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11. Urinary > 8. The Physiology of Micturition > Flashcards

8. The Physiology of Micturition Flashcards

1
Q

What is the body of the bladder?

A

The temporary store of urine.

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2
Q

What is the trigone of the bladder?

A

Ureteric orifices and internal urethral orifice are at the angles of a triangle.

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3
Q

What is the neck of the bladder?

A

Connects the bladder to the urethra.

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4
Q

What does the Latin - detrusor mean?

A

To push down.

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5
Q

What are the three layers of the detrusor muscle?

A

Inner longitudinal, middle circular, outer longitudinal.

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6
Q

How does the bladder have strength in all directions of stretch?

A

The arrangement of the muscle layers.

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7
Q

What supplies the detrusor muscle?

A

Autonomic nervous sytem, not voluntary control.

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8
Q

What is the spinal nerve supply of the detrusor muscle?

A

Bilateral.

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9
Q

What is the internal urethral sphincter?

A

Continuation of the detrusor muscle, made of smooth muscle.

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10
Q

What is at the bladder neck?

A

Physiological sphincter, no muscle thickening.

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11
Q

What is the primary muscle of continence?

A

Internal urethral sphincter.

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12
Q

What is the external urethral sphincter?

A

The anatomical sphincter, localised circular muscle thickening to facilitate action.

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13
Q

What is the external urethral sphincter derived from?

A

The pelvic floor muscles.

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14
Q

What type of muscle is the external urethral sphincter?

A

Skeletal, so voluntary control.

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15
Q

How does the external urethral sphincter hold in urine?

A

Contracts to constrict the urethra.

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16
Q

What is the parasympathetic supply of the detrusor muscle?

A

Pelvic nerve (S2-S4).

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17
Q

What is the effect of parasympathetic activity on the detrusor muscle?

A

ACh acts on M3 receptor to cause contraction.

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18
Q

What is the sympathetic supply of the detrusor muscle?

A

Hypogastric nerve (T10-L2).

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19
Q

What is the effect of sympathetic activity on the detrusor muscle?

A

NA acts on B3 receptors to cause relaxation.

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20
Q

What is the sympathetic supply of the internal urethral sphincter?

A

Hypogastric nerve (T10-L2).

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21
Q

What is the effect of sympathetic activity on the internal urethral sphincter?

A

NA acts on a1 receptors to cause contraction.

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22
Q

What is the somatic supply of the external urethral sphincter?

A

Pudendal nerve (S2-S4).

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23
Q

Where is the spinal motor outflow of the external urethral sphincter from?

A

Onof’s nucleus of the ventral horn of the cord.

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24
Q

What is the effect of the somatic supply of the external urethral sphincter?

A

ACh acts on nicotinic receptors to cause contraction.

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25
Q

What is the basic messaging pathway when the bladder is full?

A

Brain micturition centres activated -> spinal micturition centres -> parasympathetic neurones.

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26
Q

What causes the detrusor muscle to contract?

A

Increase in parasympathetic stimulation to the bladder via the pelvic nerve. This causes it to increase intravesicular pressure.

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27
Q

How does the cerebral cortex respond to a full bladder?

A

Make a conscious, executive decision to urinate. This reduces somatic stimulation to the external urethral sphincter so relaxes.

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28
Q

What leads to bladder emptying through the urethra?

A

Contraction of the detrusor muscle with paired relaxation of the external urethral sphincter.

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29
Q

Why does the intravesicular pressure of the bladder hardly change with filling?

A

The walls of the bladder have many folds, which distend when filling with urine.

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30
Q

What happens at around 400ml filling of the bladder?

A

Afferent nerves from the bladder wall start to signal the need to void the bladder.

31
Q

What is the basic signalling of storage in the bladder?

A

Brain continence centres -> spinal continence centres -> sympathetic neurones.

32
Q

What causes the detrusor to relax and internal urethral sphincter to contract?

A

Increased sympathetic stimulation to the bladder via the hypogastric nerve.

33
Q

How does the cerebral cortex respond to needing to store in the bladder?

A

It makes the conscious, executive decision to not urinate so increases somatic stimulation to the external urethral sphincter. This causes it to contract and constrict the urethra.

34
Q

What muscle action prevents micturition?

A

Detrusor muscle relaxation coupled with contraction of the internal and external urethral sphincters reduces intravesicular pressure and constricts the urethra.

35
Q

What are the types of incontinence?

A

Stress, urge, mixed, and overflow.

36
Q

What is stress urinary incontinence?

A

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

37
Q

What is urge urinary incontinence?

A

Involuntary leakage, accompanied by or immediately proceeded by urgency.

38
Q

What is mixed urinary incontinence?

A

Involuntary leakage, associated with urgency and exertion, effort, sneezing, or coughing.

39
Q

What is overflow incontinence?

A

Retention of urine causing the bladder to swell. Can be low pressure and pain free.

40
Q

What is the most common type of urinary incontinence?

A

Stress.

41
Q

How does prevalence of urinary incontinence change with age?

A

Prevalence steadily increases with age.

42
Q

What are the risk factors of urinary incontinence?

A

Anything that weakens the pelvic floor muscles, e.g. childbirth.

43
Q

What enables continent?

A

Support of the urethra by the muscles and ligaments of the pelvic floor to make the sphincter mechanisms efficient.

44
Q

What are the key things to establish in history taking for urinary incontinence?

A

Record amount of fluid passed for 2/3 days, number of pads that the patient uses, determine if continuous or intermittent, precipitating factors.

45
Q

What can make urgency and frequency of micturition worse?

A

Intravesicular inflammatory conditions, like urinary tract infections, or stone in the bladder, or a tumour.

46
Q

Why is previous surgery of the pelvic floor important in history taking of urinary incontinence?

A

May lead to denervation of parts of the baldder.

47
Q

Why is childbirth an important factor in urinary incontinence?

A

In the development of stress urinary incontinence due to sphincter damage.

48
Q

What examinations should be performed with urinary incontinence?

A

Height/weight, abdominal exam to exclude palpable bladder, digital rectal examination to examine prostate in males, external genitalia stress test in females.

49
Q

What is the mandatory investigation for urinary incontinence?

A

Urine dipstick - UTI, haematuria, proteinuria, glucosuria.

50
Q

What basic non-invasice urodynamic investigations should be done for urinary incontinence?

A

Frequency-volume chart, bladder diary, post micturition residual volume.

51
Q

What optional investigations could be performed for urinary incontinence?

A

Invasive urodynamics, pad tests, cystoscopy.

52
Q

What does management of urinary incontinence depend on?

A

Which symptoms the patient has, the degree of bother, previous/ current treatment and their adverse effects.

53
Q

What is the conservative management approach to urinary incontinence management?

A

Modify fluid intake, weight loss, stop smoking, decrease caffeine intake, avoid constipation, timed voiding - fixed schedule.

54
Q

What is the management strategy for patients unsuitable for surgery but who fail conservative and medical management?

A

Indwelling catheter (urethral or suprapubic), sheath device (like adhesive condom attached to catheter tubing and bag), incontinence pads.

55
Q

What is the specific management of stress urinary incontinence?

A

Pelvic floor muscle training - 8 contractions, three times a day for at least three months.

56
Q

What is the specific management of urge urinary incontinence?

A

Bladder training, schedule voiding - every hour during the day, can’t void between, increase interval by 15-30 mins/ week until 2-3 hours is reached, needs at least 6 weeks training.

57
Q

What is duloxetine?

A

A combined noradrenaline and serotonin uptake inhibitor.

58
Q

What is the action of duloxetine?

A

It increases the activity of the external urethral sphincter during the filling phase.

59
Q

When is duloxetine given?

A

Not first line or routine second line approach, but can be given as alternative to surgery for urinary incontinence.

60
Q

How do anticholinergics help with urinary incontinence?

A

Act on muscarinic receptors, including M3 to cause the detrusor to contract.

61
Q

How is botulinum toxin in urinary incontinence management?

A

It is a neurotoxin that inhibits ACh release so prevents detrusor muscle contraction as the pelvic nerve can’t release ACh to act on M3 receptors.

62
Q

What are permanent intention options for females with urinary incontinence?

A

Low-tension vaginal tapes, open retropubic suspension procedures, classic fascial sling procedures.

63
Q

What is the success rate of low-tension vaginal tapes in treating urinary incontinence?

A

Over 90%.

64
Q

How do low-tension vaginal tapes work to treat urinary incontinence?

A

Supports the mid urethra with a polypropylene mesh.

65
Q

What do retropubic suspension procedures do in urinary incontinence?

A

Correct the anatomical position of the proximal urethra and improve urethral support.

66
Q

What do classic fascial sling procedures do in urinary incontinence?

A

Support the urethra and increase bladder outflow resistance.

67
Q

What is done in classic fascial sling procedures?

A

Autologous transplantation of the fascia lata or rectus fascia.

68
Q

What is the temporary intention option for urinary incontinence?

A

Intramural bulking agents.

69
Q

How do intramural bulking agents work to treat urinary incontinence?

A

They improve the ability of the urethra to resist abdominal pressure by improving urethral coaptation.

70
Q

How are intramural agents administered?

A

Autologous fat, silicone, collagen, or hyaluron-dextran polymers are infected.

71
Q

What are the options for treating urinary incontinence in males surgically?

A

Artificial urinary sphincter or male sling procedure.

72
Q

What is artificial urinary sphincter?

A

The gold standard treatment in urethral sphincter deficiency. A mechanical cuff stimulates the action of normal sphincter to circumferentially close the urethra.

73
Q

What are some of the problems with artificial urinary sphincter?

A

Infection, erosion, and device failure.

74
Q

What is a male sling procedure?

A

Corrects stress urinar incontinence in men. It uses bone-anchored tape.

11. Urinary (12 decks)

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