PHYSIOLOGY

OF MICTURITION
By
Dr Ekiran Lukman Babajide
OUTLINE

• Introducti on

• Functi onal anatomy oft he female urethra and Bladder

• Ner ve supply

• Cystometrogram

• Filli ng of t he Bladder

• Emptying Of the Bladder

• Mi cturiti on Refl ex

• Clinical correlate

• Conclusion
 INTRODUCTION

• Micturiti on is the process whereby the urinary bladder empti es

when it becomes fi lled.
• The bladder fi lls progressively unti l the tension in the walls rise
s above a threshold
• This elicits the micturiti on refl ex that empti es the bladder or atl
east a conscious desire to urinate.
• It can be inhibited or facilitated by the higher brain centres.
FUNCTIONAL ANATOMY OF THE BLADDER
AND THE FEMALE URETHRA
• The urinary bladder is a muscular sac.
• Superbly covered by the parietal peritoneum.
• It consists of ill-defi ned layers of muscle fi bres.
• The Mucosa has a transiti onal epithelium.
FUNCTIONAL ANATOMY OF THE BLADDER AND URETHRA CON
T'D

• In the relaxed state the bladder has the rugae.

• The ureters enter into the bladder at the two upper angl
es of the trigone while the lower end of the trigone con
tinues into the posterior urethra.
• This is a common site for bladder infection.
FUNCTIONAL ANATOM body Y OF THE BLADDER AND URETHRA C
ONT'D

• The bladder is divided into body and the neck

• The neck is the lower part of the body which continues b
esides the posterior urethra as the internal urethral sphi
ncter( doesn't encircle it).
• Further along the urethra is the external urethral sphinc
ter.
FUNCTIONAL ANATOMY OF THE BLADDER AND URETHRA CON
T'D

• Female urethra is narrow and shorter than male urethra

• it's about 3.5cm to 4cm long
• Traverses through the urogenital diaphragm and runs alo
ng the anterior wall of the vagina.
SYMPATHETIC NERVE SUPPLY
Arises from L1 , L2 of the spinal cord.
Passes through the lateral sympathetic chain
 preganglionic fibres terminates in the hypogastric gangl
ion.
The postganglionic forms the hypogastric nerve .
PARASYMPATHETIC NERVE
• Preganglionic fibres of the parasympathetic nerves from
the pelvic nerve or nervus erigens.
• Pelvic nerve fibres arise from the S2 ,S3 ,S4 sacral segme
nts
• synapse withclose relations to the urinary bladder and i
nternal sphincter.
FUNCTION OF THE PARASYMPATHETIC NERVE
SUPPLY
• Causes contraction of the detrusor muscle and relaxatio
n of the internal urethral sphincter.
• Pelvic nerve has sensory component
SOMATIC NERVE SUPPLY
• External sphincter is innervated by the somatic nerve cal
led the pudendal nerve
• It arises from the S2,S3,S4.
• It maintains the tonic contraction of the external urethra
l sphincter
• During micturition, the nerve is inhibited.
FILLING OF THE URINARY BLADDER
Urine Is continously formed by nephrons.
When urine collects in the pelvis of the ureter,contraction
is set up in the pelvis
Peristaltic waves travelling at a velocity of 3cm/ sec and a
frequency of 1 to 5 drops per minute moves urine throug
h the ureters in to the bladder drop by drop.
CYSTOMETROGRAM
• Cystometry is the technique used to study the relationsh
ip between intravesical pressure and volume of urine in
the bladder.
• Cystometrogram is the graphical representation or recor
ding of pressure changes in urinary bladder in relations
to the volume of urine collected.
METHOD OF CYSTOMETROGRAM
• A double lumen catheter .
• First, the bladder is emptied completely.
• Then a known quantity of fluid is Introduced into the bla
dder at regular intervals.
• Intravesical pressure and volume of fluid are plotted on
a graph.
CYSTOMETROGRAM CONTINUES
• Cystometrogram shows three segments
• SEGMENT 1
• Initially when the urinary bladder is empty, the intravesi
cal pressure is 0.
• When 100ml of fluid is collected,the pressure rises shar
ply to about 10cm of H20.
CYSTOMETROGRAM CONTINUES
• SEGMENT 2
• This shows the plateau where there's no change in intrav
esical pressure.
• It remains at 10cm of H20 ,even after introducing 300ml
to 400ml of fluid.
• Due to adaptation of the urine bladder by relaxation.
• In accordance with Laplace law.
• For the bladder to begin emptying however, one obstacle must
be overcome, the external urethral sphincter.
• Nerve fi bres from the cerebral cortex descends by way of the co
rti cospinal tracts and inhibit sacral somati c neurons that norm
ally keeps the sphincter constricted.
• This is what gives a person the conscious control of when to ur
inate and the ability to stop uurinati ng midstream.
• Males expel last few drops of urine by voluntarily contracti ng th
e bulbocarvenous muscle.
SEGMENT 2 CONTINUES
• In the bladder, the tension increases as the urine increas
es as the urine is filled.
• At the same time,the radius also increases due to relaxa
tion of the detrusor muscle.
• Because of this, the pressure does not change and plate
au appears on the graph.
• The implication of this is that with 100ml of urine and
CONT'D
• And the desire for micturition occurs with associated vag
ue feeling in the perineum that can be controlled.
• An additional volume of about 200 to 300ml of urine ca
n be collected in the bladder.
• volume of urine rises beyond 400ml,the pressure starts t
o rise sharply.
SEGMENT 3

• At this point the fl uid is >400ml ,Detrusor muscle contracti on intensifi es

causing a urge and consciousness for micturiti on.
• Voluntary control is sti ll possible at this point upti ll a volume of 600 to 7
00ml of the fl uid at which the pressure is about 35cm to 40cm of H20.
• When the intravesical pressure rises above 40cm of H20,the contracti on
of detrusor muscle becomes much more Intense and micturiti on is a mus
t at this stage.
MICTURITION REFLEX
• Controlled partly by an autonomic spinal refl ex
• Filling of the bladder to about 150ml to 200ml or more excites t
he stretch receptors in the bladder wall.
• They issue signals by way of the sensory fi bres in the pelvic ner
ve to the sacral spinal cord. (S2,S3)
• Efferent signals from the spinal cord travels back to the bladder
by way of motor nerves
• Excites the detrusor and relaxes the internal sphincter.
• Owing to different adrenergic receptors in the muscles.
• This results in emptying the bladder, if there was no voluntary c
ontrol of micturiti on.
• This is the only means of control in children less than 3 years ,p
eople with spinal cord injuries that disconnects the brain from
the lower spinal cord.
• The voluntary control of micturiti on is evoked as follows
• Some Input from the stretch receptor ascends the spinal cord t
o a nucleus in the pons called the micturiti on centre
• Thus nucleus integrated informati on about the bladder tension
with informati on from other brain centres such as the posterior
hypothalamus, amygdala ,superior frontal gyrus and cerebrum.
• This urinati on can be prompted by fear or inhibited by knowled
ge that the circumstances is not appropriate for urinati on.
• fi bres from the micturiti on centre descends the spinal cord thr
ough the reti culospinal tracts.
• Some of these fi bres inhibits sympatheti c neurons that keeps the urethr
al sphincter contracted thus allowing for its relaxati on
• Other fi bres descends farther to the sacral region of the spinal cord and
excites the parasympatheti c neurons to sti mulate the detrusor and relax
the internal urethral sphincter
• The internal contracti on of the detrusor raises pressure with the bladde
r. Further exciti ng the stretch receptors that started the process.
• Thus a positi ve feedback loop is established and intensifi es bladder con
tracti on as urinati on proceeds.
• For the bladder to begin emptying however, one obstacle must be overco
me, the external urethral sphincter.
• Nerve fi bres from the cerebral cortex descends by way of the corti cospin
al tracts and inhibit sacral somati c neurons that normally keeps the sphi
ncter constricted.
• This is what gives a person the conscious control of when to urinate and
the ability to stop uriati ng midstream.
• Males expel last few drops of urine by voluntarily contracti ng the bulboc
arvenous muscle.
• If the urge to urinate arises at an incongruent ti me and one mus
t suppress it. The stretch receptors fati gue and stop fi ring.
• As bladder tension increases however the signals return with in
creasing frequency and persistence.
• Conversely, there are ti mes when the bladder is not full enough
to trigger micturiti on refl ex but one wishes it to go anyway bec
ause of a long drive or lecture coming up
• The vasalva manoeuvre also ends in empt
ying the bladder.
URINARY INCONTINENCE
• The inability to voluntarily hold urine or involuntary le
akage from the bladder leading to uncontrollable urinati
on due to brief surge in bladder pressure as in laughing,
coughing (stress incontinence) and neurological disorder
s of the spinal cord.
ATONIC BLADDER- EFFECT OF DESTRUCTION
OF SENSORY NERVE FIBRES.
• This is the urinary bladder with loss of tone in the detrusor muscle
• Caused by destructi on of sensory nerve fi bres of the urinary bladder.
• Hence bladder is fi lled without any stretch signals hence detrusor muscl
e looses the tone and becomes fl accid.
• Leading to overfl ow inconti nence
• As in Tabeti c bladder and crush injury to the sacral region of the spinal c
ord.
AUTOMATIC BLADDER
• Urinary bladder characterised by hyperacti ve micturiti on refl ex
with loss of voluntary control.
• Even a small amount of urine collected in the bladder elicits mi
cturiti on refl ex resulti ng in emptying the bladder.
• It occurs during the stage of recovery after complete transecti
on of the spinal cord above the sacral segments.
• Here the voluntary control is lacking because of the absence of
inhibiti on or facilitati on of micturiti on by the higher centres.
UNINHIBITED NEUROGENIC BLADDER.

• It is characterised by frequent and uncontrollable micturiti on caused by

lesions in the midbrain ,parti cularly the inhibitory centre.
• Also called spasti c neurogenic bladder
• The lesion in the midbrain causes conti nues excitati on of spinal micturiti
on centres,resulti ng in frequent and uncontrollable micturiti on.
• Even a small quanti ty of urine collected in the bladder will elicit the mict
uriti on refl ex.
NOCTURNAL MICTURITION
• This is the involuntary voiding of urine during the night
• Also known as enuresis or bed wetti ng.
• Occurs due to the absence of voluntary control of micturiti on.
• This is a common and normal process in infants and children bel
ow 3 years because of incomplete myelinati on of motor fi bres
of the bladder.
NOCTURNAL MICTURITION

• If nocturnal micturition occurs after 3 years of age it’s co

nsidered abnormal and could be due to neurological dis
orders and lumbosacral vertebral defects.
• It can also occur due to psychological factors.
• Impairment of the motor area of the cerebreal cortex.
• Conclusion
• Micturition requires the coordinated activity
of sympathetic, parasympathetic and somatic ne
rves. It also requires normal muscle tone and
freedom from physical obstruction and psycholo
gical inhibition. Control from our higher brai
n centres allow us to determine the right time
and place to allow this important physiologica
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