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brs (phase 1b) > (uro-renal) urinary incontinence & BPH > Flashcards

(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

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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

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3
Q

what is the function of the ureters?

A

convey urine from the kidneys to the urinary bladder

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4
Q

how long are the ureters?

A

approx 25cm long

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5
Q

where are the ureters located?

A

upper half lies in abdomen and lower half in pelvis

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6
Q

how wide are the ureters?

A

approx 3mm wide

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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

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8
Q

what are the layers of the ureters?

A

outer fibrous tissue

middle muscle layer

inner epithelium layer

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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

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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

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11
Q

which nerves supply the ureters?

A

autonomic nervous system

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12
Q

what is the function of the bladder?

A

muscular reservoir to store urine

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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)

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14
Q

what are the four angles of the bladder?

A

apex

neck

lateral angles (x2)

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15
Q

what are the four surfaces of the bladder?

A

base (posterior surface)

inferiolateral surfaces (x2)

superior surface

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16
Q

what are the three layers of the bladder?

A

outer connective tissue layer

middle muscular layer

inner transitional epithelium

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17
Q

what is the arterial blood supply of the bladder?

A

superior and inferior vesical branches of the internal iliac artery

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18
Q

what is the venous drainage of the bladder?

A

vesical plexus of the internal iliac vein

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19
Q

what is the lymphatic drainage of the bladder?

A

internal iliac nodes and then paraaortic nodes

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20
Q

what is the nerve supply of the bladder?

A

autonomic nervous system

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21
Q

what is the urethra?

A

channel from the neck of the bladder to the exterior, at the external urethral orifice

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22
Q

how long is the female urethra?

A

approx 3-4cm long

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23
Q

name the two urethral sphincters

A

internal urethral sphincter

external urethral sphincter

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24
Q

describe the internal urethral sphincter

A

detrusor muscle thickened

smooth muscle

involuntary control

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25
Q

describe the external urethral sphincter

A

skeletal muscle

voluntary control

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26
Q

what is the blood supply for the female urethra?

A

internal pudendal arteries

inferior vesical branches of the vaginal arteries

(with corresponding venous drainage)

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27
Q

what is the lymphatic drainage for the female urethra?

A

proximal urethra = internal iliac nodes

distal urethra = superficial inguinal lymph nodes

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28
Q

what is the nerve supply for the female urethra?

A

vesical plexus and the pudendal nerve

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29
Q

describe the anatomy of the male genitourinary system

A

composed of two kidneys, two ureters, urinary bladder, prostate and uretha

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30
Q

what is the function of the kidneys in males?

A

remove waste products of metabolism

remove excess water and salts from the blood

maintain the pH

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31
Q

how is the bladder different in males?

A

prostatic venous plexus which drains into internal iliac vein

(not from the vesical plexus like in females)

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32
Q

what is the prostate gland?

A

gland lying below the bladder in the male and surrounds the proximal part of the urethra

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33
Q

what does the prostate gland surround?

A

surrounds the proximal part of the urethra SO it is called the prostatic urethra

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34
Q

what is the function of the prostate gland?

A

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

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35
Q

how is the prostate linked to the bladder?

A

connected to the bladder via connective tissue

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36
Q

what are the lobes of a prostate gland?

A

anterior lobe
median lobe
posterior lobe
left & right lateral lobe

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37
Q

what is the arterial supply of the prostate gland?

A

inferior vesical artery

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38
Q

what is the venous drainage of the prostate gland?

A

prostatic plexus to the vesical plexus and internal iliac vein

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39
Q

what is the lymphatic drainage of the prostate gland?

A

internal and sacral nodes

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40
Q

what is the nerve supply of the prostate gland?

A

autonomic nervous system

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41
Q

how long is the urethra in males?

A

approx 20 cm

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42
Q

how does urethral length compare in males and females and why?

A 
females = 3-4cm
males = 20cm

male urethra transports both semen and urine

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43
Q

what structures does the male urethra run past?

A

neck of the bladder

prostate gland

floor of pelvis

perineal membrane to the penis

external urethral orifice at the tip of the male penis

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44
Q

what are the three parts of the male urethra?

A

prostastic urethra
membranous urethra
spongy urethra

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45
Q

what is the blood supply of the male urethra?

A

prostatic = inferior vesical artery

membranous = bulbourethral artery

spongy = internal pudendal artery

(with corresponding venous drainage)

46
Q

what is the lymphatic drainage of the male urethra?

A

prostatic + membranous = obturator + internal iliac nodes

spongy = deep + superficial inguinal nodes

47
Q

what is the nerve supply of the male urethra?

A

prostatic plexus

48
Q

what is normal micturition?

A

intermittent voiding of urine stored in the bladder

49
Q

what are the two phases of the bladder?

A

filling phase

voiding pahse

50
Q

explain the filling phase of the bladder

A

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
Q

explain the voiding phase of the bladder

A

bladder contracts and expels urine

external urethral sphincter relaxes and urethra opens

52
Q

how does micturition occur in infants?

A

local spinal reflex in which bladder empties on reaching a critical pressure

53
Q

how does micturition occur in adults?

A

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
Q

what is the external sphincter innervated by?

A

somatic motor fibre of the pudendal nerve

55
Q

what is the internal sphincter innervated by?

A

parasympathetic motor fibres of the pelvic nerve

56
Q

which fibres detect detrusor muscle stretch?

A

stretch receptors of parasympathetic sensory fibres of the pelvic nerve

57
Q

explain how micturition is under neural control

A

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
Q

explain the neural control of micturition once the bladder empties

A

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
Q

where do the M3 stretch receptors of the bladder originate form?

A

S2-S4 (parasympathetic stimulation)

60
Q

what is stress urinary incontinence?

A

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

61
Q

what is the incidence of stress urinary incontinence?

A

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
Q

what are the risk factors for stress urinary incontinence?

A 
obesity
ageing
smoking
pregnancy
route of delivery
63
Q

briefly summarise the pathology of stress urinary incontinence

A

impaired bladder and urethral support

impaired urethral closure

64
Q

what are the signs and symptoms of stress urinary incontinence?

A

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

65
Q

what are the investigations carried out for stress urinary incontinence?

A

positive (cough) stress test (demonstrable loss of urine on examination)

urodynamics

66
Q

what are urodynamics?

A

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
Q

how is stress urinary incontinence managed?

A

non-surgical
- physio with pelvic floor muscle exercises

surgical

  • mid urethral sling
  • colposuspension
  • periurethral bulking agents
68
Q

how does a mid-urethral sling treat SUI?

A

sling can be placed around the neck of the bladder to support it and prevent urine leaking

= reduces mobility

69
Q

how does colposuspension treat SUI?

A

lifting the neck of the bladder and stitching it in the lifted position

70
Q

how does a peri-urethral bulking agent treat SUI?

A

increases the size of the urethral walls and allows the urethra to stay closed with more force

71
Q

what is an overactive bladder?

A

urge urinary incontinence = urge to urinate with an almost empty bladder

= urinary urgency (urinary frequency and nocturia)

72
Q

what is the incidence of an overactive bladder?

A

overall prevalence of 16.6% in men and women over 40

73
Q

what are the risk factors of an overactive bladder/urge urinary incontinence?

A 
age
prolapse
increased BMI
IBS
bladder irritants (caffeine, nicotine)
74
Q

briefly summarise the pathology of an overactive bladder

A

involuntary detrusor (bladder wall) muscle contractions = idiopathic, neurogenic (loss of CNS inhibitory pathways)

bladder outlet obstruction

75
Q

what are the signs and symptoms of an overactive bladder?

urge urinary incontinence

A

urgency
frequency
urgency incontinence

nocturia
(impact on quality of life = sleep disorders, anxiety and depression)

76
Q

what must you assess for in an overactive bladder?

A

men = enlarged prostate (can squeeze the urethra and displace the neck of the bladder = incontinence)

women = prolapse (bladder outlet obstruction)

77
Q

which investigations are carried out for an overactive bladder?

A
  • exclude infection with urine dip/MSU
  • voiding diaries
  • assess post void residual volume
  • urodynamics
  • cystoscopy
78
Q

what are voiding diaries?

A

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
Q

what is post-void residual volume?

A

amount of urine retained in the bladder after a voluntary void

(normal = 50ml, abnormal = 200ml+)

80
Q

how is an overactive bladder managed?

A

lifestyle changes
bladder retraining

drugs:

  • antimuscarinic drugs
  • beta-3 agonists
  • botulinum toxin

surgery

  • neuromodulation
  • augmentation cystoplasty
  • urinary diversion
81
Q

how do antimuscarinic drugs treat an overactive bladder?

A

act primarily through antagonism at muscarinic M3 receptors

= counters overactive parasympathetic stimulation of the pelvic nerve fibres so reduced detrusor contraction

82
Q

how do beta-3 agonists drugs treat an overactive bladder?

A

increased sympathetic response

= so more detrusor relaxation and less urinary incontinence

83
Q

how does botox drugs treat an overactive bladder?

A

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
Q

what is an augmentation cystoplasty?

A

surgery to increase the capacity of the bladder

85
Q

what is urinary diversion?

A

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
Q

what are the main types of urinary incontinence?

A

urge incontinence

overflow incontinence

continuous incontinence

functional incontinence

mixed incontinence

87
Q

define mixed incontinence

A

more than one type, usually seen in older patients

88
Q

define overflow incontinence

A

involuntary leakage of urine when bladder is full

due to chronic urinary retention = from obstruction OR atonic bladder

89
Q

define continuous incontinence

A

continuous loss of urine all the time

90
Q

define functional incontinence

A

due to severe cognitive impairment or mobility limitations, preventing use of the toilet

!! bladder function is normal !!

91
Q

what causes the chronic retention of urine in overflow incontinence?

A

from obstruction OR atonic bladder

92
Q

what are the possible causes of continuous incontinence?

A

vesicovaginal fistula

ectopic ureter (from kidney to urethra or vagina)

93
Q

what are the possible causes of overflow incontinence?

A
  • underactive detrusor muscle
  • bladder neck stricture
  • urethral stricture
  • outlet obstruction (faecal impaction/BPH)

drugs = alpha adrenergics, anticholinergics, sedative

bladder denervation following surgery

94
Q

define benign prostatic hyperplasia

A

non-malignant growth or hyperplasia of prostate tissue

95
Q

what does BPH often cause in men?

A

lower urinary tract symptoms

96
Q

what is the incidence of benign prostatic hyperplasia?

A

increases with advancing age

50-60% for males in their 60s // increasing to 80-90% for those over 70

97
Q

what are the risk factors for benign prostatic hyperplasia?

A

hormonal effects of testosterone on prostate tissue

age, FHx, lack of physicla exercise

98
Q

briefly summarise the pathology of benign prostatic hyperplasia

A

hyperplasia of the lateral and median lobes
= leads to prostatic urethral compression
= bladder outflow obstruction

99
Q

what are the signs and symptoms of benign prostatic hyperplasia?

A

hesitancy in starting urination

poor stream

dribbling post micturition

increased frequency, nocturia

can present with acute urinary retention

100
Q

what are possible differential diagnoses for benign prostatic hyperplasia?

A

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
Q

what investigations are carried out for BPH?

A
  • 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
Q

what blood tests are carried out for BPH?

A

PSA (predicts prostate volume; buuut should be interpreted with caution)

103
Q

what imaging are carried out for BPH?

A

ultrasound to assess upper renal tracts

104
Q

what specialised urological tests are carried out for BPH?

A

flow studies

urodynamics

cystoscopy (if concerned about cancer)

105
Q

how is BPH treated?

A

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
Q

what conservative management is available for BPH?

A

weight loss

reduce caffeine and fluid intake at night

avoid constipation

107
Q

explain the mechanism of action of alpha blockers in BPH management

A

alpha 1-AR present on prostate stromal smooth muscle and bladder neck

= blockage of alpha 1-AR results in relaxation
= improving urinary flow

108
Q

explain the mechanism of action of 5-alpha reductase inhibitors in BPH management

A

prevents conversation of test to DHT

= less stimulation for growth and enlargement of prostate
= shrinkage
= improving urinary flow rate and obstructive symptoms

109
Q

how can BPH be surgically managed?

A

transurethral resection of the prostate

110
Q

what is a TURP surgery?

A

transurethral resection of the prostate

= debulks the prostate to produce an adequate, unobstructed channel for urine flow

111
Q

what are the possible complications of BPH?

A
  • progressive bladder distention, causing chronic painless retention
  • overflow incontinence
  • bilateral upper tract obstruction
  • renal impairment, with patient presenting with chronic renal disease

brs (phase 1b) (71 decks)

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