The document discusses the anatomy and function of the urinary bladder. It presents six case scenarios of different types of urinary incontinence and their underlying causes. These include stress incontinence from childbirth injury, urge incontinence from bladder irritation, and overflow incontinence from spinal cord injury. The document also covers the bladder's blood supply, innervation, and control during storage and micturition. It analyzes how different lesions can affect bladder function, such as atonic or spastic bladders from spinal injuries.

1. URINARY BLADDER BY Dr.NAGULA PRAVEEN 6/3/2010 1

2. 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. 6/3/2010 2

3. 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,hadprolapse 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. 6/3/2010 3

4. 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. 6/3/2010 4

5. 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. 6/3/2010 5

6. Review of cases 1.overflow incontinence---spinal shock ,UMN lesion 2.reflex neurogenicbladder,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. 6/3/2010 6

7. 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 6/3/2010 7

8. 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. 6/3/2010 8

9. 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. 6/3/2010 9

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14. Blood supply,lymphaticdrianage Superior and inferior vesical arteries----internal iliac arteries Vesical venous plexus---prostatic plexus –internal iliac vein Internal and external iliac lymph nodes 6/3/2010 14

15. 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 6/3/2010 15

16. Nerve supply Inferior hypogastric plexuses. Sympathetic post ganglionicfibresfrom L1,L2 via hypogasrtic plexuses Parsympatheticpreganglionic fibers from S2,S3,S4---inferior hypogastric plexuses—bladder wall—synapse with post ganglionicfibres Afferent sensory fibres---pelvic sphlanchnic nerves—CNS Some afferent—sympathetic—hypogastric plexus—L1,L2 6/3/2010 16

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20. 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 . 6/3/2010 20

21. 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 6/3/2010 21

22. Sympathetic fibersinteromediolateral nerve cells of T10,T11,T12 preganglionic fibers pass via inferior sphlanchnicnerves,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. 6/3/2010 22

23. 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. 6/3/2010 23

24. 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. 6/3/2010 24

25. 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. 6/3/2010 25

26. 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. 6/3/2010 26

27. 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 pontomesencephalictegmentum. 6/3/2010 27

28. 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 6/3/2010 28

29. 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. 6/3/2010 29

30. 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 dorsolateralpontinetegmentum. 6/3/2010 30

31. Increased blood flow was detected in the right pontinetegmentum,periaqueductalregion,hypothalamus,and right inferior frontal cortex Subjects prevented from voiding with full bladder-right ventral pontinetegmentum Pontine centers involved in in voiding. 6/3/2010 31

32. 6/3/2010 32 LESIONS—BLADDER FUNCTION

33. 6/3/2010 33 1.Loss of complete cord below T12

34. Trauma,myelodysplasias,tumor,venousangioma,necrotizingmyelitis. Bladder is paralysed No awareness of fullness of bladder. Overflow incontinence Voiding by credemanuevre—lower abdominal compression and straining Saddle anesthesia. Anal sphincter and colon are affected. Abolition of bulbocavernousreflexes,anal reflex Cystometrogram low pressure and no emptying contractions. 6/3/2010 34

35. 2.disease of the sacral motor neurons in the spinal gray matter,the anterior roots ,peripheral nerves 6/3/2010 35

36. 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. 6/3/2010 36

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38. 3.interupption of sensory afferents from the bladder in diabetes and tabesdorsalis motor fibers are unaltered. primary sensory bladder paralysis both afferents and efferents are affected small fibers-diabetes. Guillainbarre syndrome.. 6/3/2010 38

39. 4.upper spinal cord lesions: Reflex neurogenic bladder (spastic) Multiple sclerosis,traumaticmyelopathy Syringomyelia,myelitis,spondylosis,AVM,tropical spastic paraperesis. Sudden onset—spinal shock Urine accumulates—distended—overflows As spinal shock resolves—unable to inhibit the bladder—urgency,precipitantmicturition,incontinence result. 6/3/2010 39

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41. 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. 6/3/2010 41

42. 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 credemanuevre 6/3/2010 42

43. 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,anteriorcingulategyrus No warning signs of fullness—suddenly wet Waking hours. 8. nocturnal incontinence enuresis- Delay in acquiring inhibition of micturition 6/3/2010 43

44. Urge incontinence 6/3/2010 44

45. URGE INCONTINENCE Reduced bladder capacity Excessive and inappropriate detrusor contraction. Decreased cortical inhibition –cerebral infarction,alzheimersdisease,braintumor,parkinsons disease. Bladder irritation—trigonitis,post radiation fibrosis. Outflow tract obstruction . Frequent episodes of urgency Moderate to large volumes Nocturnal wetting 6/3/2010 45

46. Sphincter /pelvic incompetence MC form of urinary incontinence Pelvic floor laxity-ageing,vaginaldeliveries,directperineal 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 . 6/3/2010 46

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49. 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 6/3/2010 49

50. Functional incontinence Physical and mental disabilty Urinary tract is intact Sedatives may exacerbate the condition Frontal lobe dysfunction 6/3/2010 50

51. 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,alphaadrenergics,b blockers 6/3/2010 51

52. Physical examination Gen examination Suprapubic palpation Percussion of bladder after voiding Per rectal-prostate enlargement Valsalvamanuevre Stress incontinence when bladder is full Vaginal atrophy Bulbocavernous reflex’ Anal sphincter tone 6/3/2010 52

53. Lab analysis Urinalyiss BUN Creatinine Glucose USG Cystometrogram Stress tests2gm of wetting Cotton swab test Marshall and bonney test Urethroscopy 6/3/2010 53

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55. CYSTOMETROGRAM 6/3/2010 55

56. Therapy Flaccid paralysis—bethanechol Spastic paralysis—propantheline,oxybutinin Intermittent self catheterisation Chronic antibiotic therapy Vitamin C 1000mg/day Sacral stimulator 6/3/2010 56

57. summary 6/3/2010 57

58. 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,bulbocavernousreflex,anal sphincter tone by PR 6/3/2010 58

59. REFERENCES SNELLS ANATOMY PRIMARY CARE MEDICINE HARRISONS 17 TH ED ADAM AND VICTORS’ PRICIPLES OF NEUROLOGY SEVENTH ED. 6/3/2010 59

60. Thank you 6/3/2010 60