Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

I think it is. I think it's just, yeah, thank you. It's live. Hello, everyone. Uh My name is James. I'm a fy one. I'm currently uh a board member in the past uh year. I was um co-chair of CTA the year before that I was educational coordinator. Um Thank you everyone for your time and joining us this evening. Uh Today, we'll be going over urology, uh lower limb uh lower urinary tract pathologies uh by Jane Miller final year student at University of Nottingham. Um Again, any questions just post in the chat at the end, we'll be sending out a feedback form in the chat as well. Uh But without further ado I'll pass it over uh to Jade. Excellent. So, hi guys. Um Thanks for the introduction, James. So, yeah, I'm Jade and I'm final year student at Uni of Nottingham. So, my colleague yesterday did a session on upper urinary tract pathologies. So I'm gonna be going for the lower urinary tract pathologies today. Um Before we start, just a thank you to all our partners. They're all really great resources. So, um especially teaching me surgery. I use that quite a lot during medical school. So we've got quite a lot of stuff to go through today. So we're gonna be going through the male anatomy. We'll be doing some scrotal pathologies, particularly focusing on epididymitis and testicular torsion. We're also gonna be doing lower urinary tract symptoms and some of the possible causes, particularly focusing on BPH, which is benign, prostatic hyperplasia and prostate cancer. We'll also be doing a bit of um urinary incontinence, how to differentiate the different types and manage them respectively. OK. So I've just put up a diagram of the male reproductive system. So this is just a sagittal view. Um And if you guys just have a brainstorm, try and fill in the blanks and then I'll reveal them in about 30 seconds or so. Mm mm. It OK. So if we start down here um at the scrotum, we've got the testicle and then we've got the epididymis which is sort of posterior to the testes. And usually when you're palpating the testicle, you feel it posteriorly. And then we've got the vas deferens, we've got the seminal vesicle, the ejaculatory duct and the prostate and all of that comes into the urethra and that's the penis. So now we're just going to be speaking about what each of those different components do. So again, just have a quick brainstorm on what you can remember that each of these components do and then I will talk you through it as well. OK. So if we start at the testes. We've got the seminiferous tubules here, the root testes and the epididymis. This is just a cross section of the testes. Essentially. What it does is it produces and temporarily stores sperm, especially the epididymis, which acts as a temporary storage reservoir for the um for the sperm. Also, there's synthesis on secretion of important hormones like testosterone, estrogen and oxytocin. The sperm will then go through this um tube, which is the vas deferens. And that helps with the transportation of the sperm to the exterior and also the cells that line the vas deferens, um secrete things that help with the maturation of sperm. We then have the secretory glands. So here, this pink and blue structure is representing the seminal vesicles. We then have the prostate gland and then this sort of hot pink structure. In the diagram is the bulbourethral gland. Um And all of these excrete seminal fluids and nutrients to nourish the sperm um on the journey to the exterior. In fact, about 60% of the semen volume is this seminal fluid. This all goes into the urethra and then out through the penis. So the urethra um runs through the corpus spongiosum, which is this ventral cylinder here and then the two dorsal cylinders in the penis are the corpora cavernosa, which are very vascular structures and assist in erection. So that's basically um the male reproductive system in a nutshell and the clinical clinically relevant functions. If we just now touch on the prostate. So we saw it in the earlier slides, but it's a gland, it's about the size of a walnut usually superiorly. Um It's bulged by the bladder. Um, inferiorly, we've got the external urethral sphincter and infra laterally, we have the levator ani which is a muscle that makes that part of the pelvic floor clinically. Um relevant anatomy for the prostate is that there's three main zones. So you can see in this diagram, we've got the central transitional and the peripheral zone. So the majority of the prostate gland is made up um by this peripheral zone. And this is the zone that's usually affected by prostate cancer and it's located posteriorly and it's um makes up the majority of what you feel when you're doing a digital rectal examination. As you can see here in terms of the transitional zone, you can see that it surrounds the urethra and this is the zone that's primarily affected by benign prostatic hyperplasia. Um So that's why it gives way to those predominantly um l symptoms or lower urinary tract symptoms. And then last bit of anatomy, we're gonna be talking about the scrotum. So the layers of the scrotum, um it is clinically relevant anatomy. I think it comes up in MRC S from what I've heard from some of the core trainees, but it might come up in some of your preclinical exams as well. Um This is a really good pneumonic to help remember the layers of the scrotum from exterior to interior and you can see on these pictures here. So we've got the skin, we've got the DARS muscle, which is a muscle that lies just under the skin and it wrinkles um the skin to reduce the surface area for heat loss. Um And that's really important because the optimal temperature for sperm production is about five degrees lower than our core body temperature. So, a lot of the male anatomy in the testes and the scrotum um is aimed to try and optimize that sort of heat reduction property. We've also got the cremaster muscle here that you can see sort of encasing the whole testes and that retracts the testicle. So it pulls it up towards the direction of the inguinal canal. And again, that's to try and protect the testes and the sperm from extremes of heat. We've also got the tunica vaginalis, which is like a, a thin layer that covers the testicle. Um We've got parietal and visceral layers just like in the lungs with the pleura. And in that space, there's a potential for fluid to build up just like a pleural effusion, but sort of in the testes. And that's something that we call a hydrocele, which we'll talk a bit more about later. And as you can see on this diagram, we've got the spermatic cord and it's shown in a bit more detail here. So it's a really important structure and it contains a lot of important um anatomical structures as well. So, the chromista muscle that we mentioned and also blood vessels, the testicular artery, the testicular veins and the vas deferens, which is the carriage of sperm. You can see that the testicular veins are arranged in this sort of wiggly structure, which is the pampiniform plexus and it wraps around the testicular artery. So um that aims to basically act as a heat exchanger um to cool the arterial blood before it gets to the testicle. And again, it's for that sort of um keeping the testicle a slighter cooler temperature to optimize the sperm production and storage. Ok. So we're gonna talk a little bit about scrotal pathologies now. So a very vague vignette, but essentially I want you to brainstorm in your head or in the chat, whatever you prefer. Um If a man comes with a lump in his scrotum or just sort of any scrotal pathology that you can brainstorm and maybe try to categorize it into painful and painless. So I'll just give you a moment to do that before I give you the answers. Yeah. Ok. So in terms of painless and painful, these are the sort of main pathologies that you'd get in your exams and also in real life. Um So the ones in red are the ones that are really important and they're sort of the red flag pathologies that you shouldn't miss for each of the painless versus painful presentation. So we've got testicular cancer and testicular torsion. So they should sort of be at the top of your list of things to rule out if you're getting this kind of presentation. Now, let's think about how we can differentiate these before we do that. Let's just have a look at these pictures. So just for reference, this is what a normal testicle should look like. And then each of these um pictures A to F is representing a scrotal pathology. Um And I just want you guys to try and think of what they're trying to portray. Um And just to clarify, see is two images demonstrating the same pathology. It's not separate. So I'll give you a moment. And by the way, guys, I can't actually see the chart while I'm sharing my slides. So if there's anything in there that's urgent, II can't see it at the moment. Sorry. Um So I'm just gonna go through the answers now. So A is um a hydrocele. So that's what I talked about with the scrotal layers. That's the fluid collecting between the visceral and parietal layers of the tunica, vaginalis. B is epididymitis. So that's inflammation of the epididymis. You might also hear the term epididymo orchitis, which is when you have inflammation of both the epididymis and the testicle. Um The testes is sort of where the ac part comes from. C is demonstrating a varicocele. So you can see the pan penniform plexus of testicular veins that we talked about earlier. Um Essentially you get reflux of the venous blood into those veins. Um So they become engorged, dilated and have this characteristic appearance. D is meant to be demonstrating a testicular cancer. So you can see it's an irregular mass, it's not separate to the testes and it's a fixed mass on examination. E is um supposed to be an epididymal cyst and then f is a inguinal hernia. So that's I in this case, extending down into the scrotum. So next slide, we're gonna be thinking about how we're gonna be differentiating each of these on history and examination. And I've made a nice summary table for you. So these are some of the pathologies we're gonna go into a bit more detail later about epididymitis and torsion, which is why they're not here. Um And you will have access to these slides after the talk, but essentially for testicular cancer for the interest of time, I'm not gonna go through all of these points in great detail because you'll have access to them afterwards. But just some key things I want to highlight it's about sort of this painless versus painful and also um the progression of the symptoms for any of these pathologies. So, um red flag as well for malignancy and in terms of risk factors, um you'd notice that the age group that's affected by testicular cancer is relatively young compared to other cancers risk factors include things like infertility. Um And then crypto is basically just undescended testes. So you'd ask about whether the testes were both descended at birth and then um examination findings to note secondary hydros. So you can get hydrocele on examination and there might be an underlying testicular cancer. So it's something that you need to keep in the back of your mind. And also gynecomastia can be a finding especially with um these Leydig cell tumors with a high estrogen to androgen ratio with epididymal cyst. Um Some of the risk factors here is just polycystic kidney disease, cystic fibrosis and um key things compared to a cancer, it will be a smooth, it will be fluctuant um and it will be separately palpable to the testes, whereas the testicular cancer is usually fixed. Um and it's also located posterior to the testicle sort of like in that slide with the anatomy. Um You can see that the epididymis was posterior hydrocele. There's um different types which we'll go into a bit more later in one of our practice M CQ questions. Um but generally painless. And the characteristic examination finding is that transillumination, which essentially you put a porch to the skin of the scrotum and it transilluminate it, it lights up essentially all that fluid. Um and you can get above the mass, which is referring to differentiating that sort of mass from, for example, a hernia where you wouldn't be able to get above it an important thing here is in adults, especially if you can't palpate the testes underneath to be able to confidently say that it feels normal. You should do an ultrasound to rule out an underlying testicular cancer. So, varico, which we saw in the previous slide is that venous reflux. So patients can feel that sort of pressure or dragging sensation. Um and it can lead to complications like subfertility. You want to rule out that there's not an underlying renal cell carcinoma, especially on the left side. Um because the left testicular vein drains into the left renal artery. So any pathology or mass up up there can impede the venous um return of blood and lead to that varicocele. So, most of them are located on the left characteristically in SBA land, it's the bag of worms appearance. Um and it will fluctuate with things like the valsalva maneuver. So I'm just going to present to you a case here. So this is essentially a 45 year old man. Um He's got acute pain swelling on the left testicle, progressively worsening from the last two days. Um He has also, in addition, got some dysuria, urinary frequency, low grade fever, um but no urethral discharge or recent recent sexual activity. His abs are pretty unremarkable. He has a little bit of a low grade fever and based on these sort of key symptoms. Um does anybody know what this history is typical of? Um have a brainstorm So essentially what I was trying to get out with this history is um epididymitis because it's painful. But we have these urinary symptoms and the low grade fever, which is usually the giveaway. So a little question now about epididymitis, what is the most likely cause of organism in an older patient with a low risk sexual history such as outpatient. So it's e coli other things to look out for. If it was a younger patient. Um and potentially a more higher risk sexual history, then we need to be thinking about things like chlamydia or gonorrhea. Other things that are a bit more niche is like mumps, orchitis and um extrapulmonary TB. Um but those are very, very niche and might just come up in a really mean exam question. And now just to think about differentiating this presentation from sort of the other red flag presentation of um acute testicular pain. What can we do on examination to rule out other causes of acute painful testicle ie torsion C, right? That would be the chromosomic reflex and the prey. So the chromosomic reflex in this case was intact bilaterally and the prez sign was positive. So that means that when we lifted the testicle, it alleviated the pain and that happens in epididymitis because you're taking the weight off of that inflamed epididymal suspension. Um and that does relieve the pain for lots of patients. Um And we'll talk about the cremasteric reflex in a moment. Because you're very thorough. You also did a genital urinary examination and that's really important to sort of differentiate the other causes of epidermitis, like the chlamydia and gonorrhea. And also um DRE is useful because um for example, if the inflammation or the infection tracked up to affect the prostate, um cause prostatitis, that we might have a tender boggy prostate on Dre. Ok. So why is it that the cremasteric reflex is absent in testicular torsion or why is it that it's not affected in this presentation with epididymitis? And just to recap, the cremasteric reflex is when you stroke um upwards in the supramedial th um thigh and the ipsilateral testicle retracts superiorly. So, understanding why this happens relies on knowing the limbs of the reflex. So the sensory limb is the in ilioinguinal nerve which innervates this dermatome that we stroke when we try to elicit the reflex that will send the impulse to the, the spine C NS and then come back through the efferent limb, which is the genital branch of the genitofemoral nerve. And that is innovating the cremaster muscle which retracts and pulls the whole testes up towards the inguinal canal essentially. Um because this gentle branch is in case within the spermatic cord in torsion, you're getting twisting of the spermatic cord and that can impede the function of that nerve. And therefore, the chromic reflex might be absent. In reality, it's not a very sensitive um or hard and fast rule, you definitely can't rule out a torsion based on a present chromic reflex. But in SBA land, they love it. So, a good one to remember. So how should we manage this patient? Essentially, we'll do a urinalysis, um urine M CNS to see the causative organism in a younger patient. If we're considering um S TI S as an underlying cause, then the first line for testing chlamydia and gonorrhea is a first void urine sample in men and you send that off for nap, which is nucleic acid amplification testing if you're really um and ring and you're not sure. And you can't confidently say that this isn't a torsion. Um Then you can do a scrotal scrotal ultrasound and then management is basically supportive. So, analgesia, um you'll also give them empirical antibiotics, scrotal support and then some patient education about safe sex and contact tracing if it's related. I hope that makes sense. Um So let's move on to case two of a painful scrotum. In this case, we have a much younger boy. He's 15, he's got sudden onset severe um left testicular and lower abdo pain. Um approximately two hours long, it's progressively worsening, but he doesn't have any dysuria hematuria. Um and he does have one episode of vomiting. His abs are pretty unremarkable. So essentially what I'm trying to get out here is a classic history for a torsion. Um So this patient is obviously uncomfortable on examination, the lie of the testes is affected on examination. So you can see that the left testicle was positioned higher. It's exquisitely painful. Classically, the chroma reflex is absent on that left side and the pre sign is negative. Um and essentially this is a urological emergency. So it's really, really important that you get urgent surgical review and surgical intervention and you don't delay taking these patients to theater because the testes is twisted around the spermatic cord, the spermatic cord as we saw in the anatomy slides contains all of those really important blood vessels. And what will happen over time is that we'll get ischemia and necrosis of that testicle and that will impact on fertility later on for the patient. So what happens next? What is the most appropriate next step in managing this patient? Do you think we should ultrasound him to confirm the diagnosis, send him to theater and fix that testes, send him to theater and fix both of the testes bring the med reg in because they always somehow get dragged into everything or should, will this go away with a self limiting? And we just need to give analgesia? So have a think, you know, so the answer is scrotal exploration and fixing of both testes and we'll go into a little bit more why we do that in a moment. And if we did do an ultrasound, um usually we don't do it if it's very obviously um sort of clinically obvious that this is most likely a torsion because you don't want to delay diagnosis and management by and taking the patient to theater. But if you're really ring and it's not very clear based on history and examination, then you can do an ultrasound. And that would show this characteristic whirlpool sign, which is that touting of the spermatic cord that you're seeing now. So what happens next? So as the f one that saw this patient, you correctly kept him nil by mouth, you prescribed all of his supportive medications and you arranged urgent senior review. So the urology reg agrees that this patient needs to go to theater immediately. So what happens in theater? So they do a scrotal incision to gain access to that test testes and then examine that testes on the spermatic cord manually detorse it and then you need to examine it to see if um it's viable after deor things. So you'd want to see that nice pink, healthy testicle color. Um and if it is viable, then we can fix it to the scrotal wall, which is called an orchidopexy and you do that bilaterally. So a bilateral orchidopexy, this um youtube link which will be on the slides is really good because it's like a two minute video that shows an emergency testicular exploration. Um and it shows both an orchidectomy and an orchidopexy for anyone interested in watching it. So, in this patient, we did the bilateral orchidopexy. When do you think we might need to do an orchidectomy. Well, essentially, if the testes is not viable. So um trigger warning, I'm about to show a picture here of a non viable testes. Um But essentially, um in this case, um and this is taken from the youtube video that I showed the link of previously, but um upon detouring the testicle, the appearance still remains like that, um they put warm saline away to 10 minutes and it still didn't revert back to that nice, healthy pink color that we would want. So um that leaves no choice really. We have to do an orchidectomy because that testicle is necrosis essentially. And now to answer the question of why we do a bilateral orchidopexy and not just on the um affected side. Well, a la big risk factor for torsion is this anatomical variation called the bell clapper deformity and that can be bilateral in lots of cases. So, whilst you're there, you might as well fix both sides to prevent the other testes from taunting in the future. Essentially what the bell cappa deformity is. You see this gray line, that's the tunica vaginalis in the bell clapper deformity, you can see it inserts a lot higher onto the spermatic cord. So there's all this free space here for the testes to just rotate freely and then it can do this by rotating and then twisting around the spermatic cord. So that's how it predisposes to torsion. So just to finish up on torsion. These are all the possible um differentials for a torsion. Um We've got the epididymal orchitis like we discussed already the hernia. Um all the other scrotal pathologies, trauma is important to rule out too and then renal colic with that characteristic loin to groin pain. One that's really important as well, especially in the pediatric population is this thing called the torsion of the hydatid of morgagni. That is essentially a little remnant of the malarian duct that um occurs in utero. So, when you're developing embryologically, if that remnant is left behind, it can twist. And as you can see on that picture there, and it can present very similarly to torsion. Although characteristically, the Chromos reflex remains intact for this presentation, but it's very common between the age of um 12, um 7 to 12 in patients presenting like query torsion. And does anybody know what the classic examination finding is with this pathology? So it's this thing called the blue dot sign. So as you can see this little blue dot which is usually located sort of superiorly on the hemiscrotum. And that's literally the visibly infarcted appendage that you're seeing there. Um So that's quite a good diagnostic tool for this um condition. Um usually clinical diagnosis. And um if it is this, then it's self-limiting, you can um discharge the patient on analgesia after senior review, obviously. So just to wrap up um scrotal pathology section, I thought we should just do some questions to consolidate. So, if you just have a read of that, essentially, you've got a 12 hour old baby, um, uncomplicated pregnancy and delivery appears well, but he's just got this soft nontender swelling in the left hemiscrotum, you're able to get above it and it's transluminal given the likely diagnosis. What is the most appropriate next step, take care. So you've got aspiration, reassure and monitor routine surgical referral, ultrasound scan or urgent surgical referral. And um if you needed any um prompting, then this vignettes basically hinting at a hydrocil and the correct management for this is reassure and monitor. So, in terms of the types of hydrocil, this the most common type in a newborn baby, is this communicating hydrocil? Because if you remember in utero, um when babies are developing embryologically, the testes start off in the abdomen and then they just send down into the scrotum. And this um it's called the processor's vaginalis. And that sort of a remnant of that process that migration, usually that obliterates. But if it doesn't, then it's leaving a connection between the peritoneal cavity and the scrotum and it can fill with peritoneal fluid. Um So usually it goes away by itself in a few months, which is why you just reassure and monitor. If it hasn't gone away by like 18 months, two years, then they might need surgical intervention to obliterate that processor's vaginalis. OK. And now this question, we've got a 50 year old male who complains of painless swelling in his left scrotum. He also has a left flank pain and hematuria. Physical examination reveals a nontender palpable mass in the left testicle along with dilated veins in the scrotum. So which of the following conditions is most likely responsible for the patient's scrotal findings. So, from the history and the examination it's getting at that this man has a left sided varicocele. We've also got the presence of the red flag symptoms with the left sided flank pain and hematuria. So the answer is leading at a renal cell carcinoma. And the reason why this gives way to the varicocele is you can see on the left side, the left testicular vein drains right into the left renal vein. So any mass effect from above ie with a renal cell carcinoma will impede or um make it more difficult for the venous blood to flow back and into the left renal vein. And then you can get that reflux and the varicocele, it doesn't really happen as much on the right or it's very rare to get it on the right because it's directly linked to the IVC. OK. And then this is the last question for scrotal pathology. So we've got a 22 year old boy, he's attended to Ed with exquisite scrotal pain. He states that the pain happened one hour ago when he was playing football, he vomited once, um but denies further gi symptoms and he is sexually active. The pain settles before analges is given and he mentioned that he's actually experienced this um, three times in the last week and each time it's resolved without intervention, given the likely diagnosis, what is the most appropriate management? So, are we gonna give antibiotics? Are we gonna discharge a follow up? Are we gonna go for scrotal exploration and fixation? Bilaterally? Are we gonna do testicular tumor markers or an ultrasound scan? Ok. So this history is sort of car, car. Oh My God characteristic um torsion history, but it's intermittent in this case. Um So how do we manage intermittent torsion? And the answer is it's the same principle um as an a regular um testicular torsion because there's still that risk that it can tort and be permanently torted and then lead to a non viable testes and impact fertility. So we just go for the same management. Ok. So now we're gonna talk a little bit about lower urinary tract symptoms or LUTS. Um What I'd like you to do is think about these lots and group them into storage versus voiding symptoms. So I'll just give you a moment to think about that. So, ok, so the answer for storage and voiding symptoms, just for reference, there's a diagram here of the normal function of the bladder. So usually, um in terms of storage, um when the bladder is storing urine, then this urethral sphincter should remain closed. And I'm voiding, the detrusor muscle will contract and the sphincter will relax to allow that urine to pass out from the bladder. So, if you've got any sort of pathology affecting either of those um mechanisms, then they'll lead to the respective groups of symptoms. So, now to lead on from that, what pathologies do you think could cause these groups of symptoms? Ok. So in terms of our storage symptoms, characteristically, it's things like overactive bladder. So it could be because of the detrusor muscle overactivity. It could be because of inflammation or infection in the bladder, which leads on to things like the uti, it can be because of neurogenic bladder. So that could be secondary to things like dementia. MS Parkinson's diabetic neuropathy, um and also drugs like diuretics um which cause that sort of polyuria. Um and therefore the urinary frequency in terms of voiding symptoms, classically, it's things that cause bladder outlet obstruction. So things like BPH or um prostate cancer strictures that could be secondary to infection ST I um uti POSTOP or post procedure and prolapse as well. In reality, though, there's a lot of overlap between the symptoms. So, although they like to do this for the purpose of exams. In reality, most patients with these pathologies will just have a mix of the two symptoms. Um And another thing to be aware of is could it be diabetes because the polyuria associated with that can sometimes mimic um these symptoms. Um, and it's just worth doing ABM to check. So, we're gonna be focusing on these two pathologies in more detail. So, we've got Mister Thompson, he's 65 and he's presented to the clinic, um, with LUTS for the past few months. They're getting progressively worse. He's got increased frequency. He's got nocturia and incomplete emptying of the bladder, weak stream and occasional dribbling. He doesn't have any hematuria, dysuria or retention and no history of recurrent uti s. His obs are pretty unremarkable. Um So I'm sure there's quite a few differentials that come to mind. But the one that I'm trying to elude at here and most likely one is probably a BPH given the LUTS his age and the lack of red flag symptoms. But we're gonna do some investigations and examinations to try and further work up this patient. So, on examination, he looks well, has nothing abnormal on ABDO exam and it's important his bladder is not palpable. We want to make sure he's not in any form of retention. His D ra he's got an enlarged prostate, but it is smooth. Um which is important and certain things that we can consider doing is urinalysis, do that BM. Like I mentioned for diabetes, some bloods um including renal function and psa and then some imaging things. So, post void, bladder scan is good to look for. Um basically, um the residual amount of urine after a patient goes for a week to see if they're retaining any of that urodynamics and then flexi as well. They're all things to consider on a case by case basis. So in terms of B ph does anyone know what score we can calculate to help, to help guide the management? So that would be the IPSS, the international Prostate symptom score. And what that is um is it's a questionnaire, seven questions about the LS, the severity of the symptoms and the impact on quality of life. And that stratifies patients into these categories of severity. And based on those categories, it can help us to decide what the most appropriate management would be for them. So for more mild cases, we might adopt a conservative approach and just watch and wait and give some lifestyle advice. So limit fluid intake before bedtime, avoid caffeine and alcohol, which are diuretics and double voiding, which means that the patient goes for a wee um waits for a minute and then tries to wee again. Um just to make sure everything has been emptied out of the bladder as best as possible. If the I PSS is eight or more, then we can go for the alpha one antagonists. First line, most commonly you might see is tamsulosin and that basically relaxes um the urethra and the sphincter to try and aid the passage of urine because it does have that dilating effect and it can cause um side effects such as postural hypotension dizziness. We've also got the five alpha reductase inhibitors, finasteride being a common example. And that's reserved for patients if their prostate is significantly enlarged and they're considered to be at a high risk of progression. And that basically blocks um the conversion of testosterone and it leads to these kinds of side effects, ejaculation problems. One of the um ones of note is retrograde ejaculation, which means that when the patient ejaculates instead of the ejaculate coming out as it usually would, it can actually go the other way and reflux back into the bladder. So it's just, it doesn't um change the feeling at all. It just something to counsel patients that they might not actually have anything come out if they're on that medication. Also, we've got intermittent self catheterization and long term catheterization too. And then for really bad cases, um refractory treatment, then we might go for t which is transurethral resection of the prostate. And which group of medications from this list leads to a reduction in the prostate volume. Well, I've kind of already alluded to it, but it's the um five A R inhibitors. And basically what they do is in B ph, you're getting this five alpha reductase enzyme converting testosterone into DHT which is the active form that binds to the androgen receptor of the epithelial cells in the prostate and encourages proliferation. And that's sort of the mechanism behind BPH. So what the finasteride does is it blocks that enzyme and that will try to slow down um the growth of the prostate initially, but it can also over time lead to shrinkage of the prostate as well. But this takes like six months. So that's why it's not first line. Ok. And just a little bit of um extra knowledge, which one is true regarding Finasteride counseling for patients. So actually, Finasteride is really teratogenic. So you should advise that if they live with pregnant women, they shouldn't handle crushed or broken tablets. It's a bit niche, but you never know when you might need the knowledge. OK. And then this is just an image of t the procedure. So the resectoscope goes through the penile urethra. Um and then the prosthetic tissue is um removed that way and then irrigated and then just some questions on that just to consolidate that section of the talk. So we've got this 72 year old man with B Ph, he's having an elective T um and a spinal 40 minutes into the procedure, he develops a headache and visual disturbances and you send her for VBG and it notes severe hyponatremia. What is the cause of this presentation? So the answer is irrigation with glycine and this is an example of something called Turp syndrome um which does come up on past med if you've ever done the urology section. Um But essentially during the procedure, they irrigate with glycine and the solution is quite hypo osmolar. So it draws a lot of water into the um into the intravascular space and causes a dilutional hyponatremia. Um Then the glycine is broken down by the liver into ammonia and that's what leads to things like visual disturbances. So it's just something to be aware of and it does come up sometimes in exams. Ok. Um In comparison, now we've got another LUTS case, but this is an 87 year old Afro Caribbean man, he's got a gradual onset of these LUTS. Um So you can see he's got a mix of the storage and voiding symptoms. He's also got hematuria and low back pain. So those are sort of the red flags in the history and then on examination, the most um sort of key things are that he's got a firm and ir irregular nodules on his prostate and loss of the median sulcus. Um So if you just kind of contrast that to the B ph presentation, we can see that this man's got a lot more red flags. Um And this is something that should be ringing alarm bells for prostate cancer. So, Afro being Afro Carribean is a risk factor for prostate cancer. Other risk factors are things like older age, obesity, family history as well. So a little bit of um a little quiz. So what areas are the most common sites of metastasis for prostate cancer? And I'll give you a hint. There's four. OK. So lymph nodes is one, the lung, the liver and the bones in theory, though prostate cancer can spread pretty much anywhere. But, um, those are the four most common sites. So, what are we gonna do? We're gonna do some bloods. The most important one that we're gonna be looking at is the PSA which is the tumor marker. We do multiparametric MRI, um, and a biopsy and then especially in this case with the low back pain, but just for staging purposes, we'll do bone scan and pet scan. Does anybody know what scores we calculate from the MRI and the biopsy respectively. So again, I can't see the chat but I'm just gonna move on. So the MRI, we use to calculate something called the li at score and then from the biopsy, we calculate the Gleason score. So in Mr Adams case, his leer score comes back as four and just for context, this is what the Leicht score does. So it uses the findings and the report from the multiparametric MRI to stratify how likely it is that this person has prostate cancer based on the radiological images. So for Mr Adams, it is likely that he has prostate cancer. So do you know what the most appropriate next step would be in his work up? So that would be the biopsy. So if his like at score was less than three, then we would have to discuss the pros and cons of biopsy with the patient. And the reason for that is transrectal biopsy as you can see, you've got the probe going into the rectum and then you um access the prostate through the rectum. There's complications with that. Obviously, the rectum is not a sterile environment. So, sepsis um is a risk, things like pain and even chronic pain, fever, hematuria, and rectal bleeding. Um So that's why it's not sort of just done for every single patient, especially the ones with a much lower risk of prostate cancer from the MRI. And because of this risk of sepsis, actually, a lot of centers are starting to phase in transperineal biopsies instead. Um but I'm not sure if that's um everywhere yet. OK. So the Gleason score that we said we get from the biopsy. So essentially you look at the histology or II won't be doing that, but somebody will look at the histology and basically grade the most prevalent pattern. And that's A and then B is the second most prevalent pattern in the histological slides based on how differentiated the cells are. And then that gives you the risk. So for Mr Adams, his Gleason score is four plus five equals nine. And the reason we keep all those numbers in is because um four plus five is actually better than if it was five plus four because if A is five, that means the most prevalent pattern um in the slide is a very undifferentiated one if that makes sense. Also, his bone scan shows widespread metastatic disease. So they use like a um technetium labeled um diphosphonate, which gets taken up by the bones. So then you can see areas of higher metabolic activity that suggests bony mets. And you can see in this one, he's got it in his um pelvis, his spine, his ribs, his sternum. So it doesn't look great. So he gets discussed at the MDT meeting. So it would be something like this, all his demographics. He's got all of these comorbidities. His PSA is through the roof. If you look at this, um, age adjusted upper limits for reference and his ALP is raised as well and all of the investigations we've already discussed. So based on this, um, and what you think his prognosis is gonna be, how do you think Mr Adams is most likely going to be managed? So, yeah, essentially, um, most likely, obviously it's a case by case basis, but most likely this is gonna be a palliative um treatment plan. Um, because of his older age, he's got significant comorbidities and he's also got a widespread cancer. The significance of this raised AP is that AP is often raised in bony metastases and palliative um, care might look like pain relief, it might be palliative radiotherapy and then later down the line, things like hospice or symptom control as well. Ok. But obviously, for every patient, it's different. So for some patients, if they've got a very low risk cancer, and it's actually really unlikely that they're going to die from the prostate cancer and they're actually likely to die from something else. Um Then we can just go for active surveillance, which will usually involve monitoring PSA and the MRI S, there's hormone therapies that we can use. So just like BPH with that um testosterone and DHT driving the growth of the prostate epithelial cells. The mechanism is similar in prostate cancer. So we want to block those androgens. So we use um things like Gnrh agonists and then androgen receptor blockers, we can do chemo radiotherapy and then the more invasive things like radical prostatectomy. Um and actually bilateral orchidectomy, which is surgical castration um because that has that anti-androgen effect as well. And if you just look at this is the hypothalamus pituitary gonadal axis. So it kind of explains why the Gnrh agonists work. So, um initially, they would be actually increasing the LH and FSH and the testosterone released further down the pathway. But then with all of that GNRH overload, the pituitary gland would um sort of internalize or down regulate its receptors and it will have the opposite effect and reduce the testosterone secretion later on. So that's the radical prostatectomy. So they take out the prostate the seminal vesicles and sometimes they take out some of the obturator lymph nodes as well for staging a common side effect of radical prostatectomy. Um that's erectile dysfunction. Ok. So just some questions on prostate. So we've got a 53 year old man. He is asking for a PSA test because his brother has recently been diagnosed with prostate cancer. So you did a Dre first and you advise him that his prostate doesn't feel enlarged. He still wants to go ahead with the PSA test. So how are you going to advise him regarding um the timing for the PSA testing ensuring that a reliable result is obtained because essentially there's a few things that can lead to false, falsely elevated PSA levels. So you sometimes have to wait a bit between doing an intervention and the blood test. Ok. So I'm just gonna reveal the answer now. So usually we counsel patients that they need to abstain from ejaculation and vigorous exercise for 48 hours prior to the blood test because um that can cause falsely elevated levels. And then again, you'll have access to the slides afterwards. But these are all things that can cause falsely elevated PSA levels and therefore affect when you can do these blood tests for accurate results. Ok? And then we've just got a question about 78 year old man he's brought into Ed because he's got difficulty passing urine. He has a distended bladder on examination and catheter drains 880 mils. He also has some pain in his upper back over the spinal vertebrae. He has a past medical history of metastatic prostate cancer and he has recently been started on treatment which you suspect is actually causing his presentation. So, what prostate cancer treatment is he likely receiving? So, I'm going to rever the answer now. So it's Goserelin or the Gnrh Agonist family of medications, we can see that this patient is presenting with sort of what we call what they call the tumor flare phenomenon. So, um, he's got urinary retention and he's got worsening back pain on a background of metastatic prostate cancer. If you remember the um hypothalamic pituitary gonadal axis, all of that GNRH that you initially give will cause a P to secrete more LH FSH and testosterone um initially which will cause a flare or sort of rapid progression of the tumor. Um So it will cause that urinary retention and the worsening back pain. Um Things that you can give in practice to try and reduce the risk of that flare is things like the antiandrogens like the bicalutamide and similar agents. And also they're starting to develop GNRH antagonists that don't have this initial flare. Um But I don't think it's widespread use yet and I think they're still looking into those medications. Ok. So this is the last sort of section of the urology um talk. So we're gonna be talking about incontinence and there's a few different types of incontinence. But I think the most interesting way and intuitive way to sort of differentiate them is to just try and match the presentations with the names. Um So I'll give you like a minute to look through them and then reveal what the answers are. Yeah. Yeah. Ok. So in terms of stress incontinence, that's this history. So it typically um females and uh post birth, um it's leakage of urine or things like coughing, sneezing, lifting heavy objects. Basically, anything that increases intraabdominal pressure then got functional incontinence, which not necessarily anything wrong with the bladder or the mechanism of the bladder itself. But it's um, usually due to an impairment that impedes the patient's ability to get to the toilet. So it might be things like um, mobility issues. Um There might be things like dementia or sedating medications. Um Yeah. And then for mixed incontinence, it's a mix of stress and urge incontinence and then that brings us on to urge incontinence, which is characterized by those urges to urinate. Um And I've got a little pneumonic later to help you remember the symptoms of urge incontinence a bit easier and then overflow incontinence is usually due to some sort of bladder outlet obstruction. Um, and the characteristic symptoms that you probably see in S PA S is this dribbling of urine and then also incomplete emptying. Um, but dribbling is that key one that you usually see in the questions. Ok. So when we're thinking about an incontinence history, um this is sort of a good structure, I think to narrow down what's going on. So firstly, you want to know about the risk factors for incontinence So advancing age, especially elderly females, um pregnancy and childbirth because that can cause trauma to the pelvic floor muscles and can cause things like stress incontinence, especially if they've had things like forceps delivery, which are more traumatic to the pelvic floor muscles. And if they've had multiple pregnancies and childbirth. So, multiparity, high BMI hysterectomy, family history, all of that stuff. So then we want to differentiate um whether they're having like stress or urge incontinence by asking those symptoms, the storage and voiding LUTS as well. And then some associated symptoms to try and figure out what's going on. This is a really good Pneumonic hair diapers, which is sort of the reversible causes of incontinence. So you can run through that when you're doing your systems review and to try and sort of um differentiate things further um in terms of the symptoms as well for your history of presenting complaint. This pneumonic fun is the one for urge incontinence um which is like really ironic but frequency, urgency and nocturia is the classic triad for urge incontinence. You want to obviously ask about all your things that you do in the history like the red flag past medical history, especially birth history, menopausal status for things like atrophic vaginitis because that can also mean that there's atrophy in the bladder wall and it can cause like urge incontinence symptoms too and actually sometimes just giving topical estrogen to those patients can be really helpful. Um relieve their symptoms. Um And then obviously really important medications like diuretics and antimuscarinics that can affect urination. And then social history is really important as well for incontinence, caffeine and alcohol diuretics, you wanna know about their toileting and their fluid intake habits. Mobility is important whether they need like things like commodes in the house or if they're able to get to the toilet, um, especially at nighttime and falls risk in the elderly too because incontinence is a huge risk factor for falls. So in terms of investigations, um bladder diary is really useful. So what you want to do is you want to ask your patient to um write down their toileting habits and their fluid intake habits and any accidents that they have for three days. And you'd want ideally a mix of work and leisure days. Um for women, you can do the vaginal examination, look for any prolapse and also you can grade the strength of the pelvic floor and muscle contractions and you're in depth culture, urodynamics, all of that stuff. Ok. So for urge incontinence, I'm gonna talk through sort of the management for urge incontinence and then stress incontinence. Um But the conservative management is broadly the same for both of them, fluid intake advice, avoid those diuretics and excessive intake before bed. But also you want to prevent dehydration as well because that having very concentrated urine in the bladder can actually irritate it further and cause more overactive bladder symptoms, um and smoking as well can irritate that lining. So you want to advise them on that bladder retraining is essentially trying to prolong the interval that patients um take before going to the toilet. So you might say initially every five minutes, you can go to the toilet, then try and hold it every 10 and then gradually and gradually until they have more control and can hold their bladder for four hours at a time. Um First line, you've got the antimuscarinics and then for frail patients because we don't like the side effect profile. We go for things like Mirabegron and then there's some more really niche invasive things. Um And I've shown a little bit more about that on the side, but the Botox essentially paralyzes the detrusor muscle, sacral neuromodulation is like a pacemaker for your bladder on the sacrum. Um Augmented cystoplasty is basically using a bit of bladder. I mean, a bit of bowel to make the bladder larger and able to store more urine. And then the urostomy basically diverts the urine to the bowel loop. It's kind of like if you imagine like a colostomy. Um Yeah, but for urine and then a bit of key knowledge, what are the common antimuscarinic side effects? Um I'm sure a lot of you already know this. I have a very good Pneumonic for this, which I won't say a loud because I think this is being recorded. But honestly, I've never forgotten the side effects since. So like blurred vision, urinary retention, dry mouth constipation. Oh, no, no, no, I ve the answer. OK. So for Mirabegron, which of the following is a contraindication. So is it cholesterol BP, poor glycemic control, high BMI or severe asthma. And the answer is high BP. Um So if you look at the BNF patients with um severe blood, um hypertension aren't able to take mebron. If it's stage two, then they need close monitoring, which is quite important in um primary care because everybody um knows that and we actually had to do an audit on it at my GP practice, which is why I put it in stress incontinence is very much the same in terms of the lifestyle advice. Again, just avoid heavy lifting because that can precipitate the accidents. Pelvic floor exercises is the mainstay and it is effective for some patients. Um Otherwise, usually surgical things. Um And if patients decline surgery, then DULoxetine can be used, which is one of the antidepressants. And just to wrap up the talk, I just have a few questions on urinary incontinence. So we've got a 39 year old man. He notices that he has small dribbles of urine passing when he doesn't want them to. He hasn't noticed any association with the timing of symptoms and said there's no association with coughing or sneezing. His only past medical history includes a fractured risk and treatment for gonorrhea, six months ago. So, what's the most likely diagnosis? Um Yeah, it's a urethral stricture. So this is again, this classic dribbles of urine suggesting a bladder outlet obstruction and given his recent um treatment for gonorrhea, it's suggestive of stricture. Um Other things that can cause strictures like people with recurrent uti s or if he's had like a procedure um or something invasive in his urethra recently, then that would also ring your alarm bells for urethral stricture. And that's just what it looks like. Ok. And just another question. Now, for incontinence, we've got a 70 year old woman, 75 year old um with urine incontinence, she has sudden and very intense need to pass urine, often followed by incontinence. She has a positive history of Alzheimer's and a closed angle. Glaucoma. What would your preferred medical management be for this lady? So, just for prompting, Diphenacin oxybutynin and Tolterodine are all your antimuscarinics? DULoxetine is your antidepressant and Mirabegron is your um beta three, I would say agonist, but I can't remember completely. So essentially this is getting at a lady that has urge incontinence. Um but her past medical history is um significant here. She's got Alzheimer's disease. So she's probably more frail and we wouldn't want to give her antimuscarinics um because of their side effect profile and increased risk of falls. So, um the drug of choice here would be Mirabegron providing that her BP is all. Ok. So thank you very much for your time. I will let you enjoy the rest of your Wednesday evening. Um So yeah, I'm gonna look at the chat now and stop sharing. I'm just looking at the comments six months. Well, oh, so Tarp essentially, um, you put the resectoscope through the urethra and then they resect all the prostate tissue around. So once, if you remember the four parts of the urethra, you've got prostatic membranous bulbar and penile, they'll put it through up to the prostatic urethra, the prostate tissue surrounding it, then they'll resect the prostate that way and irrigate with the glycine. Yup. Cool. Well done everyone. Thank you very much. And can you breathe free? OK. Yeah, sure. Um So the Gleason score is what you um do from histology. So, from the biopsy and it just looks at it's from 1 to 5, the most prevalent pattern within. Um actually, I can go back to the slide if that's more helpful because it's a bit more visual. OK. One sec. Oh yeah, here we go. So um he's got in his case. So we're adding a being um giving a score of C. So a is the most prevalent pattern within that histology s slide. So um for his case four was the most prevalent pattern. So it's here irregular masses of neoplasm glands, basically looking at how differentiated the cells are and how similar they look to normal prostatic tissue. Basically grading the tumor five is the second most prevalent pattern within the um slide. So in that case, it's five and that gives you a summative score of nine, which is high risk, but usually they write it still with the four plus five because a five plus four is worse than a four plus five. Because if the most prevalent pattern is five, that means that um the majority of the slide is this really um high grade tumor if that makes sense. And then for your like a score. Ok. So it's basically that they just look at the MRI and based off the radiological appearance, we'll stratify whether it's unlikely or um unlikely to be cancer. And that will help guide whether they should do a biop biopsy or not. Because if it's high grade, then all these complications of the biopsy are justified pretty much. Whereas if it's very unlikely to be present, then it might be ok. Actually, we don't need to do a biopsy um If that makes sense. Ok. And I, I'm pretty sure this um session is recorded. Yeah, and you should, you will get the slides as well afterwards. It will be uploaded to the link that you would have joined um to join the webinar tonight. And then if you follow suit on Instagram, there'll be some like questions or like a summary afterwards as well. Um Just a little document summarize the main points from today. Thanks everyone. Thank you. Yeah. Thanks everyone for coming. Uh You all have a good evening. Thanks again, Jade for your teachings. Really lovely session. Thank you. Thanks James.