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The colon and anal sphincters are obedient to the same principles that govern bladder function Ileus from spinal shock, re ex neurogenic colon, and sensory and motor paralysis with megacolon are all recognized clinical entities The colon, stomach, and small intestine may be hypotonic and distended and the anal sphincters lax, either from deafferentation, de-efferentation, or both The anal and, in the male, the bulbocavernosus re ex may be abolished Defecation may be urgent and precipitant with higher spinal and cerebral lesions Since the same spinal segments and nearly the same spinal tracts subserve bladder and bowel function, meningomyeloceles and other cauda equina and spinal cord diseases often cause socalled double incontinence However, since the bowel is less often lled and its content is usually solid, fecal incontinence is less frequent than urinary incontinence In recent years there has been considerable interest in weakness of the muscles of the pelvic oor as a cause of double incontinence, more so in the female Also, it has been suggested that paradoxical contraction of the puborectus and external anal sphincter may be a cause of severe constipation (anismus) Extreme degrees of descent of the pelvic oor are believed to injure the pudendal nerves, as re ected in prolonged terminal latencies in nerve conduction studies Systemic diseases may affect the colonic sphincters; examples are myotonic dystrophy and scleroderma, which may weaken the
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Disturbances of Sexual Function
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Sexual function in the male, which is not infrequently affected in neurologic disease, may be divided into several parts: (1) sexual impulse, drive, or desire, often referred to as libido, discussed in Chap 25; (2) penile erection, enabling the act of sexual intercourse (potency); and (3) ejaculation of semen by the prostate through the urethra The arousal of libido in men and women may result from a variety of stimuli, some purely imaginary Such neocortical in uences involve the limbic system and are transmitted to the hypothalamus and spinal centers The suprasegmental pathways traverse the lateral funiculi of the spinal cord near the corticospinal tracts to reach sympathetic and parasympathetic segmental centers Penile erection is effected through sacral parasympathetic motor neurons (S3 and S4), the nervi erigentes, and pudendal nerves There is some evidence also that a sympathetic out ow from thoracolumbar segments (originating in T12 L1) via the inferior mesenteric and hypogastric plexuses can mediate psychogenic erections in patients with complete sacral cord destruction Activation from these segmental centers opens vascular channels between arteriolar branches of the pudendal arteries and the vascular spaces of the corpora cavernosa and corpus spongiosum (erectile tissues), resulting in tumescence Detumescence occurs when venous channels open widely Ejaculation involves rhythmic contractions of the prostate, compressor (sphincter) urethrae, and bulbocavernosus and
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DISORDERS OF THE AUTONOMIC NERVOUS SYSTEM, RESPIRATION, AND SWALLOWING 471
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ischiocavernosus muscles, which are under the control of both the sympathetic and parasympathetic centers Afferent segmental in uences arise in the glans penis and reach parasympathetic centers at S3 and S4 (re exogenic Visual + or Auditory erections) The organization of this neural system and Tactile "PSYCHIC the locations of lesions that can abolish normal potency Olfactory STIMULATION" are shown in Fig 26-6 Similar neural arrangements exist Gustatory Memory in females Imaginative The different aspects of sexual function may be affected separately Loss of libido may depend on both Limbic psychic and somatic factors It may be complete, as in lobe old age or in medical and endocrine diseases, or it may occur only in certain circumstances or in relation to a certain situation or individual In the latter case, which is due to psychologic factors, re ex penile erection dur+ or ing rapid-eye-movement (REM) sleep and even emission Thoracoof semen may occur, and effective sexual intercourse in lumbar erection other circumstances is possible Sexual desire can on occasion be altered in the op- center posite direction, ie, it may be excessive This too may be psychologic or psychiatric in origin, as in manic + or states, but sometimes it occurs with neurologic disease, Exteroceptive eg tactile stim such as encephalitis and tumors that affect the diencephof genitalia alon, septal region, and temporal lobes; with the demen- Sacral Pudendal "REFLEXOGENIC erection tias; and as a result of certain medications such as Lnerve STIMULATION" center Interoceptive dopa, as discussed in Chap 25 In the instances of S2, 3, 4 bowel neurologic diseases, there are usually other signs of disNervi bladder inhibited behavior as well erigentes On the other hand, sexual drive may be present but Vasodilation penile erection impossible to attain or sustain, a condition called impotence, in which nocturnal erections may Increased blood flow ERECTION or may not be preserved The commonest cause of imthru penis potence is a depressive state Prostatectomy is another, Figure 26-6 The pathways involved in human penile erection See text for details the result of damage to the parasympathetic nerves em- (Reproduced by permission from Weiss) bedded in the capsule of the gland It occurs also in patients who suffer disease of the sacral cord segments and Polyneuropathies such as those due to diabetes may be responsible; their afferent and efferent connections (eg, cord tumor, myelitis, prostatism may have a similar effect tabes, and diabetic and many other polyneuropathies), in which There are also aberrations of sexual function that occur in the case nocturnal erections are absent The parasympathetic nerves female, but they are more dif cult to analyze Lack of sexual desire cannot then be activated to cause tumescence of the corpora cavor failure to attain orgasm (frigidity) is much more frequent in the ernosa and corpus spongiosum The phosphodiesterase inhibitors female than in the male, occurring in a signi cant percentage of such as sildena l (Viagra) have proved to be useful in the treatment neurotic women and in others who exhibit no signs of psychic of impotence in some patients with sexual dysfunction of neurodisorder The activation of the pelvic re exes involved in female logic cause During sexual stimulation, it enhances the effect of orgasm is highly variable The pelvic re exes are sometimes conlocal nitrous oxide on the smooth muscle of the corpus cavergenitally de cient and the woman is anorgasmic but still sexually nosum; this results in relaxation of the smooth muscle and in ow active and fertile States of excessive sexual excitability are known of blood The high rate of success of this drug in patients with in sociopathic individuals and, rarely, in those who suffer disease spinal cord injury indicates that segmental innervation is all that is of the brain Fecundity and sterility are usually unrelated to the required for re exive erection in response to tactile stimulation of other aspects of sexuality the penis The genesis of sexual perversions is discussed in Chap 56 Diseases of the spinal cord may abolish psychogenic erecTheir origin remains obscure Endocrine, biochemical, and psychotions, leaving re exogenic ones intact In fact, the latter may belogic studies have failed to clarify the cause and mechanism Cerecome overactive, giving rise to sustained painful erections (priabral disorders of sexual function are discussed further in Chap 25 pism) This indicates that the segmental mechanism for penile (page 449) and the development of sexual function in Chap 28 erection is relatively intact There are many other nonneurologic causes for priapism, among them sickle cell anemia and other thrombotic states and perineal trauma NERVOUS SYSTEM CONTROL OF Other sexual dif culties include the premature ejaculation of RESPIRATION semen After lumbar sympathectomy, the semen may be ejected back into the bladder because of paralysis of the periurethral muscle Considering the fact that the act of breathing is entirely neurologic, within the prostate, at the verumontanum (colliculus seminalis) it is surprising how little attention it has received other than from
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