The urinary bladder is a tetrahedral shaped organ located in the pelvis. It has three surfaces and is composed of layers of muscles including the detrusor muscle. During storage, the bladder fills with urine while maintaining low pressure through relaxation of the detrusor and contraction of the internal urethral sphincter. During voiding, the detrusor contracts to increase pressure while the sphincter relaxes to allow urine outflow. Urinary incontinence can be stress-related from urethral hypermobility or urge-related from detrusor overactivity. Treatment depends on the type but may include lifestyle changes, medications, devices, bladder training, or surgery.

2. ANATOMY OF URINARY
BLADDER

3. 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)

4. 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

5. 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

6. ANATOMY OF URINARY
BLADDER (Cont…)
BLADDER NECK
 Muscle bundles are largely oblique or
longitudinal
 Little or no sphincteric action

7. Relations

8. 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

9. 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

10. 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

11. 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

12. NERVE SUPPLY

13. PHYSIOLOGY OF
MICTURATION
BLADDER FUNCTION
Storage of urine Voiding of urine

14. 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

15. 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

16. 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

17. MECHANISM OF URINARY
CONTINENCE (cont…)
During stress:
 Centripetal force of intra-abdominal pressure transmitted
to proximal urethra
 Reflex contraction of periurethral straited musculature

18. 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

19. 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

20. URINARY INCONTINENCE

21. 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

22. 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.

23. 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

24. 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

25. THANK YOU