Session 8

Question 1

Describe some general terms and definitions

Answer 1

• Micturition: to want to pass urine
• Detrusor: to push down
• Spinal root values (neural identity of spinal nerves)
• Reflexes (unlearned, automatic repeatable response to a specific stimulus – brain not necessarily involved)

Question 2

Describe the uniqueness of the bladder

Answer 2

• It is an autonomic effector organ without inherent activity of its own
• All its activity is determined by activity of the autonomic nervous system
• Without nervous system innervation it ceases to be an organ of any use
• Its activity switches between 2 bi-stable states

Storing urine
Voiding of urine
There is no in-between state

• It is operated equally by both the autonomic and somatic nervous system
• No other autonomic organ behaves as such

Question 3

Describe the general anatomy of the bladder including major functional divisions and important muscles

Answer 3

• Hollow, smooth-muscle organ derived from the hindgut
• Belongs to a series of visceral organs known collectively as midline structures

Major functional divisions of the bladder are:

• Body: temporary store of urine
• Trigone: ureteric orifices and internal urethral orifice are at angles of a triangle. There is a high density of sympathetic neurones here.
• Neck: connects bladder to the urethra

3 muscle components of note

• Detrusor urinae muscle
• Internal urethral sphincter (physiological)
• External urethral sphincter (anatomical – formed by pelvic floor muscles)

Question 4

Describe the histology of the detrusor urinae muscle

Answer 4

[*] it is formed from a plexiform meshwork of smooth muscle fibres. In cross section, the muscle fibres all have different orientations – ‘random arrangement’

Closer analysis shows the muscle fibres to be arranged in layers, rough at 90 degrees (perpendicular to each other)

• Inner layer of longitudinal muscle
• Middle layer of circular muscle
• Outer layer of longitudinal muscle

Fibres are roughly orientated in 3 general directions

• Such muscle fibre orientation confers strength to the urinary bladder, irrespective of direction of stretch. Allows the bladder to fill in all directions and contract as a single organ.

Question 5

Describe the innervation and characteristics of the detrusor urinae muscle

Answer 5

• Bilateral neural supply from the spinal cord
• NO SOMATIC SUPPLY
• Various anatomical components of the urinary bladder are supplied by different divisions of the nervous system

Characteristics

• Classified as a smooth muscle
• Mass contracting muscle (unike other smooth muscle organs, it has no myogenic activity – does not contract under stretch – stress-relaxation phenomenon)
• No peristaltic activity (but ureters do)
• Lined with transitional epithelium which is non-secretory
• Urinary bladder form and size are similar in both sexes
• It is found in the true (or lesser) pelvis in adults

Question 6

Describe the internal urethral sphincter

Answer 6

• Tissues in this area constitute a functional sphincter even though it is not designed as such from its anatomy. It is a continuation of the detrusor muscle and made of smooth muscle.
• Essentially a passive valve.
• Acts as sphincter at neck of bladder
• Thus it is known as a physiological (or functional) sphincter.
• As the urinary bladder fills up, the muscle layers collapse and close up.

Question 7

Describe the body of the urinary bladder

Answer 7

• Supplied by parasympathetic and sympathetic branches of the autonomic nervous system (which are independent of each other). There is potential for disruption of parasympathetic or sympathetic supply to bladder => producing complex set of dysfunctions
• It is not under voluntary control
• Its activities are operated via reflex pathways of the spinal cord, subject to the executive control of the brain.

Question 8

Describe the external urethral sphincter

Answer 8

• Supplied by the Somatic nervous system (derived from skeletal muscle)
• Under voluntary control from the cerebral cortex via the spinal cord
• Essentially the muscles of the pelvic floor (levator anii) – localised circular muscle thickening to facilitate aciton
• Supplied by the perineal branch of the pudendal nerve (axons arise from the ventral horn of the cord, S2-S4). (SOMATIC INNERVATION – VOLUNTARY)
• Constricts urethra for maintenance of continence – to hold in urine
• Relaxation promotes voiding

Question 9

Describe the effect of lesions on the nervous system controlling the urinary bladder

Answer 9

Lesions of the nervous system controlling the urinary bladder disturbs the ordered co-operation between the somatic and autonomic divisions of the nervous system THUS disorders of neuronal supply to the urinary bladder can therefore be very complex. They can also be life-threatening if not dealt with correctly in certain classes of patients e.g. autonomic dysreflexia.

Question 10

Describe the functions of the urinary bladder relative to the urinary tract

Answer 10

• Provide sensations of bladder filling and pain
• Allow the bladder to relax and accommodate increasing volumes or urine
• To initiate and maintain voiding so that the bladder empties completely, with minimal residual volume
• To provide an integrated regulation of the smooth muscle and skeletal muscle sphincters of the urethra

Question 11

Functional activity of the lower urinary tract is commonly divided into 2 phases. Describe the Filling phase

Answer 11

Filling (storage phase of urine/continence phase): the bladder relaxes and accommodates increasing volumes of urine while the urethral sphincters increase their tone to maintain continence. This is commanded by the sympathetic neurones

• Spinal Neural Root Values T10-L2 supply the detrusor
• Controlled by a dedicated set of neuronal apparatus (Continence Neurones)
• Damage to this neonatal apparatus will lead to failure to store urine, resulting in reduced bladder capacity, hence very frequent passing of urine.
• Failure to store urine is commonly referred to as Urinary Incontinence.
• The continence phase involves the ureters, urinary bladder, bladder neck, urethra and external urethral sphincter working together to pass urine into urinary bladder and storing the urine in the bladder over many hours (e.g. at night)
• Neural apparatus prescribing for urinary storage are known as “Continence Circuits”

Question 12

Functional activity of the lower urinary tract is commonly divided into 2 phase. Describe the Voiding phase

Answer 12

Voiding (bladder voiding phase/ EXPULSION/ELIMINATION of urine): the urethral sphincters relax and the bladder contracts. Commanded by the parasympathetic neurones (Spinal Neural Root Values S2, S3 and S4) – controlled by an entirely separate set of neurones.

• The extent of the bladder contraction is greater in men than women
• In men, the prostatic urethra (sometimes called the urethral sphincter) functions to prevent retrograde ejaculation into the bladder. These functions are accomplished by integrated activity of the two arms of the autonomic nervous system and the somatic innervation of skeletal muscle of sphincters and the pelvic floor.
• Damage to neurones that promote micturition will lead to failure to pass urine, resulting in urinary retention. Here, urine is only passed by an overflowing bladder (i.e. involuntary; overflow incontinence). Failure to void the urinary bladder is known as a state of “urinary retention”.

Question 13

Describe the expression of receptors in the urinary bladder

Answer 13

• Parasympathetic (pelvic nerves): ACh binds to M3 receptors on the wall of the body of the bladder => contraction
• Sympathetic (hypogastric nerves): NA binds to B3 receptors on the wall of the body of the bladder => relaxation and to A1 receptors on the neck of the bladder (internal urethral sphincter) => contraction
• Somatic (pudendal nerve): ACh binds to Nicotinic receptors on the external urethral sphincter => contraction

Question 14

Describe what happens when afferent neurones provide feedback

Answer 14

[*] Afferent nerves provide feedback of information, which initiates reflexes that help to coordinate the functions. The neural control of micturition is the coordination of activity of urinary bladder and external urethral sphincter.

• When the bladder relaxes, the sphincter closes/contracts
• When the bladder contracts, the sphincter relaxes
• Disturbances to this synchrony leads to Detrusor-Sphincter Dyssenergia (largely because of failure of coordination between autonomic neurones and somatic neurones)

Question 15

Quick Review of Nervous System and Somatic Innervation of Skeletal Muscle

Answer 15

[*] Major Functional Divisions of the Nervous System

• Somatic Nervous System: Under voluntary control, can be ‘on’ or ‘off’
• Autonomic Nervous System: not under voluntary control, influenced by prevailing conditions, always switched ‘on’, it is never switched ‘off’

[*] Somatic innervation of Skeletal Muscle via alpha-motoneurone

[*] Antagonist Pairing in Somatic Motor Functions: in order to make movements across a joint we need two classes of motor pools.

One Pool Supplies Muscles That Extend The Limb in question (Extensor Motor Pool) – increase in joint angle
The Other Supplies Muscles That Flex The Limb in question (Flexor Motor Pool) – a decrease in joint angle
The antagonistic muscle pairs are reciprocally connected by reflex neural circuits.

Question 16

Describe the basic process of normal micturition

Answer 16

• Urine is made in the kidney
• Urine is stored in the bladder
• The sphincter muscles relax
• The bladder muscle (detrusor contract)
• The bladder is emptied through the urethra and urine is removed from the body

Question 17

Describe the continence phase and the neuronal events

Answer 17

• The urinary bladder has a capacity of around 550 ml (range 300 to 700 ml (or 1000ml))
• If urine is produced at the rate of 60ml/hour (no water loading), it would take 9 hours to fill the bladder to capacity (e.g. sleeping).
• The ionic composition, temperature and volume or urine are continuously monitored throughout this phase.
• This phase is controlled by the Continence Centres of the brain that in turn control the “Continence Centres” of the spinal cord.
• Spinal continence is mediated exclusively by sympathetic neurones of the spinal cord.
• Neuronal events during Urinary Continence or Storage: appears to be commanded in the following order

Cerebral cortex (possible) => Pontine Continence or Storage Center (L-Region – dorsolateral region of Pons) => Sympathetic nuclei in spinal cord => Detrusor Muscle and External Urethral sphincter motoneurones in Sacral Cord

PET and fMRI studies have shown the thalamus, insula, prefrontal cortex anterior cingulate and supplementary motor area (SMA) to be activated during urinary storage

Question 18

Describe the Pontine Continence Circuits

Answer 18

Bilateral outputs from the Pons
Descending outputs do not decussate
Their actions bring about:

• Silencing of electrical activity of Detrusor muscle
• Relaxation of the Detrusor muscle (B3-receptors in the fundus and body of the bladder – some on-going revision of this point)
• Increase in urethral sphincteric pressure (some on-going revision of this point) – alpha1-adrenoceptors population in neck
• Storage of urine

Question 19

What dual activity does continence result from?

Answer 19

[*] Spinal Urinary Continence: Continence results from dual activity in

The Sympathetic Nervous System:

• Supplies the detrusor muscle to relax it (B3-receptors)
• Supplies the internal sphincter to constrict and close neck (alpha1-adrenoceptors)

Somatic Nervous System

• Activates Closure of the External Urethral Sphincter (acting via Ach at NMJ)

Taken together, these systems work together promoting bladder filling

Question 20

Describe the Spinal Urinary Continence Centres

Answer 20

Root values of sympathetic nervous system

• Thoraco-lumbar cord
• Root Values T10/T12 – L2
• Nerves are derived from Lumbar splanchnics
• T10-T12 terminate in the inferior mesenteric ganglion
• L1 and L2 terminate on neurones of the hypogastric plexus or presacral nerves

Question 21

Describe the somatic nervous system innervating the external urethral sphincter

Answer 21

• Spinal motor outflow from Onuf’s nucleus of the ventral horn of the spinal cord
• Root Values S2-S4
• There are somatic motoneurones that when active close the External sphincter

Question 22

Describe mechanical events and mechanisms during urinary continence

Answer 22

[*] Mechanical events during urinary continence or storage

• Walls of the bladder are highly folded, making them distensible
• The folds are known as rugae
• As the bladder fills with urine, internal urethral sphincter tightens/closes and rugae flatten (stretch)
• Stress-relaxation phenomenon even though it is smooth muscle, it relaxes instead of contracts.
• As rugae flatten, capacity of the bladder increases up to 700ml
• As the bladder fills with urine, pressure within the urinary bladder (intra-vesiclal pressure hardly changes

[*] Mechanisms of Urinary Continence: somatic and autonomic divisions of the nervous system act in concert to bring about continence

• The cerebral cortex (Somatic) makes a conscious effective decision not to urinate and increases somatic stimulation - commands the external urethral sphincter to close, constricting the urethra.
• The sympathetic division of ANS (Spinal root values T10/T12 – L2 (bilaterally) silences detrusor muscle activity, reduces intravesical pressures, increases contraction of the internal urethral sphincter, increases urethral pressure (constricting the urethra)

Question 23

Describe the consequences of disturbances in the pontine continence / storage centres

Answer 23

Bilateral lesions in the Pontine Continence/Storage Centre lead to

• An inability to store urine
• Reduction in bladder capacity
• Excessive detrusor muscle activity
• Relaxation of urethra
• Premature voiding
• Leaky bladder (incontinence)

Question 24

Describe the sensory functions in the bladder

Answer 24

• Afferent nerves originate in the bladder wall
• Thought to be stretch receptors, but not yet fully identified
• At around 400ml of filling, they start to signal the need to void the bladder

Pain sensation from irritation of bladder
Temperature sensation

• Travel principally with parasympathetic nerves
• Some limited routing with sympathetic fibres
• Pain sensation in bladder is well localised (not referred)

Question 25

Describe the voiding phase

Answer 25

• Mediated by an independent Neural Apparatus
• Generally a short-lasing event
• Urinary flow rate in a full bladder is about

20-25 ml/s in men (lasting around 24 seconds)
25-30 ml/s in women (lasting around 22 seconds)

• When the bladder signals to say it is full (threshold for feelings suggestive of a full bladder is around 400ml), an urge to void the bladder arises. The brain informs the spinal cord to void the bladder. Urine is expelled from the body. Also known as micturition or voiding phase – periodic and very brief in duration.
• Neural apparatus prescribing for voiding are known as “Voiding Circuits”
• This phase is controlled by the Micturition Centres of the brain that in turn control the Micturition Centres of the spinal cord.
• Spinal micturition is mediated exclusively by parasympathetic neurones of the sacral division of the spinal cord (not so much by the cerebral cortex)

Question 26

Describe the actions of voiding circuits and where they arise from

Answer 26

[*] Voiding Circuits: their action bring about

• Strong contraction of detrusor muscle
• Increase in intravesical pressure
• Relaxation of the internal urethral sphincter
• Voluntary relaxation of the external urethral sphincter (reduction in urethral pressure)
• Expulsion of urine

[*] Voiding Circuits arise from the:

• (Cerebral Cortex) Brain Micturition Centres – detect sensation of bladder filling => the Pons (M Region) (more medial and ventral than L region) => Sacral levels of Parasympathetic outflow => Detrusor muscle Contracts and increases intravesicular pressure => the Cerebral Cortex makes a conscious executive decision to urinate, reducing somatic stimulation the external sphincter - External Urethral Sphincter Relaxes (voluntary)

Question 27

Describe the Pontine Micturition Centres and the Spinal Voiding Centres

Answer 27

[*] Pontine Micturition Centres:

• Data from PET Scan studies suggests involvement of Dorsomedial Pontine tegmentum during voiding
• Also known as the M-region of the pons or Barrington’s nucleus
• Bilateral lesions of this region result in severe urinary retention

[*] Spinal Voiding Centres

• Parasympathetic neurones (Sacral sub-division of ANS, S2-S4) arise from the lateral horn of the sacral cord. Axons pass via Nervi Erigentes.
• The neurones promote bladder voiding by contracting detrusor muscle and relaxing urethral sphincter.

Question 28

Describe the mechanisms of urinary voiding

Answer 28

[*] Mechanisms of urinary voiding: a completely different set of somatic and autonomic divisions of the nervous system act in concert to promote the bladder to void urine

The cerebral cortex (somatic) (voluntary)

• Spinal root values S2-S4 (ventral horn)
• Relaxes and thereby opens the external urethral sphincter.

The parasympathetic division of ANS:

• Spinal root values S2-S4 (Lateral horns – bilaterally)
• Increases detrusor activity.

[*] Bladder, the ANS and Cortical Function

• Nerve supply to the bladder is by the ANS
• There is no sensory representation of the bladder in the sensory cortex
• There is also no motor representation of the bladder in the motor cortex

These facts mean that sensation and voiding of the bladder do not need to be under conscious control

Question 29

Describe the incidence of urinary incontinence

Answer 29

[*] Urinary Incontinence: the complain of any involuntary leakage of urine

[*] Socially disabling – massive impact on quality of life, social exclusion, sense of shame, just put up with it…one of those things

[*] Non-fatal

[*] In those patients in whom a successful outcome has been achieved by their treatment, it should be a lifelong cure

[*] Urinary continence occurs when the bladder pressure is greater than the urethral sphincter pressure. This happens either when

• Detrusor pressure is high e.g. due to increased pressure on bladder from abdomen
• Sphincter pressure is lower e.g. due to decreased support from pelvic floor muscles

[*] There are a wide variety of causes of urinary incontinence; no classification seems to work completely

[*] Continence is achieved in the urethra by the combined effect of the smooth muscle of the urethra, the surrounding peri-urethral striated muscle and the elasticity of the connective tissue. The support of the urethra by the muscles and ligaments of the pelvic floor are important for the efficiency of the sphincter mechanisms of the urethra.

• This is easily demonstrated in women who develop stress leakage of urine on coughing or sudden rises of intra-abdominal pressure.

[*] The management of patients with history of urine continence and frequency rests on a full history, examination and investigation.

Question 30

Compare Upper and Lower Motor Neurone Lesions

Answer 30

[*] Upper Motor Neurone Lesion: lesion in the spinal cord

• Leads to high pressure detrusor contractions and poor coordination with sphincters.
• This leads to Detrusor Sphincter Dyssynergia (bladder contraction and external urinary sphincter relaxation are typically unco-ordinated)
• This leads to dilated ureters and thickened detrusor with subsequent impact on renal function

[*] Lower Motor Neurone Lesion: lesion in the cauda equine and/or peripheral nerves

• Leads to low detrusor pressure
• Which leads to large residual urine (usually painless) +/- overflow incontinence (if lesion is large enough)
• Reduced perianal sensation
• Lax anal tone
• (S2, S3, S4)

Question 31

Briefly describe normal functions of the bladder

Answer 31

Filling (storage phase)

• Compliance (receptive relaxation)
• Sensation of bladder filling
• No detrusor contraction

Voiding

• Voluntary initiation
• Complete emptying

Question 32

Describe classification of lower urinary tract symptoms and types of incontinence

Answer 32

[*] Classification of Lower Urinary Tract Symptoms

• Storage: Frequency, Urgency, Nocturia, Incontinence
• Voiding: Slow stream, splitting or spraying, intermittency, hesitancy, straining, terminal dribble
• Post-micturition: post-micturition dribble, feeling of incomplete emptying

[*] Types of Incontinence

• Stress Urinary Incontinence (SUI): “the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing”
• Urge Urinary Incontinence (UUI): “the complaint of involuntary leakage of urine accompanied by or immediately proceeded by urgency”
• Mixed Urinary Incontinence (MUI): “the complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing”
• Overflow Incontinence: due to underactivity of detrusor muscle and large residual volume – retention of urine causes bladder to swell.

Question 33

Describe the prevalence of urinary incontinence

Answer 33

[*] The prevalence of Overactive Bladder Syndrome is much higher than the prevalence of Urge Urinary Incontinence.

[*] OABS can be wet (urinary incontinence) or dry (without leakage of urine)

[*] Prevalence of urinary incontinence steadily increases with age

[*] Incidence

• 47% Stress Urinary Incontinence (commonest)
• 28% Mixed Urinary Incontinence
• 21% Urge Urinary Incontinence
• 4% other

Question 34

What are the risk factors for Urinary Incontinence?

Answer 34

Predisposing Factors:

• Family predisposition
• Anatomical abnormalities
• Neurological abnormalities

Promoting Factors:

• Menopause (common due to less tone in vaginal structures)
• Drugs
• UTI
• Increased intra-abdominal pressure
• Cognitive impairment
• Increased age
• Obesity
• Co-morbidities

Obstetric and Gynaecological Causes:

• Pregnancy and childbirth (common, particularly stress urinary incontinence as vaginal delivery can weaken pelvic floor)
• Pelvic surgery / DXT (radiotherapy)
• Pelvic prolapse

Question 35

Describe the initial investigation of patients with urinary incontinence

Answer 35

[*] History: categorise type of urinary continence

[*] Examination

• Height
• Weight
• Abdominal exam to exclude palpable bladder
• Digital rectal examination (DRE): prostate (male), limited neurological examination
• Females: external genitalia (stress test) – ask them to cough to see if there is any leakage, vaginal exam

[*] Investigation

• Mandatory: urine dipstick to exclude UTI, haematuria, proteinuria, glucosuria
• Consider basic non-invasive urodynamics such as frequency-volume chart, bladder diary (for 3 or more days including timing of incontinence), post-micturition residual volume – in patients with voiding dysfunction
• Optional:

Invasive urodynamics (pressure-flow studies +/- video): a pressure transducer in the anal canal measures abdominal pressure whilst pressure transducer in bladder measures total pressure (abdominal pressure + detrusor pressure). Detrusor pressure should not change when you cough!
Pad tests (ask patient to cough, weigh pad to measure leakage)
Cystoscopy (to look for bladder cannaliculi or transitional cell carcinoma)

Question 36

How can you assess frequency of micturition and judge incontinence? What can you determine?

Answer 36

[*] Frequency of micturition can be assessed by asking the patient to record the amount of fluid they pass during the day. They measure the amount passed during 2 or 3 days; this will give an indication of the total amount of urine passed and the amount of urine passed on each occasion.

[*] Incontinence can be judged by the number of pads that the patient has to use per day to cope with the urine leakage. Can determine:

• Whether the leakage is continuous or intermittent
• What precipitating factors there are such as coughing or sneezing.
• Urgency and frequency of micturition will often be made worse if there is an intravesicular inflammatory condition.
• Typically this could be urinary infection but other causes such as a stone in the bladder or even a tumour.
• Previous surgery of the pelvic floor can be important as this may lead to denervation of parts of the bladder.
• Childbirth may be an important factor in the development of stress leakage in women due to sphincter damage.

Question 37

What does the initial management of patients with urinary incontinence depend on?

Answer 37

[*] Depends on

• Which symptoms?
• Degree of bother / nuisance - consider quality of life
• Effects of treatment on other symptoms
• Previous or current treatments

[*] Should be

• Individualised
• Systematic approach

Question 38

Describe Conservative Management and what is meant by Contained Incontinence

Answer 38

[*] Conservative Management: General lifestyle interventions

• Modify fluid intake (if it is clear patient is drinking too much)
• Weight loss (obesity is a promoting risk factor)
• Stop smoking
• Decrease caffeine intake (particularly for urge urinary incontinence)
• Avoid constipation (constipation can lead to overflow incontinence)
• Timed voiding – fixed schedule
• (Most patients do not require surgical treatment)

[*] Contained Incontinence (for patients unsuitable for surgery who have failed conservative or medical management)

• Indwelling catheter – urethral or suprapubic (through the skin). Long term, needs to be changed regularly.
• Sheath device: analogous to an adhesive condom attached to catheter tubing and bag (‘external catheter’)
• Incontinence pads

Question 39

Describe Specific Initial Management for SUI and UUI

Answer 39

[*] Initial Management of Stress Urinary Incontinence

• Pelvic floor muscle training (PFMT)
• Multiple regimes available e.g. 8 contractions x3/day, at least 3 months duration

[*] Initial Management of Urge Urinary Incontinence

• Bladder training: schedule of voiding
• Void every hour during the day
• Must not void in between – wait or leak
• Intervals increased by 15-30 minutes a week until interval of 2-3 hours reached
• At least 6 week duration

Question 40

Describe Pharmacological Management of SUI

Answer 40

• Duloxetine: combined noradrenaline and serotonin uptake inhibitor
• Increased activity in the striated sphincter during filling phase
• Not recommended by NICE as first line or routine second line treatment but may be offered as alternative to surgery
• Many patients complain of nausea

Question 41

Describe Pharmacological Management of UUI

Answer 41

[*] Pharmacological management of Urge Urinary Incontinence

1. Anticholinergics (some anticholinergics are also known as antimuscarinics)

• Act on muscarinic receptors (M2, M3)
• Side effects due to affects on M receptors at other sites

M1 – CNS, salivary glands
M2 – heart smooth muscle
M3 – smooth muscle (ocular and intestinal), salivary glands
M4 – CNS
M5 – CNS, eye

• Oxybutynin is used in the first instance – cheap and effect. Compliance is an issue due to side effects such as dry mouth and constipation. Next step is to try other anticholinergics.
  2. Newly licensed in 2014: B3-adrenoceptor agonist Mirabegron increases bladder’s capacity to store urine
  3. Pharmacological management: UUI (Refractory to anticholinergics and B3-adrenoceptor agonists)
• Botulinum toxin
• Potent biological neurotoxin
• Inhibits release of ACh at pre-synaptic neuromuscular junction causing targeted flaccid paralysis – prevents detrusor muscle contraction
• Mainly Type-1 used clinically
• Injection into wall of bladder under GA or LA
• Duration of action 3-6 months.

Question 42

List the options for Surgical Management of a SUI

Answer 42

Females: Permanent intention

• Low-tension vaginal tapes (commonest)
• Open retropubic suspension procedures (less common)
• Classical sling procedures

Females: Temporary intention e.g. if further pregnancies are planed

• Intramural bulking agents

Males:

• Artificial urinary sphincter (gold standard)
• Male sling procedure

Question 43

Describe Low-tension Vaginal Tapes, Retropubic Suspension Procedures, and Classical Fasical Sling Procedures

Answer 43

[*] Low-tension Vaginal Tapes

• Supports mid urethra
• Polypropylene mesh
• Minimally invasive techniques available

Tension-free vaginal tape (TVT)
Transobturator tape (TOT)

• Success rates >90%

[*] Retropubic suspension procedures

• Correct anatomical position of proximal urethra and improve urethral support

[*] Classical fascial sling procedures

• Supports the urethra and augments bladder outflow resistance
• Autologous (from own body)

Fascia lata
Rectus fascia

• Allograft fascia lata

Question 44

Describe Intramural Bulking Agents

Answer 44

Improve ability of urethra to resist abdominal pressure by improving urethral coaptation
Injections under General Anaesthetic/Local Anaesthetic

• Autologous fat
• Silicone
• Collagen
• Hyaluron-dextran polymers
• Macroplastique injection commonest

Question 45

Describe Male Artificial Sphincter and Artificial Sling Procedures

Answer 45

[*] Male artificial urinary sphincter

• Gold standard
• Urethral sphincter deficiency e.g. neurological or post-surgery or post-radiotherapy
• Cuff stimulates action of normal sphincter to circumferentially close the urethra
• Mechanical (hydraulic) device
• Complications: erosion, mechanical failure

[*] Male artificial sling

• Corrects SUI in men, the cause of which is usually iatrogenic (radical prostatectomy, colorectal surgery, radical pelvic radiotherapy). It is an experimental/emerging treatment, using a bone-anchored tape. The long-term results are unknown.

Question 46

List options for Surgery Management of UUI

Answer 46

[*] Surgery for UUI (Refractory to pharmacological management)

• Sacral nerve neuromodulation
• Autoaugmentation (using a piece of bowel, attaching it to bladder, increasing urinary capacity)
• Augmentation cystoplasty
• Urinary diversion