The urinary bladder

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The urinary bladder

  1. 1. contents1. ANATOMYCAL INTRODUCTION2. CAPACITY THE BLADDER3. NERVE SUPPLY4. PHYSIOLOGICAL REFLEX5. NEUROGENIC BLADDER6. INCONTINENCE7. REFERENCE
  2. 2. URINARY BLADDER
  3. 3. URINARY BLADDER ANATOMICAL INTRODUCTION Urinary bladder is the temporary store house of urine which gets emptied through the urethra. The male urethra subserving the functions of urination and ejaculation. Female urethra is for urination only.
  4. 4. CAPACITY OF THE BLADDERCapacity in an adult male 120 to 320 ml.Filling beyond 220 ml causes micturition,emptied when filled to about 250 to 300ml.Filling up to 500 ml may be tolerated, butbeyond this it becomes painful.Referred pain: lower part of the anteriorabdominal wall, perineum and penis(T11-L2,S2-S4).
  5. 5. NERVE SUPPLY
  6. 6. NERVE SUPPLYIts contains both sympathetic andparasympathetic components.Parasympathetic efferent fibersS2,S3, S4 are motor to the detrusor muscleand inhibitory to the sphincter vesicae. If these are destroyed, normalmicturition is not possible.
  7. 7. NERVE SUPPLY CONTI…. Sympathetic efferent fibers (T11 to L2): - inhibitory to the detrusor -motor to the sphincter vesicae The pudendal nerve (S2, S3, S4) -supplies the sphincter urethrae which is voluntary Sensory nerves:• pain sensations, causes: - spasm of bladder wall - carried by parasympathetic nerves and partly by sympathetic nerves
  8. 8. HIGHER CENTER Higher centers for micturition1) Inhibitory centers : midbrain -cerebral cortex2) Facilitatory centers : Pons - cerebral cortex
  9. 9. FUNCTIONS OF NERVESNerve On On On Function detrusor internal external muscle sphincter sphincterSympathetic Relaxation Constriction Not supplied Filling of urinarynerve bladderParasympathetic Constriction Relaxation Not supplied Emptying ofnerve urinary bladderSomatic nerve Not supplied Not supplied Constriction Voluntary control of micturition
  10. 10. MICTURITION REFLEX. Filling of urinary bladder Stimulation of stretch receptor Afferent impulses pass via pelvic nerve Sacral segments of spinal cord Efferent impulses via pelvic nerveContraction of detrusor muscle & relaxation of internal sphincter
  11. 11. MICTURITION REFLEX CONTI… Flow of urine into urethra and stimulation of stretch receptors Afferent impulses via pelvic nerve Inhibition of pudendal nerve Relaxation of external sphincter Voiding of urine
  12. 12. NEUROGENIC BLADDER BY: P.J.MEHTAThere are five types of neurogenic bladder:TYPE LESION1. Uninhibited bladder ..cortico regulatory tract2. Reflex bladder ..spinal cord above S23. Autonomous bladder ..at S2, S3 and S4 level4. Motor atonic bladder ..motor efferents5. Sensory atonic bladder ..sensory afferents
  13. 13. 1. UNINHIBITED BLADDERCAUSES: -cerebrovascular accidents, -head injuries, -brain tumors, etc.Voluntary control of micturition is lost.Hesitancy and precipitancy ofevacuation is present.Lesion : - the midbrain - superior frontal gyrus
  14. 14. 2.REFLEX BLADDERETIOLOGY:Transverses myelitisTraumaNeoplasmsMeningitisDisseminated sclerosisLesion : complete transection of spinal cord above sacral segments
  15. 15. REFLEX BLADDER CONTI…PATHOGENESIS:Acute transaction of the cord causesretention of urine during the stage of spinalshock.Leads to retention of residual urine.During recovery stage, reflex activity beginsand automatic evacuation of bladder results.
  16. 16. 3. AUTONOMOUS BLADDER ETOLOGY: Congenital : spina bifida, meningomyelocele Trauma: gunshot, auto accidents Infective: arachnoiditis, radiculitis Neoplasms of the cord Surgery: combined perineal and abdominal resection. LESION: sacral segment of spinal nerve.
  17. 17. AUTONOMOUS BLADDER CONTI…CLINICAL FEATURES:Loss of bladder sensationInability to initiate micturitionnormallyparalysis of pariurethral striatedmusclesassociated with anesthesia andabsent bulbocavernous reflex.
  18. 18. 4. SENSORY PARALYTIC BLADDER ETIOLOGY: Tabes dorsalis Pernicious anemia Diabetes Disseminated sclerosis Syringomyelia Lesion : afferent fibers from the bladder
  19. 19. SENSORY PARALYTIC BLADDER CONTI..PATHOGENESIS:Loss of bladder sensation, which leadsto overdistension of bladder.Initially there is normal capacityincreases and residual urine appears.CLINICAL FEATURES:Initially these patients areasymptomatic.Gradually there is terminal dribblingand later overflow incontinence.
  20. 20. 5. MOTOR PARALYTIC BLADDER ETIOLOGY: Poliomyelitis Polyradiculopathy Congenital anomalies Tumor Trauma Lesion : Efferent fibers of the bladder
  21. 21. MOTOR PARALYTIC BLADDER CONTI.. PATHOGENESIS: Since the sensory nerves are intact, bladder if left alone, distends and decompensates. CLINICAL FEATURES: Painful distention of the bladder and inability to initiate micturition. Decrease in size and force of steam and interrupted stream. Recurrent episodes of urinary infections.
  22. 22. INCONTINENCE OF URINEThe term ‘continence’ is used todescribe the normal ability of a personto store urine and faeces temporarily,with conscious control over the timeand place of micturition anddefaecation.‘Incontinence’ has been defined asthe involuntary or inappropriate passingof urine or faeces, or both, that has animpact on social functioning orhygiene(DoH 2000).
  23. 23. INCONTINENCE OF URINE Types:1. Extra urethral incontinence2.Detrusor overactivity incontinence3.Urodynemic stress incontinence4.Nocturnal enuresis5.Giggle incontinence6.Incontinence associaed with sexual activities7.Functional incontinance
  24. 24. 1.Extraurethral incontinenceLoss of urine through channelsother than the urethraCAUSEScongenital abnormality.trauma at pelvic surgery such ashysterectomyendometriosis,infection or carcinoma.Child birth(Wall 1999)
  25. 25. 2. Detrusor overactivity incontinence-present as a symptom, a sign and asa conditionThe symptoms: complains of urge incontinence,immediately preceded by urgency,that is a strong desire to void.
  26. 26. Detrusor overactivity incontinenceThe sign: conformed as a sign observedat urodynamic assessmentThe condition: May be further qualified asneurogenic, in neurological condition
  27. 27. 3.URODYNAMIC STRESS INCONTINENCE Symptom: during increased intra-abdominal pressure, such as during coughing, laughing, sneezing and lifting Sign: An involuntary spurt dribble or droplet of urine is observed to leave urethra immediately on an increase in intra-abdominal pressure
  28. 28. URODYNAMIC STRESS INCONTINENCECondition : in absence of detrusorcontraction
  29. 29. 4.NOCTURNAL ENURISISDuring sleep, or “bed wetting”15-20% of 5 year old children andup to 2% of young adults(Glazener&Evans 2003)
  30. 30. 5.GIGGLE INCONTINENCEIn girls around pubertyCaused by detrusor overactivityinduced by laughter(chandra et al2002)
  31. 31. 6.INCONTINENCE ASSOCIATED WITH SEXUAL ACTIVITY After following intercourse in young women postcoital dysuria  postmenopausal women dysuria, urgency and urinary tract infection Hilton(1988) found 24% of 324 sexually active women referred to gynaecological clinic experience incontinence – two third on penetration and one third on orgasm.
  32. 32. 7.FUNCTIONAL INCONTINENCEinvoluntary loss of urinein ability to perform toiletingfunctions secondary to physical ormental limitation
  33. 33. ReferencesP.J. mehta’s Practical MedicinePhysiotherapy in obstetrics andgynaecology, 2nd edition, jill mantleEssentials of medical physiology, 5thedition, K SembulingamB.D.Chaurasia’s human anatomy, 4theditionInternet

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