Ultrastructure of vesicourethral innervation. I. Neuroeffector and cell junctions in the male internal sphincter

[Urethral reflexes: A review]

INTRODUCTION

The urethrosphincter complex is involved not only in maintaining urinary continence, particularly during effort, but also for the achievement of a complete and effective micturition. Indeed, the urethra is not a simple passive channel for the evacuation of urine from the bladder to the urethral meatus, since its resistive capacities and its possibilities of modulation of the micturition reflex depend on its reflex role either as a sensory afferent or as a neuro-muscular effector. It also participates in many genito-sexual and ano-rectal réflexes.

MATERIAL AND METHOD

This review of the literature describes the various reflexes of the urethra as a sensory stimulus or a neuromuscular effector. All articles referenced in this review were obtained from articles indexed on Pubmed-Medline, using the keywords: "urethral reflexes; "reflex bladder"; "urination reflex"; "intravaginal; vaginal"; "anorectal; sphincter"; "Storage and voiding"; "reflexes sneezing"; "cough reflex". Other articles were selected through references of the articles issued from the first research. Only articles in English and French have been selected. The articles concerned animal and human experiments.

RESULTS

Eight hundred and sixty-four referenced articles were founded and a total of 75 articles were included, describing the various reflexes mediated by the urethra acting as a sensory afferent or mechanical effector. We differentiated the known data in humans and animals.

CONCLUSION

The urethra is a complex anatomical structure ensuring, through numerous reflex mechanisms, urinary continence. Urethral resistances are modulated during efforts and depends on the bladder capacity and the intensity of the efforts. During micturition, the coordination between the bladder and the urethra is mediated by reflex pathways organized at the cerebral, spinal and lumbosacral levels. The modulation of the micturition in term of efficacy and velocity, is due in part, to the re-afferentation of the spinal reflex by continuous stimulus of the urethral canal. Many of these reflexes are imperfectly described. Finally, the urethra is implicated in reflex loops of anal continence and sexual functions.

[Anatomy and physiology of the lower urinary tract]

Neurogenic lower urinary tract dysfunction is frequent, due to lesions of the central and/or peripheral somatic and/or autonomic nervous system whose role is to ensure the regulation and control of lower urinary tract function. Due to the presence of both smooth and striated muscle cells in structures of the lower urinary tract, nerve pathways and nerve centres belong to both the somatic and autonomic nervous systems.

Structural and functional characterization of bladder smooth muscle in fetal rats with retinoic acid-induced myelomeningocele

Myelomeningocele (MMC) is the most common cause of neurogenic bladder dysfunction (NBD). We recently developed a novel retinoic acid (RA)-induced MMC model in fetal rats. The objective of this study was to use this model to assess functional and structural characteristics of the detrusor muscle in MMC-associated NBD. Time-dated pregnant Sprague-Dawley rats were gavage fed 60 mg/kg RA dissolved in olive oil or olive oil alone [embryonic day 10 ( E10)]. Bladder specimens from olive oil-exposed fetuses (OIL; n = 71), MMC ( n = 79), and RA-exposed-no MMC (RA, n = 62) were randomly assigned for functional and histopathological evaluation and protein analysis. Contractility responses to field and agonist-mediated stimulation (KCl and bethanecol) were analyzed. The expression patterns of α-smooth muscle actin, myosin, desmin, vimentin, and collagen III and I were analyzed by immunohistochemistry and Western blotting. Spatial and temporal distribution of nerve fibers within the detrusor muscle was monitored by neurotubulin-β-III throughout gestation. Neither OIL, MMC, nor RA detrusor responded to field stimulation. MMC bladder strips showed a significant decrease in contractility after KCl and bethanechol stimulation compared with OIL and RA bladders. Bladder detrusor morphology and expression patterns of smooth muscle markers were similar between groups. Detrusor muscles in OIL and RA fetuses were densely innervated, possessing abundant intramural ganglia and nerve trunks that branch to supply smooth muscle bundles. In MMC bladders, neurotubulin-β-III-positive nerve fibers were markedly decreased with advancing gestational age and were almost completely absent at term ( E22). We conclude that the biomechanical properties of fetal rat MMC bladders are analogous to that seen in humans with MMC-associated NBD. Decreased nerve density indicates loss of peripheral neural innervation throughout gestation. The early observation of decreased innervation and decreased contractility in the absence of morphologic abnormalities in muscle structure or extracellular matrix supports a pathophysiological hypothesis that denervation is the primary insult preceding the observed alterations in bladder muscle structure and function.

Bladder sensitivity testing using a visual analogue scale: comparative cystometric study on women

AIMS

To obtain improved assessment of bladder sensitivity during cystometry by using a 10 cm visual analogue scale (VAS), and comparing it with the standard method according to the International Continence Society (ICS).

METHODS

Twenty-five patients with presumed normal bladder functioning underwent filling cystometries according to the VAS-based method and to the standard method. The order of the cystometries was set by randomization. The relationships between the bladder sensation using the VAS-based method and the volume of bladder perfusion were analyzed graphically. Various parameters were abstracted and compared to those obtained by the standard method. Correlations were searched for by principal component analysis.

RESULTS

All the curves showed continuous progression of the desire to void. Eighteen of the 25 curves (72%) had a characteristic appearance, showing a latency phase with no perception of any bladder sensation, then a second phase with linear increase of the desire to void. The latency phase corresponded to the first sensation of bladder filling (226.3 ml +/- 169.1 vs. 200.0 ml +/- 143.1, r = 0.9). The progression in desire measured by the VAS method culminated in a sensation of maximum tolerable desire to void, which corresponded to the maximum cystometric capacity (MCC; 497.3 +/- 191.2 vs. 517.4 +/- 196.7, r = 0.9). The slope of the linear regression line for the desire to void constitutes an independent parameter.

CONCLUSIONS

VAS reveals that the distinct sensations with the standard method are in fact a single sensation of a desire to void that increases continually during filling.

The inferior hypogastric plexus (pelvic plexus): its importance in neural preservation techniques

The progress in the surgery of male neurological cancers relies on the anatomico-surgical approach to the pelvic neural structures. The objective of our study was to provide a better understanding of the inferior hypogastric plexus (IHP) and its anatomical relationships in order to spare it during radical prostatectomy. Fifteen male formalin-preserved cadavers which had no sub-umbilical scar were used. In five subjects, the superior hypogastric plexus (SHP) and the pre-sacral plexus were displayed then the IHP and its sacral afferents (pelvic splanchnic nerves or erector nerves of Eckhardt) were dissected out. Serial sections of the IHP were then studied in ten subjects. This allowed its identification on certain imaging sections obtained in pelvic tumor pathology and these made up the "reference cuts". The IHP lies within a fibro-fatty plate which is flat, rectangular, sub-peritoneal, sagittal and symmetrical. It arises at the level of the intersection between the vas deferens and the terminal pelvic ureter and follows the postero-lateral aspect and circumvolutions of the seminal vesicle, with which there is a plane of surgical cleavage. The seminal vesicle is, therefore, an essential landmark for this neural structure. The plane of this cleavage may be used in pelvic cancer surgery. The safest technical means of respecting sexual function and the integrity of the IHP is to keep it at a distance. The preservation of a lateral layer of the seminal vesicle is probably a method of limiting these complications as long as this does not conflict with the oncological clearance. An irregular communicating branch was found in one of five cases between the IHP, the sacral plexus and the pudendal nerve. This communicating branch lay immediately behind the intersection between the vas deferens and the ureter in the sacral concavity. It overhangs the IHP in the seminal vesicle. Impotence remains a frequent complication after radical prostatectomy. The methods of neural preservation at the prostatic apex are known but neural preservation should also be carried out posteriorly at the lateral pole of the seminal vesicle. The possibility of posterior neural preservation may be assessed pre-operatively by study of the "reference sections". The cleavage plane between the seminal vesicle and the IHP may be used intra-operatively to spare the IHP. The cavernous nerve in particular emerges at the antero-inferior border of the IHP before running along the postero-lateral aspect of the prostate. It therefore passes in contact with the seminal vesicle and may as a result be injured during radical prostatectomy with vesiculectomy. A proximal communicating branch between the IHP and the pudendal nerve is irregular. Such communicating branches may explain a better recovery of sexual function in curative neurological cancer surgery. The essential relationship of the IHP is with the seminal vesicle. The two are in tight contact and the seminal vesicle has a true plane of surgical cleavage with IHP. The risk of injuries to the posterior erectile mechanisms can be reduced either by using the cleavage plane between the IHP and seminal vesicle or by leaving a layer of the seminal vesicle when the oncological conditions allow. During celio-surgery, the operator must be careful to retract the little bands of the seminal vesicle and divide the fibrous and vascular tracts which tighten during this maneuver. During an abdominal approach, dissection of the seminal vesicle takes place at the bottom of a real pit. The operator must carry out the division leaving a layer of the seminal vesicle in place rather than trying to extract all the seminal vesicle by placing the forceps blindly. This maneuver is naturally dependent on the oncological situation. The anatomical confirmation of a regular or irregular proximal or distal communicating branch between the IHP and the pudendal nerve is probably an explanation for the sometimes uncertain results of new techniques of neural preservation in curative cancer surgery.

Pudendal nerve stimulation induces urethral contraction and relaxation

In this study we measured urethral pressure changes in response to efferent pudendal nerve stimulation in rats. All other neural pathways to the urethra were transected, and the urethra was continuously perfused. We found fast twitch-like contractions, superimposed on a slow relaxation. The amplitude of the twitches was independent of the stimulation frequency below 26 Hz, whereas the relaxation depended highly on this frequency. The twitches were caused by striated urethral muscles, and the relaxation was caused by smooth muscles. Both were mediated by acetylcholine. We calculated the effective urethral relaxation as the absolute relaxation multiplied by the time fraction between the twitches. Maximum effective relaxation occurred at 8-10 Hz, exactly the frequency of spontaneous oscillations during bladder voiding in rats. Although the oscillatory sphincter contractions in rats during voiding may be needed in other mechanisms for efficient voiding, our data suggest that they may be a side effect of the actual purpose: urethral relaxation.

Fixation of human detrusor smooth muscle cells: role of osmolarity and magnesium ions on the ultrastructural morphology

Magnesium ions added to fixatives for processing to Transmission Electron Microscopy (TEM) have been claimed to cause relaxation of detrusor smooth muscle cells [1]. This should facilitate the morphologic evaluation of the tissue. However, magnesium ions are osmotically active and their addition may cause the fixative to become hypertonic to the tissue. To ascertain whether the presence of magnesium ions causes significant changes compared to those found where the osmolarity is raised without the presence of magnesium, human detrusor specimens were fixed in glutaraldehyde to which increasing amounts of MgCl2 or NaCl were added in different concentrations. With the addition of increasing amounts of MgCl2 and NaCl, the osmolarity of the fixative increased, causing significant changes in the morphology and morphometry of the tissue. The intercellular distances increased, the cells shrank and the shape of the cells changed from smooth and rounded to spiky and angulated. With regard to its muscle-relaxing effect, it was not possible to distinguish the specimens fixed in magnesium-containing fixatives from those without. In this study it was not possible to prove any relaxing effect of magnesium ions added to the fixative. On the contrary the magnesium ions caused an increase in the osmolarity, with significant changes in both the morphometry and the morphology of the human detrusor smooth muscle cells.

Functional anatomy of the organs of micturition

The anatomy of the organs of micturition has been the subject of study for nearly 150 years. As a result of advances in techniques and methods of clinical and research investigation, studies over the past three decades have intensified and have been increasingly directed at the functional implications and significance of organ anatomy and structure. This has led to revision of many traditional ideas about micturition and the development of new viewpoints and modalities for study of its disorders. This article summarizes the evolution of our thinking and understanding of the functional anatomy of the bladder and urethra over the years, and suggests possible directions for continued clinical study and investigation.

Structural basis of geriatric voiding dysfunction. I. Methods of a prospective ultrastructural/urodynamic study and an overview of the findings

Voiding dysfunctions are common in the elderly. Yet the pathogenesis and pathophysiology have remained largely unknown. To date there has been little information on structure of the aging detrusor. To gain insight into the structural basis of voiding dysfunction in the elderly, we examined detrusor biopsy specimens by electron microscopy. The specimens were obtained from 24 women and 11 men 65 to 96 years old (mean age 79 years) who were carefully selected by detailed clinical and neurological examination. Symptom-free subjects were particularly sought to identify those who might provide the structural/functional norm of aging detrusor. Comprehensive urodynamic study was performed in all subjects. A transurethral detrusor biopsy was obtained and processed to study ultrastructure of the smooth muscle, intrinsic nerves and interstitium. Subjects were segregated purely by urodynamic findings, regardless of symptoms, into detrusor overactivity, outlet obstruction, obstruction plus overactivity and neither (that is no obstruction and no overactivity) groups, each with a subgroup of normal and another of impaired contractility. Specimens were segregated blindly and independently by ultrastructural features into dysjunction, myohypertrophy, myohypertrophy plus dysjunction and dense band patterns, each with a subset with widespread degeneration of muscle cells and nerves, and another with minimal or no degeneration. When codes were broken, each structural pattern (and subset) matched with a specific urodynamic group (and subgroup)--with no overlap. The dysjunction pattern matched with overactivity, the myohypertrophy pattern with obstruction, the myohypertrophy plus dysjunction pattern with obstruction plus overactivity, and the dense band pattern with the neither group. Structural subsets of widespread degeneration matched with impaired contractility subgroups, and subsets with minimal or no degeneration matched with normal contractility subgroups. These observations identify specific structural bases of the major forms of geriatric voiding dysfunction, provide important insights into their pathogenesis, and introduce detrusor biopsy as a potentially valuable tool in their diagnosis and clinical management.

Structural basis of geriatric voiding dysfunction. II. Aging detrusor: normal versus impaired contractility

Little information on the structural norm of the aging detrusor is currently available. To gain insight into the pathophysiology of geriatric voiding dysfunction, detrusor biopsies were examined by electron microscopy to identify structural correlates of specific, urodynamically defined abnormalities of vesical function in 35 elderly subjects. Prospective urodynamic grouping of the subjects and segregation of the detrusor specimens by ultrastructural features were done independently and blindly. One structural pattern so identified, the dense band pattern, matched the urodynamic group with neither detrusor overactivity nor bladder outlet obstruction. This neither group included 11 women and 2 men 65 to 91 years old (mean age 76 years). Except for 2 patients with minimal stress incontinence, all were symptom-free. None of the patients had diabetes or a neurological deficit. Urodynamically, 10 patients had impaired and 3 had normal detrusor contractility. The dense band structural pattern was characterized by overall normal configuration of muscle cells and cell junctions, sarcolemma (muscle cell membrane) dominated by dense bands with depleted caveolae in interposed zones and slight widening of spaces between muscle cells with little-collagen content. Specimens from the 10 subjects with impaired contractility displayed, in addition, widespread degeneration of muscle cells and axons. The remaining 3 specimens, without degeneration, matched the subjects with normal contractility, who were continent and symptom-free. It is proposed that the dense band pattern represents the structural norm of aging detrusor, heralds a process of muscle cell de-differentiation in the detrusor accompanying natural aging, and may affect exchange and storage of ions involved in the excitation-contraction coupling mechanism of muscle cells through depletion of caveolae. Widespread degeneration of muscle cells and axons, superimposed on the dense band pattern, is proposed as the structural correlate of impaired detrusor contractility in the aging detrusor.

Structural basis of geriatric voiding dysfunction. III. Detrusor overactivity

Detrusor overactivity in the absence of outlet obstruction is common in the elderly. The few available studies on structure of the overactive detrusor generally have dealt only with its innervation. We conducted a prospective study to examine the ultrastructure of muscle cells, interstitium and nerves of the detrusor in biopsies from 35 elderly subjects to identify structural correlates of various urodynamically defined forms of voiding dysfunction. A distinctive dysjunction structural pattern was identified blindly in 15 detrusor biopsies. These patterns matched 12 women and 3 men 66 to 96 years old (mean age 79 years) who were segregated independently as a detrusor overactivity group by prospective urodynamic evaluation. All but 1 patient had incontinence and/or other symptoms, and none had diabetes or a significant neurological deficit. The dysjunction pattern was characterized by moderately widened intercellular spaces, scarce intermediate muscle cell junctions, abundant distinctive protrusion junctions and ultra-close cell abutments, and absence of profiles characteristic of enlarged hypertrophic cells. There was superimposed widespread degeneration of muscle cells and axons in 8 specimens, which matched the subgroup of patients with impaired detrusor contractility. The remaining 7 specimens with no degeneration matched the patients with normal contractility. Protrusion junctions and abutments are proposed as a possible manifestation of a process of muscle cell de-differentiation associated with natural aging, as well as the mediator in overactive detrusor of electrical coupling of muscle cells, in lieu of their normal mechanical coupling curtailed by marked reduction of intermediate cell junctions. On this basis, a bipartite myogenic mechanism is proposed to account for the involuntary contractions yet allow neurally triggered unitary voiding contractions in the overactive detrusor. Superimposed degeneration is proposed as the structural basis of impaired detrusor contractility, when also present.

Immuno-electron microscopic study of tyrosine hydroxylase in the cat urinary bladder and proximal urethra

The distribution and density of tyrosine hydroxylase (TH)-immunoreactive nerves in the cat urinary bladder and proximal urethra were similar to those of glyoxylic acid fluorescent nerves. Both TH-immunoreactive and fluorescent nerve fibres markedly decreased after 6-hydroxydopamine treatment. Hence, immuno-electron histochemistry of TH was employed to investigate adrenergic termination to the muscle layers of the cat urinary bladder and proximal urethra. A total number of 3728 TH-immunoreactive axon terminals in the lower bladder body, lateral bladder base, trigone, bladder neck and proximal urethra were examined. In the bladder base (the lateral bladder base, trigone and bladder neck) and proximal urethra, most of the TH-immunoreactive axon terminals (57.1-89.2%) lay outside smooth muscle cell fascicles, while most (69.7%) in the bladder body were inside muscle cell fascicles. The proportions of TH-immunoreactive axon terminals accompanying non-TH-immunoreactive axon terminals in the five regions were almost the same (about 70%). The present study demonstrated that the mode of adrenergic termination in the bladder base and proximal urethra notably differed from that in the bladder body, and that approximately 70% of adrenergic axon terminals were associated with non-adrenergic or cholinergic axon terminals in each region.

Bladder wall abnormalities in myelodysplastic bladders: a computer assisted morphometric analysis

Myelodysplasia represents the most common cause of neurogenic bladder dysfunction in children. The specific histological features associated with myelodysplastic bladders have not been previously characterized. Our objective was to study the relationship between smooth muscle and connective tissue in control and myelodysplastic bladders using classical morphometric analysis with the assistance of an automated image analysis system. Gross histological analysis of the bladder specimens of normal stillborn fetuses showed organized muscle bundles embedded in a small amount of connective tissue. The bladder specimens of myelomeningocele stillborn fetuses showed a marked paucity of muscle bundles as well as a significantly diminished size of the muscle bundles. The myelomeningocele bladder specimens obtained from patients undergoing autopsy and those undergoing augmentation cystoplasty revealed significant interfascicular and pericellular infiltration of the smooth muscle by dense connective tissue. Quantitative morphometric analysis showed that the myelomeningocele stillborn fetuses have a significant increase in the volumetric content of connective tissue compared to control stillborn fetuses. The bladders of myelomeningocele patients who underwent autopsy or augmentation cystoplasty had a 3-fold increase in connective tissue when compared to normal controls. These findings reveal that structural changes in the histological components of the myelodysplastic bladder can be demonstrated not only in patients of varying ages undergoing autopsy or augmentation cystoplasty but also in the developing fetus. These findings enhance our understanding of the relationship of connective tissue proliferation to smooth muscle in the myelodysplastic bladder. We discuss the relationship of these findings to pathological detrusor morphology and detrusor dysfunction.

Ultrastructure of vesicourethral innervation. III. Axoaxonal synapses between postganglionic cholinergic axons and probably SIF-cell derived processes in the feline lissosphincter

Ultrastructurally nonspecialized axoaxonal-type synapses between postganglionic cholinergic axons innervating the lissosphincter and apposed probably SIF-cell derived neuronal processes are described. These processes were considered as the peripheral extraganglionic counterparts of those belonging to type I SIF cell interneurons, described in many mammalian peripheral autonomic ganglia. On this basis, the herein reported cholinergic/probably SIF-cell derived axoaxonal-type synapses are proposed as an auxiliary mechanism of prejunctional catecholaminergic inhibition of the normally excitatory cholinergic (postganglionic parasympathetic) neuroeffector transmission in the feline lissosphincter.

Ultrastructure of vesicourethral innervation. II. Postganglionic axoaxonal synapses in intrinsic innervation of the vesicourethral lissosphincter: a new structural and functional concept in micturition

The interrelationships of postganglionic axons in intrinsic neuroplexuses of the vesicourethral lissosphincter ('internal sphincter') were studied ultrastructurally in the cat and rat of both sexes. Direct axoaxonal contracts between cholinergic and adrenergic axons were common in preterminal axon bundles and at neuroeffector junctions. Similar contacts between 2 cholinergic or 2 adrenergic axons were less frequent. Most contacts were ultrastructurally simple, but some had focal areas of very close axolemmal apposition, and some were focally specialized as bona fide chemical synaptic complexes. The axoaxonal contacts are introduced as a complex interaxonal synaptic system that chemically, and possibly also electrically, modulates neurotransmission in postganglionic axons innervating the lissosphincter, presynaptically (prejunctionally) at the infraganglionic level, especially by reciprocal cholinergic/adrenergic axonal interaction. This synaptic system is introduced as a potential, hitherto unrecognized, site of action of autonomic drugs, and as a key factor in the neural mechanism controlling continent closure of the lissosphincter during bladder filling, its opening to initiate and maintain voiding, and its closure to terminate the micturition cycle.

On a cholinergic motor innervation of the rat urethra

Choline acetyltransferase activity was demonstrated in the proximal part of the male rat urethra, indicating a cholinergic innervation of this tissue. The cholinergic nerve fibres emanated evidently from the pelvic nerves, since bilateral removal of the pelvic ganglion caused a major fall in the activity of this enzyme. The muscle activity of the circular layer of the proximal urethra was recorded in vitro. The basal activity of this segment was low. The parasympathomimetics acetylcholine and methacholine, evoked rapid and marked contractile responses; the maximal responses to these drugs were 36 and 44%, respectively, of that to potassium. The corresponding figures for phenylephrine and noradrenaline were found to be 79 and 88%, respectively. The responses evoked by the parasympathomimetics were unaffected by the ganglion blocker hexamethonium, the alpha-adrenoceptor blocker dihydroergotamine and the beta-adrenoceptor blocker propranolol. Atropine, however, abolished the responses completely. Following degeneration of adrenergic or cholinergic nerves of the urethra the parasympathomimetics still evoked contractions. Taken together these findings indicate that the parasympathomimetics exert their contractile effect through a direct action on muscarinic receptors. Parasympathectomy but not sympathectomy (caused by 6-hydroxydopamine treatment) gave rise to a supersensitivity to methacholine, as judged by a leftward shift of the dose-response curve for this drug, the ED50-value being ten times less than that of the controls. The observations seem to suggest that the proximal urethra normally is under the influence of cholinergic activity beside that of adrenergic activity previously demonstrated.