The bladder

The bladder is a hollow organ of variable capacity, with a powerful intermediate muscle coat that empties the organ when it contracts, and two muscular sphincters that keep the exit closed at all other times. This smooth muscle coat constitutes the powerful detrusor muscle. At the base of the bladder the region of the bladder neck, or trigone, is demarcated by the two ureteric orifices and the internal opening of the urethra. Muscle fibres loop around the urethral opening to form the internal sphincter, which is under involuntary control. The external sphincter consists of two layers of striated muscles under voluntary control.

The mucous membrane lining the bladder is distensible; it is ridged in the empty organ and smoothed out in distension. In micturition the longitudinal muscle of the bladder shortens to widen the bladder neck and allow urine to enter the urethra. The urethra normally contains no urine except during the act of micturition, its walls remaining apposed by muscle tone. The external sphincter can maintain continence even if the internal sphincter is not functioning.

The innervation of the bladder and urethra is complex and important. Essentially, there are three groups of nerves: (1) The parasympathetic nerves constitute the main motor supply to the detrusor; they make it contract, raise pressure within the bladder, relax the internal sphincter, and cause emptying. Afferent parasympathetic channels convey impulses from stretch receptors in the bladder wall to higher centres, permitting cognizance of the state of distension of the organ and stimulating the desire to micturate. (2) The sympathetic nerves stimulate closure of the ureteric and internal urethral orifices and contraction of the internal sphincter, and their action on the detrusor is inhibitory; i.e., the effect is to prevent bladder outflow. Thus the sympathetic nerves act to control the situation in the distending bladder up to the point when evacuation can be deferred no longer. Afferent paths in the sympathetic system convey sensations of pain, overdistension, and temperature from the mucosa of the bladder and the urethra. (3) The somatic nerves cause contraction of the external sphincter; their sensory fibres relay information as to the state of distension of the posterior urethra.

Both the parasympathetic nerves and the somatic nerves (pudendal nerve) to the external sphincter relay impulses to the second through fourth sacral segments of the spinal cord, which constitute a reflex centre for the control of bladder function. This centre connects with higher centres in the brain by ascending and descending fibres in the spinal cord.

Bladder function in micturition

Certain reflexes combine to ensure both maintenance of a steady holding state for urine and normal progressive micturition with complete emptying. When the internal pressure of the bladder rises, it contracts; and it also contracts when urine enters the urethra.

Both bladder sphincters are normally closed. As the organ fills with urine, the contractile response of the muscle wall causes a rise in internal pressure. Relaxation then occurs as an active process of adjustment so that the organ may hold its contents at a lower pressure. As urine continues to enter the bladder, this rise and fall of pressure continues in steplike fashion, with the final pressure always gradually rising.

The repeated transient contraction waves at first are small and are not consciously felt; later, stimuli reach the brain and cause pain and a sharp rise of pressure. These later major contractions can be inhibited voluntarily. The desire to micturate begins at around a content of 400 millilitres, but it can be voluntarily overridden until the content reaches 600–800 millilitres, with a resulting pressure within the bladder of up to 100 millimetres of water. Until this point the sphincters remain contracted to keep the urethral exit closed, but eventually the desire to micturate becomes urgent and irrepressible. Until that time, voluntary inhibition of the detrusor and contraction of the perineal muscles have kept the internal pressure as low as possible and have prevented urine leakage. The threshold is dependent to some extent on the rate of filling and is higher when filling is slow; and training affects the amount the bladder can retain. In young children the situation is less controllable, and even small amounts of urine may excite reflex evacuation. Emotional influences are important. Anxiety inhibits the capacity of the bladder to relax on filling, so that under conditions of stress there may be some involuntary passage of small quantities of urine.

Micturition

Micturition is a complex activity, partly reflex and unconscious and mediated by the lower spinal cord centres, and partly under conscious control by the higher centres of the brain. Voluntary micturition begins with willed messages from the brain that reach the bladder via the motor fibres of the pelvic nerves to stimulate the detrusor, at the same time actively relaxing both urethral sphincters. But the reflexes already mentioned ensure that, once the process has begun and urine has entered the urethra, the contraction of the detrusor will continue and the sphincters will remain relaxed until evacuation is complete and the bladder empty. Evacuation is aided by voluntary contraction of a wide range of accessory muscles. The muscles of the abdominal wall contract to increase pressure on the bladder from without; the diaphragm descends and the breath is held; at the same time there is relaxation of the muscles of the perineal floor. Thus voluntary initiation and control of micturition is effected partly by an active process of stimulating parasympathetic sacral nerve outflow, partly by removing the normal inhibition exerted by the higher centres on the reflex centres in the spinal cord. Once begun, micturition is carried through to completion by lower and higher centres acting in concert; sensory messages from the urine-distended urethra also play a part. It follows that even if a bladder is not particularly distended and if reflex emptying is not urgent, the bladder can nevertheless be evacuated by voluntary contraction of the abdominal wall, so initiating the reflex process that, once begun, takes over.