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Semester 3 - Urinary > Session 8 - Micturition and incontinence > Flashcards

Session 8 - Micturition and incontinence Flashcards

1
Q

Give the three main parts of the bladder

A
  • Body
    • Trigone
    • Neck
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2
Q

Give the histological layers of the bladder wall

A 
MUCOSA
	• Transitional epithelium
	• Lamina propria
	• Submucosa
NOT MUCOSA
	• Detrusor muscle
	• Adventiia
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3
Q

What is the body/fundus of the bladder?

A

• Temporary store of urine

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4
Q

What is the trigone?

A

• Ureteric orifices and internal urethral orifice are at the angles of a triangle

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5
Q

What is the neck of the bladder?

A

• Connects the bladder to the urethra

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6
Q

Outline the structure of the detrusor urinae muscle

A

• Made from a meshwork of muscle fibres in roughly 3 layers
○ Inner longitudinal
○ Middle circular
○ Outer longitundinal

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7
Q

Why does the bladder have three layers of muscle?

A

• Arrangement of muscle gives the bladder strength regardless of direction it is being stretched in

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8
Q

What is detrusor muscle supplied by?

A

• Autonomic nervous system, not under voluntary control

Spinal nerve supply is bilateral

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9
Q

What is the internal urethral sphincter?

A
  • Continuation of the detrusor muscle and made of smooth muscle
    • Physiological sphincter at the bladder neck
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10
Q

What is a physiological sphincter?

A

• A sphincter which is indistinguishable from surrounding tissue at autopsy

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11
Q

What is the primary muscle of continence?

A

• Internal Urethral Sphincter

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12
Q

What is the external urethral sphincter

A

• Anatomical sphincter

○ Localised circular muscle thickening to facilitate action

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13
Q

What is the external urethral sphincter derived from?

A

• Pelvic floor muscles

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14
Q

What type of muscle is the external sphincter?

A
  • Skeletal muscle under somatic, voluntary control

* Contracts to constrict urethra and hold in urine

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15
Q

What are the two innervations of the detrusor?

A
  • Parasympathetic

* Sympathetic

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16
Q

Outline the parasympathetic innervation of the detrusor

A
  • Pelvic nerve (S2-S4)
    • Ach - M3 receptors

Contraction

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17
Q

Outline the sympathetic innervation of the detrusor?

A
  • Hypogastric nerve (T10-L2)
    • NA -> B3 receptors
    • Relaxation
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18
Q

What is the innervation of the internal urethral sphincter?

A
  • Sympathetic
    • Hypogastric nerve (T10 - L2)
    • NA -> a1 receptors
    • Contraction
    • Parasympathetic
    • Pelvic nerve
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19
Q

What is the innervation of the external urethral sphincter?

A
  • Somatic
    • Pudendal nerve (S2-S4)
    • Spinal motor outflow from Onof’s nucelus of the ventral horn of the spinal cord
    • Ach -> Nicotinic teceptor
    • Contraction
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20
Q

What are the four main functions of the nervous system in relation to the bladder?

A

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

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21
Q

What prevents retrograde ejaculation in men?

A

• Prostatic urethra

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22
Q

Give the nerve roots which control urine storage

A

• L1 & L2

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23
Q

Give the nerve roots which control bladder voiding

A

S2-S4

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24
Q

What are the two phases of the bladder?

A
  • Emptying

* Filling

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25
Q

What occurs in the filling phase?

A
  • The bladder relaxes and accommodates increasing volumes of urine
    • The urethral sphincters increase their tone to maintain continence
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26
Q

What volume of urine is usually required to cause the urge to urinate?

A

• >150ml

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27
Q

What is the overall capacity of the urinary bladder?

A

• 350 - 750ml

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28
Q

Outline the nervous pathway which is activated once bladder has a volume of >400ml and urge to urinate arises

A

• Brain micturition centres -> Spinal micturition centres -> parasympathetic neurones -> Pelvic nerve -> Contraction of detrusor muscle -> Rise in intravesicular pressure

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29
Q

What occurs once there is a rise in intravesicular pressure in the bladder?

A

• Cerebral context makes a concious, executive decision to urinate by reducing sympathetic stimulation to the external urethral sphincter

30
Q

What causes feeling of pain/temperature in bladder as it reaches 400ml filling?

A

• Afferent nerves from the bladder wall start to signal the need to void by producing pain/temperature

31
Q

Outline the nervous pathways which is activated in the filling phase

A

• Brain continence centres -> Spinal continence centres -> Sympathetic neurones -> Hypogastric nerve

32
Q

What does an increase of sympathetic stimulation to the bladder cause in the filling phase

A
  • Hypogastric nerve stimulates relaxation of detrusor and contraction of the internal urethral sphincter
    • Cerebral cortex makes concious executive decision no to urinate by increasing somatic stimulation to the external urethral sphincter
33
Q

What three things must occur for bladder not to empty?

A
  • Relaxation of detrusor
    • Contraction of internal urethral sphincter
    • Contraction of external urethral sphincter
34
Q

Give four types of urinary incontinence

A
  • Stress Urinary Incontinence
    • Urge Urinary incontinence
    • Mixed Urinary Incontinence
    • Overflow Incontinence
35
Q

What is stress urinary incontinence?

A

• Involuntary leakage on effort or exertion, or on sneezing or coughing

36
Q

What is urge urinary incontinence?

A

• Involuntary leakage, accompanied by or immediately proceeded by urgencu

37
Q

What is mixed urinary incontinence?

A

• Involuntary leakage associated with urgency and exertion, effort, sneezing or coughing

38
Q

What is overflow incontinence?

A

• Retention of urine causing the bladder to swell. Can be low pressure and pain free

39
Q

Which type of urinary incontinence has the highest incidence?

A

• Stress urinary incontinence

40
Q

Give three categories of risk factors for urinary incontinence

A
  • Obs and Gyny
    • Promoting
    • Presdisposing
41
Q

Give three obs and gyny risk factors for urinary incontinence

A
  • Pregnancy and childbirth
    • Pelvic surgery
    • Pelvic prolapse
42
Q

Give three predisposing risk factors for urinary incontinence

A
  • Race
    • Family predisposition
    • Anatomical abnormality
43
Q

Give three promoting risk factors for urinary incontinency

A
  • UTI
    • Cognitive impairment

Obesity

44
Q

What is an important physiological factor in maintaining continence?

A

• 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 that enables continence

45
Q

Outline history taking from a patient with a history of Urinary incontinence

A
  • Ask to record the amount of fluid they pass for two or three days
    • Work out the number of pads that the patient has to use per day to cope with urine leakage
    • Assess whether leakage continous or intermittent
    • What precipitating factors are present (coughing/sneezing)
46
Q

What can make urgency and frequency of micturition worse?

A

• Intravesicular inflammatory conditions due to UTI, stone in the bladder or tumour

47
Q

How can past medical history assist in the assesment of UTI’s?

A
  • Previous surgery of the pelvic floor

* Childbirth can cause sphincter damage

48
Q

Outline what information must be gathered in a urinary examination

A 
• Height/Weight
	• Abdominal exam to exclude palpable bladder
	• Digital rectal examination (DRE)
		○ Prostate
		○ Limited neurological examination
	• (Females) External genitalia

(Female) Vaginal exam

49
Q

What investigations should be done in the case of urinary incontinence?

A 
• Mandatory 
		○ Urine dipstick
	• Basic non-invasive urodynamics
		○ Frequency volume chart
		○ Bladder diary
		○ Post micturition residual volume
	• Optional 
		○ Invasive urodynamics
		○ Pad  tests
		○ Cystoscopy
50
Q

incontinence

What does management of urinary incontinence depend on?

A
  • Symptoms patients have
    • Degree of inconvenience they suffer as a result
    • Previous or current treatments

Effects of treatments on other symptoms they may have

51
Q

Outline conservative management of urinary incontinence

A
  • Modify fluid intake
    • Weight loss
    • Stop smoking
    • Decrease caffeine intake (UUI)
    • Avoid constipation
    • Timed voiding – fixed schedule
52
Q

What treatment can be give to patients who fail conservative management but are unsuitable for surgery?

A 
• Indwelling catheter 
		○ Urethral or suprapubic
	• Sheath device
		○ Analagous to an adhesive condom attached to a catheter tubing and bag
	• Incontinence pads
53
Q

Give specific management of Stress Urinary Incontinence

A
  • Pelvic floor muscle training
    • 8 contractions, 3x a day
    • At least 3 months duration
    • Void bladder, stop stream ß use those muscles in pelvic floor training
54
Q

Give specific management of a urge urinary incontinence?

A

• 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
• At least 6 weeks of training needed

55
Q

Give three pharmacological managements of patients with urinary incontinence

A
  • Duloxetine
    • Anticholinergics

Botulinim toxin

56
Q

What is duloxetine?

A
  • A combined noradrenaline and serotonin uptake inhibitor
    • Increases the activity od the external urethral sphincter during the filling phase
    • Offered as alternative to surgery
57
Q

What is an anticholinergic?

A

• Act on muscarininc receptors, including the M3 receptors that cause the detrusor muscle to contract.

58
Q

What is a downside of using an anti-cholinergic to treat urinary incontinence?

A

Many side effects due to effect on muscarinic receptors

59
Q

Why is botulinim toxin sometimes used?

A

• A potent buiological neurtoxin that inhibits Ach release. Prevents detrusor muscle contraction as pelvi nerve cannot release Ach to act on the M3 receptors

60
Q

What are the two main types of surgery in females for urinary incontinence?

A
  • permanent intention

* Temporary intention

61
Q

Give three types of permanent intention surgery in females

A
  • Low tension vaginal tape
    • Open retropubic suspension procedures
    • Classic fascial sling procedure
62
Q

What is low tension vaginal tape?

A
  • Common, minimally invasive surgery
    • Success rate of >90%
    • Supports mid urethra with a polyprophylene mesh
63
Q

What is open retropubic suspension procedure?

A

• Corrects the anatomical position of the proximal urethra and improves urethral support

64
Q

What is the classic fascial sling procedure?

A
  • Supports urethra and increases bladder outflow resistance

* Involves autologus transplantation of the fascia late or rectus fascia

65
Q

Give a temporary female treatment for urinary incontinence?

A

• Intramural bulking agents improve the ability of the urthera to resist abdominal pressur eby improving urethral coaptation. This is achieved by injetions of autologous fat, silicone, collagen or hylauron-dextran polymers

66
Q

Give two surgical treatments in men for UI

A
  • Artificial urinary sphincter

* Male sling procedure

67
Q

Outline the insertion of an artificial urinary sphincter in amales

A

• Treatment for urethral sphincter deficiency

Cuff is a mechanical device that stimulates the action of a normal sphincter to cicrumferntially close the urethra

68
Q

Give three problems involved in the insertion of an artificial urinary sphincter

A
  • Infection
    • Eorsion

Device failure

69
Q

What is a male sling procedure?

A

• Corrects stress urinary incontinence in males

Bone anchored tape attached to urethra

70
Q

What is a male sling used to treat?

A

Stress urinary incontinence as a result of radical prostatectomy, colorectal surgery, radical pelvic radiotherapy

Semester 3 - Urinary (33 decks)

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