Lecture 23, 24 & 25: Urinary Bladder &Micturition, UTI & Overactive bladder Flashcards
What is the function of the bladder?
- A temporary storage of urine that can empty at an appropriate time
Where is the bladder situated when empty and when full?
- In the pelvic cavity
- Partly in pelvic cavity but expands superiorly into abdominal cavity
At what age does the bladder descend into the pelvis area from the abdominal area?
- By the 5th or 6th age
- It is an abdominal organ at birth and positioned in extraperitoneal area of lower abdominal wall
What are the 4 parts of the urinary bladder?
- Apex
- Base
- Superior surface
- Inferolateral surface
What is the mucosal lining of the base of the bladder like?
- Smooth firmly attached to the muscle coat of the wall
What are some features that make up urinary bladder anatomy and what are the functions?
- Ureter: Tubes that transport urine from kidney to bladder
- Internal and external sphincters: Controls release and prevents leakage
- Urethra: Tube that carries urine from bladder outside of body
What is the mucosal lining of the bladder like elsewhere besides the base?
- Folded and loosely attached to the wall
What is the trigone?
- The smooth triangular area between the openings of the ureters and urethra inside of the bladder
What are the 4 muscle/membrane layers of the bladder?
- Mucosa: inner layer
- Submucosa: connective tissue
- Detrusor muscle: muscular layer
- Adventitia/Serosa: Covers most of bladder/membrane that covers top part of bladder
What is the main difference between a male and female’s bladder and urethra?
- Males have internal and external urethra sphincter and is longer
- Females only have external one and is shorter and more prone to UTI
What does the sympathetic nerve do to the bladder?
- Transmit impulses from the pain receptors to the upper lumbar segment resulting in perception of pain sensation from the urethra and bladder
- Involves hypogastric nerve
What does the pelvic (parasympathetic) nerve do to the bladder?
- Transmit impulses from the tension and pain receptors present in the wall of the bladder to the sacral region of spinal cord resulting in both reflex micturition and sensation of bladder fullness
- Under Ach
What does the Pudendal (somatic) nerve do to the bladder?
- Transmit impulses for the sensation of:
- Distension of urethra
- Passage of urine through urethra
- Maintains the tonic contractions of the skeletal muscle fibres of the external sphincter
- Voluntary control
How does the pelvic nerve work?
- Releases Ach and binds to the M3 receptor of Detrusor muscle on the bladder to cause muscle contractions to force urine out
How does the sympathetic nerve work?
- Releases noradrenaline at the bladder beta 3 receptors in detrusor muscles and urethra alpha receptor 3 in to:
1. Inhibit contraction of the bladder then release NA for A3
2. Stimulate contraction of the urethra: fill w/ urine - Both to prevent urine release
How does the Pudendal (somatic) nerve work?
- Releases Ach at the nicotinic receptors of the external urethral sphincter to cause contraction hence preventing urine release
Which fibres supply the sympathetic system in the bladder?
- The preganglionic fibres which branch from the upper 4 lumbar vertebrae
- The postganglionic fibres arise from the hypogastric ganglia
What are the functions of the sympathetic nerves?
- Inhibitory to the bladder wall (detrusor muscle)
- Motor to the internal urethral sphincter
- Motor to the seminal vesicle, ejaculatory duct & prostatic musculature. It prevents reflux of semen into bladder
What fibres supply the parasympathetic system in the bladder?
- The preganglionic fibres from the 2nd, 3rd and 4th sacral segments of the vertebrae
- They Form the pelvic nerve which relays in the terminal ganglia embedded in the wall of the urinary bladder
What are the functions of the parasympathetic nerves?
- Motor to the bladder wall (detrusor muscle)
- Inhibitory to the internal urethral sphincter
What fibres supply the somatic system in the bladder?
- Arise from 2nd,3rd and 4th sacral segments and supplies the external urethral sphincter
What is the function of the somatic supply?
- Motor to the external urethral sphincter
When does the micturition reflex start to happen?
- From stage 1 when the bladder reaches 150-300ml
- So the early stage of feeling the urge to urinate
At what point can micturition no longer be suppressed?
- At about 700ml (break point)
- Feel pain
What is the storage phase and voiding phase of micturition?
- Filling phase
- Emptying phase
What helps to empty the female urethra and how is urine expelled in men?
- Gravity
- By several contractions of the bulbocavernosus muscle
What part of the brain receives and co-ordinates the detrusor afferent stimuli?
- The parietal lobes and thalamus
Which part of the brain provides modulation with inhibitory signals?
- The frontal lobes and basal ganglia
Where does the central co-ordination occur?
- In the pontine micturition centre
The cortical centres facilitate micturition by discharging signals which leads to what?
- Stimulation of sacral micturition centre
- Inhibition of pudendal nerves which causes relaxation of external urethral sphincter
- Contraction of anterior abdominal muscle and diaphragm to increase intra-abdominal pressure. This intensifies the micturition reflex
- Voiding under parasympathetic regulation (pelvic nerve)
If condition is unfavourable: the higher centres inhibit micturition by what?
- Inhibition of sacral micturition centre
- Stimulation of pudendal nerves -> contraction of external sphincter
- Holding of urine uder sympathetic regulation (hypogastric nerve)
What is a Cystometrogram?
- A graph of the pressure applied on the bladder against the volume of urine in the bladder
- Used to evaluate patients w/ bladder dysfunction
What are 3 types of incontinence?
- Overflow
- Stress
- Urge
What is overflow?
- The blockage of the urethra so the bladder cant empty properly
What is stress?
- When the pelvic floor is relaxed causing increased abdominal pressure
What is urge?
- When the bladder is oversensitive due to an infection that causes neurological disorders
What is atonic (hypotonic) bladder?
- When the sensory nerve fibres from the bladder are destroyed e.g. by disease or injury
- Causes the person to loose bladder control as the bladder muscle looses the tone and becomes flaccid so urine overflows and drips through the urethra
How do you treat atonic bladder?
- Bladder catherization and correction of the underlying causes
- Neurogenic problems treated with anticholinesterases to increase detrusor contraction
What type of drugs make atonic bladder worse?
- Antimuscarinics
What is spastic neurogenic (automatic) bladder?
- During spinal shock after complete transection of spinal cord above sacral centres of micturition
- Bladder looses tone and becomes flaccid and unresponsive causing overflow
- Spinal shock due to sudden separation from the spinal centres from higher centres that control them
- When bladder is filled with some urine, there is automatic evacuation of the bladder
What is unihibited neurogenic bladder?
- A lesion in some parts of the brain stem interprets inhibitory signals so we get continuous excitation of spinal micturition centres by higher centres
- Micturition is now uncontrolled increasing need to urinate
What is nocturnal micturition?
- AKA bed wetting
- Common in infants less than 3
- Occurs due to incomplete myelination of motor nerve fibres of the bladder resulting loss of voluntary control of micturition
What is Overactive Bladder syndrome?
- When the detrusor produces uncontrolled bladder contractions during normal filling
- Can be associated with stroke, spinal injury, MS
- Can also be secondary to meds already taking
- Causes urinary urgency and frequency, nocturia
What is urethral sphincter incompetence?
- Dribbing and/or continuous leakage associated with incomplete bladder emptying, due to impaired detrusor contractility and or bladder outlet obstruction
- Urethral sphincter incompetence produces stress incontinence in women (urine leakage with effort, exertion, coughing) or sphincter weakness incontinence in men.
What is the painful bladder syndrome/ interstitial cystitis (PBC/IC)?
- Urothelial abnormalities alter bladder epithelial expression of HLA Class 1 and 2 antigens
- So the bladder sensory neurones are activated during normal bladder filling
What is Nocturia?
- If woken at least once during sleep to urinate
What is Enuresis?
- Involuntary urination at night (particularly in children)
What can OAB be caused by?
- Nerve or brain related diseases
- Following a stroke
- Parkinson’s disease
- Multiple sclerosis
- After spinal cord injury
What is the risk of people having a lower quality of life with OAB?
- Need assessments for mental health, health perception and pain
- Have increased risk of UTI and skin infections
What is OAB (wet)?
- Urgency and urge incontinence with leakage on the way to toilet
- 2/3x more prevalent in older women
- Associated with increased risk of falling and fracture
What is urge incontinence?
- Sudden, strong urge to urinate and can’t hold leading to involuntary leakage
What are the risk factors for urinary incontinence for women
- Age
- Postmenopausal urogénital changes
- Being overweight
- Number of children
- Abnormalities of urogénital system: genital tract, pelvic organ prolapse
- Comorbidities: T2DM and chronic UTI increase urgency symptoms
what are some causes of Lower urinary tract symptoms in men?
- Benign prostatic enlargement
- Neurological conditions: dementia, diabetic neuropathy, infection injury to urethral area
- Drugs: diuretics/antimuscarinics and cancer
What are some red flag symptoms in women?
- Persisting bladder or urethral pain
- Palpable bladder on abdominal exam after voiding
- Benign pelvic mass
- Faecal incontinence
- Suspected neurological symptom
- Symptoms of voiding difficulty
- Previous pelvic cancer surgery
What type of treatment should be offered first in overactive bladder syndrome?
- Behavioural therapies: Bladder retraining, double voiding (going toilet again after few mins to make sure complete empty), biofeedback (sensors show muscle activity(, pelvic muscle exercise
- Lifestyle changes
What are pelvic muscle exercise and bladder retraining?
- Strengthen pelvic floor muscles, support bladder, SI
- frequent voluntary voiding, timed voiding, urge suppression techniques, takes time, record bladder habit. Minimum 6 weeks
What are some lifestyle advice for OAB?
- Drink enough fluids (2L) to avoid bladder irritation/infection. Cutting back liquid = bad as urine is more conc which irritates bladder muscle
- Limit fizzy drink, caffeine, alcohol
- If BMI above 30, advise lose weight
- Smoking cessation
Before starting treatment for medicine in OAB, what should be explained to patient?
- Liklihood of med being successful
- Adverse effects
- Substantial effects take 4 weeks to improve
- Long term effects of anticholinergic in cognitive function is un uncertain
What should be taken into account when anricholinergics are given?
- Co-existing conditions: poor bladder emptying, cognitive impairment
- Orher meds affecting total anticholinergic load
- Risk of adverse effects: cognition
What is first line for OAB or mixed UI and examples?
- Antimuscarinics (anticholinergic)
- Oxybutynin, Tolterodine and solifenacin
- Start low and slow especially in elderly
What are some adverse effects of antimuscarinics?
- Constipation, dry mouth, urinary disorders, vision disorders
dizziness, drowsiness, dyspepsia, flushing, headaches, skin reactions
What should be done if first line med treatment is not effective?
- Offer another drug
- Don’t offer oxybutynin immediate release to frail older women
- Offer transdermal to women unable to tolerate oral
What are some other drugs with significant antimuscarinics action?
- TCA, sedative antihistamines, some antipsychotic drugs, iprateopium bromide, atropine
- A high anticholinergic load can lead to physical and cognitive impairment
What are some other meds that can be used for OAB?
- Mirabegron: selective b3 agonist, antimuscarinics are contraindicated
- Desmopressin: reduce troublesome nocturia
- Duloxetine: Moderate to severe stress urinary incontinence, has more side egfects
What are older women with OAB with increased risk of?
- Falls
- Hip fractures
- Anxiety/ depression
- Social isolation
What are hidden questions to ask with urinary incontinence?
- Are you having trouble controlling your bladder
- Do you leak urine when you cough/sneeze
- Do you leak on the way to the bathroom
What is Pylonephritis?
- Upper UTI caused by Ecoli
- Kidney infection from bladder/urethral pain
- Get chills, back pain, urgency
What is Cystitis?
- Lower UTI caused by Ecoli
- Bladder infection
- burning urination, lower abdominal pain, cloudy, foul urine
What is Urethritis?
- Inflammation of urethral pain caused by STI, viral infection
- Burning urination, discharge from urethra, itching, urea
What are the causes of UTI?
- Proximity of anus/ Ecoli
- Pregnancy: hormonal changes, progesterone relaxes muscle, slows urine
- Catheter: bypass sphincter muscle, controls urinary flow
- Kidney stones
- Enlarged prostate
- Familial link (structural differences)
What are Symptoms of UTI?
- Fever/ systematically unwell
- Suprapubic pain
- Babies: poor feeding
- Increased freq
- Haemturia (blood in urine)
- Cloudy urine
- Dysuria (painful urination)
- New nocturia
What are the different differential diagnosis for UTI?
- Kidney stones
- Thrush
- Chlamydia, Gonnorhra, Herpes simplex virus, bacterial vaginosis
- Pelvic inflammatory disease
- Benign prostatic hyperplasia
What are the 2 tests done for UTI?
- Dipstick: midstream urine (skin has bacteria), changes colour when dipped
- Midstream culture: A lab test that identifies exact bacteria causing infection
What are signs of odour in urine that you have to be aware of?
- Fishy: UTI, STI
- Peardrop sweet smell - ketones (referral), asparagus can cause this
What are some colours of urine and why they are caused?
- Colourless, pale yellow: normal
- Dark: dehydration/ liver dysfunction
- Green: pseudonas infection or excretion of cytotoxic drugs
- Red-brown/bright red: heamaturia or period contamination
What are the different clarities of urine and their causes?
- Clear: normal
Cloudy to turbid: can be normal or presence of mucus, semen, prostatic fluid, skin cells, WBC/RBC, pus - Frothy: presence of protein (diabetes: should normally filter protein)
What do leukocytes, nitrites and bilirubin and uribilinogen mean in urine?
- Leucocytes: tests for leukocytes esterase, enzyme released by WBC - infection
- Nitrites: from nitrates = normal, bacteria converts (shouldn’t be there)
- Bilirubin and urobilinogen: breakdown of RBC (liver/ bile duct issues)
What does protein, pH and Hb mean in urine?
- Protein: damage to glomerulus
- Ph: 4.5-8 is normal, extreme acidity: urine stones, extreme alkanity: pseudomonas, proteus, klebisella. Consider meds
- Hb: infection, tumor, trauma, menstrual blood, kidney stones
What does high specific gravity, glucose and ketones mean in urine?
- Specific gravity: how conc urine is, higher gravity = more conc
- Glucose: Not normal, DM, gestational/steroid induced diabetes
- Ketones: Not normal, fat breakdown instead of glucose, DKA, diarrhoea, vomiting
What are some things recommended and not recommended in UTI self care?
- Water: dilute urine good for kidney, Paracetamol & Ibuprofen (depends)
- Alkalising agents, cranberry products
When should NSAID suitability be questioned?
- Asthma: can lead to bronchospasm
- Risk of GI bleed
- Elderly: Have comorbidities (poor kidney infection) - more prone to AKI (GI bleed)
- Warfarin: interaction- increase bleeding time risk of GI bleed, haemorrhage, ulcer to perforate
- HTN: NSAIDs cause sodium retention, COX2 more risk for heart attack and stroke
- SSRI/SNRI: increase bleeding time
What are first line meds for UTI?
- Nitrofurantoin (BF for 3days or 50mg QDS): need eGFR over 45
- or Trimethoprim 200mg BD for 3 days if low risk of resistance
What are other first line meds for UTI?
- Pivmecillinam (a penicillin)
- Fosfomycin
What are some red flag safety netting for UTI or kidney infection?
- Shivering, chills and muscle pain
- Confused/drowsy
- Smelly urine
- N&V
- Visible blood in urine
- Temp over 38
- Kidney pain in back
- Not passed urine all day
What are some self care prevention tips for UTI?
- Wipe from front to back after defecation
- Don’t wait to pass urine
- Urinate after sex
- Drink enough fluids
- Avoid occlusive underwear
What are signs of sepsis?
- Confusion, delirium
- Cold hands and feet
- Needed to conserve energy and keep organs perfused
What is defined as recurrent UTIs?
- 2 episodes over 6 months
- or 3/ more infections per year
What are some underlying causes of recurrent UTIs?
- Suspect malignancy
- Structural abnormalities
- Genetic susceptibility
- Post-menopausal vaginal oestrogen
- Chronic prostatis
What are some management options for recurrent UTIs?
- Patient initiated self management
- Post coital prophylaxis: taking a single dose of antibiotics after sexual intercourse to prevent a urinary tract infection (UTI)
- Continuous prophylaxis
What are some 2nd choices for recurrent UTI meds?
- Amoxicillin
- Cefalexin
What are some nitrofurantoin warnings?
- Pulmonary reactions (short/long term)
- Lung: fever, chills, cough, chest pain, dysopnea
- Liver: Yellowing of skin/eyes, RUQ pain, dark urine, pale/grey stools
What is complicated UTI and what are the treatment group considerations?
- A UTI that occurs in the presence of factors that increase the risk of severe infection, treatment failure, or recurrence.
- pregnant
- male
- catheters
- elderly
- kids
What is the presence of bacteriuria in pregnant woman associated with what should be done?
- Associated with bacteria in urine
- Premature rupture of membranes and pre-term labour
- Routine screening for asymptomatic bacteriuria by midstream urine culture to reduce risk of pyelonephritis and low birth weight
Which of the antibiotics for 1st line UTI should be given in pregnancy?
- Nitrofurantoin MR 100mg BD for 7 days
- Avoid trimethoprim
- Amoxicillin and cafalexin can be used 2nd line
What is an in dwelling catheter and what should be checked with ongoing catheterisation?
- An indwelling catheter (also known as a urethral catheter or Foley catheter) is a flexible tube inserted into the bladder to continuously drain urine — and it stays in place for an extended period of time.
- For blockages
What are the complications of a UTI in elderly?
- Cognitive impairment
- Confusion
- Asymptomatic bacteriuria is common and does not need treating
- Fuction decline issues (renal)
What are the requirements to initiate Abx for UTI in delirium?
- Need acute dysuria alone or fever
- AND new or worsening urgency/ incontinence, frequency, signs of irritation of urinary tract
In children what are the most common causes of UTI and some infection signs?
- Urinary tract structural abnormalities, deterioration to pyelonephritis can be fast
- Dysuria, new nocturia, increased urgency, cloudy urine, increased frequency, fever, back pain
What are different managements for upper UTI/ acute pyelonephritis and lower UTI in 3 months + for children in/over 3months?
- Upper UTIs Cefalexin or coamoxiclav
- Lower UTI: trimethoprim (if resistance is low), nitrofurantoin, amoxicillin or Cefalexin
What do you assess in severe illness from a UTI in children?
- Temperature
- RR
- HR
- Capillary refill time
- Effort breathing
- Colour of skin, lips, tongue
- Appearance of mucous membranes
What are the signs/symptoms of high risk of serious illness in children under 5 with UTI?
- Fever (above 38)
- Pale, mottled, blue skin/ lips
- No response to social cues
- Appearing ill to a healthcare professional.
• Not waking, or if roused not staying awake.
• Weak, high-pitched or continuous cry.
• Grunting.
• Respiratory rate greater than 60 breaths per minute.
• Moderate or severe chest indrawing.
• Reduced skin turgor: lost elasticity
• Bulging fontanelle (soft spot on baby head)
What are the signs/ symptoms that indicate intermediate risk of serious illness in children under 5 years?
Temperature of 39°C or higher in an infant aged 3–6 months (indicates at least
intermediate risk).
• Tachycardia: >160 bpm (less than 12 months), >150 bpm (12–24 months), >140 bpm (2–5 years).
• RR more than 50 breaths/minute for 6–12 mnth
• Pallor of skin, lips or tongue reported by parent or carer.
• Not responding normally to social cues.
• Not smiling.
• Waking only with prolonged stimulation.
• Decreased activity.
• Nasal flaring.
• Dry mucous membranes.
• Poor feeding in infants.
• Reduced urine output.
• Rigors.
• Capillary refill time of 3 seconds or longer.
