urinary incontinence and benign prostatic hyperplasia Flashcards
what is the anatomy of the female GU system?
ANATOMY
composed of 2 kidneys, 2 ureters, urinary bladder and urethra.
Kidneys remove waste products of metabolism, excess water and salts from the blood and maintain the pH.
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.
Blood supply:
related to region: renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage.
Lymphatics:
left ureter drains into left para-aortic nodes, right ureter drains into right paracaval and interaortocaval lymph nodes
Nerve Supply:
autonomic nervous system.
what is the anatomy of the female bladder?
Urinary bladder:
Is the 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 and 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.
Blood supply:
superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein
Lymphatics:
internal iliac nodes and then paraaortic nodes
Nerve supply: autonomic nervous system
what is the anatomy of the female urethra?
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
Blood supply:
internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage.
Lymphatics:
proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes
Nerve Supply:
vesical plexus and the pudendal nerve
what is the anatomy of the male GU system?
ANATOMY
composed of 2 kidneys, 2 ureters, urinary bladder, prostate and uretha.
Kidneys remove waster products of metabolism, excess water and salts from the blood and maintain the pH.
Ureters: same as women
Bladder:
venous drainage by prostatic venous plexus which drains into internal iliac vein
what is the anatomy of the prostate?
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.
Blood supply:
inferior vesical artery, venous drainage via prostatic plexus to the vesical plexus and internal iliac vein.
Lymphatics:
internal and sacral nodes
Nerve supply:
autonomic nervous system
what is the anatomy of the male urethra?
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
Blood supply:
prostatic-inferior vesical artery, membranous-bulbourethral artery and spongy urethra-internal pudendal artery with corresponding venous drainage.
Lymphatics:
prostatic and membranous urethra drain to obturator and internal iliac nodes, spongy urethra drains to deep and superficial inguinal nodes
Nerve supply: prostatic plexus
what is the physiology of micturition?
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
detrusor muscle contracts (it has stretch receptors in which connect to the autonomic nervous system)
parasympathetic causes peeing
sympathetic causes storage
internal sphincter is under autonomic control
external sphincter is under somatic control via the pudendal nerves
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
what is the innervation involved with micturition?
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.
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.
what is tress 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
Risk factors:
aging, obesity, smoking, pregnancy and route of delivery
Pathology:
impaired bladder and urethral support and impaired urethral closure
what are the signs and symptoms and investigations of stress urinary incontinence?
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?
Management:
Non surgical-physio with PFE (pelvic floor exercises)
Surgical-mid urethral sling, colposuspension, periurethral bulking agents
Mesh is banned in the UK, use a strip of fascia instead
Colposuspension – stitches on either side of neck of bladder, relieves pressure
what is overactive bladder/urge urinary incontinence?
Definition: urinary urgency (wanting to pee), usually with urinary frequency and nocturia, with or without urgency urinary incontinence
Incidence:
overall prevalence of 16.6% in men and women over 40
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 the signs and symptoms and investigations for overactive bladder?
Symptoms and signs:
urgency, frequency, nocturia and urgency incontinence, impact on QOL-sleep disorders, anxiety and depression.
Assess for enlarge prostate in males and prolapse in women
Investigations: exclude infection with urine dip/MSU voiding diaries - assess post void residual Urodynamics cystoscopy
Voiding diaries – 3 day bladder diaries. How much they drink, how much thy pee, any urgency or incontinence
what is the management of overactive bladder?
Management: Behavioural/lifestyle changes Bladder retraining Antimuscarinic drugs Beta-3 agonists – relax detrusor BOTOX – paralyses the detrusor Neuromodulation (PTNS/SNS) Surgical:Augmentation cystoplasty and urinary diversion
(M3 receptors cause the bladder to contract)
what is overflow incontinence?
Overflow incontinence:
Involuntary leakage of urine when bladder is full. Usually due to chronic retention secondary to obstruction or an atonic bladder
->
obstruction causes:
Outlet obstruction (faecal impaction/BPH)
Underactive detrusor muscle
Bladder neck stricture
Urethral stricture
DHx-alpha adrenergics, anticholinergics, sedative
Bladder denervation following surgery
