Download - Basic concepts in urogynaecology
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ANATOMY OF URINARY
BLADDER
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ANATOMY OF URINARY
BLADDER (Cont…)
Tetrahedral in shape
Parts: a) Apex- directed forwards
b) Base- directed backwards
c) Neck- lowest &
most fixed part
Surfaces- 3 (Superior, Right & left
inferolateral)
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ANATOMY OF URINARY
BLADDER (Cont…)
MUSCLES (Detrusor)
OUTER LONGITUDINAL- Active & dominant role in storage & voiding.
Courses downwards
At neck it forms a sling
MIDDLE CIRCULAR- More prominent in lower part of bladder
INNER LONGITUDINAL- Courses downwards
Continues to form spirals in mid urethra
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ANATOMY OF URINARY
BLADDER (Cont…)
TRIGONE
Formed by the absorption of mesonephric
ducts
Muscle is mesodermal in origin
Epithelium is endodermal as of whole bladder
Cholinergic nerve supply
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ANATOMY OF URINARY
BLADDER (Cont…)
BLADDER NECK
Muscle bundles are largely oblique or
longitudinal
Little or no sphincteric action
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Relations
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SUPPORTS OF URINARY
BLADDER
Lateral true ligament- From the side of bladder
to the arcus tendinalis
Pubovesical / pubourethral ligament
Median umbilical ligament
Posterior ligament- From base to pelvic wall
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ANATOMY OF URETHRA
3 PARTS- Proximal, mid & distal urethra
Proximal urethra- weakest part Fails to withstand rise of intra-vesical or intra-abdominal
pressure
Mid urethra- strongest part It has got additional support by:
Intrinsic striated muscles- Rhabdomyosphincter urethrae(Urethral closure at rest)
Extrinsic periurethral muscle- Levator Ani
(Support urethra on stress)
Distal urethra- Passive conduit
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ANATOMY OF URETHRA
(Cont…)
Submucous layer- Vascular layer
Venous plexi present in submucous layer
Supports urethra by its plasticity
Maintain resting urethral pressure
Mucous layer- arranged in longitudinal folds
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SUPPORTS OF BLADDER NECK &
URETHRA
Intrinsic supports: Rhabdomyosphincter urethrae
Urethral smooth muscles
Submucosal venous plexus
Estrogen increase collagen connective tissue
Sympathetic activity to maintain urethral tone
Extrinsic supports: Pubococcygeus part of levator ani
Pubourethral ligaments
Exercise to increase collagen turnover
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NERVE SUPPLY
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PHYSIOLOGY OF
MICTURATION
BLADDER FUNCTION
Storage of urine Voiding of urine
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PHYSIOLOGY OF MICTURATION
(cont…)
Storage phase:
Urine comes in the urinary bladder from ureters
drop by drop at rate of 0.5-5ml/min
Intravesical pressure kept at 10cm of H2O with
volume of 500ml. This occurs because: Proximal urethral musculature act like a sphincter by
maintaining tonic contraction
Stretching of detrusor reflexly contracts sphincteric muscles
of bladder neck
Inhibition of cholinergic system responsible for detrussor
contraction
Stimulation of β-adrenergic results in further detrusor
relaxation & α-adrenergic causing contraction of sphincter of
bladder neck
Voluntary control of intrinsic & extrinsic urethral muscles
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PHYSIOLOGY OF MICTURATION
(cont…)
Voiding phase:
When the volume of bladder reaches 250ml., a sensationof bladder filling is perceived
Spinal arc in adults is under control of hypothalamus andfrontal lobe of brain
When time & place is convenient hypothalamus nolonger inhibits detrusor
Detrusor contracts to raise intravesical pressure to 30-50then to 100 cm of H2O
Complete loss of urethrovesical angle
Funneling of bladder neck & upper urethra
Voiding starts
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MECHANISM OF URINARY
CONTINENCE
At rest:
Intraurethral pressure at rest:20-50cm of H2O
Intravesical pressure at rest: 10cm of H2O
Apposition of longitudinal mucosal folds
Submucous venous plexus
Collagen & elastin around urethra
Rhabdomyosphincter and levator ani
Urethrovesical angle- 1000
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MECHANISM OF URINARY
CONTINENCE (cont…)
During stress:
Centripetal force of intra-abdominal pressure transmitted
to proximal urethra
Reflex contraction of periurethral straited musculature
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MECHANISM OF URINARY
CONTINENCE (cont…)
Kinking of urethra due to: Hammock like attachment of pubocervical fascia with urethra,
vagina & laterally to arcus tendineus fascia. During rise of
intraabdominal pressure- urethra get compressed against anterior
abdominal wall
Bladder base rocks downwards & backwards
Bladder neck pull upwards & forwards behind pubic symphysis
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CLASSIFICATION OF URINARY
INCONTINENCE
Stress urinary incontinence
Urge urinary incontinence
Mixed incontinence
Continuous urinary incontinence- Overflow incontinence (neurogenic bladder)
Functional urinary incontinence- due to reasons other than neuro-
urologic and lower urinary tract dysfunction (eg, delirium, psychiatric disorders, urinary infection, reduced mobility)
True urinary incontinence- eg. Vesico vaginal fistula
Other incontinences-
Postural urinary incontinence
Insensible urinary incontinence
Coital incontinence
Important in
urogynaecology
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URINARY INCONTINENCE
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STRESS URINARY
INCONTINENCE Involuntary leakage of urine on stress
(sneezing, coughing)
Most common of all incontinence
More common in younger and active women
Due to: Hypermobility of urethra (most important reason)
Intrinsic sphincteric weakness or deficiency
Hypermobility of urethra may be due to: Decent of bladder neck
Injury to the hammock
(during delivery or hysterectomy)
Estrogen deficiency
Pelvic denervation
Congenital weakness of uretheral supports
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Stress urinary incontinence
(cont…)
Management: Behavioral modification & lifestyle changes
Kegel’s exercise
Postural change during stress
Fluid management
Vaginal & urethral devices
Medications: α-agonists (Imipramine, ephedrine,pseudoephidrine, phenylpropanolamine)but none of the drugs areFDA approved
Surgical treatment- Fixation of bladder neck & proximalurethra to prevent its undue moblility & its decent.
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URGE URINARY
INCONTINENCE
Involuntary leakage of urine associated with
urgency
More common in older women
Urgency, Increase day time frequency &
nocturia
Occurs due to detrusor instability and detrusor
overactivity
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Urge urinary incontinence
(cont…)
Management: Lifestyle changes: Weight loss, smoking, alcohol, caffeine
cessation
Behavioural therapy: Yoga, Silent singing, deep breathing
Bladder training, Schedule toileting program
Fluid management
Vaginal and Urethral devices
Medications: Anticholinergics (oxybutynin, tolterodine, festerodine, darifenacin, solefenacin)
β3agonist- Mirabagone, solebagone
Neurokinin inhibitors
Neuromodulation: Sacral nerve or percutaneous tibial nerve stimulation
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