Uriney Incontinence And Urinary Tract Symptoms Flashcards
Ureters length, diameter and 3 layers of tissue?
25cm long
3mm diameter
3 layers - outer fibrous tissue, middle muscle layer and inner epithelium layer
Ureters blood supply?
Renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage.
Ureters lymphatics?
Left ureter drains into left para-aortic nodes
right ureter drains into right paracaval and interaortocaval lymph nodes
Ureters nerve supply?
Autonomic
Variations in kidney anatomy?
Single kidney
Horse-shoe kidney
Ectopic kidney
Variations in ureter anatomy?
Partial duplication
Complete duplication
“Hold up” points in ureter?
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)
Bladder blood supply?
Superior and inferior vesical branches of internal iliac artery
Drained by vesical plexus -> internal iliac vein
Bladder nerve supply?
Autonomic
Female urinary tract - external urethral sphincter muscle, contraction, and nerve
External urethral sphincter- skeletal muscle, tonic contraction and also voluntary “guarding”. Controlled by pudendal nerve.
Female urinary tract bladder outlet - blood supply, lymphatics and nerve supply
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)
Prostate gland secretion?
Secretes 75% of seminal fluid which liquifies coagulated semen after deposition in female genital tract
Male genitourinary tract bladder outlet - blood supply, lymphatics and nerve supply. Prostrate
Blood supply - Prostate - inferior vesicle artery
Lymphatics - drain to obturator and internal iliac nodes
Nerve supply - vesical plexus (proximal), pudendal nerve (distal)
Bladder and outlet during storage?
Bladder relaxed, serving as reservoir
Outlet contracted, preventing leaks
Bladder and outlet during voiding?
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
Neural control of micturition?
Prefrontal cortex -> pontine micturition centre (in brainstem) to change from storage mode -> voiding
= activates the PNS (bladder contraction) + inhibits Onuf’s nucleus (sphincter relaxation)
Frontal cortex in micturition?
Decides actions based on planning ahead, social appropriateness, etc,
Pontine micturition centre in micturition?
Co-ordinates spinal centres; storage switches to voiding only if permitted
Limbic cortex in micturition?
Emotional and fear reactions
Periaqueductal gray in micturition?
Receives sensory info from visceral (subconscious), decides what goes to cortex (conscious sensation)
Thoracic spinal cord in micturition?
Sympathetic nucleus (bladder neck)
Sacral spinal cord in micturition?
Parasympathetic nucleus (detrusor)
Onuf’s nucleus (sphincter)
Micturition in infants vs adults?
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
Pelvic organ nerve supplies? PNS, SNS and pudendal
PNS - bladder
SNS - kidney, testicle, bladder neck
Pudendal - penis, vaginal vestibule/clitoris
Autonomic receptor drug targets - bladder neck?
a-adrenergic (a-1) - alpha blocker - tamsulosin
Autonomic receptor drug targets - detrusor
Cholinergic M3/M2 - anti muscarinic eg oxybutynin, solifenacin
B-adrenergic b3 agonist - mirabegron
Autonomic receptor drug targets - erectile?
Nitrergic- PDE5 inhibitor
Incontinence definition?
Any involuntary loss of urine
Stress incontinence definition, risk factors, pathology?
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
Stress urinary incontinence signs and symptoms?
Involuntary leakage from urethra with exertion/effort or sneezing or coughing
Stress incontinence upon investigation?
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
Stress urinary incontinence non-surgical and surgical management?
Non-surgical - physio, pelvic floor muscle exercises
Surgical - sling placed to support urethra using anterior vaginal wall to support urethra (colposuspension), periurethral bulking injection
Overactive bladder definition, risk factors and pathology?
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
Overactive bladder signs and symptoms?
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
Overactive bladder investigations?
exclude infection with urine dip/MSU
Bladder diary
Bladder scan (post void residual)
[Urodynamics]
Overactive bladder management?
Antimuscarinic drugs
Beta-3 agonist
Behavioural/lifestyle changes,bladder retraining, bladder injections with botox, neuromodulation , augmentation cystoplasty
Benign prostatic hyperplasia definition and risk factor?
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
BPH urethral compression?
Enlargement of the prostate due to hypertrophy can compressthe urethra, leading to a reduction in the urinary stream.
Some men experience relatively little urethral compression,as the prostate enlargement goes outwards (into therectum) rather than inwards.
BPH pathology?
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
BPH signs and symptoms?
hesitancy in starting urination
poor stream
dribbling post micturition
can present with acute retention
What to exclude due to symptoms? BPH
Bladder cancer (haematuria)
Prostate cancer (raised prostate specific antigen (PSA))
Urinary tract infections/ Prostatitis
Urethral stricture
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
BPH investigations?
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
BPH lifestyle management?
Weight loss, reduces caffeine, fluid intake in evening, avoid constipation
BPH medical treatment?
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
Surgery for BPH?
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
Male genitourinary tract bladder outlet - blood supply, lymphatics, nerve. Urethra
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)
