# Micturition

The process by which the urinary bladder

empties when it become filled
This involves two main steps:
1. The bladder fills progressively until the
tension in its walls rises above a threshold
level, which then elicits the second step
2. A nervous reflex called the micturition reflex
occurs that empties the bladders or if this
fails, at least causes a conscious desire to
urinate
-The micturition reflese is :
* an autonomic spinal cord reflex
* it can be inhibited or facilitated or
brain stem
Transport of Urine from the Kidney through
the Ureters and into the Bladder
- Urine that is expelled from the bladder has
essentially the same composition as fluid flowing
out of the collecting ducts
- There are significant changes in the composition
of urine as it flows through the renal calices and
ureters to the bladder
- Urine from collecting ducts renal calices
pace maker activity peristaltic contractions
renal pelvis ureter the bladder
- The peristaltic contraction in the ureter are
enhanced by parasympathetic stimulation and
inhibited by sympathetic stimulation
- The ureters enter the bladder through the
detrusor muscle in the trig one region of the
bladder
- Each peristaltic wave along the ureter
increases the pressure within the ureter so
that the region passing through the bladder
wall open and allows urine to flow into the
bladder

- The condition, which some of the urine in the
bladder is propelled backward into the ureter
is called vesico ureteral reflux can lead to
enlargement of the urete the pressure
renal calices + structure of renal medulla
damage to these region
- When a ureter become blocked severe pain
- The pain impulses sympathetic reflex back
to the kidneys to constrict the renal arterioles
urine output from the kidney the
ureterorenal reflex important for preventing
excessive flow of fluid into the pelvis of the
kidney with a blocked ureter
Micturition Reflex
- The micturition is a single complete cycle of :
1. Progressive and rapid increase of pressure.
2. A period of sustained pressure.
3. Return of the pressure to the basal
tone of the bladder.
- Completely autonomic spinal cord reflex.
- Inhibited or facilitated by center in the brain :
1. Strong facilitory an inhibitory centers in
the brain stem, located mainly in the pons.
2. Several centers located in the cerebral cortex.

- The final control of micturition as micturation
as follows :
1. The higher centers keep the mic reflex partially
inhibited except when micturition is desired.
2. The higher centers can prevent micturition even if
the micturition reflex does occur, by continual tonic
contraction of the external bladder sphincter until
convenient time presents itself.
3. When it is time to urinate, the cortical centers can
facilitate the sacral micturition centers to help
initiate a micturition reflex and at the same time
inhibit the external urinary sphincter so that
urination can occur.
- Voluntary urination :
Contracts abdominal muscles the pressure of the
bladder urine enter to the bladder neck
posterior urethra under pressure stressing the
bladders wall.
Abnormalities of Micturition
Types Cause
1. The Atonic Bladder - destruction of sensory
nerve fibers
2. The Automatic Bladder - Spinal Cord Damage
above the sacral region
3. The uninhibited - Lack of inhibitory signals
Neurogenic Bladder from the Brain.

General Characteristic
Ph : 6.0 (range : 4,5 8)
Specipic gravity : 1.003 1.030
Osmolarity : 855 1335 mOsm
Water content : 93 97 percent
Volume : 1200 ml/day
Color : Clear yellow
Odor : Varies depending on
composition.
Bacterial content: Sterile
Diuretic and Their Mechanism of Action
- A diuretic is a substance that increases the rate of
urine volume output
- Function of the diuretic
1. Increases the rate of urine volume output
2. Increases urinary excretion of solutes
*Sodium
*Chloride
3. Used clinically act by the rate of Na
reabsorpton from the tubules
* Natriuresis
* Diuresis

4. Reabsorption Na water reabsorption
decrease raises renal output of many solutes:
potassium (K), magnesium, calcium.
- The clinical use especially in diseases associated with
edema and hypertensi
- Can increase urine output more than 20 fold within e
few minutes after they are administered.
- The many diuretic available for clinical use have
different mechanism of action, there for, inhibit
tubular reabsorption at different sites along the renal
nephron.
Clases Diuretic
1. Osmotic Diuretic :
* Decrease water reabsorption by increasing
osmotic pressure of Tubular fluid.
* For example : urea, mannitol, sucrose
causes a marked increase in the concentration of
osmotically active molecules or ions in the tubules.
2. Loop Diuretic
* Decrease active Na Cl K reabsorption in the
thick Ascending loop of Henle.
* For example : Furosemid, ethacynic acid,
bumetanide
* Raise urine output of Na, Cl, K and other
electrolytes
* Impair the ability the kidneys to either
concentrate or dilute urine.
* Urinary dilution is impaired because the
inhibition of Na and Cl reabsorption in the loop
of Henle causes more of these ions to be excreted
a long with increased water excretion.
* Urinary concentration is impaired because the
renal medullary interstitial fluid concentration of
these ions and therefore renal medullary
osmolarity is reduced.
* Multiple effect, 20 to 30 precent of the
glomerular filtrate maybe delivered into the
urine, under acut condition, urine output to be
as great as 25 times normal for at least a few
minutes.
3. Thiazide Diuretics
* Inhibit Na Cl reabsorption in the Early distal
tubule.
* For example : Chlorotiazide.
* Under favorable condition cause 5 to 10
percent of the glomerular filtrate to pass into the
urine.
4. Carbonic Anhydrase Inhibitors :
* Block NaHCO
3
reabsorption in the P.T.
* For example : Acetazolamide
5. Competitive Inhibitors of Aldosteron
* Decrease Na reabsorption from and K secretion
into the cortical collecting tubule.
* For example : Spironolactone.
6. Diuretics that Block Na channels in the collecting
Tubules.
* Decrease Na reabsorption
* For example : Amiloride, Triamterene.

Kidney Desease
- Two main catagories
I. Acut renal failure
II. Chronic renal failure
I. Acut renal failure : Three main cztagories
1. Pre renal acute renal failure
2. Intra renal acute renal failure
3. Post renal acute renal failure
II. Chronic Renal Failure :
- An irreversible decrease in the number of
functional Nephrons
# Post Renal Acut Renal Failure
Caused by abnormalities of the lower urinary
tract
Some of the causes of post renal acute failure
include :
1. Bilateral obstruction of the ureters or renal
pelvises caused by large stone or blood clots
2. Bladder obstruction
3. Obstruction of the urethra
# Physiologic Effects of Acute Renal Failure
- The major physiologic effect is :
retention in the blood
retention extracelluler fluid water
retention waste products of metabolism and
electrolys
- This can lead to edema and hypertension,
hyperkalemia (to more than about 8 mEq/L),
metabolic acidosis.
- In the most severe cases of acut rrenal failure
complete anuria occurs.
Nephrotic Syndrome
- Excretion of Protein in the urine because of
increased Glomerular Permeability
- The kidney disease which develop is called
Nephrotic Syndrome
- There is increased permeability of the
glomerular membrane.
- Such disease include :
1. Chronic glomerulonephritis
2. Amyloidosis
3. Minimal change nephrotic syndrome more
frequently in children between the age of 2
and 6 years.
* As muchas 40 grams of plasma protein loss
into the urine each day
* Osmotic pressure falls from a normal value
of 28 to less than 10 mmHg large
amounts of fluid leak from the capillaries
all over the body into most the tissue
severe edema.
Abnormal Nephron Function in Chronic Renal Failure
- Loss of functional nephrons requires the surviving
nephrons to Excrete more water and solutes.

- Yet patient who have lost as much as 70% of their
nephrons are able to excrete normal amounts of
water and electrolytes without serious accumulation
of any of these in the body fluids reduction
nephrons falls below 5 to 10% of normal death.
Effects of Renal Failure on the Body Fluids
- Depends on :
1. The water and foot intake.
2. The degree of impairment of renal function
- Important effect include :
1. Generalize edema water and salt retention
2. Acidosis
3. High concentration of the non protein
nitrogens especially : urea, creatinine, uric
acid.
4. High concentrations of other substances
excreted by the kidney including : phenols,
sulfases, phosphates, potassium, and quanidine bases.
- The total conditions is called Uremia.
- Increase in urea and other non protein Nitrogens
Uremia (Azotemia)
- Another effects is :
1. Anemia of erythroporetin secretion
2. Osteomalacia production of active vit. D
and phosphat retentions
3. Hypertension : caused by
a.Increased renal vascular resistance
b.Decreased glomerular capillary filtration coefficient.
c.Excessive tubular sodium reabsorption.
d.Patchy renal damage and increased renal secretion of renin.
4. Kidney Diseases
- Cause loss of entire nephrons lead to renal failure,
but may not cause by hypertension
- Include : specific tubular disorders :
a. Renal glycosuria
b. Amino aciduria
c. Renal hypophosphatemia
d. Renal tubular acidosis
e. Nephrogenic Diabetes incipidus
f. Fanconis syndrome A generalized reabsorptive
defectof the renal tubules
Treatment of Renal Failure by Dialysis with an Artificial Kidney
- Indication : * aentely renal failure (severe)
* clironically (ESRF)
- The basic principles of the artificial kidney is to pass blood
through minute blood channels bounded by a thin membrane
there is a dialyzing fluid into which unwanted substances in
the blood pass by diffusion
- In normal operation of the artificial kidney, blood flows
continue or intermittently back into the vein
- The rate of move ment of solute a cross the D. membrane
depends on
1. The concentration gradient of the solute between
the two solutions
2. The permeability of the membrane to the solute
3. The surface area of the membrane, and
4. The length of time that the blood and fluid remain
in content with the membrane
- To prevent coagulation of the blood in the artificial kidney,
a small amount of heparin is infused into the blood as it
enters the artificial kidney
- The effectiveness of the artificial kidney can be expressed in
terms of the amount of plasma that is cleared of different
substances each minute
- Most artificial kidneys can clear urea from the plasma at a
rate of 100 225 ml/min, which shows that least for the
excretion of urea
- The artificial kidneys can function about twice as rapidly as
two kidneys together, whose urea clearance is only 70 ml/min
- Yet the artificial kidneys is used for only 4 to 6 hours per day,
three time a weak the overall plasma clearance is still
considerably limited when the artificial kidney replace the
normal kidneys
Thus : that the artificial kidney cannot replace some of the other
functions of the kidneys, such as secretion of
erythropoietin, which to necessary for red blood cell
production.