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Urology - SurgEazy

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Summary

This on-demand teaching session is relevant to medical professionals and will provide insight into the full scope of urinary tract symptoms and treatments. The session will cover the typical presentations and causes of storage and voiding symptoms, such as benign prostatic hyperplasia, prostate cancer and urinary stones. The presenter will also run through the necessary examinations and investigations, as well as the different medical and surgical treatment options available. This is an essential session for medical professionals and those looking to deepen their knowledge of urinary tract symptoms.

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Learning objectives

Learning Objectives:

  1. Identify the different types of urinary tract symptoms
  2. Describe the pathophysiology of benign prostatic hyperplasia
  3. Discuss the key components of a urinary dip test
  4. Explain the various treatment options for urinary tract symptoms
  5. Compare and contrast the use of surgical and medical management approaches for urinary tract symptoms
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Computer generated transcript

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

urinary tract symptoms. What it means benign prostatic hyperplasia, prostate cancer, urinary stones sticking a torsion. Um, so obviously it's tough to get the entirety of urology for finals and dissection. So the few things I haven't included, but I'm sure you could read around and find for yourself. Um, but yeah, it's the disclaimer. I have worked in urology, so I'm aware with a lot of these presentations, But, you know, my my my standard of knowledge work the same as a consultant, but I'll try my best. Okay, Points. So let's get started. So urinary tract symptoms. It's quite a broad term. It's quite important when it comes to taking a history with neurology, no matter what, that might be in a lot different. Various presentations on. Broadly speaking, this could be divided into storage symptoms and, um, voiding symptoms. So with regards to storage sentence on, these tend to retain, too, as the names chest everything that involves storage of urine with the bladder on. When this kind of goes wrong, we have difficulty said, um, these are some of the symptoms that patient, my present with that's a surgeon. See that you need Teo. You know, good mixture it quite quite suddenly they're not been increasing the frequency with that, particularly at night. That's what we call nocturia on. Often they might be in constant of urine as well on a supposed to storage symptoms you? Sometimes it's a voiding symptoms. That's things like hesitancy, poor flow, perhaps a a terminal dribble, a swell or difficulty in in having that kind of strong stream that, um, you know, young younger people would experience. So when it comes to sword and boarding symptoms, the the causes a lot of the of what might be causing each tend to defer slightly. So for storage symptoms, you look a more things like a UTI, your some count carcinoma. This will cause it too overactive bladder when it comes to voiding symptoms that tend to the things more like your benign prostatic hyperplasia or ureteral strictures. So it's important when considering this one patient explain to you the symptoms of having on what this might mean. This's 13 little case, so 54 year old man presents to GP with increasing urinary incontinence associated the frequency, poor stream and terminal dribbling On examination, he is a smooth and large prostate is urine dip is negative. It's PS. PSA is 2.1. What do you think they're likely? Diagnosis is to ask you a few seconds to It's the majority of your clothes upholding next, I think, really her on the money. Okay, so when we when we look at it, we'll break this question down. Iand there is benign prostatic hyperplasia. Um, the giveaways within this been yet is that you know, he's he's of age, where he's likely to experience BPH Well, it's prostate cancer, but they're kind of being so they're a reassuring. This is something like BPH supposed to a prostate cancer is the fact that, you know is not mentioning the alarm symptoms such as weight loss, malaise, anemia on examination is prostate's smooth, um, and his urine dip. It is so it is. Psh is over the normal range on when the gastro's urine dip. What I mean by negative is when we look infected market such as leukocytes, nitrites, even blood, it's it's negative. So all things are kind of reassuring. That points away from a more sinister cause. Okay, so, BPH when we get down to it, it's a long cancerous increase in the size of the prostate gland. Um, and it is a disease that affect majority of men. The process starts after the age of 40. On quite interesting, 80 years, 90% of men will be affected. Eso the way the the pathophysiology of how it develops is it's it's developed. It occurs through a dihydrotestosterone mediated pathway on. In response to this, the prostate with increasing slice. That's hyperplasia there. Azarias ult of this you're gonna have for this diagram here shows you can have an enlargement of the prostate, and that's going to affect the the the neck of the bladder and the flow that can go through into the into the prostatic urethra. So when you have a look, you'll see patients will complain of frequent urination. Um, they'll have trouble starting. Um ah, poor stream. And that's quite understandable. If there is compression of the wreath right on, def, it's worse. If it gets too severe, they might not have to pass urine it all, and we'll talk about that in turn. So when it comes to the kind of investigations that you want to do for this patient is important, you take into consideration where the patient is on where you're seeing. So if you're seeing those patients in a GP, you're what you're allowed in. Terms of your investigations could be much more limited. You gonna be relying on your examination skills. You can be relying on your in debt on. And if you want anything counts, we're going to have to arrange those tests, which will take time. Uh, conversely, if you're in hospital, you can get a lot of these tests a lot quicker. And so it's important, you know, that you kind of titrate the things that you don't ask for order depending on where you are. Um, so with that in mind urine dip again, we can. We can tell a lot from the urine dip. We can see if there's any ineffective markers like, you know, nitrites leukocytes in there. We can also look at whether there's any blood picked up there. Also, um, even useful other kind of use things as well. We can do a pregnancy tests as well, and that's important thing. So pregnancy test Mommy, look at MDs as well, particularly if you suspect somebody has infection thing with that. You want to send off things from across the people you can put up with more information. Um, you want to also want to do it some other investigations if you're in the hospital. This might include an ultrasound, that continuous, useful information, whether there is hydronephrosis or, um, even whether even whether there is, you know, the size of the prostate as well. Um, so much Just ask, Is it in elderly men? Is urine dip still helpful? It is. So as you may or may not know, in in patients who are over 65 years old, you tend to have positively excited nitrates because they have colonization of their bladder. Um, but it's still useful to see if there's blood in the urinary tract M. C s stands for I microscopy on cytology. Um, yeah, that's what it is. I'm seeing this, okay? And when it comes to the treatment options that we have, um, depends on the on the house affect the patients so conservatively you can ask patients to lose weight. You know, having an increase. Intraabdominal pressure is gonna works in this, um, caffeine intake can also irritate the bladder. And that's gonna cause again a worsening of the symptoms, and you'll be surprised when he speaks older patients. How much tea and coffee they might drink in a day Having 12 cups of tea. You know, 2030 years is gonna increase the irritation with bladder. Um, and it's probably gonna height in your symptoms, but father on then we've got other treatments in terms of the medications and the surgery that we can do, and we'll talk about those in the next slides. Um, okay, fire. So when it comes to medical management, there's two kind of, you know, main treatment arms. The first one is these are powerful blockers, and a useful example of that is tamsulosin. So as the name suggests, it blocks the Alpha one, a drin adrenergic receptors of smooth muscle, including in the prostate in the neck of the bladder on That's going to cause relax a shin allow easier for the patients to pass urine, and that's gonna provide them with symptomatic relief. But that's not without its kind of caveats. Okay, but you've got patients who are quite trail, quite elderly, you know. They're like supper with it may suffer with hypertension, and now box come worsen. It's it's gonna have systemic effect. We can also cause disruptions to your patient sexual life in terms of causing retrograde ejaculation or a dry orgasm. So these are things that you need to count patient on before they have them, and they don't always work immediately. It might take a couple days. That's work. Alternatively, you've also got your five out a reductase inhibitors. In the prime example of that, it's something like two nasty right on the way in that it works. It targets the pathophysiology off BPH your block, the conversion of testosterone testosterone into that for we mentioned before DHT on that will kind of prevent this promotion of prostatic growth. Caveat being it takes a bit of time for it to work up to six months before it's become optimal. And it may also negative effect the sexual function of the patients as as those tamsulosin as well. Um, quite so surgical management. So we've got a few things. It so the classical things that's been done for many, many years is a terp transurethral prostatectomy section on. But I like the image that we have on the left because it shows an orange or grapefruit on. What you conceive is you've got terp on the left on what's actually happening is you're introducing this probe into the into the into the prostate, um, through the urethra. And so the scope surgery on in it, you're using the kind of the loop to scrape away the excess prostate. A caveat to that is that this can cause a lot of bleeding of these patients. It's going to eventually regrow on your skin. Other complications. There's something called turps syndrome because you're constantly flu and flooding the thing. The urinary tract with water that can get absorbed on course. They're hyponatremia, another kind of electrolyte abnormalities. Something has emerged since then is something called Hold Up on that. So I think hold me in Nucleation of the prostates and a Z. A diagram kind of suggests it scoops out the entirety of the prostate. Um, from the inside. This tends to be used for a much larger prostates on. Then you've got more novel treatments that you can see on the right. That's an example of something called the Urolift, where kind of these like a tree bands or introduced to suspend and pull away the prostate from the your it through the process of curious her on that will again alleviate patients symptoms and allow them to party. So let's just go for a another case. So it's, um, to said, I'm confused where the probe goes into removing prostate So the program is introduced through the through the opening of the of the urethra. So in in in the end of the Penis and it we introduced through the the and three year it'll tract until it reaches the prostate just before the bladder. Interp. How much of the prostate is removed occurring with the exact findings? But it's it's quite significant. Ah, believe tough is used, the more mild to moderate size prostates and whole episode more honed in and used in in larger, massive size prostates. On whole, it isn't always something that present everywhere. It's it's no, I don't believe on my skylines, the gold standard self that remains top. But her lip is something that's being used a lot sentence, but I guess it would depend on where the patient is to determine what they actually have. Okay, so let's start with this second call question. So we've got a 74 year old chapters and of Africa are being descent is presenting with number back pain history, a voiding symptoms and you also describes ongoing malaise and is notice some weight loss. On with that, You also complains of ongoing number back pain. Um, does anyone have a guess What? What might be going on here? Good. Okay, so that everyone is kind of getting the right picture on. But then that's reflected in the chat as well. So trap sound like he's got prostate cancer and someone suggests you're quite worried that, you know, with his ongoing number back pain, has he developed metastatic disease too? It is going to talk a prostate cancer. So it is the most common mail cancer. Ah, number of risk factors, including your increasing age. If it's got a strong family history. Being a black origin unfortunately predisposes you to a swell on DPA. Set cancers tend to be a dinner cost minutes, and what they do is they affect the peripheral zone off the process. So you have a look at these diagrams on the right. You can see the prostate here and closer in, feel it down beneath. You can see how the prostate is divided into different areas. You can see the prostatic urethra travel through so you can see that you have. This peripheral zone sits on the outside. That's where the these tend to grow from on. You can imagine it's not quite in the traditional zone, so it's gonna have some degree of growth before you might notice some of these, uh, lower urinary tract symptoms, for example, um, so presentation these conveyed symptomatic. It could just be an incidental finding the patients might present with those lattes type picture that we we've already discussed. And then you kind of general alarm symptoms, you know, malaise, your weight loss, uh, sweat night sweats, that kind of thing. But you can also get things like that. The sperm. You're so having blood in your ejaculate on. You can also get back pain and kind of truck small theme of pain. And that's never a good sign either. So on P R examination, they tend to have a hard, crabby, irregular mass, and I'm sure the majority you have been to your clinical skills at the very universities, and they will have a model there where you could have a feel of what it would feel like. It tends to to feel that way quite a regular, and you're not well, well compared to a normal prostate. So in terms of spread, with that in mind, you're gonna have a local spread, and that's going to spread to surrounding structures. Your seminal vesicles part of my spelling mistake there the bladder, the rectum, Um, in terms of lymphatics is going to go to your para-aortic notes, okay. And through your blood, you're gonna have spread to the other ear. Reasoning. That's when you can develop your sclerotic bony lesions. Um, so since last question, is it scientifically proven if someone sexually active convict restore a risk of developing prostate cancer? I have heard that before, but I'm not entirely sure you'd have to to read that up, But I wouldn't worry about that. In terms of your finals. Going to respect that, be something they ask you could be, but I doubt it. Okay, so I don't know, maybe I'm showing my age here. Uh uh. Is no lemon on the deal? No deal. But psh on or or to not say on, that's often a big question when you have these patients who come in men of a certain age, you worry about the prostate. It's quite quite understandably on. You know, it comes the GP and say, I want to get my prostate checks. Um, and that raises a big question. So when it comes to PS PSA, um, perceptive prostate specific antigen. It's normal range of about 1 to 1.5. That conveyor very paces, and it can increase by certain amount with age. That's that's normal. Okay, so it's a protein. It it ends. I'm used in the liquid fication of jacket on bits, not certificate in prostate cancer. I think that's the problem. So with it, you've got increased forcible steps and false negatives so it could be falsely raised following a P R T u R P. Procedure can also do that. Prostatitis recent UTI Somebody's recently ejaculated and gives a A a PS. A sample is also another course of a race. Two ps A. So GP you tend to our patient Teo going to go for this test to avoid sex or ejaculation for 40 hours prior to toe. Having that and even riding a bike can probably not shortening mechanism. It might be similar to prostatitis so much pressure on the perineum that's causing the psh to be released. So with that issues with it, since for sensitivity specificity, 30% of you know it's it's it could be normal, intelligent of small cancers that might not, um uh um, it's a large amounts of PSC and June, um, but equally it might have a lot of false positives. And as we kind of go through to how this is investigated, it can be quite invasive. Do you think about doing a transrectal or transparent you'll ultrasound guided biopsy? You're taking little cause little needles on D T. Find the appropriate stolidly to confirm if there is a prostate cancer. And with that in mind, that's awfully quiet concerning. And it might mean that patients are inappropriately investigating treated, so it has to be used with appropriate clinical acumen. Not something that you know that my skylines a very useful for when it comes to GPS on equally, just make sure she was appropriately, you know, as as your old just might use it. So investigations that I've mentioned ups A. You also want to do you kind of full blood panel. As with anyone just to see what the patient's baseline is, you know whether there's anything else going on in the background in terms of imaging. I mentioned the ultrasound in, uh, the option used to guide biopsy, but you can also do MRI imaging of the prostate on that can give more information. Um, with regards to the type of prostate cancer will be kind of restless or where it is within the area. Um, once you kind of suspect cancers or you want to discuss patients at a multidisciplinary team meeting, you need to do a CT cat. It's that ct, chest, abdomen, pelvis, and that will be used quite appropriately to see where, if any, there's been a spread of the cancer. Um, and that's quite important. Equally, if you suspect loading metastases, it's you won't want to do. A bone scan is well, so he's kind of tailor it according to the patient on the individual needs, Um, so when you get to the staging and grading so as you will have drilled into you, your new grading follows the TNM staging method. Okay, with the prostate, you have something quite nuclear happy face in grading system. So what it does is it takes two separate course from these biopsies that will be done. It's like, you know, once in a transrectal transparent option and we'll take the cause and pathologists will look under the microscope and you're great them anywhere between three and five. Um, as that as you can imagine, how high the number, the more irregular and abnormal the cells there are more concerning they are with, the more you worry about a more aggressive cancer. Okay, so when we give a police in school, we tend to give it out of 10 to combine. Those two do so the lowest score you can and six on the high school. You go down to 10. So that's done accordingly, too. Um, yeah, how you aggressive. You think the cancer it's okay on in terms of management is quite complex. It can be quite complex, and it's more dysentery Team led. So you're gonna have your urologist there. Your oncologist, radiologist, histology ists, McMillan, nurses, various CNS nurses. Will People will help tailor and lead to care. They need to kind of be there. So you contract if I patients into whether they would see a radical treatment. That's a medical treatment since the trick. So prostate cancer when it comes to the management the gold standard of curative disease is is a prostectomy on This could be done in a number of ways. Um, open robotic, laparoscopic, robotic surgeries, kind of the exciting, but at the moment and a lot of prostatectomy, they're being done robotically because they have expected outcomes and you can control Thea. But there's a lot less post operative about complications with okay, but there's also other treatments that we can offer. Breaking therapy, uh, which is kind of internalized form of radiotherapy on then Brady therapy itself on, then following that divorce ago and got your medical treatment. So your LH are a channel locks a luteinizing hormone, um, treatments and then your anti androgens as well. On these will be things that are perhaps less used in in a curative setting, but more in terms of a palliative treatment. Um, when it comes to symptomatic relief, if you have somebody who's got extensive prostate cancer, then you might need to do a t u R p two secs. That so that they can. You know pass urine is normal. With this, you might also get you know, we mentioned that patient in the vineyard having back pain. It could be that he develops features of quarter require on before that. You know you need a court decompression, but you might also need radiotherapy to control that on. There's other kind of palliative support things that you can do your pain really for. Making some short Someone's comfortable. There's a few questions I believe. Could you please extend again? The indications. CT Cat? Um eso ct cap It is something that's usually done with most cancers. So if you if you see something that's concerning or you suspect that someone has a cancer in your phone into an M D T, such as a two week wait upgrade, then you would do a CT cap on. But it's just to see whether there's been any spread. So, for example, of the topic. But if you've got a hey, somebody with a bowel cancer, you'd want to do a CT capture C has been spread to the liver, or even to their to their chest or anywhere else. Okay, on how we calculate in school for abuse in that 10. So that that certainly have to course. Each cause mouth is measured between three and 10 after three and five. And then obviously there's two. Um, Then you're gonna have a score between six and 10.6. Since hormone therapy is very helpful to prostate cancer. Yes, I agree. Um, okay, so when it comes to these terms, I'm just going to throw out there to the to the crowd. What for? Waiting and active surveillance. Can anyone explain the difference between the two? It's they sound quite similar. Don't know. Yeah. Uh, okay, I think. Yeah, because, um, we got good answers. Okay? So watch for waiting is something that perhaps we do for patients to have a lot more coping abilities. Perhaps they're older and a judge on the trail. It might be decided that they wouldn't warrant or be able to tolerate a curative treatment or aggressive chemotherapy, which, which can be quite aggressive. And so, with that in mind, what you're waiting looks at the disease itself and sees if we can delay treatment to the time, which is necessary. Um, whereas active surveillance is used for patients who might have a really low grade disease. Um, that's quite small, Quite isolated. Um, And if we go back to the slides on looking at, um, uh, treatments past it yet, So when it comes to your prostatectomy, it is a massive surgery. So if you have someone who's got a really, really low grade limited disease, if you if you subject them to a prospect to me, they're gonna have sexual dysfunction, they're going to have, um, urinary incontinence. They can have a myriad of of issues as a result of it. So because the quite not known prostate cancer it's esteem safe that we could just monitor disease until the time and what should need treatment. So with that in mind, when you might hear about six monthly PSAT tests or using, you know, MRI periodically to review patients symptoms, it's looking at the time in which we decide that we need Teo to intervene a minute so that we can you limit the amount of times patients have to deal with the symptoms of treatment. So it was a old saying, You don't die from prostate cancer, you die with it, which is not obviously, always true, because people do die from prostate cancer, But often you will find that there will be people who die of other causes who happens to have prostate cancer. Uh, when they die. Um, And in terms of blues, um, an article about HR itch and a lot of anti androgens believe the pathophysiology of the cancer they tend to be, um uh they tend to be mediated through sex woman. So but blocking them, you can prevent, um, the disease from progressing further. Okay. See if one questions were good. Um, okay, so this is ah, uh, expected the question. So 60 old man presents TG with a one day history of inability to pass urine, and it's got a company in lower abdominal pain. It was previously seen his GP with worsening nocturia and weak urinary flow. Examination is gonna tend to pap will mass in his lower her abdomen. And I've just given the answer way. But let's pretend that one sore and we're looking at the pool, Please. Sweet to get to 100. Okay, So majority of friends got it over over 90% of you put right, answer. So when it comes to this, um, how do you manage it? Urinary catheter. Okay, so what? What? Didn't mention what you can also do You go to do a bladder scan on the water or it A. And you can get a measuring that. How much is in the in the bladder? Okay, so this patient is that you're in a catheter, But I'll tell you this style. Once you catheterize a patient who's an acute retention on, they'll thank you for really well because it's extremely painful. So definitions and classifications, it's a urinary retention. So it's the inability to voluntarily urinate when the bladder is full. Oh, classifications. We can call it acute and chronic or low or high pressure. So those are the questions were way have ah, retention is acute is a chronic, is it low? Pressure is a high pressure, and we'll go through that. Okay, So acute urinary retention is something that's abrupt. This developed development of the inability to part you're in and it's something that's happened over hours. Okay, Chronic urinary retention is something that's gradual. It's been happening in the background, perhaps months, perhaps see it on, and suddenly it's come to a point where this patient is unable to pass urine. Okay. And you could you could never sit most this stuff in the history. So it's important your history taking skills are up to up to scratch. Then we have high pressure buses, low pressure. So high pressure retention is one that you might have a large residual volume in the urine in the bladder. See my other one liter in the in the bladder, Um, have deranged renal function, a k a. Post renal AKI. Okay, well, you might have hydrated first on the imaging. You can see all of this kind of thing on the on this diagram we have on the right. Okay, um, so when we get to acute urinary retention, we divide. We did we Did we define it as an abrupt development, the inability to pass urine. So abdominal pain, visible bowel movements became They're gonna be tender on examination. So in this, you typically expect to have about 500 to 7 drug meals in the bladder. So when you do your bladder scanner so much, expect to see that's what we you to find when you go down to and it, um and in terms of how this happens, have made a little flow diagram. So you're in. We'll go from the kidneys to ureter to your bladder and and eventually out through your urethra, into the urinal toilet. Okay, so on the left is a normal prostate. On the right is an A large prostate. Okay, so on a large prostate will cause a blockage there on that means there's no flow between the bladder in the urethra on as a result, that's going to increase the amount that's in the in the bladder. It's going to create pain swelling, and then your your chaps could've popped alien. That's where you're going to see it, Okay? And, you know, really making any urine. So how we treat this insert the catheter. We bypassed the prostate. We allow drainage of urine. Um, Andi, that's what you see here. So I've gone to the option here talking about prostate, because usually it's the prostate. But that's not always strictly the cause. And we're going to talk about why that might be so how you manage each patient's. Acutely, as I mentioned, that is, you follow your 83 principles is to do with anything on. Then you insert your your catheter on. Then you watch what comes out the residual volume. And that's quite important, especially when it comes to, um, high volume, uh, high volumes in the in, the in the bladder itself. And then you should be taking your your full history examining patient. And then you might need to monitor the patient diaries. Just that's something that we'll talk about suit. Okay on. But what's really important is that if you do suspect a high pressure, um, issue there, so you expect to see a a k i in terms of erased craftsman, you see hydronephrosis or you have more than a liter. Then you more than likely you want to do an ultrasound to get further imaging and see what the cause is of this work. Okay, to confirm that it is the hydronephrosis. So in this example, I've gone for you're a little blockage on due to benign prostatic hyperplasia, but it's not always the course. Okay, so in women, it can be due to gynecological pathology. That could be a pelvic malignancy. That could be fibroids as well. I believe a, uh, vaginal prolapse is what might cause constriction of the ureter as well um Then there's common causes between men and women. You've got the UTI, so that can cause attention of urine in the elderly. A big one is constipation. Patients, you know, is a urology. Essentially market cords. The to the geriatric ward about a patient is not passing urine that stands out there constipated. Some medications can also cause it, but also it could be other, more serious. Cause is on. It's very easy to get bogged down not to realize these things. So making sure that you consider the neurogenic bladder you considering patients, you have acute urinary retention. But you know also might have people incontinence but also be having bilateral leg pain and as a result, experiencing a quarter of quiet. It's in grams. That's something that you should always be aware of and keep you out. And then there's a few other causes there. There's a few questions. Do you diagnose low, high BP with the blood scan? So with the bladder scan, that's useful in showing hydrin a big volume in the bladder and be the if there's anything in the in the ureter. So when you see let's go back a few when you see this image here on the right hip, you can see my mouth's. You see this hydronephrosis? That's not normal. Okay, What you should see is this image on the left hand side. And the reason that's not normal is because you have valves that sit at the the end of the distal ureter on there, one way of outs. So if you've got a back flow of urine in the ureter in the renal pelvis, that means that you've got back flow into these valves. That means that the pressure is so great. Introduce it equally in inside the bladder that it's causing a backflow. Um, and can we have urine retention after a prostatectomy? Sure you could, but it would be another cause. It wouldn't be due to your bladder outflow. Obstruction wouldn't be due to your prostate you don't have on. And I think I mentioned that there is well, So when it comes to high pressures, Mr Chronic retention that in that is due to incompetently little valves. Or you did true the muscle failing case. They're going a bit forward. Uh, so when it comes to your acute urinary management, so low pressure so patients who present with this one off acute urinary retention. It catheterized them. They're thanking you a lot because you believe it. All that pain, uh, because you can try them. And now what you want Do you want to commence what we called your therapy? So you want to use your upper blocker and you're five out of it up tasting together. Uh, typically, they say it's they start working in tandem together up to 40 hours. However, you tend to start the patient on these for a week, and then after one week period, you you bring the patient back constancy. Discharge him with these medications. With the capture, you bring them back to hospital to the top clinic trial without catheter. That's what talks and school on there, which is often a nurse. That clinic. You take the catheter out, you get into a Pentium. Plenty of water on. Then you bladder scanned them before they were to see how much is in their bladder, and it would look something like this. This image on the right, well, that black is the inside of the bladder on. Then you'll ask them to have a week if they can we? And enough they week you check the volume in their bladder. If it's less than about 202 100 females, you'd say that they've got, you know, a good, competent bladder, and they're safe to go home with that catheter. Okay, high pressure is different. High pressure means that you, as a result, had their k I was a post. Really? Kout, you've got, you know, perhaps features of hydronephrosis. These are all quite concerning things. Because if they were to continue, if you were to go home and just let them develop again, what would happen is eventually you get kidney failure. Yeah, you're gonna cause Post. Really? Okay, I and eventually that's gonna extend the intrinsic function of the kidney. So for that reason, you keep these patients with a capital until the time of their surgery. So your dynamics. So let's say that this patient had ah bph and they came in with, um Let's say they came in acute retention. They had an ultrasound, showed that they had a large prostate. You catheterize them? You start them on there. You you get catheterized on. Then you sent him home. Would you be confident giving that patient, um, a surgery for the prostate straightaway. A T U R p or a whole. Where is there anything that you would you would you want to do a urodynamics beforehand? Is that something that you would consider? So what I'm what I'm trying to get at is Okay. Okay. So what? What I'm trying to get at, though, is irrespective this. This patient needs a catheter, so catheters do cause infection. That's a big thing. But it respected of this. If somebody comes into you, for example, with the high pressure, Um Ah, high pressure. I'm, uh, urinary retention. You're worried because if you take the catheter out, they're going to go back into high pressure attention. They're going to develop in a k I. And it's gonna be really bad. Okay, so you have to keep the catheter in it. So they have the surgery. Okay, but can you be confident that the catheter Sorry. Did the the If if we do a, uh a, uh t u R p that we could leave it. This patient symptoms, the answer is no, Not necessarily. What can happen is that you have patient to come in with retention. Be catheterized, um, You maybe talk them. Perhaps you don't talk when you leave. The cats are in on Ben, you say? Okay, we're going to do surgery. We're going to do a T U R p or a whole it procedure toe. Alleviate this problem for you, and then you go to the procedure, and then you realize that the patient might have a true sir dysfunction of their of their bladder. Okay, so for that reason is often good practice to do urodynamics before we offer surgery. So what urodynamics essentially is is it's quite a lot of clever probes placed into the bladder into the ureter into the rectum, and it measures various pressures. It has done quite a lot in gynecology for women. Okay, on where it can be quite useful. Is it? Comptel us using a lot of the precious to to make calculations, whether the muscle of the book, the bladder, that true sir, is functioning as it should. Because if you have a a tonic bladder, a bladder that isn't doesn't squeeze it contract. It doesn't matter. Yes, they've got a large prostate or no, you take that out. It's still not gonna be able to pass urine because their bladder consequence. So for that reason, it's good practice to do a urodynamics before we offer patients definitive surgery for, for example, a BPH that's caused a acute retention. Okay, so next into consider is chronic retention. So as we mentioned, a chronic retention or something that develops over time, not something that happens acutely. Eso With that in mind, we can spit those into the low pressure and your high pressure attentions. So low pressure attentions might be to do with primary truths of failure. That's failure off the muscle itself to the muscle of the bladder to appropriately contract on allow you're into squeeze out into your ureter. Okay on. Now it can happen. Do two things at more to sclerosis or stroke or any kind of neurological condition that might affect your ability to appropriately, you know, control your ability to urinate. Okay, so what happens is if if you're the truth and muscle fails to squeeze, it will remain compliant, and as a result it will continue to stretch and stretch and stretch. So when you have patients who have chronic urinary retention, often they will have massive volumes in their bladder. Remember, we mentioned the key retention patient center apartment to 700 um mills in their bladder. Patients with chronic urinary retention might stretch to the extent that they can have upwards of two liters in their bladder. Okay, and because of the Shrek happening over time, there's a loss of sensitivities they might not necessarily could present with lots of pain. Okay, so with that in mind that you don't get high pressure attentions on. But what that is is if you've got a chronic, that's a retention or a chronic problem with your prostate, your prostate. It's grown in size over time. Over time of the time. What's happening is your bladder will have to push harder and harder and harder and harder to overcome pressure of the bladder. It's kind of similar to how you have cardiac mean remodeling in the heart as response to about the the disease. So what actually happens is you get this, would you see on the right on that's called Trabeculation, and when you do your next four cystoscopy and you have a look in the bladder, you'll see all those lines going across, and that's not normal. And that's happened in response to you kind of hypertrophy in response to the need for your bladder to have to push harder. Okay, so it might come to a point where you can't increase inside anymore, can't hypertrophy anymore. And as a result, that's when you get these patients with big bladder's you you can't push anymore. And now they're in retention. Okay, um and that's something to to consider. So something can also happen with these high pressure quality retention on that's called or I think my next light, actually, Um, yeah. So let's talk about this first. So with the chronic pretensions, when it comes to managing them, don't take the catheter out. We keep the catheter in. So once we've Once we have decompress the bladder, we keep the catheter in. Okay, And there's someone mentioned before Long term catheters are largely bad. Okay? They're associated with a myriad of problems that can be discomforting for the patient making cause capital associated UTI Um, no, no. Scomi or infections or big thing and captures our big part of that. Okay, uh, equally, they can affect someone's confidence, their their quality of life, that sex life's. It's really kind of a debilitating thing. So there's alternatives that so you might want to do something such as I s C into with, um, self catheterization. And that's where a patient pops a catheter in small packs to a number of times a day to drain your bladder avoids them, having long term capita and all the kind of problems that you have a seat for. I mentioned before kind of these primary thing truths of muscle failure or problems when patients have, like, a mess or ah, Urogenic bladder for another reason. These might be patients here suitable for a suprapubic catheter. Um, and that's something that will alleviate the problems that they would otherwise have in terms of the chronic urinary retention. Um, and when it comes to managing the defensive, you managing chronic urinary retention, all somebody is dependent on the course. So in men, it's going to be things like BPH in women public prolapse on as again, I mentioned something like neurogenic bladder. Okay, that might happen is that was a result of neurological problems. Talk is trial without catheter. I should have said that trial without capita. Okay, um, and the urodynamics isn't necessarily an examination per se. It's an investigation. So it's something that will be done in, like outpatient clinics on. But it's something that we're done with a lot of urinary incontinence and working out what the cause of the patient's urinary incontinence is. So I'd recommend going away and having a brief read of that, too. So you're aware. Okay, Um, so post obstructive diaries is this is a phenomenon that happens, uh, in patients who have massive amounts in their bladder. Okay, so someone's got, let's say, two liters in their bladder. You drain it all out immediately. They get too early. It's coming out their their bladder, into the into the character bag. Now this can stimulate something of a diary cysts. So by that be the kidneys will produce a lot. Lot more urine on gets more exactly known. Why is this happens? But it can call salt wasting as a result in cause electrolyte abnormality. So we worry about it in terms of what it might do for patients. So it's a patient. Prayers over a liter rained following a retention. What we tend to do is moments of their urine output when we say that if it's more than 200 mils for two hours, we consider that a postobstructive diary cyst on there's a result. What we do is we want to supplement with patients so they don't have a hypertensive episode or electrolyte abnormality on we give them 50% of the previous area is your lap for the subsequent hour to to clarify that, let's say someone is having 600 mils. They're just there have been drained or two liters and now every hour, draining 600 mils. What I do is I then check what they have every hour in the next hour. Give him half. So if they were having 600 mils drained in a now our the next hour, give him 300 mils. And the idea is, you don't want to do a one toe one replacement because you end up chasing a tail and you continued diaries because you're just given the more fluids. So we're giving fluids to prevent them from becoming hypotensive. But also we don't give him too much fluids that we continue to diaries, but it's just one of those phenomenons that should be aware of when you have pictures with corner paternal attention. So I've got a case it. So I got a 72 year old man, a feast or woman? A part of me with less like pain. Colic lying to growing. Um, Just got past medical history of renal stones from many years ago. Hypertension. They've had a coronary artery bypass graft. Their urine dip is negative for leukocytes nitrates, but it's positive for blood. Uh, they you get a call from a GP. You explained to history and says that they need to be admitted to the pain. Really? Do you accept the referral? Yes or no? Three people. A tick C, which is a little bit concerned. Good. Okay. Say we could about 87. You said something. So for a few more years, suspect half of it. Okay, so I'll show you the results, if you can see that. So 87% of you would have accepted the referral. So let's see what happens now. Patient's dead. Okay, Be dramatic, but they've got a triple A, so the moral of the story is undifferentiated. Back pain is an abdominal aortic aneurysm. Until proven otherwise, this is a classic scenario that comes up in, um, course surgical training interviews. So, essentially, unfortunately, less ploy to growing pain. Uh, you typically get, for example, when somebody's got a renal colic or pyelonephritis that can also occur for someone used had Triple A, you can mimic it. Okay, so when in this scenario, I mentioned at the patients had hypertension that had a coronary artery bypass graft, they're all kind of concerning things for Triple A s O. Something that you should be aware of and something you should consider. So any undifferentiated back pain, um, or flag pain is a triple A until proven otherwise. So with these patients, it's important to go through the crack parkways and a li. And if they have any sign of being human, remember the unstable. You should assume that it's a triple there. Cool. Right under. Use this your bit or forget it. I'm not gonna because quick announcement. Thank you for that. Um, sorry for interrupting everyone. Um, I'm just gonna post a Google feedback form on the chat. This just to get some extra feedback on this issue. Um, I was theories on the collaboration itself, so we really appreciate it filled this out. Um, so please, please, do you fill this out? It would really help us improve our future sessions. Um, and any upcoming sessions pants eso just posted in the chart. Now on. I will pass it on back time. A just Yes. Yeah. Thank you. And so a few questions. What? This undifferentiated me. So essentially, by that I mean in the back pain we have available the causes its undifferentiated. So it's it's a big Okay, so we still need to establish what causes before we can, um, appropriately treated. So it's quite important these patients go in the right part because with triple A's time is money on diffuse If you take the patient to the wrong part of it or if they're on the urological ward and they've actually got a triple A that's concern concerning because I need to be, you know, getting the appropriate imaging. They need to be stabilized. I need to go to Vascular that repaired, okay. And kids. Okay, So, renal colic. Eso does with my trickery. So now we'll just do a renal colic. So it's really common. Okay. Kidney stones, A really common. I'm sure you all know people who have kidney stones. You got a lifetime risk of 12% in men and women on. Then you got a peak of onset. So twenties and then forties again in in men and your tendency in in women. And that's like the younger age in the twenties and thirties. A matter of fact, I've seen quite not women in their thirties, especially the sting European. You had kidney stones. I don't know if that's just my experience may not be very anecdotal, but again, missile pain from the ureters and caused by renal colic. Remember the nerve supplies a bit more bake uh, when we talk about the abdominal viscera. So you have that dermatomal supply t 11 t L2 and it's gonna pass down that low into growing pattern. Um, and that's in keeping with the on you know, the chronic nature of the pain last you two parastatals of the ureter. Your it is a muscular tube. Okay, so peristyle cyst is trying to squeeze out that stone. That's what's causing your colicky pain. Okay, So, stone types, I won't go too much into this, but I know it's something they might expect you to know your finals. So I just be aware of the common once on day and, uh, what they might mean in terms of the imaging. How were the radio opaque or radio loosens? Okay, but calcium oxidate my father most common one. Okay, so this is a a x ray Kubot, Um, and don't tend to really do these anymore. This is something that was probably face out in most places a couple of years ago, and it's now replaced by it seats. Okay, you be so a CT kubo stand sort ct kidneys, ureters bladder on that essentially is a long contrast CT image of the abdomen and quite quickly will tell us a lot of inflation. Particularly, um, it helps us differentiate your back pain on the It's not the best part way through spotting a triple A and stop this, therefore, but it helps us confirm the presence of the stone. Nothing else going on. If you have a look at this image, you can see here in this, uh, transverse image on that current limits. There, you can see stone buying up there, the little white bits there, and one there as well. Okay, So risk factors for stones. Typically, it tends to be done a super saturation of your in. Okay, But you do get people who have what we call chronic stone formers. So they might have set in genetic predispositions or dietary predispositions That kind of leads into forming stones. Okay, um, so when it comes to when it comes to that, you want to look at things that approaching intake sodium intake is if they're having plenty of water, whether that, you know, somebody is chronically dehydrated, but also mentioned for your school family risk factors as well. Um, some of this question in GP patient present like that, what would make you think it was Triple A? So, um, well, if they were had a low BP, if they were tachycardia, if they had perhaps, I don't know, similar type of of presentation. Um, they might also have a postal expansile mass or abdomen, or they might be displaying symptoms of shot. Okay. C T k U B is preferred just because I think it's ah, better imaging modality. It's easily interpreted. If you look at this X ray here, you don't really know where that it's you just know it's somewhere in the abdomen in relation to the lumber spine. Okay, Because you look at this, I can tell you how far down the ureter that stone is. That's why I think is, um, favorable. His regular, long term and psychotic use a risk factor in may. Well, be a chance with that and something for you to go away and read up on it. Um, mention that. Okay, So history taking says I mention really important you want to follow your Socrates on route have had stones before, lightly tap stones again. They're gonna have that nausea. They're gonna have their vomiting, that frequency and urgency as well. And they're gonna have you material in the urine dip for something to take into consideration my also up testicular pain as well, cause obviously, it radiates certain classic Lloyd to going direction. Um, And you look for things like fevers and rivals. Okay. That signs of an obstructed stone, um, at an infected obstructive systems. Or tell me what heard is a urological emergency, and that needs treatment. Except okay. So when it comes to physical examination, you're looking for signs of parks, champagne panel tachycardia, the Yeah, it might be a sense of Well, and that stopped me difficult sometimes if somebody weighing up your room into a triple A versus features of shock. But that's your bus, for your clinical acumen. Comes in to get to determine between two. They're my parents, Knittig. Okay, uh, the dead giveaway is palpating their their lawyer at the back of a lot in the kidney. And there were literally you touch their not be 10 to know the little back about the bed. Okay. Um, so you mentioned in some of investigations? We do. CTK you be is great. Okay, we need to look there. You knees, electrolytes, they're renal function. We want to look at the inflammatory markers and white cell count neutrophils, that kind of thing. Urine dip to really useful as well, much. Tell us if there's a superimposed infection there. You know, it looks like a try. It's like nitrites rather Azzoni materia. But also, you want to use your common sense when it comes to anything. Abdominal pain. So a woman with abdominal pain here is an age to be pregnant topics. Okay, So you want to do your urine dip, will urinate, see GI test to experience that, um, I mentioned before about X ray kv that were stabbing pains down favor of the gold standard, which is CTK you being many centers on. You could also do a real option that might be appropriate in certain. Okay, group. See, you don't want Teo exposed Teo to radiation. Okay, So, pain management, the first line is NSAID. Okay? And that's usually PR declare fella coming about 100 mg. That's great. So it's like the best thing for back then before renal colic, and it will. It'll relieve it a lot of pain and it can be lost. You lost it to the 12 hours or so It's It's really, really good. Um, that's one thing for you to pain management on, then, when it comes to manage them entirely, you want to use your HB approach, but in terms of the definitive way we manage them, we can use medical explosion therapy of highlight this because in my experience, working, I never really used that or whether it's you some of the places I'm not sure, but the stuff you still mentioned on the nice car loans currently today on, then you got various surgical therapies, and they depend on the size of the stone in the location of the soul. So what? We tend to say stones 1 to 5 millimeters, typically in the ureter patient will pass by themselves. Okay, Um, I think 75% stones, best in six millimeters will pass by themselves. Anything bigger than that? They need admission, and they did intervention. Okay, so that's where we have the watching weight When it gets too far. 10 mills, we can use percutaneously nephro the ostomy. We can use extracorporeal shockwave lithotripsy. Yes. W o l on Urso, which is your uterus copy on def. They're particularly big. We've again you something like TCL. A swell on site matters as well. Obviously getting about the renal pelvis is bigger than the space in the movement of the ureter. So some to eat mint option can be preferable over these words became We'll talk about each of these in 10. So that's why I was kind of getting it. So in certain places renal stones, you want to use these types of treatment proximal your attack stones that may be less likely to pass by themselves? You need to have a more invasive approach on Finally, your distance. Stones. Unless they're massive, they've been in the eight that size range. You look to pass them by yourself. Okay, so this is what extracorporeal shockwave lithotripsy looks like something that's know offered everywhere. Um, it might only be often It's certainly centers, but it uses kind of shock wave therapy to to shake and disturb stones to break them up. Okay, um, we can also use this. This this is what is percutaneously for a laparotomy on that involves using the nephroscope go through the skin. Percutaneously into the bladder was about a kidney into the A basket a plane into the pelvic pelvis and then breaking up the stone that way or retrieving it that way. Then they break it up in the pull down. Um, and then finally, we have ureterostomy, which is highlighted his Urs steer or much right there. Okay. And that involves putting a scope up the bladder and then from there, going up on TV through in the in the trial on finding the the proximal your it is, um, going up. And it might be using a laser to break stone up or it might be putting a stent. You have heard the phrase J J stent, Um, putting a stent up to bypass where the stone is causing a blockage. Okay. And then in that time, that may be coming back and taking stone out another time or doing, uh, we're letting the stone kind of passing it so tight. Okay, so when when you have some news got a stone, for example in the ureter, they may have ah hydronephrosis present as a result of blockage. So putting a stent up allows you to generally drain the urine and then leave. Yet what we worry about infected a productive system. Um, so yeah, the S w l extracorporeal shockwave lithotripsy. Okay, um, so when it comes to acute mission criteria, there are a few. So if they've got signs of infection, a single function and kidney, um, real impairment, the kidneys extracted, or any imaging you might have, for example, or are the factors that might be chronic stone formers or they've been trying to you because of it or intractable pain? By that, I mean pain. It's can't be relieved. Then, in that instance, you'd want to admit the patient. Okay, When you admit them, you want to do a few different things. Okay, so if it's an infected obstructive system by that I mean sepsis caused by a stone they might have spiking temperatures in a pyelonephritis start companies it. So with that in mind, you wanna haven't intervention. So that might mean doing radiological intervention, such as, um, across to me, which is a a true placed into the side into the, um into the renal pelvis to drain the urine, alleviate the obstruction. Um, let's see if you have a blockage there, you're gonna have passing. Everything is going to be turned out. Um, alternatively from that position, they might be up to put a step down and we call that empty great sex. It goes down words. Um, alternatively, there's the old school way, which is using something similar to this. Your arrest. It put a stent up. That's what we call, um, right, great stenting. And it's always important in these patients. You might need to get you involved because they can get very, very sick on. And finally, if you want to give the patient some advice a sto what I should do and they've got a chronic stone formers. There might be something that they can do to avoid this. Just the interest of time. I'll skip passes, but you should have access to this in the slides anyway. Um, last case. So 17 year old school boy, sexually active presents with a four hour history of severe right sided scrotal pain. Pain's constant came on suddenly these writhing in pain He's got a tender right testicle tender, absent cream stir reflex. What's the most likely differential? Okay, so we worry about testicular torsion. That's the dead giveaway in the in the vigna. Okay, so stick in a torsion is the name suggests the twisting of the sweat accord around. It's kind of what around itself. Okay, on. As a result of that, it's gonna cause constriction two other blood flow to the structures of run within. Um, let's see, because the scheme year and necrosis So with that in mind, important differentials are your epididymo-orchitis and your quieted hydrated of more Ghani. Well, you control the okay, so I'll go through each of those in turn. So epididymo-orchitis isn't is ah, infection of that area where difference, um testicle talk shin is that we'll have a longer history. They might be a history of the media or the UTI that will accompany in it. Um, equally you'd expect to see leukocytes nitrites on a you're in debt on. If you did an ultrasound, you might see some findings in keeping with, uh, UTI on equally when you test the patient's cremasteric reflex that you struck skin under the scrotum, you should see that muscle regal quite vigorously compared to in a torsion where you wouldn't see that at all. Higher to did, of highlighted of more gag, more godly is what you can see here on the right side on image. You can see that little cyst on the end. Uh, this essentially, it's a testicular assistance. A remnant from embryology can sometimes get twisted and minute the pain that you experience with the testicle talk incessantly. Course it's considered and also important, always rule out warmer when it comes to your patients. Presenting noticed it in the pain as well. So when it comes to the history of the important things to gauge the onset because the onset ultimately guide, you know how much time we have to make an intervention on when it when it occurs. But then testicle torsion happens often happens at the start. Them on the right quite nicely represents. You can see the twisting of this. Okay, on it can happen because of this thing called the bell clapper deformity. Essentially what that is is you have this blue structures underneath called the Tunica Vaginalis Onda. Essentially that could in properly for on but not attached to the testings and epididymis ondas a result. You will have this thing horizontal testicle that's more prone to twisting on itself. Um, that's what we call a bell clapper deformity. And you can see that this this this angry looking testicle here on the right is twisted. And, you know, it's in the morning in a horizontal play. So with that in mind, on the right up, gotta units of a bell clapper were driving. No idea what this, uh, but it was probably something that is relevant a few 100 years ago, and they discovered this. So when it comes to the management, we talked about time. Time is tissue when it comes to this. Okay, so if you look at this diagram on the right on the on the left story. You can see that after six hours, you could a reduction in the salvage, right? So with that in mind, if you suspect to stick it auction, go delay. You don't stop around getting an ultrasound. If the history is ambiguous and you can't tell or, you know, there's a lot of risk factors to taking this patient surgery. And it's an hours, and you can get an option. You can often use it too. Television is Dr Flow Teo the Testies. But I wouldn't rely on that. Okay, Um, more than anything, you have a low threshold to take patient data to, say the testing, and you do a scrotal expiration. You doing orchidopexy, Which is the fixation of the testy. If it is twisted, if it's dead, it looks like this one here on the end. Um, then you don't get a DEC to me, which is a removal of the testicle. Okay. On that a nutshell was mentioned up your testicular torsion. Okay, so thank you again very much for your time. Really appreciate it. A said your feet back. Very welcome. A comic of minor believed it. Ah, Talk yourself for the society of pediatrics. Going got excellent resource on revision questions. Is that a lot of competition? The moment if your medical school has the most most people there, um, you get a free membership. So do you take that out If you want to see some and useful things for your denims. Thank you. I'm a think. You're brilliant sessions. It's very useful. Think he Is there any questions or anything? Any questions? Guys, please. You pop in the chance.