Urinary Incontinence and BPH Flashcards
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.
Related to region:
* Renal / Lumbar / Gonadal / Common iliac / Internal iliac / Superior vesical arteries with corresponding venous drainage
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.
- Left ureter drains into left para-aortic nodes
- Right ureter drains into right paracaval and interaortocaval lymph nodes
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.
- Autonomic nervous system
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.
- Superior and inferior vesical branches of internal iliac artery
- Drained by vesical plexus which drains into internal iliac vein
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.
- Internal iliac nodes and then paraaortic nodes
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.
- Autonomic nervous system
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
- Internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage
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
- Proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes
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
- Vesical plexus and the pudendal nerve
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.
Related to region:
* Renal / Lumbar / Gonadal / Common iliac / Internal iliac / Superior vesical arteries with corresponding venous drainage
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.
- Left ureter drains into left para-aortic nodes
- Right ureter drains into right paracaval and interaortocaval lymph nodes
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.
- Autonomic nervous system
What is the venus drainage of the male bladder?
- Venous drainage by prostatic venous plexus which drains into internal iliac vein
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.
- Inferior vesical artery
- Venous drainage via prostatic plexus to the vesical plexus and internal iliac vein.
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.
- Internal and sacral nodes
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.
- Autonomic nervous system
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
- Prostatic-inferior vesical artery, membranous-bulbourethral artery and spongy urethra-internal pudendal artery with corresponding venous drainage.
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
- Prostatic and membranous urethra drain to obturator and internal iliac nodes
- Spongy urethra drains to deep and superficial inguinal nodes
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
- Prostatic plexus
Define normal micturition.
The intermittent voiding of urine stored in the bladder
Define filling phase.
- Bladder fills and distends without rise in intravesical pressure.
- Urethral sphincter contracts and closes urethra
Define voiding phase.
- Bladder contracts and expels urine, urethral sphincter relaxes and urethra opens
How does micturition change from infancy to adulthood?
- 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.
Outline the innervation of 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 stress urinary incontinence?
- Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing
What is the incidence of stress urinary incontinence?
- Can affect up to 40% of women
- More common in older women
- 1 in 5 women over 40 having some degree of stress incontinence
What are the risk factors of stress urinary incontinence (5)?
- Aging
- Obesity
- Smoking
- Pregnancy
- Route of delivery
Outline the pathophysiology of stress urinary incontinence.
- Impaired bladder and urethral support and impaired urethral closure
What are the signs and symptoms of stress urinary incontinence?
- Involuntary leakage from urethra with exertion / effort or sneezing or coughing
What are investigations are recommended in a suspected stress urinary incontinence?
- 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
What is the management of stress urinary incontinence (2)?
-
Non surgical:
- Physio with PFE
-
Surgical:
- Mid urethral sling
- Colposuspension
- Periurethral bulking agents
What is urge urinary incontinence (overactive bladder)?
- Urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence
What is the incidence of urge urinary incontinence (overactive bladder)?
- Overall prevalence of 16.6% in men and women over 40
What are the risk factors of urge urinary incontinence (overactive bladder) (5)?
- Age
- Prolapse
- Increased BMI
- IBS
- Bladder irritants (caffeine, nicotine)
Outline the pathophysiology of urge urinary incontinence (overactive bladder).
- 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 symptoms and signs of urge urinary incontinence (overactive bladder) (5)?
- Urgency
- Frequency
- Nocturia
- Urgency incontinence
- Impact on QOL:
- sleep disorders
- Anxiety
- Depression
Assess for enlarge prostate in males and prolapse in women
What investigations are recommended for suspected urge urinary incontinence (overactive bladder) (5)?
- Exclude infection with urine dip / MSU
- Voiding diaries
- Assess post void residual
- Urodynamics
- Cystoscopy
What is the management of urge urinary incontinence (overactive bladder) (7)?
Non-surgical:
* Behavioural / lifestyle changes
* Bladder retraining
* Antimuscarinic drugs
* Beta-3 agonists
* BOTOX
* Neuromodulation (PTNS/SNS)
Surgical:
* Augmentation cystoplasty and urinary diversion
What is benign prostatic hyperplasia (BPH)?
- Non malignant growth or hyperplasia of prostate tissue, common cause of lower urinary tract symptoms in men
What is the incidence of benign prostatic hyperplasia (BPH)?
-
Increases with advancing age:
- 50-60% for males in their 60’s
- 80-90% for those over 70
What are the risk factors of benign prostatic hyperplasia (BPH)?
- Hormonal effects of testosterone on prostate tissue
Outline the pathophysiology of benign prostatic hyperplasia (BPH).
- Hyperplasia of both lateral lobes and the median lobes, leading to compression of the urethra and therefore bladder outflow obstruction
What are the signs and symptoms of benign prostatic hyperplasia (BPH) (6)?
- Hesitancy in starting urination
- Poor stream
- Dribbling post micturition
- Frequency
- Nocturia
- Can present with acute retention
What investigations are recommended for suspected benign prostatic hyperplasia (BPH) (7)?
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
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
What is the management of benign prostatic hyperplasia (BPH) (3 Lifestyle / 2 Medical / 1 Surgery)?
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
What are the possible complications of the management of benign prostatic hyperplasia (BPH)?
- Progressive bladder distention, causing chronic painless retention and overflow incontinence
If undetected can lead to bilateral upper tract obstruction and renal impairment, with patient presenting with chronic renal disease.
