Micturition

ILOs

• Describe autonomic and somatic control of

urinary bladder and sphincters.
• Describe filling the urinary bladder and
cystonetrogram.
• Explain micturation reflex and abnormalities
of micturation.
 Micturition
• It is the Process by which urinary
bladder empties.
• It is a complex act involving both
autonomic & somatic nerve
pathways & several reflexes that can
be either inhibited or facilitated by
higher centers in the brain.
 Micturition
• Micturition involves 2 important steps:

• Bladder filling:
– tension in bladder wall increases.

• Bladder emptying: micturition reflex :

– Autonomic spinal cord reflex,inhibited/facilitated
by centers in brain stem & cerebral cortex.
ANATOMY OF BLADDER :
Urinary Bladder
 Bladder Body
- Detrusor muscle:
• Arranged in spiral, longitudinal & circular
bundles
• Contraction can increase pressure in the
bladder to 40-60 mmHg
- Ureters:
• Run obliquely through the detrusor muscle
and then passes another 1-2 cm beneath the
mucosa.
• The oblique course of the ureter prevents
reflux of urine from bladder into ureter.
 Bladder Trigone
–small triangular area in the
posterior wall of bladder.

–2 ureters enter the bladder at the

uppermost angles.
Internal & External Sphincters

Internal sphincter :
formed from detrussor muscle at bladder
neck (posterior urethera).

External uretheral sphincter :

• skeletal muscle.
• under voluntary control of the
nervous system.
Bladder Nerves
 Bladder Nerves

Somatic:

• Pudental nerves (S2,S3,S4)

–motor & sensory fibres
• External urethral sphincter
 Bladder Nerves

Sympathetic:

• Hypogastric nerves : L2
–motor & sensory fibres pain
• Bladder wall relaxation
• Internal sphincter contraction
 Bladder Nerves

Parasympathetic:

• Pelvic nerves : (S2,S3,)

–motor & sensory fibres
• Bladder wall contraction.
• Internal sphincter relaxation.
Actions of bladder nerves
 Bladder nerve supply

• Sensory fibers in pelvic nerves sense the degree of

stretch in the bladder wall:

– Stretch signals from posterior urethra are more

powerful in potentiting the micturition reflex.

• Pudendal nerves:
– Control the voluntary skeletal muscle sphincter.
 Bladder nerve supply

• Sympathetic innervation:
– Important in the sensation of fullness/pa.
– In males – mediate the contraction of the
bladder muscle (internal sphincter).
– That prevents semen from entering the
bladder during ejaculation
Transport of urine into the bladder

• Urine flow out of collecting duct into :

– Renal calyces & ureter.
–Peristaltic waves sweep down the
ureters.
Frequency 1 every 10 seconds
Forces urine into the bladder.
 Blader Emptying

• First sensation of bladder filling is

experienced at a volume of 150 ml in an
adult.
• Then the 1st desire to urinate is when the
bladder contains about 150-250 ml of urine.
• The volume of urine that normally initiates a
reflex contraction is about 300-400 ml.
• An increase in volume to 700 ml creates pain
and loss of control.
Cystometrogram
 Cystometrogram

• A plot of intravesical pressure vs volume

of fluid in the bladder
Ia – initial slight rise in pressure.
Ib – long nearly flat segment.
 Cystometrogram
Ib – long nearly flat segment:
• Law of Laplace
• Pressure in a spherical viscus is equal to twice the wall
tension divided by the radius
• P = 2T / r
• Due to its ability to stretch, T (Tension) increase will
cause r (radius) increase as well, therefore P (pressure)
will not increase much.
• This gives us the ability to fill the bladder beyond
300ml
II – sudden sharp rise in pressure ( micturition reflex
triggered)
Micturition Reflex
 Micturition Reflex

Receptor:
• Stretch receptors in bladder wall.
• Receptors in the posterior urethra are highly
sensitive to stretch when the area begins to
fill with urine at the higher bladder pressures.

Afferents:
• through pelvic nerves.
 Micturition Reflex
Center:
• Spinal cord.

Efferents:
• pelvic nerves.

Effector organ:
• Detrusor muscle.
• Internal & external sphincters.
 Micturition Reflex – Process
• Urination in adults occurs when relaxation of
internal & external sphincters occurs.
 Higher Centers for Micturition

• The higer centers keep the micturition reflex

partially inhibited, except when
desired/during urination. It can prevent
micturition, even if the micturition reflex
occurs, by tonic contractions of the external
sphincter until it is convenient to urinate.
• When it is time to urinate, the cortical
centers can facilitate the sacral micturition
centers to help initiate the external urinary
sphincter so that urination can occur.
 Higher Centers for Micturition

• Facilitatory areas:
–Pons
–Posterior hypothalamus

• Inhibitory areas:
–Cerebral cortex
–Midbrain
 Micturition in young children

• Micturition is purely reflex occurs whenever

the bladder is sufficiently distended.
• Myelination is not complete.
• About 2 1/2 years old, it begins to come
under cortical control.
• About 3 years old, complete control is
achieved
• Cortex takes over control.
 ATONIC BLADDER

• Urinary Bladder loss the tone.

• Cause: sensory nerve fibers (afferent) from
bladder to spinal cord are damaged.
• Tabes dorsalis.
• Intact efferent fibers.
• All reflex contractions of bladder lost.
• Bladder becomes distended, thin-walled and
hypotonic.
• The bladder fills to capacity and overflows a few
drops at a time through the urethra.
 Denervation/Hyperactive bladder

• Cause: injury of afferent and efferent

nerves e.g D.M
• Bladder flacid & distended.
• Gradually, muscle of the ‘ bladder’
becomes active, shrunken & bladder
wall hypertrophied due to:
»De-nervation hypersensitivity
»Increase tone
 Automatic Bladder

• Cause: spinal cord damage above sacral region.

• Higher center control is lost (voluntary control
loss).
• Sacral micturition reflex centers are intact.
• Suppression of micturition reflex during spinal
shock due to loss of facilitatory impulses from
brain : retention with overflow.
• Reflex returns after spinal shock : automatic
bladder during recovery stage.