The neurological organization of micturition

Effect of magnetic therapy in bladder dysfunction and quality of life in paraplegic patients

BACKGROUND

Urinary dysfunction is linked to spinal cord injury (SCI). The quality of life (QoL) declines in both neurogenic bladder impairment and non-disordered patients.

OBJECTIVE

To ascertain the effectiveness of pulsed magnetic therapy on urinary impairment and QoL in individuals with traumatic incomplete SCI.

METHODS

This study included forty male paraplegic subjects with neurogenic detrusor overactivity (NDO) for more than one year following incomplete SCI between T6-T12. Their ages ranged from 20 to 35 and they engaged in therapy for three months. The subjects were divided into two groups of equal size. Individuals in Group I were managed via pulsed magnetic therapy once per week plus pelvic floor training three times a week. Individuals in Group II were managed with only three times a week for pelvic floor training. All patients were examined for bladder cystometric investigations, pelvic-floor electromyography (EMG), and SF-Qualiveen questionnaire.

RESULTS

There was a noteworthy increment in individuals in Group I in volume of bladder at first desire to void and maximum cystometric capacity, detrusor pressure at Qmax, and maximum flow rate. There was a momentous increment in Group I in measures of evaluation of EMG biofeedback. There was a notable rise in Group I in SF-Qualiveen questionnaire.

CONCLUSION

Magnetic stimulation should be favored as beneficial adjunct to traditional therapy in the management of bladder impairment and enhancing QoL in individuals with SCI.

Review of Animal Models to Study Urinary Bladder Function

Simple Summary

The treatment of urinary bladder dysfunction requires the knowledge of bladder function, which involves physiology, pathology, and even psychology. Several animal models are available to study a variety of bladder disorders. These models include animals from rodents, such as mice and rats, to nonhuman primates, such as rabbits, felines, canines, pigs, and mini pigs. This review adapted animal models to study bladder function according to facility, priority, and disease.

Abstract

The urinary bladder (UB) serves as a storage and elimination organ for urine. UB dysfunction can cause multiple symptoms of failure to store urine or empty the bladder, e.g., incontinence, frequent urination, and urinary retention. Treatment of these symptoms requires knowledge on bladder function, which involves physiology, pathology, and even psychology. There is no ideal animal model for the study of UB function to understand and treat associated disorders, as the complexity in humans differs from that of other species. However, several animal models are available to study a variety of other bladder disorders. Such models include animals from rodents to nonhuman primates, such as mice, rats, rabbits, felines, canines, pigs, and mini pigs. For incontinence, vaginal distention might mimic birth trauma and can be measured based on leak point pressure. Using peripheral and central models, inflammation, bladder outlet obstruction, and genetic models facilitated the study of overactive bladder. However, the larger the animal model, the more difficult the study is, due to the associated animal ethics issues, laboratory facility, and budget. This review aims at facilitating adapted animal models to study bladder function according to facility, priority, and disease.

Spinal interneurons of the lower urinary tract circuits

The storage and elimination of urine requires coordinated activity between muscles of the bladder and the urethra. This coordination is orchestrated by a complex system containing spinal, midbrain and forebrain networks. Normally there is a reciprocity between patterns of activity in urinary bladder sacral parasympathetic efferents and somatic motoneurons innervating the striatal external urethral sphincter muscle. At the spinal level this reciprocity is mediated by ensembles of excitatory and inhibitory interneurons located in the lumbar-sacral segments. In this review I will present an overview of currently identified spinal interneurons and circuits relevant to the lower urinary tract and will discuss their established or hypothetical roles in the cycle of micturition. In addition, a recently discovered auxiliary spinal neuronal ensemble named lumbar spinal coordinating center will be described. Sexual dimorphism and developmental features of the lower urinary tract which may play a significant role in designing treatments for patients with urine storage and voiding dysfunctions are also considered. Spinal cord injuries seriously damage or even eliminate the ability to urinate. Treatment of this abnormality requires detailed knowledge of supporting neural mechanisms, therefore various experiments in normal and spinalized animals will be discussed. Finally, a possible intraspinal mechanism will be proposed for organization of external urethral sphincter (EUS) bursting which represents a form of intermittent EUS relaxation in rats and mice.

Lipopolysaccharide reduces urethral smooth muscle contractility via cyclooxygenase activation

Lipopolysaccharide (LPS) is a component of gram-negative bacteria wall that elicits inflammatory response in the host through the toll-like receptor 4 (TLR4) activation. In the lower urinary tract (LUT), bacteria-derived LPS has been associated with lower urinary tract symptoms (LUTS); however, little is known about the effects of LPS in the urethral smooth muscle (USM). In the present study, we evaluated the functional and molecular effects of LPS in mouse USM in vitro, focusing on the LPS-induced TLR4-signaling pathway. Male C57BL6/JUnib and TLR4 knockout mice (TLR4 KO) were used. The USM contraction was performed in the presence of LPS (62.5-500 μg/mL), indomethacin (10 μM), L-NAME (100 μM), and TAK 242 (1 μM). The RT-PCR assay for the IL-1β, NF-kB, and COX-2 genes was also evaluated in the presence of LPS (125 μg/mL) and caspase 1 inhibitor (20 μM). Our results showed that LPS reduces mouse USM contraction elicited by phenylephrine and vasopressin. This LPS-induced urethral inhibitory effect was not reversed by the TLR4 inhibition or its absence in the TLR4 KO mice. Conversely, indomethacin (but not L-NAME) reversed the LPS-induced USM hypocontractility. Molecular protocols indicated upregulation of IL-1β, NF-kβ, and COX-2 mRNA upon LPS incubation, which were blunted by caspase 1 inhibition. Our data showed that LPS reduced mouse USM contraction independently of TLR4 activation, involving caspase 1 and IL1β, NF-kB, and COX-2 gene overexpression. Therefore, this alternative pathway might be a valuable target to reduce the LPS-induced urethral dysfunction under infection and inflammatory conditions.

Spontaneous Activity and the Urinary Bladder

The urinary bladder has two functions: to store urine, when it is relaxed and highly compliant; and void its contents, when intravesical pressure rises due to co-ordinated contraction of detrusor smooth muscle in the bladder wall. Superimposed on this description are two observations: (1) the normal, relaxed bladder develops small transient increases of intravesical pressure, mirrored by local bladder wall movements; (2) pathological, larger pressure variations (detrusor overactivity) can occur that may cause involuntary urine loss and/or detrusor overactivity. Characterisation of these spontaneous contractions is important to understand: how normal bladder compliance is maintained during filling; and the pathophysiology of detrusor overactivity. Consideration of how spontaneous contractions originate should include the structural complexity of the bladder wall. Detrusor smooth muscle layer is overlain by a mucosa, itself a complex structure of urothelium and a lamina propria containing sensory nerves, micro-vasculature, interstitial cells and diffuse muscular elements.Several theories, not mutually exclusive, have been advanced for the origin of spontaneous contractions. These include intrinsic rhythmicity of detrusor muscle; modulation by non-muscular pacemaking cells in the bladder wall; motor input to detrusor by autonomic nerves; regulation of detrusor muscle excitability and contractility by the adjacent mucosa and spontaneous contraction of elements of the lamina propria. This chapter will consider evidence for each theory in both normal and overactive bladder and how their significance may vary during ageing and development. Further understanding of these mechanisms may also identify novel drug targets to ameliorate the clinical consequences of large contractions associated with detrusor overactivity.

A Proof-of-Concept Study of Transcutaneous Magnetic Spinal Cord Stimulation for Neurogenic Bladder

Patients with chronic spinal cord injury (SCI) cannot urinate at will and must empty the bladder by self-catheterization. We tested the hypothesis that non-invasive, transcutaneous magnetic spinal cord stimulation (TMSCS) would improve bladder function in individuals with SCI. Five individuals with American Spinal Injury Association Impairment Scale A/B, chronic SCI and detrusor sphincter dyssynergia enrolled in this prospective, interventional study. After a two-week assessment to determine effective stimulation characteristics, each patient received sixteen weekly TMSCS treatments and then received "sham" weekly stimulation for six weeks while bladder function was monitored. Bladder function improved in all five subjects, but only during and after repeated weekly sessions of 1 Hz TMSCS. All subjects achieved volitional urination. The volume of urine produced voluntarily increased from 0 cc/day to 1120 cc/day (p = 0.03); self-catheterization frequency decreased from 6.6/day to 2.4/day (p = 0.04); the capacity of the bladder increased from 244 ml to 404 ml (p = 0.02); and the average quality of life ranking increased significantly (p = 0.007). Volitional bladder function was re-enabled in five individuals with SCI following intermittent, non-invasive TMSCS. We conclude that neuromodulation of spinal micturition circuitry by TMSCS may be used to ameliorate bladder function.

Non-motor features of Parkinson disease

Many of the motor symptoms of Parkinson disease (PD) can be preceded, sometimes for several years, by non-motor symptoms that include hyposmia, sleep disorders, depression and constipation. These non-motor features appear across the spectrum of patients with PD, including individuals with genetic causes of PD. The neuroanatomical and neuropharmacological bases of non-motor abnormalities in PD remain largely undefined. Here, we discuss recent advances that have helped to establish the presence, severity and effect on the quality of life of non-motor symptoms in PD, and the neuroanatomical and neuropharmacological mechanisms involved. We also discuss the potential for the non-motor features to define a prodrome that may enable the early diagnosis of PD.

Test-retest repeatability of patterns of brain activation provoked by bladder filling

OBJECTIVE

To assess short-term repeatability of an fMRI protocol widely used to assess brain control of the bladder. fMRI offers the potential to discern incontinence phenotypes as well as the mechanisms mediating therapeutic response. If so, this could enable more targeted efforts to enhance therapy. Such data, however, require excellent test-retest repeatability.

METHODS

Fifty-nine older women (age ≥60 years) with urgency incontinence underwent two fMRI scans within 5-10 min with a concurrent bladder infusion/withdrawal protocol. Activity in three brain regions relevant to bladder control was compared using paired t tests and intra-class correlation.

RESULTS

There were no statistically significant differences in brain activity between the two consecutive scans in the regions of interest. Intra-class correlation was 0.19 in the right insula, 0.32 in the dorsal anterior cingulate cortex/supplementary motor area, and 0.44 in the medial pre-frontal cortex. Such correlations are considered fair or poor, but are comparable to those from studies of other repeated fMRI tasks.

CONCLUSIONS

This is the first evaluation of the repeatability of a bladder fMRI protocol. The technique used provides a framework for comparing different fMRI protocols applied to brain-bladder research. Despite universal patient response to the stimulus, brain response had limited repeatability within individuals. Improvement of the investigational protocol should magnify brain response and reduce variability. These results suggest that although analysis of fMRI data among groups of subjects yields valuable insight into bladder control, fMRI is not yet appropriate for evaluation of the brain's role in continence on an individual level.

Serotonin and noradrenaline reuptake inhibitors improve micturition control in mice

Poor micturition control may cause profound distress, because proper voiding is mandatory for an active social life. Micturition results from the subtle interplay of central and peripheral components. It involves the coordination of autonomic and neuromuscular activity at the brainstem level, under the executive control of the prefrontal cortex. We tested the hypothesis that administration of molecules acting as reuptake inhibitors of serotonin, noradrenaline or both may exert a strong effect on the control of urine release, in a mouse model of overactive bladder. Mice were injected with cyclophosphamide (40 mg/kg), to increase micturition acts. Mice were then given one of four molecules: the serotonin reuptake inhibitor imipramine, its metabolite desipramine that acts on noradrenaline reuptake, the serotonin and noradrenaline reuptake inhibitor duloxetine or its active metabolite 4-hydroxy-duloxetine. Cyclophosphamide increased urine release without inducing overt toxicity or inflammation, except for increase in urothelium thickness. All the antidepressants were able to decrease the cyclophosphamide effects, as apparent from longer latency to the first micturition act, decreased number of urine spots and volume of released urine. These results suggest that serotonin and noradrenaline reuptake inhibitors exert a strong and effective modulatory effect on the control of urine release and prompt to additional studies on their central effects on brain areas involved in the social and behavioral control of micturition.