Urinary Incontinence and Benign Prostatic Hyperplasia Flashcards
What is the function of the kidneys?
- removes waste products of metabolism
- excess water and salts from the blood
- maintain the pH
What anatomy is part of the female genitourinary system?
- 2 kidneys
- 2 ureters
- urinary bladder
- urethra
What is the function of the ureters?
convey urine from the kidneys to the urinary bladder
Where does the ureter lie?
- upper half in abdomen
- lower half in pelvis
What is the average dimensions of the ureters?
- 3mm in diameter
- 25cm long
Where is the ureter slightly constricted?
- uteropelvic junction
- pelvic brim (crossing through iliac vessels)
- passing through the bladder wall (uretero-vesical junction)
What are the 3 layers of tissue in the ureter?
- outer fibrous tissue
- middle muscle layer
- inner epithelium layer
What is the blood supply of the ureter?
related to region: - renal/lumbar/gonadal/common iliac artery - internal iliac artery - superior vesical arteries (corresponding venous drainage)
What are the lymphatic management of the ureters?
Left ureter: - left para-aortic nodes Right ureter: - right paracaval - interaortocaval lymph nodes
What is the nerve supply of the ureter?
autonomic nervous system
What is the bladder?
a muscular reservoir of urine
Where is the bladder located?
empty: pelvic
full: abdomino-pelvic
What are the layers of the bladder?
outer: loose connective tissue
middle: detrusor muscle
inner: transitional epithelium
What is the blood supply of the bladder?
- superior and inferior vesical branches of the internal iliac
- drained by the vesical plexus which drains into the internal iliac vein
What is the lymphatics of the bladder?
- internal iliac nodes
- para-aortic nodes
What is the nerve supply of the bladder?
autonomic nervous system
What is the female urethra?
channel from the neck of the bladder to the external urethral meatus in the vaginal vestibule
Describe the structure of the urethra at the exterior?
- external urethral sphincter
- skeletal muscle
- voluntary control
- controlledby pudendal nerve
What is the female blood supply of the urethra?
- internal pudenal arteries
- inferior vesicle branches of the vaginal arteries
- corresponding venous drainage
What is the lymphatic system of the female urethra?
- proximal urethra into internal iliac nodes
- distal urethra into the superficial inguinal lymphnodes
What is the nerve supply of the female urethra?
- vesical plexus
- pudendeal nerve
What anatomy is part of the male genitourinary system?
- 2 kidneys
- 2 ureters
- urinary bladder
- prostate
- urethra
What is the venous drainage of the bladder in males?
prostatic venous plexus which drains into the internal iliac vein
What is the function of the prostate?
secrete 75% of seminal fluid which liquifies coagulated semen after deposition in the female genital tract
Where is the prostate?
- lies below the bladder
- surrounds the proximal part of the urethra
Where is the urethra in males?
through:
- neck of the bladder
- prostate gland
- floor of the pelvis
- perineal membrane
- penis
- external urethral orifice
What are the 3 parts of the male urethra?
- prostatic
- membranous
- spongy
What is the blood supply of the male urethra?
prostatic: inferior vesical artery
membranous: bulbourethral artery
spongy: internal pudenal artery
(corresponding venous drainage)
What is the lymphatics of the male urethra?
- prostatic and membranous: obturator and internal iliac nodes
- spongy: deep and superficial inguinal nodes
What is the nerve supply of the male urethra?
- vesical plexus proximally
- pudendal nerve distally
What is a normal micturition cycle?
intermittent storage and voiding of urine in the bladder
What is the filling phase?
- bladder fills and distends without rise in the intravesical pressure
- urethral sphincter contracts and closes urethra
What is the voiding phase?
- bladder contracts and expels urine
- urethral sphincter relaxes and urethra opens
How is micturition initiated in infants?
local spine reflex in which the bladder empties on reaching a critical pressure
How is micturition initiated in adults?
can be initiated or inhibited by high centre control of the external urethral sphincter keeping it closed until it is appropriate to urinate
What innervates the external sphincter?
the somatic motor fibre of the pudendal nerve
What receptors/sensory nerves are stimulated as the bladder fills?
- detrusor M3 receptors
- parasympathetic S2-S4
What happens when the M3 receptors are stimulated?
- contraction of the detrusor muscle for urination
- inhibition of the internal urethral sphincter which causes relaxation and allows for bladder emptying
What happens when the bladder empties?
- stretch fibres are inactivated
- sympathetic nervous system (T11-L2) activates the beta 3 receptors causing relaxation of the detrusor muscle allowing for bladder filling
What is stress urinary incontinence?
complaint of involuntary leakage on effort or exertion, or on sneezing or coughing
What is the prevalence of stress urinary incontinence?
- 40% of women
- common with age
- 1/5 women >40
What are the risk factors of stress urinary incontinence?
- ageing
- obesity
- smoking
- pregnancy and route of delivery
What is the pathology of stress urinary incontinence?
impaired bladder and urethral support and impaired urethral closure
What are the signs/symptoms of stress urinary incontinence?
involuntary leakage from urethra with exertion/sneezing/coughing
What are the investigations for stress urinary incontinence?
- Hx and examination
- positive stress test (demonstrable loss of urine on examination)
- Urodynamics
What would be seen on urodynamics with stress urinary incontinence?
urinary leakage during an increase in intra-abdominal pressure in the absence of a detrusor contraction
What is the management of stress urinary incontinence?
- physiotherapy with pelvic floor exercises
- surgical: mid urethral sling, colposuspension and periurethral bulking injection
What is an overactive bladder/urge urinary incontinence?
- urinary urgency
- often with nocturia and urinary frequency
- with or without urgency urinary incontinence
(urge to urinate with an empty bladder)
What is the prevalence of overactive bladder/urge urinary incontinence?
16.6% in the overall population
What are the risk factors of overactive bladder/urge urinary incontinence?
- age
- prolapse
- increased BMI
- IBS
- bladder irritants (nicotine, coffee)
What is the pathology of overactive bladder/urge urinary incontinence?
- involuntary detrusor muscle contraction
- idiopathic
- neurogenic
- bladder outlet obstruction
What are the signs/symptoms of overactive bladder/urge urinary incontinence?
- urgency
- frequency
- nocturia
- urgency incontinence
- impact of QOL
- sleep disorders
- anxiety
- depression
- enlarged prostate in males
- prolapse in females
What are the investigations to confirm overactive bladder/urge urinary incontinence?
- exclude infection with urine dip
- voiding diaries
- assess post void residual with scan
- urodynamics
- cystoscopy
What is the management of overactive bladder/urge urinary incontinence?
- behaviour/lifestyle changes
- bladder retaining
- anti-musancaric drugs
- beta-3 agonists
- BOTOX
- Neuromodulation (PTNS/SNS)
- Surgical: augmentation custoplasty and urinary diversion
What is the definition of benign prostatic hyperplasia?
non-malignant growth or hyperplasia of prostate tissue
What is the incidence of benign prostatic hyperplasia?
- increases with advancing age
- 50-60% for 60
- 80-90% in >70
What are the risk factors fo benign prostatic hyperplasia?
hormonal effects of testosterone on prostate tissue
What is the pathology of benign prostatic hyperplasia?
- hyperplasia of both lateral lobes and median lobe
- enlarged prostate leads to compression of the urethra
- bladder outflow obstruction
- hyperplasia of the stroma
What are the signs/symptoms of benign prostatic hyperplasia?
- hesitancy starting urination
- poor stream
- dribbling post micturition
- frequency, nocturia
- acute retention
What differentials should be excluded when benign prostatic hyperplasia is suspected?
- bladder/prostate cancer
- cauda equina
- high pressure chronic retention
- UTIs, STIs
- prostatitis
- neurogenic bladder (MS, Parkinsons)
- Urinary tract stones
- Urethral stricture
What investigations should be done for benign prostatic hyperplasia?
- abdominal, pelvic and rectal exam
- urine dip/MCS
- post void residual
- voiding diary
- bloods
- ultrasound to assess renal tracts
- flow studies/urodynamics
- cystoscopy
What bloods should be done to confirm benign prostatic hyperplasia?
PSA - prostatic specific antigen (predict prostate volume)
- if cancer suspected
What is the lifestyle management of benign prostatic hyperplasia?
- weight loss
- reduce caffeine
- reduce fluid intake in the evening
- avoid constipation
What is the medical management of benign prostatic hyperplasia?
- alpha blocker
- 5-alpha reductase inhibitor
What is the surgical management of benign prostatic hyperplasia?
- transurethral resection of the prostate (TURP)
- debulks prostate to produce adequate channel for urine flow
Why is an alpha blocker used in the management of benign prostatic hyperplasia?
- alpha 1-AR present on the prostate stromal smooth muscle and bladder neck
- blockage causes relaxation, improving urinary flow rate
Why is a 5-alpha reductase inhibitor used in the management of benign prostatic hyperplasia?
- prevents the conversion of testosterone to DHT (which promotes growth and enlargement of the prostate)
- causes shrinkage, improving urinary flow rate and obstructive symptoms
What are the complications associated with benign prostatic hyperplasia?
progressive bladder distention - causing painless chronic retention and overflow incontinence if untreated: - bilateral upper tract obstruction - renal impairment - chronic renal disease
Where are the hila of the kidneys?
L1
Are the kidneys intraperitoneal or retroperitoneal?
Retroperitoneal
What are some variations in kidney anatomy?
- single kidney
- horseshoe kidney
- ectopic kidney
- pelvic kidney
What are the variations in ureter anatomy?
Partial or complete duplication
What is the neural control of micturition?
- Prefrontal cortex permits the pontine micturition centre in the brainstem to change from storage mode to voiding
- activates the parasympathetic nucleus (bladder contraction), and inhibits Onuf’s nucleus (sphincter relaxation)
What is the storage phase?
- bladder relaxed, serves as resevoir
- outlet contracted, preventing leaks
What is the role of the periaqueductal gray (PAG)?
- receives sensory information from viscera
- decides what goes to cortex for conscious sensation
What is the role of the frontal cortex in micturition?
- decision making
- planning
- social appropriateness
What is the role of the pontine micturition centre (PMC)?
- coordinates spinal centres
- controls switch from storage to voiding
Where is the sympathetic nucleus to the bladder neck?
T10-L2
Where are the parasympathetic nucleus of the detrusor and onuf’s nucleus of the sphincter?
S2-S4
What is the nerve supply of the penis and vaginal vestibule/penis?
Pudendal nerve
What is the nerve supply of the kidney, testicles and bladder neck?
Sympathetic nervous system
