PHYSIOLOGY OF

MICTURITION

Dr. Jufriady Ismy, Sp.U

NEUROANATOMY OF MICTURITION

• Storage– Stability and good compliance of Bladder

• Empty – Contraction of detrusor and opening of Urethra
• Parasympathetic - Pelvic nerve
• Sympathetic - Hypogastric nerve
• Somatic nerves- Pudendal nerve
NEUROANATOMY OF
LOWER URINARY TRACT
NEUROANATOMY OF MICTURITION
• Micturition reflex center – sacral cords 2-4
• Micturition control center – pons
• Sensory motor center – frontal lobe
• Limbic system
• Cerebellum, Basal ganglia
SENSORY AFFERENTS

• A-delta fibers – Micturition reflex,

stretch and fullness sensation
• C-fibers – Noxious sensation,
capsaicin sensitive primary
afferents (CSPA)
• Dual sensory afferents in urinary
bladder
1999. Pathophisiology and Categorization of Voiding
Disfunction. Campbell’s Uro
STORAGE OF URINE

• Stable bladder
• Good compliance
• Competent urethra- mucosa, submucosa, smooth
muscles, striated skeletal muscles (external sphincter)
• Good pressure transmission and hammock effect
during stress
POSITIVE PRESSURE TRANSMISSION DURING
COUGHS IN UPP TRACING
EMPTY OF URINE

• Sustained detrusor contraction- cholinergic

parasympathetic fibers
• Relaxation of bladder neck – alpha-adrenergic
sympathetic nerves
• Relaxation of external sphincter- cholinergic pudendal
nerves
• Patent non-obstructive urethra
NEUROPHYSIOLOGY OF
MICTURITION REFLEXES

PONS

T10-L2

Medula Spinalis
S2,3,4
Bladder
Internal Sphingter
External Sphingter
INNERVATION OF
LOWER URINARY TRACT

• Bladder- cholinergic parasympathetic- contraction;

beta-adrenergic & NO– relaxation
• Bladder neck – alpha-adrenergic- contration
• Urethral muscles- cholinergic parasympathetic, NO,
cholinergic somatic nerves
PHYSIOLOGY OF URINE STORAGE

• First sensation of filling

• Fullness sensation
• Urge sensation
• Premicturition urge sensation- phasic detrusor
contraction
• Increased activity of urethral sphincter during filling
SUSTAINED DETRUSOR CONTRACTION-
URETHROVESICAL REFLEX

• Stretch receptors in urethral wall

• Detrusor overactivity in urgency- frequency syndrome and SUI
• Role of incompetent bladder neck
• Low detrusor contractility in incompetent urethral sphincter after
prostatectomy
MICTURITION DETRUSOR PRESSURE- DEPENDS ON
URETHRAL RESISTANCE

• High voiding pressure indicates a greater urethral resistance

• Low voiding pressure indicates a lower urethral resistance or a
low detrusor contractility
• Efficient bladder empty depends on a sustained detrusor
contraction
EFFICIENT BLADDER EMPTY

• Hypersensitive bladder- low detrusor contractility

• Inadequate contractility in elderly
• Bladder outlet obstruction- Bladder neck dysfunction, Prostatic
enlargement, Urethral stricture, Cystocele, External sphincter
dyssynergia