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UROLOGY TEACHING SERIES: Management of Haematuria



This on-demand teaching session is designed to help medical professionals learn about the management of hematuria. It will cover topics such as how to define and classify hematuria, recognize common causes and its differentials, initial and definitive management, when to refer to a urologist and nephrologist, common causes of significant hematuria and differentiating its mimics. Join this session to gain a better understanding of hematuria and how to help your patients get the best care.
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Learning objectives

Learning Objectives: 1. Define 'I material' 2. Classify I material when observed 3. Differentiate I material from its mimics 4. Recognize common causes of I material 5. Understand initial management, referral criteria and definitive treatment strategies for I material
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

77 plus 12 was a nine You Green live now. So just order your live now. Medic care. Good evening everyone. Uh Today we are going to be having a quick discussion on management of the Uria. Uh This will be our second episode of our monthly teachings. And it's just so that we can have a brief and I mean, a good understanding of what management of the material looks like. So I'll just proceed now. It looks like we have a good number of people in in the meeting already. So, ok, so the objectives of the presentation basically is how to define I materia. You want to know how to classify I materia. When you see one, you want to be able to differentiate i material from its mimics. And you also want to be able to recognize common causes of immaterial. And also understanding the initial management of immaterial, identify the need for a referral to a urologist and nephrologist, understanding the need for further investigations and definite management of the material. I mean, the material is something that fascinates both the nephrologist and the urologist, but not all cases of the material will go to the nephrologist. So you have to decide which one is going to go to the nephrologist and the one that is going to go to the urologist. So, uh the aim at the end of the session is we should have a good knowledge of the common causes of ter its differentials, able to identify the signs and symptoms and its initial management and also photo management and also identify when to or refer to urologist. Because I mean, this this discussion will be streamlined to management of I mean and the uh from the urology perspective. So there are some pre assessment questions. Yeah, just to have, I mean, test our knowledge and it will be good. I think there will be a pool for us to, I mean for us to answer the questions. And so at the end of the day, we can see how what our our knowledge was before the, I mean, before this presentation and also after this presentation. So people can start answering any questions, please. Uh I'm just thinking, I'll just give some few minutes for everyone to answer the questions before I proceed. So I'm not too fast. OK, I think we're on the second question now. So on the third now, I hope everyone is getting to see the questions, the polls and able to respond. So I think the fourth one is just started out now. Yeah, I think we're done with your assessment questions. Now, we will just proceed. Ok. So what is the R two at, I mean, I think everybody, when we see uh maybe a patient's urine or urine anywhere and we see a tinge of blood, I mean, and we easily recognize as, as immaterial. So, immaterial is the presence of blood in the urine and can originate anywhere in the urinary tract. Bacteria is defined as presence of at least five red blood cells per high power field in three of three consecutive centrifuge specimens obtained at least seven days apart. And IMA is actually a common presentation on emergency urology. And it's good to know that it's not a diagnosis in itself. So you need to identify its underlying cause. So if you see a case of IMAR material as a GP as a primary care physician or as someone working in the hospital, in the second practice, you need to identify why the material is happening and know if it's, is there a physiological one? Is it a pathological one? Why is this happening? So you need to ask yourself questions. So it's good to know that IMA in itself is not a diagnosis and it's been classified as VCB material or non VCB material. VHNVH just acronyms. And you in 10 past you, the material was classified as pro material or microscopic I or I IMA material basically. So why do you have to get worried about Imia when you see a case of one, I mean in material is just like bleeding from, it's just like bleeding. I mean, it's ongoing bleeding. And we know that bleeding is one of the things we are, we are always worried about in medicine and ongoing bleeding can cause anemia in itself. And it, and it also has a 10 and consequences. And I mean, there was a, there was an interesting scenario, a case study I read about, I mean, Wale syndrome, which I mean, not a very common cause of im arturia. Uh It just, I mean, in that particular patient, it was more of like any co anything causing vasa maneuver, coughing, defecation was causing her to bleed. And why was she bleeding? She just had, she had this intraparenchymal artery aneurysm and she dropped up hb so fast by the time she presented in the hospital. So mean, so a materia can result in anemia not commonly, but it can. So the other problems with a arteria is you can, especially the, I mean, the ones that are non glomerular origin, we'll talk about that, it can result in clot formation. And you know, when we, if you're having too much of clot in the urinary, I mean, in the bladder, it could also affect outflow. So the patient can be urinary retention, it can lead obstruct the urinary tract. That's also a notice for infection. And if there's obstruction of urinary tract, also, it can lead to an acute kidney injury. And the material also could not a sinister pathology and the fact that it could just be a cancer that is just manifesting itself. And it could also be a glom ris which is also a common scenario. And sometimes you also expect immaterial, we say EIC. But I mean, so for example, if someone has just had a cystoscopy procedure or a procedure along, I mean, along the U I mean, urinary tract can cause Amaia, we expect that to set it. And it could also, I mean could also occur following surgeries like trans resection of the prostate or rejection and also tus. So the origin of imar could also be glomerular or extra glomerular. We know the glomerular is the, I mean is the unit of the kidney, an important unit of the kidney but sometimes when is al when this is also affected, it causes imar and most of the cases it it will range of those that glomerular are medical in nature and the nephrologist will be the one to manage that. Oh, so this is just a picture just to show us the differentiation of the material. And from the far left, we can see that it looks there's a tinge of blood to see. So the different words we can use to describe it is clear, clear pink. And the second one, we can see we can appreciate the pinkish nature. Uh So different names there watermelon. Yeah, it looks like a watermelon rose. So there are different words that people use to describe these things. So I mean, when you are this, I mean, sort of this can also help you when you're discussing with fellow clinician or a urologist. And the next one looks, I mean, a bit, it looks more bloody compared to the first two different names also to describe it. And the fourth one looks, I mean classical, you say this is bloody and the fifth one is bloody. Yeah. Yeah, I mean the other shade you can see dark brown, brown colored, I mean, especially when you are seeing cases of emesis that those are also cases when you see immature. Yeah. OK. So this is a good picture just to show us, I mean urine in the bag. Obviously, this is in artur. So like I said earlier in material, either have v nonvisible viable, usually called cru material in times past. Also microscopic. I mean, when you say VCB material, it's plain to everyone that this is patient is having a material. I mean, it's, it's, it's I mean this material you can't argue it. And the next one is nonvisible material, which we say is mostly microscopic or dipstick positive. So is that a is you do a urinalysis, there's blood in the urine, but you need to know that it could i it could either be, I mean there's blood in the urine but you only need to confirm it with a microscopy to be sure that it's not just hemoglobinuria. So when you go ahead and you do a microscopy and there's still red blood cells. Obviously, this is a material but hemo hemoglobin area, there will be absence of red blood cells. And microscopic material is defined as when you basically see presence of three or more red blood cells per high power field and nondisciplinary material seems to be classified into two subgroups. We have the symptomatic one and asymptomatic one. When we say symptomatic nondisciplinary material, obviously, this patient does not have disc material. It's only something you probably have noted on Dipstick and PA patients is now having is also having symptoms. It could be symptoms of luos, lower urinary tract symptoms, maybe patients having frequency urgency, dysuria and super we pain or also re alcoholic. And you could also be asymptomatic patient is not having symptoms. It's just an incidental finding and maybe routine check. So, so visible material, nonvisible imar with nonvisible material, been further delineated into symptomatic and asymptomatic nonvisible material. And so it would also be good to also talk about s significant immaterial in itself. Significant. What, what we mean by immaterial being significant is that, that when you see a single episode of vi IMA for someone to have pass urine that is bloody, that's significant. If you have any single episode of symptomatic non BC P material that as a patient, we're not seeing the blood in the urine, we're probably seen it from Dipstick or and also maybe confirm with microscopy. But if there is ab and you also need to rule out the absence of urinary tract infection or other transient causes for women. I mean, menstruation could give you a false positive material. So you need to ascertain if you premenopausal woman is presenting with IMA, you need to ask questions about the last menstrual period. You want to know if she's currently on a period because that could be the reason. So you want to repeat that urine dipstick or microscopy at, at another point in our menstrual cycle. And when we have persistent asymptomatic nonvisible material. So this person is having nonvisible material, which is asymptomatic and is also persistent. And why do, when do we say it's persistent when we have two or three deep sticks that are positive for nonvisible material? So you've done three deep sticks and two are positive and you also need to ensure that you've ruled out a UT I or all transient causes. I mean, like I said, it could be menstruation. It could also be food, what the person, what the person is eating. Maybe in terms of, I mean, someone that eating rhubarb, beet roots, black grapes and also medications also because sometimes medications could also contribute to dots. Uh So other way we can classify, I mean, I mean, hematology, I mean, I material is look at it and from the urological perspective and nonurological perspective, which is basically nephrology and the upper tract and lower I tract as subunits under the urological component. So, one way to walk yourself through is, is if you're looking at, if you're trying to think what could be the cost of this bacteria, you can walk it all the way from the ra I mean, you could walk it all the way from the kidneys, the pelvis, the ureter, the bladder, the prostate and a urea and so upper urinary tract, you know, that's more of the kidneys and lower tract or be falls below. And nonurological are mostly medical and that, I mean, a couple of conditions are they post streptococcal glori ig nephropathy, port syndromes, polycystic kidney disease and the rest also pseudo arteria is just basically false in arteria. And I mean, like patient, I mean, somebody that maybe it's just due to the fact that he's taking excess of Ruba Beetroot or it's just medications that are causing it. Ok. So, uh Mr can be physiological or pathological and when we physiological and m menstruation and uh the food also, the food items is, I think that would also fall on that physiological, the be ro Ruba block groups, et cetera. And also there's this exerciseinduced cheer that happens and mostly happens with when you've done prolonged exercise, sort of running. And it's usually seen in people that run on marathons and it said that most times it should clear within 72 hours. So you most likely you, I mean, you and you would have to monitor that pe person just to be sure that it clears out and there lot of things that could contribute to it because the fact that one person is doing a straight exercise and the, the run out or the a or the person is not well hydrated in the course of running a marathon that will also contribute to in my area. But you would also, I mean, the thing is you, you need to exclude it and be sure that I mean, once it clears out, you are reassured that this is this is the exercise related because it could be another pathology also manifesting at the point where that happens. So and it has different names. Royal's bladder, mars Rana's iar artur and pathological I arteria, which is one of the ones that we are concerned majorly with infections. I mean infections along the urinary tract neoplasms also along the urinary tract, systemic processes could also cause Hema. I mean, I I mean, hemolysis would be more of hemoglobinuria because I mean sle cell anemia. So with malaria, I mean bones, et cetera and I mean, also ran out stones and also cause the common cause is that of Maria. We get, I mean that common causes that we should be familiar with urinary tract infection, bladder tumors, united track stones, urethritis, benign, prostatic hypertrophy which is seen in nose and prostate cancer. And for the common causes of the asymptomatic nonvisible material. Most of them ut I is one of the culprits. So if, and that, that's why when we're talking about the signal, I, you want to rule out, rule it out and the other trans causes first to be sure that there's no other sinister stuff because UT I is one of the common things that will give you an asymptomatic nonvisible material. The other causes could be, you know, a, a stone along the rena tract, maybe a stone that is not giving symptoms yet and also a benign prostatic alignment. However, I said that up to 5% of patients with this. No, with non vis my as are found to have a urinary tract malignancy. So that's why we are concerned about the uria. One of concerns, you know, it could be something serious or it could be a tumor somewhere along the urinary tract and you don't want to miss it because we know that cancers can metastasize. So it's better you pick it up early and treat it as soon as possible. I mean, you pick it up early, refer to the urologist or nephrologist and they treat as operate uh otherwise common causes are from trauma, radiation cystitis. I had patient has had a tu around the pelvic region. And there's been also in that, I mean, there's also been radiation to the pel, I mean to the bladder also cause radiation cystitis presenting in what area? Maybe I mean in year years later and also parasitic infections, cystic assis. Yeah, it can cause I bacteria, a common infection in, in Africa, I mean also genital urinary tuberculosis can also cause bacteria and tuberculosis can actually affect any part of the uri urinary tract. So medical causes, I think I've highlighted that earlier. Uh So this is, this is just a, I mean like the picture just to there also some causes of uria starting from the kidneys. But for the kidneys, I'll just talk about systemic causes like like rhabdomyolysis, maybe from someone that has a crush injury resulting in mylo then blood in the urine in material. Also people with clotting disorders, they also one common thing that we see is I mean, I mean, we, you know a lot of people on on anticoagulation either for previous DVC, previous pe or patients on a f with a atrial fibrillation. Those. But I said that when you see a patient with on anticoagulation presenting with term arteria, it most likely might just be that it just anticoagulation is just provoking it. So you need to identify the what is causing this. So you probably also have to investigate it. You also have to investigate. So I mean, we look at the from the Rena group talk about the me some medical and we also not forget that tumors can cause it from the les stones, presence, stones, presence of stones. Also tumors in the has also stones tumors, trans cell carcinoma and in the bladder also stones, urinary tract infection, cystitis radiation cystitis mentioned that earlier prostate a uh a benign prostatic enlargement of the prostate prostatitis itself and prosthetic C also and the urethra also, I mean trauma from ureteral catheterization can trigger that and also to more around there and vagi, I mean from the vagina also, there could also be bleeding in from which could be physiological form of menstruation in a premenopausal woman. But it is in a postmenopausal woman, you need to know what is causing that and uh on the rest. Ok. This is another slide jour a myriad of the causes of to I mean of uria just are like a few infective carditis. I mean is a medical condition but most it also causes iarc in the sense that it could also cause some immune complex deposition. It could be antibiotic. I mean later blah blah blah. So that then tumors Wims tumor majorly in Children could also present as hematuria, endometriosis for postmenopausal woman could also be a cause if there have been trauma in from of an accident that could also caused immature. Does this the decompression in art material or which is, which basically occurs after repeat, emptying and over and over distended bladder. So set set to occur due to reduction in the intra pressure and most likely be bleeding from the capillaries. Also, I mean inflammation, we talked about some of these things structural causes in the form of, I mean polycystic renal disease. It can be poly, I mean other polycystic kidney disease and all the vascular anomalies there. I mentioned in pre of the an aurm also cell disease, coagulation disorders and coag therapy, invasive pro pro gland or bladder and a cystoscopy. So that has a top, top of top and also some toxins like nsaids could also prolong use of NSAID or chronic use of of NSAID could also affect the kidneys, cyclophosphamide and also causes that. Sorry and others are ge are bleeding, menstruation mon syndrome, which is when you just try to get a nail so you don't have OK. So, so pseudo arteria I mentioned earlier is I that is basically not secondary is is false in itself is not due to the presence of hemoglobin due to medications like I said, it could be I pop. Now, when you have obstructive jaundice, myoglobin are some foods items such as B two. I mean this is something just to highlight multi vessels, hemoglobinuria and M is more of red blood cells. Hemoglobin is more hemoglobin. The color might vary. I hemoglobin may be like c color or dark brown. He might be will just be might be red or, or differentiate like the shades I presented earlier and the local causes like we've said UTIs stones, malignancies, systemic causes and for hemoglobin, most times things is causing any Mois would cause that. So uh patient presents with you with, I maybe in clinic or anywhere you want to take a, an history just to identify where this material coming from. You want to know the onset is this sort in, I mean, gradual. Is this something that's been chronic or is acute? You want to know the color, you want to have an idea of the color. You want to know if it's initial and that it is probably coming from the urethra. And if it's terminal coming from the bladder and neck or the prostate, if it's total, it could be coming up from all the way up from the kidneys. Or it could just mean that it's from the bladder itself because the bladder is, if everything is bloody in the bladder, everything comes out that bloody urine, you want to know if there's a stap pain, I mean tissue, yeah, supra, we pain, flank pain. You want to rule out. You want to also know if there's a history of lo loose, lower lo lower urinary tract symptoms and that will be in frequency, urgency could be the voiding or the storage loot. This will help you to know if so, I mean, patient has a history of BPH um benign prostatic enlargement. You also want to know if this patient has had previous episodes of this. So maybe it's not something that is new, also history of recent procedures because is is that the patient patient just had catheterization had just had a cystoscopy or the patient is just postsurgery and uh other systemic symptoms, fever, nausea and vomiting could uh occur any setting of urinary tract infection or an obstructed kidney with super is an infection. Uh red flag symptoms when you have masses, I mean weight loss, you want to rule out malignancy back pain. Also for maybe a metastatic prostate. See it also past medical history will also be good to explore because if the patient has been on medications for benign prostatic enlargement, that could be a point there patient has is is being managed for pros C. That could be a punter history of stones in the past patient that had radiation therapy in the past for one tumor, maybe on the pelvis. That could also be a pointer chemotherapy. Also if the patient has taking or does the patient have any clotting disorders also that will be in the past medical history and in the social history, you want to explore the smoking history. I mean, smoking is important for the fact that it's a a high risk factor for tumors. It's really blood. I see then also history of work in some industries. But like when you patient has been exposed to any in where they process pains and dies, that's also very important. I mean, family history, you could also of sorts, you could ask and also family history of some of these, I mean syndromes outward syndrome. I think this is also something similar to what I've explained in the previous slide and I mean, rifAMPin see where we are. Uh We know that already I I saw, also saw me do could also cause that I think causes him all this is Metronidazol also. OK. So if it's not M arteria, what else can it be? I think I've mentioned some of those things earlier. Hemoglobinuria is one thing. So immunoglobulin, we just see the deep stick a a positive, deep stick no red cells on microscopy, myoglobinuria, maybe from a crush injury causing rhabdomyolysis, food items, barber, rhubarb and drugs like nitro senna, a laxative metroNIDAZOLE porphyria also can also cause I arteria. You said that you that in understanding bilirubinuria, obstructive biliary disease, this might, I mean you might other symptoms. I give it away jaundice, itching. Last song ra OK. OK. So I think it's time to have some interaction and I would just like us to pop in answers in the chat. What do you think it is? So we'll just go through some case scenarios and just juggle our minds. So case one is a 55 year old male who has had an who has history of recurrence, painless in mater for six months. He has had no a lower urinary tract symptoms of fever. He has a history of smoking of 30 years, 30 pack years, he's got left renal mouse on examination. What do we think it could be? Well, I'm see if you can drop some comments in the chart waiting for our comments. 55 year old male history of recurrent pres in ter for six months. Yeah. So some of the is the same. Yeah, that's a possibility. Let's explore that people's idea opinions. Yeah. I re c of the differential bladder c polycystic kidney disease. Yeah. I mean, some other reason I said blood is the false differentiator anyway. Yeah, I think that those are good thoughts. I mean this man is a five year old man. He's a painless material. He's got 30 years of his of history of smoking. It could be and it has a left renal mass so it could be, it ran out of here and it could also be a polycystic kidney disease. Oh, so I think those are two good differentials but I mean Renai a might be one of on, on top of the differentials. Ok. Let's carry on. So this is a, a case of a 35 year old female presenting to the GP comp GP clinic with complaints of dysuria frequency and urgency, hos patients hopes is stable. She's got, I mean the GP has done a urine dip, blood of two pluses leukocyte, one plus nitrate positive. What do we think we can pop in some ideas in the comments? Yeah. So my da thinks is a ut I urinary tract infection. Anyone with other thoughts? Ok. Could be. The differentials are running through our mind. Urinary tract infection. It would be nice to have more engagement. I think quite a couple of a number of people in the chats in attendance from what I can see. So it would be good to see our thoughts. Any other different opinion from what I said, looks like everyone is in argument with Samuel and I, ok, just car on to the next one. So this is a 45 year old male who has history left lung pain in the last three weeks and I had two episodes and, uh, he's got history of taking over the counter medications, Diclofenac for pain relief for this colicky pain. And now he's presented in the OPD with complaints of a single episode of blood mixed with urine and is also because this ongoing pain in his left lumbar region. But our thoughts, what do we think it's happened here? So Davies has said is, is a run off stone. Any other, what else do we think this might be? And nothing that could be causing this apart from the run out stone? Ok. So I said left done someone I said ne re all different nephritis. Yeah, it just happened possibilities. Any other thoughts, any other opinions? So this one is a 45 year old male. He's got three weeks of left on pain and it looks like the pain is much for him to be using diclofenac and he's not having an oxy arteria left one achy pain two weeks pain, diclofenac for pain relief. And I now, yeah, your stone is a possibility. You could be ST in our lung anywhere in the urinary tract and they ran out in the, in the kidneys or the urethras. Yeah. All different are neris. Yeah. If, and I mean, that could also be a possibility in terms of fever also could also be a possibility. Ok. So let's move on to the next one. So this is a five year old male. It presents in the evening within about three of a week and two weeks. History of back pain, a history of Tes in the past recent weight loss of two kg is, is he has an s with BP of 160 heart rate is 60 per minute. Temperature is at seven, respiratory rate is 18 UTIs is done in the ed. Blood shows two pluses of blood nitrite positive leukocyte positive. He's got a past medical history of hypertension and he's taking amLODIPine in mind. Can we share our to and what is running through our mind? What do we think this could be? Let's keep the, let's keep suggestions running in the chat box. 75 year old male presents with the E DS got in my three of a week, two weeks. History of back pain and history of lower urinary tract symptoms in the past recent weight loss of two kg helps BP on 60 after 60 minute per minute temperature. Take seven respiratory 18 U united is showing two pluses of blood nitrite and hypotensive. So someone think some Davis thinks it's a prostate C A with a background ut I any other contrary or similar opinions is everyone in agreement with some of Davis A B ab the ra she thinks is a prostatic C A. Yeah. So we have two prostatic CS. Two people think it protic it any contrary opinion or similar opinions. I think everyone is an argument with Sam on our beat. Hocus Selena is pros with obstruction causing UT I due to urinary retention, 75 years old. Prostatic C calculi slow leaking AAA by I alum. Yeah. Ok. Uh Those are good thoughts. I must be honest. Yeah. Looking at the demographics, he's a 75 year old male who's got in my area. He's been having history of luos in the past and he's not had recent onset of back pain. And is that recent weight loss also recurrence? I mean history of verts in the past, those demographics, one support prostate C symptoms also support prostate C and now he's got an history of back pain. Sometimes per might just present to you with back pain, which is indicating metastasis and also go weight loss. So, prostate C is a good, I mean differential and also, I mean, calculi. Yes, I mean, it could be calculi also given the fact that he's got im arturia and he's also got back pain because if he's got costo vertebra tender. I mean, that might be his back pain also. But in this kind of scenario, you don't want to miss a prostate C A also, you don't want to miss ac A prostate C and now U is showing blood loss is N zide positive. It could also be a prostate C A manifesting which presenting with A and it also got a UT I on top of all of this and like someone said, it could be a calculi or what's causing all of this. Yeah, those are good thoughts. I mean, investigations would hope, I mean, would make the picture more clearer. And also someone mentioned slow leaking abdominal aortic aneurysm. Yeah, I mean, it's, it's possible it's possible, I mean, hypertensive patients presenting, presenting to presenting to the d elderly males and five year old old male is hypertensive on medications. It could be, it could be. But I think it's one of the things you should put at the back of your mind. Sometimes when these adult males background hypertension presents because sometimes you need, you can give it give, I mean, sometimes think about it things I can kill the patient fast. So that like I'm not missing anything. So sometimes it's good to also think out of the box Abdin aortic aneurysm is something that happens and it can progress rapidly and and patient can die. And also someone can argue that ok, this BP under 60 are you sure this person is not leaking blood somewhere. Our rate is 60 I mean, quite on the low side. Yeah. So I think that's a good differential to also put in mind, especially when patients is hypertensive. Maybe he's got a high BP, blah, blah, blah. Ok. So let's carry on. Thank you guys today for the thoughts and opinions. So the case five is an 85 year old man. He's got a history of recurrent UT I and has been referred by the GP. He's had two episodes of UT I treated by GP with antibiotics and he had deep stick and mar in those two episode and he's finished the last course of treatment. The material has not resolved. He still has lower urinary tract symptoms this year. He's otherwise feet un. Well, he worked in a dam pit factor in his twenties. He smoked for 60 pack years. S are stable but the urine dipstick has come out as blood two pluses, leukocyte and nitrate also two pluses. What is running for our way? Ok. I says this blood, I see. Yeah. Any other similar or contrary opinions. Why do we think it's bull, see it. Anybody with similar or contrary opinions also needs to have a bladder scan could have chronic retention, given symptoms? Yes. Yes, that's possible. Uh Yeah, because some of these people 85 year old male. Ok. Do I have one with weight? Someone said die and pains gives it away. Yeah. Those are clean shos, he's worked in a Die and Pains Factory. He's a smoker. So I, I said die pain smoker. Yeah. Yeah. So blood, I see. It is a huge possibility. You don't wanna miss this. This guy will probably have to be referred to the urologist on the two week. Wait, so you can see them. A ap. Yeah. So it's most likely the case of blood I see given the fact that smoke for 60 pack years working in a di pit factory. And this is a case of recurrent, I mean rec recurrent ut I not responding to antibiotic treatment. Ok. So we move on. How do you wanna assess someone that you've seen with a significant visible material? Patient is bleeding? Obviously uh case that is you, you also want to use your ABC D approach. Go through it systematically check your hair. Yeah. Patient patient speaking, which is in any respiratory distress b assess breathing. If he say fine, patient breathing fine, he's got good oxygen saturation. If he's got good oxygen sa if he's got low oxygen saturation, saturation, give him oxygen uh C circulation. So if someone is bleeding, you want to really know what is happening in your circulation. You want to have an idea what arteries, pulse blood pressure is especially is tachycardia, BP is 90 60 means everything. If there's an on significant ongoing blood loss, we're worried about that. You want to make sure you've got it, you get an IV access so I can get samples, baseline, full blood counts. You get AC RP, you want to check renal function. You use these, you also wanna check the clotting profile. You wanna have a group idea also because this patient might need transfusion A S A. You want to do A VPG gives you broadcast, gives you an idea of the HP gives you an idea of the lactate. Give you an idea of the Ph also. Yeah, D is basically assessing consciousness and the G CS of this patient. You can check for the sugars for, for for complement sake. E you e is basically you exposing this patient and trying to go through the assess the patient systematically check for periorbital fullness or peripheral edema pur or pet. This does more, I mean this could be point us to all things. So it's good to, I mean check the other, I mean check, I mean ex I mean expose and examine. So you don't want to forget to do your abdominal examination because that could reveal a couple of things to you. Flank a mass in the flank, super big mass, super pain. You also want to do your ge examination also. And importantly, don't forget that these starta especially in, in, in men, you want to check the size of the prostate because that could also be a pointer. Then while I mean, if the one of the rules of what of doing ABC D is you also want to intervene as on of identifying a problem. This patient is already has a physical material. I mean, if he's not got clot clots at the moment, good. You want to catheterize this patient ideally with a three way catheter and we, we check do a urine dip, send for a urine microscopy culture, sens DC. In a case where there are presence of clots, it will be good to do a bladder washout at least to clear the clots immediately so that you can have a free flow and avoid any obstruction. And in some cases, you might need to get a continuous bladder radiation. Additionally, it's good to do a PSA and it's also good to know that PSA is age. You need to look at it in respect to age and also counsel the patient appropriately because that could also be false positives UIs. Yes, you wanna check presence of white cells mucosus Neri nitric your urine microscopy at the presence of red cell car dysmorphic red blood cells. More point as to glomerular origin, you want to do imaging which we talk about basically ultrasound CT keb. And during general function if you use and are back, patient has got abnormal, I mean high creatinine urea. And I also want to check the albumin creatinine protein creatinine ratio that would help us to know if it's some glomerular things happening. I mean it issue happening and when does the medical cost you want, lets you, you want to let the nephrologist know ASAP if it depends of when you have proteinuria with Hema and those that less than 40 years old with hypertension or someone that's got a chronic kidney disease already. Ok. So this is this a picture representations of some of the things that you use when you find yourself battling with a case of eia. So we have on the left, on the left from the left, we have this three week catheter and we have another two week cat and a one week catheter. So this is the three week cathe that you typically use to when you pick that matter. So this is the catheter itself. This is what used to inflate the balloon. This is channel for urine and this can be for your continuous bladder irrigation. This is a two week, this is for the out, this is for the balloon and this looks like a silicon catheter. This is a one, it looks like a one week catheter. And this is another good thing that you need to be familiar with. Uh sorry, this is the blood A ring. So if you, if somebody's already in a three week A I mean, its nurse calls you, the nurse just calls you and tells you that the u the urine is not flowing because it's got clots in the back, blah, blah, blah. This will be helpful to do your bladder irrigation to dislocate clots and ensure the urine is flowing again. Ok. So just to highlight, I mean differences between glomerular and extra glomerular bleeding, it's more of like urology, urology. So red cell cause may present the glomerular. This most red blood cell is usually something is with glomerular proteinuria also may be present with that with that. So red cell cause most times absent in extra glomerular, the red blood cells retain their shape. So they are still uniform in extra glomerular proteinuria. Most times may be pre, it may be present in glomerular in extra most absent clots, abscess, extra is present. Color differentiates may be red or brown, may be red. OK. So this is the bladder irrigation set up. So if you want to continuous bladder irrigation set up for for a patient has had turp is like you gonna have some material because we just operated on the on the prostate. Like patient is like uh bleeding. So to prevent clot retention, which would cause urinary retention, you don't want that to happen. Most times you want to set up a co a bladder irrigation. So if you look at this picture, it might not be, I mean very clear. We have two bags of saline here. This this is the first, sorry, this is the first one. How am I right? This is the second one. Then it's got the like the set, the given set that you attach. But yet it has like it's, I mean, I'm sorry, it's not very clear you can if you can appreciate the white tips is like the clumps just like the way. I mean for you to clamp one of the given. I mean one of the flowing and you clamp the other one and you control the rate depending on how you want it. So you can see it's attached to it. This is actually a three way cut. Yeah, I got this from the video, this youtube video. So I mean, in the spare times we can, we can watch it basically. So how this different defers from a the bladder washout is the bladder washout is more you using the bladder syringe and pushing saline into the bladder, especially when you have clots so that you can dislodge possible clots in the, I mean, conite itself all in the in the bladder itself so that you can have free flow and there's no obstruction. So in material, we know it's got so many things that could cause it, but we'll tailor our investigations now to things related to urological causes. As a general rule, patients with a material would require imaging of the upper urinary tract. I may in front of it could be ultrasound ultra. The good thing about ultrasound is, is noninvasive, doesn't have radiation. It's safe for Children. It's safe for pregnant women. Men. You, I mean, you can use your first right after just to access compared to C I mean CT KBC T urogram quickly, which is more you have to use contracts. Some people can react to contract, some people's rena function might not dependent, might not, might be bad. Such that you want to cause that if you want to actually want them to go for AC TKE. And another good, another essential thing for investigating a R cystoscopic examination which could be rigid or flex. Uh and sometimes you can also take a biopsy, especially when there's a bladder mass. You wanna take a bla bla bla I mean biopsy, I'll send it to the pathologist so they can identify it. Another 10 to 2 again is urine cytology but some most is not often done because they say he misses, he could also miss some other tumors in the bladder. Yeah. So flexible cystoscopy is like, oh sorry. This type of, yeah is it is one of the gold standard. So flexible that I mean, it's just like endoscopy doing an upper G I endoscopy, a lower G I endoscope. So it's just like a 10 to going through the urethra to visualize urethra and the bladder and flexible basically is done locally. I mean, sorry, using local anesthesia and you will be more of like spinal G and like you, you you also need to do an imaging to identify a couple of things mass. This could this imaging techniques will help you to rule out a possible mass. A possible stone. You could also do, I mean an x-ray for the radio to appear any radio stones. But I mean, CTK, we will definitely identify most of these things very well for you. It would help, you know, if there's an ongoing infection, see if there's perinephric stranding, et cetera and if there's a mass on is there's an aneurysm, it will probably pick all of these things. So it's more I need to, I mean to delineate deletions more than your ultrasound. So initial investigations where a patient with symptomatic nonvisible material, persistent. So someone who has got asymptomatic nonvisible material, we need to exclude the uti I know that cause like I said earlier, you also need to check that your renal function is good. So plus my creatinine and a GFR, you need to also measure, I mean check for proteinuria, do the PCR and ACR, those are values proper values, measurement of BP. When most of this, if the BP is elevated Proia is there, plus my creatinine of ef of you might want to just the ne and let them carry it across. So when do you refer to urology? This is very good for us to take note of. You want to refer to urology. This is using the nice guidelines basically. So if the patient is 45 years old or more, and they've got an unexplained vii immaturity in the absence of a urinary tract infection or the patient has a VCB that seems to persist or recurs after treating the urinary tract infection. I think one of the scenarios you mentioned was similar to this. Yeah. And you've got a 60 year old man of, of patients and 60 year old or more and has unexplained, nonvisible eia. So, nonvisible material, which is unexplained that this is in the absence of a ET I and either dysuria or why not cause any blood test as a GP, as a primary care physician. You want to send this patient ASAP using a two week we and let the urologist see said, oh, the the last one is known or bladder see in people more than 60 years or 60 years with recurrent or persistent unexplained urinary tract infection. Yeah. So those are guidelines have been made to help hospital out work and make it more easier. So when you see some of people that fall into this category, just check the nice guideline and see if they fall into this ca So if the patient has other urological cause excluded, uh there's I mean the GP or the primary care physician and I send the patients to you and you feel like you've, you've seen this patient, you've investigated this patient, you can't find a log cause and they don't fall into this guideline. We just discussed, you might need to just, you will need to refer to nephrology and some of the things you need to consider. Look at the age 40 years or less, egfr less than 60 mils per minute. It's got significant proteinuria. It's got a BP of less than more than 1 40 90. You would want to send to the nephrologist. So, like I said earlier, immaterial is basically a presentation and it's not a diagnosis in itself. So you need to find out what is causing this immaterial so that you can treat the underlying cause. So the management of the material is basically the treatment of the underlying pathology and he has a myriad of causes. So you really want to get the problem behind the mater and solve it. So some things you can do is you want to review existing anticoagulation therapy for those non anticoagulant. You want to discuss with the anticoagulation team depend how the clotting disor that you want to correct that um those that are are iar and they are dropping their a, I mean less than 70 patient as symptomatic, those that have cardiovascular problems and HB is less than 80 you want to consider that transfusion. And also when the, when the patient has do with culture retention, you want to, you want to sort it out a a most likely because it can cause retention, which is another problem itself. And such patients you probably want to send to the ed so that the urologist can see and probably admit and so they can take care of that. And most of these patients will always require a three week catheter, a three way cat. That is very important because it can, will help you with your continuous education and also to clear your clot. And so like I said, the management of the material is based on what is causing the material. So options uh the management to be solely dependent on what is causing the materia. So, analgesia, someone has got a ran out stone and that's what you have suspected. Analgesia will be of help. Someone has got a ran out stone with obstruction and infection. Antibiotics will help ut I antibiotics will help catheterization will help some with ongoing. You want do a blood washouts, irrigation with distinct that with distinguish between what a washout is and I irrigation. We talked about the setup earlier which is basically the continuous aggregation. You have two bags of saline got an like an IV drip connecting to the three week catheter to, to irrigate. If it's due to stones, they are, they are depending on the size of the stone. That's what we determine management. So these are some of the management modalities. Benign prostate enlargement would also be more of either medical surgery depending on that. Sometimes no true waiting. Prostate C A will be dependent would either be of surgical but to be dependent on the staging of the tumor. Basically. So those are some of the modalities. Uh So this is our post assessment questions. I mean come to a head. I think we've got three minutes past time. Sorry about that. And we can just try to answer the pos again just so that we can see how, oh, I mean, what we knew before and what we've known after. Hopefully, I think the whole question of the questions should pop up now. OK. So I think the po questions are popping up. I've just seen the first one on my screen. Hopefully the second one comes in soon. Second one comes in soon. So we can call it ad and have a good evening cystoscopy. I can see a question in the chart. I will attend to that in a bit. Cystoscope is always OK. Sorry. The second question is, I mean, I think there's another pole coming up now so we can answer that. Uh So in the meantime, while we are answering the polls, we can also drop in our questions so that people can make it. Um I pop in your questions as you answer the posts. I mm 12. OK. I think we're probably done with all. So, so there's a question in the chat box I saw initially. So someone said which fluid is ideal to use in bladder irrigation, oxalin or steroid or something else? I think from what I've seen so far, I mean, no line is is what is used so far. So like the picture I showed earlier, those were two bags of no offal line 3000 CC. So they are not like your regular Saline bug that you see. So when you see huge bags of Saline beside a patient and I touch a cat that just know and you, you're seeing a bloody bag, it's like that's it. Blood aggregation set up. Continue blood aggregation set up. Yeah. And there was another question. I, so we can keep popping out questions. So we will call it a DNA beat. Uh Sorry a question and I can't remember something about SGLT and UT I can ut I risk be aggravated by treat by treatment with SGL two inhibitors. I think that sodium glucose transfer two inhibitors uh which I think we use for diabetes and prognostic medications for heart failure. Uh Well, diabetes in itself is a risk factor for UT I. But I'm not sure if uh LGL two with those, can ut I risk be aggravated by treatment? So treatment is LGLT in because aggravating or causing the UT I, I'm not sure of that. I've not heard of that. If anyone has any information on that, please kindly share. Um Yeah, so you ii I just share something with those cystoscopy is required for all cases of Imura. So nice guideline is a good guy but all visible IMA without a clear known cause should have a cystoscopy and an power tra here, like we said as a fundamental way in imaging. If you, if it's not within your purview to do that. I send it to the urological team and let them sort that out so that they can have, you can put this suggestion and uh you think this patient should have cystoscopy on an upper urinary tract i agent. Yeah. So let's not forget that cystoscopy is important because that could just be you picking a cancer that could help you pick a cancer and just prevent that. Also important to mention that for Mr please just keep dropping your questions. Hopefully we close in the next few minutes and we can end the session. Also important to mention that for material causes with possible risk of ureter damage, ureter catheters must not be done also. Pronunciation. Yeah. Yeah. So I think what this person is saying is I think what someone is saying is if you've had it, if someone, if you know that there's been a traumatic, I mean, there have been AAA ureteral damage from traumatic catheterization in the past and your the patient has difficulty re catheterization and also maybe history of IMA be very, very careful in approaching such a patient because there might have been fibrosis strictures. It might be very difficult for you to catheterize that patient again. So if you try, you probably will provoke bleeding cause more fibrosis and cause more strictures. So it's better you just send because they have to do a suprapubic cystoscopy for that patient. So let's I also take note of that. Those are, I mean, good suggestions from s from some of my colleagues. Yeah. Yeah. Do you have any questions and will be nice for everyone to please provide it a a a AAA what do you call it a feedback on so that we can improve these sessions going forward? Yeah, I mean, I think I didn't grow much on trauma as possible of possible material like I mean, so im arturia could also be as a result of trauma to the back like patient, I mean, maybe there's trauma to the retina, I mean the kidney itself, the pelvic region and also falling or stride could also cause im arturia itself. Someone has just pointed it out. Thank you very much for me some Davis. Uh it was not, I didn't mention it in the in the in the presentation. Foster is a good, is a, is a, is a risk factor for Traa. So if someone presents to you, which with, I mean, with falling, I mean falling astride, that's most likely I mean a trauma to the ure. So we are see ti of blood, I mean blood, I mean blood at the tip of the or and the blood of the that can be suggesting following a trauma, at least for a fall that could be. So you might want to speak with urologist, they think you want to cathe out patient and monitor you in hospital out patient. So I think we should take note of that. I mean, do you have any questions for questions? Suggestions? I appreciate the fact that people are put in suggestions. And also, so it means that because I mean, I think it's a big topic. I can't say everything. So, do you have any further questions? I will just, uh, we just call it a day. Any questions? I just give one more minute for a question. Then I think we'll end the session and that will be all all right. I think we'll have to call it a day. Thank you. To everyone who has joined, please. We would appreciate if you can provide feedback so that everyone can so that we can see how we can better improve the sessions going forward. It's been a delight having everyone on the call. Yeah. So thank you very much. I think we'll call it the day. I think they are. No, you have two messages in the chart. No. So it's more of the feedback and everybody say thank you. All right. Thank you. Everyone. Do have a lovely evening and a restful night. Bye.