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Year 2 - BRS > 9.7 - Urinary incontinence and urinary tract symptoms > Flashcards

9.7 - Urinary incontinence and urinary tract symptoms Flashcards

1
Q

What is the urinary tract composed of in most people?

A

Two kidneys, two ureters, urinary bladder and urethra

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2
Q

What is the role of the kidneys in the urinary tract?

A

Kidneys remove waste products of metabolism, excess water and salts from the blood, and maintain the pH

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3
Q

At what vertebral level is the hilum of the kidneys found?

A

L1

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4
Q

What is the role of the ureters in the urinary tract?

A

Convey urine from the kidneys to the urinary bladder

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5
Q

Describe the structure of the ureters.

A
  • each one is about 25cm long, upper half lies in abdomen and lower half in pelvis
  • approximately 3mm in diameter
  • 3 layers of tissue - outer fibrous tissue, middle muscle layer and inner epithelium layer
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6
Q

What is the blood supply to the urinary tract?

A

Renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries (depending on location) with corresponding venous drainage

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7
Q

What is the lymphatic drainage of the urinary tract - where do the left and right ureter drain into?

A
  • left ureter drains into left para-aortic nodes
  • right ureter drains into right paracaval and interaortocaval lymph nodes
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8
Q

What is the nerve supply to the urinary tract?

A

Autonomic nervous system

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9
Q

Describe the anatomical orientation of the organs in the pelvis.

A
  • kidneys are retroperitoneal
  • ureters descend in front of the tips of transverse spinous processes, cross sacro-iliac joint, then forwards next to rectum/vagina
  • bladder is anterior in pelvis (behind the pubis)
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10
Q

What are some variations in kidney anatomy that some people have? (3)

A
  • single kidney (1% of the population)
  • horse-shoe kidney (also lays too low down)
  • ectopic kidney
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11
Q

What are some variations in ureter anatomy that some people have? (2)

A
  • partial duplication
  • complete duplication (2 ureters)
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12
Q

What are the three constriction points in the ureter?

A
  • pelvic ureteric junction (PUJ) - where the renal pelvis joins the top of the ureter
  • pelvic brim - crossing the iliac vessels
  • uretero-vesical junction/vesicoureteric junction (VUJ) - as it passes through the bladder wall
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13
Q

Why might the constriction points of the ureter cause problems?

A

They may block urine flow, especially if a kidney stone dislodges and becomes a ureteric stone (pain, ipsilateral impaired renal function)

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14
Q

How can we use contrast scans to see kidney dysfunction?

A
  • initial - no contrast may be taken up due to the blockage, whereas normal side takes contrast
  • after some time - dysfunctional side still has contrast (not cleared by excretion) whereas the normal side has none (bladder has contrast due to working kidney excretion)
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15
Q

What is the purpose of the urinary bladder?

A

Muscular reservoir of urine

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16
Q

What lines the detrusor muscle?

A

Waterproof urothelium - a transitional epithelium

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17
Q

Describe the shape of the urinary bladder and where it resides anatomically.

A
  • when empty it is a pelvic organ, when distended it is an abdomino-pelvic organ
  • an empty bladder is a 4-sided pyramid in shape and has 4 angles - apex, neck and 2 lateral angles
  • it has 4 surfaces - base/posterior surface, 2 infero-lateral surfaces and a superior surface
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18
Q

What are the three layers of the urinary bladder?

A
  • outer loose connective tissue
  • middle smooth muscle and elastic fibres (detrusor)
  • inner layer lined with transitional epithelium
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19
Q

What is the blood supply of the urinary bladder?

A
  • superior and inferior vesical branches of internal iliac artery
  • drained by vesical plexus which drains into internal iliac vein
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20
Q

What is the lymphatic drainage of the urinary bladder?

A

Internal iliac nodes and then para-aortic nodes

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21
Q

What is the nerve supply to the urinary bladder?

A

Autonomic nervous system

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22
Q

Where does the urethra carry urine from in the female urinary tract?

A

Urethra carries urine from bladder to the external urethral meatus in the vaginal vestibule (urethra 3-4cm long)

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23
Q

Describe the external urethral sphincter (and its nervous supply) in the female urinary tract.

A
  • skeletal muscle
  • tonic contraction and also voluntary ‘guarding’
  • controlled by pudendal nerve
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24
Q

What is the blood supply of the female urinary tract?

A

Internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage

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25
Q

What is the lymphatic drainage of the female urinary tract?

A
  • proximal urethra into internal iliac nodes
  • distal urethra into superficial inguinal lymph nodes
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26
Q

What is the nerve supply to the female urinary tract?

A
  • proximal - vesical plexus
  • distal - pudendal nerve
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27
Q

What does the male urinary tract have that the female urinary tract does not?

A

Prostate gland

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28
Q

What is the role of the bladder neck in the male urinary tract?

A
  • a sphincter which stays shut except when voiding (urinating)
  • stays constricted during ejaculation to prevent urination
  • controlled by the sympathetic nervous system
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29
Q

Where is the prostate?

A
  • gland lying below the bladder in the male and surrounds the proximal part of the urethra
  • measures 4x3x2cm and conical in shape
  • connected to bladder by connective tissue
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30
Q

What are the three lobes of the prostate?

A
  • left lateral lobe
  • middle lobe
  • right lateral lobe
31
Q

What is the function of the prostate?

A

Secretes 75% of the seminal fluid which liquifies coagulated semen after deposition in the female genital tract

32
Q

Describe the external urethral sphincter (and its nerve supply) of the male urinary tract.

A
  • tonic contraction / guarding
  • opens for ejaculation
  • controlled by pudendal nerve
33
Q

Describe the blood supply of the male urinary tract (prostate and urethra).

A
  • prostate - inferior vesical artery
  • urethra - bulbourethral artery and internal pudendal artery
  • corresponding venous drainage
34
Q

Describe the lymphatic drainage of the male urinary tract.

A
  • prostatic and membranous urethra –> obturator and internal iliac nodes
  • spongy urethra –> deep and superficial inguinal nodes
35
Q

Describe the nerve supply to the male urinary tract.

A
  • proximal - vesical plexus
  • distal - pudendal nerve
36
Q

What is normal micturition?

A

Intermittent voiding of urine stored in bladder

37
Q

What are the two phases of micturition and describe them?

A
  • storage (sympathetic):
    • bladder (detrusor) relaxed, serving as reservoir
    • external sphincter (outlet) contracted, preventing leaks
  • voiding (parasympathetic):
    • bladder contracting, expelling the urine
    • external sphincter (outlet) relaxed, permitting flow
    • bladder should empty fully (<50ml ‘post void residual’)
    • 6 pees daily, 20 seconds each = 2 mins per day spent voiding
38
Q

What is the role of the prefrontal cortex in micturition?

A
  • prefrontal cortex permits the pontine micturition centre in the brainstem to change from storage mode to voiding
  • this activates the parasympathetic nucleus (bladder contraction) and inhibits Onuf’s nucleus (sphincter relaxation)
39
Q

Describe the physiology of micturition in adults.

A
  1. periaqueductal gray (PAG) - receives sensory information from viscera (subconscious) and decides what goes to cortex (conscious)
  2. frontal cortex - decides actions based on planning ahead, social appropriateness etc
  3. pontine micturition centre (PMC - controlled by prefrontal cortex) - coordinates spinal centres; storage switches to voiding only if permitted
  4. sacral S2-S4 (parasympathetic nucleus –> detrusor contraction, Onuf’s nucleus inhibition –> sphincter relaxation) + thoracic T10-L2 (sympathetic nucleus - bladder neck of male)
40
Q

What is the difference between micturition in infants and in adults?

A
  • infants - micturition is a local spinal reflex in which bladder empties on reaching a critical pressure (hence potty training needed)
  • adults - voiding can be initiated or inhibited by higher centre control of the external urethral sphincter keeping it closed until it is appropriate to urinate
41
Q

Which urinary structures get sympathetic innervation from L1-L2? (3)

A
  • kidney
  • testicle
  • bladder neck
42
Q

What urinary tract structures do the pudendal nerve (S2-S4) supply? (2)

A
  • penis
  • vaginal vestibule/clitoris
43
Q

Describe the innervation of micturition and its process.

A
  • bladder has M3 muscarinic receptors that work with parasympathetic fibres S2-S4, which are stretched and stimulated as the bladder fills
  • this results in contraction of the detrusor muscle for urination
  • at the same time, parasympathetic fibres inhibit the internal urethral sphincter causing relaxation and allows for bladder emptying
  • when bladder empties, stretch fibres become inactivated
  • sympathetic nervous system (originating T10-L2) is stimulated to activate the beta 3 receptors
  • this causes relaxation of the detrusor muscle allowing the bladder to fill again
44
Q

What are the autonomic receptor drug targets of the bladder neck?

A

Alpha-adrenergic (alpha1) –> alpha blocker e.g. tamsulosin

45
Q

What are the autonomic receptor drug targets of the detrusor?

A
  • cholinergic M3/M2 –> antimuscarinic e.g. oxybutynin, solifenacin
  • beta-adrenergic beta3 agonist e.g. mirabegron
46
Q

What are the autonomic receptor drug targets for erectile issues?

A

Nitrergic e.g. PDE5 inhibitor

47
Q

What does the International Continence Society define incontinence as?

A

Any involuntary loss of urine

48
Q

Define stress urinary incontinence.

A

Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing

49
Q

What are the incidence rates of stress urinary incontinence and who does it affect more?

A
  • can affect up to 40% of women
  • more common in older women - 1/5 women over 40 have some degree of stress incontinence
50
Q

What are the risk factors for stress urinary incontinence? (5)

A
  • aging
  • obesity (increases intra-abdominal pressure)
  • smoking
  • pregnancy (puts pressure on pelvic floor)
  • route of delivery
51
Q

Describe the pathology of stress urinary incontinence.

A
  • impaired bladder and urethral support, and impaired urethral closure
  • usually when you sneeze/cough no leaking occurs as external urethral sphincter is closed
  • in stress incontinence, the sphincter is not closed so coughing/sneezing/increased intra-abdominal pressure causes leak
52
Q

What are the signs and symptoms of stress urinary incontinence?

A

Involuntary leakage of urine from urethra with exertion/effort, or sneezing/coughing

53
Q

What investigations do we do for stress urinary incontinence?

A
  • history and examination, descent of pelvic floor on vaginal examination, positive stress test (visible loss of urine on inspection)
  • urodynamics - urinary leakage during an increase in intra-abdominal pressure in the absence of detrusor contraction (when patient coughs, you see spike in intra-abdominal Pa, spike in bladder Pa but no bladder contraction, and urine flow)
54
Q

How do we manage stress urinary incontinence? (4)

A
  • non-surgical: physiotherapist teaching pelvic floor muscle exercises
  • surgical:
    • sling placed to support urethra (mid-urethral sling)
    • colposuspension - using anterior vaginal wall to support urethra, reduces how much bladder moves when intra-abdominal Pa increases
    • periurethral bulking injection - injected around sphincter to obstruct it to prevent leakage
55
Q

Define overactive bladder (urgency, +/- urgency incontinence)

A

Urinary urgency, usually with urinary frequency and nocturia, +/- urgency urinary incontinence

56
Q

What is the incidence of overactive bladder?

A

Overall prevalence of 16.6% in men and women over 40

57
Q

What are the risk factors for overactive bladder? (5)

A
  • age
  • prolapse
  • increased BMI
  • bladder irritants (caffeine, nicotine, alcohol - increase urination)
  • IBS
58
Q

Describe the pathology of overactive bladder.

A
  • not well understood
  • involuntary ‘overactive’ detrusor (bladder wall) muscle contractions
  • cause can be idiopathic or neurogenic (loss of CNS inhibitory pathways)
59
Q

What are the signs and symptoms of overactive bladder? (6)

A
  • urgency
  • frequency
  • nocturia
  • urgency incontinence
  • impact on QoL - sleep disruption
  • anxiety and depression
60
Q

What do we assess for in males vs females in overactive bladder?

A
  • assess for enlarged prostate in males (can cause obstruction)
  • assess for prolapse in women (urethra sits in anterior vaginal wall, if this prolapses urethra is dragged down to form obstruction)
61
Q

How do we investigate overactive bladder? (4)

A
  • exclude infection with urine dip/MSU
  • bladder diary
  • bladder scan (post-void residual)
  • urodynamics - storage phase has detrusor overactivity (should be inactive) with incontinence (should be no urine flow)
62
Q

How do we manage overactive bladder? (7)

A
  • behavioural/lifestyle changes
  • bladder retraining
  • antimuscarinic drugs (block M3 = relax detrusor e.g. oxybutinin)
  • beta-3 agonist (relax detrusor)
  • bladder injections with botox (paralyse bladder)
  • neuromodulation
  • augmentation cystoplasty

Oxybutinin can however cause overflow incontinence

63
Q

What is benign prostatic hyperplasia?

A
  • non-malignant growth or hyperplasia of prostate tissue
  • common cause of lower urinary tract symptoms in men
  • outward enlargement can be felt with rectal exam
64
Q

Describe the incidence of benign prostatic hyperplasia in men of different ages?

A
  • increases with advancing age
  • 50-60% for males in their 60s
  • 80-90% for males 70+
65
Q

What risk factor is there for benign prostatic hyperplasia?

A

Hormonal effects of testosterone on prostate tissue

66
Q

Describe the pathology of benign prostatic hyperplasia.

A
  • enlargement of the prostate due to hyperplasia/hypertrophy of both lateral lobes and the medial lobe –> compression of the urethra –> bladder outflow obstruction (reduction in urinary stream)
  • you would see hyperplasia of the stroma (smooth muscle and fibrous tissue) and glands
  • some men experience relatively little urethral compression, as the prostate enlargement goes outwards into the rectum rather than inwards
67
Q

What are the signs and symptoms of benign prostatic hyperplasia? (5)

A
  • hesitancy in starting urination
  • poor stream (intermittent flow)
  • dribbling post-micturition
  • can present with acute retention
  • frequency, nocturia
68
Q

What other causes could there be instead of benign prostatic hyperplasia that we need to exclude? (4)

A
  • bladder cancer (haematuria)
  • prostate cancer (raised PSA)
  • UTIs / prostatitis
  • urethral stricture
69
Q

What investigations (including bloods and imaging) do we do for benign prostatic hyperplasia? (7)

A
  • urine dipstick/culture
  • post-void residual
  • bladder diary
  • bloods - PSA
  • imaging - ultrasound to assess upper renal tracts
  • urinary flow studies/urodynamics
  • cystoscopy if concerned about bladder cancer
70
Q

What lifestyle changes do we suggest for benign prostatic hyperplasia? (3)

A
  • weight loss
  • reduce caffeine and fluid intake in evening
  • avoid constipation - puts added pressure
71
Q

What medical treatments are there for benign prostatic hyperplasia, and how do they work? (2)

A
  • alpha blocker - alpha1 receptors on prostate stromal smooth muscle and bladder neck and blockage results in relaxation –> improved flow e.g. tamsulosin
  • 5-alpha-reductase inhibitor - prevents conversion of testosterone into dihydrotestosterone (which promotes prostate growth) so slowly results in shrinkage = improved flow and obstructive symptoms e.g. finasteride
72
Q

What surgical intervention is there for benign prostatic hyperplasia?

A

Transurethral resection of the prostate (TURP) - debulks prostate to produce adequate channel for urine to flow, can also be done with laser (not the same as radical prostatectomy for cancer)

73
Q

What are some complications of benign prostatic hyperplasia?

A
  • progressive bladder distention causing chronic painless retention and overflow incontinence
  • if undetected can lead to bilateral upper tract obstruction and renal impairment with patient presenting with chronic renal disease

Year 2 - BRS (84 decks)

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