Urology made easy

1. Urology made easy Matt Dunstan ST4 Vanessa Brown ST7

2. Topics • Haematuria • Renal Colic • Pyelonephritis • Testicular pain • Retention • Catheter problems and difficult catheterisation

3. Haematuria

4. Haematuria

5. Causes of haematuria • Infection • Cystitis, prostatitis, urethritis • TB, schistosomiasis, infective endocarditis • Tumour • kidney, ureter, bladder, prostate • Trauma • Inflammation • IgA nephropathy, glomerulonephritis, • Structural – Stones • Cysts, PCKD, • Haematological • Anticoagulants more likely to provoke rather than cause haematuria

6. Haematuria • 1 in 5 adults with macroscopic haematuria AND • 1 in 12 adults with microscopic haematuria Will have bladder cancer

7. Haematuria • History and examination • Where blood occurs in stream • Assoc dysuria • Clots • Any evidence of Retention • PR • Reasons for admission • Retention • FRANK haematuria: concern re Hb • FRANK haematuria with Clots: concern re retention

8. Haematuria • If admitted • 3 way catheter and irrigation • 30mls in balloon • Bloods inc U+Es, clotting and G+S • Urine for MC+S, cytology • If not admitted • Send urine for MC+S, cytology • Referral to haematuria clinic • US KUB/CT • Flexible cystoscopy

9. Haematuria

10. Renal Colic

11. Renal Colic • PC • Classical loin to groin pain as stone moves down ureter • Radiates into scrotum/penis as gets close to bladder / VUJ • BEWARE the older pt with 1st presentation, and PVD risk factors ?AAA • Size matters • 80% of stones <4mm pass spontaneously • 20% of stones >6mm pass spontaneously

12. What to look for on a KUB • 90% stones are radio-opaque • Ureteric stones are sausage shaped due to peristalsis of ureters • Outline of kidneys • Path of ureters • Hila of kidneys L1 • Tips of transverse processes • SIJ at pelvis • Sites of impaction • PUJ • Pelvic Brim • VUJ • Rest of abdominal film

13. Outline of kidneys Path of ureters Sites of impaction Rest of abdominal film

14. What to look for on an IVU • ALWAYS look at KUB first • CT KUB is gold standard, and only option if U+Es are abnormal • Nephrogram • Contrast in kidney • Persistent increasingly dense nephrogram in obstruction • Pyelogram • Calyces: • ?clubbed / more prominent • Extravasation of contrast • Ureters: • Peristalsis: Normal • Dilatation • Standing column

23. Renal Colic – treatment • Analgesia – codydramol + PR diclofenac • Tamsulosin 400mcg OD for ureteric spasm • Aedequate hydration • Admit if • Pain not controlled • Significant loin pain • Stone >5mm • Raised WBC / U+E • Temperature • Infected obstructed kidney requires URGENT drainage • Stent/nephrostomy (IR)

24. Pyelonephritis

25. Pyelonephritis • PC • Loin pain • Pyrexia / rigors • Assoc urinary symptom • UNWELL • Treatment • Send urine MC+S • Blood cultures • IVI/urine output • Admit for 24-48hrs iv abx • H with 1-2/52 of antibiotics

26. Testicular pain

27. Testicular pain Time means testicle!

28. Testicular pain • Apologise to patient before starting and explain about torsion • Aim is theatre within 1 hour so have to be quick • Take a full hx and examination • Main differential is between torsion and epididimo-orchitis • Make sure URGENT bloods have been sent • Urine dip

29. Torsion • SUDDEN onset pain • They remember what they were doing when it started • They are inconsolable! • No assoc urinary symptoms • No GU hx • On examination • Majority symptoms in testes • Testes high riding and horizontal lie • Pain WORSE on pulling testes down • Pain BETTER on elevation • ALWAYS discuss with Senior on call • Exploration within 6 hours to save the testicle • Consent for • Scrotal exploration +/- same side Orchidopexy +/- Same side Orchidectomy +/- Opposite side Orchidopexy

30. Epididimo-Orchitis • History • Gradual onset of pain • Assoc urinary symptoms / urethral discharge • Significant GU history • On examination • Majority of symptoms in epididimis • Tender supero-posteriorly over epididimis • Testes may be swollen and tender • Normal position and lie • Culture • Refer to GU clinic for swabs • Send MSU • Trt 6 weeks of antibiotics • IF IN DOUBT, EXPLORE

31. Acute Retention

32. Acute Retention • Definition = inability to pass urine despite desire to do so, assoc lower abdo pain • Normal bladder = 400-600ml • Desire to void 300ml • Normal residual <50mls • Retention = >500mls residual AFTER have tried to PU

33. Acute Retention • History • Examination • Do a PR - ?constipation, ?prostate • Neuro exam ?cauda equina • Beware retention in women - ?cancer – PV exam • Treat UTI / Constipation

34. Acute Retention • Reasons for admission • >800mls residual • Abnormal U+Es • WHY • Diuresis leads to dehydration and death • Back pressure hydronephrosis • Hourly urine output • If UO>300mls/hr for 3 hours then need iv fluid replacement • Replace 90% of urine output / hour with iv fluids

35. Acute retention • Either attempt TWOC as inpatient (6am) • Or referral to nurse led TWOC clinic

36. Catheter problems

37. How to put in a catheter – properly… • 1-2 tubes of instillagel • After injection, compress urethral to prevent loss • Do not inflate balloon until urine drains • If urine not draining: • Aspirate the catheter (using the instillagel syringe) • Suprapubic pressure • Get patient to sit up • ?are they dehydrated

38. Difficult catheterisation - Male • PULL penis UP towards ceiling • Feed catheter in until you meet resistance • Then pull penis DOWN towards toes

39. Difficult catheterisation - Male • Try a 16Ch first • If you cant get that, try an 18Ch or a 20Ch • Silicon catheter (in theatre) or cool in fridge • DO NOT inflate the balloon unless you see urine • Inflate the balloon SLOWLY • Make sure using LONG TERM catheter • ?Call registrar

40. Difficult catheterisation – Male • Catheterisation should be a gentle, easy pass • If you cannot after 2 attempts – CALL REGISTRAR • “Can you have one more try” – CALL REGISTRAR • Repeated traumatic catheterisation can risk strictures • Bedside suprapubic catheter insertion is DANGEROUS – bowel injury – death • Call your registrar/plan for theatre

41. Difficult catheterisation - Male • Replace the foreskin…

42. Paraphimosis • ?needs a circumcision – OPD apt • The problem is the tight band • This is what need to advance over glans • Gentle pressure on the paraphimosis to reduce oedema • Firm pressure on shaft to reduce arterial inflow • Instillagel/sugar/?ring block (NO ADRENALINE)

43. Phimosis – “I can’t catheterise” • Unable to retract foreskin • Use instillagel to “feel” for urethral opening • ?ring block (NO ADRENALINE) and dilate with clips/dorsal slit – CALL A UROLOGIST

44. Catheter problems • If a catheter is not draining • flush it • If a catheter has not drained since it was inserted and there is blood at urethral meatus • DO NOT REMOVE IT • Deflate balloon • Push catheter IN up to hilt • Aspirate urine • Then inflate • Then tell a urologist

45. Suprapubic catheter • If a suprapubic catheter falls out: • How long has it been in? When did it fall out? • Clean surrounding skin • Sterile field (minor ops pack drapes) and gloves • Instillagel+++ • Get another catheter in as soon as possible • If any difficulty – call the Urology Reg • Why do they have a suprapubic catheter? • Do they still need one? • Urethral?

46. Difficult catheterisation-FemaleKNOW YOUR ANATOMY

47. Difficult catheterisation - female • Don’t try to catheterise the clitoris! • The urethral is often more internal than expected • Ask for assistance • Patient positioning on bed • Use left hand to open introitus

48. Topics • Haematuria • Renal Colic • Pyelonephritis • Testicular pain • Retention • Catheter problems and difficult catheterisation

49. Thank you Any questions?