Bowel, Bladder, and Sexual Function PDF

Functional Human Anatomy Bowel Bladder Sexual Function D R. D O N AL M U R R AY PH D H E AV Y C O N T R IBU T I O N S BY: D R. E LLE N C O S T E LLO, PT, PH D Session Objectives Identify the anatomical structures and their function involved in the process of micturition Describe the neural control...

Functional Human Anatomy Bowel Bladder Sexual Function D R. D O N AL M U R R AY PH D H E AV Y C O N T R IBU T I O N S BY: D R. E LLE N C O S T E LLO, PT, PH D Session Objectives Identify the anatomical structures and their function involved in the process of micturition Describe the neural control involved in the micturition reflex Describe the similarities and differences between a spastic bladder and a flaccid bladder Identify the anatomical structures and describe the function of the male and female genital organs Describe the neural control involved in bowel function Urinary System Urinary Bladder Hollow organ with strong muscular walls (smooth muscle) characterized by its distensibility Detrusor Muscle forms the bladder wall Lies mostly inferior to the peritoneum Lies in the deep pelvis posterior to the pubic symphysis when empty in adults With filling it ascends into the anterior abdominal region and enters the false pelvis Always contains some urine, even after emptying Anatomic Regions include:  Apex-Anterior aspect near pubic symphysis A B  Fundus-base of bladder F formed by its posterior wall; opposite the apex  Body-major portion of T bladder between apex and N fundus  Neck-the fundus and & inferolateral surfaces of bladder meet here  Trigone-an area of the bladder defined by a smooth internal surface formed by the two ureters and the internal urethral orifice. Sensitive to expansion/stretch.  BODY Fundus: post wall Smooth trigone neck Body Apex Fundus Trigone Ureters Two 25 – 30 cm in length, muscular tubes run through the abdomen along the pelvic brim Run obliquely through a gap in the muscular wall of the urinary bladder A flap valve is formed as the ureters enter the bladder… thus contraction of the bladder musculature acts as a sphincter, preventing urine reflux back towards the kidney during bladder emptying Neural control: Ureters Innervation of ureters: via the autonomic (ANS) plexus  Sympathetic fibers  Afferent pain information follows the sympathetic fibers towards spinal cord segments T11-L2  Refers pain ipsilateral along subcostal, ilioinguinal and genitofemoral nn. distribution  Includes sensory stretch to ureter as well  Parasympathetic fibers (Vagus & S2,3, 4)  Contraction & peristaltic motion of ureters (motor)  Differential Diagnosis: http://allaboutim.webs.com/Symptoms%20Of%20Kidney %20Stone.jpg http://fce-studymode.netdna-ssl.com/images/upload- flashcards/back/3/7/40173180_m.jpg http://www.md4cancercare.com/prostate/male %20genitourinary%20system.jpg Bladder Innervation to Bladder (sensory and motor)  Via parasympathetic fibers (pelvic splanchnic nerves- S2,3,4) which carry the following neural messages…. Visceral afferent: Sensory to the detrusor muscle to determine level of stretch and relays pain from lower bladder Motor to the detrusor muscles-causes smooth muscle wall of bladder to contract Inhibition to the internal sphincter (so it relaxes and urine will flow) Bladder Innervation cont. Innervation to Bladder cont.  Via sympathetic fibers (hypogastric plexus through T11 through L2 portions of spinal cord)  Visceral afferents: sensation of Pain from the superior aspect of the bladder  Activation of the internal sphincter (so it contracts and urine will not flow) Micturition Reflex Micturition Reflex:  Visceral afferent fibers stimulated by bladder stretch (~350-400 mls) causes the bladder to contract reflexively while the internal sphincter relaxes & urine flows into the urethra  With training & intact neural pathway from supraspinal centers, we can suppress this reflex until it is convenient  E.g. External urethral sphincter remains contracted (voluntary control-pudendal nerve) http://lh3.ggpht.com/ _RIjx_Mg4ZVM/TGu0_mKVPJI/ AAAAAAAABkc/uEvJ7x2f_tY/ s1600-h/image45.png Micturition Reflex Animation: Micturition Reflex Urethra Urethra/Male  Urethra-muscular tube 18-30 cm which leads to the external urethral orifice prep  Urethra-also provides an exit for semen p  Male Urethra-divided into r o s 4 parts: t a Preprostatic-contains internal t i urethral sphincter c Prostatic – urinary and mem reproductive merge here s Membranous-passes through p o the external urethral n g sphincter e y Spongy Urinary System Anatomic Identification: Internal urethral sphincter  Involuntary sphincter of Internal urethral sphincter smooth muscle fibers (under what kind of neural control?)  (Male) Prevents retrograde movement of semen into the bladder during ejaculation Internal urethral orifice Leads to the urethra  External Urethral Sphincter External urethral sphincter: (skeletal Muscle)  Makes up part of the UG (urogential diaphragm)  UG diaphragm supports the contents of the deep pelvis along with ?  Ext Urethral sphincter: provides a means of stopping the escape of urine from the body. Under voluntary control-via somatic efferents (pudendal n. S2-S4) Male Internal Genital Organs Testes-male sex organs that lie within the scrotum; produce sperm and the male sex hormone, testosterone Epididymis-Portion of the male genital tract next to the testes where sperm maturation is partially accomplished. Receives Ductus sperm from the testes and deferens continues as the ductus deferens Ductus deferens (aka vas deferens)-A thick walled tubular structure running from each testis into the ejaculatory duct. These Seminal vesicles structures carry sperm from the epididymis towards the penis. Epididymis Seminal vesicles-produce semen, a fluid that activates and protects the sperm after it has left the testes penis during ejaculation Male Internal Genital Organs Prostate- gland in the male that surrounds a portion of the urethra. It secretes an alkaline liquid that neutralizes acid in the urethra and stimulates motility of the sperm. Bulbourethral glands (Cowper's glands) two small, rounded, pea sized bodies posterolateral to the membranous portion of the urethra. They discharge a component of seminal fluid into the urethra (not seen in this view); location= CG Ejaculatory duct-begins at the seminal vesicles, passes through the prostate, and CG empties into the urethra. During ejaculation, semen passes through the EJ ducts Cowper’s gland or EJ duct Spongey urethra Female Urethra 4-6 cm in length which leads to the external urethral orifice Lies anterior to the vagina Passes with the vagina through the pelvic diaphragm & then through the external urethral sphincter External Urethral Sphincter under voluntary control  Innervation:  branches from pudendal n. (S2-4) to external urethral sphincter Sensory Afferents (pain) from urethra run in the pelvic splanchnic nerves (parasymp)  Internal Urethral sphincter: literature suggests no function in female or it does not exist b/c function specific to male Internal Urethral Sphincter site (external) Female Internal Genital Organs Vagina-7-9 cm long extending from the cervix of the uterus passing between the levator ani muscles  Located between the urethra and rectum  Innervation: sympathetics; parasympathetics (S2-4 via pelvic splanchnics) Uterus Uterine (fallopian) tubes Ovaries Support: Round Ligament/Broad Ligament of Uterus  ANS: Compare/Contrast Bowel/ Bladder /Sexual Function Parasympathetic Sympathetic  Arise from S2-4 portions of the spinal  Arise from pregang fibers cord that arise from spinal cord ~ T10 to L2  Are generally vasodilatory to  Cause contraction of smooth arteries/arterioles ms in the internal urethral  Stimulate (motor) bladder sphincter & internal anal sphincters so you don’t contraction urinate or defecate  Inhibitory to the internal urethral  Cause smooth ms contraction sphincter (so it relaxes and your can assoc. with reproductive tract urinate) & accessory glands  Stimulate erection  Help move secretions from the epididymis and assoc.  Modulates activity of lower colon glands into the urethra to (peristalsis) form semen during ejaculation Pudendal Nerve Pudendal Nerve (S2,3,4)  Somatic motor supply to skeletal muscles: Innervation of external anal sphincter & external urethral sphincter  Afferent supply to skin of the perineal region Neural Summary by Structure Ureters Ext Urethral sphincter  Symph: T11-L2: pain &  Skeletal ms. means voluntary stretch control  Para (CN X & S2-4):  Pudendal n (S2-4) peristalsis Bladder  Smooth ms means ANS Internal Urethral sphincter control  Symph : T10-L2 keeps it  Para: S2-4: contracted sensory/stretch/pain; motor  Parasymp: S2-4 inhibits so to contract you can relax it  Symp: T11-L2: pain Anal Sphincters External Anal Sphincter  Under voluntary control; skeletal muscle  Supplied by S4 ventral ramus (branch of pudendal n.) Internal Anal sphincter  Involuntary smooth muscle  Supplied by sympathetic fibers to maintain tone  Supplied by parasympathetic fibers to inhibit tone Spinal Cord Injuries (O’Sullivan & Schmitz, 7th ed) Spastic (Automatic or reflexive) Flaccid (Autonomous or flaccid) Bladder Bladder Cord injury-above S2-4 segments Cord injury involves S2-4 levels, &/or Stretch receptors are intact to sacral ventral/dorsal roots S2-4 bladder Flaccid bladder b/c no reflex action of Micturition reflex is intact (S2-4) detrusor muscle Bladder contracts and reflexively empties in response to a certain Micturition reflex in sacral segments level of filling pressure of cord destroyed Nerve pathways between brain & Nerve pathways between brain and spinal cord S2-4 interrupted; Loss of Spinal cord interrupted; loss of inhibiting influences on spinal inhibiting influences on spinal cord reflexes Ascending sensory pathways Unable to establish reflex voiding; interrupted: loss of sensation of intermittent catheterization bladder distention & urge to urinate commonly used; Bladder training uses micturition May use Val Salva maneuver along reflex by trigger stimulus (tapping, with manual compression (Crede pulling pubic hair) to establish Maneuver) of lower abdomen planned voiding http://www.spinal-injury.net/spinal- injury-network/images/indwelling- foley-catheter.jpg Bowel Dysfunction Classified also as Spastic Bowel dysfunction or Flaccid Bowel Dysfunction Depends on level of cord injury (S2-4) Superior to S2-4=spastic Through S2-4 or roots=flaccid Spastic bowel (intact sphincters) responds well to rectal/anal stimulation and timed voiding (usually every other day) Prognosis excellent for good bowel control Hydration & fluid monitoring with high fiber diet are essential Flaccid Bowel (flaccid sphincters) arrival of stool in the rectum results in incontinence Bowel control is possible with routine daily bowel evacuation which removes the stool before it enters the rectum (manual evacuation with straining via increased abd pressure) Hydration & Fluid monitoring along with high fiber diet are keys to success Sexual Function Male Female  Little Erectile research function available is greater in incomplete lesion versus complete lesions  Reflexogenic erection:  Sensory stimulation of genitals or perineum  Requires intact reflex arc (S2-4) Let’s Recap Can you identify the anatomical structures and their function involved in the process of micturition Can you describe the neural control involved in the micturition reflex Can you explain the parasymph and sympathetic responsilbities during urination What enables you to hold your urine even though the bladder is full? If you have a spina cord lesion above S2-4 regions of the cord would you have a spastic bowel and bladder or a flaccid bowel and bladder? Why? With a flaccid bladder why would the Crede maneuver be utilized? Can you identify the anatomical structures and describe the function of the male and female genital organs Can you describe the neural control involved in bowel function Why is your diet so important if you have a spinal cord lesion?