Uro - Urinary Incontinence + BPH Flashcards
What does the female GU system consist of?
→ 2 kidneys
→ 2 ureters
→ urinary bladder
→ urethra
What do the kidneys do?
→ remove waste products of metabolism
→ remove excess water and salts from the blood
→ maintain the pH
What is the function of the ureters?
Convey urine from the kidneys to the urinary bladder
What are the dimensions + orientation of the ureters?
→ Each one is about 25cm long, upper half lies in abdomen and lower half in pelvis.
What are the constrictions of the ureters?
→ Measures 3mm in diameter but slightly constricted at 3 places (pelvic ureteric junction, pelvic brim, as it passes through the bladder wall).
What are the 3 layers of the ureters?
→ tissue-outer fibrous tissue
→ middle muscle layer
→ inner epithelium layer
What is the blood supply to the ureters?
related to region: renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage
What are the lymphatics of the ureters?
left ureter drains into left para-aortic nodes, right ureter drains into right paracaval and interaortocaval lymph nodes
What is the nervous supply of the ureters?
autonomic nervous supply
What is the function of the urinary bladder?
muscular reservoir of urine
What are dimensions + anatomical position of the bladder?
→ when empty, bladder is pelvic organ, when distended it rises up to abdominal cavity and becomes an abdomino-pelvic organ.
→ 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.
What are the 3 layers of the urinary bladder?
→ outer loose connective tissue
→ middle smooth muscle and elastic fibres
→ inner layer lined with transitional epithelium
What is the blood supply to the bladder?
superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein
What are the lymphatics of the bladder?
internal iliac nodes and then para-aortic nodes
What is the nervous supply for the bladder?
autonomic nervous supply
What is the male GU system made up of?
→ 2 kidneys → 2 ureters → urinary bladder → prostate → urethra
Where is the prostate anatomically?
Gland lying below the bladder in the male and surrounds the proximal part of the urethra (prostatic urethra)
connected to bladder by connective tissue
What is the function of the prostate?
Function is to secrete 75% of seminal fluid which liquifies coagulated semen after deposition in the female genital tract
What are the dimensions of the bladder?
Measures 4x3x2cm, conical in shape
What are the 3 parts of the prostate?
→ left lateral lobe
→ right lateral lobe
→ middle lobe
What is the blood supply to the prostate?
inferior vesical artery
venous drainage via prostatic plexus to the vesical plexus and internal iliac vein
What are the lymphatics of the prostate?
internal + sacral nodes
What is the nerve supply of the prostate?
autonomic nervous supply
What are the dimensions and pathways of the urethra?
20cm long tube Runs through: Neck of bladder Prostate gland Floor of pelvis Perineal membrane to the penis External urethral orifice at the tip of male penis
What are the 3 main parts of the urethra?
Prostatic
Membranous
Spongy
What is the blood supply for the urethra?
prostatic-inferior vesical artery,
membranous-bulbourethral artery
spongy urethra- internal pudendal artery
with corresponding venous drainage.
What are the lymphatics of the urethra?
Prostatic + membranous urethra : drain to obturator + internal iliac nodes
Spongy urethra : drains to deep + superficial inguinal nodes
What is the nervous supply of the urethra?
Prostatic plexus
What is normal micturition?
Intermittent voiding of urine stored in the bladder
What is the filling phase of micturition?
Bladder fills + distends without rise intravesical pressure
Urethral sphincter contracts + closes urethra
What is the voiding phase of micturition?
Bladder contracts + expels urine
Urethral sphincter relaxes and urethra opens
How is micturition controlled in infants?
Local spinal reflex in which bladder empties on reaching a critical pressure
How is micturition controlled in adults?
Voiding can be initiated or inhibited by higher centre control of external urethral sphincter keeping it closed until it’s appropriate to urinate
What receptors and parts of the autonomic nervous system are involved in the voiding phase of micturition?
M3 receptors
parasympathetic S2 -S4
How is the voiding phase initiated by the nervous system?
- 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 receptors and parts of the autonomic nervous system are involved in the filling phase of micturition?
Beta 3 receptors
Sympathetic (T11-L2)
How does the autonomic nervous system initiate the filling phase?
When bladder empties, M3 receptors (stretch receptors) become inactived
Sympathetic nervous system activates Beta 3 receptors
This causes relaxation of detrusor muscle, allowing bladder to fill again
What is urinary incontinence?
Involuntary urination
Uncontrolled leakage of urine
What is stress urinary incontinence?
Complaint of involuntary leakage on effort or exertion, sneezing or coughing
What is the incidence of stress urinary incontinence?
Can affect up to 40% of women
More common in older women
1 in 5 women over 40 have some degree of stress incontinence
What are some risk factors of SUI?
Ageing
Obesity
Smoking
Pregnancy + Route of delivery
What is the pathology of stress incontinence?
Impaired bladder + urethral support
Impaired urethral closure
What are some signs and symptoms of SUI?
Involuntary leakage from urethra on exertion/ effort or sneezing or coughing
What are some investigations that can be done for SUI?
- 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 conservative management of SUI?
Physio with Pelvic floor exercises (PFE)
What is the surgical management of SUI?
Mid-urethral sling
Colposuspension
Periurethral bulking agents
What is an overactive bladder (urge UI)
Urinary urgency usually with urinary frequency + nocturia, with or without urgency urinary incontinence
What is the prevalence of overactive bladder?
Overall prevalence = 16.6% in men and women over 40
What are the risk factors for overactive bladder?
Age Prolapse Increased BMI IBS Bladder irritants (caffeine, nicotine
What is the pathology of urinary incontinence?
Not well understood, involuntary detrusor (bladder wall) muscle contractions
Cause can be idiopathic, meurogenic (loss of CNS inhibitory pathways) or bladder outlet obstruction
What are the symptoms + signs of overactive bladder?
urgency + frequency nocturis urgency incontinence impact on QOL sleep disorders anxiety depression Assess for enlarge prostate in males and prolapse in women
What are the investigations that can be done for Overactive bladder?
Exclude infection with urine dipstick or MSU Voiding diary Assess post-void residue Urodynamics Cystoscopy
What is MSU?
Midstream specimen of urine (used for urine culture)
What is a Voiding diary?
A record of when a patient passes urine, how much water they drink, etc.
What is the management of overactive bladder?
Behaviour / lifestyle changes Bladder retaining Antimscarinic drugs Beta-3-agonists Botox Neuromodulation (PTNS/SNS) Surgical : augmentation custoplasty + 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 can cause overflow incontinence?
Outlet obstruction (faecal impaction/BPH) Underactive detrusor muscle
Bladder neck stricture
Urethral stricture
DHx-alpha adrenergics, anticholinergics, sedative
Bladder denervation following surgery
What is continuous incontinence?
Continuous loss of urine all the time
What can cause continuous incontinence?
Vesicovaginal fistula (fistula between bladder and vagina) Ectopic ureter (from kidney to urethra or vagina)
What is functional incontigence?
Bladder function is normal but unable to functinally use the toilet in time to urinate
What can cause functinal incontinence?
Severe cognitive impairment
Mobility limitations
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 BPH?
Increases with advancing age
50%-60% for males in their 60s
80%-90% for those over 70
What are the risk factors for BPH?
Hormonal effects of testosterone on prostate tissue
What is the pathology of BPH?
Hyperplasia of both lateral lobes + median lobes
Leads to comoression of the urethra + therefore bladder outflow obstruction
See hyperplasia of the stroma (smooth muscle and fibrous tissue) and glands
What are signs + symptoms of BPH?
- hesitancy in starting urination
- poor stream
- dribbling post micturition
- frequency, nocturia
- can present with acute retention
What other conditons can cause similar signs and symptoms to 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 can exclude other causes of BPH symptoms?
Abdominal, pelvic + rectal examination
Urethra / bladder / rectum / prostate / sphincter
What can be done to investigate BPH?
Urine dipstick / MCS post-void residual Voiding Diary Flow studies / urodynamics Cystoscopy if concerned about cancer Bloods Imaging
What bloods can be done to investigate BPH?
PSA levels can predict prostate volume
Use with caution, especially if concerned about prostate cancer
What imaging can be done to investigate BPH?
Ultrasound to assess upper renal tracts
How do you manage BPH in terms of lifestyle?
Weight loss
Reduces caffeine + fluid intake in the evening
Avoid constipation
How do you manage BPH medically?
Alpha blockers
5-alpha reductase inhibitors
How do alpha blockers help with BPH?
Alpha 1 AR present on prostate stromal smooth muscle + bladder neck
Blockage of receptors results in relaxation, thus improving urinary flow rate
How 5-alpha reductase inhibitors help with BPH?
Prevents conversion of testosterone to DHT (which promotes growth + enlargement of prostate) so results in shrinkage, thereby improving urinary flow rate and obstructive symptoms
How can BPH be managed surgically?
Transurethral resection of the prostate (TURP)
This debulks prostate to produce adequate channel for urine to flow
What are some 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
