ANATOMY OF URINARY

BLADDER

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)

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

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

ANATOMY OF URINARY

BLADDER (Cont…)

BLADDER NECK

Muscle bundles are largely oblique or

longitudinal

Little or no sphincteric action

Relations

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

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

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

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

NERVE SUPPLY

PHYSIOLOGY OF

MICTURATION

BLADDER FUNCTION

Storage of urine Voiding of urine

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

Voluntary control of intrinsic & extrinsic urethral muscles

PHYSIOLOGY OF MICTURATION

(cont…)

Voiding phase:

When the volume of bladder reaches 250ml., a sensationof bladder filling is perceived

Spinal arc in adults is under control of hypothalamus andfrontal lobe of brain

When time & place is convenient hypothalamus nolonger inhibits detrusor

Detrusor contracts to raise intravesical pressure to 30-50then to 100 cm of H2O

Complete loss of urethrovesical angle

Funneling of bladder neck & upper urethra

Voiding starts

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

MECHANISM OF URINARY

CONTINENCE (cont…)

During stress:

Centripetal force of intra-abdominal pressure transmitted

to proximal urethra

Reflex contraction of periurethral straited musculature

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

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

URINARY INCONTINENCE

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

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 areFDA approved

Surgical treatment- Fixation of bladder neck & proximalurethra to prevent its undue moblility & its decent.

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

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

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