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Shawn A. Menefee Ingrid Nygaard
Bladder storage and emptying depend on a complex interplay between the brain, spinal cord, bladder, urethra, and pelvic ﬂoor.
Urinary incontinence is common in women and generally is treated successfully with a range of nonsurgical and surgical treatments.
Stress urinary incontinence occurs with increases in abdominal pressure (such as coughing, running, lifting) and can be treated with pelvic muscle exercises, vaginal devices, lifestyle changes, and surgery.
Urgency urinary incontinence occurs with a sudden sense of urgency (such as on the way to the bathroom or when washing hands) and can be treated with bladder training, medications, lifestyle changes, and neuromodulation.
Bladder pain remains a challenging and poorly understood entity.
Physiology of Micturition
The bladder is a complex organ that has a relatively simple function: to store urine effortlessly, painlessly, and without leakage and to discharge urine voluntarily, effortlessly, completely, and painlessly. To meet these demands, the bladder must have normal anatomic support and normal neurophysiologic function.
Normal urethral closure is maintained by a combination of intrinsic and extrinsic factors. The extrinsic factors include the levator ani muscles, the endopelvic fascia, and their attachments to the pelvic sidewalls and the urethra. This structure forms a hammock beneath the urethra that responds to increases in intra-abdominal pressure by tensing, allowing the urethra to be closed against the posterior supporting shelf (Fig. 26.1). When this supportive mechanism becomes faulty for some reason—the endopelvic fascia has detached from its normal points of fixation, muscular support has weakened, or a combination of these two processes—normal support is lost and anatomic hypermobility of the urethra and bladder neck develops. For many women, this loss of support is severe enough to cause loss of closure during