1 Copyright © 2014 Elsevier Inc. All rights reserved. Chapter 29 Lower Urinary Tract Dysfunction and the Nervous System Amit Batla and Jalesh N. Panicker

2 Copyright © 2014 Elsevier Inc. All rights reserved. Figure 29-1 Innervation of the lower urinary tract A, Sympathetic fibers (shown in blue) originate in the T11–L2 segments in the spinal cord and run through the inferior mesenteric ganglia (inferior mesenteric plexus, IMP) and the hypogastric nerve (HGN) or through the paravertebral chain to enter the pelvic nerves at the base of the bladder and the urethra. Parasympathetic preganglionic fibers (shown in green) arise from the S2–S4 spinal segments and travel in sacral roots and pelvic nerves (PEL) to ganglia in the pelvic plexus (PP) and in the bladder wall, which then supply parasympathetic innervation to the bladder. Somatic motor nerves (shown in yellow) that supply the striated muscles of the external urethral sphincter arise from S2–S4 motor neurons and pass through the pudendal nerves. SHP, superior hypogastric plexus; SN, sciatic nerve; T9, ninth thoracic root B, Efferent pathways and neurotransmitter mechanisms that regulate the lower urinary tract. Parasympathetic postganglionic axons in the pelvic nerve release acetylcholine (ACh), which produces a bladder contraction by stimulating M3 muscarinic receptors in the bladder smooth muscle. Sympathetic postganglionic neurons release norepinephrine (NA), which activates β3 adrenergic receptors to relax bladder smooth muscle and activates β1 adrenergic receptors to contract urethral smooth muscle. Somatic axons in the pudendal nerve also release ACh, which produces a contraction of the external sphincter striated muscle by activating nicotinic cholinergic receptors. (From Fowler CJ, Griffiths D, de Groat WC: The neural control of micturition. Nat Rev Neurosci 9:453, 2008, with permission.)

3 Copyright © 2014 Elsevier Inc. All rights reserved. Figure 29-2 Bladder diary recorded over 24 hours demonstrating increased daytime and nocturnal urinary frequency, low voided volumes, and incontinence. These findings are seen in patients with detrusor overactivity. (From Panicker JN, Kalsi V, de Seze M: Approach and evaluation of neurogenic bladder dysfunction. p. 61. In Fowler CJ, Panicker JN, Emmanuel A (eds): Pelvic Organ Dysfunction in Neurological Disease: Clinical Management and Rehabilitation. Cambridge University Press, Cambridge, 2010, with permission).

4 Copyright © 2014 Elsevier Inc. All rights reserved. Figure 29-3 A, Urinary flow meter. The side of the uroflow transducer has been cut away to show the disc at the base of the funnel, which rotates as urine passes into the collecting vessel. B, A normal printout from the uroflowmeter. A total of 290 ml was voided (upper trace), with a maximum flow rate of 30 ml per second (lower trace). (From Dantec Medical A/S, Copenhagen, with permission.)

5 Copyright © 2014 Elsevier Inc. All rights reserved. Figure 29-4 Filling cystometry demonstrating detrusor overactivity. The dark orange line (Pabd) is the intra- abdominal pressure recorded by the rectal catheter, the dark blue line (Pves) is the intravesical pressure recorded by the bladder catheter. The pink line (Pdet) is the subtracted detrusor pressure (Pves−Pabd). Green lines represent volume infused during the test (Vinf) and volume voided (Vura) while the orange line represents urinary flow (Qura). The black arrows demonstrate detrusor overactivity and the black arrowhead indicates associated incontinence. (From Panicker JN, Fowler CJ: The bare essentials: uro-neurology. Pract Neurol 10:178, 2010, with permission.)

6 Copyright © 2014 Elsevier Inc. All rights reserved. Figure 29-5 Concentric needle electromyogram (EMG) of the external anal sphincter from a 64-year-old man presenting with parkinsonism and urinary retention. Duration of the motor unit is 17.9 msec (normal<10 msec) with a mean duration of all the motor units recorded during the study of 22.9 msec; these prolonged motor units suggest chronic reinnervation and are compatible with a diagnosis of multiple system atrophy.

7 Copyright © 2014 Elsevier Inc. All rights reserved. Figure 29-6 Algorithm for the management of neurogenic lower urinary tract dysfunction. (From Fowler CJ, Panicker JN, Drake M, et al: A UK consensus on the management of the bladder in multiple sclerosis. J Neurol Neurosurg Psychiatry 80:470, 2009, with permission.)