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Lower Urinary Tract
Terms in this set (36)
What must you consider when inserting a urinary catheter in a male?
U-bend of urethra: cannot put a straight catheter in or it will hit the back of the urethra against the rectum.
Why can vaginal problems cause urinary problems and vice versa?
Close association - female urethra is embedded in the anterior wall of the vagina.
What are the four parts of the male urethra?
How many urinary sphincters do males have? Give the features.
- smooth muscle at the top of the prostate
- involuntary control
- after prostate, embedded in membranous urethra
- voluntary control
How many urinary sphincters do females have?
Why is it uncommon for prostate cancer to invade backwards?
The rectovesical pouch is a double layer of peritoneum between the bladder and rectum.
At the bottom of the rectovesical pouch is the rectoprostatic (Denonvillier's) fascia.
This double layer of peritoneum means that prostatic cancer does not commonly invade backwards.
Where is the blood supply of the male urethra derived from?
Prostatic urethra - inferior vesical artery (branch of the internal iliac artery which also supplies the lower part of the bladder).
Membranous and bulbar urethra - bulbourethral artery (branch of the internal pudendal artery)
Spongy/penile urethra - supplied directly by branches of the internal pudendal artery.
Where will penile/prostate cancer cause nodal enlargement?
In pelvic and abdominal nodes due to venous drainage.
Where is the blood supply of the testes derived from?
From vessels through the inguinal canal and up through the retroperitoneum.
Where will penile skin cancer cause nodal enlargment?
In the groin.
What are the layers of the bladder?
What type of epithelium is in the bladder?
Describe nervous control of micturition.
Detrusor contracts in response to ACh at muscarinic receptor M3 from parasympathetic nervous system via the pelvic nerve (S2-S4).
Describe nervous control of bladder relaxation.
The sympathetic nervous system communicates with the bladder via the hypogastric nerve (T12 - L2) at adrenergic nerve endings.
It causes relaxation of the detrusor muscle. These functions promote urine retention
What are the functions of the bladder?
Reservoir for urine, does not absorb although lining not completely waterproof.
Rate of filling depends on intake
Fills WITHOUT increase in pressure (isotonic) or would cause renal impairment
At what bladder volume would a normal person feel a slight fullness, and when would discomfort be intolerable?
At 250mls, normal person feels slight fullness.
At 500mls, frequent increases in pressure (up to 100cmH2O) make discomfort intolerable.
What is the normal voiding pattern - volumes and timing?
When the bladder contains c. 300mls (and it is socially convenient) VOIDING is initiated.
Normal voiding pattern - 300-400mls per void, 4-5 per day (<7)- depending on input.
What nerve roots are the parasympathetic innervation of the lower urinary tract?
What urinary issues can spinal cord injuries cause?
Cauda equina syndrome: lose parasympathetic outflow - retention of urine
Incontinence due to other lesions.
What is the normal urinary output?
What can you ask the patient to fill out to gather information about their symptoms?
Collected by patient
Very informative: Frequency, Functional capacity, Nocturia
What are the two types of urinary symptoms?
What are the four storage symptoms?
What is frequency?
Peeing hourly or more. Increased by small functional capacity.
What is urgency?
Overwhelming desire to void.
increased by overactivity of detrusor (motor) or oversensitive nerve endings (sensory)
What is nocturia?
Getting up to pee more than once a night.
May be caused by factors other than the bladder
What is incontinence? What are the two types?
Defined as 'involuntary loss of urine that is a social or hygienic problem and is objectively demonstrable'
- urge incontinence: Involuntary loss of urine associated with strong desire to void (detrusor contraction)
- stress incontinence: Involuntary loss of urine when intra-abdominal pressure rises without detrusor contraction
What are the three voiding symptoms?
Hesitancy (long time to get started)
Poor flow: weak or intermittent stream
Terminal dribble: slow to finish
What pathology do voiding symptoms tend to reflect?
Bladder outlet obstruction. Can get voiding symptoms with other pathologies - ie neuropathic bladder, cannot push.
What are the responses to voiding symptoms in males and females?
Need to investigate in females with voiding symptoms or retention - in men, if there's no red flags then assume prostate.
How do you assess urinary symptoms?
Take history - Freq/Vol chart
- IPSS (score of urinary symptoms, and asks about quality of life)
- Flow rate
What is uroflowmetry? What does it measure? What can it predict/differentiate?
Pee into a bucket that has a flow rate meter and timer. Very common in clinic.
Measures max flow rate (without pushing or straining)
Predicts likelihood of progressing to sig problems like retention or UTI and therefore benefit to be gained from treatment
Differentiate between causes of bladder outflow obstructions (eg urethral constrictions - history of previous urethral surgery, peritoneal trauma)
What is urodynamics?
Very specialised. Used when diagnosis is not clear. Artificially fill bladder. Problems could be obstruction or muscle paralysis.
Pressure from bladder and rectum measured during filling and voiding
Patient asked to cough periodically
Subtracting rectal (abdominal) pressure from bladder = detrusor activity
What is the treatment for an idiopathic overactive bladder?
Urgency, frequency, no UTI, no neurological conditions.
Give antimuscarinic medication - blocks parasympathetic supply and relaxes bladder. M3 receptor.
Solifenacin in lothian - NICE is oxybutynin. Side effects - dry mouth, constipation, dry eyes, cognitive impairment/confusion in elderly.
Contraindication: acute angle closure glaucoma - will make them blind.
What is the general treatment for incontinence? What is the treatment for urge incontinence?
Inject botox into bladder.
What is the anti-adrenergic alpha-blocker tamsulosin used for? What are the side-effects?
400mg once per day used to relieve symptoms of urinary obstruction caused by benign prostatic hyperplasia.
Blocks adrenergic receptors that maintain BP = postural hypotension.
Will cause retrograde ejaculation - can lead to infertility.
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