Urinary Incontinence and Benign Prostatic Hyperplasia

Question 1

Describe female ureters

Answer 1

Convey urine from the kidneys to the urinary bladder.
Each one is about 25cm long, upper half lies in abdomen and lower half in pelvis.
Measures 3mm in diameter but slightly constricted at 3 places (pelvic ureteric junction, pelvic brim, as it passes through the bladder wall).
Ureters 3 layers of tissue-outer fibrous tissue, middle muscle layer and inner epithelium layer.

Question 2

Describe blood supply to ureters in females

Answer 2

renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage.

Question 3

Describe lymphatics of ureters in females

Answer 3

left ureter drains into left para-aortic nodes, right ureter drains into right paracaval and interaortocaval lymph nodes

Question 4

Describe nerve supply to ureters

Answer 4

ANS

Question 5

Describe female urinary bladder

Answer 5

Muscular reservoir of urine. When empty, bladder is pelvic organ, when distended it rises up to abdominal cavity and becomes an abdomino-pelvic organ.
An empty bladder is a 4 sided pyramid in shape and has 4 angles: apex, neck and 2 lateral angles
4 surfaces: base/posterior surface, 2 inferiolateral surfaces and a superior surface.
Has 3 layers: outer loose connective tissue, middle smooth muscle and elastic fibres and inner layer lined with transitional epithelium.

Question 6

Describe blood supply to bladder

Answer 6

Superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein.

Question 7

Describe lymphatics of bladder

Answer 7

Internal iliac nodes and then paraaortic nodes.

Question 8

Describe nerve supply of bladder

Answer 8

ANS

Question 9

Describe the female urethra

Answer 9

Is the channel from neck of bladder (internal urethral sphincter-detrusor muscle thickened, smooth muscle, involuntary control) to the exterior, at the external urethral orifice (external urethral sphincter-skeletal muscle, voluntary control).
Measures 3-4cm long

Question 10

Describe blood supply of female urethra

Answer 10

Internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage.

Question 11

Describe lymphatics of female urethra

Answer 11

Proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes

Question 12

Describe nerve supply of female urethra

Answer 12

Vesical plexus and the pudendal nerve.

Question 13

How does venous drainage of male bladder differ from female?

Answer 13

Venous drainage by prostatic venous plexus which drains into internal iliac vein.

Question 14

Describe the prostate

Answer 14

Gland lying below the bladder in the male and surrounds the proximal part of the urethra (prostatic urethra). Function is to secrete 75% of seminal fluid which liquifies coagulated semen after deposition in the female genital tract.
Measures 4x3x2cm, conical in shape. Connected to bladder by connective tissue.
Has 3 parts-left lateral lobe, right lateral lobe and middle lobe.

Question 15

Describe blood supply of prostate

Answer 15

Inferior vesical artery, venous drainage via prostatic plexus to the vesical plexus and internal iliac vein.

Question 16

Describe lymphatics and nerve supply of prostate

Answer 16

Internal and sacral nodes drain. ANS supply.

Question 17

Describe the male urethra

Answer 17

20 cm long, runs through neck of bladder, the prostate gland, the floor of pelvis and the perineal membrane to the penis and external urethral orifice at the tip of the male penis.
Has 3 parts: prostastic, membranous and spongy urethra

Question 18

Describe the blood supply to male urethra

Answer 18

Prostatic-inferior vesical artery, membranous-bulbourethral artery and spongy urethra-internal pudendal artery with corresponding venous drainage.

Question 19

Describe lymphatics of male urethra

Answer 19

Prostatic and membranous urethra drain to obturator and internal iliac nodes, spongy urethra drains to deep and superficial inguinal nodes.

Question 20

Describe nerve supply of male urethra

Answer 20

Prostatic plexus.

Question 21

What is normal micturition and phases of the same?

Answer 21

Normal micturition is the intermittent voiding of urine stored in the bladder.
Filling phase: bladder fills and distends without rise in intravesical pressure. Urethral sphincter contracts and closes urethra
Voiding phase: bladder contracts and expels urine, urethral sphincter relaxes and urethra opens

Question 22

How does micturition differ in infants and adults?

Answer 22

In infants micturition is a local spinal reflex in which bladder empties on reaching a critical pressure.

In adults voiding can be initiated or inhabited by higher centre control of the external urethral sphincter keeping it closed until it is appropriate to urinate.

Question 23

Describe how innervation enables bladder emptying

Answer 23

The M3 receptors (parasympathetic S2-S4) are stimulated as the bladder fills.
As they become stretched and stimulated this results in contraction of the detrusor muscle for urination.
At the same time the parasympathetic fibres inhibit the internal urethral sphincter which causes relaxation and allows for bladder emptying.

Question 24

How does innervation allow the bladder to fill?

Answer 24

When the bladder empties of urine the stretch fibres become inactivated, and the sympathetic nervous system (originating from T11-L2) is stimulated to activate the beta 3 receptors causing relaxation of the detrusor muscle allowing the bladder to fill again.

Question 25

Define and state incidence of stress urinary incontinence

Answer 25

Definition: Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing

Incidence: Can affect up to 40% of women, more common in older women, with 1 in 5 women over 40 having some degree of stress incontinence.

Question 26

What are risk factors and pathology of stress urinary incontinence?

Answer 26

Risk factors: aging, obesity, smoking, pregnancy and route of delivery. DAPOS.

Pathology: impaired bladder and urethral support and impaired urethral closure.

Question 27

What are signs and symptoms of stress urinary incontinence? What investigations are carried out for the same?

Answer 27

Signs and symptoms:
Involuntary leakage from urethra with exertion/effort or sneezing or coughing

Investigations:
History and examination as above, positive stress test (demonstrable loss of urine on examination)
urodynamics-urinary leakage during an increase in intrabdominal pressure in the absence of a detrusor contraction.

Question 28

How is stress urinary incontinence managed?

Answer 28

Non surgical: Physio with PFE

Surgical: Mid-urethral sling, colposuspension, periurethral bulking agents

Question 29

Define and state incidence of overactive bladder

Answer 29

Definition: urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence

Incidence: overall prevalence of 16.6% in men and women over 40

Question 30

What are the risk factors and pathology of overactive bladder?

Answer 30

Risk factors: age, prolapse, increased BMI, IBS, bladder irritants (caffeine, nicotine)

Pathology: not well understood. Involuntary detrusor (bladder wall) muscle contractions. Cause can be idiopathic, neurogenic (loss of central nervous system inhibitory pathways) or bladder outlet obstruction.

Question 31

What are symptoms and signs of overactive bladder?

Answer 31

Urgency, frequency, nocturia and urgency incontinence, impact on QOL-sleep disorders, anxiety and depression. Assess for enlarge prostate in males and prolapse in women.

Question 32

What investigations are carried out for overactive bladder?

Answer 32

Exclude infection with urine dip/MSU
Voiding diaries
Assess post void residual
Urodynamics
Cystoscopy

Question 33

What management is used for overactive bladder?

Answer 33

Behavioural/lifestyle changes
Bladder retraining
Antimuscarinic drugs
Beta-3 agonists
BOTOX
Neuromodulation (PTNS/SNS)
Surgical: Augmentation cystoplasty and urinary diversion

Question 34

What is overflow incontinence?

Answer 34

Involuntary leakage of urine when bladder is full. Usually due to chronic retention secondary to obstruction or an atonic bladder.

Question 35

What causes overflow incontinence?

Answer 35

Outlet obstruction (faecal impaction/BPH)
Underactive detrusor muscle
Bladder neck stricture
Urethral stricture
DHx-alpha adrenergics, anticholinergics, sedative
Bladder denervation following surgery

BUDUBO

Question 36

What is continuous incontinence, functional incontinence and mixed?

Answer 36

Continuous incontinence: Continuous loss of urine all the time. Could be due to vesicovaginal fistula, ectopic ureter(from kidney to urethra or vagina).

Functional incontinence: Due to severe cognitive impairment or mobility limitations, preventing use of the toilet. Bladder function is normal.

Mixed: More than 1 type, usually seen in older patients.

Question 37

Define benign prostatic hyperplasia

Answer 37

Non malignant growth or hyperplasia of prostate tissue, common cause of lower urinary tract symptoms in men.

Question 38

Describe incidence and risk factors of benign prostatic hyperplasia

Answer 38

Incidence: increases with advancing age, 50-60% for males in their 60’s, increasing to 80-90% for those over 70yrs of age
Risk factors: hormonal effects of testosterone on prostate tissue

Question 39

Describe pathology of benign prostatic hyperplasia

Answer 39

Hyperplasia of both lateral lobes and the median lobes, leading to compression of the urethra and therefore bladder outflow obstruction. See hyperplasia of the stroma (smooth muscle and fibrous tissue) and glands.

Question 40

What are signs and symptoms of benign prostatic hyperplasia?

Answer 40

Hesitancy in starting urination
Poor stream
Dribbling post micturition
Frequency, nocturia
Can present with acute retention

Question 41

What must be excluded before considering benign prostatic hyperplasia?

Answer 41

Main 3:
Bladder/prostate cancer
Cauda equina
High pressure chronic retention

Urinary tract infections/sexually transmitted infections
Prostatitis
Neurogenic bladder (can be secondary to Parkinson’s, Multiple sclerosis, etc.)
Urinary tract stones (bladder stones)
Urethral stricture

Question 42

What investigations are carried out for benign prostatic hyperplasia?

Answer 42

Investigations: urine dip/MCS, post void residual, voiding diary
Bloods: Psa-prostate specific antigen-shown to predict prostate volume-use with caution, if conered about prostate cancer
Imaging: Ultrasound to assess upper renal tracts
Flow studies/urodynamics
Cystoscopy if concerned about cancer

Question 43

What lifestyle and medical management is recommended for benign prostatic hyperplasia?

Answer 43

Lifestyle: weight loss, reduce caffeine and fluid intake in evening, avoid constipation

Medical:
1. Alpha blocker-alpha 1-AR present on prostate stromal smooth muscle and bladder neck. Blockage results in relaxation, thus improving urinary flow rate.

2. 5-alpha reductase inhibitor-prevents conversation of test to DHT (which promotes growth and enlargement of prostate) so results in shrinkage, thereby improving urinary flow rate and obstructive symptoms

Question 44

What surgical management is used for benign prostatic hyperplasia?

Answer 44

Transurethral resection of the prostate (TURP)-debulks prostate to produce adequate channel for urine to flow.

Question 45

What are possible complications of benign prostatic hyperplasia?

Answer 45

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.