Uro - Urinary Incontinence + BPH Flashcards

1
Q

What does the female GU system consist of?

A

→ 2 kidneys
→ 2 ureters
→ urinary bladder
→ urethra

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2
Q

What do the kidneys do?

A

→ remove waste products of metabolism
→ remove excess water and salts from the blood
→ 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

What are the dimensions + orientation of the ureters?

A

→ Each one is about 25cm long, upper half lies in abdomen and lower half in pelvis.

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5
Q

What are the constrictions of the ureters?

A

→ Measures 3mm in diameter but slightly constricted at 3 places (pelvic ureteric junction, pelvic brim, as it passes through the bladder wall).

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6
Q

What are the 3 layers of the ureters?

A

→ tissue-outer fibrous tissue
→ middle muscle layer
→ inner epithelium layer

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7
Q

What is the blood supply to the ureters?

A

related to region: renal/lumbar/gonadal/common iliac, internal iliac and superior vesical arteries with corresponding venous drainage

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8
Q

What are the lymphatics 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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9
Q

What is the nervous supply of the ureters?

A

autonomic nervous supply

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10
Q

What is the function of the urinary bladder?

A

muscular reservoir of urine

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11
Q

What are dimensions + anatomical position of the bladder?

A

→ 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.

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12
Q

What are the 3 layers of the urinary bladder?

A

→ outer loose connective tissue
→ middle smooth muscle and elastic fibres
→ inner layer lined with transitional epithelium

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13
Q

What is the blood supply to the bladder?

A

superior and inferior vesical branches of internal iliac artery. Drained by vesical plexus which drains into internal iliac vein

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14
Q

What are the lymphatics of the bladder?

A

internal iliac nodes and then para-aortic nodes

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15
Q

What is the nervous supply for the bladder?

A

autonomic nervous supply

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16
Q

What is the male GU system made up of?

A
→ 2 kidneys
→ 2 ureters
→ urinary bladder
→ prostate
→ urethra
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17
Q

Where is the prostate anatomically?

A

Gland lying below the bladder in the male and surrounds the proximal part of the urethra (prostatic urethra)
connected to bladder by connective tissue

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18
Q

What is the function of the prostate?

A

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

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19
Q

What are the dimensions of the bladder?

A

Measures 4x3x2cm, conical in shape

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20
Q

What are the 3 parts of the prostate?

A

→ left lateral lobe
→ right lateral lobe
→ middle lobe

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21
Q

What is the blood supply to the prostate?

A

inferior vesical artery

venous drainage via prostatic plexus to the vesical plexus and internal iliac vein

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22
Q

What are the lymphatics of the prostate?

A

internal + sacral nodes

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23
Q

What is the nerve supply of the prostate?

A

autonomic nervous supply

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24
Q

What are the dimensions and pathways of the urethra?

A
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
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25
Q

What are the 3 main parts of the urethra?

A

Prostatic
Membranous
Spongy

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26
Q

What is the blood supply for the urethra?

A

prostatic-inferior vesical artery,
membranous-bulbourethral artery
spongy urethra- internal pudendal artery
with corresponding venous drainage.

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27
Q

What are the lymphatics of the urethra?

A

Prostatic + membranous urethra : drain to obturator + internal iliac nodes
Spongy urethra : drains to deep + superficial inguinal nodes

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28
Q

What is the nervous supply of the urethra?

A

Prostatic plexus

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29
Q

What is normal micturition?

A

Intermittent voiding of urine stored in the bladder

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30
Q

What is the filling phase of micturition?

A

Bladder fills + distends without rise intravesical pressure

Urethral sphincter contracts + closes urethra

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31
Q

What is the voiding phase of micturition?

A

Bladder contracts + expels urine

Urethral sphincter relaxes and urethra opens

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32
Q

How is micturition controlled in infants?

A

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

33
Q

How is micturition controlled in adults?

A

Voiding can be initiated or inhibited by higher centre control of external urethral sphincter keeping it closed until it’s appropriate to urinate

34
Q

What receptors and parts of the autonomic nervous system are involved in the voiding phase of micturition?

A

M3 receptors

parasympathetic S2 -S4

35
Q

How is the voiding phase initiated by the nervous system?

A
  • 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
36
Q

What receptors and parts of the autonomic nervous system are involved in the filling phase of micturition?

A

Beta 3 receptors

Sympathetic (T11-L2)

37
Q

How does the autonomic nervous system initiate the filling phase?

A

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

38
Q

What is urinary incontinence?

A

Involuntary urination

Uncontrolled leakage of urine

39
Q

What is stress urinary incontinence?

A

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

40
Q

What is the incidence of stress urinary incontinence?

A

Can affect up to 40% of women
More common in older women
1 in 5 women over 40 have some degree of stress incontinence

41
Q

What are some risk factors of SUI?

A

Ageing
Obesity
Smoking
Pregnancy + Route of delivery

42
Q

What is the pathology of stress incontinence?

A

Impaired bladder + urethral support

Impaired urethral closure

43
Q

What are some signs and symptoms of SUI?

A

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

44
Q

What are some investigations that can be done for SUI?

A
  • 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
45
Q

What is the conservative management of SUI?

A

Physio with Pelvic floor exercises (PFE)

46
Q

What is the surgical management of SUI?

A

Mid-urethral sling
Colposuspension
Periurethral bulking agents

47
Q

What is an overactive bladder (urge UI)

A

Urinary urgency usually with urinary frequency + nocturia, with or without urgency urinary incontinence

48
Q

What is the prevalence of overactive bladder?

A

Overall prevalence = 16.6% in men and women over 40

49
Q

What are the risk factors for overactive bladder?

A
Age
Prolapse
Increased BMI
IBS
Bladder irritants (caffeine, nicotine
50
Q

What is the pathology of urinary incontinence?

A

Not well understood, involuntary detrusor (bladder wall) muscle contractions
Cause can be idiopathic, meurogenic (loss of CNS inhibitory pathways) or bladder outlet obstruction

51
Q

What are the symptoms + signs of overactive bladder?

A
urgency + frequency
nocturis
urgency incontinence
impact on QOL
sleep disorders
anxiety
depression
Assess for enlarge prostate in males and prolapse in women
52
Q

What are the investigations that can be done for Overactive bladder?

A
Exclude infection with urine dipstick or MSU
Voiding diary
Assess post-void residue
Urodynamics
Cystoscopy
53
Q

What is MSU?

A

Midstream specimen of urine (used for urine culture)

54
Q

What is a Voiding diary?

A

A record of when a patient passes urine, how much water they drink, etc.

55
Q

What is the management of overactive bladder?

A
Behaviour / lifestyle changes
Bladder retaining
Antimscarinic drugs
Beta-3-agonists
Botox
Neuromodulation (PTNS/SNS)
Surgical : augmentation custoplasty + urinary diversion
56
Q

What is overflow incontinence?

A

Involuntary leakage of urine when bladder is full

Usually due to chronic retention, secondary to obstruction or an atonic bladder

57
Q

What can cause overflow incontinence?

A

Outlet obstruction (faecal impaction/BPH) Underactive detrusor muscle
Bladder neck stricture
Urethral stricture
DHx-alpha adrenergics, anticholinergics, sedative
Bladder denervation following surgery

58
Q

What is continuous incontinence?

A

Continuous loss of urine all the time

59
Q

What can cause continuous incontinence?

A
Vesicovaginal fistula (fistula between bladder and vagina)
Ectopic ureter (from kidney to urethra or vagina)
60
Q

What is functional incontigence?

A

Bladder function is normal but unable to functinally use the toilet in time to urinate

61
Q

What can cause functinal incontinence?

A

Severe cognitive impairment

Mobility limitations

62
Q

What is mixed incontinence?

A

More than 1 type, usually seen in older patients

63
Q

What is benign prostatic hyperplasia?

A

Non malignant growth or hyperplasia of prostate tissue

Common cause of lower urinary tract symptoms in men

64
Q

What is the incidence of BPH?

A

Increases with advancing age
50%-60% for males in their 60s
80%-90% for those over 70

65
Q

What are the risk factors for BPH?

A

Hormonal effects of testosterone on prostate tissue

66
Q

What is the pathology of BPH?

A

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

67
Q

What are signs + symptoms of BPH?

A
  • hesitancy in starting urination
  • poor stream
  • dribbling post micturition
  • frequency, nocturia
  • can present with acute retention
68
Q

What other conditons can cause similar signs and symptoms to BPH?

A
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
69
Q

What can exclude other causes of BPH symptoms?

A

Abdominal, pelvic + rectal examination

Urethra / bladder / rectum / prostate / sphincter

70
Q

What can be done to investigate BPH?

A
Urine dipstick / MCS
post-void residual
Voiding Diary
Flow studies / urodynamics
Cystoscopy if concerned about cancer
Bloods
Imaging
71
Q

What bloods can be done to investigate BPH?

A

PSA levels can predict prostate volume

Use with caution, especially if concerned about prostate cancer

72
Q

What imaging can be done to investigate BPH?

A

Ultrasound to assess upper renal tracts

73
Q

How do you manage BPH in terms of lifestyle?

A

Weight loss
Reduces caffeine + fluid intake in the evening
Avoid constipation

74
Q

How do you manage BPH medically?

A

Alpha blockers

5-alpha reductase inhibitors

75
Q

How do alpha blockers help with BPH?

A

Alpha 1 AR present on prostate stromal smooth muscle + bladder neck
Blockage of receptors results in relaxation, thus improving urinary flow rate

76
Q

How 5-alpha reductase inhibitors help with BPH?

A

Prevents conversion of testosterone to DHT (which promotes growth + enlargement of prostate) so results in shrinkage, thereby improving urinary flow rate and obstructive symptoms

77
Q

How can BPH be managed surgically?

A

Transurethral resection of the prostate (TURP)

This debulks prostate to produce adequate channel for urine to flow

78
Q

What are some complications of BPH?

A

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