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Just started recording. Um No worries at all. Ok. It's live now. So you're welcome to start whenever you like. Ok. Hi, good evening everyone. So I apparently I wasn't live and I was just talking. My name is AA. We're starting our first series of urological emergencies, acute scrotal pain. It's quite difficult to um assess what the audience is going to be like. So I've made this initial topic quite general and I'll be relying on your feedback to help us uh moderate the content. So please at the end of this um to and kindly members to drop your feedback. Um Like I said, and my name is AO, I'm currently a core training in West Midlands and I'm interested in urology. So we'll be starting with acute scrotal pain as part of our series. And the courses and the objective is basically to identify the causes of acute scrotal pain to um properly understand the assessment of acute scrotal pain and identify treatment options for patients with this pain. Uh It's basically an umbrella term. It's basically a constellation of new pain symptoms, tenderness of both the scrotum itself and the intrascrotal contents. Quite a common presentation. Um, and this presentation depends on wherever you're practicing your medicines. So, if you're practicing acute surgical emergency on call, you would see much more frequently than so doing an unelected um, emergency. And if you are a urologist, it's probably going to be one of the most tedious uh parts of your onco because of the decision making needed. And as you would guess it requires rapid evaluation and diagnostics just to talk about the relevant anatomy of what we're going to be studying. So we're gonna be studying the scrotum and the intrascrotal content itself. And the scrotum itself is a fibromuscular bed which is a out pouching of the perineum. Um It's covered by skin subcutaneous status and the um extension of the anterior abdominal walls. Um The major nerve supply is split into two anterior and posterior. So the anterior part of the scrotum itself supplied by the genital branch of the genitofemoral nerve and also part of the ilioinguinal nerve. Um which explains why sometimes you can have pain radiating up from the left um from the left or right flank to groin region. And you've also got the posterior branch, which is the um perineal branch of the dental nerve and posterior cous femoral nerve. Talking about the intrascrotal contents itself. Pin can arise from many of the epididymis. The spermatic code on the testis itself. The test is is a so we know is the region or is the area for test and for sperm production, it is covered um adherently by the tunica genia, which is the fibrous um covering um of the testis itself and it is overlaid or covered by the tunica vaginal is which is like an extension of the peritoneum. In between these layers, you have small fluids which allow free flow of movement and prevention of and friction. The tunica vaginal is in itself covers most part of the testis but doesn't cover the all of the testes. It covers just the anterior and lateral part and leaves the posterior part for the attachment of the testes to the um posterior one of the scrotum. This attachment prevents the um twisting and no twisting of um the testes itself in people with bell clapper deformity instead of the vaginal to just um cover just the anterior and lateral parts. You have it extending further towards the top of the epidemiology cord. And basically there is no attachment to the posterior wall of the scrotum. So this allows for the testes to rotate freely on its axis. Given what is called a bell clapper deformity. The um spermatic cord itself is an extension from the inguinal canal, from the deep um inguinal all down to the scrotal cover the walls are covered by the layers of the abdominal wall. The contents you have got vessels in there. You've got veins and you've got nerves in there, carries the testicle, the testicular artery um from the abdominal um from the abdomen into the groin, straight from the um aorta also contains nerves that contains the um vas. So all of these structures can be injured um during um testicular um torsion, the etiology most times and most people when you're on call and when you have to deal with testicular pain, the question running through your mind is usually, am I going to operate or I'm not going to operate cause most other urological emergencies are usually clear cut. It's either an infected obstructive system that you need to go to theater for or um it's either a urinary tract retention which you need to relieve immediately. Testicular pain causes some kind of worry amongst practitioners deciding what to do and what not to do. So, in a way to just say the etiology, I'm also talking about of the differential diagnosis for this. I've said to split this into three parts. So is chemical traumatic. So you gra have portion of the test is itself and all the testicular appendages, you could have testicular hematoma, the varicocele could be thrombo and you could have an obstructed inguinal scrotal hernia to weak initials. It might be easier to delineate these for both for the patients. It's just SRO up into them. It could be infective or inflammatory. You have epididymitis or orchitis, phia gangrene has been slid in there. But really fun years, gangrene presentation is quite a little bit less dramatic than scrotal pain and you need much more higher level of suspicion to actually diagnose phon gangrene. Most of the patients in the early stages of phon gangrene don't come with pain. It just come with some other nonspecific symptoms and some skin changes in the scrotum. And because of the complex nerve supply to the groin and the referred pathways around it, you have neuropathic pain actually. So mid ureters, stone, inguinal hernias, aortic aneurysms, which is quite important. Remember, the test is itself descent from the the posterior abdominal wall into the groin and it carries the auto, it carries it nerve supply from the renal and aortic plexus. And there's nerve entrapments, the genital nerve, the ileal nerve and diabetic neuropathy can also have some of this just to housekeeping if you've got any comments, whi them, I just kindly remind to please use the um chat books and drop them. I'm going to have a look at them major topic for today's testicular to show. Put a nice infographic there, I think should be as clear. Um So it's basically the twisting of the spermatic cord causing strangulation of the blood supply to the testes is as plain as it is twisting of the cord causing strangulation of the blood supply to the test is it's an absolute neurological emergency um in the unselected population causing about one in 4000. And if you to break this down much more specifically, I would say um in every 1 60 man, one man is at least going to have um testicular before the age of 25 years is got by age group of presentation. Most common in the perinatal period, less than one years old and in adolescent. So teenage boys are more commonly um are more commonly likely to have testicular. There are a couple of risk factors for testicle. You could have previous undescended testes, you could have lung meso, you could have be kappa deformity. You could have previous retractile testicles like that. And one of the most important things to take away from today is it's quite time sensitive. Six hours is a gold in time to save the testes from the accurate onset of pain to when they present. Um just a bit of anatomical variation of pathophysiology like I explained earlier. You've got the tua vaginal that doesn't completely invest around. The test is um identified in this picture is just the blue covering as you can see. And in perinatal period, less than one years can neonate in an infant. Usually. Um the test is, is yet to fix um at the posterior um wall itself. So you can have twisting. So you have twisting of the old spermatic cord and the Toni. So the old test is actually twi twisting and this is almost exclusively seen in the perinatal period. The much more common one is the intravaginal where the fixation has happened and you have twisting of the spermatic cord itself with de to vaginal is in those with belt. Um This type 12% of them usually have bell clapper deformity. And other ones could be usually due to spasm of the cremaster muscle itself causing a violent twist of the testicle. So, extra vaginal prenatal perinatal period, intravaginal older people, those sense. And how does this happen? Does it twist just happen immediately and you stop blood supply. So you have to twist first. It can go far as from as high as 90 degree to 720 degree rotation. So this twist causes a physical venous state and edema and swelling and increased hydrostatic pressure. More than the partici pressure leading to arterial ischemia, there's reduced blood flow, there's reduced supply of oxygen to the testis and eventually infection and it subsequently happens um because cells need oxygen, needs all of this before you begin to have reactive oxygen species and and cell death happening. There's some time frame. This is why we say six hours. So the study of um the textbook I co I state that from the acute onset of pain up to six hours. So the risk of orchidectomy, basically, meaning the chance that the the um testicle is there is only basically 5% which is quite small. It rises ST up to 20% in 7 to 12 hours and almost categorically in pain that is persistent, not torsion, detorsion, persistent twisting after 48 hours, 90% of the testicle is gonna be dead. So which is why we say time and it's quite po you see many of us still go operate on patients after six hours because there's the higher chance that the testicle could be saved. But after 48 hours, it becomes less of a rush um clinical presentation. And this is where the um meat of the matter is. And I think testicular pain is kind of one of the few standing pillars where history is almost is much more important than investigations. I know the history um, differentiates the case for you, especially when you're on call, especially when you're in a place where you're not sure exactly what to do. The strain itself is very, very important to help us. I start with acute onset. So the pain is usually sudden acu on said severe, usually making them bend over, be sick and actually feel like vomit in themselves. Sometimes they just feel nausea, sometimes they actually actually vomit pain is usually unilateral though we say almost never say never in medicine. Um, but the pain is usually unilateral because you have one side of the testicle actually, um twisting at the time. Part of the things is part of the important thing to check. Um, when you're asking about the pain is the onset of the pain as you know, you so the pain that for the count of the radiation, the excitant factor as what they were doing. So they could either be sleeping, they could be walking, they could be running, it could be during sex, it could be traumatic. So there's so many causes and there's so many things that can predispose of the testicle. Part of the important things in the issue is to ask if the pain has remained the same since the onset or does the pain come and go? You just physically want to know if it's twisting and the twisting because you can have to de syndrome. Uh, you also need, if they had this pain before in the past, how many times have they had this pain before in the past? Um, asking about the pain itself, ask if you had any procedure done in the past. Have they had any troubles with the testicle in the past? Have they had the other testicle removed? Really? Um, did all of these, um, answers and help you weigh how much, um, risk and balance you have to decide for what to do. You need to ask for associated symptoms. You need to know if there has been any fever, any ureteral discharge, you need to know about their sexual history. Um, you want to see, you want to ask them if there's any color change on your testicle, any rash, any bump looking for four gangrene. Um, also important to ask for medical history in these patients. Are they diabetic? Are they on any, um, immunosuppressive medications? You need to ask them, do they do any heavy lifting. Does this pain come and go? Because you need to rule out common causes. You remember the um things we said earlier. So do they have a hernia? Are they having pain from anywhere else? Any abdomen or pain? Any feeling unwell? Basically trying to check for other much more sinister causes for examination of this patient. Uh It is uh it is an intimate examination. Always remember to maintain this patient's dignity. So always offer them chaperone, even if you're male or female offer a chaperone for this patient. Uh you need to examine both the abdomen and also examine the genitals itself. I usually prefer to examine the genitals first before I examine the abdomen because it help me make up my mind and you can have a look at the test. So do the IP P A. So in you're not gonna a take the testicles, but it's still quite um important. So inspect look for any swelling, check out the light itself, you can have a look and see does this look straight? It doesn't look like it's lying sideways. Um When you say high riding test is the left test is usually lies slightly lower than the right. But if the start is going to be extremely high up, almost like it's going into the groin, um You, you need to check for any skin changes, any redness, any scarification or any signs of previous surgeries, all of this is helping you make up your mind on what exactly you think is going on with this patient. If there's a swelling, try to see if this swelling arises from the groin or, or, or if it, or if arises from the scrotum and let tell, tell the patient that you're about to examine them, usually starts from the nonpainful side. So you can um appreciate what the normal anatomy is for this patient. So you, you need to touch, the test is feel for ones there. Any any different one, it difficult to differentiate from mit is whether you want or no. But you need to check if there's one, you need to palpate the testicle itself, stabilize the testicle in one hand and palp it to your other hand and check for tenderness, check for any hardness, check for masses and see if there's any swelling over or tenderness over the epididymis. The epididymis in itself tends to be much more um tender even when it's normal. So try to touch that area last way, don't make the patient uncomfortable. And usually you're able to tell if the patient is tender or not touching the testicles. For most patients is quite an uncomfortable um feeling, but you're able to distract them and speak with them if this pain is not really that serious. The friend sign is not really as reliable as the textbooks say they are. So first sign is basically where you elevate the um elevated testicle. You should have some pain relief. If there's no pain relief, it's most likely torsion. If there's some pain relief, you think of an infection, but you find that it is equivocally most times an absence prema reflex, which is basically stroking the inner thigh of the patient. And trying to see if we can activate the um cremasteric ar and get the genital branch. So um get a reflex, get a um reflex a activated and see if can cause contraction of the cremaster itself. And this contraction allows you to see like the squeezing and rising of the testicles. When you do that, make sure you complete an a full abdominal exam. Check for inguinal hernias, check for inguinal scrotal hernias, check for cough reflexes, probably palpate the abdomen, check for any swelling, check for any palpable bladder check for heart masses. Also important in some cases in older men to do APR you need to look for um a large prostate. You need to see if there's any constipation in there. And finally see if you can palpate for any expansive abdominal mass in thin patients and listen for over the um abdomen, which is where you need the uh auscultation for. Basically, you need to rule out um an abdominal aneurysm, especially in older men. By the end of this examination, you're beginning to have an idea already actually from the history, acute onset pain in the testicles, tender testicles, you're more likely diagnosed, beginning to start thinking about torsion at this point that you, you need at this point to um begin to organize um some time for this patient because of how um subjective pain can be. The twist was initially um made for in the for the pediatric population for one non experienced clinicians and also non clinicians to help them to differentiate if the child has to or not. But it's now been validated for adults and for you even amongst physicians. So you got criteria high riding test is absence, cremasteric reflex, nausea and vomiting, swelling of the testicles and hard testicles. Um 0 to 2 is low risk is likely it is not to shown 3 to 4. It all depends on the pathway your lookout pathway. If you have an ultrasound that is available, that doesn't delay your diagnosis. A do ultrasound might be helpful. Yeah, or greater than five. Absolutely need to go to theater in most centers. Their til the was just going straight to theater once patient takes more than two, it has 100% positive predictive value. So patients with scoring more than six points definitely definitely have it or shown 90% of those still high enough in those more than five have it to show it has a negative um predictive value of 100% in people with less than two. So this is quite helpful, helpful for you, helpful for your documentation, helpful for the patient and helpful for medical legal purposes. And you've got a way to score this patient and risk them helping your um decision making. So management as always, mainly by history and examination really can't stress this enough. By the time you are speaking with the patient before you even touch, the test is sometimes you already begin to think. I think this is to or not for most urologists, the problem deciding is this, is it an infection, especially in that age group where they are no really Children and they're not really more than 35. So really young adults, it's really very difficult to make up our minds on what to do. Um but this gets better with time as we see more and more of them. So it's an emergency. You always remember to resuscitate the patient every day, make sure they're stable, give some pain relief, adequate pain relief is important. Um We don't score points for saying, oh, I need somebody else to come examine do I'm not gonna give them pain because I don't want I once the um testicle to not be painful by the time they come, if your history is suggestive and your examination is suggestive, even if you need a second opinion is right to give this patient some pain relief. So they can feel better, much more comfortable really um bedside investigation. So urinalysis, check your urine dip, check for any blood in the urine check for any signs of infection. All of this doesn't mean it is noor but you have to tie all the story together if you're thinking of an infection or if you're thinking of to also to send off some urine MC, as you are suspecting some infection, you do regular bloods. Most times bloods are written and not needed for testicular pain, especially the ones that sounds like to and ultrasound Doppler, ultrasound is the gold standard of management. So the gold standard to decide if somebody has um testicular to or not, but more often than not your diagnosis and your treatment is delayed by this. So if if Doppler ultrasound is going to delay, your treatment is going to delay your diagnosis. I think the first thing to do is explore and decide afterwards in some centers, very few centers they've got do ultrasound, right? They right. And then they can be for the patients. But this is not often the case. Um as as soon as you're making your decision to escalate appropriately, if you're a junior escalate to more senior colleagues, you need to go to theater. So inform the theater team, inform the anesthetist, it's it's category one. So it's organ seven and so it's as soon as possible. And the surgical management of course is the um ultimate treatment. Couple of discussions about this surgical management. Surgical management is total exploration. But what are we going to explore? What do we tell the patient to the patients are going for surgery to the physician deciding what to do as a baseline when consenting and booking the patients and speaking with them. So at the mi at the minimum, we are doing a unilateral orchidopexy plus or minus orchidectomy depending on the viability of the testicle. And we are doing a contralateral orchidopexy. The contralateral orchidopexy is a point of various discussion among several urologists because you need to decide what to do for the testicles in theater. We know if it's to and we need to take them to um surgery, we know to have this surgery done. But usually what is done for fixing this testicle is usually what the question is. And that's where most debates um come about really um what to do intraoperatively. Most people do a median, a midline scot gray incision and there's a small group of people who do a transverse incision. There is no scope for a paramedian. Um incision doesn't help with exposure. It doesn't help with patient though cosmesis is a really consider that down there. But it also doesn't help with cosmesis. When we are consulting this patient, it's good to talk about risk of pain, chronic pain infection. It's almost impossible for it to show to happen on a fixed side. Again, we need to say there's a small risk of testicular atrophy. There's a small risk of infertility though this has not been validated. But because of various breaking the barrier, you can have some auto which affects this burn production before all of these are just projections and you've not had a concrete cause, but it's good to let the patients know when you're consenting them. And sometimes it's good to discuss with the parents because many times you are consenting Children not to let, let them know that it doesn't cause infertility. It doesn't cause testicular atrophy, but these are real and, and things that you should be aware of just in case. So, going forward and talking about what to do intraoperatively. I'm sorry, this um flush, it doesn't seem to be as clear that thought it would be, but it's from a consensus document. So I currently work in the UK. So it's a consensus document from the urology trainees and the urological um consultants. So that's boss and boss and they've had a discussion and a very wild um approach on what to do when you have um testicular pain. So clearly, when you explore if torsion is confirmed, so to confirmed on one side and if the testicles appears viable. So you've opened up the patient, you can say, oh, this was twisted, you've untwisted the testicle and the testicle appears viable. So on that side, testicle is viable. So untwist that and fix the ipsilateral side because you have a confirmed sion on one side, it is important to go over and fix the other side. So when we say fix, so, I mean, three point fixation, usually with a permanent suture and usually with a monofilament, non bra suture to decrease your risk of infection. So you find many who use prolene for this. So three point fixation, you can do medial lateral and the and the base and the apex itself. So just to tie it down, um this is appear ischemic, you untwist it to must still be confirmed, but testicle doesn't look viable. So you untwist it, you apply warm saline, go um saline soaked cause some people say ask the um anesthetist to give 100% oxygen, but that's really up to the surgeon. But most people still ask them to give 100% oxygen. Really wrap that in one goes. The next question is how long do I wait before I decide if it is ischemic, if it is viable, if it is not viable anymore. So it appears ischemic. Wrap it up. Most people say the time it takes to explore and fix the contra right side is enough to see if this testicle is viable or not. So, it depends on how fast you are. So you put 10 minutes and you put more than 10 minutes, fix the other side, then go back to the testicle itself. It is quite important. Um So by the time we are done with the contralateral side, and you have a look at the ipsilateral testicle. If it appears viable, just fix it and close up if you're not sure that um this isn't viable. Consider a stop incision on the tunica genia to see if there's any bleeding, if it is still uncertain, just fix the testicle and close it back and you can do serial ultrasound scan to see what that testes is like if the testis appears unviable. Unfortunately, an orchidectomy has to happen. In most cases in when this has to happen, you need a second opinion. So you find most registrars letting their consultants know that. Oh yes, we are going to um um we need to take out this testicle and that's going to be done. So you do a scrotal orchidectomy for these patients. That's quite clear if there is a torsion confirmed if you begin to have different types of school of thoughts when we have no torsion and you have no other pathologist saying. So you've opened up this patient, the testicle doesn't appear twisted. Um when you open, it doesn't look like there has been any twisting. So you've got no reactive fluid, no redness whatsoever. OK? And you examine the testicle, the tunica vaginal itself doesn't look like a bell clapper deformity. This consensus document states replace the testis, don't perform a fixation. That's what it said. But all the time I've seen testicular torsion and happen even when we open it and there's no pathology, we're there already. So we just fix it and close. See also no bell clapper fixed and close. But the consensus documents, especially for more junior doctors is good to follow guidelines. Rene just replace the testicles and close, don't perform the fixation. If a Bell clapper, deformity is seen on one side, you fix that testicle because there's of course, a very high risk of it retesting again. You don't want them to come back though. It is said that because of the fibrosis from recent surgery, the testicle should fix itself, but it's usually still good to fix it. And because you've seen Bell clapper on one side, it's good enough to explore the contralateral test is if there's no bell clapper deformity also it says just replaced, but you're there already. So most people just fix two and if you can see it on one side clearly fix. So basically, cla bell clapper fix, no bell clapper fix, no torsion. But you can see other pathology present. So you open it no torsion. You can see total cysto ganna there or you can see that there's some epidermitis and some inflammation and there's lots of reactive fluid without any sign of torsion. So and there is no Bell clapper and this letter. So it says replace the testicle close and address the other pathologist to take out the dotted cyst and close. This document says close, but most people they hiding in the testicles, they fix. But we are just following what this document says. And I'm sure given that we have different backgrounds where we've got different lookout guidelines on what to do for this. It would be nice to draw them in the chart. So we can see what people do in their um in their, in their centers. Um You see Bell Clapper, Y letter fix that and address the other um plus or minus, address the other um pathology. If clearly you can see an infection just close it. I mean, I think that's quite clear. So actually fix, you can clearly see that this is epidemic orchitis just close it. You also don't want to be poking into the, the um the tunic when there's an ongoing infection. So that was just one of the few times that people just close back actually, um pathology other than epidermal orchitis, they also decide to explore the contralateral testes and address all the pathology. All of this begins to go into the field of deciding on what the surgeon wants to do. But this document is very, very, very nice. It helps solve lots of um questions and debates. You can just Google the burst and bo guidelines for this. It's gonna be very helpful really. Um I thought I had a summary um document. So going back to Epy, which is just basically that's the next um common one. So I've talked about the ones where you most likely go to operate, which is torsion, these ones, you, you, you don't really, you are not going to operate and this is what most people need to make up their mind. Unfortunately, mites is far more common than torsion. So if you say 10 testicle happens, more likely than not seven or eight of them will be just e epidemiology. It's either an inflammation or an infection. Excuse me. In older people, it's more likely to be an infection in younger people. Though you need to be very, very confident and really experienced to diagnose eps in a young child, usually caused by repetitive action, joint pain, pain around you have the mi itself inflamed. Um is the most common cause of acute scrotal pain in adult, as I've explained. And usually it's in an increased age. So you can see, for example, if you're on call, a year or a six year old man has come with testicular pain, you don't react the same way when you hear, oh, a 15 year old man, boy Asco with a pain that kind of already says how um frequent we think it is. And the management itself depends on the likely etiology. Usually we give antibiotics or antimicrobials depending on the cause. And once again, this is a differentiation factor. Really slow onset. You have this nly pain that has been going on for a couple of days. They feel unwell, they've got some fever, some ureteral discharge and you've got sometimes you've got skin rash cause I stay with an ST i it could be unilateral or bilateral. It could have some swelling place, feels a bit warm, they feel quite unwell in themselves. Men, less than 35 years old and sexually active. I think it's more likely to be due to an sti I do. It can still be from bacteria from a gut bacteria. But we likely just think just a way to differentiate it either could be chlamydia or gonorrhea for men older than 35 or those not sexually active. We begin to think about gram-negative urinary pathogens. So, e coli proteus, uh, when they can have our history, it's important to see what medical conditions they've got. Are they diabetic? Ask you about sexual history? Any um immunosuppressive medication? Have they had this before in the past? Have they had any recent instrumentation into their urine tract? Both medical and nonmedical instrumentation into the ureter. Have they got issues with your bladder? Have they cause sometimes you have reflux urine into the, into the EP is causing this kind of pain. Um Have they got any um previous turps or are they taking current medications for this and ask about el or constipation too? So, medical conditions or sexual history, quite important examination itself. You need to do a scrotal, an abdominal exam similar to EOR occasionally difficult to differentiate. But you see, you find them much more unwell, you find the swelling much more pronounced compared to EOR in some case is you could be thinking they've got abscess ongoing there. The skin might not look normal, the skin might look red, painful in this um, cases and also have a very good high index of suspicion for what is called fora gangrene, which is basically necrotizing facie of the groin, the skin around the groin and the perineal region doesn't really typically present as acute scrotal pain in itself. Usually much more trickier to diagnose. You find them company of some swelling around their groin area, some blocking area, usually the diabetic large on the high PM area, poor peroneal hygiene. Previous medications kind of help you to differentiate that. It is really easy to pick up really front sign pain on testicle, up to 10% of patients will have. This sign doesn't mean they've got to or not. And also cremasteric reflex may be absent. So the question is, how do I really differentiate this distortion or not? One experience, two, multiple examinations, three use of two score and three local guidelines. For example, where I currently work, if you are a child and you walk into the department with testicular pain, even if the history is gone for more than 12 hours, you are going to have a scrotal exploration happen. It's a bit different from some other centers where you have to consider cost to the patient cost to the system too. But it's just good to have that at the back of your mind. Um Considering scrotal pain, our decision is really, is it a torsion or is it not a torsion? Um most people would like to um as you said um go on the side of, oh, I think it's, it, I think it's a torsion and I need to explore management resuscitated patients. They could be quite unwell. So do a complete sepsis, sepsis screen. Take some blood cultures, full blood counts. A urine dipstick M CS, do a complete ureteral swab, send some samples off to the sexual clinics, do full bloods for them the minute ultrasound because we're thinking more of mit is we want to see if there's an abscess in there, especially when it's big. Um, if they've got other co morbidities you need to consider, do they need BMP? Is this sco out edema? You want to check, um, you want to see if they need echo if their history and their, um, clinical presentation suggest that antibiotics depends on local guidelines. If you're thinking of an sti you give them antibiotics for sti if you're thinking it's one of the ones from the groin, you give them proper antibiotics for young patients. It's good to refer them to sexual health clinics where they can have full screening of this and decide what exactly is going on. And in summary, we've just talked about acute scrotal. Remember the course is abroad, it could be both abdominal and scrotal. It could be long standing and it could be very accurate in younger Children. We're much more worried time is going into the faster the most important thing. Investigations should not delay. They're quite academic but investigations should not delay, put the diagnosis and the management in itself and if in doubt, kindly always explore, um, I think that's the end of the presentation. Thank you. If you've got questions, um, take the questions now or you can drop them in the charts, I can see doctor Martin is around. If you've got something to add for something that we have missed, that would be very helpful too. And if you have, if you, if you also have anything to add, you can either add them on the chart, we can also see you to just pick up. Thank you. If there are no questions, if there are no suggestions is either I have just succeeded in saying myself, um what's the word again? Things that we already that we know already and just repeating the same thing. Uh I've just confused everybody. So some contribution, very helpful. So other question I was going to ask is that do we think um clinical scenarios might be better ongoing rather than just to dia lectures, give some um clinical discussions also? So we can discuss about that. This is helpful on a deformative period. So it's good to just see what um method works best for us. Really, thank you very much. I think if there are no questions, no further contributions, just please kindly remember to fill the feedback that's going to be very helpful to help us to improve these teaching sessions. Also helpful to um, decide what kind of topics we need to bring in and help us as a group also. And you also get certificates that you attended this. I think I'll leave that to the admin to try to give us to try to allow people to do feedback. I'm trying to do it from my end, but I don't think I've got that done. So if you've got no further questions, thank you all for or no questions at all whatsoever. Unfortunately, um Thank you all for coming to this first session. I think the next session will be either in a couple of weeks time, but we'll have lots of, um, notice beforehand. Thanks about everyone.