How to be an FY1 on

Surgery: Urology
Archie Allen
FY2 Whiston Hospital
[email protected]
What we will cover

• Content is what an FY1/FY2 on the job would be expected

to know.
• Day in the life of urology
• Focus on acute over chronic
• Focus on common over rare
• Overview of:
• Pyelonephritis
• Renal/ureteric stones
• Urinary retention
• Haematuria
• Testicular torsion

• ...and a few tips on catheter insertion

Day in the life of urology FY1

• Typically a consultant on call for the whole week "hot

week consultant)
• Senior ward round every day (consultant vs registrar)
• Simple document for ward round then do the jobs for
the day
• Not much else to it
Pyelonephritis
Presentation
Often presents in GP as infection
and in hospital as sepsis
• Fevers +/- rigors
• Nausea +/- vomiting
• Unilateral/bilateral loin pain
– tender
• +/- haematuria
• +/- preceding LUTS and/or
suprapubic pain
 Bloods
FBC – raised WCC
CRP – raised
First line eGFR not typically affected unless
dehydrated/septic
Investigations
Urine
• Appearance: often cloudy, smelly and
darker
• If <65 - urine dip +/- MCS if +ve
• If >65 - MCS

Imaging:
Pretty rubbish at diagnosing - typically only
used for suspected complications or ruling out
differentials
Everyone should get an ultrasound to rule out
If you see in A+E…
Consider if need admitting:
Simple uncomplicated
ADMIT FOR IV ABX IF:
cases can be
discharged with oral
• Any signs of sepsis
antibiotics and safety
• Severe pain or vomiting
netting
• Signs of significant dehydration
• Diabetic, or other relevant
comorbidities
• Oliguria/anuria
• Suspected complications
Management if admitting from
A+E...
1. IV antibiotics – local guidelines
2. IVF
3. Analgesia
4. Sepsis 6 including blood cultures if septic
5. Send MSU!
6. Consider catheterising (if poorly/oliguric)
7. If diagnosis unclear and patient unwell, consider CT abdo pelvis
8. Refer to urology (typically via general surgery SHO)
As the surgical SHO:
1. Simply ensure all previous steps completed (antibiotics, fluids, analgesia,
reg meds)
2. Decide if you agree they need admitting - if yes, tell bed manager or A+E
coordinator
a) If uncertain (and it's daytime), phone on call urology registrar
b) If uncertain during night, just admit and they will get a senior review in
the morning and can be discharged if doing better
3. If very concerned over night (deteriorating despite initial treatment)
a) Consider if you have the right diagnosis – is it worth CT
scanning overnight?
b) Phone urology registrar (asleep at home – wake them up, it's their job)
Complications to consider when
clerking

Perinephric
SEPSIS Pyonephrosis
abscess

Emphysemato
Renal abscess us
pyelonephritis
Renal tract calculi
 Renal tract calculi
=
Urolithiasis
=
Kidney or Ureteric stones
PRESENTATION
PAIN – Renal colic
• Sudden onset
• Classically loin to groin
• Constant ache with sharp
spasms ("colic")
+/- Nausea and vomiting
Haematuria (90% - typically
microscopic, found on dipstick)

Can be incidental finding – if not-

obstructing then can be
 Initial Investigations
URINE DIP
• Haematuria – 90% sensitivity using dipstick
• Exclude UTI – can have both UTI and stones
though!
PREGNANCY TEST in young women (for ALL
abdo pains)
BLOODS
• If eGFR significantly dropped – suggests
stone is causing an obstruction and a post-
renal AKI
• WCC and CRP raised? - consider infection
• LFTs, amylase, VBG to rule out OTHER
causes of abdominal pain
 What to do if suspected...

ANALGESIA – Diclofenac suppositories are the best! - typically 50mg

TDS
Are they still passing urine? - if not you NEED to rule out bladder
outlet obstruction before considering discharging
If in A+E:
If on wards:
• Safe to discharge --> Renal Colic Pathway
• If unsafe to discharge (suspected • Book CT KUB
obstruction or complications, or severe • Discuss with urology (via surgical
uncontrollable pain) then refer to urology SHO) if confirmed stone
(via surgical SHO)
 Obstructing stone

• Stone obstructs ureter --> unilateral

hydroureteronephrosis + post-renal AKI
• If stone obstructs urethral opening (VUJ) -->
Complication urinary retention

s If hydronephrosis persists you risk

pyelonephritis or chronic damage to
kidney

If stones persist for a long time you risk

deteriorating renal function, secondary
infection, and a ureteric stricture
Referring to
urology
If any evidence of obstruction – always
refer to urology
• Will likely insert nephrostomy to
relieve pressure on kidneys before
planning definitive management

Any high risk patients – e.g. one kidney,

or bilateral kidney stones

Very small stone (2mm or less) - advise

pt will usually pass spontaneously

If larger non-obstructing stone –

discuss with urology, can usually be
followed up via urology urolithiasis clinic
Urinary Retention
 Acute vs chronic retention
Acute Chronic

Sudden onset of urinary Slowly developing urinary

retention retention
Painful, distended bladder Typically painless

Acute on chronic: an acute episode of complete

retention on a background of chronic retention – often
how chronic retention first presents
 Constipation

UTI
Acute Blood clot
causes of Penile/vaginal infections
retention •
•
Balanitis
Prostatitis
• Vulvovaginitis
• Some STIs

Phimosis/PARAPHIMOSIS

Bladder calculus

PAIN

Cauda equina syndrome

Trauma (to pelvis or spine)

Drugs (e.g. opioids, anticholinergics)

Chronic Benign prostatic hypertrophy
causes of (COMMON)
retention Drugs (anticholinergics)
Pelvic cancers
(prostate/bladder/rectal)
Prolapse (acute or chronic)
Other pelvic mass (fibroids, ovarian
cysts)
Various neurological conditions
 Important times not to miss it

• Delirious patients
• If associated with back pain
and sciatica (cauda equina)
• Patient unconscious (e.g.
head injury)
• Pelvic trauma
• Chronic PAINLESS retention
Initial
Management
Bladder scan to
confirm diagnosis +
record size

CATHETERISE

Urine dip +/- MSU

Measure how much

urine is drained
What next?

Investigate • PR exam – constipation? Big prostate?

cause if not • Urine dip / MSU – infection?
• Consider PSA
already • Meds?
known
None of the
above? • Ready for discharge? --> TWOC clinic
• If inpatient for long time --> urology referral
Cause
unclear?
Testicular torsion
Classic presentation

Associated Examinatio
History
symptoms n

Sudden
onset Swollen
+/- abdominal
unilateral elevated
pain
testicular testicle
pain

Usually
Less than 24 +/- nausea and
scrotal
hours vomiting
erythema

Any age but Absent

typically cremasteric
teenager reflex
 Epididymo-orchitis

• Typically longer history (over few days) and

gradual onset
• Can be STI associated (typically younger) or
spontaneous (typically older)

Incarcerated hernia within scrotum

• Bulge in inguinal region

• Hopefully two normal testicles palpable

Differentials Tumour

• Hard irregular lump on testicle, can be painful

• CAN PRESENT WITH TORSION

Mumps

Hydrocele

• Painless
What to do if in GP

Phone surgical
Refer URGENTLY SHO or urology
straight to registrar
hospital via A+E through hospital
if suspected switch in
advance
 Analgesia
What to
do if in
Refer URGENTLY to
A+E or surgical SHO or urology
wards registrar if suspected
• Do not wait for blood results
• Based on clinical assessment
alone
If you are the surgical SHO
In hours Out of hours
• Depends on your urology • Prioritise
reg • If you suspect it – phone
• If you're not busy you urology reg.
see them • Wake them up its their
• If busy you can job.
sometimes ask reg to
see direct
• Imaging will take too
long, but consider US
testes if can get it
immediately
Prep for
Gross Haematuria
AKA visible haematuria
AKA frank haematuria
 Gross haematuria is a
COMMON thing you will be
bleeped about on all wards
Causes of gross haematuria

• Traumatic catheter insertion

• UTIs or urinary stones
• Major pelvic trauma
• Recent urological surgery
• Bladder, prostate or renal cancer
• Coagulation disorders
• Variety of kidneys diseases with inflammation
Approach to gross
haematuria when on-call
1.Stable or unstable?
2.Tinged pink or thick dark red?
3.In retention? Assess
4.Recent catheterisation?
risk
5.Symptomatic or asymptomatic?
1. LUTS?
2. Abdo pain?
 Things to consider with
haematuria

Check past medical history

Check most recent bloods

Have they got a catheter in? Why? Was

haematuria present BEFORE or AFTER
catheter insertion?
 • Your purpose is to keep
people alive and stable
until the next day, NOT to
identify the cause of every
When on- problem thrown your way
call on • If the patient is stable and
low risk of deteriorating,
wards document and ask for day
team to review
• If patient is unstable, in
retention or at high risk of
deteriorating THEN you act
When to refer to urology
If you have ruled out:
• Catheter associated trauma
• Infection (UTI)
• Kidney disorders (check protein in urine)
(refer to nephrology if high)

Then the following should be referred to

urology
• All visible haematuria
• Any symptomatic non-visible haematuria
• Any asymptomatic non-visible
haematuria if age >40
Case Study
Mr Richard Bleedin
•68 year old gentleman on respiratory ward

•Nurse bleeps you overnight

•"Doc, this man is telling me last few times he peed

there was blood in it, but he hasn't peed for the last 10
hours. He looks like he's in pain."

•What do you want to know?

Day 2 of admission for treatment of a PE – unclear
cause of PE

Obs
• NEWS 3 (4)
• Heart rate 108 (90)
• Respiratory rate 20 (22)
• Sats 96% on 2L O2 via NS (97% on 5L)
• Blood pressure 152/80 (132/72)
• Temp 37.2
 • Ur 6.2
• Cr 97
• eGFR 74
• Hb 102
What do you
Bloods • WCC 9 want to ask the
• CRP 14 nurse to do next?
• INR 1.1
• LFTs normal
• D-dimer 2456
Nurse bleeps back...
Bladder scan – 800mls in his bladder

Catheterised him and now draining urine

Pt already feeling a bit more comfortable

What do you want to ask?

What do you want to do re: his current
management?
Repeat obs

• NEWS 2
• Heart rate 86
• Respiratory rate 18
• Sats 96% on 2L O2 via NS
• Blood pressure (141/76)
• Temp 37.2
Re: management plan

• To continue apixaban vs stop apixaban

• Assess what you think is going to kill him first:

• If tinged pink and obs and Hb all stable --> consider swapping
from apixaban to treatment dose clexane and ask for day
team r/v in morning
• If frank haematuria/dropping Hb/unstable --> stop apixaban
Three hours later...

"Doc, the catheter has stopped working.

It's only drained 400mls. I've bladder
scanned him again and he still has 450mls
in his bladder."
What do you want to do now?
A bit more history from patient

• Been needing to go to the toilet more frequently for a

while now
• On and off blood in urine for a month or so now
• Tinged pink to begin with
• Recently though it has been a lot darker and more
constant
• Have been completely emptying bladder normally before
this
What now?
Catheter troubleshooting
First off – why do you think the catheter is not working?

Sequential troubleshooting
• Anything external blocking catheter draining? E.g. bed rails
• Anything visible within catheter tube?
• Any bypassing?
• Have nurses tried flushing the catheter?
• If no luck – change catheter

What type of catheter do we need for Mr Bledin?

Back to Mr Bledin

Three way catheter inserted

Now what?

Irrigation and washout

What are you going to do about the
suspected cause of the haematuria?

On your night shift – NOTHING.

• We are worried about a cancer
• This is not something that needs urgent
investigations overnight
• Simply document everything that has happened
and ask the day team to refer to urology
Tips for catheter insertion
 General bits and bobs

You'll only ever be asked to help with challenging male

catheter insertion

Ask for the catheter equipment to be set up for you

Should be sterile – but if it's very challenging then

sterility often goes out the window for clinical need
Tips and tricks
• If not passing easily
first time, use TWO
instillagels and WAIT
10 mins – this relaxes
the sphincter making it
easier to pass
• If enlarged prostate
go to urology ward and
get TIEMANN TIPPED
CATHETERS
 Tips and
tricks 2
• If oedematous (makes meatus
hard to find), squeeze for 5 mins
before inserting
• Or soak in glucose 10-20%
• If phimosis, peel foreskin back as
much as possible, thread the eye
of the phimosis with catheter, and
rummage around until tip feels it
has passed through the meatus
• You will feel it coil within
foreskin if it hasn't
 Final words of warning

Whilst you can apply a little pressure when passing, do

NOT force catheter insertion – you will create false
passages

NEVER INFLATE BALLOON UNTIL YOU SEE

URINE IN THE CATHETER
Any
Questions?