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Functional Anatomy and Innervation of the Urinary Tract Ho Siew Hong Consultant Urologist S H Ho Urology & Laparoscopy Cen...
Function of the Micturation System <ul><li>Passive reservoir for temporary storage of urine </li></ul><ul><li>Active funct...
Anatomy of Micturation System <ul><li>Bony pelvis </li></ul><ul><li>Pelvic viscera – bladder, urethra, prostate </li></ul>...
Pelvis Female Male
Bony Pelvis - Female <ul><li>Gynaecoid shaped </li></ul><ul><li>More capacious </li></ul><ul><li>Ligaments are influenced ...
Bladder <ul><li>Storage </li></ul><ul><li>low pressure </li></ul><ul><li>capacity 300 – 500 cc </li></ul><ul><li>Good vasc...
Bladder <ul><li>Bladder neck, internal urethral orifice </li></ul><ul><li>Ureteric orifice </li></ul><ul><li>Trigone </li>...
Bladder Comparison <ul><li>Clinical correlation </li></ul><ul><li>Shorter urinary tract in females </li></ul><ul><li>More ...
Urethra <ul><li>Shorter, 4cm length, 1 cm diameter </li></ul><ul><li>More exposed to ascending infections </li></ul><ul><l...
Urethra - Male <ul><li>Tightest at fossa navicularis </li></ul><ul><li>‘ S’ shape, bend at peno-scrotal junction and bulba...
Prostate Gland <ul><li>‘ Flush of Youth’ </li></ul><ul><li>Benign Prostatic Hyperplasia sets in at 55 years </li></ul><ul>...
Sphincter Unit - Female <ul><li>Internal sphincter at bladder neck – smooth muscle </li></ul><ul><li>External sphincter - ...
Sphincter Unit - Male <ul><li>Internal sphincter at bladder neck – prevents retrograde ejaculation </li></ul><ul><li>Exter...
Pelvic Floor
Pelvic Floor Female Male
Function of the Pelvic Floor <ul><li>Support pelvic visera </li></ul><ul><li>Allow passage of nerves, waste products, ie. ...
Pelvic Support <ul><li>Bone components </li></ul><ul><li>Muscular components </li></ul><ul><li>Ligamentous components </li...
Pelvic Floor –  continence in females ‘ Buttress effect’ ‘ Hammock effect’
Pelvic Floor - Female Both slow and fast twitch fibres <ul><li>Clinical correlation </li></ul><ul><li>Pelvic floor exercis...
Innervation of the Urinary Tract and Physiology of Micturition
Filling Phase <ul><li>Bladder distends without rise in intra-vesicle pressure </li></ul><ul><li>sphincter unit contracts a...
Voiding Phase <ul><li>Bladder contracts and expels urine </li></ul><ul><li>Sphincter unit relaxes and urethra opens </li><...
Innervation of  Micturation System <ul><li>Parasympathetic (S2-S4) – pelvic plexus, supplying bladder and sphincter </li><...
Control Of Micturation  - filling phase Autonomic Nervous System Spinal cord Bladder, relaxed Sphincter, closed sensory po...
Control Of Micturation  - micturation phase <ul><li>Clinical correlation -  UTI   </li></ul><ul><li>bladder and urethra ir...
Control of Micturation - input from higher centres Sphincter, activated, open Bladder, activated, contracts cortex pons Sp...
Control of Micturation - input from higher centres Sphincter, activated, open Bladder, activated, contracts cortex pons Sp...
Higher Center Modifications <ul><li>Voiding can be initiated or inhibited by higher center control of the external sphinct...
Control of Micturation - input from higher centres Sphincter, activated, open Bladder, activated, contracts cortex pons Sp...
Conclusion <ul><li>Lower urinary tract functions to store urine and expel urine </li></ul><ul><li>Innervation of lower uri...
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Functional Anatomy and Innervation of Urinary Tract

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Dr Ho Siew Hong lectured on the anatomy and innervation of the urinary tract with special emphasis on clinical relevance during the 3rd Japan ASEAN Conference 08

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Functional Anatomy and Innervation of Urinary Tract

  1. 1. Functional Anatomy and Innervation of the Urinary Tract Ho Siew Hong Consultant Urologist S H Ho Urology & Laparoscopy Centre Gleneagles Hospital With Clinical References
  2. 2. Function of the Micturation System <ul><li>Passive reservoir for temporary storage of urine </li></ul><ul><li>Active function of eliminating urine from the reservoir at an appropriate time </li></ul>
  3. 3. Anatomy of Micturation System <ul><li>Bony pelvis </li></ul><ul><li>Pelvic viscera – bladder, urethra, prostate </li></ul><ul><li>Sphincter unit </li></ul><ul><li>Pelvic floor </li></ul>
  4. 4. Pelvis Female Male
  5. 5. Bony Pelvis - Female <ul><li>Gynaecoid shaped </li></ul><ul><li>More capacious </li></ul><ul><li>Ligaments are influenced by female hormones </li></ul>Bony Pelvis - Male <ul><li>Android shaped </li></ul>
  6. 6. Bladder <ul><li>Storage </li></ul><ul><li>low pressure </li></ul><ul><li>capacity 300 – 500 cc </li></ul><ul><li>Good vascularity, innervated </li></ul><ul><li>Voiding </li></ul><ul><li>Strong detrusor contraction </li></ul><ul><li>Clinical correlation </li></ul><ul><li>Minimal sensation till filling of 150cc </li></ul><ul><li>Maximal capacity 300-500cc </li></ul><ul><li>Rises from pelvis in to abdomen during filling, bladder only palpable when adequately filled </li></ul>
  7. 7. Bladder <ul><li>Bladder neck, internal urethral orifice </li></ul><ul><li>Ureteric orifice </li></ul><ul><li>Trigone </li></ul><ul><li>Dome </li></ul><ul><li>3 layers – mucosa, muscle, serosa </li></ul><ul><li>Clinical correlation </li></ul><ul><li>Bladder muscle hypertrophy in overactive bladder </li></ul><ul><li>Unwanted / uncoordinated contraction -> urge incontinence </li></ul><ul><li>Incompetent valves in ureteric orifices results in reflux of urine into kidney </li></ul>
  8. 8. Bladder Comparison <ul><li>Clinical correlation </li></ul><ul><li>Shorter urinary tract in females </li></ul><ul><li>More susceptible to ascending infections </li></ul>
  9. 9. Urethra <ul><li>Shorter, 4cm length, 1 cm diameter </li></ul><ul><li>More exposed to ascending infections </li></ul><ul><li>Longer, 20 cm length, 1 cm diameter </li></ul><ul><li>Less likely for ascending infections </li></ul><ul><li>Challenge to catheterize </li></ul><ul><li>Clinical correlation </li></ul><ul><li>Female catheterization is more straight forward, less likely hood of trauma </li></ul><ul><li>Shorter catheters (e.g. CISC) </li></ul>
  10. 10. Urethra - Male <ul><li>Tightest at fossa navicularis </li></ul><ul><li>‘ S’ shape, bend at peno-scrotal junction and bulbar urethra </li></ul><ul><li>Subjected to compression from and enlarging prostate </li></ul><ul><li>Clinical correlation </li></ul><ul><li>Keep penis perpendicular to body during catheterization, overcoming the first bend </li></ul><ul><li>Care when reaching bulbar urethra – highest likely hood of trauma due to bend and non relaxation of external sphincter </li></ul>
  11. 11. Prostate Gland <ul><li>‘ Flush of Youth’ </li></ul><ul><li>Benign Prostatic Hyperplasia sets in at 55 years </li></ul><ul><li>Compression of prostatic urethra </li></ul><ul><li>Clinical correlation </li></ul><ul><li>Commonest cause of urinary tract obstruction in males – enlarged prostate </li></ul><ul><li>Enlarged prostate not likely to obstruct catheterization </li></ul>
  12. 12. Sphincter Unit - Female <ul><li>Internal sphincter at bladder neck – smooth muscle </li></ul><ul><li>External sphincter - not well defined structure, slow twitch voluntary muscle </li></ul><ul><li>Almost entire length of urethra with fibers concentrated at mid urethra </li></ul>
  13. 13. Sphincter Unit - Male <ul><li>Internal sphincter at bladder neck – prevents retrograde ejaculation </li></ul><ul><li>External sphincter clearly defined at level of membranous urethra – urinary continence </li></ul><ul><li>Clinical correlation </li></ul><ul><li>Retrograde ejaculation after TURP surgery – disruption of internal urinary sphincter </li></ul><ul><li>Risk of urinary incontinence after radical prostatectomy surgery (stress incontinence) but not likely after TURP surgery </li></ul>
  14. 14. Pelvic Floor
  15. 15. Pelvic Floor Female Male
  16. 16. Function of the Pelvic Floor <ul><li>Support pelvic visera </li></ul><ul><li>Allow passage of nerves, waste products, ie. Urine and faeces </li></ul>
  17. 17. Pelvic Support <ul><li>Bone components </li></ul><ul><li>Muscular components </li></ul><ul><li>Ligamentous components </li></ul>
  18. 18. Pelvic Floor – continence in females ‘ Buttress effect’ ‘ Hammock effect’
  19. 19. Pelvic Floor - Female Both slow and fast twitch fibres <ul><li>Clinical correlation </li></ul><ul><li>Pelvic floor exercise – fast and slow contractions </li></ul><ul><li>Different set of exercises for bladder (continence), uterus + rectum (prolapse) </li></ul>
  20. 20. Innervation of the Urinary Tract and Physiology of Micturition
  21. 21. Filling Phase <ul><li>Bladder distends without rise in intra-vesicle pressure </li></ul><ul><li>sphincter unit contracts and closes urethra </li></ul>Bladder
  22. 22. Voiding Phase <ul><li>Bladder contracts and expels urine </li></ul><ul><li>Sphincter unit relaxes and urethra opens </li></ul>Bladder
  23. 23. Innervation of Micturation System <ul><li>Parasympathetic (S2-S4) – pelvic plexus, supplying bladder and sphincter </li></ul><ul><li>Sympathetic (T10-L2) – supplying bladder base, internal sphincter, proximal urethra </li></ul><ul><li>Somatic (S2-S3) – pudendal nerve, supplying external sphincter </li></ul><ul><li>Somatic afferent in pudendal nerve </li></ul><ul><li>Visceral afferent in autonomic system </li></ul>
  24. 24. Control Of Micturation - filling phase Autonomic Nervous System Spinal cord Bladder, relaxed Sphincter, closed sensory pons cortex
  25. 25. Control Of Micturation - micturation phase <ul><li>Clinical correlation - UTI </li></ul><ul><li>bladder and urethra irritation </li></ul><ul><li>Uninhibited contraction of detrusor muscles due to facilitation of micturition reflex </li></ul><ul><li>Resulting in urinary frequency, leakage </li></ul>Micturition Reflex Sphincter, activated, open sensory cortex pons Spinal cord, S 2,3,4 Bladder, activated, contracts motor
  26. 26. Control of Micturation - input from higher centres Sphincter, activated, open Bladder, activated, contracts cortex pons Spinal cord Other muscle groups <ul><li>Clinical correlation - Spinal cord injury </li></ul><ul><li>Uninhibited contraction of detrusor muscles and non relaxation of sphincter due to lack of inhibition of higher centre </li></ul><ul><li>‘ Neurogenic bladder’- high pressure bladder </li></ul>
  27. 27. Control of Micturation - input from higher centres Sphincter, activated, open Bladder, activated, contracts cortex pons Spinal cord Other muscle groups <ul><li>Clinical correlation - Pelvic nerve injury in pelvic surgery </li></ul><ul><li>Loss of detrusor muscle contraction </li></ul><ul><li>Large, non contracting bladder – Acontractile bladder </li></ul><ul><li>Urinary retention with overflow incontinence </li></ul>
  28. 28. Higher Center Modifications <ul><li>Voiding can be initiated or inhibited by higher center control of the external sphincter </li></ul>
  29. 29. Control of Micturation - input from higher centres Sphincter, activated, open Bladder, activated, contracts cortex pons Spinal cord Other muscle groups <ul><li>Clinical correlation - Cerebral vascular accident (CVA) / Stroke </li></ul><ul><li>Loss of ‘fine’ tuning from higher centers </li></ul><ul><li>Micturition reflex intact </li></ul><ul><li>Mixed presentation of incontinence and retention </li></ul>
  30. 30. Conclusion <ul><li>Lower urinary tract functions to store urine and expel urine </li></ul><ul><li>Innervation of lower urinary tract is complex but can be simplified as a micturition reflex with modification from higher center </li></ul><ul><li>Good understanding of anatomy and innervation can assist our understanding of many clinical conditions </li></ul>
  31. 31. Thank you

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