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.
CAPACITY OF THE BLADDERCapacity 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).
NERVE SUPPLYIts 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.
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
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
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
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
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
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
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.
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.
AUTONOMOUS BLADDER CONTI…CLINICAL FEATURES:Loss of bladder sensationInability to initiate micturitionnormallyparalysis of pariurethral striatedmusclesassociated with anesthesia andabsent bulbocavernous reflex.
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.
5. MOTOR PARALYTIC BLADDER ETIOLOGY: Poliomyelitis Polyradiculopathy Congenital anomalies Tumor Trauma Lesion : Efferent fibers of the bladder
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.
INCONTINENCE OF URINEThe 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).
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
1.Extraurethral incontinenceLoss of urine through channelsother than the urethraCAUSEScongenital abnormality.trauma at pelvic surgery such ashysterectomyendometriosis,infection or carcinoma.Child birth(Wall 1999)
2. Detrusor overactivity incontinence-present as a symptom, a sign and asa conditionThe symptoms: complains of urge incontinence,immediately preceded by urgency,that is a strong desire to void.
Detrusor overactivity incontinenceThe sign: conformed as a sign observedat urodynamic assessmentThe condition: May be further qualified asneurogenic, in neurological condition
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
URODYNAMIC STRESS INCONTINENCECondition : in absence of detrusorcontraction
4.NOCTURNAL ENURISISDuring sleep, or “bed wetting”15-20% of 5 year old children andup to 2% of young adults(Glazener&Evans 2003)
5.GIGGLE INCONTINENCEIn girls around pubertyCaused by detrusor overactivityinduced by laughter(chandra et al2002)
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.
7.FUNCTIONAL INCONTINENCEinvoluntary loss of urinein ability to perform toiletingfunctions secondary to physical ormental limitation
ReferencesP.J. mehta’s Practical MedicinePhysiotherapy in obstetrics andgynaecology, 2nd edition, jill mantleEssentials of medical physiology, 5thedition, K SembulingamB.D.Chaurasia’s human anatomy, 4theditionInternet