Irene's Incontinence Flashcards
Where is the external urethral meatus in males?
At the tip of the glans of the penis
Where do ureters enter the bladder?
At the superolateral margins of the trigone
Where are the four parts of the male urethra?
The urethra leaving the bladder is the pre-prostatic urethra, the part which passes through prostate is prostatic urethra, the part which passes through the deep perineal pouch is the membranous urethra and the part passing through the body of the penis (made of corpus spongiosum tissue) is the spongy urethra
What do bulbourethral glands do?
Lubricate the male urethra
What is the fold of peritoneum sandwiched between uterus and bladder called?
Vesicouterine pouch
What is the smooth muscle of the scrotum called?
Dartos muscle, covered in dartos fascia
How is the dartos muscle innervated?
Sympathetic fibres accompanying the genital branch of the genitofemoral nerve
Where is the superior hypogastric plexus located, what does it turn into?
Within the abdomen at the bifurcation of the aorta, the superior hypogastric plexus descends into the pelvis and bifurcates as the right and left hypogastric nerves
Where is the iliac tubercle?
Lateral to the iliac crest
Where is the bladder in relation to the peritoneum?
Inferior
Which blood vessels supply the bladder?
The vesical vessels which are branches of the internal iliac vessels
Where do ilium, ischium and pubis join?
Acetabulum (socket of femur)
What does urogenital hiatus allow passage of in the female?
Urethra and vagina
Which artery supples pelvis?
Internal iliac artery
What is the apex of the bladder attached to in males and females?
The umbilicus via the median umbilical ligament
Where is the bladder covered in peritoneum in both sexes?
On the superior surface
How does deep perineal pouch relate to levator ani?
It is inferior
What is the name of the pouch behind the seminal vesicles in males and what does it do?
The pouch of peritoneum is called the ‘retrovesical’ pouch and it separates bladder and rectum
What bounds the false, or greater, pelvis?
The space enclosed by the pelvic girdle above and in front of the pelvic brim. It is bounded on either side by the ilium; in front it is incomplete, presenting a wide interval between the anterior borders of the ilia.
Where is the external urethral sphincter located?
In the urogenital diaphragm, in the deep perineal pouch
What does duasteride cause?
Inhibition of androgen- stimulated prostatic hyperplasia
Which sphincter do only males have and why?
The internal urethral sphincter is only present in males and constricts during ejaculation to prevent semen from entering the bladder
Name a muscarinic antagonist
Oxybutynin
What is the inner layer of the superficial fascia of the perineum called?
Colle’s fascia
When is most essential diagnostic information obtained in the consultation?
During the patient interview
Which muscle plugs the gap between piriformis and levator ani at the back of the pelvic floor?
Coccygeus
What does the puboprostatic ligament do in males?
It is continuous with the pubovesical ligament above but instead of wrapping round the urethra it wraps around the prostate
Where does the urethra leave the bladder?
Inferiorly at the inferior margin of trigone
Which two strong ligaments anchor the sacrum into place where do they arise from?
Sacrospinous arising from ischial spine and sacrotuberous and ischial tuberosity respectively
How does the female ureter get from kidney to bladder?
From lateral wall of the pelvis it passes OVER the external iliac artery then turns medially and crosses OVER the obliterated umbilical artery then it passes UNDER the uterine artery before finally reaching the bladder
Where is the major effect of urinary incontinence?
On a patient’s social life
Which structures pierce the deep perineal pouch?
Urethra in males and females but not the anal canal
What is parasympathetic innervation to the bladder?
Pelvic plexus
What is sympathetic innervation to the bladder?
Hypogastric plexus
Where is the prostate in relation to the urogenital hiatus?
Superior
Describe the course of the pudendal nerve as it enters the perineum.
Out of the pelvis laterally through the greater sciatic foramen, then enters the perineum by passing through the lesser sciatic foramen along the lower border of obturator internus where it is enclosed in a sheath of fascia known as the pudendal canal.
How does the bladder act as a valve to prevent urine reflux without actually having a physical anatomical valve?
When the bladder contracts the muscular wall closes the opening of ureters into the bladder
What makes up the lateral, anterior wall of the pelvis?
Obturator internus
What causes male LUTS most often?
Prostate hypertrophy
Where is the pouch of Douglas?
The ‘rectouterine’ pouch or pouch of Douglas is a fold of peritoneum which is posterior to the uterus and upper vagina and sandwiched between them and the rectum
What is the median umbilical ligament derived from embryologically?
The urachus
Which nervous plexuses ultimately supply the pelvic organs? Where are they?
Right and left inferior hypogastric plexuses (with both sympathetic and parasympathetic inputs) which lie either side of the rectum
Where do the urethra (as well as prostate in males and vagina in females lie)?
In the urogenital hiatus in front of the perineal body
What is the part of the bony pelvis that a person sits on?
Ischial tuberosity
What bony features does the ischium have?
A spine and a tuberosity and a ramus which fuses with that of the inferior ramus of the pubis so is the ischiopubic
What does the internal urethral sphincter do?
Prevents semen reflux
What does the sacrotuberous ligament join?
Ischial tuberosity
By what degree is the pelvic inlet tilted?
60 degrees
What are the triangles of the perineum?
They are formed by drawing an imaginary line between the ischial tuberosities. Anteriorly, the triangle is the urogenital triangle and posteriorly is the anal triangle
What causes the urothelium to have such low permeability?
Uroplakin plaques
What kind of joint is the sacroiliac joint?
Synovial
How does the male ureter get from kidney to bladder?
From lateral wall of the pelvis it passes OVER the external iliac artery then turns medially and crosses OVER the obliterated umbilical artery then it passes UNDER the ductus deferns before finally reaching the bladder
What is the inferior fascia of the deep perineal pouch called?
Perineal membrane
Where does the anal canal lie?
Between perineal and anococcygeal bodies
Where are the muscles surrounding urethra and vagina located?
In deep perineal pouch
Where do the pelvic floor muscles arise from mainly?
The fascia that lines the obturator internus and nearby bony areas
What divides urogenital hiatus and anal sphincter?
Perineal body
What is a blunter?
Patients who prefer less information to be given during the consultation
How does sperm reach the urethra?
Via ejaculatory ducts which enter the prostatic urethra posteriorly
What is the principle blood supply to the pelvis?
The internal iliac artery
What do Skene’s glands do?
Lubricate the urethra in females
What does ductus deferens insert into?
Ejaculatory ducts
What is the sympathetic contribution to the inferior hypogastric plexuses?
Mostly from the superior hypogastric plexus, which is purely sympathetic.
What can benign prostatic hypertrophy be treated with?
A1 antagonist
What is the main function of puborectalis?
Sling around the anorectal junction to pull it forwards and aid rectal continence
What glands are behind the bladder in the male?
The seminal vesicles
Which artery gives supply to prostate and seminal vesicles in men?
The inferior vesicle
Where is micturition centre located?
In the brainstem, in the pons
Which arteries supply the bladder?
Vesical arteries from the internal iliac
What is the name of the spaces either side of the anal canal?
Ischioanal fossae
What does rho kinase do?
Inhibits myosin phosphtase
What is somatic innervation to the external urethral sphincter?
Pudendal nerve
What is the superficial fasica of the scrotum?
Dartos fascia
Where does the piriformis muscle run?
Arises from the sacrum and passes out through the greater sciatic foramen
Which nerves supply the bladder?
Parasympathetic nerves (pelvic-splanchnic nerves) from S2-S4
Which part of the bladder does not contract?
Trigone
Name an A1 selective inhibitor
Silodosin
What kind of muscle are internal and external urethral sphincters made of?
External is skeletal, internal is smooth
What is the name of the region inferior to pelvic floor muscles?
Perineum
How does the venous supply in the pelvis compare to the arterial supply?
The veins match the pattern of the arteries but form major plexuses around some organs like prostate gland and rectum
What are the most important receptors in causing detrusor contraction?
M3
What kind of urethra does the bulb of the penis contain?
Spongy
Which bend in the male cannot be straightened?
The bend at the penile bulb
Where is the perineal body in relation to the deep pouch?
On the posterior border
What bony feature divides sciatic notches?
Ischial spine
What is the posterior lateral muscular margin of the pelvis?
Piriformis
Why must we be careful when inserting a catheter in males?
It may catch on the valvula fossae navicularis, which is a fold of mucosa that hangs down inside the external urethral orifice, producing pain
What constricts the urethra in females?
External urethral sphincter, compressor urethrae and sphincter urethrovaginalis
What is levator ani?
A transverse sheet of skeletal muscle formed of iliococcygeus, pubococcygeus and puborectalis
What muscle controls micturition in females?
The external urethral sphincter
Which muscles together are known as the pelvic diaphragm?
Coccygeus and levator ani
What forms the medial posterior part of the pelvis brim?
Promontory of the sacrum
What is the urogenital hiatus?
The gap at the front of the deep perineal pouch that allows passage of nerves and blood vessels
Where does the superior hypogastric plexus receive supply from?
Upper lumbar contributions from the intermesenteric plexus as well as from L3 and L4 splanchnic nerves
Which ligaments join hip bone to sacrum?
Sacroiliac
Which nerves innervate levator ani?
Perineal branch of S3 and S4 and the pudendal nerve (S2, 3, 4) which supplies the pelvic floor from below
What are the two superficial fascia layers of the anterior abdominal wall?
Camper’s fascia is the outer fatty layer and Scarpa’s fascia is the inner membranous layer
Where are the two places that the male urethra bends, making catheterisation more difficult?
- When the flaccid penis hangs down it creates a bend in the urethra, this can be easily fixed by lifting the penis to make a straight line for the catheter
- Between bulb of penis and deep perineal pouch, this cannot be corrected so the catheter must be gently guided around it.
How does the uterus relate to the bladder?
It is tilted forwards onto the superior surface of the bladder and connected to the vagina
Where is the external urethral meatus in females?
In the vestibule of the vulva, between the two labia minoria anterior to the opening of the vagina
In who is the pubourethral ligament found?
In females only
What is the major benefit to the doctor of good communication?
Reduced conflict and litigation
Which nerves supply pelvic floor?
S3/4
Why are females more prone to cystitis than males?
They have a shorter urethra
What are pelvic floor muscles anchored to?
Arcus tendineus
What prevents urinary reflex?
Passive occlusion by pressure at the vesicoureteric junction
What is the large hole between pubis and ischium called?
Obturator foramen
Describe the course of the ducts involved in semen production in males.
The ducts of seminal vesicles join to the ducts of the testes (ductus deferens) which are located above the seminal vesicles and this forms the ejaculatory duct. This duct enters the posterior wall of the prostate gland and then into the prostatic urethra.
Why can enlargement of the prostate in males lead to incomplete emptying of the bladder?
The prostate gland is inferior to the bladder and may push the bladder up if enlarged resulting in stagnant pools of urine
Give three branches of the pudendal nerve and where they supply.
Inferior rectal nerve to the external anal sphincter and anal skin.
Perineal nerve to scrotum, urethra, the labia
The dorsal nerve to penis/clitoris
What is the issue with information given to patients about their condition?
Too complex
What does cAMP cause in smooth muscle?
Inhibition of Ca2+ influx
Where does the bladder sit in the females?
Directly above the deep perineal pouch
What does the deep perineal pouch lie between?
The ischial tuberosities and the pubic symphysis
Which part of levator ani includes the anal sphincter?
Puborectalis
What does Ley’s cognitive model claim?
Patient satisfaction depends on patient understanding
What do the sacrospinous and sacrotuberous ligaments do?
Prevent sacrum tilting too much
How is bladder fullness detected?
Stretch of urothelial cells
What are the wings of the sacrum?
The ala
What is the perineum?
The region below the pelvic floor containing anal canal, urethra and vagina in females.
Which nerves control the internal urethral sphincter?
Sympathetic nerves L1-L2
What bony spines does the ilium have?
The anterior superior iliac spine and the anterior inferior iliac spine
When is information from a consultation best recalled?
Early or late in consultation
Which muscle moves the urethra towards the vagina?
Compressor urethrae
What does the pelvic girdle consist of?
Ilium, ischium and pubis
Where are the seminal vesicles located?
Behind the bladder
Name a B3 specific antagonist
Mirabegron
What do PDE5 inhibitors cause?
Increased production of nitric oxide
What bony features does the pubis have?
Tubercle, crest and superior and inferior rami
Where do ureters pass in females?
Anterior to external iliac artery and posterior to uterine artery
Where does the apex of the bladder sit in both sexes?
Behind pubic symphsis
Where do ureters pass in males?
Anterior to external iliac artery and obliterated umbilical artery
What is the pubovesical ligament?
It is short ligament arising from the pubis which inserts near the neck of the bladder helping to support urethra
What does stimulation of M2 receptors cause?
Inhibition of adenylate cyclase
What does the superficial perineal pouch contain?
Everything lying below the deep pouch such as external genitalia
Where does obturator internus arise from?
Arising from an area around the obturator foramen
What are the attachments of levator ani?
Pubis in front, the fascia that lines the obturator internus at the side and the ischial spine posteriorly. In the midline it attaches to a pair of fibrous masses called the perineal body and the anococcygeal body as well as the coccyx
Which structures transverse levator ani and where?
Urethra (and vagina in females) and the anal canal
What is the triangular smooth region between the three tubes that enter and leave the bladder?
The trigone
What is the key nerve of the perineum?
The pudendal nerve
What bounds the true, or lesser, pelvis?
The space enclosed by the pelvic girdle and below the pelvic brim: between the pelvic inlet and the pelvic floor. This cavity is a short, curved canal, deeper on its posterior than on its anterior wall.
What is the deep fascia of the penis called?
Buck’s fascia
What ligament is the pubovesical ligament continuous with in the female?
The pubocervical ligament that runs back over the bladder to the cervix of the uterus
Which part of urethra is closest to bladder in males?
Pre-prostatic
What is the pelvic inlet?
The superior margin of the true pelvis
What does the deep perineal pouch contain?
Bands of muscle, the membranous part of the male urethra and the bulbourethral gland of males as well as the female vagina
What does botulinum toxin cause?
Prevent of acetylcholine release
Describe the three foraminae of the pelvis
The greater and lesser sciatic foraminae created by the sacrospinous and sacrotuberous ligaments and the obturator foramen which is medial to the sciatic foraminae and covered in membrane except for a small gap, the obturator canal, that allows vessels and nerves to reach the leg
Where is the apex of the bladder?
Anterior
What muscles cover the iliac fossae?
Iliacus muscles
