Uriney Incontinence And Urinary Tract Symptoms

Question 1

Ureters length, diameter and 3 layers of tissue?

Answer 1

25cm long
3mm diameter
3 layers - outer fibrous tissue, middle muscle layer and inner epithelium layer

Question 2

Ureters blood supply?

Answer 2

Renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage.

Question 3

Ureters lymphatics?

Answer 3

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

Question 4

Ureters nerve supply?

Answer 4

Autonomic

Question 5

Variations in kidney anatomy?

Answer 5

Single kidney
Horse-shoe kidney
Ectopic kidney

Question 6

Variations in ureter anatomy?

Answer 6

Partial duplication
Complete duplication

Question 7

“Hold up” points in ureter?

Answer 7

Where the renal pelvis joins the top of the ureter- pelvic ureteric junction (PUJ, or UPJ)
Pelvic brim, crossing the iliac vessels
As it passes through the bladder wall; uretero-vesical junction (UVJ, or VUJ)

Question 8

Bladder blood supply?

Answer 8

Superior and inferior vesical branches of internal iliac artery
Drained by vesical plexus -> internal iliac vein

Question 9

Bladder nerve supply?

Answer 9

Autonomic

Question 10

Female urinary tract - external urethral sphincter muscle, contraction, and nerve

Answer 10

External urethral sphincter- skeletal muscle, tonic contraction and also voluntary “guarding”. Controlled by pudendal nerve.

Question 11

Female urinary tract bladder outlet - blood supply, lymphatics and nerve supply

Answer 11

Blood - internal pudendal arteries and inferior vesicle branches of vaginal arteries (corresponding venous drainage)
Lymphatics - proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes
Nerve supply - vesical plexus (proximal), pudendal nerve (distal)

Question 12

Prostate gland secretion?

Answer 12

Secretes 75% of seminal fluid which liquifies coagulated semen after deposition in female genital tract

Question 13

Male genitourinary tract bladder outlet - blood supply, lymphatics and nerve supply. Prostrate

Answer 13

Blood supply - Prostate - inferior vesicle artery
Lymphatics - drain to obturator and internal iliac nodes
Nerve supply - vesical plexus (proximal), pudendal nerve (distal)

Question 14

Bladder and outlet during storage?

Answer 14

Bladder relaxed, serving as reservoir
Outlet contracted, preventing leaks

Question 15

Bladder and outlet during voiding?

Answer 15

Bladder contracting, expelling the urine.
Outlet relaxed, permitting flow.
Bladder should empty fully (<50 ml “post void residual”).
6 pees daily, 20 secs each means 2 mins per day spent voidin

Question 16

Neural control of micturition?

Answer 16

Prefrontal cortex -> pontine micturition centre (in brainstem) to change from storage mode -> voiding
= activates the PNS (bladder contraction) + inhibits Onuf’s nucleus (sphincter relaxation)

Question 17

Frontal cortex in micturition?

Answer 17

Decides actions based on planning ahead, social appropriateness, etc,

Question 18

Pontine micturition centre in micturition?

Answer 18

Co-ordinates spinal centres; storage switches to voiding only if permitted

Question 19

Limbic cortex in micturition?

Answer 19

Emotional and fear reactions

Question 20

Periaqueductal gray in micturition?

Answer 20

Receives sensory info from visceral (subconscious), decides what goes to cortex (conscious sensation)

Question 21

Thoracic spinal cord in micturition?

Answer 21

Sympathetic nucleus (bladder neck)

Question 22

Sacral spinal cord in micturition?

Answer 22

Parasympathetic nucleus (detrusor)
Onuf’s nucleus (sphincter)

Question 23

Micturition in infants vs adults?

Answer 23

In infants, is local spinal reflex which bladder empties on reaching critical pressure
In adults, can be initiated by higher control centres of external urethral sphincter

Question 24

Pelvic organ nerve supplies? PNS, SNS and pudendal

Answer 24

PNS - bladder
SNS - kidney, testicle, bladder neck
Pudendal - penis, vaginal vestibule/clitoris

Question 25

Autonomic receptor drug targets - bladder neck?

Answer 25

a-adrenergic (a-1) - alpha blocker - tamsulosin

Question 26

Autonomic receptor drug targets - detrusor

Answer 26

Cholinergic M3/M2 - anti muscarinic eg oxybutynin, solifenacin B-adrenergic b3 agonist - mirabegron

Question 27

Autonomic receptor drug targets - erectile?

Answer 27

Nitrergic- PDE5 inhibitor

Question 28

Incontinence definition?

Answer 28

Any involuntary loss of urine

Question 29

Stress incontinence definition, risk factors, pathology?

Answer 29

Definition - Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing Risk factors - age, obesity, pregnancy, smoking, route of delivery Pathology - impaired bladder and urethral support and impaired urethral closure

Question 30

Stress urinary incontinence signs and symptoms?

Answer 30

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

Question 31

Stress incontinence upon investigation?

Answer 31

Descent of pelvic floor on vaginal examination Positive stress test (visible loss of urine on inspection) URO dynamics - leakage during increase intra-abdominal pressure in absence of detrusor contraction

Question 32

Stress urinary incontinence non-surgical and surgical management?

Answer 32

Non-surgical - physio, pelvic floor muscle exercises Surgical - sling placed to support urethra using anterior vaginal wall to support urethra (colposuspension), periurethral bulking injection

Question 33

Overactive bladder definition, risk factors and pathology?

Answer 33

Urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence Risks - age, prolapse, increased BMI, bladder irritants (caffeine, nicotine) Pathology - involuntary overactive detrusor muscle contractions, loss of central nervous system inhibitory pathways

Question 34

Overactive bladder signs and symptoms?

Answer 34

urgency, frequency, nocturia and urgency incontinence. Impact on QoL due to sleep disruption, anxiety and depression. Assess for enlarge prostate in males and prolapse in women

Question 35

Overactive bladder investigations?

Answer 35

exclude infection with urine dip/MSU Bladder diary Bladder scan (post void residual) [Urodynamics]

Question 36

Overactive bladder management?

Answer 36

Antimuscarinic drugs Beta-3 agonist Behavioural/lifestyle changes,bladder retraining, bladder injections with botox, neuromodulation , augmentation cystoplasty

Question 37

Benign prostatic hyperplasia definition and risk factor?

Answer 37

non malignant growth or hyperplasia of prostate tissue, common cause of lower urinary tract symptoms in men. Outward enlargement can be felt with rectal exam. Risk factors - hormonal effects of testosterone on prostate tissue

Question 38

BPH urethral compression?

Answer 38

Enlargement of the prostate due to hypertrophy can compress the urethra, leading to a reduction in the urinary stream.  *Some men experience relatively little urethral compression, as the prostate enlargement goes outwards (into the rectum) rather than inwards.*

Question 39

BPH pathology?

Answer 39

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

Question 40

BPH signs and symptoms?

Answer 40

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

Question 41

What to exclude due to symptoms? BPH

Answer 41

Bladder cancer (haematuria) Prostate cancer (raised prostate specific antigen (PSA)) Urinary tract infections/ Prostatitis Urethral stricture

Question 42

Complications of BPH?

Answer 42

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

Question 43

BPH investigations?

Answer 43

Investigations: urine dipstick/ culture, post void residual, bladder diary Bloods: PSA Imaging: ultrasound to assess upper renal tracts Urinary flow studies/urodynamics Cystoscopy if concerned about bladder cancer

Question 44

BPH lifestyle management?

Answer 44

Weight loss, reduces caffeine, fluid intake in evening, avoid constipation

Question 45

BPH medical treatment?

Answer 45

α blocker- prostate stromal smooth muscle and bladder neck. Blocking the receptor relaxes muscle tone 5-α reductase inhibitor-prevents conversion of testosterone into di-hydro-testosterone (which promotes prostate growth) so slowly results in shrinkage

Question 46

Surgery for BPH?

Answer 46

Transurethral resection of the prostate (TURP)-debulks occluding part to produce adequate channel for urine to flow. Can also be done with laser. This is not the same as radical prostatectomy for cancer

Question 47

Male genitourinary tract bladder outlet - blood supply, lymphatics, nerve. Urethra

Answer 47

Blood supply - bulbourethral artery and internal pudendal artery with corresponding venous drainage Lymphatics - membranous urethra drains to obturator and internal iliac nodes, spongy urethra to deep and superficial inguinal nodes Nerve supply - vesical plexus (proximal), pudendal nerve (distal)