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BRS UROLOGY & RENAL > 1b// Urinary Incontinence and Urinary Tract Symptoms > Flashcards

1b// Urinary Incontinence and Urinary Tract Symptoms Flashcards

1
Q

How long are ureters and what is their diameter

A

25cm long and 3mm diameter

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2
Q

What are the layers of the ureters?

A

Ureters 3 layers of tissue-outer fibrous tissue, middle
muscle layer and inner epithelium layer.

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3
Q

What is the blood supply of the urinary tract?

A

renal/lumbar/gonadal/common iliac,
internal iliac and superior vesical arteries with corresponding venous drainage.

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3
Q

What is the nerve supply of the urinary tract?

A

autonomic nervous system

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3
Q

Where does the ureter reach?

A

L1 to sacroiliac joint

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4
Q

What are the lymphatics of the urinary tract?

A

left ureter drains into left para-aortic nodes
right ureter drains into right paracaval
interaortocaval lymph nodes

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5
Q

What is the placement of the organs in the urinary tract?

A

Kidneys are retroperitoneal.

Ureters descend in front of the tips of transverse spinous processes, cross sacro-iliac joint, then forwards next to rectum/ vagina.

Bladder is anterior in pelvis.

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6
Q

What are the anatomical variations in kidneys that can be found?

A

Single kidney (1% of the population)
Horse-shoe kidney
Ectopic kidney

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7
Q

What are the anatomical variations in ureters that can be found?

A

Partial duplication
Complete duplication

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8
Q

Where are the hold up points in the ureter?

A

Constriction points may block urine flow, especially if a kidney stone dislodges and becomes a ureteric stone (pain, ipsilateral impaired renal function):

Where the renal pelvis joins the top of the ureter- pelvic ureteric junction (PUJ, or UPJ)

Pelvic brim, crossing the iliac vessels

As it passes through the bladder wall; uretero-vesical junction (UVJ, or VUJ)

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9
Q

Where is the urinary bladder when filled and not filled?

A

Urinary bladder is the reservoir of urine. Detrusor muscle, lined with waterproof urothelium- a transitional epithelium

When empty, bladder is in the pelvis, when distended it is an abdomino-pelvic organ.

An 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 infero-lateral surfaces and a superior surface.

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10
Q

What is the blood supply of the urinary 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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11
Q

What are the lymphatics of the urinary bladder?

A

internal iliac nodes and then paraaortic nodes

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12
Q

What is the nerve supply of the urinary bladder?

A

autonomic nervous system

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13
Q

What is the female urinary tract: bladder outlet like?

A

Urethra carries urine from bladder to the external urethral meatus in the vaginal vestibule. 3-4cm long.

External urethral sphincter- skeletal muscle, tonic contraction and also voluntary “guarding”. Controlled by pudendal nerve.

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14
Q

What is the blood supply for female urinary tract?

A

internal pudendal arteries and inferior vesical branches of the vaginal arteries with corresponding venous drainage.

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15
Q

What is the lymphatic supply for female urinary tract?

A

proximal urethra into internal iliac nodes, distal urethra to superficial inguinal lymph nodes.

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16
Q

What is the nerve supply for the female urinary tract?

A

vesical plexus (proximal), pudendal nerve (distal).

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17
Q

What is the male urinary tract: bladder outlet like?

A

The bladder neck; a sphincter which stays shut except when voiding. Controlled by the sympathetic nervous system.

Prostate gland; 4x3x2cm, conical shape, 2 (lateral) lobes, surrounds the proximal urethra. Secretes 75% of the seminal fluid which liquifies coagulated semen after deposition in the female genital tract.

External urethral sphincter- tonic contraction/ guarding. Opens for ejaculation. Controlled by pudendal nerve.

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18
Q

What is the blood supply for male urinary tract?

A

prostate- inferior vesical artery, urethra- bulbourethral artery and internal pudendal artery with corresponding venous drainage.

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19
Q

What is the lymphatic supply for male urinary tract?

A

prostatic and membranous urethra drain to obturator and internal iliac nodes, spongy urethra to deep and superficial inguinal nodes.

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20
Q

What is the nerve supply for the male urinary tract?

A

vesical plexus (proximal), pudendal nerve (distal).

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21
Q

What is involved in the micturition cycle?

A

storage –><– voiding

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22
Q

What is the storage aspect of micturition?

A

Bladder relaxed, serving as reservoir.

Outlet contracted, preventing leaks.

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23
Q

What is the voiding aspect of micturition?

A

Bladder contracting, expelling the urine.

Outlet relaxed, permitting flow.

Bladder should empty fully (<50 ml “post void residual”).

6 pees daily, 20 secs each means 2 mins per day spent voiding.

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24
Q

What is the neural control of micturition (summary)?

A

Prefrontal cortex permits the pontine micturition centre in the brainstem to change from storage mode to voiding.

This activates the parasympathetic nucleus (bladder contraction), and inhibits Onuf’s nucleus (sphincter relaxation)

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25
Q

What may men say when they have a problem with their ureter?

A

testicular pain

26
Q

What is micturition like in children?

A

In infants, micturition is a local spinal reflex in which bladder empties on reaching a critical pressure.

27
Q

How can voiding of micturition be inhibited or initiated?

A

In adults, voiding can be initiated or inhabited by higher centre control of the external urethral sphincter keeping it closed until it is appropriate to urinate

28
Q

Where are the areas of the brain involved with the physiology of micturition?

A

Frontal cortex
Pontine micturition centre (PMC)
Limbic cortex
Periaqueductal gray (PAG)
Thoracic spinal cord
Sacral spinal cord
Anterior cingulate gyrus

29
Q

What does the frontal cortex do for micturition?

A

Decides actions based on planning ahead, social appropriateness, etc,

30
Q

What does the Pontine micturition centre (PMC) do for micturition?

A

Co-ordinates spinal centres; storage switches to voiding only if permitted

31
Q

What does the limbic cortex do for micturition?

A

Emotional and fear reactions

32
Q

What does the Periaqueductal gray (PAG) do for micturition?

A

Receives sensory information from viscera (subconscious), decides what goes to cortex (conscious sensation)

33
Q

What does the Thoracic spinal cord do for micturition?

A

Sympathetic nucleus (bladder neck)

34
Q

What does the sacral spinal cord do for micturition?

A

Parasympathetic nucleus (detrusor)
Onuf’s nucleus (sphincter)

35
Q

What are the pelvic organ nerve supplies?

A

ureter and bladder in plexiform arrangement

plexiform around rectum

36
Q

What are the autonomic receptor drug targets for micturition?

A

bladder neck
detrusor
erectile

37
Q

What are the drug targets and drug for the bladder neck and example drugs?

A

α-adrenergic (α-1)- alpha blocker, eg tamsulosin

38
Q

What are the drug targets and drug for the detrusor and example drugs?

A

Cholinergic M3/ M2. Antimuscarinic,
eg oxybutynin, solifenacin

β-adrenergic β-3 agonist eg mirabegron

39
Q

What is the drug for the erectile and example drugs?

A

nitrergic. PDE5 inhibitor

40
Q

Why does bowel disease also cause urinary problems?

A

e.g., it can cause excessive urination

because there is also sensory innervation e.g., if with IBD there is hot rectum= more pee

41
Q

What is the definition of incontinence?

A

any involuntary loss of urine

42
Q

What is stress urinary incontinence?

A

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

43
Q

What are the risk factors of stress urinary incontinence?

A

aging, obesity, smoking, pregnancy and route of delivery (guarding reflex is gone)

44
Q

What is the pathology of stress urinary incontinence?

A

impaired bladder and urethral support and impaired urethral closure

45
Q

What are the signs and symptoms of stress urinary incontinence?

A

Involuntary leakage from urethra with exertion/effort or sneezing or coughing.

46
Q

What are the investigations for stress urinary incontinence?

A

History and examination; descent of pelvic floor on vaginal examination, positive stress test (visible loss of urine on inspection).

Urodynamics-urinary leakage during an increase in intrabdominal pressure in the absence of a detrusor contraction.

47
Q

What is the management of stress urinary incontinence?

A

Non-surgical: physiotherapist teaching pelvic floor muscle exercises.

Surgical: a sling placed to support the urethra, using the anterior vaginal wall to support the urethra (colposuspension), periurethral bulking injection

48
Q

What is this showing?

A

Urodynamics test in the storage phase, showing stress incontinence - 3 big coughs causing 2 spikes of urine flow (there should be no urine flow during storage)

49
Q

What is overactive bladder?

A

urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence

50
Q

What are the risk factors of overactive bladder?

A

age, prolapse, increased BMI, bladder irritants (caffeine, nicotine)

51
Q

What is the pathology of overactive bladder?

A

not well understood. Involuntary “overactive” detrusor (bladder wall) muscle contractions. Cause can be idiopathic or neurogenic (loss of central nervous system inhibitory pathways)

52
Q

What is this?

A

Urodynamics test in the storage phase, showing 4 episodes of detrusor overactivity (detrusor should be inactive) with incontinence (there should be no urine flow during storage)

53
Q

What are the signs and symptoms of overactive bladder?

A

urgency, frequency, nocturia and urgency incontinence. Impact on QOL due to sleep disruption, anxiety and depression. Assess for enlarge prostate in males and prolapse in women

54
Q

What are the investigations for overactive bladder?

A

exclude infection with urine dip/MSU

Bladder diary

Bladder scan (post void residual)

[Urodynamics]

55
Q

What is the management for overactive bladder?

A

Behavioural/lifestyle changes

Bladder retraining

Antimuscarinic drugs

Beta-3 agonist

Bladder injections with botox

Neuromodulation

Augmentation cystoplasty

56
Q

What is benign prostatic hyperplasia?

A

non malignant growth or hyperplasia of prostate tissue, common cause of lower urinary tract symptoms in men. Outward enlargement can be felt with rectal exam.

57
Q

What are the risk factors for benign prostatic hyperplasia?

A

hormonal effects of testosterone on prostate tissue

58
Q

How does prostate enlargement affect urinary output?

A

Enlargement of the prostate due to hypertrophy can compress the urethra–>

leading to a reduction in the urinary stream. Some men experience relatively little urethral compression, as the prostate enlargement goes outwards–>

(into the rectum) rather than inwards

59
Q

What is the pathology of benign prostatic enlargement?

A

hyperplasia of both lateral lobes and the median lobe, leading to compression of the urethra and therefore bladder outflow obstruction. See hyperplasia of the stroma (smooth muscle and fibrous tissue) and glands

60
Q

What are the signs and symptoms of benign prostatic hyperplasia?

A

hesitancy in starting urination
poor stream
dribbling post micturition
can present with acute retention

61
Q

What are the investigations for benign prostatic enlargement?

A

Investigations: urine dipstick/ culture, post void residual, bladder diary

Bloods: PSA

Imaging: ultrasound to assess upper renal tracts

Urinary flow studies/urodynamics

Cystoscopy if concerned about bladder cancer

62
Q

What are the complications that can come from benign prostatic hyperplasia?

A
63
Q

What is the management of benign prostatic hyperplasia?

A

BRS UROLOGY & RENAL (10 decks)

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