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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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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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