Module One: Introduction to Urinary Continence/Incontinence

Topic 101 Terminology

Bladder capacity or amount of urine inside the bladder that has been measured
bladder volume
Voided volumes measurement of the micturitions in a bladder diary
Voiding frequency daytime voiding measured using a bladder diary – a frequency above 7 times per
day is high and less than 4 is low
Expected bladder capacity calculate EBC = (age +1) x 30 millilitres
(EBC) teenagers EBC reaches adult size of approx. 400 millilitres
Polyuria nocturnal urine production greater that 130% of the child’s EBC
Enuresis night wetting whilst asleep- term not used before 5years, daytime incontinence
and enuresis may co-exist
Continuous incontinence constant dribbling of urine, term is relevant term for all ages
Intermittent incontinence incontinence in discrete amounts
Monosymtomatic enuresis enuresis but no daytime symptoms of disturbed lower urinary tract function
Nonmonosymptomic enuresis with day time wetting or any other LUT symptoms such as urgency
enuresis
Primary enuresis no dry period has occurred
Secondary enuresis the child has been dry at night for 6 months or more before wetting starts
Nocturia wakes at night with a need to pass urine
Urgency sudden, unexpected and strong need to void
Overactive bladder Urinary urgency, usually accompanied by frequency and nocturia, with or
without urgency urinary incontinence, in the absence of urinary tract infection
(UTI)
Detrusor overactivity observed uninhibited detrusor contractions during the storage phase during
cystometry
Underactive bladder or child needs to raise intraabdominal pressure in order to be able to void.
detrusor Detrusor underactivity is cystometircally demonstrated
Voiding postponement refers to children who habitually postpone micturition using holding
manoeuvres
Dysfunctional voiding child habitually fails to relax sphincter of pelvic floor muscles during voiding and
produces a staccato or interrupted flow pattern

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Topic 102 Anatomy of Lower Urinary Tract
Organs and functional units

• Bladder: hollow organ with three-layered wall

• Urothelium: provides a barrier between the
urine and the body fluids

Striated sphincter

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Urethra

Difference between male after puberty and female

The pelvic floor

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Connective tissue

• Ligaments: neuro-bibro-vascular
structures which suspend pelvic organs
(and vagina in girls)

Muscle structure

• Levator ani: muscle part of pelvic floor –

forms hiatuses through which rectum and
urethra pass (and vagina in girls)

Pubococcygeus

• Pubococcygeus ligaments originate

from pubic bone connect to coccyx

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Puborectalis

• Originates from pubic bone either side

of median line

Iliococcygeus muscle

• Bilaterally form the Levator plate that

supports the pelvic organs

Topic 103 Physiology of Lower Urinary Tract

• Phases: the bladder-sphincter-perineal complex can be divided into 2 phases

o Storage phase (1st phase) – collecting urine from the 2 ureters
o Voiding phase (2nd phase) – expulsion of urine through the urethra
• Micturition cycle: repeated storage and voiding phases
o Regulated by a neurological control complex.

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Motor innervation

• Autonomic innervation is responsible for control

of involuntary functions of the lower urinary tract
and is composed of sympathetic and
parasympathetic parts
• Somatic innervation is under voluntary control

Sensory innervation

• The sensory fibres send to the spinal cord and

the higher centres information related to
bladder storage and tactile, heat and pain
stimuli from the whole bladder-sphincter-
perineal complex

Spinal nerves

• The spinal nerves originate in the spinal cord

and are formed by the fusion of an anterior
motor root and a posterior sensory root.
These are mixed nerves that come out of the
spinal canal through intervertebral foramina

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 • The posterior root is sensory: it contains nerve
fibres that carry all information related to
sensation to the spinal cord and to the higher
centres. The cell bodies of the neurons form the
sensory ganglion (attached to the posterior root of
the spinal nerves). The anterior root is motor; it
contains nerve fibres that carry the nerve impulses
to the muscles.

Grey and white matter

• The grey matter is the central part of the spinal cord

and consists of the cell bodies of the neurons. The
white matter is the peripheral part of the spinal
cord and it consists of the axons that carry motor
and sensory information from the periphery to the
higher centres and vice versa.

Dorsal and ventral horn

• The dorsal or posterior horn is the posterior area of

the grey matter to which the extensions of sensory
neurons reach. The ventral or frontal horn is the
anterior area of the grey matter where the motor
roots of spinal nerves originate.

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Interneurons

• The motor neurons of the anterior horns receive

information from higher centres and transfer it to
the organs through its own axons that form the
anterior root, translating the message into action
and producing muscle contraction. A particular
type of nerve cell is also present in the grey matter,
the interneuron, which is a connector between two
or more sensory and/or motor neurons.

Hypogastric nerves

• Hypogastric nerves predominantly innervate

the smooth muscles of the bladder neck and
partly the detrusor

Pelvic nerve

• Postganglionic fibres responsible for the

innervation of the detrusor originate from
the ganglia in the bladder wall

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Pudendal nerve

• The somatic innervation fibres originate from

Onuf’s nucleus and innervate the urethral
striated sphincter
• Motor innervation of somatic type is received by
the pelvic-perineal floor
• Sensory fibres come from the urethra, bladder
neck, bladder wall and pelvic floor. Largest
contingent of sensory afferents continue upward
to the medulla and reach higher centres.

Pontine centres

• 2 centres involved in the physiology of urination

are present in the pons:
o Pontine Micturition Centre (M-region),
controls detrusor contraction and
coordination between this contraction and
relaxation of the urethral striated sphincter
o Pontine Continence Centre (L-region), through
Onuf’s nucleus, maintains sphincter closure.

Central control

• Sensory information related to bladder storage

converges in the higher centres of the
hypothalamus
• The centres allow urination in socially
appropriate times and places

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Micturition reflex

• The collection and expulsion process is complex and

involves the detrusor, the bladder neck, the urethral
striated sphincter, the muscles of the pelvic floor, the
innervation of the whole bladder-sphincter-perineal
complex and the higher centres. Most of this process
is involuntary and known as the micturition reflex.

Storage phase

• During the storage phase the urethral striated

sphincter is kept constantly contracted thanks to the
action of the L-region of the pons on Onuf’s nucleus.
The detrusor is inactive in this phase. As the volume
of urine increases the bladder progressively relaxes.

Reaching bladder capacity

• When the bladder is full the hypothalamic region is

activated

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Voiding phase

• Hypothalamus stimulates the M-region:

o Inhibits the activity of the L-region on Onuf’s
nucleus
o Stimulates the sacral micturition centres –
causing the contraction of the detrusor
• The bladder neck, sphincter and the pelvic floor relax
and the contracting detrusor expels the urine till the
bladder is empty

Voluntary control

• In continent children the micturition reflex is

controlled by the activity of the areas of the cerebral
cortex
• After micturition and detrusor contraction, the
bladder neck, urethral striated sphincter and the
perineal muscles of the pelvic-perineal floor contract
again and the micturition cycle starts again

Urethral pressure and bladder pressure

• The leakage of urine during the storage phase is

prevented by maintaining a pressure gradient
• Bladder pressure consistently lower than urethral
pressure
• Urethral pressure ensured by activity of the urethral
striated sphincter

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Mechanisms inherent in women

• In girls after puberty there are 2 additional

mechanisms that contribute to keeping the urethra
closed.
• Intrinsic mechanisms related to trophic changes of
urethral mucosa and integrity of vascular gaps of
submucosal plexus (guaranteed by presence of
oestrogens)

Conditioning factors

• Neurological mechanism of the control of

micturition cycle interacts with a series of activities
relate to and associated with numerous social,
environmental and behavioural factors

Topic 104 Anatomy and Physiology of the Lower Gastrointestinal Tract

Gross anatomy

• The function of the colon is to store, mix, and slowly

transit its contents to allow for water and electrolyte
absorption. It exposes its contents to microorganisms
to liberate additional nutrients and it controls
expulsion of undigested matter.

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Colon

• The colon is a tube whose structure from inside to

out consists of a mucosal cell layer, submucosal
layer, circular smooth muscle, longitudinal smooth
muscle, a thin outer serous layer and a coat of
mesentery

The anorectum

• Defaecation is usually stimulated by rectal

distension that is detected by stretch receptors
situated in the wall of the rectal ampulla. Anal
closure pressure is maintained by the
haemorrhoidal plexus, and the internal and
external anal sphincters with contribution from
puborectalis

Neurological control

• The colon and rectum are innervated by a system of

nerves contained entirely within the gut called the
enteric nervous system (see below), as well as an
extrinsic system of autonomic efferent and viscera
afferent neurones, originating in central nervous
system.

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Extrinsic nerve supply
• The vagus nerve provides the colon with parasympathetic fibres down to and including the transverse
colon
• Through the pelvic nerves, the second to fourth spinal segments provide parasympathetic and
associated visceral afferent supply to the descending colon, sigmoid and rectum
• The T5 to T12 spinal cord provides sympathetics to the colon, while L1 to L3 provides sympathetics to
the rectum

Neurophysiology
• Parasympathetic nerves stimulate the bowel to contract
• Sympathetic are inhibitory to activity
• Extrinsic nerves coordinate perception, responses to meals and defaecation
• Central connections are essential for coordinated smooth muscle contraction of bowel

The enteric nervous system

• Has more neurons than the entire spinal cord
• Has complex integration of nerve cells and ganglia that monitor and manipulate the muscular
contractile state of the gut wall, secretory activity of the mucous glands, blood flow and contents of
the lumen

• Excitatory and inhibitory motor nerves work

harmoniously to co-ordinate the pattern of
contraction and relaxation that allows both mixing,
segmentation and propagation of contents

Enteric nerve subgroups and neurotransmitters

• Afferent enteric nerves help transmit mechanical and
chemical stimuli from the lumen of the colon to the
enteric interneurons and motor nerves
• The motor nerves also receive inputs from autonomic
nerves (especially parasympathetic) and visceral
afferents.
• The arrangement of neurones in the myenteric plexus
in replicated in the submucosal plexus which regulates
glandular activity and blood vessel diameter, controlling
absorptive functions of the gut epithelium and neuro-
immune activities.

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Colonic motility

• 2 forms of colorectal motility

o Mixing (or non-propagating) contractions
maximise epithelial contact
o Peristaltic activity
• Propagating sequences move contents several
centimetres
• High amplitude propagating sequences move
contents up to 35 centimetres

Abnormalities
• Some children with severe constipation have been shown to have abnormalities in colonic motility,
differences in neurotransmitters and lack of high amplitude propagating sequences. Abnormalities in
motility may lead to abnormal stool consistency and also slow passage of bowel contents into the
rectum – both of these factors then affect rectal sensation and perception.

Bowel control

• The internal anal sphincter, the external anal

sphincter and puborectalis are the muscles that
prevent passage of bowel contents by anal closure

• The external anal sphincter is a striated muscle which

has reflex and voluntary roles: it contributes to both
resting pressure and is particularly active during
increases in intraabdominal pressure
• Puborectalis:
o creates a loop around the anorectum without
attachment to coccyx
o Creates the anorectal angle
o Innervated by Levator Ani nerve and some branches
from pudendal nerve

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 • Illococcygeus and ischiococcygeus form the Levator plate
providing rectal support
• Fibres from pubococcygeus join the longitudinal muscle
between the internal and external anal sphincters to form
the conjoined longitudinal muscle or tendon – important
during defaecation in shortening the anal canal
• The anal canal is an extremely sensitive structure and its
upper parts allow discrimination of rectal contents.

Defaecation
• Process by which faeces are eliminated from digestive tract via the anus
• When bowel contents enter rectum the firing of the stretch receptors in the ampulla initially trigger
the ‘recto-anal inhibitory reflex’
• Internal anal sphincter relaxes
• External anal sphincter and puborectalis contract. This allows contents to be identified whilst
continence is maintained
• As stretching increases the defaecation threshold volume is reached and urge to defaecate is
perceived
• Rectum shortens and widens
• Anorectal angle increased from approx. 100’ to 135’ as external anal sphincter and puborectalis relax
• Evacuation occurs via rectal wall peristalsis
• Appropriate posture may make defaecation easier
o Leaning forward whilst seated with feet supported lengthens anal opening and widens
anorectal angle
• Children usually gain bowel control at much the same age as bladder control

Topic 105 The Development of Continence

Urinary Continence

Achieving bladder control during development is related to

three anatomical-physiological factors:

• Reaching of normal bladder storage function

• Maturation of urethral-sphincter function
• Development of neurological-voluntary control of sphincter
function

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The foetus

• Normal development of the bladder and sphincter in the

foetus represents the precondition for normal bladder-
sphincter function after birth
• The bladder originates as an invagination of the
endodermic surface of the cloaca, the caudal portion of
the foetus.
• The subsequent development of the bladder depends on
its function, especially on mechanical stretching and
contraction
• In the last trimester of gestation, micturition cyclically
occurs into the amniotic fluid at irregular intervals

From birth to first year

• Newborn child is not socially continent
• All neurons and reflex arcs needed for micturition are present and there is evidence for some degree
of higher awareness of bladder filling and micturition already at this stage of development.
• At one year of age the myelination of the medullary tract is complete (enabling child to stand) while
coordination is still incomplete
• Up to 2 years of age child cannot decide when to urinate and full coordination of micturition comes
later

Pre-school age (2-4 years)

• In the 3rd year many children already have complete voluntary control of the bladder and sphincter
• In the 4th year the sphincter reaches its final horseshoe shape

Factors affecting maturation

• The maturation path is affected by a number of factors that need to be developed in parallel:
o The perception of the bladder sensory input
o The awareness of bladder fullness
o Increase in bladder volume
o Efficient and coordinated emptying thanks to a better supra-spinal control
o Decreased nocturnal urinary production

School age (4-5 years)

• Between 4th and 5th year of life the morphological and functional maturation of the bladder-sphincter
system is complete
• Girls generally reach complete control before boys
• Variability also influenced by environment in which the child grows and the toilet training the child
experiences

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Adolescence
• Reproductive development causes morphological transformations in bladder-sphincter system
o In the male due to the development of the prostate
o In the female due to urethral lengthening and increased production of oestrogens

Development of the bowel from intrauterine to solid foods

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Dietary transition from breast milk to solids
• Profound modifications in both digestive and transport functions from birth also impact on bowel
development and function

Development of the bowel control

• The development of bowel control follows a similar

course to that of urinary control in that it is a process
involving:
o Parasympathetic, sympathetic & somatic neural
pathways integrating with supra spinal centres,
cortical awareness and control
o However, it has the added intricacies of the
enteric nervous system, developing digestion,
bowel microflora and immune processes.

Frequency of defaecation

• The first bowel motion or meconium is normally

passed within the first day of life. After that there
is a gradual decline of frequency from 4-5 per day
in the first week of life to 1-2 per day by age 4
years

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 • The internal anal sphincter increases in thickness
during childhood and the external anal sphincter
develops more ‘holding’ ability as the child
becomes ambulant. If bowel motility is normal, it is
the integration of the awareness of rectal
contents, be they gas, liquid or solid, and the
ability to voluntarily reinforce anal closure that
develops between the second and third year that
allows children to become bowel toilet trained.

Toilet training vs incontinence • Voluntary bladder and bowel control learned at

toilet training can be challenged by a variety of
factors as the child develops – resulting in
incontinence.
• These include:
o Medical issues such as constipation
o Urinary tract infection or pain
o Environmental influences such as resisting the
use of school toilets
o Behavioural factors such as inattention or
opposition
o physical impact on pelvic floor muscles such as
chronic coughing
o or a combination of these
• When treating incontinence in children it may be
that addressing the reversible causative factors
Topic 106 Bladder and Bowel Dysfunction results in regaining control

Bladder bowel inter-relationship

• The close relationship between bladder and bowel

can be clinically relevant as symptoms affecting both
organs often coexist in patients
• Therapeutic relief in one system can improve
symptoms and function in the other

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 • If constipated, faeces stored in rectum for prolonged periods of time it will cause the rectum to
compress the bladder from behind and can lead to detrusor overactivity and urge incontinence
• If the bladder is overactive the child may try to manage detrusor contractions by forcefully
contracting the muscles of the pelvic floor – this habit may lead to constipation

Faecal incontinence
Faecal incontinence is defined as “passage of stools in an inappropriate place in a child of 4 or more years”.
This used to be called encopresis but this term is now outdated. It can be divided into functional faecal
incontinence or organic faecal incontinence.

o Functional faecal incontinence

o Constipation-associated – commonest type
o Non retentive faecal incontinence – no evidence of an inflammatory, anatomical, metabolic or
neoplastic process and no evidence off faecal retention

o Organic faecal incontinence

Other definitions include:

• Faecal impaction
o Severe constipation with a large faecal mass in either the rectum or the abdomen

• Pelvic floor dyssynergia

o Child is unable to relax or else actively contracts the pelvic floor muscles and anal sphincter
when trying to defaecate

Constipation
• Functional constipation
o Over 60% of children with functional constipation have a history of painful or distressing
defaecation – hence child withholds stools

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 o As a result of withholding, bowel contents become harder and more difficult to evacuate
reinforcing discomfort and withholding
• Secondary consequences

Withholding

Slow transit constipation

• There is a spectrum of severity in constipation

symptoms in children. A sub-group with more severe
symptoms have a total slowing throughout the colon
rather than just in the sigmoid and rectum, which
occurs with withholding. This is referred to as slow
transit constipation. Chronic faecal retention in the
rectum may contribute to slow transit constipation but
deficiencies in neurotransmitters and less co-
ordinated contractions of the bowel have also been
demonstrated
• These children have less bowel activity on waking and
after meals and may respond poorly to laxative
treatment

Behavioural co-morbidities

Children with constipation and faecal incontinence present

with behavioural scores in the clinical range from 3.5 to 5
times more than other children. They exhibit behavioural
disorders such as:

• Separation anxiety
• Specific phobia
• Anxiety
• Attention deficit hyperactivity disorder
• Oppositional defiant disorder
• They have a poorer quality of life

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