Urology made easy Matt Dunstan ST4 Vanessa Brown ST7

Topics 1. Haematuria 2. Renal Colic 3. Pyelonephritis 4. Testicular pain 5. Retention 6. Catheter problems and difficult catheterisation

Haematuria

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

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

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

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

Haematuria

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 1 st presentation, and PVD risk factors ?AAA Size matters 80% of stones <4mm pass spontaneously 20% of stones >6mm pass spontaneously

What to look for on a KUB 90% stones are radio-opaque Ureteric stones are sausage shaped due to peristalsis of ureters 1. Outline of kidneys 2. Path of ureters Hila of kidneys L1 Tips of transverse processes SIJ at pelvis 3. Sites of impaction PUJ Pelvic Brim VUJ 4. Rest of abdominal film

1.Outline of kidneys 1.Path of ureters 1.Sites of impaction 1.Rest of abdominal film

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 1. Nephrogram Contrast in kidney Persistent increasingly dense nephrogram in obstruction 2. Pyelogram Calyces: ?clubbed / more prominent Extravasation of contrast Ureters: Peristalsis: Normal Dilatation Standing column

Renal Colic – treatment 1. Analgesia – codydramol + PR diclofenac 2. Tamsulosin 400mcg OD for ureteric spasm 3. 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)

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

Testicular pain

Time means testicle!

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

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

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

Acute Retention

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

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

Acute Retention Reasons for admission >800mls residual Abnormal U+Es WHY Diuresis leads to dehydration and death Back pressure hydronephrosis 1. Hourly urine output 2. If UO>300mls/hr for 3 hours then need iv fluid replacement 3. Replace 90% of urine output / hour with iv fluids

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

Catheter problems

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

Difficult catheterisation - Male 1. PULL penis UP towards ceiling 2. Feed catheter in until you meet resistance 3. Then pull penis DOWN towards toes

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

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

Difficult catheterisation - Male Replace the foreskin…

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)

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

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

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?

Difficult catheterisation-Female KNOW YOUR ANATOMY

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

Topics 1. Haematuria 2. Renal Colic 3. Pyelonephritis 4. Testicular pain 5. Retention 6. Catheter problems and difficult catheterisation

Thank you Any questions?