Microurition Flashcards
Explain how micturition physiology works
- Bladder sends a message to the brainstem via S2,3,4 – keeps everything of the floor
- There is a sensory feedback through pelvis nerves to the micturition centre which asks the rain if it is socially acceptable to pee
- Brain decides sits and weights
- Sends a message through the pudendal nerve (somatic – something we control) S2,3,4 to the sphincter
- Opens the sphincter
- Reflex action to the parasympathetic system to the bladder
- Can close pelvic floor voluntarily
- Or push harder using abdominal muscles \cannot change bladder function as it is a smooth muscle
- Sympathetic supply to the bladder – hypogastric – blood vessels in the bladder
- Parasympathetic squeeze – and about erections
describe the storage phase of bladder filling and describe the emptying phase
bladder filling
- detrusor muscle relaxes
- internal sphincter constricts
- pelvic floor contracts
emptying
- detrosur contractions
- internal sphincter relaxes
- pelvic floor relaxes
what phase does the bladder spend most of its time in
- spends most of its time in the storage mode
How often does a normal 70Kg adult micturates
4 times/24 hours passing 1500mls of urine
how long does each micturition take
- It takes 1 minute to complete so the bladder contracts for only 0.3% of 24 Horus
what is normal bladder contraction stimulated by
- it is caused by release of ACh from cholinergic nerves
- this stimulates muscarinic receptors on the detrusor smooth muscle
what does LUST stand for
Lower urinary tract symptoms
what are the types of lower urinary tract symptoms
- Storage irritative symptoms – frequency, nocutria, urgency, urgency incontinence
- Voiding (obstructive) symptoms – hesitancy, straining, poor flow, intermittency, incomplete emptying – also terminal dribbling, dysuria, haematuria (blood in urine)
- Overactive bladder (to do with storage symptoms)– urgency with or without incontinence usually with frequency and nocutira
how do you diagnose lower urinary tract symptoms
- Symptom history (acute/chronic, fever, haematuria, trauma)
- Personal history (smoker, occupation, family history)
- Past medical history (cardiovascular medicatios/anticoagultnts, previous cancer)
- Physical examination (vitals, abdominal, external genitalia, external genitalia, DRE)
who is the international prostate symptom score scored by and why is this important
- by the patient
- this is reproducible as well as you can see how the score as changed once you provide intervention
what factors make up the international prostate symptom score
- incomplete emptying
- frequency
- incontinency
- urgency
- weak stream
- straining
- nocturia
what are the levels of the internal prostate symptom score
mild 0-7
- Reassure
- Watch and wait
- Reassess regularly
Moderate 8-19 severe 20-35 Based on QOFL score - Low QOFL -w atch and wait - Med to high QoFL – lifestyle and education, medication, surgery
what investigations can you carry out
- Inspect fresh urine sample
- Urine dipstick/urine M C and S
- FBC/UandEs/PSA
- Uroflowmetery and post void residual volume
- Urodynamics (Pressure/flow studies)
- XR KUB
- Ultrasound KUB and TRUS prostate
- CT KUB
- Nuclear imaging
what is flow rate recording
- this records how fast your flow rate is - the patient pees in the funnel and it measures the flow rate
as you get older…
urinary flow decreases
what are the disorders grouped into
can be - anatomical - functional - medical or - outlet - pump - control - constituents
name some disorders of
- anatomical
- functional
- medical
- Anatomical disorders – obstructive, incontinence
- Functional disorders – stroke, spinal cord injury, neurologic disease, idiopathy
- Medical disorders – cardiac, hepatic and renal failure
name some disorders of
- outlet
- pump
- control
- constituents
- Outlet – bladder neck, prostate, stricture (women rarely get this – underactive bladder is more common), meatus, foreskin
- Pump 0 bladder – OAB, sensory, failure, cardiac, medications (antipsychotics can do this)
- Control – neurology – stroke, spina bifida, cord injury, MS, tumour, Parkinson’s
- Constituents – UTI, cancer, inflammation, stones (ureteric stones and bladder stones)
name some - storage - voiding - both or neither symptoms
storage
- incomplete emptying
- frequency
- urgency
voiding
- intermittency
- weak stream
- straining
both or niether
- nocturia
why does BPH grow inwards and obstruct the bladder
- Humans have a capsule on the prostate like an orange therefore it can only grow so far therefore it can grow inwards and obstructive the urinary tract
what is end fill overacitivyt
as the bladder is obstructive the bladder over a period of time starts to do its own thing and gets excited near the time it needs to pass urine
what is the management of BPH and LUTS
Fluid - Type - Amount Bladder drill - pass urine every 4 hours, try to get them to do that Food Smoking Urethral milking Pads and convenes Not catheters – last resort and CISC best type
what is fluid management
- 1500-2500ml
- use a voiding diary
- dry to hold for 4 hours at a time
- record what you drink and how much
what can cause irritant to the bladder
- food and smoking
food such as champagne, chicken liver, onion, curry
what is urethral milking
- this is when there is a U band in the uretra
- the penis is suspended by a suspenocyory ligament
- urine can get trapped in U band therefore if you lift penis up it can help remove the trap
describe medical therapy that can be used for LUST and BPH
- Alpha blockers- Tamsulosin, doxazosin, terazosin – helps symptoms – works on small prostate
- 5 alpha reductase inhibitors – finasteride, Dutasteride – work on large prostate shrink the bread back
- PDE5 inhibitors
- Anitmuscarinocs for OAB
- Combination
what is the surgery for LUTs
- TURP – electic loop to carve out prostatic chips, 1:10 risk of transfusion, TUR syndrome, erection issues
- HoLEP/Greenlight – modern laser operation, better at tissue remoal, 1;100 risk of transufion, no TUR syndrome, fewer erection issues, expensive, HoLEP any size
- UroLift – newest technique, pruelry mechanical, preserves erections, 5 year data only, has to be the right shape prostate ad less than 80ml
- prostatic artery embolism - via a vascular route - has caused a penile embolism and parietal bladder embolism
- rezum - any shape prostate, steam therapy, no vertical issues - reoperatuion for 20% in 3 years
what is urinary urgency
- this can happen with or without incontinence - this is when there is stress on the bladder or an urge problem
what is a stress urinary incontinence and what is an urge urinary incotinenace
- Stress UI – leakage on effort or exertion (increased abdonomial pressure)
- Urge UI – leakage accompanied by urgery
- Mixed UI – both
what is the treatment for urinary incontinance and urge
Treatment - Always treat the overactive component first Conservative measures - Fluid intake - Caffeine and stimulants - Pads - Timed voiding Pelvic floor exercsies – short term use - Tablets - Posterior tibial nerve sitmulation - Botox - Sacral nerve stimualtin - Surgery
what tablets and drugs can you take for OAB/urge incontiance
anticholinergics - such as oxybutynin, solifenacin, tolterodine, fesoterodine
- this blocks acetylcholine in parasympathetic nerves
- blocks elsewhere too like salivary glands
b3 adrenegics such as mirabegron
- B3 adrenoreceptors unregulated in OAB
- hypertension may be an issue
Botulminun Toxin A (BOTOX)
- fuses synaptic vesicles with motor end plate
- issues with hyper continence
describe where the lesions are in the bladder and what can that mean
- Lesions above the pontine micturition centres are safe e.g. coordinated – CVA, parkinsons, brain injury, MS
- Lesions in between are unsafe – uncoordinated and thereofre high pressures in the resting bladder results – trauma, tumours, spina bifida
- Lesions below T12 are safe as bladder and sphincter are flaccid and at low pressure
