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Hello, everyone. Welcome to today's session. It's our final session of Soap Does anatomy series. And today, what we're going to be having a look at is urology. We're going to be going through anatomy and some surgical applications of that. And our teacher for today is Dr Lacosta. She's currently an F one in Guilford and she's very suited to teach you today. She's actually done an anatomy degree and a medical degree on top of that. And she also has a medical educational page on Instagram that she'll talk to you a bit more about when this goes on. So you're in for a treat today. If you have any questions, pop them in the chat, we're both really friendly and we'll try to answer them and at the end of this session will send out and feedback form. So make sure you go uh doing the river TV. Dance with uh everyone. Have a lovely session. Okay. Hi. Hi guys. It's, I'm pro Cheskuh. Um I'm just, I'm enough one really uh in uh well, sorry County Hospital. And today I'm gonna just have a chat with you about urology. Um If you have any questions just put them in the chat and, um, I'll try and get through the slides quite quickly, but I think the slides are quite thorough anyway. So, um, yeah, you can, you can review the size anyway any time as well. Um, cool. So, can everyone see my slides? Hello week in Canberra? Fine. Okay. So the Grace Anatomy of the kidneys. Um, sorry, I'm going to kill the, kill this in a minute. Fine. Um, So the question after we have the kidney, so you've got the renal capsule on the outside, okay, which is a clean from around the kidneys. And then you've got the renal cortex, which is this kind of um pink shade in between. Um Then you've got the medulla after the cortex inside and then within and then you've got the renal pelvis, which is just around here and the renal pelvis is where the renal artery and renal vein enter. Okay. And the you Rita exits. Um And then you, you've got the hilum of the kidney. I think that's quite straightforward. Yes. And with the, with the renal pyramids. So you've got the um minor calluses and you've got major calluses as well. Um So you may, you may be asked in the exam questions to spot this out on um on some sort of imaging. So you might want to try and you might want to go back and see how you can spot this on, on imaging itself. So, did you read it. Um There quite long actually, they're, they're 25 to 30 centimeters long and approximately 3 to 4 millimeters in diameter to um they have an in the mucosal layer. Okay. Um And then a muscular layer around here, you can see that in a darker purple and then the adventitia um is this lighter color, lighter color. You can barely see the adventitia actually. And the advantage is quite a fibrous layer. Um And that provides structural support to the U E to um and the muscular layer, um they're made of smooth muscles that um that contract to allow the urine to, to go through. Um Okie Dokie, he's on the enemy coz it just um allows for like expansion really back back. Ok. So you have the anatomical supply to the yuri to I think, I think that's what we were meant to cover anyway. So you've got branches of the renal artery, as you can see here, branches off the gonadal artery, um branches of the aorta and um branches from the common. I lack arteries. Um Yeah, I've covered that. Okay. Is there any questions so far today? Hello? Okay. I'm just going to go on. So we've got the um and asked me off the bladder. Um So does anyone know um what kind of epithelium the bladder has? I can't really see the chat or anything. Hello? Okay. Um So I don't, I don't know if you heard me to the anatomy of the bladder. Hang on. Um, I just messaged Hannah, she can hear me at all. So, you've got your Trigon, which is this kind of triangular section here. Um, and that's how the base of the bladder. Um, it has two of the openings um, that are from the, your etta's okay. Um, and the urethra which is here. Um, it's got also, I don't have to hear me at all. Um, but, uh, okey dokey, he's so, um, and then you've got the Treasure muscle, which is a smooth muscle that allows um, contraction and, um to actually expel the urine from the bladder. And then you've got the urethra which is a single tube that carries it from the bladder to the outside world essentially. Um, and that's controlled by an external sphincter. Um, so you can voluntarily contract it. What's the internal sphincter? Um, is a smooth muscle and that's involuntary contraction. Um You've got the mucosa, so you've got the muscular Rs, you've got the submucosa and then you've got the mucosa. Um, and this is a transitional epithelial cells as we've covered before that can stretch and that can accommodate for more, more of the bladder volume, sorry about my e most popping up at all. Okay. So, um, we are on the anatomy of the bladder. So, um, the bladder itself receives blood supply from the internal anucha tree, um, and the superior vehicle arteries. Um, the nurse that innovate the bladder are from the pelvic nurse and they provide both sympathetic and parasympathetic fibers. Um And so the sympathetic fibers um are to the external sphincter to maintain continents. So you can voluntarily contract um uh sorry, are to the internal spincter. Um So you don't have to think about contracting and the parasympathetic muscles are to the Treasurer muscle. So um about the anatomy of the urethra. Hang on, I'm going to call Hannah cause I don't know if you guys can hear me at all. Hello? Can you hear me? Okay? Okay, fine. Okay, cool. Sorry guys. So the anatomy of the urethra in females. So um in females, the announced me, um the re threat is much shorter and approximately 40 to me. Citizen name it runs um and period the vaginal opening um posterity of Kottaras and the urethra is lined by a mucous membrane and it contains an x, internal sphincter and external sphincter as we've covered before. Um fine and the external sphincter is voluntarily controlled the mail in males. However, it's divided into three parts. So you've got the membrane iss prosthetic. Um So, so prosthetic membrane iss and um penile urethra. So you've got the prostatic urethra which is the widest part, the membrane is is the shortest part and of course, the, you know, is the longest part the, so in, in males, the, the membranous part runs between the internal and external sphincter's and it works similarly in terms of um conscious contraction and unconscious contraction as in females. Um And this runs through until the external urethra orifice, which is like the tip of the penis um at the external urethra or office with our office just means opening of the ps. So the male urethra um I've said that it has an internal spincter and an external sphincter um fine, okay. So the kidneys are supplied by the renal arteries and this, this comes off from L2 of the abdominal aorta. Um So the the arteries come into something called into low by arteries because it's in between the lobes or in between the pyramids of the uh of the kidney. And then they divide into our Q eight arteries or it's not really labeled here. Oh, there we go. R Q eight arteries here and then these arteries um then furthers have divide into interlobular arteries which give the blood supply to the gamma rely. So these are the filtering um units of the kidneys similarly with our renal veins. So the renal veins, uh we start off with our interlobular veins which drain into the RQ it veins which drain into the inter Lobel veins and then which drain into the renal vein and then which drain, which further drains into our imperial been a Kaveh. So we've got our sympathetic nervous um that innovate the kidneys and originate from the thoracic spinal cord um and pass through the sympathetic chain Ganguly er before reaching the renal plexus. I should really have a diagram. Sorry, I didn't have one here. Um And we've also got parasympathetic nerves that innovate the kidneys and originate from the vagus nerve. So, um your typical patient who comes in with renal calculi um will have loin to grow in pain. So, pain coming from the kidneys to die groin, they'll have severe nausea and vomiting. They may have uh blood in the urine, okay. Um But typically more typically than that, they have painful urination, frequent urination and a history of urinary tract infections. Okay. So there are various risk factors for renal calculus. So, if you're dehydrated, um you have a diet which is high in salt or oxalate rich food. So, um typically chocolate um can increase the risk of stone formation. Um if you have a family history of kidney stones and um your parents have kidney stones. Um Do you all you increase your risk? If you have certain medical conditions such as hyperparathyroidism, which kind of increase the levels of calcium um in your system or renal tubular acidosis, you can increase your risk. Um medications, uh obesity is a big one and as I said, urinary tract infections. So, in clinics, what I would really say is it's from dehydration diet and uh urinary tract infections as the key ones which you would typically see. Um and hopefully those will appear in your exam questions. Um So what, what would you do if someone has a renal calculi. You would give them, well, I would give them a stronger pain killer than an NSAID. But you typically started with an NSAID and, uh, bump it up to opioid. Um, because these patient's will be rolling around in pain. Okay. You would give them, just put them straight on an IV drip. Okay. And if the renal calculi is small enough, I don't know if you know the measurements for the renal calculi. But I think if they're less than six millimeters, they can try and pass normally. But if they're greater than that, they try and operate. So certain medications such as alpha blockers can try and help relax that center, um, to make the stone easily pass through. So there's surgical management for renal calculi. So you've got extra corporal shockwave lithotripsy. Um That's, as you can see here on my image, you can, um, it's basically like a radio, uh, not radioactive. It's, it's not correct for me to say, but it sends shockwaves to break up that stone. Okay. And that's, uh, for patient's, you have uh, renal stones smaller than two centimeters, um, laser lithotripsy. Um, it's a similar procedure. Um, oh gosh. Um, where, where you break up the larger stones, um, by in inserting a scope through, through the ureters and physically breaking them up. Um, percutaneous, uh, nephrolithotripsy, um, is shown here where it's a similar procedure again where you go through the, I think you go through the kidney itself to break up the kidney stone and um open surgery, but that's quite rare. So UTI S as a quite a common question in exams. So, um, the patient will have a frequent urination, dysuria, cloudy or strong smelling urine and law into growing pain and is typically caused by the bacteria. E coli. And I've got a lovely picture here just to show you guys. So. Okay. Dokey. I don't know if there's any questions at all, shut them out if you want to. Um And then if the patient does have a uti um then they may go on to develop something called pilon authorities um which is where bacteria colonize in the, in the bladder itself and then track up the, your Etta's into the kidneys and these patient's will, will be very unwell and you'll have a high fever chills, nausea and vomiting. Um some flank pain and pride in arthritis can often lead to sepsis as well if it's left untreated. So you've, you've really got to um look out for those results on the V B G really again with pollen arthritis commonly, um you'd have E coli um but you can also have these other bacteria. So don't miss out on these other bacteria in your, in your exam questions. So, klebsiella pneumoniae, proteus mirabilis and pseudomonas, aeruginosa. Um and it can, it may also be a feral bungle viral infection, but I mean, this isn't as common. So, this is one of my favorite topics, actually, congenital condition called kidney. So you can have a renal a Genisys. So this is a photograph of regional renal a genesis and it's when one or more one or both kidneys failed to develop properly um during uh during kidney development. Um and it may may lead to um other formations such as a pelvic kidney or a horseshoe kidney. A pelvic kidney is when the kidneys fail to ascend in, in embryology. And um it may not cause any physical conditions, but it may lead to the increased risks of like urinary tract infections or renal stones um just because of its anatomical position. Um and it may further develop complications. Um if the if the patient needs extra surgical procedures such as hysterectomy or prostatectomy. So, a horseshoe kidney is um quite common exam question. Um If you, if you follow my my page, you'll know that it um fails to ascend past the inferior mesenteric artery, okay, which is uh and that is found at all three in, in the vegetable level. Um And it's when these two kidneys fused together and it cannot, it fails to ascend properly because of its um cause along the aorta. Um And then you've got multi cystic dysplastic kidney. I think this, this is said on the tin really um and it fails to form properly and instead we have multiple cysts appearing um these multiple cysts as in many conditions such as like pancreatic tumor's. If you have cysts, you're going to be more predisposed to developing tumor's. So, um renal tumor's are quite common. And because the renal cysts um really um anatomically kind of compress upon the renal arteries, then you're, you're more likely to get hypertension as well and also hypertension because the kind of they, they've the parent climber within the, within the kidneys, um kind of control hypertension. So, if you're encroaching on my anatomical space, you increase your risk of hypertension. So, um unfortunately, some, some patient's may experience something called renal cell cross, no murmur. Um And as you can see this, these um symptoms are quite common. Um quite, quite similar, sorry, I should say to uh the uti S if we can cross swell back here. Um Oh, sorry, I think it's really know calculus. Yeah, they're quite similar to renal calculus story. I meant renal calculi. Um So in these conditions, you would have um as you would do in renal calculi blood in your urine flank pain. But in renal cell carcinoma, you may feel a lump in the abdomen. I personally have never felt this, but you may do, you may have fatigue weight loss. Um but you would also have fever hypertension, um Renal cell carcinoma, I think it's quite important in terms of medical school exams as well. Um that you can have a Varicocele um with these. So it's a Dip Orton Association and um it says paraneoplastic syndrome here. Um I think typically you'd have a varicocele weight loss and fatigue in, in the exam question. These will be typical clues. Uh Sorry. Um So you have a mechanism of hydronephrosis as well. Also, hydronephrosis is a, the accumulation of the urine within the renal pelvis itself and it can be caused by the following. Uh They're following things. So you can have literal uh simple obstructions such as kidney stones, tumor's um in large prostate, either by BPH. I think we're going to discuss that later or um or prostate cancer. Um I wouldn't really worry about blood clots or congenital abnormalities here. Um And as you're having this accumulation of urine, um it cannot pass through um the renal capsule, which is the clean film around will get stretched. Um And because the renal capital get stretched, you've got your sympathetic and parasympathetic nerve fibers which um which will then, you know, be triggered and cause that's what caused your pain in your flank area. Um Yeah. So as, as the doing develops, as you can see here with moderate then in the renal pelvis also really don't renal hire him. I should say um you would cause compression of your renal arteries as well. And because the urine is so stagnant, um this causes a breeding ground for bacteria. So you would increase the risk of infection and um of course, success. So, um we've got a bit of a management of hydronephrosis. So, um, kind of in mild or moderate symptoms. Um, there's not much can be done apart from observation. Again, our alpha blockers, which can relax those sphincters in the, your eat a so to allow the passage of urine, um, you can put a ureteral stent here. Sorry, that's not your, it'll say you're still sent in the, in the ureters itself or nephrostomy tube, which is just a tube here. And, um you just have a bag here. I think this is the nephrostomy tube. Yeah. Yeah, it is. And um this, I find it quite fascinating that the, that the tube is then coiled in the renal pelvis, which is quite cool and in some cases surgery. But I think this is again, quite rare with acute urinary retention. Um The patient would be unable to pass urine for a short amount of time and um it can lead to serious complications such as like Gladys extension, uh urinary tract infection, um and kidney damage as well. Um as we can see in the hydronephrosis because the urine would track back into the kidneys. Um So this can be caused by a variety of factors such as in, in large prostate glands, um in males and in females, it may be because of pelvic organ prolapse or UTIs, which is um not enabling um your urine to pass through. Okay. Okay. So, um as we said here, um it may may cause a severe in that inability to urinate and you will have a strong urge to do so. And it can also be associated with nausea, vomiting and fever. And uh these patient's typically need an ultrasound scan or CT scale. And again, um alpha blockers or catheterization, um, maybe used to drain this bladder. Um, so with chronic urinary retention, um it's over a longer period of time. Um and you may, it may be associated with nerve damage, um blockages in the, you know, tracked weak bladder muscles and medication side effects as well. And instead of a sudden inability to pass urine, you may um have a slow urinary stream. Um and this might be week as well. Um Of course, you'd have like the more common things such as um you would experience in BPH, um such as a frequent urination, difficulty starting or stopping urine flow, um etcetera, and the diagnosis of chronic urinary retention can be done an ultrasound or Euro dynamic testing. Um And you might want um the patient's to undergo bladder training as well in, in most cases, especially in hospitals and you just inter long term catheters um in these patient's um and complications of these. Uh you chronic urinary retention include um stuff like yuri tract infections, um bladder stones, which we covered um and incontinence. So, uh we've just covered this. But what's the management of a few urinary urinary retention? So, you might have categorization um and patient some lots of patient's. Um, nowadays I put on a long term capita. You've got medications which is the alpha blockers, um, to relieve the, um, Yuri to, or you've got surgery. Um, but the, the, the, the things compressing, it must be like either if the surgery's sorry, surgeries for patient's who have very large stones or, you know, tumor's, which are respectable. And so management of chronic urine retention, it's quite similar. Again, you've got catheterization, you've got alpha blockers, blockers or five alpha reductase inhibitors, you've got bladder training or you can have surgery as well. Um So I actually learned something from this. So, trial without catheter. So, patient's um after they have the catheter and um the fluid has been drained, you may want to um do a trial without the catheter. So you encourage the patient to drink plenty of fluids. Um You um try and perform an ultrasound or a bladder scan to measure the amount of urine um in the bladder. And if the, if the patient is able to urinate naturally, then you've achieved it what you want to achieve. But if the patient is still experiencing those same symptoms, the the Cataflam maybe need to be reinserted again. Okey dokey. So deep and superficial in green, all hernias are quite common. So, um the deep ones is when there's a weakness in the deep in green or canal, deep in greener ring, which is um this one, I think. So, activities that increase abdominal pressure, such as heavy lifting, coughing, straining, um, can also contribute to this hernia. So not so there's increased pressure of the adamant, there's congenital weakness of the wall. So if there's a quite a thin wall that would increase the risk of developing a hernia, um, previous surgery, so you could have, um, again, that would contribute to the weakness of the war as well and um, age related deterioration and then superficial in green, all hernias. Oh gosh, I'm sorry. So this is the formation of deep and superficial in green or hernias, sorry about the confusion. So, the deep in green or hernias are these ones that also called um in directing green or hernias. Um and that just above the midpoint of the inguinal um in green or ligament, okay. Um The superficial um in green, a hernia um does not, doesn't, does not travel through um the inguinal canal and it says this type of plan is typically located medial to the deep um in green or rink and doesn't travel. Yeah, as I said, it doesn't travel in the green or canal. And just overall, I would say the deep green all hernias are more common than the superficial, angry, no hernias um and then much more likely to undergo complications such a strangulation and this is a medical emergency if they undergo strangulation. So, um urological anatomy of the test is so each of the test is, is covered by a fibrous capsule called the tunica al Virginia. Um And this is made of collagen fibers and elastic tissue. Um The tuna al Virginia is um surrounded by several layers of connective tissue and smooth muscle fibers um which help to support the testes as well and inside the testes, um there are smaller compartments called lobules. So you can see these here and um they each contain a seminar, um seminar, first tutorials. And if this is where the sperm is produced and this is um that's called spermatogenesis as you know um these this is then transported to the head of the epidemic to miss um and these are coil tubules on the back of each testicle. Um So the academic uh um so I think that's just some technical issues now, but we'll reconnect as soon as possible. Um So everyone just bear with will be back very soon. Um But in the meanwhile, if anyone has any questions, feel free to pop them in the chat and I'll also just upload the feedback form for later on. So if you wanted to fill that out whilst you're waiting also feel free to do that, it will just be in the chat box. Mhm. Uh mhm. Um So Doctor Francesca is just logging back in because her laptop has unfortunately died. So just bear with for a few more minutes. Um So uh Doctor Lacoste has just joined back. So hopefully we'll be beginning soon everyone. Yeah, today. Um we can hear you right. Sorry. I'm so sorry guys, my computer decided to cut out completely. Hang on. Can you see slides again? Yes, we can see the slides. Okay. Thank you. All right, I'm ready. Sorry, guys. Okay. So from to acute chronic urinary retention. Yeah. So we're going through the anatomy, the testes. So it's formed by a fibrous capsule around it called the tuna tuna cal Virginia. And um that's made of collagen and elastic tissue. And um this is um surrounded by more connective tissue and smooth muscle fibers which help protect and support the testes. Uh the testes themselves are created by lobules and these each lobby or contains seminar for uh tutorials which is where the sperm is produced. And um these leaves up to the Epiduo diverse, which is a coil tube behind the sperm little bit, sorry behind the test is um and that goes um connects to the vast deference which is here um which doesn't connect to the um uh connect sorry from the epididymis to the urethra. Um So for ejaculation to a car, these um testicles don't forget about the Leydig cells. I'm sure you know which produce testosterone. Um and they're located in the interstitial tissue between the seminar frist tubules. So, in these blue gaps here, that's where the lady cells. Um oh um So these testicles are supplied by the testicular arteries which branch from the abdominal aorta. It's very important to know that and then they are drained um via the cramp in a form plexus, which is, I love the pamplona complexes for some reason, but it's these network of um veins okay. And then they link up to the testicular vein to drain the testes. I hate this but structures in the spermatic cord. So you've got the vast deference, which is this one here. I think this uh this diagram really simplifies it nicely. Um You've got the testicular artery, uh testicular veins which are draining from the cramping a form places, but they haven't managed to put the cramp in the four places here. The autonomic nurse um which and these nerves regulate the blood flow and the function of the testis and epididymis and the cream is the muscle um which is a thin layer that's of muscle that surrounds the smartmatic cord, which is here. And um and that's, that's quite important in regulating the um the position of the test is within the scrotum and of course, the fascia around the, around the testis. Um We've said several also connecting tissue um including the external spermatic fascia, the cremasteric fashion and the internal spermatic fascia. Um Yeah. And these are listed here. So you've got um so internal spermatic fascia, uh cremaster, cremaster muscle, which is in pink here. So you can't really see it. And in power pole here, you've got the external spermatic fascia all the way around. So, gosh, ok. So the scrotum is we've gone through OK. The square drum itself is several layers of tissue. We've done skin fashion. We've just discussed smooth muscle, which is your Cremaster muscle. No. Sorry. Chromos Musselman in it. I don't, sorry, I don't think cremaster muscles move muscle. Sorry, my bad and connective tissue. Um So the smooth muscle within the scrotum is called the Dartos muscle. And that's the, that's the one that regulates the temperature. Um uh And so it's, it contracts and relaxes. So when it contracts, it pulls the testes uh towards, towards the body to, to make sure that they have the right to heat regulation. Um We set uh temperature regulation and the blood supply um to the scrotum is by the scrotal arteries which are branches from the external, external pudendal artery and um the veins that drain it is this grow, it'll veins which again, um drain by the pump, uniform plexus into the testicular veins. And the innovation is by the ilioinguinal nerve, gentle femoral nerve and pudendal nerve. And you've got to learn this. I'm sorry, I'm really, really sorry. But so this is the ilioinguinal. You've got the gentle femoral here as well and I don't know, it's not showing pudendal okay, but that's the idea you can quit on gentle femoral. I really would know this in your med school years. Okay. Um Epididymal, we've done the epididymis, but basically there's a head, um body and tail here. Um uh But you some middle section. Yeah, sorry, I got lots of text here. The the epididymis is um pseudostratified columnar epithelium and it contains um so conciliate it sells also help the help the sperm propel through the vast difference and then eventually onto the U E throw. Um So it's, it's the spurs that is the sperm's tail itself. Um the cilia um and the non ciliated, see uh cells secrete fluids to provide the nutrients and protection um for the sperm to further develop. So, um for like two to mature in, in themselves, um so they're exposed, as I just said to fluid secreted by the epidermal epididymal cells. Um and these contractions through the epididymal helped also too to make the sperm kind of swim along the blood supply to the epididymis is from the branches of the testicular artery. And that and they are innovated by the sympathetic and parasympathetic nurse. Okay, that regulates its function. So, the vast deference um okay, the fast difference is quite long in structure. So it comes from the from the head of the epididymis. So the epididymis and then you go into the best deference here, I don't know if you can see my mouse um but it passes through the superficial inguinal rank. Um So and then it passes posterior. Basically, the main things you have to get is it travels posteriorly along the lateral aspect of the bladder. It joins the seminal vesicle uh to form the ejaculatory duct um and then passes through the prostate glands and, and then opens into the urethra. Um It's surrounded by a left smooth muscle which allows the contraction. Um as we said through, through the, through the duct. Um uh Yeah, I've said this already. So it helps transport firm. The sperm are stored in the epididymis until they're, until they're ready to be transported. Um Yeah, we've already said that. So the blood supply under innovation is by the superior and inferior v sickle arteries and their branches of the internal, I'll yokai a tree. I really should, would know this for your exams. I think that would be like an aim star question really. Um And it's also innovated by sympathetic and parasympathetic note. We know this. Um So if a man wants to be sterilized, um there's something called a mastectomy and this is where the vast deference um is partially removed or blocked and this prevents the sperm reaching the urethra um uh during ejaculation. Um But it doesn't prevent against sexually, sexually transmitted infections. So that's quite a useful point. I know you guys know that, but it's quite a useful point to take home in the Oscar. The, if you're kind of advising a patient, um you just have to remember these little little things that seem quite obvious to us, but maybe not to patient's. So where flags for scrotal pain. Um So swelling and redness is quote good one. So, abdominal pain blood in the semen, difficulty urinating and then sudden and severe scrotal pain. I mean, typically this would be um testicular torsion, which we will come onto so to stick here too or shin. Um That, that's that diagram is not to stick your torsion, by the way, um is when the testicle twists on itself on, on its own spermatic cord along along that access. Um I think along that access is that if you're having written exams, you should, you should be saying that as well and it causes severe pain, swelling and redness. And um if you, if you don't treat it immediately, you may ultimately lose a testicle or um because it can make the tissue to closed. Um So surgery is the most common treatment for testicular torsion and it must, it's a medical emergency. Oh, sorry. I mean, surgical emergency. Really? You've got four years grand green as well in which um bacteria kind of infect the scrotum and the surrounding tissues and that's caused yet in pain, swelling and a tissue death. Um It's kind of a, it's a type of necrosing fresh artis really Fournier gangrene and you want to be doing surgical deprived mint and removal of a needed tissue. You can find, um I wouldn't really worry too much about the others. We've talked about hydro steal, epididymal orale cotis. Um The epididymal becomes inflamed because of an infection or injury and that causes again, pain, swelling and tenderness. We've gone through this before. Um, and again, surgery may be required. Um, quite a common exam question is what um uh kind of bacteria are, are associated with evidence of MS o'rourke itis, especially in the final year exams. So, um, I would watch out for that rupture testicle. It's not very common. I've never seen it in any exam questions, but it's when it's when the testicle literally ruptures and um you have to do immediate theater for them because uh you'll, you'll have sepsis on your hands. So, features of epididymal, my epididymitis. So you can see here that this is your testicle um which is tea and then you've got your epididymal, but it's grossly inflamed. So it should be just from here to here really, but this is like really, really inflamed. So, pain and swelling um well, will be severe swelling, wetness and warmth of the testicles um or within, within the scrotum, at least um discomfort during urination, discharge from the penis, fever and chills because you've got an infection and swollen lymph nose again because you've got an infection, you're going to have these two. So five and six are quite easy to remember pain and swelling. It says it as it is almost 10, you don't really have to remember this lack of power. As long as you understand it, you'll be fine. And so epididymitis um can be from sexually transmitted infections or urinary tract infections. So I was told to talk about the differentials for epididymitis. I've got a quick summary against each one. Um But we've spoken about testicular torsion where it rotates on its axis and statistic your artery is compromised. Um alk itis, um the where the testicle itself becomes inflamed um in green, oh hernias. Um because if they, if they become, if they cause pain in this greater my groin area, but I think you'd be able to, to tell within green all highness because you can induce a cough reflex, uh varicose seals. But that would be more prominent in someone with, as we said, renal cell carcinoma, uh prostatitis, your arthritis as well. So friends sign is um also known as the suicide. So for these differentials, you, you have to kind of keep in your mind about appendicitis as a common differential. So the friend sign is, I've really never done it in clinics admittedly. But um it's when you place uh the patient on the left hand side with the right hip flex and, and knee bent and then you passively extend the patient's right hip. Um So you're that, that means you're stretching the, so it's muscles. Um And if the patient has a pain in the right lower quadrant, um or the right iliac fossa, um then, then you've got a positive friend sign, the Cremaster reflex. As we said, the cremaster muscle is the muscle, um which is surrounding the spermatic cord. Um And what it says, an tesco predominantly the spermatic cord, okay and regulates temperature. So, um you can have a physiological response. So if you kind of stroke the um inner thigh or a patient, um then you should get the cremasteric reflex. As you can see here. If you don't get this reflex, then you, you know that there's a problem with the genital branch of the genitofemoral nerve. Um And yeah, and then you can, you can undergo further tests really. So, testicular torsion, uh we've, we've done this over and over again, I'm sorry to bore you. Um But it rotates on this access. Um It lowers the blood supply to this ethical um and it might over over time, if you have um prolonged, reduced supply to the testicle, it can cause irreversible damage to that testicle. Um It can be caused by many factors. So there's, there could be a congenital abnormality, there can be trauma or sudden movements. Um Typically it's, it's trauma or sudden movements actually um in, in clinics that can cause it to um uh this is a car spontaneously. Um It can be partial or complete the testicular torsion. Um So your your patient or your exam question, uh may have severe onset of uh severe testicular pain, swelling and redness. Um So the the effect of test score might be situated a bit higher and it might be tender to touch. Um And the pain may radiate the lower abdomen or groin. I think that's quite essential as well. Um, you don't necessarily have to whisk these patient's off to surgery. You may be able to manually, um, deet ort it. Um, but if this is unsuccessful, then you, you need, need to whisk them off to surgery. Really. So, um, lower urinary tract infections, we've covered this over and over. I'm sure you've covered this over and over in medical school. Um, but it's a urinary frequency urgency hesitancy. So, um a difficulty to start the urination week or interrupted urinary stream dribbling, uh incomplete, emptying of the bladder, painful urination and sometimes blood in the urine, not always. Um common conditions of uh lower urinary tract infections. Um So sorry, your lower urinary tract symptoms, I should say is BPH, is, is BPH, UTI S are the most common. The rest are less and prostate cancer possibly, but then the less the rest are less common. So BPH is when you have an enlargement of your prostate gland. Um And these patient's typically uh have uh have the, those symptoms that we were describing UTIs. Uh quite common as well. Bladder dysfunction. So you might have patient's with an overactive or underactive bladder. I think we're going to talk about that later on. So I won't go into too much. Um Neurological disorders. Don't, don't forget these. So, patient's with Parkinson's disease, multiple sclerosis can have dysfunction of their bladder and this predominantly as what causes patient's to um have a kind of a lesser quality of life, um, medications as well such as um alpha blockers or anti depressants, um prostatitis, um bladder or Urotrol stage, which recovered before uh prostate cancer. Uh urethral stricture and pelvic floor and muscle dysfunction. So BPH, as we said before is uh enlargement of the prostate gland, it's not cancerous, it's benign. So, um alpha one blockers, um we, we said it will relax the urethra as we, we've mentioned a million times in this lecture. Um So these include tamsulosin alpha Neurosin and Doctor Susan, I mean, tamsulosin is the most common one alpha reductase inhibitors um such as uh Finasteride and um due to asteroid, I mean, again, Finasteride, as of most common use, you can have a combination therapy where you use both alpha blockers and alpha five alpha reductase inhibitors and you can also have phytotherapy. Um But I mean, I've never seen phytotherapy used in clinics. It's usually um alpha one blockers that we give and fell five alpha reductase inhibitors. Um So it's a surgical management for BPH. You can have a Terp. Um So that removes um the, the obstruction. Um So you obstructing prostate tissue by using a rectoscope or a camera passed through the urethra. Um And this is, this is different from uh TUIP um transurethral incision of the prostate where you kind of surgically scrape um to relieve, relieve some of the obstruction as well. So I'm gonna have a right. Mm Then you can have laser therapy, um, where you remove the obstructing prostate tissue and of course, you can have a prostatectomy and when you remove the entire product land. And, um, it's, it's, um, I believe prostatectomy predominantly open surgery, but please double check me on that. You can also have medical management for prostate cancer as well. So some patient's, the prostate cancer might be quite slowly growing. So you just might have active surveillance with PS PSA test, DRS and prostate biopsies. Um But also you can have a radiation therapy. Um This can be externally. Um As you can see here in this image, I think these machines are pretty cool, aren't they? And they kind of draw across where you can see exactly where you need to target. So that's external radiation or you can have internally where they put beads um with brachytherapy um hormone therapy as well. Um You, you where you block the effects of testosterone. So this this includes um uh LHRH agonist, anti androgens and androgen receptor blockers and you can also have chemotherapy as well, which is quite good for prostate cancer. Um So, surgical management of prostate cancer, um you can have radical prostatectomy. So where that's when you radical means like the whole prostate. So you remove the whole entire prostate, including the seminal vesicles. Um and this can be an open or laproscopic. Now, robotic approach, you can have transurethral resection of the prostates. Um So the way you remove the inner portion of the prostate gland using a rectoscope, as you can see here. And you can also have price surgery, which you can see here, which is kind of freezing to kill the to kill the prostate gland. Uh, cancer of the prostate gland, you don't want to kill the prostate gland. Fabulous. So, during continents, uh we, we brushed on it briefly. So you've got stress incontinence, urge incontinence, mix incontinence, overflow, incontinence, functional incontinence and transit incontinent. So you're stressing continent um is typically when, when the patient has incontinence on coughing or sneezing um or lifting heavy objects. Um Urge incontinent is when um you have a strong urge to urinate. Um And you have involuntary, a lot of urine mixing continent. Um uh Does this a combination of stress and urge incontinent overflowing continent um when you're unable to empty the blooding completely and you're constantly dribbling Yuri. Um that that may be because um of an obstruction in the urinary track. So black BPH or weak bladder muscle, functional incontinence. Um So you can have, when, when a person is unable to reach the toilet. So this can happen in um all these patient's um where, where they're kind of mobility is produced and transient incontinence. Um So, yeah, this is like typically caused by medications um UTI S or constipation really. So, um lastly, I'm sorry, I know this has been so long. Um So what, what medications are used to treat urinary incontinence. So, anti muscarinic can be treated or used to treat urge incontinence. Um and this relaxes the bladder muscle. So you've got oxybutynin. Um but you have to admit the side effects. So these side effects are dry mouth, constipation, blurred vision or cognitive impairment. You've got be to three agonists um which, which relax the bladder muscle again. And um these are examples like the Mirabegron um but they can cause headache, not in hypertension. I think headache is the most common one with Mirabegron um alpha blockers. Um So this uses is used to treat overflow incontinence, okay. Uh As we said by, by relaxing the prostates and um bladder neck in the muscles in men. So, tamsulosin is the most common one but this can be uh causing dizziness, hypertension and retrograde ejaculation. Um which you need to, I think, I think these side effects are quite important to note for your Rosky xas. Well, it's very, very good to know them. Um estrogen. Um I mean, we don't really use estrogen or uh um it provides really but in it reminds know the side effects, um it's usually so um it provides, is used to relax the bladder muscle and increase the tone of this uh urethral sphincter. Um but this may cause dry mouth business and constipation. All right. Thank you very much. I'm going to stop showering. Um Great. Thank you so much, Doctor Lacosta for that, very thorough. Rundown of the kidneys and all that kind of pathology associated with that. Um The feedback form has already been sent on the chat and this will be available to watch on the sector page on metal. So thank you everyone and have a lovely weekend. Bye. Thank you.