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UROLOGY AND RENAL MEDICINE 2 > URINARY INCONTINENCE AND BPH > Flashcards

URINARY INCONTINENCE AND BPH Flashcards

1
Q

Name and describe the differences between the male and female genito-urinary system

A

Men have a prostate

URETHRA
Male urethra runs through neck of bladder, prostate, floor of pelvis and perineal membrane to penis and external urethral orifice - 20 cm
Female urethra from neck of bladder to external urethral orifice - 3/4 cm

Blood supply:
- Male: prostatic-inferior vesical artery, membranous-
bulbourethral artery and spongy urethra-internal
pudendal artery with corresponding venous drainage
- Female: internal pudendal arteries and inferior vesical
branches of the vaginal arteries with corresponding
venous drainage

Lymphatics:
- Male: prostatic and membranous urethra drain to
obturator and internal iliac nodes, spongy urethra drains
to deep and superficial inguinal nodes
- Female: proximal urethra into internal iliac nodes, distal
urethra to superficial inguinal nodes

Nerve supply:

  • Male: prostatic plexus
  • Female: vesical plexus and the pudendal nerve
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2
Q

What are the walls of the ureters made of?

A

3 layers:

  • Outer fibrous tissue
  • Middle muscular layer
  • Inner epithelium
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3
Q

Around how long is each ureter?

A

25 cm

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4
Q

What is the blood supply to the ureters?

A

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

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5
Q

Describe the lymphatic drainage of ureters

A

Left drains into left para-aortic nodes

Right drains into right paracaval and interaortocaval nodes

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6
Q

What nervous system is in charge of supplying the ureters?

A

Autonomic nervous system

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7
Q

Describe the dimensions of a empty bladder

A

4 sided pyramid with 4 angles (apex, neck, 2 lateral angles) and 4 surfaces (base/posterior, superior dome, 2 inferiolateral surfaces)

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8
Q

What are the 3 layers of the bladder?

A

Outer loose connective tissue
Middle smooth muscle and elastic fibres
Inner layer lined with transitional epithelium

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9
Q

What is the blood supply to the urinary bladder?

A

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

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10
Q

Describe the lymphatic drainage of the urinary bladder

A

Internal iliac nodes and then paraaortic nodes

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11
Q

What nervous system supplies the urinary bladder?

A

The autonomic system

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12
Q

Where is the bladder located?

A

When empty, pelvic organ

When full, rises up and becomes abdomino-pelvic organ

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13
Q

What is the prostate and describe its function

A

Gland below bladder and surrounds prostatic urethra

Secretes 75% of seminal fluid which liquifies coagulated semen after deposition in female genital tract

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14
Q

Describe the anatomy of the prostate

A

Conical shape, 4x3x2cm
Connected to bladder via connective tissue

3 parts:

  • left lateral lobe
  • right lateral lobe
  • middle lobe
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15
Q

Why can infants not control their micturition?

A

In infants, micturition is a local spinal reflex where the bladder empties upon reaching a critical pressure

In adults, higher centres control the external urethral sphincter keeping it closed until appropriate

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16
Q

How does urination of micturition occur?

A

As bladder fills, M3 stretch receptors are stimulated (PNS S2-S4)
Detrusor muscle contracts for urination
PNS inhibits internal urethral sphincter at same time causing relaxation allowing bladder emptying

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17
Q

How do we stop urination of the micturition reflex?

A

When bladder empties, stretch receptors become inactivated and the SNS (T11-L2) is stimulated to activate the beta 3 receptors causing relaxation of the detrusor muscle allowing bladder to fill again

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18
Q

What is stress urinary incontinence and what is the pathology behind it?

A

Involuntary leakage of bladder on effort or exertion e.g. sneezing/coughing…

Impaired bladder and urethral support and impaired urethral closure

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19
Q

What population group does stress urinary incontinence occur most in?

A

Older women

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20
Q

What are the risk factors for stress urinary incontinence?

A

Ageing
Obesity
Smoking
Pregnancy and route of delivery

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21
Q

What investigations can we undertake for a patient suspected with stress urinary incontinence?

A

History and examination - positive stress test

Urodynamics if above not clear

22
Q

What is urodynamics?

A

Objective assessment of bladder function.

Catheter with a pressure line fed into bladder and another pressure line through the anus to sense abdominal pressure.
Patient is asked to cough and urinary leakage during an increase in intra-abdominal pressure in the absence of a detrusor contraction

23
Q

What does the management for a patient with stress urinary incontinence look like?

A

Physiotherapy with pelvic floor exercises
Lose weight if overweight

Surgery:
- Mid urethral support e.g. sling
- Colposuspension (2 stitches either side of bladder neck
to elevate it and reduce the amount it moves and thus
leaks)
- Periurethral bulking agents (Injections around urethral
sphincter to bulk it up)

24
Q

What is overactive bladder/urge urinary incontinence and its symptoms?

A

Urge to urinate with almost empty bladder

Urinary frequency
Urinary urgency
Nocturia - QOL sleep disorders, anxiety, depression
With/out urgency urinary incontinence (leaking)

25
Q

What are the risk factors for overactive bladder?

A 
Age
Prolapse
Increased BMI
IBS
Bladder irritants (caffeine, nicotine)
26
Q

What is the pathology behind an overactive bladder?

A

Not well understood

Involuntary detrusor muscle contractions - idiopathic, neurogenic or bladder outlet obstruction

27
Q

In patients with an overactive bladder what should you assess for?

A

Enlarged prostate in men
Prolapse in women

Both can cause obstruction

28
Q

What investigations can we undertake for a patient suspected with overactive bladder?

A

Voiding diaries
Assess post void residual by scanning (increase can cause UTIs)
Cystoscopy
Urodynamics when conservative management/medication not working to plan further management
Urine dipstick/MSU to exclude infection

29
Q

Why is cystoscopy done for patient suspected with an overactive bladder?

A

Look inside the bladder with camera for features of overactivity:

  • Tribeculations (white stripes showing hypertrophy)
  • Small haemorrhages (red spots)
30
Q

What does the management of a patient with an overactive bladder look like?

A
  • Lifestyle changes
  • Bladder retraining physio to prolong urgency
  • Antimuscarinic drugs (prevents detrusor contraction)
  • Beta-3 agonists (relaxes detrusor)
  • BOTOX (blocks NMJ)
  • Neuromodulation

Surgical (last resort):

  • Augmentation cystoplasty
  • Urinary diversion
31
Q

What are the risks associated with botox for patients with urge urinary incontinence/overactive bladder?

A 
UTI (antibiotics given to patient to cover)
Urinary retention (too much botox given so bladder can't contract at all)
32
Q

What is neuromodulation?

A

Stimulate/deliver impulses to modify the nerves which innervate the bladder

2 ways:
Peripheral approach - tibial nerve
(indirectly linked to sacral nerves which innervate bladder)

Directly stimulate S3 with lead attached to pacemaker

33
Q

Describe augmentation cystoplasty and what you have to be careful for

A

Bladder cut in half and bowel put on top to increase bladder capacity

Exposing bowel to urine so need to do check-ups in case of malignancy

34
Q

Describe urinary diversion

A

Last resort for urge urinary incontinence/overactive bladder

E.g. Mitrofanoff procedure - attach one end of appendix to bladder and other end to skin.

35
Q

What are some urinary incontinence disorders other than stress/urge urinary incontinence?

A

Overflow incontinence
Continuous incontinence
Functional incontinence
Mixed

36
Q

What is overflow incontinence?

A

Involuntary leakage when bladder is full. Usually due to chronic retention secondary to obstruction/atonic bladder

37
Q

What are some causes of overflow incontinence?

A 
Outlet obstruction
Underactive detrusor muscle
Bladder neck stricture
Urethral stricture
Bladder denervation post surgery

Drugs - alpha adrenergics, anticholinergics, sedatives

38
Q

What is continuous incontinence and some causes?

A

Continuous loss of urine all the time

Vesicovaginal fistula
Ectopic ureter

39
Q

What is functional incontinence?

A

Severe cognitive impairment or mobility limitations stopping use of toilet. Bladder function is normal

40
Q

What is benign prostatic hyperplasia (BPH)?

A

Hyperplasia of prostate tissue - commonly causes lower urinary tract symptoms in men

41
Q

What are the risk factors for benign prostatic hyperplasia?

A

Age

Effects of testosterone on prostate tissue

42
Q

Why does BPH often cause urinary tract symptoms?

A

Hyperplasia of both lateral lobes and the median lobes leads to compression of urethra and bladder outflow obstruction

43
Q

What are the symptoms of BPH?

A 
Hesitancy in starting urination
Poor stream - intermittent
Dribbling post micturition
Frequency and nocturia (some urine is left)
Can present with acute retention
44
Q

How do you diagnose BPH?

A

Exclude other causes of its symtoms

45
Q

What are some differential diagnoses for BPH?

A 
Bladder/prostate cancer
Cauda equina
High pressure chronic retention
UTI/STDs
Prostatitis
Neurogenic bladder
Urinary tract stones
Urethral stricture
46
Q

What are the investigations you can do if you suspect a patient of having BPH?

A

Urine dipstick/MCS
Post void residual
Voiding diary
Flow studies/urodynamics

Bloods:
- Prostate specific antigen (PSA) to predict prostate
volume

Ultrasound to assess upper renal tracts
Cytoscopy if concerned about cancer

47
Q

How is BPH managed?

A

Lifestyle changes e.g. weight loss, avoid constipation

Alpha blocker
5-alpha reductase inhibitor

Surgery - transurethral resection of prostate (TURP - debulks prostate)

48
Q

How do alpha blockers help BPH?

A

Alpha 1-AR present on prostate stromal smooth muscle and bladder neck. Blockage causes smooth muscle relaxation improving urinary flow rate

49
Q

How do 5-alpha reductase inhibitors help BPH?

A

Prevents conversion of testosterone into DHT which is what promotes growth of prostate.

50
Q

What complications are associated with BPH?

A

Progressive bladder distention (causes chronic painless retention and overflow incontinence)

If undetected with lead to bilateral upper tract obstruction and renal impairment with chronic renal disease

UROLOGY AND RENAL MEDICINE 2 (5 decks)

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