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. NERVE SUPPLY
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

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

10. FUNCTIONS OF NERVES
Nerve On On On Function
detrusor internal external
muscle sphincter sphincter
Sympathetic Relaxation Constriction Not supplied Filling of urinary
nerve bladder
Parasympathetic Constriction Relaxation Not supplied Emptying of
nerve urinary bladder
Somatic nerve Not supplied Not supplied Constriction Voluntary control
of micturition

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

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:
TYPE LESION
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. 1. UNINHIBITED BLADDER
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. 2.REFLEX BLADDER
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. 3. AUTONOMOUS BLADDER
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. 4. SENSORY PARALYTIC BLADDER
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. 5. MOTOR PARALYTIC BLADDER
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, 2nd edition, jill mantle
Essentials of medical physiology, 5th
edition, K Sembulingam
B.D.Chaurasia’s human anatomy, 4th
edition
Internet