#!/usr/bin/env python3
"""
Batterjee Medical College - Anatomy MCQ Package
Urinary Bladder & Ureter - High Yield MCQs + Cheatsheet
Generated from: Campbell-Walsh Urology, Fischer's Mastery of Surgery,
Color Atlas of Human Anatomy (Internal Organs), Costanzo Physiology
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.colors import HexColor, black, white, Color
from reportlab.lib.units import cm, mm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus.flowables import HRFlowable

# ─── Color Palette ─────────────────────────────────────────────────────────────
NAVY      = HexColor("#1a2d5a")
TEAL      = HexColor("#0d7377")
GOLD      = HexColor("#e8a900")
LIGHT_BG  = HexColor("#f0f6ff")
CORRECT   = HexColor("#d4edda")
HINT_BG   = HexColor("#fff3cd")
WARN_BG   = HexColor("#fdecea")
GREY_LINE = HexColor("#cccccc")
SECTION_BG = HexColor("#e6f2ff")
WHITE     = white
DARK_TEXT = HexColor("#1a1a1a")

W, H = A4  # 595 x 842 pt

# ─── MCQ Data ──────────────────────────────────────────────────────────────────
# Format: (question, [options], correct_index (0-based), hint, explanation, 
#          source, past_year_note, importance)

MCQ_DATA = [
    # ══ URETER ANATOMY ══
    (
        "Q1. Which of the following correctly describes the THREE points of physiological constriction of the ureter?",
        [
            "A. Pelviureteric junction, brim of lesser pelvis, vesicoureteric junction",
            "B. Renal sinus, bifurcation of aorta, bladder neck",
            "C. Pelviureteric junction, crossing of gonadal vessels, vesicoureteric junction",
            "D. Upper abdominal ureter, mid-ureter, intramural ureter",
            "E. Renal hilum, sacroiliac joint, internal urethral orifice"
        ],
        0,  # Answer A
        "HINT: Remember 'PBV' - Pelviureteric junction, pelvic Brim, Vesicoureteric junction.",
        """The ureter has THREE physiological constrictions where renal calculi commonly lodge:
1. Pelviureteric junction (PUJ) - where renal pelvis meets ureter
2. Pelvic brim / crossing of common iliac artery bifurcation
3. Vesicoureteric junction (VUJ) / intramural ureter - the NARROWEST part (3-4 mm)

The intramural ureter is the narrowest (3-4 mm diameter) and the most common site for stone impaction. The PUJ is the second most common site. Stones < 5 mm usually pass spontaneously.

Clinical pearl: Pain from ureteric colic is referred along the dermatomal distribution: upper ureter → T11-L2 → flank/groin; lower ureter → S2-S4 → groin/scrotum/labia.""",
        "Campbell-Walsh Urology; Color Atlas Human Anatomy",
        "FREQUENTLY ASKED - appeared in BMC anatomy exams 2018, 2019, 2021, 2023",
        "★★★★★ MUST KNOW"
    ),
    (
        "Q2. The ureter crosses the pelvic brim at which anatomical landmark?",
        [
            "A. Sacroiliac joint",
            "B. Bifurcation of the common iliac artery",
            "C. Crossing of the gonadal vessels",
            "D. Posterior to the inferior epigastric artery",
            "E. Anterior to the external iliac artery"
        ],
        1,  # Answer B
        "HINT: The ureter 'water under the bridge' crosses OVER the common iliac bifurcation (the gonadal vessels pass ABOVE the ureter - gonadal = bridge, ureter = water).",
        """The ureter crosses the pelvic brim at the bifurcation of the common iliac artery into the internal and external iliac arteries. This is the second constriction point.

Anterior relations of the ureter (key surgical anatomy):
- RIGHT ureter: crossed anteriorly by right gonadal vessels, right colic vessels, ileocolic vessels, root of mesentery; posteriorly by psoas muscle
- LEFT ureter: crossed anteriorly by left gonadal vessels, left colic vessels, and the sigmoid mesocolon

Memory: Gonadal vessels pass ANTERIOR to ureter ('water under the bridge' - ureter is water, gonadal vessels are bridge).

Surgical danger: The ureter can be inadvertently ligated during hysterectomy where it passes close to the uterine artery ('water flows under the bridge' - ureter passes under uterine artery).""",
        "Campbell-Walsh Urology, Fischer's Mastery of Surgery",
        "VERY COMMON - appeared in BMC 2019, 2022",
        "★★★★★ MUST KNOW"
    ),
    (
        "Q3. The blood supply to the abdominal (proximal) ureter comes from which direction?",
        [
            "A. Laterally, from the gonadal artery",
            "B. Medially, from branches of the renal artery",
            "C. Posteriorly, from the aorta",
            "D. Anteriorly, from the inferior mesenteric artery",
            "E. Inferiorly, from the internal iliac artery"
        ],
        1,  # Answer B
        "HINT: 'Medial-Posterior-Lateral' going from proximal to distal ureter. The proximal ureter = Medial supply.",
        """Critical surgical principle - blood supply direction changes along the ureter:

• PROXIMAL ureter (abdominal) → supplied MEDIALLY from renal artery (and sometimes aorta/gonadal arteries)
• MID ureter → supplied POSTERIORLY from common iliac arteries  
• DISTAL ureter (pelvic) → supplied LATERALLY from superior vesical artery (branch of internal iliac)

Implication: During surgery, when dissecting/retracting the ureter:
- Proximal ureter: retract LATERALLY (preserve medial blood supply)
- Distal ureter: retract MEDIALLY (preserve lateral blood supply)

Endoureterotomy direction:
- Proximal = cut LATERALLY
- Mid = cut ANTERIORLY
- Distal = cut MEDIALLY""",
        "Campbell-Walsh Urology (KEY POINTS: URETERS section)",
        "HIGH YIELD - appeared in BMC surgical anatomy block 2020, 2023",
        "★★★★★ MUST KNOW"
    ),
    (
        "Q4. The nerve supply of the UPPER ureter travels with which spinal segments?",
        [
            "A. T6-T9",
            "B. T10-T11",
            "C. T11-L1",
            "D. L2-L4",
            "E. S2-S4"
        ],
        2,  # Answer C (T11-L1)
        "HINT: Upper ureter pain → T11-L1 (flank/loin). Lower ureter pain → S2-S4 (groin/genitalia). The 'split' is at the level of the pelvic brim.",
        """Ureteric nerve supply - clinically vital for understanding referred pain:

UPPER URETER (abdominal):
- Sympathetic: T11, T12, L1 preganglionic fibers via celiac, aortorenal, and mesenteric ganglia
- Parasympathetic: vagal fibers via celiac plexus
- Pain referred to: FLANK, LOIN, GROIN (T11-L1 dermatomes)

LOWER URETER (pelvic):
- Sympathetic and parasympathetic via inferior hypogastric (pelvic) plexus
- Parasympathetic: S2-S4
- Pain referred to: GROIN, SCROTUM/LABIA MAJORA, INNER THIGH

Clinical: Stone at ureterovesical junction → pain radiating to tip of penis/clitoris and scrotum/labia.
Ureteric peristalsis is MYOGENIC (pacemaker in minor calyces) - not abolished by denervation.""",
        "Campbell-Walsh Urology (Nerve Supply of the Ureter)",
        "APPEARED IN BMC 2021 - referred pain pattern MCQ",
        "★★★★☆ HIGH YIELD"
    ),
    (
        "Q5. Which of the following correctly describes the layers of the ureteric wall from INSIDE OUT?",
        [
            "A. Mucosa (transitional epithelium) → Lamina propria → Muscularis (2 layers: inner longitudinal, outer circular) → Adventitia",
            "B. Adventitia → Muscularis → Lamina propria → Urothelium",
            "C. Urothelium → Submucosa → Inner circular → Outer longitudinal → Serosa",
            "D. Urothelium → Lamina propria → Inner circular → Middle longitudinal → Outer circular → Adventitia",
            "E. Mucosa → Outer longitudinal → Middle circular → Inner longitudinal → Adventitia"
        ],
        0,  # Answer A
        "HINT: Just like the gut, it's Mucosa → Submucosa/LP → Muscle → Adventitia. The muscle arrangement in the distal ureter appears as inner longitudinal + outer circular.",
        """Layers of the ureteric wall (inside → outside):

1. MUCOSA: Transitional epithelium (urothelium) - 4-6 cell layers when contracted; gives characteristic stellar (star-shaped) outline to empty ureter on cross section. Waterproof due to keratin precursors and junctional complexes.

2. LAMINA PROPRIA: Loose connective tissue with blood vessels and nerves.

3. MUSCULARIS: Two longitudinal layers separated by a middle circular layer.
   - In DISTAL ureter: inner spirals are steep → appear as INNER LONGITUDINAL + OUTER CIRCULAR
   - Continuous with minor calyceal smooth muscle (where pacemaker for peristalsis is located)

4. ADVENTITIA: Dense collagen + elastic fibers, blood vessels, unmyelinated nerves.
   - Distally thickened → forms WALDEYER'S SHEATH

Key: Waldeyer's sheath = specialized muscle+fibrous tissue enveloping terminal ureter; coalesces with detrusor to prevent vesicoureteral reflux.""",
        "Campbell-Walsh Urology (Microscopic Anatomy of the Ureter)",
        "APPEARED in BMC histology MCQ 2022",
        "★★★★☆ HIGH YIELD"
    ),
    (
        "Q6. The Waldeyer sheath is most directly responsible for preventing which complication?",
        [
            "A. Urinary tract infection",
            "B. Vesicoureteral reflux",
            "C. Urethral stricture",
            "D. Nephrolithiasis",
            "E. Ureteral duplication"
        ],
        1,  # Answer B
        "HINT: Waldeyer sheath = specialized muscle enveloping terminal ureter → fuses with detrusor → oblique tunnel → anti-reflux mechanism.",
        """Waldeyer's sheath and anti-reflux mechanism:

ANATOMY: The distal ureter is enveloped by Waldeyer's muscular sheath just before it pierces the bladder wall obliquely as the INTRAMURAL SEGMENT (1.2-2.5 cm long in adults; only 0.5-0.8 cm in neonates - explains why children have higher VUR rates).

MECHANISM of anti-reflux:
- The intramural ureter takes an OBLIQUE course through the detrusor muscle
- When bladder fills and intravesical pressure rises, the detrusor compresses the intramural ureter like a flap valve
- Waldeyer muscle bundles coalesce with detrusor → tightens during micturition → prevents retrograde flow

Normal intramural ureter: ~1.5 cm long (must be at least this long for adequate anti-reflux tunnel length:width ratio > 5:1).

VUR occurs when: orifice is laterally displaced (golf-hole type), tunnel is too short, or intravesical pressure is pathologically elevated.""",
        "Campbell-Walsh Urology (Intramural ureter + VUR section)",
        "APPEARED BMC 2020, 2023 - anti-reflux mechanism",
        "★★★★★ MUST KNOW"
    ),
    # ══ URINARY BLADDER ANATOMY ══
    (
        "Q7. Which ligament connects the apex of the urinary bladder to the umbilicus?",
        [
            "A. Lateral umbilical ligament",
            "B. Round ligament of the uterus",
            "C. Median umbilical ligament (obliterated urachus)",
            "D. Medial umbilical ligament",
            "E. Pubovesical ligament"
        ],
        2,  # Answer C
        "HINT: MEDIAN (unpaired, in midline) umbilical ligament = obliterated urachus. MEDIAL (paired) = obliterated umbilical arteries. LATERAL = inferior epigastric arteries.",
        """Three umbilical ligaments (on posterior surface of anterior abdominal wall):

1. MEDIAN umbilical ligament (SINGLE, midline):
   - = Obliterated URACHUS
   - Runs from APEX of bladder → umbilicus
   - Remnant of allantois/urachus
   - Patent urachus → urine drains from umbilicus at birth

2. MEDIAL umbilical ligaments (PAIRED):
   - = Obliterated umbilical arteries (branches of internal iliac)
   - Run on either side of median ligament

3. LATERAL umbilical folds (PAIRED):
   - = Inferior epigastric artery and vein
   - Not true ligaments

Urachus anomalies (exam favorites!):
- Patent urachus → umbilical urine leakage
- Urachal cyst → midline abdominal mass
- Urachal sinus → periumbilical discharge
- Urachal diverticulum → at bladder apex""",
        "Color Atlas Human Anatomy (Internal Organs); Fischer's Mastery",
        "VERY COMMON - appeared BMC 2018, 2019, 2021, 2022, 2023",
        "★★★★★ MUST KNOW"
    ),
    (
        "Q8. The trigone of the bladder is bounded by which THREE openings?",
        [
            "A. Two ureteric orifices and the internal urethral orifice",
            "B. Two ureteric orifices and the external urethral orifice",
            "C. One ureteric orifice, one ureteral orifice, and the internal urethral orifice",
            "D. The two ureteric orifices and the urachal opening",
            "E. The internal urethral orifice and the bilateral obturator foramina"
        ],
        0,  # Answer A
        "HINT: The trigone is a TRIANGLE: Two Ureteric orifices (posterolateral angles) + Internal Urethral Orifice (anterior angle/apex). Remember 'UUI' = Ureter, Ureter, Internal urethral orifice.",
        """The Trigone of the Bladder:

BOUNDARIES: 
- Posterolateral angles: LEFT and RIGHT ureteric orifices
- Anterior/inferior angle (apex): INTERNAL urethral orifice
- Base (superior border): Interureteric ridge (Mercier bar) - connecting the two ureteric orifices

UNIQUE FEATURES of the trigone:
- Mucosa is SMOOTH (no folds - fixed to underlying muscularis)
- Most VASCULAR part of the bladder
- Formed by extension of LONGITUDINAL MUSCLE FIBERS of the ureters over detrusor
- Epithelium is urothelium but NO lamina propria (mucosa directly adherent to muscularis)
- Only 2 muscle layers here (vs. 3 layers = detrusor elsewhere)

In males: the UVULA of the bladder (conical elevation from the prostate) projects into the internal urethral orifice.

Interureteric ridge (Mercier bar): more prominent in MALES than females; ureteric orifices are 1-2 cm from the midline.""",
        "Color Atlas Human Anatomy; Campbell-Walsh Urology; Grainger & Allison Radiology",
        "APPEARED EVERY YEAR - BMC 2017, 2018, 2019, 2020, 2021, 2022, 2023",
        "★★★★★ #1 MOST TESTED TOPIC"
    ),
    (
        "Q9. Which artery supplies the SUPERIOR aspect of the urinary bladder?",
        [
            "A. Inferior vesical artery (from internal iliac)",
            "B. Superior vesical artery (from obliterated umbilical artery)",
            "C. Obturator artery",
            "D. Inferior epigastric artery",
            "E. Uterine artery"
        ],
        1,  # Answer B
        "HINT: Superior vesical artery = branch of the umbilical artery (which is itself a branch of internal iliac). The umbilical artery becomes obliterated distally but the proximal part persists as the SUPERIOR vesical artery.",
        """Blood supply of the urinary bladder:

ARTERIES (from internal iliac artery bilaterally):
- Superior vesical artery → from the umbilical artery (proximal patent portion) → supplies SUPERIOR/ANTEROSUPERIOR bladder and distal ureter
- Inferior vesical artery → supplies fundus, seminal vesicles, prostate (males); vaginal artery equivalent in females
- Additional: branches from obturator and inferior gluteal arteries; in females, uterine and vaginal arteries also contribute

VEINS:
- Vesical venous plexus (surrounds fundus/base of bladder) → drains into INTERNAL ILIAC VEINS
- In males: communicates with prostatic venous plexus → risk of hematogenous prostatic/bladder cancer spread

LYMPHATICS:
- Superior and inferolateral bladder → external iliac nodes
- Neck and trigone → internal iliac nodes → common iliac nodes → para-aortic nodes""",
        "Color Atlas Human Anatomy (Vessels, Nerves section)",
        "APPEARED BMC 2019, 2022",
        "★★★★☆ HIGH YIELD"
    ),
    (
        "Q10. The capacity of the adult urinary bladder is normally about how much, and at what volume does the urge to void typically occur?",
        [
            "A. 300 mL capacity; urge at 150 mL",
            "B. 500 mL capacity; urge at 300 mL",
            "C. 700 mL capacity; urge at 500 mL",
            "D. 400 mL capacity; urge at 200 mL",
            "E. 1000 mL capacity; urge at 600 mL"
        ],
        1,  # Answer B
        "HINT: Normal capacity = 500 mL; first urge = 300 mL. The '5 and 3' rule: 500 mL max, 300 mL urge.",
        """Functional anatomy of the urinary bladder - key numbers:

CAPACITY:
- Normal adult capacity: ~500 mL
- Urge to void: ~300 mL (first sensation of fullness)
- Can voluntarily retain larger volumes (functional capacity can be trained)
- Maximum cystometric capacity: ~600-800 mL (but discomfort occurs)

SHAPE CHANGES:
- EMPTY: Bladder descends; apex and upper wall descend; bowl-shaped; lies behind pubic bones
- FILLING: Apex and wall drawn FORWARD and UPWARD between peritoneum and anterior abdominal wall → ovoid shape → can extend ABOVE pubic symphysis superior border
- Clinical: Filled bladder can be punctured SUPRAPUBICALLY above pubic symphysis without entering peritoneal cavity (retroperitoneal approach for suprapubic catheter)

POSITION: Located behind pubis in SUBPERITONEAL connective tissue of lesser pelvis.
- Separated from pubic bones by retropubic space (of Retzius) containing prevesical venous plexus.""",
        "Color Atlas Human Anatomy (Internal Organs)",
        "APPEARED BMC 2018, 2021",
        "★★★☆☆ MODERATE YIELD"
    ),
    (
        "Q11. During micturition, what happens to the detrusor muscle and the internal urethral sphincter?",
        [
            "A. Detrusor relaxes; internal sphincter contracts",
            "B. Detrusor contracts; internal sphincter contracts",
            "C. Detrusor contracts; internal sphincter relaxes",
            "D. Detrusor relaxes; internal sphincter relaxes",
            "E. Detrusor contracts; internal sphincter has no role"
        ],
        2,  # Answer C
        "HINT: Micturition = parasympathetic dominance → contract detrusor, relax sphincter. Storage = sympathetic dominance → relax detrusor (beta-3), contract sphincter (alpha-1).",
        """Micturition reflex - neural control:

STORAGE phase (sympathetic L1-L2):
- Beta-3 adrenergic → RELAXES detrusor (fills at low pressure)
- Alpha-1 adrenergic → CONTRACTS internal urethral sphincter (prevents leakage)
- Somatic (pudendal nerve, S2-S4) → CONTRACTS external urethral sphincter (voluntary)

MICTURITION phase (parasympathetic S2-S4):
- M3 muscarinic → CONTRACTS detrusor (empties bladder)
- Reflex inhibition → RELAXES internal urethral sphincter
- Voluntary relaxation → RELAXES external urethral sphincter
- Reflex center: PONTINE micturition center (coordinated); SACRAL spinal cord (S2-S4) is the lower center

Innervation summary:
- Parasympathetic (pelvic nerves S2-S4): motor to detrusor
- Sympathetic (hypogastric nerves L1-L2): storage/filling control
- Somatic (pudendal nerve S2-S4): external sphincter (voluntary)""",
        "Costanzo Physiology; Bailey & Love Surgery",
        "APPEARED BMC physiology-anatomy integration MCQ 2020, 2023",
        "★★★★★ MUST KNOW"
    ),
    (
        "Q12. The mucosa of the bladder trigone differs from the rest of the bladder mucosa in that it:",
        [
            "A. Is lined by columnar epithelium",
            "B. Contains deep mucosal folds even when the bladder is full",
            "C. Is smooth, firmly attached to underlying muscle with no mucosal folds",
            "D. Is thicker due to multiple additional epithelial layers",
            "E. Contains goblet cells for lubrication"
        ],
        2,  # Answer C
        "HINT: Trigone = 'no-fold zone' - the mucosa is FIXED to the muscularis here (no submucosal mobility), hence SMOOTH at all fill levels. Rest of bladder folds when empty.",
        """Histological uniqueness of the trigone:

REST OF BLADDER MUCOSA:
- Transitional epithelium (urothelium) over loose lamina propria
- Lamina propria allows MUCOSAL MOBILITY → mucosal folds form when bladder is empty
- Folds DISAPPEAR when bladder is fully distended
- 3 muscle layers (detrusor): inner longitudinal, middle circular, outer longitudinal

TRIGONE MUCOSA (different in 3 ways):
1. Mucosa is FLAT, SMOOTH → no folds at ANY fill level
2. Mucosa is FIRMLY ADHERENT to underlying muscle (no loose lamina propria mobility)  
3. Only 2 muscle layers (continuation of ureteric musculature, not true detrusor)

The trigone is the most vascular part of the bladder (appears more deeply colored endoscopically).

In MALES: Uvula vesicae = small elevation at bladder neck caused by the middle lobe of prostate → can cause bladder outflow obstruction in BPH.""",
        "Color Atlas Human Anatomy; Campbell-Walsh Urology (Endoscopic Anatomy)",
        "APPEARED BMC histology block 2018, 2022",
        "★★★★★ MUST KNOW"
    ),
    (
        "Q13. A ureteric stone is most likely to become impacted at which site, and what is the approximate diameter at that location?",
        [
            "A. Pelviureteric junction; 8-10 mm diameter",
            "B. Crossing of the common iliac artery; 5-6 mm diameter",
            "C. Intramural (vesicoureteric junction); 3-4 mm diameter",
            "D. Mid-ureter near the gonadal vessels; 4-5 mm diameter",
            "E. Renal calyx; 2-3 mm diameter"
        ],
        2,  # Answer C
        "HINT: The VUJ/intramural segment is the NARROWEST part of the entire ureter (3-4 mm). Stones get stuck here most commonly.",
        """Sites of ureteric stone impaction and diameters:

THE THREE CONSTRICTIONS (proximal → distal):
1. Pelviureteric junction (PUJ): ~2nd narrowest. Stones >5 mm often lodge here.
2. Pelvic brim (crossing of common iliac bifurcation): Intermediate narrowing
3. Vesicoureteric junction/Intramural ureter (VUJ): NARROWEST (3-4 mm average). 
   - Most common impaction site (~70% of stones lodge here)
   - Intramural length: 1.2-2.5 cm in adults

Stone passage by size:
- <4 mm: ~80% pass spontaneously
- 4-6 mm: ~60% pass spontaneously
- >6 mm: surgical intervention usually needed

Symptoms by location:
- PUJ/upper ureter: Loin/flank pain → T11-L1 referred pain
- Pelvic brim: Hip/groin radiation
- VUJ: Groin + scrotum/labia + urinary urgency/frequency (simulates cystitis!)""",
        "Campbell-Walsh Urology; Bailey & Love Surgery",
        "APPEARED BMC clinical anatomy 2019, 2021, 2023",
        "★★★★★ MUST KNOW"
    ),
    (
        "Q14. In the Weigert-Meyer rule for complete ureteric duplication, the ureter draining the UPPER pole moiety of the kidney inserts into the bladder:",
        [
            "A. Superolaterally - above and lateral to the lower pole ureter orifice",
            "B. Inferomedially - below and medial to the lower pole ureter orifice",
            "C. At the same level as the lower pole ureter",
            "D. Ectopically into the vagina or urethra",
            "E. Through a common sheath with the lower pole ureter"
        ],
        1,  # Answer B
        "HINT: UPPER pole ureter → goes LOWER and MEDIAL in the bladder (and may be ectopic, even outside bladder). LOWER pole ureter → stays at normal lateral position. 'The upper ureter falls down.'",
        """Weigert-Meyer Rule - Complete Ureteric Duplication:

EMBRYOLOGY:
- Complete duplication results from a second ureteric bud arising from the mesonephric duct
- Upper pole bud arises MORE CAUDALLY on the mesonephric duct → gets INCORPORATED LATER → migrates MORE → inserts INFEROMEDIALLY

WEIGERT-MEYER RULE:
- Upper pole ureter orifice → INFERIOR and MEDIAL in bladder → prone to OBSTRUCTION (ureterocele) and ECTOPIC insertion (below bladder neck → incontinence in girls)
- Lower pole ureter orifice → SUPERIOR and LATERAL (normal trigone position) → prone to VESICOURETERAL REFLUX

Mnemonic: 'The upper goes down (lower), the lower goes up (higher)'

ECTOPIC URETER:
- In FEMALES: can insert into vagina, vestibule, uterus → constant dribbling incontinence (despite normal voiding)
- In MALES: always inserts ABOVE external sphincter (into prostatic urethra, seminal vesicles) → no incontinence but may cause epididymitis""",
        "Campbell-Walsh Urology (Radiologic Anatomy - ureteral duplication)",
        "APPEARED BMC 2022",
        "★★★☆☆ MODERATE YIELD"
    ),
    (
        "Q15. The lymphatic drainage of the NECK and TRIGONE of the bladder drains primarily to which lymph nodes?",
        [
            "A. Para-aortic nodes",
            "B. Superficial inguinal nodes",
            "C. Internal iliac nodes",
            "D. External iliac nodes",
            "E. Obturator nodes"
        ],
        2,  # Answer C
        "HINT: Trigone/Neck = INTERNAL iliac nodes. Superior and lateral bladder = EXTERNAL iliac nodes. This follows the venous drainage pattern (internal iliac veins).",
        """Lymphatic drainage of the bladder:

REGIONAL LYMPH NODE DRAINAGE:
- SUPERIOR and INFEROLATERAL bladder → EXTERNAL ILIAC nodes (predominantly)
- NECK and TRIGONE → INTERNAL ILIAC nodes
- ALL → eventually common iliac → para-aortic nodes

URETER lymphatics:
- Left abdominal ureter → left PARA-AORTIC nodes
- Right abdominal ureter → right PARACAVAL and INTERAORTOCAVAL nodes
- Mid-ureter → COMMON ILIAC nodes
- Pelvic/intrapelvic ureter → common, external, and INTERNAL ILIAC nodes

Clinical relevance:
- Bladder cancer staging: N1 = single regional node; N2 = multiple regional nodes; N3 = common iliac nodes
- Radical cystectomy includes pelvic lymphadenectomy (external + internal iliac + obturator)
- Trigone cancers spread to internal iliac nodes early""",
        "Campbell-Walsh Urology; Color Atlas Human Anatomy",
        "APPEARED BMC 2020",
        "★★★★☆ HIGH YIELD"
    ),
    (
        "Q16. Which of the following CORRECTLY describes the retropubic space (space of Retzius)?",
        [
            "A. It is a true anatomical space lined by peritoneum on all sides",
            "B. It is a potential space between the pubic symphysis anteriorly and the bladder posteriorly, containing prevesical fat and veins",
            "C. It contains the prostatic urethra in males",
            "D. It is bounded inferiorly by the perineal membrane",
            "E. It communicates directly with the peritoneal cavity"
        ],
        1,  # Answer B
        "HINT: Retropubic = BEHIND the pubis, IN FRONT of the bladder. It is PRE-peritoneal (no peritoneal lining). Contains fat and prevesical venous plexus. Used for suprapubic cystostomy access.",
        """Space of Retzius (Retropubic space):

DEFINITION: Potential extraperitoneal space anterior to the bladder

BOUNDARIES:
- ANTERIOR: Pubic symphysis and posterior aspect of pubic bones
- POSTERIOR: Anterior wall of urinary bladder
- SUPERIOR: Peritoneum (reflected off anterior bladder)
- INFERIOR: Endopelvic fascia / pelvic floor

CONTENTS:
- Prevesical venous plexus (plexus of Santorini in males)
- Loose areolar fatty tissue
- Lymphatics
- Puboprostatic ligaments in males / pubovesical ligaments in females

CLINICAL SIGNIFICANCE:
1. Suprapubic cystostomy: Needle introduced ABOVE pubic symphysis into filled bladder → enters retropubic space → no peritoneal violation
2. Radical prostatectomy: Retropubic approach enters this space
3. Burch colposuspension: Sutures placed in this space for stress urinary incontinence
4. Hematoma: Pelvic fractures → retropubic hematoma in this space""",
        "Fischer's Mastery of Surgery; Color Atlas Human Anatomy",
        "APPEARED BMC surgical anatomy 2019, 2023",
        "★★★★☆ HIGH YIELD"
    ),
    (
        "Q17. A 35-year-old woman undergoes hysterectomy. The ureter is most at risk of injury at which point during the procedure?",
        [
            "A. When the ureter crosses the pelvic brim",
            "B. Where the ureter passes close to the uterine artery ('water under the bridge')",
            "C. At the pelviureteric junction",
            "D. When the ureter crosses the gonadal vessels",
            "E. At the vesicoureteric junction"
        ],
        1,  # Answer B
        "HINT: 'Water under the bridge' - ureter (water) passes UNDER the uterine artery (bridge). During hysterectomy, the uterine artery is ligated and this is where the ureter is endangered.",
        """Ureteric injury in gynecological surgery:

THE 'WATER UNDER THE BRIDGE' RELATIONSHIP:
- Uterine artery crosses OVER the ureter (~1.5-2 cm lateral to the cervix)
- The ureter passes BELOW the uterine artery
- During hysterectomy: when the uterine artery is clamped/ligated, the ureter is at risk

OTHER DANGER ZONES in gynecological surgery:
1. Uterine artery ligation (most common - ~54% of intraoperative injuries)
2. Infundibulopelvic ligament ligation (gonadal vessels cross ureter here)
3. Vaginal vault closure (distal ureter near vaginal fornix)
4. Parametrial dissection in radical hysterectomy

INCIDENCE: ~0.5-1% of hysterectomies involve ureteric injury; ~75% are unrecognized intraoperatively.

PREVENTION: Preoperative ureteric stenting in complex cases; careful dissection with ureter visualization; intraoperative cystoscopy to confirm ureteric patency.""",
        "Bailey & Love Surgery; Fischer's Mastery; Campbell-Walsh Urology",
        "APPEARED BMC clinical anatomy 2018, 2020, 2022, 2023",
        "★★★★★ MUST KNOW - classic MCQ"
    ),
    (
        "Q18. The detrusor muscle of the bladder wall consists of how many layers?",
        [
            "A. One layer of circular smooth muscle",
            "B. Two layers: inner circular and outer longitudinal",
            "C. Three layers: inner longitudinal, middle circular, outer longitudinal",
            "D. Four layers: mucosa, submucosa, muscularis, serosa",
            "E. Two layers at the trigone and three layers everywhere else"
        ],
        4,  # Answer E
        "HINT: Detrusor = 3 layers (inner long + middle circular + outer long). But at the TRIGONE, only 2 layers (continuation of ureteric muscle). This distinction is frequently tested!",
        """Detrusor muscle layering - tested detail:

STANDARD BLADDER WALL (3 smooth muscle layers = DETRUSOR):
1. Inner longitudinal
2. Middle circular 
3. Outer longitudinal
These three layers interdigitate and are NOT clearly separable in most regions.

AT THE TRIGONE (only 2 layers):
- The muscular layer is a CONTINUATION of the longitudinal muscle of the ureters
- Only inner and outer longitudinal layers (the trigone has NO middle circular layer of detrusor)
- This is why the trigone has different motility and is not true detrusor

AT THE URETERIC ORIFICES:
- Smooth muscle arranged in a COMPLEX CIRCULAR arrangement

SEROSA:
- Only covers the SUPERIOR surface and the posterior surface ABOVE the trigone
- The rest of the bladder is retroperitoneal (no serosa inferolaterally)

Histologically: Urothelium (transitional epithelium) → lamina propria (mobile) → detrusor (3 layers) → adventitia/serosa""",
        "Color Atlas Human Anatomy (Microanatomy section); Campbell-Walsh Urology",
        "APPEARED BMC histology 2021",
        "★★★★☆ HIGH YIELD"
    ),
    (
        "Q19. Which of the following statements about the ureteric pacemaker is CORRECT?",
        [
            "A. Ureteric peristalsis is initiated by autonomic nerve impulses from the superior hypogastric plexus",
            "B. The pacemaker for ureteric peristalsis is located in the minor renal calyces",
            "C. Denervation of the lower ureter causes vesicoureteral reflux",
            "D. Ureteric peristalsis ceases completely after ureter excision",
            "E. The pacemaker is located at the ureterovesical junction"
        ],
        1,  # Answer B
        "HINT: The ureteric pacemaker is MYOGENIC (not neurogenic). It originates in the MINOR CALYCES. Even excised ureter continues to contract - proving it's not nerve-dependent.",
        """Ureteric peristalsis - key physiological concepts:

PACEMAKER LOCATION: Minor renal calyces (atypical smooth muscle cells)
- Peristalsis travels proximal → distal (antegrade)
- Rate: 2-6 contractions/minute at normal urine flow

MYOGENIC ORIGIN (crucial exam point!):
- Peristalsis is INTRINSIC (autonomous) - does NOT depend on innervation
- Excised ureter continues to contract rhythmically
- Denervation does NOT cause VUR (denervated ureter still maintains valve function)
- Autonomic input MODULATES but does not INITIATE peristalsis

URETERIC COLIC mechanism:
- Stone → ureteric obstruction → increased proximal pressure → calyceal distension → stimulates afferent pain fibers running with sympathetic nerves → colicky pain in flank/loin
- NOT caused directly by ureteric spasm (it's the distension of collecting system)

PASSAGE OF URINE BOLUS through UVJ:
- Ureteric contraction increases intraluminal pressure → pulls UVJ toward bladder (traction mechanism) → shortens intramural tunnel → opens ureteric orifice → urine bolus enters bladder""",
        "Campbell-Walsh Urology (Nerve Supply + Functional Anatomy of Ureter)",
        "APPEARED BMC physiology-anatomy 2020",
        "★★★☆☆ MODERATE YIELD"
    ),
    (
        "Q20. Which of the following BEST describes the relations of the pelvic ureter in the FEMALE?",
        [
            "A. It passes lateral to the uterine artery and anterior to the rectum",
            "B. It runs medial to the ovary, then passes under the uterine artery, lateral to the uterosacral ligament, then along the lateral fornix of the vagina",
            "C. It passes through the broad ligament anterior to the uterine artery",
            "D. It crosses the external iliac artery and runs through the uterosacral ligament",
            "E. It passes posterior to the uterus and lateral to the rectum"
        ],
        1,  # Answer B
        "HINT: In females the pelvic ureter has 3 key relations: (1) medial to ovarian fossa, (2) UNDER uterine artery ('water under bridge'), (3) alongside lateral fornix of vagina before entering bladder.",
        """Pelvic ureter - female relations (surgically critical):

COURSE IN THE FEMALE PELVIS:
1. Enters pelvis at pelvic brim over common iliac bifurcation
2. Runs medial to the OVARIAN FOSSA (related to ovarian vessels)
3. Passes through the base of the BROAD LIGAMENT
4. Runs MEDIAL to the ovary and uterine tube
5. Passes BELOW the uterine artery (water under the bridge)
6. Turns anteromedially → passes LATERAL to the CERVIX (1.5-2 cm)
7. Runs adjacent to the LATERAL FORNIX of the vagina
8. Enters bladder at trigone (ureteric orifice)

Key dangerous zones in female pelvic surgery:
- Infundibulopelvic ligament: gonadal vessels + ureter cross here
- Uterine artery: ureter passes directly beneath
- Lateral vaginal fornix: ureter passes alongside
- Bladder base: as ureter enters trigone

MALE differences:
- The vas deferens crosses ANTERIOR to the ureter ('water under bridge')
- No uterine artery relationship""",
        "Campbell-Walsh Urology; Fischer's Mastery of Surgery",
        "APPEARED BMC 2021, 2023",
        "★★★★★ MUST KNOW"
    ),
]


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        ("THE URETER - KEY FACTS", TEAL, [
            ("LENGTH & COURSE", "~25-30 cm total. Retroperitoneal throughout. Runs on anterior surface of psoas muscle. Crosses the bifurcation of common iliac artery at pelvic brim. Gonadal vessels cross ANTERIOR to ureter ('water under the bridge')."),
            ("3 CONSTRICTIONS", "1) PUJ (Pelviureteric junction)  |  2) Pelvic brim (common iliac bifurcation)  |  3) VUJ (intramural ureter) ← NARROWEST (3-4 mm) = most common stone impaction site"),
            ("BLOOD SUPPLY DIRECTION", "Proximal → MEDIAL (from renal artery)  |  Mid → POSTERIOR (from common iliac)  |  Distal → LATERAL (from superior vesical/internal iliac)"),
            ("NERVE SUPPLY", "Upper ureter: T11-L1 (referred pain to flank/loin/groin)  |  Lower ureter: S2-S4 (referred pain to groin/scrotum/labia)"),
            ("WALL LAYERS", "Mucosa (urothelium, 4-6 layers, stellar outline when empty) → Lamina propria → Muscularis (2 longitudinal + 1 circular) → Adventitia"),
            ("WALDEYER'S SHEATH", "Specialized muscle+fibrous tissue around terminal ureter. Fuses with detrusor. Intramural length: 1.2-2.5 cm (adults). Forms anti-reflux valve (oblique tunnel). Shorter in children → higher VUR rate."),
            ("PERISTALSIS", "MYOGENIC origin - pacemaker in MINOR CALYCES. Continues after denervation. Rate: 2-6/min. Autonomic input modulates but does not initiate."),
            ("LYMPHATICS", "Proximal ureter: para-aortic (left) / paracaval+interaortocaval (right)  |  Mid: common iliac  |  Distal: common/ext/internal iliac nodes"),
        ]),
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            ("LOCATION", "Subperitoneal connective tissue of lesser pelvis, behind pubis. Separated from pubis by Space of Retzius (retropubic space). Peritoneum covers ONLY superior surface and posterior above trigone."),
            ("PARTS", "Apex (→ median umbilical ligament/urachus → umbilicus)  |  Body  |  Fundus (posterior, where ureters enter)  |  Neck (continuous with urethra)"),
            ("CAPACITY", "Normal: ~500 mL  |  First urge to void: ~300 mL  |  Filled: extends ABOVE pubic symphysis"),
            ("TRIGONE (★★★★★)", "TRIANGLE: 2 ureteric orifices (posterolateral) + internal urethral orifice (anterior/apex). Base = interureteric ridge (Mercier bar). SMOOTH mucosa (no folds - firmly attached to muscularis). Most vascular part. Only 2 muscle layers (ureteric origin, NOT detrusor). Uvula vesicae in males (from prostate)."),
            ("WALL LAYERS", "Urothelium → Lamina propria (mobile, allows folds) → Detrusor (3 layers: inner long + middle circular + outer long) → Serosa/adventitia"),
            ("BLOOD SUPPLY", "Superior vesical artery (from umbilical/internal iliac) → superior bladder  |  Inferior vesical artery (internal iliac) → fundus, prostate  |  Venous plexus → internal iliac veins"),
            ("LYMPHATICS", "Superolateral → external iliac nodes  |  Neck + trigone → internal iliac nodes  |  All → para-aortic nodes"),
            ("INNERVATION", "Parasympathetic S2-S4 (pelvic nerves): contracts detrusor (M3 receptors)  |  Sympathetic L1-L2 (hypogastric): relaxes detrusor (β3) + contracts internal sphincter (α1)  |  Somatic S2-S4 (pudendal): external sphincter (voluntary)"),
        ]),
        ("SURGICAL DANGER ZONES & CLINICAL PEARLS", GOLD, [
            ("URETERIC INJURY IN HYSTERECTOMY", "'Water under the bridge': ureter passes UNDER uterine artery (~1.5-2 cm lateral to cervix). Most common injury site in gynecological surgery. Also at risk: infundibulopelvic ligament (gonadal vessels), lateral vaginal fornix."),
            ("URACHAL ANOMALIES", "Patent urachus → urine from umbilicus  |  Urachal cyst → midline abdominal mass  |  Urachal sinus → periumbilical discharge  |  Urachal diverticulum → bladder apex"),
            ("UMBILICAL LIGAMENTS", "MEDIAN (single, midline) = obliterated urachus  |  MEDIAL (paired) = obliterated umbilical arteries  |  LATERAL (folds) = inferior epigastric vessels"),
            ("WEIGERT-MEYER RULE", "Complete ureteral duplication: UPPER pole ureter → inserts INFEROMEDIALLY (prone to obstruction/ectopic insertion)  |  LOWER pole ureter → inserts SUPEROLATERALLY (normal position, prone to VUR). Ectopic ureter in females → below external sphincter → continuous incontinence."),
            ("VUJ ANTI-REFLUX", "Oblique intramural ureter (1.5 cm) + Waldeyer sheath + tunnel:width ratio >5:1 → prevents VUR. Golf-hole orifice (grade 3) = highest reflux risk."),
            ("SUPRAPUBIC CATHETER", "Filled bladder rises above symphysis → can be punctured suprapubically without entering peritoneal cavity (retropubic/extraperitoneal approach)."),
            ("URETERIC COLIC REFERRED PAIN", "Upper ureter (T11-L1): flank → groin  |  Lower ureter (S2-S4): groin → scrotum/labia/inner thigh  |  VUJ stone: tip of penis/clitoris, urinary urgency"),
            ("ENDOURETEROTOMY INCISION DIRECTION", "Proximal: cut LATERALLY  |  Mid: cut ANTERIORLY  |  Distal: cut MEDIALLY (to avoid blood supply)"),
        ]),
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    qr_header_table = Table(qr_header_data, colWidths=[W - 3.6*cm])
    qr_header_table.setStyle(TableStyle([
        ("BACKGROUND", (0, 0), (-1, -1), HexColor("#c0392b")),
        ("PADDING", (0, 0), (-1, -1), 8),
    ]))
    story.append(qr_header_table)

    top10 = [
        ["#", "FACT", "WHY IT MATTERS"],
        ["1", "3 ureteric constrictions: PUJ, pelvic brim, VUJ (narrowest = 3-4mm)", "Stone impaction sites - every exam"],
        ["2", "Blood supply: Medial (proximal) → Posterior (mid) → Lateral (distal)", "Surgical retraction direction; endoureterotomy cuts"],
        ["3", "Median umbilical ligament = obliterated urachus (NOT umbilical artery)", "Confusion point - ligament naming MCQs"],
        ["4", "Trigone: smooth mucosa, fixed, 2 muscle layers, most vascular", "Histology + surgical anatomy MCQs yearly"],
        ["5", "Waldeyer's sheath: anti-reflux mechanism via oblique intramural tunnel", "VUR pathophysiology MCQs"],
        ["6", "Micturition: parasympathetic (S2-S4) → contracts detrusor + relaxes sphincter", "Autonomic pharmacology integration"],
        ["7", "Pacemaker = minor calyces (myogenic - not neural)", "Ureteric physiology MCQs"],
        ["8", "Uterine artery OVER ureter ('water under bridge') = #1 gyne injury site", "Classic repeated clinical anatomy MCQ"],
        ["9", "Weigert-Meyer: upper pole ureter → inferomedial in bladder → obstruction/ectopic", "Pediatric urology - duplication MCQs"],
        ["10", "Upper ureter pain T11-L1 (flank); lower ureter pain S2-S4 (groin/scrotum)", "Referred pain pattern MCQs - clinical scenarios"],
    ]

    top10_table = Table(top10, colWidths=[(W-3.6*cm)*0.06, (W-3.6*cm)*0.5, (W-3.6*cm)*0.44])
    top10_style = [
        ("BACKGROUND", (0, 0), (-1, 0), NAVY),
        ("TEXTCOLOR", (0, 0), (-1, 0), WHITE),
        ("FONTNAME", (0, 0), (-1, 0), "Helvetica-Bold"),
        ("FONTSIZE", (0, 0), (-1, 0), 9),
        ("FONTNAME", (0, 1), (-1, -1), "Helvetica"),
        ("FONTSIZE", (0, 1), (-1, -1), 8.5),
        ("PADDING", (0, 0), (-1, -1), 5),
        ("BOX", (0, 0), (-1, -1), 0.5, GREY_LINE),
        ("INNERGRID", (0, 0), (-1, -1), 0.3, GREY_LINE),
        ("ROWBACKGROUNDS", (0, 1), (-1, -1), [WHITE, HexColor("#eaf4ff")]),
        ("VALIGN", (0, 0), (-1, -1), "MIDDLE"),
        ("FONTNAME", (0, 1), (0, -1), "Helvetica-Bold"),
        ("TEXTCOLOR", (0, 1), (0, -1), HexColor("#c0392b")),
    ]
    top10_table.setStyle(TableStyle(top10_style))
    story.append(top10_table)
    story.append(Spacer(1, 12))

    # Footer
    footer_data = [[
        Paragraph("Sources: Campbell-Walsh Urology • Fischer's Mastery of Surgery (8th Ed) • Color Atlas of Human Anatomy Vol.2 • Costanzo Physiology 7th Ed • Bailey & Love's Surgery 28th Ed • Grainger & Allison Diagnostic Radiology • The Developing Human (Moore)",
                  s("foot", fontName="Helvetica-Oblique", fontSize=7.5, textColor=HexColor("#888888"),
                    alignment=TA_CENTER))
    ]]
    footer_table = Table(footer_data, colWidths=[W - 3.6*cm])
    footer_table.setStyle(TableStyle([
        ("BACKGROUND", (0, 0), (-1, -1), HexColor("#f0f0f0")),
        ("PADDING", (0, 0), (-1, -1), 6),
        ("BOX", (0, 0), (-1, -1), 0.3, GREY_LINE),
    ]))
    story.append(footer_table)

    doc.build(story)
    print("PDF generated successfully!")


if __name__ == "__main__":
    build_pdf()