04/18/20231

URINARY BLADDER

BY Dr.NAGULA PRAVEEN

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Case scenarios

1. A 45 year old male came to ED few hours after sustaining a fall from the steps and injured his spine—MRI spine showed the cord compression at T11, T12,L1—on examination the patient had paraplegia, areflexia,hypotonia.incontinence of bowel and bladder.

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2. A 35 yr old female k/c/o multiple sclerosis came with bladder complaints—cystometrogram showed uninhibited contractions of the bladder,detrusor is hyperactive,dysynergia present--?

3.A 55 yr old female,had prolapse of uterus and incontinence of urine while coughing and sneezing.she had h/o vaginal deliveries at home and perineal injury due to delivery.no treatment taken.

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4. a 45 yr old ,grossly pallor,k/c/ TB,cachetic patient was found to be incontinent before he could reach the toilets.cystometrogram revealed normal bladder function.

5.A 43 yr old female suffering from frequent UTI presented with incontinence of urine before reaching the toilet.nocturnal wetting present.

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6. a 65 yr old case of BOO came with complaints of frequent passage of urine,patient giving history of pressure over the abdominal muscles while voiding but voiding is incomplete—USG showed high residual volume.

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Review of cases

1.overflow incontinence---spinal shock ,UMN lesion

2.reflex neurogenic bladder,spastic as sacral nerves are intact.cortical inhibition is lost.UMN

3.stress incontinence. 4.functional incontinence. 5.urge incontinence. 6. atonic bladder due to BOO.

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Anatomy

immediately behind the pelvic bones Empty bladder within pelvis. pyramidal in shape when empty. Ovoid when filled with urine. Parts—apex, base,neck,superior

surface ,two inferolateral surfaces. Epithelium-transitional---plastic

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Apex connected to the umbilicus by median umbilical ligament—remnant of urachus.

Superolateral angle joined by ureters. Inferior angle gives rise to urethra. Base or posterior surface is triangular. Vas deferens on the posterior surface of

bladder.. Peritoneal covering is peeled off the

lower part of anterior abdominal wall,as the bladder fills,lies in direct contact with anterior abdominal wall.

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held in position by puboprostatic ligaments.

Mucous membrane -rugae –disappear when filled.

Trigone-smooth,firmly adherent to the underlying muscular wall.

Between ureters is called as interureteric ridge.

Ureters enter obliquely. Muscle of the bladder-smooth muscle-

detrusor. Sphincter vesicae at neck of bladder.

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Blood supply,lymphatic drianage

Superior and inferior vesical arteries----internal iliac arteries

Vesical venous plexus---prostatic plexus –internal iliac vein

Internal and external iliac lymph nodes

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sphincters

Assure continence In male ,internal sphincter prevents the

reflux of semen from urethra during ejaculation.

to relax during micturition. Int. sphincter-sphincter vesicae-sym-

adrenergic Ext,sphincter –sphincter urethrae-

int.pudendal nerve

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Nerve supply Inferior hypogastric plexuses. Sympathetic post ganglionic fibres

from L1,L2 via hypogasrtic plexuses Parsympathetic preganglionic fibers

from S2,S3,S4---inferior hypogastric plexuses—bladder wall—synapse with post ganglionic fibres

Afferent sensory fibres---pelvic sphlanchnic nerves—CNS

Some afferent—sympathetic—hypogastric plexus—L1,L2

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BLADDER FUNCTION

Storage and intermittent evacuation of urine are served by three structural components –bladder itself,detrusor ,functional internal sphincter composed of smooth muscle,striated external sphincter or urogenital diaphragm .

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Detrusor muscle innervation

DETRUSOR CENTER S2,S3,S4 ofspinal cord intermediolateral columns of gray matter pre ganglionic fibers synapse in parasympathetic ganglia within the bladder wall short post ganglionic fibers end on ----muscarnic acetylcholine receptors of muscle fibers.

Cause contraction of bladder. Antagonised by atropine—5mg

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Sympathetic fibers interomediolateral nerve cells of T10,T11,T12 preganglionic fibers pass via inferior sphlanchnic nerves,inferior mesenteric ganglia-----hypogastric nerve---beta adrenergic receptors in dome of bladder,alpha adrenergic to internal sphincter and trigone

Filling phase of urine. Causes relaxation of bladder. Relaxation of sphincter.

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Anterolateral horns of S2,S3,S4----densely packed group of somatomotor neurons—(nucleus of onuf)—pudendal nerves---External urethral and anal sphincter are composed of striated muscle fibers.

Ventrolateral part —innervate external urethral sphincter

Mediodorsal part--- anal sphincter Respond to nicotinic effects of Ach.

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Urethra,external sphincter –afferent fibers---pudendal nerves—sacral segments of spinal cord---higher centers

Impulses for reflex activities Sensation of bladder fullness Some go through hypogastric plexus---

transverse lesions of the cord as high as T 12 report vague discomfort of urethra.

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Special feature of Detrusor muscle

Unlike striated muscle ,detrusor muscle is capable of some contractions,imperfect at best due to its postganglionic system—after complete transection of the sacral segments of spinal cord.

Do not empty the bladder completely. Dysynergia of detrusor and external

sphincter muscles---as coordination occur at supraspinal levels.

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Micturition center lies in locus cereleus. Medial region—triggers micturition. Lateral region—continence. Afferents from sacral segments Efferents ---reticulospinal tracts in the lateral

funiculi of the spinal cord ---cells of onuf—sacral segments.

Fibers from motor cortex—corticospinal tracts—AHC-external sphincter.

Mid brain tegmentum are inhibitory Pontine tegmentum are facilitatory From cortico spinal tract is inhibitory.

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Normal micturition

Possible only when the spinal segments.,together with their afferent and efferent nerve fibers,are connected with so called micturition centers in the pontomesencephalic tegmentum.

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The act of micturition is both reflex and voluntary.

Normal person on voiding 1.voluntary relaxation of the perineum 2.increased tension of the abdominal

wall 3.slow contraction of the detrusor 4.opening the internal sphincter 5.relaxation of the external sphincter. Detrusor contraction is spinal stretch

reflex

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Assisted by abdominal muscle contraction –raises intrabdominal pressure—external pressure on bladder

It is a simple reflex in young children,inhibited by crebral cortex in adults—corticospinal tracts –S2,S3,S4

Voluntary control of micturition –sphincter urethrae contraction—2-3 yr of life.

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The abdominal muscles have no power to initiate micturition except when the detrusor muscle is not functioning normally.

The voluntary restraint of micturition is a cerebral affair—arise from frontal lobes

Integration of detrusor and external sphincteric function depends mainly on the descending pathway from the dorsolateral pontine tegmentum.

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Increased blood flow was detected in the right pontine tegmentum,periaqueductal region,hypothalamus,and right inferior frontal cortex

Subjects prevented from voiding with full bladder-right ventral pontine tegmentum

Pontine centers involved in in voiding.

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LESIONS—BLADDER FUNCTION

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1.Loss of complete cord below T12

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Trauma,myelodysplasias,tumor,venous angioma,necrotizing myelitis.

Bladder is paralysed No awareness of fullness of bladder. Overflow incontinence Voiding by crede manuevre—lower

abdominal compression and straining Saddle anesthesia. Anal sphincter and colon are affected. Abolition of bulbocavernous reflexes,anal

reflex Cystometrogram low pressure and no

emptying contractions.

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2.disease of the sacral motor neurons in the spinal gray matter,the anterior roots ,peripheral nerves

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Ex—lumbar meningomyelocele,tethered cord syndrome.

LMN paralysis of the bladder Paralyzed bladder.—tone is lost. Voluntary intiation of micturition is lost.

—loss of cortical fibres Bladder distends as urine accumulates

until there is overflow in continence. Sacral and bladder sensation are

intact. It is ATONIC bladder.

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3.interupption of sensory afferents from the bladder

in diabetes and tabes dorsalis motor fibers are unaltered. primary sensory bladder paralysis both afferents and efferents are

affected small fibers-diabetes. Guillain barre syndrome..

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4.upper spinal cord lesions: Reflex neurogenic bladder (spastic) Multiple sclerosis,traumatic

myelopathy Syringomyelia,myelitis,spondylosis,AV

M,tropical spastic paraperesis. Sudden onset—spinal shock Urine accumulates—distended—

overflows As spinal shock resolves—unable to

inhibit the bladder—urgency,precipitant micturition,incontinence result.

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Intiationof voluntary micturition is impaired and bladder capacity is reduced

Bladder sensation upon sensory tracts Preservation of bulbocavernous and anal

reflexes Uninhibited contractions of bladder in

relation to low volume of urine If the lesion develops slowly—no flaccid

stage,incontinence worsen with time In case of cervical cord injury there is

persistent hypotonicity.

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5.mixed type of neurogenic bladder Multiple sclerosis Tethered cord syndrome, Multiple level lesions Combination of sensory motor,spastic bladder

paralysis

6.stretch injury of the bladder Anatomic obstruction of bladder neck Repeated voluntary retention of urine Repeated overdistention leads to

decompensation—atonia,hypotonia Emptying contractions are inadequate. Large residual volume even after the crede

manuevre

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7.frontal lobe incontinence Confused mental state Ignores the desire to void Subsequent incontinence Supranuclear type of hyperactivity and

precipitant evacuation Posterior part of superior frontal

gyrus,anterior cingulate gyrus No warning signs of fullness—

suddenly wet Waking hours. 8. nocturnal incontinence enuresis- Delay in acquiring inhibition of micturition

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Urge incontinence

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URGE INCONTINENCE Reduced bladder capacity Excessive and inappropriate detrusor

contraction. Decreased cortical inhibition –cerebral

infarction,alzheimers disease,brain tumor,parkinsons disease.

Bladder irritation—trigonitis,post radiation fibrosis.

Outflow tract obstruction . Frequent episodes of urgency

Moderate to large volumes Nocturnal wetting

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Sphincter /pelvic incompetence

MC form of urinary incontinence Pelvic floor laxity-ageing,vaginal

deliveries,direct perineal injury cystocele prostatic surgery

Partial denervation. Incontinence at times of straining –

coughing,laughing,sneezing.lifting Small to moderate volume of urine Very infrequent night time leakage Little post voidal residual .

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Reflex incontinence Spinal cord damage above sacral cord level Detrusor spasticity Functional outflow obstruction Unable to sense the need to void Spinal cord injury is most common Day and night time with equal frequency Without warning or precipitating stress Moderate volumes Frequent voiding Perineal sensation reduced Sacral reflexes intact

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Functional incontinence

Physical and mental disabilty Urinary tract is intact Sedatives may exacerbate the

condition Frontal lobe dysfunction

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WORK UP History—precipitants Timing Frequency Volume of urine loss Warning symptoms Intactness of perineal and bladder

sensations Diary of events and contributing factors Medications—anticholinergics,alpha

adrenergics,b blockers

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Physical examination

Gen examination Suprapubic palpation Percussion of bladder after voiding Per rectal-prostate enlargement Valsalva manuevre Stress incontinence when bladder is full Vaginal atrophy Bulbocavernous reflex’ Anal sphincter tone

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Lab analysis Urinalyiss BUN Creatinine Glucose USG Cystometrogram Stress tests2gm of wetting Cotton swab test Marshall and bonney test Urethroscopy

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CYSTOMETROGRAM

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Therapy

Flaccid paralysis—bethanechol Spastic paralysis—

propantheline,oxybutinin Intermittent self catheterisation Chronic antibiotic therapy Vitamin C 1000mg/day Sacral stimulator

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summary

incontinence detrusor features

Detrusor instability Unstable detrusor Frequent episodesNocturnal wettingSmall post voidal residualIntact reflexesNormal sensation

Stress incontinence Inadequate sphincter

Upon strainingSmall to moderate volumesRarely at nightSmall post voidal

Reflex incontinence Autonomous bladder

No warning or pptDuring day and nightModerate volumeReflexes intactLoss of control and sensation

Overflow incontinence

Distended bladderLoss of reflexesPost voidal residual

Functional incontinence

Inability to reach toilet due to illness

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TAKE HOME MESSAGE Stress incontinence is a feature of elderly. Urge Incontinence in case of chronic trigonitis Functional incontinence in case of severel ill

patients. Cystometrogram is important for evaluation. Self catheterisation by the patient to be

encouraged. USG showing residual volume over 20 ml—

neurogenic bladder. Every case of incontinence check for sacral

area for sensations,bulbocavernous reflex,anal sphincter tone by PR

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REFERENCES

SNELLS ANATOMY PRIMARY CARE MEDICINE HARRISONS 17 TH ED ADAM AND VICTORS’ PRICIPLES OF

NEUROLOGY SEVENTH ED.

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Thank you