Urinary Incontinence Flashcards
Female GU system
- 2 kidneys
- 2 ureters
- Urinary bladder
- Urethra
What is the function of the kidneys? (3)
- Remove waste products of metabolism
- Remove excess water and salts from blood
- Maintain the pH
What do the ureters do?
Convey urine from kidney to urinary bladder
25 cm in length- upper half lies in abdomen and lower half in pelvis
3mm in diameter
What places are the ureters constricted at
- Pelvic ureteric junction
- Pelvic brim
- As it passes through bladder wall at the utero vesical junction
- Outer fibrous tissue
What 3 layers make up the ureters
- Outer fibrous tissue
- Middle muscle layer
- Inner epithelium layer
Starts at around L1
Blood supply to ureters
- Dependent on where it is- renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries
- Corresponding venous drainage
Lymphatics-wise where do the left and right ureter drain into?
- Left ureter → left para-aortic nodes
- Right ureter → right paracaval and interaortocaval lymph nodes
Nerve supply for ureters
Autonomic nervous system
Purpose of urinary bladder
Muscular reservoir for urine
Detruosr muscle lined with waterproof urothelium which is a transitional epithelium that copes with volume changes
Describe urinary bladder shape
- When empty it’s a pelvic organ and when distended it rises into the abdominal cavity to become an abdomino-pelvic organ
- An empty bladder is a 4 sided pyramid and has 4 angles- apex, neck and 2 lateral angles
- It has 4 surfaces- the base, 2 inferiolateral surfaces and a superior surface
What 3 layers make it up urinary bladder
- Outer loose connective tissue
- Middle smooth muscle and elastic fibres (detrusor)
- Inner layer lined with transitional epithelium
Blood supply for urinary bladder
- Superior and inferior vesical branches of internal iliac artery
- Drained by vesical plexus which drains into internal iliac vein
What does the bladder drain into lymphatically
Internal iliac nodes and then paraaortic nodes
What is the nerve supply for the bladder
Autonomic nervous system
Where does the urethra run from and too in females
from neck of bladder to exterior at external urethral meatus in the vaginal vestibule 3-4 cm long
Describe the difference between the internal urethral sphincter and external urethral sphincter
- Internal urethral sphincter- detrusor muscle thickened, smooth muscle, involuntary control
- External urethral sphincter- skeletal muscle, voluntary control
Blood supply to the urethra in females
Internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage
Where do the proximal and distal urethra drain into lymphatically? Females
- Proximal urethra → internal iliac nodes
- Distal urethra → superficial inguinal lymph nodes
Nerve supply for urethra
Vesical plexus and pudendal nerve
Male GU system
- 2 kidneys
- 2 ureters
- Urinary bladder
- Prostate
- Urethra
Venous drainage for male bladder
Venous drainage by prostatic venous plexus which drains into internal iliac vein
Prostate
- Gland lying below the bladder in the male and surrounds the proximal part of the urethra
- Measures 4x3x2cm and conical in shape
- Connected to bladder by connective tissue
Secreted 75% of seminal fluid which liquifies semen after deposition into female genitalia tract
3parts of prostate
- Left lateral lobe
- Middle lobe
- Right lateral lobe
Function of prostate
Secrete 75% of seminal fluid which liquifies coagulated semen after deposition in the female genital tract
Blood supply for prostate
- Inferior vesical artery
- Venous drainage via prostatic plexus to the vesical plexus and internal iliac vein
Nerve supply for prostate
Autonomic nervous system
Where does urethra go and come from jn males
- 20cm long
- Runs through neck of bladder, prostate, floor of pelvis and perineal membrane to the penis and external urethral orifice at the tip of the male penis
Blood supply to urethra
- Prostatic part- inferior vesical artery
- Membranous part- bulbourethral artery
- Spongy urethra- internal pudendal artery
- Corresponding venous drainage
Describe lymphatics for urethra
Prostatic and membranous urethra drain to obturator and internal iliac nodes, spongy urethra drains to deep and superficial inguinal nodes
Nerve supply for lymphatics males
Vesical plexus (proximal) and pudendal nerve (distal)
What is normal micturition?
Storage and voiding
Storage is when bladder is released serving as a reservoir
Outlet contracted preventing leaks
2 phases of micturition
- storage phase-bladder relaxed serving as reservoir, outlet contracted preventing leaks
- Voiding phase- bladder contracts and expels urine, outlet relaxed permitting flow. Bladder empties fully thus less than 50ml post void residual left
6 pees daily ,20seconds each so 2 mins per day spent voiding
How does micturition happen in infants?
It’s a local spinal reflex where bladder empties on reaching a critical pressure
How does micturtuon differ to adults and children
adults, voiding can be initiated or inhibited by higher control centre of the external urethral sphincter keeping it closed until it is appropriate to urinate
Describe the innervation of micturition and its process up until bladder emptying
- Bladder has M3 (muscarinic type 3) receptors that work with parasympathetic fibres S2-4 which are stretched and stimulated as the bladder fills
- This results in contraction of the detrusor muscle for urination
- At the same time parasympathetic fibres inhibit the internal urethral sphincter causing relaxation and allows for bladder emptying
Acts as a drug target for antimuscarinic drug oxybutynin and solifenacin
What happens when the bladder empties?
- The stretch fibres become inactivated
- The sympathetic nervous system (originating from T11-L2) is stimulated to activate the beta 3 receptors
- This causes relaxation of the detrusor muscle allowing the bladder to fill again
*target for drug b 3 agonist eg mirabegron**
What’s stress urinary incontinence
Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing
What are incidence rates and who does it affect more urinary incontinence
- Can affect up to 40% of women
- More common in older women → 1/5 women over 40 have some degree of stress incontinence
Risk factors of stress urinary incontinence
- Ageing
- Obesity (increases intraabdominal pressure)
- Smoking
- Pregnancy (puts pressure on pelvic floor)
- Route of delivery
Describe the pathology of urinary stress incontinence
Impaired bladder and urethral support and impaired urethral closure
Usually when you sneeze or cough no leaking occurs because external urethral sphincter is closed but in stress incontinence the sphincter isn’t closed so coughing/sneezing or anything else that raises intraabdominal pressure causes leak
What signs and symptoms are there for urinary stress incontinence
Involuntary leakage from urethra with exertion/effort or sneezing or coughing
Investigations for urinary stress incontinence
- History and exam as above, positive stress test (demonstrable loss of urine on exam) and descent of pelvic floor on vaginal examination
- Urodynamics (put pressure line in bladder and another in back passage which tells us intraabdominal pressure- when the patient with stress incontinence coughs you can see spike in intraabdominal pressure but no bladder contraction but urinary leakage
How do we manage urinary stress incontinence
- Non surgical- physio with PFE (pelvic floor exercises)
- Surgical
Mid urethral sling- what is it?
Synthetic mesh that’s put under urethra to provide it support
Colposuspension- what is it?
We put 2 stitches on either side of bladder abdominally to elevate it
Reduces how much the bladder moves when patient coughs/sneezes so limits fluid loss
Periurethral bulking agents
Injections that are injected around urethral sphincter to bulk it to obstruct it so if patient coughs or sneezes, they don’t leak
Overactive bladder
Urinary urgency, usually with urinary frequency (as many times as is bothersome for that particular patient) and nocturia, +/- urgency urinary incontinence (leaking)
Incidence of over reactive bladder
Overall prevalence of 16.6% in men and women over 40
Risk factors for overactive bladder
- Age
- Increased BMI
- Prolapse
- IBS
- Bladder irritants (caffeine, nicotine, alcohol, spicy and tomato based foods)
Pathology of overactive bladder
- Not well understood
- Caused by involuntary detrusor (bladder wall) muscle contractions
Cause can be idiopathic or neurogenic (loss off cns inhibitory pathways)
Name 3 causes for these involuntary muscle contractions
- Could be idiopathic
- Could be neurogenic (loss of central nervous system inhibitory pathways)
- Could be bladder outlet obstruction at urethra- if urine can’t get out then bladder muscle keeps trying to squeeze to get the urine out which makes it irritable
Overactive bladder symptoms and signs
- Urgency
- Frequency
- Nocturia
- Urgency incontinence
- Impact on QOL- sleep disorders
- Anxiety and depression
What do we assess in males and females for overactive bladder
- Enlarged prostate in males- can cause obstruction
- Prolapse in women- urethra sits in anterior vaginal wall and if that prolapses down it drags urethra with it to form obstruction
How do we investigate overactive bladder
- Exclude infection with urine dip/MSU
- Voiding diaries- what are these?
- 3 day bladder diaries
- They document:
- volume of what they’re drinking and what time
- How often they go toilet and what volumes they’re voiding
- Whenever they have urgency or urge incontinent episodes
- Assess post void residual- what is this for?
- Check the patient is emptying bladder properly- sometimes they say they feel like there’s a little bit left after they’ve gone to the toilet
- Do this by scanning bladder post voiding to see residual
- How much should it be normally in ml?<100ml or 1/3 or less than voided volume
- What is the risk if they have increased post void residual?That they develop UTI
- Urodynamics- when do we do this?
- Objective assessment of bladder function
- ## Do this in patients who have overactive bladder where conservative measures/medication haven’t worked and you do urodynamics to plan further management
How do we manage overactive bladder
- Behavioural/lifestyle changes
- Bladder retraining- what is this?Giving patients techniques to defer how often they’re going to the toilet e.g. distraction techniques, pelvic floor techniques
- Antimuscarinic drugs- how does this help?it’s the M3 receptors on detrusor muscle that contracts it so we block these
- Beta-3 agonists- how does this help?these cause detrusor muscle to relax
- BOTOX- how does this help?
- blocks neuromuscular junction to paralyse detrusor muscle
- Works for 6-9 months
- What 2 risks are there?
- 10% risk of UTI so we give antibodies
- Risk of patients going into retention (can’t empty so we have to teach them how to empty bladder themselves)
- Neuromodulation (PTNS/SNS)- what does this mean?
- Stimulate nerves that innervate bladder either:
- peripherally by stimulating tibial nerve which indirectly connects to sacral nerves that innervate bladder
- directly by stimulating S3 with a lead attached to pacemaker which gives impulses
- These modify the way the nerves innervate the bladder
- Improvement is 40-60%
- Stimulate nerves that innervate bladder either:
- Surgery- what 2 interventions are there?
- Augmentation cystoplasty- what does this involve?Cut bladder in half and put some bowel over the top to increase bladder capacity
- What do these patients need surveillance for and why?
- For malignancy inside bladder
- Because part of bowel is exposed to urine where it’s not meant to be
- What do these patients need surveillance for and why?
- Urinary diversion- what does this involve?
- Augmentation cystoplasty- what does this involve?Cut bladder in half and put some bowel over the top to increase bladder capacity
BPH
- Non malignant growth or hyperplasia of prostate tissue
- Common cause of lower urinary tract symptoms in men
Incidence for BPH
- Increases with advancing age
- 50-60% for males in their 60s
- 80-90% for males >70
What risk factor is there for BPH
Hormonal effects of testosterone on prostate tissue
Pathology for BPH
- Hyperplasia of both lateral lobes and the median lobes- of the stroma (smooth muscle and fibrous tissue) and the glands
- Leads to compression of the urethra and therefore bladder outflow obstruction
Signs and symptoms for BPH
- Hesitancy in starting urination
- Poor stream- stop-start stream leading to intermittent flow
- ## Dribbling post micturition
Investigations for BPH
- Urine dip/MCS
- Post void residual
- bladder diary
- Flow studies/urodynamics
- Cystoscopy if concerned about cancer
Prostate-specific antigen (PSA)- shown to predict prostate volume
US to assess upper renal tracts
Lifestyle factors for BPH
- Weight loss
- Reduce caffeine and fluid intake in evening
- Avoid constipation- puts pressure on everything
What medical management is there for BPH
- Alpha blockers- how do these work?there are alpha-1 receptors on prostate stromal smooth muscle and bladder neck and blockage results in relaxation → improving urinary flow rate
- 5-alpha reductase inhibitors- how do these work?Prevents conversion of T to DHT (which promotes growth and enlargement of prostate) so results in shrinkage → improving urinary flow rate and obstructive symptoms
Surgical intervention of BPH
Transurethral resection of the prostate (TURP)- debulks prostate to produce adequate channel for urine to flow
Complications for BPH
- Progressive bladder distention causing chronic painless retention and overflow incontinence
- If undetected can lead to bilateral upper tract obstruction and renal impairment with patient presenting with chronic renal disease
Partial and complete duplication in ureters
Congenital abnormalities
Partial-2 ureters originate from the kidney but merge into a single ureter ,usually asymptomatic but can cause UTI
Complete-2 ureters arise from one kidney
Ectopic kidney
Kidney located in an abnormal position due to improper migration
Horseshoe kidney is a type of this where kidneys fuse onto IMA
Physiology of micturition
Frontal cortex-decides actions based on planning ahead,social appropriateness etc
Pontine micturition centre-storage switches to voiding if permitted
Limbic lobe-involved in emotional and fear reactions causing urine release
Periaquedectal gray-receives sensory info from viscera (subconscious)and decides what goes to the cortex (conscious sensation)
Sympathetic nucleus-bladder neck (thoracic spinal chord)
Parasympathetic-detrusor (sacral spinal cord
Drug targets for erectile tissue
Nitrergic PDE5 inhibitor
What other exams should we include for BPH
Bladder cancer(haematuria)
Prostate cancer (raised PSA)
UTI/prostatitis
Urethreal stricture
