Urinary Bladder 9 & 10 PDF

Urinary Bladder  Urinary bladder Surgical anatomy: It’s a hollow muscular organ, act as a reservoir for urine, lined with transitional epithelium, the dome covered by peritoneum. Normal bladder capacity 400-500 ml. Physiology:...

Urinary Bladder  Urinary bladder Surgical anatomy: It’s a hollow muscular organ, act as a reservoir for urine, lined with transitional epithelium, the dome covered by peritoneum. Normal bladder capacity 400-500 ml. Physiology: Normal bladder function requires *coordination of motor and sensory component of both somatic and autonomic nervous system, and *coordination between detrusor muscle and sphincter muscle. We have two sphincter component. 1- internal sphincter (bladder neck). 2- external sphincter (prostatic & membranous urethra in male and mid-urethral zone in female).  Urinary bladder Bladder extrophy: It’s a congenital anomaly in which the bladder exposed and everted on the lower abdominal wall. male: female- 4-1. occurs in 1:50,000 live birth. It’s probably caused by failure of cloacal membrane to retract. It’s usually associated with VUR, inguinal hernia (especially boys), epispadias (both male & female) and widely separated pubic sym- phesis. Treatment: 1- bladder closure with iliac osteotomy within 1st year of life. 2- later on reconstruction of bladder neck & sphincter and some time need augmented cystoplasty.  Urinary bladder Bladder Trauma: Etiology: 1- blunt trauma, fracture pelvis (RTA). 2- iatrogenic injury e.g. C/S, hysterectomy, hernia repair and TUR procedure. Types: 1- Intraperitoneal rupture: (20%): usually due to blow or fall on a distended bladder. 2- Extraperitoneal rupture: (80%): blunt trauma or surgical damage.  Urinary bladder Clinical features: 1- Gross hematuria, less common microscopic. 2- Pelvic or lower abdominal pain. 3- O/E, tender lower abdomen & suprapubic area, evidence of lower abdominal trauma, in cases of intraperitoneal rupture, there is sign of acute abdomen. Investigations: 1- plain x-ray, can see pelvic fracture, if present. 2- IVU, show urine leak. 3- Retrograde cystogram, confirm the diagnosis. 4- CT-scan. Superior.  Urinary bladder Treatment: 1- correction of haemodynamic state e.g. treatment of shock. 2- In case of extraperitoneal rupture, catheter drainage for 10 days, but in cases with large blood clot or injury to the bladder neck, these cases should be treated surgically. 3- In cases of intraperitoneal rupture, surgical intervention should be done. Complications: 1- In cases of extraperitoneal rupture, there may be pelvic hematoma with abscess formation. 2- Peritonitis in cases of intraperitoneal rupture. 3- Incontinence of urine in cases where bladder neck involved.  Urinary bladder Retention of urine: In ability to pass urine, either acute or chronic. Acute retention: The most common cause. Male: 1- bladder outlet obstruction (most common). 2- urethral stricture. 3- acute urethritis or prosttitis. 4- phimosis. Female: 1- retroverted uterus. 2- bladder neck obstruction (rare).  Urinary bladder Both: 1- blood clot. 2- urethral stone. 3- rupture urethra. 4- neurogenic bladder. 5- fecal impaction. 6- anal pain. 7- spinal anesthesia. 8- drug e.g. antihistamine, anticholenergic agent. Clinical features: 1- no urine pass for several hours. 2- suprapubic pain. 3- bladder is visible, palpable, tender & dull in percussion. 4- neurological examination to exclude neurological cause.  Urinary bladder Treatment: 1- urethral catheter, if failed, suprapubic drainage (cystostomy or punc). 2- treat the cause. Chronic retention: There is no pain, the patient at risk of upper track dilatation due to increase in intravesical pressure. *After neglected chronic retention, there is overflow incontinence with small amount of urine passing involuntary from bladder.  Urinary bladder Vesical Stone: Bladder stones are most commonly found in adult males with symptoms of BOO and in male child lived in poor country. It’s either primary originate in the kidney or secondary occur in the presence of infection, outflow obstruction, impaired bladder emptying and foreign body. Most vesical stone are mixed stone.  Urinary bladder Clinical features: 1- asymptomatic. 2- frequency and incomplete emptying. 3- pain in the end of micturation, referred to the tip of penis or to labia majora, worsened by movement. In young boys screaming and pulling of penis with the hand at the end of voiding is indicative of bladder stone. 4- terminal hematuria. 5- other symptoms of UTI.  Urinary bladder Investigations: 1- GUE: pus ,crystals, RBC. 2- KUB, U/S. 3- cystoscopy, (diagnostic & therapeutic). Treatment: 1- treatment of the cause e.g. BPH, neurogenic bladder. 2- treatment of stone. A- Cystoscopic vesicolithotomy. B- Open vesicolithotomy. Complications: 1- hematuria. 2- repeated UTI. 3- urine retention. 4- carcinoma.  Urinary bladder Urodynamic study: It’s a graphic representation of detrussor and sphincter function, consist the following, 1- Uroflowmetry. 2- Cystometry. 3- Profilometry. 4- EMG of sphincter.  Urinary bladder Uroflowmetry: Measurement of urine flow / second. In male 20ml/sec. While in female 25ml/sec. it’s significant in diagnosing bladder outlet Obstruction (BPH, urethral stricture, neurogenic bladder). Cystometry: The 1st sensation for desire to void at 150ml, and the maximum bladder capacity 350-450ml (40-50cm H2O pressure). Resting pressure is equal or less than 15cm H2O. Cystometry is important in evaluation of neurogenic bladder, in which low capacity & high pressure mean spastic bladder, while high Capacity & low pressure mean flaccid bladder.  Urinary bladder Profilometry: measure urethral sphincter pressure, the normal urethral pressure is 80-120cm H2O. Usefulness of urodynamic study: 1- distinguish genuine urine incontinence from detrussor instability. 2- distinguish detrussor instability from BOO. 3- classification of neurogenic bladder dysfunction. 4- investigation of incontinence.  Urinary bladder Neurogenic bladder: Can classified according to neurological defect. 1- In upper motor neuron lesion, lead to spastic neurogenic bladder in which we found, high pressure, low capacity, patient complain of frequency and incontinence. 2- In Lower motor neuron lesion, lead to paralytic or flaccid neuro- genic bladder in which we found, low pressure, high capacity, patient complain urine retention and over- flow incontinence.  Urinary bladder Urodynamic classification: Another type of classification, depends on the state of detrussor muscle and sphincter. Type1: high muscle tone, low sphincter tone (incontinence). Type2: high sphincter tone (retention). Type3: low muscle tone, normal or high sphincter tone (retention). Type4: low muscle tone, low sphincter tone (incontinence).  Urinary bladder Treatment: 1- Medications: depending on fact that the detrussor muscle action under control of cholinergic receptors and sphincter action under control of adrenergic receptors. Type1: cholinergic antagonist (oxybutinan), adrenergic agonist (ephid). Type2: adrenergic antagonist (phenoxybenzamin, terazocin). Type3: cholinergic agonist(urecholin), adrenergic antagonist(terazocin). Type4: adrenergic agonist.  Urinary bladder 2- Physical: Catheter, condom, clean intermittent catheter. (CIC). 3- Surgical: a- motor or sensory rhizotomy. b- pacemaker. c- augmentation cystoplasty. (ileal or caecum). d- reduction cystoplasty. e- artificial sphincter: associated with many complication, composed of cuff around the urethra connected to a reservoir.