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
What are general examination for acute kidney infection?
- General appearance (Pallor, Uraemia, Nails, Rashes, Bruises)
- CVS/RS (BP, Fluid balance – (JVP, RR, O2 saturation, Chest sounds), Heart sounds – (Additional sounds, murmurs), Bruits)
- GIS/GUS (Palpable masses including bladder, Pain, Ballotable kidneys, Abdominal bruits, Urine outputs)
What are the features of urine microscopy?
- Infection – send for culture
- Crystals (Look under microscope, Gout, Pseudogout)
- Casts
- Red cell casts
What are the predisposing factors to UTI?
- Shorter urethra
- Obstruction
- Neurological problems
- Ureteric reflux
Which organism is commonly associated with UTI?
E-Coli
What are the virulence factors of E.coli that allow it to evade the immune defence?
- Fimbriae allow attachment to host epithelium
- Haemolysins damage host membranes and cause renal damage
- K antigen permits production of polysaccharide capsule
- Urease breaks down urea creating a favourable environment for bacterial growth
What are common syndromes presented as a result of UTI?
- Cystitis –frequency and dysuria (lower UTI)
- Acute pyelonephritis (upper UTI)
- Chronic pyelonephritis
- Asymptomatic bacteriuria (e.g. pregnancy)
- Septicaemia +/- shock
What are the clinical symptoms of lower UTI?
- Dysuria
- Frequency
- Urgency
- Low grade fever sometimes
What are the clinical symptoms of upper UTI?
- Fever
- Loin Pain
- May have dysuria and frequency
What is an uncomplicated UTI?
Defined as infection by a usual organism in a patient with a normal urinary tract and normal urinary function.
What is a complicated UTI?
UTI when one or more factors are present that predispose the person to persistent infection, recurrent infection, or treatment failure.
What are examples of predisposing factors to complicated UTI?
- Abnormal urinary tract (e.g., vesico-ureteric reflux, indwelling catheter, etc).
- Virulent organism (e.g.Staph. aureus).
- Impaired host defences (e.g. poorly controlled diabetes, immunosuppression).
- Impaired renal function
What are most cases of UTI in children, men and pregnant women treated as?
Complicated UTI
What is the investigation undertaken in UTI?
- In healthy non-pregnancy women of child-bearing age, no need to culture urine
- Culture urine in complicated UTI
How are patient screened for UTI?
- Turbidity
- Dipstick testing (useful to exclude UTI)
When is a dipstick testing not useful for in diagnosis of UTI?
- Acute uncomplicated UTI in women
- Men with typical/severe symptoms
- Catheterised patients
- Older patient without features of infection
What is the treatment for uncomplicated UTI?
- Increase fluid intake
- Address underlying disorders
- 3 days course of Trimethoprim or nitrofurantoin
- Check with cultures post treatment in children and pregnant women
What is the treatment for simple cystitis?
- Uncomplicated infections can be treated with trimethoprim or nitrofurantoin
- 3 days course
How are complicated lower UTI’s treated?
- Trimethoprim (7 day)
- Nitrofurantoin – specific to bladder
- Cephalexin
What is the treatment for pyelonephritis/septicaemia?
- Co-amoxiclav
- Ciprofloxacin (7 days also effective)
- Gentamicin IV
How is UTI prophylactically prevented?
Trimethoprim or nitrofurantoin
- Single nightly dose
- Ensure all breakthrough infections documented
- Three or more episodes a year but not treatable underlying conditons
