Methodological Instructions for Students Theme: Instrumental Methods of Examination in Urology. Aim: Introduction of instrumental procedures in urology (cystoscopy, catheterization etc). To teach the construction and usage of some of them. Showing urinary bladder catheterization, cystoscopy and to introduce process of catheterization of ureter. Professional Motivation: In every urological practice Instrumental and Endoscopic methods of Examination of urinary bladder in patients plays very important role. To learn the usage of catheters, uretherscopy and cystoscopy. Basic Level: 1. Usage of Instruments in Diagnosis and Examination. 2. Anatomic-Morphological functions of the upper and lower urinary tracts. Student's Independent Study Program I. You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following: 1. The method of catheterisation of urinary canal with plastic catheter. After proper cleansing and lubrication, the catheter can be manipulated with a sterilegloved hand. However, it may be simpler to grasp the catheter near its tip with a sterile clamp and hold the other end of the catheter between the fourth and fifth fingers of the same hand. The catheter can then be advanced with the clamp without being touched by the unsterile hand. Begin catheterization with the penis pointed slightly drawn out. 2. Types of urethral catheters. In general, straight rubber catheters are used for routine diagnostic catheterization. However, a coude (elbow) catheter, which is stiffer and has a curved tip, may be more readily manipulated over an enlarged prostate that has elevated the bladder neck. Urethral catheters are: Foley, Whistle-tip, Pezzer, Malecot, Robinson, Coude. 3. Method of catheterization of urinary canal with metallic catheter (in women and men). After proper urethral lubrication, the tip of the conductor enters the urethra. The conductor is in the horizontal position over the groin. The penis is pulled out on the conductor, which is advanced drown the urethra and moved simultaneously to the midline; its handle is gradually moved to the vertical position. The conductor will usually pass through the external urinary sphincter if gentle pressure is exerted on the handle at right angles to its shaft with one finger. When the conductor has passed all the way into the bladder it should be possible to rotate it freely. 4. Filiform & Followers. Filiform and followers are instruments used to dilate narrow strictures. Filiforms have woven fiber cores with a coated surface; they are very pliable and smooth. Useful sizes are 3-6F. The follower is made of metal or of woven pliable fiber. Useful sizes are 8-30F. 5. Technique of passing filliforms. After lubricant jelly has been instilled into the urethra, the filiform is introduced. If it is arrested, it must be partially withdrawn, and readvanced. If this fails, one or filiforms should be added to the first and all manipulation should be repeated.. 6. Observation of cystoscopy. Modern cystourethroscopes have a metal sheath ranging in size from 8F to 26F and interchangeable fiberoptic telescopes allowing a view from 0 to 170 degrees. The 0- or 30-degree lenses are best for visualizing the urethra, whereas the bladder walls are best inspected with the 70-degree lens. A retrograde (170-degree) lens must be used to see the vesical side of the bladder neck, particularly where prostatic tissue obstructs the view. Complete endoscopic studies are among the most precise diagnostic tests in all medicine. Any urethral lesion ( eg, verrucae, tumors, strictures and diverticula), as well as the size and configuration of the prostate and bladder neck, are noted before the bladder is inspected. When the bladder is entered, the trigone is visualized and the size, shape, position, and number of ureteral orifices noted. The bladder wall is carefully inspected for tumours, stones, diverticula, ulcers, trabeculation, haemorrhage, and oedema. The normal and abnormal cystourethroscopic findings must be specifically described. 7. Contraindications to cystoscopy. Cystoscopy is contraindicated in acute urinary tract infection, because trauma may exacerbate the infection and lead to sepsis. It is relatively contraindicated in the presence of severe symptoms of prostatic obstruction, since trauma may produce just enough oedema of the bladder neck to cause complete urinary retention. Of course, if cystoscopy is essential, this risk must be accepted. 8. Condition which is not necessary to carry on with cystoscopy. Passage of urethra, volume of bladder more than 75 ml, transparence of environment. 9. Normal cystoscopic picture. The bladder wall is dynamic, and as the bladder fills, small lesions will move away and may escape the examiner’s field. Special care must be taken not to overdistend the bladder and to make sure that all areas have been completely inspected, often with the bladder minimally filled initially. In adults, most of the bladder wall cannot be seen if the bladder contains more than 200300 mL of urine. 10. Method of punction of urinary bladder. A suprapubic catheter is useful in males when the urethra is impassable (eg, traumatic disruption or stricture), when there is epididymitis or severe urethritis, or when prolonged bladder drainage by means of an indwelling catheter is necessary. An indwelling urethral catheter predisposes to meatitis, urethritis, and epididymitis. The skin of the suprapubic area is prepared and infiltrated with a local anaesthetic. If the patients are in urinary retention, the bladder is usually readily palpated. The bladder must usually contain a minimum of 200-300 mL of urine before a suprapubic catheter can be inserted successfully. The patient may be placed in the Trendelenburg position to move the intestine upwards. A thin lumbar puncture needle is inserted above the symphysis pubica and angled toward the perineum to locate the bladder a troacar is inserted into the bladder and the suprapubic tube passed. Size 8F, 10F, and 12F suprapubic catheters are available in pre-packaged sets. 11. Ureteral catheterization. These techniques are utilized in the evaluation of hematuria, chronic or recurrent urinary infection, unexplained urologic symptoms (eg, enuresis, frequency), and evaluation of congenital anomalies. They are also useful in any clinical situation in which excretory urograms have suggested pathologic change but have not furnished all the information necessary for definitive diagnosis and treatment. Key words and phrases: Cystoscopy, cromocystoscopy, catheter. П. Tests and Assignments for Self-assessment. Multiple choices. Choose the correct answer/statement: 1. With the help of which substance urological instruments work out? (cystoscope, resectoscope)? A. Glycerine. B. Vaseline. C. Kolargol. D. Novocaine. 2. What is the physiological capacity of urinary bladder? A. 100-150 ml. B. 400-450 ml C. 200-250 ml. D. 300-400 ml. Real life situation to be solved: 1. Patient P., 36 years complains of intensive pain in the left abdominal and right below the rib cage, a frequent urination. She felt sick a day ago after a very tiresome travel (vibrations). On examination stomach was normal and soft, in accordance to the left part under the rib cage. Pasternatskiy’s Symptom positive on the left part. Approximate diagnosis? What should be done to give exact diagnosis? 2. Patient L., 68 years after frequent urge to avoid urination, pain below stomach, after which there was retention or (suppresion) of urine ischuria. Which type of medical aid is necessary to provide? What should be done to give accurate diagnosis? III. Answers to the Self-assessment. The correct answers to the tests: 1. A. 2. С. The correct answers to the real life situations: 1. Left sided Renal colic. Chromocystoscopy should be done. 2. Catheterate urinary bladder. To get accurate diagnosis cystoscopy should be done. Visual Aids and Materials. 1. Slides 1. 1 Rezektoscopy. 1. 2 Uretroscopy. 2. Instrumentation (different types of catheters, bouge, catheterization cystoscop, operative cystoscop). Students' Practical Activities: Students must know: 1. Anatomical and physiologal position especially the upper and lower urinary canals. 2. Method of catheterization of urinary bladder with metallic catheter. 3. To know catheters, bouge, cystoscope. 4. How to use cystoscope and chromocystoscope. 5. Normals in cystoscope. 6. Methodic of punction of urinary bladder. Students should be able to: 1. Know how to provide catheterization of urinary bladder with elastic catheter. 2. Know all instruments ready to be used in urology. 3. To know normal graphs in instrumental examination of patients (cystoscope, chromoscope and etc).