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Renal system > Anatomy of the bladder, urethra and micturition > Flashcards

Anatomy of the bladder, urethra and micturition Flashcards

1
Q

where is the bladder located?

A

in the pelvis

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2
Q

where do the ureters enter the pelvis?

A

pelvic inlet at the sarcoiliac joint

ureters pass anterior to bifurcation of common iliacs and continue down the pelvic wall to join the base of the bladder

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3
Q

urinary bladder

A

extraperitoneal structure

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4
Q

bladder in empty state

A

superior border

superior margin of pubic bone

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5
Q

bladder in full state

A

extends superiorly encroaching on abdominal cavity but remains retroperitoneal

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6
Q

where can the bladder rupture?

A

into peritoneum or extraperitoneally

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7
Q

urethra course

A

passes through pelvic floor

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8
Q

bladder in children

A

has a much higher position in the abdomen

it descends into the pelvis by the end of puberty

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9
Q

shape of bladder

A

pyramidal shape

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10
Q

base of bladder

A

posterior

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11
Q

apex of bladder

A

anterior

urachus is present - remnant of allantois

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12
Q

surfaces of bladder

A

left and right inferolateral surfaces

superior surface

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13
Q

where in the bladder do the ureters join?

A

pelvoureteric junction

upper corners of base of bladder

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14
Q

where does the urethra drain from?

A

the inferior portion of the bladder base

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15
Q

what is anterior to the bladder?

A

pubic symphysis

retroperitoneal space

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16
Q

what is posterior to the bladder?

A

vaginal and cervix in females
vas deferens and seminal vesicles - lateral as well in males
rectum

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17
Q

what is lateral to the bladder?

A

pelvic floor muscles
levator ani
obturator internus

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18
Q

what is superior to the bladder?

A

peritoneum - covers the dome
intestines
intra-peritoneal contents
uterus in females

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19
Q

what are the pelvic floor muscles?

A 
pubococcygeus
puborectalis
iliococcygeus 
all make up levator ani complex
obturator internus 
coccygeus makes up rest of pelvic floor
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20
Q

what muscles make up the levator ani?

A

pubococcygeus
iliococcygeus
puborectalis

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21
Q

bladder wall

A

made up of detrusor muscle

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22
Q

what is the detrusor muscle?

A

smooth muscle

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23
Q

sympathetic control of bladder

A

detrusor muscle relaxed during the filling phase of micturition via sympathetic branches

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24
Q

where do the sympathetic branches of the bladder originate?

A

thoracic and lumbar spinal cord

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25
Q

parasympathetic control of bladder

A

contracts when urinating via parasympathetic branches

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26
Q

where do the parasympathetic branches of the bladder originate?

A

sacral spinal cord

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27
Q

arrangement of detrusor muscles

A

in loops around ureteral openings to prevent reflux of urine back into ureters

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28
Q

internal urethral sphincter

A

thickening of detrusor muscle around bladder neck

only in males

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29
Q

external urethral sphincter

A

present in both sexes
at pelvic diaphragm
skeletal muscle

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30
Q

what is the trigone?

A

smooth triangular area between the internal urethral sphincter and 2 openings from the ureters

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31
Q

what is the role of the trigone?

A

highly sensitive to expansion and when stretched sends signals to the brain that the bladder is filling
as it stretches signals become stronger and more frequent

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32
Q

where is the neck of the bladder

A

inferior most point of bladder
at urethral opening
where the bladder meets the 2 inferolateral surfaces
most fixed part of bladder

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33
Q

what holds the neck of the bladder in place?

A

a pair of tough fibromuscular bands which connect it and the proximal part of the urethra to the pubic bone

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34
Q

female fibromuscular bands of bladder

A

pubo-vesical ligaments

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35
Q

male fibromuscular bands of bladder

A

pubo-prostatic ligaments

because they blend with the fibrous capsule of the prostate that also surrounds the urethra and bladder neck

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36
Q

what else holds the bladder in place?

A

perineal membrane
levator ani muscle
pubic bone

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37
Q

what arteries supply the bladder?

A

superior and inferior vesical arteries

branches of internal iliac artery

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38
Q

what does the superior vesical artery supply?

A

anterior and superior portion of bladder

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39
Q

blood supply to bladder in females?

A

inferior vesical arteries largely replaced with the vaginal arteries

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40
Q

venous drainage of bladder

A

follows arterial supply
vesical venous plexus
drains into internal iliac veins

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41
Q

what lines the bladder and ureters?

A

transitional epithelial cells

42
Q

bladder cancer

A

caused by transitional cell carinomas

43
Q

what lines the urethra?

A

proximal - as it exits bladder transitional epithelium continues
becomes pseudostratified columnar then stratified squamous epithelial cells near the external urethral orifice

44
Q

other cells within urethra

A

mucus secreting urethral glands that help protect the epithelium from corrosive urine

45
Q

what is the urethra?

A

muscular tube that conveys urine from bladder to outside

in males it carries semen during ejaculation

46
Q

female urethra

A

short
4cm
slightly curved

47
Q

what does the female urethra pass through

A

pelvic floor into perineum
deep perineal pouch - where the external urethral sphincter is
perineal membrane
opens in the vestibule between the labia minora

48
Q

male urethra

A

longer
up to 20cm
bends twice along course when penis is flaccid

49
Q

course of male urethra

A 
begins at base of bladder 
passes inferiorly
through prostate
deep perineal pouch 
then perineal membrane 
enters root of penis
50
Q

parts of male urethra

A 
4 parts
preprostatic
prostatic
membranous
spongy - within penis
51
Q

preprostatic part of urethra

A

short within wall of bladder
associated with internal urethral sphincter - important for continence and preventing retrograde ejaculation into bladder

52
Q

prostatic part of urethra

A

passes through prostate

where ejaculatory ducts and seminal vesicles open into urethra

53
Q

membranous part of urethra

A

passes through deep perineal pouch

location of external urethral sphincter

54
Q

spongy part of urethra

A

surrounded by erectile tissue and muscles of penis

forms a bulb at the end of penis

55
Q

bulb at end of penis

A

navicular fossa

56
Q

what muscles control the urethra?

A

internal and external urethral sphincter in males and just the external urethra sphincter in females

57
Q

internal urethral sphincter

A 
males only
junction of bladder and urethra
continuation of detrusor muscle
smooth muscle so involuntary
prevents reflux during ejaculation
58
Q

external urethral sphincter

A 
located in deep perineal pouch
part of pelvic floor
inferior to prostate in males
skeletal muscle so voluntary 
innervated by pudendal nerve
59
Q

pudendal nerve

A

main nerve of perineum

60
Q

nerve roots of pudendal nerve

A

S2-4

61
Q

course of pudendal nerve

A

through both greater and lesser sciatic foramen of pelvis

through pudendal canal

62
Q

branches of pudendal nerve

A

into perineal interior rectal and dorsal nerve of penis and clitoris in females

63
Q

sensory supply of pudendal nerve

A

external genitalia
anus
perineum

64
Q

motor supply of pudendal nerve

A

pelvic floor muscles
external urethra sphincter
anal sphincter

65
Q

pudendal nerve block

A

done for episiotomy

66
Q

when will the desire to urinate begin?

A

150ml as bladder wall is stretched

67
Q

law of laplace

A

as the volume of the urine increases the bladder is able to maintain constant pressure as the bladder expands to accommodate more urine - due to Laplace’s law

68
Q

what causes the law of laplace?

A

relaxation of the detrusor muscle increases the radius and so despite the volume of urine increasing there is minimal increase in pressure to 400ml

69
Q

what happens in the bladder when filled over 400ml

A

there is a high pressure increase

resulting in a strong urge to urinate

70
Q

how to measure pressure and volume in bladder

A

cystogram

71
Q

phases of micturition

A

2 phases:
bladder filling - filling phase
bladder emptying - voiding phase

72
Q

what happens in the filling phase of micturition

A

pressure remains low due to detrusor relaxation as the bladder fills - law of laplace without increase in sensation to urinate
stretch receptors in bladder fire low level action potentials via sensory neurons to sacral part of spinal cord as it fills and stretches
causes detrusor muscle relaxation to allow the bladder to stretch and fill by excitement of sympathetic innervation and inhibiting parasympathetic neurons
sympathetic neurons cause contraction of bladder neck and internal urethral sphincter
stretch
contraction of external urethral sphincter via excitation of Onuf’s nucleus and the pudendal nerve

73
Q

what is Onuf’s nucleus?

A

group of neurons in the anterior horn of the sacral region of the spinal cord - origin of pudendal nerve

74
Q

voiding phase of micturition

A

when the bladder is almost full
afferent signals from sensory neurons from stretch receptors increase so you become consciously aware of the need to urinate as they activate the pontine micturition centre in the brainstem
continue to increase
when you are ready to urinate the pontine micturition centre fires signals to excite sacral parasympathetic neurons causing contraction of detrusor and increases pressure inside the bladder
overcomes sympathetic control of internal sphincter in males
sends signals to inhibit onuf’s nucleus to relax the external urethral sphincter via pudendal nerve

75
Q

inhibiting urination

A

sympathetic innervation to internal urethral sphincter in males can prevent urination until the parasympathetic NS fired enough to overcome it

76
Q

post-micturition - emptying of the urethra

A

in females the urethra is emptied by gravity

in males it is emptied by bulbospongiosus muscle contraction

77
Q

automatic bladder reflex

A

in babies
stretching of the bladder due to filling causes it to contract under reflex control
internal sphincter in males relaxes
urine moves down urethra
can be learnt to be suppressed by potty training

78
Q

overactive bladder

A

involuntary muscle contraction - response to distension
urgent uncontrollable need to urinate even if bladder is not full
causes incontinence and frequency

79
Q

what causes an overactive bladder?

A

infection
medications
caffeine
alcohol

80
Q

treatment for overactive bladder

A

many

pelvic floor muscle exercises

81
Q

neurogenic bladder causes

A

spinal injury
MS
stroke
neurodegenerative diseases

82
Q

types of neurogenic bladder

A

spastic and flaccid

83
Q

spastic bladder causes

A

upper motor neuron deficit

injury above T10

84
Q

flaccid bladder causes

A

lower motor neuron lesion

peripheral nerves effected

85
Q

mixed neurogenic bladder

A

spinal cord injury patients
monitored with ultrasound
needs self-catheterisation or suprapubic catheter

86
Q

what happens with a spastic bladder?

A 
hyperreflexive 
detrusor and sphincter dyscoordination 
urinary retention 
small bladder 
increased tone
87
Q

what happens with a flaccid bladder?

A

hypotonic
detrusor doesn’t contract
large bladder

88
Q

supra-pubic catheter

A

permanent or semi-permanent bypass to drain bladder drainage

89
Q

passage of supra-pubic catheter

A

passed through anterior abdominal wall
superior and medial to pubic symphysis
to anterior aspect of bladder

90
Q

indications for suprapubic catheterisation

A

neurological cause preventing urination
physical cause - blockage e.g. cancer
trauma to urethra
physical or neurological deficits - management

91
Q

bladder rupture

A

significant trauma
motor vehicle crash
most common type is extraperitoneal rupture within the extraperitoneal space and leakage of contents

92
Q

what causes extraperitoneal bladder rupture?

A

pelvic fracture

penetrating injury

93
Q

management of extraperitoneal bladder rupture?

A

conservative
catheter
bladder heals itself

94
Q

what are the types of bladder ruptures ?

A

extraperitoneal
intraperitoneal
combined

95
Q

intraperitoneal bladder rupture

A

less common

leakage of bladder contents into peritoneal cavity

96
Q

causes of intraperitoneal bladder rupture

A

direct blow to bladder in distended state

97
Q

treating intraperitoneal bladder rupture

A

requires surgical repair

98
Q

urethral injury

A

more common in males

99
Q

types of urethral injury

A

complete rupture
partial tear
anterior or posterior classification in males

100
Q

anterior urethral injury

A

penile/ bulbar
straddle injury
compressed against pubic bone
isolated injury

101
Q

posterior urethral injury

A

membranous/ prostatic
crushing force from motor vehicle accident
shearing, blunt trauma or straddle injury
associated with fractures and bladder injury

102
Q

causes of urethral injury

A

blunt trauma - straddle injury
motor vehicle accidents
iatrogenic - from catheterisation
penetrating trauma

Renal system (17 decks)

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