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Physiology of Micturition
Hann-Chorng KuoDepartment of Urology
Buddhist Tzu Chi General Hospital, Hualien
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Neuroanatomy of Micturition
Storage– Stability and good compliance of BladderEmpty – Contraction of detrusor and opening of UrethraParasympathetic - Pelvic nerveSympathetic - Hypogastric nerveSomatic nerves- Pudendal nerve
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Neuroanatomy of Lower Urinary Tract
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Neuroanatomy of Micturition
Micturition reflex center – sacral cords 2-4Micturition control center – ponsSensory motor center – frontal lobeLimbic systemCerebellum, Basal ganglia
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Neuroanatomy of Micturition
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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
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Dual Sensory Innervation of Urinary Bladder
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Storage of Urine
Stable bladderGood complianceCompetent urethra- mucosa, submucosa, smooth muscles, striated skeletal muscles (external sphincter)Good pressure transmission and hammock effect during stress
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Stable Bladder in Filling Phase
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Positive Pressure Transmission during Coughs in UPP Tracing
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Poor Pressure Transmission during Coughs in Stress UPP
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High Leak Point Pressure in SUI with good Hammock Effect
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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
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Detrusor Contraction during Voiding Phase
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Bladder Outlet Obstruction during Voiding Phase in Man
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Bladder Outlet Obstruction during Voiding Phase in Woman
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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
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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
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Innervation of Lower Urinary Tract
Bladder- cholinergic parasympathetic- contraction; beta-adrenergic & NO– relaxationBladder neck – alpha-adrenergic- contrationUrethral muscles- cholinergic parasympathetic, NO, cholinergic somatic nerves
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Physiology of Urine Storage
First sensation of fillingFullness sensationUrge sensationPremicturition urge sensation- phasic detrusor contractionIncreased activity of urethral sphincter during filling
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Urodynmic Tracing in Micturition
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Initiation of Micturition- Relaxation of External Sphincter
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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
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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
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Detrusor instability and Inadequate contractility (DHIC)
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Low Detrusor Pressure in Woman with SUI
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Low Detrusor Pressure and BOO
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Detrusor overactivity and BPO
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Efficient Bladder Empty
Hypersensitive bladder- low detrusor contractilityInadequate contractility in elderlyBladder outlet obstruction- Bladder neck dysfunction, Prostatic enlargement, Urethral stricture, Cystocele, External sphincter dyssynergia
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Urethral Stricture and BOO
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Anterior Urethral Valve and BOO
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Cystocele and BOO
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Autonomic Dysreflexia
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Detrusor External Sphincter Dyssynergia
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Dysfunctional Voiding in Woman
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Pseudodyssynergia in Girl with Incontinence and UTI
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Pharmacology of Micturition- Increase storage efficiency
Reduce detrusor overactivityAnticholinergic agents- oxybutynine, flavoxate, imipramineGanglion blocker- bentylBeta-adrenergic agentsBotulinum toxinVanilloid receptor blockers- capsaicin, resiniferatoxin
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Detrusor Overactivity after Resiniferatoxin Treatment
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Initial Excitatory Responses after Capsaicin Treatment
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Pharmacology of Micturition- Increase empty efficiency
Parasympathomimetic agent- UrecholineAdrenergic blockers- inhibition of detrusor relaxation (?)
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Pharmacology of Micturition- Increase outlet resistance
Increase smooth muscle tone Imipramine, methylephedrine
Increase striated muscle tone Nitric oxide synthase inhibitor Pelvic floor muscle training
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Pharmacology of Micturition- Decrease outlet resistance
Decrease bladder neck & urethral resistanceAlpha-adrenergic blockers- dibenyline, terazosin, tamsulosin, doxazosinNitric oxide donorsBotulinum toxin Polysynaptic blocker – baclofen, diazepam
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Reduction of MUCP after Nitric Oxide Donors (NTG)
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Improved Voiding Efficiency after Botulinum Toxin Injection
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Decreased MUCP after Botulinum Toxin Injection
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Combination of Medication- Improve Voiding Efficiency
Increased bladder sensation- intravesical capsaicin, RTXDetrusor overactivity- anticholinergic, intravesical RTX, botulinum toxinDetrusor underactivity – parasympathomimetics, alpha-blocker, NO donors, striated muscle relaxant, periurethral botulinum toxin injection
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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
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Combined Medication- Improved Storage Efficiency
Detrusor Overactivity- anticholinergics, sympathomimetics, imipramineIntrinsic sphincter deficiency- imipramine, sympathomimeticsDHIC- depends on voiding efficiency and grades of incontinence