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Obstetrics and Gynaecology > Disorders of the urinary tract > Flashcards

Disorders of the urinary tract Flashcards

1
Q

What is normal lower urinary tract function dependant on?

A

Adequate bladder capacity during the filling phase of the cycle and a competent urethral sphincter.

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2
Q

What is the voiding phase dependent on?

A

Detrusor contractility and coordinated urethral relaxation

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3
Q

How much fluid can the bladder hold and when do you get the urge to go?

A

It can hold about 500mL but you get the first urge to urinate at 200mL.

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4
Q

What is the role of parasympathetic and sympathetic nerves in voiding?

A

Parasympathetic nerves aid voiding, sympathetic nerves prevent it.

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5
Q

What makes up the voiding reflex?

A

It consists of afferent fibres, which respond to distension of the bladder wall and pass to the spinal cord. Efferent parasympathetic fibres pass back to the detrusor muscle and cause contraction. They also enable bladder neck opening. Efferent sympathetic fibres to the detrusor muscle are inhibited.

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6
Q

What controls the micturition reflex?

A

It is controlled by the level of the pons. The cerebral cortex modifies the reflex and can relax or contract the pelvic floor and the striated muscle of the uterus

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7
Q

What is continence dependent on?

A

It is dependent on the pressure in the urethra being greater than the bladder.

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8
Q

What is bladder pressure influenced by?

A

Detrusor pressure and external (intra-abdominal) pressure.

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9
Q

What is urethral pressure influenced by?

A

The inherent urethral muscle tone and also by external pressure, namely the pelvic floor and, normally, intra-abdominal pressure

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10
Q

How does the detrusor muscle affect bladder pressure?

A

The detrusor muscle is expandable; as the bladder fills, there is no increase in pressure.

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11
Q

How do increases in abdominal pressure affect bladder and urethra pressure?

A

Increases in abdominal pressure such as coughing will be transmitted equally to the bladder and upper urethra because both lie within the abdomen. Normally, therefore, coughing does not alter the pressure difference and does not lead to incontinence

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12
Q

When does micturition occur?

A

It results when bladder pressure exceeds urethral pressure. This occurs voluntarily by a simultaneous drop in urethral pressure (pelvic floor relaxation) and an increase in bladder pressure due to detrusor muscle contraction

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13
Q

What are the two main causes of female incontinence?

A

Uncontrolled increases in detrusor pressure and increased intra-abdominal pressure.

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14
Q

What is the most common cause of uncontrolled increases in detrusor pressure?

A

Overactive bladder or urge incontinence

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15
Q

What is uncontrolled increases in detrusor pressure?

A

Increasing bladder pressure beyond that of the normal urethra

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16
Q

What is increased intra-abdominal pressure?

A

Increased intra-abdominal pressure transmitted to the bladder but not the urethra because the upper urethra neck has slipped from the abdomen. Bladder pressure therefore excess urethral pressure when intra-abdominal pressure is raised

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17
Q

What is the most common cause of increased intra-abdominal pressure?

A

Urinary stress incontinence

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18
Q

What are some general common urinary symptoms?

A

Urinary incontinence; daytime frequency; nocturia; nocturnal enuresis; urgency; bladder pain; urethral pain; dysuria; haematuria

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19
Q

What is urinary incontinence?

A

The complaint of involuntary urinary leakage, which can be divided, broadly, into stress incontinence and urge incontinence

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20
Q

What is daytime frequency?

A

The number of times a woman voids during her waking hours. This should normally be between 4 and 7 voids per day but increased frequency is all personal to what is normal for that patient.

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21
Q

What is nocturia?

A

Having to wake at night one or more times to void. Up to 70 years old, once per night is normal

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22
Q

What is nocturnal enuresis?

A

Urinary incontinence occurring during sleep

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23
Q

What is urgency?

A

Sudden compelling desire to pass urine, which is difficult to deter. Usually caused by detrusor overactivity or UTI’s

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24
Q

What is bladder pain?

A

It can be felt suprapubically or retropubically. Typically pain occurs with bladder filling and is relieved by emptying it. May be indicative of malignancy

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25
Q

What is dysuria?

A

Pain experienced in the bladder or urethra on passing urine. Associated with UTI

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26
Q

What investigations can be performed in urinary tract pathologies?

A

Urine dipstick; urinary diary; postmicturition ultrasound or catheterisation; urodynamic studies (cystometry); ultrasonography; methylene dye test; cystoscopy

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27
Q

What is urinary stress incontinence?

A

Involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Can only be confirmed after OAB is excluded

28
Q

What is the difference between urinary stress incontinence and urodynamic stress incontinence?

A

Urodynamic stress incontinence is when urinary stress incontinence is confirmed on urodynamic studies.

29
Q

What is the most common cause of urinary stress incontinence?

A

It commonly arises as a result of urethral sphincter weakness

30
Q

What are the risk factors/causes of urinary stress incontinence?

A

Pregnancy and vaginal delivery, particularly prolonged labour and forceps delivery, obesity and age (particularly postmenopausal).

31
Q

What is the mechanism of urinary stress incontinence (long answer)?

A

Increase in intra-abdominal pressure (stress), the bladder is compressed and increased pressure. If the bladder neck has slipped below the pelvic floor because the support is weak, it will not be compressed and its pressure remains unchanged. If the rest of the urethra and the pelvic floor are unable to compensate, the bladder pressure exceeds urethral pressure and incontinence results.

32
Q

What investigations would you do on urinary incontinence?

A

bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies

33
Q

What would you advise to the patient when managing urinary stress incontinence?

A

If obese, the patient is encouraged to lose weight. Should reduce excessive fluid intake

34
Q

What is the aim of conservative urinary stress incontinence management?

A

It is aimed at strengthening the pelvic floor.

35
Q

What is first line conservative treatment of urinary stress incontinence?

A

Pelvic floor muscle training (PFMT) for at least 3 months and is taught by a physio.

36
Q

What is pelvic floor muscle training?

A

It should consist fat least eight contractions, three times per day. If it is beneficial then continue an exercise programme.

37
Q

What are vaginal ‘cones’ and how do they work?

A

They are used to alleviate incontinence adequately in more than half of patients. The ‘cones’ are inserted into the vagina and held in position by voluntary muscle contraction. Increasing sizes are used as muscle strength increases.

38
Q

What drug would you use to treat urinary stress incontinence?

A

Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:

  1. bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
  2. bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’
  3. mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

If stress incontinence is predominant:

  1. pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
  2. surgical procedures:
    - colposuspension
    - autologous rectus fascial sling
    - mid-urethral mesh sling procedures
39
Q

What type of drug is duloxetine and how does it work?

A

A serotonin and noradrenaline reuptake inhibitor (SNRI) that enhances urethral striated sphincter activity via a centrally mediated pathway.

40
Q

When would you consider surgery for urinary stress incontinence?

A

It can be considered when conservative measures have failed and the woman’s quality of life is compromised.

41
Q

What is the definition of overactive bladder?

A

Urgency, with or without urge incontinence, usually with frequency or nocturia, in the absence of proven infection.

42
Q

What is detrusor overactivity?

A

A urodynamic diagnosis characterised by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked by, for instance, coughing

43
Q

What is the mechanism of incontinence in overactive bladder?

A

The detrusor contraction is normally felt as urgency. If strong enough, it causes the bladder pressure to overcome the urethral pressure and the patient leaks This can occur spontaneously or with provocation (a running tap).

44
Q

What are the symptoms of overactive bladder?

A

Urgency and urge incontinence, frequency and nocturia are usual. Stress incontinence is common. Some patients leak at night or at orgasm.

45
Q

What will a urinary diary show with overactive bladder?

A

Frequent passage of small volumes of urine, particularly at night, and may show high intake of caffeine-containing drinks such as tea/coffee or colas.

46
Q

What would cystometry show with overactive bladder?

A

It demonstrates contractions on filling or provocation. Occasionally, the bladder pressure merely rises steadily with filling.

47
Q

What simple advice would you give to manage overactive bladder?

A

Reduce fluid intake, avoid caffeine. try diuretics and antipsychotics

48
Q

What does bladder training consist of ?

A

[1] Education
[2] Timed voiding with systematic delay in voiding
[3] Positive reinforcement
The women is asked to resist the urgency and void according to the timetable

49
Q

How do anticholinergics work to treat overactive bladder?

A

They suppress detrusor overactivity by blocking the muscarininc receptors that mediates detrusor smooth muscle contraction, relaxing the detrusor muscle

50
Q

What is a side effect of anticholinergics?

A

Dry mouth

51
Q

What symptoms does vaginally administered oestrogen treat?

A

Urgency, urge incontinence, frequency and nocturia

52
Q

How does botulinum toxin A treat overactive bladder?

A

It blocks the neuromuscular transmission, causing the affected muscle to become weak.

53
Q

What is the most common treatment for overactive bladder?

A

Anticholinergics

54
Q

What can be done surgically to treat overactive bladder?

A

Electrical stimulation
Transcutaneous sacral nerve stimulation (TENS)- provide continuous stimulation of the S3 nerve root via an implanted electrical pulse generator and improves the ability to suppress detrusor contractions.

55
Q

What are the causes of incontinence?

A 
Stress incontinence (50%)
Overactive bladder (35%)
Mixed
Overflow incontinence
Fistulae
Unknown
56
Q

What are the causes of urgency and frequency?

A 
Urinary infection
Bladder pathology
Pelvic mass compressing the bladder
Overactive bladder
Urodynamic stress incontinence
57
Q

What is acute urinary retention?

A

The patient is unable to pass urine for 12h or more.

58
Q

What are the causes of acute urinary retention?

A

Childbirth, particularly with epidural; vulval or perineal pain (herpes simplex); surgery; drugs (anticholinergics); pelvic masses; neurological disease; UTI

59
Q

Why does urinary overflow/chronic retention occur?

A

Leaking occurs because bladder over distension eventually causes overflow.

60
Q

What are some causes of urinary overflow/chronic retention?

A

Either urethral obstruction (pelvic mass and incontinence surgery) or detrusor inactivity (autonomic neuropathies e.g. diabetes, previous over distension of the bladder)

61
Q

What are the clinical features of urinary overflow/chronic retention?

A

Presentation may mimic stress incontinence or urinary loss may be continuous

62
Q

What would you find on examination of chronic retention?

A

A distended non-tender bladder

63
Q

How do you manage chronic retention?

A

Intermittent self-catheterisation is commonly required

64
Q

What is painful bladder syndrome?

A

A condition in which a patient experiences suprapubic pain related to bladder filling, accompanied by other symptoms such as frequency, in the absence of UTI or other obvious pathology.

65
Q

What is interstitial cystitis?

A

Patients with painful bladder symptoms who have characteristic cystoscopic and histological features.

66
Q

What is the treatment for interstitial cystitis?

A

Dietary changes, bladder training, tricyclic antidepressants, analgesic and intravesical infusion of various drugs

67
Q

What are fistulae?

A

Abnormal connections between the urinary tract and other organs. The most common are vesciovaginal and urethrovaginal fistulae.

Obstetrics and Gynaecology (27 decks)

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