Urinary: Bladder Flashcards
How is the detrusor muscle controlled?
Purasympatheically through an M3 receptor
How is the sphincter muscle controlled?
Somatic innervation via the Pudendal nerve
S2, S3, S4
What is the features of the bladder phases?
Storage phase
- Compliance
- Sensation of bladder filling
- No detrusor contraction
Voiding phase
- Voluntary initiation
- Complete emptying
What is the effect of a lower motor neurone lesion?
- Low detrusor pressure
- Large residual urine
- Reduced perianal seasntion
- Lax anal tone
+/- overflow incontinence
What is the effect of an upper motor neurone lesion?
- High pressure detrusor contractions
- Poor coordination with sphincters
Stops the inhibitor of the parasympathetic nerves
What are the types of incontinence?
- Stress Urinary incontinence
- Urge Urinary Incontinence
- Mixed Urinary Incontinence
- Overflow Incontinence
What are risk factors for incontinence?
- Pregnancy and childbirth
- Pelvic surgery
- Pelvic prolapse
- Race
- Family predisposition
- Anatomical abnormalities
- Neurological abnormalities
- Menopause
- Drugs
- UTI
- Co-morbidities
- Obesity
- Age
- Increase in intra-abdominal pressure
How is uriniary incontinence examined?
History to categorise type of UI
Examination
- BMI
- Abdominal exam
- Digital Rectal examination (prostate, limited neurological examination)
- Females (external genitalia stress test, vaginal exam)
What are investigations undertaken for urinary incontinence?
- Urine dipstick mandatory
- Basic non-ivasic urodynamics (frequency-volume chart, bladder diary, post micturition residual volume)
Optional
Invasive urodynamic
Pad tests
Cystoscopy
What are the conservative management options for Urinary Incontinence?
- Modify fluid intake
- Weight loss
- Stop smoking
- Decrease caffeine intake
- Avoid constipation
- Timed voiding - fixed schedule
What is contained incontinence?
- Indwelling catheter
- Sheath device
- Incontinence pads
For patient suitable for surgery who have failed conservative or medical management
What are the management options for stress urinary incontinence?
Initial management
-Pelvic floor muscle training
Pharmacological Management
-Duloxetine for combined noradrenaline and serotonin uptake inhibitor and increased activity in striated sphincter during filling phase
Surgery. Permanent (P) and Temporary (T)
Females
- Low tension vaginal tapes (P)
- Open retropubic suspension procedures (P)
- Classic sling procedures (P)
- Intramural bulking agents (T)
Males
- Artificial urinary sphincter
- Male sling procedure
What are the specific management of Urge Urinary Incontinence?
Initial management
-Bladder training (schedule of voiding for at least 6 weeks)
Pharmacological management
- Anticholinergics (oxybutynin) which acts on muscurrinic receptors (M2,M3). Has side effects on other sites.
- B3 adrenoreceptor agonist (Mirabegron) to increase bladder’s capacity to store urine
- Intravesical injection of Botulinum toxin to inhibit release fo Act at pre-synaptic neuromuscular junction causing flaccid paralysis
Surgery
- Sacral nerve neuromodulation
- Autoaugmentaion
- Augmentation cystoplasty
- Urinary diversion
Which area can stones lodge to cause hydronephrosis?
-Pelvo-Ureteric junction can be an area in which stone can lodge causing Hydronephrosis. This can lead to AKI.
What can stasis of Urine lead to?
Can lead to pyelonephritis due to stasis of the urine leading to infection
What are the borders of the trigone?
- Both Internal ureteric entrance
- External urethral meatus.
- Imaginary line connecting these forms the Trigone
What is the most strongly tethered portion of the bladder?
Trigone is the most strongly tethered portion of the bladder.
Where is the trigone derived?
Trigone derived from the Wolffian ducts whilst remainder is from endoderm derived urogenital sinus
Why is the back of the bladder tethered down?
Back of the bladder is tethered down due different different embryological origin
Which spaces are filled when a patient lays down?
The rectovesicular pouch and uterovesicular pouch is where fluid collects
What are structures found within the bladder?
-Bladder wall has rugae. Then detrusor muscle as well
What cancers can present in the bladder?
- Bladder normally has a transitional cell carcinoma
- At the tip of the bladder if there is a cancer, it can be an adenocarcinoma due to a different embryological origin of the Urachus
What is the course of the urethra?
- Penile Urethra
- Spongy urethra
- Bulbuous urethra
- Membranous urethra (urogenital diaphragm)
- Prostatic urethra
Why can inacrurances occur in urine dipstick?
- Extreme exercise can cause proteinuria and haematuria
- Menstruation
- Indwelling catheters (always have an infection
