Neural Control of Lower Urinary Tract Function. William C. de Groat University of Pittsburgh Medical School
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1 Neural Control of Lower Urinary Tract Function William C. de Groat University of Pittsburgh Medical School
2 Disclosures Current funding: NIH Grants, DK093424, DK , DK , DK Other financial relationships: Research Contract from Astellas; Consultant for Bayer Pharma AG, NeuSpera Medical, Amphora Medical. Conflicts of interest: None
3 Topics Lower urinary tract: functions, anatomy and innervation. Properties of bladder afferent nerves Central neural control of voiding Mechanisms underlying urine storage and voiding dysfunction
4 Functions of the Lower Urinary Tract Urine storage in a reservoir (bladder) Urine release through an outlet (urethra) Both functions controlled by circuitry in the central nervous system. Neural circuitry acts like a switch to turn micturition off and on. Micturition requires the coordination of smooth and striated muscle.
5 Lower Urinary Tract Innervation Reservoir Urethral Outlet
6 TYPS OF VOIDING Defect in Maturation INVOLUNTARY (Reflex) (infant & fetus) Maturation INVOLUNTARY (Reflex) (adult) THRAPY VOLUNTARY (adult) Parkinson s, MS, stroke, brain tumors, spinal cord injury, aging, cystitis
7 Micturition Switching Circuit Low level afferent activity Bladder limination OFF Storage ON CNS Switch Urethral Sphincter
8 Micturition Switching Circuit High level afferent activity Bladder Distension limination ON Storage OFF CNS Switch Urethral Sphincter
9 Two Types of Bladder Afferents A-fiber type: small myelinated axons that respond to bladder distension and trigger sensation of bladder fullness and desire to void. C-fiber type: unmyelinated axons that do not respond to bladder distension but do respond to noxious stimuli. These afferents trigger painful sensations and may be responsible for urgency and urge incontinence.
10 Healthy: mpty Bladder Aδ-Fiber C-Fiber URINARY BLADDR
11 Healthy: Bladder Distension Aδ -Fiber C-Fiber Input Silent ON Mechano-sensitive Aδ afferents Mechano-insensitive C-fiber afferents URINARY BLADDR
12 Reflexes voked by Aδ Afferents in the Pelvic Nerve Spinal Storage Reflexes Supraspinal Voiding Reflexes Fowler, Griffiths & de Groat, Nature Rev Neurosci., 9: 453, 2008
13 Pathology: Bladder Distension Aδ -Fiber Input C-Fiber Input ON ON Distension Pathology alters the properties of C-fiber afferents inducing mechano-sensitivity OAB Bladder Urgency Incontinence Pain
14 Central Pathways Activated by C-Fiber Afferents Brain/PAG/PMC ascending pathway A -fiber 1 PMC = Pontine micturition center PAG = Periaqueductal grey descending pathway 2 3 C-fiber 1 4 Spinal Cord Bladder 1 = Primary afferent neuron 2 = Spinal tract neuron 3 = xcitatory interneuron 4 = Parasympathetic preganglionic Neuron
15 Neuronal subtypes in the pontine micturition center of the cat Similar subtypes are present in the PAG Contractions recorded in a distended bladder under isovolumetric conditions
16 de Groat, W., et. al., Behav Brain Res, 1998; Sasaki, M. J Physiol, 2004; Br Res 2005, J Comp Neurol, 2005
17 Pons Periaqueductal gray Direct neuron D xcitatory Circuit Circuit # 1 Spinal cord Sensory neuron Computer model based on axonal tracing and single unit recordings in the PMC and PAG Bladder Full Bladder US U r e t h r a US de Groat & Wickens, 2013
18 Pons Periaqueductal gray Direct neuron D Inverse neuron I Feed-forward Inhibitory Circuit Circuit # 2 Spinal cord Sensory neuron Computer model based on axonal tracing and single unit recordings in the PMC and PAG Partially filled bladder Bladder Full Bladder US U r e t h r a US de Groat & Wickens, 2013
19 Pons Periaqueductal gray Direct neuron D Inverse neuron I Combined xcitatory and Inhibitory Circuits Spinal cord Sensory neuron Circuits # 1 & # 2 Bladder Full Bladder US U r e t h r a US
20 Storage Pons Periaqueductal gray I I D Inverse neuron I T Tonically active independent neuron Tonically active independent neuron R During Storage Tonically Active Inhibitory Neurons Suppress the xcitatory Circuit Spinal cord Sensory neuron Bladder mpty Bladder U S U r e t h r a U S
21 Voiding Pons Periaqueductal gray I I D Inverse neuron I T Tonically active independent neuron Tonically active independent neuron R Voiding is initiated by increased afferent excitatory input which overcomes tonic inhibition and turns off the inhibitory circuit Spinal cord Bladder U S U r e t h r a U S Sensory neuron Full Bladder Cystometry
22 Voiding Pons Periaqueductal gray I I D Inverse neuron I T Tonically active independent neuron Tonically active independent neuron R 8 Types of neurons can create an on-off switch Spinal cord Cystometry The switch requires mutual inhibition and tonically active inhibitory neurons Bladder U S U r e t h r a U S Sensory neuron Full Bladder
23 Storage Pons Periaqueductal gray I I D Inverse neuron I T Tonically active independent neuron Tonically active independent neuron R Neurotransmitters Inhibitory: GABA Opioid peptides Spinal cord Cystometry Sensory neuron xcitatory: Glutamate Bladder mpty Bladder U S U r e t h r a U S
24 L3-L4 spinal cord is also involved in bladder and sphincter function This region of the spinal cord has been ignored until recently because it does not contain autonomic neurons that innervate the bladder or motoneurons that innervate the uretharal sphincter L3-L4 lumbar spinal cord US
25 L3-L4 spinal cord contains a lumbar spinal coordinating center (LSCC) lectrical stimulation in these segments induces phasic sphincter activity in rats After spinal injury in rats L3- L4 lumbar spinal mechanisms are essential for coordinating bladder and sphincter activity. Bladder LSCC Void US Sphincter (US MG) Chang, H. et al., AJP Renal 2007
26 L3-L4 spinal cord contains a lumbar spinal coordinating center (LSCC) These segments of the cord also contain the central pattern generator for locomotion. Thus electrical epidural stimulation was applied in this region to improve motor function in spinal cord injured patients. LSCC US Unexpectedly bladder function including voluntary voiding and bladder sensation also improved. (Harkema et al., 2015)
27 Pseudorabies Virus (PRV) Transneuronal Tracing LSCC LSCC DCM L3: Central Canal PRV-RFP US PRV-GFP L6: US-MN RFP: Red Fluorescent Protein GFP: Green Fluorescent Protein Bladder
28 Bridge gray matter area containing LSCC neurons Bridge is in the region of the dorsal commissure Wings Transverse slice of the spinal cord (P20-P24)
29 Dorsal Column Bridge Wing Wing Central Canal
30 2015july30_H12-P18_L4#16_PRV_c1 Axon
31 LSCC
32 PRV-RFP Labelling in L6 spinal cord LSCC DCM US MN PRV614-RFP in US reveals US-related propriospinal neurons in L3-L4
33 de Groat, Griffiths & Yoshimura, 2015 LSCC
34 Conclusions The etiology of OAB is uncertain but may be neurogenic, myogenic, or both Neurogenic theory Reduced pontine or suprapontine inhibition Damaged axonal paths in the spinal cord and/or brain Increased primary afferent input Loss of peripheral or spinal inhibition nhanced excitatory neurotransmission in the micturition reflex pathway Myogenic theory xcitability lectrical coupling between myocytes Propagation of coordinated contractions
35 Spinal And Supraspinal US Reflex Mechanisms Spinal Bursting Mechanism in the L3-L4 Spinal Cord Chang, H., et al., AJP Renal 2007
36 Fig 5
37
38
39 Pons Periaqueductal gray Direct neuron D xcitatory Circuit Circuit # 2 Spinal cord Sensory neuron Computer model based on axonal tracing and single unit recordings in the PMC and PAG Bladder Full Bladder US U r e t h r a US de Groat & Wickens, 2013
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