The detrusor muscle, which provides the propulsive force for emptying the bladder, consists of interlacing fibers of smooth muscle that are under parasympathetic autonomic control through the pelvic nerves from sacral spinal cord segments S2, S3 and S4. the smooth muscle of the trigonal portion of the bladder, between the ureteral orifices and the posterior area of the bladder outlet, is innervated by motor fibers from thoraco-lumbar segments (T11 to L2) of the sympathetic nervous system, in which alpha receptor site predominates. This layer of muscle extends into the posterior urethra and acts as an involuntary internal sphincter that helps maintain urinary continence even in the absence of voluntary control. The external urethral sphincter and perineal muscles are under voluntary control via the pudendal nerves.

Sensory tracts of pain, temperature and distension pass from the bladder via the pelvic nerves to sacral spinal levels S2, S3 and S4, creating a spinal voiding reflex between the bladder and the sacral spinal cord. The sensory tracts from the bladder further ascend through sacrobulbar pathways to the medulla of the brain and ultimately to cortical centres, from which impulses arise, pass back down the lateral and ventral reticulospinal tracts, and normally suppress the sacral spinal reflex are controlling bladder emptying.

The normal adult bladder can accommodate approximately 400 ml fluid without a significant increase in intravesical pressure. Above this point, sensations of fullness are transmitted to the sacral cord. If not suppressed by cortical control, the sacral cord reflexly discharges motor impulses that cause powerful sustained detrusor contraction. Urination can be prevented by cortical suppression of the reflex arc or by voluntary contraction of the external sphincter and perineal muscles. Infants and adults with spinal cord damage above S2 urinate spontaneously when the bladder fills sufficiently.

Normal urination is initiated by voluntary suppression of cortical inhibition of the reflex arc and by relaxation of the muscles of the pelvic floor and the external sphincter. The base of the bladder falls; then the trigone contracts, an action that occludes the ureters as they pass through the bladder wall and helps to prevent vesicoureteral reflux of urine during voiding. Finally, the detrusor contracts and voiding occurs.

Urinary incontinence

Urinary incontinence indicates loss of bladder control. In this condition, the bladder becomes prone to uncontrollable contractions – that cause incontinence – because inhibitory neural pathways are damaged. Among the elderly, detrusor instability causes as much as 70 percent of urinary incontinence and arises from the diseases of central nervous system such as cerebro-vascular accidents, Alzheimer’s disease, and neoplasia and possible normal-pressure hydrocephalus.

Any lesion that disrupts the lateral and ventral reticulospinal tracts can reduce or abolish descending inhibiting impulses to the sacral spinal reflex and result in detrusor instability.

If the descending tracts are completely destroyed, the bladder will empty automatically. Bladder or pelvic infection or tumor, fecal impaction, uterine prolapse and prostatic hypertrophy are other causes.

Stress incontinence

This condition is common in post menopausal parous women. The structures of the female urethra atrophy when deprived of estrogen, and many women become unable to resist the passage of urine under the stress of increased intra-abdominal pressure during coughing, sneezing, climbing stairs and other physical activity. Parturition may damage the pelvic support of the bladder so that the bladder and urethra can slip downward from their normal position above the pelvic diaphragm. As they do, the urethra shortens and the normal urethra vesical angle, important in closing the urethral sphincter is lost.

In men, stress incontinence usually is secondary to prostatic surgery for benign prostatic hypertrophy or prostatic carcinoma. If the external sphincter is damaged during operation, total incontinence may result. Surgical elevation of the urethrovesical angle is helpful in women. Estrogen replacement therapy may prevent atrophy of the urethral mucosa.

Mechanical incontinence

Some congenital anomalies, extrophy of the bladder, patent urachus and ectopic ureteral openings distal to the vesical neck cause mechanical incontinence. They are corrected only by surgery. Mechanical incontinence can follow Tran’s urethral resection of the prostate that damages both the internal and external sphincter mechanisms. Pelvic surgery or irradiation of the uterus or rectum may cause incontinence because of vesico vaginal, uretero vaginal, vesico perineal or uretero perineal fistulas.

Overflow incontinence

This form of incontinence arises from large residual volume of urine secondary to obstruction at the bladder neck or the urethra (urethral stricture) or from neurologic damage. Benign prostatic hyperplasia afflicts upward of 75 percent of older men. It is manifested by nocturia, reduced size and force of the urinary stream, straining to urinate and terminal dribbling, all due to outflow obstruction. Functional outflow obstruction can occur because of spinal cord disease; the detrusor and external sphincter contract dyssynergistically i.e. at the same time.

Hypotonic neurogenic bladders may occur in diseases that produce autonomic peripheral neuropathy, such as diabetes mellitus, uremia, hypothyroidism, chronic alcoholism, Guillain Barre syndrome, collagen vascular diseases, and toxic neuropathies associated with some carcinomas (especially lung and kidney). It may also occur because of prolonged over distension of the bladder. Hydronephrosis and impaired renal function can occur with chronic overflow incontinence. All causes produce a dilated, palpable bladder. Especially, in diabetes, patients can control micturition but lose their sensory awareness of bladder filling. Their incontinence can be avoided by scheduled reminders.

Outlet obstruction is treated surgically.

Psychogenic and functional incontinence

Children and even some young adults draw attention to them by feigning incontinence and thereby derive some secondary emotional satisfaction.

A complete diagnostic evaluation is necessary to rule out organic disease even when psychogenic incontinence is strongly suspected. In elderly people, especially those with a limited ability to walk or who are confused because of central nervous system disease or drugs, incontinence may be functional i.e. due simply to an inability to reach toilet in time. Treatment depends on correcting the individual problem in each case.

Cystitis

The term ‘cystitis’ refers to inflammation of the urinary bladder. The recurrence of cystitis, in some cases, is associated with kidney troubles.

Causes and symptoms

The patient complains of an almost continual urge to void and a burning sensation on passing urine. There may be a feeling of pain in the pelvis and lower abdomen. The urine may become thick, dark and stingy. It may have an unpleasant smell and may contain blood or pus. Some pain in the lower back may also be felt in certain cases. In an acute stage, there may be a rise in body temperature. In the chronic form of cystitis, the symptoms are similar but generally less severe and long lasting without a fever.

Cystitis may result from infections in other parts connected with or adjacent to the bladder such as the kidneys, the urethra, the vagina or the prostate gland. There may be local irritation and inflammation in the bladder if urine is retained there for an unduly long time. Cystitis may also result from severe constipation. Other conditions like an infected kidney, stones in the kidneys and bladder, or an enlarged prostate may also lead to this disorder.

Herbal Pack for bladder problems

• Chanderprabha vati – 2 tablets twice daily

• Rencure formula – 2 capsules twice daily

• Varunadi vati – 2 tablets twice daily