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Bladder Anatomy and Bladder Outlet Obstruction
This document provides an overview of bladder anatomy, function, and bladder outlet obstruction. It describes the key parts of the bladder including relations to other organs. Normal micturition and factors that assist storage are explained. Causes of bladder outlet obstruction include anatomical and functional issues. Common symptoms include hesitancy, weak stream, and urinary tract infections. Investigations help locate the site of obstruction and assess kidney and bladder function.
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Bladder Anatomy and Bladder Outlet Obstruction
- 1. Tutorial on Bladder OutflowObstruction K. Kavindya M. Fernando JMJ 1
- 2. Anatomy of thebladder • Made of whorls of smooth muscles, adapted for mass contraction • Distended bladder globular (ovoid) shape • Empty bladder three sided pyramid • Mean capacity of the bladder 220 ml • Relations • Apex • Base (posterior surface) • Inferolateral surface • Superior surface • Neck of the bladder JMJ 2
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- 5. JMJ 5 APEX • Directedtowards the top of the pubic symphysis • Attached to the uraches ( obliterated median umbilican ligaments) BASE (POSTERIOR SURFACE) • Upper part has peritoneal covering in males (recto vesical pouch) • Lower part has no peritoneal coverings • Males seminal vesicles & ductus differences are attached • Uterers enter bladder at superolaretal edge • Females firmly attached to the anterior vaginal wall with connective tissue INFERO-LATERAL SURFACES • Slopes downwards and medially • Lying against the pelvic diaphragm and obturator internus • Attached anteriorly to pubic bone (pubo vesical ligament) SUPERIOR SURFACE OF THE BLADDER • Covered by peritoneum • Distended bladder reaches the abdominal cavity, while stripping peritoneum from anterior abdominal wall NECK OF THE BLADDER • Base and inferior surface meet together • Pierced by urethra • Attached to the base of the prostate gland • Most fixed part • In females it is related to the pelvic fascia
- 6. Interior of thebladder • Empty bladder • Thick and folded mucus membrane • Distended bladder • Thin and stretched mucus membrane • Trigone of bladder • Lies in the posterior wall • Bounded by 2 ureteric orifices and internal urethral meatus • Least mobile part • Only slight increase in breath with distention of bladder • Mucus membrane is smooth & firmly adhere to the underlying mucus layer • Ureters pierce bladder wall obliquely to lie at the lateral extremity of trigone(flap valve to prevent reflux) JMJ 6
- 7. Ligaments of thebladder • True ligaments • Condensation of pelvic fascia around the neck and base of the bladder • Lateral true ligament • Lateral puboprostatic ligament • Medial puboprostatic ligament ( females; pubovesical) • Medial umbilical ligament • Posterior ligament of bladder JMJ 7
- 8. Ligaments of thebladder • False ligaments • These are peritoneal folds • They do not form any support to the bladder • Median umbilical fold • Medial umbilical fod • Lateral false ligament (formed by peritoneum of the perivesical fossa) • Posterior false ligament ( formed by peritoneum of sacrogenital folds) JMJ 8
- 9. Arterial supply tothe bladder • Mainly superior and inferior vesicle arteries • Branches of internal iliac artery • Small contribution from • Obturator artery • Inferior gluteal artery • Uterine artery • Vaginal artery JMJ 9
- 10. Venous drainage ofthe bladder • Do not follow arteries • From a plexus and drain to vesico-prostatic plexus • Then to internal iliac vein JMJ 10
- 11. Lymphatic drainage ofthe bladder • Runs along the arteries to • Internal iliac nodes • External iliac nodes JMJ 11
- 12. Nervous supply tothe bladder JMJ 12 PARASYMPATHETIC NERVES • Main motor supply • Via pelvic splanchnic nerves SYMPATHETIC NERVES • Vasomotor and inhibitory to the bladder muscle • From L1-2 via hypogastric and pelvic plexus • Supply • Superficial trigonal • Internal urethral sphincter (prevent reflux ejaculation of semen into bladder) SENSORY NERVES • Sensory nerves of bladder distention, • (bladder stretch receptors), • Travel along, Parasympathetic nerves to spinal cord (s1-2) • Pain from bladder stone travel along sympathetic and parasympathetic fibers to spinal cord
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- 14. Special features ofbladder that assist storage function • Transitional epithelium • Can be stretched without damage • Impermeable to salt and water • No exchange • Bladder smooth muscle • Plasticity • Spherical structure • Obeys laws of Laplace in filling • P – 2T=r JMJ 14
- 15. • First urgeto void is felt at a bladder volume of about 150ml • Marked sense of fullness – 400 ml • Micturition is a spinal autonomic neural reflex JMJ 15
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- 17. Micturition reflex • Stimulus- bladder volume of 300-400 ml • Receptors- bladder stretch receptors • Afferent - pelvic nerves • Central - spinal cord, segments S2-4 • Efferent - parasympathetic fibers (thru pelvic nerves) • Effector - detrusor muscle (contracts) • Perineal muscle relax • Internal and external sphincter reflex • Urine is expelled through urethra JMJ 17
- 18. After Urination •Female •urethraempties by gravity •Male •Empties urethra by contraction of bulbocavenosus muscle JMJ 18
- 19. Regulation • Tonic inhibitoryimpulses from higher centres keep external urethral sphincter closed • Voluntary control of micturition is acquired with age • Reflex can be voluntarily inhibited or facilitated by higher centres in brain • Brain stem • Cortex JMJ 19
- 20. Abnormalities of micturition •Damage to afferents – de afferentation • Damage to both afferents and efferents • Spinal cord transection JMJ 20
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- 22. Causes for BOO FUNCTIONAL •Detrusor- sphincter dyssynergia (DSD) • Primary bladder neck obstruction ANATOMICAL • Primary bladder neck obstruction MEN • Benign prostatic enlargement (BPH) • Urethral stricture FEMALE • Incontinence procedure (surgery for stress incontinence) JMJ 22
- 23. • Whatever theetiology, BOO produces compression or resistance upon the bladder outflow channel at any location from the bladder neck to urethral meatus. JMJ 23
- 24. Symptoms of BOO •May be minimal • Hesitancy, narrowing and diminished force of the urinary stream, terminal dribbling – typical features • Infections commonly occur • Increased frequency, urge incontinace, dysuria, passage of foul smelly urine • May precipitate acute retention JMJ 24
- 25. Signs of BOO •Loin tenderness may be present • An enlarged hydrinephrotic kidney may palpable • In acute or chronic urine retention, the enlarged bladder can be felt or percussed JMJ 25
- 26. Lower urinary tract symptoms(LUTS) OBSTRUCTIVE • Hesitancy • Sensation of incomplete bladder emptying • Diminished urinary stream • Post voiding urinary dribbling IRRITATIVE • Urinary urgency • Frequency of urination • Occasional dysuria • Nocturia JMJ 26
- 27. Investigations • Blood chemistriesto look for signs of kidney damage • Cystoscopy and retrograde urethrogram (x-ray) to look for narrowing of the urethra • Tests to determine how fast urine flows out of the body (uroflowmetry) • Tests to see how much the urine flow is blocked and how well the bladder contracts (urodynamic testing) • Ultrasound to locate the blockage of urine and find out how well the bladder empties • Urinalysis to look for blood or signs of infection in the urine • Urine culture to check for an infection JMJ 27
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