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

An important link in the process of urination is the occurrence of the urge to defecate. The operation of this mechanism is ensured by the innervation of the bladder - numerous nerve endings of the organ promptly send signals necessary for the body. Disruption of the nervous system can also lead to dysfunction of bowel movements. You can understand the relationship between structures by considering the mechanism of urine secretion.

Urinary excretion algorithm

The average bladder volume is 500 ml. Slightly more for men (up to 750 ml). In women, as a rule, it does not exceed 550 ml. The continuous functioning of the kidneys ensures that the organ is periodically filled with urine. Its ability to stretch the walls allows urine to fill the organ up to 150 ml without causing discomfort. When the walls begin to stretch and pressure on the organ increases (usually this occurs when urine volume exceeds 150 ml), a 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, and a little lower there is another one - the external one. In the normal state, these muscles are compressed and prevent the involuntary release of urine. When there is a urge to get rid of urine, the valves relax, which ensures contraction of the muscles of the urine-accumulating organ. This is how the bladder is emptied.

Bladder innervation model

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

Parasympathetic innervation

The parasympathetic center of the bladder is located in the sacral part of the spinal cord. Preganglionic fibers originate from there. They take part in the innervation of the pelvic organs, in particular, they form the pelvic plexus. The fibers stimulate the ganglia located in the walls of the urinary system organ, after which its smooth muscle contracts, accordingly, 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 fluid accumulates in the bladder. It is for this purpose that sympathetic nerve endings are concentrated in large numbers in the triangle of the bladder and the neck. These nerve fibers have virtually no effect on motor activity, that is, the process of urine leaving the body.

The role of sensory nerves

The reaction to stretching of the walls of the bladder, in other words, the emergence of a desire to defecate, is possible thanks to afferent fibers. They originate in the proprioceptors and noniceceptors of the organ wall. The signal through them goes to the spinal cord segments T10-L2 and S2-4 through the pelvic, pudendal and hypoastral nerves. This is how the brain receives an impulse to empty the bladder.

Disturbance of the nervous regulation of urination

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

1. Hyper-reflex bladder - urine stops accumulating and is immediately released, which is why 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.
2. Hyporeflex bladder. Urine accumulates in large quantities, but its exit from the body is difficult. The bladder is significantly full (up to one and a half liters of fluid can collect 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.
3. Reflex bladder, in which the patient does not influence urination. It occurs on its own 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. Identifying pathology based 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. To denote the dysfunction of the urine reservoir due to nervous disorders, the term “neurogenic bladder” has been introduced in medicine. Different types of nerve fiber lesions impair the excretion of urine from the body in different ways. The main ones are discussed below.

Brain lesions that disrupt innervation

Multiple sclerosis affects 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 urine output and difficulty in 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 urges and nocturnal bowel movements. However, due to the preservation of coordination of the work of the basic muscles of the bladder, the required level of pressure is maintained in it, which eliminates the occurrence of urological ailments.

Peripheral paralysis also blocks reflex muscle contractions, causing the inability to independently relax the lower sphincter. Diabetic neuropathy causes problems with the detrusor function of the bladder. Lumbar spinal stenosis affects the urinary system according to the type and level of the destructive process. With cauda equina syndrome, incontinence due to overfilling of the hollow muscular organ and delayed urine output are possible. Latent spinal dysraphism causes impaired bladder reflexion, in which conscious bowel movements are impossible. The process occurs independently at the moment of maximum filling of the organ with urine.

Variants of dysfunction in severe brain damage

Complete spinal cord interruption syndrome is manifested by the following consequences for the urinary system:

1. In the case of dysfunction of the suprasacral 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, the intravesical pressure is very high and the volume of urine output is very small.
2. When the sacral segments of the spinal cord are damaged due to injury or disc herniation, on the contrary, there is a decrease in the frequency of bowel movements 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 bladder overflow.

Diagnosis and treatment of the disease

The first signal for examination is changes in the frequency of bowel movements. In addition, the patient loses control over the process. Diagnosis of the disease is carried out only in combination: the patient is given an X-ray of the spine and skull, abdominal cavity, they may be prescribed magnetic resonance imaging, ultrasound of the bladder and kidneys, general and bacteriological tests of blood and urine, uroflowmetry (recording the speed of urine flow during normal urination), cytoscopy (examination of the inner surface of the affected organ).

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

• Electrical stimulation of the urine collector, groin muscles and anal sphincter. The goal is to activate the reflexion 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 parts of the autonomic nervous system. Drugs indicated for use: “Isoptin”, “Ephedrine hydrochloride”, “Aceclidine”, “Cytochrome C”.
• Tranquilizers and antidepressants restore and maintain autonomic regulation.
• Calcium ion antagonists, anticholinergic, anticholinergic drugs, a-andrenostimulants restore the patient’s ability to control urine output, normalize urine retention in the bladder, and regulate the smooth functioning of the sphincter and detrusor. Atropine sulfate, Nifedipine, Pilocarpine are prescribed.

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

Regulation of urination function is carried out by both reflex (involuntary) and voluntary mechanisms. It is known that the bladder contains 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 segments S2-S4. 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 detrusor of the bladder, i.e., it inhibits its emptying. It is believed that lesions of sympathetic fibers do not lead to urinary disorders. 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) pathways; 4 - sympathetic trunk; 5 - hypogastric nerves (sympathetic innervation); 6 - pelvic nerves (parasympathetic innervation); 7 - pudendal nerves (somatic innervation); 8 - muscle that pushes urine out; 9 - sphincter of the bladder.

The functioning of the bladder is ensured by the spinal reflex: contraction of the sphincter is accompanied by relaxation of the detrusor - the bladder fills with urine. When it is full, the detrusor contracts and the sphincter relaxes, and urine is expelled. This type of urination occurs in children in the first years, when the act of urination is not consciously controlled, but is carried out through the mechanism of an unconditioned reflex. In a healthy adult, urination occurs as a conditioned reflex: a person can consciously hold urination when the urge arises and empty the bladder at will. Voluntary regulation is carried out with the participation of cortical sensory and motor areas. The supraspinal control mechanisms also include the pontine center (Barington), which is part of the reticular formation. The afferent part of this conditioned reflex begins with receptors that are located in the area of ​​the internal sphincter. Next, the signal through the spinal ganglia, dorsal roots, dorsal cords, medulla oblongata, pons, midbrain is sent to the sensory area of ​​the cortex (girus fornicatus), from where, along 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 corticospinal tract passes in the lateral and anterior cords of the spinal cord and ends in the spinal micturition centers (S2-S4 segments), which have a bilateral cortical connection. Next, the fibers through the anterior roots, genital plexus and 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 muscle tenses, but also the muscles of the diaphragm and abdominal press, 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 ensure 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) urination centers, urination disorders of the central type occur, which can manifest as complete urinary retention (retention urinae), which occurs during 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 reflex to empty the bladder - 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. Subsequently (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 released periodically in small portions as it accumulates in the bladder; that is, the bladder empties automatically and 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 urinary disorder 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, an imperative urge to urinate occurs. In such cases, the patient feels the urge, but cannot consciously delay it. This disorder occurs due to increased reflex contraction of the bladder and is combined with other neurological manifestations of disinhibition of spinal reflexes: high tendon reflexes, foot clonus, 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 disrupted, dysfunction of the pelvic organs of the peripheral type occurs. In the acute period of the disease, as a result of detrusor paralysis and preservation of the elasticity of the bladder neck, complete urinary retention occurs, or paradoxical urinary retention (ishuria paradoxa) with the release of urine in drops when the bladder is full 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, so true urinary incontinence (incontinence 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. From congenital defects of the terminal spine and spinal cord to dysfunction of the nervous regulation of the sphincter, all these disorders can trigger the appearance of neurogenic bladder symptoms. These disorders may be the consequences of injury and explained by other pathological processes of the brain, such as:

• Multiple sclerosis.
• Stroke.
• Discirculatory 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. The most common: traumatic brain injuries. cardiovascular diseases. tumors.

1. Cauda equina syndrome. Causes incontinence due to overflow of the urinary organ or interruption of excretion.
2. Diabetic neuropathy. Causes dysfunction in pushing urine out of the organ cavity. A narrowing (stenosis) occurs in the lumbar spine. The urinary system is disrupted.
3. Peripheral paralysis. Muscles cannot contract reflexively. The lower sphincter does not relax on its own.
4. 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 underlying muscles is preserved, blood pressure is normal, and there is no threat of urological diseases.
5. Multiple sclerosis- disrupts the functions of the lateral, posterior columns of the cervical spinal cord, which leads to areflexivity. Symptoms develop gradually.

Classification

The connection between the urinary system and the central nervous system is carried out through parasympathetic, sympathetic, and sensory fibers. The slightest interruptions in these areas lead to various disorders.

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

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

Sensitive nerves located in the posterior part of the 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 disruptions in the innervation of the organ.

Diseases provoked by the innervation of an organ in a state filled and empty of urine

Excess of innervation leads to a neurogenic bladder. This disease indicates the beginning of incorrect functioning of the urinary canals. Urinary tract problems can be acquired during life or can be a congenital disorder related to the nerves.

The connection between the bladder and the nervous system is very important for a person to live a full life. When the disease occurs, the patient’s urinary canals atrophy, or they work too actively. Such disorders can manifest themselves with injuries or parallel diseases (pathologies of the anterior part of the 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.

Disorders of 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 child’s life, and yet it unpleasantly complicates the child’s socialization: complexes arise and the quality of life is disrupted.

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 sphincter control, which is carried out with the help of the brain and spinal cord, develops sufficiently, the child asks to go to the potty, and then learns to go to the toilet on his own. If a child three years or older is unable to control the process of urination, this indicates a violation:

• pathologies of the central nervous system;
• neoplasms in the spine (malignant or benign);
• spina bifida;
• encephalitis;
• neuritis;
• pathologies in the development of the sacrum and coccyx;
• disturbances in the functioning of the autonomic nervous system;
• hypothalamic-pituitary insufficiency.

Typically, 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 tests for children is no different from adults. This also includes a general blood test, blood biochemistry, ultrasound, etc.

During treatment, excessive physical and emotional stress is contraindicated for children; hypothermia should not be allowed. Parents should be understanding about their child’s health problems and not scold them for wet clothes or bed.

Signs and symptoms

Let us consider each deviation separately in order. Thus, a hyperreflex bladder is characterized by a constant urge to empty. This occurs because the impulse enters the spinal cord too quickly when the bladder is only half full. At the same time, very little fluid is released with each urination. The cause of a hyperreflex bladder may be a disruption of the central nervous system (CNS).

A hyporeflexive bladder is characterized by excessive fluid filling of the bladder as a result of the inability to empty. In this case, the bladder does not contract. This occurs due to disturbances in the functioning of the sacral part of the spinal cord, because it is known that the spine affects the bladder (where the spinal cord is located in humans).

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

The main causes of urinary dysfunction or neurogenic bladder:

• encephalitis;
• tuberculomas;
• cholesteatomas;
• post-vaccination neuritis;
• diabetic neuritis;
• demyelinating diseases;
• nervous system injuries;
• spinal cord pathologies;
• pathologies of development of the central nervous system.

Signs and symptoms

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

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

Hypertensive type of neurogenic bladder

This type appears when the function of the part of the nervous system that is located above the pons of the brain is impaired. 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 disturbance in the innervation of the bladder, the process of urination can begin at any time, and often this happens in an inconvenient place for the person, which leads to serious social and psychological problems.

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

• Strangury is pain in the urethra.
• Nocturia is frequent urination at night.
• Urgent urinary incontinence is a rapid flow of urine with a strong urge.
• Severe tension in the pelvic floor muscles, which sometimes causes urine to flow back through the ureter.
• Frequent urge to urinate with small amounts of urine.

Hypoactive type of neurogenic bladder

The hypotonic type develops when the area of ​​the brain below the pons is affected, 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 a complete absence of contractions, which is called detrusor areflexia.

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

• A feeling of insufficient emptying of the bladder, which ends with a feeling of fullness.
• There is no urge to urinate.
• Very sluggish stream of urine.
• Pain along the urethra.
• Bladder sphincter incontinence.

Disruption 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 abnormalities 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.

After excluding all causes, it is worth conducting neurological examinations. For this purpose, EEG, CT, MRI are performed and various techniques are used.

Neurogenic bladder is treatable. For this purpose, anticholinergics, adrenergic blockers, means to improve blood supply, and, if necessary, antibiotics are used. Therapeutic exercise, rest and balanced nutrition will help you overcome the process faster.

To make an accurate diagnosis, the patient needs to consult a urologist and neurologist. The doctor will interview the patient and suggest the following methods:

• For several days, keep a log of time, volume of liquid drunk and urination.
• Submit bacterial culture and OAM for infections.
• Get an X-ray with a contrast agent, MRI, ultrasound to exclude tumors and inflammatory processes.
• To exclude pathological changes in the brain and spinal cord - CT, MRI.
• Additionally - uroflowmetry and cystoscopy.

If this diagnosis does not allow the cause to be determined, a diagnosis is made - a neurogenic bladder of unknown origin.

If there are any disturbances in the urinary function in the body, you should immediately contact a urologist. After collecting your medical history, your doctor may send you for the following tests:

1. X-ray of the spine and skull.
2. X-ray of the abdominal cavity.
3. MRI (magnetic resonance imaging).
4. Ultrasound of the kidneys and bladder.
5. UAC - general blood test.
6. blood culture tank.
7. uroflowmetry.
8. cytoscopy.

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

An X-ray of the abdominal cavity can diagnose pathologies of the kidneys and bladder. A significant advantage of MRI compared to X-rays is the ability to see human organs in a 3D image, which will allow the doctor to accurately diagnose the cause of the patient’s disease.

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

A general blood test is a mandatory component of a set of tests when diagnosing any disease. This study can 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 identify the presence of bacteria in the patient’s blood and determine their sensitivity to various types of antibiotics.

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

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

The effect of innervation disturbances on the urinary tract

With improper innervation, the blood supply to the urinary tract organs is disrupted. Thus, with a neurogenic bladder, cystitis is often associated, which can cause microcysts.

Microcysts are a decrease in the size of the bladder due to chronic inflammation. With microcysts, bladder function is significantly impaired. Microcysts are one of the most complex complications of chronic cystitis and neurogenic bladder.

If urine remains in the bladder, the risk of inflammatory diseases of the urinary tract increases. If the neurogenic bladder is complicated by cystitis, then this poses 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 anal sphincter is prescribed.

To restore and activate the efferent parts of the ANS, calcium ion antagonists, adrenomimetics, coenzymes, and 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, surgery is prescribed. Based on the reasons, adjustments can be made to the nervous system of the organ or plasticity of the muscular-ligamentous apparatus.

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

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

1. electrical stimulation (urine collector, groin muscles and anal sphincter).
2. drug therapy (coenzymes, adrenomimetics, cholinomimetics, calcium ion antagonists).
3. taking antidepressants, tranquilizers.
4. taking anticholinergic, anticholinergic medications, and andrenostimulants.

Unfortunately, there is no treatment for bladder innervation disorders using folk remedies. If you have any problems with urinary function, 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 using the method of exercise therapy (therapeutic physical education).

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 applying electrical stimulation to the muscles of the groin and anal sphincter. The procedure restores the relationship between the sphincter and detrusor.
• Drug therapy. Isoptin, Aceclidine or Cytochrome C is prescribed to activate the efferent impulses of the VNS. Preparations based on: coenzymes, calcium ion antagonists, adrenomimetics and cholinomimetics.
• Tranquilizers and antidepressants have a complex effect on the entire nervous system.
• Cholinometic and anticholinergic medications restore the ability to control the process and stabilize the pressure inside the organ.

In other options, a decision is made to perform surgery.

Consequences

Untimely treatment of bladder innervation disorders 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, and vesicoureteral reflux may also occur.

Innervation of the bladder in any of its manifestations negatively affects human health and can lead to trophic disorders. If the functioning of the sac-like organ with nerves is abnormal, the blood supply to the urinary organs is disrupted.

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

Residues of urine increase the risk of developing infections in the organ and inflammation throughout the canal. Typically, neurogenic bladder disease complicated by cystitis is resolved with surgical methods.

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

Filtration of blood from toxic products of nitrogen metabolism and the formation of urine are carried out in specific kidney cells - nephrons. It then flows through the collecting ducts into the renal calyces and pelvis.

And from there - into the ureter. Thanks 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 to 250 - 300 ml.

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

The anatomical structure of the bladder is divided into several sections. This is a narrowed apex, body and bottom with a neck located at the very bottom.

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

The muscular lining of the bladder consists of three layers of smooth muscle - two longitudinal and one circular. It's called the detrusor. Under the influence 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 transitional epithelium. The mucous membrane forms pronounced folds along the entire internal surface with the exception of the cervical area.

Mechanism of urination

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 close proximity to it.

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.

Structure of the bladder

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

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

The pelvic nerves also contain sensory fibers that transmit signals about the degree of bladder filling. This type of innervation is responsible for the formation of the urge to urinate.

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

Bladder pathologies

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

Intravesical pressure remains the same. If the act of urination does not occur, then further filling of the bladder continues.

The impulses constantly intensify 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 defecate for a certain time. Disruption of its functioning leads to neurogenic bladder syndrome.

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.

Parkison's disease

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

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

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

Frequent urge

So-called urgency urinary incontinence may also occur. This is such a strong urge to urinate that a person is unable to hold it back for more than a few seconds.

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

If urination completely stops, urgent hospitalization is necessary to restore the outflow of urine. For this purpose, special catheters are inserted into the bladder through the urethra or directly.

With neurogenic disorders in the system of formation of the 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, cramps.

Treatment

When treating pathologies of innervation of the bladder, it is first necessary to identify its cause. To do this, a complete examination of the nervous system is performed.

Ultrasound of the brain

They do an X-ray of the skull and spine, computer or magnetic resonance imaging of the brain and spinal cord, an encephalogram, and an 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, and psychological problems.

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

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 the disorder occurred.

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

This study allows us to determine the contractility of the detrusor, intraperitoneal pressure, and evaluate the functioning of the urethral sphincters.

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

Diagnostic tests

Micture cystometry is a method of recording changes in bladder pressure during urination. This study checks the functioning of the detrusor-sphincter system.

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

For the symptomatic treatment of bladder dysfunction, the following groups of drugs are widely used: anticholinergics, adrenergics, cholinomimetics and adrenergic agonists.

This is explained by the peculiarities of the innervation of the smooth muscles of the bladder.

The detrusor contraction occurs 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 functioning of these receptors normalizes the frequency of urination and alleviates the patient’s condition.

Antidepressants are also prescribed in combination with these drugs.

Urinary problems can be corrected with physiotherapeutic procedures.

Of great practical importance is the identification of dysfunctions of the bladder, which arise in connection with a disorder of its innervation, which is provided mainly by the autonomic nervous system (Fig. 13.4). Afferent somatosensory fibers originate from the proprioceptors of the bladder, which respond to its stretching. The nerve impulses arising in these receptors penetrate through the spinal nerves S„-SIV Fig. 13.4. Innervation of the bladder (according to Müller). 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 - detrusor of the bladder; 11 - internal sphincter of the bladder; 12 - external sphincter of the bladder. into the posterior cords of the spinal cord, subsequently enter the reticular formation of the brain stem and further into the paracentral lobules of the large hemispheres, while along the way, some of these impulses pass to the opposite side. Thanks to the information going along the indicated peripheral, spinal and cerebral structures to the paracentral lobules, the stretching of the bladder when it fills is realized, and the presence of incomplete crossover 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 occur only when both paracentral lobes are affected (for example, with falx meningioma). 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 spinal cord segments 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 nervous regulation of the bladder, it is necessary to preserve the pathways that connect these structures of the brain and spinal cord with each other, as well as the formations of the peripheral nervous system that provide innervation to 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). 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, contracts; in this case, as the bladder fills, the muscle of its wall stretches - the muscle that pushes urine out (i.e. detrusor vesicae). All this ensures urine retention, 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 (p. 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 counter proprioceptive afferent signals from these muscles also pass through the pudendal nerves. Parasympathetic innervation of the pelvic organs is carried out by preganglionic fibers coming from the parasympathetic center of the bladder, located in the sacral part of the 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 a 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 detrusor bladder (detrusor overactivity) leads to urinary incontinence. Detrusor overactivity can be neurogenic (for example, in multiple sclerosis) or idiopathic (in the absence of an identified cause). Urinary retention (retentio urinae) most 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 is caused by dyssynergia of the detrusor and bladder sphincters (contraction of the internal sphincter and relaxation of the detrusor). This happens, for example, with traumatic damage to the spinal cord, intravertebral tumor, multiple sclerosis. In such cases, the bladder becomes full 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 to the detrusor of the bladder. The cause of paresis or paralysis of the detrusor can be either a lesion of the specified level of the spinal cord or a disorder of the function 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. Along with urinary retention, neuropathic fecal retention (retencia alvi) usually occurs. Partial damage to the spinal cord above the level of the autonomic spinal centers responsible for the innervation of the bladder can lead to disruption of voluntary control of urination and the emergence of the so-called imperative urge to urinate, in which the patient, feeling the urge, is unable to hold urine. A major role is likely to be a disturbance in 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 cords 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 release of urine in drops - true urinary incontinence (incontinentia urinae vera) as it is produced by the kidneys, while the bladder is practically empty. True urinary incontinence may be caused by 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 with diabetes mellitus or primary amyloidosis. When urinary retention occurs 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, which are in a state of spastic contraction, are stretched, In this regard, urine is constantly released through the urethra in drops or periodically in small portions while the bladder remains full - paradoxical urinary incontinence (incontinentia urinae paradoxa), which can be detected by visual examination, as well as by palpation and percussion of the lower abdomen, standing the bottom of the bladder above the pubis (sometimes up to the navel). If the parasympathetic spinal center (segments of the spinal cord S1-S3) and the corresponding roots of the cauda equina are damaged, weakness may develop and a simultaneous disturbance in the sensitivity of the muscle that pushes out urine (i.e. detrusor vesicae), and urinary retention occurs. However, in such cases, over time, it is possible to restore reflex emptying of the bladder; it begins to function in an “autonomous” mode (autonomous bladder). Clarifying the nature of bladder dysfunction can help determine the topical and nosological diagnoses of the underlying disease. In order to clarify the characteristics of bladder function disorders, along with a thorough neurological examination, if indicated, radiography of the upper urinary tract, bladder and urethra is performed using radiopaque solutions. The results of urological examinations, in particular cystoscopy and cystometry (determining the pressure in the bladder during filling with liquid or gas), can help clarify the diagnosis. In some cases, electromyography of the periurethral striated muscles may be informative.