Micturition

 Both the filing and emptying phases of urinary bladder

function are dependent on the coordinated control of a
storage chamber, the bladder body, and its outlet, the
urethra.
The essence of this control is the ability of the bladder
to increase in volume at relatively low, but sufficient,
intra-vesical pressure to prevent the over distension of
the bladder while the bladder outlet (urethra) remains in
a contracted or tonic state to maintain bladder
continence.

 Several reports indicate that the smooth muscle in the

bladder body is in a constant state of controlled
contraction during the filling stage, while the bladder
outlet is closed.
Bladder emptying is accompanied by a reversal of
function in which contractile forces predominate in the
bladder body smooth muscle with a concomitant
reduction in outlet resistance of the bladder neck and
urethra associated with the relaxation of the smooth
muscle.
While there is still considerable controversy regarding
the mechanisms that control micturition, there is little
question that the mechanical events occur in a
coordinated manner to facilitate storage and rapid
emptying of the bladder.
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 The bladder wall has three main layers of muscle:

- mucosa
- submucosa
- detrusor muscle.
The mucosa is the innermost layer and is composed of
transitional cell epithelium.
The submucosa lies immediately beneath the mucosa
and its basement membrane. It is composed of blood
vessels which supply the mucosa with nutrients and the
lymph nodes which aid in the removal of waste
products.
The detrusor is a thick layer of smooth muscle which
expands to store urine and contracts to expel urine.
The urethra is a small tube which leads from the floor or
neck of the urinary bladder to the outside of the body.
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 Storage and emptying of the bladder are regulated by the

internal and external urethral sphincters.
Sphincters are made up of a ring-like band of muscle
fibres close off a natural opening in the body.
Sphincters are normally in a closed position and need
stimulation to open.
Continence depends on two factors: normal lower urinary
tract support and normal sphincteric function.
Lying below the internal sphincter is the external
sphincter which is made up of smooth muscle mixed with
striated, or striped, muscle of the pelvic floor or pelvic
diaphragm.
Unlike the smooth muscles that an individual can not
consciously control, the striated muscles of the external
sphincter allow for voluntary interruption of abdominal
pressure to prevent urine leakage, such as occurs in
coughing or sneezing.
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 These three sets of muscles must work in close unison

to control the various stages of urinary bladder filling
and emptying.
During the filling stage, only minimal activity is needed
to produce closure of the external urethral sphincter.
At a certain point during bladder filling, the internal
pressure within the bladder becomes strong enough to
activate stretch receptors in the bladder wall (and
posterior urethra)
When these stretch receptors send a message to the
nervous system, small contractile waves occur in the
detrusor muscle and the internal urethral sphincter
automatically relaxes and becomes funnel shaped.
This information is transmitted up the spinal cord via the
spinothalamic tracts to the central nervous system.
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 The external sphincter must now be consciously

tightened, and the urge to urinate becomes very
apparent. To urinate, a person must relax the external
sphincter.
The advantage of this system is that, during the early
stages of bladder filling, a person remains unaware of
the slowly accumulating urine and is not required to
keep the external sphincter tightly closed.
This only becomes necessary when enough urine
collects to relax the internal sphincter.
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 Approximately 300 cc of urine within the bladder is

necessary before the intravesicle pressure rises enough
for the brain to recognize a sense of bladder fullness.
With low bladder volumes, the sympathetic nervous
system is stimulated and parasympathetic system is
inhibited resulting in internal sphincter contraction and
detrusor relaxation.
When the bladder is full and micturition is desired, the
inhibitory signals from the brain are replaced by
impulses which stimulate the parasympathetic system
resulting in detrusor contraction, and inhibit the
sympathetic system resulting in internal sphincter
relaxation.
The intravesicle pressure then rises to a point at which it
exceeds the resistance within the urethra, and urine
flows out of the bladder.
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 Once the bladder has emptied, the brain again sends

impulses resulting in parasympathetic inhibition and
sympathetic stimulation resulting in detrusor relaxation
and internal sphincter contraction. The urinary bladder
is again ready to be filled with urine.

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Micturition Reflex
1.
2.
3.
4.
5.
6.
7.

Stretch of bladder wall

Increase activity in sensory neurones
Increase parasympathetic activity
Increase detrusor muscle contraction
Inhibition of pudendal nerve
Results in skeletal muscle relaxing
Urine voided

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 The brain sends inhibitory signals when detrusor

relaxation is desired
Excitatory signals when detrusor contraction is desired.
This information from the brain is carried down the
spinal cord to the urinary bladder via the dorsal
columns and corticospinal tracts.

The bladder has somatic, parasympathetic, and

sympathetic innervation.

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Neural Innervation

The micturition reflex is completely autonomic spinal

cord reflex but it can be inhibited or facilitated by
centres in the brain

These centres include:

Brain stem, in particular pons
Centres located in cerebral cortex

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 The principle nerve supply of the bladder is by way of

the pelvic nerves
These connect with the spinal cord through the sacral
plexus, mainly connecting with cord segments S-2 and
S-3
Coursing through the pelvic nerves are both sensory
and motor nerve fibres
The sensory fibres detect the degree of stretch in the
bladder wall
Stretch signals from the posterior urethra especially
strong and mainly responsible for initiating reflexes that
cause bladder emptying
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 Motor nerves transmitted in pelvic nerves are

parasympathetic fibres
Terminate in wall of bladder innervating detrusor muscle
The pudendal nerve is the somatic component of
bladder innervation (skeletal motor fibres) and
innervates the external sphincter.
When stimulated, it produces contraction of the external
urethral sphincter.
The external sphincter plays an infrequent role in
maintaining continence, since it is only able to remain
tightly contracted for a short period of time.
This sphincter normally contracts with transient
increases in intra-abdominal pressure such as occurs
with coughing sneezing, and laughing.
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 The parasympathetic nerve fibres arise from the 2nd

through the 4th segments of the sacral spinal cord, and
innervate the detrusor muscle.
Stimulation occurs when the individual desires
micturition.
When stimulated, the detrusor contracts resulting in
elevated intravesicular pressure.
The internal urinary sphincter is innervated by the
sympathetic nerves fibres exiting mainly from the L-2
segment of the spinal cord.
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Excitation of stretch
receptors when
~300ml of urine

Pelvic nerves

Relayed to
parasympathetic
NS
Pelvic nerves

micturition
Pudendal
impulses
nerve
inhibited

Bladder outlet
pulled open,
increase in
pressure

Contraction of
bladder

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 The micturition reflex is a single complete cycle of:

1. Progressive and rapid increase of pressure
2. A period of sustained pressure
3. Return of the pressure to the basal tone of the
bladder
Once a micturition reflex has occurred but has not
succeeded in emptying the bladder, the nervous
elements of the reflex remain in an inhibited state for 1
minute up to an hour before the reflex occurs again
As bladder becomes more and more filled, micturition
reflexes occur more and more often and more and
more powerfully
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