Bladder Anatomy and

Dysfunction

UROLOGY SSST
Neuroanatomy of Micturition
From the Top Down
 Micturition - Anatomy
Micturition center is located where in the
brain?
– Frontal lobe
Function of micturition center (excitatory or
inhibitory?)
– Send tonically inhibitory signals to the detrusor
muscle to prevent the bladder from emptying
(contracting) until a socially acceptable time
and place to urinate is available.
 Next stop is the…..
Pons
 Pons
The major relay center between the brain and
the bladder
What is the function of the pons?
– Coordinating the activities of the urinary sphincters
and the bladder so that they work in synergy
What is the specific anatomic location?
– Pontine micturition center
– The PMC coordinates the urethral sphincter relaxation
and detrusor contraction to facilitate urination
 Pontine Micturition Center
Bladder filling  detrusor muscle stretch
receptors  signal to the pons  brain
– Perception of this signal (bladder fullness) as a
sudden desire to go to the bathroom
– Normally, the brain sends an inhibitory signal to the
pons to inhibit the bladder from contracting until a
bathroom is found.
Brain  deactivating signal to PMC
– Urge to urinate disappears
– When urination appropriate, brain sends excitatory
signals to the pons, allowing voiding
 Pontine Micturition Center
Excitatory or inhibitory?
– Excitatory
Stimulation of the PMC causes what actions of the…
– Urethral sphincter?
Open
– Detrusor?
Contract
The PMC is affected by emotions
– Hence, some urinate when they are excited or scared
– The brain’s control of the PMC is part of the social training that
children experience during growth and development
– Brain takes over the control of the pons at age…
2 - 4 years
 Next Stop After the PMC….
Spinal cord
 Normal Micturition – Spinal
Cord
Function
– Long communication pathway between the brainstem
and the sacral spinal cord
– Sensory information from bladder  Sacral cord 
Pons  Brain  Pons  Spinal cord  Sacral cord
 Bladder
Normal bladder filling/emptying
– Spinal cord acts as an important intermediary
between the pons and the sacral cord
– Intact spinal cord is critical for normal micturition
 Normal Micturition – Spinal
Cord
Sacral spinal cord – what is the
significance?
– Sacral reflex center
Responsible for bladder contractions
Primitive voiding center
– In infants, the brain is not mature enough to command
the bladder
– SRC controls urination in infants and young children
– When urine fills the infant bladder, an excitatory signal 
sacral cord  spinal reflex center  detrusor contraction
 involuntary detrusor contractions with coordinated
voiding
Bladder – Normal
Neuroanatomy
Bladder - Anatomy
 Neuroanatomy - Peripheral
Nervous System
3 components

1. Somatic nervous system via

____Pudendal_____nerve
Autonomic nervous system
2. Sympathetics via ____Hypogastric__ nerve
3. Parasympathetics via ____Pelvic______ nerve
 Bladder Neuroanatomy
Sympathetic receptors & their locations
1. _____________________
2. _____________________
 Bladder NeuroAnatomy
Sympathetic receptors
– Adrenergic
_ 1
– Trigone, bladder neck, urethra
– Maintain continence by contraction of bladder neck
smooth muscle
2-Adrenergics
– Bladder neck and body of bladder
– Inhibitory when active to
Relax bladder neck on void
Relax bladder body for storage (minor)
 Bladder Neuroanatomy –
Parasympathetic receptor
Parasympathetic receptors
– Muscarinic
Type
– Cholinergic
Anatomic location
– Bladder, trigone, bladder neck, urethra
 Normal Micturition - ANS
Normally, bladder and the internal urethral
sphincter primarily are under sympathetic vs.
parasympathetic nervous system control?
– Sympathetic
SNS activity
– Bladder can increase capacity without increasing
detrusor resting pressure
– Stimulates the internal urinary sphincter to remain
tightly closed
– Inhibits parasympathetic stimulation
– Micturition reflex is inhibited
Normal Micturition – Autonomic
Nervous System
Parasympathetic nervous system
– Stimulates detrusor to _______________
– Immediately preceding parasympathetic
stimulation, sympathetic influence on the
internal urethral sphincter becomes
suppressed so that the internal sphincter
relaxes and opens
– Pudendal nerve is inhibited  external
sphincter opens  facilitation of voluntary
urination
Normal Micturition – Somatics
Regulates the actions of voluntary muscles
– External urinary sphincter
– Pelvic diaphragm
Innervation is via the….
– ______________________________
Originates from the nucleus of Onuf
Activation of the pudendal nerve causes  contraction
of the external sphincter and the pelvic floor muscles
Neuropraxia of pudendal may occur with….
– Difficult or prolonged vaginal delivery, causing stress urinary
incontinence
Normal Micturition - Physiology
2 phases
– Filling and emptying
Normal micturition cycle requires that the urinary
bladder and the urethral sphincter work together
as a coordinated unit to store and empty urine
– Storage
Bladder is a low-pressure receptacle
Urinary sphincter – closed with high resistance to urinary flow
– Emptying
Bladder contracts to expel urine
Urinary sphincter – opens to allow urinary flow
Normal Micturition - Physiology
Filling phase
– Bladder
Accumulates increasing volumes of urine
Pressure inside the bladder remains low
Pressure within the bladder must be __________ than
the urethral pressure during the filling phase
– Bladder filling dependent on
Intrinsic viscoelastic properties of the bladder
Inhibition of the parasympathetic nerves
– Bladder filling primarily is a passive or active event?
Normal Micturition - Physiology
Bladder filling
– Sympathetic nerves also facilitate urine
storage
Inhibition of the parasympathetic nerves from
triggering bladder contractions
Directly cause relaxation and expansion of the
detrusor muscle.
Close the bladder neck by constricting the internal
urethral sphincter
– Thus, sympathetic input to the lower urinary
tract is constantly active during bladder filling.
 Normal Micturition
During bladder filling - pudendal nerve becomes
excited.
– Pudendal nerve stimulation  contraction of the external
urethral sphincter
– Urethral pressure maintained by the continence
mechanism, which is composed of ??
Contraction of the external sphincter
Contraction of the internal sphincter
Pressure gradients
– Continence = urethral pressure > or < bladder pressure
– Incontinence = urethral pressure < or > intravesical
pressure is abnormally high
Normal Micturition - Physiology
Pressure Gradients
– During bladder filling –
Small  in intravesical pressure
When the urethral sphincter is closed, the intraurethral
pressure > the intravesical pressure
– With  intraabdominal pressure (cough, sneeze,
laugh, physical activity), some pressure transmitted to
both the bladder and urethra
If the pressure is evenly transmitted to both the bladder
and urethra, Ø incontinence
If pressure transmitted to the bladder is > urethra,
stress incontinence results
Normal Micturition - Emptying
Involuntary (reflex) or voluntary
– Infants involuntarily reflex void when the volume of
urine exceeds the voiding threshold
Bladder wall stretch receptors  sacral cord 
pudendal nerve 
– relaxation of the levator ani relaxation of pelvic floor muscle
– Opens external sphincter
Also, sympathetic nerves  relaxation of internal
sphincter
Parasympathetic nerves  detrusor contraction
Bladder pressure > urethral pressure  urinary flow
Normal Micturition - Emptying
A repetitious cycle of bladder filling and
emptying occurs in newborn infants
As the infant brain develops, the PMC also
matures and gradually assumes voiding control
– During childhood, primitive voiding reflex becomes
suppressed and the brain dominates bladder function
Toilet training usually is successful at age 2-4 years
Primitive voiding reflex may reappear in people with
SCI
 Delayed/Voluntary Voiding
Healthy adults are aware of bladder filling and
can willfully initiate or delay voiding
Normally, the PMC functions as an on-off switch
that is activated by stretch receptors in the
bladder wall and is modulated by inhibitory and
excitatory neurologic influences from the brain.
When voiding must be delayed
– Brain bombards the PMC with inhibitory signals to
prevent detrusor contractions
– Individual actively contracts the levator muscles to
keep the external sphincter closed
Normal Micturition – Delayed
Emptying
Voiding = coordination of both the ANS
and somatic nervous system, which are in
turn controlled by the PMC located in the
brainstem and regulated by the brain
 Work-Up
U/a and c & s
BUN & Cr
– if compromised renal function is suspected
Postvoid residual urine
– If high, the bladder may be contractile or the
bladder outlet may be obstructed
 Work-Up
Filling cystogram
– Bladder capacity
– Bladder compliance
– Presence of phasic
contractions (detrusor
instability)
 Work-Up - Cystogram
Static Cystogram
– Confirm the presence of
stress incontinence
– Degree of urethral motion
– Presence of a cystocele
– Intrinsic sphincter
deficiency
– Vesicovaginal fistula
– Bladder diverticulum
Voiding cystogram
– Bladder neck and
urethral function
(internal and external
sphincter) during filling
and voiding phases
– Urethral diverticulum
– Urethral obstruction
– Vesicoureteral reflux
 Work-Up - Cystometrogram
Volume vs pressure graph
Evaluates
– Detrusor compliance
– Stability of detrusor
 Pressures
Rectal pressure = abdominal pressure
True detrusor pressure = intravesical pressure –
rectal (abdominal) pressure
Normal bladder resting pressure =
– 8 – 40 cm H20
Nl compliance is <= 15 cm H20 increase in
pressure during filling
Avg urethral closure pressure is
– 60 cm H20
– 80 cm H20
 Work-Up - Urodynamics
Filling cystometry
Flow/pressure study
– Detrusor pressure at maximum flow
– Obstruction to passage of urine (high pressure, low flow) can be
distinguished from a lack of tone in the detrusor muscle (low
pressure, low flow)
Electromyography
– Coordinated or uncoordinated voiding
– Detrusor sphincter dyssynergia
Videocystourethography
– Combined x-ray or ultrasound
 Normal Cystometry

Rectal P

Intravesical P

Detrusor P

Infused volume
Stable Bladder with Rectal
Cancellation
Stable Bladder
 Detrusor Hyperactivity

The normal detrusor if filled slowly accepts 300 - 600 ml without rise in
pressure. If the bladder undergoes phasic contraction while the patient
is trying to inhibit voiding this is called Detrusor overactivity. Note the
low bladder capacity
Low Compliance Bladder
Neurogenic Detrusor Hyperactivity

Cystometry Neurogenic detrusor overactivity is overactivity in the

presence of confirmed neuropathy in this case Multiple Sclerosis.
Often the detrusor is unstable without sensation and the pressure
involved tend to be higher than idiopathic instability
 Work-Up - Cystoscopy
Cystoscopy
– Bladder cancer
– Bladder stone
– Indicated in persistent irritative voiding symptoms or
hematuria
 Problems and Treatment
Classification
– Failure to store because of the bladder
– Failure to store because of the outlet
– Failure to empty because of the bladder
– Failure to empty because of the outlet
 Medications
Alpha-adrenergic drugs
– Location - Bladder neck receptors
– Function - Increase bladder outlet resistance
by contracting the bladder neck
– Example - pseudoephedrine
 Medications
Estrogen derivatives
– Mechanism - Increases the tone of urethral
muscle by up-regulating the alpha-adrenergic
receptors in the surrounding area
– Mechanism - Enhances alpha-adrenergic
contractile response to strengthen pelvic
muscles
– Use in…Stress incontinence
 Medications
Anticholinergic drugs
– Function - Inhibit involuntary bladder contractions
– Adverse effects
Blurred vision
Dry mouth
Heart palpitations
Drowsiness
Facial flushing
– Ex. Pro-banthine, Levsin
 Medications
Antispasmodic drugs
– Function - Relax the smooth muscles of the urinary
bladder
– Function - Direct spasmolytic action on the smooth
muscle of the bladder
– Adverse effects similar to anticholinergic agent
Impaired mental alertness and physical coordination
– Ex. Ditropan, Detrol
 Medications
Tricyclic antidepressant drugs
– Mechanism - Increase norepinephrine and
serotonin levels
– Mechanism - Anticholinergic and direct
muscle relaxant effects on the urinary bladder
– Ex. elavil
 Pathophysiology
Brain Lesions – stroke, tumor, CP, Parkinsons
disease, hydrocephalus
– Above the pons
Destroys the master control center, causing a complete
loss of voiding control
Primitive voiding reflex remains intact
S/Sx
– Urge incontinence or spastic bladder
Bladder empties too often with relatively low quantities
Storing urine in the bladder is difficult
 Pathophysiology
SCI (after resolution of spinal shock)
– Urge incontinence
– External sphincter may have paradoxical
contractions
Detrusor-sphincter dyssynergia
 Pathophysiology
Peripheral nerve injury - Diabetes mellitus,
severe genitoanal herpes, pernicious
anemia, neurosyphilis, and AIDS
– Result in silent/painless urinary retention
– DM - lose the sensation of bladder filling first,
then difficulty urinating
 CVA
Brain may enter into a temporary acute cerebral
shock phase
– Bladder retention with detrusor areflexia
Then detrusor hyperreflexia with coordinated
urethral sphincter activity
– PMC released from the cerebral inhibitory center
– S/Sx
Urinary frequency, urgency, and urge incontinence
Treatment
– Early – indwelling catheter or CIC
– Hyperreflexia – Timed void ± anticholinergics
 Brain Tumor
Detrusor hyperreflexia with coordinated
urethral sphincter
S/Sx
– Urinary frequency
– Urgency
– Urge incontinence
Treatment
– Anticholinergics
 Parkinsons Disease
Characterized by detrusor hyperreflexia and
urethral sphincter bradykinesia
S/Sx
– Urinary frequency
– Urgency
– Nocturia
– Urge incontinence
Treatment
– Anticholinergic agents
 Multiple Sclerosis
Focal demyelinating lesions of the CNS often
involve the posterior and lateral columns of the
C spinal cord
Poor correlation between the clinical symptoms
and urodynamic findings
UD
– Detrusor hyperflexia (50-90% with MS)
– Approx 50% demonstrate DSD-DH
– 20-30% have detrusor areflexia
Treatment individualized
 Diabetic cystopathy
Usually, 10+ years after the onset of DM
Autonomic and peripheral neuropathy
– Segmental demyelination
– Impaired nerve conduction
S/Sx
– Loss of sensation of bladder filling
– Loss of motor function
Urodynamics
– Elevated residual urine
– Decreased bladder sensation
– Impaired detrusor contractility
– Detrusor areflexia.
 Herniated Disc
Lumbar disc herniation  irritation of the
sacral nerves  detrusor hyperreflexia
Acute compression of sacral roots
(trauma)  detrusor areflexia.
Urodynamics
– Sacral nerve injury
Detrusor areflexia with intact bladder sensation
 internal sphincter denervation may occur
Striated sphincter is preserved