MICTURITION INTRODUCTION * Micturition, a process by which urinary bladder empties when it becomes filled ° 2-steps: 1. Filling of bladder progressively until tension in its walls rises above a threshold level 2. Micturition reflex, nervous reflex to void the bladder or a conscious desire to urinate * Can be controlled voluntarily to some extent except in young children.FUNCTIONAL ANATOMY OF URINARY BLADDER(' ‘uB) UB consist of body, neck & internal urethral sphincter. Body : main part where urine is collected Neck : funnel shaped extension of body,connecting urethra with Internal sphincter(Posterior urethra ) a Ax Detrusor muscle(DM), smooth muscle & Cc» in the body of UB =) 3 layers in DM 1. Middle circular layer i 2. Outer longitudinal layer 3. Internal longitudinal layer+ DM fibers extend in all directions and when contracted, can increase pressure in bladder to 40 -60 mmHg * Contraction of DM is a major step in emptying the UB * Smooth muscle cells of DM fuse with one another so that low - resistance electrical pathways exist from one muscle cell to another * So an Action potential can spread throughout the DM cells and entire UB can be contracted at once+ TRIGONE, a small triangulararea on the posterior wall of UB just above bladder neck + 2-uretersopen at 2 upper angles of Trigone and lower angle open at bladder neck + Mucosa of Trigone is smooth whereas remaining bladder mucosa is folded to form rugae* Bladder neck is 2-3 cm long and its wall is composed of DM interlaced with a large amount of elastic tissue which form Internal sphincter * Urogenital Diaphragm separates the Bladder neck and urethra * Voluntary skeletal muscle present in Urogenital diaphragm forms the External sphincter which is under voluntary control of nervous systemNERVE SUPPLY TO URINARY BLADDER & SPHINCTERS P; thet Bympatiatc herve arasympalhelic neve Urinary bladder & Internal L S& sphincter are supplied by i Ss, sympathetic & 2 Ss, parasympathetic divisions of . ANS. Sympathetic ~~~ Pelvic nerve chain Hypogastric ~~ Hypogastric ganglion ganglion Hypogastric -—- Ss, nerve 2 Internal ~ s * External sphincter is supplied sphincler Ss, by the somatic nerve fibers. Urethra ~ en — Pudendal nerve Somatic nerveFUNCTIONS OF SYMPATHETIC NERVE ‘Sympathetic nerve Parasympathetic nerve Sympathetic ~Pelvic nerve chain Hypogastric —... -—-~ Hypogastric ganglion ganglion Hypogastric ————~ s, nerve Intemal S sphincter S Urethra ~~ i; Exteel —- Pudendal nerve sphincter ‘Somatic nerve * Stimulation of sympathetic nerve causes relaxation of detrusor muscle and constriction of internal sphincter. ¢ Itresults in filling of Urinary bladder + Sympatheticnerve “Nerve of filling”.2. PARASYMAPATHETIC NERVE SUPPLY Sympathetic nerve Parasympathetic nerve s L, : L ‘ (2 5 Sympathetic —- --= Pelvic nerve chain Hypogastric ~~ Hypogastric ganglion ganglion Hypogastric ~~ s, nerve Internal ~~~ Ss; sphincter s, Urethra External sphincter Pudendal nerve Somatic nerve * Preganglionic fibers of parasympathetic nerves form Pelvic nerve (Nervous Erigens). * Pelvic nerve fibers arise from Sy, S3, &S,4 of spinal cord. * These fibers run through Hypo gastric ganglion & synapse with postganglionic neurons in Urinary bladder & Internal sphicter.FUNCTIONS OF PARASYMPATHETIC NERVE ‘Sympathetic nerve Hypogastric __{ 4 Internal sphincler Urethra ---—~ External ~~ sphincter Parasympathelic nerve }-—~Hypogastric ganglion i Pudendal nerve Somatic nerve + Stimulation of parasympathetic nerve causes contraction of Detrusor muscle and relaxation of Internal sphincter resulting to emptying of Urinary bladder & micturition. . Therefore parasympathetic nerve is called “ Nerve of Micturition”. * Pelvic nerve has some sensory fibers to carry impulses from stretch receptors of Urinary bladder & urethra to CNS .3. SOMATIC NERVE SUPPLY ‘Sympathetic nerve Parasympathetic nerve + External shincter is innervated by somatic L | & nerve called Pudendal nerve Ss (2 8, Sympathetic —~ (/p~Pelvic nerve Y/ )--—~ Hypogastric ganglion ganglion * Itarises from $1,S3& S,of spinal cord Internal sphincler Urethra External sphincter Pudendal nerve Somatic nerveFUNCTIONS OF PUDENDAL NERVE Sympathelic nerve Parasympathelic nerve L, | ® L Sy 2 Ss ‘Sympathetic ~~ ( ~ Pelvic nerve chain LD Hypogastric ~~~ Hypogastric ganglion ganglion Hypogastric ~~ nerve Internal sphincter Urethra ——— i i External ~~ Pudendal nerve Sphincter Somatic nerve * It maintains tonic contraction of skeletal muscle fibers of EUS and keeps the EUS constricted always. * During micturition Pudendal nerve is inhibited causing relaxation of External shincter. This results in voiding of urine. * Thus this nerve is responsible for voluntary control of micturition.FILLING OF URINARY BLADDER PROCESS OF FILLING * Urine is continuously formed in nephrons and is transported into Urinary bladder through ureters. * Collected urine in the pelvis of ureter reaches the Urinary bladder through ureters in the form of peristaltic wave. + The wave develops at a frequency of 1-5/min and velocity of 3 cm/sec.Contd... * Avalvular arrangement is present at the entrance of ureters into Urinary bladder to prevent back flow of urine. * About 300- 400ml of urine can be stored in UB without any discomfort and much increase in intravesical pressure.MICTURITION REFLEX * Micturition occurs due to reflex Sympathetic nerve Parasympatheicneve — mechanism \ & |e [2] S, + Stretch receptors of UB stimulated when S, about 400 ml of urineis collected — generation of sensory impulses. Sympabeic Pehic nave Hypogastric Hypooastic * Sensoryimpulses from these receptors ganglion ganglion reach the sacral segment of spinal cord typogaste via sensory fibers of pelvic nerve i.e. nerve: parasympathetic. Internal ————— sphincer s + Motor impulses produced in Spinal cord Urethra ——-~ travel through motor fibers of pelvic nerve towards UB &IUS. sphincter Pudendal nerve Somatic nerve * Motor impulses causes contraction of Detrusor muscle and relaxation of IUS : thaturine enters the urethra from the U)* When urine reaches urethra, stretch receptors ‘Sympathetic nerve Porasympathetcneve are stimulated and send sensory impulses to L ms spinal cord via pelvic nerve fibers. u % V3 s, Sympathetic chain (7}~-Pevicneve » These impulses inhibit Pudendal nerve activities He f and EUS relaxes causing micturition. wos — Bigot) tone Hypogastric 5 nerve “|® Internal ——— s * Once micturition starts, it is auto regulated i.e. sphineter 7 5 initial contraction of UB further activates Veta —— bs receptors tocause still further increase in External ——~ sensory impulses from UB & urethra. sphincter Pudendal neve Somatic nerve* These impulses in turn cause further increase in reflex contraction of UB. * The cycle of stimulation continues repeatedly until force of contraction of UB reaches maximum and _ urine is voided out completely. * Flowofurine during micturition is also facilitated by voluntary contraction of abdominal muscles.Role of Higher centers in micturition * Spinal centers for micturition are presentin e wr =—t \ianrree _sacraland lumber segments of Spinal Cord. ote: mato pao a — eon et mk ieee san + These spinal centers are further regulated by a a highercenters of brain to control the = micturition. * The higher centers are of two types: @syrpere| vd + Inhibitory center sa * Facilitatorycenter =| * The centersin Midbrain & Cerebral cortex inhibit micturition by suppressing Spinal micturition centers. * The centers in Pons & Cerebral cortex facilitate micturition via spinal center.CYSTOMETROGRAM * CYSTOMETRY- Technique to demonstrate the relationship between intravesical pressure and volume of urine in the bladder. * CYSTOMETROGRAI- Graphical recording of pressure changes in UB in relation to rise in volume of urine collected in it. Volume mtMethod of recording Cystometrogram + Adouble lumen catheter is introduced into the UB * One of the lumen is used to infuse fluid into the UB and other one is used to record the pressure changes by connecting to a recorder. * Subject is asked to empty the UB completely anda small & known quantity of fluid is introduced into the UB at regular intervals.+ The intravesical pressure developed by the fluid is recorded continuously. * Agraph is obtained by plotting all the values of volume & pressure i.e. Cystometrogram as shown. 0 100 200 0 40 500 6m 700 Velume— mi,Cystometrogram in detail : Cystometrogram shows 3 Segments SEGMENT-/ * The intravesicular pressure is O, when UB is empty. * When about 100 ml of fluid is collected the © 100 200 300 400 500 600 700 pressure rises sharply to about 10 cm H,0. Volume = mi.SEGMENT -II + Shows a plateau phase * Here the intravesicular pressure remains at about 10 cm H,0 without any change even after introducing 300-400 ml of fluid . * Itis possible due to elasticity and adaptation of UB to relax. It follows the law of Laplace. 0 100 mo 300 00 500 600 700 Vourne =m + Lawof Laplace states the pressure ina spherical organ is inversely proportion to its radius, tone remaining constant.SEGMENT- Ill * The contraction of detrusor muscle becomes more and more intense when fluid in UB exceeds 400 ml and urge for micturition starts. * When intravesical pressure rises above 40 cm water pain sensation starts due to intense contraction of detrusor muscle and voluntary control is not possible. 0 100 200 300 400 $00 600 700 Volume = mtApplied Physiology in micturition 1. ATONIC BLADDER is Occurs due to loss of tone in Detrusor muscle caused by destruction of sensory nerve fibers i.e. Pelvic nerve of UB, » Here UB is filled up with urine without any stretch signals to spinal cord. * As Detrusor muscle loses tone it becomes flaccid. . Due to lack of micturition contraction, the urir overflows when UB is completelyfilled.. This condition is also called Overflow incontinence, Overflow dribbling or Flaccid neurogenic bladder. I Itoccurs in 1* stage of spinal shock after complete T.S. of Spinal cord above sacral segment. = Atonic bladder can occur in spinal injury or Tabes dorsolis of syphilis.AUTOMATIC BLADDER Occurs due to hyperactive micturition reflex where voluntary control of micturition is lost. Here, the mictutrition reflex starts even with small amount of urine collected in the UB. It occurs during 2 stage of spinal shock after complete transection of spinal cord. 24 stage is recovery period where micturition reflex returns but voluntary control is lost du to lack of higher control by the Brain.Female Urinary Bladder and Urethra THE UNINHIBITED NEUROGENIC BLADDER Occurs due to lesions in Brainstem causing frequentand uncontrollable micturition. Due to continuous excitation of spinal micturition centers, even a small quality of urine in UB will elicit micturition reflex. Itis also called Spastic neurogenic bladder or Hyperactive neurogenic bladder.4. Nocturnal Micturition (enuresis) + Also called bed wetting, occurs in infants and children below 3 yrs. * Itoccurs due to incomplete myelination of motor nerve fibers of UB. * After the complete myelination of nerves, voluntary control of micturition develops & Enuresis stops usually, vewesruttertockeam «79882806 + If Enuresis continues even after 3 yrs it is abnormal & may develop due to lumbosacial vertebral defects, psychological factors or some lesionsin motor area of the Brain.