Urinary incontinence + Benign prostatic hyperplasia

Question 1

Describe the ureters

Answer 1

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).

Lymphatics: left ureter drains into left para-aortic nodes, right ureter drains into right paracaval and interaortocaval lymph nodes
Nerve Supply: autonomic nervous system.

Question 2

How many layers do the ureters have

Answer 2

Ureters 3 layers of tissue-outer fibrous tissue, middle muscle layer and inner epithelium layer.

Question 3

What is the ureters blood supply?

Answer 3

Blood supply: related to region: renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage.

Question 4

What is the Urinary bladder?

Answer 4

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.

Question 5

What is the urinary bladders blood supply?

Answer 5

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

Question 6

What is the nerve supply + lymphatics of the urinary bladder?

Answer 6

lymphatics: internal iliac nodes and then paraaortic nodes

Nerve supply: autonomic nervous system

Question 7

Describe the urethra f

Answer 7

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

Question 8

What is the urethra’s blood supply? f

Answer 8

: internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage.

Question 9

What is the nerve supply + lymphatics of the urethra? f

Answer 9

Lymphatics: proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes
Nerve Supply: vesical plexus and the pudendal nerve

Question 10

Describe the urethra m

Answer 10

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

Question 11

What is the urethra’s blood supply m?

Answer 11

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

Question 12

What is the nerve + lymphatic supply of the urethra m?

Answer 12

Lymphatics: prostatic and membranous urethra drain to obturator and internal iliac nodes, spongy urethra drains to deep and superficial inguinal nodes
Nerve supply: prostatic plexus

Question 13

What is Micturition?

Answer 13

Normal micturition is the intermittent voiding of urine stored in the bladder.

Question 14

What happens in the filling phase of micturition?

Answer 14

: bladder fills and distends without rise in intravesical pressure. Urethral sphincter contracts and closes urethra

Question 15

What happens during the voiding phase of micturition?

Answer 15

Voiding phase: bladder contracts and expels urine, urethral sphincter relaxes and urethra opens

Question 16

How does micturition take place in infants?

Answer 16

In infants micturition is a local spinal reflex in which bladder empties on reaching a critical pressure.

Question 17

How does micturition take place in adults?

Answer 17

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 18

Describe what happens in micturition

Answer 18

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.

Question 19

What happens when the bladder empties of urine?

Answer 19

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 20

Define Urinary incontinence

Answer 20

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

Question 21

What is the incidence of urinary incontinence?

Answer 21

can affect up to 40% of women, more common in older women, with 1 in 5 women over 40 having some degree of stress incontinence

Question 22

What are the risk factors for urinary incontinence?

Answer 22

aging, obesity, smoking, pregnancy and route of delivery

Question 23

What is the pathophysiology of incontinence?

Answer 23

impaired bladder and urethral support and impaired urethral closure

Question 24

What are the signs of incontinence?

Answer 24

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

Question 25

What investigations should be done for incontinence?

Answer 25

History and examination as above, positive stress test (demonstrable loss of urine on examination)
urodynamics-urinary leakage during an increase in intrabdominal pressure in the absence of a detrusor contraction

Question 26

What is the management for incontinence?

Answer 26

Non surgical-physio with PFE

Surgical-mid urethral sling, colposuspension, periurethral bulking agents

Question 27

What happens in overactive bladder?

Answer 27

Definition:
urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence

Incidence:
overall prevalence of 16.6% in men and women over 40

Risk factors:
age, prolapse, increased BMI, IBS, bladder irritants (caffeine, nicotine)

Question 28

What are the symptoms of urinary incontinence?

Answer 28

urgency, frequency, nocturia and urgency incontinence, impact on QOL-sleep disorders, anxiety and depression.
Assess for enlarge prostate in males and prolapse in women

Question 29

What investigations should be done for urinary incontinence?

Answer 29

exclude infection with urine dip/MSU
voiding diaries
assess post void residual
Urodynamics
cystoscopy

Question 30

What is the management for urinary incontinence?

Answer 30

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

Question 31

What is Overflow incontinence?

Answer 31

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

Question 32

What is Continuous incontinence?

Answer 32

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

Question 33

What is Functional incontinence?

Answer 33

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

Question 34

What is mixed incontinence?

Answer 34

more than 1 type, usually seen in older patients

Question 35

What is benign prostatic hyperplasia?

Answer 35

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

Question 36

What is the incidence of benign prostatic hyperplasia?

Answer 36

increases with advancing age, 50-60% for males in their 60’s, increasing to 80-90% for those over 70yrs of age

Question 37

What are the risk factors for benign prostatic hyperplasia?

Answer 37

hormonal effects of testosterone on prostate tissue

Question 38

What is the pathophysiology of Benign prostatic hyperplasia?

Answer 38

hyperplasia of both lateral lobes and the median lobes, leading to compression of the urethra and therefore bladder outflow obstruction. See hyperplasia of the stroma (smooth muscle and fibrous tissue) and glands

Question 39

What are the signs + symptoms of Benign prostatic hyperplasia?

Answer 39

hesitancy in starting urination
poor stream
dribbling post micturition
frequency, nocturia
can present with acute retention

Question 40

What causes do you need to exclude that could have the same symptoms as BPH?

Answer 40

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 41

What investigations should be done for BPH?

Answer 41

urine dip/MCS, post void residual, voiding diary

Question 42

What Bloods should be done for BPH?

Answer 42

Psa-prostate specific antigen-shown to predict prostate volume-use with caution, if conered about prostate cancer

Question 43

What further investigations should be done for BPH?

Answer 43

Imaging:ultrasound to assess upper renal tracts
Flow studies/urodynamics
Cystoscopy if concerned about cancer

Question 44

What is the management for BPH?

Answer 44

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 45

What are the complications of BPH?

Answer 45

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