Function of the Urinary

bladder
Dr Neville D Perera.
Department of Urology
The National Hospital of Sri Lanka.
 Bladder Function
Storage(Filling)
• impermeable -urothelium
minimal lymphatics
• Expandable-receptive relaxation
Visco-elastic properties
soft pelvic tissues
• Retaining mechanisms-Sphincters
internal(bladder neck/Smooth muscles)
External(Urethral wall/pelvic muscles )
 Mechanism of filling
• Filling rate -1 ml/min
• first sensation at 150 ml-can suppress
• bladder pressure - 5 cm H2O up to 350 ml
• No detrusor contractions up to 350 ml
• Strong desire ,increasing pressure >350 ml
• painful contractions and voiding > 450 ml
• No vesico ureteric reflux at any stage.
• Sphincters are closed->100 cm H2O( 24/7/365)
 Voiding(Micturition)
• Micturition reflex
• afferents -parasympathetics at S 2,3,4 level
• stimulated by increased detrusor pressure
• mediated by “sacral center”
• efferents -parasympathetics at S2,3,4
somatic -pudendal nerves
• Inhibited by “cortical centers”
• Co-ordinated through “Pontine centers”
 Mechanism of voiding
• Under voluntary control.
• Initiated by inhibiting “cortical inhibition”
• Activation of “Micturation reflex”
• Coordinated contraction of detrusor with relaxaton
of sphincters by “pontine center”
• Sphincter pressure decreased-< 40 cm H2O
• Urine flow rate-15-25 ml/sec
• trigonal contraction prevent U-V reflux
• No post void residue(PVR)
• At the end Mict. refex is inhibited
 Bladder dysfunction
• Due to abnormal structure

• Due to abnormal function

(damaged nerves but intact structure)
 Bladder dysfunction - symptoms
Filling problems Voiding problems
• Frequency • Hesitancy
• Urgency
• Poor steam, dribbling
• Nocturia
• interrupted stream
• Sense of incomplete
voiding • Acute retention
• incontinence • chronic retention
Total • Back pressure effects
Stress / Urge (renal failure)
Overflow
Structural Problems in filling.
Can not contain
• Ectopia vesicae-epispadias complex (Congenital)
• Vesical fistulae-Vesico vaginal/colic (Acquired)

Can not accommodate (Expandability)

• chronic inflammation (TB, radiation, Int. Cystitis)
• frozen pelvis
• Detrusor instability

Can not retain

• Sphincter trauma
• (obstetric, iatrogenic, RTA)
 Structural Problems in voiding.
Obstruction to outlet
Conginital
• phimosis, meatal stenosis
• posterior urethral valves

• I;6000 boys, failure of regression of mesonephric duct,

associated with UV reflux(40%) ,hydronphrosis+,renal failure+
• Diagnosis- antenatal, poor stream. palpable bladder/kidneys.
• Mx- MCUG, catheterisation, Vesicostomy, endoscopic ablation
 Structural Problems in voiding
• Obstruction to outlet
• Acquired-
• Urethra-Meatal stenosis (BXO)
Strictures-Inflammatory (GC,NGC)
traumatic- External,instrumental
malignant
• present with LUTS,obstructive uropathy, ARU,Renal
failure
• Mx-urethrography,Abx,dilatation, Urethrotomy,
urethroplasty
• malignant-amputation of penis
 Structural Problems in voiding
Obstruction to outlet
Prostatic obstruction
• androgen dependant,exact function
unknown.enlarges due to
BPH,malignancy or inflammation.
• Leads to symptoms -obstructive/
Irritative
 Functional Problems
Neuropathic(neurogenic)bladder
• UMN lesion
• (Spastic neurogenic bladder)
• (automatic bladder)

• LMN lesion
• (Atonic bladder)
• (Autonomous bladder)
Level of damage
 ICS classification
• Detrusor: Normal, hypereflexic +++, atonic ----

• Striated Sphincter: Normal, hyperactive +++,

incompetent---

• Sensation: Normal, increased + , diminished -

 Level of damage

• Important to differentiate
bladders with high bladder
pressures from low bladder
pressures to prevent
damage to kidneys
Management of neuropathic bladder
• Keep empty – void by the clock, CSIC, Indwelling
cath.

• Maintain bladder compliance/capacity –

medications to paralyse bladder wall, surgery

• Mx of incontinence – regular emptying, sheaths,

increase capacity, diversion
 Questions ?

THANK YOU- See you all at the urology Department !