this problem? And he made out off calcium oxalate assisting struvite cancer Prostate for your it. I don't give her a second to go down there, so I suppose I just supposed to the whole I can see the whole Yeah, called. Let me know when you want it to him. Yeah, we're We're We're a third have voted two thirds of you. Get off Google. Click a button. I'm not here tomorrow. Go home. Look. Oh, yeah. All right. You were just over half way. But we are 50 seconds into the voting, so I'm gonna stop it there. Uh, so Oh, thank you very much. Uh, the dominant answer be given is C, which is excellent. That is indeed the correct answer with a couple of scattered dances for the other options. So this is a stock on countless with topical C is Korea. What was their nose? It'd cycle because feeling multiple cases in a single kidney, if it was one of the bypasses completely normal. There's nothing wrong with the bones for the ski interpretation of X rays. Um, now the reason behind it, this is the stream or compass. We could guess that fronts just the Optivar is the cycle calculate. You have for me large volume on our usual full because that's recurrent infections and kidney, um, out of times fills up with street, which is kind of lucky, slightly stuff that I know in the strictest sense that's radiolucent. But actually, any source, total force and kidney is gonna get gradually calcified. So the meat of that stone is going to actually radiolucent street fights with just enough calcium in that. So that is visible on that ray or a CT scan. That's what it's like uncomfortable. So the most common stones off course, our calcium oxalate on gasoline phosphate cut actors a mixed component to a lot of stones, but majority of its calcium oxalate, Um, and then your rate of the second most common time. For instance, they both you know, there's lots of reasons that one could get one. So if you think of and this is the original, uh, serum counseling with your serum uric, because if you go too much of the blood, so you can have too much with secreted in the urine. Um, so you know, the consequences of this, uh, for hot calcium is going to be probably hypoparathyroidism. Um, you're a things and have about two, maybe, um so if you got a patient, you got a stone facing the fact that you're gonna say it's a stone. You're not going to try and diagnose the type of that based on the CT KB because it's still preliminary screening thing. You should just check that counseling levels on the urea just to make sure they haven't got anything that's going to make them recurrent stone formers. Basic simple screening. Cystine stones. Follow the out. Why the the least common for countless on the chest condition cause that is beautiful. Good cyst in your area, which is that you have a cyst in your area, doesn't it? Doesn't in this more 60 and new urine on. They confirm cirrhosis for which is unfortunate, but I think 16 you're it doesn't actually have any other symptoms I usually only presents is the formation of county way in the kidneys. Um, so you just a quick sorry slide here as I say oxygen, phosphate, both the commonest forms. Dehydration. You know, it's like having seven in a stream. If it's not flowing quick enough against gunky at the bottom, you know a little bit of grip, for it's exactly the same in the kidneys, although much smaller scale. So dehydration reduced flow essentially is going to be what's causing the majority of the stones. But then course hypocalcemia related. You're right. Too much of the blood in between in the urine street light. Very much recurring, UTI is insisting. Sounds really to be seen. Assisting area, I think fine, but I need to make. It's just, you know, the patient in question with a C spine injury. Men don't generally get you to us, especially for you. Tea Ice Special in there 56 his big predisposing risk factors. Fact. He's got C spine injury on quadriplegia, which unfortunately suppose you took all kinds of things because just nothing works. That's what we do. See a lot of companies in men with your old Clinton is yeah, so if I don't make sense, but I will move on to the next question. Just sorry, guy, someone asked, was a recurrent uti the main indicator here. I'll leave that to you. Sounds Course So the indicated for the answer is literally that cycle Calculus it, You know, it is always probably made out street. But, um, what needs you to be cares? In the history that is not has recurrent uti is on Has that first formed a stock unconscious? Okay, you can't have what's called matrix calculus up there, which is ST why that's not yet calcified. It's know, for just a nice stack wood. And that would be, uh, going keeping it only showed very much. That's right. But if you see a stock hold back by that street five with a little bit mixed in, um, the usual just kind of explain why he's got no street unconscious. So trying the answer, the answer is based on the X ray. Well, the lesion is because of this. It's probably relevant. Pop the history that you should wear a moment if you see this in clinical practice. Okay? Yeah, I think so. No, Nobody. Yep. Yes, thank you very much. I food writer on to the next one. So what I said for this one. Oh, fantastic. Another good old classic year old You are 25 year old chap with a suspected renal colic, whatever that means from ET. He's had a single episode of Pain in the Light. It's now 10 o'clock in the morning on His pain is now subsided. He's had a CT KGB, which shows he's got five millimeter minute. You're a Turk Stone with multiple to hydrin versus uh, otherwise that fit well, if I chap on his bloods on his observations are on the street. Uh huh, which for those if you don't have a news chart handy, his heart rate is fine enough. Your pressure's fine enough on these is a federal with no respirator. Sounds on his bloods is one sensory little bit on the high side. See a piece above normal. Uh, Testim is fine. That is easy for 67 was a bit weird for a 25 year old chap, but in true 25 year old chapel fashion has never had blood stuff, Um, which really makes getting her accurate 100 quite difficult. So where are we going with this job today? What's what's the next time we could put a urinary extended could refer him or do it Also, we have haven't, er some extracorporeal wave lithotripsy She's handy is a test of issue and you created we concert forced me taking for primary. You're off. Your ureter is to be on the laser lithotripsy. Well, we could destruction on See him later in the clinic. Got it. Oh, I'm really loving seeing the wife pull. This is a lawful six out of 30 so far. Okay, right. At 50 seconds. I think that's probably a good amount of time for people who have made up my mind. So speaking out forever hold your peace. 22 results. So, um, the answer is on this seems to be controversial thing. Really? Discharging. Um And I did go through the nice guidelines to make sure I wasn't insane with this. So bear with me for a moment. Most stones. Well, first I was on six weeks will pass with Austria. Absolutely nothing at all on without us doing any medical explosive therapy without doing any operations. Yes dot Your nothing at all. No, that's where they are. They will probably go. What's usually nice is if we're gonna leave them toe mind, you know, pass a stone on their own. Then we'll just get a follow up set of imaging. So being seated, you be be a CT pelvis or, you know, state stones nicely radiopaque abdominal. All sounds of it. Contentious. But let's not get into the, um so I think justified my pulses here. Okay? Yeah, they go so long. Complicated on on completed stone without pain, that is under six mil. You can usually pile of intervention. Um, I don't have the right thing in medicine is to do nothing. Um, the three reasons the Big three when you think you're you're a tear a counselor. Oh, do they have an infection behind that stone? Because if there's an infection in a pool of urine, that's not going anywhere. You got this European, uh, feel are surface with an infection. The middle it's it's actually an abscess, isn't a nearly real treatment, has to drain it. Which, of course, would be a ureter extent if they got real failure. So I'm not talking about someone who's not got here. Far of 90 going down 67. I mean, he's got no g fro greater than 90. It's not three, and they're becoming unsafe Obviously we need to get that could be draining again in the very near future on some of his pain is just unmanageable. So we've given, um, opiates. We couldn't in their neck suppositories on. Still, they're having bouts of pain or ongoing on severe because, you know, they they get better. Me. That stuff started, we'll check. This junk is a fibro is what cells are a little high, but that's actually really common with so a seat up here 15 and surgical terms mites will be normal. Um, all those got Martin Luther Hypophosis that is in the absence off any complicating factors. Most people who do present with real cortical half some 100 process because of the obstruction actually causes the pain. Um, pains most of you felt when you're you got the Paris starts, it's against instructed system. Seems any colic, Um, so if his pain is getting better with these obstructions improving, so it's paid A settled is really function's not too bad. He's not infected just fine. Um, see, as I said, if you're doing infection obstruction, you're looking a stent. You working on a frost? Me because prostates to come out. It's no good doing something that's gonna leave the past there. So your s or yes, you are. And, well, just actually just on settle things as opposed to green that pulls out. And I've mentioned it here, which is American exposed to therapy, which is basically giving your patients talking. Losing it's a bit of contention subject. I think there is now enough evidence to say that it's got some benefit with district Calculi. Um, no, uh, complacent features with our little miss your tire company. So it's a pretty safe that we give to most of our patients. Just say, at least we're doing something great. Um, I was kind of the justification for that. So when you when you look at SARS, this was a huge study. I think it's mimic studying. Don't hold me to it. I didn't read the paper. I just like the pictures. Basically, what they've done is a long term observational study off thousands of patients, and they assessed who's stones past within a four week period. I think this study's based on um, and it's quite nice because you can see it actually, let us decent group here who stones are more likely to pass, and they are to stay. So anyone who's got stone less than five mills is pretty much a guarantee. Positive has made it all the way down. Forget about it. You know, this is pretty much out, isn't it? We've got shop use. Our chops is 5 to 7 pills in the mid ureter. So he's, you know, it's on the borderline, but his problem probably will pass without doing anything. And actually, since he's paid, settled, could really function. Doesn't have any doesn't really sepsis. We're safe to do that. Um, and of course I can't retrain those three things in off. These are conditions where if you got a stone involved with this, that needs sort of now, okay on. Well, mostly, I want to mention about the S w Well, wait about kids. This is for your professional Should feel about this before. If you think about the mid ureter for calculate overlying that is bogus at the front and the back, you got the pelvis. So anyone who's trying to target that for Shockwave lithotripsy is gonna have a really rough time on so shocked is gently better officers or really district and again you got a bunch. So against the risk? Well, I said the risks and the benefits of just doing nothing myself. Well, stones again. Just checking if there's any questions about was Oh, move on from here. But the more of the story is drainage for infected one's sort it out for renal failure. And if they're absolutely fine with uncomplicated stone, that's probably the past that go from it. Uh, that's all completely rough ID by the nice guidelines. So move on to our third case. We've got a 72 year old chap. It was coming from hematology clinic. Um, where's it? Come? Please come to me. You have a so is reflected by see Because Got a great big abdominal mass which the GP things is probably a lymphoma. But his pre could months the show that he's got renal failure on the gel for of two, which is oppositional. Great. Eso the hematologist has had taken a look at this Oh shit and sent in to the medical assessment unit. Now the patient reports these after probably this water works or not. You know, it's not greatly sometimes has to rush the loop occasion. He wets the bed at night before he's working up to realize he needs a week. He has some dysuria. Has been going on for about a week or so. It's actually seeing quite a lot. It stinks on you. Get something to stop it, but it looks like chicken soup. Um, so you said Catherine, this man, um on, you know to say is your It's become a bit red. After about a half hour or so you check his blood. Well, the blood results that were done by the Michigan State who's graciously the PSSA on it's 18. So, with all of that information, what is the most likely cause of this man's renal failure? Oh, yeah, go ahead. Observations. That's a very nice And he got a bit of crepitation on his lungs. Um, the coverage was a bit too late. Is a fibril on when he was seeing another big doll mass. So is this. A UTI sets amount of urosepsis accounting for his crushing renal failure. Is it? Prostate cancer is a myeloma. Tells you have acute your attention was high pressure. Chronic retention. Uh, can we open the post? Please? Please let the Yeah. Okay. Right Oh, we were at 50 seconds socially. Closed the polls there. Thanks very much. So, um answer. Generally correct. Among the, uh, the poor results Is high pressure quite retention? No, this is possibly the most. Well, one of the most common cause is off obstructive. You're a piece of a post renal AKI. Essentially, the bladder is so full, it's starting starting pressure on, you know, as it's going to retention. Really, That pressure is not going down with that's going back upwards into the kidneys, which generally don't enjoy being a high pressure environment. I eventually will cause renal failure, which can be trusted to the degree in this case, your some walking with the gyn for to the red flag symptom that I want to start driving a stent into nocturnal enuresis is a very harsh. You're like a way of saying they went the better light. Thanks. I want to really clear. This is no. They wake up, they need a weight on. They've already peed themselves. This is they've woken up in the bed, is soaking wet. Thought on that is essentially the pressures only getting released when that completely relaxed when they're asleep. A little bit of pressure gets her on something. The that's flooded and they won't wake up for that. So they were noticed after they've been catheterized. There's a phenomenon called decompression bleeding, which is all these blood vessels have been stretched out for so long. I just snapped back on, started bleeding. So this is very fresh red show of blood that gradually become quite dark. So dusty looking, I suppose, is the phrase dusky and then settled it quickly of them. So the next 12 hours, Um, that's generally nothing to worry about. They also have a tendency to diaries after this so you can throw out quite a bit of water if you want. Number two. That's 200 miles per hour. Eso anything over 200? Most primer starts needing IV replacement. Um, but fall up when you know keeps is quite good, actually, for decompression because it keeps it irrigated. Accused throwing that one's stopped that clotting stops you getting into trouble, Which is nice, isn't it? Um, I think I mentioned here save 18 in here. That's just probably just not back to being retention. Um, so your other points about this case, the gentleman for it does have a UTI. So if he's sitting there with, you know, a liter of urine in the bladder, Uh, that's not moving anywhere. There's going to be bugs and stuff accumulated the bottom that's gonna end up giving the UTI. But it's symptoms weren't really crossing urosepsis. Not clinically dry. You know his heart rate's okay. Is blood Pressure's all right, but he's a February. So for so for our NCQA question question asking that's not classical for year or sepsis. Um, prostate cancer. The bill for twice you know, he could have, you know, across that he could have a prostate cancer. I'm not saying like it's patient doesn't have it, but the more common way that prostate cancer causes obstructive uropathy is actually obstructing the year. It is directly so. Think of prostate sitting in the bladder with the ureters, so either side of the bladder neck it's really invades through the blood muscle themselves. So yours is directly so you don't end up with a great big full bladder. You just end up with bilateral in the first segment of rather city empty bladder, Um, and then they wouldn't suffer from the telling, restated have a high pressure environment that would be causing his scooters. Um, so you mentioned multiple my liver, or so I changed. This is Katie. I've changed to you for free light chains in the, um What religion sees can present. Similarly, people do come in with, you know, lymphoma, myeloma. Do you farm to completely interviewed them. But as I said, you know, he's got your a lot of symptoms and symptoms consistent with high pressure. Attention, um, you know, is decompressed. Often it's, you know, his bottle. This is your old record. Know he eats a lot of this is also based on the actual case where we did take a patient from even told you, Clinic, who did have a double mass on was very scared that yet, Yeah, I mention it to your attention, but that's that's always painful. You know, I should go get your attention, and you have to deal with that. Hopefully. So I've got a little bit of pocket speech at all retention because I think it's very important subject. Um, broadly speaking, you can divide it into acute, and you can divide into, like, so we do with these separately. But you is a nice and simple beast, really, is the painful inability to fully into your bladder. People could be wearing nothing at all, or they could be avoided in tiny little drops. That's just not enough to relieve the pain. So we know that's painful winner that's relatively sure in onset. On what? We definitely notice that after catheter, they feel a lot better. Um, so it's It's fairly something to right you guys want to do with now when we get that investigating, it's a bit more complicated by and large, and people go into acute retention on then that's because they got prostates. It's off the age of 50. It's pretty inconvenient organ that just exists and causes problems. Um, of the biggest cause of your attention is benign prostatic hyperplasia. Now that's not enough to take you into retention as you see something else on top of it. So that could be a neurological. It's off. That could be they've taken too many opiates or some anticholinergic. So maybe that's the bit constipated. Maybe they got a UTI literally anything on. Suddenly they're in acute retention. Um, now, the thing to do this essentially is once you've catheterized, um, you've treated the condition. You need to recognize what? Your purse if you know, Do they have BPH? Do they have persistent and then treat them accordingly as well? I want you treated. You're perceptive. You're in a position to toe. So trying to the cath from your talk as it is moving over to crack retention, I be This is divided nice and high and low pressure high, of course, being the last e one. Uh, I have it on this. Okay, so I've kind of done backwards. Location, assault, the symptoms of low pressure that will work well, storage symptoms. So bladder is two full. So they're getting up at night because, you know, the tank is still feeling at night on, so they will constantly just filling up this tank on there for me to get up. Two week, 34 times a night, Something like that. See, because you know, the space between empty bladder completely full bladder needed to eat is very low, so it doesn't take much different to needing to mature it again. Frequency exactly the same. And then the sensation of incomplete voiding. It's a bit of a vague want, but it's quite rival, you know. They've gone for a week, then something to about half an hour later. I feel like they do, even if it's normal. So high pressure attention will have all of these symptoms potentially or none of them. But again, the red flag is nocturnal enuresis. And actually these guys can progress to being completely incontinent, which still doesn't relieve the pressure because, you know, the president really significant to be completely incontinent the time and still mostly go back up the path of least resistance. The other thing is, you know, when this will that you know, on imaging, they'll have bilateral hydronephrosis. Uh, they usually come in with reading failure. That's why the other, uh, but if they go by Friday versus not tell any recents and a great big bladder, this is calling Be a now or in the future, All of this I said, Mother, Oh, yeah, low pressure. Attention is pretty benign. Beasts. Really. It doesn't do much, but it does predispose you to UTI. So because that you're it's not shifting. So you got a bug in there. It's not going anywhere for a good, long while. I completely switched to bladder stones as well, which are miserable. Uh, that's a settlement accumulating. It's, you know, shedded, pulse shedding, blood lining. Things like that just crystalized the bottom. Very unpleasant. So Nocturia is sort of just answering the messages. I was asked me to explain the difference. You know, total any recent bacteria nocturia is waking up. I need a way. Oh, my God, It's the third time. It's not good for a week. Eso they did get up, but they recognize they need to pass water and they go to the toilet. Even if they don't make it to the toilet. That's still just nocturia if you know if they're not, if I've got one c and they you know where themselves on the way, at least they try it. Not totally. Any recent is very much they've woken up. Looked out Oh my God, I'm so he again they don't feel the need. They don't wake up essentially for this. They might also still wake up because they way but have already gone on. Then just need another one. Eso that's the rep and you got be really clear when you're questioning his people's you say Or do you pass water my little year? Lots. You could be said Well, is it? You know, we're waiting on what? Or you get up Feeling of you know nocturia is, uh, not your It's so not tonight. Urea getting up at night. Um, I'll come back the question Second cousin just, uh, finished. It's like So if you go back to precipitants again So retention Chronic retention load. Fresh corn retention again primarily down to nine. Processing kind of pleasure. You want to get to treat it a failure. So the muscle of the bladder itself not being generated Adequate amount of pressure to empty itself. And then the other thing that can cause bladder obstruction is quite common is a urethra stricture. Take you some time off. Urological intervention. Sorry, we do that on that high pressure. They get it. So it's bladder obstruction. This one is not to choose a failure. This is the muscle still works, which is great. Um, but unfortunate pushing against a block. And it's not going anywhere. So sometimes. So that's what causes low versus high pressure attention. So the resistance of the same as in there something downstream there stocking things were going downwards. If it's going up, we don't know. Basically what causes alter from low to high pressure retention. Some people you know, we'll see people for years now 600 miles in their bladder and be completely fine. They get occasional UTI pretty okay. And then what did they come in with? CF are in in their boots on They've got a liter and a half from the bladder and they're in high pressure retention. We, frankly just don't know what the difference is. We do know that generally the high pressures have a larger volume of residual to the process. Jeremy talking about under 800 meeting. But high pressure is very Ressie under one liter residual volume of urine. Whether it's the accumulations finally stretched the blood to a point where it's able to exert pressure again. We don't know on we have two huge observation stories to actually says that lovely had like, um so final bit the high pressure attention like there's so much stuff. I just need to drilling about why I think important topics. The course of this is that kidneys all and now, after little we need to have established I'm going to change now. Obviously the shortest, actually, in the short term, this committee catheter, isn't it? Most the time. Um, easiest route is obviously you refilled. They generally do have Great Big Gladys of actually, you want to try out for people with good candidates for it, but that unlike your key retention too Well, thank you. Afterwards, these guys will not because they will feel exactly the same. Um, they can sort of get a see if someone's able to teach in the acute setting. But generally those things will celebrate. Wouldn't experience now. In the long term, they could still have an indwelling urethra constant. They could still have a suprapubic. They could do. I see for the rest of their lives. Um, but really, what they need is something to channel up their prostate on the quickest route to this is usually a top. So the transurethral resection of prostate will just knock him out, go up for what's fighting shape with prostatitis in my speaker channel and what I don't dissection a lot of stool putting pressure down, but it's never get going against a really resistant water pipe down below. It's a nice open one that just let the water come straight down. So the high pressure drops down to do quite well after top. They usually pass urine because that one is still working because otherwise it wouldn't be exact. Any pressure? Uh, yeah, I do get routine. I just can't give the Tamsulosin Southern home. No, that's no, that's not safe. Little time. You know, if you've got a patient who's willing to risk going into renal failure, maybe. And actually, you know you will have patients. You know, Mr Smith. He's 97. He comes from care home. He's got advanced dementia. He doesn't already his catheter, but he's got high pressure. Attention, you could say. Well, actually, is it worth coming into the hospital every week for us to replace his traumatic self talk? Uh, well, we're going to be discussing. Actually, you know, renal failure might be the counter option in this situation along fairly challenging discussion, but quite necessary. So keep your protection again. Just not well, so BPH is the baking course, but then there's just so many other things behind as well. Uh, of course, prosecutes. It is possible to cause it, but it's a rare, uh, cause of an acute retention. Well, there can be patient, be increased since the prospect in men it's pretty easy to much is you do have to stick finger up the bottom. I just feel it's actually the question that you know we want. As as you know, the urology team will answer is, Is that prostate cancers or is it not cancerous? Because magic, a small and a big prostate for acute attention is basically the same. But if there are cancer, we need to know. And if you think that process is cancerous, then appears is quite helpful but always be GBs of borderline like you said, because UTI uh, catheterization retention on having a d. R E will raise the PSA so that comes up with 30 was completely meaningless. Um, but if it comes out of 400 office, see, very useful for, like, a zero really used, because then we know they definitely don't have prostate cancer. Line between this, you know, make sure you've got a plan for you. The information. So we treated course. So be pitch in the country that in a day, but the rest of this a part of the prostate cancer where I'm actually quite quickly and easily. So I just need to treat it up and then take Katherine some point and you can even get in terms of those in just to relax the bladder neck, make it real easy for them to pee afterwards if they would not, Uh, that was not women's a bit weary. You rarely see acute you hurt. You do see it, but it's always important that you do a neurological examination because they shouldn't be going into retention. So is this first presentation Venice, um, or something else. And I'll see you should be doing a pelvic examination. Uh, ideally, see images. We'll just rule out any nasty pelvic masses. Got a collectible, counselors, etcetera, etcetera. And then it comes right out of saving. Treat Any calls that you find take the catheter out when it's appropriate on. I did Russia and grab some catheters earlier. So that's all they ever see any of that just to go through them because, basically, uh, is released cancer people on. Yeah, this is you started campuses a Foley 16 French, which has got a nice rounded Actually, you can see hopefully um, that's a I'd say that's 16. French maid of silicon is a pretty standard thing you want to avoid the other ones. They're like brown and really bend even cause more damage on the way in. If you're struggling to catch for someone, this is, uh, my cheeks. She essentially this is a team and tipped catheter, which is it's not end up here gets big prostates so great for catheterizing pretty much any man on. Actually, if you're really starting to catheterize now, only woman, it's probably because of atrophic vaginitis, which means that using that ongoing for words, you'll probably find urethra and just bend it up into it. Which is fantastic, not mentioned cloths on the screen, which means a three week after, which sounds terrifying to a lot of people. But they're really lovely things. So three ports. So we've got a balloon port out flow and in flow, which, for some reason I've spirited on a catheter that isn't in anyone on again. This one's got a nice curve tip to go around those horrible prostate things. Find out what this is because this is the catheter of the devil. This is a 22 friends rigid tip three way, which I mean, honestly, you could draw through walls with this thing is, you know, fist of with those aren't That's about the end of my rental retention. So thank you for bearing with me for a moment, please. You tell me to shut up to going to talk about that again. My daughter. So you on something? Oh, yeah. So let me know if there's any question about that after I was on a lot of stuff and probably need to breathe for a moment and actually would have my sympathy go right. So next question six month boy brought into pediatrics because his father is quite worried His just pick him up from his mom who looked after in the week when he was changing his nappy day. He's noticed the left side of description is a bit swollen compared to the right. Uh, like I said, his mom had, um, a week and didn't tell the doctor there was any any concerns. So you have a look at the child. Everything else seems to be okay, but on examination, the left hemiscrotum it's definitely swollen. Maybe 10 to maybe know when you examine it? Still would say, six months old. There's no induration skin. It's not cellulitic. It's appears to be a flexion swelling. So what is the underlying anatomical abnormality? Does the child have a patient processes? Vaginalis a posterior urethra valve bell clapper to 40. A dilated pumping of all plexus Will indirect inguinal hernia. We're going to invest in the, uh, the clock music from jeopardy. Just, uh, keep this bit rolling over. I got you. I got a lot of opinions on this one. Anyone else? Let's stop the clock there. So the majority of you are correct? I have to say, um, the underlying album, Captain, Multi. If this is a patient processes and vaginal this this is because the president said acute presentation. The presentation is that of a hydrocele in a relatively young child on the most common cause of hives. Still in a young child is a painting process of vaginal lists On high doses, of course, are for pain this unilateral swelling, which is actually this child is presenting with. So I find worried parents always exaggerating lot of pain. Actually, when there is littering, okay, paper processes, vegetables can cause inguinal hernias. Just because it's our figured I go out in the next life was that helps works. And they can also cause interruption. Morphology. So they got appendicitis really interesting or hemorrhage. You get a possible blood dropping down the scrotum. Been lucky. I'll show you the diagram here. Um, so, normally last me can be seen on the left. Is your closed specialist. You see here, this is the Paris people lining. Uh, what was the Paris name is is off, too, which is nice. It goes up, we'll see. In development, the tests is dropped down from, uh, the out. Um, I thought this little folder Paris name here and after it closes up the anterior aspect that becomes an institute in fractional list on coats, the testes from the, uh oh. It could be a tetanus around to the front of the testes and fixes on to the court. Now it's fairly common. The testicles come down on off which this little bit of personal hasn't closed up at the top. It's remain open. So there's just this flocks of fluid it's dropping down from the ultimate is there's normally a little bit fluid inside the cavity and gravity being the cruel mistress that she has, everything is falling down. It's right into that nice pepper potential space in the scrotum, and so they get a high dose it on that, which is great because nice and simple to fix is that you just empty the food up. Close up. Bob's your uncle older. That's a patient possessive about, um, alternative. See, that's also excellent root for about abdominal conference Go down. That's how they can get a indirect inguinal hernia. Down the same tracks was a fairly common, uh, presentation. Children. So what else we talked about? So, yeah, posterior uterus falls. Um oh, they're pretty rare. Pretty subtle anatomical abnormality on it's actually, they could cause a flare up in the ureter that whenever they're trying to empty their bladder, it increases theophylline pressure. Which is really bad, because I said that means you get Children who have high pressure, chronic retention, and often they present with UTI. So sometimes they present with real failure because, you know, high pressure for attention. Real failure. Yeah. Uh, so they're very different. They could be very different spot. Um, and they could be very dangerous, but you know. Well, they're suppose you know, you might be worried. Does he have epididymo-orchitis? Because you got used to it Because he's got big, full bladder again. Six months bit early. And there's no listen to you too. Well crafted. 40. So bell clapper to 40 is the underlying abnormality. That is introduction. I'm sorry if I didn't make the already clear. It is vaguely related to patient assistance, vaginalis. But this patient is not presenting with a torsion because you'd be expecting extreme of pain. Extreme tetanus. You'd be expecting injury did skin, so you would be a a relatively happy child to be in front of you. That's a dilated pumping for plexuses coming. Most a zavara conceal, which is a little bite forms, getting very you feel on it. Yeah. The the examination just isn't consistent with your, um I think I'd just rather if I hope that's got its function swelling. Um, I did. That's fine. Um, it's always hard. You were not be functioning. Few it filled. So before I move on bell clapper to 40 exceed the Tunica Vaginalis is here wraps, um, quite tight belt matter. If so, fix is higher up more posteriorly because it's got that, uh, great court is free on the inside of the Tunica. It twists around inside, and that's what institution, Um, so because of your that's pretty close to it. But there's no way to screen, for it happens if you see a patient with torsion. When the surgeon fixes it all removes the testicle. They will usually fix the other side if they confirm the torsion. Um, and that's because if they've got a bell clapper to 14, what's that? It's probably both, um, so packing varicocele. Because I know that's what the answers really common. On the left side, I think the swelling was that was delivered three off. Very sorry, Momma. Um, the reason they don't present on the left is this problem up here? Um, so unlike every considerate organ, the testies have a very colorful blood supply. But what's important is that they dropped off in the abdomen on the right. This is fine, right? Testis is draining. Put me into the IV C, which is very rarely going to be a high pressure system. But the left one is draining into the left renal vein or your left Anyway, which obviously, is that right ankle on. It's a slightly tight a vessel that in the ivc, so people are predisposed to get our practice. He was on the left, and I was Why, as I said earlier, Please do live enough is any questions in the chap. But it was all to keep pounding through because I'm aware I've ranted for a while, so apologies. Lots of I think so. We've got a 25 year old chap between regimens. We're not working today. Vital Top who hadn't orchidectomy two weeks ago for suspected testicle cancer. The macroscopic appearances are malignant lesion with several different tissue types inside the main mass, with the muscle fibers in for the funny stuff in that his CT stage interesting because and periaortic lymph adenopathy What is the most like a type of tumor? Does he have a teratoma in that mixed, non seven inches? Germ cell tumor? Is it a lady sell it to testicle size or a pure testicular Korea carcinoma? I feel that this is a slightly mean question because, um, you know, there's a lot of different types of testing to achieve and honestly, as a product in half one more. That's a job. Even the most important is being able to recognize when it just doesn't feel right. But I feel like, for example, this is this is probably some relevant knowledge. So let's give you a few more seconds on the clock because I can see people still going. All right, So that way, over 50 seconds. Lovely. So answer is most likely a mixed on seven Otis in terms of humor. So most, uh, no seven inches stream is all mixed big on the individual components of choriocarcinoma. Tear it, um, very rarely develop on their own. Seven over is usually a pure seven over, But not so no, she's she was usually a mix on. The composition of these could be extraordinary variable. So I think I've written it down here, So yeah, territory. So obviously everything I've said in that was leading towards her toe. Um, which is very much like a don't know, insist it's it's a germ cell tumor, but I usually been lying. They could take all kinds of very well differentiated stuff, but has very little million potentially in it of itself. Um, but elsewhere you get that, you know, is that the changes with teeth kind of deal, isn't it? They don't usually metastasize on. They are most commonly seen in the testicle sense, seen with other sole images. So something like a choriocarcinoma wife try to put in that say that is that he's got separate have been from Nazi. That's kind of my invite. Say this is not lasting malignancy. It's spreading somewhere. That's pretty good evidence in this off histological and DT sense that this is gone, you know that this family needs This isn't just don't want this as a lady XL Tumors are one of the types of struggle Cheevers that could be seeing the testicle again. There are single soul in your pretty need to tidy, and they don't really do very much, uh, testicle itself off the most contact with the nerve up 50% overall, that generally presents. So 35 to 50 year old men on again there, and I sleep different cheeses, some type. So you scored nice. Want to clean to assume I have a clean tumor on testing Korea cost of them, I think, is actually one of the rarest side testicle cancer. That's it also noticed human It's a very rescue. Yeah, rat to get on on. So Ms is seven inches tumor off one so lineage. But if he was getting one of one of the things that would be these in first, Um, now, again, I just put a little summary slight, which for the life of me line I have long since we got most of this, most of this. And I'll be incredibly surprised on a little bit. Flattered if What if you remember this, Um, I think the most important things to think off our to Marcus, um, I'm leaving potential. Really? So seven, I was you know that the most common, they're about 50% after this one is around 50%. But actually, you know this these two kind of share about 50% with that being a one C virus was group, um seven or miss classes, screen HCG. So if you see someone who's got another beta hcg on the blood work, I'm leaving. Feeling testicle? Just my statistics that probably didn't have ah seven over fair effect isn't now. As I said, your nonsense. Just teamers. There's a whole host of things that could be on. They do so you know territory because it has a whole different tissue drops in that considering anything, uh, the other three. It's a mix of HT or F p. So you see, if you're thinking that the non services job so tumor and probably mixed lineage because most of them are mixed and again these could be quite aggressive. Choriocarcinoma is incredibly aggressive in this is go. There's a very poor prognosis. How fortunate have ah by motor instance? I think so. It's about Children on the 10. And then it's 20 to 30 I think struggled Cheevers last time here. Don't worry about really, Um, but, you know, if you are encountering ah, benign tumor with no Children arcus it could be one of those ones. And finally, I didn't really mention this inside before because it wasn't particularly relevant. But it is rather know which is in older chops, you could get testicular lymphoma, uh, which solved over the age of 50. You should be thinking off as a primary diagnosis. A silvery fasting rather than seven or more will not have noticed. Um, so she was You should be thinking for lymphoma. So some comes in there you know, 65 whatever. They got a seven month history of testicular swelling on that. You just look at the white cells. That might be enough to tip you off. Be thinking lymphoma. And on this Taltz, you know, you'd be very careful. Um, of course, I think I've mentioned it just because the parent to confirm up the the testicles have dropped out from the ultimate. So the first place that you start seeing a note of disease is actually periaortic. Well, see, with screws off itself in oil but tested testicles way up in the para-aortic region on I think I think that's made on. So I'll give you a couple of minutes of questions. But that's not the end of me grilling you guys as feedback for me is on the chapped. If everyone just take a minute to fill that in that we really appreciate this. I greatly appreciate it. Um, Well, slaves to our pool for years, um, on I greatly appreciate the help can show the last question. I get almost exciting of questions because I can't do that. Well, it doesn't want this. Any questions, which is great. Biden happy that you seem to stop eso. I'll be calling off in a moment. Yeah. Yep, that's fine. Think if doesn't questions then we connected there on yet. Just everyone. Just click on the feedback when link. Now before were Squire like, click on the feedback guys. Important stuff, um, guys back tomorrow to deliver Pop, too. So be sure to come back here at six. And I'll post a link on Facebook around five. PM tomorrow again. So I think by is everything for today, Isn't that I think what it is for my and Yeah, absolutely. All right. Gonna end it here. Okay. Flight for attending and run. That's supposed to mean it. No worries by right.