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Can you see my, my powerpoint? OK. Um So essentially the issue is that the audience can actually say anything. So at certain points, if you're asking a question or something, you might just have to go back to the metal and see if there's any answers on the chart. I see. But then it takes me take this weird screen that looks like this. Yeah, I know. I don't think it's anywhere around that. My OK. Sorry. Sorry. Yeah. Um Yeah, but yeah, you can begin now. OK. Great. So you can see that. Yeah. Um All right. So this um lecture gonna quickly run through the Urological Cancers B Ph and urinary incontinence. I think this is the last of the urinary lectures. So, um that's good. And I think it's also one of the easiest in my opinion. Um And that's just the order we are gonna do things I am gonna start by um um talking about the urinary tract. I don't know if you can see my cancer. Hopefully you can, if not, I will try and make it clear exactly what I'm talking about. Um Here, this is a simple diagram of urinary tract. You have your kidneys, um which drain urine into your ureter and that is collected in the bladder, the bladder um drains the urine via this urethra. And in a male, there'll be a prostate underneath uh just underneath the bladder and this is the inside of the, the kidney. Um The outside edge is the renal cortex. The inner part is the medulla made up of these triangular medullary pyramids which um drained by these calices into the renal pelvis. Uh not the, not the generic pelvis, but the pelvis of the kidney, which itself drains via the ureter into the, the bladder. And here's some diagrams that you are probably familiar with from um um your Rohan's anatomy textbook. Again, just the kidney, the ureter, the bladder. This diagram over here, slightly more confusing because the kidneys have been taken out and there's lots of these white strands. Um So how do you tell which one is the ureter? It's this one that crosses over inwards uh towards the bladder as opposed to these nerves which are all pointing outwards. And again, this is just a, a diagram of the, the kidney, uh the inside cortex, medulla calices, pelvis, and ureter. And I just want to draw your attention to these three important um areas. These are points where the there's likely to be some amount of obstruction because the ureter is narrowing. So the first one is at the point where the ureter starts the pelvic ureteric junction again, that's the renal pelvis. Um The second is towards the end where the ureter crosses over this um iliac vessel. Uh and it causes some amount of narrowing. And then at the end, the ureterovesical junction is the point where the ureter joins the bladder. And that also has some narrowing and likely to have some blockage. If there is a blockage, it's likely to be in one of these places. Um For example, a kidney stone, I'll just highlight those areas of that. This, this middle one is called the pelvic brim. Let's be the one over here. Ok. Uh And just to highlight some differences between the male urinary tract and the female urinary tract. So in the male urinary tract, um we have the bladder over here with this big muscular wall, the detrusor muscle, which we'll talk more about in a minute underneath. You have the prostate through which the first part of the urethra um goes. So that's the prosthetic urethra. Then the urethra continues. This is the membranous urethra until it goes through this um sa spongy area called the spongy urethra. Um Whereas in the female urinary tract, obviously, there's no um there's no prostate, but you can hear the bladder don't confuse it here with the uterus, which is slightly further back, the bladder is always further forward. Um And then a a shorter urethra, of course, and in both, there's the internal and external urethral sphincters. So in the male, um urinary system, the internal and external are just above and below the prostate respectively. Whereas in the female, obviously, there is no prostate. So they just sort of follow one after the other. Um And in this diagram, it's not super visible, but it's still there. And I'm not gonna go through all the um sort of generic uh arterial supply and venous drainage and the lymphatic drainage. But I just want to draw your attention to two main notes on nervous control, which is that the proximal or the upper urinary tract is controlled by the vesical plexus and the distal or the lower part of the urinary tract, including the external urethral sphincter, which will be important when we talk about incontinence is controlled by the pudendal nerve. Now, let's just quickly run through the micturition cycle. So this is um the way in which urination occurs. So you have two stages, fa filling stage, um or the storage phase, uh which begins with a detrusor that big bladder muscle relaxed and that's caused by inhibition of the parasympathetic nerves. So, the parasympathetic nerve system was of course rest and digest. Um And when you're actually urinating, that is a rest and digest activity. So the parasympathetic is going to be activated, but here before the urination, it's inhibited. That's how you can remember it. Um Whereas the sympathetic nervous system is activated and that helps to contract the sphincters of bladder is filling, you want the sphincters to be contracting nervous system to ensure that urine doesn't leak out. So the bladder, the pressure rises and there's no urge to urinate at the moment. Um OK. And then you switch to this, the voiding phase. This is when you actually urinate and this switch is mediated obviously by um higher centers of the brain because it's uh something that's consciously controlled. You decide when and when you're going to urinate. So the prefrontal cortex makes this decision. It sends a signal to the pontine micturitions. Um It's in the name, that's where the decision or the, the switch to actual micturition starts. And from there signals are sent to the bladder. So this is the order in which things happen. First, you have the stimulation of these m three receptors in the bladder. They send a signal via the pudendal nerve to the the brain to tell you that the bladder is full, it's distended, it's time to urinate. And then you have the exact opposite of what we had in the filling phase. The detrusor contracts because you get parasympathetic activation. Again, that's logical because parasympathetic is rest and digest um and urination is rest and digest activity. So that's activated, the sympathetic nervous system is going to be inhibited. Um And that's relaxation of the internal urethral sphincter, the external urethral sphincter is slightly different because it's under somatic control. You know, you, you consciously control when that's open and closed and that's er, done by, um, again, the pudendal nerve because that's a, a lower urinary um uh tract area, but it's all done under contras somatic control. And now we're going to discuss when this goes slightly wrong. So that's urinary incontinence, the definition of urinary incontinence being when there's unintentional passing of, of urine, we're gonna focus mainly on these first two overactive bladder and stress incontinence. Um And then make brief mention of these last three as well. Ok, overactive bladder really simply overactive bladder just means that you constantly feel the urge or frequently feel the urge to go to the toilet even though the bladder is not full. And this may result in incontinence if you constantly need the urge to go. Um and then you don't make it to the toilet, you are going to be incontinent and the pathology is not really well understood. Often it is just idiopathic, there is no known cause. There can be a noticed loss of inhibitory control from the central nervous system. Um, but essentially it, it is not really known the age factors. Sorry, the risk factors I should say are age prolapse of any pelvic organs. BM. I um irritable bowel syndrome. Er, and IBS is a uh psychosomatic condition as well. So it might indicate that it's related to urinary, er, this overactive bladder, which may also be somewhat psychosomatic. Um and of course, any bladder irritants are going to increase the the frequency of of this urgency. So, caffeine, I think nicotine as well is a, is an example of a bladder irritant. And the symptoms are, as you'd expect from the definition, you constantly just have this urge to go. It's frequent urination at night, it can lead to incontinence, it might impact quality of life. Um And you also want to assess any symptoms of prolapse because that was one of the the risk factors. So just basically means on a really simple level, constant urge to go to the toilet and how do you uh investigate it. So, first of all, you want to do a urine dip uh to exclude an infection, which is another cause of increased urgency. And then you just wanna keep a bladder diary when and where you're going. Urinary flow studies. Basically. Um just looking at the rate of the flow of the urine, how much volume is there. And then urodynamics is a more general er scan of the urinary tract system to look at, you know, how's the bladder filling, what's the pressure like how the ureter is filling? And that just gives some indication about what's going on but, but nothing too exciting. And then when it comes to management, we have these three levels which are going to be the mainstay of, of the management for all types of incontinence. We wanna start off with the most conservative form. So in this case, there might be lifestyle changes or bladder retraining from then you can move on to medications and the medications again, are very logical. Antimuscarinic drugs are going to block the detrusor muscle from being too active. Um, and then beta, beta three agonists are going to, um.