Spontaneous Activity and the Urinary Bladder

Abstract

The urinary bladder has two functions: to store urine, when it is relaxed and highly compliant; and void its contents, when intravesical pressure rises due to co-ordinated contraction of detrusor smooth muscle in the bladder wall. Superimposed on this description are two observations: (1) the normal, relaxed bladder develops small transient increases of intravesical pressure, mirrored by local bladder wall movements; (2) pathological, larger pressure variations (detrusor overactivity) can occur that may cause involuntary urine loss and/or detrusor overactivity. Characterisation of these spontaneous contractions is important to understand: how normal bladder compliance is maintained during filling; and the pathophysiology of detrusor overactivity. Consideration of how spontaneous contractions originate should include the structural complexity of the bladder wall. Detrusor smooth muscle layer is overlain by a mucosa, itself a complex structure of urothelium and a lamina propria containing sensory nerves, micro-vasculature, interstitial cells and diffuse muscular elements. Several theories, not mutually exclusive, have been advanced for the origin of spontaneous contractions. These include intrinsic rhythmicity of detrusor muscle; modulation by non-muscular pacemaking cells in the bladder wall; motor input to detrusor by autonomic nerves; regulation of detrusor muscle excitability and contractility by the adjacent mucosa and spontaneous contraction of elements of the lamina propria. This chapter will consider evidence for each theory in both normal and overactive bladder and how their significance may vary during ageing and development. Further understanding of these mechanisms may also identify novel drug targets to ameliorate the clinical consequences of large contractions associated with detrusor overactivity.