urogynae Flashcards by Jessica Hepplewhite

what is the most common type of incontinence

A - stress incontinence
B - urge incontinence
C- mixed stress and urge incontinence
D- overflow

A - stress incontinence

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Which type of incontinence does not require any urodynamics?

a) Stress incontinence
b) Mixed incontinence
c) Urge incontinence
d) Voiding dysfunction

a) stress incontinence - guided by history and examination

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What is the minimum time period should a bladder diary span?

a) 2 days
b) 3 days
c) 5 days
d) 1 week

b - 3 days

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What supplies the sympathetic innervation of the bladder?

a) Pelvic nerve
b) Hypogastric nerve
c) Pudendal nerve
d) Vesical nerve

B - hypogastric nerve

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what is the role of the sympathetic nerve supply to the bladder?

a) contraction of the bladder and relaxation of the urethral sphincters
b) relaxation of the bladder and contraction of the urethral sphincter

b - relaxation of the bladder and contraction of the urethral sphincters facilitates storage of urine (this is during the filling phase)

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What is the role of the parasympathetic nerve supply to the bladder

parasympathetic nerve supply via the pelvic nerve (s2-s4) induces contraction of the bladder smooth muscle (detrusor) via release of Ach binds to m3 receptors in the bladder smooth muscle and relaxation of the urethral sphincter by release of ATP and NO

parasympathetic aids voiding (p = peeing)

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what is the somatic nerve supply to the bladder

A) pelvic nerve
B ) hypogastric nerve
C) pudendal nerve
D) inguinal nerve

C) pudendal nerve

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is the somatic nerve (pudendal nerve) to the bladder under voluntary or involuntary control

voluntary control - this is the nerve that activates when we want to hold our urine and not go for a wee!

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what neurotransmitter does the sympathetic nerve release in order to co-ordinate relaxation of the smooth muscle and where does it act

A) ATP
B) noradrenaline
C) Ach
D) nitrous oxide

noradrenaline is released from the hypogastric nerve and this binds to B3 receptors in the smooth (detrusor) muscle to cause relaxation of the bladder

It also binds to alpha 1 receptors in the internal urethral sphincter to cause constriction

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what neurotransmitter does the pudenal nerve release and where does it act

pudendal nerve (somatic supply) releases Ach and this binds to the nicotinic receptors in the external urethral sphincter causing it to contract

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what neurotransmitter does the parasympathetic nerve transmit and where does this bind?

Ach binds to M3 (muscarinic receptors) in the bladder detrusor muscle causing contraction.

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what are the spinal segments that the hypogastric nerve originates from

T11-L2 (some quote T12-L2)

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what are the spinal segments that the pelvic nerve supplying the bladder originate from

S2-s4

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what are the spinal segments that the pudendal nerve supplying the bladder originate from

S2-S4

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what are the four parts of the bladder

Apex - located superiorly and projects toward the pubic symphysis - this is connected to the umbilicus via the median umbilical ligament (remnant of the urachus)
Body - main part of the bladder
Fundus - located posterior, triangle shape with the top of the triangle pointing backwards
Neck - formed by the convergence of the fundus and two inferolateral surfaces continuous with the urethra

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in what part of the bladder would you find the trigone?

base of the fundus - is covered by smooth muscle
it is triangular area located at the base of the fundus with the 2 orifces of the ureters

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what does the trigone develop from in embryology?

fusion of the mesonephric ducts and hence is covered by smooth muscle, whereas the rest of the bladder is formed from the sinovaginal bulb

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what epithelium lines the bladder

Transitional epithelium

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In terms of embryological development what does the the majority of the bladder (excluding the trigone) develop from

the sinovaginal bulb

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what is the name of the smooth muscle that makes up the bladder

detrusor muscle

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what is the arterial blood supply to the bladder

branches of internal iliac artery
- superior vesical branch and
males- inferior vesicle branch
females - vaginal arteries

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what is the venous drainage from the bladder

vesical venous plexus this drains into internal iliac veins

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what lymph nodes does the superior lateral aspect of the bladder drain into:

A - external iliac nodes
B- internal iliac nodes
C- common iliac nodes
D- femoral nodes

A- external iliac nodes

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what lymph nodes does the fundus and neck of the bladder drain into (select more than one)

A - external iliac nodes
B- internal iliac nodes
C- common iliac nodes
D- femoral nodes
E- sacral iliac nodes

B, C , E

internal, common and sacral iliac nodes

(basically the bladder drains into the iliac nodes)

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in males how many urethral sphincters are there and what are they called

2 - internal and external urethral sphincter (whereas women just have external urethral sphincter)

what are the three layers of the urethra

outer striated muscle middle smooth muscle inner mucosal layer

what is the nerve supply to the outer striated muscle of the uretha - is this under voluntary or involuntary control

Pudendal (s2-s4) somatic nerve supply to the outer striated muscle, under voluntary control

what is the nerve supply to the middle smooth muscle of the urethra

middle smooth muscle of the urethra is under sympathetic and parasympathetic control - sympathetic causes contraction and parasympathetic relaxation this is under involuntary control

what is the arterial supply to the urethra

internal pudendal arteries

what is the venous drainage of the urethra

internal pudendal veins

what is the innervation to the urethra

vesical plexus of the pudendal nerve

what are the pelvic floor muscle components

Levator ani and coccygeus

what are the three muscles that comprise levator ani

1. Puborectalis 2. pubococcygeus 3. iliocococcygeus

can you name three roles of levator ani

1. provide support to the pelvic organs 2. maintain urinary and faecal continence 3. resistance to increases in intra pelvic and abdominal pressure

micturition is controlled by what centre in the brainstem

pons micturition centre

in addition to the efferent nerve supply to the bladder, what types of nerves send signals to the brain and tell the brain when the bladder is full?

afferent nerves have stretch receptors in the bladder muscle and as the bladder fills the increase in stretch on the bladder increases and this sends signals to the brainstem specifically the pons micturition centre

is the pons micturition centre under involuntary or voluntary control

voluntary - when the stretch reflex activates (i.e. as the bladder is filling ) we as humans can override this and not go for a wee

up to the age of 5 micturition in children is thought to be under voluntary or involuntary control

involuntary

what nerve is stimulated on filling of the bladder as the bladder is stretched A) hypogastric nerve B) pudendal nerve C) afferent pelvic nerve D) pudendal nerve

C- afferent pelvic nerve

what are the common symptoms of overactive bladder (urge incontinence)

urgency, frequency, nocturia, urge incontinence

what would a patient describe if you thought the diagnosis was stress incontinence

urinary leakage on coughing/ exercise (urinary leakage on increase of abdominal pressure in the absence of detrusor activity)

what is the pathophysiology of urge incontinence (OAB)

detrusor overactivity leads to involuntary bladder contraction

what are some of the causes of OAB

can be idiopathic (increasing age is a risk factor) neurogenic - neurological conditions e.g. MS, parkinsons, DM, spinal cord injury stroke and dementia

what type of incontinence is the following definition describing ' Involuntary detrusor contractions during the filling phase which may be spontaneous or provoked'

overactive bladder (urge inconitence )

what type of urinary incontinence is the following definition describing 'Involuntary leakage of urine during increased intra-abdominal pressure in the absence of detrusor contraction'

Stress incontinence

How can you assess pelvic floor tone? what grading system can be used

PV examination and ask the patient to squeeze your finger use the oxford grading system - grades pelvic floor contraction of a scale of 0-5 (0 meaning no contraction, to 5 which is good 'normal' contraction)

when would you consider doing urodynamics studies

urge incontinence or mixed picture someone that has surgery for stress incontinence symptoms of voiding dysfunction apical or anterior prolapse note not required in stress incontinence

what are the general lifestyle measures you can offer for any type of incontinence

reduce fluid intake smoking cessation weight loss if BMI >30 decrease caffeine intake - only really for OAB

what is the first line non pharmacological treatment for urge (OAB) incontience

bladder retraining for 6 weeks

what is the first line non pharmacological treatment for stress incontinence

pelvic floor exercises for minimum of 3 months (need to be doing a minimum of 8 pelvic floor contractions TDS)

how long should pelvic floor exercises be done for treatment of stress incontinence A) 6 weeks B) 3 months C) 6 months D) 12 months

B - 3 months

Sally is a 48 year old female that has been diagnosed with urge incontinence. She has been doing bladder retraining for over 6 weeks now and has returned your clinic as symptoms are a little bit better but still present. She wants to know what the next step in management is

pharmacological treatment with anticholinergics/ anti-muscarinics e.g. oxybutynin, tolterodine, solifenancin,

what is the mode of action of antimuscarinics/anti-cholinergics in the treatment of OAB

they work to block the muscarinic receptors in the bladder by blocking the action of acetylcholine (remember Ach is the main parasympathetic neurotransmitter which works to contract the bladder, therefore by blocking this we cause relaxation of the bladder)

what are the main side effects of anticholinergics

dry eyes, dry mouth and constipation

in an elderly female which type of the anti-cholinergic should you avoid and why?

oxybutynin thought to increase risk of dementia/cognitive impairment instead try a OD release

Sally has tried a couple of different anti-cholinergic medications for treatment of OAB but hasn't had much success. what is the second line pharmacological treatment we could offer Sally? A - Tolterodine B- oxybutynin C- Mirabegron D- solifenacin

C - mirebegron - B3 agonist

what is the mode of action of mirabegron

B3 agonist - remember that B3 receptors are responsible for smooth muscle relaxation in the bladder therefore increasing the activity of the B3 receptors should help improve muscle relaxation of the bladder

when could you consider using desmopressin

mainly for nocturia in OAB (it is an anti-diuretic; synthetic analogue of vasopressin so works to decrease renal excretion of water)

for women with OAB that have tried first and second line pharmacological Rx (anticholinergics and mirabegron) what is another type of medication that could be used off licence if they want to avoid surgical or invasive treatments?

Duloxeteine (SNRI)

what are two invasive (non surgical) treatment options used in Rx of OAB

1. botox injection 2. percutaneous sacral nerve stimulation both have risks of causing urinary retention

what are the two surgical options used in the management of OAB when all other treatment options have failed

1. augmentation cytoplasty (makes bladder bigger) 2. Urinary diversion - urostomy

what are some of the risk factors for stress incontinence

increasing age polypharmacy/ drugs e.g. ace inhibitors -cause cough perineal trauma - multiparty, vaginal delivery - assisted vaginal delivery smoking obesity increasing age constipation

what are the general principles that you should advice a female who you suspect has stress incontinence

lose weight esp if BMI >30 decrease fluid intake smoking cessation

what is the first line treatment option for stress incontinence

pelvic floor for 3/12

are there any pharmacological treatments for stress incontinence

off licence could trial duloxexteine (SNRI) thought to increase activity of the nerve that stimulates the urethral sphincter - inhibits presynaptic uptake of serotonin and noradrenaline in Onuf's nucleus of spinal cord, so we get increase in serotonin and noradrenaline ht vein the synaptic cleft leading to increase contraction of urethral sphincter -enhances uretheral striated sphincter activity by central mediated pathway

what is the main form of treatment in stress incontinence once pelvic floor physio has been tried

surgical measures e.g. colposuspension, autologous rectal sling, intramural bulking agents, retropubic mid urethral sling)

urogynae Flashcards

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