2. contents 1.ANATOMYCAL INTRODUCTION 2.CAPACITY THE BLADDER 3.NERVE SUPPLY 4.PHYSIOLOGICAL REFLEX 5.NEUROGENIC BLADDER 6.INCONTINENCE 7.REFERENCE

3. URINARY BLADDER

4. URINARY BLADDER ANATOMICAL INTRODUCTION  Urinary bladder is the temporary store house of urine which gets emptied through the urethra.  The male urethra subserving the functions of urination and ejaculation.  Female urethra is for urination only.

5. CAPACITY OF THE BLADDER  Capacity in an adult male 120 to 320 ml.  Filling beyond 220 ml causes micturition, emptied when filled to about 250 to 300 ml.  Filling up to 500 ml may be tolerated, but beyond this it becomes painful.  Referred pain: lower part of the anterior abdominal wall, perineum and penis(T11- L2,S2-S4).

6. NERVE SUPPLY

7.  Its contains both sympathetic and parasympathetic components.  Parasympathetic efferent fibers S2,S3, S4 are motor to the detrusor muscle and inhibitory to the sphincter vesicae.  If these are destroyed, normal micturition is not possible.

8. NERVE SUPPLY CONTI….  Sympathetic efferent fibers (T11 to L2): - inhibitory to the detrusor -motor to the sphincter vesicae  The pudendal nerve (S2, S3, S4) -supplies the sphincter urethrae which is voluntary  Sensory nerves: pain sensations, causes: - spasm of bladder wall - carried by parasympathetic nerves and partly by sympathetic nerves NERVE SUPPLY CONTI….

9. HIGHER CENTER  Higher centers for micturition 1) Inhibitory centers : midbrain -cerebral cortex 2) Facilitatory centers : Pons - cerebral cortex

10. FUNCTIONS OF NERVES NerveOn detrusor muscle On internal sphincter On external sphincter Function Sympathetic nerve RelaxationConstrictionNot suppliedFilling of urinary bladder Parasympathetic nerve ConstrictionRelaxationNot suppliedEmptying of urinary bladder Somatic nerveNot supplied ConstrictionVoluntary control of micturition

11. MICTURITION REFLEX. Filling of urinary bladder Stimulation of stretch receptor Afferent impulses pass via pelvic nerve Efferent impulses via pelvic nerve Contraction of detrusor muscle & relaxation of internal sphincter Sacral segments of spinal cord

12. MICTURITION REFLEX CONTI… Flow of urine into urethra and stimulation of stretch receptors Afferent impulses via pelvic nerve Inhibition of pudendal nerve Relaxation of external sphincter Voiding of urine

13. NEUROGENIC BLADDER BY: P.J.MEHTA There are five types of neurogenic bladder: TYPELESION 1.Uninhibited bladder..cortico regulatory tract 2. Reflex bladder..spinal cord above S2 3. Autonomous bladder..at S2, S3 and S4 level 4. Motor atonic bladder..motor efferents 5. Sensory atonic bladder..sensory afferents

14. CAUSES: -cerebrovascular accidents, -head injuries, -brain tumors, etc.  Voluntary control of micturition is lost.  Hesitancy and precipitancy of evacuation is present. Lesion : - the midbrain - superior frontal gyrus

15. ETIOLOGY:  Transverses myelitis  Trauma  Neoplasms  Meningitis  Disseminated sclerosis Lesion : complete transection of spinal cord above sacral segments

16. REFLEX BLADDER CONTI… PATHOGENESIS:  Acute transaction of the cord causes retention of urine during the stage of spinal shock.  Leads to retention of residual urine.  During recovery stage, reflex activity begins and automatic evacuation of bladder results.

17. ETOLOGY:  Congenital : spina bifida, meningomyelocele  Trauma: gunshot, auto accidents  Infective: arachnoiditis, radiculitis  Neoplasms of the cord  Surgery: combined perineal and abdominal resection. LESION: sacral segment of spinal nerve.

18. AUTONOMOUS BLADDER CONTI… CLINICAL FEATURES:  Loss of bladder sensation  Inability to initiate micturition normally  paralysis of pariurethral striated muscles  associated with anesthesia and absent bulbocavernous reflex.

19. ETIOLOGY:  Tabes dorsalis  Pernicious anemia  Diabetes  Disseminated sclerosis  Syringomyelia Lesion : afferent fibers from the bladder

20. SENSORY PARALYTIC BLADDER CONTI.. PATHOGENESIS:  Loss of bladder sensation, which leads to overdistension of bladder.  Initially there is normal capacity increases and residual urine appears. CLINICAL FEATURES:  Initially these patients are asymptomatic.  Gradually there is terminal dribbling and later overflow incontinence.

21. ETIOLOGY:  Poliomyelitis  Polyradiculopathy  Congenital anomalies  Tumor  Trauma Lesion : Efferent fibers of the bladder

22. MOTOR PARALYTIC BLADDER CONTI.. PATHOGENESIS:  Since the sensory nerves are intact, bladder if left alone, distends and decompensates. CLINICAL FEATURES:  Painful distention of the bladder and inability to initiate micturition.  Decrease in size and force of steam and interrupted stream.  Recurrent episodes of urinary infections.

23. INCONTINENCE OF URINE  The term ‘continence’ is used to describe the normal ability of a person to store urine and faeces temporarily, with conscious control over the time and place of micturition and defaecation.  ‘Incontinence’ has been defined as the involuntary or inappropriate passing of urine or faeces, or both, that has an impact on social functioning or hygiene(DoH 2000).

24. INCONTINENCE OF URINE Types: 1. Extra urethral incontinence 2.Detrusor overactivity incontinence 3.Urodynemic stress incontinence 4.Nocturnal enuresis 5.Giggle incontinence 6.Incontinence associaed with sexual activities 7.Functional incontinance

25. 1.Extraurethral incontinence  Loss of urine through channels other than the urethra CAUSES  congenital abnormality.  trauma at pelvic surgery such as hysterectomy  endometriosis,  infection or carcinoma.  Child birth(Wall 1999)

26. 2. Detrusor overactivity incontinence -present as a symptom, a sign and as a condition  The symptoms: complains of urge incontinence, immediately preceded by urgency, that is a strong desire to void.

27. Detrusor overactivity incontinence  The sign: conformed as a sign observed at urodynamic assessment  The condition: May be further qualified as neurogenic, in neurological condition

28. 3.URODYNAMIC STRESS INCONTINENCE Symptom: during increased intra-abdominal pressure, such as during coughing, laughing, sneezing and lifting Sign: An involuntary spurt dribble or droplet of urine is observed to leave urethra immediately on an increase in intra-abdominal pressure

29. URODYNAMIC STRESS INCONTINENCE Condition : in absence of detrusor contraction

30. 4.NOCTURNAL ENURISIS  During sleep, or “bed wetting”  15-20% of 5 year old children and up to 2% of young adults(Glazener &Evans 2003)

31. 5.GIGGLE INCONTINENCE  In girls around puberty  Caused by detrusor overactivity induced by laughter(chandra et al 2002)

32. 6.INCONTINENCE ASSOCIATED WITH SEXUAL ACTIVITY  After following intercourse in young women postcoital dysuria  postmenopausal women dysuria, urgency and urinary tract infection  Hilton(1988) found 24% of 324 sexually active women referred to gynaecological clinic experience incontinence – two third on penetration and one third on orgasm.

33. 7.FUNCTIONAL INCONTINENCE  involuntary loss of urine  in ability to perform toileting functions secondary to physical or mental limitation

34. References  P.J. mehta’s Practical Medicine  Physiotherapy in obstetrics and gynaecology, 2 nd edition, jill mantle  Essentials of medical physiology, 5 th edition, K Sembulingam  B.D.Chaurasia’s human anatomy, 4 th edition  Internet