Urinary Incontinence Flashcards
What is BPH?
Benign Prostatic Hyperplasia
What is the main influencing hormone for prostate developement?
dihydrotestosterone
What are the three zones?
Transition: 10% of the glandular tissue of the prostate
Site of origin of benign prostatic hyperplasia
Central: 25% of the glandular tissue of the prostate
Peripheral: 65% of the glandular tissue of the prostate
What is the function of the prostate?
Liquefy ejaculate
What is the role of the capsule?
The capsule transmits the ‘pressure’ of tissue expansion to the urethra and leads to an increase in urethral resistance
How is active smooth muscle tone regulated?
by the adrenergic nervous system
⍺1A adrenoreceptor is most abundant in prostate
What is LUTS in men with BPH related to?
Obstruction induced changes, changes in bladder function rather than to outflow obstruction directly.
What are the two classes of symptoms of BPH?
Voiding
Storage
What is important to ask about in BPH?
Fluid intake
What comprised the BPH examination?
General examination Palpable bladder Ballotable kidneys Phimosis Meatal stenosis Enlarged prostate on DRE, size, consistency, nodules, anal tone and sensation
What are obstruction-induced changes?
Detrusor instability/↓ compliance → frequency and urgency
↓ detrusor contractility → Further deterioration in the force of the urinary stream Intermittency Increased residual urine Sometimes detrusor failure Hesitancy
What are voiding symptoms?
Reduced flow
Incomplete emptying
Strangury
Hesitancy
What are storage symptoms?
Frequency (daytime and nocturia)
Urgency
Incontinence
What are other symptoms seen in BPH?
Visible haematuria
Infection
What investigations are done for BPH?
Urine dipstick Bladder diary Flow rate + PVR IPSS Questionnaire PSA, creatinine Flexible cystoscopy in some circumstances TRUS prostate Urodynamic studies
USS KUB if impaired renal function, loin pain, haematuria, renal mass on examination
What is a IPSS?
Validated patient reported outcome measures
Specifically designed for BPH
What is a bladder diary?
Record when and how much fluid
Record volume of urine passed and when
What are the management options for BPH?
Watch and wait
Lifestyle changes
Pharmacological treatment
Surgical
What lifestyle changes can be made for BPH
What they drink How much they drink Tweaks to improve urinary symptoms e.g. stop drinking late at night to limit passing urine at night cut out caffeine
What are some 5-alpha-reductase inhibitors?
e.g. Finasteride, Dustasteride
to prevent disease progression, reducing the development of AUR/requirement for surgery
What are some alpha-adrenergic antagonists?
e.g. Tamsulosin, alfuzosin, doxazosin
reduction in symptoms of 30-40% and improvement in flow rates of 16-25%
What are the surgical options for BPH?
TURP - transurethral resection of prostate
What is urinary incontinence?
significant health problem worldwide associated with considerable social and economic impact on individuals and society
Describe the epidemiology of UI?
In women, prevalence 5-72% among community-dwelling women
It may be significantly under-reported as it is an embarrassing problem to many women
Women with SI are less likely to seek help than those with OAB
What is stress UI?
the complaint of involuntary leakage on exertion/sneezing/coughing/pregnancy
increased intraabdominal pressure overwhelms sphincter muscles and allows urine to leak out
What is urge UI?
the complaint of an involuntary leakage accompanied by or immediately preceded by urgency
especially at night
usually uninhibited detrusor muscle
What is mixed UI?
the complaint of an involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing
What is continuous incontinence?
continuous leakage
What is overflow incontinence?
leakage associated with urinary retention
blockage in urine flow (BPH) or ineffective detrusor
can cause weak/intermittent flow or hesitancy
What is nocturnal enuresis?
the complaint of loss of urine occurring during sleep
What is Post-micturition dribble?
the complain of an involuntary loss of urine immediately after passing urine
What are risk factors for UI?
Age Pregnancy and vaginal birth Obesity Constipation Drugs e.g. ACE inhibitors Smoking FHx Prolapse/Hysterectomy/Menopause
What investigations are done for UI?
Urine dipstick Flow rate and post-void residual Bladder diary Pad tests Patient symptom scores/validated QoL questionnaire Urodynamic/video-urodynamic studies
What are the lifestyle changes for SI in women?
Weight loss Smoking cessation Modification of high/low fluid intake Supervised pelvic floor exercises Bladder re-training
What are the possible pharmacological treatments for SI?
Oestrogen therapy if there is evidence of atrophy
Oral medical therapy in rare cases
What are the surgical options for SI?
Occlusive e.g. bulking, compressive (AUS)
Supportive (mid-urethral sling, colposuspension)
Ileal conduit diversion
What are the three causative theories of SI in men?
Sphincter incompetence
Reduction in urethral sphincter length
Post-operative strictures
What are the 5 structures that control continence?
Detrusor muscle Internal sphincter Ureterotrigonal muscles Levator muscles Rhabdosphincter (external sphincter muscle)
What is OAB?
Over-active bladder
Symptom syndrome
What symptoms comprise overactive bladder?
Urinary frequency
Urgency
Nocturia with or without leak
What are differentials surrounding UUI?
UTI DO Urethral syndrome Urethral divertivulum Interstitial cystitis Bladder cancer Large residual volume
What are lifestyle changes for UUI?
decreasing caffeine intake
stopping smoking
losing weight if obese
What pharmacotherapy can be used for UUI?
Efficacy is 50-75%
Anti-cholinergics e.g. solifenacin, tolterodine, trospium
Beta-3-agonists e.g. betmiga
What are the surgical options for UUI?
Posterior tibial nerve stimulation
Intravesical injection of botulinum toxin A
Neuromodulation
Clam (augmentation) cystoplasty
Urinary diversion
What is the efficacy for botox injections?
efficacy is 36-89%, mean efficacy is 70%, upto a mean time of 6 months
What is the efficacy for neuromodulation in UI treatment?
50% cure rate, 25% significant improvement of symptoms, 25% failure rate
What is the efficacy of clam cystoplasty?
50% cure rate, 25% significant improvement of symptoms, 25% failure rate
medical treatments of BPH
alpha blockers - symptom relief (relax bladder neck)
5a reductase inhibitors (prevents test-DHT so results in shrinkage improving obstructive symptoms)
what is functional UI?
severe congitive impairment of mobility limitations preventing use of toilet
bladder function normal
phases of micturition
filling phase - bladder fills/distends wtihout rise in intravesical pressure. urethral sphincter contracts and closes urethra
voiding phase - bladder contracts and expels urine, urethral sphincter relaxes and urethra opens
what is in control of external urethral sphincter
pudendal nerve S2-4
voluntary control in adults
process of micturition
M3 receptors stimulated by full bladder (parasympathetic)
contraction of detrusor muscle by parasympathetic S2-4, inhibits internal urethral sphincter for bladder emptying
voluntary pudendal nerve (S2-4) relaxation of external urethral sphincter
once empty, sympathetic fibres (T11-L2) stimulated to activate beta-3 receptors to cause relaxation of detrusor muscle
lymphatic drainage of female ureters
left - paraaortic
right - paracaval and interaortocaval
anatomical constrictions of ureters
pelvic uteric junction
pelvic brim
as it passes through bladder wall
blood supply of bladder
superior and inferior vesical branches of internal iliac artery
female drainage by vesical plexus - internal iliac vein
male drainage by prostatic plexus - internal iliac vein
