General Facts

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.

Location

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.

Topographic Relationships

Female Pelvis

Superior

• 
  

  peritoneum

  
  
• 
  

  small intestinal loops

  
  
• 
  

  uterus (depending on location)

Anterior

• 
  

  pubis

  
  
• 
  

  peritoneum

  
  
• 
  

  when bladder is full: anterior abdominal wall

Inferior

• 
  

  uterine cervix

  
  
• 
  

  vagina

  
  
• 
  

  urethra

  
  
• 
  

  pelvic floor (levator ani)

  
  
• 
  

  obturator internus

Posterior

• 
  

  uterine cervix and isthmus

  
  
• 
  

  vagina

  
  
• 
  

  ureter

Lateral. Peritoneum, runs into the broad ligament of the uterus.

Male Pelvis

Superior

• 
  

  peritoneum

  
  
• 
  

  intestinal loops

Anterior

• 
  

  pubis

  
  
• 
  

  peritoneum

  
  
• 
  

  when bladder is full: anterior abdominal wall

Inferior. Prostate gland.

Posterior

• 
  

  vas deferens

  
  
• 
  

  seminal vesicle

  
  
• 
  

  rectum

  
  
• 
  

  ureter

  
  
• 
  

  peritoneum

  
  
• 
  

  small intestinal loops

Lateral

• 
  

  peritoneum

  
  
• 
  

  levator ani

  
  
• 
  

  obturator internus

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.

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

Branches of the internal iliac artery, e.g.:

• 
  

  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

Internal and external iliac nodes.

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

Maximal time: 3–5p.m.

Minimal time: 3–5a.m.

Organ-Tooth Interrelationship

For basic information, see page 34.

Continued Path in the Male Body

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.

Continued Path in the Female Body

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.

Arterial

The arterial supply is provided by branches of the arteries in its vicinity:

• 
  

  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

Mobility

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.

Motility

During the expiratory phase, we see a movement postero-superiorly, and during the inspiratory phase in the opposite direction.

Mechanism of Bladder Filling and Voiding

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.

Micturition

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 par-asympathetically), 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.

Symptoms that Require Medical Clarification

Cystitis

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:

• 
  

  stricture of the urinary tract, e.g., prostatic hyperplasia

  
  
• 
  

  vesicoureteral reflux

  
  
• 
  

  neurogenic disturbance of bladder voiding

  
  
• 
  

  calculi

  
  
• 
  

  diabetes mellitus

  
  
• 
  

  immunosuppressive therapy

Clinical

• 
  

  dysuria

  
  
• 
  

  pollakiuria

  
  
• 
  

  subfebrile temperatures