Incon Reg Flashcards
Female ureter
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
Female ureter lymphatics
Left ureter drains into left para-aortic nodes, right ureter drains into right paracaval and interaortocaval lymph nodes
Female bladder
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
Female bladder blood supply
Superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein
Female bladder lymphatics
Internal iliac nodes and then paraaortic nodes
Female urethra
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
Female urethra blood supply
Internal pudendal arteries and inferior vesical branches of vaginal arteries with corresponding venous drainage
Female urethra lymphatics
Proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes
Female urethra nerve supply
Vesical plexus and pudendal nerve
Male bladder
Venous drainage by prostatic venous plexus which drains into internal iliac vein
Male prostate blood supply
Inferior vesical artery, venous drainage via prostatic plexus to the vesical plexus and internal iliac vein
Male prostate nerve supply
Autonomic nervous system
Male prostate lymphatics
Internal and sacral nodes
Male urethra
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
Male urethra blood supply
Prostatic-inferior vesical artery, membranous-bulbourethral artery and spongy urethra - internal pudendal artery with corresponding venous drainage
Male urethra lymphatics
Prostatic and membranous urethra drain to obturator and internal iliac nodes, spongy urethra drains to deep and superficial inguinal nodes
Male urethra nerve supply
Prostatic plexus
Filling phase
Bladder fills and distends without rise in intravesical pressure. Urethral sphincter contracts and closes urethra
Inner action of micturition
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
Stress urinary incontinence risk factors
Aging Obesity Smoking Pregnancy Route of delivery
Stress urinary incontinence pathology
Impaired bladder and urethral support and impaired urethral closure
Stress urinary incontinence investigations
History and examination,positive stress test
Urodynamics-urinary leakage during an increase in intrabdominal pressure in the absence of detrusor contraction
Stress urinary incontinence management
Non surgical-physio with PFE
Surgical mid urethral sling, colposuspension, periurethral bulking agents
Overactive bladder
Urinary urgency, usually with urinary frequency and nocturnal, with or without urgency, urinary incontinence
Overactive bladder incidence
Overall prevalence of 16.6% in men and women over 40
Overactive bladder risk factors
Age Prolapse Increased BMI IBS bladder irritants
Overactive bladder pathology
Involuntary detrusor muscle contractions
Cause can be idopathic, neurogenic or bladder outlet obstruction
Overactive bladder investigations
Exclude infection with urine dip/MSU Voiding dairy Assess post void residual Urodynamics Cystoscopy
Overactive bladder management
Lifestyle change Bladder retraining Antimuscarinic drugs Beta 3 agonist Botox Neuromodulation Surgical - augmentation cystoplasty and urinary diversion
Overflow incontinence
Involuntary leaks of urine when bladder is full. Usually due to chronic retention secondary to obstruction or an atonic bladder
Overflow incontinence pathology
Outlet obstruction Under active detrusor muscle Bladder neck stricture Urethral stricture DHx-alpha adrenergics, anticholinergics, sedative Bladder denervation following surgery
Benign prostatic hyperplasia
Non malignant growth of hyperplasia of prostate tissue, common cause of lower urinary tract symptoms in men
Benign prostatic hyperplasia incidence
Increases with age
50-60% for males in 60’s
Increasing to 80-90% for those over 70 years of age
Benign prostatic hyperplasia risk factors
Hormonal effects of testosterone on prostate tissue
Benign prostatic hyperplasia pathology
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
Benign prostatic hyperplasia symptoms
Hesitancy in starting urination Poor stream Dribbling post micturition Frequency, nocturia Possibly acute retention
Benign prostatic hyperplasia other causes for symptoms
Bladder/prostate cancer Cauda equina High pressure chronic retention UTI Urethral stricture
Benign prostatic hyperplasia investigations
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
Benign prostatic hyperplasia management
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
Benign prostatic hyperplasia complications
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
