排尿障礙治療中心版權所有 physiology of micturition hann-chorng kuo department of...

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Physiology of Micturition

Hann-Chorng KuoDepartment of Urology

Buddhist Tzu Chi General Hospital, Hualien


Neuroanatomy of Micturition

Storage– Stability and good compliance of BladderEmpty – Contraction of detrusor and opening of UrethraParasympathetic - Pelvic nerveSympathetic - Hypogastric nerveSomatic nerves- Pudendal nerve


Neuroanatomy of Lower Urinary Tract



Micturition reflex center – sacral cords 2-4Micturition control center – ponsSensory motor center – frontal lobeLimbic systemCerebellum, Basal ganglia


Sensory Afferents

A-delta fibers – Micturition reflex, stretch and fullness sensationC-fibers – Noxious sensation, capsaicin sensitive primary afferents (CSPA)Dual sensory afferents in mammalian urinary bladder


Dual Sensory Innervation of Urinary Bladder


Storage of Urine

Stable bladderGood complianceCompetent urethra- mucosa, submucosa, smooth muscles, striated skeletal muscles (external sphincter)Good pressure transmission and hammock effect during stress


Stable Bladder in Filling Phase


Positive Pressure Transmission during Coughs in UPP Tracing


Poor Pressure Transmission during Coughs in Stress UPP


High Leak Point Pressure in SUI with good Hammock Effect


Empty of Urine

Sustained detrusor contraction- cholinergic parasympathetic fibersRelaxation of bladder neck – alpha-adrenergic sympathetic nervesRelaxation of external sphincter- cholinergic pudendal nervesPatent non-obstructive urethra


Detrusor Contraction during Voiding Phase


Bladder Outlet Obstruction during Voiding Phase in Man


Bladder Outlet Obstruction during Voiding Phase in Woman


Neurophysiology of Micturition Reflexes

排尿中樞 PONS

胸腰髓 T10-L2

薦髓 S2,3,4

交感神經節

膀胱膀胱頸括約肌


Modulation of Sympathetic nerves in Parasympathetic Ganglion

往橋腦排尿中樞

T10-L2 髓

薦髓 S2,3,4 逼尿肌核SIN

副交感神經節

尿道外括約肌


Innervation of Lower Urinary Tract

Bladder- cholinergic parasympathetic- contraction; beta-adrenergic & NO– relaxationBladder neck – alpha-adrenergic- contrationUrethral muscles- cholinergic parasympathetic, NO, cholinergic somatic nerves


Physiology of Urine Storage

First sensation of fillingFullness sensationUrge sensationPremicturition urge sensation- phasic detrusor contractionIncreased activity of urethral sphincter during filling


Urodynmic Tracing in Micturition


Initiation of Micturition- Relaxation of External Sphincter


Sustained Detrusor Contraction- Urethrovesical Reflex

Stretch receptors in urethral wallDetrusor overactivity in urgency- frequency syndrome and SUIRole of incompetent bladder neckLow detrusor contractility in incompetent urethral sphincter after prostatectomy


Micturition detrusor pressure- depends on urethral resistance

High voiding pressure indicates a greater urethral resistanceLow voiding pressure indicates a lower urethral resistance or a low detrusor contractilityEfficient bladder empty depends on a sustained detrusor contraction


Detrusor instability and Inadequate contractility (DHIC)


Low Detrusor Pressure in Woman with SUI


Low Detrusor Pressure and BOO


Detrusor overactivity and BPO


Efficient Bladder Empty

Hypersensitive bladder- low detrusor contractilityInadequate contractility in elderlyBladder outlet obstruction- Bladder neck dysfunction, Prostatic enlargement, Urethral stricture, Cystocele, External sphincter dyssynergia


Urethral Stricture and BOO


Anterior Urethral Valve and BOO


Cystocele and BOO


Autonomic Dysreflexia


Detrusor External Sphincter Dyssynergia


Dysfunctional Voiding in Woman


Pseudodyssynergia in Girl with Incontinence and UTI


Pharmacology of Micturition- Increase storage efficiency

Reduce detrusor overactivityAnticholinergic agents- oxybutynine, flavoxate, imipramineGanglion blocker- bentylBeta-adrenergic agentsBotulinum toxinVanilloid receptor blockers- capsaicin, resiniferatoxin


Detrusor Overactivity after Resiniferatoxin Treatment


Initial Excitatory Responses after Capsaicin Treatment


Pharmacology of Micturition- Increase empty efficiency

Parasympathomimetic agent- UrecholineAdrenergic blockers- inhibition of detrusor relaxation (?)


Pharmacology of Micturition- Increase outlet resistance

Increase smooth muscle tone Imipramine, methylephedrine

Increase striated muscle tone Nitric oxide synthase inhibitor Pelvic floor muscle training


Pharmacology of Micturition- Decrease outlet resistance

Decrease bladder neck & urethral resistanceAlpha-adrenergic blockers- dibenyline, terazosin, tamsulosin, doxazosinNitric oxide donorsBotulinum toxin Polysynaptic blocker – baclofen, diazepam


Reduction of MUCP after Nitric Oxide Donors (NTG)


Improved Voiding Efficiency after Botulinum Toxin Injection


Decreased MUCP after Botulinum Toxin Injection


Combination of Medication- Improve Voiding Efficiency

Increased bladder sensation- intravesical capsaicin, RTXDetrusor overactivityanticholinergic, intravesical RTX, botulinum toxinDetrusor underactivity – parasympathomimetics, alpha-blocker, NO donors, striated muscle relaxant, periurethral botulinum toxin injection


Combined Medication – Improved Voiding Efficiency

Urethral sphincter hypertonicity- alpha-blocker, NO donors, striated skeletal muscle relaxantUrethral sphincter overactivity- alpha-blocker, striated muscle relaxant, NO donors, botulinum toxinBladder neck dysfunction- alpha-adrenergic blocker


Combined Medication- Improved Storage Efficiency

Detrusor Overactivity- anticholinergics, sympathomimetics, imipramineIntrinsic sphincter deficiency- imipramine, sympathomimeticsDHIC- depends on voiding efficiency and grades of incontinence

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排尿障礙治療中心版權所有 physiology of micturition hann-chorng kuo department of...