URINARY BLADDER

The urinary bladder is an organ that serves to collect urine to be voided through urination after the
urine is filtered through the kidneys (where the necessary ions are reabsorbed if physiologically
needed through feedback mechanisms found throughout the body and in the nephrons of the
kidneys, such as the macula densa).

Histologically, the urinary bladder is lined with transitional epithelium and does not produce
mucus.

Anatomy

The urinary bladder is a hollow viscus with strong muscular walls, and pear-shaped distensible
elastic organ that sits on the pelvic floor. It is characterized by its distensibility. It receives urine
via the ureters, which are thick tubes running from each kidney down to the superior part of the
bladder.

The bladder is a temporary reservoir for urine, and varies in size, shape, position, and
relationships according to its content, and the state of neighboring viscera. When empty, the adult
urinary bladder is located in the lesser pelvis, lying partially superior to and partially posterior to
the pubic bones. It is separated from these bones by the potential retropubic space (of Retzius)
and lies mostly inferior to the peritoneum, resting on the pubic bones and pubic symphysis
anteriorly and the prostate (males) or anterior wall of the vagina (females) posteriorly.

The bladder is relatively free within the extraperitoneal subcutaneous fatty tissue, except for its
neck, which is held firmly by the lateral ligaments of bladder and the tendinous arch of the pelvic
fascia—especially its anterior component, the puboprostatic ligament in males and the
pubovesical ligament in females.
In females, since the posterior aspect of the bladder rests directly upon the anterior wall of the
vagina, the lateral attachment of the vagina to the tendinous arch of the pelvic fascia, the
paracolpium, is an indirect but important factor in supporting the urinary bladder.

In infants and young children, the urinary bladder is in the abdomen even when empty. The
bladder usually enters the greater pelvis by 6 years of age; however, it is not located entirely
within the lesser pelvis until after puberty. An empty bladder in adults lies almost entirely in the
lesser pelvis, its superior surface level with the superior margin of the pubic symphysis. As the
bladder fills, it enters the greater pelvis as it ascends in the extraperitoneal fatty tissue of the
anterior abdominal wall.
In some individuals, a full bladder may ascend to the level of the umbilicus.

At the end of micturition (urination), the bladder of a normal adult contains virtually no urine.
When empty, the bladder is somewhat tetrahedral and externally has an apex, body, fundus, and
neck. The bladder’s four surfaces (superior, two inferolateral, and posterior) are most apparent
when viewing an empty, contracted bladder that has been removed from a cadaver, when the
bladder appears rather boat shaped.

The apex of the bladder points toward the superior edge of the pubic symphysis when the bladder
is empty.

The fundus of the bladder is opposite the apex, formed by the somewhat convex posterior wall.
It is the base of the bladder, and contains the trigone of the bladder. (The trigone is the structure
that contains the outlet (urethra) of the bladder).

The body of the bladder is the major portion of the bladder between the apex and the fundus.
The fundus and inferolateral surfaces meet inferiorly at the neck of the bladder.

The bladder bed is formed by the structures that directly contact it. On each side, the pubic
bones and fascia covering the levator ani and the superior obturator internus lie in contact with
the inferolateral surfaces of the bladder. Only the superior surface is covered by peritoneum.
Consequently, in males the fundus is separated from the rectum centrally by only the fascial
rectovesical septum and laterally by the seminal glands and ampullae of the ductus deferentes.

In females the fundus is directly related to the superior anterior wall of the vagina. The bladder is
enveloped by a loose connective tissue visceral fascia.

The walls of the bladder are composed chiefly of the detrusor muscle. Toward the neck of the
male bladder, the muscle fibers form the involuntary internal urethral sphincter. This sphincter
contracts during ejaculation to prevent retrograde ejaculation (ejaculatory reflux) of semen into
the bladder. Some fibers run radially and assist in opening the internal urethral orifice.

In males, the muscle fibers in the neck of the bladder are continuous with the fibromuscular tissue
of the prostate, whereas in females these fibers are continuous with muscle fibers in the wall of
the urethra.

The ureteric orifices and the internal urethral orifice are at the angles of the trigone of the
bladder.

The ureteric orifices are encircled by loops of detrusor musculature that tighten when the bladder
contracts to assist in preventing reflux of urine into the ureter. The uvula of the bladder is a slight
elevation of the trigone; it is usually more prominent in older men owing to enlargement of the
posterior lobe of the prostate.

Urine is collected in the body of the bladder, and finally it is voided through the urethra. While
the general volume of the human bladder will vary from person to person, the range of urine that
can be held in the bladder is roughly 400 mL to 1000 mL, with the average capacity being 400 to
600 mL.

BLOOD SUPPLY

The main arteries supplying the bladder are branches of the internal iliac arteries. The superior
vesical arteries supply anterosuperior parts of the bladder. In males, the inferior vesical arteries
supply the fundus and neck of the bladder. In females, the vaginal arteries replace the inferior
vesical arteries and send small branches to posteroinferior parts of the bladder. The obturator and
inferior gluteal arteries also supply small branches to the bladder.

The veins draining blood from the bladder correspond to the arteries, and are tributaries of the
internal iliac veins. In males, the vesical venous plexus is continuous with the prostatic venous
plexus, and the combined plexus complex envelops the fundus of the bladder and prostate, the
seminal glands, the ductus deferentes, and the inferior ends of the ureters. It also receives blood
from the deep dorsal vein of the penis, which drains into the prostatic venous plexus. The vesical
venous plexus is the venous network that is most directly associated with the bladder itself. It
mainly drains through the inferior vesical veins into the internal iliac veins; however, it may drain
through the sacral veins into the internal vertebral venous plexuses. In females, the vesical venous
plexus envelops the pelvic part of the urethra and the neck of the bladder, receives blood from the
dorsal vein of the clitoris, and communicates with the vaginal or uterovaginal venous plexus.

Innervation of Bladder

Sympathetic fibers are conveyed from inferior thoracic and upper lumbar spinal cord levels to the
vesical (pelvic) plexuses primarily through the hypogastric plexuses and nerves, whereas
parasympathetic fibers from sacral spinal cord levels are conveyed by the pelvic splanchnic
nerves and the inferior hypogastric plexus. The parasympathetic fibers are motor to the detrusor
muscle and inhibitory to the internal urethral sphincter of the male bladder. Hence, when visceral
afferent fibers are stimulated by stretching, the bladder contracts reflexively, the internal urethral
sphincter relaxes (in males), and urine flows into the urethra. With toilet training, we learn to
suppress this reflex when we do not wish to void. The sympathetic innervation that stimulates
ejaculation simultaneously causes contraction of the internal urethral sphincter, to prevent reflux
of semen into the bladder.

A sympathetic response at moments other than ejaculation (e.g., self- consciousness when
standing at the urinal in front of a waiting line) can cause the internal sphincter to contract,
hampering the ability to urinate until parasympathetic inhibition of the sphincter occurs.

Sensory fibers from most of the bladder are visceral; reflex afferents follow the course of the
parasympathetic fibers, as do those transmitting pain sensations (such as results from
overdistension) from the inferior part of the bladder. The superior surface of the bladder is
covered with peritoneum and is therefore superior to the pelvic pain line; thus pain fibers from the
superior bladder follow the sympathetic fibers retrogradely to the inferior thoracic and upper
lumbar spinal ganglia (T11–L2 or L3).
CLINICALS

Suprapubic Cystotomy

Although the superior surface of the empty bladder lies at the level of the superior margin of the
pubic symphysis, as the bladder fills it extends superiorly above the symphysis into the loose
areolar tissue between the parietal peritoneum and anterior abdominal wall. The bladder then lies
adjacent to this wall without the intervention of peritoneum. Consequently, the distended bladder
may be punctured (suprapubic cystotomy) or approached surgically superior to the pubic
symphysis for the introduction of indwelling catheters or instruments without traversing the
peritoneum and entering the peritoneal cavity. Urinary calculi, foreign bodies, and small tumors
may also be removed from the bladder through a suprapubic extraperitoneal incision.
Rupture of Bladder

Because of the superior position of the distended bladder, it may be ruptured by injuries to the
inferior part of the anterior abdominal wall or by fractures of the pelvis. The rupture may result in
the escape of urine extraperitoneally or intraperitoneally. Rupture of the superior part of the
bladder frequently tears the peritoneum, resulting in extravasation (passage) of urine into the
peritoneal cavity. Posterior rupture of the bladder usually results in passage of urine
extraperitoneally into the perineum.

Cystoscopy

The interior of the bladder and its three orifices can be examined with a cystoscope. During
transurethral resection of a tumor, the instrument is passed into the bladder through the urethra.
Using a high frequency electrical current, the tumor is removed in small fragments that are
washed from the bladder with water.

Hernia of Bladder

Loss of bladder support in females by damage to the pelvic floor during childbirth (e.g.,
laceration of perineal muscles or a lesion of the nerves supplying them, or rupture of the fascial
support of the vagina, the paracolpium can result in collapse of the bladder onto the anterior
vaginal wall. When intraabdominal pressure increases (as when “bearing down” during
defecation), the anterior wall of the vagina may protrude through the vaginal orifice into the
vestibule.
Other Clinical notes
Problems with the muscles of the urinary bladder or sphincters can lead to incontinence
(involuntary urination). In babies, the nervous system has not yet developed further, so a baby's
bladder fills to a set point, then automatically contracts and empties. As the child matures, so
does the nervous system, which means the brain can now receive messages from the filling
bladder and prevent it from automatically emptying until convenient. Failures in this control
mechanism results in incontinence, but there are many different ways that lead to mechanism
failure (e.g. neurologic injury, congenital defects, strokes, multiple sclerosis, and aging).
Oftentimes, what is found in urine can be helpful in diagnosis or evaluation of a patient’s state
of health. For example, excessive protein (proteinuria) found in the urine can mean more
serious underlying problems in the body such as intrinsic renal failure (nephrotic syndromes),
diabetic nephropathy, or infections. Accumulation of too much cholesterol or protein in the
urine can also lead to kidney stones. Sometimes, urinary incontinence or inadequate voiding of
urine can lead to a urinary tract infection.
Another common issue is frequent urination. This can be due to excessive urine production,
small bladder capacity, irritability, incomplete emptying, or simply consumption of too many
liquids either consciously or due to a disease state (e.g. diabetes insipidus). In addition, males
with an enlarged prostate urinate more frequently since the prostate is found posterior to the
bladder and enlarges in elderly men, therefore pressing against the bladder and increasing
bladder sensations. The definition of an overactive bladder is when a person urinates more than
eight times per day.
If blood is found in the urine (known as hematuria) that is not from an external cut or apparent
source, it is an indication to seek medical attention without delay, as it could be a symptom of
bladder cancer or bladder/kidney stones.