O slideshow foi denunciado.
Seu SlideShare está sendo baixado. ×

Basic concepts in urogynaecology

Anúncio
Anúncio
Anúncio
Anúncio
Anúncio
Anúncio
Anúncio
Anúncio
Anúncio
Anúncio
Anúncio
Anúncio
Carregando em…3
×

Confira estes a seguir

1 de 25 Anúncio
Anúncio

Mais Conteúdo rRelacionado

Diapositivos para si (20)

Quem viu também gostou (20)

Anúncio

Semelhante a Basic concepts in urogynaecology (20)

Basic concepts in urogynaecology

  1. 1. ANATOMY OF URINARY BLADDER
  2. 2. 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)
  3. 3. 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
  4. 4. 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
  5. 5. ANATOMY OF URINARY BLADDER (Cont…) BLADDER NECK  Muscle bundles are largely oblique or longitudinal  Little or no sphincteric action
  6. 6. Relations
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. NERVE SUPPLY
  12. 12. PHYSIOLOGY OF MICTURATION BLADDER FUNCTION Storage of urine Voiding of urine
  13. 13. 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
  14. 14. PHYSIOLOGY OF MICTURATION (cont…) Voiding phase:  When the volume of bladder reaches 250ml., a sensation of bladder filling is perceived  Spinal arc in adults is under control of hypothalamus and frontal lobe of brain  When time & place is convenient hypothalamus no longer inhibits detrusor  Detrusor contracts to raise intravesical pressure to 30-50 then to 100 cm of H2O  Complete loss of urethrovesical angle  Funneling of bladder neck & upper urethra  Voiding starts
  15. 15. 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
  16. 16. MECHANISM OF URINARY CONTINENCE (cont…) During stress:  Centripetal force of intra-abdominal pressure transmitted to proximal urethra  Reflex contraction of periurethral straited musculature
  17. 17. 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
  18. 18. 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
  19. 19. URINARY INCONTINENCE
  20. 20. 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
  21. 21. 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 are FDA approved  Surgical treatment- Fixation of bladder neck & proximal urethra to prevent its undue moblility & its decent.
  22. 22. 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
  23. 23. 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
  24. 24. THANK YOU

×