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Neurogenic disturbance of the function of the pelvic organs
Short anatomy of vegetative nervous system.
Vegetative (autonomic) nervous system regulates the activity of internal organs and systems, secretory glands and blood vessels. It ensures constancy of the internal medium (homeostasis) of organism and various forms of mental and physical activity. The vegetative nervous system includes the hypothalamus, limbic system, reticular formation and peripheral divisions of sympathetic and parasympathetic nervous system. Hypothalamus, limbic system and reticular formation ensure the integration of vegetative regulation with other functional states - emotions, thinking, sleep and wakefulness. Hypothalamus (the most important structure of neuroendocrine system) obtains extensive information because of its close connection with different divisions of the brain and special features of blood supply. In the hypothalamus, the releasing factors are formed and enter the hypophysis and stimulate the production of gonadotropic, thyrotropic and adrenocoritcotropic hormones of hypophysis. The activation of anterior part of hypothalamus leads to an increase in the parasympathetic activity, while the activation of its posterior part increases sympathetic activity. Along the descending ways the hypothalamus is connected with the reticular formation of midbrain, which carries its impulses to the peripheral sympathetic and the parasympathetic from vegetative nervous system. Limbic system is located in the deep divisions of frontal and temporal lobes of brain, it has extensive connections with different divisions of nervous system, and it participates in both vegetative regulation and in the formation of motivations, regulation of sleep and wakefulness, attention. Sympathetic neurons are localized in the lateral horns of thoracic and upper lumbar segments of spinal cord (Th1-L2). Parasympathetic neurons are located in nuclei of cranial nerves (oculomotor, facial, glossopharyngeal and vagus) and in the sacral segments of spinal cord (S2-S4). The axons of vegetative neurons leave together with the cranial nerves or the anterior rootlets of spinal cord and they reach the ganglia, where switching pulses from the preganglionic neurons to the postganglionic occurs. Sympathetic fibers in the composition of the anterior rootlets of spinal cord reach the units of sympathetic stem (paravertebral and prevertebral ganglia), where their switching to the postganglionic neurons occurs. Sympathetic stem has about 24 pairs of units (3 pairs neck, 12 pairs of breast, 5 pairs of lumbar and 4 pairs of sacral). Postganglionic fibers in the composition of peripheral nerves or vessels reach the appropriate organs. The preganglionic parasympathetic fibers are longer than sympathetic, because ganglia are located near final organs, and postganglionic parasympathetic fibers respectively shorter. Parasympathetic nervous system ensures predominantly the homeostasis (trophotrophic function), sympathetic nervous system - various forms of the activity (ergotrophic function). Sympathetic nerve fibers render brake influence on the muscles of internal organs, of bladder, of rectum and stimulating action on heart, sweat, lacrimal, salivary and digestive glands. Parasympathetic fibers in the composition of the vagus nerve innervate heart, light and internal organs of abdominal cavity, with exception of part of large intestine and the rectum, as the bladder, sex organs are innervated by sacral division of parasympathetic nervous system. The activation of parasympathetic system causes decrease of cardiac rhythm, decrease in arterial pressure (BP), and increase in the peristalsis of bowels. Noradrenaline is mediator of sympathetic nervous system, in the parasympathetic - acetylcholine. The parasympathetic innervation of eye is presented earlier with the description of oculomotor nerve. The sympathetic innervation of eye is accomplished from the lateral horns of spinal cord at the level C8-Th1. The axons of these sympathetic neurons are passed, without being switched, through the upper breast and lower neck sympathetic ganglia they conclude in the upper neck sympathetic unit. The axons of postganglionic
fibers reach internal carotid artery, they braid it and on the eye socket artery they reach the eye socket, where they innervate the muscle, which expands the pupil, (m. dilatator pupillae), the muscle, which expands the ocular slot (m. tarsalis superior) and the ciliary muscles, which ensure certain position of anterior eyeball.
Symptoms and the syndromes of the vegetative the disturbances
The defect of hypothalamus can lead to different neuroendocrine syndromes (disease Itsenko-Cushing, diabetes melltitus and other), whose detailed account is given in the appropriate divisions of the course of endocrinology. The diffuse defect of the peripheral vegetative nervous system (predominantly sympathetic neurons) causes the peripheral vegetative insufficiency - syndrome, which is manifested by the disturbance of innervations of internal organs, vessels and secretary glands. More frequent and severe manifestation of peripheral vegetative insufficiency – orthostatic hypotension: head spins, shroud before eyes or development of syncope when changing from horizontal position to vertical or when prolonged standing. In expressed orthostatic hypotension, patient can be riveted to the bed. Orthostatic hypotension can be provoked by abundant food, alcohol use, by physical load. For diagnostics, the orthostatic test is conducted: BP investigation is measured at lying position, it’s which it preliminarily was located not less than 15 min, but then in vertical position for several minutes. Test is considered positive, if 3 min after getting up, systolic BP decreases 20 mmHg and more and diastolic more than 10 mmHg and according to the relation to BP in horizontal position. Other manifestations of peripheral vegetative insufficiency can be observed as constant tachycardia (“fixed pulse”), sleep apneas (cessation of respiration in the sleep period), dyskinesia of gastrointestinal tract, pelvic disorders, disturbance of perspiration (increased sweating or hypohydrosis and hyperthermia), cyanosis or hyperemia of the skin, peripheral edemas, dry eyes and mouth cavity. In damage of ciliospinal center where sympathetic fibers exit from, it appears as the disturbance of the eye sympathetic innervation in the form of Claude-Bernard-Horner syndrome: the contraction of ocular slot (ptosis), the contraction of pupil (myosis), the retraction of eyeball (enophthalmos), and also the disturbance of perspiration (anhydrosis) and reddening, the dryness of the skin. Horner's syndrome in the form of ptosis, myosis and enophthalmos is developed also with the defect of the brain stem (dorsolateral divisions of medulla oblongata with Wallenberg-Zakharchenko syndrome) on the side of damage as a result of the involvement of central sympathetic fibers, which go to ciliospinal center from hypothalamus.
Reasons of vegetative disturbances and their treatments
Vegetative disturbances are observed with different psychic, neurological or somatic diseases. Primary vegetative insufficiency appears in vegetative polyneuropathy, Parkinson's disease and other degenerative diseases of nervous system. Secondary vegetative insufficiency is possible with polyneuropathies of different genesis (diabetic, alcoholic, and other), multiple sclerosis, tumors of head and spinal cord. Primary vegetative insufficiency (vegetative polyneuropathy) is established only after the exclusion of the intake of medical drugs (hypotensive, etc), which can cause orthostatic hypotension, and also diseases of the blood, heart, endocrine system and electrolyte disturbances, which can be manifested by similar symptoms. Table 9.1 Basic syndromes of defect of the peripheral of vegetative nervous system Syndromes of defect Localization of defect Peripheral vegetative insufficiency: orthostatic Predominantly sympathetic neurons hypotension, constant tachycardia, sleep apneas, disturbance of perspiration, hyperthermia, cyanosis or hyperemia of skin, peripheral edemas, dry eyes and mouth cavity
Syndrome Claude-Bernard-Horner: Lateral horns of spinal cord on the level ptosis, myosis, enophthalmos, disturbance of the of the segments C8-Th1, and sympathetic perspiration and reddening, dryness of the skin fibers from spinal cord to eye. Central sympathetic fibers at level of medulla oblongata The treatment of peripheral vegetative insufficiency is directed toward the basic disease, which causes this insufficiency. In orthostatic hypotension, patient should avoid the provoking factors (sharp getting up, a prolonged stay in the vertical position, abundant food and other), to eliminate the possible drugs which render hypotensive action, to increase the consumption of salt (up to 4-10g/day) and liquid (up to 3 L/day), to wear elastic stockings. If the non-medical means are ineffective, it is possible to use fludrocortisones (florinef) with 0,05 ppm of 1 mg/day, ephedrine on 12,5-25 mg/day, midodrine (gutron) with 5-15 mg/day. Claude-Bernard-Horner syndrome appears in defect of the brainstem (stroke, craniocerebral injury, multiple sclerosis, tumor and other), zone of C8-Th1 spinal cord segments, (tumor, syringomyelia and other), and also sympathetic fibers elongated from spinal cord to the eye, which can be as a consequence of damage to carotid or eye socket artery, and also somatic diseases (neck lymphadenitis, tumor of apical lung and others).
Brief anatomical-physiological data of the neurogenic regulation of pelvic organs.
The bladder represents the hollow organ composes of detrusor muscle in major portion, which pushes out urine (smooth muscle). Urination is achieved with the contraction of detrusor muscle and relaxation of internal sphincter (smooth muscle) and external sphincter (transverse striated muscle). The filling of the bladder causes its tension and excitation of detrusor receptors, which leads to the impulse flow of the afferent fibers into the cone (sacral division S2-S4 of spinal cord). The activation of parasympathetic neurons appears because it is transferred by their fibers and is caused contraction of detrusor and the relaxation of internal sphincter, which leads to the emptying of the bladder. So, involuntary or reflex urination occurs, which occurs in children up to a year and those with diseases, which lead to the disturbance of central control of urination. The arbitrary control of urination is achieved in a following manner. Impulses of filling of bladder are transferred by sensitive fibers of peripheral nerves, to posterior rootlets, to posterior cords to the reticular formation of pons and further to the paracentral lobule, located on the medial surface of frontal portions. Arbitrary urination is achieved from motor part of the paracentral lobule by means of the pulses, which reach the anterior horns of spinal cord at the level S2-S4 (along the fibers, located next to the fibers of crustcerebrospinal way), and them they go along the fibers of somatic peripheral nerves to the external sphincter and its relaxation is caused. This leads to the reflector relaxation of internal sphincter, the reduction of detrusor and the emptying of the bladder. The reduction of muscles of abdominal press can contribute to urination. The restraining of urination is ensured by the pulses, which go along the same way and which cause the reduction of external sphincter. The neurogenic regulation of rectum has some similarities to the control of bladder. The activation of parasympathetic fibers causes the peristalsis of rectum and relaxation of internal sphincter, which leads to defecation. Activation of sympathetic fibers slows down the peristalsis of rectum. The filling of rectum causes the tension of its walls, the excitation of receptors and the propagation of pulses on sensitive fibers of peripheral nerves, posterior cords to the reticular formation of pons and further to the paracentral lobule. From the motor part of the paracentral lobule, impulses go along the lateral cords of spinal cord into the anterior horns of the spinal cord (S2-S4), from them to the external sphincter, whose relaxation causes the reflex relaxation of internal sphincter, the peristalsis of rectum and defecation. The neurogenic inspection of sex organs is complex and more in detail it is presented in the course of urology. In men, activation of parasympathetic fibers causes erection, while activation of sympathetic fibers causes ejaculation. The central the inspection of sex
organs realizes through the reticulospinal tract, and also from the hypothalamus by means of the humoral influences.
Symptoms and the syndromes of pelvic neurogenic disorders
Neurogenic pelvic disorders are manifested in the form isolated disturbance of urination, defecation and sexual function or their combination disorder. In its development, in the majority of the cases are observed other manifestations of the defect of nervous system (pareses, sensory disorder and others); less frequent they are the first and only symptoms of neurological disease. The neurogenic disturbance of bladder function is manifested as non-retention and/or retention of urine. It appears in the defect of paracentral lobule, sacral division of spinal cord, peripheral nerves going to bladder, and also with a bilateral injury of the conductors between the sacral division of spinal cord and the paracentral lobule (hemisphere of large brain, brain stem and spinal cord). In defect of the cone of the spinal cord or rootlets of cauda equine, retention of urine can appear as result of the atony (hypo-reflection) of bladder. If paralysis of sphincters is developed, then the true non-retention of urine (constant secretion of urine drop by drop) or paradoxical of ishuria (urine it is separated drop by drop, but because of the atony of detrusor muscle, it accumulate large quantity of urine in the bladder) can be observed. In complete damage of the sensitive fibers, which go from the bladder, its filling and passage of urine during the urination are not perceived; more frequently appear atony and overcrowding of the bladder, retention of urine. In the acute stage of spinal injury where it is higher than the cone (higher than the sacral segments S2-S4) usually retention of urine is developed, but subsequently it, as rule, is changed by the non-retention of urine as a result of the increased excitability of the receptors (hyper-reflection) of the bladder. During the incomplete damages of spinal cord (for example, with multiple sclerosis) the patients experience difficulties in the retention of urine, appear imperative (imperative), sometimes false urges for the urination. In the diseases of brain (stroke, tumor, Alzheimer's disease the rest) both the delay and the nonretention of urine can develop. For refining the type of the dysfunction of the bladder (hyper– or hypo-reflex of the bladder) and the exception of the organic defects of urinary tracts, cystometry is used with the consultation of urologist. The non-retention of urine during the sleep at the age of older than 4-5 years is called night enuresis. The reason for disorder is obscure, delay of growth of urination regulation system is assumed; hereditary predisposition and/or psychogenesis frequently is noted. At 5-year old, night enuresis is suffered in approximately 15% boys and 10% girls, at 10 year old, only in half of them remain, and at 15 year old, it passes in the majority, remaining only in 1-3% of adult. If changes in urine analysis developed, consultation of urologist, and study of urinary tracts are indicated. The neurogenic disturbance of the function of rectum is manifested in the form the non-retention of feces or bolt. It appears with the defect of paracentral lobule, sacral division of spinal cord, peripheral nerves going to the rectum, and also with a bilateral injury of the conductors between the sacral division of spinal cord and the paracentral lobule (hemisphere of large brain, the brain stem and spinal cord). The transverse defect of spinal cord higher than its cone usually causes bolt. The defect of sacral division of spinal cord or fibers to or from the rectum leads to the non-retention of feces and loss of anal reflex. During the complete damage of the sensitive fibers, which go from rectum, its filling and passage of feces with defecation are not perceived. To exclude the organic defeats of rectum, consultation of proctologist and rectoromanoscope are needed. The disturbance of the sex organs function in the form of disturbance of erection and ejaculation (impotence) appears with the transverse defect of spinal cord, cone of spinal cord and fibers to or from the sex organs.
Reasons of neurogenical pelvic disorders and their treatment
The neurogenic disturbances of urination, defecation and sexual function developed with the injury of spinal cord, cerebral or spinal stroke, tumor of head or spinal cord either of rootlets of cauda equina, multiple sclerosis, Alzheimer's disease and other dementia, vegetative poly-neuropathy (for example, in diabetes mellitus, amyloidosis) and other illnesses, which lead to the defect of pelvic nerves, rootlets of cauda equina or bilateral defect of spinal cord and brain.
In retention of urine, drainage with the use of a constant or intermittent catheterization is required. For the stimulation of the reflex report of urination, the regular over compression of a constant catheter up to 2-3 h can help, and also by making pressures using hand above pubic symphysis. In difficulty of bladder emptying, it is possible to use cholinomimetics (carbocholine, aceclidine, amiridine), anticholinesterase drugs (proserine, calimine), electrical stimulation, and in the resistance to the conservative therapy cases surgical treatment transurethral resection of neck of bubble with the plastic of neck, external of sphincterotomy and others). In nonretention of urine, use the adaptations for the external collection of urine ([kondomnyy] urine dump in men), of [pampersy], periodic catheterization, implanted sphincter devices. The anticholinergic means can help with the light degree of nonretention or the imperative urges for the urination: hydroxybutyneine (driptan) on 2.5-5 mg/day, detruzitol on 2-4 mg/day, tricyclic antidepressants, for example Melipramin on 10-75 mg/day. Neurogenic bolt and nonretention of feces appear as a result of the same reasons as neurogenic bladder, but frequently they be absent also during the expressed disturbances of urination. consultation of gastroenterologist, surgeon, proctologist are need to exclude of the diseases of large intestine. In bolt, daily suppository or enema before the restoration of independent defecation, regular attempts of defecation, use of diet (use of prunes, bran) and/or of purgative means; the use of preparations, which cause bolt is contraindicated. In chronic non-retention of feces, it is possible to place the morning or evening enema (to reduce the risk of involuntary defecation in the course of day), to bear padding, to carry out exercises for the inspection of the external sphincter and other muscles, capable of retaining fecal masses. In night enuresis, it is recommended to limit intake of liquid at night, required urination before the sleep, favorable family atmosphere, and use of a special device (“alarm clock”), which wakes child up at the beginning of urination. The anticholinergic substances can help if nonmedicamental measures is uneffective: hydroxybutyneine (driptan) 2.5-5 mg/day, Melipramins 10-75 mg/day. Psychotherapy is frequently effective. The disturbance of sexual function in men (erectile dysfunction, impotence) frequently appears with multiple sclerosis, vegetative neuropathies (diabetes mellitus, alcoholism, amyloidosis and other), epilepsy and Parkinson's disease. To confirm the diagnosis and treatment is necessary the consultation of sexopathologist. Manifestations of neurogenic bladder, localization the defect
Manifestations Delay and/or the nonretention of the urine True non-retention of urine Paradoxical ishuria Imperative urges to urinate Localization of the defect Paracentral lobe and other divisions brain, lateral cords of spinal cord or the cone of spinal cord, the root of cauda equina, peripheral nerves Cone of the spinal cord, root of cauda equina, peripheral nerves Cone of the spinal cord, root of cauda equina, peripheral nerves Paracentral lobe and other divisions brain, lateral cords of spinal cord