Violation of the nervous regulation of the bladder. Violation of innervation

An important link in the process of urination is the occurrence of the urge to defecate. The work of this mechanism is ensured by the innervation of the bladder - numerous nerve endings of the organ timely give the signals necessary for the body. Violation of the nervous system can also lead to dysfunction of emptying. You can understand the relationship of structures by considering the mechanism for excreting urine.

Urination algorithm

The average bladder volume is 500 ml. A little more in men (up to 750 ml). In women, as a rule, it does not exceed 550 ml. The continuous work of the kidneys ensures the periodic filling of the organ with urine. Its ability to stretch the walls allows urine to fill the organ up to 150 ml without discomfort. When the walls begin to stretch and the pressure on the organ increases (usually this occurs when urine is formed in excess of 150 ml), the person feels the urge to defecate.

The reaction to irritation occurs at the reflex level. At the point of contact between the urethra and the bladder, there is an internal sphincter, a little lower one is an external one. Normally, these muscles are compressed and prevent the involuntary release of urine. When the urge to get rid of urine occurs, the valves relax, which ensures that the muscles of the organ that accumulates urine contract. This is how the bladder is emptied.

Bladder innervation model

The connection of the urinary organ with the central nervous system is ensured by the presence of sympathetic, parasympathetic, spinal nerves in it. Its walls are equipped with a large number of receptor nerve endings, scattered neurons of the autonomic nervous system and nerve nodes. Their functionality is the basis for stable controlled urination. Each type of fiber performs a specific task. Violations of innervation lead to various disorders.

Parasympathetic innervation

The parasympathetic center of the bladder is located in the sacral region of the spinal cord. From there originate preganglionic fibers. They take part in the innervation of the pelvic organs, in particular, form the pelvic plexus. The fibers stimulate the ganglia located in the walls of the organ of the urinary system, after which its smooth muscle contracts, respectively, the sphincters relax, and intestinal motility increases. This ensures emptying.

Sympathetic innervation

The cells of the autonomic nervous system involved in urination are located in the intermediate lateral gray column of the lumbar spinal cord. Their main purpose is to stimulate the closure of the cervix, due to which there is an accumulation of fluid in the bladder. It is for this that sympathetic nerve endings are concentrated in large numbers in the triangle of the bladder and neck. These nerve fibers have practically no effect on motor activity, i.e., the very process of the exit of urine from the body.

Role of sensory nerves

The reaction to the stretching of the walls of the bladder, in other words, the desire to have a bowel movement, is possible due to the afferent fibers. They originate in the proprioreceptors and noniceptors of the organ wall. The signal through them goes to the segments of the spinal cord T10-L2 and S2-4 through the pelvic, pudendal and hypoastral nerves. So the brain receives an impulse about the need to empty the bladder.

Violation of the nervous regulation of urination

Violation of the innervation of the bladder is possible in 3 variants:

Hyperreflex bladder - urine stops accumulating and is immediately excreted, and therefore the urge to go to the toilet is frequent, and the volume of fluid released is very small. The disease is a consequence of damage to the central nervous system.
Hyporeflex bladder. Urine accumulates in large quantities, but its exit from the body is difficult. The bubble is significantly overfilled (up to one and a half liters of liquid can accumulate in it), inflammatory and infectious processes in the kidneys are possible against the background of the disease. Hyporeflexia is determined by lesions of the sacral part of the brain.
Areflex bladder, in which the patient does not affect urination. It occurs by itself at the moment of maximum filling of the bubble.

Such deviations are determined by various reasons, among which the most common are: traumatic brain injuries, cardiovascular diseases, brain tumors, multiple sclerosis. To identify pathology, relying only on external symptoms, is quite problematic. The form of the disease directly depends on the fragment of the brain that has undergone negative changes. The term "neurogenic bladder" has been introduced in medicine to refer to dysfunction of the urine reservoir due to nervous disorders. Different types of lesions of nerve fibers in different ways disrupt the excretion of urine from the body. The main ones are discussed below.

Brain damage that disrupts innervation

Multiple sclerosis affects the work of the lateral and posterior columns of the cervical spinal cord. More than half of patients experience involuntary urination. Symptoms develop gradually. Sequestration of the intervertebral hernia at the initial stage causes a delay in the release of urine and difficulty emptying. This is followed by symptoms of irritation.

Supraspinal lesions of the motor systems of the brain disable the urination reflex itself. Symptoms include urinary incontinence, frequent urination, and nocturnal bowel movements. However, due to the preservation of the coordination of the work of the basic muscles of the bladder, the necessary level of pressure is maintained in it, which eliminates the occurrence of urological ailments.

Peripheral paralysis also blocks reflex muscle contractions, causing an inability to relax the lower sphincter on its own. Diabetic neuropathy causes detrusor dysfunction in the bladder. Stenosis of the lumbar spine affects the urinary system according to the type and level of the destructive process. With cauda equina syndrome, incontinence is possible due to overflow of a hollow muscular organ, as well as a delay in the excretion of urine. Hidden spinal dysraphism causes a violation of the reflection of the bladder, in which a conscious bowel movement is impossible. The process occurs independently at the moment of maximum filling of the organ with urine.

Variants of dysfunctions in severe brain damage

The syndrome of complete interruption of the spinal cord is manifested by such consequences for the urinary system:

In the case of dysfunction of the supracacral segments of the spinal cord, which can be caused by tumors, inflammation or trauma, the mechanism of damage is as follows. Development begins with detrusor hyperreflexia, followed by involuntary contractions of the bladder and sphincter muscles. As a result, intravesical pressure is very high and the volume of urine output is very small.
When the sacral segments of the spinal cord are affected due to injuries or disc herniation, on the contrary, there is a decrease in the frequency of emptying and a delay in the release of urine. A person loses the ability to independently control the process. Involuntary leakage of urine occurs due to overflow of the bladder.

Diagnosis and treatment of the disease

Changes in the frequency of bowel movements are the first signal for examination. In addition, the patient loses control over the process. Diagnosis of the disease is carried out only in a complex: the patient is given an x-ray of the spine and skull, the abdominal cavity, they can prescribe magnetic resonance imaging, ultrasound of the bladder and kidneys, general and bacteriological blood and urine tests, uroflowmetry (recording the speed of urine flow during the usual act of urination), Cytoscopy (examination of the inner surface of the affected organ).

There are 4 methods to help restore the innervation of the bladder:

Electrical stimulation of the urinal, groin muscles and anal sphincter. The goal is to activate the reflection of the sphincters and restore their common activity with the detrusor.
The use of coenzymes, adrenomimetics, cholinomimetics and calcium ion antagonists to activate the efferent links of the autonomic nervous system. Indicated drugs for taking: "Isoptin", "Ephedrine hydrochloride", "Aceclidin", "Cytochrome C".
Tranquilizers and antidepressants restore and support autonomic regulation.
Calcium ion antagonists, cholinergic, anticholinergic drugs, a-andrenostimulators restore the patient's ability to control urine output, normalize the retention of urine in the bladder, and regulate the smooth functioning of the sphincter and detrusor. Atropine sulfate, Nifedipine, Pilocarpine are prescribed.

Bladder innervation can be restored. Treatment depends on the extent and nature of the lesion and can be medical, non-pharmacological and surgical. It is extremely important to observe a sleep schedule, regularly walk in the fresh air, and perform a set of exercises recommended by doctors. It is impossible to restore innervation with the help of folk remedies at home. In order for the disease to be treated, it is necessary to follow all the prescriptions of the attending physician.

The regulation of the function of urination is carried out both by reflex (involuntary) and arbitrary mechanisms. It is known that the bladder has smooth muscles (detrusor and internal sphincter). The detrusor performs the function of stretching the bladder when urine accumulates in it, as well as contracting when emptying it. The function of urinary retention is provided by the sphincter.

The bladder has dual autonomic (sympathetic and parasympathetic) innervation. The spinal parasympathetic center is located in the lateral horns of the spinal cord at the level of S2-S4 segments. From it, parasympathetic fibers go as part of the pelvic nerves and innervate the smooth muscles of the bladder, mainly the detrusor. Parasympathetic innervation ensures contraction of the detrusor and relaxation of the sphincter, i.e., it is responsible for emptying the bladder. Sympathetic innervation is carried out by fibers from the lateral horns of the spinal cord (segments T11-T12 and L1-L2), then they pass as part of the hypogastric nerves (n. hypogastrici) to the internal sphincter of the bladder. Sympathetic stimulation leads to contraction of the sphincter and relaxation of the bladder detrusor, i.e., it inhibits its emptying. Consider that defeats of sympathetic fibers do not lead to disturbances of an urination. It is assumed that the efferent fibers of the bladder are represented only by parasympathetic fibers.

1 - brain stem; 2 - afferent pathways; 3 - efferent (pyramidal) paths; 4 - sympathetic trunk; 5 - hypogastric nerves (sympathetic innervation); 6 - pelvic nerves (parasympathetic innervation); 7 - pudendal nerves (somatic innervation); 8 - muscle pushing out urine; 9 - sphincter of the bladder.

The functioning of the bladder is provided by the spinal reflex: the contraction of the sphincter is accompanied by the relaxation of the detrusor - the bladder is filled with urine. When it is full, the detrusor contracts and the sphincter relaxes, urine is expelled. According to this type, urination is carried out in children in the first years, when the act of urination is not controlled consciously, but is carried out by the mechanism of an unconditioned reflex. In a healthy adult, urination is carried out according to the type of conditioned reflex: a person can consciously delay urination when an urge occurs and empty the bladder at will. Voluntary regulation is carried out with the participation of cortical sensory and motor zones. The supraspinal control mechanisms also include the bridge center (Barrington), which is part of the reticular formation. The afferent part of this conditioned reflex begins with receptors located in the area of the internal sphincter. Further, the signal through the spinal ganglions, posterior roots, posterior cords, medulla oblongata, pons, midbrain is sent to the sensory area of the cortex (girus fornicatus), from where, along the associative fibers, impulses enter the cortical motor center of urination, which is localized in the paracentral lobule (lobulus paracentralis) . The efferent part of the reflex as part of the cortical-spinal tract passes through the lateral and anterior cords of the spinal cord and ends in the spinal centers of urination (S2-S4 segments), which have a bilateral cortical connection. Further, the fibers through the anterior roots, the pudendal plexus and the pudendal nerve (n. pudendus) reach the external sphincter of the bladder. When the external sphincter contracts, the detrusor relaxes and the urge to urinate is inhibited. When urinating, not only the detrusor is tensed, but also the muscles of the diaphragm, abdominals, in turn, the internal and external sphincters relax.

Thus, the unconditioned spinal reflex of emptying and closing the bladder is subject to cortical influences that provide conscious urination.

Neurogenic forms of urination disorders. Neurogenic bladder is a syndrome that combines urination disorders that occur when the nerve pathways or centers that innervate the bladder and provide the function of voluntary urination are damaged. With bilateral damage to the cortex and its connections with the spinal (sacral) centers of urination, urination disorders of the central type occur, which can manifest as complete urinary retention (retention urinae), which occurs in the acute period of the disease (myelitis, spinal injury, etc.). In this case, the reflex activity of the spinal cord is inhibited, spinal reflexes disappear, in particular, the bladder emptying reflex - the sphincter is in a state of contraction, the detrusor is relaxed and does not function. Urine stretches the bladder to a large size. In such cases, catheterization of the bladder is necessary. In the future (after 1-3 weeks), the reflex excitability of the segmental apparatus of the spinal cord increases and urinary retention is replaced by incontinence. Urine is excreted periodically in small portions as it accumulates in the bladder; that is, the bladder empties automatically, functions as an unconditioned (spinal) reflex: the accumulation of a certain amount of urine leads to relaxation of the sphincter and contraction of the detrusor. This violation of urination is called periodic (intermittent) urinary incontinence (incontinention intermittens).

As a result of partial damage to the lateral cords of the spinal cord at the level of the cervicothoracic segments, there is an imperative urge to urinate. In such cases, the patient feels the urge, but he cannot consciously delay it. This violation occurs due to increased reflex contraction of the bladder and is combined with other neurological manifestations of disinhibition of spinal reflexes: high tendon reflexes, clonus of the feet, protective reflexes, etc.

If the pathological process is localized in the sacral segments of the spinal cord, the roots of the cauda equina and peripheral nerves (n. hypogastricus, n. pudendus), i.e., the parasympathetic innervation of the bladder is disturbed, dysfunction of the pelvic organs occurs according to the peripheral type. In the acute period of the disease, as a result of paralysis of the detrusor and maintaining the elasticity of the bladder neck, there is a complete retention of urine, or paradoxical retention of urine (ishuria paradoxa) with the release of urine in drops with an overflowing bladder in case of urinary retention (due to mechanical overstretching of the bladder sphincter). Subsequently, the neck of the bladder loses its elasticity, and the sphincter in this case is open, denervation of the internal and external sphincters occurs, therefore, true urinary incontinence (incontinention vera) occurs with the release of urine as it enters the bladder.

The normal functioning of the bladder is regulated by a large number of nerve plexuses at several levels. Starting from congenital defects of the terminal spine and spinal cord to dysfunction of the nervous regulation of the sphincter, all these disorders can provoke the appearance of symptoms of a neurogenic bladder. These disorders may be the consequences of trauma and be explained by other pathological processes in the brain, such as:

Multiple sclerosis.
Stroke.
Encephalopathy.
Alzheimer's disease.
Parkinsonism.

Spinal cord lesions such as spondyloarthrosis, osteochondrosis, Schmorl's hernia, and trauma can also cause the development of a neurogenic bladder.

All types of violations have different causes. Most common: traumatic brain injury. cardiovascular diseases. tumors.

Cauda equina syndrome. Causes incontinence due to overflow of the urinary organ or suspension of excretion.
Diabetic neuropathy. Causes dysfunction of expulsion of urine from the organ cavity. There is a narrowing (stenosis) in the lumbar spine. The urinary system is disturbed.
peripheral paralysis. Muscles cannot contract reflexively. The lower sphincter does not relax on its own.
Supraspinal disorders of the motor systems of the brain. The reflex function of urination is affected. Enuresis develops, frequent urges even at night. The functionality of the basic muscles is preserved, the pressure is normal, there is no threat of urological diseases.
Multiple sclerosis- violates the functions of the lateral, posterior columns of the cervical spinal cord, which leads to reflex. Symptoms develop gradually.

Classification

The connection of the urinary system with the central nervous system is carried out through parasympathetic, sympathetic, sensitive fibers. The slightest disruption in these areas leads to various disorders.

The parasympathetic center (excitatory fibers), located in the sacral spinal cord, is involved in the innervation of the pelvic organs. Responsible for relaxing the sphincter muscles, excreting urine.

The sympathetic center (vegetative), located in the intermediate lateral column of the lumbar spinal cord, stimulates the closure of the neck and retention of urine in the cavity of the bladder.

Sensory nerves located in the posterior urethral canal stretch the walls of the bladder and are responsible for the appearance of a reflex to empty its cavity.

Distortion of the nervous regulation of urination leads to failure of the innervation of the organ.

Diseases provoked by the innervation of the organ in the state filled and emptied of urine

The kurtosis of innervation leads to a neurogenic bladder. This disease indicates the beginning of the incorrect operation of the urinary canals. Urinary tract problems can be acquired throughout life or be a congenital disorder associated with nerves.

The connection of the bladder with the nervous system is very important for a full human life. When a disease occurs in a patient, the urinary canals atrophy, or they work too actively. Such disorders can manifest themselves with injuries or parallel diseases (pathologies of the anterior central nervous system, multiple sclerosis, stroke, parkinsonism, Alzheimer's disease, spinal cord lesions). The patient completely loses control over the process of removing urine from the body.

In turn, the neurogenicity of the muscular organ is divided into hyperactive and hypoactive types of disease development.

Violation of the innervation of the bladder in children

According to statistics, 10% of children suffer from neurogenic bladder. This disease does not pose a threat to the life of the child, and yet it unpleasantly complicates the socialization of the baby: complexes arise, the quality of life is disturbed.

It is known that infants and children under two or three years of age are not able to control the act of urination. However, when the control of the sphincter is sufficiently developed, which is carried out with the help of the brain and spinal cord, the child asks for a potty, and then learns to go to the toilet on his own. If a child of three years and older is not able to control the process of urination, this indicates violations:

pathologies of the central nervous system;
neoplasms in the spine (malignant or benign);
spinal hernia;
encephalitis;
Do not lie;
pathologies in the development of the sacrum and coccyx;
disruption of the autonomic nervous system;
hypothalamic-pituitary insufficiency.

Usually, children suffering from a neurogenic bladder are prescribed therapy only after a complete examination of the child's body for possible developmental pathologies. The complex of analyzes in children is no different from adults. This also includes a complete blood count, blood biochemistry, ultrasound, etc.

During treatment, children are contraindicated in excessive physical and emotional stress, hypothermia should not be allowed. Parents should be sympathetic to the health problems of the baby, not to allow abuse for wet clothes or bedding.

Signs and symptoms

Let's consider each deviation separately. Thus, a hyperreflex bladder is characterized by a constant urge to empty. This is because the impulse enters the spinal cord too quickly when the bladder is only half full. At the same time, very little fluid is excreted with each urination. The cause that caused the hyperreflex bladder may be a violation of the central nervous system (central nervous system).

The hyporeflex bladder is characterized by excessive filling of the bladder with fluid as a result of the impossibility of emptying. In this case, the bladder does not contract. This is due to disturbances in the functioning of the sacral spinal cord, because it is known that the spine affects the bladder (the spinal cord is located in it in humans).

If the patient has an areflex bladder, this means that his brain is not able to control the process of urination. As a result, a person experiences severe stress, because when the bladder is full, urine can begin to be released at the most inopportune moment.

The main causes of violations of the process of urination or neurogenic bladder:

encephalitis;
tuberculomas;
cholesteatoma;
post-vaccination neuritis;
diabetic neuritis;
demyelinating diseases;
injuries of the nervous system;
spinal cord pathology;
developmental pathology of the central nervous system.

Signs and symptoms

In the presence of neurogenic dysfunction of the bladder, the ability to voluntarily control the process of urination is lost.

Manifestations of neurogenic bladder are of 2 types: hypertonic or hyperactive type, hypoactive (hypotonic) type.

Hypertonic type of neurogenic bladder

This type appears when there is a violation of the function of the part of the nervous system that is located above the bridge of the brain. At the same time, the activity and strength of the muscles of the urinary system becomes much greater. This is called detrusor hyperreflexia. With this type of innervation disorder of the bladder, the process of urination can begin at any time, and often this happens in a place that is inconvenient for a person, which leads to serious social and psychological problems.

Having an overactive detrusor eliminates the possibility of urine accumulating in the bladder, so people feel the need to go to the toilet very often. Patients with hypertensive type of neurogenic bladder feel the following symptoms:

Stranguria is pain in the urethra.
Nocturia - frequent urination at night.
Urgent urinary incontinence - a rapid expiration with a strong urge.
Strong tension in the muscles of the pelvic floor, which sometimes provokes the reverse direction of the flow of urine through the ureter.
Frequent urge to urinate with little urine.

Hypoactive type of neurogenic bladder

The hypotonic type develops when the area of the brain below the pons of the brain is damaged, most often these are lesions in the sacral region. Such defects of the nervous system are characterized by insufficient contractions of the muscles of the lower urinary tract or the complete absence of contractions, which is called detrusor areflexia.

In a hypotonic neurogenic bladder, there is no physiologically normal urination, even with a sufficient amount of urine in the bladder. People feel these symptoms:

Feeling of insufficient emptying of the bladder, which ends with a feeling of fullness.
No urge to urinate.
Very sluggish urine stream.
Pain along the urethra.
Urinary sphincter incontinence.

Violation of innervation at any level can cause trophic disorders.

After collecting a detailed history, it is important to take urine and blood tests to exclude the inflammatory nature of the disease. Indeed, often the symptoms of inflammatory processes are very similar to the manifestation of a neurogenic bladder.

It is also worth examining the patient for the presence of anatomical anomalies in the structure of the urinary tract. To do this, radiography, urethrocystography, ultrasound, cystoscopy, MRI, pyelography and urography are performed. Ultrasound gives the most complete and clear picture.

Once all causes have been ruled out, neurological examinations should be performed. For this purpose, EEG, CT, MRI are performed and various techniques are used.

A neurogenic bladder is treatable. For this, anticholinergics, adrenoblockers, means to improve blood supply, and, if necessary, antibiotics are used. Physiotherapy exercises, rest and rational nutrition will help to overcome the process faster.

For an accurate diagnosis, the patient must consult a urologist and a neurologist. The doctor will interview the patient, suggest the following methods:

Keep a log of time, fluid intake, and urination for several days.
To hand over bakposev, OAM for infections.
Pass an x-ray with a contrast agent, MRI, ultrasound to exclude tumors, inflammatory processes.
To exclude pathological changes in the brain, spinal cord - CT, MRI.
Additionally - uroflowmetry and cystoscopy.

If this diagnosis does not allow to determine the cause, a diagnosis is made - a neurogenic bladder of uncertain origin.

In case of any violations of the urinary function in the body, you should immediately contact a urologist. After taking your medical history, your doctor may send you for the following tests:

X-ray of the spine and skull.
abdominal x-ray.
MRI (magnetic resonance imaging).
Ultrasound of the kidneys and bladder.
UAC - general blood analysis.
blood culture tank.
uroflowmetry.
cytoscopy.

An X-ray of the spine and skull will reveal abnormalities in the patient's brain and spinal cord.

X-ray of the abdominal cavity is able to diagnose pathologies of the kidneys, bladder. A significant advantage of MRI compared to X-ray is the ability to see human organs in a 3D image, which will allow the doctor to diagnose the cause of the patient's disease with high accuracy.

Ultrasound of the kidneys and bladder will help to identify various pathologies and neoplasms in the kidneys and bladder, for example, stones, polyps.

A complete blood count is an obligatory component of a complex of tests in the diagnosis of any disease. This study is able to identify the quantitative components of blood (blood cells): leukocytes, erythrocytes, platelets. Any deviations from the norm in their composition will indicate the development of the disease.

A blood culture tank will help to identify the presence of bacteria in the patient's blood, to identify their sensitivity to various kinds of antibiotics.

Uroflowmetry is a procedure by which you can find out the main properties of the patient's urine. This procedure will help to identify: the speed of urine flow, its duration, quantity.

Cytoscopy - examination of the inner walls of the bladder. For cytoscopy, a special device is used - a cystoscope.

The effect of impaired innervation on the urinary tract

With improper innervation, the blood supply to the urinary tract is disturbed. So, with a neurogenic bladder, cystitis often accompanies, which can cause microcysts.

A microcyst is a decrease in the size of the bladder due to chronic inflammation. With a microcyst, the function of the bladder is significantly impaired. Microcyst is one of the most difficult complications of chronic cystitis and neurogenic bladder.

Remaining urine in the bladder increases the risk of inflammatory diseases of the urinary tract. If the neurogenic bladder is complicated by cystitis, then this is a health hazard and sometimes requires surgical intervention.

Diagnosis and treatment of neurogenic bladder and its type

In this case, drug, non-drug treatment is used. To restore the reflex function of the sphincters and their activity with the detrusor, electrical stimulation of the muscles of the bladder, groin, and anus sphincter is prescribed.

To restore and activate the efferent links of the ANS, calcium ion antagonists, adrenomimetics, coenzymes, cholinomimetics are prescribed. Commonly used: Aceclidine, Ephedrine hydrochloride, Cytochrome C, Isoptin.

To maintain and restore the regulation of the ANS, the doctor individually selects tranquilizers and antidepressants.

In exceptional cases, a surgical operation is prescribed. Based on the causes, the nervous apparatus of the organ or the plasticity of the musculoskeletal apparatus can be corrected.

Violation of the innervation of the bladder is a common phenomenon. It is important to take steps to fix the problem at the first symptoms.

In order to restore the normal innervation of the bladder, the following methods are used:

electrical stimulation (urine collector, groin muscles and anal sphincter).
drug therapy (coenzymes, adrenomimetics, cholinomimetics, calcium ion antagonists).
taking antidepressants, tranquilizers.
taking cholinergic, anticholinergic drugs, andrenostimulants.

Unfortunately, there is no therapy for bladder innervation disorders with the help of folk remedies. If you have any problems with urinary dysfunction, you should immediately contact a urologist. True, in order to increase the effectiveness of drug therapy, you should move more, regularly walk in the fresh air, and perform exercises according to the method of exercise therapy (therapeutic physical culture).

Treatment of the disorder depends on the etiology of the disease, as well as on concomitant inflammatory diseases. There are four types of effective conservative treatment:

electrical stimulation. Sphincter reflexes can be activated by electrical stimulation of the muscles of the groin and anal sphincter. The procedure restores the relationship between the sphincter and the detrusor.
Medical therapy. Isoptin, Aceclidin or Cytochrome C is prescribed to activate the efferent impulses of the ANS. Preparations based on: coenzymes, calcium ion antagonists, adrenomimetics and cholinomimetics.
Tranquilizers and antidepressants act in a complex way on the entire nervous system.
Cholinometric, anticholinergic drugs restore the ability to control the process, stabilize the pressure inside the organ.

In other cases, a decision is made to conduct surgery.

Consequences

Untimely treatment of violations of the innervation of the bladder can lead to unpleasant consequences. The quality of life may be significantly impaired: sleep will be restless, the patient may suffer from depression and other psychological disorders. Chronic cystitis, chronic renal failure, pyelonephritis, vesicoureteral reflux may also occur.

Innervation of the bladder in any of its manifestations negatively affects human health and can lead to trophic disorders. With deviations in the functioning of the saccular organ with nerves, the blood supply to the organs of the urinary organs fails.

In addition to the whole bouquet of unpleasant sensations, cystitis may also begin to bother, which can transform into microcystitis. Microcystitis leads to a decrease in the size of the bladder due to chronic inflammation. Microcystitis is quite strong and negatively affects all functions of the bladder. This disease is characterized as the most dangerous among chronic cystitis and neurogenic bladder.

Remaining urine increases the risk of developing infections in the organ and inflammation throughout the canal. Usually, the disease of the neurogenic bladder, complicated by cystitis, is solved by surgical methods.

The innervation of the bladder ensures the formation of the urge to urinate, the relaxation of the muscles for the excretion of urine, and the containment of its release for the required time.

Blood filtration from toxic products of nitrogen metabolism and urine formation are carried out in specific kidney cells - nephrons. It then travels through the collecting ducts to the renal calyces and pelvis.

And from there - into the ureter. Due to the rhythmic contractions of the muscular walls of the ureter, urine enters the bladder.

It ensures the accumulation and excretion of urine. The formation of the urge to urinate begins when the bladder is filled with 250 - 300 ml.

The critical volume at which its emptying occurs uncontrollably is about 700 ml.

In the anatomical structure of the bladder, several departments are distinguished. This is a narrowed top, body and bottom with a neck located at the very bottom.

It is also sometimes called the vesical triangle - in two corners are the mouths of the ureters, in the third is the internal sphincter of the urethra.

The muscular membrane of the bladder consists of three layers of smooth muscles - two longitudinal and one circular. It's called a detrusor. Under the action of the innervation system, the muscles contract, the bladder contracts and empties.

From the inside, it is covered with a mucous membrane, which consists of a transitional epithelium. The mucous membrane forms pronounced folds along the entire inner surface, with the exception of the neck area.

Mechanism of urinary excretion

The human nervous system is divided into two large groups: sympathetic and parasympathetic. The nerve nodes of the parasympathetic system are located in the tissue of the organ or in its immediate vicinity.

And the plexuses of the sympathetic nervous system are located at a distance from the organ they regulate.

The bladder is innervated by the vesical plexus. It is represented by several types of nerve fibers.

Contraction and relaxation of the detrusor are regulated by parasympathetic innervation. Nerve fibers approach the muscles along with the pelvic nerves from the sacral spine.

The structure of the bladder

Excitation of nerve endings leads to simultaneous contraction of the detrusor and relaxation of the urethral sphincters.

Under the influence of an impulse from the sympathetic nerve endings, the internal sphincter of the bladder contracts, and the smooth muscles of its wall relax. At the same time, urinary retention occurs.

Also in the composition of the pelvic nerves there are sensory fibers that transmit signals about the degree of filling of the bladder. This type of innervation is responsible for the formation of the urge to urinate.

The urinary reflex is formed as follows. As the bladder fills, intravesical pressure increases.

Pathology of the bladder

In this case, the activation of the stretch receptors of the innervation system occurs. From them, the signal is transmitted to the spinal cord and returns along the parasympathetic fibers, causing muscle contraction and urination.

Intravesical pressure becomes the same. If the act of urination has not occurred, then further filling of the bladder continues.

The impulses constantly increase and become more frequent, and when a critical volume of filling is reached, urination occurs spontaneously. Reflex control of urination is carried out in the brain.

Thanks to the innervation system, an adult is able to restrain the urge to empty it for a certain time. Violation of its work leads to the syndrome of neurogenic bladder.

Pathology of the nervous regulation of urination

Most often, a violation of the innervation of the bladder is expressed in urinary incontinence or, conversely, in urinary retention.

Parkinson's disease

The causes of damage to nerve fibers can be multiple sclerosis, vascular or tumor diseases of the brain and spinal cord, trauma.

Manifestations of dysfunction depend on which part of the innervation system is damaged.

With an increased tone of the detrusor, a critical increase in intravesical pressure occurs even with a small filling of the bladder. This causes frequent urination.

Frequent calls

A so-called urgency incontinence may also occur. This is such a strong urge to urinate that a person is not able to restrain it for more than a few seconds.

Violation of the innervation of the sphincters of the ureter leads to urinary retention or difficulty urinating. After urination, a large amount of urine may still remain in the bladder.

With a complete cessation of urination, urgent hospitalization is necessary to restore the outflow of urine. For this purpose, special catheters are inserted directly into the bladder through the urethra or directly.

With neurogenic disorders in the system of formation of a reflex to urination, the patient does not feel symptoms of bladder filling.

This can only be judged by indirect signs - increased blood pressure or sweating, spasms.

Treatment

In the treatment of pathologies of bladder innervation, it is first necessary to identify its cause. To do this, conduct a complete examination of the nervous system.

brain ultrasound

They do an x-ray of the skull and spine, computed or magnetic resonance imaging of the brain and spinal cord, an encephalogram, and ultrasound of the brain.

In addition, the diagnosis is aimed at identifying possible other causes of urinary retention or incontinence.

These include inflammatory diseases, obstructive processes in urolithiasis, muscle atony, tumor processes, anatomical pathologies, psychological problems.

To do this, an ultrasound examination of all parts of the genitourinary system, MRI, positron emission tomography, clinical blood and urine tests are carried out.

To determine the causes of urinary pathology, urodynamic research methods are widely used. With their help, you can find out at what stage of the innervation of the bladder a violation occurred.

Urofluometry is the recording of the rate of urine flow during free urination.

This study allows you to determine the contractility of the detrusor, intraperitoneal pressure, evaluate the work of the sphincters of the urethra.

With cystometry, the bladder is filled with fluid and changes in intravesical and detrusor pressure are recorded. This method allows you to identify a violation of the detrusor when filling the bladder with urine.

Diagnostic studies

Voiding cystometry is a method of recording changes in bladder pressure during urination. In this study, the work of the detrusor-sphincters system is checked.

Electromyography records the activity of the pelvic floor muscles involved in urinary retention. This examination reveals a violation of innervation during the transmission of an impulse about filling the bladder to the brain.

For symptomatic therapy of bladder dysfunction, the following groups of drugs are widely used: anticholinergic, adrenergic drugs, cholinomimetics and adrenomimetics.

This is due to the peculiarities of the innervation of the smooth muscles of the bladder.

The detrusor contraction is carried out when the substance acetylcholine acts on M-cholinergic receptors in the wall of the bladder. And its relaxation is caused by the stimulating effect of norepinephrine on β-adrenergic receptors.

Therefore, a competent selection of drugs that affect the work of these receptors normalizes the frequency of urination and alleviates the patient's condition.

Antidepressants are also prescribed in combination with these drugs.

Violation of urination is corrected by physiotherapeutic procedures.

Of great practical importance is the identification of violations of the functions of the bladder, which occurs in connection with the disorder of its innervation, which is provided mainly by the autonomic nervous system (Fig. 13.4). Afferent somatosensory fibers originate from the proprioreceptors of the bladder, which respond to its stretching. The nerve impulses arising in these receptors penetrate through the spinal nerves Sn-SIV. 13.4. Innervation of the bladder (according to Muller). 1 - paracentral lobule; 2 - hypothalamus; 3 - upper lumbar spinal cord; 4 - lower sacral spinal cord; 5 - bladder; 6 - genital nerve; 7 - hypogastric nerve; 8 - pelvic nerve; 9 - plexus of the bladder; 10 - bladder detrusor; 11 - internal sphincter of the bladder; 12 - external sphincter of the bladder. into the posterior funiculi of the spinal cord, then enter the reticular formation of the brain stem and then into the paracentral lobules of the cerebral hemispheres, while along the way some of these impulses go to the opposite side. Thanks to the information going through the indicated peripheral, spinal and cerebral structures to the paracentral lobules, the bladder is stretched when it is filled, and the presence of an incomplete intersection of these afferent pathways leads to the fact that, with the cortical localization of the pathological focus, a violation of control over pelvic functions usually occurs only when both paracentral lobules are affected (for example, with falx meningioma). The efferent innervation of the bladder is carried out mainly due to the paracentral lobules, the reticular formation of the brain stem and spinal autonomic centers: sympathetic (neurons of the lateral horns of the Th11-L2 segments) and parasympathetic, located at the level of the segments of the spinal cord S2-S4. Conscious regulation of urination is carried out mainly due to nerve impulses coming from the motor zone of the cerebral cortex and the reticular formation of the trunk to the motor neurons of the anterior horns of the S3-S4 segments. It is clear that to ensure the nervous regulation of the bladder, it is necessary to preserve the pathways connecting these structures of the brain and spinal cord with each other, as well as the formations of the peripheral nervous system that provide innervation of the bladder. Preganglionic fibers coming from the lumbar sympathetic center of the pelvic organs (L1-L2) pass as part of the presacral and hypogastric nerves in transit through the caudal sections of the sympathetic paravertebral trunks and along the lumbar splanchnic nerves (pi. splanchnici lumbales) reach the nodes of the inferior mesenteric plexus (plexus mesentericus inferior). The postganglionic fibers coming from these nodes take part in the formation of the nerve plexuses of the bladder and provide innervation primarily to its internal sphincter. Due to sympathetic stimulation of the bladder, the internal sphincter, formed by smooth muscles, is reduced; at the same time, as the bladder fills, the muscle of its wall stretches - the muscle that pushes urine out (i.e., detrusor vesicae). All this ensures the retention of urine, which is facilitated by the simultaneous contraction of the external striated sphincter of the bladder, which has somatic innervation. It is carried out by the pudendal nerves (pp. pudendi), consisting of axons of motor neurons located in the anterior horns of the S3-S4 segments of the spinal cord. Efferent impulses to the pelvic floor muscles and counterproprioceptive afferent signals from these muscles also pass through the pudendal nerves. The parasympathetic innervation of the pelvic organs is carried out by preganglionic fibers coming from the parasympathetic center of the bladder located in the sacral spinal cord (S1-S3). They participate in the formation of the pelvic plexus and reach the intramural (located in the wall of the bladder) ganglia. Parasympathetic stimulation causes contraction of the smooth muscle that forms the body of the bladder (i.e. detrusor vesicae), and the concomitant relaxation of its smooth sphincters, as well as increased intestinal motility, which creates conditions for emptying the bladder. Involuntary spontaneous or provoked contraction of the bladder detrusor (detrusor overactivity) leads to urinary incontinence. Detrusor overactivity can be neurogenic (eg, in multiple sclerosis) or idiopathic (in the absence of an identified cause). Urinary retention (retentio urinae) often occurs due to damage to the spinal cord above the location of the spinal sympathetic autonomic centers (Th10-L2), responsible for the innervation of the bladder. Urinary retention leads to dyssynergy of the state of the detrusor and sphincters of the bladder (contraction of the internal sphincter and relaxation of the detrusor). This happens, for example, with traumatic lesions of the spinal cord, intravertebral tumor, multiple sclerosis. The bladder in such cases overflows and its bottom can rise to the level of the navel and above. Urinary retention is also possible due to damage to the parasympathetic reflex arc, which closes in the sacral segments of the spinal cord and provides innervation of the bladder detrusor. The cause of paresis or paralysis of the detrusor can be either a lesion of the indicated level of the spinal cord or a dysfunction of the structures of the peripheral nervous system that make up the reflex arc. In cases of persistent urinary retention, patients usually need to empty the bladder through a catheter. Simultaneously with urinary retention, neuropathic fecal retention (retencia alvi) usually occurs. Partial damage to the spinal cord above the level of the location of the autonomic spinal centers responsible for the innervation of the bladder can lead to a violation of voluntary control over urination and the emergence of the so-called imperative urge to urinate, in which the patient, having felt the urge, is not able to hold urine. A large role is likely to be played by the violation of the innervation of the external sphincter of the bladder, which normally can be controlled to a certain extent by willpower. Such manifestations of bladder dysfunction are possible, in particular, with bilateral damage to the medial structures of the lateral funiculi in patients with an intramedullary tumor or multiple sclerosis. A pathological process that affects the spinal cord at the level of the location of the sympathetic autonomic centers of the bladder (cells of the lateral horns of the Th1-L2 segments of the spinal cord) leads to paralysis of the internal sphincter of the bladder, while the tone of its protrusor is increased, in in connection with this, there is a constant excretion of urine in drops - true urinary incontinence (incontinentia urinae vera) no matter how it is produced by the kidneys, the bladder is practically empty. True urinary incontinence may be due to a spinal stroke, spinal cord injury, or spinal tumor at the level of these lumbar segments. True urinary incontinence can also be associated with damage to the structures of the peripheral nervous system involved in the innervation of the bladder, in particular in diabetes mellitus or primary amyloidosis. With urinary retention due to damage to the structures of the central or peripheral nervous system, it accumulates in the overstretched bladder and can create such high pressure in it that under its influence, the internal and external sphincters of the bladder that are in a state of spastic contraction are stretched, In this regard, urine is constantly excreted through the urethra in drops or periodically in small portions while maintaining the overflow of the bladder - paradoxical urinary incontinence (incontinentia urinae paradoxa), which can be established by detection during visual examination, as well as during palpation and percussion of the lower abdomen, protrusion the bottom of the bladder above the pubis (sometimes up to the navel). With damage to the parasympathetic spinal center (segments of the spinal cord S1-S3) and the corresponding roots of the cauda equina, weakness may develop and a simultaneous violation of the sensitivity of the muscle that ejects urine (i.e. detrusor vesicae), while urinary retention occurs. However, in such cases, over time, it is possible to restore the reflex emptying of the bladder, it begins to function in an "autonomous" mode (autonomous bladder). Clarification of the nature of bladder dysfunction may contribute to the definition of topical and nosological diagnoses of the underlying disease. In order to clarify the features of disorders of the functions of the bladder, along with a thorough neurological examination, according to indications, X-rays of the upper urinary tract, bladder and urethra are performed using radiopaque solutions. The results of urological examinations, in particular, cystoscopy and cystometry (determination of pressure in the bladder during its filling with liquid or gas), can help clarify the diagnosis. In some cases, electromyography of the periurethral striated muscle may be informative.