the internal sphincter, maintains urethral pressure (resistance) higher than normal Bladder pressure. The combination of both Urinary sphincters is known as the continence mechanism.The pressure gradients within the Bladder and urethra play an important functional role in normal micturition. As long as the urethral pressure is higher than that of the Bladder, patients will remain continent. If the urethral pressure is abnormally low or if the intravesical pressure is abnormally high, Urinary incontinence will result.As the Bladder initially fills, a small rise in pressure occurs within the Bladder (intravesical pressure). When the urethral sphincter is closed, the pressure inside the urethra (intraurethral pressure) is higher than the pressure within the Bladder. While the intraurethral pressure is higher than the intravesical pressure, Urinary continence is maintained.During some physical activities and with coughing, sneezing, or laughing, the pressure within the abdomen rises sharply. This rise is transmitted to both the Bladder and urethra. As long as the pressure is evenly transmitted to both the Bladder and urethra, urine will not leak. When the pressure transmitted to the Bladder is greater than the urethra, urine will leak out, resulting in stress incontinence.Emptying phase: The storage phase of the Urinary Bladder can be switched to the voiding phase either involuntarily (reflexively) or voluntarily. Involuntary reflex voiding occurs in an infant when the volume of urine exceeds the voiding threshold. When the Bladder is filled to capacity, the stretch receptors within the Bladder wall signal the sacral cord. The sacral cord, in turn, sends a message back to the Bladder indicating that it is time to empty the Bladder.At this point, the pudendal nerve causes relaxation of the levator ani so that the pelvic floor muscle relaxes. The pudendal nerve also signals the external sphincter to open. The sympathetic nerves send a message to the internal sphincter to relax and open, resulting in a lower urethral resistance.When the urethral sphincters relax and open, the parasympathetic nerves trigger contraction of the detrusor. When the Bladder contracts, the pressure generated by the Bladder overcomes the urethral pressure, resulting in Urinary flow. These coordinated series of events allow unimpeded, automatic emptying of the urine.A repetitious cycle of Bladder filling and emptying occurs in newborn infants. The Bladder empties as soon as it fills because the brain of an infant has not matured enough to regulate the Urinary system. Because urination is unregulated by the infant's brain, predicting when the infant will urinate is difficult.As the infant brain develops, the PMC also matures and gradually assumes voiding control. When the infant enters childhood (usually at age 3-4 years), this primitive voiding reflex becomes suppressed and the brain dominates Bladder function, which is why toilet training usually is successful at age 3-4 years. However, this primitive voiding reflex may reappear in people with spinal cord injuries.Delaying voiding or voluntary voiding:Bladder function is automatic but completely governed by the brain, which makes the final decision on whether or not to void. The normal function of urination means that an individual has the ability to stop and start urination on command. In addition, the individual has the ability to delay urination until a socially acceptable time and place. The healthy adult is aware of Bladder filling and can willfully initiate or delay voiding.In a healthy adult, the PMC functions as an on-off switch that is activated by stretch receptors in the Bladder wall and is, in turn, modulated by inhibitory and excitatory neurologic influences from the brain. When the Bladder is full, the stretch receptors are activated. The individual perceives the activation of the stretch receptors as the Bladder being full, which signals a need to void.When an individual cannot find a bathroom nearby, the brain bombards the PMC with a multitude of inhibitory signals to prevent detrusor contractions. At the same time, an individual may actively contract the levator muscles to keep the external sphincter closed or initiate distracting techniques to suppress urination.Thus, the voiding process requires coordination of both the ANS and somatic nervous system, which are in turn controlled by the PMC located in the brainstem.Pathophysiology: If a problem occurs within the nervous system, the entire voiding cycle is affected. Any part of the nervous system may be affected, including the brain, pons, spinal cord, sacral cord, and peripheral nerves. A dysfunctional voiding condition results in different symptoms, ranging from acute Urinary retention to an overactive Bladder or to a combination of both.Urinary incontinence results from a dysfunction of the Bladder, the sphincter, or both. Bladder over activity (spastic Bladder) is associated with the symptoms of urge incontinence, while sphincter under activity (decreased resistance) results in symptomatic stress incontinence. A combination of detrusor over activity and sphincter under activity may result in mixed symptoms. Brain lesion: Lesions of the brain above the pons destroy the master control center, causing a complete loss of voiding control. The voiding reflexes of the lower Urinary tract—the primitive voiding reflex—remain intact. Affected individuals show signs of urge incontinence, or spastic Bladder (medically termed detrusor hyperreflexia or over activity). The Bladder empties too quickly and too often, with relatively low quantities, and storing urine in the Bladder is difficult. Usually, people with this problem rush to the bathroom and even leak urine before reaching their destination. They may wake up frequently at night to void.Typical examples of a brain lesion are stroke, brain tumor, or Parkinson disease. Hydrocephalus, cerebral palsy, and Shy-Drager syndrome also are brain lesions. Shy-Drager syndrome is a rare condition that also causes the Bladder neck to remain open.Spinal cord lesion: Diseases or injuries of the spinal cord between the pons and the sacral spinal cord also result in spastic Bladder or overactive Bladder. People who are paraplegic or quadriplegic have lower extremity spasticity. Initially, after spinal cord trauma, the individual enters a spinal shock phase where the nervous system shuts down. After 6-12 weeks, the nervous system reactivates. When the nervous system becomes reactivated, it causes hyper stimulation of the affected organs. For example, the legs become spastic.These people experience urge incontinence. The Bladder empties too quickly and too frequently. The voiding disorder is similar to that of the brain lesion except that the external sphincter may have paradoxical contractions as well. If both the Bladder and external sphincter become spastic at the same time, the affected individual will sense an overwhelming desire to urinate but only a small amount of urine may dribble out. The medical term for this is detrusor-sphincter dyssynergia because the Bladder and the external sphincter are not in synergy. Even though the Bladder is trying to force out urine, the external sphincter is tightening to prevent urine from leaving.The causes of spinal cord injuries include motor vehicle and diving accidents. Multiple sclerosis (MS) is a common cause of spinal cord disease in young women. Those with MS also may exhibit visual disturbances, known as optic neuritis. Children born with myelomeningocele may have spastic Bladders and/or an open urethra. Conversely, some children with myelomeningocele may have a hypo contractile Bladder instead of a spastic Bladder.Sacral cord injury: Selected injuries of the sacral cord and the corresponding nerve roots arising from the sacral cord may prevent the Bladder from emptying. If a sensory neurogenic Bladder is present, the affected individual may not be able to sense when the Bladder is full. In the case of a motor neurogenic Bladder, the individual will sense the Bladder is full and the detrusor may not contract, a condition known as detrusor areflexia. These individuals have difficulty eliminating urine and experience overflow incontinence; the Bladder gradually over distends until the urine spills out. Typical causes are a sacral cord tumor, herniated disc, and injuries that crush the pelvis. This condition also may occur after a lumbar laminectomy, radical hysterectomy, or abdominoperineal resection.Some teenagers suddenly develop an abnormal voiding pattern and often are evaluated for tethered cord syndrome, a neurologic condition in which the tip of the sacral cord is stuck near the sacrum and cannot stretch as the child grows taller. Ischemic changes of the sacral cord associated with the tethering cause the manifestation of dysfunctional voiding symptoms.Type of incontinence-Symptomatologic categories:Stress incontinence=involuntary leakage from effort or exertion, or sneezing or coughing. Usually related to poor sphincter function and/or increased urethral mobility.Urge incontinence=involuntary leakage accompanied or proceeded by urgency. Usually related to detrusor overactivityMixed incontinence=features of bothOverflow incontinence=associated with overdistention of the Bladder, e.g. form detrusor paralysis or Bladder outflow obstruction.Post prostectatomy BD:Following the removal of prostate the length of the remaining urethra is very important. It should be 18 mm in rest, and 13 mm in strain. If the length of opposition tissue or the functional urethra which is left is less than 13mm, the patient is incontinent and must always use a pad. Between these two lengths the patient will have leaks during daily activities. Manipulation of this functional urethra during operation worsens the continents. Preserving the tissue round the urethra will improve.Now what are the diagnoses of the mentioned disorders?The young man who voids before reaching the WC suffered from detrusor instability and pons malfunction.The girl who has to wake up five times at night suffered from detrusor overactive and urge incontinence.In the case of the young man who voids his Bladder before reaching the WC, the diagnosis is sphincter dyssynergia, detrusor instability and pons malfunctions.The two women: the one who used pads as she wetted herself constantly and the other case who wet herself while she rolled in bed suffered from the above mentioned dysfunctions.The lower activity of the detrusor is common in old age. Those who feel their Bladder is not empty although they have voided and no residue is left have continuous detrusor activity.The man who wakes up every hour was because of improper operation since the Bladder sphincter has been damaged and 5mm of functional urethra has been left open. Therefore, as soon as urine reaches the open area it triggers the external sphincter to open.Chronic prostatitis inputs an impulse to the Bladder to void.As far as treatment is concerned its not my specialty to discuss, I should say there is no proper cure for all the cases. Anti-cholinergic drugs relax the Bladder and increase the tone of the external sphincter, so it is the benefit of over activity. The anti alpha-adrenogenic decreases and relaxes the internal sphincter, urethra and prostetic smooth muscles. They are three types"