Neural control of the lower urinary tract

Transcription

1 Neural control of the lower urinary tract Jalesh N. Panicker Consultant Neurologist and Honorary Senior Lecturer The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology Queen Square, London Neurogenic bladder course QS

2 Outline The neural control of the lower urinary tract in health What happens following neurological injury

3 Bladder filling Fowler 2006 Micturition Control: An example of Goal Orientated Behaviour capacity SD FD FS Initiation and imagination Time Exploring & foraging voiding Attainment & satiation

4 The lower urinary tract... is unique Dependence on the central nervous system Element of voluntary control Functions depend upon learned behaviour Neural circuitry: phasic vs tonic activity

5 Fowler, Griffiths, de Groat Nat Rev Neurosc 2008

6 bl mf det D.N.Landon and Clare J.Fowler, 2002

7 Human bladder; PGP9.5 1:4000

8

9 Onuf s nucleus in sacral spinal cord

10 How full is my bladder? Is this the right time and place to void? S2-4 in cauda equina pelvic & pudendal ns

11 Periaqueductal grey of the midbrain From Holstege

12 Matsuura et al, 2002 Athwal et al, 2001

13 Gray s anatomy 1918

14 Interoception The sense of the physiological condition of the entire body Includes pain and temperature, formerly regarded together with touch as exteroceptive sensations Afferent input is through small diameter (Aδ and C) fibres and enter cord through lamina 1 Project via spinolthalamic tracts to hypothalamus and PAG and in humans and higher order primates to thalamus and non-dominant insula Craig, 2003

15 Activation of interoceptive cortex directly correlated with graded cooling of the hands in humans Craig et al., 2000

16 Responses to bladder infusion among 10 normal females Smaller volumes Larger volumes Griffiths and Tadic, 2007

17 Insula and adjacent lateral frontal areas activated during withholding of urine or full bladder Griffiths and Tadic, 2007

18 Insula = interoceptive or homeostatic afferent cortex The homeostatic afferents are the missing sensory limb of efferent autonomic nervous system Interoceptive sensations are associated with an affective, motivational aspect, hence their value in homeostasis.

19

20 B A C Lt Lt PAG acg Matsuura et al, 2002 Athwal et al, 2001

21 Anterior Cingulate cortex ACC associated with motivation and affective aspect of interoceptive sensations (dacc) Output correlates with sympathetic activation mediates context-driven modulation of bodily arousal states Insula= limbic sensory cortex, Anterior Cingulate Cortex = limbic motor cortex Both frequently co-activated

22

23 Patients lost feeling of gradual distention only had sensation of imminent micturition Andrew and Nathan, 1964

24 Orbitofrontal cortex Has extensive interconnections with limbic system, including hypothalamus, insula and ACC Provides hedonic valence i.e. feelings of pleasantness or unpleasantness according to body s needs Medial prefrontal cortex Involved in decision making about voiding

25 Pontine micturition centre = Barrington s nucleus Griffiths, Holstege et al., 1990 in cat Blok et al, 1997

26 LUT control: two neural programs and a switch > 99% Detrusor Sphincter Storage phase Relaxed Active Voiding phase Active Relaxed

27 Storage ACC TH MPFC OPFC/RI H PAG PMC

28 Voiding ACC TH MPFC OPFC/RI H PAG PMC

29 PMC S2-4 in cauda equina pelvic & pudendal ns

30 Suprapontine Spinal Stroke Parkinson s Disease Tumours Trauma Dementias Multiple Sclerosis Trauma Tumour Sacral / Infrasacral Disc prolapse Tumour Pelvic nerve injury Small fibre neuropathy

31 Suprapontine lesion Detrusor overactivity Pons Intact neural programs synergic contraction of the detrusor and urethral sphincter muscles Sacral cord

32 Spinal lesion PMC S2-4 in cauda equina pelvic & pudendal ns

33

34 Spinal lesion Involuntary bladder contractions Small capacity Incomplete bladder emptying

35 Detrusor sphincter dyssynergia Disrupted neural programs Detrusor muscle contracts concurrent with sphincter contraction

36 Spine Spinal cord Spinal cord ends at L1

37 Sacral/Infrasacral lesion Pons Voiding difficulties Chronic retention Variable loss of bladder sensations Sacral cord

38 Incontinence: is it always due to an overactive bladder? Overactivity Stress incontinence Overflow Functional: Mobility, toilet access Cognitive impairment: visuospatial disorientation, memory, aphasia, compulsive behaviour, social inhibition, apraxia

39 (ml) Nocturnal polyuria in PD (n=17) Day-time Night-time 0 x1 x2 x3 > x4 Night-time frequency Percentage nocturnal urine output found also to increase with increasing night time frequency Smith et al.

40 Suprapontine Stroke Parkinson s Disease Tumours Trauma Dementias Spinal Multiple Sclerosis Trauma Tumour Storage symptoms PVR: < 100mL Detrusor overactivity Storage / voiding symptoms PVR: usually elevated Detrusor overactivity, detrusor sphincter dyssynergia Sacral / Infrasacral Disc prolapse Tumour Pelvic nerve injury Small fibre neuropathy Predominantly voiding symptoms PVR: elevated Often acontractile detrusor

41 Conclusion The neural control of the bladder is widely distributed throughout the nervous system The processing of bladder sensation and the switching on of co-ordinated voiding requires the CNS to be intact Neurogenic bladders - one size does not fit all Suprapontine lesions- do not usually produce incomplete emptying Spinal lesions do Pattern of bladder dysfunction and outcome depends upon: site of lesion, nature of disease

42 Acknowledgements Department of Uro-Neurology