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Mhm. Drive me. Hi, good evening everyone. I think we'll just wait for more people to join. Probably around, uh, let's see, five minutes or we can continue. Ok. Ok. I think we're just going to start now. Can everyone hear me? Yeah. Perfect. Great. So, my name is AO, I am currently a core trainee with West Midlands England and today I'll just be discussing, um, urinary retention as you can get. It's quite common. And if anyone is practicing as a medical doctor, they have encountered some people or somebody with at least one episode of urinary retention. Basically, we're just going to run through a quick background, talk about some clinical scenarios and talk about evaluation and management as pertains to the current, um, climb I walk in. Um, just before I do that, I'm just going to do a quick anatomy and basically we can see the sagittal views of both male and female pelvic organs. Um, the female urethra is extremely short, about 45 centimeters. On the other hand, we have the male urethra as long as 15 to 25 centimeters with multiple areas of curvature and multiple areas of extrinsic compression. So of course, as we know, we've got the behind in males, we've also got the rectum behind in females. But also, in addition to that, we've got the vaginal and the uterus just around there specific for the males. We've got the prostate around the neck of the bladder. And as we know, this is a very, very common cause of urinary tract obstruction. So for the urinary retention, we're gonna talk about the, we'll be focusing on retention beneath the bladder downwards. So, from the bladder neck downwards, we're not gonna be talking about the kidneys and the ureters. So basically, acute retention is painful, relatively short onset of inability to pass urine. Whilst chronic retention is usually painless. Usually they've got long standing symptoms, they usually have various sort of lower urinary tract symptoms. So they could have frequency, they could have dribbling nocturia, strung rate. They could also actually have had recent or recurrent urinary tract infection. But the key thing with them is that when they come with the inability to pass urine is usually painless may be discovered incidentally or as a market on chronic retention. The incidence like I said is quite common. This is a UK study. It's around um 3 to 1000 patients per year. And in almost all the cases, you see you, you notice that men are much more likely to have urinary tract infection. I mean retention, 10% of men who are lucky enough to live up to 70 to 75 years will at some point have acute generic retention, quick summary or quick anatomy or slash physiology. It's just that bladder capacity is about 300 to 400 mils. The physiology of micturations itself is a all course and is a all topic. We're not going to finish this. We will start discussing about the nitte gritty of the physiology of micturations. Just the basics um for today. Um basically via autonomic control, via the parasympathetic and the sympathetic nervous system. The paras activation of the paras system allows urination to occur via um contraction of the and inhibitory and relaxation of the internal ureteral sphincter because although this is autonomic, we've still got some cortical control and some voluntary control over the. So that which is why we have the somatic nerves, we had to put in our nerves to four. And this helps with the voluntary control of the extra ureter skin. This is why we don't just go to pass in every time our uh our stretch receptors from the blood have activated the para system just to make it a little bit interesting before I go ahead to talk about a start discussion. We'll just run through a couple of scenarios. And if I could ask, I'm not going to create a po today. But if you can just impute the answers in the message box, so we can have an idea as to what um is going through our mind. So the first one is a 60 year old man. It's coming with a history of nocturia frequency and poor stream. It's coming to the emergency department with frequent dribbling urine. So it's complain today that doctor I can't seem to stop going to the toilet multiple times. I can go up to 20 times a day and it's usually just very small amounts coming out of every time. Observations are stable. The heart rate was about 110. On examination, there was a palpable mass in the lower abdomen. We run a couple of blood tests. Renal function is GFR is quite bad of 30 his creatinine is accurate at 300 was probably five. Just neutral force questions. Really, you can just say ABC de and just tro force. So tro force first line investigation is a CT abdomen. It urgently needs a catheter inserted, should be 12 in 24 in 24 hours to 7 to 2 days. You may be at risk of dias and you will benefit from an al block up. If we can get responses in the chart, that would be fine. I doubt you appreciate it. But if people want to talk about it, you can mute your microphone and just talk about it. You can make this a little bit interactive. Yeah, guys are coming in. Yeah. Just not it still on the first scenario now, right? So just go ahead because of time and just talk about what I think um the situation is with this patient. So 60 year old man is coming with nocturia. There is no pain, which is key in this one, but he's got symptoms that sounds like this has been going on for a long while before I go to answer the question. I think he's got accurate and chronic urinary tract urinary retention chronic because it's painless. 12 acute because I can feel it probable mass in his bladder. And he has deranged renal function and he has probably and very significant um risk factors for him to be in retention questions. The first line investigation would be a ct abdomen. Answer is no, he, he urgently needs a catheter inserted. That's true. It should be 12 in 24 to 7, 77 days. That's four because apart from it being acute on chronic urinary retention, he's also got a drop in his renal function. So this could actually be a high pressure, chronic re retention. And for this set of people, you never talk them. So you never have to remove the catheter. You remove the catheter. When there is one, a definitive um management of whatever is causing that obstruction or two, you leave them with the catheter forever. And then last one, you may benefit from an alpha blocker because we think the most common cause in men is enlarged prostate. So yes, the family comes in those things and not can help this patient. So, yeah, some and not be basically, yeah, almost right there. Second scenario is a 72 year old lady nursing home resident with dementia. She presented with severe lower abdominal pain, she's unable to, as you're unable to ascertain any history from her and she's been weak and off legs for a few days. Our observations are stable troph forces and MRI spine may be indicated. Laxatives have a role in the management of this patient. A bladder scan is indicated she can be talked in 24 to 7 hours. She has chronic urinary retention, same as before. You could just drop your answers in the chart box or you can just un mute your microphone and talk about it. Actually. Do we think she's in chronic retention or acute retention? Yeah, someone is right. I think she's got a genetic retention but couple of things could be causing it, but we may not be sure what is going on with this lady, Abe. Thanks for answering. So true to a true to B. True to C and fours to D and E. OK. Ok. So just to run through the scenario, 72 year old lady lady in board and on the line and everything when a woman has come in with things that we think and suspect is urinary retention. Our our cup comes up and we should be very, very, very worried about them. So some year old lady nursing home resident with dementia presented with severe lower abdominal pain, unable to ascertain history from her. She's been off for a few days and observation is stable because we're having a discussion of urinary retention. We can assume this is about urinary retention. Questions are an MRI spine may be indicated. Yes, because she's female 12 because she's been off that for a few days three and because she has no abdominal pain, she could be an acute urinary retention and one of the common cause. One of the causes not so common is corneal syndrome. So yeah, MRI spine may be indicated. That's true. Laxatives have a role in the management of this patient, nursing home dementia constipation slash fecal infection is a very embarrassing cause of urinary retention, embarrassing because when many people miss it just like egg on your face. Really. Basically. So, yeah, laxatives can have a role in the management of this patient. A bladder scan is indicated appropriately. Yeah, but Habiba somewhere I said falls to um she can be talked in 24 to I seven days anyway. So 24 to 7 days, 24 hours to seven days. Yes, she can be Tweed. If it's accurate urinary retention, you found the cause in the patient and there is no other indication or reason to keep the catheter in, especially in females. You can tw them and give them a chance to pass urine by themselves. And no, she doesn't have chronic urinary retention because she is in pain. Last scenario before we go back to our discussion. So young chap, 30 year old man is coming with inability to pass urine for 24 hours. He's all way as well. They have been fewer attempts by the ed team is the leucocyte plus plus plus plus. What do we think is going on with these patients? But before we answer true falls, I seem to have a meet people on this chart. You just pop your answers in the message box or you can mute your microphone and we can talk to you about it. OK. I'm just gonna crack on and have a discussion later that year old man in this pass rate for 24 hours is otherwise. Well ed at them by the ed team urine DICY positive for the purposes of this discussion mechanism. One, this job as acute retention and two, he has urethra stricture. So urinary tract infection is the most common is the most likely cause of retention in this gentleman. Yeah, he is a young gentleman. Definitely not prostate, no enlarged ut I can be a cause can be the most likely cause in young people. But we need to also consider the fact that there could be a stricture there. And especially as I've said, they have failed attempts by the D team. So someone has tried to pop in a catheter in a young person and they've been unable to put it. It's either there's meatal stenosis is either there's stricture within the urethra itself is very much unlikely to be due to an enlarged prostate. If it's due to a urinary tract infection, it's either due to a chronic sexual infection. So you have strictures from gonorrhea and all of that or likely to just be caused by pain cause if it's caused by pain from uti catheter is gonna go in smoothly. So the multiple field things by the I is the, as I would say in Anger Banana. In the question, um sexual history of screening is important. Yes. For these people, you need to find significant history. Have they had any history of um previous sexually transmitted infection that has been treated? Have they had any ureteral instrumentation, either medical or for pleasure. So that's true. Flexible cystoscopy is indicated at some point this chap as to we so we can ahead and do a flexible guided um ureter insertion by guide wire or dilatation as we want to do or you can insert this catheter. So it is also indicated. So true, true, true. Adoro urinary tract infection is the most likely cause in this patient. I think he has got a stricture. Thank you. Happy and summer. So away from all of these scenarios. So back to our um talk um so common causes. So I've just stated, there's so many ways to classify this when it is, is there's so many ways to classify it. It means there's so many causes. Um So it could be obstructive. I like this one. It could be either due to infection or inflammatory. It could be due to medications or it could be neurological. So, obstruction could either be intrinsic or extrinsic if you want to subclass find that deep. But it can just go through males, common ones, older people, most common one actually is an, is an enlarged prostate. There could be meatal stenosis, paraphimosis will be painful, fimosis in people that are uncircumcised with some BXO and some scar over the meatal um opening and prostatic. See not very common in early prostate here because most times when um prostatic C start, start out towards the area rather than the central area. So you really, you don't have um prostatic obstruction that early females, if you remember the picture we showed earlier, so they could have organ prolapse. It could, it could be due to a cystic, it could be due to the rectum falling in um grav uterus is a common cause in women and also gynecological masses in both males and females. Um compression could be except fecal impaction G I, cancers, bladder stones, bladder cancer, ureteral strictures and foreign bodies who put all sorts of things into their urethras these days. So don't be surprised, someone comes with inability to pass urine and even if they don't um volunteer that information themselves at some point, when you do a flexible cystoscopy for them you're gonna see it. Um So infection, this is usually due to pain spasm. So ballis prostatic abscess or prostatitis is very common, very nasty, very painful. You do AD R A for these patients, they jump off the bed and almost punch you in the face. Uh for women. So, acute vocal vaginitis basically still due to pain and spasm, spasms and inflammations, cystitis, Riis and sexually transmitted diseases. Medications that either affect any of the um micturations reflex pathways can cause um these so opioids are very common. Anesthetics is very common, not sure exactly why that happens. But post surgery, many people go into urinary tract retention, anticholinergics, like I explained earlier from the um physiology of MTU alcohol, benzodiazepines and te relaxants. Sometimes you've got some ladies coming in because they've had this long 10 years of Suen and they're like, oh, I'm unable to pass your. Now, you go into the record and you see they've got Suen, they've got me in their drugs basically. Yeah. At some point, the bladder is going to stop working. Then neurological, this has multi level from spinal peripheral nerves and all the way up to cortical levels. So you can have spinal cord pathologies. Everyone is always scared of trauma, compression, spinal stenosis, transverse myelitis could have some autonomic neuropathies which can affect any nerve really in the body. So GM and G BS, if you've got questions, you can just pop them into the chart box. So I see it as a um discussion is ongoing and you could have stroke or anything in the brain, like I said, cortical control. So Parkinson's is usually a very common cause in older people. Co true now as to what we want to do to manage this patients. So starting with acute urinary tract infection, I mean retention, I keep saying infection, sorry. Um starting with acute urinary retention, there is one thing that is absolute for them. You're not gonna get anything out of them until you pop in the catheter or until you relieve them of the obstruction, you're meant to follow the ABC D protocol. So make sure you join of your airway because it's, it is an acute urology emergency. But it's important to recognize the patient that is in urinary retention and relieve them of that retention. There's no point in giving them analgesia. There's no point in your real life scenario. They, are you screaming in pain? And these are one of the things you suspect in men, women, old or young, screaming in pain, old in their bellies, scan their bladder if you're not sure and pop in the catheter for them. In the ones that you've already, you were able to successfully relieve the obstruction. You can do your history and examination history as by the ology I've just discussed and you can start with their age. Have they been having lower urinary tract symptoms for a long while? Sexual history medication history when, as they open their bowels, history of ureteral instrumentation, any previous procedures have they had their prostate taken out before in the past? Um, and things like that, have they had previous radiation to the pelvic area because ureteral strictures after radiation is also very important. After you establish the history from the history. Usually you have an idea of what is the cause in these patients can go ahead to examine them. So, observations, heart rate is almost always risk because they're in pain. Um, temperature might be fine, temperature might be high. They could be having a fever if they think they've got some infection ongoing and abdominal examinations are quite important. So previous cause, previous symptom, I just have had recent surgery. So you can see the dressings up there. You need to see if the bladder is palpable if the pain is so painful, that really helps you to determine if it's chronic or acute. It's very important in patients that have come in with retention for us to put a finger into their rectum and examine them. Couple of things to check just by that singular examination. Perianal sens sensation you're able to see in our wink. Are you able to feel in our wink? Check the inr tone, you are able to check and assess the content of the rectum itself. If there's hard rock like stones in there, you have your diagnosis already, you're able to palpate the prostate and feel for how firm it is. If it enlarged, is it hard and craggy, you're able to feel the pre of other masses in there. And also you can be to check for sensation. I think I've said that already in females and males good to examine the genitals. You could see some enlarged prolapse. You could see several sorts of things that cause obstructions and a complete neurological examination. If you are suspecting Cor Corona syndrome and the bladder scans, bladder scan is an adjunct really most times by the time you reach the end of your examination, you know, if they have retention or not. And the bladder scan sometimes is you need to just for completeness sake. After you've made the diagnosis you've put in the catheter. Always remember, especially also for exams. There's no point talking about everything we're going to do. There's no point talking about the full A two A assessment. If you've not mentioned your need, you've not mentioned the need to please put in a cat or try to relieve the obstruction in these patients. Investigations, urine dipstick in older people, urine dipstick is more, more or less useless. Might be much more useful in younger people send off urine cultures. If you suspected infection, even in the place of a negative dipstick, um full blood counts useful to check for um low HB if you're suspecting a cancer, very useful to check for what the white cell count is. If you're suspecting an infection use. And ye is are very important because you, you need to know what rena function is like and has been put as an A joins. If eventually you are going to need to do some interventions like super catheter insertion imaging, ultrasound kidneys, ureters and bladder. Very important in patients with chronic retention with the range renal function. It gives us a diagnosis of high pressure, chronic retention and cross sectional imaging eventually because you want to check for in patients that need it. So patients that need it, that will be older people. People, you suspected the possibility of other masses, people that un known to have prostate cancer, you're checking for other um spread or metastasis, people that have really weird symptoms and you don't seem to understand why exactly they've got retention. So you can cross section their um abdomen and pelvis to see if we find anything there. So that's the investigation really. Um just gonna wait for the slide to come up. I think I've talked about the management in a very brief one. So accurate retention. Put in a catheter. Most common catheter is 14 F or 16 F straighten, monitor the residual urine to make sure they are no diur in because if they are in accurate retention and they passed more than one liter resid out straight away or they passed more than 200 meals over the next over consecutive 2 to 3 hours, they are at risk of postobstructive diuresis. Uh you need to keep them in and replace their fluid and monitor them. So they don't go into kidney infection, kidney failure, identify and treat the cost. So, always wise to identify and treat the cause if it's accu gene retention. Both the American and the European guidelines have said you need to plan for a cat, the thyroid removal. It all depends on what you think the cost is. But within 24 to 7 days, you should plan to remove it in older men with very high risk of BPA. You can palpate their prostate. You can start them on tamsulosin. Give them, give a chance for tamsulosin to work. And depending on your local guidelines, you can remove the catheter between four days and up to two weeks. So basically, tamsulosin is just to help relax the bladder neck and give them a higher chance of passing to work. Acute urinary retention with no Diacin. And there's an identifiable cause. We should always plan for catheter removal. Usually before they leave the hospital. And when you have chronic retention, most people with chronic retention either come in through the clinics one. So they come in incidentally. So they've just done random blood tests by their GPS or their family doctors and they found out that their kidney function has dropped. And the next thing usually will be that, oh, you need to go do an ultrasound and they go to do an ultrasound and the ultrasound comes with massive hydro nephrosis. They've got about one liter size bladder in them and they're fine. They're talking to you. No problem whatsoever. That's one group of people, the other group, we, those with no symptoms, no symptoms of pain, but they've just come with frequency because they are having overflow incontinence. Those are the other group and the last group are the ones that come with acute or chronic tension. So older men, they have been retaining for a while, their bladder has expanded and is big and it's just laxed and at some point they need to go. So they come with that patients with eye pressure, chronic retention. This is very useful, especially for our medical colleagues. Um So patient is gone and they've got established renal failure and they came with retention. It means their bladder is back, pressuring into their kidneys and is balling of their kidneys. If it continues like that, they're going to go into chronic kidney failure. So the key or the goal here is to keep the drainage ongoing, especially older people. So we cannot talk them. So we cannot remove the catheter unless there's a plan for treatment. So for example, if a 70 year old man has come, like the man in our scenario had come with what he has and his renal function is deranged. We put in a catheter, we observe that his renal function is improving. After we've done that we need to plan for a couple of things. If it's fit for surgery, we need to plan him for a turp. If it's not fit for surgery, the options are to leave the long term catheter in place. That's one also, I would prefer to have a suprapubic catheter. But the point and the goal is here is that for high pressure coric retention, that is retention with deranged rena function, we do not talk them chronic retention, no derangement in renal function, you need to plan for cancer depending on the cause. If there's a mass, we need to treat the mass. If it's because of constipation, we need to deal with that. But in most people is, I mean, most men, it is usually due to um enlarged prostate. There's another class or another form which is an old speciality on itself. It's called neurogenic bladder. So these guys that have spastic bladder or they have dilated bladder that it's just like a balloon treatment can be discussed in a different um topic as a different topic entirely. Really? I think the next slide there be few practical tapes on difficulty ization currently working in urology. So for a short time, I've seen lots of things, uh lot, lot of things can be done, especially in patients. No one likes to be called for it cause it has to be changed, but it has to be done. So in males, most common cause is an enlarged prostate or a stricture really. And one of the most common things when people try to put in the catheter is that they are really not straightening the penis long enough as you can see in the curve here, the penis has so many curvatures. And if you're just timid with the penis and not grabbing it and pulling it up straight up, like you want to pull it up towards the roof. That's the trick. People say just straighten the penis 45 degrees to the body just because you want a very nice, smooth angle. But the thing is that I don't know if you can see my arrows, hopefully you can. But if you can't, if you look at the bladder neck in this picture or the prostate, sometimes usually so enlarged and so high that when you put it in at that angle, you meet the resistance. So if the, if the obstruction is at the prostate, you meet very large resistance there, the point is not to jam it in there. If you keep jamming it towards the angle, you're going to form a false passage downward there. That becomes a trouble, you feel it resistance. So drop the pen slowly like you're dropping it back down alongside to the body. This kind of brings out the angle and straighten it up because if you remember the curvature, it kind of curves upwards as it's going into the bladder and usually you can just slowly twist a non COV tip catheter. So it goes into the obstruction if you're still having difficulty in it, it depends on your lookout practice. Some people usually have this latex very soft catheter that might not work. You might need to find a silicon catheter which is stronger and it a little bit much more rigid for people that we suspect that, oh, this is most likely due to a prostate enlargement. You can go slightly higher up in size because it's basically you need something to push through. If that is too small, you might need something really stiffer and stronger to push through the um prostate. And that usually helps, you can put double lubrication because that helps to relax the patients. One. And if the patient is much more relaxed, you have a higher chance of that external ureter sphincter relaxing enough for you to navigate through a difficult prostate. If the obstruction is due to a stricture as in this is as was the case. And the gentleman we saw earlier, I we discussed earlier, you just usually just feel it just going through a very short tip. Usually it stops at the b by urethra never reaches that angle down towards the prostate. Clearly, something is going on there also try not to use force, never force a catheter through your penis cause you're most likely going to cause more harm than good. You can go in, you can go into a smaller size catheter and see if you can go into this trick job. That's for males in females. This is basically just 45 centimeters. The problem is not usually the urethra. The problem is usually entrance to the urethra. Most common problem is that our, the patient is quite on the big side and you can't really properly assess the um vulva to look for the urethra. And this is usually just help. This is just counter by getting much more people around to help you and getting the patient more to cooperate to. So that you can probably part the um part the vulva and actually see the um urethra opening, cysto. So you can also block the open. So you don't see anything. And in some older patients, especially older ladies um that have some vaginal atrophy, the position of the urethra. The may have been dis in such a way that it looks to be appearing in the wall of the anterior vagina. So sorry, in the anterior vaginal wall. So you're like, oh you can't find the urethra opening, but it's just down there and meatal stenosis and also in some patients that have had radiation to the pelvis, they could have some ureter, even though even the short in femur, this could also affect them. So basically, for males, you need some adjusting and always call for help if you've tried to put in the catheter twice and it's not going to just call for help for somebody call the urologist. They've got lots of toys to play with. And one of the most common toys is the inserting the catheter under the guidance. So you put a flexible cystoscopy, I think that was the next slide. So you put a flexible cystoscopy, um cystoscope through that and you can view everything that is going on. And once you get into the bladder successfully, there's several parts through the cystoscope through which you can pass this small looking round thing here called the guide wire. And this guide wire goes through the, once the guide wire is in, we are sure the guide wire is in the bladder. We take out the cystoscope and pass the catheter through the guide wire know. Now we are sure that we're not gonna cause a force passage because we know the guide wire is in the bladder and you can apply a little bit of more force and this helps you just gives you the confidence to navigate that into the bladder. Another thing we can do is the use of the code tip. So there are different types of cove tips we can use just when you remember the angle of curvature of the prostate. So there's a tier tape which goes through that, then the tape and the pot and tip catheter. All of these are just um mechanical ways to go through um an enlarged prostate. So flexible guided cystoscopy, you can do a bedside ureter dilation in patients, you can see some strictures in, if it allows the hydrophilic ace dilators to which you can pass through the um urethra bedside really and try to help them, um, relieve this obstruction. And in pe in people with all of that, those failed. And without um, a contraindication, a catheter is actually easier to manage than a ureteral catheter. Even for, for patients who have been advised to go on long term catheter, an S PC might actually be a better option for them and it's easy to change. The only problem is that the first change should be done by a urologist and any change afterwards. This is usually after three months after you've had the first change, anybody can change a catheter as long as the tract has not closed and the track closes really quickly. You will be shocked within eight hours of an S PC falling off. The tract usually is closed already. I want to go to the to do a different one. So basically does the end a very short um discussion on urinary retention things to take away acute retention. Most common cause in men is in older men or men altogether is an enlarged prostate in females. We need to be careful and we need to think about all that causes. We need to think about possibility of cardiac co syndrome. We need to think about constipation, we need to think about radiation. Uh We need to think about neurogenic causes chronic urinary retention with deranged renal function plus or minus hydronephrosis on ultrasound, the catheter should not be taken off and for patients with simple acu nine retention, it is the aim to get them catheter free as quick as possible. This is usually by identifying and treating the costs, giving them medications that gives them a higher chance of passing to work when they eventually it's worked and also trying to find definitive management for them. I would not go through the scenario questions again, I would just leave it here. So you can have a look at it and people can ask questions especially as to the ones they don't agree with and see how we can discuss about it. So if you've got any questions for me, please kindly ask now or drop it in the chart in the chart box. I'm not sure if that was fast paced or that was just any questions guys. Ok. So right in the action, in the absence of any question, I would ask my colleague to send out the feedback form so we can have the feedback competed, improve on our sessions. Ok? Looks like we've got some and we can, I think the next mechanism is about in two weeks times and you can also drop suggestions on topics you would like to cover. So we are giving or delivering topics and to change appropriate for the level of people attending this. I think the feedback is open. So thank you everyone. Thanks for attending. Have a lovely evening.