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Urinary System > 15) Micturition and Incontinence > Flashcards

15) Micturition and Incontinence Flashcards

1
Q

What structures of the bladder are involved in storage and micturition?

A

Detrusor muscle
Internal urethral sphincter (often only in males)
External urethral sphincter

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2
Q

At what volume do we first sense there is urine in the bladder?

A

150ml

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3
Q

Describe SNS activity on bladder in storage:

A

Hypogastric nerve (T10-L2) acts on beta 3 receptors in detrusor muscle to relax it

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4
Q

Describe SNS activity on internal urethral sphincter in storage:

A

Hypogastric nerve (T10-L2) acts on alpha 1 receptors in internal urethral sphincter to contract it

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5
Q

What does the SNS have an effect on during micturition?

A

Bladder and internal urethral sphincter to allow storage

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6
Q

What acts on external urethral sphincter during storage?

A

Somatic motor neurones from pudendal nerve (S2-4) act on nAChr to cause contraction

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7
Q

How do we know how full the bladder is?

A

Stretch receptors in wall which feed sensory information regarding bladder stretch back to spinal cord

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8
Q

What is the L centre and what does it control?

A

Is the pontine storage centre in the brainstem and controls storage phase of micturition:
Stimulates SNS and somatic NS
Inhibits PSNS

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9
Q

What does the PSNS have an effect on during micturition?

A

Pelvic nerve (S2-4) acts on M3 receptors to cause contraction of detrusor muscle

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10
Q

What stimulates the M centre and PSNS?

A

Afferent impulses from bladder stretch

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11
Q

What is the M centre and what does it control?

A

Pontine micturition centre in brainstem that:
Inhibits L centre -> relaxes EUS
Inhibits SNS
Stimulates PSNS

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12
Q

What are the M and L centre controlled by?

A

Cortex which can override these centres

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13
Q

Why can’t babies control when they micturate?

A

No descending neuronal modulation from brainstem, so automatic voiding when bladder reaches certain level

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14
Q

Where is the detrusor muscle located?

A

Below the submucosa and surrounded in adventitia

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15
Q

What are the muscle layers of the bladder and why are they important?

A

3: inner longitudinal, circular and outer longitudinal

Allow strength in all directions of stretch

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16
Q

What is the internal urethral sphincter?

A

Continuation of detrusor muscle at bladder neck

17
Q

What is the external urethral sphincter?

A

Skeletal muscle derived from pelvic floor muscles

18
Q

What effect does a lower motor neurone (below T12) lesion have on bladder?

A

Flaccid bladder - damage to parasympathetic outflow so detrusor muscle can’t contract. Bladder fills uncontrollably until overflow incontinence

19
Q

What effect does a upper motor neurone (above T12) lesion have on bladder?

A

Reflex bladder - no afferent signals from bladder wall so no awareness of filling, micturition reflex so bladder empties as it fills. May get dyssynergia, where sphincters are poorly co-ordinated

20
Q

How would you classify lower urinary tract symptoms?

A

Problems with storage, voiding or post micturition

21
Q

How may storage problems present?

A

Frequency, urgency and nocturia

22
Q

How may voiding problems present?

A

Slow stream
Hesitancy
Straining
Terminal dribble

23
Q

How may post-micturition problems present?

A

Feeling of incomplete emptying or dribble

24
Q

What is urinary incontinence?

A

Complaint of any involuntary leakage of urine

25
Q

What is stress UI?

A

Involuntary leakage on effort or exertion, or on sneezing or coughing

26
Q

What is urge UI?

A

Involuntary leakage accompanied by or immediately proceeded by urgency

27
Q

What is mixed UI?

A

Involuntary leakage associated with urgency and exertion

28
Q

What is overflow incontinence?

A

Retention of urine causes bladder to swell until it can’t hold anymore

29
Q

What is overactive bladder syndrome?

A

Encompasses both MUI and UUI, and with symptoms of urgency, frequency and nocturia

30
Q

What is the association of incontinence and age?

A

Increasing prevalence with age

31
Q

What are some risk factors for incontinence?

A 
Weakened pelvic floor muscles (child-birth, surgery)
Age
Obesity
UTI
Menopause
32
Q

What examinations may you do to investigate incontinence?

A

BMI
Abdominal examine to exclude palpable bladder
Digital rectal examination
Stress test

33
Q

What investigations may you carry out?

A

Urine dipstick
Freq-vol chart
Post-micturition residual volume - ultrasound
Invasive urodynamics - contrast and video
Cytoscopy - looking for cancer or stones

34
Q

What general management may be recommended?

A 
Modify fluid intake 
Weight loss
Stop smoking
Decrease caffeine 
Fixed schedule for voiding
35
Q

What can be used if patients can’t have surgery and conservative management hasn’t worked?

A

Indwelling catheter
Sheath device - condom catheter
Incontinence pads

36
Q

What specific management for SUI is there?

A

Pelvic floor muscle training - 8 contractions, 3 times a day for 3 months
Duloxetine - combined noradrenaline and serotonin uptake inhibitor, increases activity of EUS in filling, but many side effects

37
Q

What surgical options can be offered for females with SUI?

A

Permanent intention:
Low-tension vaginal tapes - support mid-urethra
Retropubic suspension procedures - corrects position of proximal urethra
Classical sling procedures - supports urethra

Temporary intention:
Intramural bulking agents - allows urethra to resist abdominal pressure

38
Q

What surgical options can be offered for males with SUI?

A

Artificial urinary sphincter - stimulates normal sphincter to close
Male sling procedure

39
Q

What specific management for UUI is there?

A 
Bladder training 
Anticholinergics (M2, M3) - oxybutynin 
B3 agonist - mirabegron
Botulinum toxin - prevents ACh release so no detrusor muscle contraction, 3-6 months
Surgery - sacral nerve neuromodulation

Urinary System (10 decks)

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