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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
What is the basic messaging pathway when the bladder is full?
Brain micturition centres activated -> spinal micturition centres -> parasympathetic neurones.
26
What causes the detrusor muscle to contract?
Increase in parasympathetic stimulation to the bladder via the pelvic nerve. This causes it to increase intravesicular pressure.
27
How does the cerebral cortex respond to a full bladder?
Make a conscious, executive decision to urinate. This reduces somatic stimulation to the external urethral sphincter so relaxes.
28
What leads to bladder emptying through the urethra?
Contraction of the detrusor muscle with paired relaxation of the external urethral sphincter.
29
Why does the intravesicular pressure of the bladder hardly change with filling?
The walls of the bladder have many folds, which distend when filling with urine.
30
What happens at around 400ml filling of the bladder?
Afferent nerves from the bladder wall start to signal the need to void the bladder.
31
What is the basic signalling of storage in the bladder?
Brain continence centres -> spinal continence centres -> sympathetic neurones.
32
What causes the detrusor to relax and internal urethral sphincter to contract?
Increased sympathetic stimulation to the bladder via the hypogastric nerve.
33
How does the cerebral cortex respond to needing to store in the bladder?
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
What muscle action prevents micturition?
Detrusor muscle relaxation coupled with contraction of the internal and external urethral sphincters reduces intravesicular pressure and constricts the urethra.
35
What are the types of incontinence?
Stress, urge, mixed, and overflow.
36
What is stress urinary incontinence?
Involuntary leakage on effort or exertion, or on sneezing or coughing.
37
What is urge urinary incontinence?
Involuntary leakage, accompanied by or immediately proceeded by urgency.
38
What is mixed urinary incontinence?
Involuntary leakage, associated with urgency and exertion, effort, sneezing, or coughing.
39
What is overflow incontinence?
Retention of urine causing the bladder to swell. Can be low pressure and pain free.
40
What is the most common type of urinary incontinence?
Stress.
41
How does prevalence of urinary incontinence change with age?
Prevalence steadily increases with age.
42
What are the risk factors of urinary incontinence?
Anything that weakens the pelvic floor muscles, e.g. childbirth.
43
What enables continent?
Support of the urethra by the muscles and ligaments of the pelvic floor to make the sphincter mechanisms efficient.
44
What are the key things to establish in history taking for urinary incontinence?
Record amount of fluid passed for 2/3 days, number of pads that the patient uses, determine if continuous or intermittent, precipitating factors.
45
What can make urgency and frequency of micturition worse?
Intravesicular inflammatory conditions, like urinary tract infections, or stone in the bladder, or a tumour.
46
Why is previous surgery of the pelvic floor important in history taking of urinary incontinence?
May lead to denervation of parts of the baldder.
47
Why is childbirth an important factor in urinary incontinence?
In the development of stress urinary incontinence due to sphincter damage.
48
What examinations should be performed with urinary incontinence?
Height/weight, abdominal exam to exclude palpable bladder, digital rectal examination to examine prostate in males, external genitalia stress test in females.
49
What is the mandatory investigation for urinary incontinence?
Urine dipstick - UTI, haematuria, proteinuria, glucosuria.
50
What basic non-invasice urodynamic investigations should be done for urinary incontinence?
Frequency-volume chart, bladder diary, post micturition residual volume.
51
What optional investigations could be performed for urinary incontinence?
Invasive urodynamics, pad tests, cystoscopy.
52
What does management of urinary incontinence depend on?
Which symptoms the patient has, the degree of bother, previous/ current treatment and their adverse effects.
53
What is the conservative management approach to urinary incontinence management?
Modify fluid intake, weight loss, stop smoking, decrease caffeine intake, avoid constipation, timed voiding - fixed schedule.
54
What is the management strategy for patients unsuitable for surgery but who fail conservative and medical management?
Indwelling catheter (urethral or suprapubic), sheath device (like adhesive condom attached to catheter tubing and bag), incontinence pads.
55
What is the specific management of stress urinary incontinence?
Pelvic floor muscle training - 8 contractions, three times a day for at least three months.
56
What is the specific management of urge urinary incontinence?
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
What is duloxetine?
A combined noradrenaline and serotonin uptake inhibitor.
58
What is the action of duloxetine?
It increases the activity of the external urethral sphincter during the filling phase.
59
When is duloxetine given?
Not first line or routine second line approach, but can be given as alternative to surgery for urinary incontinence.
60
How do anticholinergics help with urinary incontinence?
Act on muscarinic receptors, including M3 to cause the detrusor to contract.
61
How is botulinum toxin in urinary incontinence management?
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
What are permanent intention options for females with urinary incontinence?
Low-tension vaginal tapes, open retropubic suspension procedures, classic fascial sling procedures.
63
What is the success rate of low-tension vaginal tapes in treating urinary incontinence?
Over 90%.
64
How do low-tension vaginal tapes work to treat urinary incontinence?
Supports the mid urethra with a polypropylene mesh.
65
What do retropubic suspension procedures do in urinary incontinence?
Correct the anatomical position of the proximal urethra and improve urethral support.
66
What do classic fascial sling procedures do in urinary incontinence?
Support the urethra and increase bladder outflow resistance.
67
What is done in classic fascial sling procedures?
Autologous transplantation of the fascia lata or rectus fascia.
68
What is the temporary intention option for urinary incontinence?
Intramural bulking agents.
69
How do intramural bulking agents work to treat urinary incontinence?
They improve the ability of the urethra to resist abdominal pressure by improving urethral coaptation.
70
How are intramural agents administered?
Autologous fat, silicone, collagen, or hyaluron-dextran polymers are infected.
71
What are the options for treating urinary incontinence in males surgically?
Artificial urinary sphincter or male sling procedure.
72
What is artificial urinary sphincter?
The gold standard treatment in urethral sphincter deficiency. A mechanical cuff stimulates the action of normal sphincter to circumferentially close the urethra.
73
What are some of the problems with artificial urinary sphincter?
Infection, erosion, and device failure.
74
What is a male sling procedure?
Corrects stress urinar incontinence in men. It uses bone-anchored tape.

11. Urinary (12 decks)

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