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Mechanism of Micturition, Voiding Dysfunction

Functions of Bladder Urethral Sphincter (Male, Female)

Collection, Storage of Urine Expulsion of Urine Internal External
(↓ Pressure) (at appropriate Time, Place) Involuntary Smooth Muscle Voluntary Striated-Muscle
Bladder Wall able to Synchronous Activation of all Bladder Neck Male Female
Stretch, Rearrange itself to Smooth Muscles Prostate Mid Urethra
allow ↑ Bladder Volume (if only part of wall contracted, the ↓

(without significant ↑ in Pressure) uncontracted compliant areas would Membranous

Stretch, Prevent ↑ in Pressure Urethra
Extremely Compliant
necessary for urine expelled through
urethra) Internal Sphincter (Bladder Neck Sphi ncter)
Condensation of Smooth Muscle of Detrusor
Histology Rich in Sympathetic Innervation
Outer Middle Innermost Closed Open
Adventitial Connective Smooth Muscle Coat Transitional Cell Filling Phase Spontaneous Contraction
Tissue Layer (Detrusor) Epithelium Provide Continence Mechanism Contraction Induced by Stimulation of
Functional Syncytium of Elastic Barrier that is Pelvic Nerve
Interlacing Muscle Impervious to Urine
Bundles External Sphincter
Slow-Twitch, Small Muscle Fibers
Functional Features of Bladder Located between Fascial Layers of Urogenital Diaphragm
Normal Capacity 400 – 500 ml Voluntary Sphincter Mechanism
Sensation of Fullness • Maintain constant Tonus
Accommodate various Volumes • 1° Continence Mechanism
(without change in Intraluminal Pressure) Levator Muscles
Initiate, Sustain a Contraction until Bladder is Empty • Contribute to Continence (sup port of Bladder Base)
Voluntary Initiation, Inhibition of Voiding Relaxation of Sphincter – Voluntary Act
(despite Involuntary Nature of Organ) (without which Voiding is Normally Inhibited)

Anatomy Urethra
Male

Female
Striated Muscular Sphincter
(Invests Distal 2/3 of Urethra)
• Complete Ring of Muscle Proximally
• Fibres passes onto Posterior,
Lateral Vaginal Walls
• At Vestibule, Fibres encompasses
both Urethral, Vaginal Opening
(Urethrovaginal Sphincter)
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Pelvic Diaphragm Micturition Innervations

Formed by
Coccygeus
Levator Ani (Iliococcygeus, Pubococcygeus, Pubore ctalis)
Fibers
Type I Type II
Tonic Support to Pelvic Structures For Sudden ↑ in
Intra-Abdominal Pressure

In Females
Peritoneum on Superior Surface of Bladder is
• Reflected over the Uterus (Vesicouterine Pouch)
• Continuous Posteriorly over the Uterus (Rectouterine Pouch)
Contraction of Pelvic Diaphragm
Elevates Bladder Neck
Draws it Anteriorly
In Women with Stress Urinary Incontinence
Bladder Neck Drops below Pubic Symphysis
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Micturition Cycle

Bladder Filling (Urine Storage) Bladder Emptying (Voiding)

Require Require
Accommodation of ↑ Volumes of Urine at ↓ Intravesical Pressure Coordinated Contraction of Bladder Smooth Mus culature
(Normal Compliance) with appropriate Sensation (adequate Magnitude, Duration)
Bladder Outlet that is Closed Concomitant ↓ Resistance at level of Smooth, Striated Sphincter
• At Rest Absence of Anatomic Obstruction (as oppose d to Functional)
• Remains during ↑ Intra-Abdominal Pressure Pathway (Afferent)
Absence of Involuntary Bladder Contractions (Detrusor Overactivity) Cerebral Cortex Sensory Perception
↑
Pathway (Urine Storage)
Pons Medial PMC
Cerebral Cortex Facilitation, Inhibition ↑
↙
Thoracolumbar Cord Lateral Spinothalamic
Pons Lateral PMC ↑
↓
Sacral Cord Sacral Cord
Thoracolumbar Cord Stimulate Sympathetic ↑
↓
Bladder Receptors in Muscle of Bladder
Sacral Cord Inhibit Parasympathetic Stimulate Somatic
Wall, Mucosa
Neurons Neurons ↑
↓ ↓
Bladder Distended with Urine
Bladder Detrusor Relax Sphincter Contract
↓ ↓ Pathway (Micturition)
Closed Bladder Neck, Proximal Sphincter Cerebral Cortex Facilitation, Inhibition
↓
Bladder Response (during Filling)
Pons Medial PMC
Normal Adult Bladder response to Filling (at Physiologic Rate)
(Almost Imperceptible Change in Intravesical Pressure - ↑ Compliant) Thoracolumbar Cord
1° due to Elastic, Viscoelastic Properties
When Collagen Component ↑, Compliance ↓ Sacral Cord Stimulate Inhibit Somatic
(main component of Bladder Stroma) Parasympathetic Neurons Neurons
↓ ↓
Occur in Bladder Detrusor Contract Sphincter Relax
• Chronic Inflammation ↘ ↙
• Bladder Outlet Obstruction (BOO) Micturition
• Neurologic Decentralisation
Outlet Response (during Filling)
Gradual ↑ in Pressure during Bladder Filling
(contributed at Striated Sphincter Element, Smooth Sphincter Elements)
Guarding Reflex
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Voiding Dysfunction

Filling (Storage) Failure Emptying (Voiding) Failure

Bladder Overactivity Outlet Underactivity Bladder Underactivity Outlet Overactivity, Obstruction
Expressed as Result from Result from Temporary, Permanent Men ↑
• Phasic Involuntary Contractions • Damaged Sphincter Alteration in one of the Due to Anatomical Obstruction
• ↓ Compliance (Smooth, Striated, Both) Neuromuscular Mechanisms (mostly)
• Combination • Support of Bladder Outlet in (necessary to Initiate, Maintain a Due to Failure of Relaxation, Active
Female Normal Detrusor Contraction) Contraction of Striated, Smooth
Bladder-related storage failure may also occur in absence of Overactivity Sphincter during Bladder Contraction
because of ↑ Afferent Input from Inflammation, Irritation, other causes of
Hypersensitivity, Pain

Bladder Overactivity
Involuntary Contractions
Neurologic Disease, Injury
↑ Afferent Input (Inflammation,
Irritation of Bladder, Urethral Wall)
BOO
Stress Urinary Incontinence
Aging
Idiopathic
↓ Compliance
Neurologic Disease, Injury
• Sacral, Infrasacral Level
• Result from any process that
Destroy Viscoelastic, Elastic
Properties of Bladder Wall

Outlet Underactivity
May occur with
Neurologic Disease, Injury
Surgical, Mechanical Trauma
Aging
Sphincter Incontinence will Ensue
Genuine Stress Incontinence (GSI)
Associated with
• Hypermobility of Bladder Outlet
• Urethral Hypermobility
Due to Poor Pelvic Support
Outlet that was
• Competent at Rest
• Lost its Competence when
↑ Intra-Abdominal Pressure
Intrinsic Sphincter Deficiency (ISD)
Nonfun ctional at Rest
(Poorly Functional)
• Bladder Neck (BN)
• Proximal Urethra
Stress-Related Urinary Incontinence
(SUI)
Symptoms that arise 1° from
Damaged to
• Muscles
• Nerves
• Connective Tissues
• Combination within Pelvic Floor
Urethral Support is Important in
Female

Urethral Hypermobility
Weakness of Pelvic Floor supporting structures
During ↑ in Intra-Abdominal Pressure
(Descent of Bladder Ne ck, Proximal Urethra)
If Outlet opens concomitantly, SUI ensues