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Disturbances of Bladder Function
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The familiar functions of the bladder and lower urinary tract the storage and intermittent evacuation of urine are served by three structural components: the bladder itself, the main component of which is the large detrusor (transitional type) muscle; a functional internal sphincter composed of similar muscle; and the striated external sphincter or urogenital diaphragm The sphincters assure continence; in the male, the internal sphincter also prevents the re ux of semen from the urethra during ejaculation For micturition to occur, the sphincters must relax, allowing the detrusor to expel urine from the bladder into the urethra This is accomplished by a complex mechanism involving mainly the parasympathetic nervous system (the sacral peripheral nerves derived from the second, third, and fourth sacral segments of the spinal cord and their somatic sensorimotor bers) and to a lesser extent, sympathetic bers derived from the thorax The brainstem micturition centers, with their spinal and suprasegmental connections, may contribute (Fig 26-5) The detrusor muscle receives motor innervation from nerve cells in the intermediolateral columns of gray matter, mainly from the third and also from the second and fourth sacral segments of the spinal cord (the detrusor center ) These neurons give rise to preganglionic bers that synapse in parasympathetic ganglia within the bladder wall Short postganglionic bers end on muscarinic acetylcholine receptors of the muscle bers There are also betaadrenergic receptors in the dome of the bladder, which are activated by sympathetic bers that arise in the intermediolateral nerve cells of T10, T11, and T12 segments These preganglionic bers pass via inferior splanchnic nerves to the inferior mesenteric ganglia (Figs 26-1 and 26-4); pre- and postganglionic sympathetic axons are conveyed by the hypogastric nerve to the pelvic plexus and the bladder dome The internal sphincter and base of the bladder (trigone), consisting of smooth muscle, are also innervated to some extent by the sympathetic bers of the hypogastric nerves; their receptors are mainly of alpha-adrenergic type, which makes it possible to therapeutically manipulate the function of the sphincter
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CARDINAL MANIFESTATIONS OF NEUROLOGIC DISEASE
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of the upper cord, the function of sacral segments is abolished for several weeks in the same way as the motor neurons of Afferent fibers skeletal muscles (the state of spinal shock) Th 12 Efferent fibers The storage of urine and the ef cient emptying of the bladder is possible only when the spinal segments, together L1 Sympathetic with their afferent and efferent nerve bers, are connected Mesenteric chain L2 plexuses with the so-called micturition centers in the pontomesencephalic tegmentum In experimental animals, this center (or L3 centers) lies within or adjacent to the locus ceruleus A medial L4 region triggers micturition, while a lateral area seems more Superior hypogastric important for continence These centers receive afferent implexus Pelvic nerves pulses from the sacral cord segments; their efferent bers (presacral n) (parasympathetic) course downward via the reticulospinal tracts in the lateral Hypogastric nerves funiculi of the spinal cord and activate cells in the nucleus of 2 Onuf as well as in the intermediolateral cell groups of the Sacral Inferior 2 hypogastric sacral segments (Holstege and Tan) In cats, the pontomesenganglia 3 cephalic centers receive descending bers from anteromedial Sacral constriction Plexus o 3 Vas nerves parts of the frontal cortex, thalamus, hypothalamus, and cere4 bellum, but the brainstem centers and their descending path4 ways have not been precisely de ned in humans Other bers, from the motor cortex, descend with the corticospinal bers Postganglionic to the anterior horn cells of the sacral cord and innervate the parasympathetic external sphincter According to Ruch, the descending pathfibers ways from the midbrain tegmentum are inhibitory and those from the pontine tegmentum and posterior hypothalamus are Int pudendal Internal sphincter facilitatory The pathway that descends with the corticospinal nerve tract from the motor cortex is inhibitory Thus the net effect of lesions in the brain and spinal cord on the micturition reExternal sphincter ex, at least in animals, may be either inhibitory or facilitaFigure 26-5 Innervation of the urinary bladder and its sphincters tory (DeGroat) Almost all of this information has been inferred from animal experiments; there is little human pathologic material to with adrenergically active drugs as well as the more commonly corroborate the role of central nuclei and cortex in bladder control used cholinergic ones (see further on) What information is available is reviewed extensively by Fowler, The external urethral and anal sphincters are composed of striwhose article is recommended Also of interest here is the study ated muscle bers Their innervation, via the pudendal nerves, is by Blok and colleagues, who performed positron emission tomogderived from a densely packed group of somatomotor neurons (nuraphy (PET) studies in volunteer subjects during micturition Incleus of Onuf ) in the anterolateral horns of sacral segments 2, 3, creased blood ow was detected in the right pontine tegmentum, and 4 Cells in the ventrolateral part of Onuf s nucleus innervate periaqueductal region, hypothalamus, and right inferior frontal corthe external urethral sphincter, and cells of the mediodorsal part tex When the bladder was full but subjects were prevented from innervate the anal sphincter The muscle bers of the sphincters voiding, increased activity was seen in the right ventral pontine respond to the nicotinic effects of ACh tegmentum The meaning of these lateralized ndings is unclear, The pudendal nerves also contain afferent bers coursing from but the study supports the presumption that pontine centers are the urethra and the external sphincter to the sacral segments of the involved in the act of voiding spinal cord These bers convey impulses for re ex activities and, The act of micturition is both re ex and voluntary When the through connections with higher centers, for sensation Some of normal person desires to void, there is rst a voluntary relaxation these bers probably course through the hypogastric plexus, as inof the perineum, followed sequentially by an increased tension of dicated by the fact that patients with complete transverse lesions the abdominal wall, a slow contraction of the detrusor, and an asof the cord as high as T12 may report vague sensations of urethral sociated opening of the internal sphincter; nally, there is a relaxdiscomfort The bladder is sensitive to pain and pressure; these ation of the external sphincter (Denny-Brown and Robertson) It is senses are transmitted to higher centers along the sensory pathways useful to think of the detrusor contraction as a spinal stretch re ex, described in Chaps 8 and 9 subject to facilitation and inhibition from higher centers Voluntary Unlike skeletal striated muscle, the detrusor, because of its closure of the external sphincter and contraction of the perineal postganglionic system, is capable of some contractions, imperfect muscles cause the detrusor contraction to subside The abdominal at best, after complete destruction of the sacral segments of the muscles have no power to initiate micturition except when the despinal cord Isolation of the sacral cord centers (transverse lesions trusor muscle is not functioning normally The voluntary restraint of the cord above the sacral levels) and their peripheral nerves of micturition is a cerebral affair and is mediated by bers that permits contractions of the detrusor muscle, but they still do not arise in the frontal lobes (paracentral motor region), descend in the empty the bladder completely; patients with such lesions usually spinal cord just anterior and medial to the corticospinal tracts, and develop dyssynergia of the detrusor and external sphincter muscles terminate on the cells of the anterior horns and intermediolateral (see below), indicating that coordination of these muscles must cell columns of the sacral segments, as described above The cooccur at supraspinal levels (Blaivas) With acute transverse lesions
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