I9I2 HUMAN ANATOMY. 



ease. Its summit may then pass above the level of the umbilicus and it may fill 

 almost the whole abdomen. 



Retention of nrine — inability to empty the bladder — may be due (a) to obstruc- 

 tion at the neck of the bladder, the prostate, or the urethra, as from clots in bleeding 

 frorn the kidneys, ureters, or the bladder itself, prostatic hypertrophy, stricture, or 

 rupture of the urethra ; {b') to affections of the bladder muscles, as paresis or 

 paralysis of the detrusors in cerebral or spinal injury or disease, or reflex spasm of the 

 sphincter after operations on the anus or rectum ; or incoordination, as in hysteria, 

 or neurasthenia, or shock. 



The distended bladder forms a rounded fluctuating tumor in the hypogastric 

 region, which, as the intestines are pushed up with the fold of peritoneum back of 

 the urachus (plica vesico-umbilicalis), is always dull on percussion. If the disten- 

 tion is acute, the pressure on the sensory nerves of the bladder gives rise to dis- 

 tressing pain. If it takes place slowly, or if it follows cerebral or spinal injury, it 

 may be quite painless. 



After a time, in cases of great distention, the sphincter vesicae and compressor 

 urethrae yield to the pressure and the urine overflows the bladder more or less con- 

 tinuously, — incontinence of retention, — a condition which should always be suspected 

 to exist in aged male patients who have either very frequent urination or constant uri- 

 nary dribbling. Great paresis or actual paralysis of the detrusors may result from 

 distention, so that the power to empty the bladder is temporarily or permanently lost 

 even after all obstruction has been removed. 



During marked distention certain changes take place in its relations that are of 

 much practical importance. The neck of the bladder is so firmly fixed in position by 

 the base of the prostate, with its dense capsule continuous with the deep layer of the 

 triangular ligament (page 1977), by the anterior true ligaments of the bladder itself, 

 and by its close attachment to the rectum or to the uterus and vagina, that it does not 

 participate in the upward movement of the summit and body, but if the rectum is 

 not distended, rather sinks slightly in the pelvis. The looseness of the fatty con- 

 nective tissue occupying the space of Retzius (page 1906) and separating the antero- 

 lateral walls of the bladder below the peritoneal reflection from the pubes and the 

 obturator internus and levator ani muscles permits the elevation, during distention, of 

 all the remainder of the bladder. 



The anterior peritoneal fold, which, with the bladder undistended, reaches to the 

 symphysis pubis, is so raised that if the summit of the bladder is half-way between 

 the pubes and the umbilicus, there will be from 5-6.5 cm. (2-23^ in.) of the non- 

 peritoneal portion of the anterior bladder-wall in close apposition with a similar area 

 of the inner surface of the abdominal wall. In a male child five years of age the 

 space between the upper edge of the symphysis pubis and the reflection of the peri- 

 toneum will be one inch when the bladder contains three ounces of liquid. The close 

 attachment of the peritoneum to the summit of the bladder and its very loose attach- 

 ment to the parietes (necessitated by the changes in size and position of the bladder) 

 permit this upward displacement. 



Coincident distention of the rectum by a rubber bag limits the backward and 

 downward extension of the distended bladder, adds slightly to its elevation in the 

 abdomen, keeps it in close contact with the abdominal parietes, and increases the 

 distance between the recto-vesical fold and the anus from two and a half inches to 

 three and a half inches. The use of the rectal bag has practical disadvantages which 

 have led to its abandonment in most cases. The Trendelenburg position elevates 

 the partly distended bladder and carries upward the peritoneal folds by gravity. 

 Various operations {vide infra) are so planned as to take advantage of this uncover- 

 ing of the bladder-wall, which permits access to that viscus and to its cavity without 

 danger of peritoneal infection. 



Prevesical inflammation may follow infection through an operation or other 

 wound, involving the prevesical space of Retzius, or may be caused by extravasa- 

 tion of urine into that space ; and as the connective tissue occupying it is continuous 

 superiorly with the abdominal and inferiorly with the pelvic extraperitoneal tissue, a 

 cellulitis beginning there may be widespread, or may result fatally. Some of the 

 relations of this space are indicated in the fact that such infection has been known to 



