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Urinary > 7 > Flashcards

7 Flashcards

1
Q

What is micturition?

A

Can be broken down as:

  • urine is made in kidney
  • urine is stored in bladder
  • sphincter muscles relax
  • bladder muscle (detrusor) contracts
  • bladder is emptied through urethra and urine is removed from body
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2
Q

What are the functions of the nervous system in relation to the lower urinary tract?

A
  • provide sensations of bladder filling and pain
  • to allow bladder to relax and accommodate increasing volumes of urine
  • to initiate and maintain voiding so that bladder empties completely, with MINIMAL residual volume
  • to provide an integrated regulation of smooth muscle and skeletal muscle sphincters of the urethra
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3
Q

What is the Pontine micturition centre (PMC)?

A

-collection of neuronal cell bodies located in the rostral pons in the brainstem involved in the supraspinatous regulation of micturition

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4
Q

What are the two regions within the PMC?

A

L region and M region

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5
Q

What does L region do?

A

-has sympathetic fibres associated with storage and relaxation of the bladder and contraction of the EUS

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6
Q

What does M region do?

A

-has parasympathetic NS and involved in voiding

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7
Q

What is the periaqueductal gray (PAG)?

A

-acts as a relay station for ascending bladder info from spinal cord and incoming signals from higher brain areas

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8
Q

What does the M region do in regards to bladder filling and distension?

A
  • helps to control the detrusor muscle of bladder and inhibitory inter neurons regulating onuf’s nucleus
  • during bladder filling, neurons within M region are turned off
  • but at a critical level of bladder distension, the afferent info will switch M region on and enhance activity
  • activation results of relaxation of EUS and contraction of bladder
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9
Q

What are the two phases of the functional activity of the lower urinary tract?

A
  • filling

- voiding

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10
Q

What is the filling phase?

A
  • bladder relaxes and accommodates increasing volumes of urine (bladder filling)
  • urethral sphincters increase their tone to maintain continence
  • storage phase
  • no detrusor contraction
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11
Q

What occurs in the voiding phase?

A
  • urethral sphincters relax and bladder contracts
  • bladder contraction is greater in men than women
  • voluntary initiation
  • complete emptying
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12
Q

What types of innervation does the bladder and its sphincters receive?

A
  • sympathetic
  • parasympathetic
  • somatic
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13
Q

How does sympathetic innervation occur in the bladder?

A
  • originates from neurons from T10 to L2
  • preganglionic fibres pass through lumbar splanchnic nerves to superior hypogastric plexus where they give rise to left and right hypogastric nerves
  • in the plexus, fibre synapse with postganglionic fibres
  • postganglionic fibres go to bladder wall
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14
Q

How does parasympathetic innervation to the bladder occur?

A
  • originates from S2-S4
  • preganglionic fibres go to bladder via pelvic splanchnic nerve
  • then synapse with postganglionic neurons in the body and neck of bladder
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15
Q

How does somatic innervation occur in the bladder?

A
  • originates from motor neurons arising from S2-S4

- through the pudendal nerve these motor neurons innervate and control the voluntary skeletal muscle of EUS

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16
Q

How can i make sense of the innervation to bladder?

A

STUDY DIAGRAM

NOv 6 2019 note

17
Q

What is urinary incontinence?

A
  • non-fatal but socially disabling condition
  • occurs when the bladder pressure is greater than the urethral sphincter pressure
  • happens either when the detrusor pressure is high or the sphincter pressure is low
18
Q

How is continence achieved?

A
  • combined effect of smooth muscle of urethra, surrounding peri-urethral striated muscle and the elasticity of the connective tissue
  • support of the urethra by the muscles and ligaments of the pelvic floor
19
Q

What will happen to the bladder if you get a lower motor neurone lesion?

A
  • low detrusor pressure
  • large residual urine
  • overflow incontinence
  • S2, 3, 4 affected
  • reduced perianal sensation
  • lax anal tone
20
Q

What will happen to the bladder in an upper motor neurone lesion?

A
  • high pressure detrusor contractions
  • poor coordination with sphincters
  • detrusor sphincter dyssnergia
  • thickened detrusor
  • dilated ureters
21
Q

What are the different types of incontinence?

A

Stress Urinary Incontinence (SUI)
-complaint of involuntary leakage on effort or exertion, or on sneezing or coughing

Urgency Urinary Incontinence (UUI)
-complaint of involuntary leakage (of urine) accompanied by or immediately proceeded by urgency

Mixed Urinary Incontinence (MUI)
-complaint of involuntary leakage (of urine) associated with urgency and also with exertion, effort, sneezing or coughing

Overflow Incontinence

22
Q

What type of incontinence is the most common?

A

SUI

23
Q

What are the risk factors for urinary incontinence?

A

O and G

  • pregnancy and childbirth
  • pelvic surgery
  • pelvic prolapse

Promoting

  • co-morbidities
  • obesity
  • age
  • rise in intra-abd pressure
  • cognitive impairment
  • UTI
  • drugs
  • menopause

Predisposing

  • race
  • family predisposition
  • anatomical abnormalities
  • neurological abnormalities
  • radiotherapy makes pelvis less compliant
24
Q

What type of history and examination would you do for a pt. Suspected with UI?

A

History
-categories type of UI

Examination

  • BMI
  • abd exam to exclude palpable bladder
  • digital rectal examination
  • stress test for external genitalia
25
Q

What investigations would you do for someone with UI?

A

Mandatory
-urine dipstick (UTI, haematauria, proteinuria, glucosuria)

Consider basic non-invasive urodynamics

  • frequency-volume chart
  • bladder diary
  • post-micturition residual volume (in patients with voiding dysfunction)

Optional

  • invasive urodynamics
  • pad tests
  • cystoscopy
26
Q

What conservative management would you do for UI?

A
  • modify fluid intake
  • weight loss
  • stop smoking
  • decrease caffeine intake
  • avoid constipation
  • timed voiding
27
Q

How would you treat contained incontinence for patients who have failed conservative or medical management?

A
  • indwelling catheter: urethral or suprapubic
  • sheath device: analogous to an adhesive condom attached to catheter tubing and bag
  • incontinence pads
28
Q

What initial management would you do for SUI?

A

-pelvic muscle floor training

29
Q

What pharmacological management would you do for SUI?

A
  • give duloxetine
  • combined noradrenaline and serotonin uptake inhibitor
  • Increased activity in the striated sphincter during filling phase
  • not recommended by NICE as first-line defence
30
Q

What surgeries would you do for SUI?

A

Females

  • permanent intention: sling procedure, low-tension vaginal tapes
  • temporary intention (if further pregnancies are planned): intramural bulking agents

Males

  • artificial urinary sphincter
  • male sling procedure
31
Q

What initial management would you give for UUI?

A
  • bladder training
  • schedule of voiding
  • at least 6 weeks duration
32
Q

What pharmacological management would you give for UUI?

A
  • anticholinergics

- acts on muscuarinic receptors

33
Q

What pharmacological management would you give for UUI?

A
  • B3-adrenoceptor agonist
  • Mirabegron
  • increase in bladder’s capacity to store urine
34
Q

What surgeries may be done to treat UUI?

A
  • sacral nerve neuromodulation
  • autoaugmentation
  • augmentation cytoplasty
  • urinary diversion
35
Q

What is enuresis?

A
  • bed wetting: involuntary wetting during sleep at least two times a week in children aged >5 years with no CNS defects
  • mainly happens in children
36
Q

How would you manage enuresis in children?

A

Primary enuresis without daytime symptoms

  • usually managed in primary care
  • reassurance, alarms with positive reward system, desmopressin

Primary enuresis with daytime symptoms

  • usually caused by disorders of the lower urinary tract (ex. Anatomical, OAB)
  • NICE recommends referral to secondary care

Secondary enuresis

  • treat underlying cause if it has been identified
  • ex. UTIs, constipation, diabetes, psychological problems, family problems, physical or neurological problems
  • primary/secondary care

Urinary (11 decks)

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