Urinary Incontinence and Benign Prostatic Hyperplasia Flashcards
Describe female ureters
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.
Describe blood supply to ureters in females
renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage.
Describe lymphatics of ureters in females
left ureter drains into left para-aortic nodes, right ureter drains into right paracaval and interaortocaval lymph nodes
Describe nerve supply to ureters
ANS
Describe female urinary bladder
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.
Describe blood supply to bladder
Superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein.
Describe lymphatics of bladder
Internal iliac nodes and then paraaortic nodes.
Describe nerve supply of bladder
ANS
Describe the female urethra
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
Describe blood supply of female urethra
Internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage.
Describe lymphatics of female urethra
Proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes
Describe nerve supply of female urethra
Vesical plexus and the pudendal nerve.
How does venous drainage of male bladder differ from female?
Venous drainage by prostatic venous plexus which drains into internal iliac vein.
Describe the prostate
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.
Describe blood supply of prostate
Inferior vesical artery, venous drainage via prostatic plexus to the vesical plexus and internal iliac vein.
Describe lymphatics and nerve supply of prostate
Internal and sacral nodes drain. ANS supply.
Describe the male urethra
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
Describe the blood supply to male urethra
Prostatic-inferior vesical artery, membranous-bulbourethral artery and spongy urethra-internal pudendal artery with corresponding venous drainage.
Describe lymphatics of male urethra
Prostatic and membranous urethra drain to obturator and internal iliac nodes, spongy urethra drains to deep and superficial inguinal nodes.
Describe nerve supply of male urethra
Prostatic plexus.
What is normal micturition and phases of the same?
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
How does micturition differ in infants and adults?
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.
Describe how innervation enables bladder emptying
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.
How does innervation allow the bladder to fill?
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.
Define and state incidence of stress urinary incontinence
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.
What are risk factors and pathology of stress urinary incontinence?
Risk factors: aging, obesity, smoking, pregnancy and route of delivery. DAPOS.
Pathology: impaired bladder and urethral support and impaired urethral closure.
What are signs and symptoms of stress urinary incontinence? What investigations are carried out for the same?
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.
How is stress urinary incontinence managed?
Non surgical: Physio with PFE
Surgical: Mid-urethral sling, colposuspension, periurethral bulking agents
Define and state incidence of overactive bladder
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
What are the risk factors and pathology of overactive bladder?
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.
What are symptoms and signs of overactive bladder?
Urgency, frequency, nocturia and urgency incontinence, impact on QOL-sleep disorders, anxiety and depression. Assess for enlarge prostate in males and prolapse in women.
What investigations are carried out for overactive bladder?
Exclude infection with urine dip/MSU Voiding diaries Assess post void residual Urodynamics Cystoscopy
What management is used for overactive bladder?
Behavioural/lifestyle changes Bladder retraining Antimuscarinic drugs Beta-3 agonists BOTOX Neuromodulation (PTNS/SNS) Surgical: Augmentation cystoplasty and urinary diversion
What is overflow incontinence?
Involuntary leakage of urine when bladder is full. Usually due to chronic retention secondary to obstruction or an atonic bladder.
What causes overflow incontinence?
Outlet obstruction (faecal impaction/BPH)
Underactive detrusor muscle
Bladder neck stricture
Urethral stricture
DHx-alpha adrenergics, anticholinergics, sedative
Bladder denervation following surgery
BUDUBO
What is continuous incontinence, functional incontinence and mixed?
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.
Define benign prostatic hyperplasia
Non malignant growth or hyperplasia of prostate tissue, common cause of lower urinary tract symptoms in men.
Describe incidence and risk factors of benign prostatic hyperplasia
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
Describe pathology of benign prostatic hyperplasia
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.
What are signs and symptoms of benign prostatic hyperplasia?
Hesitancy in starting urination Poor stream Dribbling post micturition Frequency, nocturia Can present with acute retention
What must be excluded before considering benign prostatic hyperplasia?
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
What investigations are carried out for benign prostatic hyperplasia?
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
What lifestyle and medical management is recommended for benign prostatic hyperplasia?
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.
- 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
What surgical management is used for benign prostatic hyperplasia?
Transurethral resection of the prostate (TURP)-debulks prostate to produce adequate channel for urine to flow.
What are possible complications of benign prostatic hyperplasia?
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.
