15 The Urinary Bladder The bladder’s normal capacity lies at 500mL, but strong urinary urgency occurs already with 300 mL. In patients with voiding dysfunctions after surgery, up to 2000mL can collect. The urinary bladder is located in the lesser pelvis behind the symphysis. An empty bladder does not extend with its superior pole beyond the symphysis; a full bladder can be palpated up to 3 cm above the symphysis. Superior Anterior Inferior Posterior Lateral. Peritoneum, runs into the broad ligament of the uterus. Fig. 15.1 Topography of the female lesser pelvis. Fig. 15.2 Fascial attachments of the organs in the lesser pelvis. Fig. 15.3 Topography of the male lesser pelvis. Superior Anterior Inferior. Prostate gland. Posterior Fig. 15.4 Ligaments of the bladder, frontal view. Fig. 15.5 Ligaments of the bladder, sagittal view. Lateral Retropubic space (Retzius space): Located between the pubic bone/abdominal wall and the urinary bladder, bordered caudally by the pubovesical ligament and medially by the median umbilical ligament. Fig. 15.6 Ligaments of the bladder, side view, in the male body. Fig. 15.7 Ligaments of the bladder, in the male body (view from the front). Branches of the internal iliac artery, e.g.: Internal and external iliac nodes. Maximal time: 3–5p.m. Minimal time: 3–5a.m. For basic information, see page 34. The ureter is 25–30cm long and approximately 5mm thick. There are three physiologic bottlenecks where kidney stones are most likely to get impacted: The ureter runs caudal on top of the psoas major, passes across the bifurcation of the common iliac artery (left) or the external iliac artery (right) as it enters the lesser pelvis, and then descends further caudally along the lateral wall of the pelvis near the peritoneum. Fig. 15.8 Location of the ureter. Roughly at the level of the ischiadic spine, it changes its course medially and anteriorly in the direction of the urinary bladder. Slightly above the seminal vesicle, it reaches the posterior lateral wall of the bladder, where it is crossed by the vas deferens. Here, the vas deferens lies closer to the peritoneum than the ureter. Continuing on, the ureter crosses the bladder diagonally from posterolat-eral to anteromedial. Roughly at the level of the ischiadic spine, it changes its course medially and anteriorly in the direction of the urinary bladder. It initially lies in the base of the broad ligament of the uterus, and then it is crossed by the uterine artery. In its continued path, it proceeds at a distance of about 1–2cm away from the supravaginal part of the uterine cervix. Right in front of the urinary bladder, it lies on top of the anterior and lateral vaginal vault. Entry into the urinary bladder takes place diagonally, as in the male body. See “Location”; in addition: Fig. 15.9 Topographic relationships of the ureter. The arterial supply is provided by branches of the arteries in its vicinity: The urinary bladder moves together with the sacrum and uterus: during inhalation posteriorly and superiorly and during exhalation anteriorly and inferiorly. Another movement results when the bladder is filled with urine and then voided. During the expiratory phase, we see a movement postero-superiorly, and during the inspiratory phase in the opposite direction. Urine reaches the bladder in portions. The peristaltic contraction of the ureter opens and closes the opening of the ureter. The ureter penetrates the urinary bladder diagonally. As a result, the internal pressure of the bladder keeps the entrance of the ureter closed except for during peristaltic waves. This mechanism prevents a reflux of urine. The pelvic floor becomes limp, and the bladder consequently shifts lower, its neck assuming a funnel shape. Urine enters the urethra up to the inner sphincter, the detrusor muscle of the bladder contracts (innervated parasympathetically), and the funnel shape is reinforced. The sphincter opens. The urethra muscles and the external sphincter become limp. To conclude micturition, the pelvic floor as well as the internal and external sphincter contract, and the neck of the bladder loses its funnel shape. Definition. Infection of the upper urinary tract due to pathogenic organisms. Causes. Highly virulent organisms coinciding with a weakened state of defense. Precipitating factors include: Clinical
Anatomy
Anatomy of the Urinary Bladder
General Facts
Location
Topographic Relationships
Female Pelvis
peritoneum
small intestinal loops
uterus (depending on location)
pubis
peritoneum
when bladder is full: anterior abdominal wall
uterine cervix
vagina
urethra
pelvic floor (levator ani)
obturator internus
uterine cervix and isthmus
vagina
ureter
Male Pelvis
peritoneum
intestinal loops
pubis
peritoneum
when bladder is full: anterior abdominal wall
vas deferens
seminal vesicle
rectum
ureter
peritoneum
small intestinal loops
peritoneum
levator ani
obturator internus
Attachments/Suspensions
peritoneum (anterior, lateral, and in men also posterior attachment)
median umbilical ligament (with urachus)
medial umbilical ligament (obliterated umbilical artery)
pubovesical ligament (with muscle fibers from the bladder), corresponds to the puboprostatic ligament
connective tissue of the lesser pelvis
Circulation
Arterial
inferior vesical artery
internal pudendal artery
obturator artery
Venous
vesical venous plexus (anastomoses to the prostatic and vaginal venous plexus)
internal iliac vein
Lymph Drainage
Innervation
sympathetic nervous system from L1 to L2 via the intermesenteric plexus and hypogastric nerves to the inferior hypogastric plexus and vesical plexus
sacral parasympathetic nervous system (S2–S4) via the inferior hypogastric plexus and vesical plexus
Organ Clock
Organ–Tooth Interrelationship
Anatomy of the Ureter
General Facts
Location
Continued Path in the Male Body
Continued Path in the Female Body
Topographic Relationships
peritoneum
psoas fascia
genitofemoral nerve
inferior vena cava (right)
duodenum (right)
testicular/ovarian vessel
right colic artery
ileocolic artery
inferior mesenteric artery or left colic artery
root of the mesentery
root of the sigmoid mesocolon
Attachments/Suspensions
adipose capsule of the kidney
peritoneum
retro- and extraperitoneal connective tissue
Circulation
Arterial
renal artery
abdominal aorta
testicular/ovarian artery
common iliac artery
internal iliac artery
inferior vesical artery
uterine artery
Venous
testicular/ovarian vein
internal iliac vein
vesical plexus
Lymph Drainage
internal/communal/external iliac nodes
lumbar nodes
renal lymph nodes
Innervation
sympathetic nervous system from T10 to L1 via the lesser and lowest splanchnic nerves and the lumbar splanchnic nerves 1 and 2 to the celiac plexus, aorticorenal ganglion, renal plexus, and posterior renal ganglion
vagus nerve (via the celiac plexus)
sacral parasympathetic system (S2–S4) via the superior hypogastric plexus to the renal plexus
Movement Physiology according to Barral
Mobility
Motility
Physiology
Mechanism of Bladder Filling and Voiding
Micturition
Pathologies
Symptoms that Require Medical Clarification
Cystitis
stricture of the urinary tract, e.g., prostatic hyperplasia
vesicoureteral reflux
neurogenic disturbance of bladder voiding
calculi
diabetes mellitus
immunosuppressive therapy
dysuria
pollakiuria
subfebrile temperatures
Osteopathic Practice
Cardinal Symptoms
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