2. ANATOMY OF URINARY
BLADDER

3. ANATOMY OF URINARY
BLADDER (Cont…)
 Tetrahedral in shape
 Parts: a) Apex- directed forwards
b) Base- directed backwards
c) Neck- lowest &
most fixed part
 Surfaces- 3 (Superior, Right & left
inferolateral)

4. ANATOMY OF URINARY
BLADDER (Cont…)
MUSCLES (Detrusor)
OUTER LONGITUDINAL-
 Active & dominant role in storage & voiding.
 Courses downwards
 At neck it forms a sling
MIDDLE CIRCULAR-
 More prominent in lower part of bladder
INNER LONGITUDINAL-
 Courses downwards
 Continues to form spirals in mid urethra

5. ANATOMY OF URINARY
BLADDER (Cont…)
TRIGONE
 Formed by the absorption of mesonephric
ducts
 Muscle is mesodermal in origin
 Epithelium is endodermal as of whole bladder
 Cholinergic nerve supply

6. ANATOMY OF URINARY
BLADDER (Cont…)
BLADDER NECK
 Muscle bundles are largely oblique or
longitudinal
 Little or no sphincteric action

7. Relations

8. SUPPORTS OF URINARY
BLADDER
 Lateral true ligament- From the side of bladder
to the arcus tendinalis
 Pubovesical / pubourethral ligament
 Median umbilical ligament
 Posterior ligament- From base to pelvic wall

9. ANATOMY OF URETHRA
3 PARTS- Proximal, mid & distal urethra
 Proximal urethra- weakest part
 Fails to withstand rise of intra-vesical or intra-abdominal
pressure
 Mid urethra- strongest part
 It has got additional support by:
 Intrinsic striated muscles- Rhabdomyosphincter urethrae
(Urethral closure at rest)
 Extrinsic periurethral muscle- Levator Ani
(Support urethra on stress)
 Distal urethra- Passive conduit

10. ANATOMY OF URETHRA
(Cont…)
 Submucous layer- Vascular layer
Venous plexi present in submucous layer
Supports urethra by its plasticity
Maintain resting urethral pressure
 Mucous layer- arranged in longitudinal folds

11. SUPPORTS OF BLADDER NECK &
URETHRA
Intrinsic supports:
 Rhabdomyosphincter urethrae
 Urethral smooth muscles
 Submucosal venous plexus
 Estrogen increase collagen connective tissue
 Sympathetic activity to maintain urethral tone
Extrinsic supports:
 Pubococcygeus part of levator ani
 Pubourethral ligaments
 Exercise to increase collagen turnover

12. NERVE SUPPLY

13. PHYSIOLOGY OF
MICTURATION
BLADDER FUNCTION
Storage of urine Voiding of urine

14. PHYSIOLOGY OF MICTURATION
(cont…)
Storage phase:
 Urine comes in the urinary bladder from ureters
drop by drop at rate of 0.5-5ml/min
 Intravesical pressure kept at 10cm of H2O with
volume of 500ml. This occurs because:
 Proximal urethral musculature act like a sphincter by
maintaining tonic contraction
 Stretching of detrusor reflexly contracts sphincteric muscles
of bladder neck
 Inhibition of cholinergic system responsible for detrussor
contraction
 Stimulation of β-adrenergic results in further detrusor
relaxation & α-adrenergic causing contraction of sphincter of
bladder neck

15. PHYSIOLOGY OF MICTURATION
(cont…)
Voiding phase:
 When the volume of bladder reaches 250ml., a sensation
of bladder filling is perceived
 Spinal arc in adults is under control of hypothalamus and
frontal lobe of brain
 When time & place is convenient hypothalamus no
longer inhibits detrusor
 Detrusor contracts to raise intravesical pressure to 30-50
then to 100 cm of H2O
 Complete loss of urethrovesical angle
 Funneling of bladder neck & upper urethra
 Voiding starts

16. MECHANISM OF URINARY
CONTINENCE
At rest:
 Intraurethral pressure at rest:20-50cm of H2O
 Intravesical pressure at rest: 10cm of H2O
 Apposition of longitudinal mucosal folds
 Submucous venous plexus
 Collagen & elastin around urethra
 Rhabdomyosphincter and levator ani
 Urethrovesical angle- 1000

17. MECHANISM OF URINARY
CONTINENCE (cont…)
During stress:
 Centripetal force of intra-abdominal pressure transmitted
to proximal urethra
 Reflex contraction of periurethral straited musculature

18. MECHANISM OF URINARY
CONTINENCE (cont…)
 Kinking of urethra due to:
 Hammock like attachment of pubocervical fascia with urethra,
vagina & laterally to arcus tendineus fascia. During rise of
intraabdominal pressure- urethra get compressed against anterior
abdominal wall
 Bladder base rocks downwards & backwards
 Bladder neck pull upwards & forwards behind pubic symphysis

19. CLASSIFICATION OF URINARY
INCONTINENCE
 Stress urinary incontinence
 Urge urinary incontinence
 Mixed incontinence
 Continuous urinary incontinence- Overflow incontinence
(neurogenic bladder)
 Functional urinary incontinence- due to reasons other than neuro-
urologic and lower urinary tract dysfunction (eg, delirium, psychiatric disorders,
urinary infection, reduced mobility)
 True urinary incontinence- eg. Vesico vaginal fistula
 Other incontinences-
 Postural urinary incontinence
 Insensible urinary incontinence
 Coital incontinence
Important in
urogynaecology

20. URINARY INCONTINENCE

21. STRESS URINARY
INCONTINENCE
 Involuntary leakage of urine on stress
(sneezing, coughing)
 Most common of all incontinence
 More common in younger and active women
 Due to:
 Hypermobility of urethra (most important reason)
 Intrinsic sphincteric weakness or deficiency
 Hypermobility of urethra may be due to:
 Decent of bladder neck
 Injury to the hammock
(during delivery or hysterectomy)
 Estrogen deficiency
 Pelvic denervation
 Congenital weakness of uretheral supports

22. Stress urinary incontinence
(cont…)
 Management:
 Behavioral modification & lifestyle changes
 Kegel’s exercise
 Postural change during stress
 Fluid management
 Vaginal & urethral devices
 Medications: α-agonists (Imipramine, ephedrine,
pseudoephidrine, phenylpropanolamine)but none of the drugs are
FDA approved
 Surgical treatment- Fixation of bladder neck & proximal
urethra to prevent its undue moblility & its decent.

23. URGE URINARY
INCONTINENCE
 Involuntary leakage of urine associated with
urgency
 More common in older women
 Urgency, Increase day time frequency &
nocturia
 Occurs due to detrusor instability and detrusor
overactivity

24. Urge urinary incontinence
(cont…)
Management:
 Lifestyle changes: Weight loss, smoking, alcohol, caffeine
cessation
 Behavioural therapy: Yoga, Silent singing, deep breathing
 Bladder training, Schedule toileting program
 Fluid management
 Vaginal and Urethral devices
 Medications: Anticholinergics (oxybutynin, tolterodine,
festerodine, darifenacin, solefenacin)
 β3agonist- Mirabagone, solebagone
 Neurokinin inhibitors
 Neuromodulation: Sacral nerve or percutaneous
tibial nerve stimulation

25. THANK YOU