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Micturition

 Micturition is the process by which the urinary bladder empties when it


becomes filled.
 It involves two main steps:
1- Filling of the bladder.
2- Micturition reflex: initiated when the tension in the wall rises above a
threshold level.
Micturition reflex is a spinal autonomic reflex, which can be inhibited or
facilitated by higher centers in the cerebral cortex or brain stem.

 Physiologic Anatomy of the urinary bladder:


The urinary bladder is composed of two parts:
1. Body: the smooth muscles of the bladder wall is called detrusor muscle. Its
fibers act as a functional syncitium i.e. Its fibers contract at once to increase
the pressure in the bladder to 40-60 mm Hg to cause emptying of the
bladder.
2. Neck: it is a funnel - shaped extension of the body:
- It is 2-3 cm long.
- It's surrounded by the internal urethral sphincter, which is an extension of
the detrusor muscle.

 Functions of the internal sphincter:


a) Its natural tone keeps the posterior urethra empty of urine, therefore
prevents emptying of the bladder until the pressure in the bladder body
rises above a threshold level.
b) lt prevents reflux of semen into the bladder during ejaculation.

1
The external urtheral sphincter: Is voluntary skeletal muscle. It is used to
consciously control micturition. (Fig 1).

Fig. (1): Urinary bladder & its innervation

* Innervation of the bladder and sphincters


Parasympathetic Sympathetic Somatic
Supplies Detrusor muscle in wall Internal External
of urinary bladder and uretheral urtheral
the internal uretheral sphincter. sphincter.
sphincter.
Origin S2 and S3 L2 S2 and S3

2
Afferent 1. Detect degree of 1. Sensation of From stretch
stretch in the bladder fullness receptors in
2. From the posterior 2. Pain sensation posterior urethra
urethra initiate the due to over transmits
reflexes of bladder stretch or sensation of
emptying. infection. urine flow to the
Efferent Contraction of the Contraction of urethra.
Control the
detrusor muscle in the the internal external urethral
bladder wall and urethral sphincter sphincter.
relaxation of the internal to prevent reflux
urethral sphincter. of semen into the
bladder during
ejaculation.
 Bladder filling:
Peristaltic contractions that spread along the ureter force the urine from the
renal pelvis towards the bladder. The ureters course obliquely for several
centimeters through the bladder wall and then pass another 1-2 cm beneath
the bladder mucosa before emptying into the bladder. The normal tone of the
detrusor muscle compresses the ureters and prevents backflow (reflux) of
urine from the urinary bladder into the ureters with rise of intravesical
pressure.
Urine enters the bladder without producing much increase in intravesical
pressure until the bladder is well filled. This can be explained by Laplace law:
As the bladder fills with urine, the tension in the wall rises, but so does the
radius. Therefore, the pressure increase is slight until the organ is relatively
full. 2T
P
r

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But at a certain volume, the T markedly increases and intravesical pressure
rises sharply.
 Cystometrogram:
A plot of the intravesical pressure against the volume of urine in the
bladder.
From the cystometrogram in figure (2).

Fig. (2): Cytometrogram in a normal human

 It can be observed that:


1. Intravesical pressure is 0 when there is no urine in the bladder.
2. Segment la: Pressure rises to 5-10 cm water by time 50 ml of urine has
collected.
3. Segment Ib: Small additional rise in pressure with further increase in
volume to 200 - 300 ml.
4. Segment II; Sharp rise in pressure at a volume of 400 ml.
The first urga to void is felt at a bladder volume of about 150 ml and
marked sensation of fullness at about 400 ml.

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 Micturition reflex:
In adults, the volume of urine in the bladder that initiates micturition reflex is
about 300 - 400 ml.
- Components of the micturition reflex:
1) Receptors: These are stretch receptors in the bladder wall and posterior
urethra.
2) Afferent: Pelvic parasympathetic.
3) Center: S2 and S3.
4) Efferent: pelvic parasympathetic.
5) Effector and response: Detrusor muscle: contraction.
Internal uretheral sphincter: relaxation.
Micturition reflex is self-regenerative, i.e. once it begins; contraction of
the bladder further activates the stretch receptors  further increase in
sensory impulses from the bladder and posterior urethera further increase in
reflex contraction of the bladder.
Once the micturition reflex becomes powerful enough, it causes
another reflex, which passes through the pudendal nerve to inhibit the external
urethral sphincter.

 Higher control of the micturition reflex:


The micturition reflex is controlled by facilitatory and inhibitory higher,
centres:
- Facilitator centres:
a) Pontine centres: b) Posterior hypothalamus
- Inhibitory centre: mid-brain

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The Cortical Micturition Centre (CMC):
Is located in the superior frontal gyrus.
It may facilitate or inhibit the spinal micturition reflex.
These higher centres exert final control of micturition in the following way:
a) They keep micturition reflex partially inhibited except when micturition
is desired.
b) They can prevent micturition even if micturition does occur by
contraction of the external urethral sphincter.
c) When it is time to urinate, the cortical areas facilitate the sacral centres to
initiate micturition reflex and to inhibit the external uretheral sphincter.

 Mechanism by which voluntary urination is initiated:


1. Relaxation of the pelvic floor muscles leads to downward tug on the
detrusor muscle to initiate its contraction.
2. Voluntary contraction of the abdominal muscle: increase intravesical
pressure  entry of urine in the bladder neck stretch of the bladder
neck stimulate stretch receptors excite micturition reflex.
3. Simultaneous relaxation of the external urethral sphincter.
After urination, the female urethra empties by gravity. However, urine
remaining in the male urethra is emptyied by contraction of the
bulbocavernous muscle.

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 Abnormalities of Micturition:

Deaffernation Denervation Sp.Cord damage


Cause Damage of the Destruction of Transection of the
dorsal root by the afferent and spinal cord leaving
e.g. syphilis efferent nerves. sacral segments
(Tabes intact.
Micturition Abolished. Abolished. 1.Spinal shock: lost.
dorsalis)
refelex 2.Recovery stage:

Voluntary Lost. Lost. return.


Lost.
control
Bladder Thin-wall, Thick-wall Shock stage:
distended and shrunkens and Flaccid. Recovery
hypotonic. hyperactive stage Hypertrophied
(Denervation with reduced
hypersensitivity capacity.
Urination The bladder ).
Hyperactive Retention with
fills to capacity bladder expels overflow in shock
and over flows dribbles of stage. Automatic
few drops at a urine. bladder in recovery
time because of stage.
the intrinsic
response of the
detrusor
muscle. *****************