(uro-renal) urinary incontinence & BPH Flashcards
1
Q
describe the anatomy of the female genitourinary system
A
composed of two kidneys, two ureters, urinary bladder and urethra
2
Q
what is the function of the kidney in females?
A
remove waste products of metabolism, excess water and salts from the blood and maintain the pH
3
Q
what is the function of the ureters?
A
convey urine from the kidneys to the urinary bladder
4
Q
how long are the ureters?
A
approx 25cm long
5
Q
where are the ureters located?
A
upper half lies in abdomen and lower half in pelvis
6
Q
how wide are the ureters?
A
approx 3mm wide
7
Q
where are the three ureteric constrictions and why are they physiologically important?
A
- pelviureteric junction
- vesicoureteric junction
- as it enters the pelvic brim
= most narrow points of the ureter where urinary stones are most likely to get lodged
8
Q
what are the layers of the ureters?
A
outer fibrous tissue
middle muscle layer
inner epithelium layer
9
Q
describe the ureteric blood supply and venous drainage
A
renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage
10
Q
describe the lymphatic drainage of the ureters
A
left ureter drains into left para-aortic nodes
right ureter drains into right paracaval and interaortocaval lymph nodes
11
Q
which nerves supply the ureters?
A
autonomic nervous system
12
Q
what is the function of the bladder?
A
muscular reservoir to store urine
13
Q
what type of organ is the bladder in its filled and empty states?
A
empty = pelvic organs
filled = abdominopelvic organ (fills, swells up and becomes distended and rises up into abdominal cavity)
14
Q
what are the four angles of the bladder?
A
apex
neck
lateral angles (x2)
15
Q
what are the four surfaces of the bladder?
A
base (posterior surface)
inferiolateral surfaces (x2)
superior surface
16
Q
what are the three layers of the bladder?
A
outer connective tissue layer
middle muscular layer
inner transitional epithelium
17
Q
what is the arterial blood supply of the bladder?
A
superior and inferior vesical branches of the internal iliac artery
18
Q
what is the venous drainage of the bladder?
A
vesical plexus of the internal iliac vein
19
Q
what is the lymphatic drainage of the bladder?
A
internal iliac nodes and then paraaortic nodes
20
Q
what is the nerve supply of the bladder?
A
autonomic nervous system
21
Q
what is the urethra?
A
channel from the neck of the bladder to the exterior, at the external urethral orifice
22
Q
how long is the female urethra?
A
approx 3-4cm long
23
Q
name the two urethral sphincters
A
internal urethral sphincter
external urethral sphincter
24
Q
describe the internal urethral sphincter
A
detrusor muscle thickened
smooth muscle
involuntary control
25
describe the external urethral sphincter
skeletal muscle
voluntary control
26
what is the blood supply for the female urethra?
internal pudendal arteries
inferior vesical branches of the vaginal arteries
(with corresponding venous drainage)
27
what is the lymphatic drainage for the female urethra?
proximal urethra = internal iliac nodes
distal urethra = superficial inguinal lymph nodes
28
what is the nerve supply for the female urethra?
vesical plexus and the pudendal nerve
29
describe the anatomy of the male genitourinary system
composed of two kidneys, two ureters, urinary bladder, prostate and uretha
30
what is the function of the kidneys in males?
remove waste products of metabolism
remove excess water and salts from the blood
maintain the pH
31
how is the bladder different in males?
prostatic venous plexus which drains into internal iliac vein
(not from the vesical plexus like in females)
32
what is the prostate gland?
gland lying below the bladder in the male and surrounds the proximal part of the urethra
33
what does the prostate gland surround?
surrounds the proximal part of the urethra SO it is called the prostatic urethra
34
what is the function of the prostate gland?
secrete 75% of seminal fluid which liquifies coagulated semen after deposition in the female genital tract
35
how is the prostate linked to the bladder?
connected to the bladder via connective tissue
36
what are the lobes of a prostate gland?
anterior lobe
median lobe
posterior lobe
left & right lateral lobe
37
what is the arterial supply of the prostate gland?
inferior vesical artery
38
what is the venous drainage of the prostate gland?
prostatic plexus to the vesical plexus and internal iliac vein
39
what is the lymphatic drainage of the prostate gland?
internal and sacral nodes
40
what is the nerve supply of the prostate gland?
autonomic nervous system
41
how long is the urethra in males?
approx 20 cm
42
how does urethral length compare in males and females and why?
```
females = 3-4cm
males = 20cm
```
male urethra transports both semen and urine
43
what structures does the male urethra run past?
neck of the bladder
prostate gland
floor of pelvis
perineal membrane to the penis
external urethral orifice at the tip of the male penis
44
what are the three parts of the male urethra?
prostastic urethra
membranous urethra
spongy urethra
45
what is the blood supply of the male urethra?
prostatic = inferior vesical artery
membranous = bulbourethral artery
spongy = internal pudendal artery
(with corresponding venous drainage)
46
what is the lymphatic drainage of the male urethra?
prostatic + membranous = obturator + internal iliac nodes
spongy = deep + superficial inguinal nodes
47
what is the nerve supply of the male urethra?
prostatic plexus
48
what is normal micturition?
intermittent voiding of urine stored in the bladder
49
what are the two phases of the bladder?
filling phase
| voiding pahse
50
explain the filling phase of the bladder
bladder fills and distends without rise in intravesical pressure, so the bladder pressure remains lower then the urethral pressure
external urethral sphincter + bladder neck contracts = maintain continence
51
explain the voiding phase of the bladder
bladder contracts and expels urine
external urethral sphincter relaxes and urethra opens
52
how does micturition occur in infants?
local spinal reflex in which bladder empties on reaching a critical pressure
53
how does micturition occur in adults?
can be initiated or inhabited by higher centre control of the external urethral sphincter keeping it closed until it is appropriate to urinate
(voluntary control_
54
what is the external sphincter innervated by?
somatic motor fibre of the pudendal nerve
55
what is the internal sphincter innervated by?
parasympathetic motor fibres of the pelvic nerve
56
which fibres detect detrusor muscle stretch?
stretch receptors of parasympathetic sensory fibres of the pelvic nerve
57
explain how micturition is under neural control
the M3 parasympathetic stretch receptors will detect increased stretching when the bladder fills with urine
send nerve impulse via the pelvic nerve parasympathetic fibres to the higher centres in the brain
send impulse back down the motor parasympathetic fibres of the pelvic nerve to relax the internal urethral sphincter and contract the detrusor muscle
= facilitates urination
(voluntary = impulse also send down the somatic motor fibres of the pudendal nerve to stimulate relaxation of the external urethral sphincter)
58
explain the neural control of micturition once the bladder empties
bladder empties and so reduced stimulation for activation of M3 parasympathetic receptors = inactivated
sympathetic nervous system activated (T11-L2) (due to beta 3 receptor activation) and causes
- relaxation of the detrusor muscle
- contraction of the internal urethral sphincter
= bladder can fill again
59
where do the M3 stretch receptors of the bladder originate form?
S2-S4 (parasympathetic stimulation)
60
what is stress urinary incontinence?
involuntary leakage on effort or exertion, or on sneezing or coughing
61
what is the incidence of stress 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
62
what are the risk factors for stress urinary incontinence?
```
obesity
ageing
smoking
pregnancy
route of delivery
```
63
briefly summarise the pathology of stress urinary incontinence
impaired bladder and urethral support
impaired urethral closure
64
what are the signs and symptoms of stress urinary incontinence?
involuntary leakage from urethra with exertion/effort or sneezing or coughing
65
what are the investigations carried out for stress urinary incontinence?
positive (cough) stress test (demonstrable loss of urine on examination)
urodynamics
66
what are urodynamics?
test to see if there is urinary leakage during increase in intrabdominal pressure in the absence of detrusor contraction = measure bladder and abdominal pressure
(via the insertion of a catheter)
67
how is stress urinary incontinence managed?
non-surgical
- physio with pelvic floor muscle exercises
surgical
- mid urethral sling
- colposuspension
- periurethral bulking agents
68
how does a mid-urethral sling treat SUI?
sling can be placed around the neck of the bladder to support it and prevent urine leaking
= reduces mobility
69
how does colposuspension treat SUI?
lifting the neck of the bladder and stitching it in the lifted position
70
how does a peri-urethral bulking agent treat SUI?
increases the size of the urethral walls and allows the urethra to stay closed with more force
71
what is an overactive bladder?
urge urinary incontinence = urge to urinate with an almost empty bladder
= urinary urgency (urinary frequency and nocturia)
72
what is the incidence of an overactive bladder?
overall prevalence of 16.6% in men and women over 40
73
what are the risk factors of an overactive bladder/urge urinary incontinence?
```
age
prolapse
increased BMI
IBS
bladder irritants (caffeine, nicotine)
```
74
briefly summarise the pathology of an overactive bladder
involuntary detrusor (bladder wall) muscle contractions = idiopathic, neurogenic (loss of CNS inhibitory pathways)
bladder outlet obstruction
75
what are the signs and symptoms of an overactive bladder?
| urge urinary incontinence
urgency
frequency
urgency incontinence
nocturia
(impact on quality of life = sleep disorders, anxiety and depression)
76
what must you assess for in an overactive bladder?
men = enlarged prostate (can squeeze the urethra and displace the neck of the bladder = incontinence)
women = prolapse (bladder outlet obstruction)
77
which investigations are carried out for an overactive bladder?
- exclude infection with urine dip/MSU
- voiding diaries
- assess post void residual volume
- urodynamics
- cystoscopy
78
what are voiding diaries?
allows patients to record
1) how much liquid they drink
2) how often they urinate
3) when they experience urine leakage
= essential to assess symptoms of na overactive bladder
79
what is post-void residual volume?
amount of urine retained in the bladder after a voluntary void
(normal = 50ml, abnormal = 200ml+)
80
how is an overactive bladder managed?
lifestyle changes
bladder retraining
drugs:
- antimuscarinic drugs
- beta-3 agonists
- botulinum toxin
surgery
- neuromodulation
- augmentation cystoplasty
- urinary diversion
81
how do antimuscarinic drugs treat an overactive bladder?
act primarily through antagonism at muscarinic M3 receptors
= counters overactive parasympathetic stimulation of the pelvic nerve fibres so reduced detrusor contraction
82
how do beta-3 agonists drugs treat an overactive bladder?
increased sympathetic response
= so more detrusor relaxation and less urinary incontinence
83
how does botox drugs treat an overactive bladder?
causes more relaxation of the detrusor muscle
(allows more time before bladder pressure exceeds urethral pressure)
!!! too much relaxation can lead to urinary retention tho !!!
84
what is an augmentation cystoplasty?
surgery to increase the capacity of the bladder
85
what is urinary diversion?
surgical procedure that creates a new way for urine to exit your body when urine flow is blocked or when there is a need to bypass a diseased area in the urinary tract
86
what are the main types of urinary incontinence?
urge incontinence
overflow incontinence
continuous incontinence
functional incontinence
mixed incontinence
87
define mixed incontinence
more than one type, usually seen in older patients
88
define overflow incontinence
involuntary leakage of urine when bladder is full
| due to chronic urinary retention = from obstruction OR atonic bladder
89
define continuous incontinence
continuous loss of urine all the time
90
define functional incontinence
due to severe cognitive impairment or mobility limitations, preventing use of the toilet
!! bladder function is normal !!
91
what causes the chronic retention of urine in overflow incontinence?
from obstruction OR atonic bladder
92
what are the possible causes of continuous incontinence?
vesicovaginal fistula
ectopic ureter (from kidney to urethra or vagina)
93
what are the possible causes of overflow incontinence?
- underactive detrusor muscle
- bladder neck stricture
- urethral stricture
- outlet obstruction (faecal impaction/BPH)
drugs = alpha adrenergics, anticholinergics, sedative
bladder denervation following surgery
94
define benign prostatic hyperplasia
non-malignant growth or hyperplasia of prostate tissue
95
what does BPH often cause in men?
lower urinary tract symptoms
96
what is the incidence of benign prostatic hyperplasia?
increases with advancing age
| 50-60% for males in their 60s // increasing to 80-90% for those over 70
97
what are the risk factors for benign prostatic hyperplasia?
hormonal effects of testosterone on prostate tissue
| age, FHx, lack of physicla exercise
98
briefly summarise the pathology of benign prostatic hyperplasia
hyperplasia of the lateral and median lobes
= leads to prostatic urethral compression
= bladder outflow obstruction
99
what are the signs and symptoms of benign prostatic hyperplasia?
hesitancy in starting urination
poor stream
dribbling post micturition
increased frequency, nocturia
can present with acute urinary retention
100
what are possible differential diagnoses for benign prostatic hyperplasia?
urethral stricture
urinary tract stones
bladder/prostate cancer
prostatitis
cauda equina
high pressure chronic retention
UTIs/STIs
neurogenic bladder (aecondary to Parkinson's, MS)
101
what investigations are carried out for BPH?
- urine dipstick
- MCS (microbial culture & sensitivities)
- post-void residual volume
- voiding diary
```
bloods = PSA
imaging = ultrasound
```
- flow studies/urodynamics
- cystoscopy (if concerned about cancer)
102
what blood tests are carried out for BPH?
PSA (predicts prostate volume; buuut should be interpreted with caution)
103
what imaging are carried out for BPH?
ultrasound to assess upper renal tracts
104
what specialised urological tests are carried out for BPH?
flow studies
urodynamics
cystoscopy (if concerned about cancer)
105
how is BPH treated?
lifestyle
- weight loss
- reduce caffeine & fluid intake in the evening
- avoid constipation
medical
- alpha blockers
- 5-alpha reductase inhibitors
surgery
- transurethral resection of the prostate
106
what conservative management is available for BPH?
weight loss
reduce caffeine and fluid intake at night
avoid constipation
107
explain the mechanism of action of alpha blockers in BPH management
alpha 1-AR present on prostate stromal smooth muscle and bladder neck
= blockage of alpha 1-AR results in relaxation
= improving urinary flow
108
explain the mechanism of action of 5-alpha reductase inhibitors in BPH management
prevents conversation of test to DHT
= less stimulation for growth and enlargement of prostate
= shrinkage
= improving urinary flow rate and obstructive symptoms
109
how can BPH be surgically managed?
transurethral resection of the prostate
110
what is a TURP surgery?
transurethral resection of the prostate
= debulks the prostate to produce an adequate, unobstructed channel for urine flow
111
what are the possible complications of BPH?
- progressive bladder distention, causing chronic painless retention
- overflow incontinence
- bilateral upper tract obstruction
- renal impairment, with patient presenting with chronic renal disease
