B8.041 The Bladder and Prostate

Question 1

what is the ureter

Answer 1

25-30 cm muscular tubes tubes that undergo peristalsis

carry urine from renal pelvis to the bladder

Question 2

are the ureters intra or retroperitoneal

Answer 2

retroperitoneal

Question 3

where do the ureters enter the pelvis

Answer 3

cross the pelvic brim near the bifurcation of the common iliac into external and internal arteries

Question 4

how do the ureters enter the bladder

Answer 4

on the posterolateral surface
enter at an oblique angle
junction = ureterovesicular junction

Question 5

function of oblique pathways of ureter through bladder wall

Answer 5

natural one way valve

-lets urine into the bladder but doesn’t transfer pressure (or urine) back up the ureters

Question 6

positioning of the ureters relative to male structures

Answer 6

run under and lateral to the ductus deferens at the bladder junction (water under the bridge)

Question 7

movement of kidneys and testes during development

Answer 7

metanephric kidney rises to posterior abdominal wall while the testis drops into the scrotum

Question 8

positioning of the ureters relative to female structures

Answer 8

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

Question 9

common sites of ureter damage

Answer 9

1. pelvic brim (where it crosses the common iliac)
2. beneath uterine artery
3. near ureterovesicular junction

Question 10

what are kidney stones (renal calculi)

Answer 10

can be released from kidney and lodge and disrupt urine flow

Question 11

common sites for stones to get stuck

Answer 11

1. ureteropelvic junction
2. as ureters cross pelvic brim
3. ureterovesicular junction (where ureters pass into bladder)

Question 12

treatment of kidney stones

Answer 12

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)

Question 13

epidemiology of duplication of ureters

Answer 13

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

Question 14

pathophys of duplicated ureters

Answer 14

ureteric bud either splits or arises twice

in most cases, kidney is divided into two parts (upper and lower lobe) with some intermingling

Question 15

bifid ureter

Answer 15

slips between bladder and kidney

Question 16

bladder relationship

Answer 16

lies under the peritoneal membrane

-extraperitoneal

Question 17

bladder location

Answer 17

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

Question 18

newborn bladder

Answer 18

fusiform in shape

extends in abdominal cavity up into the umbilicus

Question 19

movement of bladder in childhood

Answer 19

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

Question 20

exstrophy of the bladder

Answer 20

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

Question 21

what is AFP

Answer 21

glycoprotein produced by the yolk sac, allantois, and the liver during fetal development
fetal form of albumin

Question 22

function of AFP

Answer 22

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

Question 23

conditions with elevated AFP

Answer 23

omphalocele
gastroschisis
HCC
neural tube defects
nonseminomatous germ cell tumors
youlk sac tumor
exstrophy of the bladder

Question 24

pathophys of patent urachus

Answer 24

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)

Question 25

urachal cyst

Answer 25

small fluid filled cyst superior to the bladder and inferior to the umbilicus (43% of urachal anomalies)

Question 26

urachal sinus

Answer 26

remnant of the urachus that connects to the umbilicus | 35% of urachal anomalies

Question 27

urachal diverticulum

Answer 27

develops off the apex of the bladder typically goes unnoticed (2% of urachal anomalies)

Question 28

symptoms of urachal fistula

Answer 28

leaking of urine and periumbilical inflammation

Question 29

typical progression of the urachus

Answer 29

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

Question 30

epidemiology of urachal defects in general

Answer 30

1-1.6% of population | males more frequent

Question 31

symptoms of persistent urachal anomalies

Answer 31

continuous bladder and urine drainage around the umbilicus recurrent UTI urachal carcinoma (rare)

Question 32

how to treat urachal defects

Answer 32

surgical resection

Question 33

describe the anatomy of the bladder

Answer 33

smooth muscular vessel | inner surface of the mucosa is thrown into folds, rugae, except for the trigone

Question 34

detrusor

Answer 34

smooth muscle of the wall of the bladder

Question 35

trigone

Answer 35

triangular area between the two ureters opening and the internal urethral opening

Question 36

innervation of detrusor

Answer 36

predominantly parasympathetic causes contraction of the bladder wall, thus increasing internal pressure and causing micturation if the urethral sphincters are open

Question 37

space of Retzius

Answer 37

retropubic space between pubic symphysis and bladder | normally filled with loose connective tissue

Question 38

how is the internal urethral sphincter kept closed

Answer 38

smooth muscle fibers and elastic fibers | closed it bladder has less than 250 mL of urine

Question 39

parasympathetic innervation of bladder

Answer 39

S2,3,4 pelvic splanchnic nerves innervate mainly the detrusor muscle via inferior hypogastric plexus some innervation of internal urethral sphincter

Question 40

sympathetic innervation of bladder

Answer 40

T11, L1,2 vesicle nerve plexus innervates mainly the internal urethral sphincter via superior hypogastric plexus

Question 41

bladder contraction

Answer 41

parasympathetic

Question 42

bladder retention

Answer 42

sympathetic

Question 43

purpose of sympathetic discharge at emission/ejaculation

Answer 43

prevents retroejaculation of semen into the bladder

Question 44

function of internal urethral sphincter

Answer 44

keeps urine in bladder prevents retroejaculation in males sympathetic system maintains tonic contractions parasympathetics relax muscle during micturation

Question 45

external urethral sphincter

Answer 45

under learned, voluntary control formed by compressor urethra muscle (both males and females) and urethrovaginal sphincter muscle (females only) innervated by pudendal nerve (somatic)

Question 46

sphincter innervation

Answer 46

``` internal = sympathetic (a lil para) external = pudendal (voluntary) ```

Question 47

paruresis

Answer 47

inability to urinate in the presence of others | due to sympathetic discharge causing closure of internal urethral sphincter

Question 48

when do adults feel bladder fullnes

Answer 48

300 mL of urine | stretch receptors appear to return information via sym and para pathways (para most important) as the bladder fills

Question 49

what initiates the feeling of bladder fullness

Answer 49

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

Question 50

potty training

Answer 50

learning to override the reflex to keep sphincters, especially the external sphincter, closed against periodic contractions of the detrusor

Question 51

prevalence of incontinence

Answer 51

77% of incontinent patients are women | 88% of all incontinent patients have stress incontinence

Question 52

stress incontinence

Answer 52

problem with the closing mechanism of the urinary tract outlet (urethral sphincter most important)

Question 53

result of stress incontinence

Answer 53

involuntary leakage while sneezing, coughing, laughing, or lifting heavy weights

Question 54

epidemiology of stress incontinence

Answer 54

common in women, esp following childbirth

Question 55

treatment of stress incontinence

Answer 55

Kegels estrogen a agonists

Question 56

use of a agonists in stress incontinence

Answer 56

increase contractions of the smooth muscle at the neck of the bladder help increase sphincter strength and may improve symptoms

Question 57

MMK procedure for stress incontinence

Answer 57

bladder neck suspension | adds support to bladder neck and urethra, reducing the risk of stress incontinence

Question 58

urge incontinence

Answer 58

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

Question 59

solifenacin

Answer 59

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

Question 60

overflow incontinence

Answer 60

in patients who's bladder no longer contracts properly, thus have a constantly full bladder and tend to constantly dribble catheterization may help

Question 61

who gets overflow incontinence

Answer 61

diabetics who lost autonomic innervation to the bladder males who suffer BPH blockage of urethra with a kidney or bladder stone

Question 62

a-1 adrenergic blockers in overflow incontinence

Answer 62

relax smooth muscle contraction within the prostate to reduce prostatic urethral resistance

Question 63

bethanechol in overflow incontinence

Answer 63

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

Question 64

automatic reflex bladder

Answer 64

bladder response of an infant | seen in those w spinal cord damage > complete transection of the spinal cord above the sacral segments

Question 65

ureter pain

Answer 65

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

Question 66

male bladder blood supply

Answer 66

superior vesicle arteries: off medial umbilical artery (branch of internal iliac) inferior vesicular arteries: supply fundus and neck

Question 67

female bladder blood supply

Answer 67

superior vesicle arteries: off medial umbilical artery (branch of internal iliac) vaginal arteries: supply lower portion

Question 68

vesicouterine pouch

Answer 68

peritoneal space between bladder and uterus

Question 69

rectouterine pouch (of Douglas)

Answer 69

peritoneal space behind the uterine/vaginal junction and anterior to the rectum lowest point in pelvic cavity in females

Question 70

retrovesical fossa

Answer 70

peritoneal space between the bladder and the rectum | lowest point in pelvic cavity in males

Question 71

paravesical fossa

Answer 71

peritoneal reflection on each side of the bladder (only present when bladder is distended)

Question 72

pararectal fossa

Answer 72

peritoneal reflection on each side of the rectum

Question 73

vas deferens course

Answer 73

35 cm long, 3 mm in diameter 1. begins at the tail of the epididymis 2. ascends the spermatic cord 3. passes through inguinal canal 4. crosses the external iliac vessels 5. passes along the lateral pelvic wall before moving medially, stays extraperitoneal 6. widens into an ampulla which lies just superior to the seminal vesicles 7. joins the seminal vesicle ducts to form the common ejaculatory ducts

Question 74

vasovasectomy

Answer 74

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

Question 75

seminal vesicles positioning

Answer 75

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

Question 76

function of seminal vesicles

Answer 76

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

Question 77

what is in the seminal vesicle secretion

Answer 77

1. fructose 2. prostaglandins (stimulate smooth muscle contraction in female repro tract to aid in sperm transport) 3. proteins responsible for semen coagulation 4. ascorbic acid

Question 78

prostate gland

Answer 78

exocrine gland below bladder does not contain a true organ connective tissue around it branching tubular alveolar glands embedded in fibromuscular connective tissue

Question 79

function of prostate

Answer 79

secretes 0.5 mL of thin, opalescent fluid in first portion of ejaculate

Question 80

components of prostate secretion

Answer 80

PAP PSA spermine fibrinolysin

Question 81

prostatic acid phosphatase

Answer 81

may enhance the infectivity of HIV in semen

Question 82

prostate specific antigen

Answer 82

serine protease responsible for liquefaction of semen upon standin and liquefaction of cervical mucus produced by both normal and malignant cells

Question 83

spemrine

Answer 83

oxidation responsible for musk odor of semen | antibacterial properties

Question 84

fibrinolysin

Answer 84

responsible for liquefaction of semen (with PSA)

Question 85

where do sperm and seminal vesicle secretions enter the urethra

Answer 85

within the prostatic urethra | between internal urethral sphincter and external urethral sphincter

Question 86

zones of prostate

Answer 86

transition (5%) central (25%) peripheral (70%) periurethral (small)

Question 87

periurethral zone (+transitional)

Answer 87

mucosal gland, smallest region lies immediately around urethra resistant to inflammation and carcinoma, but the site of BPH

Question 88

peripheral zone

Answer 88

70% of prostate | site of prostate cancer

Question 89

what does prostate cancer feel like

Answer 89

local bump or lump

Question 90

what does BPH feel like

Answer 90

general enlargement of the gland