GU System And Beningn Prostatic Hyperplasia Flashcards
What is the female GU system composed of?
2 kidneys, 2 ureters, urinary bladder and urethra
What are the main functions of the kidneys
Remove waste products of metabolism, excess water and salts from the blood and maintain the pH
What is the function of the ureters
Convey urine from the kidneys to the urinary bladder
Outline the anatomy of the ureters
Each one is about 25cm long, upper half lies in abdomen and lower half in pelvis.
•Measures 3mm in diameter but slightly constricted at 3 places (pelvic ureteric junction, pelvic brim, as it passes through the bladder wall).
•Ureters 3 layers of tissue-outer fibrous tissue, middle muscle layer and inner epithelium layer.
What blood supply do the ureters recieve?
related to region: renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage.
Outline the lymphatic drainage of the ureters?
left ureter drains into left para-aortic nodes, right ureter drains into right paracaval and interaortocaval lymph nodes
From where do the ureters receive their nerve supply?
Autonomic nervous system
What is the urinary bladder?
Muscular reservoir of urine
How does the placement of the urinary bladder change depending on how full the bladder is?
When empty, bladder is pelvic organ, when distended it rises up to abdominal cavity and becomes an abdomino-pelvic organ.
Outline the shape of an empty urinary bladder
An empty bladder is a 4 sided pyramid in shape and has 4 angles-apex, neck and 2 lateral angles and 4 surfaces-base/posterior surface, 2 inferiolateral surfaces and a superior surface.
What are the three layers of the urinary bladder?
Has 3 layers: outer loose connective tissue, middle smooth muscle and elastic fibres and inner layer lined with transitional epithelium.
What blood supply does the female urinary bladder recieve? how does this differ from the blood supply in males?
Supplied by superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein
In males the venous drainage is via the prostatic venous plexus which drains into internal iliac vein
What is the lymphatic supply to the female urinary bladder?
Internal iliac nodes and then paraaortic nodes
What nerve supply innervates the female urinary bladder?
Autonomic nervous system
What is the female urethra?
is the channel from neck of bladder (internal urethral sphincter-detrusor muscle thickened, smooth muscle, involuntary control) to the exterior, at the external urethral orifice (external urethral sphincter-skeletal muscle, voluntary control).
How long is the female urethra?
3-4cm
From where does the female urethra recieve its blood supply?
Internal pudendal arteries and inferior vesicle branches of the vaginal arteries with corresponding venous drainage
From where does the female urethra recieve its lymphatic drainage?
proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes
From where does the proximal female urethra recieve its lymphatic drainage?
Into internal iliac nodes
From where does the distal female urethra recieve its lymphatic drainage?
To superficial inguinal lymph nodes
What nerve supply innervates the female urethra?
Vesicle plexus and the pudendal nerve
What is the male GU system composed of?
composed of 2 kidneys, 2 ureters, urinary bladder, prostate and uretha.
From where does the male bladder receive its blood supply?
Supplied by superior and inferior vesical branches of internal iliac artery
Venous drainage via prostatic venous plexus which drains into internal iliac vein
What is the prostate gland?
Gland lying below the bladder in the male and surrounds the proximal part of the urethra (prostatic urethra)
What is the function of the prostate gland?
To secrete 75% of seminal fluid which liquifies coagulated semen after deposition in the female genital tract
How is the prostate gland connected to the bladder
Via connective tissue
What are the three parts of the prostate gland?
Left lateral lobe, right lateral lobe, middle lobe
From where does the prostate gland receive its blood supply?
inferior vesical artery, venous drainage via prostatic plexus to the vesical plexus and internal iliac vein.
What is the lymphatic supply to the prostate gland?
Internal and sacral nodes
What nerve supply does the prostate gland receive?
Autonomic nervous system
Outline the anatomy of the male urethra
20 cm long, runs through neck of bladder, the prostate gland, the floor of pelvis and the perineal membrane to the penis and external urethral orifice at the tip of the male penis
Hat are the three parts of the male urethra?
Prostatic, membranous and spongy urethra
From where does the male urethra receive its blood supply?
Prostatic-inferior vesicular artery, membranous-bulbourethral artery and spongy urethra-internal pudendal artery with corresponding venous drainage
What is the lymphatic supply to the male urethra?
Prostatic and membranous urethra drain into obdurate and internal iliac nodes, spongy urethra drains to deep and superficial inguinal nodes
What nerve supply does the male urethra receive?
Prostatic plexus
What is normal micturition?
The intermittent voiding of urine stored in the bladder
What happens in the filling phase of micturition?
Bladder fills and distends without rise in intravesical pressure. Urethral sphincter contract and closes urethra
what happens during the voiding phase of micturition?
Bladder contracts and expels urine, urethral sphincter relaxes and urethra opens
What is the difference in the physiology of micturition between adults and infants?
In infants micturition is a local spinal reflex in which bladder empties on reaching a critical pressure.
In adults voiding can be initiated or inhabited by higher centre control of the external urethral sphincter keeping it closed until it is appropriate to urinate
How does micturition become innervated?
The M3 receptors (parasympathetic S2-S4) are stimulated as the bladder fills.
•As they become stretched and stimulated this results in contraction of the detrusor muscle for urination.
•At the same time the parasympathetic fibres inhibit the internal urethral sphincter which causes relaxation and allows for bladder emptying.
As the bladder fills, which receptors on which nerves are stimulated?
M3 receptors on parasympathetic S2-S4
What happens to the stretch fibres in the bladder when it empties of urine? how does this affect the detrusor muscle?
Become inactivated, the sympathetic nervous system (T11-L2) is stimulated to active the beta 3 receptors causing relaxation of the detrusor muscle allowing the bladder to fill again
Which nerves are involved in the stimulation of beta 3 receptors causing relaxation of the detrusor muscle?
Sympathetic nerves from T11-L2
The sympathetic nerves from T11-L2 activate which receptors to cause relaxation of the detrusor muscle, what does this allow?
Activate beta-3 receptors causing relaxation of the detrusor muscle allowing the bladder to fill again
Define stress urinary incontinence?
Compliant of involuntary leakage on effort or exertion, or on sneezing or coughing
what is the incidence of stress urinary incontinence?
can affect up to 40% of women, more common in older women, with 1 in 5 women over 40 having some degree of stress incontinence
What risk factors are associated with stress urinary incontinence?
Aging, obesity, pregnancy and route of delivery
What is the pathology behind stress urinary incontinence?
impaired bladder and urethral support and impaired urethral closure
What are the signs and symptoms of stress urinary incontinence?
Involuntary leakage from urethra with exertion/effort or sneezing or coughing
What investigations are made into stress urinary incontinence?
History and examination, positive stress test (demonstrable loss of urine on examination)
urodynamics-urinary leakage during an increase in intrabdominal pressure in the absence of a detrusor contraction
What are the management options for stress urinary incontinence?
Non surgical-physio with PFE
•Surgical-mid urethral sling, colposuspension, periurethral bulking agents
What is the definition of Overactive bladder (Urge Urinary incontinence)
urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence
What is the incidence of urge urinary incontinence?
16.6% in men and women over 40
What risk factors are associated with urge urinary incontinence?
Age, prolapse, increased BMI, IBS, bladder irritants (caffeine, nicotine)
What is the pathology behind urge urinary incontinence?
not well understood. Involuntary detrusor (bladder wall) muscle contractions. Cause can be idiopathic, neurogenic (loss of central nervous system inhibitory pathways) or bladder outlet obstruction
What are the signs and symptoms associated with urge urinary incontinence?
urgency, frequency, nocturia and urgency incontinence, impact on QOL-sleep disorders, anxiety and depression.
Assess for enlarge prostate in males and prolapse in women
What investigations are made into urge urinary incontinence>?
•exclude infection with urine dip/MSU
•voiding diaries
•assess post void residual
•Urodynamics
•cystoscopy
What are the management options for urge urinary incontinence?
•Behavioural/lifestyle changes
•Bladder retraining
•Antimuscarinic drugs
•Beta-3 agonists
•BOTOX
•Neuromodulation (PTNS/SNS)
•Surgical:Augmentation cystoplasty and urinary diversion
What is overflow incontinence?
Involuntary leakage of urine when bladder is full. Usually due to chronic retention secondary to obstruction or an atonic bladder
What can cause overflow incontinence?
Outlet obstruction (faecal impaction/BPH)
Underactive detrusor muscle
Bladder neck stricture
Urethral stricture
DHx-alpha adrenergics, anticholinergics, sedative
Bladder denervation following surgery
What is continuous incontinence?
Continuous loss of urine all the time. Could be due to vesicovaginal fistula, ectopic ureter(from kidney to urethra or vagina)
What is functional incontinence?
due to severe cognitive impairment or mobility limitations, preventing use of the toilet. Bladder function is normal
Define benign prostatic hyperplasia
non malignant growth or hyperplasia of prostate tissue, common cause of lower urinary tract symptoms in men
What is the incidence of benign prostatic hyperplasia?
increases with advancing age, 50-60% for males in their 60’s, increasing to 80-90% for those over 70yrs of age
What risk factors are associated with BPH?
hormonal effects of testosterone on prostate tissue
Outline the pathology behind BPH
hyperplasia of both lateral lobes and the median lobes, leading to compression of the urethra and therefore bladder outflow obstruction. See hyperplasia of the stroma (smooth muscle and fibrous tissue) and glands
What are the signs and symptoms of BPH?
hesitancy in starting urination
•poor stream
•dribbling post micturition
•frequency, nocturia
•can present with acute retention
What can be the other causes that cause the same symptoms as BPH?
Bladder/prostate cancer
Cauda equina
High pressure chronic retention
Urinary tract infections/sexually transmitted infections
Prostatitis
Neurogenic bladder (can be secondary to Parkinson’s, Multiple sclerosis, etc.)
Urinary tract stones (bladder stones)
Urethral stricture
What investigations are made into BPH?
Investigations: urine dip/MCS, post void residual, voiding diary
What blood testing is done for BPH?
Bloods:Psa-prostate specific antigen-shown to predict prostate volume-use with caution, if concerned about prostate cancer
What imaging is done for BPH?
ultrasound to assess upper renal tracts
Other than urine dips, bloods and imaging, what other investigations are made into BPH?
Flow studies/urodynamics
Cystoscopy if concerned about cancer
What are the lifestyle management options for BPH?
Lifestyle: weight loss, reduce caffeine and fluid intake in evening, avoid constipation
What are the medical management options for BPH?
alpha blocker-alpha 1-AR present on prostate stromal smooth muscle and bladder neck. Blockage results in relaxation , thus improving urinary flow rate
5-alpha reductase inhibitor-prevents conversation of test to DHT (which promotes growth and enlargement of prostate) so results in shrinkage, thereby improving urinary flow rate and obstructive symptoms
What are the surgical management options for BPH?
Surgery: transurethral resection of the prostate (TURP)-debulks prostate to produce adequate channel for urine to flow
What complications are associated with BPH?
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
