TYPES OF URINARY BLADDER

DYSFUNCTION PRESENTED BY:

SHILPA K. PRAJAPATI (1st year MPT)

contents1. ANATOMYCAL INTRODUCTION2. CAPACITY THE BLADDER3. NERVE SUPPLY4. PHYSIOLOGICAL REFLEX5. NEUROGENIC BLADDER6. INCONTINENCE7. REFERENCE

URINARY BLADDER

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.

CAPACITY OF THE BLADDERCapacity 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).

NERVE SUPPLY

NERVE SUPPLYIts 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.

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….

HIGHER CENTER Higher centers for micturition

1) Inhibitory centers : midbrain -cerebral cortex 2) Facilitatory centers : Pons - cerebral cortex

FUNCTIONS OF NERVES

Nerve On

detrusor muscle

On internal sphincter

On external sphincter

Function

Sympathetic nerve

Relaxation Constriction Not supplied Filling of urinary bladder

Parasympathetic nerve

Constriction Relaxation Not supplied Emptying of urinary bladder

Somatic nerve Not supplied Not supplied Constriction Voluntary control of micturition

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

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

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

1. UNINHIBITED BLADDERCAUSES: -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

2.REFLEX BLADDERETIOLOGY:Transverses myelitis Trauma NeoplasmsMeningitisDisseminated sclerosisLesion :

complete transection of spinal cord above sacral segments

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.

3. AUTONOMOUS BLADDERETOLOGY: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.

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.

4. SENSORY PARALYTIC BLADDERETIOLOGY:Tabes dorsalisPernicious anemiaDiabetesDisseminated sclerosisSyringomyeliaLesion : afferent fibers from the bladder

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.

5. MOTOR PARALYTIC BLADDERETIOLOGY:PoliomyelitisPolyradiculopathyCongenital anomaliesTumorTraumaLesion : Efferent fibers of the bladder

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.

INCONTINENCE OF URINEThe 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).

INCONTINENCE OF URINETypes:

1. Extra urethral incontinence2.Detrusor overactivity incontinence3.Urodynemic stress incontinence4.Nocturnal enuresis5.Giggle incontinence6.Incontinence associaed with sexual activities7.Functional incontinance

1.Extraurethral incontinenceLoss of urine through channels other than the urethraCAUSEScongenital abnormality.trauma at pelvic surgery such as hysterectomy endometriosis, infection or carcinoma.Child birth(Wall 1999)

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.

Detrusor overactivity incontinence

The sign: conformed as a sign observed at urodynamic assessment

The condition: May be further qualified as neurogenic, in neurological condition

3.URODYNAMIC STRESS INCONTINENCE

Symptom: during increased intra-abdominal pressure, such as during coughing, laughing, sneezing and liftingSign:An involuntary spurt dribble or droplet of urine is observed to leave urethra immediately on an increase in intra-abdominal pressure

URODYNAMIC STRESS INCONTINENCE

Condition : in absence of detrusor contraction

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

5.GIGGLE INCONTINENCE

In girls around puberty

Caused by detrusor overactivity induced by laughter(chandra et al 2002)

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.

7.FUNCTIONAL INCONTINENCE

involuntary loss of urine in ability to perform toileting functions secondary to physical or mental limitation

ReferencesP.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 editionInternet

THANKING YOU….