ELIMINATION

Bowel and urine

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ELIMINATION URINARY FISIOLOGY
Urinary elimination depends on the coordinated
function of the kidneys, ureters, bladder, and
urethra.

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• Kidneys remove wastes (excess water
and byproducts of metabolism) from the
blood to form urine. Ureters transport
urine from the kidneys to the bladder.
The bladder stores urine until the urge
to urinate develops.
• Micturition (urination) occurs when a
complex neural response allows the
bladder to contract, the urethral
sphincter to relax, and urine to leave the
body through the urethra
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 UPPER URINARY
TRACT
Kidney

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• The kidneys lie on either side of the
vertebral column behind the peritoneum
and against deep muscles of the back.
• The kidneys extend from the twelfth
thoracic vertebra to the third lumbar
vertebra
• Normally, the left kidney is higher than
the right one because of the anatomical
position of the liver.

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• Waste products of metabolism that collect in the blood are filtered in the kidneys.
• Blood reaches each kidney by a renal (kidney) artery that branches from the abdominal aorta.
• The nephron is the functional unit of the kidney, where waste products are removed and urine
is formed.
• A cluster of blood vessels forms the capillary network of the glomerulus of the nephron, which
is the initial site of filtration of the blood and the beginning of urine formation.
• The glomerular capillaries permit filtration of water, glucose, amino acids, urea, creatinine, and

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major electrolytes. Large proteins and blood cells normally do not filter through the
glomerulus.
• The glomerulus filters approximately 125 millilitres (mL) of plasma per minute (180 litres [L]
per day). Most (99%) of the filtrate is reabsorbed into the plasma, with the remaining 1%
excreted as urine. The reabsorption process maintains fluid and electrolyte balance.
• Normal urine production ranges from 1 to 2 L per day and is affected by many factors,
including fluid intake and body temperature. An output of less than 30 mL per hour may
indicate renal alterations.
• The kidneys play a role in other functions including the production of red blood cells (RBCs),
blood pressure regulation, and bone mineralization. 5
• Renin, another hormone produced by the kidneys, plays a role in blood pressure control by
regulating renal blood flow via the renin–angiotensin–aldosterone system (RAAS).
• The kidneys also produce prostaglandin E2 and prostacyclin, which are important in maintaining
renal blood flow through vasodilation.
• The kidneys play a role in calcium and phosphate regulation by producing a substance that
converts vitamin D into its active form.

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URETERS
• Urine enters the renal pelvis from the collecting ducts and travels to the bladder through the
ureters.
• The ureters are tubular structures that enter the urinary bladder obliquely through the posterior
wall, at the ureterovesical junction (the juncture of the ureters and the bladder).
• Peristaltic waves cause urine to enter the bladder in spurts rather than steadily. Contraction of
the bladder compresses the ureters at the junction during micturition to prevent the reflux of
urine.

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 LOWER URINARY TRACT
Bladder
• The urinary bladder is a hollow, distensible muscular organ lined with uroepithelium that stores
and excretes urine. It is composed of the lower trigone base, lying between the ureter and
urethral openings, and the upper dome of the detrusor muscle.
• When empty, the bladder lies behind the symphysis pubis in the pelvic cavity. It rests against the
anterior wall of the rectum in men and against the anterior walls of the cervix and vagina in

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women.
• The bladder expands as it becomes filled with urine. When the bladder is full, it expands and
extends above the symphysis pubis. Contraction of the detrusor expels urine from the body.
URETHRA
• Urine travels from the bladder through the urethra (a fibromuscular tube) and passes outside of
the body through the urethral meatus. The urethra transverses the pelvic floor muscles, a layer
of skeletal muscle that stabilizes the urethra and forms part of the continence mechanism.

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• Circular smooth muscle and striated sphincter muscle (also known as the external sphincter, or
rhabdosphincter) in the urethra also contribute to closure between voids and aid in continence
• In women, the urethra is approximately 3–4 cm long. The male urethra is about 18–20 cm long.

ACT OF URINATION
• Urination, also known as micturition or voiding, is the process of bladder emptying. Micturition
requires simultaneous contraction of the bladder and relaxation of the outlet.

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• Neural control of voiding and continence is dependent on a complex flow of information
between the bladder, spinal cord, and brain, involving both autonomic and somatic nerves.
• Sensory nerves from the bladder and urethra carry efferent signals through the spinal reflex arc
and up the spinal cord to the pontine micturition centre in the brainstem.
• Afferent signals move back down, inhibiting sympathetic fibres of the hypogastric nerve
innervating the bladder and Onuf's nucleus in the sacral spinal cord where motor neurons
innervating the rhabdosphincter are located, resulting in relaxation of the sphincter and
contraction of the detrusor muscle.

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• As the child matures, voluntary control over bladder emptying develops with involvement of
• higher-level brain structures including the forebrain, allowing for suppression of the voiding
reflex. Forebrain circuits for safety, emotions, and societal propriety play a role in voluntary
micturition.
• Voluntary contraction of the pelvic floor muscles also plays a role in maintaining continence
• In adults, the first urge to void is usually felt when there is 250 to 300 mL of urine
accumulated in the bladder, with a strong urge at 500 mL.

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Factors Influencing Urination

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 Common Alterations in Urinary Elimination

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PLEASE FIND A COMMON ALTERATIONS IN
URINARY ELIMINATION !

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 BOWEL
Elimination

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 ELIMINATION BOWEL FISIOLOGY
The GI tract begins at the mouth and continues through to
the anus.

• The purposes of the GI tract are to ingest food,

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prepare food for both absorption and use by the
body's cells, and provide temporary storage of
feces.
• The mouth, esophagus, and stomach receive food,
and initial digestion occurs. The duodenum,
jejunum, and ileum are where most digestion and
absorption occurs. Finally, the cecum, colon, and
rectum store and then eliminate waste. The
salivary glands, liver, and pancreas are accessory
organs that aid digestion.
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MOUTH
• The mouth is the point of entry into the GI tract. The mouth mechanically and chemically
breaks down nutrients into usable sizes and forms. The teeth masticate food, breaking it
down into a soft, moist ball (a bolus) suitable for swallowing. Saliva, which is produced by the
salivary glands in the mouth, dilutes and softens the food in the mouth for easier swallowing
and commences digestion of carbohydrates. In addition, mucus from the salivary glands
lubricates the passage of the bolus through the pharynx and down the esophagus during
swallowing.

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 ESOPHAGUS
• The esophagus provides a conduit to the stomach through the chest cavity. The esophagus is a
straight tube about 25 cm in length. Smooth muscle layers of the esophagus provide the
peristaltic contraction to move food along its length. Its mucous membranes secrete mucus that
aids in the lubrication of food. Sphincter on either end of the esophagus prevent air from
entering the esophagus and stomach during breathing and reflux of stomach contents into the

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esophagus.

STOMACH
• The stomach performs several tasks: stroge of swallowed food and liquid, mixing of food with liquid and gastric
digestive juices, and the controlled emptying of its contents through the pyloric sphincter into the small intestine.
The stomach is a baglike structure located in the upper quadrant of the abdomen.
• Peristaltic and mixing contractions of the stomach are controlled by the intrinsic pacemaker activity of the
smooth muscle cells. The stomach is innervated by the enteric nervous system and connections to the
parasympathetic and sympathetic nervous systems. The emptying of the stomach is regulated by neural and
hormonal mechanisms.

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• The stomach produces two key GI hormones : gastrin and ghrelin. Gastrin stimulates gastric
acid secretion. Gherlin is newly discovered and has growth hormone-releasing activity
andstimulates food intake and digestion while reducing energy expenditures. Gastrin and
somatostatin regulate the secretion of acid and pepsin in the stomach.
• The stomach also secretes hydrochloric acid (HCl) and the intrinsic factor. HCl facilitates the
digestion of protein and is antibacterial.
• The rate at which the stomach empties depends on the content of the dissolved and partially
digested bolus (chyme).

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• Water diffuses from both the stomach and the small intestine and is emptied rapidly.
Carbohydrates are emptied only slightly more slowly, particularly if they are not strongly
acidic. Proteins empty even more slowly and in smaller amounts as determined by the acidity
of the chyme. Fats are emptied the slowest of all. The controlled emptying allows the
pancreatic secretions and bile to neutralize the chime and secrete enzymes for luminal
digestion

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 SMALL INTESTINE
• The small intestine consists of the duodenum, jejunum, and ileum. The duodenum is about 22 cm
long and connects the stomach to the jejunum. The duodenum also contains the opening for the
common bile duct and main pancreatic duct. The jejunum and ileum are over 7 m long and are
folded closely to fit in the abdomen.
• The duodenum continues to process the chyme from the stomach. The chyme that enters the
duodenum is acidic and contains partially digested protein, carbohydrates, and unemulsified fats.
The presence of these substances stimulates the release of the hormones secretin and

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cholecystokinin from the duodenal mucosa. Secretin stimulates the pancreas to secrete
bicarbonate to neutralize the acid. Cholecystokinin stimulates the pancreas to secrete the
following enzymes:
 amylases, which convert carbohydrates to disaccharides
 proteases, which further hydrolyze proteins into smaller peptides;
 lipases, which hydrolyze triglycerides into fatty acids and monoglycerides.

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• The second section of the small intestine, the jejunum, is approximately 2.7 m long. Its primary
function is the absorption of carbohydrates and proteins. The ileum, which is approximately 3.7
m long, specializes in the absorption of water, certain vitamins, iron, fats, and bile salts. Most
nutrients and electrolytes are absorbed in the small intestine, specifically by the duodenum and
the jejunum.
LARGE INTESTINE
• The lower GI tract is called the large intestine because it is larger in
diameter than the small intestine; however, at 1.5 to 1.8 m in length, it

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is much shorter. The large intestine is the primary organ of bowel
elimination and is divided into the cecum, the colon, and the rectum.
• Chyme from the terminal ileum enters the cecum of the large
intestine, propelled by waves of peristalsis through the ileocecal
sphincter, a circular muscle layer that regulates ileal emptying and
prevents regurgitation of fecal contents. After a meal, the gastroileal
reflex causes the terminal ileum to contract regularly, and the
sphincter opens with each contraction, thereby pushing the ileal
contents into the colon.
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• The colon is divided into the ascending, transverse, descending, and sigmoid colons. The colon's
muscular tissue allows it to accommodate and eliminate large quantities of waste and gas
(flatus). The colon has three functions: absorption, secretion, and elimination. Each day, a large
volume of water and significant amounts of sodium and chloride are absorbed by the colon.
• Two types of muscle contractions occur in the colon: slow-mixing contractions and mass
peristalsis (or mass movement). Slow-mixing contractions move contents through the colon
and expose the chyme to the mucosa, where active absorption of sodium and chloride causes
water absorption and dries the chyme to feces. Intestinal content is the main stimulus for the
slow-mixing contractions. Mass peristalsis movements then push the feces toward the rectum.

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The ingestion of food is the main stimulus for mass peristalsis, which is known as the
gastrocolic reflex. In adults, these mass movements occur only three or four times each day
• When the slow-mixing contractions increase and the mass peristalsis diminishes, water continues
to be absorbed and the feces dry out, resulting in constipation. Conversely, when the mixing
movements are decreased and the mass peristalsis is increased, the water has less time to be
absorbed, and the stool will be watery (diarrhea)

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• The secretory function of the colon aids in electrolyte balance. Bicarbonate is secreted in
exchange for chloride. Approximately 4 to 9 mmol of potassium is also excreted daily. Extreme
alterations in colon function (e.g., diarrhea) can cause severe electrolyte disturbances
• The volume of fluids absorbed by the GI tract is high. Oral fluid intake is approximately 1.2 L per
day; an additional 7 L of fluid enters from the blood as the result of the secretion of digestive
enzymes by the mucosa, liver, gallbladder, and pancreas, and by osmosis as the numbers of
molecules in the lumen increase by digestion. Absorption from the small and large intestine
amounts to 8.1 L per day, leaving 100 mL to be excreted in the feces. Therefore, maintaining fluid
and electrolyte balance is a key function of the GI system.

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ANUS AND RECTUM
• The rectum is the final portion of the large intestine. Normally, the rectum is empty of waste
products, or feces, until just before defecation. The rectum contains vertical and transverse folds
of tissue that may help to temporarily hold fecal contents during defecation. Each fold contains
an artery and vein that can become distended from pressure during straining. This distension can
result in the formation of hemorrhoids.

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• Feces and flatus are expelled from the rectum through the anal canal and the anus. Contraction
and relaxation of the internal anal sphincter is under autonomic (unconscious) control,
whereas the external anal sphincter is under somatic neural (conscious) control. The anal canal
is richly supplied with sensory and motor nerve fibres to help control continence. Additionally,
the maintenance of the acute anorectal angle formed by the puborectalis and levator ani (pelvic
floor) muscles plays a key role in continence.
• When feces enter the rectum, the internal anal sphincter relaxes and this enables the anal canal
to determine if the contents are solid or liquid. This action occurs concurrently with the
reflexive contraction of the external sphincter. Additionally, this contraction can be

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accompanied by a voluntary squeeze of the sphincter muscles. The rectum is able to hold feces
until their presence stimulates stretch receptors in the mucosa, producing an urge to defecate.
The patient then seeks out an appropriate place to defecate, assumes a squatting position to
straighten the anorectal angle, and voluntarily relaxes the external sphincter. Bearing down
tenses abdominal muscles. The pelvic floor muscles relax and the feces enter the lower rectum.
Involuntary propulsive contractions continue until the rectum is emptied. When the last of the
feces passes, the external anal sphincter reflexively closes.

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 Factors Affecting Normal Bowel Elimination
• Diet
• Fluid Intake
• Physical Activity
• Personal Bowel Habits

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• Privacy

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COMMON BOWEL ELIMINATION

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PLEASE FIND A COMMON ALTERATIONS IN URINARY
ELIMINATION !

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Thank
You
Jens Martensson
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