Incon Reg

Question 1

Female ureter

Answer 1

Convey urine from kidneys to urinary bladder
Each about 25cm long upper half in abdomen and lower in pelvis
3mm in diameter but slightly constricted at 3 places - pelvic ureteric junction, pelvic brim, through bladder wall)
3 layers of tissue - outer fibrous tissue, middle muscle layer, inner epithelium layer

Question 2

Female ureter lymphatics

Answer 2

Left ureter drains into left para-aortic nodes, right ureter drains into right paracaval and interaortocaval lymph nodes

Question 3

Female bladder

Answer 3

Muscular reservoir of urine
Pelvic organ when empty
When distended rises up to abdominal cavity and becomes abdomino-pelvic organ
Empty bladder is 4 sided pyramid and has 4 angles (apex, neck, 2 lateral angles) and 4 surfaces - base/posterior surface, 2 inferolateral surfaces and a superior surface
3 layers - outer loose connective tissue, middle smooth muscle and elastic fibres and inner layer lined with transitional epithelium

Question 4

Female bladder blood supply

Answer 4

Superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein

Question 5

Female bladder lymphatics

Answer 5

Internal iliac nodes and then paraaortic nodes

Question 6

Female urethra

Answer 6

Channel from neck of bladder (internal urethral sphincter-detrusor muscle thickened, smooth muscle, involuntary control) to exterior at external urethral orifice (external urethral sphincter-skeletal muscle, voluntary control)
3-4cm long

Question 7

Female urethra blood supply

Answer 7

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

Question 8

Female urethra lymphatics

Answer 8

Proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes

Question 9

Female urethra nerve supply

Answer 9

Vesical plexus and pudendal nerve

Question 10

Male bladder

Answer 10

Venous drainage by prostatic venous plexus which drains into internal iliac vein

Question 11

Male prostate blood supply

Answer 11

Inferior vesical artery, venous drainage via prostatic plexus to the vesical plexus and internal iliac vein

Question 12

Male prostate nerve supply

Answer 12

Autonomic nervous system

Question 13

Male prostate lymphatics

Answer 13

Internal and sacral nodes

Question 14

Male urethra

Answer 14

20cm, run through neck of bladder, prostate gland, floor of pelvis and perineal membrane to the penis and external urethral orifice at tip of male penis
3 parts - prostatic, membranous and spongy

Question 15

Male urethra blood supply

Answer 15

Prostatic-inferior vesical artery, membranous-bulbourethral artery and spongy urethra - internal pudendal artery with corresponding venous drainage

Question 16

Male urethra lymphatics

Answer 16

Prostatic and membranous urethra drain to obturator and internal iliac nodes, spongy urethra drains to deep and superficial inguinal nodes

Question 17

Male urethra nerve supply

Answer 17

Prostatic plexus

Question 18

Filling phase

Answer 18

Bladder fills and distends without rise in intravesical pressure. Urethral sphincter contracts and closes urethra

Question 19

Inner action of micturition

Answer 19

M3 receptors (parasympathetic S2-S4) are stimulated as bladder fills
As they become stretched and stimulated this results in contraction of the detrusor muscle for urination
Parasympathetic fibres inhibit the internal urethral sphincter which causes relaxation and allows for bladder emptying
When bladder empties of urine the stretch fibres become inactivated, and the sympathetic nervous system (originating T11-L2) is stimulated to activate the beta 3 receptors causing relaxation of detrusor muscle allowing bladder to fill again

Question 20

Stress urinary incontinence risk factors

Answer 20

Aging
Obesity
Smoking
Pregnancy
Route of delivery

Question 21

Stress urinary incontinence pathology

Answer 21

Impaired bladder and urethral support and impaired urethral closure

Question 22

Stress urinary incontinence investigations

Answer 22

History and examination,positive stress test

Urodynamics-urinary leakage during an increase in intrabdominal pressure in the absence of detrusor contraction

Question 23

Stress urinary incontinence management

Answer 23

Non surgical-physio with PFE

Surgical mid urethral sling, colposuspension, periurethral bulking agents

Question 24

Overactive bladder

Answer 24

Urinary urgency, usually with urinary frequency and nocturnal, with or without urgency, urinary incontinence

Question 25

Overactive bladder incidence

Answer 25

Overall prevalence of 16.6% in men and women over 40

Question 26

Overactive bladder risk factors

Answer 26

Age
Prolapse
Increased BMI
IBS
bladder irritants

Question 27

Overactive bladder pathology

Answer 27

Involuntary detrusor muscle contractions

Cause can be idopathic, neurogenic or bladder outlet obstruction

Question 28

Overactive bladder investigations

Answer 28

Exclude infection with urine dip/MSU
Voiding dairy
Assess post void residual
Urodynamics
Cystoscopy

Question 29

Overactive bladder management

Answer 29

Lifestyle change 
Bladder retraining 
Antimuscarinic drugs
Beta 3 agonist 
Botox
Neuromodulation 
Surgical - augmentation cystoplasty and urinary diversion

Question 30

Overflow incontinence

Answer 30

Involuntary leaks of urine when bladder is full. Usually due to chronic retention secondary to obstruction or an atonic bladder

Question 31

Overflow incontinence pathology

Answer 31

Outlet obstruction
Under active detrusor muscle
Bladder neck stricture
Urethral stricture
DHx-alpha adrenergics, anticholinergics, sedative
Bladder denervation following surgery

Question 32

Benign prostatic hyperplasia

Answer 32

Non malignant growth of hyperplasia of prostate tissue, common cause of lower urinary tract symptoms in men

Question 33

Benign prostatic hyperplasia incidence

Answer 33

Increases with age
50-60% for males in 60’s
Increasing to 80-90% for those over 70 years of age

Question 34

Benign prostatic hyperplasia risk factors

Answer 34

Hormonal effects of testosterone on prostate tissue

Question 35

Benign prostatic hyperplasia pathology

Answer 35

Hyperplasia of both lateral lobes and median lobes, leading to compression of urethra and therefore bladder outflow obstruction. See hyperplasia of storms (smooth muscle and fibrous tissue) and glands

Question 36

Benign prostatic hyperplasia symptoms

Answer 36

Hesitancy in starting urination 
Poor stream 
Dribbling post micturition
Frequency, nocturia
Possibly acute retention

Question 37

Benign prostatic hyperplasia other causes for symptoms

Answer 37

Bladder/prostate cancer
Cauda equina 
High pressure chronic retention 
UTI
Urethral stricture

Question 38

Benign prostatic hyperplasia investigations

Answer 38

Urine dipstick, post void residual, voiding diary
Bloods - prostate specific antigen - if concerned about prostate cancer
Imaging - ultrasound to assess upper renal tracts
Flow studies/urodynamics
Cystoscopy if concerned about cancer

Question 39

Benign prostatic hyperplasia management

Answer 39

Lifestyle - weight loss, reduce caffeine and fluid intake in evening, avoid constipation

Medical

• 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 - 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

Surgery - transurethral resection of the prostate (TURP)-debulks prostate to produce adequate channel for urine to flow

Question 40

Benign prostatic hyperplasia complications

Answer 40

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