URINARY INCONTINENCE AND BPH Flashcards
Name and describe the differences between the male and female genito-urinary system
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
What are the walls of the ureters made of?
3 layers:
- Outer fibrous tissue
- Middle muscular layer
- Inner epithelium
Around how long is each ureter?
25 cm
What is the blood supply to the ureters?
Renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage
Describe the lymphatic drainage of ureters
Left drains into left para-aortic nodes
Right drains into right paracaval and interaortocaval nodes
What nervous system is in charge of supplying the ureters?
Autonomic nervous system
Describe the dimensions of a empty bladder
4 sided pyramid with 4 angles (apex, neck, 2 lateral angles) and 4 surfaces (base/posterior, superior dome, 2 inferiolateral surfaces)
What are the 3 layers of the bladder?
Outer loose connective tissue
Middle smooth muscle and elastic fibres
Inner layer lined with transitional epithelium
What is the blood supply to the urinary bladder?
Superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein
Describe the lymphatic drainage of the urinary bladder
Internal iliac nodes and then paraaortic nodes
What nervous system supplies the urinary bladder?
The autonomic system
Where is the bladder located?
When empty, pelvic organ
When full, rises up and becomes abdomino-pelvic organ
What is the prostate and describe its function
Gland below bladder and surrounds prostatic urethra
Secretes 75% of seminal fluid which liquifies coagulated semen after deposition in female genital tract
Describe the anatomy of the prostate
Conical shape, 4x3x2cm
Connected to bladder via connective tissue
3 parts:
- left lateral lobe
- right lateral lobe
- middle lobe
Why can infants not control their micturition?
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
How does urination of micturition occur?
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
How do we stop urination of the micturition reflex?
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
What is stress urinary incontinence and what is the pathology behind it?
Involuntary leakage of bladder on effort or exertion e.g. sneezing/coughing…
Impaired bladder and urethral support and impaired urethral closure
What population group does stress urinary incontinence occur most in?
Older women
What are the risk factors for stress urinary incontinence?
Ageing
Obesity
Smoking
Pregnancy and route of delivery
What investigations can we undertake for a patient suspected with stress urinary incontinence?
History and examination - positive stress test
Urodynamics if above not clear
What is urodynamics?
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
What does the management for a patient with stress urinary incontinence look like?
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)
What is overactive bladder/urge urinary incontinence and its symptoms?
Urge to urinate with almost empty bladder
Urinary frequency
Urinary urgency
Nocturia - QOL sleep disorders, anxiety, depression
With/out urgency urinary incontinence (leaking)
What are the risk factors for overactive bladder?
Age Prolapse Increased BMI IBS Bladder irritants (caffeine, nicotine)
What is the pathology behind an overactive bladder?
Not well understood
Involuntary detrusor muscle contractions - idiopathic, neurogenic or bladder outlet obstruction
In patients with an overactive bladder what should you assess for?
Enlarged prostate in men
Prolapse in women
Both can cause obstruction
What investigations can we undertake for a patient suspected with overactive bladder?
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
Why is cystoscopy done for patient suspected with an overactive bladder?
Look inside the bladder with camera for features of overactivity:
- Tribeculations (white stripes showing hypertrophy)
- Small haemorrhages (red spots)
What does the management of a patient with an overactive bladder look like?
- 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
What are the risks associated with botox for patients with urge urinary incontinence/overactive bladder?
UTI (antibiotics given to patient to cover) Urinary retention (too much botox given so bladder can't contract at all)
What is neuromodulation?
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
Describe augmentation cystoplasty and what you have to be careful for
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
Describe urinary diversion
Last resort for urge urinary incontinence/overactive bladder
E.g. Mitrofanoff procedure - attach one end of appendix to bladder and other end to skin.
What are some urinary incontinence disorders other than stress/urge urinary incontinence?
Overflow incontinence
Continuous incontinence
Functional incontinence
Mixed
What is overflow incontinence?
Involuntary leakage when bladder is full. Usually due to chronic retention secondary to obstruction/atonic bladder
What are some causes of overflow incontinence?
Outlet obstruction Underactive detrusor muscle Bladder neck stricture Urethral stricture Bladder denervation post surgery
Drugs - alpha adrenergics, anticholinergics, sedatives
What is continuous incontinence and some causes?
Continuous loss of urine all the time
Vesicovaginal fistula
Ectopic ureter
What is functional incontinence?
Severe cognitive impairment or mobility limitations stopping use of toilet. Bladder function is normal
What is benign prostatic hyperplasia (BPH)?
Hyperplasia of prostate tissue - commonly causes lower urinary tract symptoms in men
What are the risk factors for benign prostatic hyperplasia?
Age
Effects of testosterone on prostate tissue
Why does BPH often cause urinary tract symptoms?
Hyperplasia of both lateral lobes and the median lobes leads to compression of urethra and bladder outflow obstruction
What are the symptoms of BPH?
Hesitancy in starting urination Poor stream - intermittent Dribbling post micturition Frequency and nocturia (some urine is left) Can present with acute retention
How do you diagnose BPH?
Exclude other causes of its symtoms
What are some differential diagnoses for BPH?
Bladder/prostate cancer Cauda equina High pressure chronic retention UTI/STDs Prostatitis Neurogenic bladder Urinary tract stones Urethral stricture
What are the investigations you can do if you suspect a patient of having BPH?
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
How is BPH managed?
Lifestyle changes e.g. weight loss, avoid constipation
Alpha blocker
5-alpha reductase inhibitor
Surgery - transurethral resection of prostate (TURP - debulks prostate)
How do alpha blockers help BPH?
Alpha 1-AR present on prostate stromal smooth muscle and bladder neck. Blockage causes smooth muscle relaxation improving urinary flow rate
How do 5-alpha reductase inhibitors help BPH?
Prevents conversion of testosterone into DHT which is what promotes growth of prostate.
What complications are associated with BPH?
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
