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DISORDERS OF THE AUTONOMIC NERVOUS SYSTEM, RESPIRATION, AND SWALLOWING 469
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ordination of detrusor and external sphincteric function depends mainly on the descending pathway from the posited centers in the dorsolateral pontine tegmentum With regard to the neurologic diseases that cause bladder dysfunction, multiple sclerosis, usually with urinary urgency, is by far the most common In Fowler s clinic, other spinal cord disorders accounted for 12 percent of cases, degenerative diseases (Parkinson disease and multiple system atrophy) for 14 percent, and frontal lobe lesions for 9 percent These data and the physiologic principles elaborated above enable one to understand the effects of the following lesions on bladder function: Complete destruction of the cord below T12, ie, the conus, as from trauma, myelodysplasias, tumor, venous angioma, and necrotizing myelitis The bladder is paralyzed for voluntary and re ex activity and there is no awareness of the state of fullness; voluntary initiation of micturition is impossible; the tonus of the detrusor muscle is abolished and the bladder distends as urine accumulates until there is over ow incontinence; voiding is possible only by the Crede maneuver, ie, lower abdominal compression and abdominal straining Usually the anal sphincter and colon are similarly affected, and there is saddle anesthesia and abolition of the bulbocavernosus and anal re exes as well as the tendon re exes in the legs The cystometrogram shows low pressure and no emptying contractions 2 Disease of the sacral motor neurons in the spinal gray matter, the anterior sacral roots, or peripheral nerves innervating the bladder, as in lumbosacral meningomyelocele and the tethered cord syndrome This is, in effect, a lower motor neuron paralysis of the bladder The disturbance of bladder function is the same as in (1) above except that sacral and bladder sensation are intact Various causes pertain in cauda equina disease, the most frequent being compression by epidural tumor or disc, neoplastic meningitis, and radiculitis from herpes or cytomegalovirus It is noteworthy that a hysterical patient can suppress motor function and suffer a similar distention of the bladder (see below) 3 Interruption of sensory afferent bers from the bladder, as in diabetes and tabes dorsalis, leaving motor nerve bers unaffected This is a primary sensory bladder paralysis The disturbance in function is the same as in (1) and (2) above Although a accid (atonic) paralysis of the bladder may be purely motor or sensory, as described above, in most clinical situations there is interruption of both afferent and efferent innervation, as in cauda equina compression or severe polyneuropathy Neuropathies affecting mainly the small bers are the ones usually implicated (diabetes, amyloid, etc), but urinary retention also occurs in certain acute neuropathies such as Guillain-Barre syndrome 4 Upper spinal cord lesions, above T12 These result in a re ex neurogenic (spastic) bladder In addition to multiple sclerosis and traumatic myelopathy, which are the commonest causes, myelitis, spondylosis, arteriovenous malformation (AVM), syringomyelia, and tropical spastic paraparesis may cause a bladder disturbance of this type If the cord lesion is of sudden onset, the detrusor muscle suffers the effects of spinal shock At this stage, urine accumulates and distends the bladder to the point of over ow As the effects of spinal shock subside, the detrusor usually becomes re exly overac1
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tive, and since the patient is unable to inhibit the detrusor and control the external sphincter, urgency, precipitant micturition, and incontinence result Incomplete lesions result in varying degress of urgency in voiding With slowly evolving processes involving the upper cord, such as multiple sclerosis, the bladder spasticity and urgency worsen with time and incontinence becomes more frequent In addition, initiation of voluntary micturition is impaired and bladder capacity is reduced Bladder sensation depends on the extent of involvement of sensory tracts Bulbocavernosus and anal re exes are preserved The cystometrogram shows uninhibited contractions of the detrusor muscle in response to small volumes of uid Most puzzling to the authors have been cases of cervical cord injury in which re ex activity of the sacral mechanism does not return; the bladder remains hypotonic Mixed type of neurogenic bladder In diseases such as multiple sclerosis, subacute combined degeneration, tethered cord, and syphilitic meningomyelitis, bladder function may be deranged from lesions at multiple levels, ie, spinal roots, sacral neurons or their bers of exit, and higher spinal segments The resultant picture is a combination of sensory, motor, and spastic types of bladder paralysis Stretch injury of the bladder wall, as occurs with anatomic obstruction at the bladder neck and occasionally with voluntary retention of urine, as in hysteria Repeated overdistention of the bladder wall often results in varying degrees of decompensation of the detrusor muscle and permanent atonia or hypotonia, although the evidence for this mechanism is uncertain The bladder wall becomes brotic and bladder capacity is greatly increased Emptying contractions are inadequate, and there is a large residual volume even after the Crede maneuver and strong contraction of the abdominal muscles As with motor and sensory paralyses, the patient is subject to cystitis, ureteral re ux, hydronephrosis and pyelonephritis, and calculus formation Urinary retention has been observed in women with polycystic ovaries In one study of 62 such women, it was found that myotonic-like discharges activated the urethral sphincter, interfering with its relaxation during micturition There were increasing amounts of residual urine, followed, nally, by complete retention This obscure mechanism has been offered as an explanation of some cases of hysterical urinary retention Fowler describes unusual patterns of electromyographic (EMG) activity in the bladder and sphincter of patients we would have classi ed as hysterical urine retention Frontal lobe incontinence Often the patient, because of his abulic or confused mental state, ignores the desire to void and the subsequent incontinence There is also a supranuclear type of hyperactivity of the detrusor and precipitant evacuation These types of frontal lobe incontinence are considered on page 393 Nocturnal enuresis, or urinary incontinence during sleep, due presumably to a delay in acquiring inhibition of micturition, is discussed in Chap 19
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As discussed earlier, a role for pontine centers in human micturition is implied from animal experiments; to our knowledge, there are no well-studied examples of human bladder dysfunction due solely to a brainstem lesion There are few clinical data except perhaps the PET studies mentioned to support the existence of these
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