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Hi, everyone. So thank you for joining us today. Um My name is Prudence. I'm one of the educational coordinators Receptor. So, this week we have um the urology sessions and today we have session one and we're very happy to have Gerry from the University of Nottingham presenting the um upper urinary tract. So, um I'll just hand over to um in a second and I just want to tell everyone that um the slides and the recording will be uploaded about 2 to 3 days after the actual session. So, um and please also stay till the end so that I'll, I can send everyone the feedback form and upon the completion of the feedback form, you'll get a certificate of attendance as well. So I will just share my screen now, right? Ok. So, yeah, when you're ready. Yep. So, uh hi, everyone. Uh So for today, I like uh Prudence mentioned, I'm just going to be focusing on upper urinary tract. Um There will be some overlaps with some of the lower urinary tract as well. Um And yeah, um I hope that you learned something from today and apologies if it is um a lot of overload of information, but we'll try and get through as many of the learning objectives today. Uh Next slide, please. So, yeah, thanks to our partners. And um so these will be the learning objectives that we'll be covering today. Um I'll just be going through essentially all of this. Um So yeah, next slide, these, yeah. So uh the anatomy of the kidneys. So essentially the kidneys and the urinary systems eliminate urea and they basically ensure that there's a balance of the electrolytes, uh such as potassium and sodium as well as water. So, anatomically, the kidneys lie Retroperitoneally, which is basically the layer that surrounds tissues of the abdomen at the back and is at, they lie Retroperitoneally at both sides of the abdomen. Um So its length kind of extends from t 12 to L3 and the right side is uh the right side of the kidney is slightly lower than the left side due to the presence of the liver on the right side. Um So the kidneys arranged in four layers which are the renal capsule, uh perirenal fat, renal fascia, and pararenal fat. So just a little bit more about um the renal parenchyma. So this can be divided into two main areas. You've got the outer cortex and the inner medulla, which we can see in the picture in the bottom. So the cortex extends into the medulla, dividing it into triangular shapes which you can see as the renal pyramids in the third on the right. So the top of each renal pyramid is called the renal papilla. And each renal papilla is associated with a structure known as a minor calyx. So these are what collects the urine from the pyramids. And several of these minor Calyxes merge and form a major Calix, which we can see again in the picture, there are about 2 to 4 major calices in each kidney and the urine passes through the major calices into the renal pelvis, which you can see um on the second down to the left of the picture and that's essentially a flattened and final shaped structure where you're in passes. Er, and it's from here that the urine then drains into the ureter which then transports it to the bladder for storage, which I'm not sure. But you can see a little bit of in the top image. Uh Next slide, please. Oh, sorry. No, that's fine. Yeah. Um So yeah, the neurovascular supply of kidneys. So I'll be focusing on the arteries first. So the kidneys are supplied with blood via the renal arteries. Uh This arises from the abdominal aorta, uh which is immediately distal to the origin of the superior mesenteric artery. Um So, due to the anatomical position of the abdominal aorta, which is slightly to the left of the midline, the right renal artery is actually longer and crosses the vena cava posterior. I think if that was too wordy, essentially just know that the right renal artery is longer than the left. Um the renal artery enters the kidney via the renal hilum. So, at the highland level, the renal artery forms an anterior and posterior division which carries uh respectively 75% and 25% of the blood supply to the kidneys. So, there are five segmental uh arteries that originate from these two divisions. So the posterior branch passes, which passes behind the renal pelvis. It and goes on to supply the posterior region of the kidney. Hence the name. And when it comes to the anterior branch, this is further divided into the apical, anterior, superior, anterior, inferior and inferior segmental arteries which each supply the respective areas that I mentioned uh anteriorly. So once they reach the level of the uh minor calluses, the branch of the anterior renal arteries, further subdivide into the interlobar arteries, which is what we can see at number two, uh that courses around the borders of the medullary pyramids. Um at the base of the pyramids, these arteries are referred to as arcuate arteries, which we can see as number three. Finally, the arteries enter the nephrons, which are the functional units of the kidneys at the interlobular arteries. Uh Number four, where they then lead into afferent arterioles that bring blood to the glomerulus to be filtered. Uh It's important to know that the, the afferent arterioles pass into the glomerulus and creating a network of capillaries and these capillaries are what allow selective passage of smaller particles into the renal tubules and keeps larger blood cells in the vessels. And essentially this is what aids in the process of ultrafiltration. Uh Next slide, please. Yeah, yeah. So uh these capillaries leave the glomerulus as efferent arterial. So they enter as afferent and leave as efferent. Uh after which they form two capillary beds around the nephrons loop of Henry which we can see on the bottom right image. In the outer two thirds of the renal cortex, the capillary beds are called peritubular capillaries. Uh Whilst in the juxtamedullary nephrons, uh or the inner third of the cortex, the capillary beds are long straight arteries called the vasa. So the upper third is known as the juxtamedullary nephrons. And the outer two thirds of the renal cortex is where the loop of Henry is. So these capillary uh beds facilitate BP regulation and ionic homeostasis both passively and under uh various different hormones. Um at the capillaries uh sorry as the capillaries leave the nephrons, they then form the interlobular veins, which we can see as number five which is similar to the branches of the renal arteries I mentioned on the previous slide, the interlobular veins then become aqua veins. Uh number six at the base of the medullary pyramids, then they become interlobular, sorry, interlobar veins, number seven and about five or six, interlobar veins join together to form each renal vein um unlike the branches of the renal arteries, the branch of the renal vein communicate with each other. And then finally, the renal vein drains into the inferior vena cava at the level of L2. So essentially the the blood supply of the veins are kind of the opposite of the blood supply as the arteries go into the kidneys. Uh Next slide, please. Ok. Uh So uh sorry. Yeah, I think um I was meant a beat. Yeah. Could you go to the next slide please? Next slide, it's just this slide. Yes. Um So if anyone just wants, I'll just give a couple of uh seconds just to try and attempt to do this question. Are you able to see the chat, Jerry? Um I think, I mean, it just says verified but um if someone maybe could just maybe type something just so I can see something comes up because I can't see the chat um because I'm sharing the screen. Oh, ok. Um Yes, I can see. Uh was, thank you. Yeah, I can see the chat. That's great. Um Yeah, I just gave another 10 seconds. Yeah. And the next slide. Yep. Should I go back or is it just one to the next slide? Basically? Yeah. Yeah. Yeah. So the answer is d uh renal artery then to the arcuate artery, then to the interlobular artery and uh the afferent arterial. Um So, yeah, it just takes a while, but it's essentially just memorizing um these words and once you know the arteries, essentially the veins are the other way around. Um Next slide please. Right. Uh So the neurovascular supply of the kidneys. So, with the lymphatic system, uh so the superficial lymphatic vessels form a plexus under the renal capsule, which is the thin layer that covers the kidneys. And this is known as the subcapsular lymphatic plexus. Um They along with the medullary lymph vessels communicate with cortical lymph vessels that travel alongside uh interlobular, arcuate and interlobar arteries. The renal lymphatics then drain directly to the lumbar lymph trunks and to paraaortic nodes which include pre caval lumbar and post caval nodes. The lymphatic system essentially serves to remove excess fluids, proteins and cellular debris from the renal interstitium. And this helps to maintain the proper balance of fluid and solutes within the kidneys. The lymphatic vessels also play a role in the immune surveillance and response and facilitates the transport of lymphocytes. So, understanding the lymphatic drainage of the kidneys is important in the context of renal surgeries because disruption of these vessels can lead to lymphatic leaks. Uh lymphoceles or lymphedema with cases of renal transplant. It's important to preserve the lymphatic system and uh proper lymphatic dama er drainage are critical to prevent post operative complications and optimize graft functions. Next slide, please. So this uh yeah. Yeah. So yeah, this is the last anatomy slide just for the kidneys. Um So sorry if it's been a bit wordy. But yes, when it comes to uh the nerves itself, the kidneys receive innervation from both the sympathetic and parasympathetic divisions of the autonomic nervous system. Although the sympathetic nervous system predominates uh sympathetic nerves that innervate the kidneys originate from the renal sympathetic plexus, which is part of the celiac plexus and the greater lesser and least splanchnic nerves. The sympathetic nerves follow the course of the renal arteries and their branches into the kidney. So, sympathetic innovations play a crucial role in regulating renal blood flow and glomerular filtration rate, also known as G FR by adjusting the diameter of the renal blood vessels. So the sympathetic activation and basically reduce the renal blood flow. And G FR which helps conserve fluid volume and maintains BP during states of hypovolemia or low BP. When this is dysregulated, it can contribute to conditions such as hypertension and uh kidney dysfunction. Finally, parasympathetic innervation of the kidney is relatively limited compared to sympathetic innervation. But the parasympathetic fibers that innervate the kidneys originate from the vagus nerve, also known as cranial nerve. 10, next step, please. So for the next two slides, I would just go through a quick overview of the anatomy of the ureter, bladder and urethra. Um the ureters are muscular tubes, sorry uh that carry urine from the kidneys to the bladder. So, uh in both males and females, each kidney has only one ureter. The ureter originates from the renal pelvis, which is the funnel shaped structure that I mentioned earlier, uh that collects urine from the kidneys, collecting ducts. The ureters enter the bladder at an angle that allows the pressure of the urine to close off the ure urethral orificial opening. Uh during the bladder spilling. This essentially is what prevents urine from going back up into the kidneys. In males, the ureters enter the bladder at the base of the Trigon which is a triangular area. Hence the name Trigon, uh formed by the openings of the ureters and the urethra. In females, the ureters enter the bladder more laterally through the urethral opening. So now on into the bladder, the bladder is a hollow muscular organ that stores urine uh in females. So we can see structure a it lies anterior or in front of the vagina and inferior below to the u uterus. And in males, the which is b sorry, the bladder is in front of the rectum and just above the prostate gland. In males, the bladder neck is surrounded by the internal urethral sphincter and the prostate gland. And in females, the bladder neck is surrounded by the urethra and the pelvic floor of muscles. Uh next slide is so, so yeah, when it comes to the anatomy of the urethra, uh the urethra is a tube that carries uh urine from the bladder to the external urethral orifice where it is expelled. Then uh during urination. So in males, the urethra is actually longer and more complex compared to females due to its role in both urination and ejaculation in males. The average length is about 20 centimeters. And in an adult woman, the average length is about four centimeters. And this is actually reflected in procedures such as catheterization where smaller catheters are used for females as a result that this causes less trauma due to smaller distances and causing male catheterization to actually be more difficult. Um My colleague will go into more depth about the surrounding structures in tomorrow's session. Next slide, please. So yeah. Uh Just another question uh for I want to try, I'll give another 40 seconds maybe. Yeah. So, um the slides will be made available in two days which Prudence mentioned. And um I think with the feedback form, I'll ask uh Prudence, will the feedback form be posted here? Yes, it'll be posted at the end of the session and also through email as well. Yeah. Um So yeah. Uh So for this, um so the next slide, please. So the answer for this question is uh B and alpha adrenergic blockers. I'll go on to this later on. But uh an example of this is uh tamsulosin which is commonly used to facilitate the passage of kidney stones uh by relaxing the muscles of the ureter. Um But yeah, uh next slide please. Ok. So now we're kind of away from the anatomy. Um So kidney stones, uh kidney stones are also known as urinary tract stones or urolithiasis. And this refers to crystal aggregations that form in the urinary system from substances that are present in urine. Uh renal colic is the condition that is characterized by severe pain caused by the presence of stone in the urinary tract. So you can have kidney stones but not necessarily have uh renal colic. For instance, uh urinary stones is caused by dehydration, dietary factors, medical conditions such as gout, family histories, certain medications and some of the other uh causes are uh anatomical or lifestyle factors. So, when it comes to signs and symptoms, you've got severe flank pain. So this is typically the most prominent symptom. The pain can be intense and sudden and is often described as sharp and cramping and it usually comes, oh sorry, it starts in the back or side below the ribs and this can radiate to the lower abdomen or groin. So, which you may have heard as the low to groin kind of typical kind of pain. Uh The pain may come in waves and does vary in intensity. We then have hematuria which is blood in urine. So this can either be gross, which is uh blood that can be seen by the naked eye or microscopic, which is hence by, by the name, um only viewed with a microscope. Uh You can have some other urinary symptoms such as increased urgency, uh discomfort during urination or frequency and sometimes people may also report a difficulty in starting or stopping the urine flow. Uh We also have nausea and vomiting. Uh This is just associated with the severe pain or it can also be associated due to an increase in the sympathetic nervous system activity. We also have UTI S. So with the kidney stones, these can basically cause an obstruction of the urinary flow. And this leads to a stagnant of the urine and promotes uh bacterial overgrowth. Uh hence predisposing patients to UTI S. So, it's important to also just look out for any kind of fevers, chills, burning sensations, uh during urination and even foul smelling urine. Uh So yeah, as I mentioned earlier, fevers and chills, uh you can also have painful urination. It's also important to uh sorry the next uh point and one more point. Yeah. Yeah. So um after general, like generally taking a history examination, urine dipsticks, uh culture and blood ensure to take a noncontrast CT ku um which is a CT, a noncontrast ct of the kidneys, ureter and bladder. And this should be performed on all patients within 14 hours of admission. Um Something that I found was useful is to know that calcium oxalate is a common composition of stones. Um It does come up quite a few times in exams. So it's a useful um fact to remember and next slide, please. So the management of renal stones when it comes to watchful rating. Uh So patients with small kidneys, stones usually less than five millimeters. Uh These are usually stones that don't cause symptoms. So the best approach would be in this case to take a conservative uh watchful rating. Um but they are advised to maintain the normal kind of hydration and maybe given pain medications if they start experiencing any uh discomfort. So I mentioned in the medical aspect, uh nsaids, um this is used for pain management antiemetics for any nausea and vomiting, uh antibiotics for any UTI S or um just infections. And as mentioned earlier from the question, tamsulosin, the alpha blockers, which is prescribed to relax the muscles in the ureter and helps to ease the passage of kidney stones. Uh and like every other kind of condition, wherever medical management and conservative approaches are not enough surgical managements are used. So when it comes to the kidneys, um with renal stones, we have extracorporeal shockwave lithotripsy. Uh This is a noninvasive procedure that uses shock waves to break up kidney stones into smaller fragments which makes them easier to pass through the urinary tract. We then have ureteroscopy and laser lithotripsy. Uh This is just, this involves passing a thin flexible scope through the urethra and bladder up into the ureter to directly visualize and remove kidney stones. It's usually effective for stones that are located in the lower and middle aspect of the ureter. Uh Can I just check if there's one more picture? Yeah. 00, no. Before you. Um So yeah, and finally, we've got percutaneous nephrolithotomy. So, this is a minimally invasive procedure that is used to remove large kidney stones or stones located in the kidney itself. It involves making a small incision in the back and uses some instruments to access and remove the stones. Uh finding we have open surgery. So this is rarely performed today and is usually only reserved for complex cases where the other treatments mentioned before have failed uh or not feasible. So, it involves making a larger incision in the abdomen or the flanks to access and remove the stones. Next slide, please. Um Yeah. So another question for everyone to try. Yeah. So uh yes. Uh it is option B in this case, uh E coli is the most common pathogen responsible for uncomplicated uh UTI S in otherwise healthy individuals. So this usually accounts for approximately uh 70% of community acquired UTI S and is a gram negative bacterium commonly found in the gi tract. Uh Next slide, please. Sorry. Is there a slide just before that? I don't think so. Ok. Um Could you just skip the next one for now? Yeah. So yeah, urinary tract infection. Uh UTI S typically refers to an infection of the uh lower urinary tract which includes the bladder. So, inflammation of the bladder is known as cystitis and the urethra which is also known as urethritis. Symptoms of a uti I may include frequent urination, urgency to urinate a burning sensation during urination, cloudy or foul smelling urine and pelvic discomfort. So, some of the red flag symptoms such as hematuria, loin pain, uh rigo nausea and vomiting or even altered mental state. Uh may indicate a more serious infection. These patients may have or could be at risk of developing pyelonephritis, which I will explain in the next slide and uh depending on it, being more severe may need referral to A and L. So, the treatment uh for this is with uh nitrofurantoin or trimethoprim. So, the patients should be advised also on uh conservative measures to reduce the risk of further uh infection. So, these can be uh regular fluid intake, post coital voiding and uh some hygiene of the perineal region when it comes to duration of the antibiotics. This is something useful to know. Um three days of antibiotics are given for simple lower urinary tract infection in women. And it's seven days of antibiotics in men, pregnant woman or catheter related uti S. But it's important to remember that you do not need to treat patients with antibiotics if they have ca a catheter and are asymptomatic. Next slide, please. Yeah. So uh pyelonephritis is a bacterial infection of the kidney or both kidneys and it's usually caused by the ascent of bacteria from the lower urinary tract, the bladder and ureters into the kidneys. So, the UTI S are usually what is referred to as lo lower uti and Pyonephritis is usually e encompasses both upper uti s and the inflammation of the ureters. So, it can also be caused by e coli from the lower urinary tract and other colonic commensal. Uh So this includes klebsiella pneumoniae and proteus mirabilis. It may also be due to bloodstream spread of infections. So, this can include sepsis. It often presents with symptoms similar to the those of the uti S uh such as frequent urination and painful urination. Um high grade fever and symptoms specific to kidneys such as fever, chills and flank pain. So the pain in the sides or the back nausea, vomiting and sometimes even systemic symptoms like sepsis if they are left untreated and this can also lead to fatigue or confusion. So, due to this, uh patients are given antibiotics for 7 to 14 days and if they're especially vulnerable, uh it's important to admit them to the hospital for some IV antibiotics. Uh This can include broad spectrum cephalosporin quinolone or for an example, a uh ciprofloxacin. Uh Next slide, please. I think there might be one more. Yeah. Um So yeah, congenital abnormalities of the kidneys refer to structural or functional defects in the kidneys that occur during fetal development. Uh These these abnormalities can vary widely in severity and presentation and they may affect one or both the kidneys. Uh So some of these can include uh renal agenesis, which is when one or both the kidneys uh fail to develop during fetal growth. So you have unilateral renal agenesis, which is absence of one kidney. And this is usually asymptomatic and may go undetected unless an imaging studies are performed for usually unrelated reasons. Um bilateral renal agenesis is the absence of both kidneys and this is usually incompatible with life without any medical intervention. So, these interventions are usually dialysis or acute kidney transplantation as soon as birth, soon after birth. And when it comes to the next one renal dysplasia, this involves the abnormal development of kidney tissues, uh which results in structural abnormalities such as cysts, abnormal tubules and an immature glomeruli. It can affect just one or even both kidneys and may lead to impaired kidney function and hypertension. Uh we then have uh so polycystic kidney disease, which can be inherited uh from a genetic component and is essentially just characterized with multiple cysts on a kidney. Or you can also have multicystic dysplastic kidney, which is a common form of renal dysplasia. And that's characterized by multiple cysts of varying size. Uh that replaces the normal kidney tissue and the kidney that actually has the cysts typically does not function properly and may just be nonfunctional management for uh usually involves monitoring for any complications and in some cases, a surgical removal of the kidney, if complications such as infection or hypertension arises, we then have horseshoe kidney, which is uh what you can see as the image on the right. So, in this condition, the lower end of the two kidneys are fused together across the midnight by a band of tissue that forms a horseshoe shaped like structure. Um Whilst this may not always cause symptoms, it is associated with an increased risk of complications such as kidney stones, uti s and obstructions. Uh So, in this case, surgical interventions may be necessary to manage the complications or correct any of these uh anomalies as well. Finally, we have uh a duplex kidney. So these are also known as duplicated collecting system uh which occurs when a kidney has two separate, basically has two ureters for one kidney. Uh and this condition predispose individuals to uti s kidney stones and obstruction of the urinary tract because they have an extra ureter, they're likely to basically have more chance of these risks. And uh surgical interventions may be required to correct the urinary tract obstructions or reflux especially in cases where these symptoms are recurrent. Um So when it comes to like the surgical significance of these uh abnormalities, it lies in the fact of understanding this and then treating it appropriately. So, surgical interventions may be necessary to address condition uh complications such as urinary tract obstructions, recurrent infections, hypertensions, or the presence of nonfunctional or dysplastic kidneys. So, additionally, surgical corrections or removal of abnormal kidneys may be indicated to prevent further complications and improve overall health outcomes. Next slide, please. Uh So yeah, just another question based on some of the facts I said earlier. Um I understand it was an overload. So try your best. So I'll just give it another 10 seconds and I'll just say the answer. Yeah. So uh next slide please, the answer is ea multicystic dysplastic kidney. So it's because of the presence of a nonfunctional kidney tissue and the multiple cysts of varying size. Um which is why it indicates that as the answer with all more dominant polycystic kidney disease, um you'd also have a kind of family history which would usually be mentioned on uh the questions to them as well. Uh Next slide piece. So, renal cell carcinomas account for over 80% of all kidney cancers. It's actually the seventh most common cancer in men and the 10th most common cancer in females. Uh They're thought to be variants of renal cell ca cancer. But one specific cause is triggered by the mutation of the Von Hippel lindau tumor suppressor gene which is inactivated in renal cell carcinoma. So I'm gonna mention it as VHL from er now on. But uh normally the VHL protein helps regulate the activities of hypoxia inducible factors, also known as H I FS uh which are involved in oxygen sensing and plays a role in angiogenesis which is essentially the formation of new blood vessels and cell proliferation. The mutation in the VHL leads to the dysregulation of uh H I FS which results in increased expression of genes involved in angiogenesis and cell growth which is what promotes uh the formation of these tumors. So, some modifiable causes that increases the risk of renal cell carcinoma are obesity, smoking, hypertension and poor diet. Whilst it is thought that non modifiable risk factors such as uh being of a European or North American descent are believed to increase the risk of renal cell carcinoma. Uh Next slide please. So when it comes to the signs and symptoms, it can vary. But when it comes to questions, especially for us, medical students, uh it's usually the triad of the flank pain hematuria, which can be again, gross or microscopic and a palpable abdominal mass, uh which should give you a high suspicion of renal cell carcinoma. Uh In reality, it's not always this triad, but um it's a good place to always query from if you see these three signs. So another sign that's significant is a left sided varicocele and this is caused by the tumor compressing on the left renal vein. So this has an anatomical relationship to the left testicular vein which takes venous return to the left renal vein. Um Again, my colleague will go into more details about varicoceles in tomorrow's presentation. So, if the renal cell carcinoma spreads to nearby lymph nodes or affects kidney function, this can also cause fluid retention and edema. So these are also signs to look out for. And we have also something called paraneoplastic syndromes. So these are kind of syndromes in areas around uh not just the area itself. So these can include such as uh polycythemia. So, some of the renal cell carcinomas can increase, can produce erythropoietin. The hormone that is used to stimulate the production of red blood cells in the bone marrow. And you can also have something called Storfer syndrome, which is a rare syndrome that is characterized by hepatic dysfunction. So when you are querying renal cell carcinoma, it is useful to also look at liver function tests to look for this rare syndrome. And it's also important to remember that as it is a cancer to screen for the the normal kind of symptoms of night sweats, fever, weight loss and loss of appetite, but also to screen for advanced cancers such as metastatic sites of the lung, liver, bone and brain when it comes to renal cell carcinomas, uh surgery is the mainstay for any localized diseases. And uh this involves radical nephrectomy and lymph node dissection. And when it comes to metastatic disease, usually systemic therapies are used. Uh looks like this. Um One I think. Yeah. Can you try one more time? Yeah, thank you. Um So when it comes to hydronephrosis, this is a condition that is characterized by the swelling or enlargement of kidneys due to the build up of urine. So, this can occur when urine flow is obstructed, uh preventing it from draining properly from the kidneys to the bladder. So, these obstructions can occur from some of the S uh conditions I mentioned earlier. So, renal stones, even tumors and the congenital abnormalities as well as strictures or uh even pregnancy uh can cause hydronephrosis. So, in some cases, hydronephrosis can occur because of a black a backflow of urine. Uh due to a condition known as vesicoureteric reflux. Uh This reflux occurs due to a malfunction of the valves known as the ureter vesical valves and that prevents urine from flowing backwards from the bladder into the ureter. So, if this valve is malfunctioning, it essentially causes urine to flow backwards uh leading to hydronephrosis. So I just got this table from passed. Uh I just found it quite useful to know some of the causes. Uh Just remember that unilateral causes tend to be triggered by pathologies above the bladder and bilateral are usually the bladder and below. Next slide, please. Can you try one more time? Yes. 00, yeah, sorry. That's ok. And so yeah, when it comes to hydronephrosis, uh first line is ultrasounds which identifies the presence of the hydronephrosis within the kidneys. Uh it's also useful sometimes to do CT scans or IV urograms, which can be used to also assess this. Uh But before exams, it's usually the useful fact to remember is ultrasounds are first line. So treatment is dependent uh due to what is causing the issue. So, if it's kidney stones, as mentioned earlier, uh to treat it as per kidney stones or tumors, uh which requires uh surgical interventions um in order to relieve the obstruction in an acute situation, a percutaneous nephrostomy, which we can see in the bottom left picture can be used. So this is a tube through the skin and kidney into the ureter under radiological guidance or in chronic obstructions. A stent can be placed through the kidney into the ureter. Um and this allows the blockage to be removed before reaching the bladder. Next slide, please. So, acute urinary retention is when a person is suddenly usually over a period of hours or less, um unable to voluntarily pass urine and it is considered a medical emergency. Um in males, this can be caused by a condition called uh benign prostatic hyperplasia, which is a condition that again, uh my colleague will go into more detail tomorrow, but essentially the prostate becomes large and it compresses on the urethra and interrupts the flow of urine, uh strictures which are abnormal narrowings of the uh urethra which can be caused by trauma or infection. And we also have medications that can cause this such as anticholinergics and tricyclic antidepressants that affect the nerve signals of the bladder causing the urine to basically be retained. We can also have spinal cord compressions and multiple sclerosis associated with um acute urinary retention. So it's a good information to just know in case I questions stem, happens to mention something like this. Um when it comes to signs and symptoms. Uh these include the inability to pass urine, uh, lower abdominal discomfort, pain or distress, suprapubic tenderness or a mass and even delirium, which is usually found in the elderly population. Next slide, please. Ok. Ok. Yeah. So, uh, when it comes to the investigations, uh, some of the standard investigations would include, um, bladder scans, ultrasounds, uh, of the ultrasounds and uh, sorry or ultrasounds of the renal tract. Uh, we have DRE exams also known as digital rectal exams, urinalysis and urine M CS, evaluation of post void residue residue or uh blood tests such as FBC S and renal profile. In order to relieve uh patients symptoms, uh decompression of the bladder is done through catheterization which can be indwelling or intermittent after this is done. It's important to understand what is the cause and then treat appropriately. For instance, if the cause was benign prostatic hyperplasia, this would include uh medical management or surgical interventions. And the same can be said for neurogenic causes too. So, just to take home from this, when it comes to acute urinary retention, it's important to decompress the bladder, um which will make it uh the patient's symptoms essentially symptomless and then to find out what the cause is. Um it's important to know that there is a complication known as post obstructive diuresis. So, following the relief of the obstruction, the kidneys may then respond to a sudden increase in urinary flow by increasing uh urine production. This excess in diuresis is thought to be a compensatory mechanism and uh it eliminates not just accumulated fluid and waste products and um uh just basically removes all of these and um this can lead to fluid and electrolyte imbalances. So, um why this is bad is because it may result in dehydration uh and electrolyte imbalances such as hypernatremia or hypokalemia and metabolic abnormalities. So, the management for this is usually careful monitoring of the fluid and electrolyte balances and replacement of lost fluids and electrolytes. Uh close observations for signs of dehydration or electrolyte disturbances and in severe cases, just to make sure that the patient is on IV fluid therapy and electrolyte supplementation to ensure that the balances are corrected. Uh Next slide, please. So, uh chronic urinary retention very similar to um acute urinary retention, but it's defined as a consistent long term inability for the bladder to completely evacuate its contents. So it doesn't just have to mean that you can't pass urine. It just means that you're not able to completely void as much as you want to as well. Uh This state leads to progressive bladder enlargement and may culminate in bladder contraction failure. So, this is usually seen in older men and again, similarly caused by benign prostatic hyperplasia and other causes. As mentioned earlier on the previous slide, some of the signs and symptoms are seen are incontinence, which is the involuntary loss of urine from the bladder nocturia, which is the need to wake up from sleep to urinate and dribbling, which is the slow and steady leakage of urine from the urethra. After urination is complete, uh, you can also have hesitancy which is the difficulty in initiating urination or a delay in starting the urine stream despite feeling the urge to urinate. So sometimes even just after urinating, if there is still more urine going, it's good to also think of chronic urinary retention. And again, management is the same. Uh so to relieve the symptoms, a catheter is um best in acute situations and then it's good to find out what the cause is and to treat accordingly. Uh Next slide piece. Um Yes. So another question just based on um acute and chronic urinary retention, you guys, we'd like to try just another 10 more seconds. Yeah. So next slide, please. So option E is the correct answer. Uh post void residual urine measurement is the most appropriate diagnostic test to confirm the diagnosis of from these options of chronic urinary retention in this patient. So, uh it's also known as PVR PVR. Measurements, assess the volume of urine remaining in the bladder after voiding and is typically performed using a bladder ultrasound or catheterization. Uh in chronic urinary retention, the PVR urine volume is often elevated. So above 100 to 200 mL and this indicates uh incomplete bladder emptying despite urination. And as mentioned before, would point you towards a diagnosis of chronic urinary retention. Um Next slide please? Ok. So apologies based on the learning objectives. So I try to make the topics flow through as much as possible, but we will be jumping between some er conditions just to make sure we take all the er learning objectives. So the next one is a trial without catheter. So this typically refers to a clinical practice where a urinary catheter is removed from a patient to assess their ability to urinate spontaneously. Uh This can occur post surgery. Uh This practice is often used in patients who have had a urinary catheter in place for uh a specific period such as just after surgery or during hospitalization to monitor their bladder function and determine if they can urinate on their own. So after the catheter is removed, the patient is encouraged to fill their bladder slowly by drinking sufficient fluid and then they are closely monitored a, a minimum of three times for signs of urinary retention or difficulty urinating. Uh Monitoring may involve assessing the patient's ability to pass urine, measuring the volume of urine voided and evaluating any symptoms such as discomfort or urinary urgency if the patient is unable to urinate spontaneously or has trouble in voiding during the trial, without the catheter interventions may be provided to assist with emptying of the bladder. So this could include measures such as intermittent catheterization medications that promote bladder emptying or other bladder me management techniques as well. Neck slightly. So. So, yeah, this is the final uh topic. So, um we're almost there guys. Um a hernia occurs when an organ or a tissue, uh protrudes through an abnormal opening or a weak spot in the wall of the body's cavity that normally contains it. Uh hernias can develop in various different spots, uh parts of the body, as you can see in the picture on the right, but they most commonly occur in the abdomen as seen there. So, some of the types of hernias we have is an inguinal hernia, which I'll go into a little bit more depth in the next slide. But uh essentially, this is the most common type of hernia that occurs in the groin area when parts of the intestine intestine, sorry protrudes through a weak spot in, in the abdominal wall. We also have a femoral hernia, which is also similar to an inguinal hernia, uh where parts of the intestine protrudes through the wall of the femoral canal, which is located in the groin area below the inguinal ligament. So usually a good way to know is an inguinal hernia is kind of above and medial to the inguinal ligament and a femoral hernia is inferior and lateral. Um but again, it can always vary when it comes to i in, in practice, but usually when it comes to M CQ questions, these are kind of good telltales of what type of hernias they are. Uh We also have umbilical hernia. So this type of hernia occurs when parts of the intestines protrude through the umbilical wall near the belly button, also known as the umbilicus. Uh we also have incisional hernia. So this is a hernia that develops at the site of a previous surgical incision because the abdominal muscles have weakened or separated. Um and then some other ones, there's a hiatal hernia, which is where parts of the stomach protrudes upwards into the chest cavity through an opening in the diaphragm, uh or an epigastric hernia, uh which occurs in the upper abdomen just below the breast bone, also known as the sternum and uh the umbilicus. So hernias can develop due to a combination of factors, uh which include congenital predisposition, uh weakening of the abdominal walls, uh or even increased intraabdominal pressure such as heavy lifting, uh chronic coughing or straining during bowel movements. Usually you find that quite a few um kind of medical school exams include this kind of history, whether it being in Apy or um in past papers as well. Um You can also have hernias being caused by pregnancy because of the increased intraabdominal pressure, obesity, uh and even previous abdominal surgery as mentioned earlier. So some of the symptoms uh when it comes to symptoms of a hernia, they vary depending on the type and the location. But generally, they may include a visible bulge or a lump, uh especially when lifting, as mentioned earlier, or straining, a aching or burning sensation at the site of the hernia and in some cases, nausea, vomiting, or even difficulty passing stool or gas. And finally, when it comes to diagnosis, hernias are typically diagnosed through a physical examination uh by a clinician. But additional tests such as ultrasounds, CT scans or MRI S may be performed to confirm the diagnosis or evaluate the extent of the hernias. Uh Next slide, please. Ok. Um So superficial inguinal hernias. So they're also known as indirect inguinal hernia is a hernia where abdominal contents follow the path of the descent of the testes, which can occur via the processus vaginalis. Uh during fetal development, it enters the internal inguinal ring and they are typically congenital and often are observed in males. It protrudes through a superficial inguinal ring which is the opening in the external oblique aponeurosis and may extend into the inguinal canal. As we can see in the picture in the bottom, right. Uh inguinal hernias have a low risk of strangulating than a femoral hernia. So, strangulation is where blood supply is compromised, leading to ischemia and necrosis. And when this is occurring, strangulation is essentially a surgical emergency. Hernias are basically treated either through key hole or open surgery. And this allows the hernia to be either pushed back into its original position and repaired. A mesh is placed into the abdominal wall at the weak spot where the hernia came through to strengthen it. And finally, when the repair is complete, your skin usually is sealed with stitches and they usually dissolve on their own within a few days of the operation. If however, the, the hernia has become strangulated and parts of the bowel is damaged, then the management is slightly different in that the affected segment uh may need to be removed and the two ends of the healthy bowels are then rejoined. Uh Next slide, please. Uh So deep inguinal hernias also known as a direct inguinal hernia is where abdominal contents protrude through a weakness in the posterior wall of the inguinal canal canal, uh close to the pubic bone. And this typically does not extend as far into the scrotum or labii. Uh abdominal contents usually fatty tissue or even bowel, for instance, are forced directly through this defect into the inguinal canal. Uh So direct inguinal hernias bulge directly through the floor of the inguinal canal. And this distinction in the anatomical location helps differentiate between the two types of inguinal hernias. Um I think I did mention uh I did forget to mention about uh incarcerated hernia. So this is where it cannot be reduced. And so when a hernia is incarcerated, uh the reason why it is clinically significant is because there's a higher chance of it being um strangulated. So it's important to monitor these patients as well. And as mentioned earlier, when it comes to the surgeries, uh sorry, the management of these types of hernias are also surgeries and pretty much similar to uh an indirect inguinal hernia. Next slide, please. So, yeah, final question, I promise. OK. All right. Just give 10 more seconds. OK. Yeah. Uh Next slide. So, yeah, for this one, it was actually b I think. Yeah. Yeah. And um so the clinical presentation in the question is consistent with a direct inguinal hernia. Um So direct inguinal hernias typically occur in older males and result from weakening of the transversalis fascia that allows abdominal contents to protrude through the weakened area at the medial aspect of the inguinal canal, known as the Hesselbach triangle. Uh the hernia sac of a direct inguinal hernia usually protrudes through the superficial inguinal ring which is located directly above the pubic cubicle um to the reason. So when it comes to indirect inguinal hernias, these typically present as a mass protruding through the inguinal ring. Uh due to the passage of abdominal contents through the persistent patent process, vaginalis, which is the congenital defect I mentioned earlier. So, in contrast, this question describes a mass protruding through the superficial inguinal ring. Uh and therefore, the location is characteristic of a direct inguinal hernia where the herniation occurs, du due to the weakness of the transversalis fascia. And again, because it cannot be, it can be reduced, it's unlikely to be an incarcerated. It's not an incarcerated inguinal hernia. And yeah. Yes. Thank you very much. Uh everyone for your kindness and patience, listening to all that you just go back. Great. Thank you very much, Jerry. Uh we stop this. Yup. Um Does anyone have any questions? Wouldn't both indirect and direct come through the Inguinal Ring? Um I think in this kind of question, I was just because as mentioned, also indirect inguinal hernias two in um so, yeah, because for this question that I mentioned also the uh congenital aspect of it as well. Uh The fact that it also appeared later on in this uh patient's um history, sorry, patient's life. Uh I wanted to kind of go towards a direct inguinal hernia in reality, questions will be a bit more um straightforward and kind of would point you towards one rather than the other. This I do admit this question was quite hard to just cipher between the two. But um yeah, I hope that answers your question. Yep. Um If we don't have any questions, um I am having trouble sending the feedback form in the chat, but I believe everyone after this session should receive an email to fill in the feedback form anyway. Um So if everyone can fill in the feedback at the end, that would be really helpful. Um I'll just make sure that everyone received the email. Um And if no one else has any questions, um Thank you so much for attending. Um And please come support session two tomorrow, which will be at 6 p.m. as well. And thank you Gerry for presenting. Thank you for having me. Great. Ok, I hope, uh, everyone enjoys the rest of their evening and, yeah, thank you. Bye.