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Medicine Phase 2a GU > Lectures > Flashcards

Lectures Flashcards

1
Q

Normal function of LUT

A

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

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2
Q

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

A

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

Distal sphincter = True:
Relaxes during voiding

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3
Q

What nerve roots drive detrusor contraction

A

Parasympathetic (cholinergic) S2-4

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4
Q

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

A

Sympathetic (noradrenergic) T10-L2

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5
Q

Types of LUTS (lower urinary tract symptoms)

A

Storage

Voiding

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6
Q

Examples of LUTS storage symptoms

A

Frequency
Nocturia
Urgency
Urgency Incontinence

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7
Q

Examples of LUTS voiding symptoms

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

Haematuria
Dysuria

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8
Q

What does BPH stand for

A

Benign Prostatic Hyperplasia

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9
Q

BPE stand for

A

Benign Prostatic Enlargement

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10
Q

BOO stand for

A

Bladder Outflow Obstruction

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11
Q

Epidemiology of BPH - Benign Prostatic Hyperplasia

A

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
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12
Q

What is BPH

A

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

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13
Q

Causes of BPH

A

Increase in cell number
Decrease apoptosis
Combination

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14
Q

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

A

40%

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15
Q

Dynamic component of benign prostatic obstruction

A

alpha-1 adrenoceptor mediated prostatic smooth muscle contraction

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16
Q

Static component of benign prostatic obstruction

A

volume effect of BPE

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17
Q

Do androgens cause BPE?

A

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.

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18
Q

Example of scoring system for LUTS

A

IPSS

International Prostate Symptom Score

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19
Q

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

A 
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
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20
Q

Examinations for LUTS

A 
General examination i.e fitness for surgery
Abdominal examination
External genitalia
Digital rectal examination (DRE)
Focused neurological examination
Urinalysis
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21
Q

LUTS investigations

A 
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
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22
Q

Prevalence of LUTS

A

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

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23
Q

LUT anatomy in women

A

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).

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24
Q

Why do women who have given birth undergo stress incontinence

A

Weakened pelvic floor muscles

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25
Q

LUT anatomy in men

A

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

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26
Q

Why do men have 2 sphincters after bladder

A

For ejaculate

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27
Q

Role of cortex of brain for LUT

A 
Sensation
Voluntary initiation (of urination)
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28
Q

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

A

Pontine Micturition Centre/Peri Aqueductal Grey

in pons

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29
Q

Spinal reflexes affecting LUT

A

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)

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30
Q

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

A

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

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31
Q

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

A

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

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32
Q

Neural control of LUT: Somatic

A

Striated sphincter contraction/relaxation (control)

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33
Q

Describe storage of bladder

A

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

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34
Q

Describe voiding of bladder

A

1% of time

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

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35
Q

Classification of LUTS

A

Storage
Voiding
Post-micturition

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36
Q

Classification of LUTS: Storage

A

Frequency
Urgency
Nocturia
Incontinence

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37
Q

Classification of LUTS: Voiding

A 
Slow-stream
Splitting or spraying
Intermittency
Hesitancy
Straining
Terminal dribble
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38
Q

Classification of LUTS: Post-micturition

A

Post-micturition dribble

Feeling of incomplete emptying

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39
Q

How would you define frequent

A

> 8 times per day or whenever feels more than normal

40
Q

Define urinary urgency

A

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

41
Q

Define Nocturia

A

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

42
Q

Define incontinence

A

Inability to hold urine or involuntary loss of urine

Failure of storage

43
Q

Parameters that can be measured by a Bladder Diary

A 
Frequency/day
Frequency/night
Volume/day
Volume/night
Nocturnal volume/24h volume (should be <1/3)
Functional capacity
Incontinence/day
44
Q

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

A

~2.7 litres in 24 hours

45
Q

Define nocturnal polyuria

A

Nocturnal volume/24h volume >1/3

46
Q

What is functional capacity

A

How much bladder can hold

~400ml

47
Q

Normal Frequency to urinate/day

A

2-8

48
Q

Normal frequency to urinate/night

A

0-1

49
Q

Normal volume to urinate/day

A

<2.7L (polyuria is over 2.7L)

50
Q

Normal volume to urinate/night

A

<900ml

51
Q

Normal nocturnal volume/24h volume

A

<1/3

52
Q

Normal functional capacity

A

> 400ml

53
Q

Normal incontinence/day

A

0 (abnormal finding)

54
Q

Types of incontinence

A 
Urgency
Stress
Mixed (U+S)
Continuous 
Overflow
Social
55
Q

Urgency incontinence

A

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

56
Q

Stress incontinence

A

associated with coughing or straining

57
Q

Cause of continuous incontinence

A

Fistula

58
Q

Overflow incontinence

A

Occurs in presence of a full bladder

59
Q

Social incontinence

A

Occurs in those with dementia

60
Q

Define Over Active Bladder (OAB) syndrome

A

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

61
Q

Over Active Bladder cardinal symptom

A

Urgency

62
Q

Overactive Bladder Management in order

A 
Behavioural therapy
Anti-muscarinic agents
B3 agonists
Botox
Sacral neuromodulation
Surgery
63
Q

Overactive Bladder Management: Behavioural Therapy

A

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

64
Q

Overactive Bladder Management: Anti-muscarinic agents

A

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

65
Q

Overactive Bladder Management: B3 agonists

A

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

66
Q

Overactive Bladder Management: Botox (and SEs)

A

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
Q

Overactive Bladder Management: Sacral neuromodulation

A

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

68
Q

Overactive Bladder Management: Surgery

A

Augmentation cystoplasty

Involves major surgery

69
Q

Stress incontinence in females - causes

A

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

70
Q

Management of urinary stress incontinence

A

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

71
Q

Causes of stress incontinence in men

A

Rare
Neurogenic
Iatrogenic (prostatectomy leaving only one sphincter)

72
Q

Examples of disease causing obstructive voiding problems

A

BPE (Benign Prostatic Enlargement)
Urethral stricture
Prolapse/mass

73
Q

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

A

Alpha blockers
5 alpha reductase inhibitor
TURP

74
Q

Treatment of detrusor under-activity (non-obstructive)

A

Long term catheterisation to empty (ISC/LTC/SPC)

Sacral neuromodulation in trial phase - works in Fowlers syndrome

75
Q

Management of BPE and ED in men in order

A

PDE5 inhibitor
Alpha antagonist
TURP/injections/implant

76
Q

Management of OAB in men and women in order

A

Men:
Antimuscarinic
B3 agonist, Alpha antagonist
Botox

Women:
Antimuscarinic
B3 agonist
Botox

77
Q

Management of Mixed incontinence in men in order

A

Alpha antagonist/muscarinic
B3 agonist
TURP/Botox

78
Q

Management of SUI in men in order

A

Physiotherapy

Surgery

79
Q

Features of spastic spinal cord injury on bladder

A 
UMN:
Lost co-ordination and completion of voiding
Reflex bladder contractions
Detrusor sphincter dyssynergia
Poorly sustained bladder contraction
80
Q

Features of flaccid spinal cord injury on bladder

A 
LMN:
Loss of reflex bladder contraction, guarding reflex and receptive relaxation
Areflexic bladder
Stress incontinence
Risk of poor compliance
81
Q

Aims of management of neurogenic bladder

A

Bladder safety
Continence/symptom control
Prevent autonomic dysreflexia

82
Q

Lesions over what spinal cord level cause autonomic dysreflexia

A

Lesions over T6

83
Q

What is autonomic hysreflexia

A

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

84
Q

Clinical presentation of autonomic hyperreflexia

A

Headache
Severe hypertension
Flushing

85
Q

Treatment via reflex bladder

A
  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
Q

Causes of raised bladder pressure

A

Prolonged detrusor contraction

Loss of compliance

87
Q

Result of raised bladder pressure

A

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

88
Q

What is an unsafe bladder

A

One that puts kidneys at risk of damage

89
Q

Risk factors of unsafe bladder

A

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

90
Q

What is a paraplegic

A

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

91
Q

Bladder management of paraplegic

A 
Suprapubic catheter
OR
Suppress reflexes or poorly compliant
bladder converting bladder to safe type
and then empty regularly using ISC
92
Q

Potential issues with catheter

A

Infections
Stones
Autonomic dysreflexia

93
Q

What can be given to suppress bladder reflex contractions

A 
Anticholinergics
 Mirabegron
 Intravesical botulinum toxin
 Posterior rhizotomy
 Cystoplasty
94
Q

Examples of flaccid and low spinal lesions

A 
Spina bifida
Sacral fracture
Transverse myelitis
Ischaemic injuries
Cauda equina
95
Q

Features of complete loss of distal cord function

A 
Flaccid paraplegia
Areflexic bladder
Stress Incontinence
Areflexic bowels
Loss of REFLEX erections
96
Q

Treatment of Neurogenic Stress Incontinence

A

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

97
Q

Bladder problems in MS

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

Medicine Phase 2a GU (18 decks)

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