Urination disorders. Bladder innervation. What symptoms indicate violations of the innervation of the bladder? What is bladder innervation

Much in the functioning of an organ depends on its innervation. In case of violation of innervation, the organ may have either an excessive number of impulses, or very little, on which its ability to perform its actions directly depends. Against the background of these disorders, there are many nosologies of diseases. Among them is a neurogenic bladder.

Neurogenic bladder implies a whole range of disorders that are associated with dysfunction of the urinary system. A disease such as a neurogenic bladder develops against the background of acquired or congenital pathologies nerves that are responsible for the process of voluntary urination. This damage to the nervous system makes the urinary system inactive or, conversely, overactive.

Causes of neurogenic bladder development

Normal operation Bladder regulated by a large number nerve plexuses on several levels. Starting from birth defects terminal spine and spinal cord to dysfunction of the nervous regulation of the sphincter - all these disorders can provoke the appearance of symptoms of a neurogenic bladder. These disorders may be the consequences of trauma and be explained by other pathological processes in the brain, such as:

• Multiple sclerosis.
• Stroke.
• Encephalopathy.
• Alzheimer's disease.
• Parkinsonism.

Spinal cord lesions such as spondylarthrosis, osteochondrosis, Schmorl's hernia, and trauma can also cause the development of a neurogenic bladder.

The main symptoms of a neurogenic bladder

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

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

Hypertonic type of neurogenic bladder

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

Having an overactive detrusor eliminates the possibility of urine accumulating in the bladder, so people feel the need to go to the toilet very often. Patients with hypertonic type neurogenic bladder feel the following symptoms:

• Stranguria is pain in the urethra.
• Nocturia - frequent urination at night.
• Urgent urinary incontinence - a rapid expiration with a strong urge.
• Strong tension in the muscles of the pelvic floor, which sometimes provokes the reverse direction of the flow of urine through the ureter.
• Frequent urge to urinate with little urine.

Hypoactive type of neurogenic bladder

The hypotonic type develops when the area of ​​the brain below the pons of the brain is damaged, most often these are lesions in the sacral region. For such defects of the nervous system, insufficient contractions of the muscles of the lower urinary tract or complete absence contractions called detrusor areflexia.

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

• Feeling of insufficient emptying of the bladder, which ends with a feeling of fullness.
• No urge to urinate.
• Very sluggish urine stream.
• Pain along the urethra.
• Urinary sphincter incontinence.

Violation of innervation at any level can cause trophic disorders.

The effect of impaired innervation on the urinary tract

With improper innervation, the blood supply to the urinary tract is disturbed. So, with a neurogenic bladder, cystitis often accompanies, which can cause microcysts.

A microcyst is a decrease in the size of the bladder due to chronic inflammation. With a microcyst, the function of the bladder is significantly impaired. Microcyst is one of the most difficult complications of chronic cystitis and neurogenic bladder.

Residual urine in the bladder increases the risk inflammatory diseases urinary tract. If the neurogenic bladder is complicated by cystitis, then this is a health hazard and sometimes requires surgical intervention.

Diagnosis and treatment of neurogenic bladder and its type

After collecting a detailed history, it is important to take urine and blood tests to exclude the inflammatory nature of the disease. Because often the symptoms inflammatory processes very similar to the manifestation of a neurogenic bladder.

It is also worth examining the patient for the presence of anatomical anomalies 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.

Once all causes have been ruled out, neurological examinations should be performed. For this purpose, EEG, CT, MRI are performed and various techniques are used.

A neurogenic bladder is treatable. For this, anticholinergics, adrenoblockers, means to improve blood supply, and, if necessary, antibiotics are used. Physiotherapy, rest and balanced diet help you get through the process faster.

The nervous regulation of the function of the bladder provides for the alternation of long periods of filling and short periods of emptying.

Parasympathetic(exciting)fibers from sacral department spinal cord (Fig. 27-1) as part of the pelvic nerves are sent to the muscle that pushes urine ( m. detrusor vesicae). Excitation of the nerves leads to contraction of the detrusor and relaxation of the internal bladder sphincter.

Sympathetic(delaying)fibers from the lateral nuclei of the lower spinal cord are sent to the inferior mesenteric node. From here, the excitation is transmitted along the hypogastric nerves to the muscles of the bladder. Irritation of the nerves causes contraction of the internal sphincter and relaxation of the detrusor, that is, leads to a delay in urine output.

Sensitive fibers. The pelvic nerves also contain sensory nerve fibers that transmit information about the degree of stretching of the bladder wall. The strongest signals about stretching come from the posterior urethra, they are responsible for the occurrence reflexemptyingurinarybubble.

Rice. 27–1 . Bladder innervation

somatic motor fibers. As part of the genital nerves are somatic motor fibers that innervate the skeletal muscles of the external sphincter.

urinary reflex

Bladder pressure that has reached suprathreshold levels irritates stretch receptors in the bladder wall, especially receptors in the posterior urethra. Impulses from stretch receptors are conducted to the sacral segments of the spinal cord through the pelvic nerves and reflexively return to the bladder through the parasympathetic nerve fibers of the same pelvic nerves. If the bladder is partially filled, urethral contractions are replaced by relaxation, the pressure returns to its original level. If the bladder continues to fill with urine, the urinary reflexes become more frequent and cause progressively increasing contractions of the detrusor muscle. The first contraction of the bladder activates the stretch receptors, which send even more impulses, and there is a further strengthening of the contraction. This cycle repeats over and over again until a strong degree of contraction is reached. A few seconds later or more, the bladder relaxes. Thus, the urethral reflex cycle includes: a rapid increase in pressure, a period of pressure retention, a return of pressure to its original value.

Voluntary urination starts like this. The individual voluntarily contracts the abdominal muscles, which increase the pressure in the bladder, with the subsequent entry of additional portions of urine into the bladder neck and external urinary canal, stretching their wall. This stimulates the stretch receptors, which excite the urinary reflex and simultaneously inhibit the external urethral sphincter. The muscles of the perineum and the external sphincter can contract arbitrarily, stopping the flow of urine into the urethra or interrupting urination that has already begun. It is well known that adults are able to keep the external sphincter in a contracted state, and they are, accordingly, able to delay urination caused by the necessary circumstances. After urination, the urethra of women is emptied by gravity. In men, the urine remaining in the urethra is pushed out by several contractions of the bulbospongiosus muscles.

Reflex control. The stretch receptors in the bladder wall do not have a special regulatory motor innervation. However, the threshold of the emptying reflex, like the stretch reflexes of skeletal muscles, is controlled by the activity of the facilitating and inhibitory centers of the brainstem. Facilitating areas are localized in the zone of the bridge and the posterior hypothalamus, inhibitory - in the area of ​​the midbrain and superior frontal gyrus.

Urination is carried out by concerted activity m . sphincter pupillae and m. detrusor pupillae.

This happens when the somatic and autonomic nervous systems interact.

The bladder has dual autonomic (sympathetic and parasympathetic) innervation.

Spinal parasympathetic center located in the lateral horns of the spinal cord the level of segments S 2 -S 4 (Onuf's core). From it, parasympathetic fibers go as part of the pelvic nerves and innervate the smooth muscles of the bladder, mainly the detrusor. Parasympathetic innervation provides contraction of the detrusor and relaxation of the sphincter, which ensures the emptying of the bladder.

Sympathetic innervation is carried out by fibers from the lateral horns of the spinal cord (segments L 1 -L 2), then they pass as part of the hypogastric nerves (nn. hypogastrici) to the internal sphincter of the bladder. Sympathetic stimulation leads to contraction vesicular triangle muscles which prevents the reflux of urine into the bladder when urinating.

The functioning of the bladder is provided by the spinal reflex: the contraction of the sphincter is accompanied by the relaxation of the detrusor - the bladder is filled with urine. When it is full, the detrusor contracts and the sphincter relaxes, urine is expelled. According to this type, urination is carried out in children in the first years of life, when the act of urination is not controlled consciously, but is carried out by the mechanism of an unconditioned reflex.

In a healthy adult, urination is carried out according to the type of conditioned reflex: a person can consciously delay urination when an urge occurs and empty the bladder at will. Voluntary regulation is carried out with the participation of cortical sensory and motor zones. Supraspinal control mechanisms include Bridge Center (Barington), included in the reticular formation. The afferent part of this conditioned reflex begins with receptors located in the area of ​​​​the internal sphincter. Further, the signal through the spinal nodes, posterior roots, posterior cords, medulla oblongata, pons, midbrain goes to the sensory area of ​​the cortex (girus fornicatus), from where, along the associative fibers, the impulses arrive at 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 cortical-spinal tract passes through the lateral and anterior cords of the spinal cord and ends in the spinal centers of urination (S 2 -S 4 segments), which have a bilateral cortical connection. Further, the fibers through the anterior roots, the pudendal plexus and the pudendal nerve (p. 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 is tensed, but also the muscles of the diaphragm, abdominals, in turn, the internal and external sphincters relax.

neurogenic bladder - this 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 lesions of the cortex and its connections with the spinal (sacral) centers of urination, urination disorders occur central type, which can be manifested by complete retention of urine (retention urinae), which occurs in acute period diseases (myelitis, spinal injury, etc.). In this case, the reflex activity of the spinal cord is inhibited, spinal reflexes disappear, in particular, the bladder emptying reflex - 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. In the future (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 excreted periodically in small portions as it accumulates in the bladder; that is, the bladder empties automatically, 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 violation of urination is called periodic (intermittent) urinary incontinence (incontinention intermittens).

If a pathological process localized in sacral segments of the spinal cord, roots of the cauda equina and peripheral nerves(n. hypogastricus, n. pudendus), i.e., the parasympathetic innervation of the bladder is disturbed, there are violations of the function of the pelvic organs according to peripheral type . In the acute period of the disease, as a result of paralysis of the detrusor and preservation of the elasticity of the bladder neck, there is a complete retention of urine, or paradoxical retention of urine (ishuria paradoxa) with the release of urine in drops with an overflowing bladder 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, therefore, true urinary incontinence (incontinention vera) occurs with the release of urine as it enters the bladder.

Autonomic innervation of the rectum and its sphincters is carried out according to the type of innervation of the bladder. The difference is that there is no detrusor muscle in the rectum, and the abdominal muscles play its role.

Innervation is the process of regulating the excretion of fluid from the human body. This process is controlled by such systems in the body as:

• central;
• peripheral;
• autonomic nervous system.

To innervate means to provide a connection between organs and tissues. human body with the central nervous system through nerve connections between these organs and tissues.

The mechanism of regulation of urination is triggered by the sensory and motor parts of the spinal cord. The fact is that the walls of the bladder are densely dotted with sensitive receptors, which immediately work when this organ is filled with urine, which contributes to its stretching. Then an impulse enters the sacral spinal cord, which will then be sent to the brain. When the impulse enters the brain, the person will understand that it is time to empty the bladder - go to the toilet.

The bladder has a different volume in men and women. So, in women, this organ is able to accumulate five hundred milliliters of urine, and in some men, the volume of the bladder can reach marks in 750 ml. The correct functioning of the kidneys helps to fill the bladder.

So, we see that the correct regulation of urination is ensured by the coordinated work of certain systems and organs of the human body. And the brain and spinal cord are responsible for this process. This means that any deviation in the functioning of the brain, spinal cord, kidneys, as well as incorrect functioning nervous systems leads to a violation of the innervation of the bladder, which can be represented by three points:

1. hyperreflex bladder ().
2. hyporeflex bladder (inability to empty the bladder).
3. areflexory bladder ().

Let's consider each deviation separately. Thus, a hyperreflex bladder is characterized by a constant urge to empty. This is because the impulse enters the spinal cord too quickly when the bladder is only half full. At the same time, very little fluid is excreted with each urination. The cause that caused the hyperreflex bladder may be a violation of the central nervous system (central nervous system).

The hyporeflex bladder is characterized by excessive filling of the bladder with fluid as a result of the impossibility of emptying. In this case, the bladder does not contract. This is due to disturbances in the functioning of the sacral spinal cord, because it is known that the spine affects the bladder (the spinal cord is located in a person in it).

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

The main causes of violations of the process of urination or neurogenic bladder:

• tuberculomas;
• cholesteatoma;
• post-vaccination neuritis;
• diabetic neuritis;
• demyelinating diseases;
• injuries of the nervous system;
• spinal cord pathology;
• developmental pathology of the central nervous system.

Diagnostics

In case of any violations of the urinary function in the body, you should immediately contact a urologist. After taking your medical history, your doctor may send you for the following tests:

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

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

X-ray of the abdominal cavity is able to diagnose pathologies of the kidneys, bladder.
A significant advantage of MRI compared to x-rays is the ability to see human organs in 3D image which will allow the doctor to diagnose the cause of the patient's disease with high accuracy.

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

A complete blood count is an obligatory component of a complex of tests in the diagnosis of any disease. This study is able to 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 to identify the presence of bacteria in the patient's blood, to identify their sensitivity to various kinds of antibiotics.

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

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

Violation of the innervation of the bladder in children

According to statistics, neurogenic bladder suffers 10% of children. This disease does not pose a threat to the life of the child, and yet it unpleasantly complicates the socialization of the baby: complexes arise, the quality of life is disturbed.

It is known that infants and children up to two or three years unable to control the act of urination. However, when the control of the sphincter is sufficiently developed, which is carried out with the help of the brain and spinal cord, the child asks for a potty, and then learns to go to the toilet on his own. If a child of three years and older is not able to control the process of urination, this indicates violations:

• pathologies of the central nervous system;
• neoplasms in the spine (malignant or benign);
• spinal hernia;
• encephalitis;
• Do not lie;
• pathologies in the development of the sacrum and coccyx;
• disruption of the autonomic nervous system;
• hypothalamic-pituitary insufficiency.

The vast majority of children suffering from this unpleasant disease are girls. This is because estrogens regulate the sensitivity of the bladder.

Typically, children suffering from neurogenic bladder are treated only after complete examination child's body for possible pathologies in development. The complex of analyzes in children is no different from adults. This also includes general analysis blood, blood biochemistry, ultrasound, etc.

During treatment, children are contraindicated in excessive physical and emotional stress, hypothermia should not be allowed. Parents should be sympathetic to the health problems of the baby, not to allow abuse for wet clothes or bedding.

Treatment

In order to restore the 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 cholinergic, anticholinergic drugs, andrenostimulants.

Unfortunately, there is no therapy for bladder innervation disorders with folk remedies. If you have any problems with urinary dysfunction, you should immediately contact a urologist. Truth to improve efficiency drug therapy you should move more, regularly walk in the fresh air, perform exercises according to the method of exercise therapy (therapeutic physical culture).

Effects

Untimely treatment of violations of the innervation of the bladder 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. It may also occur, chronic kidney failure vesicoureteral reflux.

Prevention

Preventive measures to prevent violations of the innervation of the bladder can be aimed at timely diagnosis of the disease.

The patient should immediately contact a specialist if any symptoms of the disease occur.

In addition, it is important to carry out prevention and treatment in time. nervous disorders to avoid disruption of the central nervous system.

SPINAL NERVES.

Spinal nerves (SMN) are formed by the fusion of the anterior (motor) and posterior (sensory) roots of the spinal cord.

Each SN after exiting the spinal canal is divided into 4 branches:

1. Rear.

2. Front- form plexuses: cervical, brachial, lumbar, sacral and coccygeal.

3. Meningeal- return to spinal cord and innervate its shells.

4. Connecting belong to the autonomic nervous system.

The spinal cord grows unevenly, so the roots of the SMN in the upper section are located horizontally, on the middle - obliquely down, in the lower - vertically, forming a bundle of nerves - " ponytail».

In function, most SMNs are mixed, so they have 2 branches:

1. Motor (muscular);

2. Sensitive (skin)

REAR BRANCHES

Thinner than the anterior, pass between the transverse processes of the vertebrae.

1) suboccipital nerve- only motor, formed by the posterior branches of C1 SMN. Innervates large and small rectus posterior muscles of the head.

2) Greater occipital nerve- formed by the posterior branches of C1 and C2 SMH. The motor branch innervates the semispinalis muscle of the head, the belt muscle of the head and neck, and the longest muscle of the head.

The sensory branch innervates the skin of the occipital region, closer to the midline.

3) back branches C3 - Co1 SMN innervate the muscles and skin of the back, as well as the skin of the upper and middle parts of the buttocks.

THORACIC SMN (nervi thoracici)

Tangles do not form. There are 12 pairs of them, they are separated from the posterior branches and are called intercostal nerves. 12 pair of thoracic SM is called hypochondrium. The thoracic SMN innervates the intercostal muscles, the transverse chest muscle, the levator ribs muscle, the serratus posterior muscles, the external and internal oblique muscles of the abdomen, the rectus and transverse abdominal muscles, the skin of the anterior and lateral surfaces of the chest and abdomen. Nerves running in 4 - 6 intercostal spaces , innervate the mammary gland.

PLEXES SMN

Plexus formed anterior branches of the SMN.

Violation of innervation.