B8.041 The Bladder and Prostate Flashcards
what is the ureter
25-30 cm muscular tubes tubes that undergo peristalsis
carry urine from renal pelvis to the bladder
are the ureters intra or retroperitoneal
retroperitoneal
where do the ureters enter the pelvis
cross the pelvic brim near the bifurcation of the common iliac into external and internal arteries
how do the ureters enter the bladder
on the posterolateral surface
enter at an oblique angle
junction = ureterovesicular junction
function of oblique pathways of ureter through bladder wall
natural one way valve
-lets urine into the bladder but doesn’t transfer pressure (or urine) back up the ureters
positioning of the ureters relative to male structures
run under and lateral to the ductus deferens at the bladder junction (water under the bridge)
movement of kidneys and testes during development
metanephric kidney rises to posterior abdominal wall while the testis drops into the scrotum
positioning of the ureters relative to female structures
pass inferior to the uterine artery but superior to the vaginal arteries
-important bc uterine artery is often clamped during hysterectomies, have to be careful not to damage the ureter
common sites of ureter damage
- pelvic brim (where it crosses the common iliac)
- beneath uterine artery
- near ureterovesicular junction
what are kidney stones (renal calculi)
can be released from kidney and lodge and disrupt urine flow
common sites for stones to get stuck
- ureteropelvic junction
- as ureters cross pelvic brim
- ureterovesicular junction (where ureters pass into bladder)
treatment of kidney stones
may be dislodged by increased fluid intake
invasive option: cystoscope and ureteroscope used to endoscopically grasp or break up the stone
increasingly, smooth muscle relaxants are being used (tamsulosin)
epidemiology of duplication of ureters
most common renal abnormality occurs in 1% of the population found in 8% of children with recurrent UTIs more common in caucasians more common in females
pathophys of duplicated ureters
ureteric bud either splits or arises twice
in most cases, kidney is divided into two parts (upper and lower lobe) with some intermingling
bifid ureter
slips between bladder and kidney
bladder relationship
lies under the peritoneal membrane
-extraperitoneal
bladder location
anteriorly - symphysis pubis
posteriorly - rectum in males, and the uterus and part of the vagina in females
inferiorly - prostate in males, pelvic diaphragm in females
newborn bladder
fusiform in shape
extends in abdominal cavity up into the umbilicus
movement of bladder in childhood
by age 6, generally the bladder is located in the greater pelvis
as bladder recedes into the greater pelvis, it leaves behind the median umbilical fold over the urachus conncted to the umbilicus
by puberty, empty bladder lies in the true pelvis
exstrophy of the bladder
failure of abdominal wall closure during fetal development
protrusion of the anterior portion of the bladder wall through the lower abdominal wall
cover with film and irrigate with diaper changes until surgery can be performed
what is AFP
glycoprotein produced by the yolk sac, allantois, and the liver during fetal development
fetal form of albumin
function of AFP
measured in pregnant women through the analysis of maternal blood or amniotic fluid
screens for a subset of developmental abnormalities
“triple screen” at 16-19 wks
conditions with elevated AFP
omphalocele gastroschisis HCC neural tube defects nonseminomatous germ cell tumors youlk sac tumor exstrophy of the bladder
pathophys of patent urachus
on rare occasion, the urachus can re-canalize (in infants or the elderly) leading to a dribbling of urine from the umbilicus
(20% of urachal anomalies)
urachal cyst
small fluid filled cyst superior to the bladder and inferior to the umbilicus
(43% of urachal anomalies)
urachal sinus
remnant of the urachus that connects to the umbilicus
35% of urachal anomalies
urachal diverticulum
develops off the apex of the bladder
typically goes unnoticed
(2% of urachal anomalies)
symptoms of urachal fistula
leaking of urine and periumbilical inflammation
typical progression of the urachus
usually seals off and obliterates around the 12th week of gestation and all that is left is a small fibrous cord between the bladder and umbilicus called the median umbilical ligament
epidemiology of urachal defects in general
1-1.6% of population
males more frequent
symptoms of persistent urachal anomalies
continuous bladder and urine drainage around the umbilicus
recurrent UTI
urachal carcinoma (rare)
how to treat urachal defects
surgical resection
describe the anatomy of the bladder
smooth muscular vessel
inner surface of the mucosa is thrown into folds, rugae, except for the trigone
detrusor
smooth muscle of the wall of the bladder
trigone
triangular area between the two ureters opening and the internal urethral opening
innervation of detrusor
predominantly parasympathetic
causes contraction of the bladder wall, thus increasing internal pressure and causing micturation if the urethral sphincters are open
space of Retzius
retropubic space between pubic symphysis and bladder
normally filled with loose connective tissue
how is the internal urethral sphincter kept closed
smooth muscle fibers and elastic fibers
closed it bladder has less than 250 mL of urine
parasympathetic innervation of bladder
S2,3,4
pelvic splanchnic nerves
innervate mainly the detrusor muscle via inferior hypogastric plexus
some innervation of internal urethral sphincter
sympathetic innervation of bladder
T11, L1,2
vesicle nerve plexus
innervates mainly the internal urethral sphincter via superior hypogastric plexus
bladder contraction
parasympathetic
bladder retention
sympathetic
purpose of sympathetic discharge at emission/ejaculation
prevents retroejaculation of semen into the bladder
function of internal urethral sphincter
keeps urine in bladder
prevents retroejaculation in males
sympathetic system maintains tonic contractions
parasympathetics relax muscle during micturation
external urethral sphincter
under learned, voluntary control
formed by compressor urethra muscle (both males and females) and urethrovaginal sphincter muscle (females only)
innervated by pudendal nerve (somatic)
sphincter innervation
internal = sympathetic (a lil para) external = pudendal (voluntary)
paruresis
inability to urinate in the presence of others
due to sympathetic discharge causing closure of internal urethral sphincter
when do adults feel bladder fullnes
300 mL of urine
stretch receptors appear to return information via sym and para pathways (para most important) as the bladder fills
what initiates the feeling of bladder fullness
stretch receptors stimulate a spinal reflex arch, causing parasympathetic nerve firing, leading to contraction of the wall of the bladder
this causes urination if the bladder wall contraction is sufficiently strong to open the internal urethral sphincter
potty training
learning to override the reflex to keep sphincters, especially the external sphincter, closed against periodic contractions of the detrusor
prevalence of incontinence
77% of incontinent patients are women
88% of all incontinent patients have stress incontinence
stress incontinence
problem with the closing mechanism of the urinary tract outlet (urethral sphincter most important)
result of stress incontinence
involuntary leakage while sneezing, coughing, laughing, or lifting heavy weights
epidemiology of stress incontinence
common in women, esp following childbirth
treatment of stress incontinence
Kegels
estrogen
a agonists
use of a agonists in stress incontinence
increase contractions of the smooth muscle at the neck of the bladder
help increase sphincter strength and may improve symptoms
MMK procedure for stress incontinence
bladder neck suspension
adds support to bladder neck and urethra, reducing the risk of stress incontinence
urge incontinence
need to urinate more than 7x a day or 2x at night
common in older adults
treatment: anticholinergics to inhibit parasympathetic stimulation of the detrusor muscle contractions
solifenacin
competitive muscarinic subtype 3 ACh receptor antagonist
reduced smooth muscle tone in the bladder, allowing the bladder to retain larger volumes of urine, thus reducing number of bladder contractions, urgency, and incontinent episodes
overflow incontinence
in patients who’s bladder no longer contracts properly, thus have a constantly full bladder and tend to constantly dribble
catheterization may help
who gets overflow incontinence
diabetics who lost autonomic innervation to the bladder
males who suffer BPH
blockage of urethra with a kidney or bladder stone
a-1 adrenergic blockers in overflow incontinence
relax smooth muscle contraction within the prostate to reduce prostatic urethral resistance
bethanechol in overflow incontinence
parasympathomimetic choline ester that selectively stimulates muscarinic receptors without any effect on nicotinic receptors
longer duration of action than ACh bc not broken down by cholinesterase
stimulate smooth muscle contractions
automatic reflex bladder
bladder response of an infant
seen in those w spinal cord damage > complete transection of the spinal cord above the sacral segments
ureter pain
carried in a general visceral afferent that returns to the spinal cord along sympathetic nerve to T11-L1
usually referred to the ipsilateral lower quadrant of the abdomen, esp to groin/external genitalia
male bladder blood supply
superior vesicle arteries: off medial umbilical artery (branch of internal iliac)
inferior vesicular arteries: supply fundus and neck
female bladder blood supply
superior vesicle arteries: off medial umbilical artery (branch of internal iliac)
vaginal arteries: supply lower portion
vesicouterine pouch
peritoneal space between bladder and uterus
rectouterine pouch (of Douglas)
peritoneal space behind the uterine/vaginal junction and anterior to the rectum
lowest point in pelvic cavity in females
retrovesical fossa
peritoneal space between the bladder and the rectum
lowest point in pelvic cavity in males
paravesical fossa
peritoneal reflection on each side of the bladder (only present when bladder is distended)
pararectal fossa
peritoneal reflection on each side of the rectum
vas deferens course
35 cm long, 3 mm in diameter
- begins at the tail of the epididymis
- ascends the spermatic cord
- passes through inguinal canal
- crosses the external iliac vessels
- passes along the lateral pelvic wall before moving medially, stays extraperitoneal
- widens into an ampulla which lies just superior to the seminal vesicles
- joins the seminal vesicle ducts to form the common ejaculatory ducts
vasovasectomy
reversal of vasectomy
reanastomosis and opening of cut and sealed vasal ends
pregnancy rates lower than expected, likely due to antisperm antibodies which develop with increased frequency since time of vasectomy
seminal vesicles positioning
posterior to fundus of the bladder and anterior to the rectum, superior to the prostate
help form ejaculatory ducts
lie inferior to ampulla of vas deferens
function of seminal vesicles
secrete 2 mL of viscous, slightly yellow fluid which is present in highest concentration in last half of the ejaculate
help wash sperm out of the urethra
what is in the seminal vesicle secretion
- fructose
- prostaglandins (stimulate smooth muscle contraction in female repro tract to aid in sperm transport)
- proteins responsible for semen coagulation
- ascorbic acid
prostate gland
exocrine gland below bladder
does not contain a true organ connective tissue around it
branching tubular alveolar glands embedded in fibromuscular connective tissue
function of prostate
secretes 0.5 mL of thin, opalescent fluid in first portion of ejaculate
components of prostate secretion
PAP
PSA
spermine
fibrinolysin
prostatic acid phosphatase
may enhance the infectivity of HIV in semen
prostate specific antigen
serine protease responsible for liquefaction of semen upon standin and liquefaction of cervical mucus
produced by both normal and malignant cells
spemrine
oxidation responsible for musk odor of semen
antibacterial properties
fibrinolysin
responsible for liquefaction of semen (with PSA)
where do sperm and seminal vesicle secretions enter the urethra
within the prostatic urethra
between internal urethral sphincter and external urethral sphincter
zones of prostate
transition (5%)
central (25%)
peripheral (70%)
periurethral (small)
periurethral zone (+transitional)
mucosal gland, smallest region
lies immediately around urethra
resistant to inflammation and carcinoma, but the site of BPH
peripheral zone
70% of prostate
site of prostate cancer
what does prostate cancer feel like
local bump or lump
what does BPH feel like
general enlargement of the gland
