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Part 1 MFSRH 2024 > Urogynaecology > Flashcards

Urogynaecology Flashcards

1
Q

How long are the ureters?

A

30cm

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2
Q

What type of muscle makes up the ureters?

A

Smooth muscle

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3
Q

What cell type is the ureter lined with?

A

Transitional cell eipthelium

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4
Q

What is the journey of the ureter from the kidney to bladder?

A

Descends over medial aspect of psoas major, crossed by ovarian artery

Crosses bifurcation of common iliac artery, to enter pelvic retroperitoneally

Crosses behind the ovarian fossa, in close proximity to the internal iliac artery - peristalsis visible at this point (vermiculation)

Descends further, crossed by infundibulopelvic ligament, and then underneath the broad ligament

Uterine artery crosses over ureter, 1-2 cm lateral from the internal os of the cervix (water under the bridge)

Passes through cardinal ligament, before entering the trigone of bladder

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5
Q

What is the arterial supply to the ureters?

A

Renal artery
Common iliac artery
Internal iliac artery –> superior and inferior vesical artery

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6
Q

What is the venous supply to the ureters?

A

Renal veins draining the upper ureters, and the vesicular and gonadal veins draining the lower ureters

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7
Q

What is the lymph node supply to the ureters?

A

Aortic nodes
Right paracaval and interaortocaval nodes
Left paraaortic nodes
Common/internal/external iliac nodes

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8
Q

What is the nerve supply of the ureters?

A

Renal, aortic and hypogastric nerve plexuses

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9
Q

What is the normal bladder capcity?

A

400-600ml

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10
Q

At what bladder volume does the urge to void occur from?

A

150ml

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11
Q

What cell lines the bladder?

A

Transitional cell epithelium

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12
Q

What are the layers of the bladder?

A

1) Mucosa
2) Submucosa
3) Detrusor
4) Adventitia

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13
Q

What are the different parts of the bladder?

A

Apex
Body
Fundus
Neck

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14
Q

What connects the apex and the umbilicus?

A

Median umbilical ligament (urachus)

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15
Q

Where is the internal urethral sphincter found?

A

The bladder neck
Circular muscle
Contraction is responsible for continence (and ejaculation in males)

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16
Q

What is the arterial supply to the bladder?

A

Superior vesical artery
Inferior vesical artery
Additional supply from vaginal and uterine arteries (females)

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17
Q

What is the venous supply of the bladder?

A

Vesicovenous plexus

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18
Q

What are the lymph nodes draining the bladder?

A

Common, internal and external iliac LNs

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19
Q

The sympathetic nervous system has what effect on the bladder?

A

Relaxation of detrusor muscle
Contraction of the internal urethral sphincter

Therefore STORAGE
Sympathetic = ‘fight or flight’ (don’t pee yourself when fighting or running)

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20
Q

What is the sympathetic supply to the bladder?

A

Hypogastric nerve
T12-L2

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21
Q

The parasympathetic nervous system has what effect on the bladder?

A

Contraction of the detrusor muscle
Relaxation of the internal urethral sphincter

Therefore PEEING
Parasympathetic = peeing

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22
Q

What is the parasympathetic supply to the bladder?

A

Pelvic nerve
S2-S4

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23
Q

Which nerve controls the external urethral sphincter and therefore voluntary control of bladder?

A

Pudendal nerve
S2-S4

“PUDendal = no PUDdle”
“S2-S4 keeps pee off the floor”

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24
Q

How long is the female urethra?

A

4cm

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25
Q

What is the arterial/venous supply of the female urethra?

A

Internal pudendal
Vaginal

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26
Q

What is the nervous supply of the female urethra?

A

Vesicle plexus
Pudendal nerve (somatic control)

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27
Q

What type of epithelium line the female urethra?

A

Stratified columnar epithelium

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28
Q

What mucous glands, found at the distal end of the female urethra, are homologous for the male prostate?

A

Skene’s glands

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29
Q

What are the layers of the urethra?

A

OUTER - striated muscle layer
MIDDLE - smooth muscle layer
INNER mucosal and submucosal layer

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30
Q

What muscles make up the female pelvic floor?

A

Coccygeus + levator ani (puborectalis; pubococcygeus; iliococcygeus)

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31
Q

What are the different parts of the levator ani?

A
  1. Puborectalis
  2. Pubococcygeus
  3. Iliococcygeus
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32
Q

Which muscle is most important in maintaining female urinary continence?

A

Pubococcygeus

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33
Q

Which muscle is most important in maintaining female faecal continence?

A

Puborectalis - forms the urogenital hiatus

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34
Q

The perineal nerve is a branch of what nerve?

A

Pudendal nerve

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35
Q

The perineal nerve provides motor function for which muscles?

A

Bulbospongiosus
Ischiocavernosus
Levator ani: iliococcygeus, pubococcygeus, puborectalis
External urethral sphincter

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36
Q

The perineal nerve provides sensory function for which structures?

A

Perineal skin
Labia minora/majora
Posterior scrotum

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37
Q

How long is the urethra in men?

A

18-22cm

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38
Q

What are the different parts of the male urethra?

A

Intramural (pre-prostatic)
Prostatic
Membranous
Spongey

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39
Q

In which part of the urethra do the prostatic and ejaculatory ducts open into?

A

Prostatic urethra

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40
Q

The ejaculatory ducts form from a combination of what?

A

Ductus deferens
Seminal glands

41
Q

What is the widest part of the male urethra?

A

Prostatic urethra

42
Q

What is the narrowest part of the male urethra?

A

Membranous urethra

43
Q

In which part of the male urethra is the external urethral sphincter found?

A

Membranous urethra

44
Q

What is the longest part of the male urethra?

A

Spongey urethra

45
Q

In what part of the male urethra do the bulbourethral glands empty into?

A

Spongey urethra

46
Q

In which part of the male urethra is transitional epithelium found?

A

Pre-prostatic and prostatic urethra

47
Q

In which part of the male urethra is pseudostatified columnar epithelium found?

A

Membranous and spongey urethra

48
Q

What type of epithelium is found at the penile meatus?

A

Stratified squamous epithelium

49
Q

What is the arterial/venous supply of the male urethra?

A

Inferior vesicular
Middle rectal
Dorsal artery to the penis

50
Q

What is the nervous supply of the male urethra?

A

Prostatic nerve plexus
Pudendal nerve (somatic control)

51
Q

What level of the brain can over-ride the micturition or sympathetic storage reflexes?

A

Pons

52
Q

Describe the guarding reflex:

A

Initiated when one laughs, sneezes, or coughs, which causes increased bladder pressure. Glutamate = primary excitatory transmitter for the reflex.
Glutamate activates NMDA and AMPA receptors which produce action potentials at Onuf’s nucleus (origin of pudendal nerve)
These action potentials activate the release of acetylcholine causing the external urethral sphincter to contract

53
Q

What is the most common type of prolapse?

A

Anterior wall prolapse (cystocele)

54
Q

How often should a pessary be replaced?

A

6-monthly

55
Q

What measurements are taken in a POP-Q?

A

Ant wall (Aa)/Ant wall (Ba)/Cervix or cuff (C)

Genital hiatus (gh)/Perineal body (pb)/(TVL)

Post wall (Ba)/Post wall (Bp)/Post fornix

56
Q

What are the measurement you might expect on a POP-Q with no prolapse?

A

-3 / -3 / -8
2 / 3 / 10
-3 / -3 / -10

57
Q

What is a POP-Q Stage 1 prolapse?

A

The most proximal portion of prolapse is greater than 1 cm above the level of the hymen

58
Q

What is a POP-Q Stage 2 prolapse?

A

The most proximal portion of prolapse is found between 1 cm higher than hymen and 1cm beneath hymen

59
Q

What is a POP-Q Stage 3 prolapse?

A

The most distal part of the prolapse extends more than 1cm beneath the hymen but no further than 2 cm

60
Q

What is a POP-Q Stage 4 prolapse?

A

Vaginal eversion has taken place or eversion to with 2cm of TVL

61
Q

What type of drug is oxybutynin?

A

Anticholinergic - non-selective muscarinic receptor antagonist (M1, M2 and M3 receptors)

62
Q

The intended MOA for oxybutynin is on which receptor?

A

M3 - M3 receptor antagonism inhibits detrusor muscle contraction allowing the bladder longer filling time and reducing urgency/incontinence symptoms

63
Q

Because oxybutynin is non-selective, by also acting on the M1 and M2 receptors (as well as the intended M3 receptors) what side effects does it have?

A

M1 receptor antagonism causes confusion, reduced cognition and delirium

M2 receptor antagonism causes cardiovascular side effects such as tachycardia, hypertension, arrhythmia

64
Q

What type of drug is solifenacin?

A

Anticholinergic - competitive muscarinic receptor antagonist

65
Q

What is the MOA of solifenacin?

A

Selective for the M3 receptor (G protein-coupled receptor)

Acetylcholine normally activates M3 receptors located on the detrusor to cause smooth muscle contraction

Blockade of the M3 receptor inhibits detrusor muscle contraction allowing the bladder longer filling time and reducing urgency/incontinence symptoms

66
Q

What type of drug is duloxetine?

A

Serotonin-noradrenaline re-uptake inhibitor

67
Q

What is the MOA of duloxetine?

A

Increased availability of serotonin and noradrenaline within Onuf’s nucleus

This increases motor neuron activation of the striated muscle of the external urethral sphincter

Increased sphincter tone improves continence during sudden increases in intrabdominal pressure

68
Q

What is the standard dose of duloxetine?

A

20-40mg BD

69
Q

What type of drug is mirabegron?

A

Selective beta-3 adrenergic agonist

70
Q

What is the MOA of mirabegron?

A

Activation of beta-3 receptors on the detrusor results in smooth muscle relaxation

Acetylcholine normally activates M3 receptors located on the detrusor to cause smooth muscle contraction

This allows the bladder longer filling time and reducing urgency/incontinence symptoms

71
Q

What type of drug is tolteradine?

A

Anticholinergic - non-selective muscarinic receptor antagonist

72
Q

What is the MOA of tolteradine?

A

Predominantly antagonises the M2 and M3 receptors

M3 receptor antagonism inhibits detrusor muscle contraction allowing the bladder longer filling time and reducing urgency/incontinence symptoms

M2 receptor antagonism causes cardiovascular side effects such as tachycardia, hypertension, arrhythmia

73
Q

What is the review/follow-up period after starting a medication for OAB?

A

4 weeks

74
Q

What is the anticholinergic burden (ACB) calculator?

A

The ACB calculator generates a score based on the patients medications which reflects the anticholinergic burden

A score of 3 or more is associated with increased cognitive impairment and mortality

75
Q

What is the biggest risk factor for developing urinary incontinence?

A

Increasing age

76
Q

What are the layers of the detrusor?

A

OUTER - longitudinal
MIDDLE - circular
INNER

77
Q

For how long should a bladder diary be kept?

A

3 days (min 3 days according to NICE)

78
Q

What type of muscle is the detrusor?

A

Smooth muscle

79
Q

What are the different types of incontinence?

A

Stress urinary incontinence - 37%​

Urge urinary incontinence - 20%​

Mixed urinary incontinence - 33%​

Other - overflow incontinence, fistula, urethral diverticulum

80
Q

What are the causes of stress urinary incontinence?

A

Urethral hypermobility
Intrinsic sphincter deficiency

(often a combination of both)

81
Q

What are the risk factors for stress urinary incontinence?

A

Increasing age - cognitive impairment; impaired mobility; polypharmacy

Parity - multi; VD; instrumental

Deficiency in supporting tissues - e.g. prolpase; menopause; connective tissue disorders

Smoking

Obesity

Constipation

82
Q

A residual bladder volume of what is abnormal?

A

> 100ml

83
Q

For what presentations are urodynamics indicated?

A
  1. Urge-predominant mixed urinary incontinence or urinary incontinence in which the type is unclear
  2. Symptoms suggestive of voiding dysfunction
  3. Anterior or apical prolapse
  4. A history of previous surgery for stress urinary incontinence
84
Q

How is urodynamics carried out?

A
  • 2 catheters in bladder, 1 for filling, 1 for measuring bladder pressure. Rectal catheter to measure intra-abdo pressure
  • Bladder filled 50 ml/min with saline
  • As it fills, bladder pressure catheter measures intravesical pressure (Pves) while rectal pressure catheter measures intra-abdo pressure (Pabd). - – Detrusor pressure (Pdet) can be calculated by subtracting Pabd from Pves (Pves – Pabd = Pdet)
85
Q

What would you expect to see on urodynamics with detrusor overactivity causing urge incontinence?

A

At times of peaking intravesical pressure (Pves), when leakage occurs, detrusor pressure (Pdet) will also peak, but intra-abdominal pressure (Pabd) will not

86
Q

What would you expect to see on urodynamics when actually stress incontinence is implicated?

A

At times of peaking intravesical pressure (Pves), when leakage occurs, detrusor pressure (Pdet) will NOT rise, but intra-abdominal pressure (Pabd) WILL

87
Q

What are the lifestyle recommendations for urinary incontinence?

A

Caffeine reduction (OAB)
Modify fluid intake accordingly
Lose weight if BMI >30 (UI or OAB)

88
Q

What is the minimum course for pelvic floor muscle training (stress of mixed incontinence)?

A

12 weeks - 8 contractions TDS
(16 weeks with prolapse)

89
Q

What is the minimum time period for which bladder training should be offered (urgency or mixed)?

A

6 weeks

90
Q

What are the first-line treatments for overactive bladder?

A

Oxybutynin (not in frail elderly)
Tolterodine
Darifenacin

91
Q

What are the second-line treatments for overactive bladder?

A

Mireabegron

92
Q

What are the adjuvant treatments for overactive bladder?

A

Desmopressin (if nocturia)
Duloxetine (if not suitable for surgery)

93
Q

What are the invasive treatment options for OAB?

A

Botox (type A) injection - where urodynamics shows detrusor overactivity to be the cause of OAB - 100 units initial dose

Percutanous sacral nerve stimulation (where botox has not worked.not willing to accept risk of ned for cathter use with botox)

Augmentation cystoplasty - for idiopathic detrusor overactivity. Restricted use - no response to non-surgical methods, willing to self-catherterise

Urinary diversion - again, restricted use. Only when non-surgical management = no response, and Botox/nerve stimulation and augmentation cystoplasty no appropriate/acceptable.

94
Q

What is the F/U period for augmentation cystoplasty and urinary diversion?

A

Lifelong F/U

95
Q

What are some of the risks/complications associated with augmentation cystoplasty?

A
  • Bowel disturbance
  • Metabolic acidosis
  • Mucus production and/or retention in the bladder
  • UTI
  • Urinary retention
  • Small risk of malignancy occurring in the augmented bladder
96
Q

What are the invasive treatment options for SUI?

A

Colposuspension (open or laparoscopic)

Autologous rectus fascial sling

Retropubic mid-urethral mesh sling

Intramural bulking agents

97
Q

What may be offered for stress incontinence where previous surgery ahas failed?

A

Artificial urinary sphincters

98
Q

What medications can exacerbate bladder symptoms?

A

Diuretics – increase urine production - OAB

Alpha blockers (Doxazocin) – relax smooth muscle of bladder neck – SUI

ACE inhibitors – cause cough – exacerbate SUI

Sedatives (diazepam, haloperidol) – impair cognition and mobility - increase OAB

Opiates and amitriptyline – urinary retention

Part 1 MFSRH 2024 (20 decks)

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