Urogynaecology Flashcards
1
Q
How long are the ureters?
A
30cm
2
Q
What type of muscle makes up the ureters?
A
Smooth muscle
3
Q
What cell type is the ureter lined with?
A
Transitional cell eipthelium
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
5
Q
What is the arterial supply to the ureters?
A
Renal artery
Common iliac artery
Internal iliac artery –> superior and inferior vesical artery
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
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
8
Q
What is the nerve supply of the ureters?
A
Renal, aortic and hypogastric nerve plexuses
9
Q
What is the normal bladder capcity?
A
400-600ml
10
Q
At what bladder volume does the urge to void occur from?
A
150ml
11
Q
What cell lines the bladder?
A
Transitional cell epithelium
12
Q
What are the layers of the bladder?
A
1) Mucosa
2) Submucosa
3) Detrusor
4) Adventitia
13
Q
What are the different parts of the bladder?
A
Apex
Body
Fundus
Neck
14
Q
What connects the apex and the umbilicus?
A
Median umbilical ligament (urachus)
15
Q
Where is the internal urethral sphincter found?
A
The bladder neck
Circular muscle
Contraction is responsible for continence (and ejaculation in males)
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)
17
Q
What is the venous supply of the bladder?
A
Vesicovenous plexus
18
Q
What are the lymph nodes draining the bladder?
A
Common, internal and external iliac LNs
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)
20
Q
What is the sympathetic supply to the bladder?
A
Hypogastric nerve
T12-L2
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
22
Q
What is the parasympathetic supply to the bladder?
A
Pelvic nerve
S2-S4
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”
24
Q
How long is the female urethra?
A
4cm
25
What is the arterial/venous supply of the female urethra?
Internal pudendal
Vaginal
26
What is the nervous supply of the female urethra?
Vesicle plexus
Pudendal nerve (somatic control)
27
What type of epithelium line the female urethra?
Stratified columnar epithelium
28
What mucous glands, found at the distal end of the female urethra, are homologous for the male prostate?
Skene's glands
29
What are the layers of the urethra?
OUTER - striated muscle layer
MIDDLE - smooth muscle layer
INNER mucosal and submucosal layer
30
What muscles make up the female pelvic floor?
Coccygeus + levator ani (puborectalis; pubococcygeus; iliococcygeus)
31
What are the different parts of the levator ani?
1. Puborectalis
2. Pubococcygeus
3. Iliococcygeus
32
Which muscle is most important in maintaining female urinary continence?
Pubococcygeus
33
Which muscle is most important in maintaining female faecal continence?
Puborectalis - forms the urogenital hiatus
34
The perineal nerve is a branch of what nerve?
Pudendal nerve
35
The perineal nerve provides motor function for which muscles?
Bulbospongiosus
Ischiocavernosus
Levator ani: iliococcygeus, pubococcygeus, puborectalis
External urethral sphincter
36
The perineal nerve provides sensory function for which structures?
Perineal skin
Labia minora/majora
Posterior scrotum
37
How long is the urethra in men?
18-22cm
38
What are the different parts of the male urethra?
Intramural (pre-prostatic)
Prostatic
Membranous
Spongey
39
In which part of the urethra do the prostatic and ejaculatory ducts open into?
Prostatic urethra
40
The ejaculatory ducts form from a combination of what?
Ductus deferens
Seminal glands
41
What is the widest part of the male urethra?
Prostatic urethra
42
What is the narrowest part of the male urethra?
Membranous urethra
43
In which part of the male urethra is the external urethral sphincter found?
Membranous urethra
44
What is the longest part of the male urethra?
Spongey urethra
45
In what part of the male urethra do the bulbourethral glands empty into?
Spongey urethra
46
In which part of the male urethra is transitional epithelium found?
Pre-prostatic and prostatic urethra
47
In which part of the male urethra is pseudostatified columnar epithelium found?
Membranous and spongey urethra
48
What type of epithelium is found at the penile meatus?
Stratified squamous epithelium
49
What is the arterial/venous supply of the male urethra?
Inferior vesicular
Middle rectal
Dorsal artery to the penis
50
What is the nervous supply of the male urethra?
Prostatic nerve plexus
Pudendal nerve (somatic control)
51
What level of the brain can over-ride the micturition or sympathetic storage reflexes?
Pons
52
Describe the guarding reflex:
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
What is the most common type of prolapse?
Anterior wall prolapse (cystocele)
54
How often should a pessary be replaced?
6-monthly
55
What measurements are taken in a POP-Q?
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
What are the measurement you might expect on a POP-Q with no prolapse?
-3 / -3 / -8
2 / 3 / 10
-3 / -3 / -10
57
What is a POP-Q Stage 1 prolapse?
The most proximal portion of prolapse is greater than 1 cm above the level of the hymen
58
What is a POP-Q Stage 2 prolapse?
The most proximal portion of prolapse is found between 1 cm higher than hymen and 1cm beneath hymen
59
What is a POP-Q Stage 3 prolapse?
The most distal part of the prolapse extends more than 1cm beneath the hymen but no further than 2 cm
60
What is a POP-Q Stage 4 prolapse?
Vaginal eversion has taken place or eversion to with 2cm of TVL
61
What type of drug is oxybutynin?
Anticholinergic - non-selective muscarinic receptor antagonist (M1, M2 and M3 receptors)
62
The intended MOA for oxybutynin is on which receptor?
M3 - M3 receptor antagonism inhibits detrusor muscle contraction allowing the bladder longer filling time and reducing urgency/incontinence symptoms
63
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?
M1 receptor antagonism causes confusion, reduced cognition and delirium
M2 receptor antagonism causes cardiovascular side effects such as tachycardia, hypertension, arrhythmia
64
What type of drug is solifenacin?
Anticholinergic - competitive muscarinic receptor antagonist
65
What is the MOA of solifenacin?
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
What type of drug is duloxetine?
Serotonin-noradrenaline re-uptake inhibitor
67
What is the MOA of duloxetine?
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
What is the standard dose of duloxetine?
20-40mg BD
69
What type of drug is mirabegron?
Selective beta-3 adrenergic agonist
70
What is the MOA of mirabegron?
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
What type of drug is tolteradine?
Anticholinergic - non-selective muscarinic receptor antagonist
72
What is the MOA of tolteradine?
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
What is the review/follow-up period after starting a medication for OAB?
4 weeks
74
What is the anticholinergic burden (ACB) calculator?
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
What is the biggest risk factor for developing urinary incontinence?
Increasing age
76
What are the layers of the detrusor?
OUTER - longitudinal
MIDDLE - circular
INNER
77
For how long should a bladder diary be kept?
3 days (min 3 days according to NICE)
78
What type of muscle is the detrusor?
Smooth muscle
79
What are the different types of incontinence?
Stress urinary incontinence - 37%
Urge urinary incontinence - 20%
Mixed urinary incontinence - 33%
Other - overflow incontinence, fistula, urethral diverticulum
80
What are the causes of stress urinary incontinence?
Urethral hypermobility
Intrinsic sphincter deficiency
(often a combination of both)
81
What are the risk factors for stress urinary incontinence?
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
A residual bladder volume of what is abnormal?
>100ml
83
For what presentations are urodynamics indicated?
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
How is urodynamics carried out?
- 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
What would you expect to see on urodynamics with detrusor overactivity causing urge incontinence?
At times of peaking intravesical pressure (Pves), when leakage occurs, detrusor pressure (Pdet) will also peak, but intra-abdominal pressure (Pabd) will not
86
What would you expect to see on urodynamics when actually stress incontinence is implicated?
At times of peaking intravesical pressure (Pves), when leakage occurs, detrusor pressure (Pdet) will NOT rise, but intra-abdominal pressure (Pabd) WILL
87
What are the lifestyle recommendations for urinary incontinence?
Caffeine reduction (OAB)
Modify fluid intake accordingly
Lose weight if BMI >30 (UI or OAB)
88
What is the minimum course for pelvic floor muscle training (stress of mixed incontinence)?
12 weeks - 8 contractions TDS
(16 weeks with prolapse)
89
What is the minimum time period for which bladder training should be offered (urgency or mixed)?
6 weeks
90
What are the first-line treatments for overactive bladder?
Oxybutynin (not in frail elderly)
Tolterodine
Darifenacin
91
What are the second-line treatments for overactive bladder?
Mireabegron
92
What are the adjuvant treatments for overactive bladder?
Desmopressin (if nocturia)
Duloxetine (if not suitable for surgery)
93
What are the invasive treatment options for OAB?
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
What is the F/U period for augmentation cystoplasty and urinary diversion?
Lifelong F/U
95
What are some of the risks/complications associated with augmentation cystoplasty?
- 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
What are the invasive treatment options for SUI?
Colposuspension (open or laparoscopic)
Autologous rectus fascial sling
Retropubic mid-urethral mesh sling
Intramural bulking agents
97
What may be offered for stress incontinence where previous surgery ahas failed?
Artificial urinary sphincters
98
What medications can exacerbate bladder symptoms?
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
