Aranilla, Hanako S.

March 27, 2020

Micturition Dr. Salazar

1. Which muscles in the urinary tract are voluntary and involuntary?

Involuntary Muscles

A. Detrusor Muscle
• Located within the walls of the bladder and is composed of smooth
muscle fibers that are longitudinal and circular.
• Layers of detrusor muscle:
• Inner- longitudinal
• Middle- circular
• Outer- longitudinal
The muscle is continuous with the Internal Urethral Sphincter.

B. Internal Urethral Sphincter (IUS)

• Located at the inferior end of the bladder and the proximal end of
the urethra. The IUS also lies at the junction of the urethra with the
urinary bladder and is the continuation of the detrusor muscle.
• IUS muscle controls the flow of urine by contracting around the
internal urethral orifice.
• Involuntary control through the Autonomic Nervous System
• Sympathetic NS- maintains tonic contraction of the IUS
• Parasympathetic NS- relaxes the IUS during micturition

Voluntary Muscle

A. External Urethral Sphincter (EUS)

• EUS is a secondary sphincter to control the flow of urine through
the urethra.
• Females- located at the distal inferior of the bladder
• Males- located at the level of the membranous urethra
• Composed of skeletal muscle, voluntarily controlled through the
Somatic Nervous System
 2. Comment on doing “Bladder Training” while an indwelling catheter is in
place.

Urethral Catheterization is often performed to drain urine from patient’s

bladder when the patient is unable to micturate. (1)
When an indwelling catheter is in place, the detrusor muscle does not
actively contract the bladder wall to stimulate emptying, because urine is
continuously draining from the bladder. As a result, the detrusor muscle may
not immediately respond to bladder filling when the catheter is removed,
resulting in either urine retention or urinary incontinence. (2)
Clamping the indwelling catheter before removal was first recommended by
Ross in 1936. (3) The clamping process is supposed to strengthen and improve the
tone of the detrusor muscle, and stimulate normal filling and emptying of the
bladder. (4)
No clear guidelines for clamping have been listed in clinical practice.
Cochrane reviews and some trials showed insufficient evidence that support
effectiveness of clamping in short-term indwelling catheter patients. (5)
Clamping poses risks, such as increased incidence of overdistention and
urethral injury, if not done and monitored properly. These incidences could
prolong the period of catheterization and increase risks for infection.
However, there is another option that could be employed, which is
immediate bladder retraining after the indwelling catheter is removed.
The patient is placed on a timed-voiding schedule, usually every 2 to 3 hours,
and then instructed to void. The bladder is then scanned for residual urine. If it’s
more than 100 ml, straight catheterization may be done to completely empty the
bladder. After a few days, bladder function usually returns to normal. If the
patient had prolonged indwelling catheterization, bladder retraining will take
much longer.
 3. You have two different patients presenting with behavioral changes—
uncooperative, shouting, aggressive thus requiring restraints. Patient 1 had
urinary incontinence and Patient 2 pointed at the restroom, where he
peed. Which patient has a problem that is likely neurological in nature?
Why?

Patient 1 with urinary incontinence.

“Urinary Continence is a severe test of neurological integrity.” (6)

In addition to the complex neuroanatomical and physiological reflexes to

maintain continence, there are other faculties involved. An intact cognition is
important to perceive the sensation of bladder fullness with the ability to
postpone micturition after the first sensation. (7) Maintenance of continence
requires mobility, manual dexterity, mental capacity and motivation. In
addition, the ability to locate the toilet with clear direction and access also
contribute to continence. Persons with cognitive impairment are vulnerable to
developing problems in these domains. (8)

SOURCES:
1. Gray’s Anatomy for Students 3rd ed. P.469
2. Brunner’s and Suddarth’s Textbook of Medical Surgical Nursing 10th ed.
P.1282
3. J. Ross. Some Observations on the indwelling catheter. Practitioner, 126
(1936), P. 638-644
4. S. Fillingham, J. Douglas. Urological Nursing. 3rd ed. 2005
5. C.M. Nyman, J. Johansson, M.A. Gustatsson. Randomized controlled trial
on the effect of clamping the indwelling urinary catheter in patients with
hip fracture. J.Clin Nurs, 19 (2010), P.405-413
6. C. Fowler. Neurological disorders of micturition and their treatment.
Brain, Vol 122, Issue 7, July 1999, P.1213-1231
7. Sakakibara R, Uchiyama T, Yamanishi T, Kishi M (2008) Dementia and
the lower urinary dysfunction: with a reference to anticholinergic use in
the elderly population. Int J Urol 15:778-788
8. Yap P, Tan D. Urinary Incontinence in dementia-a practical approach.
Aust Fam Physician. 2006 Apr;35 (4) 237-45