 Our next speaker of today's session is Dr. Mohamed Shahidhani, who is about educators on urological emergencies and how to handle them. Good evening all of you, for the last session of the day, all are eager to be in the next room, but I am in the middle of a session where I have to finish it fast to keep up the promise of the stomachs now. So compared to the other specialities, urological emergencies are rare, it is why you do not find urologists more in the emergency room. But then yes, we also do share a few emergencies where we can classify into two groups, the non-traumatic and the traumatic group. Generally, we have hematuria as the most common cause of emergency where the patients rush to the OPD as well as emergency room with hematuria. Most of the hematurias with origin of from the urological side are self-limiting, but then they are great. So what do you do? We have to go to a long list of questions just to make sure that these do not cause any problem. So elderly male with hematuria, yes, they do come with this problem, generally the most common cause of hematuria in elderly male is enlarged prostate. But yes, tumors of the bladder and also tumors of the pelvic-calatial system is also a second diagnosis. The duration of hematuria is also important. Usually they come up with the first episode of hematuria, they land up into the OPD or the emergency room. One important question is whether this hematuria is painful or painless is critical because generally patients having hematuria with a slight back pain will give us an idea that the origin of blood is somewhere in the upper tracts. So they cause something called as clot colic. And then the timing of hematuria, whether the hematuria is initial or whether it is in the middle of passing urine or it is terminal. Terminal hematuria gives us an idea that the origin of blood is somewhere distal to the prostate, somewhere in the urethra or TIP patients with simple thymosis can also land up with initial hematuria. But with terminal or midstream hematuria somewhere the location could be in the bladder or around the prostate. I am sorry, the terminal hematuria can be at the level of the bladder or the prostate. And how dark the color of the blood is? This is something which is very subjective. Generally we see a lot of patients with hematuria will be able to gauge at whether this bleed is an acute or a chronic. Generally the bleed, what patients come is a dark colored bleed. So this is something where there is already a clot formed and the urine flows over this clot and this gives somewhat a dark colored bleed. So they should not worry much to the clinician as to take a decision. But if the hematuria is quite red, fresh blood then yes it initiates evaluation at early stage. So gross hematuria is the thing which pulls the patient to the emergency room. It has to, the history should be taken as to what is the origin of the bleed. Investigations to support the diagnosis in the form of ultrasonography which screens the upper tract. We will have to look for any hydrophrosis, if there is any stone, if there is any clot, if there is any clot in the bladder, if there is a stone in the bladder or if there is any tumor arising in the bladder or the upper tracts. So what do we do in emergency situation if the patient comes, that is a common question. So make sure that the patient is not in retention in the first step. So pulpit the bladder if there is no clot, non-tentor abdomen, patient is voiding normally but associated with hematuria then it is not a cause of worry in the initial setup. Suppose if patient is having severe symptoms, unable to void, is dribbling urine, is passing clots then you have to get a screening ultrasound of the bladder. Make sure if there are any clots then plan to evacuate those clots in the emergency by putting a three-way catheter. We have catheters ranging from 12 French to 24 French. The biggest possible caliber of the catheter should go in the case of hematuria. Pass, give a bladder wash and if there is any ongoing existing bleed start an irrigation of the bladder. Suppose if the irrigation is not going maybe you can do a catheter change, try to aspirate those clots through a septocerein and then again reinitiate the bladder wash. The next commonest cause of emergency is a ureteric colic or a renal colic. But then the generally this pain starts from flank, goes down to the groin and sometimes to the external genitalia also. When this type of pain comes it has to be have, this pain should be, should have a differential diagnosis with sometimes pneumonia, ovarian pathologies, acute appendicitis, sometimes rare cause of torsion testis as well. Just to be, to give a clinical idea, we had a patient which was referred from Tupkur. He had a pain duration of about 6 to 8 hours. They got an ultrasound which showed a 7 millimeter of ureteric stone in the lower ureter and he was referred to us. Just while examining at the end had just had a look at his external genitalia which is showing the right testis slightly enlarged. We just saw with, we just confirmed that swelling with an ultrasound flotum and that showed a complete torsion testis with absent flow. So just to have, to highlight the point that any abdominal examination or acute abdomen you have to complete your examination of the external genitalia, have a sneak down there before you get into trouble. So in those cases it is very difficult to counsel as to what is the cause of pain but generally acute torsion of testis holds the upper hand, holds the priority where you have to treat that torsion with in fact, orchidectomy and then clear the stone later. So when you have a ureteric colleague what is to be done? There is a dilemma whether to do an ultrasound first or a CT first. So as a urologist I would be more comfortable to tell that a CT KUB is the most, is the best choice to diagnose a ureteric colleague provided in what centre or what situation you are. The guidelines say that CT KUB is the best one but yes, ultrasonography is non-inferior also. It is has lesser, it has no risk of radiation, it can be repeated multiple times. But ultrasonography has inferior sensitivity in diagnosing ureteric colleagues in patients with higher BMI and in pregnant women, yes it is the only choice available. So these are the sensitivities and specificities of imaging modalities in ureteric stones. I just wanted to highlight that the CT has the best sensitivity and specificity. Yes, ultrasonography also has increased sensitivity but it is lesser specific. Generally when you have lower ureteric stones, the diagnostic specificity and sensitivity goes much more lesser compared to a pain CT KUB. So MRI has a small role especially pregnant women where we cannot expose them to ionizing radiation but this modality is used very rarely. The first thing to be done in ureteric colleague is pain relief. Generally NSA IDs are the best one to relieve pain. Additionally you can add opiates also. So what do you do for ureteric colleague? You do an ultrasound, you have a size of stone, you have a location of stone and then you give pain relief. Now what do you do next? That was a question I think got from the audience. We keep a cut off of about 5 to 6 millimeter of stone in the ureter as a sufficient size to have a watchful waiting up to 4 weeks provided there are no other factors, it should not be a diabetic, it is not in sepsis, it is not having any high fever or a UTI. If all these things are ruled out, a simple 5 to 6 millimeter of stone can be managed conservatively with analysis. Additionally you can ask the patient to have good amount of fluids. A key point here is ask the patient not to take excessive fluids during the time of colic because that increases his symptoms. So you can ask them to have, you can cut down the fluids during the time of colic, take the pencler and watch them. Suppose at about 2 to 4 weeks if the stone is not coming out and there is recurrent UTI, there is any flank pain and if it is a solitary kidney, yes all these things should be referred to a urologist for a removal of the stone. So that is what I have told that the indications of interventions are, the pain does not, appeals to respond with analysis, is there any associated fever, if the renal functions are increasing, if the obstruction is unreleaved after 4 weeks and due to personal or occupational reason if the patient has to travel abroad or somewhere else, then if they have a stone sticking in the ureter then I think it is probably best thing to do is to stand that patient and send him. The next emergency, common emergency what we see is urinary retention. Now this can be an acute or a chronic event. Patient will have an acute pain abdomen unable to void with a severe lower abdomen pain and occasionally associate with hematuria. This patients are typically elderly and the most common cause for acute urinary retention is enlarged prostate as there are multiple other causes also. Common urinary retention, yes these patients also have a full bladder but they are usually pain free. Common causes include enlargement of prostate gland either because of benign nature or carcinoma of the prostate, ureteral structure this especially is seen in younger adults, a prostatic abscess in immunocompromised or diabetic patients, we should have suspicion of this and ureteric stones and stone sitting at the bladder neck also can cause urinary retention. Occasionally patients having dysfunctional voiding can cause with the secondary constipation also can have urinary retention. Occasionally in patients in acute postoperative phase where patients have undergone a perineal surgery in the form of a hemorrhoidectomy with severe perineal pain also can land up in urinary retention also. One more cause what we get in the ward is patients after some time ENT surgeries where they use phenylaprin or nasal decongestants these patients also have that those can also precipitate urinary retention. So make sure that these things are well taken care of in the history taking. Females also can present with urinary retention especially with pelvic organ prolapse, ureteral stenosis and post surgery for urinary incontinence in the form of obturator tripping. So the best modality to decompress bladder is the Fully's catheter. So the most common question is to what size of catheter is to be used. The best thing is to place a catheter with the minimal most strength. Usually what we do what we have a thumb rule is an adult with a reasonable height and VMI would start with 14 French and we can go up to 18 French. In a children yes we have option from infant feeding tube feeding tube up to from 6 up to 12 French of Fully's catheter. If catheter does not go yes we have to decompress the bladder suprapubically.