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Flashcards in Lectures Deck (97):
1

Normal function of LUT

Convert a continuous process of excretion (urine production) to an intermittent process of elimination.
Store urine insensibly
Void urine when convenient

2

Which of these are True or False:
Detrusor muscle Relaxes during Voiding
Distal sphincter contracts during storage

Detrusor = False:
Relaxes during storage (compliant)
Contracts during voiding

Distal sphincter = True:
Relaxes during voiding

3

What nerve roots drive detrusor contraction

Parasympathetic (cholinergic) S2-4

4

What nerve roots drive sphincter/urethral contraction or inhibit detrusor contraction

Sympathetic (noradrenergic) T10-L2

5

Types of LUTS (lower urinary tract symptoms)

Storage
Voiding

6

Examples of LUTS storage symptoms

Frequency
Nocturia
Urgency
Urgency Incontinence

7

Examples of LUTS voiding symptoms

Hesitancy
Straining
Poor-intermittent stream
Incomplete emptying
Post-micturition dribbling

Haematuria
Dysuria

8

What does BPH stand for

Benign Prostatic Hyperplasia

9

BPE stand for

Benign Prostatic Enlargement

10

BOO stand for

Bladder Outflow Obstruction

11

Epidemiology of BPH - Benign Prostatic Hyperplasia

Common in men (more with age)
-23% of men aged 41 to 50 yrs
-42% of men aged 51 to 60 yrs
-71% of men aged 61 to 70 yrs
-82% of men aged 71 to 80 yrs

12

What is BPH

Increase in epithelial and stromal cell numbers in the periurethral area of the prostate

13

Causes of BPH

Increase in cell number
Decrease apoptosis
Combination

14

What % of area density of hyperplastic prostate is accounted for by smooth muscle

40%

15

Dynamic component of benign prostatic obstruction

alpha-1 adrenoceptor mediated prostatic smooth muscle contraction

16

Static component of benign prostatic obstruction

volume effect of BPE

17

Do androgens cause BPE?

No but are a requirement for BPH:
Castration prior to puberty or genetic diseases that inhibit androgen action or production, men do not develop BPH. Androgen withdrawal leads to partial involution of established BPH.

18

Example of scoring system for LUTS

IPSS
International Prostate Symptom Score

19

Examples of categories on IPSS (scored on how much related to you):
0-7 is mild
8-19 is moderate
20-35 is severe

Frequency
How often do you have sensation o needing to urinate
Intermittent
Urgency
Weak stream
Strain to start urination
Nocturia
Quality of Life due to symptoms

20

Examinations for LUTS

General examination i.e fitness for surgery
Abdominal examination
External genitalia
Digital rectal examination (DRE)
Focused neurological examination
Urinalysis

21

LUTS investigations

Flow rates and residual volume
Frequency volume chart
Renal biochemistry
Imaging
PSA
TRUSS – trans-rectal ultrasound scan (for size)
Flexible cystoscopy (if infection, stones, haematuria or recent onset storage symptoms)
Urodynamics

22

Prevalence of LUTS

25% of population
(48% above 65)
24% of >80 visits to GP/primary care due to LUTS
Variation between genders

23

LUT anatomy in women

Women only have urethral sphincter (along whole length of urethra) - therefore more likely to have incontinence. Support however by pelvic floor muscles (but also in men).

24

Why do women who have given birth undergo stress incontinence

Weakened pelvic floor muscles

25

LUT anatomy in men

Men have 2 sphincteric mechanisms:
Bladder neck mechanism
Distal urethral sphincter
Also have longer urethra so more resistance in male so men less likely to suffer from stress incontinence due to sphincteric deficiency - generally have opposite problem: inability to void

26

Why do men have 2 sphincters after bladder

For ejaculate

27

Role of cortex of brain for LUT

Sensation
Voluntary initiation (of urination)

28

What part of brain is responsible for Co-ordination and Completion of voiding

Pontine Micturition Centre/Peri Aqueductal Grey
(in pons)

29

Spinal reflexes affecting LUT

Reflex bladder contraction - Sacral micturition centre
Guarding reflex (prevents you pissing yourself) - Onuf's nucleus
Receptive relaxation - sympathetic (accept more urine without rise in pressure)

30

Neural control of LUT: Parasympathetic (Cholinergic) - functions and spinal roots

S3-5
Detrusor contraction
Smooth muscle sphincter relaxation
(About peeing or voiding)

31

Neural control of LUT: Sympathetic (Noradrenergic) - functions and spinal roots

T10-L2
Smooth muscle sphincter contraction
Inhibit detrusor contraction (allows bladder relaxation)

32

Neural control of LUT: Somatic

Striated sphincter contraction/relaxation (control)

33

Describe storage of bladder

99% of time
Sympathetic causes detrusor relaxation and sphincter contraction
Bladder fullness increases, messages to the pons and higher centres to consider voiding
Can be postponed until it is convenient

34

Describe voiding of bladder

1% of time
PMC co-ordinates voiding via parasympathetic causes detrusor contraction and sphincter relaxation at same time

35

Classification of LUTS

Storage
Voiding
Post-micturition

36

Classification of LUTS: Storage

Frequency
Urgency
Nocturia
Incontinence

37

Classification of LUTS: Voiding

Slow-stream
Splitting or spraying
Intermittency
Hesitancy
Straining
Terminal dribble

38

Classification of LUTS: Post-micturition

Post-micturition dribble
Feeling of incomplete emptying

39

How would you define frequent

>8 times per day or whenever feels more than normal

40

Define urinary urgency

an immediate unstoppable urge to urinate,
difficult to defer
due to a sudden involuntary contraction of the muscular wall of the bladder

41

Define Nocturia

Waking up with need to pee with intension of going back to sleep

42

Define incontinence

Inability to hold urine or involuntary loss of urine
Failure of storage

43

Parameters that can be measured by a Bladder Diary

Frequency/day
Frequency/night
Volume/day
Volume/night
Nocturnal volume/24h volume (should be <1/3)
Functional capacity
Incontinence/day

44

How much urine would an average 70kg male pass in 24 hours

~2.7 litres in 24 hours

45

Define nocturnal polyuria

Nocturnal volume/24h volume >1/3

46

What is functional capacity

How much bladder can hold
~400ml

47

Normal Frequency to urinate/day

2-8

48

Normal frequency to urinate/night

0-1

49

Normal volume to urinate/day

<2.7L (polyuria is over 2.7L)

50

Normal volume to urinate/night

<900ml

51

Normal nocturnal volume/24h volume

<1/3

52

Normal functional capacity

>400ml

53

Normal incontinence/day

0 (abnormal finding)

54

Types of incontinence

Urgency
Stress
Mixed (U+S)
Continuous
Overflow
Social

55

Urgency incontinence

Associated with an urgent desire to void which is difficult to defer

56

Stress incontinence

associated with coughing or straining

57

Cause of continuous incontinence

Fistula

58

Overflow incontinence

Occurs in presence of a full bladder

59

Social incontinence

Occurs in those with dementia

60

Define Over Active Bladder (OAB) syndrome

Urgency with frequency, with or without nocturia, when appearing in the absence of local pathology
Urgency is cardinal symptom

61

Over Active Bladder cardinal symptom

Urgency

62

Overactive Bladder Management in order

Behavioural therapy
Anti-muscarinic agents
B3 agonists
Botox
Sacral neuromodulation
Surgery

63

Overactive Bladder Management: Behavioural Therapy

Frequency volume chart
Cut caffeine, alcohol
Bladder drill - slowly train bladder to hold more by progressively increasing time before can next urinate

64

Overactive Bladder Management: Anti-muscarinic agents

Decrease parasympathetic activity by blocking M2/3 receptors but have S/E- dry mouth, constipation, vision issues

65

Overactive Bladder Management: B3 agonists

Increase sympathetic activity at B3 receptor in bladder (stop bladder itself being overactive)

66

Overactive Bladder Management: Botox (and SEs)

Blocks neuromuscular junction for Ach release
Effects last 6-9 months
S/E Incomplete bladder emptying and need to catheterise in 15%, risk of retention
Most potent toxin to humans
Daycase procedure

67

Overactive Bladder Management: Sacral neuromodulation

Insertion of electrode to S3 nerve root to modulate afferent signals from bladder

68

Overactive Bladder Management: Surgery

Augmentation cystoplasty
Involves major surgery

69

Stress incontinence in females - causes

Usually secondary to birth trauma:
-Denervation of pelvic floor and urethral sphincter
-Weakening of fascial support of bladder and urethra
Neurogenic
Congenital

70

Management of urinary stress incontinence

*Pelvic floor physiotherapy
Duloxetine (alot of SEs)
Surgery: Sling, colposuspension, bulking agents, artificial sphincter

71

Causes of stress incontinence in men

Rare
Neurogenic
Iatrogenic (prostatectomy leaving only one sphincter)

72

Examples of disease causing obstructive voiding problems

BPE (Benign Prostatic Enlargement)
Urethral stricture
Prolapse/mass

73

Management of BPE (no ED) causing obstructive problems in order (men)

Alpha blockers
5 alpha reductase inhibitor
TURP

74

Treatment of detrusor under-activity (non-obstructive)

Long term catheterisation to empty (ISC/LTC/SPC)
Sacral neuromodulation in trial phase - works in Fowlers syndrome

75

Management of BPE and ED in men in order

PDE5 inhibitor
Alpha antagonist
TURP/injections/implant

76

Management of OAB in men and women in order

Men:
Antimuscarinic
B3 agonist, Alpha antagonist
Botox

Women:
Antimuscarinic
B3 agonist
Botox

77

Management of Mixed incontinence in men in order

Alpha antagonist/muscarinic
B3 agonist
TURP/Botox

78

Management of SUI in men in order

Physiotherapy

Surgery

79

Features of spastic spinal cord injury on bladder

UMN:
Lost co-ordination and completion of voiding
Reflex bladder contractions
Detrusor sphincter dyssynergia
Poorly sustained bladder contraction

80

Features of flaccid spinal cord injury on bladder

LMN:
Loss of reflex bladder contraction, guarding reflex and receptive relaxation
Areflexic bladder
Stress incontinence
Risk of poor compliance

81

Aims of management of neurogenic bladder

Bladder safety
Continence/symptom control
Prevent autonomic dysreflexia

82

Lesions over what spinal cord level cause autonomic dysreflexia

Lesions over T6

83

What is autonomic hysreflexia

Overstimulation of sympathetic nervous system below level of lesion in response to a noxious stimulus

84

Clinical presentation of autonomic hyperreflexia

Headache
Severe hypertension
Flushing

85

Treatment via reflex bladder

1. Harness reflexes to empty bladder into
incontinence device (may not keep bladder
safe!)
2. Suppress reflexes converting bladder to
flaccid type and then empty regularly

86

Causes of raised bladder pressure

Prolonged detrusor contraction
Loss of compliance

87

Result of raised bladder pressure

Problems with drainage of urine from the kidneys and ultimately hydronephrosis and renal failure

88

What is an unsafe bladder

One that puts kidneys at risk of damage

89

Risk factors of unsafe bladder

Raised bladder pressure
Vesico-ureteric reflux
Chronic infection (residual urine or stones)

90

What is a paraplegic

Paralysed from the waist down
Normal upper body function
Relies on reflex bladder

91

Bladder management of paraplegic

Suprapubic catheter
OR
Suppress reflexes or poorly compliant
bladder converting bladder to safe type
and then empty regularly using ISC

92

Potential issues with catheter

Infections
Stones
Autonomic dysreflexia

93

What can be given to suppress bladder reflex contractions

Anticholinergics
Mirabegron
Intravesical botulinum toxin
Posterior rhizotomy
Cystoplasty

94

Examples of flaccid and low spinal lesions

Spina bifida
Sacral fracture
Transverse myelitis
Ischaemic injuries
Cauda equina

95

Features of complete loss of distal cord function

Flaccid paraplegia
Areflexic bladder
Stress Incontinence
Areflexic bowels
Loss of REFLEX erections

96

Treatment of Neurogenic Stress Incontinence

Ensure bladder safe before treating
Men = artificial sphincter
Women = Autologous sling, Artificial Sphincter, Synthetic Tapes TVT/TOT not
recommended by NICE

97

Bladder problems in MS

-Overactive bladder syndrome urinary urgency and frequency, caused by neurogenic detrusor overactivity
-Incomplete bladder emptying