Lecture 6- Anatomy of Urinary Bladder and Urethra 1.

Urinary Bladder - Sac containing fluid which collects and stores urine until it is ready to be excreted - The body know when to urinate when its time to urinate - LOCATION: Muscular, hollow pelvic organ varies in size, shape, position & relations according to content and state of neigbouring organs Empty adult urinary bladder located in lesser pelvic, superior & posterior to pubic bones. Separated by retropubic space Lies mostly under cover of peritoneum Resting on pubic bones

Located above the urogenital diaphragm

Male sagittal section

Female sagittal section 2. External structure of urinary bladder : 4 surfaces ( superior, 2 inferolateral, inferoposterior)

4 ducts: 2 ureters, urachus(median umbilical fold), urethra

Apex: points toward superior edge of pubic symphysis Fundus(base) : opposite to apex (formed by convex posterior wall) Body : major portion between apex and fundus Neck: where fundus and inferolateral surfaces meet Wall has 3 layers o Mucosa : forms ruga which in contact with urine ( also line ureters and urethra)

o o

Submucosa (layer that lines the mucosa layer) : blood and lymphatic vessels

o Muscularis: 3 layers of smooth muscles 1 circular between longitudinal layers

o o

Internal sphincter- involuntary because it is a type of smooth muscle External sphincter- voluntary because it is a skeletal muscle

o o o

Trigone : ureters attach via superior/posterolateral angles [right and left ureterovesical orifices] and open through internal urethral meatus Urethra drains urine via neck of bladder Trigone: when all three orifices are connected, it is a smooth, relatively indistensible area within the base

o o

Bladder relatively free within extraperitoneal subcutaneous fattu tissue but it is firmly held by Local fascia Median umbilical ligament Lateral umbilical ligament Retropubic fat Tendinous arch of pelvic fascia ( for male called puboprostatic ligaments and for female is called pubovesical ligamnets) Urogenital diaphragm

3. Blood supply for urinary bladder

It is supplied by superior, middle and inferior vesical arteries that form anastomoses with internal iliac ( hypogastric) artery All the blood is drain back into internal iliac vein that and then prostatic venous plexus in men External and internal iliac nodes

4. Innervation of urinary bladder - Autonomic nervous system SNS= from T11-T12 PSNS= from S2-S4 - Somatic nerves, from S2,S3,S4(pudendal nerve)

5. Urethra - Passage of urine out of neck of bladder to exterior - Male: 18cm, Female: 4 cm - Human males do not have stronger urethral sphincter muscles than females - Females pee more frequently because bladder shares space with uterus and vagina

Urethral sphincters(US)

Internal US is located at bladders inferior end as a continuation of detrusor muscle (therefore autonomic control as they are smooth muscle). Its primary muscle for prohibiting release of urine. Ureteric orifices tighten when bladder contracts to help prevent urine reflux into ureter External US is a secondary sphincter at bladder distal end ( somatic) Regulation of urination Bladder fills Stretch receptors sense the filling Internal sphincter relaxes SPONTANEOUSLY External sphincter can be relaxed VOLUNTARILY

Male Internal urethral sphincter Contracts involuntarily during ejaculation to prevent retrograde ejaculation of semen into bladder

Male Urethra : 2 FUNCTIONS

Prostatic urethra o Travels through prostate and here it meets with ejaculatory ducts which carry sperm from vas deferens and seminal fluid from seminal vesicles Membranous urethra o Travels through UG diaphragm then forms voluntary external urethral sphincter Spongy penile urethra o From urogenital diaphragm to outside Female External US : 3 PARTS

Female urethra passes through UG diaphragm

Sphincter urethrae : wraps solely around urethra ( as in males) Urethrovaginal muscle : wrap along vagina and urethra. Contraction leads to constriction of both Compressor urethrae- wraps anteriorly around urethra. Contraction squeeze urethra against vagina The shorter urethra the female have cause them to be more susceptible to Urinary tract infections 6. Nerve supply of Urethra - Release of urine is controlled by autonomic NS (via the hypogastric plexus) PSNS-The Preganglionic Parasympathetic nerves from S2, S3 and S4 travel in the pelvic nerve and synapse in the cholinergic ganglia in the pelvic plexus. They also provide the major motor innervation to the Detrusor muscle (wall of the bladder). Detrusor muscle is made of smooth muscle. When detrusor muscle relaxed, the internal urethral sphincter is close. When detrusor muscle is contracted, it force the internal sphincter to open SNS- lumbar. Internal sphincter receives sympathetic innervation which causes contraction of the sphincter The external sphincter is innervated by somatic motor neurons that cause contaction.

7. Clinical aspects - Extravasation of urine in males Escape of fluid (blood, urine) into surrounding tissue Urethra typically in males is the most common site. Interruption of urethra leads to collection of urine in other activities : perineal spaces, scrotum, penis, thigh

The membranous or spongy urethra get damaged usually due to trauma, periurethral abscess [pus around ureter] or incorrectly placed devide [bougienage : an insertion of bougie to increase a structures calibre] Fractures of pelvic girdle often cause rupture of membranous urethra. This will result in extravasation of urine and blood from ruptured blood vessels into deep perineal space; may distribute extraperitoneally around prostate and bladder Rupture in spongy urethra will cause extravastion into penis[forceful blow to perineum, incorrect passage of transurethral catheter or device that fails to negotiate angle of urethra in bulb of penis or superficial perineal space with rupture of bucks fascia/ corpus spongiosum [Attachments of perineal fascia determine direction of flow: loose connective tissue in scrotum, around penis, superiorly deep to membranous layer of connective tissue of lower anterior abdominal wall

Extravasation from bladder- due to superior position of distended bladder, injuries to inferior anterior abdominal wall or pelvic fractures may rupture the bladder. This will cause urine to escape either extra or intra peritoneally Superior rupture often tears the peritoneum and lead to extravasation of urine into peritoneal cavity. Posterior rupture cause passage of urine extraperitoneally into perineum

The combination of urine and infection produces severe oedema of a patient's scrotum and abdominal wall. If this is not treated, the skin over his scrotum, penis, and anterior abdominal wall may slough. He may be very ill, toxic, febrile, dehydrated, anaemic, or uraemic, or all of these things. If his renal function is impaired, as it often is after a long standing stricture, extravasation may kill him.

Treatments include : Intravenous fluid replacement Catherization

Divert urine flow

Drain urine out of tissue Antibiotics