Urinary Incontinence and BPH

Question 1

What is the blood supply and drainage of the female ureters?

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.

Answer 1

Related to region:
* Renal / Lumbar / Gonadal / Common iliac / Internal iliac / Superior vesical arteries with corresponding venous drainage

Question 2

What is the lymphatic drainage of the female ureters?

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.

Answer 2

• Left ureter drains into left para-aortic nodes
• Right ureter drains into right paracaval and interaortocaval lymph nodes

Question 3

What is the nerve supply of the female ureters?

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.

Answer 3

• Autonomic nervous system

Question 4

What is the blood supply and drainage of the female urinary 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.

Answer 4

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

Question 5

What is the lymphatic drainage of the female urinary 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.

Answer 5

• Internal iliac nodes and then paraaortic nodes

Question 6

What is the nerve supply of the female urinary 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.

Answer 6

• Autonomic nervous system

Question 7

What is the blood supply and drainage 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

Answer 7

• Internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage

Question 8

What is the lymphatic drainage 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

Answer 8

• Proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes

Question 9

What is the nerve supply 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

Answer 9

• Vesical plexus and the pudendal nerve

Question 10

What is the blood supply and drainage of the male ureters?

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.

Answer 10

Related to region:
* Renal / Lumbar / Gonadal / Common iliac / Internal iliac / Superior vesical arteries with corresponding venous drainage

Question 11

What is the lymphatic drainage of the male ureters?

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.

Answer 11

• Left ureter drains into left para-aortic nodes
• Right ureter drains into right paracaval and interaortocaval lymph nodes

Question 12

What is the nerve supply of the male ureters?

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.

Answer 12

• Autonomic nervous system

Question 13

What is the venus drainage of the male bladder?

Answer 13

• Venous drainage by prostatic venous plexus which drains into internal iliac vein

Question 14

What is the blood supply and drainage 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.

Answer 14

• Inferior vesical artery
• Venous drainage via prostatic plexus to the vesical plexus and internal iliac vein.

Question 15

What is the lymphatic drainage 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.

Answer 15

• Internal and sacral nodes

Question 16

What is the nerve supply 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.

Answer 16

• Autonomic nervous system

Question 17

What is the blood supply and drainage 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

Answer 17

• Prostatic-inferior vesical artery, membranous-bulbourethral artery and spongy urethra-internal pudendal artery with corresponding venous drainage.

Question 18

What is the lymphatic drainage 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

Answer 18

• Prostatic and membranous urethra drain to obturator and internal iliac nodes
• Spongy urethra drains to deep and superficial inguinal nodes

Question 19

What is the nerve supply 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

Answer 19

• Prostatic plexus

Question 20

Define normal micturition.

Answer 20

The intermittent voiding of urine stored in the bladder

Question 21

Define filling phase.

Answer 21

• Bladder fills and distends without rise in intravesical pressure.
• Urethral sphincter contracts and closes urethra

Question 22

Define voiding phase.

Answer 22

• Bladder contracts and expels urine, urethral sphincter relaxes and urethra opens

Question 23

How does micturition change from infancy to adulthood?

Answer 23

• 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.

Question 24

Outline the innervation of micturition.

Answer 24

• 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.

Question 25

What are the main forms of urinary incontinence (6)?

Answer 25

* Stress urinary incontinence * Urge Urinary incontinence (Overactive bladder) * Overflow incontinence * Continuous incontinence * Functional incontinence * Mixed incontinence

Question 26

What is overflow incontinence?

Answer 26

* Involuntary leakage of urine when bladder is full. * Usually due to chronic retention secondary to obstruction or an atonic bladder.

Question 27

What is continuous incontinence?

Answer 27

* Continuous loss of urine all the time. * Could be due to vesicovaginal fistula, ectopic ureter (from kidney to urethra or vagina).

Question 28

What is functional incontinence?

Answer 28

* Due to severe **cognitive impairment or mobility limitations**, preventing use of the toilet. * Bladder function is normal.

Question 29

What is mixed incontinence?

Answer 29

* More than 1 type, usually seen in older patients.

Question 30

What is stress urinary incontinence?

Answer 30

* Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing

Question 31

What is the incidence of stress urinary incontinence?

Answer 31

* Can affect up to 40% of women * More common in older women * 1 in 5 women over 40 having some degree of stress incontinence

Question 32

What are the risk factors of stress urinary incontinence (5)?

Answer 32

* Aging * Obesity * Smoking * Pregnancy * Route of delivery

Question 33

Outline the pathophysiology of stress urinary incontinence.

Answer 33

* **Impaired bladder** and **urethral support** and **impaired urethral closure**

Question 34

What are the signs and symptoms of stress urinary incontinence?

Answer 34

* Involuntary leakage from urethra with exertion / effort or sneezing or coughing

Question 35

What are investigations are recommended in a suspected stress urinary incontinence?

Answer 35

* History and examination, positive stress test * **Involuntary leakage from urethra with exertion** / effort or sneezing or coughing * **Urodynamics-urinary leakage during an increase in intrabdominal pressure** in the absence of a detrusor contraction

Question 36

What is the management of stress urinary incontinence (2)?

Answer 36

* **Non surgical:** * Physio with PFE * **Surgical:** * Mid urethral sling * Colposuspension * Periurethral bulking agents

Question 37

What is urge urinary incontinence (overactive bladder)?

Answer 37

* Urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence

Question 38

What is the incidence of urge urinary incontinence (overactive bladder)?

Answer 38

* Overall **prevalence of 16.6%** in men and women **over 40**

Question 39

What are the risk factors of urge urinary incontinence (overactive bladder) (5)?

Answer 39

* Age * Prolapse * Increased BMI * IBS * Bladder irritants (caffeine, nicotine)

Question 40

Outline the pathophysiology of urge urinary incontinence (overactive bladder).

Answer 40

* 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**

Question 41

What are the symptoms and signs of urge urinary incontinence (overactive bladder) (5)?

Answer 41

* **Urgency** * **Frequency** * **Nocturia** * **Urgency incontinence** * Impact on **QOL**: * sleep disorders * Anxiety * Depression ## Footnote Assess for enlarge prostate in males and prolapse in women

Question 42

What investigations are recommended for suspected urge urinary incontinence (overactive bladder) (5)?

Answer 42

* Exclude infection with **urine dip** / MSU * Voiding **diaries** * **Assess post void residual** * **Urodynamics** * **Cystoscopy**

Question 43

What is the management of urge urinary incontinence (overactive bladder) (7)?

Answer 43

Non-surgical: * Behavioural / **lifestyle changes** * **Bladder retraining** * **Antimuscarinic drugs** * **Beta-3 agonists** * **BOTOX** * **Neuromodulation** (PTNS/SNS) Surgical: * **Augmentation cystoplasty and urinary diversion**

Question 44

What is benign prostatic hyperplasia (BPH)?

Answer 44

* Non malignant growth or hyperplasia of prostate tissue, common cause of lower urinary tract symptoms in men

Question 45

What is the incidence of benign prostatic hyperplasia (BPH)?

Answer 45

* **Increases with advancing age:** * 50-60% for males in their 60’s * 80-90% for those over 70

Question 46

What are the risk factors of benign prostatic hyperplasia (BPH)?

Answer 46

* Hormonal effects of **testosterone** on prostate tissue

Question 47

Outline the pathophysiology of benign prostatic hyperplasia (BPH).

Answer 47

* **Hyperplasia of both lateral lobes and the median lobes**, leading to compression of the urethra and therefore bladder outflow obstruction

Question 48

What are the signs and symptoms of benign prostatic hyperplasia (BPH) (6)?

Answer 48

* **Hesitancy** in starting urination * **Poor stream** * **Dribbling** post micturition * **Frequency** * **Nocturia** * Can present with **acute retention**

Question 49

What investigations are recommended for suspected benign prostatic hyperplasia (BPH) (7)?

Answer 49

Investigations: * **Urine dip** / MCS * **Post void residual** * **Voiding diary** Bloods: * **Psa**-prostate specific antigen-shown to predict prostate volume-use with caution, if concerned about prostate cancer Imaging: * **Ultrasound** to assess upper renal tracts Flow studies/**urodynamics** **Cystoscopy** if concerned about cancer ## Footnote Exclude other causes for above symptoms Abdominal, pelvic and rectal examination (urethra/bladder/rectum/prostate/sphincter) * 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

Question 50

What is the management of benign prostatic hyperplasia (BPH) (3 Lifestyle / 2 Medical / 1 Surgery)?

Answer 50

Lifestyle: * **Weight loss** * **Reduce caffeine** and **fluid intake** in evening * **Avoid constipation** Medical: * **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 Surgery: * **Transurethral resection of the prostate (TURP)** - debulks prostate to produce adequate channel for urine to flow

Question 51

What are the possible complications of the management of benign prostatic hyperplasia (BPH)?

Answer 51

* **Progressive bladder distention**, causing chronic **painless retention** and **overflow incontinence** ## Footnote If undetected can lead to bilateral upper tract obstruction and renal impairment, with patient presenting with chronic renal disease.