MICTURITION

Dr. Akin Olanipekun

OUTLINE

1. Introduction/Definition.
2. Urinary Bladder.
3. Physiologic-anatomy of Urinary Bladder and sphincters.
4. Innervation of Urinary Bladder and sphincters
5. Filling of Urinary Bladder.
6. Cystometrogram.
7. Micturition Reflex.
INTRODUCTION
• Micturition is the process by which the urinary bladder empties when it
becomes filled.
• This process involves two main steps:
– First, the bladder fills progressively until the tension in its walls rises above a
threshold level.
– This tension elicits the second step, which is a nervous reflex called the
micturition reflex that empties the bladder.
• Although the micturition reflex is an autonomic spinal cord reflex, it can
also be inhibited or facilitated by centers in the cerebral cortex or brain
stem.
Urinary Bladder

• Urinary bladder is a triangular hollow organ located in lower abdomen.

• The urinary bladder is a storage sac for urine, and its shape is determined by
the amount of urine it contains.
• An empty urinary bladder is pyramidal; as it fills, it becomes ovoid and bulges
upward into the abdominal cavity.
• The ureters enter the urinary bladder through the detrusor muscle in the
trigone region of the bladder.
• The urinary bladder is drained inferiorly by the tubular urethra.
 Physiologic-Anatomy of Urinary Bladder

• The urinary bladder is a smooth muscle chamber composed of two main parts:
– The body, which is the major part of the bladder in which urine collects, and
– The neck, which is a funnel-shaped extension of the body, passing inferiorly and
anteriorly into the urogenital triangle and connecting with the urethra.
• The smooth muscle of the bladder is called the detrusor muscle. Contraction of
the detrusor muscle is a major step in emptying the bladder.
• On the posterior wall of the bladder, lying immediately above the bladder neck, is
a small triangular area called the trigone.
• At the lowermost apex of the trigone, the bladder neck opens into the posterior
urethra and the two ureters enter the bladder at the uppermost angles of the
trigone.
• Each ureter, as it enters the bladder, courses obliquely through the detrusor

muscle and then passes another 1 to 2cm beneath the bladder mucosa
before emptying into the bladder.
• Inner surface of urinary bladder is lined by mucus membrane.

• In empty bladder, the mucosa falls into many folds called rugae.

• The bladder epithelium is made up of a superficial layer of flat cells and a

deep layer of cuboidal cells.

 Internal and external Sphincters
1. Internal urethral sphincter:
1. This sphincter is situated between neck of the bladder and upper end of urethra.
2. It is made up of smooth muscle fibers and formed by thickening of detrusor muscle.
3. It is innervated by autonomic nerve fibers.
4. It prevents emptying of the bladder until the pressure in the main part of the bladder
rises above a critical threshold.
2. External urethral sphincter:
1. This sphincter is located in the urogenital diaphragm.
2. This sphincter is made up of circular skeletal muscle fibers, which are innervated by
somatic nerve fibers.
3. The external sphincter muscle is under voluntary control of the nervous system
4. Consciously prevent urination even when involuntary controls are attempting to empty
the bladder.
 Innervation of Urinary Bladder

• Urinary bladder and the internal urethra

sphincter are supplied by sympathetic

and parasympathetic divisions of
autonomic nervous system.
• The external urethra sphincter is

supplied by the somatic nerve fibers.

Sympathetic Nerve

• Preganglionic fibers of sympathetic nerve arise from L1,L2 and L3 of spinal

cord.
• After leaving spinal cord, the fibers pass through lateral sympathetic chain a
and finally terminate in hypogastric ganglion.
• The postganglionic fibers arising from this ganglion form the hypogastric
nerve, which supplies the detrusor muscle and internal sphincter.
Function of Sympathetic Nerve
• Relaxation of detrusor muscle
• constriction of the internal urethra sphincter.
• It results in filling of urinary bladder and so, the sympathetic nerve is called
nerve of filling.
 Parasympathetic Nerve
• Preganglionic fibers of parasympathetic nerve form the pelvic nerve.
• Pelvic nerve fibers arise from S2, S3 and S4 of spinal cord.
• These fibers run through hypogastric ganglion and synapse with postganglionic
neurons situated in close relation to urinary bladder and internal sphincter
Function of Parasympathetic Nerve
• Contraction of detrusor muscle.
• Relaxation of the internal sphincter leading to emptying of urinary bladder.
• Parasympathetic nerve is called the nerve of emptying or nerve of micturition.
 Somatic Nerve

• External sphincter is innervated by the somatic nerve called pudendal nerve.

It arises from S2, S3 and S4 of spinal cord.
Functions of Pudendal Nerve
• Pudendal nerve maintains the tonic contraction of the skeletal muscle fibers
of the external sphincter and keeps the external sphincter constricted always.
• During micturition, this nerve is inhibited, this leads to relaxation of external
sphincter leading to voiding of urine.
• Thus, the pudendal nerve is responsible for voluntary control of micturition
 Filling of Urinary Bladder
• The walls of the ureters contain smooth muscle arranged in spiral, longitudinal,
and circular bundles.
• Regular peristaltic contractions of ureter occurring one to five times per minute
move the urine from the renal pelvis to the bladder.
• The ureters pass obliquely through the bladder wall.
• At the entrance of ureters into urinary bladder, a valvular arrangement is present.
• When peristaltic wave pushes the urine towards bladder, this valve opens towards
the bladder.
• The position of ureter and the valvular arrangement at the end of ureter prevent
the back flow of urine from bladder into the ureter when the detrusor muscle
contracts.
• Thus, urine is collected in the urinary bladder drop by drop.
Cystometrogram

• Cystometrogram is the graphical recording of pressure changes in urinary

bladder in relation to volume of urine collected in it.
• A plot of intravesical pressure against the volume of fluid in the bladder is
called a cystometrogram
• Cystometry is the technique used to study the relationship between
intravesical pressure and volume of urine in the bladder.
 Cystometogram

• When there is no urine in the bladder,

the intravesicular pressure is about 0.
• By the time 30 to 50 milliliters of urine
have collected, the pressure rises to 5
to 10 centimeters of water.
• Additional urine—200 to 300mls—can
collect with only a small additional rise
in pressure; this constant level of
pressure is caused by intrinsic tone of
the bladder wall.
• Beyond 300 to 400mls, collection of
more urine in the bladder causes the
pressure to rise rapidly.
 Micturition Reflex
• Micturition reflex is the reflex by which micturition occurs.
• This is the nervous reflex that empties the bladder.
• Although the micturition reflex is an autonomic spinal cord reflex, it can also be
inhibited or facilitated by centers in the cerebral cortex or brain stem.
• This reflex is elicited by the stimulation of stretch receptors situated on the wall
of urinary bladder and urethra.
• When about 300 to 400 mL of urine is collected in the bladder, intravesical
pressure increases.
• This stretches the wall of bladder resulting in stimulation of stretch receptors
and generation of sensory impulses.
• Once a micturition reflex begins, it is self-regenerative.
Micturition reflex
Facilitation or Inhibition of Micturition by the Brain

The micturition reflex is an autonomic spinal cord reflex, but it can be

inhibited or facilitated by centers in the brain. These centers include:
1. Strong facilitative and inhibitory centers in the brain stem, located mainly in
the pons.
2. Several centers located in the cerebral cortex that are mainly inhibitory but
can become excitatory.
The micturition reflex is the basic cause of micturition, but the higher
centers normally exert final control of micturition as follows:
1. The higher centers keep the micturition reflex partially inhibited, except when
micturition is desired.
2. The higher centers can prevent micturition, even if the micturition reflex
occurs, by tonic contraction of the external bladder sphincter until a
convenient time presents itself.
3. When it is time to urinate, the cortical centers can facilitate the sacral
micturition centers to help initiate a micturition reflex and at the same time
inhibit the external urinary sphincter so that urination can occur
Applied Physiology (Abnormalities of Micturition)

1. Atonic Bladder and Incontinence Caused by Destruction of Sensory

Nerve Fibers.
2. Automatic Bladder Caused by Spinal Cord Damage Above the Sacral
Region. The urinary bladder is characterized by hyperactive micturition
reflex with loss of voluntary control. This occurs during the second stage
(stage of recovery) after complete transection of spinal cord above the
sacral segments
3. Uninhibited Neurogenic Bladder Caused by Lack of Inhibitory Signals
from the Brain. The lesion in midbrain causes continuous excitation of spinal
micturition centers resulting in frequent and uncontrollable micturition.
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