Vegetative nervous system and vegetative

disturbance.
Neurogenic disturbance of the function of the
pelvic organs
Short anatomy of vegetative nervous system.
Vegetative (autonomic) nervous system regulates the activity of internal organs and
systems, secretory glands and blood vessels. It ensures constancy of the internal medium
(homeostasis) of organism and various forms of mental and physical activity. The
vegetative nervous system includes the hypothalamus, limbic system, reticular formation
and peripheral divisions of sympathetic and parasympathetic nervous system.

Hypothalamus, limbic system and reticular formation ensure the integration of

vegetative regulation with other functional states - emotions, thinking, sleep and
wakefulness. Hypothalamus (the most important structure of neuroendocrine system)
obtains extensive information because of its close connection with different divisions of the
brain and special features of blood supply. In the hypothalamus, the releasing factors are
formed and enter the hypophysis and stimulate the production of gonadotropic, thyrotropic
and adrenocoritcotropic hormones of hypophysis. The activation of anterior part of
hypothalamus leads to an increase in the parasympathetic activity, while the activation of
its posterior part increases sympathetic activity. Along the descending ways the
hypothalamus is connected with the reticular formation of midbrain, which carries its
impulses to the peripheral sympathetic and the parasympathetic from vegetative nervous
system. Limbic system is located in the deep divisions of frontal and temporal lobes of
brain, it has extensive connections with different divisions of nervous system, and it
participates in both vegetative regulation and in the formation of motivations, regulation of
sleep and wakefulness, attention.

Sympathetic neurons are localized in the lateral horns of thoracic and upper lumbar
segments of spinal cord (Th1-L2). Parasympathetic neurons are located in nuclei of cranial
nerves (oculomotor, facial, glossopharyngeal and vagus) and in the sacral segments of
spinal cord (S2-S4). The axons of vegetative neurons leave together with the cranial nerves
or the anterior rootlets of spinal cord and they reach the ganglia, where switching pulses
from the preganglionic neurons to the postganglionic occurs. Sympathetic fibers in the
composition of the anterior rootlets of spinal cord reach the units of sympathetic stem
(paravertebral and prevertebral ganglia), where their switching to the postganglionic
neurons occurs. Sympathetic stem has about 24 pairs of units (3 pairs neck, 12 pairs of
breast, 5 pairs of lumbar and 4 pairs of sacral). Postganglionic fibers in the composition of
peripheral nerves or vessels reach the appropriate organs. The preganglionic
parasympathetic fibers are longer than sympathetic, because ganglia are located near final
organs, and postganglionic parasympathetic fibers respectively shorter.

Parasympathetic nervous system ensures predominantly the homeostasis

(trophotrophic function), sympathetic nervous system - various forms of the activity
(ergotrophic function). Sympathetic nerve fibers render brake influence on the muscles of
internal organs, of bladder, of rectum and stimulating action on heart, sweat, lacrimal,
salivary and digestive glands. Parasympathetic fibers in the composition of the vagus
nerve innervate heart, light and internal organs of abdominal cavity, with exception of part
of large intestine and the rectum, as the bladder, sex organs are innervated by sacral
division of parasympathetic nervous system. The activation of parasympathetic system
causes decrease of cardiac rhythm, decrease in arterial pressure (BP), and increase in the
peristalsis of bowels. Noradrenaline is mediator of sympathetic nervous system, in the
parasympathetic - acetylcholine.

The parasympathetic innervation of eye is presented earlier with the description of

oculomotor nerve. The sympathetic innervation of eye is accomplished from the lateral
horns of spinal cord at the level C8-Th1. The axons of these sympathetic neurons are
passed, without being switched, through the upper breast and lower neck sympathetic
ganglia they conclude in the upper neck sympathetic unit. The axons of postganglionic
fibers reach internal carotid artery, they braid it and on the eye socket artery they reach
the eye socket, where they innervate the muscle, which expands the pupil, (m. dilatator
pupillae), the muscle, which expands the ocular slot (m. tarsalis superior) and the ciliary
muscles, which ensure certain position of anterior eyeball.

Symptoms and the syndromes of the vegetative the disturbances

The defect of hypothalamus can lead to different neuroendocrine syndromes (disease
Itsenko-Cushing, diabetes melltitus and other), whose detailed account is given in the
appropriate divisions of the course of endocrinology.

The diffuse defect of the peripheral vegetative nervous system (predominantly

sympathetic neurons) causes the peripheral vegetative insufficiency - syndrome, which is
manifested by the disturbance of innervations of internal organs, vessels and secretary
glands. More frequent and severe manifestation of peripheral vegetative insufficiency –
orthostatic hypotension: head spins, shroud before eyes or development of syncope when
changing from horizontal position to vertical or when prolonged standing. In expressed
orthostatic hypotension, patient can be riveted to the bed. Orthostatic hypotension can be
provoked by abundant food, alcohol use, by physical load. For diagnostics, the orthostatic
test is conducted: BP investigation is measured at lying position, it’s which it preliminarily
was located not less than 15 min, but then in vertical position for several minutes. Test is
considered positive, if 3 min after getting up, systolic BP decreases 20 mmHg and more
and diastolic more than 10 mmHg and according to the relation to BP in horizontal position.
Other manifestations of peripheral vegetative insufficiency can be observed as constant
tachycardia (“fixed pulse”), sleep apneas (cessation of respiration in the sleep period),
dyskinesia of gastrointestinal tract, pelvic disorders, disturbance of perspiration (increased
sweating or hypohydrosis and hyperthermia), cyanosis or hyperemia of the skin, peripheral
edemas, dry eyes and mouth cavity.

In damage of ciliospinal center where sympathetic fibers exit from, it appears as the
disturbance of the eye sympathetic innervation in the form of Claude-Bernard-Horner
syndrome: the contraction of ocular slot (ptosis), the contraction of pupil (myosis), the
retraction of eyeball (enophthalmos), and also the disturbance of perspiration (anhydrosis)
and reddening, the dryness of the skin. Horner's syndrome in the form of ptosis, myosis
and enophthalmos is developed also with the defect of the brain stem (dorsolateral
divisions of medulla oblongata with Wallenberg-Zakharchenko syndrome) on the side of
damage as a result of the involvement of central sympathetic fibers, which go to ciliospinal
center from hypothalamus.

Reasons of vegetative disturbances and their treatments

Vegetative disturbances are observed with different psychic, neurological or somatic
diseases.
Primary vegetative insufficiency appears in vegetative polyneuropathy, Parkinson's disease
and other degenerative diseases of nervous system. Secondary vegetative insufficiency is
possible with polyneuropathies of different genesis (diabetic, alcoholic, and other), multiple
sclerosis, tumors of head and spinal cord. Primary vegetative insufficiency (vegetative
polyneuropathy) is established only after the exclusion of the intake of medical drugs
(hypotensive, etc), which can cause orthostatic hypotension, and also diseases of the
blood, heart, endocrine system and electrolyte disturbances, which can be manifested by
similar symptoms.
Table 9.1
Basic syndromes of defect of the peripheral of vegetative nervous system
Syndromes of defect Localization of defect
Peripheral vegetative insufficiency: orthostatic Predominantly sympathetic neurons
hypotension, constant tachycardia, sleep apneas,
disturbance of perspiration, hyperthermia,
cyanosis or hyperemia of skin, peripheral
edemas, dry eyes and mouth cavity
 Syndrome Claude-Bernard-Horner: Lateral horns of spinal cord on the level
ptosis, myosis, enophthalmos, disturbance of the of the segments C8-Th1, and sympathetic
perspiration and reddening, dryness of the skin fibers from spinal cord to eye.
Central sympathetic fibers at level of
medulla oblongata

The treatment of peripheral vegetative insufficiency is directed toward the basic

disease, which causes this insufficiency. In orthostatic hypotension, patient should avoid
the provoking factors (sharp getting up, a prolonged stay in the vertical position, abundant
food and other), to eliminate the possible drugs which render hypotensive action, to
increase the consumption of salt (up to 4-10g/day) and liquid (up to 3 L/day), to wear
elastic stockings. If the non-medical means are ineffective, it is possible to use
fludrocortisones (florinef) with 0,05 ppm of 1 mg/day, ephedrine on 12,5-25 mg/day,
midodrine (gutron) with 5-15 mg/day.

Claude-Bernard-Horner syndrome appears in defect of the brainstem (stroke,

craniocerebral injury, multiple sclerosis, tumor and other), zone of C8-Th1 spinal cord
segments, (tumor, syringomyelia and other), and also sympathetic fibers elongated from
spinal cord to the eye, which can be as a consequence of damage to carotid or eye socket
artery, and also somatic diseases (neck lymphadenitis, tumor of apical lung and others).

Brief anatomical-physiological data of the neurogenic regulation of

pelvic organs.
The bladder represents the hollow organ composes of detrusor muscle in major portion,
which pushes out urine (smooth muscle). Urination is achieved with the contraction of
detrusor muscle and relaxation of internal sphincter (smooth muscle) and external
sphincter (transverse striated muscle).
The filling of the bladder causes its tension and excitation of detrusor receptors, which
leads to the impulse flow of the afferent fibers into the cone (sacral division S2-S4 of spinal
cord). The activation of parasympathetic neurons appears because it is transferred by their
fibers and is caused contraction of detrusor and the relaxation of internal sphincter, which
leads to the emptying of the bladder. So, involuntary or reflex urination occurs, which
occurs in children up to a year and those with diseases, which lead to the disturbance of
central control of urination.
The arbitrary control of urination is achieved in a following manner. Impulses of filling
of bladder are transferred by sensitive fibers of peripheral nerves, to posterior rootlets, to
posterior cords to the reticular formation of pons and further to the paracentral lobule,
located on the medial surface of frontal portions. Arbitrary urination is achieved from
motor part of the paracentral lobule by means of the pulses, which reach the anterior
horns of spinal cord at the level S2-S4 (along the fibers, located next to the fibers of crust-
cerebrospinal way), and them they go along the fibers of somatic peripheral nerves to the
external sphincter and its relaxation is caused. This leads to the reflector relaxation of
internal sphincter, the reduction of detrusor and the emptying of the bladder. The
reduction of muscles of abdominal press can contribute to urination. The restraining of
urination is ensured by the pulses, which go along the same way and which cause the
reduction of external sphincter.
The neurogenic regulation of rectum has some similarities to the control of bladder.
The activation of parasympathetic fibers causes the peristalsis of rectum and relaxation of
internal sphincter, which leads to defecation. Activation of sympathetic fibers slows down
the peristalsis of rectum. The filling of rectum causes the tension of its walls, the excitation
of receptors and the propagation of pulses on sensitive fibers of peripheral nerves,
posterior cords to the reticular formation of pons and further to the paracentral lobule.
From the motor part of the paracentral lobule, impulses go along the lateral cords of spinal
cord into the anterior horns of the spinal cord (S2-S4), from them to the external sphincter,
whose relaxation causes the reflex relaxation of internal sphincter, the peristalsis of
rectum and defecation.
The neurogenic inspection of sex organs is complex and more in detail it is presented
in the course of urology. In men, activation of parasympathetic fibers causes erection,
while activation of sympathetic fibers causes ejaculation. The central the inspection of sex
organs realizes through the reticulospinal tract, and also from the hypothalamus by means
of the humoral influences.

Symptoms and the syndromes of pelvic neurogenic disorders

Neurogenic pelvic disorders are manifested in the form isolated disturbance of urination,
defecation and sexual function or their combination disorder. In its development, in the
majority of the cases are observed other manifestations of the defect of nervous system
(pareses, sensory disorder and others); less frequent they are the first and only symptoms
of neurological disease.
The neurogenic disturbance of bladder function is manifested as non-retention and/or
retention of urine. It appears in the defect of paracentral lobule, sacral division of spinal
cord, peripheral nerves going to bladder, and also with a bilateral injury of the conductors
between the sacral division of spinal cord and the paracentral lobule (hemisphere of large
brain, brain stem and spinal cord). In defect of the cone of the spinal cord or rootlets of
cauda equine, retention of urine can appear as result of the atony (hypo-reflection) of
bladder. If paralysis of sphincters is developed, then the true non-retention of urine
(constant secretion of urine drop by drop) or paradoxical of ishuria (urine it is separated
drop by drop, but because of the atony of detrusor muscle, it accumulate large quantity of
urine in the bladder) can be observed. In complete damage of the sensitive fibers, which
go from the bladder, its filling and passage of urine during the urination are not perceived;
more frequently appear atony and overcrowding of the bladder, retention of urine. In the
acute stage of spinal injury where it is higher than the cone (higher than the sacral
segments S2-S4) usually retention of urine is developed, but subsequently it, as rule, is
changed by the non-retention of urine as a result of the increased excitability of the
receptors (hyper-reflection) of the bladder. During the incomplete damages of spinal cord
(for example, with multiple sclerosis) the patients experience difficulties in the retention of
urine, appear imperative (imperative), sometimes false urges for the urination. In the
diseases of brain (stroke, tumor, Alzheimer's disease the rest) both the delay and the
nonretention of urine can develop. For refining the type of the dysfunction of the bladder
(hyper– or hypo-reflex of the bladder) and the exception of the organic defects of urinary
tracts, cystometry is used with the consultation of urologist.

The non-retention of urine during the sleep at the age of older than 4-5 years is called
night enuresis. The reason for disorder is obscure, delay of growth of urination regulation
system is assumed; hereditary predisposition and/or psychogenesis frequently is noted. At
5-year old, night enuresis is suffered in approximately 15% boys and 10% girls, at 10 year
old, only in half of them remain, and at 15 year old, it passes in the majority, remaining
only in 1-3% of adult. If changes in urine analysis developed, consultation of urologist, and
study of urinary tracts are indicated.
The neurogenic disturbance of the function of rectum is manifested in the form the
non-retention of feces or bolt. It appears with the defect of paracentral lobule, sacral
division of spinal cord, peripheral nerves going to the rectum, and also with a bilateral
injury of the conductors between the sacral division of spinal cord and the paracentral
lobule (hemisphere of large brain, the brain stem and spinal cord). The transverse defect of
spinal cord higher than its cone usually causes bolt. The defect of sacral division of spinal
cord or fibers to or from the rectum leads to the non-retention of feces and loss of anal
reflex. During the complete damage of the sensitive fibers, which go from rectum, its filling
and passage of feces with defecation are not perceived. To exclude the organic defeats of
rectum, consultation of proctologist and rectoromanoscope are needed.
The disturbance of the sex organs function in the form of disturbance of erection and
ejaculation (impotence) appears with the transverse defect of spinal cord, cone of spinal
cord and fibers to or from the sex organs.

Reasons of neurogenical pelvic disorders and their treatment

The neurogenic disturbances of urination, defecation and sexual function developed with
the injury of spinal cord, cerebral or spinal stroke, tumor of head or spinal cord either of
rootlets of cauda equina, multiple sclerosis, Alzheimer's disease and other dementia,
vegetative poly-neuropathy (for example, in diabetes mellitus, amyloidosis) and other
illnesses, which lead to the defect of pelvic nerves, rootlets of cauda equina or bilateral
defect of spinal cord and brain.
 In retention of urine, drainage with the use of a constant or intermittent catheterization
is required. For the stimulation of the reflex report of urination, the regular over
compression of a constant catheter up to 2-3 h can help, and also by making pressures
using hand above pubic symphysis. In difficulty of bladder emptying, it is possible to use
cholinomimetics (carbocholine, aceclidine, amiridine), anticholinesterase drugs (proserine,
calimine), electrical stimulation, and in the resistance to the conservative therapy cases -
surgical treatment transurethral resection of neck of bubble with the plastic of neck,
external of sphincterotomy and others). In nonretention of urine, use the adaptations for
the external collection of urine ([kondomnyy] urine dump in men), of [pampersy], periodic
catheterization, implanted sphincter devices. The anticholinergic means can help with the
light degree of nonretention or the imperative urges for the urination: hydroxybutyneine
(driptan) on 2.5-5 mg/day, detruzitol on 2-4 mg/day, tricyclic antidepressants, for example
Melipramin on 10-75 mg/day.
Neurogenic bolt and nonretention of feces appear as a result of the same reasons as
neurogenic bladder, but frequently they be absent also during the expressed disturbances
of urination. consultation of gastroenterologist, surgeon, proctologist are need to exclude
of the diseases of large intestine. In bolt, daily suppository or enema before the restoration
of independent defecation, regular attempts of defecation, use of diet (use of prunes, bran)
and/or of purgative means; the use of preparations, which cause bolt is contraindicated. In
chronic non-retention of feces, it is possible to place the morning or evening enema (to
reduce the risk of involuntary defecation in the course of day), to bear padding, to carry
out exercises for the inspection of the external sphincter and other muscles, capable of
retaining fecal masses.
In night enuresis, it is recommended to limit intake of liquid at night, required urination
before the sleep, favorable family atmosphere, and use of a special device (“alarm clock”),
which wakes child up at the beginning of urination. The anticholinergic substances can
help if nonmedicamental measures is uneffective: hydroxybutyneine (driptan) 2.5-5
mg/day, Melipramins 10-75 mg/day. Psychotherapy is frequently effective.
The disturbance of sexual function in men (erectile dysfunction, impotence) frequently
appears with multiple sclerosis, vegetative neuropathies (diabetes mellitus, alcoholism,
amyloidosis and other), epilepsy and Parkinson's disease. To confirm the diagnosis and
treatment is necessary the consultation of sexopathologist.

Manifestations of neurogenic bladder, localization the defect

Manifestations Localization of the defect
Delay and/or the non- Paracentral lobe and other divisions brain, lateral cords of
retention of the urine spinal cord or the cone of spinal cord, the root of cauda
equina, peripheral nerves
True non-retention of Cone of the spinal cord, root of cauda equina, peripheral
urine nerves
Paradoxical ishuria Cone of the spinal cord, root of cauda equina, peripheral
nerves
Imperative urges to Paracentral lobe and other divisions brain, lateral cords of
urinate spinal cord