Urinary incontinence + Benign prostatic hyperplasia Flashcards
Describe the 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).
Lymphatics: left ureter drains into left para-aortic nodes, right ureter drains into right paracaval and interaortocaval lymph nodes
Nerve Supply: autonomic nervous system.
How many layers do the ureters have
Ureters 3 layers of tissue-outer fibrous tissue, middle muscle layer and inner epithelium layer.
What is the ureters blood supply?
Blood supply: related to region: renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage.
What is the 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.
What is the urinary bladders blood supply?
superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein
What is the nerve supply + lymphatics of the urinary bladder?
lymphatics: internal iliac nodes and then paraaortic nodes
Nerve supply: autonomic nervous system
Describe the urethra f
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
What is the urethra’s blood supply? f
: internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage.
What is the nerve supply + lymphatics of the urethra? f
Lymphatics: proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes
Nerve Supply: vesical plexus and the pudendal nerve
Describe the urethra m
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
What is the urethra’s blood supply m?
: prostatic-inferior vesical artery, membranous-bulbourethral artery and spongy urethra-internal pudendal artery with corresponding venous drainage.
What is the nerve + lymphatic supply of the urethra m?
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
What is Micturition?
Normal micturition is the intermittent voiding of urine stored in the bladder.
What happens in the filling phase of micturition?
: bladder fills and distends without rise in intravesical pressure. Urethral sphincter contracts and closes urethra
What happens during the voiding phase of micturition?
Voiding phase: bladder contracts and expels urine, urethral sphincter relaxes and urethra opens
How does micturition take place in infants?
In infants micturition is a local spinal reflex in which bladder empties on reaching a critical pressure.
How does micturition take place in adults?
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
Describe what happens in 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.
What happens when the bladder empties of urine?
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.
Define Urinary incontinence
Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing
What is the incidence of urinary incontinence?
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
What are the risk factors for urinary incontinence?
aging, obesity, smoking, pregnancy and route of delivery
What is the pathophysiology of incontinence?
impaired bladder and urethral support and impaired urethral closure
What are the signs of incontinence?
Involuntary leakage from urethra with exertion/effort or sneezing or coughing
What investigations should be done for incontinence?
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
What is the management for incontinence?
Non surgical-physio with PFE
Surgical-mid urethral sling, colposuspension, periurethral bulking agents
What happens in overactive bladder?
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)
What are the symptoms of urinary incontinence?
urgency, frequency, nocturia and urgency incontinence, impact on QOL-sleep disorders, anxiety and depression.
Assess for enlarge prostate in males and prolapse in women
What investigations should be done for urinary incontinence?
exclude infection with urine dip/MSU voiding diaries assess post void residual Urodynamics cystoscopy
What is the management for urinary incontinence?
Behavioural/lifestyle changes Bladder retraining Antimuscarinic drugs Beta-3 agonists BOTOX Neuromodulation (PTNS/SNS) Surgical:Augmentation cystoplasty and urinary diversion
What is Overflow incontinence?
Involuntary leakage of urine when bladder is full. Usually due to chronic retention secondary to obstruction or an atonic bladder
What is Continuous incontinence?
Continuous loss of urine all the time. Could be due to vesicovaginal fistula, ectopic ureter(from kidney to urethra or vagina)
What is Functional incontinence?
due to severe cognitive impairment or mobility limitations, preventing use of the toilet. Bladder function is normal
What is mixed incontinence?
more than 1 type, usually seen in older patients
What is benign prostatic hyperplasia?
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?
increases with advancing age, 50-60% for males in their 60’s, increasing to 80-90% for those over 70yrs of age
What are the risk factors for benign prostatic hyperplasia?
hormonal effects of testosterone on prostate tissue
What is the pathophysiology of Benign prostatic hyperplasia?
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
What are the signs + symptoms of Benign prostatic hyperplasia?
hesitancy in starting urination poor stream dribbling post micturition frequency, nocturia can present with acute retention
What causes do you need to exclude that could have the same symptoms as BPH?
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 investigations should be done for BPH?
urine dip/MCS, post void residual, voiding diary
What Bloods should be done for BPH?
Psa-prostate specific antigen-shown to predict prostate volume-use with caution, if conered about prostate cancer
What further investigations should be done for BPH?
Imaging:ultrasound to assess upper renal tracts
Flow studies/urodynamics
Cystoscopy if concerned about cancer
What is the management for BPH?
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 complications of 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
